Acid Base Balance by: Susan Mberenga RN, BSN, MSN

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1 Acid Base Balance by: Susan Mberenga RN, BSN, MSN

2 Acid Base Balance Refers to hydrogen ions as measured by ph Normal range: Acidosis/acidemia: ph is less than 7.35 Alkalosis/alkalemia: ph is greater than 7.45 (McCance et al., 2008)

3 Acid-Base Balance Acids release H+ ions The less hydrogen ions that are present, the more acidic a solution becomes Bases receive H+ ions The more hydrogen ions that are present, the more basic a solution becomes

4 Regulators of Acid Base Balance Keeps everything in balance Constantly working to prevent acidosis/alkalosis Buffers Carbonic Acid/Bicarbonate Phosphate Protein Respiratory system Renal system (Bartelmo, 2011)

5

6 Buffers Maintain equilibrium by adding or subtracting H+ ions thus regulating ph First responders Primary regulators Cannot maintain ph without adequate renal and respiratory function (Bartelmo, 2011)

7 Carbonic acid-bicarbonate buffer system If there is too much acid the body will cause the lungs to increase respirations and blow off CO++ and H2O and the kidneys will release H+

8 Carbonic acid-bicarbonate buffer system If there isn t enough acid the kidneys will hang on to H ions and the lungs will slow down respirations

9 Respiratory System Lungs regulate CO 2 Respiratory center in medulla controls breathing Responds within minutes/hours to changes in acid/base Increased respiratory rate leads to increased CO 2 hyperventilation elimination and decreased CO 2 in blood (blowing off CO 2 )-hypoventilation

10 Renal System Kidneys regulate bicarb (HCO 3 ) by eliminating or adding H + Re-absorption and secretion of electrolytes Takes the longest to respond (hours to days) Kidneys usually function by retaining bicarbonate and secreting acidic urine Kidneys work to increase or decrease ph as a compensatory mechanism

11 Parameter Arterial ph PaCO 2 Bicarbonate mm Hg meq/l Arterial blood gasses- laboratory sample of arterial blood that is used to monitor a patient s acid base status Can be done by a respiratory therapist or an RN who has been checked off on the competency ABG Components and Normal Values

12 ABG ph ACIDOSIS= ph<7.35 Remember- acidosis is sliding on down = low ph Causes: high (CO 2 )- hyperventilation Low (HCO 3 ) ALKALOSIS=pH>7.45 Remember- alkalosis is kicking on up= high ph Causes: High (HCO 3 )- Low (CO 2 )- hypoventilation

13 ABG Components HCO meq/l Regulated by kidneys Kidneys secrete H+ ions (making acidic urine) or retain HCO3 PaCO mm Hg Regulated by lungs lungs hyperventilate CO2 Result: body becomes more basic Lungs hypoventilate CO2 Result: body becomes more acidic

14 ABG Components O 2 saturation: infrared light measures the % of O 2 bound to Hgb molecules in RBC. PaO 2 : Blood test that measures the amount of oxygen molecules dissolved in the blood which determines how well 0 2 is carried from lungs to the blood.

15 Discussion: Which patient is in a better situation and why? 1. A 45-year-old male with a COPD exacerbation. He states he has been progressively getting worse over the last 3 weeks and has presented to the ED for treatment. 2. A 22-year-old patient that presents to the ED after a traumatic injury with a respiratory rate of 7.

16 ABG Interpretation 1. Evaluate ph (acidosis or alkalosis) Sliding on down, kicking up 2. Analyze PaCO Analyze HCO Determine if CO 2 or HCO 3 matches the alteration Could be both, that s ok the one most imbalanced is usually 5. Decide if the body is attempting to compensate The one least imbalanced is usually trying to compensate the cause

17 ABG Interpretation ROME- respiratory is opposite metabolic is equal Respiratory Arrows move in opposite direction ph, PaCO 2 = respiratory alkalosis ph, PaCO 2 = respiratory acidosis Metabolic Arrows move in the same direction ph, HCO 3 = metabolic alkalosis ph, HCO 3 = metabolic acidosis For compensatory mechanisms, look for the one that is the least out of whack!

18 Body attempts to correct blood ph changes ph <6.9 or >7.8 usually fatal Respiratory system more sensitive to acid-base changes; can begin compensating in seconds to minutes Kidneys more powerful; result in rapid changes in ECF composition; fully triggered for imbalance of several hours to days Compensation 18

19 FYI of ABG s 1. Evaluation of Oxygenation Status: Hypoxemia (PaO 2 ) Mild: PaO 2 <80 mm Hg, moderate: PaO 2 <60 mm Hg, severe: PaO 2 < 40 mm Hg 2. Compare to previous blood gases 3. Compare the results to the patient s clinical picture and your assessments 4. Report changes and new findings

20 Blood Gas Alterations Microsoft Clip Art

21 Case Study A 25-year-old female was admitted to the hospital for attempted suicide. She has had a 24-hour sitter at the bedside for the last 3 days and is to be discharged today. The primary care provider stated that she no longer needs a sitter at the bedside. When you enter the room to give her discharge instructions, you find an empty pill bottle laying next to her.

