Acid Base Balance ABB

Respiratory acidosis Interventions

1. Monitor for signs of respiratory distress. 2. Administer O2 as prescribed. 3. Place the client in a semi-Fowler's position. 4. Encourage and assist the client to turn, cough, and deep breathe. 5. Encourage hydration to thin secretions. 6. Reduce restlessness by improving ventilation rather than by administering tranquilizers, sedatives, or opioids, because these medications further depress respirations. 7. Prepare to administer respiratory treatments as prescribed; suction the client's airway, if necessary. 8. Prepare for endotracheal intubation and mechanical ventilation if CO2 levels rise above 50 mm Hg and signs of acute respiratory distress are present.

Metabolic Alkalosis Interventions

1. Monitor for signs of respiratory distress. 2. Prepare to administer medications and intravenous fluids as prescribed to promote the kidney excretion of bicarbonate. 3. Prepare to replace potassium as prescribed. Monitor the client experiencing excessive vomiting or the client with gastrointestinal suctioning for manifestations of metabolic alkalosis.

Respiratory alkalosis Interventions

1. Monitor for signs of respiratory distress. 2. Provide emotional support and reassurance to the client. 3. Encourage appropriate breathing patterns. 4. Assist with breathing techniques and breathing aids if needed and as prescribed (voluntary holding of breath, using a rebreathing mask, CO2 breaths with rebreathing into a paper bag). 5. Provide cautious care with ventilator clients so that they are not forced to take breaths too deeply or rapidly. 6. Prepare to administer calcium gluconate for tetany as prescribed.

Collection of an ABG specimen

1. Obtain vital signs. 2. Determine whether the client has an arterial line in place (allows for arterial blood sampling without further puncture to the client). 3. Perform the Allen's test to determine the presence of collateral circulation (see Priority Nursing Actions). 4. Assess factors that may affect the accuracy of the results, such as changes in the O2 settings, suctioning within the past 20 minutes, and the client's activities. 5. Provide emotional support to the client. 6. Assist with the specimen draw; prepare a heparinized syringe (if not already prepackaged). After obtaining a specimen, prevent any air entering the syringe, because air can cause a blood gas analysis alteration. 7. Apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes or for 10 minutes if the client is taking an anticoagulant to decrease the risk of hematoma. Reassess the radial pulse after removing the pressure. 8. Appropriately label the specimen and transport it on ice to the laboratory. 9. On the laboratory form, record the client's temperature and the type of supplemental O2 that the client is receiving.

Mixed acid-base disorders

1. Occurs when 2 or more disorders are present at the same time. 2. The pH will depend on the type and severity of the disorders involved, including any compensatory mechanisms at work, e.g., respiratory acidosis combined with metabolic acidosis will result in a greater decrease in pH than either imbalance occurring alone. 3. Example: Mixed alkalosis can occur if a client begins to hyperventilate due to postoperative pain (respiratory alkalosis) and is also losing acid due to gastric suctioning (metabolic alkalosis).

Potassium (K+)

1. Potassium plays an exchange role in maintaining acid-base balance. 2. The body changes the potassium level by drawing hydrogen ions into the cells or by pushing them out of the cells (potassium movement across cell membranes is facilitated by transcellular shifting in response to acid-base patterns). 3. The potassium level changes to compensate for hydrogen ion level changes. a. During acidosis, the body protects itself from the acidic state by moving hydrogen ions into the cells. Therefore, potassium moves out to make room for hydrogen ions and the potassium level increases. b. During alkalosis, the cells release hydrogen ions into the blood in an attempt to increase the acidity of the blood; this forces the potassium into the cells and potassium levels decrease. When the client experiences an acid-base imbalance, monitor the potassium level closely, because the potassium moves in or out of the cells in an attempt to maintain acid-base balance. The resulting hypokalemia or hyperkalemia predisposes the client to associated complications.

Respiratory acid-base imbalances

1. Remember that the respiratory function indicator is the Paco2. 2. In a respiratory imbalance, you will find an opposite relationship between the pH and the Paco2; in other words, the pH will be elevated with a decreased Paco2 (alkalosis) or the pH will be decreased with an elevated Paco2 (acidosis). 3. Look at the pH and the Paco2 to determine whether the condition is a respiratory problem. 4. Respiratory acidosis: The pH is decreased; the Paco2 is elevated. 5. Respiratory alkalosis: The pH is elevated; the Paco2 is decreased.

Metabolic acid-base imbalances

1. Remember, the metabolic function indicator is the bicarbonate ion (HCO3-). 2. In a metabolic imbalance, there is a corresponding relationship between the pH and the HCO3-; in other words, the pH will be elevated and HCO3- will be elevated (alkalosis), or the pH will be decreased and HCO3- will be decreased (acidosis). 3. Look at the pH and the HCO3- to determine whether the condition is a metabolic problem. 4. Metabolic acidosis: The pH is decreased; the HCO3- is decreased. 5. Metabolic alkalosis: The pH is elevated; the HCO3- is elevated.

PaCO2

35-45 mmHg -Elevated levels may indicate pneumonia, asthma, COPD, anesthesia effects or use of opioids (respiratory acidosis) -Decreased levels may indicate hyperventilation (respiratory alkalosis)

pH

7.35 - 7.45 Elevation may indicate metabolic or respiratory alkalosis Decreased levels may indicate metabolic or respiratory acidosis

When the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis?

An elevated pH, decreased PCO 2 In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO 2 level is low because carbon dioxide is lost through hyperventilation.

Clinical Manifestations of Metabolic Alkalosis

Clinical Manifestations of Alkalosis Metabolic (↑ pH, ↑ HCO3) -Neurological: Lethargy Irritability Confusion Headache -Cardiovascular: Low blood pressure Tachycardia Dysrhythmias -Gastrointestinal: Anorexia Nausea, vomiting -Neuromuscular: Tetany Tremors Tingling of extremities Muscle cramps, hypertonic muscles Seizures -Respiratory: Respiratory rate and depth decrease as a compensatory action by the lungs (hypoventilation)

Respiratory Alkalosis Manifestations

Clinical Manifestations of Alkalosis Respiratory (↑ pH, ↓ Paco2) -Neurological: Dizziness Lightheadedness Confusion Headache -Cardiovascular: Low blood pressure Tachycardia Dysrhythmias -Gastrointestinal: Nausea, vomiting, diarrhea Epigastric pain -Neuromuscular: Tetany Numbness Tingling of extremities Hyperreflexia Seizures -Respiratory: Respiratory rate and depth decrease as a compensatory action by the lungs. However, when there is a respiratory problem and lungs are unable to compensate, hyperventilation can occur.

DKA assessment (table 46.3)

Diabetic Ketoacidosis (DKA) -Onset: Sudden -Precipitating factors: Infection, Other stressors, Inadequate insulin dose -Manifestations: *Ketosis- Kussmaul's respiration, "fruity" breath, nausea, abdominal pain *Dehydration or electrolyte loss: Polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma -Laboratory Findings: *Serum glucose- > 300 mg/dL (> 16.7 mmol/L) *Osmolarity- Variable *Serum ketones- Positive at 1:2 dilution *Serum pH- < 7.35 *Serum HCO3- < 15 mEq/L (15 mmol/L) *Serum Na- Low, normal, or high *Serum K Normal; elevated with acidosis, decreases following hydration *BUN- > 20 mg/dL (> 7.1 mmol/L); elevated because of dehydration *Creatinine- > 1.5 mg/dL (> 132.5 mcmol/L); elevated because of dehydration *Urine ketones- Positive

DKA Treatment

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Hydration is the initial treatment in diabetic ketoacidosis.

DKA manifestations

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

Which signs and symptoms would the nurse include when teaching a client about ketoacidosis?

Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.

A client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3 L/min nasal cannula. Four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. Which intervention would the nurse implement at this time?

Discontinue or decrease the oxygen flow rate With emphysema, the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe but rather to lowered oxygen levels; therefore the nurse needs to lower the delivered oxygen to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicated a preserved hypercarbic drive. Clinical application of this theory requires more research. A confused client cannot answer questions about the confusion. There are no indications of increased respiratory secretions.

The nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations would the nurse expect?

Dry skin is a sign of dehydration in response to polyuria associated with the osmotic effect of an elevated serum glucose level. Abdominal pain is associated with diabetic ketoacidosis. In the absence of insulin, glucose cannot enter the cell or be converted to glycogen, so it remains in the blood. Breakdown of fats as an energy source causes an accumulation of ketones, which results in acidosis. The lungs, in an attempt to compensate for lowered pH, will blow off CO 2 (Kussmaul respirations). An absence of ketones in the urine indicates adequate production of glucose for energy. Insulin deficiency stimulates production of ketones as a by-product of fat oxidation for energy. Blood glucose level of less than 72 mg/dL (4 mmol/L) indicates hypoglycemia, not ketoacidosis.

Metabolic acidosis in babies

Effects of cold stress. When a newborn is stressed by cold, oxygen (O2) consumption increases and pulmonary and peripheral vasoconstriction occur, decreasing O2 uptake by the lungs and O2 delivery to the tissues; anaerobic glycolysis increases; and there is a decrease in partial pressure of oxygen (Po2) and pH.

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. A diagnosis of gastric ulcer is made. Which is the primary nursing concern?

Electrolyte imbalance The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death. Although pain is associated with gastric ulcers and requires intervention, it is not life threatening as an electrolyte imbalance would be. Although the risk for injury is a concern, it is not the priority. Although respirations may be shallow when the client is experiencing pain, this is not the priority.

Which interventions are appropriate for a child poisoned by ingestion of cleaning products?

Gastric lavage and activated charcoal would be appropriate for a child who has been poisoned by ingesting cleaning products. Hemodialysis is reserved for rare instances of severe acidosis from ingestion of toxic substances such as aspirin. Chelation therapy is used in heavy metal poisoning. Whole-bowel irrigation is most likely to be useful when a client has swallowed an object or is suffering from heavy metal poisoning; it carries a high risk of electrolyte imbalance.

Which early signs of respiratory acidosis would the nurse expect the client with a restrictive airway disease to exhibit?

Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

Which clinical sign would the nurse expect when assessing a school-age child with type 1 diabetes who is admitted with ketoacidosis?

