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Acid-base balance plays an integral role in maintaining homeostasis in the body. Physical assessment of an individual with acid-base imbalance can be challenging. Treatment focuses on the underlying cause of the imbalance.
Acid-base balance plays an integral role in maintaining homeostasis in the body. Physical assessment of an individual with acid-base imbalance can be challenging. Treatment focuses on the underlying cause of the imbalance.
Acid-base balance plays an integral role in maintaining homeostasis in the body. Physical assessment of an individual with acid-base imbalance can be challenging. Treatment focuses on the underlying cause of the imbalance.
2 Abstract Acid-base balance plays an integral role in maintaining homeostasis in the body. An overview of acid-base balance in the human body is reviewed to aid in understanding physical assessment, pathophysiological factors and pharmacotherapies. Physical assessment of an individual with acid-base imbalance can be challenging due to the limited clinical manifestations. There are a few key clinical manifestations including respiratory alterations and decreased level of consciousness. Various underlying conditions may result in acid-base imbalances including chronic obstructive pulmonary disorders, prolonged diarrhea and diabetic ketoacidosis. The process of each is reviewed. Treatment of acid-base imbalance focuses on the underlying cause of the imbalance and customarily involves respiratory support and/or fluid and electrolyte support. Keywords: acid-base imbalance, acidosis, alkalosis
ACID BASE BALANCE
3 The Concept of Acid Base Balance The dynamic functions of the body to maintain homeostasis are a continuous process. If this process is disturbed, various manifestations in the body can result. Acid-base balance is one process in our body that must remain balanced to maintain homeostasis. Cellular and organ function impairment can result from imbalance, preventing ideal function of the body (Giddens, 2013). If an imbalance is not resolved, it can result in death. The purpose of this paper is to examine how acid-base balance is related to the professional nursing practice. This will include a review of physical assessment, pathophysiological considerations and pharmacotherapeutic principles. Overview of Acid-Base Balance The definition for acid-base balance is the process of regulating the pH, bicarbonate concentration, and partial pressure of carbon dioxide of body fluids (Giddens, 2013). Some key terms that are essential to understanding acid-base balance include acid, base, pH and bicarbonate (HCO3). Acids are substances that are responsible for releasing hydrogen ions, while bases are substances responsible for taking up hydrogen ions. Bicarbonate is the most important base in our body and plays a significant role in acid-base balance. pH measures the acidity of a solution, the normal range in our body is 7.35-7.45. A pH that is low is acidic whereas a pH that is high is alkaline. There are three processes in which acid-base balance is maintained: acid production, acid buffering, and acid excretion (Edwards, 2008; Giddens, 2013). Acid production is continuously occurring through cellular metabolism. During cellular metabolism, carbonic acid and metabolic acids are produced. The human body has natural buffers in the body fluids that aid in acid-base balance. These buffers are pairs of acids and bases, which will either take up or release hydrogen
ACID BASE BALANCE
4 ions allowing the pH in the body to remain normal. Acid excretion involves removing acid from the body, this can happen through the lungs or kidneys. There are three categories of acid-base balance: optimal acid-base balance, acidosis, and alkalosis (Giddens, 2012). When there are not underlying conditions causing imbalances in the body and the buffer system is not overwhelmed, the body is in optimal acid-base balance. Signifying acid production is balanced with acid excretion. When acid excretion is less than acid production or acid intake, too much acid remains in body fluids causing acidosis (Giddens, 2012). This can be caused by either too much carbonic acid or metabolic acid. Carbonic acid is excreted in gaseous form from the lungs. If there is too much carbonic acid in the body, acidosis is called respiratory acidosis. Metabolic acid is excreted through the kidneys. Excess metabolic acid in the body is termed metabolic acidosis. Alkalosis is a term used when there is too little acid in body fluids. The rate of acid excretion is greater than acid production in alkalosis or the body is retaining too much bicarbonate (Giddens, 2012). As aforementioned, our lungs are responsible for excretion of carbonic acid. Too little carbonic acid is termed respiratory alkalosis. Metabolic alkalosis is too little metabolic acid in the body fluids. To maintain optimal acid-base balance, the body must work in perfect harmony. Acid production must match acid excretion and the buffering system must maintain balance. When an imbalance does occur, it is almost always related to an underlying condition or a fluid and electrolyte imbalance (Edwards, 2008). Physical Assessment Skills Physical assessment of patients with an unknown acid-base balance can be challenging. Imbalances are nearly always related to an underlying condition (Ball et al., 2015; Giddens,
