Medical Surgical Nursing

Topic: Acid-Base Balance

- Silver nitrate
Acid
• Acid - Barium sulfate
- compound that yields hydrogen ions - Ferrous sulfate
when dissociated in solution - Sodium bicarbonate
• Properties: Organs responsible in acid base balance
- Acts as an electrolyte in H20 • Lungs
- Reacts with base to form H20 & salt - maintain acid-base balance by
- Destroy body tissues controlling CO2 in the body.
• Common Acids: • Kidneys
- Hydrochloric acid - it maintains acid-base balance by
- Carbonic acid controlling HC03
- Acetic acid
- Lactic acid

Hydrochloric Acid
• Secreted by the parietal cells of the stomach,
transform pepsinogen into pepsin

Carbonic Acid
• one form in which CO2 is transported in the
blood
• part of the bicarbonate buffer system

Lactic Acid
• Builds up in muscle tissue during exercise & it
is transported to the liver via the circulatory
system where it is completely oxidized into
CO2, H20 & energy

Bases
• A compound that combines with an acid to
form H20 & a salt
• properties:
- Acts as an electrolyte in H20
- Destroy body tissue
• Common base:
- Magnesium Hydroxide
- Aluminum Hydroxide
- Ammonium Hydroxide

Salts
• Compound formed when an acid is
neutralized by a base
• Properties:
- Acts as an electrolyte in H20
- Crystalline in nature
- “Salty” taste
• Common Salts:
- Sodium chloride
- Potassium chloride
Medical Surgical Nursing
Topic: Acid-Base Balance
Solutions develop after movement catecholamines, and a diminished response to the
• Hypertonic solution effects and actions of certain medications.
- higher concentration of solutes in the
When the pH is above 7.45, the blood is said
solution.
to be alkalotic. An alkalotic state interferes with tissue
• Hypotonic solution
oxygenation and normal neurological and muscular
- Lesser concentration of solutes in the
functioning. Significant changes in the blood pH
solution
above 7.8 or below 6.8 will interfere with cellular
functioning, and if uncorrected, will lead to death.

Components of the Arterial Blood Gas

• pH: Measurement of acidity or alkalinity,
based on the hydrogen (H+) ions present. The
normal range is 7.35 to 7.45
• PaO2: The partial pressure of oxygen that is
dissolved in arterial blood. The normal range
is 80 to 100 mm Hg.
• SaO2: The arterial oxygen saturation. The
normal range is 95% to 100%. PaCO2: The
amount of carbon dioxide dissolved in
arterial blood. The normal range is 35 to 45
mm Hg.
• HCO3: The calculated value of the amount of
bicarbonate in the bloodstream. The normal
range is 22 to 26 mEq/liter

Steps in Acid-Base Balance

• Step One
- Assess the pH to determine if the blood is
within normal range, alkalotic or acidotic.
If it is above 7.45, the blood is alkalotic. If
it is below 7.35, the blood is acidotic.
• Step Two
Overview: Interpretation of the Arterial Blood Gas - If the blood is alkalotic or acidotic, we now
The pH is a measurement of the acidity or need to determine if it is caused primarily
alkalinity of the blood. It is inversely proportional to by a respiratory or metabolic problem. To
the number of hydrogen ions (H+) in the blood. The do this, assess the PaCO2 level.
more H+ present, the lower the pH will be. Likewise, Remember that with a respiratory
the fewer H+ present, the higher the pH will be. The pH problem, as the pH decreases below 7.35,
of a solution is measured on a scale from 1 (very the PaCO2 should rise. If the pH rises
acidic) to 14 (very alkalotic). A liquid with a pH of 7, above 7.45, the PaCO2 should fall.
such as water, is neutral (neither acidic nor alkalotic). Compare the pH and the PaCO2 values. If
pH and PaCO2 are indeed moving in
The normal blood pH range is 7.35 to 7.45. In
opposite directions, then the problem is
order for normal metabolism to take place, the body
primarily respiratory in nature.
must maintain this narrow range at all times. When
• Step Three
the pH is below 7.35, the blood is said to be acidic.
- Finally, assess the HCO3 value. Recall that
Changes in body system functions that occur in an
with a metabolic problem, normally as
acidic state include a decrease in the force of cardiac
the pH increases, the HCO3 should also
contractions, a decrease in the vascular response to
Medical Surgical Nursing
Topic: Acid-Base Balance
increase. Likewise, as the pH decreases,
so should the HCO3. Compare the two
values. If they are moving in the same
direction, then the problem is primarily
metabolic in nature. The following chart
summarizes the relationships between
pH, PaCO2 and HCO3.