Hyperpnea Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.

An adolescent with type 1 diabetes mellitus is admitted to the intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL (9.4 mmol/L). A continuous insulin infusion is started. Which adverse reaction to the infusion is most important for the nurse to monitor?

Hypokalemia Insulin moves potassium into the cells along with glucose, thus lowering the serum potassium level. Insulin does not lead to a reduced blood volume. Insulin does not directly alter the sodium levels. Insulin does not affect the calcium levels.

Malnutrition

Improper metabolism of nutrients causes fat catabolism, leading to an excess buildup of ketones and acids. (Metabolic Acidosis)

ABBpyramid

In acidosis, the pH is decreased. In alkalosis, the pH is elevated. The respiratory function indicator is the Paco2. The metabolic function indicator is the bicarbonate ion (HCO3-). If pH is in normal range, Fully compensated

Which statement explains why metabolic acidosis develops with kidney failure?

Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

Which insulin will the nurse prepare for the emergency treatment of ketoacidosis?

Insulin aspart is a rapid-acting insulin (within 10-20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; Insulin detemir is a long-acting insulin; for diabetic acidosis, the individual needs rapid-acting insulin.

An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?

Ketones The ketones produced excessively in diabetes are a byproduct of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.

A pathology report states a client's urinary calculus is composed of uric acid. Which food item would the nurse instruct the client to avoid?

Liver A low-purine diet controls the development of uric acid stones. Clients with uric acid stones should avoid foods high in purine, such as organ meats and extracts. The client should avoid milk if he or she had calcium stones, not uric acid stones. The client should avoid cheese or animal protein if he or she had cysteine stones, not uric acid stones. The client does not need to avoid vegetables when on a low-purine diet.

When caring for a client in late hypovolemic shock, which complication will the nurse anticipate?

Metabolic acidosis Decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock, metabolic or respiratory acidosis occurs. The Pco 2 level will increase in profound shock.

The nurse prepares an intravenous (IV) solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. Which condition will improve if the administration of lactated Ringer solution is effective?

Metabolic acidosis Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of IV lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of IV lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of IV lactated Ringer solution.

A critically ill 5-year-old child exhibits Kussmaul respirations. Which would the nurse suspect may be causing an increasing acid-base imbalance?

Metabolic acidosis caused by a concentration of cations in body fluids Metabolic acidosis results from an excess concentration of hydrogen cations. The kidneys cannot convert ammonium to ammonia, and there is inadequate base bicarbonate to maintain an appropriate acid-base balance. With Kussmaul respirations there is an excess of hydrogen ions, the opposite of an excess of base bicarbonate. Carbonic acid blown off as CO 2 is a compensatory mechanism to counter the present metabolic acidosis. There is an excess of hydrogen ions from a metabolic problem rather than an excess of carbonic acid resulting from retained CO 2.

metabolic alkalosis are caused by

Metabolic alkalosis results from a dysfunction of metabolism that causes an increased amount of available base solution in the blood or a decrease in available acids in the blood

respiratory status assessment

Monitor the client's respiratory status closely. *During acidosis, the respiratory rate and depth increase in an attempt to exhale acids. *During alkalosis, the respiratory rate and depth decrease; CO2 is retained to neutralize and decrease the strength of excess bicarbonate.

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis?

Monitoring breathing status The nursing priority for preventing complications when caring for clients with respiratory acidosis is to monitor breathing status hourly and intervening changes. Assessing the nail beds for cyanosis, which is usually a late finding in acidosis, is not a priority intervention. Listening to breath sounds and assessing how easily air moves into and out of the lungs can be a second priority intervention. Checking muscle contractions in the neck region is a later priority intervention.

Which independent nursing action would be included in the plan of care for a client after an episode of ketoacidosis?

Monitoring for signs of hypoglycemia resulting from treatment During treatment for acidosis, hypoglycemia may develop; careful observation for this complication will be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine.

The nurse adds 20 mEq of potassium chloride to the intravenous solution of a client with diabetic ketoacidosis. Which purpose would this medication serve?

Prevents hypokalemia Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with replacement fluids, is needed to prevent hypokalemia. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. There is no mention of dysrhythmias in the scenario; they are not a universal finding in diabetic ketoacidosis (and are commonly absent) and hypokalemia does not always cause these to occur.

Which postoperative feeding regimen is most appropriate for the infant who had surgery to correct hypertrophic pyloric stenosis?

Regular formula feeding within 24 hours of the surgery An initial feeding of glucose and electrolytes in water or breast milk is given 4 to 6 hours after surgery. Once clear fluids are being retained, formula feedings are begun within 24 hours. Thickened formula 24 hours after surgery is not necessary. Regular formula should be started within 24 hours after surgery in an attempt to gradually return the infant to a full feeding schedule. Withholding feedings for the first 24 hours and providing additional glucose feedings as desired after the first 24 hours are not necessary.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

Respiratory acidosis The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

Respiratory Alkalosis S/S

Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

Metabolic acidosis in kids

Severely burned children are at increased risk for fluid and heat loss, dehydration, and metabolic acidosis compared with adults. The major concerns when a child is having diarrhea are the risk of dehydration, the loss of fluid and electrolytes, and the development of metabolic acidosis. Orthostatic vital signs are helpful in assessing hydration status. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate.

