ALTERATIONS IN HOMEOSTASIS

ACID–BASE BALANCE
NURS 409
CHRIS HENYON MSN, RN

NEED A BALANCE BETWEEN ACIDS/BASES OR

CELLS CAN’T FUNCTION PROPERLY.

• WHERE DO ACIDS COME FROM?______________

• BREAKDOWN OF _______ PRODUCE ACIDS.

PROTEIN ____________________
LIPIDS _____________________
CARBOHYDRATES ______________

• MANY INGESTED TOXINS ARE ACIDIC

PH OF BODY FLUID
PH IS THE INDIRECT MEASURE OF H+ ION CONCENTRATION
THAT ARE PRODUCED FROM CELLULAR ENERGY METABOLISM
0= MAX ACIDITY

2
3 GASTRIC JUICE
4

6 = URINE
7= NEUTRAL

7.35-7.45 ARTERIAL BLOOD

8 = INTESTINAL FLUID
8.4-8.9 PANCREATIC JUICE

14 MAX ALKALINITY

1
 ARTERIAL BLOOD GAS (ABG) MAJOR
DIAGNOSTIC TOOL FOR EVALUATING ACID-BASE
STATUS
HTTP://WWW.YOUTUBE.COM/WATCH?V=TV7GNAUGKJM&LIST=PL6DCEC7880383E5E7
HTTPS://WWW.YOUTUBE.COM/WATCH?V=6KO6YBPO4AE&LIST=PL6DCEC7880383E5E7&INDEX=2

WHY IS ARTERIAL BLOOD USED?

HOW LONG DO YOU HOLD PRESSURE?
WHAT MEDICATIONS WILL AFFECT BLEEDING TIME?

THE ABC’S OF ABG

LEMONE TABLE 10-10 P. 223
• PH 7.35 - 7.45 OVERALL STATE
• PACO2 35 - 45 MM HG THINK ACID
• HCO3 22 - 26 MEQ/L THINK BASE

• PAO2 80 - 100 MMHG

• SAO2 96 - 100%
• BASE EXCESS -3.0 TO 3.0
at iron receptor site
• TELLS US ABOUT COMPENSATION

• ANION GAP 8-14 MEQ/L – FOUND ON BMP NOT ABG

• MEASUREMENT OF METABOLIC ACIDS

REGULATORS OF ACID/BASE
• BUFFERS – ACTION IMMEDIATE
• THINK SUBSTANCES THAT BIND AND RELEASE H+
IONS
• PHOSPHATES, PROTEIN

• RESPIRATORY SYSTEM – ACTION FAST

• MINUTES TO HOURS
• THINK CO2 (ACID)

• RENAL SYSTEM – ACTION SLOW

• HOURS TO DAYS
• THINK HCO3 (BASE)

2
 INTERPRETATION OF ABGS

• LOOK AT THE PH
• EVALUATE PACO2 (RESPIRATORY COMPONENT)
• EVALUATE HCO 3 (METABOLIC COMPONENT)

• DETERMINE WHICH COMPONENT MATCHES THE PH

COMPENSATION
• ABSENT
• PH IS NOT WITHIN NORMAL RANGE. THE
COMPONENT THAT DOES NOT MATCH THE PH
IMBALANCE IS STILL WITHIN ITS NORMAL RANGE
• PARTIAL
• PH IS NOT WITHIN NORMAL RANGE. THE
COMPONENT THAT DOES NOT MATCH THE PH
DISORDER IS ABOVE OR BELOW THE NORMAL RANGE.
• COMPLETE
• PH IS WITHIN THE NORMAL RANGE AND BOTH
COMPONENTS ARE EITHER ABOVE OR BELOW
NORMAL RANGE

INTERPRETATION OF ABGS
• PH 7.34
• PACO2 67
• PAO2 47

• HCO3 26
• WHAT IS THIS?

3
 INTERPRETATION OF ABGS
• PH 7.18

• PACO2 38
• PAO2 70

• HCO3 15
• WHAT IS THIS?

10

INTERPRETATION OF ABGS
• PH 7.60

• PACO2 30
• PAO2 60

• HCO3 22
• WHAT IS THIS?