Compensation
• When a patient develops an acid-base
imbalance, the body attempts to
compensate. Remember that the lungs and
the kidneys are the primary buffer response
systems in the body. The body tries to
overcome either a respiratory or metabolic
dysfunction in an attempt to return the Ph
into the normal range.
• A patient can be uncompensated, partially
compensated, or fully compensated. When
an acid-base disorder is either
uncompensated or partially compensated,
the pH remains outside the normal range. In
fully compensated states, the pH has
returned to within the normal range, although
the other values may still be abnormal. Be
aware that neither system has the ability to
overcompensate
Medical Surgical Nursing
Topic: Acid-Base Balance
Types of Acid-Base Disturbances
• Acidosis
- depression of the central nervous system,
as evidenced by disorientation followed
by coma
• Alkalosis
- Overexcitability of the nervous system;
muscles may go into a state of tetany and
convulsions

Nursing Management of Respiratory Acidosis

• ASSESSMENT
- Health Hx: complaints of headache,
confusion, lethargy, nausea, irritability,
nausea, irritability, anxiety, dyspnea, and
blurred vision, preexisting condition
- Physical Examination: lethargy to stupor
to coma, tachycardia, hypertension,
cardiac dysrhythmias, airway patency

• EXPECTED PATIENT OUTCOMES include but

are not limited to:
1. Will maintain airway patency and
adequate breathing rate and rhythm will
return of ABGs to patient’s normal level
Medical Surgical Nursing
Topic: Acid-Base Balance
2. Will be alert and oriented to time, place, - Assist the patient to identify coping
and person, or to his or her normal mechanisms to deal with anxiety and
baseline level of consciousness stress
3. Will cope with anxiety 4. Enhancing coping mechanisms
4. Will exhibit effective coping and - Provide support and information to family
awareness of effective support systems members about the patient’s ongoing
5. Will have secretions that are normal for condition
self in amount and can be raised - Reassure them that there is a physiologic
6. Will maintain adequate rate and depth of cause for the patient’s behavior
respirations using pursed lip and other - Encourage questions and open
breathing techniques when necessary (as communication
in the patient with COPD) 5. Promote airway clearance
- Implement regular breathing and
Nursing Management of Patient with Respiratory
coughing exercises
Acidosis
• INTERVENTIONS - Do suctioning as necessary

1. Supporting effective gas exchange - Maintain good hydration

- Provide a position of comfort to allow - Do chest physiotherapy as appropriate

ease of respiration 6. Promoting an effective breathing pattern

- Obtain and monitor ABG results and VS. - Maintain alveolar ventilation

Refer accordingly - Teach the patient proper breathing

- Provide and monitor supplemental techniques as well as panic control

oxygen as ordered breathing

- Turn the patient q2 and PRN • Evaluation. Achievement of outcomes is

successful when the patient
- Provide pulmonary hygiene PRN
- Maintain adequate hydration 1. Demonstrates improved ventilation and

- Provide comfort measures such as mouth oxygenation

care 1.1 Has vital signs, ABGs, and cardiac rhythm

within own normal range
- Assist with ADLs
- Instruct patient regarding coughing and 2. Returns to baseline LOC

deep breathing and management of 3. Reports reduced anxiety

disease condition, especially COPD 4. Family uses adequate coping mechanisms

2. Coping with disturbed thought processes 5. Is able to raise secretions on own

- Do frequent neurologic assessments 6. Demonstrate effective breathing

- Monitor and document person’s baseline techniques

LOC frequently Respiratory Alkalosis

- Reorient as necessary by providing
calendars, clocks, etc.
3. Relieving anxiety
- Provide a calm, relaxed environment
- Give clear, concise explanations of
treatment plans
- Encourage expression of feelings
- Provide support and information to
patient and family
- Teach relaxation techniques
Medical Surgical Nursing
Topic: Acid-Base Balance
• Interventions
1. Allay anxiety
- Give antianxiety medications as ordered
- Have patient breath into a paper bag
- Teach relaxation techniques when initial
anxiety attack is over
2. Promoting an Effective Breathing Pattern
- Encourage the patient to slow his or her
RR
- Maintain a calm and comforting attitude
- Position the patient to promote maximal
ease of inspiration
Nursing Management of Respiratory Alkalosis
• Assessment - Assist the patient with relaxation
- Health Hx: anxiety, shortness of breath, techniques
muscle cramps or weakness, 3. Coping with Disturbed Thought Processes

palpitations, panic, dyspnea - Do frequent reorientation

- Physical Examination: light-headedness, - Encourage family to participate in
confusion as a result of cerebral hypoxia, patient’s care
hyperventilation, tachycardia or - Use simple, direct statements or

arrhythmia, muscle weakness, (+) directions

Chvostek’s sign or Trousseau’s sign - Allow the patient adequate time to
indicating a low ionized serum calcium respond
level secondary to hyperventilation and 4. Preventing injuries
alkalosis, hyperactive deep tendon - Perform neurologic assessment
reflexes, unsteady gait, muscle spasms frequently and document
to tetany, agitation, psychosis, seizures - Institute safety and seizure precautions
in extreme cases, decreased potassium - Assess frequently for muscle strength

