Kafr Elsheikh University
Fuculty of Nursing
Acid Base balance and imbalance
Section Dr. Seham Attia
Prepared by / Ibrahim Waheed Taha
:Outlines
1: Introduction.
2: Definitions of PH, acid and base.
3: Body Buffer system
Chemical buffers.
Respiratory system.
The kidney.
4: Diagnosing acid-base imbalance.
-Arterial blood gases interpretation.
5: Acid base imbalance:
- Metabolic acidosis.
-Metabolic alkalosis.
-Respiratory acidosis.
-Respiratory alkalosis.
6: References
Introduction
As with electrolytes, correct balance of acids and bases in the body is
essential to proper body functioning. Even a slight variance outside of
normal can be life-threatening, so it is important to understand normal
acid-base values, as well their causes and how to correct them. The
kidneys and lungs work together to correct slight imbalances as they
occur. As a result, the kidneys compensate for shortcomings of the lungs,
and the lungs compensate for shortcomings of the kidneys.
Definitions of PH, acid and base.
pH is a scale from 0-14 used to determine the acidity or alkalinity of a
substance. A neutral pH is 7, which is the same pH as water. Normally,
the blood has a pH between 7.35 and 7.45. A blood pH of less than 7.35
is considered acidic, and a blood pH of more than 7.45 is considered
alkaline.
Acid: substance that consists of molecules that can give or donate
hydrogen ions (H) to other molecules. e.g. (carbonic acid
Base: substance that consist of molecules that can accept hydrogen
ions.e.g. (bicarbonate)
3: Body Buffer system Buffer Is a solution that resists the change
in PH when strong acid or alkali was added to the solution. And usually
prepared from a mixture of weak acids and their salt of strong base. e.g.
bicarbonate buffer which is formed of carbonic acid and sodium
bicarbonate.
➢ Chemical buffers Chemical buffers: the body maintains a healthy PH
in part through buffers substances that minimize changes in PH by
combining with the excess acids or bases Which is in the blood ,
intracellular fluid and interstitial fluid. There are three main chemical
buffering system include: 1. Bicarbonate buffer system
2. phosphate buffer system
3. protein buffer system
1. Bicarbonate buffer system: Is the major buffer system in the body and
responsible for buffering blood and interstitial fluid. Kidney assists in
regulating production of Bicarbonate and lungs assist by regulating the
production of Carbonic acid.
2. phosphate buffer system: Depend on a series of chemical reactions to
minimize PH. When changes occur the phosphate buffers react with
either acids or bases to form compounds that slightly alter PH.
3. protein buffer system: The most plentiful in the body work inside and
outside cells. e.g., Hemoglobin in RBCs combines with hydrogen ions to
act as buffer.
➢ Respiratory system Second line of defense against acid-base
imbalances, the lungs regulate blood level of carbon dioxide gas that
combines with water to form carbonic acid (H2O+CO2 →H2CO3)
Increase levels of carbonic acid lead to a decrease in PH, chemo receptors
in the medulla of the brain senses those PH changes & vary the rate
&depth of breathing to compensate. Breathing faster or more deeply
eliminates more CO2 from the lung, the more CO2 is lost, the less
carbonic acid is made &as a result the PH rises. The effectiveness of
ventilation can be assessed by looking at the partial pressure of CO2in
arterial blood. PaCo2: reflects the concentration of carbon dioxide in
blood &range from 35-45 mmHg
➢ The kidney Serve as another body mechanism for maintaining acid-
base balance. They can reabsorb or excrete acids &bases into the urine
&produce bicarbonate to replenish lost supplies. If blood contains too
much acid or not enough base, the PH drops & the kidneys reabsorb
bicarbonate (in the form of sodium bicarbonate). the kidney also excrete
hydrogen (in combination with phosphate or ammonia) the urine becomes
more acidic than normal. If blood contains more base &less acid, the PH
rises &the kidney compensates by excreting bicarbonate &retaining more
hydrogen ions as a result urine become more alkaline &bicarbonate level
in blood drops.
4: Diagnosing acid-base imbalance.
The more common one is ABG, a sample obtained from an arterial
puncture. The test allows for the assessment of the effectiveness of
ventilation &over all acidbase balance &patient response to treatment.
PH: 7.35-7.45
It measures of hydrogen ions concentration of the blood.
PaCO2: 35-45mmHg
Measure partial pressure of carbon dioxide in arterial blood.
HCO3: 22-26meq/L
Represents the Metabolic component of the body's acid-base balance.
PaO2 :80-100mmHg
Measure the partial pressure exerted by oxygen dissolved in arterial
blood. SaO2 :95-100%
Measures the percentage of hemoglobin actually carrying oxygen.
