Perfecting your

acid-base
balancing act
How to detect and correct acid-base disorders
By Michelle Fournier, MN, RN, CCRN

WHEN IT COMES TO ACIDS AND

BASES, the difference between life
and death is balance. The bodys
acid-base balance depends on some
delicately balanced chemical reactions. The hydrogen ion (H+)
affects pH, and pH regulation influences the speed of cellular reactions, cell function, cell permeability, and the very integrity of cell
structure.
When an imbalance develops,
you can detect it quickly by knowing how to assess your patient and
interpret arterial blood gas (ABG)
values. And you can restore the
balance by targeting your interventions to the specific acid-base disorder you find.

Basics of acid-base balance

Before assessing a patients acidbase balance, you need to understand how the H+ affects acids,
bases, and pH.
An acid is a substance that can
donate H+ to a base. Examples
include hydrochloric acid, nitric
acid, ammonium ion, lactic acid,
acetic acid, and carbonic acid
(H2CO3).
A base is a substance that can
accept or bind H+. Examples include ammonia, lactate, acetate,
and bicarbonate (HCO3-).
pH reflects the overall H+ con-

centration in body fluids. The

higher the number of H+ in the
blood, the lower the pH; and the
lower the number of H+, the
higher the pH.
A solution containing more base
than acid has fewer H+ and a higher pH. A solution containing more
acid than base has more H+ and a
lower pH. The pH of water (H2O),
7.4, is considered neutral.
The pH of blood is slightly alkaline and has a normal range of 7.35
to 7.45. For normal enzyme and
cell function and normal metabolism, the bloods pH must remain in
this narrow range. If the blood is
acidic, the force of cardiac contractions diminishes. If the blood is alkaline, neuromuscular function becomes impaired. A blood pH below
6.8 or above 7.8 is usually fatal.

CE

1.8 contact
hours

LEARNING OBJECTIVES
1. Identify four disturbances of acidbase balance.
2. Discuss nursing interventions for
patients with acid-base
imbalances.
3. Describe how to interpret arterial
blood gas values.

pH also reflects the balance between the percentage of H+ and the

percentage of HCO3-. Generally, pH
is maintained at a ratio of 20 parts
HCO3- to 1 part H2CO3. (See Fast
facts on acid-base balance.)

Regulating acid-base balance

Three regulating systems maintain
the bodys pH: chemical buffers,
the respiratory system, and the renal system.
Chemical buffers, substances that
combine with excess acids or
bases, act immediately to maintain
pH and are the bodys most efficient pH-balancing force. These
buffers appear in blood, intracellular fluid, and extracellular fluid. The
main chemical buffers are bicarbonate, phosphate, and protein.
The second line of defense
against acid-base imbalances is the
respiratory system. The lungs regulate carbon dioxide (CO2) in the
blood, which combines with H2O
to form H2CO3. Chemoreceptors in
the brain sense pH changes and
vary the rate and depth of respirations to regulate CO2 levels. Faster,
deeper breathing eliminates CO2
from the lungs, and less H2CO3 is
formed, so pH rises. Alternatively,
slower, shallower breathing reduces
CO2 excretion, so pH falls.
The partial pressure of arterial
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17

Fast facts on acid-base balance

The more hydrogen ion (H+) in the blood, the lower the pH.
The less H+ in the blood, the higher the pH.
When partial pressure of arterial carbon dioxide (PaCO2) rises, pH falls.
When PaCO2 falls, pH rises.
In respiratory acid-base disorders, pH and PaCO2 move in opposite directions.
Bicarbonate (HCO3-) remains normal until compensation occurs.
In metabolic acid-base disorders, pH and HCO3- move in the same direction.
PaCO2 remains normal until compensation occurs.

CO2 (PaCO2) level reflects the level

of CO2 in the blood. Normal PaCO2
is 35 to 45 mm Hg. A higher CO2
level indicates hypoventilation from
shallow breathing. A lower PaCO2
level indicates hyperventilation. The
respiratory system, which can handle twice as many acids and bases
as the buffer systems, responds in
minutes, but compensation is temporary. Long-term adjustments require the renal system.
The renal system maintains acidbase balance by absorbing or excreting acids and bases. Also, the
kidneys can produce HCO3- to replenish lost supplies. The normal
HCO3- level is 22 to 26 mEq/L.
When blood is acidic, the kidneys
reabsorb HCO3- and excrete H+.
When blood is alkaline, the kidneys
excrete HCO3- and retain H+. Unlike
the lungs, the kidneys may take 24
hours before starting to restore normal pH.

Compensating for imbalances

The two disorders of acid-base balance are acidosis and alkalosis. In
acidosis, the blood has too much
acid (or too little base). In alkalosis,
the blood has too much base (or
too little acid). The cause of these
acid-base disorders is either respiratory or metabolic. If the respiratory
system is responsible, youll detect
it by reviewing PaCO2 or serum CO2
levels. If the metabolic system is responsible, youll detect it by reviewing serum HCO3- levels.
To regain acid-base balance,
the lungs may respond to a metabolic disorder, and the kidneys
18

American Nurse Today

may respond to a respiratory disorder. If pH remains abnormal,

the respiratory or metabolic response is called partial compensation. If the pH returns to normal,
the response is called complete
compensation. Keep in mind that
the respiratory or renal system
will never overcompensate. A
compensatory mechanism wont
make an acidotic patient alkalotic
or an alkalotic patient acidotic.

Understanding acidosis and

alkalosis
Caused by hypoventilation, respiratory acidosis develops when the
lungs dont adequately eliminate
CO2. The hypoventilation may result from diseases that severely affect the lungs, diseases of the
nerves and muscles of the chest
that impair the mechanics of
breathing, or drugs that slow a patients respirations. Respiratory acidosis causes a pH below 7.35 and a
PaCO2 above 45 mm Hg. HCO3- is
normal. (See Causes of acid-base
imbalances at a glance.)
Caused by hyperventilation, respiratory alkalosis develops when
the lungs eliminate too much CO2.
The most common cause of hyperventilation is anxiety. Respiratory
alkalosis causes a pH above 7.45
and a PaCO2 below 35 mm Hg.
HCO3- is normal.
Metabolic acidosis may result
from:
ingestion of an acidic substance
or a substance that can be metabolized to an acid
production of excess acid

Volume 4, Number 1

an inability of the kidneys to excrete normal amounts of acid

a loss of base.
Metabolic acidosis causes a
HCO3- below 22 mEq/L and a pH
below 7.35. PaCO2 is normal.
Metabolic alkalosis may result
from:
loss of stomach acid
an excess loss of sodium or
potassium
a renal loss of H+
a gain of base.
Metabolic alkalosis causes a
HCO3- above 26 mEq/L and a pH
above 7.45. PaCO2 is normal.

ABG analysis in four steps

ABG analysis is a diagnostic test
that helps you assess the effectiveness of your patients ventilation
and acid-base balance. The results
also help you monitor your patients response to treatment. ABG
analysis provides several test results, but only three are essential
for evaluating acid-base balance:
pH, PaCO2, and HCO3-. Memorize
these normal values for adults:
pH: 7.35 to 7.45
PaCO2: 35 to 45 mm Hg
HCO3-: 22 to 26 mEq/L.
Remember, the key to interpreting ABG values at the bedside is
consistency. Follow these four simple steps every time:
Step 1. List the results for the
three essential values: pH, PaCO2,
and HCO3-.
Step 2. Compare them with
normal values. If a result indicates excessive acid, write an
A next to it. If a result indicates excessive base, write a
B next to it. And if a result indicates a normal balance, write
an N next to it. The pH will
tell you whether the patient
has acidosis or alkalosis.
Step 3. If youve written the same
letter for two or three results, circle them. If you circle pH and
PaCO2, your patient has a respiratory disorder. If you circle pH
and HCO3-, your patient has a

Causes of acid-base imbalances at a glance

Listed below are specific causes of the four acid-base disorders.
Respiratory acidosis
The primary problem is alveolar hypoventilation (increased partial pressure of
arterial carbon dioxide [PaCO2]), which may result from:
acute pulmonary edema
central nervous system depression
chronic respiratory disease
disorders of respiratory muscles and chest wall
inadequate mechanical ventilation
oversedation
severe pulmonary infections.
Respiratory alkalosis
The primary problem is alveolar hyperventilation (decreased PaCO2), which may
result from:
anxiety
early sepsis
excessive mechanical ventilation
exercise
fear
heart failure
hypermetabolic states such as fever
hypoxemia
liver failure
pain.
Metabolic acidosis
The primary problems are increased acid and decreased bicarbonate (HCO3-).
Increased acid results from:
anaerobic metabolism
hyperalimentation
ketoacidosis
renal failure
salicylate intoxication
severe sepsis
starvation.
Decreased HCO3- results from:
anhydrase inhibitors such as acetazolamide
diarrhea
hyperkalemia
intestinal fistulas.
Metabolic alkalosis
The primary problems are increased HCO3- and decreased acid. Increased HCO3results from:
excessive ingestion of antacids
excessive use of bicarbonate
lactate administration in dialysis.
Decreased acid results from:
hyperaldosteronism
hypokalemia
hypochloremia
loop or thiazide diuretics
nasogastric suction
steroids
vomiting.

metabolic disorder. If you circle

all three results, your patient has
a combined respiratory and
metabolic acid-base disturbance.
(See Interpreting arterial blood
gas values.)
Step 4. To check for compensation, look at the result you didnt circle. If it has moved from
the normal value in the opposite direction of those circled,
compensation is occurring. If
the value remains in the normal
range, no compensation has occurred. Once compensation is
complete, the pH will return to
normal.
Keep in mind that several factors
can make ABG results inaccurate:
using improper technique to
draw the arterial blood sample
drawing venous blood instead of
arterial blood
drawing an ABG sample within
20 minutes of a procedure, such
as suctioning or administering
respiratory treatment
allowing air bubbles in the
sample
delaying transport of the sample
to the lab.

Nursing implications
ABG values provide important information about your patients condition. But never underestimate the
importance of your clinical assessment and judgment. As a nurse,
you are the most important advocate for your patients because you
are constantly at the bedside, monitoring, assessing, intervening, and
reevaluating.
Your role begins with identifying
patients at risk for acid-base disturbances, including those who have
or are at risk for:
significant electrolyte imbalances
net gain or loss of acids
net gain or loss of bases
ventilation abnormalities
abnormal kidney function.
Assess patients carefully to
identify early clues of acid-base
disturbances. Consider what your
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Interpreting arterial blood gas values

The table shows the values for acid-base disorders.

Disorder

pH

PaCO2

HCO3

Compensation

Respiratory acidosis

HCO3- > 26 mEq/L

Respiratory alkalosis

HCO3- < 21 mEq/L

Metabolic acidosis

PaCO2 > 45 mm Hg

Metabolic alkalosis

PaCO2 < 35 mm Hg

PaCO2 = partial pressure of arterial carbon dioxide

HCO3- = bicarbonate
= increased level; = decreased level; N = normal level.

patients vital signs are telling you.

Count your patients respirations
for a full minute. What are the rate
and the depth? Are they clues to
an impending or underlying respiratory or metabolic problem? What
is your patients level of consciousness? Confusion can be an
early sign of an acid-base disturbance. Correlate your patients fluid balance and creatinine levels
with kidney function. Always correlate your assessment findings
with your patients diagnosis. Do
they match? Or is some clue pointing in a different direction? Be
sure to double-check the implications and adverse effects of all
drugs you administer.

Treating acid-base imbalances

Treatment for metabolic acidosis
focuses on correcting the underlying cause. For a diabetic patient,
treatment consists of controlling
blood glucose and insulin levels.
In a case of poisoning, treatment
focuses on eliminating the toxin
from the blood. Correcting the underlying cause of sepsis may include antibiotic therapy, fluid administration, and surgery. You may
also treat the acidosis directly. If
its mild, administering I.V. fluid
may correct the problem. If acidosis is severe, you may give bicarbonate I.V., as prescribed.
Treatment for metabolic alkalosis
also focuses on the underlying
cause. Frequently, an electrolyte im20

American Nurse Today

balance causes this disorder, so

treatment consists of replacing fluid,
sodium, and potassium.
The treatment goal for respiratory acidosis is to improve ventilation. Expect to administer drugs
such as bronchodilators to improve
breathing and, in severe cases, to
use mechanical ventilation. Maintain
good pulmonary hygiene.
Usually, the only treatment goal
for respiratory alkalosis is to slow
the breathing rate. If anxiety is the
cause, encourage the patient to
slow his or her breathing. Some
patients may need an anxiolytic.
If pain is causing rapid, shallow
breathing, provide pain relief.
Breathing into a paper bag allows
a patient to rebreathe CO2, raising
the level of CO2 in the blood.

Practice makes perfect

Use the case histories below to test
your acid-base knowledge with
some examples. Read each history
and try to determine the cause of
the signs and symptoms. Then,
read the interpretation section to
see how well you did. (See Beyond
pH, PaCO2, and HCO3-.)
Case history 1
Mary Barker, 34, comes to the
emergency department (ED) with
acute shortness of breath and pain
on her right side. She smokes one
pack of cigarettes a day and recently started taking birth control
pills. Her blood pressure is 140/

Volume 4, Number 1

80 mm Hg; her pulse is 110

beats/minute; and her respiratory
rate is 44 breaths/minute. Her
ABG values are as follows:
pH: 7.50
PaCO2: 29 mm Hg
Partial pressure of arterial oxygen (PaO2): 64 mm Hg
HCO3-: 24 mm Hg
Oxygen saturation (SaO2): 86%.
Interpretation: These ABG values
reveal respiratory alkalosis without
compensation. The patients pH
and PaCO2 are alkalotic, and her
HCO3- is normal, indicating no
compensation. You would administer oxygen (O2) therapy, as ordered, to increase SaO2 to more
than 95%; encourage the patient to
breathe slowly and regularly to decrease CO2 loss; administer an analgesic, as ordered, to ease pain; and
support her emotionally to decrease
anxiety. Based on the clues, the
probable underlying cause is pulmonary embolism.
Case history 2
John Stewart, 22, is brought to the
ED for an overdose of a tricyclic
antidepressant. Hes unconscious
and has a respiratory rate of 5 to 8
breaths/minute. His ABG values are
as follows:
pH: 7.25
PaCO2: 61 mm Hg
PaO2: 76 mm Hg
HCO3-: 26 mm Hg
SaO2: 89%.
Interpretation: These ABG values
reveal respiratory acidosis without
compensation. The patients pH and
PaCO2 are acidotic, and his HCO3- is
normal, indicating no compensation.
You would administer O2, as ordered. The patient may be intubated
to protect his airway and placed on
a mechanical ventilator. You would
also treat the underlying cause by
performing gastric lavage and administering activated charcoal. This
patients condition may progress to
metabolic acidosis. If so, you would
give sodium bicarbonate to reverse
the acidosis.

Back in balance

Beyond pH, PaCO2, and HCO3To identify acid-base disorders, you need only three arterial blood gas (ABG)
valuespH, partial pressure of arterial carbon dioxide (PaCO2), and bicarbonate
(HCO3-). But depending on the circumstances, you may find value in other ABG
values.
One is a measurement of the partial pressure of arterial oxygen (PaO2). The normal range for PaO2 is 80 to 100 mm Hg. But PaO2 varies with age and decreases after age 60 without signs of hypoxia. PaO2 levels may also be lower in people who
live at higher altitudes.
Another valuable ABG value is oxygen saturation (SaO2), which is a measure of
the percentage of hemoglobin actually carrying oxygen. The normal range for
SaO2 is 95% to 100%.

