1. Note the pH. This tells you whether the person is in acidosis (pH < 7.

35) or alkalosis
(pH > 7.45); but it does not tell you the cause.
2. Next, check the PCO2 to see if this is the cause of the acid-base imbalance. Because the
respiratory system is a fast-acting system, an excessively high or low PCO2 may
indicate either that the condition is respiratory systemcaused or that the respiratory
system is compensating. For example, if the pH indicates acidosis and:
1. The PCO2 is over 45 mm Hg, the respiratory system is the cause of the problem
and the condition is a respiratory acidosis.
2. The PCO2 is below normal limits (below 35 mmHg), the respiratory system is
not the cause but is compensating.
3. The PCO2 is within normal limits; the condition is neither caused nor
compensated by the respiratory system.
3. Check the bicarbonate level. If step 2 proves that the respiratory system is not
responsible for the imbalance, then the condition is metabolic and should be reflected
in increased or decreased bicarbonate levels. Metabolic acidosis is indicated by HCO3values below 22 mEq/L, and metabolic alkalosis by values over 26 mEq/L. Notice
that whereas PCO2 vary inversely with blood pH (PCO2 rises as blood pH falls), HCO3levels vary directly with blood pH (increased HCO3- results in increased pH). Beyond
this bare-bones approach there is something else to consider when you are assessing
acid-base problems. If an imbalance is fully compensated, the pH may be normal even
when the pH is normal, carefully scrutinize the PCO2 or HCO3- values for clues to what
imbalance may be occurring.

Causes and Consequences of Acid-Base imbalances

Metabolic acidosis:

Uncompensated (uncorrected) HCO3- < 22 mEq/L; pH < 7.4

o Severe diarrhea: Bicarbonate-rich intestinal (and pancreatic) secretions
rushed through digestive tract before their solutes can be reabsorbed;
bicarbonate ions are replaced by renal mechanisms that generate new
bicarbonate ions.
o Renal disease: failure of the kidneys to rid body of acids formed by normal
metabolic processes.

o Untreated diabetes mellitus: lack of insulin or inability of tissue cells to

respond to insulin, resulting in inability to use glucose; fats are used as
primary energy fuel, and ketoacidosis occurs.
o Starvation: Lack of dietary nutrients for cellular fuels, body proteins and fat
reserves are used for energyboth yield acidic metabolites as they are broken
down for energy.
o High ECF potassium concentrations: Potassium ions compete with H+ for
secretion in renal tubules; when ECF levels of K+ are high, H+ secretion is
inhibited.
Metabolic alkalosis:

Uncompensated (HCO3- >26 mEq/L; pH > 7.4)

o Vomiting or gastric suctioning: loss of stomach HCl requires that H+ be
withdrawn from blood to replace stomach acids; thus H+ decreases and HCO3proportionally.
o Selected diuretics: cause K+ depletion and H2O loss. Low K+ directly
stimulates the tubule cells to secrete H+. Reduced blood volume elicits the
renin-angiotensin mechanism, which stimulates Na+ reabsorption and H+
secretion.
o Ingestion of excessive sodium bicarbonate (antacid): bicarbonate moves
easily into ECF, where it enhances natural alkaline reserve.
o Constipation: prolonged retention of feces, resulting in increased amounts of
HCO3- being reabsorbed.
o Excessive aldosterone: (adrenal tumors) promotes excessive reabsorption of
Na+, which pulls increased amount of H+ into urine. Hypovolemia promotes
the same relative effect because aldosterone secretion is increased to enhance
Na+ (and H2O) reabsorption.

Respiratory acidosis:

Uncompensated (PCO2 >45 mm Hg; pH <7.4)

o Impaired gas exchange or lung ventilation (chronic bronchitis, cystic
fibrosis, emphysema): Increased airway resistance and decreased expiratory
air flow, leading to retention of carbon dioxide.
o Rapid, shallow breathing: Tidal volume markedly reduced.

o Narcotic or barbiturate overdose or injury to the brain stem: depression of

respiratory centers, resulting in hypoventilation and respiratory arrest.