levels and coordination

• Evaluation. Achievement of outcomes is
successful when the patient:
1. Reports reduction in anxiety levels
2. a. Demonstrates effective normal
breathing patterns
b. Has ABG results within patient’s
normal baseline
3. Returns to normal baseline LOC and
orientation level
• EXPECTED PATIENT OUTCOMES include but
4. Remains free from injury; no seizure
are not limited to:
activity
1. Will report decreased anxiety; verbalizes
methods to cope with anxiety
2. Will return to normal respiratory rate
and rhythm or at least decreased
hyperventilation, with return to baseline
ABGs
3. Will exhibit reorientation to person,
place, and time as per patient’s baseline
4. Will be free from injury
Medical Surgical Nursing
Topic: Acid-Base Balance
Metabolic Acidosis • EXPECTED PATIENT OUTCOMES include but
are not limited to:
1. Will return to usual baseline LOC
2. Will return to normal baseline
parameters for vital signs with improved
CO and decreased or resolved
dysrhythmias
3. Will remain in a safe, secure environment
without injury
4. Will maintain fluid and electrolyte
balance and stable renal status
• Interventions
1. Coping with disturbed thought processes
- Monitor LOC and reorient as necessary
- Monitor VS, esp. RRR, BP, and T
- Monitor ABGs to assess the effects of
treatment
- Institute cardiac monitoring as ordered
2. Supporting cardiac output
- Monitor VS, MIO, and fluid and electrolyte
balance
- Institute cardiac monitoring to evaluate
cardiac status
3. Promoting safety
Nursing Management of Metabolic Acidosis - Provide a safe, secure and monitored
• Assessment environment
- Health Hx: anorexia, nausea, vomiting, - Institute safety precautions
abdominal pain, headache, thirst if the 4. Promoting return of fluid and electrolyte
patient is dehydrated balance
- Physical Examination: confusion, - Monitor MIO
hyperventilation, warm, flushed skin, - Administer medications per medical
bradycardia and other dysrhythmias, order
decreasing LOC, nausea, vomiting, • Evaluation. Achievement of outcomes is
diarrhea, Kussmaul respirations, and successful when the patient:
acetone breath, especially if acidosis is 1. Exhibits baseline-level consciousness and
due to ketoacidosis. Symptoms may orientation
progress to coma if untreated 2. Returns to normal baseline parameters
for vital signs and Cardiac Output with
cardiac dysrhythmias resolved
3. Remains free from injury
4. Maintains fluid and electrolyte balance
and stable renal function
Medical Surgical Nursing
Topic: Acid-Base Balance
Metabolic Alkalosis

• EXPECTED PATIENT OUTCOMES include but

are not limited to:
1. Will return to usual baseline LOC and
orientation
2. Will return to normal baseline
parameters for vital signs with improved
CO with resolution of electrolyte
imbalances and decreased or resolved
cardiac dysrhythmias
3. Will remain in a safe, secure environment
without injury
4. Will maintain fluid and electrolyte
balance
• Interventions
1. Coping with disturbed thought processes
- Monitor LOC and reorient as necessary
Nursing Management of Metabolic Alkalosis
- Monitor VS, esp. RRR, BP, and T
• Assessment
- Monitor ABGs to assess the effects of
- Health Hx: Prolonged vomiting or
treatment
nasogastric suctioning, frequent self-
- Institute cardiac monitoring as ordered
induced vomiting, muscle weakness,
2. Supporting cardiac output
lightheadedness, ingestion of large
- Monitor VS, MIO, and fluid and electrolyte
amounts of licorice or antacids, use of
balance
diuretics, muscle cramping, twitching, or
- Institute cardiac monitoring to evaluate
tingling
cardiac status
- Physical Examination: mental confusion,
3. Promoting safety
dizziness, changes in LOC, hyperreflexia,
- Provide a safe, secure and monitored
tetany, dysrhythmias, seizures,
environment
respiratory failure, positive Chvostek’s or
- Institute safety precautions
Trousseau’s sign if the patient has a low
4. Promoting return of fluid and electrolyte
ionized serum calcium level, decreased
balance
hand grasps, generalized muscle
- Monitor MIO
weakness, decreased serum calcium or
- Administer medications per medical
potassium level, impaired concentration,
order
seizures, ECG changes consistent with
• Evaluation. Achievement of outcomes is
hypokalemia
successful when the patient
1. Manifests mental status has returned to
baseline
2. Is free from cardiac dysrhythmias
Medical Surgical Nursing
Topic: Acid-Base Balance
3. Remains free from injury
4. Maintains fluid balance at baseline level