NUTRITION AND DIET
| Chapter 6
Topic Outline:
● Acid-base imbalances
● Fluids requirement by weight
ACID BASE IMBALANCES
ACID-BASE BALANCE
Acid - Base balance is primarily concerned with
two ions:
o Hydrogen (H+)
o Bicarbonate (HCO3-)
Derangements of hydrogen and bicarbonate
concentrations in body fluids are common in
disease processes
Regulatory mechanisms to maintain normal pH
Normal blood pH: 7.35-7.45
CHEMICAL BUFFERS
Normal acid-base ratio is 1:20; 1 part acid to 2
Carbonic acid-bicarbonate buffer system
parts bicarbonates
Hemoglobin-oxyhemoglobin buffer system
The concentration of hydrogen ions in body
Protein buffer
fluids determines acidity or alkalinity
Phosphate buffer system
Acids release H+ ions, alkaline accepts H+ in
solution React very rapidly (less than a second)
pH reflects the balance between: The body uses pH buffers in the blood to guard
o carbon dioxide (regulated by the lungs); against sudden changes in acidity
and A pH buffer works chemically to minimize
o bicarbonates (regulated by the kidneys) changes in the pH of a solution
ACID-BASE REGULATION
H+ ION
1. The Bicarbonate (HCO3-) Buffer System
has special significance because of the narrow
ranges that it must be maintained in order to be
H+ + HCO3- H2CO3 H2O + CO2
compatible with living systems
reversible depending on the equilibrium between
EFFECTS OF PH
the substrates and products.
The most general effect of pH changes are on
The lungs constantly remove CO2
enzyme function
REGULATORY MECHANISMS TO MAINTAIN NORMAL
o Also affect excitability of nerve and pH
muscle cells RESPIRATORY COMPENSATION
o v pH v Excitability Second-line defense against acid-base imbalance
o ^pH ^Excitability Works within seconds to minutes
Partial pressure of carbon dioxide in arterial
blood (PaCO2) reflects carbon dioxide levels
RESPIRATORY REGULATION
Carbon dioxide is an important by-product of
metabolism and is constantly produced by cells
The blood carries carbon dioxide to the lungs
where it is exhaled
When breathing is increased, the blood carbon
dioxide level decreases and the blood becomes
more Base
G.O| 1
When breathing is decreased, the blood carbon oCardiac arrest, trauma, ingestion of
dioxide level increases and the blood becomes foreign body
more Acidic Chronic: long term pulmonary disease
By adjusting the speed and depth of breathing, o Emphysema, asthma
the respiratory control centers and lungs are able CAUSES: RESPIRATORY ACIDOSIS
to regulate the blood pH minute by minute Drugs that depress the respiratory control
Lungs regulate the respiratory side of acid base center’s sensitivity (narcotics, sedatives,
disturbances anesthetics)
o Lungs are fast CNS trauma/ lesions which impair ventilatory
o Indicator is carbon dioxide (CO2) drive
o Carbon dioxide is POTENTIAL ACID Chest wall trauma leading to pneumothorax
RENAL COMPENSATION Neuromuscular disorders (GBS, MG,
Regulate HCO3 ion concentration in ECF and poliomyelitis)
excrete acid by-products of metabolism Asphyxia
Reacts slowly (minutes to hours) Parenchymal lung disease (COPD)
Acidemia results in renal elimination of excess Iatrogenic factors
hydrogen ions which may combine with
phosphate or ammonia to form titratable acids,
thus increasing blood pH
Alkalosis results in renal elimination of
bicarbonates usually with sodium ions thus
decreasing Ph
KIDNEY REGULATION
Excess acid is excreted by the kidneys, largely
in the form of ammonia
The kidneys have some ability to alter the
amount of acid or base that is excreted, but this
generally takes several days S/Sx: RESPIRATORY ACIDOSIS
ARTERIAL BLOOD GAS Dyspnea
Reflects acid-base balance throughout the entire Shallow, rapid respirations
body better than venous blood
Tachycardia
Provides information about the effectiveness of
Headache (dull)
the lungs in oxygenated blood
Sleep disturbances
Diaphoresis
Elements Normal Significance ↓ deep tendon reflexes
Measured Value Confusion – stupor – coma
pH 7.35 – 7.45 Reflects H+ ion Cyanosis
concentration Tachypnea, hypoventilation with hypoxia
PaCO2 35 – 45 Partial pressure of CO2 Dx TEST RESULT
mmHg in arterial blood ABG:ph<7.35 and PaCO2>45 mmHg
PaO2 80 -100 Partial pressure of O2 in S.electrolytes: K+ mEq/L – Hyperkalemia
mmHg arterial blood *<80 ABG FINDINGS: RESPIRATORY ALKALOSIS