11

INTERPRETATION OF ABGS
• PH 7.58
• PACO2 35
• PAO2 75

• HCO3 50
• WHAT IS THIS?

12

4
 INTERPRETATION OF ABGS
• PH 7.33

• PACO2 62
• PAO2 70

• HCO3 32
• WHAT IS THIS?

13

INTERPRETATION OF ABG
• PH 7.36
• PACO2 62
• PAO2 70
• HCO3 32
• WHAT IS THIS?

14

RESPIRATORY ACIDOSIS
RETAIN CO2 – CAN’T GET IT OUT
◼ Causes
– Hypoventilation – Airway
– Respiratory obstruction
failure – COPD
– Drug OD – Neuromuscular
– Opioids/barbiturates disease
– Chest trauma – CNS trauma or
– Pulmonary edema brain lesions

15

5
 CLINICAL MANIFESTATIONS
pH PaCO2 HCO3
Respiratory Hypercapnia ↑ if compensating
Acidosis nl
Hypoxemia
Hyperkalemia &
Hypercalcemia

↓pH causes vasodilation

- Compensation
2 °Electrolyte imbalance

16

COLLABORATIVE CARE

• TREAT UNDERLYING CAUSE THAN TX ACID/BASE IMBALANCE

• NEXT SLIDE

• VENTILATORY SUPPORT
• RESPIRATORY TREATMENTS
• PULMONARY HYGIENE

• SAFETY MEASURES
• PROTECT CONFUSED PATIENT

17

TREAT UNDERLYING CAUSE

• HYPOVENTILATION − Chest trauma
• REVERSE SEDATION • Pain medication
• INCENTIVE SPIROMETER − Pulmonary edema
• BIPAP/CPAP • Diuretic
• ANTIBIOTIC TO TREAT − COPD
INFECTION
• Purse lip
• HOB ELEVATED
breathing
• RESPIRATORY FAILURE • Neb treatments
• VENTILATOR • Steroids
• Encourage fluid
intake

18

6
 RESPIRATORY ALKALOSIS
• CAUSES

• HYPERVENTILATION
• ANXIETY, PAIN

• HYPERMETABOLIC STATE
• FEVER, THYROTOXICOSIS, SEPSIS

• VENTILATED CLIENT
• INAPPROPRIATE VENTILATOR SETTINGS

19

CLINICAL MANIFESTATIONS
pH PaCO2 HCO3

Respiratory ↑ ↓ nl
Alkalosis
• Light Headed/Dizziness
• Anxious/Restless
• Confusion
• Paresthesia
• Electrolyte Imbalance
• Hypokalemia
• Arrhythmia (EKG)
• Hypocalcemia
• Tremor
• Tetany (Chevostek)
Sign

20

COLLABORATIVE CARE
• TREAT CAUSE
• SAFETY & SEIZURE PRECAUTIONS
FOR ELECTROLYTE IMBALANCE
• BREATHING TECHNIQUES
• REDUCE STIMULI
• DIVERSION ACTIVITIES

• MECHANICAL VENTILATION
• ADJUST SETTINGS

21

7
 METABOLIC ACIDOSIS
• CAUSES
• OVERPRODUCTION OF KETONE BODIES
• DIABETES MELLITUS (DKA), CHRONIC ALCOHOLISM – HEPATIC DISORDERS,
SEVERE MALNUTRITION

• ANAEROBIC METABOLISM
• LACTIC ACIDOSIS - STRENUOUS EXERCISE, SEPSIS, CARDIAC ARREST

• RENAL FAILURE
• EXCESSIVE GI LOSS
• POISONING

22

CLINICAL MANIFESTATIONS
pH PaCO2 HCO3

Metabolic ↓ nl ↓
Acidosis

Respiratory Cardiac
Neurologic GI
Hyperventilation ↑K ↑Ca ↓CO
∆ LOC Diarrhea
Kussmaul’s arrhythmias
Weakness Vomiting is
during compensation
Malaise compensatory