An infant undergoes surgery for the repair of a myelomeningocele and develops metabolic acidosis, accompanied by decreased urine output. Which medication would the nurse anticipate providing teaching for?

Sodium Lactate Sodium lactate is converted to sodium bicarbonate; it helps correct the sodium deficiency and the metabolic acidosis. Normal saline solution results in the combination of the chloride with the hydrogen ion, intensifying the acidosis. Albumin is a colloid found in blood plasma; it is not used in the treatment of metabolic acidosis. Potassium is not administered until urine function has been restored.

A client with severe hyperkalemia develops acidosis. Immediate administration of which medication can help prevent a life-threatening crisis?

Sodium bicarbonate decreases the potassium level if acidosis is present. Infusion of sodium bicarbonate moves the pH toward alkalinity and thereby increases cellular uptake of potassium. Administration of glucose and insulin can promote movement of potassium into cells, but glucose alone doesn't have this effect. Loop diuretics such as furosemide are useful for mild to moderate hyperkalemia, but when the severity of the condition has progressed to a stage of acidosis, other medications are indicated. Epinephrine is an emergency medication, but it is not indicated for this purpose.

Hypoxia

Stimulates the respiratory center in the brainstem, which causes an increase in the respiratory rate in order to increase oxygen (O2); this causes hyperventilation, which results in a decrease in the CO2 level.

Respiratory Alkalosis analysis

The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalytic condition, the pH is elevated. The values identified indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred.

Carbonic acid-bicarbonate system

a. Primary buffer system in the body b. The system maintains a pH of 7.4 with a ratio of 20 parts bicarbonate (HCO3-) to 1 part carbonic acid (H2CO3) (Fig. 9-1). c. This ratio (20:1) determines the hydrogen ion concentration of body fluid. d. Carbonic acid concentration is controlled by the excretion of CO2 by the lungs; the rate and depth of respiration change in response to changes in the CO2. e. The kidneys control the bicarbonate concentration and selectively retain or excrete bicarbonate in response to bodily needs.

Interventions for DKA

a. Restore circulating blood volume, and protect against cerebral, coronary, or renal hypoperfusion. b. Correct dehydration with IV infusions of 0.9% or 0.45% saline as prescribed. c. Correct hyperglycemia with IV regular insulin administration as prescribed. d. Monitor vital signs, urine output, and mental status closely. e. Correct acidosis and electrolyte imbalances as prescribed. f. Administer oxygen as prescribed. g. Monitor blood glucose level frequently. h. Monitor potassium level closely, because when the child receives insulin to reduce the blood glucose level, the serum potassium level changes; if the potassium level decreases, potassium replacement may be required. i. The child should be voiding adequately before administering potassium; if the child does not have an adequate output, hyperkalemia may result. j. Monitor the child closely for signs of fluid overload. k. IV dextrose is added as prescribed when the blood glucose reaches an appropriate level. l. Treat the cause of hyperglycemia.

Hemoglobin system

a. System maintains acid-base balance by a process called chloride shift. b. Chloride shifts in and out of the cells in response to the level of oxygen (O2) in the blood. c. For each chloride ion that leaves a red blood cell, a bicarbonate ion enters. d. For each chloride ion that enters a red blood cell, a bicarbonate ion leaves.

Metabolic acidosis (renal insufficiency)

a. The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis. b. Administer alkalizers such as sodium bicarbonate as prescribed. c. Note that clients with CKD adjust to low bicarbonate levels and as a result do not become acutely ill.

DKA Insulin Administration

a. Use short-duration insulin only. b. An IV bolus dose of short-duration regular U-100 insulin (usually 5 to 10 units) may be prescribed before a continuous infusion is begun. c. The prescribed IV dose of insulin for continuous infusion is prepared in 0.9% or 0.45% NS as prescribed. d. Always place the insulin infusion on an IV infusion controller. e. Insulin is infused continuously until subcutaneous administration resumes, to prevent a rebound of the blood glucose level. f. Monitor vital signs. g. Monitor urinary output and monitor for signs of fluid overload. h. Monitor potassium and glucose levels and for signs of increased intracranial pressure. i. The potassium level will fall rapidly within the first hour of treatment as the dehydration and the acidosis are treated. j. Potassium is administered intravenously in a diluted solution as prescribed; ensure adequate renal function before administering potassium.

Urinalysis in DKA

presence of ketones may indicate impending ketoacidosis

Causes of Respiratory Alkalosis (assessment)

results from conditions that cause overstimulation of the respiratory system ▪ Fever: Causes increased metabolism, resulting in overstimulation of the respiratory system. ▪ Hyperventilation: Rapid respirations cause the blowing off of carbon dioxide (CO2), leading to a decrease in carbonic acid. ▪ Hypoxia: Stimulates the respiratory center in the brainstem, which causes an increase in the respiratory rate in order to increase oxygen (O2); this causes hyperventilation, which results in a decrease in the CO2 level. ▪ Overventilation by mechanical ventilators: The administration of O2 and the depletion of CO2 can occur from mechanical ventilation, causing the client to be hyperventilated. ▪ Pain: Overstimulation of the respiratory center in the brainstem results in a carbonic acid deficit. ▪ Severe anxiety and hysteria: Often is neurogenic and related to a psychoneurosis; however, this condition leads to vigorous breathing and excessive exhaling of CO2.