mmHg - hypoxemia pH PaCO2 HCO3-
Uncompensated
HCO3- 22- 26 Bicarbonate Above
7.45
Below
35
normal
mEq/L concentration in plasma Partially Above Below Below
RESPIRATORY ACIDOSIS Compensated 7.45 35 22
PaCO2 is greater than 45 mmHg and pH <7.35 Below Below
Normal or 22
Compensated above 7.45 35
Underlying mechanism: alveolar NURSING INTERVENTIONS
hypoventilation
Acute: sudden failure in ventilation
2
Stay with the patient during periods of extreme Reduce environmental stimuli, orient pt. as
stress and anxiety, decrease environmental needed
stimuli Provide good oral hygiene
Administer sedatives or anti-anxiety drugs Monitor respiratory function and ABG results
Administer O2 Eliminate underlying condition e.g. insulin to
Instruct client to breathe in a paper reverse DKA
bag/rebreather mask Monitor I & O
Provide undisturbed sleep periods METABOLIC ALKALOSIS
METHABOLIC ACIDOSIS Characterized by bld pH > 7.45 accompanied by
Base bicarbonate deficit serum HCO3 level above 26 mEq/L
Bld pH: < 7.35 and serum bicarbonate less than Underlying mechanism:
22 mEq/L o dec metabolic acids
o Inc base bicarbonates
CAUSES: METABOLIC ACIDOSIS
Ketoacidosis
Lactic acidosis
Renal insufficiency and failure CAUSES: METABOLIC ALKALOSIS
Excessive GI losses Excessive acid losses from the GI tract
Poisoning and drug toxicity Drugs: diuretics, corticosteroids and antacids
hypoaldosteronism Massive blood transfusion
S/Sx: METABOLIC ACIDOSIS Cushing’s disease – causes Na and Cl retention
Confusion, stupor, coma and loss of H+ and K+
Hypotension Chronic vomiting – excessive loss of H+ ion
Tachypnea: Kussmaul’s respiration – deep & Continuous GI suctioning
rapid S/Sx: METABOLIC ALKALOSIS
Warm flush skin Paresthesia
Diminished deep tendon reflexes Slow, shallow respirations
Arrhythmias, bradycardia, cardiac arrest Tetany
Weakness, fatigue Seizures
Dx TESTS Bradycardia
ABG: ↓pH ↓PaCO2 Irritability progressing to confusion and coma
Serum K+ elevated Dx TESTS
Glucose and ketones ↑ in DM ABG: ↑ pH ↑ HCO3
pH PaCO2 HCO3- S. electrolytes: decrease serum K+, Ca++ and
Uncompensated Below Cl-
Above
normal
ECG: low T wave
7.35 22
Partially Above Below Below
Compensated 7.35 35 22
ABG FINDINGS: METABOLIC ALKALOSIS
Compensated
Normal or
Slightly lower
Below
35
Below
22 pH PaCO2 HCO3-
Uncompensated
NURSING INTERVENTION Above
7.45
normal
Below
26
Administer sodium bicarbonate if prescribed Partially Above Below Below
Compensated 45 26
7.45
Position pt. to promote chest expansion and Below
Normal or Below
facilitate breathing compensated Slightly lower 45 26
NURSING INTERVENTIONS
3
Administer IV solution containing potassium 2. PaCO2 shows circulating CO2 is high, and as
Observe seizure precautions, provide safe CO2 is related directly to the respiratory system,
environment and orient patient as needed this indicates respiratory acidosis.
Irrigate NG tube with 0.9% sodium chloride 3. Since there is no HCO3 -, there is no response
instead of plain H2O to prevent loss of gastric yet from the kidneys to the acidosis.
electrolytes example
Observe ECG for arrhythmias Respiratory Acidosis: Partial Compensated
Watch for muscle weakness, tetany Phase With the partial compensated phase, all
Monitor I&O the values are out of balance and the kidneys
Assess pts. LOC frequently begin to respond.
QUICK ABG INTERPRETATION o PH - decrease
Check the pH o PaCO2 - increase
o Below 7.35- acidosis o HCO3 - increase
o Above 7.45-alkalosis 1. pH is still acidotic.
2. PaCO2 is high and shows that the respiratory
Determine PaCO2
system is still the reason for the acidosis.
o If it’s abnormal
3. The kidneys are starting to respond to the
o Normal = 35-45 mm Hg
acidosis by increasing the amount of circulating
o Hyperventilation < 35 mmHg (“blowing HCO3
it off”) Respiratory Acidosis: Full Compensation Phase
o Hypoventilation > 45 mmHg With full compensation, the pH returns to a low
(“retaining”) normal range - which was the goal in the first
Watch HCO3 place, but PaCO2 and HCO3- levels are still
Look for compensation- more closely high
corresponds to change in pH o PH - Normal
o Complete- pH falls within normal limits o PaCO2 - increase
o Partial- pH outside normal range o HCO3- increase
1. pH has returned to normal.
pH -7.29 ACIDOSIS 2. PaCO2 is still high due to hypoventilation.