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5 2013). The signs and symptoms of acid-base balance are often vague and can be associated with other conditions. For example, decreased level of consciousness is common among individuals with acid-base imbalance. Due to the signs and symptoms of acid-base balance not always being clearly evident, it is important to consider the patient signs and symptoms in perspective of current health issues (Giddens, 2013). The nurse will focus on the respiratory system, renal system or any other condition that could lead to an imbalance. Other considerations could be recent history of excessive vomiting or diarrhea, use of new medications, or change in diet. It is important to examine the underlying cause of the imbalance. The underlying cause will need to be identified and treated to resolve the imbalance and maintain optimal acid-base balance. For example, excessive vomiting can result in loss of acid leading to metabolic alkalosis or excessive diarrhea can result in loss of bases leading to metabolic acidosis. Patients starting to new diets, such a high fat, low carbohydrate diets could cause starvation ketoacidosis in a normally, healthy individual. There are common clinical findings for each acid-base imbalance. Though the clinical findings are different from imbalance to imbalance, decreased level of consciousness is common among all four imbalances (Giddens, 2013). Due to decreasing level of consciousness, safety will be a primary concern for each patient. The clinical findings associated with acid-base imbalance are related to impaired cellular and organ function resulting from the imbalance (Ball et al., 2015). Hypoventilation is a key clinical finding with respiratory acidosis. Other findings common to respiratory acidosis include headache, cardiac dysrhythmias, and potentially
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6 hypotension (Giddens, 2013). When assessing a patient with respiratory acidosis, frequent cardiac and respiratory assessments are necessary, as well as cardiac monitoring and vital signs. Patients with metabolic acidosis may present with abdominal pain, nausea and vomiting, cardiac dysrhythmias, and hyperventilation (Giddens, 2013). Hyperventilation is a compensatory mechanism; it is the bodys attempt at reaching balance again. Metabolic acidosis assessment should include frequent respiratory and cardiac assessment, gastrointestinal assessment, cardiac monitoring, and frequent vital signs. In addition, it is essential to manage vomiting to prevent further disruption to the bodys balance. Hyperventilation will be found with respiratory alkalosis. Other clinical findings may include diaphoresis, cardiac dysrhythmias, perioral and finger numbness and tingling, and lightheadedness (Giddens, 2013). Again, respiratory and cardiac assessment will be necessary, as well as cardiac monitoring with frequent vital signs. Patient safety will be concern related to lightheadedness. Monitoring of intake and output will be necessary to maintain fluid balance that could be impaired by diaphoresis. Metabolic alkalosis can cause excitation, perioral and digital numbness and tingling, signs of volume depletion, and potentially hypokalemia (Giddens, 2013). Hypokalemia is a common cause of metabolic alkalosis. This highlights the need to assess electrolyte labs. Hypoventilation may also be evident, in the bodys attempt to balance the body A conclusive test for acid-base imbalance is arterial blood gas (ABG) measurement. ABG measurements reveal much information about acid-base balance in the body fluids, including pH level, partial pressure of carbon dioxide in the arterial blood, bicarbonate concentration, and base excess. The measurements of ABG allow for diagnosing a patient with an acid-base imbalance and can guide treatment.
ACID BASE BALANCE
7 Pathophysiological Factors The human body is continuously producing acids through cellular metabolism. At times, the buffering system can become overwhelmed resulting in acidosis. Diabetic ketoacidosis is a type of metabolic acidosis. In diabetic ketoacidosis, a lack of insulin and an excess of glucagon result in abnormal cellular metabolism. The abnormal cellular metabolism results in production of ketoacids at a higher rate than the kidneys can excrete the ketoacids. The buildup of ketoacids results in metabolic acidosis. Prolonged diarrhea can lead to metabolic acidosis, as well. Metabolic acidosis occurs through prolonged diarrhea due to an altered acid buffering. Prolonged diarrhea causes bicarbonate loss when excess alkaline intestinal substances are excreted. As bicarbonate is lost, acid buffering is altered and too much metabolic acid results, causing metabolic acidosis. Chronic obstructive pulmonary disease (COPD) can lead to respiratory acidosis as a result of altered acid excretion (Bruno & Valenti, 2012). As the cells in the body metabolize oxygen, carbonic acid is produced. Patients with COPD are unable to effectively excrete carbonic acid. The cells continue to produce carbonic acid as a product of respiration, but the lungs cannot excrete enough carbonic acid due to obstructed airways caused by excessive mucus and structural changes (Giddens, 2013). This results in respiratory acidosis and overtime these patients may develop chronic respiratory acidosis. Hyperventilation can cause excessive excretion of carbonic acid resulting in respiratory alkalosis. Hyperventilation is usually caused by an underlying condition such as pain or anxiety and are usually short term concerns (Giddens, 2013). The aim of treatment will be to treat the underlying concern and return breathing to a normal pattern resulting in a stable carbonic acid excretion.
