Fluid &

Electrolyte
Conference #1
Acid Base Imbalance

PREVIEW Questions
1. A RN is caring for a patient who has been
diagnosed with respiratory acidosis secondary to
hypoxia. When reviewing the patients lab data, which
value should the RN anticipate?
A. Increased pH
B. Increased PaCO2
C. Deceased HCO3
D. Decreased serum Ca level
ANS: B

2. A RN is caring for a patient who is experiencing 9/10

pain. VS are: BP 126/72, HR 90, RR 30. Which acid-base
imbalance should the RN associate with these signs
and symptoms?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
ANS: D

View Videotape:

Acid Base Imbalance:

Ups and Downs of PH
Follow along with notetaking guide

Adaptive Mechanisms
Chemical Buffer System
Respiratory System
Renal System

Chemical Buffer System

Primary regulator
Immediate action
Action

Acidosis

Alkalosis

o Chemicals that combine with acids and bases to minimize pH changes

Respiratory System
Secondary system
Responds within minutes
Action
o Elimination or retention of carbon dioxide

Renal System
Secondary system
Responds within 2-3 days
Action
o Secretion or reabsorption
of hydrogen and bicarbonate

Determining Acid Base

Imbalance
Arterial blood gas analysis
Performed to assess
o Acid base balance
o Need for oxygen therapy
o Change in oxygen therapy

ABG Interpretation
Normal Values:
o
o
o
o
o

pH 7.35 - 7.45
paCO2 35-45mm Hg
HCO3 24-30mEq/L
paO2 75-100mm Hg
O2 sat 92-100%

Nursing Responsibilities ABG

Indicate use of O2
Avoid change in O2 therapy 20 min. prior to
obtaining sample
Use heparinized syringe
Expel air bubbles
Place sample on ice
Pressure to artery for 5 minutes

3 Step Method Step 1

Look at the pH

o If > 7.45
Alkalosis

o If < 7.35
Acidosis

3 Step Method Step 2

Look at the pCO2

Respiratory conditions will have

a change in the PaCO2.

o Metabolic conditions:
No change
o Respiratory
conditions:
Opposite pattern
Please note:

o pCO2 and pH are inversely

related (or respiratory
opposite).
o An in one will cause an
in the other.

3 Step Method Step 3

Look at the HCO3

o Metabolic conditions will

have a change in HCO3

o Respiratory conditions:
No change
o Metabolic conditions:
Equal pattern
Please note:
o Both pH and HCO3 will
change in same (or
metabolic equal) direction.

Interpreting ABGs

pH
7.25
paCO2 62
HCO3 27

Step 1: Look at the pH

o Is the pH value above

7.45?
No

o Is the pH value below

7.35?
Yes

Step 2: Look at the paCO2

o Is there a change?
Yes

o Is it a respiratory
condition?
Yes

Step 3: Look at the HCO3

o Is there a change?
No
o Therefore, it is a
Respiratory
Condition
o Answer:
RESPIRATORY
ACIDOSIS

Think-Pair-Vote
Complete all 6 practice
ABG questions.
Divide into groups of 2
and compare answers.
As a class, VOTE
A=Respiratory Acidosis
B=Respiratory Alkalosis
C= Metabolic Acidosis
D= Metabolic Alkalosis

Interpreting ABGs
Practice Exercise
1

Acid Base Imbalance

pH

PaCO2

HCO3

7.17

52 mm/Hg

27 mEq/L

Respiratory Acidosis

7.68

30 mm/Hg

29 mEq/L

Respiratory Alkalosis

7.19

40 mm/Hg

20 mEq/L

Metabolic Acidosis

7.47

42 mm/Hg

38 mEq/L

Metabolic Alkalosis

7.51

28 mm/Hg

26 mEq/L

Respiratory Alkalosis

7.07

38 mm/Hg

18 mEq/L

Metabolic Acidosis

.
2
.
3
.
4
.
5
.
6
.