Imbalances

***Respiratory acid-base imbalances*** 1. Remember that the respiratory function indicator is the Paco2. 2. In a respiratory imbalance, you will find an opposite relationship between the pH and the Paco2; in other words, the pH will be elevated with a decreased Paco2 (alkalosis) or the pH will be decreased with an elevated Paco2 (acidosis). 3. Look at the pH and the Paco2 to determine whether the condition is a respiratory problem. 4. Respiratory acidosis: The pH is decreased; the Paco2 is elevated. 5. Respiratory alkalosis: The pH is elevated; the Paco2 is decreased. ***Metabolic acid-base imbalances*** 1. Remember, the metabolic function indicator is the bicarbonate ion (HCO3-). 2. In a metabolic imbalance, there is a corresponding relationship between the pH and the HCO3-; in other words, the pH will be elevated and HCO3- will be elevated (alkalosis), or the pH will be decreased and HCO3- will be decreased (acidosis). 3. Look at the pH and the HCO3- to determine whether the condition is a metabolic problem. 4. Metabolic acidosis: The pH is decreased; the HCO3- is decreased. 5. Metabolic alkalosis: The pH is elevated; the HCO3- is elevated.

Movement of potassium in response to changes in the extracellular fluid hydrogen ion concentration.

-Under normal conditions, the intracellular potassium content is much greater than that of the extracellular fluid. The concentration of hydrogen ions is low in both compartments. -In acidosis, the extracellular hydrogen ions move into the intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions leave the cell, creating a relative hyperkalemia. -In alkalosis, more hydrogen ions are present in the intracellular fluid than in the extracellular fluid. Hydrogen ions move from the intracellular fluid into the extracellular fluid. To keep the intracellular fluid electrically neutral, potassium ions move from the extracellular fluid into the intracellular fluid, creating a relative hypokalemia.

Metabolic Acidosis Interventions

1. Monitor for signs of respiratory distress. 2. Monitor intake and output and assist with fluid and electrolyte replacement as prescribed. 3. Prepare to administer solutions intravenously as prescribed to increase the buffer base. 4. Initiate seizure precautions.

Acids

1. Produced as end products of metabolism 2. Contain hydrogen ions 3. Are hydrogen ion donors; they give up hydrogen ions to neutralize or decrease the strength of an acid or to form a weaker base.

Insulin deficiency leading to ketoacidosis

Insulin deficiency --> Impaired metabolism of fats proteins and carbs --> Hyperglycemia --> Fatigue, hunger, weight loss --> Polyuria, cellular starvation --> Ketones produced in response to starvation, can not nourish cell because of absence of insulin --> Ketoacidosis

Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock?

Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

Selective regulation of bicarbonate occurs in the kidneys.

a. The kidneys restore bicarbonate by excreting hydrogen ions and retaining bicarbonate ions. b. Excess hydrogen ions are excreted in the urine in the form of phosphoric acid. c. The alteration of certain amino acids in the renal tubules results in a diffusion of ammonia into the kidneys; the ammonia combines with excess hydrogen ions and is excreted in the urine.

Diabetic ketoacidosis (DKA)

a. life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. b. The main clinical manifestations include hyperglycemia, dehydration, ketosis, and acidosis

insulin

should not be withheld during illness, infection, or stress, because hyperglycemia and ketoacidosis can result.

Buffers

1. Buffers are the fastest-acting regulatory system. 2. Buffers provide immediate protection against changes in hydrogen ion concentration in the extracellular fluid. 3. Buffers are reactors that function only to keep the pH within the narrow limits of stability when too much acid or base is released into the system, and buffers absorb or release hydrogen ions as needed. 4. Buffers serve as a transport mechanism that carries excess hydrogen ions to the lungs. 5. Once the primary buffer systems react, they are consumed, leaving the body less able to withstand further stress until the buffers are replaced.

Bases

1. Contain no hydrogen ions 2. Are hydrogen ion acceptors; they accept hydrogen+ ions from acids to neutralize or decrease the strength of a base or to form a weaker acid. 3. Normal serum levels of bicarbonate (HCO3-) are 21 to 28 mEq/L (21 to 28 mmol/L).

Performing the Allen's Test Before Radial Artery Puncture

1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries simultaneously. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar artery while compressing the radial artery. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings.

DKA Metabolic Acidosis Interventions

1. Give insulin as prescribed to hasten the movement of glucose into the cells, thereby decreasing the concurrent ketosis. 2. When glucose is being properly metabolized, the body will stop converting fats to glucose. 3. Monitor for circulatory collapse caused by polyuria, which may result from the hyperglycemic state; osmotic diuresis may lead to extracellular volume deficit.

Interventions in kidney disease (Metabolic acidosis)

1. Dialysis may be necessary to remove protein and waste products, thereby lessening the acidotic state. 2. A diet low in protein and high in calories decreases the amount of protein waste products, which in turn lessens the acidosis.

