Fluids & Electrolytes 3:

Acid-Base
Balance

Mary J. Aigner RN, MSN, FNPC

 What the heckDepending on age, gender,
and body fat … water

is it? makes up 45-80%

of body weight

 Body fluid is measured in units of hydrogen

ion (H+) concentration or pH units.
 Acids are substances that release H+
when dissolved in water (< pH, > H+
concentration)
 Bases are substances that bind H+
when dissolved in water (> pH, < H+
concentration)
 A substance that acts as A or B is a buffer
 Normal pH
 arterial blood is 7.35 to 7.45
So what?
 Very small changes in pH can
cause major problems … affecting
 Hormones
 Electrolytes
 Electrical impulses in the heart
 GI tract
 Nerves and muscles
 Medication activity and distribution
 A-B balance regulation:
chemical, renal, &
respiratory
 Base sources:
 NaOH (sodium hydroxide)
 NH3 (ammonia)
 Acid sources:  (made from amino acid
 CO2 from breakdown of metabolism)
glucose  AloH3 (Aluminum
 Fat metabolism = fatty hydroxide)
acids, keto acids  HCO3 (bicarbonate)
 Protein metab = sulfuric
acid
 Anaerobic glucose metab
= lactic acid
 Cell destruction releases
intracellular acids into
ECF
 *Why given IV

The role of buffers

in an emergency

 First line of defense

against imbalance
 Always present in body
fluids
 Include:
 Bicarbonate – immediate*
 ECF, ICF
 Phosphate – quick

ICF as bicarbonate
 Proteins – rapid
 ICF as Hgb, ECF as albumin
and globulins
 CO2 and pH: second line
of defense in pH changes
 Resp system reacts to acute pH changes
when buffers are not effective
 CO2 converts to H+ via carbonic anhydrase
reactions in the arterial blood
 Thus – when breathing
 Body releases excess CO2
 If breathing decreases
 Body retains CO2 (< pH)

 But - mechanism under CNS control –

 This is why if someone with COPD is given too much O2,
their breathing <, CO2>, pH <.
3rd line of defense: Renal
 Most powerful mechanisms for A-B
balance regulation – but takes longer to
begin
 3 major renal mechanisms to
compensate:
 Tubular kidney movement of bicarb
 Bicarb can move into blood if H+ high, or be
excreted in urine if H+ low
 Kidney tubule formation of acids
 Formation of NH4 (ammonium) from amino
acid catabolism
 Usually ammonia formed … in kidneys, extra H+
attached that is then excreted in urine …. <H+ =
Practice Q’s
1. Name the 3 lines of 1. Proteins are buffers
defense against pH found in the ICF as
changes. ____ and in the ECF
as ____ and _____,
Buffers, Respiratory mechanism, all work rapidly.
And renal mechanisms
ICF:Hgb,
ECF: albumin, globulin
6. Bicarbonate is often
given IV in 5. True or False:
emergencies Normal arterial
because? blood pH range is
Acts immediately 7.32 to 7.42.
False: this is venous range.
Two Main Types of
Imbalances
 Respiratory (carbonic acid)
Our bodies
 Acidosis pH <7.35
 Alkalosis pH >7.45
Will try to
Compensate
 Metabolic (bicarbonate) For the
 Acidosis pH <7.35
imbalance
 Alkalosis pH>7.45

 Ratio 20:1 (bicarb to carbonic)

 But there are also Mixed Types!
 What’s carbonic acid?
 An inadequate exchange of O2 and CO2
cause retention of CO2, this decreases
the pH. The retention of CO2 creates
carbonic acid (H2CO3) which then
separates into H+ ions and bicarbonate
ions. The free H+ ions in the blood
create acidosis.