SUMMARY GUIDELINES FOR

ABG INTERPRETATION
1. Use assessment data from the client to assist you in
determining acid-base imbalances.
2. pH below 7.35 state of acidosis
pH above 7.45 state of alkalosis
3. CO2 is an acid
HCO3 is a base
4. Changes in CO2 Reflects a respiratory change
Changes in HCO3 Reflects a metabolic change

ACID BASE CHARTs

In groups of 2, place the appropriate cards in the
correct column.
Respiratory Acidosis

Respiratory Alkalosis

Metabolic Acidosis

Metabolic Alkalosis

Respiratory Acidosis

pH = <7.35 (acidosis) Etiology

o Shallow respirations
PaCO2 = >45
Pain
(carbonic excess)
Narcotics
HCO3 = normal
Atelectasis

Pneumonia
COPD
Asthma

Respiratory Acidosis
Assessment
o Shallow respirations
o Hypoxia
o Mental changes
Disorientation
Drowsiness
Dizziness

o Flushed, warm skin

o Weakness

Nursing Diagnosis
o Impaired Gas
Exchange
o Disturbed Thought
Processes
o Activity Intolerance
o Risk for Injury

Respiratory Acidosis

Interventions

o Assessment
o Treat cause of shallow respirations

Cough and deep breath

Ambulate
Treat pain
Reduce narcotic dose
O2

o Protect from injury

Respiratory Alkalosis
Etiology
o Fast respirations

Anxiety
Fever
Respiratory
infections
Pain

pH = >7.45 (alkalosis)
PaCO2 = <35
HCO3 = normal

Respiratory Alkalosis
Assessment
Lightheadedness
Confusion
Tachycardia
Numbness in
extremities
o SOB
o Anxiety
o
o
o
o

Nursing Diagnosis
o Ineffective Breathing
Pattern
o Disturbed Thought
Processes
o Risk for Injury

Respiratory Alkalosis
Interventions
o Assessment
o Treat underlying cause of hyperventilation

Encourage slow breathing

Breathing into paper bag
o Sedatives
o Protect from injury

Metabolic Acidosis
Etiology
o Loss of intestinal contents

Diarrhea
o Diabetes
o Renal failure

pH = <7.35 (acidosis)
PaCO2 = normal
HCO3 = <24

below waist = loss of base

Metabolic Acidosis
Assessment
o
o
o
o
o

Kussmaul respirations
Weakness
Nausea & vomiting
Abdominal pain
CNS symptoms

Headache
Confusion
Lethargy
Drowsiness

Nursing Diagnosis
o Deficient Fluid Volume
o Risk for Injury

Metabolic Acidosis
Interventions
o
o
o
o

Assessment
Treat underlying cause
Give IV sodium bicarbonate
Protect from injury

Metabolic Alkalosis
pH = >7.45 (alkalosis)
PaCO2 = normal
HCO3 = >30

Etiology
o Loss of gastric acid
contents

Vomiting
NG suction
o Diuretics

GI: above waist = loss of acid

Metabolic Alkalosis
Assessment

o CNS Symptoms
Dizziness
Confusion
Irritability

o
o
o
o

Tetany
Tingling in extremities
Tachycardia
Hypoventilation

Nursing Diagnosis

o Deficient Fluid Volume

o Risk for Injury

Metabolic Alkalosis
Interventions
o
o
o
o

Assessment
Treat underlying cause
IV fluid replacement
Protect from injury

Think-Pair-Share
With a partner, create
a concept map for the
each Acid-Base
Imbalance.
Roll the die to see what
pair gets to present
what acid-base
imbalance.
Use the chart on the
next slide as a guide.