PaCO2- 17 ALKALOSIS 3. HCO3- is high to correct the acidosis.
HCO3-19 ACIDOSIS ABG FINDINGS: RESPIRATORY ACIDOSIS
Met. acidosis w/ compensatory respiratory pH PaCO2 HCO3-
alkalosis Uncompensated Below Above
normal
Determine the PaO2 & SaO2 Partially
7.35 45
Below
COMPENSATION Compensated 7.35
Above
45
Above
26
Uncompensated phase - The onset of the compensated Normal or Above Above
problem ABG FINDINGS:
below 7.35RESPIRATORY ALKALOSIS
45 26
Partial compensation phase - Shows which pH PaCO2 HCO3-
Uncompensated
system and to what extent the compensatory Above
7.45
Below
35 normal
mechanism is responding Partially Above Below Below
Compensated 35
7.45 22
Full compensation phase - Shows what systems compensated Below
Normal or Below
are involved in the correction of the body's pH above 7.45 35 22
imbalance ABG FINDINGS: METABOLIC ACIDOSIS
Respiratory Blood Gas Imbalances Respiratory pH PaCO2 HCO3-
Acidosis: Uncompensated Phase Uncompensated Above Below
7.35 normal 22
o PH - decrease Partially Above Below Below
o PaCO2 - increase Compensated 7.35 35 22
compensated Below
o HCO3 - normal Normal or
Slightly lower
Below
35 22
ABG FINDINGS: METABOLIC ALKALOSIS
pH PaCO2 HCO3-
1. pH is low because of the existing acidosis Uncompensated
Above Above
7.45 normal 26
4
2) Total the amount of losses: 1
Partially
Compensated
Above
7.45
Above
45
Above
26
glass=8 oz;1 oz=30 ml 8 glasses x 8
compensated Normal or Above Above oz / glass x 30 ml / oz = 1920ml
3) Then compare with theTBW,
45 26
slightly above
1.92L / 100 L = 1.92% of water loss
= mild DHN
FLUID REQUIRMENTS BY WEIGHT
Weight Water requirement
0-10kg 4ml/kg/hr
10-20kg 40ml/hr+2ml/kg/hr for each kg>10kg
>20kg 60ml/hr+1ml/kg/hr for each kg>20kg
If patient weighs 8 kg, then
= 8 kg x 4 ml / kg / hr
ADDENDUM TO FLUID IMBALANCE = 32 ml/hr or 768 ml/day( 32x24)
FACTORS AFFECTING WATER CONTENT
AGE If patient weighs 18 kg, then
Percentage of TBW of human body: = 40ml/hr + (8kg x 2ml/kg/hr)
o Fetus – 100% = 40ml/hr + 16ml/hr = 56ml/hr or 1344ml/day
o At birth – 80% What if, the patient weighs
o Adult male – 60% Weight Fluid requirement by weight
o Elderly – 50% 75kg 60ml/hr + (55kg x 1ml/kg/hr) = 115 ml/hr
DEGREE OF DEHYDRATION 45kg 60ml/hr + (25kg x 1ml/kg/hr) = 85 ml/hr
1. Mild - 1-2L of water lost or 2% of BW 19kg 40ml/hr + (9kg x 2ml/kg/hr) = 58 ml/hr
2. Moderate – 3-5L of water lost or 6% of BW 2.5kg 2.5kg x 4 ml/kg/hr = 10 ml/hr
3. Severe – 5-10L of water lost or 9% of BW 15kg 40ml/hr + (5kg x 2ml/kg/hr) = 50 ml/hr
If for 24 hours,
EXAMPLE OF ASSESSMENT OF DEGREE OF 115 ml/hr * 24 hrs = 2760 ml/day
DEHYDRAAATION 85 ml/hr * 24 hrs = 2040 ml / day
58 ml/hr * 24 hrs = 1392 ml / day
1) An 8 month old 7 kg infant with who vomited 3 10 ml/hr * 24 hrs = 240 ml /day
times approximately of 200 ml of fluid and had
50 ml/hr * 24 hrs = 1200 ml /day
5 episodes of diarrhea totaling to about 280 ml.
Assess for the Degree of Dehydration
Answer:
1) Calculate the TBW for patient,
7 kg x .8 (% of TBW) = 5.6kg or 5.6 L
of fluid
2) Total the amount of losses,
200 + 280 ml = 480 ml
3) Then compare with the TBW
480ml / 5600 ml = 8.5% of water loss =
mod. DHN
2) An 200kg elderly client is rushed into the
hospital for severe episodes of diarrhea.
According to the client, he vomited
approximately 8 glasses of water. Assess the
Degree of DHN.
Answer:
1) Calculate the TBW for patient,
kg x .5 (% of TBW) = 100L
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