Definition: Identification of high-risk, dependent child relationships and actions to prevent possible or further infliction of physical, sexual, or emotional harm or neglect of basic necessities of life

Activities:

• Identify mothers who have a history of no or late (4 months or later) prenatal care

• Identify parents who have had another child removed from the home or have placed previous children with relatives for extended periods

• Identify parents who have a history of substance abuse, depression, or major psychiatric illness

• Identify parents who demonstrate an increased need for parent education (e.g., parents with learning problems, parents who verbalize feelings of inadequacy, parents of a first child, teen parents)

• Identify parents with a history of domestic violence or a mother who has a history of numerous “accidental” injuries

• Identify parents with a history of unhappy childhoods associated with abuse, rejection, excessive criticism, or feelings of being worthless and unloved

• Identify crisis situations that may trigger abuse (e.g., poverty, unemployment, divorce, homelessness, domestic violence)

• Determine whether the family has an intact social support network to assist with family problems, respite child care, and crisis child care

• Identify infants and children with high-care needs (e.g., prematurity, low birth weight, colic, feeding intolerances, major health problems in the first year of life, developmental disabilities, hyperactivity, attention deficit disorders)

• Identify caretaker explanations of child’s injuries that are improbable or inconsistent, allege self-injury, blame other children, or demonstrate a delay in seeking treatment

• Determine whether a child demonstrates signs of physical abuse (e.g., numerous injuries, unexplained bruises and welts, burns, fractures, unexplained facial lacerations and abrasions, human bite marks, whiplash, shaken infant syndrome)

• Determine whether the child demonstrates signs of neglect (e.g., failure to thrive, wasting of subcutaneous tissue, consistent hunger, poor hygiene, constant fatigue and listlessness, skin afflictions, apathy, unyielding body posture, inappropriate dress for weather conditions)

• Determine whether the child demonstrates signs of sexual abuse (e.g., difficulty walking or sitting, torn or bloody underclothing, reddened or traumatized genitals, vaginal or anal lacerations, recurrent urinary tract infections, poor sphincter tone, acquired sexually transmitted diseases, pregnancy, promiscuous behavior, history of running away)

• Determine whether the child demonstrates signs of emotional abuse (e.g., lags in physical development, habit disorders, conduct learning disorders, neurotic traits or psychoneurotic reactions, behavioral extremes, cognitive developmental lags, attempted suicide)

• Encourage admission of child for further observation and investigation, as appropriate

• Record times and durations of visits during hospitalizations

• Monitor parent-child interactions and record observations

• Determine whether acute symptoms in child abate when child is separated from family

• Determine whether parents have unrealistic expectations or negative attributions for their child’s behavior

• Monitor child for extreme compliance, such as passive submission to invasive procedures

• Monitor child for role reversal, such as comforting the parent, or overactive or aggressive behavior

• Listen to pregnant woman’s feelings about pregnancy and expectations about the unborn child

• Monitor new parents’ reactions to their infant, observing for feelings of disgust, fear, or disappointment in gender

• Monitor for a parent who holds newborn at arm’s length, handles newborn awkwardly, asks for excessive assistance, and verbalizes or demonstrates discomfort in caring for the child

• Monitor for repeated visits to clinics, emergency rooms, or physicians’ offices for minor problems

• Establish a system to flag the records of children who are suspected victims of child abuse or neglect

• Monitor for a progressive deterioration in the physical and emotional state of the infant or child

• Determine parent’s knowledge of basic care needs and provide appropriate child care information, as indicated

• Instruct parents on problem solving, decision making, and childrearing and parenting skills, or refer parents to programs where these skills can be learned

• Help families identify coping strategies for stressful situations

• Provide parents with information on how to cope with protracted infant crying, emphasizing that they should not shake the baby

• Provide the parents with noncorporal punishment methods for disciplining children

• Provide pregnant women and their families with information on the effects of smoking, poor nutrition, and substance abuse on the baby’s and their health

• Engage parents and child in attachment-building exercises

• Provide parents and their adolescents with information on decision-making and communication skills and refer to youth services counseling, as appropriate