PO2

80-100 mmHg Elevations may indicate excessive O2 administration Decreased levels may be indicative asthma, anemia, respiratory distress syndrome, cancer of the lungs, or other causes of hypoxia

types of respiration

-Cheyne-Stokes respirations: rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. -Neurogenic hyperventilation: a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. -Ataxic respirations: are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. -Apneustic respirations: are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

Compensation

1. Compensation refers to the body processes that occur to counterbalance the acid-base disturbance. 2. When full compensation has occurred, the pH is within normal limits.

Kidneys

1. The kidneys provide a more inclusive corrective response to acid-base disturbances than other corrective mechanisms, even though the renal excretion of acids and alkalis occurs more slowly. 2. Compensation requires a few hours to several days; however, the compensation is more thorough and selective than that of other regulators, such as the buffer systems and lungs. 3. During acidosis, the pH decreases and excess hydrogen ions are secreted into the tubules and combine with buffers for excretion in the urine. 4. During alkalosis, the pH increases and excess bicarbonate ions move into the tubules, combine with sodium, and are excreted in the urine. 5. Selective regulation of bicarbonate occurs in the kidneys.

Lungs

1. The lungs are the second defense of the body; they interact with the buffer system to maintain acid-base balance. 2. During acidosis, the pH decreases and the respiratory rate and depth increase in an attempt to exhale acids. The carbonic acid created by the neutralizing action of bicarbonate can be carried to the lungs, where it is reduced to CO2 and water and is exhaled; thus, hydrogen ions are inactivated and exhaled. 3. During alkalosis, the pH increases and the respiratory rate and depth decrease; CO2 is retained and carbonic acid increases to neutralize and decrease the strength of excess bicarbonate. 4. The action of the lungs is reversible in controlling an excess or deficit. 5. The lungs can hold hydrogen ions until the deficit is corrected or can inactivate hydrogen ions, changing the ions to water molecules to be exhaled along with CO2, thus correcting the excess. 6. The process of correcting a deficit or excess takes 10 to 30 seconds to complete. 7. The lungs are capable of inactivating only hydrogen ions carried by carbonic acid; excess hydrogen ions created by other mechanisms must be excreted by the kidneys. Monitor the client's respiratory status closely. During acidosis, the respiratory rate and depth increase in an attempt to exhale acids. During alkalosis, the respiratory rate and depth decrease; CO2 is retained to neutralize and decrease the strength of excess bicarbonate.

Hydrogen ions

1. Vital to life because hydrogen ions determine the pH of the body, which must be maintained in a narrow range 2. Expressed as pH; the pH scale is determined by the number of hydrogen ions and goes from 1 to 14; 7 is considered neutral. 3. The number of hydrogen ions in the body fluid determines whether it is acid (acidosis), alkaline (alkalosis), or neutral. 4. The pH of body fluid is between 7.35 and 7.45.

Respiratory acidosis caused by

1. is caused by primary defects in the function of the lungs or changes in normal respiratory patterns. 2. Any condition that causes an obstruction of the airway leading to hypoventilation or depresses the respiratory system can cause respiratory acidosis.

HCO3

21-28 mEq/L -Elevated levels may indicate respiratory acidosis as compensation for primary metabolic alkalosis -Decreased level may indicate respiratory alkalosis as compensation for primary metabolic acidosis

Which information would the nurse include in a teaching plan about what causes diabetic acidosis?

A breakdown of fat stores for energy In the absence of insulin, which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a byproduct of fat metabolism, accumulate, causing metabolic acidosis (pH less than 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.

Respiratory acidosis

A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2. Monitor the client's respiratory status closely. During acidosis, the respiratory rate and depth increase in an attempt to exhale acids.

metabolic acidosis treatment

Administer IV fluids; sodium bicarbonate may be prescribed.

Diabetes mellitus or diabetic ketoacidosis

An insufficient supply of insulin causes increased fat metabolism, leading to an excess accumulation of ketones or other acids; the bicarbonate then ends up being depleted. (Metabolic Acidosis)

Labs for diabetic ketoacidosis

Below normal serum sodium

Intervention for respiratory alkalosis

Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

Regulatory Systems for Hydrogen Ion Concentration in the Blood

Buffers Primary buffer systems in extracellular fluid Lungs Kidneys Potassium (K+) (The underlying cause of an acid-base imbalance needs to be identified and the cause needs to be treated to resolve the imbalance.)

High-fat diet

Causes a much too rapid accumulation of the waste products of fat metabolism, leading to a buildup of ketones and acids. (Metabolic Acidosis)

Excessive ingestion of acetylsalicylic acid

Causes an increase in the hydrogen ion concentration. (Metabolic Acidosis)

DKA in kids

Children may need to be admitted directly to the pediatric intensive care unit because of the manifestations of diabetic ketoacidosis, which may be the initial occurrence leading to diagnosis of diabetes mellitus.

Clinical Manifestations of Respiratory Acidosis

Clinical Manifestations of Acidosis Respiratory (↓ pH, ↑ Paco2) -Neurological: Lethargy Confusion Dizziness Headache Coma -Cardiovascular: Decreased blood pressure Dysrhythmias (related to hyperkalemia from compensation) Warm, flushed skin (related to peripheral vasodilation) -Gastrointestinal: No significant findings -Neuromuscular: Seizures -Respiratory: The respiratory rate and depth increase in an attempt to exhale acids. However, when there is a respiratory problem and the lungs are unable to compensate, hypoventilation with hypoxia occurs.

Kassmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. (DKA)

Which clinical findings support the diagnosis of diabetic ketoacidosis (DKA)?

Deep respirations and a fruity odor to the breath are classic signs of DKA, because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremors, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.

Respiratory Alkalosis Lungs

During alkalosis, the respiratory rate and depth decrease; CO2 is retained to neutralize and decrease the strength of excess bicarbonate.

acid-base imbalance, monitor

For any acid-base imbalance, it is important to closely monitor the client's level of consciousness, use protective measures to ensure safety, and monitor electrolyte levels and follow-up ABG test results. If the client has a condition that causes an obstruction of the airway or depresses the respiratory system, monitor the client for respiratory acidosis.

Primary buffer systems in extracellular fluid

Hemoglobin system Plasma protein system Carbonic acid-bicarbonate system Phosphate buffer system

Which laboratory value supports the presence of diabetic ketoacidosis in a client with type 1 diabetes?

Increased blood urea nitrogen levels With diabetic ketoacidosis, blood urea nitrogen level generally is increased because of dehydration. With diabetic ketoacidosis, the serum glucose levels are generally greater than 300 mg/dL (16.7 mmol/L). The calcium level is unrelated to diabetic ketoacidosis. Serum bicarbonate levels are less than 15 mEq/L (15 mmol/L).

Renal insufficiency, acute kidney injury, or chronic kidney disease

Increased waste products of protein metabolism are retained; acids increase, and bicarbonate is unable to maintain acid-base balance. (Metabolic Acidosis)

Severe diarrhea

Intestinal and pancreatic secretions are normally alkaline; therefore, excessive loss of base leads to acidosis. (Metabolic Acidosis)

Severe anxiety/panic attack

Physical symptoms are caused by stimulation of the sympathetic nervous system (e.g., headache, nausea, dizziness, sleep disturbances), increased tremors, pounding heart rate, and hyperventilation.

Which common cause of diabetic ketoacidosis would the nurse consider when caring for a postoperative client with diabetes?

Presence of infection Infection increases the body's metabolic rate, and insulin is not available for increased demands. Although emotional stress will affect glucose levels, diabetic ketoacidosis will rarely result. Increased insulin dose will lead to insulin coma (hypoglycemia) if diet is not increased as well. Inadequate food intake will result in insulin coma.

Hyperventilation

Rapid respirations cause the blowing off of carbon dioxide (CO2), leading to a decrease in carbonic acid.

hypoventilation

Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis.

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?

The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.

Which factor may have precipitated ketoacidosis in a client with type 1 diabetes who has been adhering to a prescribed insulin regimen?

Upper respiratory infection Infection is a stress that increases adrenocortical secretion of glucocorticoids, which will increase the blood glucose level. Exercise requires glucose for muscle contraction, which decreases the blood glucose level. Decreased food intake will decrease the blood glucose level. Working the night shift will have no effect on the blood glucose level.

Respiratory acidosis s/s

When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias.

Insufficient metabolism of carbohydrates

When the oxygen supply is not sufficient for the metabolism of carbohydrates, lactic acid is produced and lactic acidosis results. (Metabolic Acidosis)

Diabetic ketoacidosis

a. Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. b. Diabetic ketoacidosis is a life-threatening condition. c. Hyperglycemia that progresses to metabolic acidosis occurs. d. Diabetic ketoacidosis develops over several hours to days. e. The blood glucose level is greater than 300 mg/dL (greater than 17.14 mmol/L), and urine and serum ketone tests are positive.

DKA Interventions

a. Restore circulating blood volume and protect against cerebral, coronary, and renal hypoperfusion. b. Treat dehydration with rapid IV infusions of 0.9% or 0.45% NS as prescribed; dextrose is added to IV fluids when the blood glucose level reaches 250 to 300 mg/dL. (Too rapid administration of IV fluids; use of the incorrect types of IV fluids, particularly hypotonic solutions; and correcting the blood glucose level too rapidly can lead to cerebral edema.) c. Treat hyperglycemia with insulin administered intravenously as prescribed. d. Correct electrolyte imbalances (potassium level may be elevated as a result of dehydration and acidosis). e. Monitor potassium level closely, because when the client receives treatment for the dehydration and acidosis, the serum potassium level will decrease and potassium replacement may be required. f. Cardiac monitoring should be in place for the client with DKA due to risks associated with abnormal serum potassium levels.

Phosphate buffer system

a. System is present in cells and body fluids and is especially active in the kidneys. b. System acts like bicarbonate and neutralizes excess hydrogen ions.

Plasma protein system

a. The system functions along with the liver to vary the amount of hydrogen ions in the chemical structure of plasma proteins. b. Plasma proteins have the ability to attract or release hydrogen ions.

