Nursing Care Plan Metabolic Alkalosis (Primary Base Bicarbonate Excess)

Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range ( 7.35-7.45 ). This is usually the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations.

CARE SETTING

This condition does not occur in isolation but rather is a complication of a broader problem that may require inpatient care in a medical-surgical or subacute unit.

RELATED CONCERNS

1. Plans of care specific to predisposing factors
2. Fluid and electrolyte imbalances
3. Renal dialysis
4. Respiratory acidosis (primary carbonic acid excess)
5. Respiratory alkalosis (primary carbonic acid deficit)
6. Patient Assessment Database (Dependent on Underlying Cause)

CIRCULATION

May exhibit: 

1. Tachycardia, irregularities/dysrhythmias
2. Hypotension
3. Cyanosis

ELIMINATION

May report: 

1. Diarrhea (with high chloride content)
2. Use of potassium-losing diuretics (Diuril, Hygroton, Lasix, Edecrin)
3. Laxative abuse

FOOD/FLUID

May report: 

1. Anorexia, nausea/prolonged vomiting
2. High salt intake; excessive ingestion of licorice
3. Recurrent indigestion/heartburn with frequent use of antacids/baking soda

NEUROSENSORY

May report: 

1. Tingling of fingers and toes; circumoral paresthesia
2. Muscle twitching, weakness
3. Dizziness

May exhibit: 

1. Hypertonicity of muscles, tetany, tremors, convulsions, loss of reflexes
2. Confusion, irritability, restlessness, belligerence, apathy, coma
3. Picking at bedclothes

SAFETY

May report: 
Recent blood transfusions (citrated blood)

RESPIRATION

May exhibit: 
Hypoventilation (increases PCO2 and conserves carbonic acid), periods of apnea

TEACHING/LEARNING

1. History of Cushing’s syndrome; corticosteroid therapy
2. Discharge plan
3. DRG projected mean length of inpatient stay depends on underlying cause
4. May require change in therapy for underlying disease process/condition.
5. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Arterial pH: Increased, higher than 7.45.
2. Bicarbonate (HCO3): Increased, higher than 26 mEq/L (primary).
3. PaCO2: Slightly increased, higher than 45 mm Hg (compensatory).
4. Base excess: Increased.
5. Serum chloride: Decreased, less than 98 mEq/L, disproportionately to serum sodium decreases (if alkalosis is hypochloremia).
6. Serum potassium: Decreased.
7. Serum calcium: Usually decreased. Prolonged hypercalcemia (nonparathyroid) may be a predisposing factor.
8. Urine pH: Increased, higher than 7.0.
9. Urine chloride: Less than 10 mEq/L suggests chloride-responsive alkalosis, whereas levels higher than 20 mEq/L suggest chloride resistance.
10. ECG: May show hypokalemic changes including peaked P waves, flat T waves, depressed ST segment, low T wave merging to P wave, and elevated U waves.

NURSING PRIORITIES

1. Achieve homeostasis.
2. Prevent/minimize complications.
3. Provide information about condition/prognosis and treatment needs as appropriate.

DISCHARGE GOALS

1. Physiological balance restored.
2. Free of complications.
3. Condition, prognosis, and treatment needs understood.
4. Plan in place to meet needs after discharge.

Because no current nursing diagnosis speaks clearly to metabolic imbalances, the following interventions are presented in a general format for inclusion in the primary plan of care.