• Provide older children with concrete information on how to provide for the basic care needs of their younger siblings

• Provide children with positive affirmations of their worth, nurturing care, therapeutic communication, and developmental stimulation

• Provide children who have been sexually abused with reassurance that the abuse was not their fault and allow them to express their concerns through play therapy appropriate for age

• Refer at-risk pregnant women and parents of newborns to nurse home visitation services

• Provide at-risk families with a Public Health Nurse referral to ensure that the home environment is monitored, that siblings are assessed, and that families receive continued assistance

• Refer families to human services and counseling professionals, as needed

• Provide parents with community resource information (e.g., addresses and phone numbers of agencies that provide respite care, emergency child care, housing assistance, substance abuse treatment, sliding-fee counseling services, food pantries, clothing distribution centers, domestic abuse shelters)

• Inform physician of observations indicative of abuse or neglect

• Report suspected abuse or neglect to proper authorities

• Refer a parent who is being battered and at-risk children to a domestic violence shelter

• Refer parents to Parents Anonymous for group support, as appropriate

2nd edition 1996; revised 2000, 2013

6403

Abuse Protection Support: Domestic Partner

Definition: Identification of high-risk, dependent domestic relationships and actions to prevent possible or further infliction of physical, sexual, or emotional harm or exploitation of a domestic partner

Activities:

• Screen for risk factors associated with domestic abuse (e.g., history of domestic violence, abuse, rejection, excessive criticism, or feelings of being worthless and unloved; difficulty trusting others or feeling disliked by others; feeling that asking for help is an indication of personal incompetence; high physical care needs; intense family care responsibilities; substance abuse; depression; major psychiatric illness; social isolation; poor relationships between domestic partners; multiple marriages; pregnancy; poverty; unemployment; financial dependence; homelessness; infidelity; divorce; or death of a loved one)

• Screen for symptoms of a history of domestic abuse (e.g., numerous accidental injuries, multiple somatic symptoms, chronic abdominal pain, chronic headaches, pelvic pain, anxiety, depression, post-traumatic stress syndrome, and other psychiatric disorders)

• Monitor for signs and symptoms of physical abuse (e.g., numerous injuries in various stages of healing; unexplained lacerations, bruises, or welts; patches of missing hair; restraining marks on wrists or ankles; “defensive” bruises on forearms; human bite marks)

• Monitor for signs and symptoms of sexual abuse (e.g., presence of semen or dried blood, injury to external genital, acquired sexually transmitted diseases; or dramatic behavioral or health changes of an undetermined etiology)

• Monitor for signs and symptoms of emotional abuse (e.g., low self-esteem, depression, humiliation and defeat; overly cautious behavior around partner; aggression against self or suicidal gestures)

• Monitor for signs and symptoms of exploitation (e.g., inadequate provision for basic needs when adequate resources are available, deprivation of personal possessions, unexplained loss of social support checks, lack of knowledge of personal finances or legal matters)

• Document evidence of physical or sexual abuse using standardized assessment tools and photographs

• Listen attentively to individual who begins to talk about own problems

• Identify inconsistencies in explanation of cause of injury(ies)

• Determine congruence between the type of injury and the description of cause

• Interview patient or knowledgeable other about suspected abuse in the absence of partner

• Encourage admission to a hospital for further observation and investigation, as appropriate

• Monitor partner interactions and record observations, as appropriate (e.g., record times and duration of partner visits during hospitalization, under- or overreactions by partner)

• Monitor the individual for extreme compliance, such as passive submission to hospital procedures

• Monitor for progressive deterioration in the physical and emotional state of individuals

• Monitor for repeated visits to a clinic, emergency room, or physician’s office for minor problems

• Establish a system to flag individual records where there is suspicion of abuse

• Provide positive affirmation of worth

• Encourage expression of concerns and feelings which may include fear, guilt, embarrassment, and self-blame

• Provide support to empower victims to take action and make changes to prevent further victimization

• Assist individuals and families in developing coping strategies for stressful situations

• Assist individuals and families to objectively evaluate strengths and weaknesses of relationships

