Tic Tac Toe Method- determining acid base imbalance

Question 1

Step #1 Determine nml range:
pH 7.35-7.45 (> 7.45 means alkaline)
PCO2 35-45* ACIDIC (>45 means acidic)
HCO3 22-26

Step #2 Make grid;    
          Acid/NML/Base
PH
PCO2
HCO3

Step #3 Put X in grid for pt results for each value:

Answer 1

Ex: Patient Results: 
ph 7.47: base; PCO2 31: base; HCO3 24: nml
             Acid/NML/Base
PH                             X
PCO2                        X
HCO3             X
Pt has Respiratory Alkalosis!

Question 2

Acid/NML/Base
PH
PCO2
HCO3
* Pt values: pH 7.46; PO2 86; HCO3 24

Answer 2

Acid/NML/Base
PH
PCO2
HCO3
Pt has:

Question 3

Acid/NML/Base
PH
PCO2
HCO3
Patient values: pH 7.57; PO2 88; PCO2 36; HCO3 30

Answer 3

Acid/NML/Base
PH
PCO2
HCO3
Patient has:

Question 4

Acid/NML/Base
PH
PCO2
HCO3
Patient values: pH 7.3; PO2 72; PCO2 50; HCO3 26

Answer 4

Patient has:

Question 5

Acid/NML/Base
PH
PCO2
HCO3
Patient values: pH 7.14; PO2 70; PCO2 35; HCO3 19

Answer 5

Patient has:

Question 6

Sources of Acid/Base in the Body:

Acids:

Answer 6

H+ ions
Ketoacids
carbon dioxide
lactic acid 
Results: low K (hypokalemia)

Question 7

Sources of Acid/Base in the Body:

Base:

Answer 7

Bicarbonate

Results: increased pH

Question 8

Sources of Acid/Base in the Body:

Compensatory mechanism:

Answer 8

*chemical buffers on the scene- in seconds
*respiratory- retention OR elimination of CO2- in minutes
*renal- regulates bicarbs (HCO3) to combat hydrogen losses & gains- in hours, but > permanent when other 2 mechanisms fail.
(Renal system slowly gets to work & requires up to 5 days to complete healing.)

Question 9

General ACIDOSIS sxs: “low, slow, & weak”

Answer 9

Neuro: confusion- 1st sxs
             decreased DTRs
              muscle weakness
CV:        weak pulses
              bradycardia
              hypotension

Question 10

General ACIDOSIS sxs: “low, slow, & weak”

Causes:

Answer 10

Hypoventilation
Drug overdose
Pulmonary Edema
Mechanical ventilation
Mechanical NM Dz

Question 11

Respiratory Acidosis

Answer 11

ph LOW

CO2 HIGH

Question 12

Metabolic Acidosis

Answer 12

ph LOW

HCO3 LOW

Question 13

Metabolic Acidosis

Causes:

Answer 13

DKA
ASA (salicylic acid) overdose
Renal failure
severe diarrhea 
shock

Question 14

Respiratory Acidosis

TXMT:

Answer 14

Meds:
(ex: naloxone, bronchodilators, mucolytics- thin secretions)

O2 (w/ caution! Use lowest art possible)
Mechanical ventilation
Tx the Cause

Question 15

Metabolic Acidosis

Txmt:

Answer 15

Tx the cause (i.e., stop diarrhea, provide O2/insulin drip)

Give sodium bicarbs if pH < 7.2

Question 16

Hyperventilation

Results in:

Answer 16

Respiratory Alkalosis

Question 17

Respiratory Alkalosis

Answer 17

pH high

CO2 low

Question 18

Respiratory Alkalosis

Causes:

Answer 18

initial stages of Pulmonary Emboli
hypoxia
fever 
pregnancy
high altitudes
anxiety

Question 19

Metabolic Alkalosis:

Answer 19

pH high

HCO3 high

Question 20

Metabolic Alkalosis:

Causes:

Answer 20

Overuse of antacids
K+ wasting diuretics
(Increased loss of H+)
Loss of gastric juices

Question 21

General Alkalosis SXS “Excitable & Weak”

Answer 21

Dizziness
Confusion
Hyperreflexia
Numbness/tingling (mouth/toes)
Cramps/Twitching
Tachycardia

Question 22

Alkalosis

TXMT:

Answer 22

Tx the cause
Fall precautions
Rebreather mask (respiratory alkalosis)

Question 23

ABG Interpretation Rules to Remember:

Answer 23

CO2= Respiratory & ACID
HCO3= Metabolic (kidney) & base/alkaline

Question 24

ABG Interpretation Rules to Remember:
Steps:
-Acid or Base? look at the pH
Respiratory or Metabolic? use ROME method

Answer 24

ROME:
Respiratory pH high; PCO2 low
Opposite pH low; PCO2 high
Metabolic pH high; HCO3-high (alkalosis)
Equal pH low; HCO3-low (acidosis)

Question 25

Na+ Imbalance Electrolyte | Fx/indication of imbalance

Answer 25

* Na+ serves as primary determinant of blood osmolarity. | * It's an important regulating acid/base balance & contributes to Fx of nervous system & other excitable tissue.

Question 26

Na+ Imbalance Electrolyte | SXS of Hyponatremia:

Answer 26

``` Muscle cramps weakness HA depression apprehension feeling impending doom personality changes lethargy stupor coma anorexia N/V abd cramps diarrhea ```

Question 27

Na+ Imbalance Electrolyte | SXS of HYPERnatremia:

Answer 27

* Polydipsia * oliguria/anuria/high urine specific gravity * dry skin/mucous membranes; decreased tissue turgor * tongue- rough/fissured * decreased salivation/tears * agitation/restlessness * HA/SZ/coma/decreased reflexes * tachycardia; weak, thready pulse; low BP/vascular collapse

Question 28

Cl- (chloride) Fx/indications of imbalance (extracellular)

Answer 28

Most often assoc w/ Na+ | Plays role in reg of acid/base balance

Question 29

Cl- (chloride) LOW LEVELS: hypochloremia SXS:

Answer 29

``` increased muscle tone twitching weakness tetany shallow breathing respiratory arrest mental confusion ```

Question 30

Cl- (chloride) HIGH LEVELS: HYPERchloremia SXS:

Answer 30

``` metabolic acidosis deep, rapid breathing weakness HA diminished cognitive ability cardiac arrest ```

Question 31

Imbalance of K+ K+ is intracellular cation Fx/indication of imbalance:

Answer 31

Distribution of K+ b/w intracellular & extracellular compartments regulates electrical membrane potentials, controlling excitability of nerve & muscle cells & contractility of skeletal, cardiac, & smooth muscle tissue.

Question 32

Hypokalemia | sxs:

Answer 32

``` dizziness muscle weakness/leg cramps cardiac arrhythmias/hypotension nausea/anorexia/thirst poorly concentrated urine/polyuria ```

Question 33

HYPERkalemia | sxs:

Answer 33

``` N/V/D/abd/intestinal cramps cardiac arrhythmias paresthesias/weakness muscle cramps EKG changes; R/F: cardiac arrest (w/ very elevated K+) ```

Question 34

Mg++ (intracellular) Fx/indication of imbalance:

Answer 34

Acts as a cofactor in many IC enzyme reactions; is essential to all reactions requiring ATP, for every step r/t replication & transcription of DNA; & for translation of mRNA & required for cellular energy metabolism.

Question 35

Hypomagnesemia | sxs:

Answer 35

Usually occurs w/ hypocalcemia & hypokalemia | sxs: personality changes, athetoid or choreiform movts, nystagumus, tetany...tachcardia, HTN, & cardiac arrhythmias.

Question 36

HYPERmagnesemia | sxs:

Answer 36

lethargy hyporeflexia confusion/coma hypotension/cardiac arrhythmias/cardiac arrest

Question 37

``` HCO3 bicarbonate (extracellular) fx/indication of imbalance: ```

Answer 37

One way the body maintains nml pH is via chemical buffers in the ICF & ECF. The most important is HCO3 buffer system. * A reduction in pH d/t increased HCO3: metabolic acidosis * An elevation in pH d/t increased HCO3 levels: metabolic alkalosis

Question 38

Metabolic Acidosis | sxs:

Answer 38

``` anorexia/N/V/abd pain weakness/lethargy/general malaise confusion/stupor/coma depression of vital fx: peripheral vasodilation, decreased HR, cardiac arrhythmias skin- warm/flushed bone dz (e.g. chronic acidosis) ```

Question 39

Metabolic Alkalosis | sxs:

Answer 39

confusion/increased DTRs/tetany/convulsions hypotension/arrythmias respiratory acidosis d/t decreased respiratory rate

Question 40

Ca+ (extracellular) Fx/indications:

Answer 40

Provides strength & stability for skeletal system & serves as exchangeable source to maintain EC calcium levels. It plays role in many metabolic processes, including activity of enzyme systems, generation of action potential, & muscle contraction.

Question 41

Hypocalcemia | sxs:

Answer 41

``` paresthesias (esp numbness/tingling) skeletal muscle cramps abd spasms/cramps increased DTRs carpopedal laryngeal spasm tetany hypotension s/o cardiac insufficiency failure to respond to drugs that act by calcium-mediated mechanisms...osteomalacia, bone pain/deformities, & fx ```

Question 42

HYPERcalcemia | sxs:

Answer 42

polyuria/polydipsia flank pain s/o acute renal insufficiency/ s/o kidney stones anorexia/N/V/constipation muscle weakness/atrophy/ataxia/loss of muscle tone osteoporosis lethargy/personality & behavioral changes/stupor/coma HTN/shortening of QT interval * AV block on EKG

Question 43

Na | values; nml/critical

Answer 43

Nml range 135-145 mEq/L | critical values <120 or >160 mEq/L

Question 44

Hypernatremia | causes:

Answer 44

``` diabetes insipidus exc perspiration copious diarrhea impaired renal fx decreased fluid intake nephrotic syndrome ```

Question 45

Hypernatremia | (early) sxs:

Answer 45

dry, red, sticky tongue/mouth restless irritable

Question 46

Hypernatremia | (later) sxs:

Answer 46

``` delirium twitching sz coma increased muscle tone hyperactive DTRs metabolic acidosis death ```

Question 47

Hypernatremia | txmt:

Answer 47

hypotonic saline solution (0.45%) NaCl sodium restricted diet lasix, HCTZ

Question 48

Hyponatremia | causes:

Answer 48

``` <136 mEq/L extensive vomiting/diarrhea Addison's dz extensive burns low-sodium diets, diuretic tx increased water renal failure ```

Question 49

Hyponatremia | (early) sxs:

Answer 49

``` thirsty anorexia abd cramping confusion lethargy muscle twitching ```

Question 50

Hyponatremia | (late) sxs:

Answer 50

sz loss of coordination generalized weakness coma

Question 51

Hyponatremia | txmt:

Answer 51

nml saline infusion serum Na 2-4 hrs daily weights

Question 52

K | values:

Answer 52

3.5-5 mEq/L | critical <2.5 or > 6.5 mEq/L

Question 53

Hyperkalemia | causes:

Answer 53

``` renal failure acidosis cellular damage w/ crushing injury burns other causes ```

Question 54

Hyperkalemia | sxs: (early)

Answer 54

``` cramps muscle twitching nausea weakness abd/genral ```

Question 55

Hyperkalemia | sxs: (later)

Answer 55

apathy confusion paresthesias low, ascending paralysis lead to respiratory arrest EKG changes severe bradycardia arrhythmias lead to 3rd degree heart block asystole

Question 56

Hyperkalemia | txmt:

Answer 56

``` monitor levels 4-6 hrs monitor HR/rhythm monitor I&O restrict this electrolyte in diet Kayexalate lasix- K+ depletion NaHCO3 (K+ moves into cells) - life threatening ```

Question 57

Hypokalemia | causes:

Answer 57

``` <3.5; critical < 2.5 excessive v/d diuretics DKA TPN Meds: geocillin; diamox; garamyan w/ CHG & chronic HTN ```

Question 58

Hypokalemia | sxs: (early)

Answer 58

``` muscle weakness cramps lethargy apathy drowsiness confusion irritability decreased bowel motility cardiac abnormalities ```

Question 59

Hypokalemia | txmt:

Answer 59

IV or oral replacement monitor this electrolyte lab q8 hrs increase foods with this electrolyte

Question 60

Mg++ | values:

Answer 60

1.3-2.1 mEq/L | critical values < 0.5 mEq/L or > 3 mEq/L

Question 61

Hypomagnesemia | causes:

Answer 61

``` alcoholism malabsorption d/t colitis cancer hyperthyroidism corticosteroid drugs massive blood transfusion ```

Question 62

Hypomagnesemia | sxs: (early)