Risk Factors

Nursing
Diagnosis

Signs and
Symptoms

Acid-Base
Imbalance

Outcomes

ABG Values

Nursing
Interventions

Review Questions
1. A RN is caring for a patient who has been
diagnosed with acute renal failure. The patients blood
pH is 7.15. When reviewing the patients lab data, what
other abnormalities should the RN anticipate? (Select
all that apply.)
A. Decreased HCO3 level.
B. Increased serum K level.
C. Increased serum Ca level.
D. Decreased PaO2.
E. Normal PaCO2.
ANS: A, B, E

2. An RN is caring for a patient in DKA (diabetic

ketoacidosis). Which ABG values would the RN
anticipate?
pH 7.18, pCO2 52, HCO3 27
pH 7.68, pCO30, HCO3 29
pH 7.21, pCO2 40, HCO3 20
pH 7.48, pCO2 42, HCO3 38
ANS: C

Complete Case Studies in class,

if time, otherwise use as postconference review.

Case Study #1
1. Identify two symptoms related to her acid-base
imbalance?
o Unresponsive
o Breathing deeply at 32/minute.
2. What Acid Base Imbalance does the ABG
indicate?
o Metabolic Acidosis

Case Study #1
continued
3. How are the clients lungs compensating for the
acid-base imbalance?
Deep rapid respirations (lungs are blowing off
excess acid)
4. What is the probable cause of acid-base
imbalance?
Loss of intestinal contents (diarrhea), means loss of
bicarbonate.

Case Study #1
continued
5. The physician orders IV fluids with sodium
bicarbonate. Why was this ordered?

To correct the acidosis though the

administration of a base (bicarbonate)

6. What are 2 high priority Nursing Diagnosis for F. E.?

Deficient fluid volume r/t diarrhea

Risk for injury r/t CNS symptoms (weakness and

confusion)

Case Study #1
continued
Deficient fluid volume r/t diarrhea
Outcomes:

CNS symptoms will resolve within one hour

Pulse, blood pressure, RR will remain within
normal limits throughout shift

Therapeutic Nursing Interventions:

Assess CNS for any signs of dizziness, confusion

or irritability; report changes
Assess P, BP, RR including any signs of
respiratory distress; report changes
Monitor I/Os q 2-4 hours
Administer ordered IV fluids

Case Study #1
continued

Risk for injury r/t CNS symptoms (weakness and confusion)

Outcomes:

No injuries or falls throughout shift

Explain ways to prevent injuries

Therapeutic Nursing Interventions:

Monitor for CNS symptoms (headache, confusion,

lethargy); report changes
Provide safety measures while the patient is dizzy,
such as bedside rails and assistance with basic
needs and ambulation
Complete a fall risk assessment and place client on
appropriate level of fall prevention
Monitor RR and status; report changes

Case Study # 2
1. What assessment indicates the client might have
an acid base imbalance?
o Lethargic
o Breathing shallowly at 8/min
2. What Acid Base Imbalance does the ABG
indicate?
o Respiratory acidosis

Case Study #2
continued

3.What is the probable cause of acid-base

imbalance?
Anesthesia has not worn off and/or too much
opioids
4. What independent nursing intervention(s) could
the RN anticipate?

Stimulate patient to wake up and take deep

breaths; turn, cough, deep breath

Case Study #2
continued
5. If these interventions are unsuccessful, what
physician order would the RN anticipate?

Naloxone

6. What are 2 high priority Nursing Diagnosis for J.

O.?
Impaired gas exchange r/t alveolar-capillary
membrane exchange

Risk for Injury r/t hypoxia

Case Study #2
continued
Impaired gas exchange r/t alveolar-capillary membrane exchange
Outcomes:

Therapeutic Nursing Interventions:

Demonstrate improved oxygenation by improved

O2 saturation of >92% within 1 hour
No sign of respiratory distress and improved RR

(12-20/minute) within 1 hour

Monitor RR, distress, and breathing pattern

frequently (q 15-30 minutes); report changes
Administered O2 to correct hypoxia.
Encourage client to turn, cough, and deep breathe
Monitor level of consciousness; report changes

Case Study #2
continued
Risk for injury r/t hypoxia
Outcomes:

No injuries or falls throughout shift

Explain ways to prevent injuries

Therapeutic Nursing Interventions:

Monitor RR, distress, and breathing pattern

frequently (q 15-30 minutes); report changes
Administer O2 to correct hypoxia
Provide safety measures while the patient is
lethargic, such as bedside rails and assistance with
basic needs and ambulation
Encourage client to turn, cough, and deep breathe
to correct hypoxia

Case Study #3

1. What assessment indicates the client might have an

acid base imbalance?
o Weakness
o Difficulty breathing
2. What Acid Base Imbalance does the ABG indicate?
o Metabolic Alkalosis

Case Study #3
continued
3. How are the clients lungs compensating for
the acid-base imbalance?
Hypoventilation (lungs are holding onto CO2)
4. What is the probable cause of acid-base
imbalance?