How did you do? Whether you

aced this practice quiz or not, remember that integrating your ABG
interpretation skills into your patient assessments takes practice. By
becoming more adept at identifying
specific acid-base disorders, you
can ensure that patients receive the
appropriate nursing interventions
and get back in balance as quickly
as possible.

Selected references

Case history 3
Steve Burr, 38, has type 1 diabetes. He hasnt been feeling well
for the last 3 days and hasnt eaten or injected his insulin. Hes
confused and lethargic. His respiratory rate is 32 breaths/minute,
and his breath has a fruity odor.
His serum glucose level is 620
mg/dL. While receiving 40% O2,
his ABG values are:
pH: 7.15
PaCO2: 30 mm Hg
PaO2: 130 mm Hg
HCO3-: 10 mm Hg
SaO2: 94%.
Interpretation: These ABG values reveal metabolic acidosis with
partial respiratory compensation.
The patients pH and HCO3- indicate acidosis. His PaCO2 is lower
than normal, reflecting the lungs
attempt to compensate. Because
pH is abnormal, you know com-

pensation isnt complete.

ABG values only
Try interpreting this set of ABG values without a clinical scenario:
pH: 7.49
PaCO2: 40 mm Hg
PaO2: 85 mm Hg
HCO3-: 29 mm Hg
SaO2: 90%
Interpretation: These values reveal uncompensated metabolic alkalosis. The pH and HCO3- indicate
alkalosis. PaCO2 is normal, indicating no compensation.
Now, interpret these values:
pH: 7.25
PaCO2: 56 mm Hg
PaO2: 80 mm Hg
HCO3-: 15 mm Hg
SaO2 : 93%
Interpretation: These values reveal mixed acidosis. The pH, HCO3-,
and PaCO2 all indicate acidosis.

CE POST-TEST
Perfecting your acid-base balancing act
Instructions
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please go to www.AmericanNurseToday.com/ce. Once youve
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Please allow 4 to 6 weeks for CE processing.

Allibone L, Nation N. Guide to regulation of

blood gases: part two. Nurs Times.
2006;102(46):48-50.
Ayers P, Warrington L. Diagnosis and treatment of simple acid-base disorders. Nutr
Clin Pract. 2008;23(2):122-127.
Morton P, Fontaine D, Hudak C, Gallo B.
Critical Care Nursing: A Holistic Approach.
8th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2004.
Price S, Wilson L. Pathophysiology: Clinical
Concepts of Disease Processes. 6th ed. St.
Louis, MO: Mosby; 2003.
Rhoades R, Pflanzer R. Human Physiology.
4th ed. Fort Worth, TX: Saunders College
Publishing; 2003.
Simpson H. Interpretation of arterial blood
gases: a clinical guide for nurses. Br J Nurs.
2004;13(9):522-528.

Michelle Fournier is Founder and CEO of A Choice

Above in Denver, Colorado, and a healthcare
consultant for ja thomas & Associates in Smyrna,
Georgia. The planners and author of this CNE activity
have disclosed no relevant financial relationships
with any commercial companies pertaining to this
activity.

Provider accreditation
The American Nurses Association Center for Continuing Education
and Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers
Commission on Accreditation.
ANA is approved by the California Board of Registered Nursing,
Provider Number 6178.
Contact hours: 1.8
Expiration: 12/31/2010

Purpose/goal: To provide nurses with information so they can better

care for patients with an acid-base imbalance.

January 2009

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CE

POST-TEST Perfecting your acid-base balancing act

Earn contact hour credit online at www.AmericanNurseToday.com/ce

many acids and bases as the buffer system.

Please circle the correct answer.

1.

2.

Which statement about acid is correct?

a. An acid can take hydrogen (H+) from a base.
b. An acid can donate H+ to a base.
c. Ammonia is an acid.
d. Bicarbonate is an acid.
Which statement about pH is correct?
a. The pH of blood is neutral.
b. The pH of blood is slightly acidic.
c. pH reflects the overall H+ concentration in body
fluids.
d. pH reflects the overall bicarbonate (HCO3-) concentration in body fluids.