22 Case Study Vital signs are as follows: HR 109, RR-6, Temp-98.6, BP- 90/52. What are your first actions as the primary nurse? What acid base imbalance would you expect to see with this patient and why?

23 Respiratory Acidosis ph and pco 2 Lower ph due to CO 2 accumulation in the blood greater than the normal value PaCO 2 greater than 45mmHg Causes: Depression of respiratory center Respiratory muscle paralysis Chest wall disorders Disorders of lung parenchyma

24 Respiratory Acidosis ph and pco 2 Patients may present with: Bradypnea CNS depression Dysrhythmias Muscle twitching Electrolyte abnormalities Compensation: Kidneys increase excretion of H + and retain HCO 3 - HCO 3- may be normal or elevated, depending on whether the condition is acute or chronic ABGs = high PaCO 2 and near normal ph

25 Respiratory Acidosis ph and pco 2 Treatment: Physical stimulation Turn cough and deep breathe, incentive spirometer, bronchodilators Medical Mechanical ventilation Reversal of sedatives or narcotics

26 Case Study Microsoft Clip Art

27 Case Study Your patient, Ms. C, was just told she has 6 months to live by her oncologist. She rings the call bell for assistance. She is talking very quickly and you can barely understand her. When you enter the room, you see that your patient is diaphoretic and unable to speak. Vital signs are: HR-115, RR- 50, Temp-99.0, BP- 128/92. What acid base imbalance would you expect to see and why?

28 Respiratory Alkalosis ph and pco 2 Blood contains too little carbonic acid CAUSES: Hypermetobolic states Fever, sepsis Hypoxia Heart failure, pneumonia, pulmonary embolism Anxiety-hyperventilation Psychogenic CNS stimulation Incorrect ventilator settings

29 Respiratory Alkalosis ph and pco 2 Patients may present with: Headache Vertigo Paresthesia Tinnitus Electrolyte abnormalities

30 Respiratory Alkalosis ph and pco 2 TREATMENT: Identify and treat underlying cause: pain or anxiety, fever, medical problems etc. Correct hypoxia Diuretics Mechanical ventilation Compensation Kidneys will excrete bicarbonate ABGs = low HCO 3- and near normal ph

31 Case Study Microsoft Clip Art

32 Case Study A 70-year-old patient with a history of insulin dependent diabetes and congestive heart failure is admitted to your unit for nausea and vomiting. Upon entry to the room, he is extremely confused and does not know where he is. You check a blood glucose, and the glucometer states that his blood sugar is greater than 600 and his urine tests positive for ketones. What acid base imbalance do you think you will find and why?

33 Metabolic Acidosis ph and HCO 3 ph is low (less than 7.35) due to decrease in bicarbonate and/or increase in acids pco 2 is normal or decreased HCO 3 - less than 22mEq/L

34 Metabolic Acidosis ph and HCO 3 CAUSES: Overproduction of organic acids Ketoacidosis and starvation -DKA Impaired renal excretion of acid Abnormal loss of HCO 3 - Diarrhea and vomiting Ingestion of acid ASA overdose, antifreeze ingestion Anaerobic metabolism

35 Metabolic Acidosis ph and HCO 3 Patient may present with: Cardiac arrhythmias Electrolyte abnormalities Increased calcium and chloride may appear The serum potassium level is often high in acidosis as the body attempts to maintain electroneutrality during buffering Flushed skin Nausea

36 Metabolic Acidosis ph and HCO 3 Compensation: Respiratory system attempts to blow off CO 2 by hyperventilation to increase ph When the body tries to compensate using respirations, a typical pattern of breathing is Kussmaul s respirations 3Js

37 Metabolic Acidosis ph and HCO 3 Treatment - Dependent on cause: Administer fluids and insulin Dialysis Treat infection Improve nutritional intake Rehydration Support of respiratory and cardiac functions

38 Case Study Microsoft Clip Art

39 Case Study A 22-year-old patient has been sick with the flu for the past 4 days. She states she has had fever and body aches and complains that she has been vomiting 5 times a day and been unable to hold anything down for the last 4 days. What acid base imbalance would you expect to see and why?

40 Metabolic Alkalosis ph and HCO 3 ph is increased and HCO 3 level is high or an excessive loss of acids has occurred (ph greater than 7.45) PaCO 2 normal or increased HCO 3- greater than 28 meq/l CAUSES Large loss of gastric contents Loss of potassium Ingestion of large amounts of bicarbonate Prolonged use of diuretics

41 Patient may present with: Diaphoresis Shallow breathing Nausea and vomiting ECG changes Tachycardia LOC changes Confusion, lethargy, weakness Electrolyte abnormality Decreased Ca, lowe K and increased HCO3 Metabolic Alkalosis ph and HCO 3

42 Metabolic Alkalosis ph and HCO 3 Treatment Underlying cause must be corrected Replace KCL losses Nursing care Monitor neurological status Implement seizure precautions Reorient patient as needed

43 Metabolic Alkalosis ph and HCO 3 Compensation: Hypoventilation limited to ceiling of mm Hg CO 2, then hypoxic drive will kick in Kidneys will attempt to correct by increasing excretion of HCO 3 - ABGs = Decreased HCO 3 and near normal ph

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