Lesson 43: Acid-Base Balance
Respiratory Acidosis Nursing Considerations
Description
In respiratory acidosis, the total concentration of buffer base is
lower than normal and accompanied by a relative increase in the
concentration of hydrogen ions, resulting in a greater number of
hydrogen ions circulating in the blood than can be absorbed by the
buffer system.
Any condition that causes an obstruction of the airway or depresses
respiratory status (e.g., atelectasis) can cause respiratory acidosis.
Increased respiratory rate and depth result from the body's attempt
at compensation; respirations are variable and ineffective, resulting
in hypoventilation and hypoxia.
The client experiences headache.
Restlessness and mental status changes (e.g., drowsiness and
confusion) may occur.
Blood pressure drops.
The skin is warm and flushed.
Cyanosis sets in as hypoxia becomes more acute.
Hyperkalemia is present.
Dysrhythmias (rapid, irregular pulse) lead to ventricular fibrillation.
Nursing Considerations
Monitor the client for signs of respiratory distress.
Administer oxygen as prescribed.
Place the client in the semi-Fowler position unless this is
contraindicated.
Help the client turn, cough, and deep-breathe and prepare to
administer respiratory treatments as prescribed.
Encourage hydration to thin secretions unless excess fluid intake is
contraindicated.
Perform suctioning, if necessary and if it is not contraindicated.
Reduce restlessness by improving ventilation rather than
administering tranquilizers, sedatives, or opioids, which further
depress respiration.
Monitor the serum potassium level closely; when acidosis is being
treated, potassium will move back into the cell and the serum
potassium level will decrease.
Administer antibiotics for infection or other medications as
prescribed.
Prepare for intubation and mechanical ventilation if the CO2 level
rises above 50 mm Hg and if signs of acute respiratory distress are
present.
Respiratory Alkalosis
Description
Respiratory alkalosis is a deficit of carbonic acid and a decrease in
hydrogen-ion concentration.
Certain conditions result in overstimulation of respiratory status
and, in turn, respiratory alkalosis.
Initially hyperventilation and respiratory stimulation cause abnormal
rapid respirations (tachypnea); respiratory rate and depth then
decrease in the body's attempt to compensate.
The client may experience a headache.
Nausea and vomiting and epigastric pain are all possible.
The client may be lethargic and lightheaded.
Mental status changes (e.g., confusion) may occur.
Paresthesias (e.g., tingling of fingers and toes) are possible.
Hypokalemia, hypocalcemia, hyperreflexia, and seizures may
develop.
Tachycardia and dysrhythmias are consequences of hypokalemia.
Monitor the client for signs of respiratory distress.
Provide emotional support and reassurance to the client.
Encourage an appropriate breathing pattern.
Assist the client in using breathing techniques and breathing aids as
prescribed such as voluntary breath-holding, rebreather mask, and
CO2 breathing (i.e., rebreathing into a paper bag).
Exercise caution care with ventilator clients to help ensure they are
not forced to take too-deep or too-rapid breaths.
Monitor electrolyte values, particularly potassium and calcium.
Administer medications as prescribed.
Prepare to administer calcium gluconate as prescribed to help
prevent tetany.
Metabolic Acidosis
Description
Metabolic acidosis is the term used to describe a lower-than-normal
total concentration of buffer base accompanied by a relative
increase in the concentration of hydrogen ions.
It results from a variety of conditions and disease states,
including diabetes mellitus, diabetic ketoacidosis, and malnutrition.
Kussmaul's respirations (deep and rapid) represent the body
attempts to blow off the extra carbon dioxide and compensate for
the acidosis.
The client may experience a headache.
Nausea and vomiting and diarrhea are possible.
Fruity-smelling breath is caused by improper fat metabolism.
The skin is warm and flushed.
CNS depression manifests as drowsiness, confusion, and coma.
Hyperkalemia may develop.
Dysrhythmias are possible.
Nursing Considerations
Monitor the client for signs of respiratory distress.
Assess the client's level of consciousness as a means of detecting
CNS depression.
Monitor the client's intake and output; assist with fluid and
electrolyte replacement as prescribed.
Prepare to administer intravenous solutions as prescribed that will
increase the buffer base.
Initiate safety and seizure precautions.
Monitor the serum potassium level closely; when acidosis is being
treated, potassium will move back into the cell and the serum
potassium level will decrease.
In diabetes mellitus and diabetic ketoacidosis, insulin (to hasten the
movement of serum glucose into the cell) and fluids for hydration
are administered.
In renal failure, dialysis may be used to remove protein and waste
products, thereby ameliorating the acidotic state; additionally, a diet
low in protein and high in calories will decrease the amount of
protein waste products to mitigate the acidosis.
Metabolic Alkalosis
Description
Metabolic alkalosis is a deficit of carbonic acid and an accompanying
decease in hydrogen-ion concentration.
It is the result of the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids.
The condition may result from any of a variety of causes.
 Respiratory rate and depth decrease as the body attempts to
conserve carbon dioxide.
The client may experience anorexia and nausea and vomiting.
CNS changes include drowsiness, nervousness, dizziness, and
confusion.
