Running head: ACID BASE BALANCE

The Concept of Acid Base Balance

Amy J. Herrington
Ferris State University

ACID BASE BALANCE

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,

ACID BASE BALANCE

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

ACID BASE BALANCE

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.

ACID BASE BALANCE

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.

ACID BASE BALANCE

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.

ACID BASE BALANCE

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