Acid-Base Disturbances

By:

Jay Aries T. Gianan, EMT-B, RM, RN, LPT, MAN

Assistant Professor II
Learning Objectives:
• What is acid-based balance?
• Blood pH
• Homeostatic mechanism
• Bicarbonate buffering system
• What are the types of acid-
based disorders?
• Causes
• How to interpret ABG test
result?
Across 1
B U F F E R
1. chemical system that prevents a radical 3
change in fluid pH I A
2. soluble base has a pH greater than 7.45 C C
2 2
3. body fluid that carries nutrients & oxygen A L K A L I N E
R I D
3
Down B D B L O O D
1. also known as HCO3 O N S
2. remove waste & toxins from the bloodstream N E I
3. overproduction of acid that builds up in the A Y S
blood
T S
E
What is acid-based balance?
Acid-based balance
• The balance between input (intake &
production) & output (elimination) of
hydrogen ion.

• The right balance of acidic & basic

(alkaline) compounds to function
properly
• Acid
• CO2
• carbon dioxide (an acid)
• Base
• HCO3-
• bicarbonate (a base)
Blood pH
• Indicator of hydrogen ion (H+)
concentration
• Refers to acidity & alkalinity of the
blood.
• It’s the concentration of Hydrogen
Ion (H+) that dictates the pH.

• Blood pH level
• 7.35 – 7.45
• ↓7.35 – acidic
• ↑7.45 – alkalotic
Homeostatic Mechanism
• The body uses different mechanisms to
control the blood's acid-base balance.
1. Lungs
• Regulate carbon dioxide level (CO2)
2. Kidneys
• Regulate bicarbonate level (HCO3−)
3. Buffer systems
a. Bicarbonate-carbonic acid
buffer system
b. Inorganic phosphate buffer
c. Plasma protein buffer
d. Plasma
e. Hemoglobin
Bicarbonate buffering system
• An acid-base homeostatic mechanism
involving the balance of:
• carbon dioxide (CO2)
• carbonic acid (H2CO3) &
• bicarbonate ion (HCO3−)in order to
maintain pH in the blood

• Bicarbonate ion - weak alkaline

• Carbonic acid - weak acid
Question
The primary organs involved in
pH regulation are:
a. Kidneys & lungs.
b. Heart & intestines.
c. Lung & endocrine glands.
d. Skin & kidneys.
Question
A chemical set up to resist
changes, particularly in the level
of pH, is:
a. A base.
b. A buffer.
c. A salt.
d. An acid.
Normal Arterial Blood Gas
What are the categories
of acid-based disorders?
Types of Acid-Base Disorders
• There are 2 abnormalities of acid-
base balance:
• Acidosis
• The blood has too much acid or
• An overabundance of acid in the blood
or excessive loss of bicarbonate from
the blood
• resulting in a decrease in blood pH.
• Alkalosis
• The blood has too much base or
• An overabundance of bicarbonate in the
blood or excessive loss of acid from the
blood
• resulting in an increase in blood pH.
Types of acidosis & alkalosis
• Acidosis & alkalosis are
categorized depending on their
primary cause as:
• Metabolic
• Metabolic acidosis & metabolic
alkalosis
• d/t imbalance in the production of
acids or bases & their excretion by
the kidneys.
• Respiratory
• Respiratory acidosis & respiratory
alkalosis
• changes in CO2 exhalation d/t lung
or breathing disorders.
What are the types of acid-
based imbalances?
Metabolic Acidosis
Metabolic acidosis
• Characterized by low pH level
• d/t an ↑ H+ concentration & low
plasma bicarbonate concentration or
• accumulation of metabolic acids

• a clinical disturbance defined by

• Low pH level
• <7.35
• Low serum HCO3 level
• <22 mEq/L
Causes of Metabolic acidosis
• d/t direct lose of bicarbonate
• Diarrhea
• Renal failure
• DKA
• Lower intestinal fistulas
• Ureterostomies
• Use of diuretics
• Early renal insufficiency
• Excessive administration of chloride
• Administration of parenteral
nutrition
• w/o bicarbonate producing solutes
Clinical manifestations
• Headache
• Confusion
• Drowsiness
• Kussmaul respiration
• Deep rapid breathing
• N/V
• Dangerous cardiac arrhythmias
• Abdominal pain
• Flushing
• Anorexia
Diagnostic findings
• ABGs
• pH is decreased
• <7.35
• HCO3 is decreased
• <22 mEq/L
• Hyperkalemia
• High K+ levels (H+ move into cell; K+
out)
• then low K+ levels when acidosis is
corrected
Nursing intervention
• Monitor
• V/S
• Neuro status
• ABG's
• K+ levels carefully
• moving K+ in & out of cells can cause
renal failure.
• Make sure client has large-bore IV
• Orient pt. as needed
• O2 as needed
• High fowlers position
• to promote chest expansion
Treatment
• Treat the underlying cause
• Replace fluid & electrolytes
• Sodium Bicarbonate
• in severe metabolic acidosis or
shock
• Respiratory support
• mechanical ventilator
• Dialysis
• pt. w/ renal failure
• Peritoneal dialysis
Metabolic Alkalosis
Metabolic alkalosis
• Characterized by high pH level
• d/t an ↓ H+ concentration & high
plasma bicarbonate concentration or
• Accumulation of excess bicarbonate

