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Altered Acid Base Balance Edapt week 1
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Altered Acid Base Balance Edapt week 1
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Nursing Care – Altered Acid-Base BalanceAcid-base balance is one way the body maintains homeostasis, a complex system of
checks and balances that keeps the serum (blood) pH between 7.35 and 7.45.
Measured as the ratio of bicarbonate (HCO3‾) to carbonic acid (H2CO3), a 20:1
ration must be maintained for the pH to remain close to 7.4. Although the pH of
other body fluids vary, serum pH is the measure used to assess the overall acid-base
balance within the human body.
Building on an understanding of the normal acid-base balance acquired in anatomy
and physiology and the conditions that contribute to acid-base imbalances learned in
pathophysiology, this lesson provides learners the opportunity to apply their
knowledge of the nursing process, critical thinking, health assessment, and
pharmacology to the care of clients experiencing acid-base imbalances.
By completing these learning activities, the learner will gain the knowledge and skills
needed to:
• Identify the health promotion needs for patients with acid-base imbalances.
• Develop individualized nursing care for patients experiencing acidbase
imbalances.
• Utilize clinical judgement and the nursing process when caring for patients
with acid-base imbalances.
,An arterial blood gas (ABG) test measures the acidity (pH), levels of oxygen, and
carbon dioxide in arterial blood. ABG’s are often used in conjunction with other tests
to check how well the lungs can move oxygen into the blood and remove carbon
dioxide from the blood.
Although other tests, such as potassium, may be obtained with an ABG, they must be
prescribed in addition to the ABG.
Your response is correct!
,Data Interpretation: Arterial Blood Gas
Analysis
Matt presents to the emergency department with severe vomiting for 72 hours,
irritability, hand tremors and muscle cramps that began today. The health care
provider prescribes several items, including an arterial blood gas (ABG).
The nurse is using the Tic-Tac-Toe method to evaluate the results. Drag the elements
used to evaluate acid-base balance to the correct locations for these results:
• pH 7.51
• PaCO2 40
• HCO3‾ 36,
• O2 Sat 94%
• PaO2 90
Feedback for 1 - The pH and HCO3‾ are alkaline (high) and the PaCO2 is normal. The
O2 Sat and PaO2 are used to assess oxygenation levels, not acid-base balance, and
are not included in the analysis of ABGs.
Prioritizing Cues: Worsening of
Altered Acid-Base Balance
While caring for Matt the nurse observes changes in the physical assessment. Which
findings provide cues that Matt’s acid-base balance is getting worse? Select all that
apply.
Hematemesis
Dysrhythmias
Lethargy
, Hypertonic muscles
Hyperreflexia
Slow, deep respirations
Based on Matt’s initial symptoms (severe vomiting for 72 hours, irritability, hand
tremors and muscle cramps) assessment findings that indicate a worsening acid-base
balance include lethargy, dysrhythmias, hypertonic (tight) muscles, and slow, deep
respirations that result from the increasing pH and electrolyte imbalances that occur
as the body tries to compensate for the altered pH.
Hyperreflexia indicates excitable muscles and is associated with respiratory alkalosis.
Hematemesis, or blood present in Matt’s vomit, is not related to his acid-base
balance.
Your response is correct!
Conditions Associated With Altered Acid-
Base Balance
Although clients experiencing alterations in acid-base balance are often seriously ill
and being treated in critical care areas, individuals at risk for alterations are present
in all health care settings and community. In fact, people at risk for acid-base
imbalance are everywhere, living their lives as usual, without being recognized.
• A cousin with breast cancer.
• The grocery store employee who is obese.
• A grandparent with chronic obstructive lung disease (COPD).
• A roommate who has a very high fever and lost their sense of taste and smell.
• A person attending synagogue, temple, or church who is living with diabetes
mellitus.
When at risk individuals seek health care, the nurse is responsible for recognizing the
risk and planning care to detect acid-base alterations early. Before clicking on each
image below, write down as many conditions that contribute to acidosis and
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