alveolar-capillary membrane changes
Possibly evidenced by
Changes in mentation
Desired Outcomes/Evaluation Criteria—Client Will
Electrolyte and Acid-Base Balance
Demonstrate improved ventilation and adequate oxygenation of tissue as evidenced by ABGs within client’s acceptable limits and absence of symptoms of respiratory distress.
Verbalize understanding of causative factors and appropriate interventions.
Participate in treatment regimen within level of ability or situation.
Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and effort; ascertain cause of hyperventilation if possible, for example, anxiety, pain, and improper ventilator settings.
Rationale: Identifies alterations from usual breathing pattern and influences choice of intervention.
2. Assess level of awareness and cognition. Note neuromuscular status—strength, tone, reflexes, sensation, and presence of tremors.
Rationale: Decreased mentation (mild to severe) and tetany or seizures may occur when alkalosis is severe due to shifts in calcium.
3. Instruct and encourage client to breathe slowly and deeply. Speak in a low, calm tone of voice. Provide safe environment.
Rationale: May help reassure and calm the agitated client, thereby aiding the reduction of respiratory rate. Assists client to regain control. Note: Clients with hyperventilation syndrome as a cause of their respiratory alkalosis may particularly benefit from reassurance and client education in breathing techniques.
4. Demonstrate appropriate breathing patterns, if appropriate, and assist with respiratory aids, such as rebreathing mask or bag.
Rationale: Decreasing the rate of respirations can halt the “blowing off” of CO2, elevating PaCO2 level and normalizing pH.
5. Provide comfort measures; encourage use of meditation and visualization. Use tepid sponge bath or cool cloths.
Rationale: Promotes relaxation and reduces stress. Control and reduction of fever reduces potential for seizures and helps reduce respiration rate.
6. Provide safety and seizure precautions, such as bed in low position, padded side rails, frequent observation.
Rationale: Changes in mentation and CNS and neuromuscular hyperirritability may result in client harm, especially if tetany or convulsions occur.
7. Discuss cause of condition, if known, and appropriate interventions and self-care activities.
Rationale: Promotes participation in therapeutic regimen and may reduce recurrence of disorder.
8. Assist with identification and treatment of underlying cause.
Rationale: Respiratory alkalosis is a complication, not an isolated occurrence and rarely requires emergent treatment (unless pH is greater than 7.5); thus, correction of alkalosis is undertaken by addressing the primary condition, such as hyperventilation of panic attack, organ failure, severe anemia, and drug effect. Because respiratory alkalosis usually occurs in
response to some stimulus, treatment is unsuccessful unless the stimulus is controlled.
9. Monitor and graph serial ABGs and pulse oximetry.
Rationale: Identifies therapy needs and effectiveness. Note: Rapid correction of PaCO2 in individual with chronic respiratory alkalosis (has a lower serum bicarbonate) may cause metabolic acidosis to develop.
10. Monitor serum potassium and replace, as indicated.
Rationale: Hypokalemia may occur as potassium is lost via urine or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis.