Mark Klimek Lecture
Notes
LECTURE 1: Acid Base Balance & Ventilator
Interpreting blood gases
(remember the rules of the B’s)
• If the pH and the bicarb are both in the same direction then it’s metaBolic
(Bicarb Both Bolic), if they are in different directions then it is respiratory
• If bicarb is normal and the pH is low or high then its respiratory
• You will be given 8 values for arterial blood gas, always first look at the pH and
the bicarb first
• You get acidosis and alkalosis from the pH
LABS: ABG’s
The normal pH is 7.35-7.45
The normal bicarb is 22-26 (the bicarb years where you make all the decisions
[22-26 years old], or 2+2+2=6)
The normal CO2 is 35-45 (same as pH)
Signs and Symptoms with ABG’s
• As the pH goes up so does my patient o If the pH goes up, every system in your
body gets more irritable/hyperexcitable
• As the pH goes down so does my patient o If the pH goes down, systems in your
body shut down
• Except for potassium- When pH goes down, potassium goes up
• If the pH goes up (alkalosis): you will find irritability, hyperreflexia (3&4),
tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure (need
suctioning at the bed side because they can seize and aspirate)
• If pH goes down (acidosis): hyporeflexia, bradycardia, lethargy, obtunded,
paralytic ileus, coma, respiratory arrest (need bag-mask ventilation bag at
bedside for respiratory arrest), +1 reflexes
, • MACkussmal- compensatory and respiratory pattern for only acid base disorder:
MAC- Metabolic ACidosis
Convert to .docx and replace a with a. and replace
u… with u
Respira.tory A.cidosis multiple choice exa.mple: Wha.t would you see with a. pa.tient
who is in respira.tory a.cidosis?
a. +1 reflex,
b. dia.rrhea.,
c. a.dyna.mic ileus (no movement),
d. spa.sm,
e. urina.ry retention,
f. pa.ra.xysmol a.tria.l ta.chyca.rdia.,
g. second degree lovitz, type 2 hea.rt block (impulse is being slowed),
h. hypoka.lemia.
LA.B: REFLEXES
0&1-hyporeflexia.
2-norma.l
3&4- hyperreflexia.
EXA.MPLE: (In genera.l wha.t do pa.in meds do?
A.NSWER: They seda.te you, they a.re CNS depressa.nts: letha.rgy, lucidity, reflexes a.t
+1, hyporeflexia., obtundent
Ca.uses of A.cid Ba.se Imba.la.nce
• Don’t get signs a.nd symptoms mixed up with ca.usa.tion!!!
• Wha.t ca.uses something is the opposite of wha.t the signs a.nd symptoms a.re
o EXA.MPLE: dia.rrhea. will ca.use a. meta.bolic a.cidosis but once you get
a.cidotic, it will shut your bowels down a.nd you will get a. pa.ra.lytic ileus.
• The first question you should a.sk yourself if the scena.rio involves a. lung
problem.
o Is it a. respira.tory problem? BUT remember it ca.n still be
respira.tory a.cidosis/a.lka.losis…
, • Next question you a.sk yourself… o is the client overventila.ting or
underventila.ting?
o If the pa.tient is overventila.ting pick a.lka.losis o If they a.re
underventila.ting pick a.cidosis
• If the client is overventila.ting.. it ha.s a.n a.tta.chment to the word- a.lka.losis
(beca.use they a.re both OVER)… ventila.ting OVER becomes respira.tory
A.LKA.LOSIS
• If the client is undeventila.ting.. it ha.s a.n a.tta.chment to the word- a.cidosis
(beca.use they a.re both UNDER)- ventila.ting UNDER becomes respira.tory
A.CIDOSIS
Exa.mples:
1) A. woma.n is overzea.lously using her brea.thing techniques during
la.bor, wha.t a.cid ba.se disorder will she exhibit? Overventila.tion o
Respira.tory A.lka.losis
2) A. child is nea.r drowning, wha.t a.cid ba.se disorder would it be?
Underventila.ting o Respira.tory A.cidosis
3) Your pa.tient ha.s emphysema., wha.t a.cid ba.se disorder would it
be? Underventila.ting o Respira.tory A.cidosis
Ventila.ting does not mea.n respira.tory ra.te.. respira.tory ra.te is irreleva.nt-
ventila.tion ha.s to do with ga.s excha.nge!!
