ACID-BASE BALANCE

Ma’am Cheena
Quiz time
Q: What makes an acid an acid?
A: The hydrogen ion (H+).
Q: What makes a base a base?
A: The bicarbonate ion (HCO3−).
Q: If many hydrogen ions (H+) are present in a liquid, is this liquid an acid
or a base?
A: An acid.
Q: What happens to the pH of this liquid?
A: The pH decreases. The more acidic a solution, the lower the pH.
Q: Does this liquid, if infused into a client, make the client acidic
(acidotic) or basic (alkalotic)?
A: Acidotic, because hydrogen ions are acidic.
Q: If a lot of base is in a liquid, is this liquid acidic or basic?
A: You know the answer is basic!
Q: What happens to the pH of this liquid?
A: The pH increases because the more basic (alkaline) a solution,
the higher the pH.
8. Q: If this liquid is infused into a client, does the client become
acidotic or alkalotic?
A: Alkalotic, because the client has high levels of bicarbonate (a
base) in the blood.
AN OVERVIEW OF ACID–BASE
IMBALANCES
 Respiratory acidosis and alkalosis overview

• carbon dioxide---an acid

• carbon dioxide + water =carbonic acid.
• get rid of carbon dioxide exhaling
Respiratory acidosis and alkalosis overview

Lungs: carbon dioxide.

In an acid–base imbalance such as respiratory acidosis or
alkalosis, the lungs are sick.
compensating organs:kidneys
manipulating the chemicals bicarbonate and hydrogen to
correct the imbalance and bring the pH back into normal range
Respiratory acidosis and alkalosis overview

This is done by secreting bicarbonate and

excreting hydrogen.
Kidneys: slow but effective
 Metabolic acidosis and alkalosis overview
• Kidneys: ORGANS in metabolic acidosis and
metabolic alkalosis
• Bicarbonate and hydrogen are considered the
problem chemicals when the kidneys are sick.
• compensating organs: lungs
• Lungs can blow off or retain carbon Dioxide quickly
Respiratory acidosis
 Respiratory acidosis

• An acid–base imbalance that occurs when the pH is

decreased, partial pressure of carbon dioxide (PCO2) is
increased—greater than 45 mm Hg.
• When you hypoventilate…?
Carbon dioxide builds up in the blood: Hypercapnia--
buildup of carbon dioxide in the blood to levels greater than 45 mm Hg.
 Causes

• respiratory acidosis: “breathing”

• Decreased alveolar ventilation: carbon dioxide
retention
• Anytime poor gas exchange exists, CO2
builds up in the blood Respiratory acidosis
 Causes

• Respiratory arrest
• Some drugs (narcotics, sedatives hypnotics, anesthesia,
ecstasy)
• Sleep apnea
• Excessive alcohol
• Surgical incisions (especially abdominal), broken ribs
 Causes
• Collapsed lung (pneumothorax, hemothorax)
• Weak respiratory muscles (myasthenia gravis, Guillain–Barré syndrome)
• Airway obstruction (poor cough mechanism, laryngeal spasm)
• Brain trauma (specifically medulla)
• High-flow O2 in chronic lung disease
• Severe respiratory distress syndrome
 Signs and symptoms

Vary depending on the initial cause:

• Neurological changes: headache, confusion,
blurred vision, lethargy coma,
• Papilledema
• Hyperkalemia
• Acute respiratory acidosis causes
hyperkalemia. With chronic respiratory
acidosis, the K+ may be normal as the
kidneys have time to readjust and get the
K+ back into the normal range.
 Signs and symptoms

• Vary depending on the initial cause:

• Neurological changes: headache, confusion, blurred
vision, lethargy coma,
• Papilledema
• Hyperkalemia
• Decreased muscle tone; decreased DTRs
 Signs and symptoms
• Hypotension
• Restlessness; tachycardia
• Arrhythmias
• Cardiac arrest
• Acidic urine
• Warm skin
 Diagnostic tests and treatments

• Treat the cause.