• Refer individuals at risk for abuse or who have suffered abuse to appropriate specialists and services (e.g., public health nurse, human services, counseling, legal assistance)

• Refer abusive partner to appropriate specialists and services

• Provide confidential information regarding domestic violence shelters, as appropriate

• Initiate development of a safety plan for use in the event that violence escalates

• Report any situations where abuse is suspected in compliance with mandatory reporting laws

• Initiate community education programs designed to decrease violence

• Monitor use of community resources

3rd edition 2000; revised 2004, 2013

6404

Abuse Protection Support: Elder

Definition: Identification of high-risk, dependent elder relationships and actions to prevent possible or further infliction of physical, sexual, or emotional harm; neglect of basic necessities of life; or exploitation

Activities:

• Identify elder patients who perceive themselves to be dependent on caretakers due to impaired health status, limited economic resources, depression, substance abuse, or lack of knowledge of available resources and alternatives for care

• Identify care arrangements that were made or continue under duress with only minimal consideration of the elder’s care needs (e.g., the caregivers’ abilities, characteristics, and competing responsibilities; need for environmental accommodations; and the history and quality of the relationships between the elder and the caregivers)

• Identify family crisis situations that may trigger abuse (e.g., poverty, unemployment, divorce, homelessness, death of a loved one)

• Determine whether the elder patient and their caretakers have a functional social support network to assist the patient in performing activities of daily living and in obtaining health care, transportation, therapy, medications, community resource information, financial advice, and assistance with personal problems

• Identify elder patients who rely on a single caretaker or family unit to provide extensive physical care assistance and monitoring

• Identify caretakers who demonstrate impaired physical or mental health (e.g., substance abuse, depression, fatigue, back injuries due to unassisted lifting, injuries that were inflicted by patient); financial problems or dependency; failure to understand patient’s condition or needs; intolerant or hypercritical attitudes towards patient, burnout; or those who threaten patient with abandonment, hospitalization, institutionalization, or painful procedures

• Identify family caretakers who have a history of being abused or neglected in childhood

• Identify caretaker explanations of patient’s injuries that are improbable, inconsistent, allege self injury, blame others, include activities beyond elder’s physical abilities, or demonstrate a delay in seeking treatment

• Determine whether elder patient demonstrates signs of physical abuse (e.g., numerous injuries in various stages of healing, unexplained lacerations, abrasions, bruises, burns or fractures, patches of missing hair, human bite marks)

• Determine whether the elder patient demonstrates signs of neglect (e.g., poor hygiene, inadequate or inappropriate clothing, untreated skin lesions, contractures, malnutrition, inadequate aids to mobility and perception [canes, glasses, hearing aids], no dentures or decayed fractured teeth, vermin infestation, medication deprivation or oversedation, deprivation of social contacts)

• Determine whether the elder patient demonstrates signs of sexual abuse (e.g., presence of semen or dried blood, injury to external genital, acquired sexually transmitted diseases, dramatic behavioral or health changes of undetermined etiology)

• Determine whether the elder patient demonstrates signs of emotional abuse (e.g., low self esteem, depression, humiliation and defeat, overly cautious behavior around caretaker, aggression against self or suicidal gestures)

• Determine whether the elder patient demonstrates signs of exploitation (e.g., inadequate provision for basic needs when adequate resources are available, deprivation of personal possessions, unexplained loss of Social Security or pension checks, lack of knowledge of personal finances or legal matters)

• Encourage admission of patient for further observation and investigation, as appropriate

• Monitor patient-caretaker interactions and record observations

• Determine whether acute symptoms in patient abate when they are separated from caretakers

• Determine whether caretakers have unrealistic expectations for patient’s behavior or if they have negative attributions for the behavior

• Monitor for extreme compliance to caretakers’ demands or passive submission to invasive procedures

• Monitor for repeated visits to clinics, emergency rooms, or physicians’ offices for injuries, inadequate health care monitoring, inadequate surveillance, or inadequate environmental adaptations

• Provide patients with positive affirmation of their worth and allow them to express their concerns and feelings, which may include fear, guilt, embarrassment, and self-blame

