Module 3 - Alterations in Acid-Base Balance Flashcards

1
Q

How many acid base disturbances are important to us?

A

4

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2
Q

How does ABG help us with acid base imbalances?

A

Gives us numbers from arterial blood that can indicate any acid base disturbances and imbalances

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3
Q

What needs to be done before each ABG?

A

An Allens Test

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4
Q

Hydrogen Ions (H+)

A

Ions vital to life with low concentration in the body compared to Na, K, etc, but equally as important

Has 2 forms

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5
Q

How are H+ ions expressed

A

They are expressed as pH (logarithmic form)

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6
Q

What are the 2 forms of Hydrogen Ions in the Body

A
  1. Volatile Hydrogen of Carbonic Acids
  2. Nonvolatile form of Hydrogen and Organic Acids (Fixed)
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7
Q

Carbonic Acid

A

Most important acid in the body

H2CO3

It breaks down into and is made up of CO2 and H2O (think of breathing!)

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8
Q

What two areas of the body control acid base balance?

A

Lungs
Kidneys

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9
Q

What area of the body controls volatile forms of hydrogen ions?

A

Lungs

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10
Q

What area of the body controls nonvolatile forms of hydrogen ions?

A

Kidneys

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11
Q

What is the normal pH range for the body?

A

7.35 to 7.45 (slightly alkalotic)

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12
Q

Acids

A

produced as the end products of metabolism (ex: Lactic acids cause achy muscles from anaerobic glycolysis)

Contain H+ Ions

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13
Q

Acids are Hydrogen Ion ___

A

Donors

they give up H+ to neutralize or decrease the strength of an acid or to form a weaker base (makes acid weaker giving away H+)

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14
Q

Strength of an acid is determined by …

A

the number of hydrogen ions it contains

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15
Q

The number of hydrogen ions in body fluid determines…

A

acidity, alkalinity, or neutrality of the body fluid

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16
Q

More H+ = More ____ = ___ pH

A

More H+ = More acidic = lower pH

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17
Q

Discuss Lung excretion of acids

A

Lungs excrete 13000-30000 mEq of volaile hydrogen per day in the form of carbonic acid (H2CO3) as CO2

The respiratory rate increases to get rid of the acids make things more alkalotic/neutral

The fast workhorse of acid base balance

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18
Q

Discuss Kidney excretion of acids

A

Kidneys excrete 50mEq of nonvolatile acids per day

The kidney releases a lot less than the lungs but the difference they make could be what determines the difference between life and death

The slow fine tuners of acid base balance

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19
Q

Bases

A

contain no Hydrogen ions (H+)

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20
Q

Most important Base in the body?

A

Bicarb (HCO3-)

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21
Q

Bases are hydrogen ion (H+) ____

A

acceptors

they accept H+ from acids to neutralize or decrease the strength of a base or to form a weaker acid

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22
Q

What is pH

A

it reflects the hydrogen ion concentration (H+) in a fluid

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23
Q

The greater the concentration of H+ ions, the ___ the pH and the more ___ the blood

A

lower the pH; the more acidic the blood

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24
Q

The lower the concentration of H+ ions, the ___ the pH and the more ___ the blood

A

higher the pH; the more alkalotic the blood

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25
Acids are formed from ...
Metabolic activity (or other substances) ex: Glucose --> Carbonic Acid (H2CO3) ex: incomplete oxidation of fats --> Ketoacids
26
What is the normal ratio of alkali (bicarbonate) to acid (H2CO3) ?
20:1 1 part acid to 20 part alkali
27
What balance situations lead to acidosis?
Increased acid with normal alkali Normal acid with decreased Alkali
28
What balance situations lead to alkalosis?
Normal acid with increased alkali Decreased acid with normal alkali
29
What is the acidosis (non death) range of pH
<7.35 but > 6.80
30
What is the alkalosis (non death) range of pH
>7.45 but <7.80
31
What is the acidosis (death) range of pH
< 6.80
32
What is the alkalosis (Death) range of pH
>7.80
33
What is an example of acidosis?
DKA
34
What is an example of alkalosis
Hyperventilation (blowing off a lot of CO2 and Water (which makes up carbonic acid) which raises pH and you become more numb, tingling, etc)
35
Buffer
a weak acid/base that can combine with strong acids/bases to minimize changes in pH of the blood they sense what is wrong in the body and try to keep pH in a healthy range End Goal - keep pH 7.35 to 7.45
36
Major Intracellular Buffer System
Potassium - Hydrogen Ion Exchange H+ increase (acidic)--> H+ moves into cells and K+ moves out H+ decreases (alkalotic) --> H+ moves out of cells and K+ moves in
37
Major Extracellular Buffer Systems
Protein Buffers Bicarbonate Buffers Phosphate Buffers Bone Buffers
38
What makes up 80% and 20% of Protein Buffers Respectively?
80% - Hgb 20% - Albumin and plasma globulin
39
Bicarbonate Buffer
ECF Buffer Exchange of Carbonic Acid in the Lungs w/ breathing (Fast) and Bicarbonate from the Kidneys (Slow)
40
Bone Buffer
ECF Buffer More common in chronic conditions Exchanges of pH between bones and blood Causes kidney stones and demineralization of bones)
41
Where else can buffer systems take place?
Cells Blood interstitial Tissue Bones Etc
42
What are the 3 most important things to know for Buffers as a Regulatory System of H+ Concentration in the Blood?
1. Fast Acting 2. Reacts Immediately - protection against H+ changes in ECF 3. Functions to keep pH in narrow limits of stability where there is too much acid or base released
43
What other things do Buffer Systems do?
Absorb or release H+ as needed Serve as a transport mechanism that carries excess hydrogen ions (H+) to the lungs
44
What is important to know about what happens after a primary buffer system reacts?
Once they are consumed, the body is less able to withstand further stress until the buffers are replaced (autonomic process)
45
What is the major intracellular buffer and how does it shift pH?
Potassium The K level changes to compensate for H+ level changes There is tons of K+ in cells
46
How does the Potassium Buffer work with Acidosis?
The body protects itself from the acid state by moving H+ INTO cells --> K+ then moves out to make room for the H+ in the cells and serum potassium levels rise This is when Serum H+ is high and pH is low
47
How does the Potassium Buffer work with Alkalosis?
Cells release hydrogen ions (H+) into the blood in an attempt to increase acidity of the blood and combat alkalinity --> K+ then moves into the cells and serum K+ levels decrease This is when Serum H+ is low and pH is high
48
The body prioritized what balance?
pH balance before electrolyte balance (so temporary imbalances can occur)
49
What can happen regarding potassium and alkalosis? Acidosis?
Hypokalemia/ Hyperkalemia can occur making people not feel well for a little while Ex: cardiac arrhythmias, GI issues with innervation
50
What is the Major Buffer System of ECF and how does it balance pH?
HG Systems (80%) Acid Base balance is maintained with chloride exchanges for bicarbonate between the RBCs/HGB Chloride shifts in and out of cells in response to level of O2 in the blood
51
A cation must be exchanged for a ___ and an anion must be exchanged for a ___
cation; anion
52
How does the HGB buffer fix low serum bicarbonate (Acidosis)?
Less base = acidic --> pH is lower --> RBC will let HCO3 out and Cl- in --> Serum chloride decreases
53
How does the HGB buffer fix high serum bicarbonate (Alkalosis)?
More base= alkalotic --> pH is higher --> RBC lets HCO3- in and Cl- out --> Serum Chloride increases
54
The benefit of the HGB system is what?
You do not feel symptoms of hypo or hyperchloremia unless it is extreme Hyper - Fluid Volume Excess Hypo - Dehydration, Fluid Loss, Vomiting, Diarrhea
55
Plasma Protein Systems
ECF Buffer Functions in conjunction with the liver (via albumin, globulin, etc) to vary the amount of hydrogen ions (H+) in the chemical structure of protein
56
What special acid base function does plasma proteins have?
they have the ability to attract or release H+ ions
57
What would the action be of the Plasma Protein Buffer System if there is Metabolic Alkalosis?
H+ ions release from plasma proteins and enter serum to increase acidity --> H+ will then bind to unbound calcium and decrease total ionized calcium --> nL pH with Hypocalcemia occurs ex: Hyperventilation --> Alkalosis --> Correction --> Serum Ionized Levels Drop --> Hypocalcemia w/ dizziness, tingling, etc because of lowered threshold
58
What would the action be of the Plasma Protein Buffer System if there is Metabolic Acidosis?
Too many serum H+ --> H+ goes into a plasma protein and calcium unbinds and enters the blood --> Increase in ionized Ca and decrease in bound Ca --> Hypercalcemia and nL pH ex: DKA --> Acidosis --> Correction --> Serum ionized levels rise --> hypercalcemia w/ longer distance to firing and slowing of muscle and nerve innervation
59
Phosphate buffer system
ECF Buffer present in cells and body fluids especially active in the kidneys acts like bicarb and clears spare H+ ions by exchanging phosphorous with calcium at the level of the kidneys
60
The only acid that the lungs can get rid of, unlike the kidneys which can get rid of many, is what?
Carbonic Acid
61
What does the Carbonic Acid/Bicarbonate System do?
it is a buffer system for ECF it maintains a pH of 7.4 with a 20 bicarb to 1 carbonic acid ratio (20:1)
62
The 20:1 ratio determines what?
Hydrogen ion (H+) concentration of body fluid
63
Carbonic acid concentration is controlled by what?
The excretion of CO2 by the LUNGS The rate and depth of respiration changes then in response to the changes in CO2
64
Bicarbonate concentration is controlled by what?
the KIDNEYS which selectively retain or secrete bicarb in response to body needs
65
How does DKA cause Kussmaul breathing?
DKA occurs with productions of ketoacids which lower pH and deplete bicarb while creating carbonic acid. The buildup leads to an increase in rate and depth of respiration by the lungs to try and raise the pH
66
In what directions/areas can Carbonic Acid go
To the lungs: H2CO3 H2O and CO2 To the Kidney H2CO3 H+ and HCO3-
67
What is needed for carbonic acid to turn into bicarb and hydrogen or carbon dioxide and water?
Carbonic Anhydrase - an enzyme that breaks down carbonic acid into these components
68
If blood buffer systems are the first defense for acid base balance, what are the second and third/final?
second - lungs third/final - Kidneys
69
What occurs during Acidosis regarding the lungs and pH?
pH decreased so RR and Depth increase to try and blow off acids Carbonic acid can be carried to the lungs and reduced to CO2 and Water to be exhaled, thus H+ ions are inactivated and excreted
70
What occurs during Alkalosis regarding the lungs and pH?