Numbness and tingling in the extremities are possible.
The client may experience twitching of the extremities.
Seizures are possible.
Hypokalemia, accompanied by dysrhythmias, may develop.
Nursing Considerations
Monitor the client for signs of respiratory distress.
Treat the underlying cause of the condition.
Monitor potassium and calcium serum levels.
Institute safety precautions.
Prepare to administer medications as prescribed to promote renal
excretion of bicarbonate.
Prepare to replace potassium chloride as prescribed.
Arterial Blood Gases
Description
Normal values are:
pH: 7.35 to 7.45
Partial pressure of carbon dioxide (PCO2): 35 to 45 mm Hg
Bicarbonate: 22 to 27 mEq/L
Partial pressure of oxygen (PO2): 80 to 100 mm Hg
Nursing Considerations
To obtain an arterial blood gas specimen:
Obtain vital signs.
Determine whether the client has an arterial line in place; if so, the
specimen may be drawn from this line.
Perform the Allen test to determine the presence of collateral
circulation if the specimen is being drawn from the radial artery.
Assess factors that may affect the accuracy of the results (e.g.,
changes in oxygen settings, suctioning within the preceding 20
minutes, client activity).
Explain the procedure to the client and provide emotional support.
Assist with the specimen draw by preparing a heparinized syringe;
use an arterial blood gas kit if one has been supplied by the agency.
Apply pressure to the puncture site immediately after the blood
draw; maintain pressure for 5 minutes, or for at least 10 minutes if
the client is taking anticoagulants or has a bleeding disorder.
Appropriately label the specimen and transport it on ice to the
laboratory.
On the laboratory form, record the client's temperature and the
type of supplemental oxygen the client is receiving.
Respiratory Imbalances
PCO2 is the respiratory function indicator.
In a respiratory imbalance, you will note opposite responses of the
pH and PCO2; in other words, the pH will be down with an increased
PCO2 (acidosis) or the pH will be up with the PCO2 down (alkalosis).
Look at the pH and PCO2 to determine whether the condition is a
respiratory problem.
In respiratory acidosis, pH is down and PCO2 up.
In respiratory alkalosis, pH is up and PCO2 down.
Metabolic Imbalances
Bicarbonate (HCO3) is the metabolic function indicator.
In a metabolic imbalance, you will find a corresponding response
between the pH and HCO3; that is, the pH and HCO3 will both be
down (acidosis) or the pH and HCO3 will both be up (alkalosis).
Look at pH and HCO3 to determine whether the condition is a
metabolic problem.
In metabolic acidosis, pH is down and HCO3 down.
In metabolic alkalosis, pH is up and HCO3 up.
Compensation Status
In respiratory acidosis and respiratory alkalosis:
When compensation has occurred, the pH will be within normal
limits.
Partial compensation has occurred if the HCO3 is abnormal.
An uncompensated condition exists if the bicarbonate is normal.
In metabolic acidosis and metabolic alkalosis:
When compensation has occurred, the pH will be within normal
limits.
Partial compensation has occurred if the PCO2 is abnormal.
An uncompensated condition is present if the PCO2 is normal.
Nursing Considerations
Assessing Blood Gas Results
Step 1: Look at the pH. Is it up or down? If it is up, alkalosis may be
present. A decreased pH reflects acidosis.
Step 2: Look at the PCO2. Is it up or down? If its response is opposite
that of the pH, you know that the condition is a respiratory
imbalance. If its response is not opposite that of the pH, move on to
step 3.
Step 3: Look at the bicarbonate (HCO3). Does the change in HCO3
correspond with that of the pH? If it does, the condition is a
metabolic imbalance.
Step 4: Compensation has occurred if the pH is in the normal range
of 7.35 to 7.45. If the pH is not within the normal range, look at the
respiratory or metabolic function indicators to determine the degree
of compensation.
Assessing Compensation Status
Respiratory Imbalances
If the condition is a respiratory imbalance, look at the bicarbonate
(HCO3) reading to determine the state of compensation.
If the HCO3 reading is normal, the condition is uncompensated.
If the HCO3 reading is abnormal, the condition is partially
compensated.
Metabolic Imbalances
If the condition is a metabolic imbalance, look at the PCO2 to
determine the state of compensation.
If PCO2 is normal, the condition is uncompensated.
If PCO2 is abnormal, the condition is partially compensated.
Priority Points to Remember!
In acidosis, the serum potassium level increases.
In alkalosis, the serum potassium level decreases.
In acidosis, the pH goes down and respiratory rate and depth
increase.
In alkalosis, the pH goes up and respiratory rate and depth decrease.
Any condition that results in an obstruction of the airway or
depresses respiratory status can cause respiratory acidosis.
Conditions that result in overstimulation of the respiratory status
can cause respiratory alkalosis.
 Diabetes mellitus or diabetic ketoacidosis can cause metabolic
acidosis.
Common causes of metabolic alkalosis include the use of diuretics,
excessive vomiting, and gastrointestinal suctioning.
The Allen test is performed before blood is drawn from the radial
artery to assess collateral circulation to the hand.
Compensation has occurred if the pH is in the normal range of 7.35
to 7.45.