• Airway clearance: possible intubation.
• Administer drugs to open up the airways and thin out secretions
so they can be coughed up.
• Increase fluids to liquefy secretions so they can be coughed up
more easily.
• Oxygen therapy.
 Diagnostic tests and treatments
• Respiratory therapy: breathing treatments.
• Elevate head of bed (HOB) for lung expansion.
• Monitor ABGs.
• Monitor for electrolyte imbalances.
• Monitor pulse oximetry.
• Administration of Pulmocare: a tube feeding sometimes used to
decrease CO2 retention.
 Diagnostic tests and treatments

MORE ON OXYGEN THERAPY

• low-dose oxygen-- chronic lung conditions
• high dose oxygen– acute lung conditions
• pH What do the ABGs look like?
• Less than 7.35
• PaCO2
• Greater than 45 mm Hg
• PaO2
• Less than 80 mm Hg
• HCO3
• Normal until kidney compensation starts; then will start to rise above 26
mEq/L
 What can harm my client?

Respiratory arrest.
Arrhythmias: leading to cardiac arrest and
shock.
Severe decrease in LOC.
 Recap of respiratory acidosis

• The name “respiratory” tips you off to the fact that a lung
problem exists
• Since it is a lung problem, the problem chemical is the acid carbon
dioxide
• Acidosis from a lung problem is due to irregular breathing.
Perhaps the client is hypoventilating—breathing only 2 to 4 times
a minute, causing retention of carbon dioxide (CO2).
 Recap of respiratory acidosis

• Maybe the client has stopped breathing

altogether—possibly not exhaling carbon dioxide
(CO2) at all. The client retains all of this carbon
dioxide (CO2), which causes a buildup of acid in
the body
• This buildup of acid causes the pH to decrease.
Respiratory Alkalosis
 Respiratory alkalosis

• an acid–base imbalance where the PaCO2 is less than 35 mm Hg

and the pH is greater than 7.45.
• Decrease PaCO2 in the blood: excessive exhalation—
hyperventilation.
• When the lungs are impaired, the kidneys compensate with their
own chemicals—bicarbonate and H+.
• The kidneys will retain H+ because this is acid.
 Respiratory alkalosis

• The kidneys will excrete bicarbonate because this is base/alkalotic.

• This excretion of the base will help raise acid levels and restore
the body to a normal pH.
• Respiratory alkalosis means that the client has lost excessive
CO2 (acid), thus making the client alkalotic.
• Hypocapnia: occurs when the CO2 is low
 Causes

• Hysteria; anxiety • High altitudes

• High mechanical • Anemia
ventilator setting • Hypoxia
• Aspirin overdose • Labor and delivery
• Fever measures!
• Sepsis
 Signs and symptoms

• Hyperventilation
• Light-headedness, dizziness fainting
• Rapid pulse
• Hypokalemia
• Arrhythmias
• Hypocapnia stimulates the autonomic nervous
system, which cause anxiety, changes in
respiration, tingling, and sweating.
• Calcium acts like a sedative. Hypocapnia
decreases serum calcium so the muscles may get
tight. This can lead to tetany and seizures!
Why do you breathe into the brown bag
when you are hyperventilating?
 Diagnostic tests and treatments

• Treat the cause.

• Monitor vital signs, especially respirations.
• Monitor electrolytes.
• Administer antianxiety medications as ordered.
 Diagnostic tests and treatments
• Place on mechanical ventilator to control respiratory
rate in severe cases.
• Monitor ABGs.
• Calm the client.
• Have client breathe into paper bag or rebreather mask
to encourage CO2 retention.
• pH What do the ABGs look like?
• Greater than 7.45 (alkalosis makes pH go up)
• PaCO2
• Less than 35 mm Hg (because it is being exhaled)
• PaO2
• Greater than 100 mm Hg
• HCO3
• Normal until kidney compensation starts; then will be less than 22
mEq/L
 Complications