pH increased so RR and Depth decrease to try and blow off acids CO2 is retained and carbonic acid builds up (CO2 + H2O) to neutralize and decrease the strength of excess bicarbonate
71
How do the lungs mechanically compensate for acidosis and alkalosis?
Acidosis: increase RR and Depth Alkalosis: decrease RR and depth
72
How fast are the lungs in fixing excess or deficit?
The action of the lungs is reversible and only takes 10-30 seconds to correct
73
Why is Bicarbonate considered volatile?
it is in a gaseous form - in lungs 30,000 mEq of volatile acids are removed with only 50 mEq removed via kidneys so we do need constant buffering
74
What occurs with acid base balance, buffering, and diarrhea?
Diarrhea gets rid of bases, letting the body get acidotic. So respiration rate and depth increase to blow off carbonic acids and raise pH. This only takes 10-30 seconds to correct.
75
The lungs can only deal with ___ ___, everything else is handled by the ___
deal with CARBONIC ACID handled by the KIDNEYS
76
Why can the lungs only deal with carbonic acid?
the lungs can only inactivate H+ carried by carbonic acid, excess H+ on other carriers and from other problems need to be excreted by the kidneys
77
How does the lungs exactly retain or get rid of H+ ions
Lungs can either hold H+ with CO2 and making Carbonic acid until deficit is corrected Or it can inactivate H+ and turn them into water molecules to be exhaled as CO2 to correct excess
78
How long does acid base compensation by the kidneys take?
Few hours to several days, but this is more selective and thorough than other regulators as its the ultimate correction
79
What is the action of correcting acidosis for the kidneys?
pH has gone down, so excess H+ are secreted into the tubules and combine with buffers for excretion in the urine the urine is outside normal pH and more acidic but we only care about blood pH at the moment so this is ok
80
What is the action of correcting alkalosis for the kidneys?
pH has gone up, so bicarbonate ions move into the tubules, combine with sodium, and are excreted in the urine this urine is outside normal pH and more alkalotic but we only care about blood pH at the moment so this is ok
81
What are the 3 methods for the kidneys to selectively regulate bicarbonate and rid of acids?
1. Conservation of bicarbonate that is filtered by releasing H+ and holding onto Bicarb ions 2. Extra H+ is turned into phosphoric acid (using phosphorous) and is excreted in urine 3. Amino Acid alteration in renal tubules diffuses ammonia into the kidneys which then combines with excess H+ (into ammonium) and is excreted in the urine
82
Respiratory: ___ + ___ Carbonic Acid __ + __ :Renal
Respiratory: CO2 + H2O Carbonic Acid (via Carbonic Anhydrase) H+ + HCO3- :Renal
83
In health there is a ratio of what?
20 bicarb (base) for 1 part Carbonic acid (acid) (or CO2) 20b:1a --> pH of 7.4 (within 7.35 to 7.45)
84
What happens if the ratio of bases:acids increases?
ex: 30:1 --> blood pH increases --> alkalosis
85
What happens if the ratio of bases:acids decreases?
ex: 13:1 --> blood pH decreases --> Acidosis
86
Slower and shallower breathing leads to ...
retention of CO2 --> production of acid can correct alkalosis
87
Faster and deeper breathing leads to ...
elimination of CO2 --> elimination of acid can correct acidosis
88
Response difference between the lungs and kidneys?
Lungs: Rapid response occurring within minutes with a maximum of 12-24 hours (with effect declining thereafter) Kidney: Slow response occurring within 1 to 2 days
89
Decreased pH (acidosis) leads to what occurring in the kidneys?
decreased pH --> secrete more H+ (and less K+) and phosphate --> reabsorb more bicarbonate (and less Cl-) this can raise the pH
90
Increased pH (alkalosis) leads to what occurring in the kidneys?
increased pH --> secrete less H+ (and more K+) --> Reabsorbs less bicarb (and more Cl-) this can lower the pH
91
BMP
Basic Metabolic Panel Drawing venous blood (rather than arterial for ABG) to check electrolyte and acid base balance
92
A BMP CO2 levels comes from what type of blood and represents what?
venous blood Venous CO2 is actually a measure of Bicarbonate so, high CO2 values means alkalosis, and low CO2 levels means acidosis
93
Metabolic Acidosis
Total concentration of buffer base (Bicarbonate) is lower than normal with a relative increase in H+ concentration
94
Metabolic means what?
it is dealing within the body so in the case of metabolic acidosis, there is a kidney problem and the lungs must compensate
95
When does Metabolic Acidosis occur?
as a result of losing too many bases (ex: diarrhea) and holding too many acids without sufficient bases (ex: DKA)
96
Potential causes for Metabolic Acidosis
Diabetes and DKA Renal Insufficiency or Failure Insufficient Metabolism of Carbohydrates Excessive ingestion of Acetylsalicylic Acid (Aspirin) Severe Diarrhea Malnutrition High Fat Diet
97
The most common and main reason for Metabolic Acidosis is?
DKA and Diabetes
98
Why are kidneys the problem for Metabolic Acidosis?
kidneys will hold back bicarbonate, but eventually this system is exhausted. The lungs will then blow off carbonic acid to try and compensate
99
How does DKA and Diabetes lead to Metabolic Acidosis
insufficient insulin causes increased fat metabolism because the glucose cannot get into cells this leads to accumulation, in excess, of ketones and other acids that exhaust the bicarbonate system
100
How does Renal Failure/Insufficiency cause Metabolic Acidosis
Increased waste products of protein metabolism are retained because the kidney cannot metabolize them and rid of the acids excessive acid build up thus overpowers bicarbonates ability to maintain balance
101
How does Insufficient metabolism of carbohydrates cause Metabolic Acidosis
insufficient supplies of O2 are available for proper burning of CHO, glc, and H2O --> this leads to lactic acid buildup, and insufficient metabolism of carbs causes Lactic Acidosis
102
What must the lungs do when there is Lactic Acidosis causing Metabolic Acidosis?
It cannot blow off lactic acid, so it must blow off Carbonic acid
103
How does excessive ingestion of acetylsalicylic acid (aspirin) cause Metabolic Acidosis?
excessive ingestion of acetylsalicylic acid causes an increase in H+ concentration because it metabolizes into H+ This is a mixed imbalance though
104
How is Acetylsalicylic Acid causing a mixed imbalance of Metabolic Acidosis?
Aspiring poisoning in the early stages is associated with respiratory alkalosis -d/t aspirin impact on resp centers - so they will breath fast, but once aspirin is metabolized the acids will build up and metabolic acidosis occurs
105
How does severe diarrhea cause Metabolic Acidosis
intestinal and pancreatic secretions are normally alkaline so excessive loss of base in this case causes MA faster and deeper respirations occur as a result
106
How does malnutrition lead to Metabolic Acidosis
improper metabolism of nutrients causes fat catabolism leading to excess build up of ketones and acids (like DKA a little)
107
How does a High fat Diet lead to metabolic acidosis
high intake of fat causes a much too rapid accumulation of waste products of fat metabolism leading to a build up of ketones and acids think Atkins diet
108
Anion Gap
Lab that describes the difference between the serum concentration of the major measured cation, Sodium (Na+), and the sum of measured major anions, Chloride and Bicarbonate. The difference between the major measured cation and the major measured anions represents the concentration of unmeasured anions (like phosphates, sulfates, ketone bodies, lactic acid, and proteins) AG = [Na+] - ([HCO3-]+[Cl-]) This will tell us whether they have too much acid or loss of bases