23

COLLABORATIVE CARE
• TREAT CAUSE
• DKA - INSULIN
• MALNUTRITION – FEED PATIENT (ENTERAL, IV, SUPPLEMENTS)
• EXCESSIVE GI LOSS ADMINISTER ANTIDIARRHEAL MED
• RENAL FAILURE – DIALYSIS
• POISONING – ACTIVATED CHARCOAL, ? DIALYSIS
• NA BICARB MAY BE GIVEN PO OR IV (CAUTIOUSLY)

24

8
 METABOLIC ALKALOSIS
• CAUSES
• LOSS OF ACIDS
• LOSS OF GASTRIC JUICES
• ENDOCRINE DISORDERS
• EXCESS CORTISOL CAUSES RETENTION OF NA+ AND CL- & LOSS OF K+ AND H+
• THIAZIDE DIURETICS – RARE
• CAUSED BY ELECTROLYTE EXCHANGES BETWEEN K+ AND H+ IONS

• EXCESSIVE CONSUMPTION OF SODIUM BICARBONATE

• OVERUSE OF ANTACIDS
• MEDICAL TREATMENT
• TPN

25

CLINICAL MANIFESTATIONS
pH PaCO2 HCO3

Metabolic ↑ nl ↑
Alkalosis

Cardiac Neuromuscular
Respiratory ↓K+, ↓Ca++, ↓BP excitability
Hyoventilation GI
Confusion
Initially for
∆ LOC
compensation
Muscle twitching
Tetany, seizures

26

COLLABORATIVE CARE
• TREAT CAUSE
• ANTIEMETIC FOR VOMITING
• EDUCATION ON MEDICATIONS W/ SODIUM BICARBONATE

• FLUID & ELECTROLYTE REPLACEMENT

• MONITOR I&O
• HYPOKALEMIA – REPLACE K+ IN IVF, PO, OR WITH DIET

• SAFETY & SEIZURE PRECAUTIONS

27

9
 QUESTION #1
• A 57YO CLIENT IS ADMITTED WITH A DIAGNOSIS OF
ACUTE MYOCARDIAL INFARCTION. ABG PH 7.36, PACO 2
29, HCO3 20, SAO2 100%. THE NURSE INTERPRETS THAT
THIS CLIENT IS:

• A. WELL-OXYGENATED WITH UNCOMPENSATED RESPIRATORY ALKALOSIS

• B. HYPOXEMIC WITH COMPENSATED RESPIRATORY ACIDOSIS.
• C. WELL OXYGENATED WITH COMPENSATED METABOLIC ACIDOSIS
• D. HYPOXEMIC WITH COMPENSATED METABOLIC ACIDOSIS

28

QUESTION #2
THE NURSE IDENTIFIES WHICH OF THE FOLLOWING
CLIENTS TO BE AT RISK FOR DEVELOPING METABOLIC
ALKALOSIS? THE CLIENT WHO: (SELECT ALL THAT
APPLY)
A. HAS AN NGT TO CONTINUOUS SUCTION
B. HAS HAD DIARRHEA FOR TWO DAYS
C. IS ADMITTED WITH A SALICYLATE TOXICITY
D. TAKES ANTACIDS FREQUENTLY FOR HEARTBURN
E. IS ADMITTED WITH ASTHMATIC BRONCHITIS.

29

QUESTION #3
THE NURSE ASSESSES A CLIENT WITH UNCONTROLLED
TYPE I DM FOR WHICH OF THE FOLLOWING ACID-
BASE IMBALANCES?
A. METABOLIC ALKALOSIS

B. RESPIRATORY ALKALOSIS
C. RESPIRATORY ACIDOSIS

D. METABOLIC ACIDOSIS

30

10
 QUESTION #4
A CLIENT WITH PNEUMONIA HAS THE FOLLOWING ABG
RESULTS PH 7.29, PACO2 62MM HG, HCO3 23 MEQ/L
WHAT NURSING INTERVENTIONS WOULD BE THE MOST
EFFECTIVE IN TREATING THIS DISORDER?

A. ADMINISTER SEDATIVE FOR ANXIETY

B. IMPLEMENT PULMONARY HYGIENE MEASURES
C. SUPPLEMENTAL HIGH FLOW OXYGEN
D. MAINTAIN A CALM, QUIET ENVIRONMENT

31

11