• Assist caretakers to explore their feelings about relatives or patients in their care and to identify factors that are disturbing and appear to contribute to abusive and neglectful behaviors

• Assist patients in identifying inadequate and harmful care arrangements and help them and their family members identify mechanisms for addressing these problems

• Discuss concerns about observations of at-risk indicators separately with the elder patient and the caretaker

• Determine the patient’s and caretaker’s knowledge and ability to meet the patient’s care and safety needs and provide appropriate teaching

• Help patients and their families identify coping strategies for stressful situations, including the difficult decision to discontinue home care

• Determine deviations from normal aging and note early signs and symptoms of ill health through routine health screenings

• Promote maximum independence and self-care through innovative teaching strategies and the use of repetition, practice, reinforcement, and individualized pacing

• Provide environmental assessment and recommendations for adapting the home to promote physical self-reliance or refer to appropriate agencies for assistance

• Assist with restoration of full range of activities of daily living as possible

• Instruct on the benefits of a routine regimen of physical activity, provide tailored exercise regimens, and refer to physical therapy or exercise programs as appropriate in order to prevent dependency

• Implement strategies to enhance critical thinking, decision-making, and remembering

• Provide a public health nurse referral to ensure that the home environment is monitored and that the patient receives continued assistance

• Provide referrals for patients and their families to human services and counseling professionals

• Provide elder patients and their caretakers with community resource information (e.g., addresses and phone numbers of agencies that provide senior service assistance, home health care, residential care, respite care, emergency care, housing assistance, transportation, substance abuse treatment, sliding-fee counseling services, food pantries and Meals on Wheels, clothing distribution centers)

• Caution patients to have their Social Security or pension checks directly deposited, not to accept personal care in return for transfer of assets, and not to sign documents or make financial arrangements before seeking legal advice

• Encourage patients and their families to plan in advance for care needs, including who will assume responsibility if the patient becomes incapacitated, and how to explore abilities, preferences, and options for care

• Consult with community resources for information

• Inform physician of observations indicative of abuse or neglect

• Report suspected abuse or neglect to proper authorities

2nd edition 1996; revised 2000, 2004, 2013

6408

Abuse Protection Support: Religious

Definition: Identification of high-risk, controlling religious relationships and actions to prevent infliction of physical, sexual, or emotional harm and/or exploitation

Activities:

• Identify individuals who are dependent on the religious “leader” due to impaired or altered religious development, mental or emotional impairment, depression, substance abuse, lack of social resources, or financial issues

• Identify patterns of behavior, thinking, and feeling in which a person experiences “control over” his/her religious journey by another

• Identify church/family history for religious and/or ritual abuse, problem solving and coping methods, emotional stability, degree of persuasive and manipulative techniques used, and religious addiction

• Determine whether the individual demonstrates signs of physical abuse, emotional abuse, exploitation, or religious addiction

• Monitor individual and “leader” interactions noting level of obedience demanded, tolerance for differences, persuasive and manipulation techniques employed, maturationally appropriate methods, content, and sense of “love” principle/life force/deity

• Determine whether individual has a religious functional network to assist in meeting needs for belonging, care, and transcendence in a healthy manner

• Offer prayer and healing services for the person and for past generational healing of the family/congregation

• Help identify resources to meet the religious “safety” and support of the individual and group

• Provide interpersonal support on a regular basis as needed

• Refer for appropriate religious counseling

• Refer to professional specialist if occult and/or satanic ritual abuse is suspected

• Report suspected abuse to proper church and/or legal authorities

3rd edition 2000

1910

Acid-Base Management

Definition: Promotion of acid-base balance and prevention of complications resulting from acid-base imbalance

Activities:

• Maintain a patent airway

• Position to facilitate adequate ventilation (e.g., open airway and elevate head of bed)

• Maintain patent IV access

• Monitor trends in arterial pH, PaCO₂, and HCO₃ to determine particular type of imbalance (e.g., respiratory or metabolic) and compensatory physiologic mechanisms present (e.g., pulmonary or renal compensation, physiological buffers)

• Maintain concurrent examination of arterial pH and plasma electrolytes for accurate treatment planning

• Monitor arterial blood gases (ABGs) and serum and urine electrolyte levels, as appropriate

• Obtain ordered specimen for laboratory analysis of acid-base balance (e.g., ABGs, urine, and serum), as appropriate

• Monitor for potential etiologies before attempting to treat acid-base imbalances as it is more effective to treat etiology than imbalance

• Determine pathologies needing direct intervention versus those requiring supportive care

• Monitor for complications of corrections of acid-base imbalances (e.g., rapid reduction in chronic respiratory alkalosis resulting in metabolic acidosis)

• Monitor for mixed acid-base derangements (e.g., primary respiratory alkalosis and primary metabolic acidosis)

• Monitor respiratory pattern

• Monitor determinants of tissue oxygen delivery (e.g., PaO₂, SaO₂, hemoglobin levels, and cardiac output), if available

• Monitor for symptoms of respiratory failure (e.g., low PaO₂ and elevated PaCO₂ levels, and respiratory muscle fatigue)

• Monitor determination of oxygen consumption (e.g., SvO₂ and avDO₂ levels), if available

• Monitor intake and output

• Monitor hemodynamic status, including CVP, MAP, PAP, and PCWP levels, if available

• Monitor for loss of acid (e.g., vomiting, nasogastric output, diarrhea, and diuresis), as appropriate

• Monitor for loss of bicarbonate (e.g., fistula drainage and diarrhea), as appropriate

• Monitor neurological status (e.g., level of consciousness and confusion)

• Provide mechanical ventilatory support, if necessary

• Provide for adequate hydration and restoration of normal fluid volumes, if necessary

• Provide for restoration of normal electrolyte levels (e.g., potassium and chloride), if necessary

• Administer prescribed medications as based on trends in arterial pH, PaCO₂, HCO₃, and serum electrolytes, as appropriate

• Instruct patient to avoid excessive use of medications containing HCO₃, as appropriate

• Sedate patient to reduce hyperventilation, if appropriate

• Treat fever, as appropriate

• Administer pain medication, as appropriate

• Administer oxygen therapy, as appropriate

• Administer microbial agents and bronchodilators, as appropriate

• Administer low flow oxygen and monitor for CO₂ narcosis, in case of chronic hypercapnia

• Instruct the patient and/or family on actions instituted to treat the acid-base imbalance

1st edition 1992; revised 2013

1911

Acid-Base Management: Metabolic Acidosis

Definition: Promotion of acid-base balance and prevention of complications resulting from serum HCO₃ levels lower than desired or serum hydrogen ion levels higher than desired

Activities:

• Maintain a patent airway

• Monitor respiratory pattern

• Maintain patent IV access

• Monitor for potential etiologies before attempting to treat acid-base imbalances (i.e., it is more effective to treat etiology than imbalance)

• Determine pathologies needing direct intervention versus those requiring supportive care

• Monitor for causes of HCO₃ deficit or hydrogen ion excess (e.g., methanol or ethanol ingestion, uremia, diabetic ketoacidosis, alcoholic ketoacidosis, lactic acidosis, sepsis, hypotension, hypoxia, ischemia, isoniazid or iron ingestion, salicylate toxicity, diarrhea, hyperalimentation, hyperparathyroidism)

• Calculate anion gap to assist in determining causes of metabolic acidosis (e.g., non-anion gap indicates electrolyte influenced causes; anion gap indicates loss of bicarbonate causes)

• Use mnemonics to assist in determining causes of metabolic acidosis (e.g., MUDPILES: Methanol ingestion, Uremia, Diabetic, alcoholic, or starvation ketoacidosis, Paraldehyde ingestion, Isoniazid or iron poisoning, Lactic acidosis, Ethylene glycol ingestion, Salicylate ingestion; HARDUP: Hyperalimentation, Acetazolamide, Renal tubular acidosis, renal insufficiency, Diarrhea and diuretics, Uteroenterostomy, Pancreatic fistula)