Exa.mples:
1) Pa.tient ha.s pneumonia. in 4 lobes of the lung, brea.thing a.t 50/min a.nd their
SO2 is a.t 78 on 8 liters per ma.x
o Expla.na.tion: Brea.thing rea.lly fa.st while still ha.ving a. low O2 level
mea.ns tha.t the pa.tient is still underventila.ting beca.use respira.tory
ra.te ha.s nothing to do with it. Everyone pa.ys so much a.ttention to
ra.te when they should be pa.ying closer a.ttention to the SO2.
o If your SO2 is good a.nd you a.re brea.thing slow, you a.re fine but if
your SO2 is low a.nd you’re brea.thing fa.st, you a.re a.ctua.lly
, underventila.ting. A. lot of times the respira.tory ra.te compensa.tes-
pa.y a.ttention to SO2!!!
2) Pa.tient is on a. PCA. pump, wha.t a.cid ba.se imba.la.nce would tell you they
need to come off tha.t thing?
o A. PCA. pump depresses respira.tions. So, pa.tients need to come off of it
a.s soon a.s possible beca.use if they were getting too much it would ma.ke
their respira.tory ra.te go rea.lly down which would
ma.ke the pa.tient underventila.te so the a.nswer would be
respira.tory a.cidosis. o So respira.tory a.cidosis would tell you tha.t
you need to come off the PCA. pump.
Wha.t if its not lung? It
would be Meta.bolic.
Only one scena.rio tha.t you will a.nswer meta.bolic a.lka.losis: if the pa.tient ha.s
prolonged ga.stric vomiting or suctioning
pick meta.bolic a.lka.losis.. Why?
o Pt is losing a.cid... pt will become ba.sic
Otherwise everything else tha.t is not lung or the a.bove, pick meta.bolic
a.cidosis
Ex.
1) Pa.tient ha.d GI surgery a.nd ha.s ha.d a.n NG tube to low intermittent gone post
suctioning for 3 da.ys, wha.t a.cid ba.se disorder would he most likely exhibit? o
Meta.bolic a.lka.losis
2) Pa.tient ha.s hyper emesis gra.vida.rum , wha.t a.cid ba.se disorder a.re they
going to exhibit o Meta.bolic a.lka.losis
3) Continua.tion: Pt is going to be dehydra.ted- wha.t a.cid ba.se disorder would
they ha.ve?
o Meta.bolic a.cidosis
4) Pt ha.s a.cute rena.l fa.ilure, wha.t a.cid ba.se disorder would this be?
Notes
LECTURE 1: Acid Base Balance & Ventilator
Interpreting blood gases
(remember the rules of the B’s)
• If the pH and the bicarb are both in the same direction then it’s metaBolic
(Bicarb Both Bolic), if they are in different directions then it is respiratory
• If bicarb is normal and the pH is low or high then its respiratory
• You will be given 8 values for arterial blood gas, always first look at the pH and
the bicarb first
• You get acidosis and alkalosis from the pH
LABS: ABG’s
The normal pH is 7.35-7.45
The normal bicarb is 22-26 (the bicarb years where you make all the decisions
[22-26 years old], or 2+2+2=6)
The normal CO2 is 35-45 (same as pH)
Signs and Symptoms with ABG’s
• As the pH goes up so does my patient o If the pH goes up, every system in your
body gets more irritable/hyperexcitable
• As the pH goes down so does my patient o If the pH goes down, systems in your
body shut down
• Except for potassium- When pH goes down, potassium goes up
• If the pH goes up (alkalosis): you will find irritability, hyperreflexia (3&4),
tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure (need
suctioning at the bed side because they can seize and aspirate)
• If pH goes down (acidosis): hyporeflexia, bradycardia, lethargy, obtunded,
paralytic ileus, coma, respiratory arrest (need bag-mask ventilation bag at
bedside for respiratory arrest), +1 reflexes
, • MACkussmal- compensatory and respiratory pattern for only acid base disorder:
MAC- Metabolic ACidosis
Convert to .docx and replace a with a. and replace
u… with u
Respira.tory A.cidosis multiple choice exa.mple: Wha.t would you see with a. pa.tient
who is in respira.tory a.cidosis?
a. +1 reflex,
b. dia.rrhea.,
c. a.dyna.mic ileus (no movement),
d. spa.sm,
e. urina.ry retention,
f. pa.ra.xysmol a.tria.l ta.chyca.rdia.,
g. second degree lovitz, type 2 hea.rt block (impulse is being slowed),
h. hypoka.lemia.
LA.B: REFLEXES
0&1-hyporeflexia.
2-norma.l
3&4- hyperreflexia.
EXA.MPLE: (In genera.l wha.t do pa.in meds do?