• a clinical disturbance defined by

• High pH level
• >7.45
• High serum HCO3 level
• >26 mEq/L
Causes of Metabolic alkalosis
• Severe vomiting
• Prolonged gastric suctioning
• Hypokalemia
• Excessive alkali ingestion
• Antacids w/ bicarbonate or sodium bicarbonate
during cardio resuscitation
• Diuretic therapy
• Thiazide, furosemides
• Excessive mineralocorticoids.
• ACTH secretion
• Cushing's disease, hyperaldosteronism
• Villous adenoma in GI tract
• Cystic fibrosis
• Chronic ingestion
• Milk & calcium carbonate
Clinical manifestations
• Hypocalcemia
• Tingling of the fingers & toes
• Dizziness
• Tetany
• Slow RR
• GI motility & paralytic ileus
• d/t hypokalemia
Diagnostic findings
• ABGs
• pH is increased
• >7.45
• HCO3 is increased
• >26 mEq/L
Nursing intervention
• Assess:
• V/S
• I&O
• LOC
• HR & rhythm
• Neuro status
• ABG's
Treatment
• Correct underlying cause
• Discontinuation of thiazide diuretics
• Chlorothiazide
• Antiemetics
• If vomiting is the cause
• Proton pump inhibitors
• Omeprazole
• To reduce production of gastric HCl
• Acetazolamide
• ↓ respiratory depression
• manage alkalaemia
• Administer PNSS solution
• KCl
• For hypokalemia
Respiratory Acidosis
Respiratory acidosis
• Characterized by low pH level
• ↑ CO2 level l/t increase plasma
carbonic acid concentration

• a clinical disturbance defined by

• Low pH level
• <7.35
• High PaCO2 level
• >45mmHg
Causes of Respiratory acidosis
• Low & slow respirations
• Hypoventilation
• Sleep apnea
• Head trauma
• Post operative
• CNS depressant
• Opioid overdose
• Naloxone as antidote
• Alcohol intoxication
• Benzodiazepines (diazepam)
• Pneumonia, ARDS, COPD or asthma attack
• Alcohol intoxication
• Respiratory infection
• Heart failure
Clinical manifestations
• Ventricular fibrillation
• 1st sign of respiratory acidosis in anesthetized pt.
• ↑ RR, PR, BP
• Headache
• Drowsiness
• Lethargy
• Anxiety
• Sleepiness
• Fatigue
• Memory loss
• Restlessness
• Muscle weakness
• Slowed breathing
• Gait disturbance
• Blunted deep tendon reflexes
• Disorientation
Diagnostic findings
• ABGs
• pH is decreased
• <7.35
• PaCO2 is increased
• >45mmHg
• Serum electrolytes
• K+, Mg+, Ca++
• Chest x-ray
• Drug screen
• Anesthetics, hypnotics, opioids, sedatives
• EKG
• hyperkalemia could cause arrhythmias
Nursing intervention
• Monitor I&O, VS & ABGs
• Elevate the head of the bed
• Suction secretions
• as indicated
• Give prescribed meds
• Provide adequate fluids
• orally if possible.
• Provide small
• frequent meals to minimize energy
expenditure
• Auscultate heart & lung sounds for
changes
Nursing intervention
• Improve respiratory ventilation via:
• Mechanical ventilation or
• Noninvasive positive pressure ventilation
• Teach pt.
• Proper coughing, turning, deep breathing
postural drainage
• Using incentive spirometer
• Prepare for possible dialysis
• Assess LOC for changes
• Obtain specimens for laboratory
• ABG
• Serum electrolyte levels.
• Obtain daily weights
• Check skin turgor.
Treatment
• Bronchodilators
• Antibiotics
• If the cause is bacteria
• Anticoagulants
• Supplemental oxygen
• beware if chronic hypercapnia
• COPD pt.'s are accustomed to ↑ CO2
levels
• lack of O2 called hypoxic drive stimulates
these pt.'s to breathe
• Bronchodilators
• Albuterol sulfate
• Ipratropium bromide
• Theophylline
• Tiotropium bromide
Treatment
• Sodium bicarbonate (rare)
• Antidotes
• Flumazenil
• for benzodiazepine overdose
• Naloxone
• for opioid overdose
Question
The nurse expects which clients to
be in respiratory acidosis
a. Morphine
b. Panic attack
c. Sleep apnea
d. COPD
e. Asthma attack
f. Alcohol intoxication
Respiratory Alkalosis
Respiratory alkalosis
• Characterized by high pH level
• ↓ CO2 level l/t decrease plasma
carbonic acid concentration