➢ Arterial blood gases interpretation 1. Check PH, If it is higher than
7.45 it is alkalosis and if it is less than 7.35 it is acidosis .And if we know
the acidotic or alkalotic, we determine which system (respiratory or
metabolic) 2. PaCO2: provides information about the respiratory
component of acid-base balance. if it lower than 35mmHg or higher than
45mmHg, it indicates that the problem is primarily respiratory. 3. HCO3:
provides information about the metabolic aspect of acid-base Balance. if
it lower than 22meq/L or higher than 26meq/L, it indicates that the
problem is primarily metabolic. 4. Compensation sometimes you will see
change in both the PaCO2 &HCO3 level, one will indicate the source of
PH changes &other reflect the body's effort to compensate for that
disturbance. If results indicate a primarily metabolic acidosis any
compensation will come in the form of respiratory alkalosis.
5: Acid base imbalance:
➢ Metabolic acidosis: is an increase in hydrogen ions (H+) or a loss of
bicarbonate (HCO3-). PH lowers than 7.35 and HCO3 lowers than 22
meq/L
How it happens: Loss of HCO3 from extra cellular fluid, an accumulation
of metabolic acids or a combination. Characterized by again in acids or
loss of base from plasma, this condition may be related to an over
production of ketone bodies when glucose supplies have been used up
&the body draws on fat stores for energy.
Causes:
✓ DM & Chronic alcoholism & Severe malnutrition
✓ Poor dietary intake of carbohydrates & Hyperthyroidism
✓ Sever infection with accompanying
✓ Renal failure
✓ Lactic acidosis occurs secondary to shock and heart failure.
Signs and symptoms:
✓ Hyperventilation.
✓ Increase depth of respiration &rapid breathing
. ✓ PH drops, the central nervous system is further depressed.
✓ Fruity odor to his breath (stems from catabolism of fats &excretion of
acetone through the lungs).
✓ Lungs try to compensate by lowering off CO2.
✓ Cardiac output &BP drop.
✓ Arrhythmias may occur if the patient also has hypokalemia.
✓ Warm, dry skin (peripheral dilatation) &as shock develop cold,
clammy skin and Weakness
✓ Deterioration level of consciousness from confusion to stupor &coma.
✓ GIT (anorexia, nausea & vomiting)
Nursing role:
✓ Maintain patent I.V. line to administer emergency drugs.
✓ Monitor V.S. &assess cardiac rhythm
✓ Prepare for mechanical ventilation or dialysis
✓ Monitor patient neurological status closely
✓ Position the patient to promote chest expansion &facilitate breathing.
✓ Monitor the patient renal function by recording intake &output
✓ Watch for serum electrolyte changes & monitor ABG.
✓ Watch for worsening of CNS status.
✓ Watch for deteriorating lab values,
➢ Metabolic alkalosis: elevation of the body's pH above
7.45, and increase in serum bicarbonate (HCO3-) concentration above
26meq/L ,due to a loss of H+ from the body or a gain in HCO3-
Causes:
✓ Excessive acid loss from GIT, through vomiting causes loss of
hydrochloric acid from the stomach or Nasogastric suctioning.
✓ Diuretics Thiazide &loop diuretics can lead to H, K&CL ions loss
from the kidneys.
✓ Cushing's disease-causing retention of Na and Cl and urinary loss of K
and H.
✓ Post hypercapnia alkalosis when chronic Co2 retention is corrected by
mechanical ventilation &the kidneys have not yet corrected the
chronically high bicarbonate levels.
✓ Kidney disease as renal artery stenosis &multiple transfusions.
✓ Certain drugs as (corticosteroids &antacids) that contain baking soda
Signs and symptoms: ✓ Shallow and slow respiration.
✓ Hypotension.
✓ ECG changes as hypokalemic or hypocalcemia.
✓ Neuromuscular excitability such as muscle twitching, weakness,
tetany, hyper reflexes and numbness.
✓ Neurological symptoms such as Apathy, confusion, seizures, stupor
and coma.
✓ GIT (anorexia, nausea and vomiting)
➢ Respiratory acidosis: is a medical emergency in which
decreased ventilation causes increased blood carbon dioxide
concentration and ultimately leads to decrease in the pH level. During
Alveolar hypoventilation there is an increase in CO2 thus leads to an
increased PaCO₂. The pH is less than 7.35 and the partial pressure of
carbon dioxide in the arterial blood(paCo2) is more than 45 mmHg
Causes: ✓ Hypoventilation from central nervous system, trauma or
brain lesion .g. tumors, vascular disorder, infection & drugs (narcotics,
hypnotics, sedatives &anesthetics).
✓ Airway obstruction that leads to carbon dioxide retention in the lungs
caused by:
✓ retained secretion, tumors, laryngeal spasm & anaphylaxis.
✓ Post-operative patien If fear of pain prevents him from participating in
pulmonary hygiene measures &also analgesics or sedatives can depress
the medulla which is responsible for controlling respiration.