• Monitor for electrolyte imbalances associated with metabolic acidosis (e.g., hyponatremia, hyperkalemia or hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia), as appropriate

• Monitor for signs and symptoms of worsening HCO₃ deficit or hydrogen ion excess (e.g., Kussmaul-Kien respirations, weakness, disorientation, headache, anorexia, coma, urinary pH level less than 6, plasma HCO₃ level less than 22 mEq/L, plasma pH level less than 7.35, base excess less than -2 mEq/L, associated hyperkalemia, and possible CO₂ deficit)

• Administer fluids as indicated for excessive losses from underlying condition (e.g., diarrhea, diuretics, hyperalimention)

• Administer oral or parenteral HCO₃ agents, if appropriate

• Use parenteral HCO₃ agents cautiously in premature infants, neonates, and small children

• Avoid administration of medications resulting in lowered HCO₃ level (e.g., chloride-containing solutions and anion exchange resins), as appropriate

• Prevent complications from excessive HCO₃ administration (e.g., metabolic alkalosis, hypernatremia, volume overload, decreased oxygen delivery, decreased cardiac contractility, and enhanced lactic acid production)

• Administer prescribed insulin, fluid hydration (isotonic and hypotonic) and potassium for treatment of diabetic ketoacidosis, as appropriate

• Administer prescribed medications for treatment of inappropriate substance ingestion (e.g., alcohol, salicylate, ethylene glycol) or renal insufficiency

• Monitor intake and output

• Monitor determinants of tissue oxygen delivery (e.g., PaO₂, SaO₂, hemoglobin levels, and cardiac output), as appropriate

• Reduce oxygen consumption (e.g., promote comfort, control fever, and reduce anxiety), as appropriate

• Monitor loss of bicarbonate through the GI tract (e.g., diarrhea, pancreatic fistula, small bowel fistula, and ileal conduit), as appropriate

• Monitor for decreasing bicarbonate and acid buildup from excessive nonvolatile acids (e.g., renal failure, diabetic ketoacidosis, tissue hypoxia, and starvation), as appropriate

• Prepare renal failure patient for dialysis (i.e., assist with catheter placement for dialysis), as appropriate

• Assist with dialysis (e.g., hemodialysis or peritoneal dialysis), as appropriate

• Institute seizure precautions

• Provide frequent oral hygiene

• Maintain bed rest, as indicated

• Monitor for CNS manifestations of worsening metabolic acidosis (e.g., headache, drowsiness, decreased mentation, seizures, and coma), as appropriate

• Monitor for cardiopulmonary manifestations of worsening metabolic acidosis (e.g., hypotension, hypoxia, arrhythmias, and Kussmaul-Kien respiration), as appropriate

• Monitor for GI manifestations of worsening metabolic acidosis (e.g., anorexia, nausea, and vomiting), as appropriate

• Provide adequate nutrition for patients experiencing chronic metabolic acidosis

• Provide comfort measures to deal with the GI effects of metabolic acidosis

• Encourage diet low in carbohydrate to decrease CO₂ production (e.g., administration of hyperalimentation and total parenteral nutrition), as appropriate

• Monitor calcium and phosphate levels for patients experiencing chronic metabolic acidosis to prevent bone loss

• Instruct the patient and/or family on actions instituted to treat the metabolic acidosis

1st edition 1992; revised 2013

1912

Acid-Base Management: Metabolic Alkalosis

Definition: Promotion of acid-base balance and prevention of complications resulting from serum HCO₃ levels higher than desired

Activities:

• Maintain a patent airway

• Monitor respiratory pattern

• Maintain patent IV access

• Monitor for potential etiologies before attempting to treat acid-base imbalances (i.e., it is more effective to treat etiology than imbalance)

• Determine pathologies needing direct intervention versus those requiring supportive care

• Monitor for causes of HCO₃ buildup or hydrogen ion loss (e.g., gastric fluid loss, vomiting, NG drainage, persistent diarrhea, loop or thiazide diuretics, cystic fibrosis, posthypercapnia syndrome in mechanically ventilated patients, primary aldosteronism, excessive ingestion of licorice)