109
Anion Gap is only looked at in the case of ...
metabolic acidosis
110
Normal Anion Gap range?
12 +/- 2 mEq/L
111
What does elevated anion gap mean?
elevation is occurring from accumulation of acids (these are the unmeasured anions of acids) ex: lactate in lactic acidosis, acetoacetate in ketoacidosis, sulfates and phosphates in RF - unmeasured anions of acids
112
What does a Normal Anion Gap represent?
a loss of base (bicarb)
113
What does a lowered anion gap mean?
It is a rare occurrence It occurs from a decrease in proteins like in cancer and cirrhosis it either comes from a decrease in unmeasured anions or an increase in unmeasured cations ex: low albumin, hyperkalemia, hypercalcemia, hypermanesemia
114
What are the etiologies for a High anion gap?
1. Excess production of metabolic acids (lactic acidosis, DKA, starvation, alcoholic intoxication, aspirin poisoning) 2. Impaired elimination of metabolic acids (ex: RF)
115
What are the etiologies for a Normal anion gap?
1. Loss of intestinal secretions (diarrhea, intestinal suction, biliary or pancreatic fistula) 2. increased renal losses (renal tubular acidosis, tx with carbonic anhydrase inhibitors, HYPOaldosteronism) 3. Increased chloride levels (excess reabsorption of chloride by the kidney, sodium chloride infusion, ileal conduit)
116
Ileal Conduit
placed for bladder cancer ureter attached to Small intestine instead of emptying urine via the bladder urine then mixes with feces causing chloride absorption allowing for a normal anion gap and thus loss of bases
117
Assessment of Metabolic Acidosis shows what?
Headache Nausea Vomiting (low pH stims vomit centers) Diarrhea Fruit smelling breath from improper fat metabolism Twitching Mental Dullness (!!) Drowsiness Stupor Coma Convulsions Hyperpnea with Kussmaul Breathing - due to an attempt to blow off extra CO2 and compensate for the acidosis
118
Neural Manifestations of Metabolic Acidosis
Weakness Lethargy General Malaise Confusion Stupor Coma
119
Cardiovascular Manifestations of Metabolic Acidosis
Peripheral Vasodilation (Decreased HR and BP) Decreased HR Cardiac Dysrhythmias
120
GI Function Manifestations of Metabolic Acidosis?
Anorexia Nausea and Vomiting Abdominal Pain
121
Non Cardiac, GI, or Neural Manifestations of Metabolic Acidosis?
Skeletal - bone disease if MA is chronic Skin - flushed warm and dry (from peripheral vasodilation)
122
What is the Stupor, Coma, and Confusion related to in metabolic acidosis manifestations?
An increase in ionized calcium from the plasma protein buffer system (H+ moves to proteins but those proteins release Ca2+)
123
The most important Metabolic Acidosis manifestations are?
Neural Cardiovascular GI Function
124
How does the Body compensate for Metabolic Acidosis?
Respiratory: Kussmaul breathing - increased RR and depth Hyperkalemia Acidic Urine Increased Ammonium in Urine *kidneys are trying, but they are also the issue, so lungs are the compensatory part
125
General Interventions for Metabolic Acidosis
Determine the Cause of the Acidosis!!! Maintain a patent airway Assess LOC for CNS depression - a chance of seizure exists if the body is acidotic Monitor Lyte values maintain I and O and assist with fluid and lyte replacement as prescribed Initiate safety precautions for convulsions and coma Prepare to administer IV solutions like isotonic saline, 5d1/2NS (hypertonic to pull fluid from cells to return circulating volume), sodium lactate or bicarbonate to increase the buffer base Monitor K level very closely (as K moves with GIK for example)
126
Why do Potassium levels need to be monitored very closely in Metabolic Acidosis?
When acidosis is being treated, K will move back into the cell and blood levels will drop rapidly
127
Metabolic Acidosis Interventions if it is caused by DKA
Insulin (GIK) is given to hasten movement of serum glucose into cells --> decreases concurrent ketosis (making ketone acids) When glc is being properly metabolized, body will stop making fats into glucose Monitor for circulatory collapse d/t polyuria which may come from the hyperglycemic state, as polyuria or diuresis may lead to ECF volume deficit
128
Metabolic Acidosis Interventions if it caused by Renal Failure
Dialysis may be used to remove protein and waste products thereby lessening the acidosis state - potential primary need / main treatment Diets low in protein and high in calories will lessen the amount of protein waste products d/t protein catabolism; this in turn will lessen acidosis - but this is slower and not the main fix in the end
129
Treatments for Metabolic Acidosis
Monitor patients at risk (DM, sepsis, shock) Monitor VS (esp RR and depth) Monitor ABGs and K+ levels Administer Sodium Bicarb (NaHCO3) Cardiac Monitoring for low serum K+ levels CORRECT UNDERLYING CAUSE OF ACIDOSIS Administer IV fluids with lactate (unless contraindicated)
130
Treatment for DKA Metabolic Acidosis?
Insulin + Normal Saline
131
Treatment for Lactic Acidosis Metabolic Acidosis
IV fluids and oxygen
132
Treatment for Renal Failure, Drug Overdose, or Drug Poisoining Metabolic Acidosis
Dialysis
133
Treatment for CHRONIC Metabolic Acidosis
Increase in Carbohydrates and Decrease in Fat diet
134
Why is DKA Metabolic Acidosis treatment so serious?
Metabolic acidosis compensation is making K+ move into cells which then is lost in urine, while DKA GIK treatment moves it in so we are at double risk for low potassium levels that could lead to arrhythmias (higher resting membrane to reach)
135
Define Metabolic Acidosis
Fixed Acid Excess - too much acid
136
Causes of Metabolic Acidosis
1. Acid Accumulation - excessive Metabolic acids 2. Loss of bicarbonate base (HCO3-) This is a problem via the KIDNEYS
137
What compensates for Metabolic Acidosis
Respiratory excretion of H2CO3 (CO2 + H2O) the LUNGS ARE COMPENSATORY
138
What are normal PaCO2 levels?
35-45 (thinks of 7.35-7.45) PaCO2 is the respiratory marker and partial pressure of CO2
139
What are normal HCO3- levels?
22-26 HCO3- is the renal/metabolic marker
140
What are the pH, PaCO2, and HCO3- levels like in uncompensated Metabolic Acidosis?
pH - << 7.35 (ex: 7.3) PaCO2 - normal range (35-45) HCO3- -<22 (low)
141
What are the pH, PaCO2, and HCO3- levels like in partially compensated Metabolic Acidosis?
pH - <7.35 (slightly low) PaCO2 - <35 (slightly lower now) HCO3- - No change (still <22)
142
What are the pH, PaCO2, and HCO3- levels like in compensated Metabolic Acidosis?
pH - low normal (ex: 7.35 exactly) PaCO2 - << 35 (much lower) HCO3- - No change (still <22)
143
Why are the pH, PaCO2, and HCO3- levels like an elevator?
the levels never increase or decrease compared to one another, they either decrease together, increase together, or they may increase or decrease with some having no change (all going in same direction)
144
Why does PaCO2 decrease and HCO3- stay relatively the same in Metabolic Acidosis compensation?
PaCO2 decreases because the compensatory system for MA (lungs) will blow it off fast to correct/raise pH Bicarbonate stays largely the same (low) because the kidneys are the problem here, not the compensatory mechanism
145
Why does the body allow such a drop in PaCO2 for metabolic acidosis compensation?
Because it cares more about correcting pH than the Co2 amount
146
How may the ratio of bases:acids be in normal, uncompensated, and compensated Metabolic Acidosis?
Normal: 20:1 with ex: 24 mEq/L of Bicarb and 40 mmHg of PaCO2 and a pH of 7.4 Uncompensated: 13:1 with ex: 16 mEq/L of Bicarb and 40 mmHg of PaCO2 with a pH of 7.2 Compensated: 20:1 with an ex: 18 mEq/L of bicarb (largely the same but slightly corrected since kidneys are still working) and 30 mmHg of PaCO2 with a pH of 7.38