• Life-threatening arrhythmias.
• Seizures.
 Recap of respiratory alkalosis

• The name “respiratory” tips you off to the fact that a lung problem
exists
• Since it is a lung problem, the problem chemical is the acid carbon
dioxide (CO2)
• Excessive exhalation causes PaCO2 to decrease in the blood. Acid is
lost.
• When the lungs are impaired, the kidneys compensate with their own
chemicals—bicarbonate and H+. The kidneys will retain H+ because
this is acid.
 Recap of respiratory alkalosis
• We want to keep acid since the body is losing acid from
the excessive exhalation.
• The kidneys will excrete bicarbonate—a base—in order
to create a more acidic environment and return the pH
to normal
• Respiratory alkalosis means that the client has lost
excessive CO2 (acid), thus making the client alkalotic
Metabolic Acidosis
 Metabolic acidosis

• An acid–base imbalance where the pH is less than

7.35 and the bicarbonate level is less than 22
mEq/L.
• Acid (H+ ions) builds up in the body, or too
much bicarbonate has been lost from the body.
 Metabolic acidosis

• The less bicarb you have in the body, the more acid you will be.
• Kidneys: Metabolic disorders
• Bicarbonate and H+
• The decrease in the alkaline substances (bases) causes a build up
of acids in the body, causing acidosis.
• Lungs: compensate in just a few minutes
 Causes

• Diabetic ketoacidosis, malnutrition, starvation

• Lactic acidosis
• Shock
• Kidney illness
 Causes

• Gastrointestinal (GI) illness: diarrhea

• Drugs: Diamox, Aldactone
• Aspirin overdose
 Signs and symptoms

• if renal failure is the initial cause, you will see

signs and symptoms related to renal failure;
• if diabetic, ketoacidosis is the initial cause
 Signs and symptoms

• Hyperkalemia
• Arrhythmias
• Increased respiratory rate
• Headache, decreased LOC, coma
 Signs and symptoms

• Muscle twitching and burning, oral numbness,

weakness, flaccid paralysis (severe hyperkalemia)
• A Kussmaul’s respiration is an increase in rate and
depth of respiration.
• When Kussmaul’s respirations are present, CO2 is
being blown off in increased amounts.
 Diagnostic tests and treatments

• Monitor ABGs.
• Treat the cause.
• Monitor and manage hyperkalemia.
• Monitor and manage arrhythmias.
• Monitor and manage hypercalcemia.
 Diagnostic tests and treatments
• Administer sodium bicarbonate IV to decrease acidity of
blood.
• Monitor LOC closely.
• Administer lactated Ringers (LR) given IV to increase base
level.
• Institute seizure precautions (brain doesn’t like it when the
pH is messed up).
 What do the ABGs look like?

• pH • Normal
• Less than 7.35 • HCO3
• PaCO2 • Less than 22 mEq/L
• Will decrease to less than 35
mm Hg as it is blown off
• PaO2
• Sodium bicarbonate:
• should be used only as a quick, temporary fix for
increased acid levels and should be given
according to specific ABG values rather than
generously as we used to do in the past during
code situations.
 Complications

• Life-threatening arrhythmias.
• Cardiac arrest.
 Recap of metabolic acidosis

• The problem is with the kidneys, not the lungs.

• Bicarbonate (base) and H+ (acid) are associated
with the kidneys.
• Metabolic acidosis can be caused by loss of
bicarbonate through diarrhea, and renal
insufficiency.
 Recap of metabolic acidosis

• The decrease in the alkaline substances (bases) causes

a buildup of acids in the body. It can also be caused
by diseases that increase acid levels (OFA)
• The lungs compensate increasing respiratory rate and
depth to blow off CO2 and increase pH. This is called
a Kussmaul’s respiration.
Metabolic alkalosis
 Metabolic alkalosis

• an acid–base imbalance where the pH is greater than

7.45 and the bicarbonate level is greater than 26
mEq/L.
• There is an excess of base in the body and a loss of
acid.
• Basically, pH is increased and bicarbonate is increased.
 Metabolic alkalosis

• Metabolic: kidneys, which involve bicarbonate

and H+.
• The lungs compensate by retaining CO2 by
means of hypoventilation.
• This compensates for the alkalosis and helps the
pH go down into normal range.
 Causes