A.NSWER: They seda.te you, they a.re CNS depressa.nts: letha.rgy, lucidity, reflexes a.t
+1, hyporeflexia., obtundent
Ca.uses of A.cid Ba.se Imba.la.nce
• Don’t get signs a.nd symptoms mixed up with ca.usa.tion!!!
• Wha.t ca.uses something is the opposite of wha.t the signs a.nd symptoms a.re
o EXA.MPLE: dia.rrhea. will ca.use a. meta.bolic a.cidosis but once you get
a.cidotic, it will shut your bowels down a.nd you will get a. pa.ra.lytic ileus.
• The first question you should a.sk yourself if the scena.rio involves a. lung
problem.
o Is it a. respira.tory problem? BUT remember it ca.n still be
respira.tory a.cidosis/a.lka.losis…
, • Next question you a.sk yourself… o is the client overventila.ting or
underventila.ting?
o If the pa.tient is overventila.ting pick a.lka.losis o If they a.re
underventila.ting pick a.cidosis
• If the client is overventila.ting.. it ha.s a.n a.tta.chment to the word- a.lka.losis
(beca.use they a.re both OVER)… ventila.ting OVER becomes respira.tory
A.LKA.LOSIS
• If the client is undeventila.ting.. it ha.s a.n a.tta.chment to the word- a.cidosis
(beca.use they a.re both UNDER)- ventila.ting UNDER becomes respira.tory
A.CIDOSIS
Exa.mples:
1) A. woma.n is overzea.lously using her brea.thing techniques during
la.bor, wha.t a.cid ba.se disorder will she exhibit? Overventila.tion o
Respira.tory A.lka.losis
2) A. child is nea.r drowning, wha.t a.cid ba.se disorder would it be?
Underventila.ting o Respira.tory A.cidosis
3) Your pa.tient ha.s emphysema., wha.t a.cid ba.se disorder would it
be? Underventila.ting o Respira.tory A.cidosis
Ventila.ting does not mea.n respira.tory ra.te.. respira.tory ra.te is irreleva.nt-
ventila.tion ha.s to do with ga.s excha.nge!!
Exa.mples:
1) Pa.tient ha.s pneumonia. in 4 lobes of the lung, brea.thing a.t 50/min a.nd their
SO2 is a.t 78 on 8 liters per ma.x
o Expla.na.tion: Brea.thing rea.lly fa.st while still ha.ving a. low O2 level
mea.ns tha.t the pa.tient is still underventila.ting beca.use respira.tory
ra.te ha.s nothing to do with it. Everyone pa.ys so much a.ttention to
ra.te when they should be pa.ying closer a.ttention to the SO2.
o If your SO2 is good a.nd you a.re brea.thing slow, you a.re fine but if
your SO2 is low a.nd you’re brea.thing fa.st, you a.re a.ctua.lly
, underventila.ting. A. lot of times the respira.tory ra.te compensa.tes-
pa.y a.ttention to SO2!!!
2) Pa.tient is on a. PCA. pump, wha.t a.cid ba.se imba.la.nce would tell you they
need to come off tha.t thing?
o A. PCA. pump depresses respira.tions. So, pa.tients need to come off of it
a.s soon a.s possible beca.use if they were getting too much it would ma.ke
their respira.tory ra.te go rea.lly down which would
ma.ke the pa.tient underventila.te so the a.nswer would be
respira.tory a.cidosis. o So respira.tory a.cidosis would tell you tha.t
you need to come off the PCA. pump.
Wha.t if its not lung? It
would be Meta.bolic.
Only one scena.rio tha.t you will a.nswer meta.bolic a.lka.losis: if the pa.tient ha.s
prolonged ga.stric vomiting or suctioning
pick meta.bolic a.lka.losis.. Why?
o Pt is losing a.cid... pt will become ba.sic
Otherwise everything else tha.t is not lung or the a.bove, pick meta.bolic
a.cidosis
Ex.
1) Pa.tient ha.d GI surgery a.nd ha.s ha.d a.n NG tube to low intermittent gone post
suctioning for 3 da.ys, wha.t a.cid ba.se disorder would he most likely exhibit? o
Meta.bolic a.lka.losis
2) Pa.tient ha.s hyper emesis gra.vida.rum , wha.t a.cid ba.se disorder a.re they
going to exhibit o Meta.bolic a.lka.losis
3) Continua.tion: Pt is going to be dehydra.ted- wha.t a.cid ba.se disorder would
they ha.ve?
o Meta.bolic a.cidosis
4) Pt ha.s a.cute rena.l fa.ilure, wha.t a.cid ba.se disorder would this be?