147
Metabolic Alkalosis
Issue with the kidneys, compensated by the lungs Deficit of carbonic acid (H2CO3) and a decrease in hydrogen ion concentration pH > 7.45 2nd most common acid base disorder in hospital patients opposite effect of metabolic acidosis
148
What can result in metabolic alkalosis?
Results from the accumulation of base or from a loss of acid without a comparable loss of base in body fluids
149
What are 2 potential causes for the increase in available basic solution in the blood and decrease in available acids in the blood in Metabolic Alkalosis?
1. Ingestion of excess sodium bicarbonate (ex: excessive ingestion of sodium bicarb like in Alka-Seltzer or baking soda causes an increase in the amount of base in the blood 2. Excessive Vomiting (leads to an excessive loss of acids)
150
What are some examples of events/disease that cause Metabolic Alkalosis?
1. GI Suctioning - leads to an excessive loss of acids from the suctioning 2. Diuretics - loss of H+ ions and K+ ions causes a compensatory increase in the bicarbonate in the blood 3. Hyperaldosteronism - increased renal tubule reabsorption of sodium occurs with the resultant loss of H+ 4. Massive Transfusion of Whole Blood - citrate, and anticoagulant in the whole blood, metabolizes into bicarb
151
What is the most common reason for causing Metabolic Alkalosis
Gastrointestinal Suctioning
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How does Hyperaldosteronism cause Metabolic Alkalosis?
The increased reabsorption of sodium causes Na to stay and H+ to leave in the urine Also called Conns Syndrome
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General Etiologies for Metabolic Alkalosis
Excess gain of bicarb. Increased bicarb retention Excessive H+ loss Volume contraction Abrupt correction of respiratory acidosis by mechanical ventilation
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What are some ways a person with metabolic alkalosis ended up with excess gain of bicarbonate
1. Administration/Ingestion of HCO3 (e.g. alka seltzer) 2. Adminsitration of TPN containing ACETATE, solutions with LACTATE, or CITRATE in whole blood - all will metabolize into Bicarb 3. NaHCO3 administration during CPR
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Why is bicarbonate retention increased in Metabolic Alkalosis?
d/t a loss of chloride
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How can H+ be lost in excess leading to Metabolic Alkalosis?
1. NG Suctioning (most common reason) 2. Vomiting 3. Bulimia 4. Potassium Deficit d/t diuretic therapy or hyperaldosteronism
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What does volume contraction mean as an etiology for metabolic alkalosis
loss of body fluids through something like diuretic therapy
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Things that can be seen on assessment for Metabolic Alkalosis
DECREASED RR AND DEPTH OF BREATHING (conserve volatile acid CO2) Nausea and Vomiting Diarrhea Numbness and Tingling in the extremities Restlessness and twitching in the extremities Hypokalemia Hypocalcemia Sinus Tachycardia Dysrhythmias
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What is causing the twitching/neuro excitability and hypocalcemia in Metabolic Alkalosis?
Low H+ leads to calcium attaching to plasma proteins to release H+ which lowers the unbound amount of calcium. There is then hypocalcemia occurring which lowers the threshold for firing allowing for neuro excitability
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Important Areas of Manifestations in Metabolic Alkalosis?
Neural Cardiovascular GI Function Compensatory
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Neural Manifestations of Metabolic Alkalosis?
Confusion Hyperactive DTR Tetany Paresthesias in the Fingers and Toes Circumoral Paresthesias (tingling around the mouth) Carpopedal Spasm *All of this d/t hypocalcemia lowering threshold
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Cardiovascular Manifestations of Metabolic Alkalosis?
Hypotension Dysrhythmias
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What are the compensatory manifestations of Metabolic Alkalosis?
Respiratory rate decreases and depth decreases Urine pH increases because the kidneys are trying to get rid of some bicarb - but these areas are the problem still and cannot do too much
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Interventions for Metabolic Alkalosis?
Maintain a patent airway (may have spasms) Monitor vitals, I&O, Lyte values, muscle weakness Institute safety precautions for tetany and convulsions Prepare K and Cl-- as prescribed, to administer meds as prescribed to promote kidney excretion of excess bicarb, and to administer acidifying solutions as ammonium chloride and arginine chloride as prescribed
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Treatments for Metabolic Alkalosis?
Monitor pts at risk (ex: those with GI fluid loss) Assess I&O Monitor VS (esp., RR and Depth) Monitor ABGs Correct the underlying cause of imbalance IV fluids (NS) and lyte supplements to replace fluid volume and K+ and Cl- losses Supply sufficient Cl- to enable renal reabsorption of NaCl and renal excretion of excess Bicarb Cardiac monitor for hypokalemia teach about excess sodium bicarb ingestion and supplemental KCl for thiazide and loop diuretic therapy
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What is the hallmark/most important treatment for Metabolic Alkalosis behind treating the underlying cause?
Teaching them about other methods of treating dyspepsia (not alka seltzer or baking soda)
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Definition of Metabolic Alkalosis
Fixed acid deficit
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Causes for Metabolic Alkalosis
Base Accumulation Loss of Acids
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Compensation Mechanism for Metabolic Alkalosis
Respiratory retention of H2CO3 (CO2+H2O)
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What would pH, PaCO2, and HCO3- levels look like in Uncompensated Metabolic Alkalosis?
pH >> 7.45 (ex: 7.5) PaCO2 = normal range (35-45) HCO3- > 26 (high like 32)
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What would pH, PaCO2, and HCO3- levels look like in Partially compensated Metabolic Alkalosis?
pH > 7.45 (slightly lower now - maybe 7.48) PaCO2 > 45 (retention of CO2 is occurring to lower pH) HCO3- = No change (still greater than 26 since this is not really the compensatory thing)
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What would pH, PaCO2, and HCO3- levels look like in Compensated Metabolic Alkalosis?
pH = High normal (ex: pH = 7.45 - compensated) PaCO2 >> 45 (much greater because it was retained to lower pH) HCO3- = no change (still greater than 26, maybe a little lower like 28-30, but this is not the compensatory mechanism)
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Respiratory Acidosis
Total concentration of buffer base is lower than normal with a relative increasing H+ concentration - a greater number of H+ ions are circulating in the blood than can be absorbed by the buffer system (too much acid not enough base) In this case respiratory is where the problem is at with metabolic/kidney being the compensator
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Root Mechanical Cause for Respiratory Acidosis
Defects in the function of the lungs or by changes in normal respiratory patterns due to secondary problems (like lack of perfusion) Any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosis
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What is pH and PaCO2 like in (uncompensated) respiratory acidosis?
pH < 7.35 and PaCO2 >45
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Potential Causes for Respiratory Acidosis
Hypoventilation Infection Medications Pneumonia Atelectasis Brain Trauma emphysema asthma bronchitis pulmonary edema bronchiectasis
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How does Hypoventilation cause Resp Acidosis
CO2 is retained and H+ increase causing an acidic state Carbonic acid is retained d/t slow and shallow breaths making pH lower
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How does Infection cause Resp Acidosis
inflammation and bacterial agents can decrease aeration in the lungs from obstruction leading to acid buildup
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How do Medications and what Medications cause Resp Acidosis
Sedatives, narcotics, anesthetics They depress the respiratory center leading to hypoventilation --> increase in H+ then leads to CO2 narcosis
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Narcosis
stupor or unconsciousness due to medication impact
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How does Pneumonia cause Resp Acidosis
infection, irritants, and immobility lead to pneumonia which causes obstruction of airway passages leading to inadequate oxygenation from fluid accumulation COVID pneumonia leads to consolidation that decreases lung volume potentially even
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How does Atelectasis (lung collapse) cause Resp Acidosis
Excessive mucus collection with the collapse of alveolar sacs d/t mucus plugs, infectious drainage, or anesthetic medication causes decreases respiration or no exchange occurring
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How does Brain trauma cause Resp Acidosis
excessive pressure on the respiratory center or medulla oblongata depresses respiration ability/rate
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How does Emphysema cause Resp Acidosis
Loss of elasticity of alveoli sacs restricts air flow in and out, mostly out, leading to an increased CO2 level
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How does Asthma cause Resp Acidosis
spasms from allergens, irritants, or emotions can lead to smooth muscles of the bronchioles constricting causing decreased oxygenation and loss of CO2
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How does Bronchitis cause Resp Acidosis
Inflammation causes airway obstruction
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How does Pulmonary Edema cause Resp Acidosis
Extracellular accumulation of fluid in acute CHF causes disturbances in alveolar diffusion and perfusion (plus it is more difficult to expand the lungs)
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How does bronchiectasis cause Resp Acidosis
Bronchi become dilates from inflammation; destructive changes and weakness of the bronchi then occur which leads to decreased and hindered perfusion and less effective bronchiole walls this is a part of COPD
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Acute Etiologies of Respiratory Acidosis
Lung Disease - Acute pulmonary edema, aspiration, atelectasis, pneumothorax, severe pneumonia Depression of respiratory center - sedative or narcotic overdose, head injury
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Chronic Etiologies of Respiratory Acidosis
Chronic lung diseases - chronic bronchitis, asthma, cystic fibrosis, emphysema, COPD Chest wall and respiratory muscle issues - obesity, post op pain, high abdominal or thoracic incisions, abdominal distension from ascites or bowel obstruction (all of these prevent lung expansion)
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Why are acute problems particularly/especially dangerous for Respiratory Acidosis in comparison to chronic issues?
Acute happens quickly, but the compensatory mechanisms of the kidneys are very slow - therefore we may need to give outside help in the hospital because of the low speed With chronic, the kidneys have time to compensate, so while lyte balance may be abnormal, it can still be compensated for efficiently
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Things assessed and found for Respiratory Acidosis?
RR and depth drop headaches and mental status changes (ex: confusion, drowsiness, restlessness, visual disturbances) Diaphoresis cyanosis as hypoxia becomes mroe acute hyperkalemia rapid and irregular pulse leading to dysrhythmias and ventricular fibrillation The nervous system is depressed, much like Metabolic Acidosis in many ways
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___ leads to restlessness in people
hypoxemia
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Important group Manifestations of Respiratory Acidosis
Neural Cardiac Skin Respiratory
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Neural Manifestations of Respiratory Acidosis
Dilation of cerebral vessels and depression of neural function (to get oxygen to the brain) Feeling of fullness in the head headache weakness behavior changes like confusion, depression, paranoia, hallucinations tremors paralysis depressed DTR *neural depression from hypercalcemia
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Skin Manifestations of Resp Acidosis
warm and flushed from dilation of vessels to get more O2 and get rid of more CO2
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Cardiac Manifestation of Resp Acidosis
Tachycardia
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Respiratory Manifestations of Resp Acidosis
Dyspnea Cyanosis
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How does the kidney compensate for Resp Acidosis
Makes the urine more acidic by getting rid of acids (H+)
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Interventions for Respiratory Acidosis
Maintain patent airway improve ventilation and aeration based on the clinical manifestations Monitor for signs of respiratory distress administer O2 as prescribed place in semi fowlers unless contraindicated since they may have orthopnea encourage and assist client to turn cough and deep breath prepare to administer chest physiotherapy and postural drainage as prescribed encourage hydration to thin secretions unless excess fluid intake is contraindicated
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What needs to be reduced, monitored, avoided, and administered with Respiratory Acidosis
Reduce - restlessness by improving ventilation rather than by administering sedatives or narcotics Monitor - lyte values Avoid - tranquilizers, narcotics, hypnotics because they depress respiration Administer - antibiotics for infection as prescribed
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Treatment for Respiratory Acidosis
TCDB (turn cough deep breathing) every 2 hours IS - incentive spirometer use chest PT suctioning semi fowlers or orthopneic position encourage fluids (unless contraindicated) supplemental O2 to treat hypoxemia Monitor VS, ABGs, Serum K+ use bronchodilators give antibiotics for pneumonia administer sedatives with caution be prepared for intubation and mechanical ventilation
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Why do we need to be careful giving supplemental O2 to treat hypoxemia in respiratory acidosis for COPD patients?
it may cause a loss of hypoxemic stimulus to breath
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Definition of Respiratory Acidosis
Carbonic Acid (H2CO3) excess
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Cause of Respiratory Acidosis
Altered alveolar ventilation leading to retention of CO2