• a clinical disturbance defined by

• High pH level
• >7.45
• Low PaCO2 level
• <35mmHg
Causes of Respiratory alkalosis
• Hyperventilation
• Kussmaul respirations
• Anxiety/Panic attack
• High fever
• Salicylate poisoning
• Nicotine
• Pain
• Hypoxemia
• Mechanical ventilation
• too fast or too deep
Clinical manifestations
• rapid RR
• light-headedness
• d/t vasoconstriction & ↓ cerebral blood
flow
• inability to concentrate
• d/t cerebral artery vasoconstriction
• decreased LOC
• numbness & tingling of fingers/toes
• d/t ↓ Ca+ ionization in the bloodstream
• tachycardia
• tinnitus
• carpopedal spasms & tetany
• r/t decreased Ca
Diagnostic findings
• ABGs
• pH is increased
• >7.45
• PaCO2 is decreased
• <35mmHg
Nursing intervention
• Monitor V/S, & LOC
• Encourage pt. to breathe more
slowly
• teach breathing & stress reduction
techniques.
• Administer sedative or anti-
anxiety agent
• as ordered.
• Monitor ventilator settings.
• Administer O2 as ordered.
• Maintain fluid status.
Nursing intervention
• Provide calm, quiet, low-
stimulation environment
• to ↓ the patient's anxiety or
panic.
• ABGs monitoring
• prior to administration of meds or
O2 therapy.
• Teach pt.
• to breath in a bag or cupped
hands
Treatment
• Sedative or antianxiety agent
• Use of CO2 rebreather mask
How to interpret ABG test
result?
Arterial Blood Gas (ABG) Test
• Measures the acidity (pH) & the
levels of O2 & CO2 in the blood
from an artery.

• Usually done by respiratory

therapist (RT)
Procedure
• Before the procedure:
• The RT will prepare to draw blood from the
radial artery, & do an Allen’s Test (to
determine the patency of the ulnar artery)
1. Client makes a fist & the RT occludes the
radial artery & ulnar artery
2. Palm is open to reveal a pale palm from
the lack of blood flow
3. Releasing the ulnar artery 1st, the palm
should regain its color in about 15 seconds
or less

• Priority procedure!
• Hold firm pressure on the
puncture site since we just
puncture an artery.
• d/t risk for bleeding
Exam question!
• What is the most important objective
data when determining if a client is
hypoxic?
• Arterial Blood Gases (ABGs)

• What is the best diagnostic test to

evaluate a pt.’s oxygenation &
ventilation after a traumatic brain
injury?
• Arterial Blood Gases (ABGs)
ABG Tic Tac Toe method
pH - 7.25, PaCO2 – 55, HCO3 – 24
1. Know the normal values 1st
• pH - 7.35 – 7.45
• PaCO2 - 35 – 45 Respiratory
• HCO3 - 22 – 26 Metabolic
2. Identify the pH if acidic or alkalotic
3. Identify which buffer cause the pH to be acidic
or alkalotic, is it the PaCO2 or the HCO3?
4. Identify if uncompensatory or compensatory.
5. If compensatory, identify if it is full Acidic Normal Alkalotic
compensatory or partial compensatory.
Ph - 7.25 HCO3 – 24
a. If the pH become normal, its full
compensatory
b. If the pH is not normal, its partial PaCO2 – 55
compensatory Respiratory acidosis uncompensated
 Acidic Normal Alkalotic