Respiratory alkalosis:

Uncompensated (PCO2 < 35 mm Hg; pH > 7.4)

o Direct cause is always hyperventilation: hyperventilation is pain/anxiety,
asthma, pneumonia, and at high altitude represents effort to raise PO2 at the
expense of excessive carbon dioxide excretion.
o Brain injury or tumor: abnormality of respiratory controls.

Neuro Nursing Diagnosis

Nursing Diagnosis for Ischemic Stroke:

Impaired physical mobility related to hemiparesis, loss of balance and coordination,

spasticity, and brain injury

Acute pain (painful shoulder) related to hemiplegia and disuse

Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related
to stroke sequelae

Disturbed sensory perception related to altered sensory reception, transmission, and/or

integration

Impaired swallowing

Total urinary incontinence related to flaccid bladder, detrusor instability, confusion,

or difficulty in communicating

Disturbed thought processes related to brain damage, confusion, or inability to follow

instructions

Impaired verbal communication related to brain damage

Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased

mobility

Interrupted family processes related to catastrophic illness and caregiving burdens

Nursing Diagnosis for Hemorrhagic Stroke:

Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm

Disturbed sensory perception related to medically imposed restrictions (aneurysm

precautions)

Anxiety related to illness and/or medically imposed restrictions (aneurysm

precautions)

Nursing Diagnosis for Altered Level of Consciousness

Ineffective airway clearance related to altered LOC

Risk of injury related to decreased LOC

Deficient fluid volume related to inability to take fluids by mouth

Impaired oral mucous membrane related to mouth-breathing, absence of pharyngeal

reflex, and altered fluid intake

Risk for impaired skin integrity related to immobility

Impaired tissue integrity of cornea related to diminished or absent corneal reflex

Ineffective thermoregulation related to damage to hypothalamic center

Impaired urinary elimination (incontinence or retention) related to impairment in

neurologic sensing and control

Bowel incontinence related to impairment in neurologic sensing and control and also
related to changes in nutritional delivery methods

Disturbed sensory perception related to neurologic impairment

Interrupted family processes related to health crisis

Nursing Diagnosis for Patient with Increased Intracranial Pressure

Ineffective airway clearance related to diminished protective reflexes (cough, gag)

Ineffective breathing patterns related to neurologic dysfunction (brain stem

compression, structural displacement)

Ineffective cerebral tissue perfusion related to the effects of increased ICP

Deficient fluid volume related to fluid restriction

Risk for infection related to ICP monitoring system (fiberoptic or intraventricular

catheter)

Nursing Diagnosis for Craniotomy

Ineffective cerebral tissue perfusion related to cerebral edema

Risk for imbalanced body temperature related to damage to the hypothalamus,

dehydration, and infection

Potential for impaired gas exchange related to hypoventilation, aspiration, and

immobility

Disturbed sensory perception related to periorbital edema, head dressing, endotracheal

tube, and effects of ICP

Body image disturbance related to change in appearance or physical disabilities

Nursing Diagnosis for Epilepsy

Risk for injury related to seizure activity

Fear related to the possibility of seizures

Ineffective individual coping related to stresses imposed by epilepsy

Deficient knowledge related to epilepsy and its control

Nursing Diagnosis for Brain Injury

Ineffective airway clearance and impaired gas exchange related to brain injury

Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and
possible seizures

Deficient fluid volume related to decreased LOC and hormonal dysfunction

Imbalanced nutrition, less than body requirements, related to increased metabolic

demands, fluid restriction, and inadequate intake

Risk for injury (self-directed and directed at others) related to seizures, disorientation,
restlessness, or brain damage

Risk for imbalanced body temperature related to damaged temperature-regulating

mechanisms in the brain

Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia,
immobility, or restlessness

Disturbed thought processes (deficits in intellectual function, communication,

memory, information processing) related to brain injury

Disturbed sleep pattern related to brain injury and frequent neurologic checks

Interrupted family processes related to unresponsiveness of patient, unpredictability of

outcome, prolonged recovery period, and the patients residual physical disability and
emotional deficit

Deficient knowledge about brain injury, recovery, and the rehabilitation process