Alkalosis S/S (CNS)

central nervous system activity increases manifests: paresthesias positive Chvostek sign positive Trousseau sign anxiety and irritability

ketoacidosis

condition that increases fluid loss causing Hypertonic dehydration (fluid volume deficit)

mechanical ventilator

delivers the preset tidal volume when the client initiates a breath while allowing the client to control the rate of breathing. If the client's spontaneous ventilatory rate increases, the ventilator continues to deliver a preset tidal volume with each breath, which may cause hyperventilation and respiratory alkalosis.

Metabolic Alkalosis

high pH, high HCO3 A deficit of carbonic acid and a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids.

respiratory alkalosis

high pH, low CO2 hyperventilation A deficit of carbonic acid and a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids.

Manifestations of diabetic ketoacidosis

include signs of hyperglycemia, Kussmaul's respirations, acetone (fruity) breath odor, increasing lethargy, and decreasing level of consciousness.

clinical manifestations of respiratory alkalosis

lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities.

Respiratory Acidosis

low pH, high CO2 The total concentration of buffer base is lower than normal, with a relative increase in hydrogen ion concentration; thus, a greater number of hydrogen ions is circulating in the blood than can be absorbed by the buffer system.

Metabolic acidosis manifestations

low pH, low HCO3 -Neuro: Lethargy, confusion, dizziness, headache, coma -Cardiovascular: decreased BP, dysrhythmias (related to hyperkalemia compensation), cold clammy skin -GI: Nausea, vomiting, diarrhea, abdominal pain -Neuromuscular: muscle weakness -Respiratory: Kassmaul's respirations (Deep, rapid respirations-compensatory action by the lungs)

metabolic acidosis

low pH, low HCO3 Abnormal condition of high hydrogen ion concentration in the extracellular fluid caused by either a primary increase in hydrogen ions or a decrease in bicarbonate.

DKA

more prevalent in those with schizophrenia, and it may be due to interactions with psychotropic medications.

Causes of Respiratory Acidosis

▪ Asthma: Spasms resulting from allergens, irritants, or emotions cause the smooth muscles of the bronchioles to constrict, resulting in ineffective gas exchange. ▪ Atelectasis: Excessive mucus collection, with the collapse of alveolar sacs caused by mucous plugs, infectious drainage, or anesthetic medications, results in ineffective gas exchange. ▪ Brain trauma: Excessive pressure on the respiratory center or medulla oblongata depresses respirations. ▪ Bronchiectasis: Bronchi become dilated as a result of inflammation, and destructive changes and weakness in the walls of the bronchi occur. ▪ Bronchitis: Inflammation causes airway obstruction, resulting in inadequate gas exchange. ▪ Central nervous system depressants: Depressants such as sedatives, opioids, and anesthetics depress the respiratory center, leading to hypoventilation (excessive sedation from medications may require reversal by opioid antagonist medications); carbon dioxide (CO2) is retained and the hydrogen ion concentration increases. ▪ Emphysema and chronic obstructive pulmonary disease: Loss of elasticity of alveolar sacs restricts air flow in and out, primarily out, leading to an increased CO2 level. ▪ Hypoventilation: CO2 is retained and the hydrogen ion concentration increases, leading to the acidotic state; carbonic acid is retained and the pH decreases. ▪ Pneumonia: Excess mucus production and lung congestion cause airway obstruction, resulting in inadequate gas exchange. ▪ Pulmonary edema: Extracellular accumulation of fluid in pulmonary tissue causes disturbances in alveolar diffusion and perfusion. ▪ Pulmonary emboli: Emboli cause obstruction in a pulmonary artery resulting in airway obstruction and inadequate gas exchange.

Causes of Metabolic Acidosis

▪ Diabetes mellitus or diabetic ketoacidosis ▪ Excessive ingestion of acetylsalicylic acid ▪ High-fat diet ▪ Insufficient metabolism of carbohydrates ▪ Malnutrition ▪ Renal insufficiency, acute kidney injury, or chronic kidney disease ▪ Severe diarrhea

metabolic alkalosis causes

▪ Diuretics: The loss of hydrogen ions and chloride from diuresis causes a compensatory increase in the amount of bicarbonate in the blood. ▪ Excessive vomiting or gastrointestinal suctioning: Leads to an excessive loss of hydrochloric acid. ▪ Hyperaldosteronism: Increased renal tubular reabsorption of sodium occurs, with the resultant loss of hydrogen ions. ▪ Ingestion of and/or infusion of excess sodium bicarbonate: Causes an increase in the amount of base in the blood. ▪ Massive transfusion of whole blood: The citrate anticoagulant used for the storage of blood is metabolized to bicarbonate.

DKA Client Education: Guidelines During Illness

▪ Take insulin or oral antidiabetic medications as prescribed. ▪ Determine the blood glucose level and test the urine for ketones every 3 to 4 hours. ▪ If the usual meal plan cannot be followed, substitute soft foods 6 to 8 times a day. ▪ If vomiting, diarrhea, or fever occurs, consume liquids every 30 to 60 minutes to prevent dehydration and to provide calories. ▪ Notify the primary health care provider if vomiting, diarrhea, or fever persists; if blood glucose levels are higher than 250 to 300 mg/dL; when ketonuria is present for more than 24 hours; when unable to take food or fluids for a period of 4 hours; or when illness persists for more than 2 days.