H2O + CO2 H2CO3 H+ (+) HCO3-

Excess H+ in blood causes other electrolyte imbalances, especially
other + ions such as Na+, K+, and Ca+
Respiratory Acidosis
(pH<7.35)
Carbonic acid level increases
 Hyperventilation, CO2 retention
 COPD, asthma – common causes
 Also – CNS depression 2° anesthesia
or a narcotic overdose

 Compensation: Kidneys retain

bicarbonate – slow, hours to days
to restore normal pH
Respiratory Alkalosis
(pH>7.45)
Carbonic acid levels decrease
 Hyperventilation - > CO2 exhaled
 Anxiety, psychogenic – common
causes
 Also fever, resp infections

 Compensation: Kidneys will

excrete bicarbonate to return pH
to normal (slow process). Usually,
cause eliminated sooner and
balance restored.
Metabolic Acidosis
(pH<7.35)
 Bicarbonate levels low in relation
to amount of carbonic acid in body
 Eg. Renal failure (kidneys unable to
excrete H ion and produce
bicarbonate)

 Too much acid produced in body

 Eg. DM ketoacidosis, starvation (fat
tissue broken down for energy), renal
impairment
 There are other causes of
metabolic acidosis (pH = ?)
 Conditions that decrease bicarbonate in
body
 Prolonged or severe diarrhea
 Excessive infusion of chloride-containing IV
fluids
 Eg. NaCl

 Compensation: > resp rate, more CO2

exhaled … occurs within minutes
 Often rapid, deep breathing - Kussmaul
Metabolic Alkalosis
(pH>7.45)
 Either loss of acid
 Prolonged vomiting
 NG suction
 Or gain in bicarbonate
 Ingestion of baking soda
 Compensation: decreased resp
rate to increase plasma CO2.
Kidneys also excrete bicarb.
 Mixed Types
 Resp + Metabolic Acidosis
 eg. Severe pneumonia + severe diarrhea
 Causes greater <pH in combination

 Resp acidosis +Metabolic alkalosis

 Eg. COPD + diuretic therapy

Results in near normal pH

 Resp + Metabolic Alkalosis

 Eg. Hyperventilation 2° postop pain + NG
suction (loss of acid)
 Results in greater >pH in combination
Cardiopulmonary arrest
=?
 Hypoventilation >CO2 level
(acidosis)
 Anaerobic metabolism produces
lactic acid (acidosis)

 Two or more disorders can cause

mixed types of either acidosis or
alkalosis
 Common causes of
Acidosis
 Respiratory  Metabolic
 COPD  Diabetic
 Sedative/barbituate ketoacidosis
overdose  Lactic acidosis
 Chest wall abnormality  Starvation
 eg. Obesity  Severe diarrhea
 Atelectasis  Renal tubular
 Severe pneumonia acidosis
 Resp muscle weakness  Renal failure

Eg. Guillain-Barre  GI fistulas
syndrome  shock
Lewis, chart on page
 Common Causes of
Alkalosis
 Respiratory  Mechanical
 Hyperventilation  Severe vomiting

Eg. Hypoxia, anxiety,  Excess NG
PE, fear, pain, suctioning
exercise, fever
 Diuretic therapy
 Stimulated resp
center caused by  K deficit

Septicemia, brain  Excess NaHCO3
injury, encephalitis, intake
salicylate poisoning 
Baking soda
 Mechanical  Excessive mineral-
hyperventilation corticoids

Lewis, chart on page 352

 Metabolic Alkalosis:
Lab Findings
Lewis,
Plasma Kee
pH >
HCO3 >
pCO2 normal = uncomp
as measured on ABG > = compensated
BE >
Metabolic Acidosis: Normals: Urine pH >6 = comp
Plasma pH <
HCO3 < pH = 7.35 – 7.45
pCO2 normal = uncomp paCO2 = 35-45 mm Hg Normal Urine
< = compensated HCO3 = 24-28 mEq/l pH = 4.5 – 8
BE < BE (base excess) = Av: 6
Urine pH <6 = comp +2 to -2 mEq/l

Resp Acidosis: Resp Alkalosis:

Plasma pH < Plasma pH >
pCO2 > pCO2 <
HCO3 normal = uncomp HCO3 normal = uncomp
> = compensated < = compensated
BE = normal BE = normal
Urine pH <6 = comp Urine pH >6 = comp
Per Kee – another look
 Respiratory Acidosis
 pH < 7.35, PaCO2 > 45 mm Hg
 Clinical causes
 COPD (emphysema, chronic bronchitis,
severe asthma)
 ARDS (acute respiratory distress
syndrome)
 Guillain-Barre syndrome
 Anesthesia
 Pneumonia
 Drug influence
 narcotics
 sedatives
 Per Kee