Practice test

1. pH - 7.25, PaCO2 - 55, HCO3 - 25 1. Respiratory acidosis, uncompensated

2. pH - 7.57, PaCO2 - 25, HCO3 - 22 2. Respiratory alkalosis, uncompensated
3. pH - 7.21, PaCO2 - 39, HCO3 - 19 3. Metabolic acidosis, uncompensated
4. pH - 7.32, PaCO2 - 55, HCO3 - 42 4. Respiratory Acidosis, Partially compensated
5. pH - 7.55, PaCO2 - 49, HCO3 – 35 5. Metabolic Alkalosis, Partially Compensated
6. pH - 7.37, PaCO2 - 52, HCO3 - 32 6. Respiratory Acidosis, Fully Compensated
7. pH - 7.43, PaCO2 - 48, HCO3 - 33 7. Metabolic Alkalosis, Fully Compensated
Question
• George Kent is a 54-year-old widower with a history of
chronic obstructive pulmonary disease & was rushed to
the emergency department with increasing SOB, pyrexia,
& a productive cough with yellow-green sputum. He has
difficulty communicating because of his inability to
complete a sentence. One of his sons, Jacob, says he has
been unwell for three days. Upon examination, crackles &
wheezes can be heard in the lower lobes; he has
tachycardia & a bounding pulse. Measurement of arterial
blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28
mmol/L, & PaO2 60 mm Hg. How would you interpret
this?
a. Respiratory Acidosis, Uncompensated
b. Respiratory Acidosis, Partially Compensated
c. Metabolic Alkalosis, Uncompensated
d. Metabolic Acidosis, Partially Compensated
Question
• Carl, an elementary student, was rushed to the
hospital d/t vomiting & a ↓ LOC. The pt. displays
slow & deep (Kussmaul breathing), & he is lethargic
and irritable in response to stimulation. He appears to
be dehydrated—his eyes are sunken & mucous
membranes are dry—& he has a two-week history of
polydipsia, polyuria, & weight loss. Measurement of
arterial blood gas shows pH 7.0, PaO2 90 mm Hg,
PaCO2 23 mm Hg, & HCO3 12 mmol/L; other results
are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95
mmol/L. What is your assessment?
a. Respiratory Acidosis, Uncompensated
b. Respiratory Acidosis, Partially Compensated
c. Metabolic Alkalosis, Uncompensated
d. Metabolic Acidosis, Partially, Compensated
Question
• A cigarette vendor was brought to the emergency
department of a hospital after she fell into the
ground and hurt her left leg. She is noted to be
tachycardic & tachypneic. Painkillers were carried
out to lessen her pain. Suddenly, she started
complaining that she is still in pain & now
experiencing muscle cramps, tingling, &
paresthesia. Measurement of arterial blood gas
reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg,
& HCO3 25 mmol/L. What does this mean?
a. Respiratory Alkalosis, Uncompensated
b. Respiratory Acidosis, Partially
Compensated
c. Metabolic Alkalosis, Uncompensated
d. Metabolic Alkalosis, Partially Compensated
Question
• Baby Angela was rushed to the ER following
her mother’s complaint that the infant has
been irritable, difficult to breastfeed, & has
had diarrhea for the past 3 days. The infant’s
RR is elevated & the fontanels are sunken. The
ER physician orders ABGs after assessing the
ABCs. The results from the ABG results
show pH 7.39, PaCO2 27 mmHg, & HCO3 19
mEq/L. What does this mean?
a. Respiratory Alkalosis, Fully Compensated
b. Metabolic Acidosis, Uncompensated
c. Metabolic Acidosis, Fully Compensated
d. Respiratory Acidosis, Uncompensated
Question
• Mr. Wales, who underwent post-abdominal
surgery, has a nasogastric tube. The NOD notes
that the nasogastric tube (NGT) is draining a
large amount (900 cc in 2 hours) of coffee
ground secretions. The client is not oriented to
person, place, or time. The nurse contacts the
attending physician & STAT ABGs are ordered.
The results from the ABGs show pH 7.57, PaCO2
37 mmHg & HCO3 30 mEq/L. What is your
assessment?
a. Metabolic Acidosis, Uncompensated
b. Metabolic Alkalosis, Uncompensated
c. Respiratory Alkalosis, Uncompensated
d. Metabolic Alkalosis, Partially Compensated
Question
• How does the nurse expect the
client to show compensation for
the following ABG values?
pH - 7.20
PaCO2 - 37 mm Hg
HCO3 - 15 mEq/L

a. ↓ respiratory rate
b. ↑ respiratory rate
c. ↑ renal retention of bicarbonate
d. ↓ renal retention of bicarbonate
 Activity
• A 30-year-old woman comes into the ER with a
temp. of 39.4°C (103°F). For the last 4 days she
has had a productive cough & has experienced
dyspnea ↑ in severity. Her serum laboratory
results are as follows: WBC = 20,000, pH = 7.59,
PaCO2 = 26, PaO2 = 40, SaO2 = 80, HCO3 = 20, Na+
= 140, K+ = 4.2, Cl− = 106, CO2 = 20.
• What treatments & relevant nursing
actions r/t the underlying disorder &
its treatment should the nurse
anticipate?