• Calculate urine chloride concentration to assist in determining causes of metabolic alkalosis (e.g., saline responsive is indicated when urine chloride concentration is < 15mmol/L; non-saline responsive is indicated when urine chloride concentration is >25mmol/L)

• Use mnemonics to assist in determining causes of metabolic alkalosis (e.g., DAMPEN: Diuretics; Adenoma secretor; Miscellaneous including Bartter’s syndrome, penicillin, potassium deficiency, bulimia; Posthypercapnia; Emesis; Nasogastric tube; A BELCH: Alkali ingestion with decreased glomerular filtration rate, 11-B-hydroxylase deficiency, Exogenous steroids, Licorice ingestion, Cushing’s syndrome and disease, Hyperaldosteronism)

• Obtain ordered specimen for laboratory analysis of acid-base balance, as appropriate

• Monitor arterial blood gases (ABGs) and serum and urine electrolyte levels, as appropriate

• Administer dilute acid (e.g., isotonic hydrochloride, arginine monohydrochloride), as appropriate

• Administer H₂ receptor antagonist (e.g., ranitidine and cimetidine) to block hydrochloride secretion from the stomach, as appropriate

• Administer carbonic anhydrase-inhibiting diuretics (e.g., acetazolamide and metazolamide) to increase excretion of bicarbonate, as appropriate

• Administer chloride to replace deficient anion (e.g., ammonium chloride, arginine hydrochloride, normal saline), as appropriate

• Administer prescribed IV potassium chloride until underlying hypokalemia is corrected

• Administer potassium-sparing diuretics (e.g., spironolactone and triamterene), as appropriate

• Administer antiemetics to reduce loss of HCl in emesis, as appropriate

• Replace extracellular fluid deficit with IV saline, as appropriate

• Irrigate NG tube with isotonic saline to avoid electrolyte washout, as appropriate

• Monitor intake and output

• Monitor for complications of corrections of acid-base imbalances (i.e., rapid reduction in metabolic alkalosis results in metabolic acidosis)

• Monitor for mixed acid-base derangements (e.g., primary metabolic alkalosis and primary respiratory acidosis) presenting as inappropriate metabolic compensations shrouding a primary respiratory disorder

• Calculate differences in observed HCO₃ and expected change in HCO₃ to determine presence of mixed acid-base derangement

• Monitor determinants of tissue oxygen delivery (e.g., PaO₂, SaO₂, hemoglobin levels, cardiac output), if available

• Avoid administration of alkaline substances (e.g., IV sodium bicarbonate, PO or NG antacids), as appropriate

• Monitor for electrolyte imbalances associated with metabolic alkalosis (e.g., hypokalemia, hypercalcemia, hypochloremia), as appropriate

• Monitor for associated excesses of bicarbonate (e.g., hyperaldosteronism, glucocorticoid excess, licorice abuse), as appropriate

• Monitor for renal loss of acid (e.g., diuretic therapy), as appropriate

• Monitor for GI loss of acid (e.g., vomiting, NG suctioning, high chloride content diarrhea), as appropriate

• Monitor patient receiving digitalis for toxicity resulting from hypokalemia associated with metabolic alkalosis, as appropriate

• Monitor for neurological and/or neuromuscular manifestations of metabolic alkalosis (e.g., seizures, confusion, stupor, coma, tetany, hyperactive reflexes)

• Monitor for pulmonary manifestations of metabolic alkalosis (e.g., bronchospasm, hypoventilation)

• Monitor for cardiac manifestations of metabolic alkalosis (e.g., arrhythmias, reduced contractility, decreased cardiac output)

• Monitor for GI manifestations of metabolic alkalosis (e.g., nausea, vomiting, diarrhea)

• Instruct the patient and/or family on actions instituted to treat the metabolic alkalosis

1st edition 1992; revised 2004, 2013

1913

Acid-Base Management: Respiratory Acidosis

Definition: Promotion of acid-base balance and prevention of complications resulting from serum PaCO₂ levels higher than desired or serum hydrogen ion levels higher than desired