ACID BASE BALANCE
8 An abnormal shift of hydrogen ions into the cells can cause metabolic alkalosis. The most common cause of metabolic alkalosis is hypokalemia. Hypokalemia can result from the use of diuretics, vomiting, or folic acid deficiency (Mayo Clinic, 2014). Hypokalemia causes potassium ions to leave the cells, resulting in hydrogen ions shifting to enter the cells to sustain an electrical charge balance (Giddens, 2013). The shift of hydrogen ions into the cells results in too little acid in the blood, called metabolic alkalosis. Critical Thinking Hyperventilation is a clinical manifestation of metabolic acidosis. As the metabolic acidosis imbalance increases and metabolic acids continue to buildup, the body attempts to compensate by excreting another form of acid. The respiratory system increases the depth and rate of respirations in an attempt to excrete more carbonic acid. The excretion of carbonic acid is the bodys attempt at maintaining homeostasis. Hypoventilation is a clinical manifestation/cause of respiratory acidosis. Respiratory acidosis can result from disorders of the brain or respiratory system that impair breathing or effective gas exchange. Hypoventilation results in hypoxemia, as well as hypercapnia (the lungs are not excreting adequate amounts of carbonic acid). Another clinical manifestation of respiratory acidosis is decreased level of consciousness. The decreased level of consciousness is caused by both the hypoxemia and hypercapnia. Metabolic acidosis is common in individuals with renal failure. The kidneys are responsible for excretion of metabolic acids. When kidney function is impaired, as it is in renal failure, metabolic acids cannot be adequately excreted resulting in metabolic acidosis and the need for dialysis. As metabolic acids build up, the individual will develop nausea, vomiting, poor appetite, and fatigue.
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9 Most clinical manifestations of acid-base imbalance are related to the underlying condition. Clinical manifestations that are present early on in the imbalance process often are overlooked, as symptoms of the underlying condition are more severe. If acid-base balance goes untreated or is not adequately treated, clinical manifestations can become more evident as the imbalance becomes more severe. Pharmacotherapeutic Principles Acid-base imbalance requires treatment. If left untreated, acid-base imbalance can be fatal. Treatment of acid-base imbalance must be collaborative, focusing not only on returning balance but managing the underlying condition. Treating the underlying cause may return the imbalance to a normal state (Giddens, 2013). Managing acid-base imbalance will primarily be focused on treating the underlying cause. If the imbalance is respiratory related, respiratory support will likely be needed. The amount of respiratory support can vary from oxygen therapy via nasal cannula to airway management and ventilator support. Treating the cause of hyperventilation, such as pain or anxiety, can result in stabilization of acid-base balance quickly. Metabolic acid-base imbalances are often treated with fluid and electrolyte support (Giddens, 2013). This could involve potassium administration for individuals in a metabolic alkalosis state or insulin and fluids to treat diabetic ketoacidosis. When acid excretion is impaired due to renal disease, dialysis can be utilized as treatment to manage metabolic acidosis. Intravenous sodium bicarbonate can be used in instances when the pH is very low, however it is used with caution (Giddens, 2013). Use of intravenous sodium bicarbonate can lead to fluid volume excess, delay of renal excretion of acids, or lead to metabolic alkalosis.
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10 The best treatment for acid-base balance is to prevent imbalance. This will involve patient education for individuals with risk factors. For example, diabetes education and management for individuals with diabetes mellitus to prevent ketoacidosis is a prevention strategy. Encouraging safe weight loss techniques to prevent starvation ketoacidosis is another preventative measure. Conclusion Acid-base balance is a complex process. Even a minimal alteration in acid-base balance can result in imbalance and impairment of cellular and organ function. If acid-base imbalance is not recognized and treated, it can be fatal. It is essential that nursing professionals understand the skills needed to assess for imbalance, as well as the physiological changes that can lead to imbalance.
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11 References Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidels Guide to Physical Examination (8th ed.). St. Louis, MO: Mosby-Elsevier. Bruno, C. M. & Valenti, M. (2012). Acid-base disorders in patients with chronic obstructive disease: A pathophysiological review. Journal of Biomedicine and Biotechnology, 2012, 1-8. Edwards, S. L. (2008). Pathophysiology of acid base balance: The theory of practice relationship. Intensive and Critical Care Nursing, 24, p. 28-40. Giddens, J. F. (2013). Concepts for Nursing Practice. St. Louis, MO: Mosby-Elsevier. Mayo Clinic. (2014). Low potassium. Retrieved from http://www.mayoclinic.org/symptoms/low-potassium/basics/causes/sym-20050632