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Compensation for Respitaory Acidosis
Occurs in the kidneys Renal retention of HCO3- occurs slowly acidic urine is excreted
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If Metabolic Acid-Base issues are like an elevator, what are Respiratory Acid-Base issues like?
A see saw/ teeter totter because values move in opposite directions rather than together
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What is the respiratory and metabolic markers for Respiratory acid base disturbances and what is the marker we are most concerned with?
Resp - PaCO2 Metabolic - HCO3- We are most concerned with the PaCO2 since it is what is causing this issue (and the lungs)
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pH, PaCO2, and HCO3- values in uncompensated Respiratory Acidosis
pH << 7.35 (very low) PaCO2 > 45 (very high) HCO3- normal range (22-26)
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pH, PaCO2 and HCO3- values in partially compensated Respiratory Acidosis
pH < 7.35 (still low but slight increase/H+ decreases to make it more basic) PaCO2 - no change (slightly lower but not much) HCO3- >26 (increased)
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pH, PaCO2, and HCO3- values in compensated Respiratory Acidosis?
pH = low normal (7.35 ish) PaCO2 - not much change (slight decrease) HCO3- >> 26 (much higher)
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Respiratory Alkalosis
deficit of carbonic acid (H2CO3) and a decrease in H+ concentration results from the accumulation of base or from loss of acid without a comparable loss of base in body fluids
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What are the pH and CO2 levels like in Respiratory Alkalosis
pH >> 7.45 CO2 <35
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Causes for Respiratory Alkalosis Occurring
Conditions that cause over stimulation of the respiratory system: Hyperventilation Hysteria Overventilation by Mechanical Ventilators Conditions that increase metabolism such as Fever Pain or Brain Trauma Salicylates Hypoxia
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What happens calcium levels in Respiratory Alkalosis?
they drop (hypocalcemia) since calcium binds to plasma proteins to release H+ This leads to neuromuscular excitability and cardiac issues
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How does Hyperventilation cause Respiratory Alkalosis
rapid respiration causes blowing off of CO2 --> leads to a decrease in carbonic acids
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How does Hysteria cause Resp Alkalosis
often neurogenic in nature and related to psychoneurosis, but this conditions causes hyperventilation and excessive exhaling of CO2
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How does Over-Ventilation by mechanical ventilators cause Resp Alkalosis
administration of O2 and the depletion of CO2 can end up occurring and the patient may be hyperventilated by the mechanical ventilator
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What do we commonly do in regard to acid-base balance if a patient has cranial swelling?
We want to vasoconstrict to prevent too increased ICP so we might keep them slightly alkalotic on a ventilator to cause vasodilation
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What stimulates change in blood vessel tone?
pH O2 and CO2 levels
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What levels will cause vasoconstriction?
high pH, high O2, low CO2
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What levels will cause vasodilation?
low pH, low O2, high CO2
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How does Pain or Brain Trauma cause Resp Alkalosis
overstimulation of the resp center in the brain stem with a resultant carbonic acid deficit due to the changes
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How do Salicylates cause Resp Alkalosis?
They stimulate the respiratory center causing hyperventilation initially
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What is unique about acid base changes and Salicylates/Aspiring?
It will cause initial Resp Alkalosis by stimulating the respiratory center in the brain to lead to hyper ventilation Later on though it will cause Metabolic Acidosis as more acids are absorbed and then the lungs need to try and compensate
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How does hypoxia cause resp Alkalosis?
causes resp stimulation with resultant carbonic acid deficit
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Main Etiologies of Resp Alkalosis
Excessive Ventilation Excessive Mechanical Ventilation Pregnancy Hyperventilation during Labor and Delivery
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Examples of Excessive Ventilation leading to Resp Alkalosis?
Extreme Anxiety (most common) Hypoxemia Stimulation of Resp Center d/t high fever, early salicylate poisoning, encephalitis, CNS lesions affecting resp center, increased blood ammonia
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Why may excessive mechanical ventilation be deliberate?
to cause vasoconstriction to prevent cerebral edema
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Why does pregnancy and labor and delivery sometimes cause respiratory alkalosis
Pregnant women are more sensitive to CO2 and are stimulated to breath more L&D causes hyperventilation potentially when pushing
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What is seen on Assessment of Resp Alkalosis
Initially hyperventilation and resp stimulation will cause abnormal rapid respiation (Tachypnea), in an attempt to compensate, resp rate and depth will then go down! headache Mental status changes vertigo lightheadedness paresthesias as tingling of the fingers and toes Hypokalemia Hypocalcemia (lowers threshold) tetany convulsions
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Manifestations of Resp Alkalosis?
Cerebral Vasoconstriction from pH and O2 increases and CO2 decreases Neuromuscular Irritability Cardiovascular Dysrhythmias Hyperventilation (high RR and depth) Dry mouth GI function problems like pain
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Cerebral Vasoconstriction manifestations for Respiratory Alkalosis?
lightheadedness, syncope inability to concentrate blurred vision, vertigo loss of consciousness
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Neuromuscular Irritability manifestations for Respiratory Alkalosis
paresthesias tinnitus carpopedal spasms (Trousseaus sign) Spasms (chvostek)) tetany and twitching hyperactive DTR seizure, convulsion, coma
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Interventions for Respiratory Alkalosis
Emotional support and reassurance Maintain patent airway encourage appropriate breathing patterns assist with breathing techniques and apply breathing aids as prescribed voluntary holding of breath rebreathe exhaled CO2 rebreathing mask as prescribed CO2 breaths as perscribed provide cautious care with ventilator clients so that the client is not forced to take breaths too deeply or rapidly monitor lyte values administer meds as ordered prepare to administer calcium gluconate for tetany as prescribed
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Calcium Gluconate for tetany treats the underlying issue of ___
hypocalcemia
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Treatments for Respiratory Alkalosis
Monitor VV especially RR and Depth Encourage slow breathing and less deep breathing Breathe into paper bag use rebreather mask administer sedatives (FOR ANXIETY NOT RESP DEPRESSION) correct underlying cause (pain, anxiety) monitor ABGs adjust mechanical ventilator settings monitor serum K+ levels provide emotional support