 Respiratory Alkalosis
 pH > 7.45, PaCO2 <35mm Hg.
 Causes
 Salicylate toxicity (early phase),
anxiety, hysteria, tentany,
strenuous exercise (swimming,
running), fever, hyperthyroidism,
delirium tremens, PE
 Per Kee
 Metabolic Acidosis
 pH < 7.35, HCO3 <24 mEq/l
 Causes:
 Diabetic ketoacidosis, severe
diarrhea, starvation/malnutrition,
shock, burns, kidney failure, acute
myocardial infarction
 Per Kee
 Metabolic Alkalosis
 pH > 7.45, HCO3 > 28 mEq/l
 Causes:
 Severe vomiting, gastric suction, peptic
ulcer, K loss, excess administration of
bicarbonate, hepatic failure, cystic fibrosis
 Drug Influence:
 NaHCO3 (sodium bicarbonate)
 K oxalate
Clinical Manifestations -
Acidosis
 Neuro
 Drowsiness: Resp
or Metab
 Disorientation:
Resp
 Confusion: Metab
 Headache: Resp or
Metab
 Dizziness: Resp
 Coma: Resp or
Clinical - Acidosis
 Cardiovascular
 < BP: Resp or Metab
 Warm flushed skin (related to
peripheral vasocilation): Resp
or Metab
 V Fib (related to >K from
compensation): Resp
 Arrhythmias (related to >K
from compensation): Metab
Clinical - Acidosis
 GI
 N/V, diarrhea, abd pain: Metab
 Nothing significant: Resp
 Neuromuscular
 Seizures: Resp
 Nothing significant: Metab
 Resp
 Hypoventilation w/hypoxia: Resp
 Deep, rapid resp
(compensation): Metab
 Clinical Manifestations -
Alkalosis
 Neuro
 Cardiovascular
 Lethargy: Resp
 Tachycardia: Resp
or Metab
 Light-headedness:
Resp
 Arrhythmias
(related to <K
 Confusion: Resp or
from
Metab
compensation):
 Dizziness: Metab Resp or Metab
 Irritability: Metab
 Nervousness:
Metab
 Clinical - Alkalosis
 GI
 Neuromuscular
 Tetany: Resp or Metab
 Nausea: Resp  Seizures: Resp or Metab
or Metab  Numbness: Resp
 Vomiting: Resp  Tingling of extremities:
or Metab Resp
 Epigastric pain:  Tingling of fingers/toes:
Resp Metab
 Anorexia:
 Hyperreflexia: Resp
Metab
 Muscle cramps: Metab
 Hypertonic muscles:
Clinical - Alkalosis
 Respiratory
 Hyperventilation
(lungs unable to
compensate):
Resp

 Hypoventilation
(compensatory
action by lungs):
Metab
Arterial vs Venous values
ABG vs VBG
 Parameter ABG VBG
 pH 7.35-7.45 7.32-7.42
 pCO2 35-45 45-55
 HCO3 20-30 20-30
 PO2 80-100 40-50
 O2 Sat 96-100% 60-
85%
 BE ±2.0 ±2.0
 A few questions to ponder

In respiratory
acidosis, does
Is this metabolic carbonic acid
acidosis or alkalosis? increase or
Respiratory Alkalosis decrease?
pH < 7.35,
can be caused by
HCO3 <24 mEq/l
hyper- or hypo-
ventilation?
Functional Health Patterns
 Health perception-Health management
pt currently has F,E, or A/B problem
 Obtain description of illness including
 Onset, course, treatment

 Nutritional-metabolic
 Questions re diet
 Any special diets? (weight-loss, low-Na, fad)
 Determine ability to comply with dietary
prescriptions
More patterns
 Elimination
 Usual b/b habits
 Any deviations? Diarrhea?
Nocturia? Polyuria?
 Activity-exercise
 Usual level
activity/exercise
 Excessive perspiration?
 Exposure to high temps?
 What do they do to
replace lost F/E?
 One more pattern
 Cognitive-perceptual
 Any changes in sensations?
 Numbness? Tingling? Fasciculations
(uncoordinated twitching of a single muscle
group)?
 Ask pt and family
 Any changes in mentation or alertness?

Confusion? memory impairment? Lethargy?