Acid Base

Heather Wacholz
TCCC
Acid-Base Balance (pH)

Acidsubstance containing
hydrogen ions that can be
liberated or released
Basesubstance that can trap
hydrogen ions
Homeostasis
Major Homeostatic Regulators of Hydrogen
Ions

Buffer systems
Carbonic acidsodium bicarbonate
Phosphate
Protein
Respiratory mechanisms
Renal mechanisms
Hydrogen Ion Balance
 Homeostatic Mechanism

Plasma pH is an indicator of hydrogen ion (H+) concentration

Measures the acidity or alkalinity of the blood
Homeostatic mechanism keep pH within normal range (7.35-7.45)
The buffer system is the kidneys and lungs
The H+ is extremely important
The greater the concentration the more acidic the solution therefore the
lower the pH and the less the concentration the higher the pH and the
more alkaline.
 Normal values
Arterial Blood

pH 7.35 7.45
 Normal PCO2
Arterial Blood

35 45
PCO2
mmHg mmHg
 Normal PO2
Arterial Blood

80 100
PO2
mmHg mmHg
 Normal PO2
Arterial Blood

22 26
HCO3-
mEq/L mEq/L
The Kidney and Lung Help Regulate pH
 Role of Lungs

The lungs control the CO2

The lungs control the carbonic acid of the extracellular
fluid (ECF)
This works by adjusting the ventilation in response to the
level of CO2 in the blood
For example: A patient with a PCO2 80 mmHg (Arterial
Blood Gas) may breathe 40 breaths per minute to
remove the high CO2.
 Role of the Kidney

The kidneys regulate the bicarbonate level in the ECF

The kidney can regenerate or reabsorb bicarbonate
During respiratory acidosis and most cases of metabolic acidosis the
kidneys excrete H+ ions and conserve HCO3- to help restore balance
During respiratory alkalosis and metabolic alkalosis the kidneys hold onto H+
ions and excrete HCO3-
If the patient is in renal failure the kidneys can not compensate for acidosis
Acid-Base Imbalances

Occur when carbonic acid or bicarbonate levels become

disproportionate
Respiratory acidosisprimary excess of carbonic acid in ECF
Respiratory alkalosisprimary deficit of carbonic acid in ECF
Metabolic acidosisproportionate deficit of bicarbonate in ECF
Metabolic alkalosisprimary excess of bicarbonate in ECF
 Tests for Monitoring Acidosis and
Alkalosis

Monitor with Arterial blood gas (ABG)

Monitor with Venous blood gas (VBG)
Monitor with Capillary blood gas
(CBG)
 Causes of Metabolic Acidosis and
Manifestations
Direct loss of HCO3-
Diarrhea, diuretic use, early renal
insufficiency, excessive administration of
chloride,
Headache, confusion, drowsiness,
increased respiratory rate, nausea, and
vomiting
Example ABG Displaying Metabolic
Acidosis
 Treatment of Metabolic Acidosis

Correcting the imbalance

Bicarbonate is administered
Eliminating chloride
With the reversal of acidosis the patient may go from hyperkalemia to
hypokalemia (the K+ moves back into the cell as the acidosis corrects)
Example the diabetic ketoacidosis patient.
Monitor serum K+ level closely
With chronic metabolic acidosis treat calcium level first
 Causes of Metabolic Alkalosis and
Manifestations
A common cause is gastric suctioning, vomiting, pyloric stenosis, diuretics
that promote the excretion of potassium, excessive antacid abuse, and
ACTH excretion
The kidneys conserve K+ and H+ excretion increases; K+ leaves the cell and
H+ enters to try and maintain balance
Symptoms of decreased Ca+ ionization, tingling of fingers and toes,
dizziness, hypertonic muscles
Sometimes decreased respirations
Tachycardia
Symptoms of chronic the same as acute
Example of ABG Metabolic Alkalosis
 Causes of Respiratory Acidosis and
Manifestations
Inadequate secretion of CO2
This can cause a decrease in oxygen levels too
Symptoms include elevated HR, RR, elevated BP, and VF
Confusion
Increased ICP
Patient's with chronic COPD may not develop symptom
of high CO2 because of compensated renal changes
Example of Respiratory Acidosis
Treatment of Respiratory Acidosis

Improve ventilation
Bronchodilators and antibiotics
Blood thinners if cause of acidosis PE
Mechanical ventilation (Intubate patient)
Decrease CO2 slowly because the kidneys can
not excrete Bicarbonate too quickly
Treatment the same for chronic
 Causes of Respiratory Alkalosis and
Manifestations
Hyperventilation
Extreme anxiety, hypoxemia, early stage of ASA overdose
Gram negative bacteria, inappropriate ventilator settings
Symptoms include lightheadedness, numbness and tingling of
fingers and toes
Decreased ability to concentrate
Loss of consciousness
Tachycardia
Example ABG of Respiratory Alkalosis
 Treatment for Respiratory Alkalosis

Monitor electrolytes
Treat the underlying cause
Instruct the patient to breath slower; give
the patient a paper bag to breath in
If the cause is anxiety get an order for
Xanax or Ativan
 When You Think of CO2

LUNGS Monitor pH

CO2 Look at CO2

 When you Think of Bicarbonate

Kidneys Monitor pH

Look at HC03-
HC03-
Alkalosis and Acidosis
 Five Step Approach

1) First note the pH is it normal, high, or low

2) Next note the primary cause of problem. This is done by evaluating the
PaC02 and HCO3- in relation to pH
3) Next look at compensation
4) This means if the patient has both respiratory and metabolic alkalosis or
acidosis
5) If metabolic acidosis occurs calculate anion gap (AG) to determine the
cause
 What is AG?

This test looks at electrically charged particles in your blood to help your
doctor diagnose acid-base imbalances. The test results are calculated
from the results of an electrolyte panel, another blood test.
The value for the anion gap tells your doctor something about which
charged particles besides sodium, chloride, and bicarbonate ions must be
in your blood to make it neutral.
This test gives clues about different types of acidosis, when your blood is too
acidic; and alkalosis, when your blood is not acidic enough. Acidosis in
particular can be life-threatening, so it's important to find the cause and
treat it as soon as possible
 Calculating AG

AG = Na (CL + HC03- )
Normal AG = 10 to14 mmol/L
For example patient Na = 140, CL = 105 and HC03- = 25
AG = 140 (105 + 25) = 10 so this would be a normal AG
 References

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of

medical-surgical nursing. Bethlehem, Pennsylvania: Wolters
Kluwer/Lippincott Williams & Wilkins.
University of Rochester Medical Center. (2015, January 19). Retrieved from
http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeI
D=167&ContentID=anion_gap_blood