(ANT090101)

6. An excessive loss of sodium or potassium can

cause:
a. metabolic alkalosis.
b. metabolic acidosis.
c. respiratory alkalosis.
d. respiratory acidosis.
7.

Excessive ingestion of antacids can cause:

a. metabolic alkalosis.
b. metabolic acidosis.
c. respiratory alkalosis.
d. respiratory acidosis.

3. The bodys most efficient pH-balancing force is

the:
a. chemical buffer system.
b. respiratory system.
c. renal system.
d. metabolic system.

8. What is the acid-base status of a patient with these

arterial blood gas (ABG) results: pH, 7.28; PaCO2, 48 mm
Hg; and HCO3-, 25 mEq/L?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

4. Which statement correctly describes the kidneys

role in acid-base balance?
a. The kidneys restore balance within minutes.
b. The kidneys restore balance within 8 hours.
c. When blood is alkaline, the kidneys excrete
HCO3- and retain H+.
d. When blood is alkaline, the kidneys excrete H+
and retain HCO3-.

9. What is the acid-base status of a patient with

these ABG results: pH, 7.26; PaCO2, 40 mm Hg; and
HCO3-, 18 mEq/L?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

5. Which statement correctly describes the lungs

role in acid-base balance?
a. A high carbon dioxide (CO2) level indicates hypoventilation from shallow breathing.
b. A low CO2 level indicates hypoventilation from
shallow breathing.
c. The respiratory system can handle as many acids
and bases as the buffer system.
d. The respiratory system can handle three times as

10. Which statement about respiratory acid-base

disorders is correct?
a. pH and PaCO2 move in the same direction.
b. pH and PaCO2 move in opposite directions.
c. HCO3- increases.
d. HCO3- decreases.
11. What is the acid-base status of a patient with
these ABG results: pH, 7.43; PaCO2, 30 mm Hg; and
HCO3-, 18 mEq/L?
a. Uncompensated metabolic alkalosis

Evaluation form (required)

1. In each blank, rate your achievement of each objective from 1 (low/poor) to 5
(high/excellent).
(1.) Identify four disturbances of acid-base balance. ____
(2.) Discuss nursing interventions for patients with acid-base
imbalances. ____
(3.) Describe how to interpret arterial blood gas values. ____

CE: 1.8 contact hours

b. Compensated metabolic acidosis

c. Uncompensated respiratory acidosis
d. Compensated respiratory alkalosis
12. An appropriate treatment for a patient with respiratory alkalosis is:
a. increasing the breathing rate.
b. slowing the breathing rate.
c. administering a bronchodilator.
d. administering electrolytes.
13. Which statement about patient assessment is
correct?
a. The patients creatinine level is an important reflection of lung function.
b. Confusion is usually a late sign of acid-base disturbances.
c. Drawing an ABG sample 10 minutes after suctioning can lead to inaccurate results.
d. Including an air bubble when drawing an ABG
sample ensures accurate results.
14. Which statement about acid-base balance is correct?
a. An electrolyte imbalance is frequently the cause
of metabolic alkalosis.
b. An electrolyte imbalance is frequently the cause
of respiratory acidosis.
c. The primary problem in respiratory alkalosis is
alveolar hypoventilation.
d. The primary problem in respiratory acidosis is
alveolar hyperventilation.
15. Administering bicarbonate I.V. may be appropriate for:
a. mild respiratory acidosis.
b. mild respiratory alkalosis.
c. mild metabolic acidosis.
d. severe metabolic acidosis.

Also rate the following from 1 to 5.

2. The relatedness and effectiveness of the purpose, objectives, content, and
teaching strategies. ____
3. The author(s) competence and effectiveness. ____
4. The activity met your personal expectations. ____
5. The application to and usefulness of the content in your nursing practice. ____
6. Freedom from bias due to conflict of interest, commercial support, product
endorsement or unannounced off-label use. ____
7. State the number of minutes it took you to read the article and complete the
post-test and evaluation. ____
Comments: ______________________________________________________
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