• Vomiting; bulimia; nasogastric (NG) tube suctioning

• Excess antacid ingestion
• Blood transfusions
• Sodium bicarbonate
• Thiazide and loop diuretics
 Causes
• Baking soda
• Hypokalemia
• Activation of renin–angiotensin system
• Steroids
• Dialysis
• Licorice
 Signs and symptoms

• Arrhythmias, flattened T-wave

• Decreased respirations, hypoventilation
• Hypokalemia
• Tightening of muscles, tetany, LOC changes, seizures, tingling in
fingers and toes
• LOC changes
• Hepatic encephalopathy
 What do the ABGs look like?

• pH • Remains the same

• Greater than 7.45 • HCO3
• PaCO2 • − Greater than 26 mEq/L
• Normal; increases with
compensation
• PaO2
 Diagnostic tests and treatments

• Treating the cause of the acid–base imbalance

(antiemetics for vomiting, etc.).
• Monitoring ABGs for further complications.
• Treating arrhythmias.
• Stopping client bicarbonate intake.
• Monitoring potassium levels and correcting hypokalemia.
 Diagnostic tests and treatments
• Monitoring respirations and LOC.
• Assessing for hypotension.
• Treating dehydration if present.
• Assessing DTRs.
• Administering ammonium chloride IV in severe cases to increase acidity
(increases H+).
• Administering acetazolamide (Diamox) to increase excretion of bicarbonate
through the kidneys.
 Complications

Metabolic alkalosis can cause the following life-

threatening illnesses:
• Arrhythmias.
• Cardiac arrest.
• Seizures.
 Recap of metabolic alkalosis

• The problem is with the kidneys, not the

lungs
• Bicarbonate (base) and H+ (acid) are
associated with the kidneys
 Recap of metabolic alkalosis

• Metabolic alkalosis can be caused by increased

bicarbonate through diuretic therapy, prolonged
nasogastric suctioning, and excessive vomiting,
resulting in ↑ pH levels
• The lungs compensate by retaining CO2 by means
of hypoventilation. This compensates for the
alkalosis
• Metabolic alkalosis is the most common acid–
base imbalance.
• It accounts for 50% of all acid–base
disturbances.
 SUMMARY
• The respiratory and renal systems can be both the cause
and “cure” for pH imbalances.
• Remember that the lungs control carbon dioxide levels and
the kidneys control bicarbonate levels.
• By monitoring your client’s carbon dioxide, bicarbonate,
and pH levels you can successfully prevent and treat any
acid–base imbalances.
 SUMMARY

• Acidosis:
• Think hyperkalemia and hypercalcemia.
• Alkalosis:
• Think hypokalemia and hypocalcemia.
The ability of the body’s regulatory system to
correct acid–base imbalances is a process called:
a. Compensation.
b. Modification.
c. Ventilation.
d. Diffusion.
The process of excreting bicarbonate out of the
body to correct an acid–base imbalance occurs
through the:
a. Lung.
b. Kidney.
c. Liver.
d. Pancreas.
A client with diabetes mellitus is admitted to the
hospital complaining of lethargy, weakness,
headache, nausea, and vomiting. The physician
orders arterial blood gas testing. The nurse suspects
the lab results will confirm:
a. Metabolic acidosis.
b. Metabolic alkalosis.
c. Respiratory acidosis.
d. Respiratory alkalosis.
A client is admitted to the emergency department
(ED) with a diagnosis of respiratory alkalosis. The
nurse recognizes a symptom of this condition as:
a. Nausea.
b. Kussmaul respirations.
c. Hyperventilation.
d. Bradycardia.
When performing an assessment of a client
admitted with metabolic alkalosis, the nurse should
ask about the use of ?
a. Aspirin.
b. Acetaminophen.
c. Antacids.
d. Antihistamines.
The nurse should watch for which electrolyte
imbalance in a client who has chronic respiratory
acidosis?
a. Hyperkalemia.
b. Hypomagnesemia.
c. Hyperphosphatamia.
d. Hypocalcemia.
END