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Definition of Respiratory Alkalosis
Carbonic Acid (H2CO3) deficit
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Cause of Respiratory Alkalosis
Hyperventilation leading to excessive elimination of CO2
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Compensation for Respiratory Alkalosis
Renal Excretion of HCO3-
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What does pH, PaCO2, and HCO3- looks like in uncompensated Resp Alkalosis
pH >> 7.45 (high, up) PaCO2 <35 (low, down) HCO3- Normal
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What does pH, PaCO2, and HCO3- looks like in partially compensated Resp Alkalosis
pH >7.45 (still up) PaCO2 No change (it is the problem) HCO3- <22 (lower now, down)
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What does pH, PaCO2, and HCO3- looks like in compensated Resp Alkalosis
pH High Normal (7.45) (this is now corrected) PaCO2 - no change - may be slightly higher but not by much since its not the compensator HCO3- <<22 (very low, down to correct pH)
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What to do before obtaining an Arterial Blood Gas Specimen?
Obtain VS Determine if there is an Arterial Line Performed Allen's Test Assess factors that may impact accuracy Assist with specimen draw by having a heparinized syringe Provide emotional support Apply pressure Label specimen and transport on ice to Lab Record clients Temp, and type of supplemental O2 that client is receiving on lab form
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What does an Allen Test do?
it determines the presence of collateral circulation
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What must be done to take an ABG Specimen after a suctioning or client activities?
Wait 20 minutes
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How long must you put pressure on an ABG site after getting a specimen?
apply pressure for 5 to 10 minutes (since anticoagulants)
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How to do an Allen's Test
1. Ask client to make a tight fist 2. Occlude ulnar and radial arteries 3. tell them to open their hands with occlusion still occurring 4. let go of one artery and check for color return 5. Do it again for the other side
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Normal H+ concentration
7.35-7.45
250
pH range that leads to acidosis
<7.35
251
pH range that leads to Alkalosis
>7.45
252
pH ranges that are deadly?
<6.8 or >7.8
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Normal PaCO2 level (partial pressure of CO2 in arterial blood)
35-45 mmHg
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A PaCO2 <35 indicates what
hypocapnia/hypocarbia and Respiratory Alkalosis
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A PaCO2 >45 indicates what
Hypercapnia/Hypercarbia and Respiratory Acidosis
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What is the normal PaO2 (partial pressure of O2 in arterial blood)
80-100 mmHg
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What does PaO2s of <80, <60, and <40 indicate?
<80 - mild hypoxemia <60 - moderate hypoxemia <40 - severe hypoxemia
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What is the normal HCO3- Concentration
22-26 mEq/L
259
% Hgb molecules saturated with O2 in a normal healthy person is..
>95%
260
HCO3- concentration <22 indicates?
Metabolic Acidosis
261
HCO3- concentration >26 indicates?
Metabolic Alkalosis
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What are the 3 important indicators on an ABG to look at
pH, PCO2, and HCO3- concentration
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Why is PaO2 not a good thing to know, but a non-used indicator for acid base imbalance on an ABG?
You can have normal PaCO2 and be hypoxemic or have normal O2 with Hypercarbia The levels depend on what is wrong with the person. Such as a COPD patient can get O2 in (normal) but cannot get CO2 out (Hypercarbia) So the level changes do not necessarily mean much for acid base
264
Major Forms of Acid Base Imbalances
Primary Imbalance Compensated Imbalances Combined or Mixed Imbalances
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Primary imbalance
Primary cause of the problem originates from an acute condition either respiratory or metabolic in origin
266
Compensated Imbalances
Respiratory imbalances compensated by the renal system Metabolic imbalances compensated by the respiratory system
267
Combined or Mixed Imbalances
involve both respiratory and metabolic imbalances at the same time (both acidosis, both alkalosis, or one acidosis and one alkalosis) ex: Salicylate Poisoning causes initial Respiratory Alkalosis followed by Metabolic Acidosis
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Steps for Analyzing ABG Results
1. Look at blood gas report 2. look at pH, is it up or down? if up then its alkalosis, if down then its acidosis 3. Look at PCO2, is it up or down? If it is an opposite response/direction to pH then it is d/t a respiratory imbalances. if not reflecting opposite response as pH then move to next step 4. Look at HCO3-, does it reflect a corresponding/same direction response with the pH? If so, then condition is metabolic imbalance 5. Keep in mind compensation has occurred if pH in 7.35 to 7.45 range (low and high ends), and if the pH is not in normal limits it is important to look at the resp or metab function indicators to determine if partially compensated (pH starting to go in normal direction) or uncompensated
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In Respiratory Acidosis, pH is ___ and PCO2 is ___
pH down, PCO2 up
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In Respiratory Alkalosis, pH is __ and PCO2 is ___
pH is up and PCO2 is down
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In Metabolic Acidosis, pH is ___ and HCO3 is ___
pH is down and HCO3 is down
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In Metabolic Alkalosis, pH is ___ and HCO3 is ___
pH is up and HCO3 is up
273
When compensation has occurred for Respiratory Acidosis and Alkalosis, what occurs to the ABG levels
compensation -pH is in normal limits partial compensation if HCO3 is abnormal Uncompensated if HCO3 is normal
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When compensation has occurred for Metabolic Acidosis and Alkalosis, what occurs to the ABG levels
Compensation - pH in normal limits Partial - PCO2 is abnormal Uncompensated - PCO2 is normal
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In acidosis, pH is ___
down
276
In alkalosis, pH is __
UP
277
The respiratory function indicator is the ___
PCO2
278
The metabolic function indicator is the ___
HCO3
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What sort of thing could cause a Mixed Imbalance of Metabolic and Respiratory Acidosis
Cardiopulmonary Arrest - the hypoxemia --> lactic acidosis and CO2 retention
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What sort of thing could cause a Mixed Imbalance of Metabolic and Respiratory Alkalosis
Vomiting during pregnancy - out of breath/hyperventilate + losing acids
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What sort of thing could cause a Mixed Imbalance of metabolic acidosis and respiratory alkalosis?
Salicylate/ASA poisoning - first Aspirin stimulates resp centers to cause respiratory alkalosis - second the metabolism of the aspirin causes acids leading to metabolic acidosis (which increases breathing yet again)