Loss of gastric contents from NGT suction,

means loss of acid

Loss of H+ ions secondary to diuretic

therapy (Lasix)

Case Study #3
continued
5. What are 2 high priority Nursing Diagnosis for J. D.?
Deficient fluid volume r/t NGT suction and
diuretic therapy

Risk for injury r/t CNS symptoms (dizziness)

Case Study #3
continued
Deficient fluid volume r/t NGT suction and diuretic therapy
Outcomes:

CNS symptoms will resolve within one hour

Pulse, blood pressure, RR will remain within
normal limits throughout shift

Therapeutic Nursing Interventions:

Assess CNS for any signs of dizziness, confusion

or irritability; report changes
Assess P, BP, RR including any signs of respiratory
distress; report changes
Monitor I/Os q 2-4 hours
Administer ordered IV fluids

Case Study #3
continued
Risk for injury r/t CNS symptoms (dizziness)
Outcomes:

No injuries or falls throughout shift

Explain ways to prevent injuries

Therapeutic Nursing Interventions:

Monitor for CNS excitability; report tetany-like

symptoms
Administer O2 to correct hypoxia
Provide safety measures while the patient is
dizzy, such as bedside rails and assistance with
basic needs and ambulation
Complete a fall risk assessment and place client
on appropriate level of fall prevention

Answers to Pre-Conference
Matching Exercise
4.
o A

5.
o B

6.
o F

1.
o C

2.
o E

3.
o D

Post-Conference Answers

ABG Interpretation
Worksheet
o
o
o
o
o
o
o
o
o

1.b
2.a
3.c
4.a
5.b
6.b
7.a
8.c
9.a

Acid Base Imbalance

Matching Activity
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis

Post-Conference Answers

Matching
Match the acid-base imbalances:
a.
b.
c.
d.
e.
f.
g.

4
3
2
1
4
3
1

Prolonged vomiting
Renal Failure
Response to anxiety, fear, and pain
Respiratory failure
Baking soda use as antacid
Diabetic ketosis
Sedative or opioid overuse
1.
2.
3.
4.

Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis

Nursing Interventions

ABG Changes

Clinical Examples

Respiratory
Acidosis

Low pH
High pCO2
Normal HCO3

Accumulation of CO2 most

often due to
Hypoventilation perhaps
after surgery
COPD
Narcotics
(hypoventilation)
Pneumonia
asthma
atelectasis

Treat underlying cause of

shallow respiration and
hypoventilation
Incentive spirometer
Early ambulation
Improve ventilation
Reduce narcotic dose
Give oxygen as indicated

Respiratory
Alkalosis

High pH
Low pCO2
Normal HCO3

Hyperventilation
Rapid respirations as with
anxiety
Fever
All eliminate lots of CO2

Treat underlying cause of

hyperventilation
Slow breathing sedatives
Have patient breathe into a
paper bag

Metabolic
Acidosis

Low pH
Low HCO3
Normal CO2

Loss of intestinal contents

(loss bicarb)
Diabetes ketoacidosis,
renal failure
Diarrhea
Intestinal fistulas
Lactic acidosis

Treat Underlying Cause

Give Na Bicarbonate

Metabolic
Alkalosis

High pH
High HCO3
Normal CO2

Loss of gastric contents

(loss of acid)
Vomiting, NG suctioning
Diuretic therapy from loss
of Hydrogen ion

Treat Underlying Cause

IVF replacement

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