Answer 62

``` N/V/D/anorexia muscle tremors muscle twitches agitation irritability ```

Question 63

Hypomagnesemia | sxs: (late)

Answer 63

hyperactive DTRs ataxia vertigo

Question 64

Hypomagnesemia | sxs: (severe)

Answer 64

``` clonus hallucinations tetany hypotension nystagmus coma/sz delirium cardiac arrhythmias CHF ```

Question 65

Hypomagnesemia | txmt:

Answer 65

``` increase this electrolyte in the diet use antacids with this electrolyte MgSulfate IM/IV serum level after q16 mEq keep supine handle pts gently ```

Question 66

Hypermagnesemia | causes:

Answer 66

renal failure heavy use of antacids/laxatives dialysis or TPN hypoaldosteronism

Question 67

Hypermagnesemia | sxs: (early)

Answer 67

``` weak hypotensive flushed/hot absent DTRs slurred speech drowsiness lethargy cardiac arrthymias ```

Question 68

Hypermagnesemia | sxs: (later)

Answer 68

``` flaccid muscle paralysis respiratory depression leading to coma apnea heart block cardiac arrest ```

Question 69

Hypermagnesemia | txmt:

Answer 69

IV hydration thiazide diuretics calcium chloride or gluconate

Question 70

Phosphate (PO4) | values/critical:

Answer 70

3-4.5 mg/dL | critical values < 1 mg/dL

Question 71

Hypophosphatemia | causes:

Answer 71

``` malabsorption syndromes colitis shortened GI tract excess thiazide diuretics ```

Question 72

Hypophosphatemia | sxs: (early)

Answer 72

``` weakness tissue hypoxia (disruption of cellular fx) ```

Question 73

Hypophosphatemia | sxs: (late)

Answer 73

mental confusion irritability severe anemia bone brittleness (stress fx)

Question 74

Hypophosphatemia | txmt:

Answer 74

oral supplements neutra soda phospho-soda (now off-market bc contributed kidney issues)

Question 75

Hyperphosphatemia | causes:

Answer 75

renal failure | usually hypocalcemia concurrently

Question 76

Hyperphosphatemia | sxs:

Answer 76

sxs similar to hypocalcemia

Question 77

Hyperphosphatemia | txmt:

Answer 77

phosphate binders | restrict increased phosphate foods

Question 78

Calcium | values/critical

Answer 78

9-10.5 mg/dL critical values < 6 (may lead to tetany) critical values > 14 (may lead to coma/cardiac arrest)

Question 79

Hypocalcemia | causes:

Answer 79

malabsorption parathyroid hormone deficiency burns copies wound drainage

Question 80

Hypocalcemia | sxs: early

Answer 80

``` numbness/tingling lips anxiety/irritiability twitching, cramps grimacing increased DTRs ```

Question 81

Hypocalcemia | sxs: late

Answer 81

``` bruising impaired coagulation general muscle spasms gluconate convulsion cardiac arrhythmias ```

Question 82

Hypocalcemia | txmt:

Answer 82

Trousseau's Phenomenon Chyostek's sign monitor serum levels of this electrolyte monitor EKG diet rich in foods w/ this electrolyte & Vitamin D this electrolye-gluconate or chloride

Question 83

+ Trousseau's sign

Answer 83

carpopedal spasm that dev usually 2-5 min after applying & inflating BP cuff to ~20 mmHG higher than systolic pressure on upper arm. This spasm occurs as the blood supply to ulnar nerve is obstructed.

Question 84

Hypercalcemia | causes:

Answer 84

``` excessive use of milk/alkali products for peptic ulcer multiple fx multiple myeloma renal failure prolonged immobilization malignant growths ```

Question 85

Hypercalcemia | sxs: early

Answer 85

``` lethargy depression/apathy malaise/weakness constipation N/V anorexia diarrhea arrhythmias ```

Question 86

Hypercalcemia | sxs: (later)

Answer 86

``` HA coma polydipsia abd pain flaccid paralysis renal failure renal calculi/polyuria clumsiness confusion/slurred speech/memory loss/stupor HTN EKG changes ```

Question 87

Hypercalcemia | txmt:

Answer 87

``` IV fluids- isotonic saline 5-6 L 1st 24 hrs/3L/day thereafter lasix force fluids (cranberry neutra phos/fleets phospho-soda (may be off-market now d/t kidney issues) ```