✓ Neuromuscular problems as Gulliain Bare syndrome, poliomyelitis.
✓ Respiratory muscle fails to respond properly to the respiratory drive.
✓ Lung disease that decreases the amount of pulmonary surface area
available for gas exchange e.g., respiratory infection, pulmonary edema,
physiologic &anatomic shunts.
Signs and symptoms:
✓ Altered level of consciousness ranging from restlessness, confusion to
coma.
✓ Shallow rapid respiration, Hypoxemia.
✓ Ventricular arrhythmias, Tachycardia
✓ Fine flapping tremor, Depressed reflexes.
✓ Nausea &vomiting.
✓ Skin warm & flushed.
✓ Cyanosis is the late sign.
Nursing role:
✓ Maintain a patent airway.
✓ Assist with removing any foreign bodies from the airway establish an
artificial airway.
✓ Monitor V.S. &assess cardiac rhythm (tachycardia, alteration in
respiratory rate, rhythm, hypotension, arrhythmias & cardiac arrest).
✓ Assess patient s neurological status& report any significant changes.
✓ Give medication as antibiotic, bronchodilator as prescribed.
✓ Administer oxygen as ordered.
✓ Perform tracheal suctioning, incentive spirometry, postural drainage,
coughing &deep breathing.
✓ Maintain adequate hydration through oral or I.V. fluid intake.
✓ Maintain accurate intake &output records.
✓ Provide reassurance to the patient & family.
✓ Keep in mind that any sedatives you give to the patient can decrease
his respiratory rate.
✓ Safety measures to protect a confused patient.
➢ Respiratory alkalosis: PH is greater than 7.45 and paCo2 is
less than 35mmHg. Results from alveolar hyperventilation and
hypocapnia. The condition may be acute resulting from a sudden increase
in ventilation or chronic and difficult to identify as the renal
compensation.
Causes: ✓ Hyperventilation:
✓ Most common cause of respiratory alkalosis associated with anxiety
and pain.
✓ Use of nicotine &xanthine's (aminophylline)
✓ Hyper metabolic state (fever, sepsis)
✓ Liver failure.
✓ Drugs (catecholamine's, nicotine, salicylates, aminophylline.
✓ Condition affect brain respiratory control center.
✓ stimulated by progesterone of pregnancy, injured by stroke or trauma.
✓ Hypoxia: this may over stimulate the respiratory center to make the
patient breath faster &deeper as in:
✓ Pulmonary disease
✓ Pulmonary embolus
✓ Severe anemia
✓ Hypotension
✓ Over ventilation: during mechanical ventilation causes more CO2 to be
blown off resulting in respiratory alkalosis.
Signs and symptoms: ✓ Tachycardia, Restlessness.
✓ Muscle weakness, Difficulty breathing and Anxiety.
✓ Confusion or syncope.
✓ Altering period of apnea (decrease CO2 in blood) &hypoventilation.
✓ Tingling in fingers &toes.
✓ ECG changes.
✓ Calcium level drop less than 8 meq/L because of vasoconstriction of
peripheral and cerebral vessels resulting from hypoxia.
✓ Hyperreflexia, carpopedal spasm, tetany, arrhythmias, decrease level of
consciousness and coma.
Nursing role: Monitor patient who are at risk for developing
respiratory alkalosis.
✓ Decrease anxiety whenever possible to prevent hyperventilation.
✓ Recommended activities that promote relaxation.
✓ Assist the patient with breathing into a paper bag.
✓ Monitor V.S &report any changes in neurologic, neuromuscular or
cardiovascular functioning.
✓ Monitor ABG &serum electrolyte level.
✓ Check ventilator setting frequently.
✓ Provide undisturbed rest periods after the patient respiratory rate return
to normal.
✓ Offer reassurance& maintain a calm &quite environment.
✓ Safety measures &seizures precautions.
6: References
1. Mitchel, J. H., Wildenthal, K., & Johnson Jr., R. L. (1972). The
effects of acid-base disturbances on cardiovascular and pulmonary
function. Kidney International, 1, 375-389.
2. WakeMed Pathology Laboratories. (2016). Critical values.
3. Forciea, B. (2017, May 10). Acid-base balance: Bicarbonate ion
buffer. [Video]. YouTube. All rights reserved. Video used with
permission.
4. RegisteredNurseRN. (2015, May 6). ABGs made easy for nurses
w/ tic tac toe method for arterial blood gas interpretation. [Video].
YouTube. All rights reserved. Video used with permission.
5. Feller-Kopman, D. J., & Schwartzstein, R. M. (2020). The
evaluation, diagnosis, and treatment of the adult patient with acute
hypercapnic respiratory failure. UpToDate.
12. Hopkins E, Sanvictores T, Sharma S. Physiology, Acid Base
Balance. In: StatPearls Treasure Island (FL): StatPearls Publishing;
