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ACID-BASE BALANCE

METABOLIC ACIDOSIS
Attempts to return pH to normal by increasing rate and depth of respirations. Risk Factors Acute lactic acidosis due to shock or cardiac arrest Type 1 DM at risk for developing DKA Acute/chronic renal failure Diarrhea, intestinal suction, or abdominal fistulas Pathophysiology Three mechanisms can cause metabolic acidosis: accumulation of metabolic acids, excess loss of bicarbonate, or an increase in chloride levels. Manifestations Weakness and fatigue, headache, and general malaise. Anorexia, N/V, and abd pain LOC declines, leading to stupor and coma Cardiac dysrhythmias develop, and cardiac arrest may occur Skin is often warm and flushed Compensatory mechanism: Kussmaul respirations (labored, deep, rapid); may complain of SOB or dyspnea. Medications Bicarbonate may be given if pH is <7.2 to reduce the effects of acidosis on cardiac function. Tx for DKA includes IV insulin and fluid replacement. Alcohol ketoacidosis is tx c saline solutions and glucose. Nursing Dx and Interventions Decreased Cardiac Output Monitor VS and ECG pattern for changes characteristic of hyperkalemia. Risk for Fluid Volume Excess Monitor heart and lung sounds Assess urine output hourly Risk for Injury Monitor neurologic function

METABOLIC ALKALOSIS
Attempts to return pH to normal by slowing the respiratory rate. Risk Factors Hospitalization, hypokalemia, and tx c alkalinizing agents (bicarb). Manifestations and Complications Numbness and tingling around mouth, fingers, and toes. Dizziness, Trousseaus sign, and muscle spasm. Medications KCl and NaCl In severe cases, dilute hydrochloric acid or ammonium chloride may be administered. Nursing Dx and Interventions Risk for Impaired Gas Exchange

ACID-BASE BALANCE
Place in semi-fowlers or fowlers as tolerated. Schedule nursing care activities to allow rest periods. Fluid Volume Deficit Assess VS q4h

RESPIRATORY ACIDOSIS
Kidneys compensate by retaining bicarbonate Risk Factors Pneumonia, COPD, excess narcotic analgesics, airway obstruction, or neuromuscular disease Manifestations In acute: hypercapnia, headache, blurred vision, irritability, mental cloudiness, decreased LOC, skin warm and flushed, elevated pulse rate. In chronic: weakness and a dull headache, sleep disturbances, daytime sleepiness, impaired memory, personality changes. Medications Bronchodilator drugs and antibiotics If excess narcotics caused it, use drugs to reverse the effects such as naloxone. Respiratory Support Pts c severe respiratory acidosis and hypoxemia may require intubation and mechanical ventilation. Pts c chronic respiratory acidosis, oxygen is administered cautiously to avoid carbon dioxide narcosis. Nursing Dx and Interventions Impaired Gas Exchange Frequently assess resp status and LOC Administer oxygen as ordered. Ineffective Airway Clearance Encourage pt c chronic to use pursed lips breathing Encourage fluid intake up to 3,000 mL/day as tolerated or allowed.

RESPIRATORY ALKALOSIS
Risk Factors Anxiety disorders and mechanical ventilation Pathophysiology Anxiety-based hyperventilation is most common cause. Other causes: high fever, hypoxia, gram-negative bacteremia, and thyrotoxicosis. Manifestations Lightheadedness, panic and difficulty concentrating Circumoral and distal extremity paresthesias, tremors Positive Chvosteks and Trousseaus signs Tinnitus, a sensation of chest tightness, and palpitations Seizures and loss of consciousness may occur

ACID-BASE BALANCE
Medications A sedative or antianxiety agent Additional drugs to correct underlying problem may be ordered. Respiratory Therapy Anxiety-related: breathe slowly or breathe into paper bag/rebreather mask. If excessive ventilation by a mechanical ventilator, ventilator settings are adjusted. When hypoxia is underlying cause, oxygen is administered. Nursing Dx and Interventions Ineffective Breathing Pattern Reassure the pt that he/she is not having a heart attack and that manifestations will resolve when breathing returns to normal.

ACID-BASE BALANCE

CAUSES OF METABOLIC ACIDOSIS Lactic acidosis Ketoacidosis r/t diabetes, starvation, or alcoholism Salicylate toxicity Renal failure Diarrhea, ileostomy drainage, intestinal fistula Biliary or pancreatic fistulas NaCl IV solutions Renal tubular acidosis Carbonic anhydrase inhibitors

MANIFESTATIONS OF METABOLIC ACIDOSIS Anorexia N/V Abd pain Weakness, fatigue General malaise, decreasing LOC Dysrhythmias, bradycardia Warm, flushed skin

CAUSES OF METABOLIC ALKALOSIS Vomiting, gastric suction Hypokalemia Bicarbonate of soda Excess bicarb administration

MANIFESTATIONS OF METABOLIC ALKALOSIS Confusion Decreasing LOC Hyperreflexia, tetany Dysrhythmias, hypotension Seizures Respiratory failure

CAUSES OF RESPIRATORY ACIDOSIS Acute: pulmonary edema, pneumonia, acute asthma, opiate overdose, foreign body aspiration, chest trauma. Chronic: COPD, CF, multiple sclerosis, other neuromuscular diseases, stroke.

MANIFESTATIONS OF RESPIRATORY ACIDOSIS Acute: headache, warm flushed skin, blurred vision, irritability, altered mental status, decreasing LOC, cardiac arrest. Chronic: weakness, dull headache, sleep disturbances c daytime sleepiness, impaired memory, personality changes. MANIFESTATIONS OF RESPIRATORY ALKALOSIS Dizziness Numbness and tingling around mouth, hands, and feet Palpitations Dyspnea, chest tightness Anxiety/panic attack Tremors, tetany Seizures, loss of consciousness

CAUSES OF RESPIRATORY ALKALOSIS Anxiety-induced hyperventilation Fever Early Salicylate intoxication Hyperventilation c mechanical ventilator

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