Metabolic Alkalosis Nursing Care Plan

February 28, 2014

Metabolic alkalosis is characterized by a high pH (loss of hydrogen ions) and high plasma bicarbonate caused by excessive intake of sodium bicarbonate, loss of gastric/intestinal acid, renal excretion of hydrogen and chloride, prolonged hypercalcemia, hypokalemia, and hyperaldosteronism. Compensatory mechanisms include slow, shallow respirations to increase CO₂ level and an increase of bicarbonate excretion and hydrogen reabsorption by the kidneys.

Nursing Care Plan

These are general interventions for patients with Metabolic Alkalosis.

Desired Outcomes

Display serum bicarbonate and electrolytes WNL.
Be free of symptoms of imbalance, e.g., absence of neurological impairment/irritability.

Nursing Interventions	Rationale
Monitor respiratory rate, rhythm, and depth.	Hypoventilation is a compensatory mechanism to conserve carbonic acid and represents definite risks to the individual (hypoxemia and respiratory failure).
Assess level of consciousness and neuromuscular status, strength, tone, movement; note presence of Chvostek’s or Trousseau’s signs.	The CNS may be hyperirritable (increased pH of CNS fluid), resulting in tingling, numbness, dizziness, restlessness, or apathy and confusion. Hypocalcemia may contribute to tetany (although occurrence is rare).
Monitor heart rate and rhythm.	Atrial and ventricular ectopic beats and tachy dysrhythmias may develop.
Record amount and source of output. Monitor intake and daily weight.	Helpful in identifying source of ion loss and potassium and HCl are lost in vomiting and GI suctioning.
Restrict oral intake and reduce noxious environmental stimuli; use intermittent and low suction during NG suctioning; irrigate gastric tube with isotonic solutions rather than water.	Limits gastric losses of HCl, potassium, and calcium.
Provide seizures and safety precautions as indicated. Pad side rails, protect the airway, put bed in low position and frequent observation.	Changes in mentation and CNS or neuromuscular hyperirritability may result in patient harm, especially if tetany or convulsions occur.
Encourage intake of foods and fluids high in potassium and possibly calcium (dependent on blood level), canned grapefruit and apple juices, bananas, cauliflower, dried peaches, figs, and wheat germ.	Useful in replacing potassium losses when oral intake permitted.
Review medication regimen for use of diuretics, such as thiazides (Diuril, Hygroton), furosemide (Lasix), and ethacrynic acid (Edecrin).	Discontinuation of these potassium-losing drugs may prevent recurrence of imbalance.
Instruct patient to avoid use of excessive amounts of sodium bicarbonate.	Ulcer patients can cause alkalosis by taking baking soda and milk of magnesia in addition to prescribed alkaline antacids.
Assist with identification and treatment of underlying disorder.	Addressing the primary condition (prolonged vomiting and/or diarrhea, hyper aldosteronism, Cushing’s syndrome) promotes correction of the acid-base disorder.
Monitor laboratory studies as indicated: ABGs/pH, serum electrolytes (especially potassium), and BUN.	Evaluates therapy needs and effectiveness and monitors renal function.
Administer medications as indicated:	Correcting sodium, water, and chloride defects may be all that is needed to permit kidneys to excrete bicarbonate and correct alkalosis, but must be used with caution in patients with HF or renal insufficiency.
Sodium chloride PO/Ringer’s solution IV unless contraindicated	Hypokalemia is frequently present. Chloride is needed so kidney can absorb sodium with chloride, enhancing excretion of bicarbonate.
Ammonium chloride or arginine hydrochloride	Although used only in severe cases, ammonium chloride may be given to increase amount of circulating hydrogen ions. Monitor administration closely to prevent too rapid a decrease in pH, hemolysis of RBCs. Note: May cause rebound metabolic acidosis and is usually contraindicated in patients with renal or hepatic failure.
Acetazolamide (Diamox)	A carbonic anhydrase inhibitor that increases renal excretion of bicarbonate.
Spironolactone (Aldactone)	Effective in treating chloride-resistant alkalosis, e.g., Cushing’s syndrome.
Avoid or limit use of sedatives or hypnotics.	If respirations are depressed, may cause hypoxia and respiratory failure.
Encourage fluids IV/PO.	Replaces extracellular fluid losses, and adequate hydration facilities removal of pulmonary secretions to improve ventilation.
Administer supplemental O₂ as indicated and respiratory treatments to improve ventilation.	Respiratory compensation for metabolic alkalosis is hypoventilation, which may cause decreased Pao₂ levels or hypoxia.
Prepare patient for and assist with dialysis as needed.	Useful when renal dysfunction prevents clearance of bicarbonate.