Fluid and Electrolyte Imbalances

Nursing Management Nursing Care Plan Discharge Planning Core Competencies

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Marnela Kathleen V. Pasamba, RN Staff Nurse Executive Care Unit 1 St. Lukes Medical Center Global City

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Nursing Care Plan

Priorities

Restore homeostasis Prevent/minimize complications Provide information about condition/prognosis and treatment needs
Homeostasis be restored Free of complications Condition/prognosis and treatment understood Plan in place to meet needs after discharge

Discharge Goals

Fluid Imbalances
Fluid Volume Excess

(Hypervolemia)
Fluid Volume Deficit

(Hypovolemia)

Fluid Volume Excess

Predisposing Factors
-

Excess Na intake Rapid administration of hypertonic/isotonic fluids Increased release of ADH Decreased plasma proteins CKD/ARF; Heart failure

Fluid Volume Excess

Assessment
Fatigue - Increased BP - Edema - Decreased UO; polyuria (normal kidneys) - Increased abdominal girth - Weight gain - LOC changes - SOB; increased RR with or without dyspnea
-

Fluid Volume Excess

Desired Outcomes
Patient will demonstrate stabilized fluid volume as evidenced by balanced I & O, vital signs within normal range, stable weight and absence of edema. Patient will verbalize understanding of individual dietary/fluid restrictions. Patient will demonstrate behaviors to monitor fluid status and prevent/limit its recurrence.

Fluid Volume Excess

Interventions
1. 2. 3. 4. 5. 6. 7.

Vital signs taking, also CVP Auscultate lungs and heart sounds Assess for presence of edema, neck and peripheral distention Maintain accurate I & O; note urine output and fluid balance on 24 hour calculations Weigh as indicated Give oral fluids with caution Monitor infusion of fluids

Fluid Volume Excess

Interventions
8. Encourage deep breathing exercise 9. Maintain semi-fowlers position 10. Turn, reposition and provide skin care 11. Provide safety precautions

Fluid Volume Excess

Interventions
-

(Collaborative) Assist with identification and treatment of underlying cause Monitor lab studies Provide balanced CHON, decrease Na in diet and restrict fluids Prepare to administer diuretics

Fluid Volume Deficit

Predisposing Factors
-

Excessive fluid losses Decreased fluid intake Systemic infections, fever Intestinal obstruction or fistulas DI, Kidney disease

Fluid Volume Deficit

Assessment
Decreased BP - Flattened neck veins - Decreased urine volume - Weight loss - Tingling of extremities - Increased RR, rapid shallow breathing
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Fluid Volume Deficit

Desired Outcomes
Patient will maintain fluid volume at a functional level as evidenced by adequate urine output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill. Patient will verbalize understanding of causative factors and purpose of therapeutic interventions. Patient will demonstrate behaviors to monitor and correct deficit.

Fluid Volume Deficit

Interventions
1. 2.

3.
4. 5. 6.

Vital signs taking, also CVP; watch out for postural BP changes and observe for fever Palpate peripheral pulses; note capillary refill Monitor urine output and measure/estimate fluid losses from all sources Weigh as indicated and compare with 24 hours fluid balance Evaluate patients ability to swallow Ascertain patients beverage preference

Fluid Volume Deficit

Interventions
7. Turn frequently, massage skin and protect bony prominences 8. Provide skin and mouth care 9. Apply lotion as indicated 10. Provide safety precautions 11. Investigate reports of sudden sharp chest pain, dyspnea, cyanosis and restlessness

Fluid Volume Deficit

Interventions
-

(Collaborative) Assist with identification and treatment of cause Monitor laboratory studies Administer IV solutions as indicated Administer sodium bicarbonate, if indicated Provide tube feedings, including free water

Electrolyte Imbalances

Hyponatremia

Hypernatremia
Hyperkalemia

Hypokalemia

Hypochloremia

Hyperchloremia Hypercalcemia

Hypocalcemia

Hypomagnesemia

Hypermagnesemia

Sodium
135-145 mEq/L Major cation of ECF Neuromuscular conduction/transmission of impulses Maintains acid-base balance

Potassium
3.5-5.0 mEq/L Major cation of ICF Regulates neuromuscular excitability Aids in maintenance of acid-base balance Helps in synthesis of protein and metabolism of carbohydrate

Chloride
95-108mEq/L Aids cell integrity by osmotic pressure Acid-base balance Water balance Competes with bicarbonate to combine with sodium Usually in combination with hydrochloric acid and sodium chloride

Calcium
4.5-5.3 mEq/L or 2.1 2.6 mEq/L (ionized calcium) Bone formation/reabsorption Neural transmission/muscle contraction Regulation of enzyme systems Coenzyme in blood coagulation

Magnesium
1.5-2.5 mEq/L Influences carbohydrate metabolism Affects secretion of PTH, Na/K transport across the cell membrane and synthesis of protein and nucleic acid

Electrolyte Imbalance Care Plan

Predisposing Factors
Assess for the contributing factors that may lead to excess or deficit of a specific electrolyte.

Assessment
Look for specific signs and symptoms characteristic to the electrolyte imbalances based on their functions in the body.

Desired Outcomes
Make sure that the patient will be able to manifest signs and symptoms which are stable and leading towards recovery. Aside from this, patient should manifest behavior geared towards the attainment of balance in the body: e.g. monitoring dietary intake, noting fluid and electrolyte balance.

Electrolyte Imbalance Care Plan

Nursing Diagnoses

Depends on the manifestations exhibited by the patient. Depends on the current needs both of the patient and their families. It is a must to be keen in observing the verbal and nonverbal cues of the patient and family. Once needs are identified, prioritize them well.

Electrolyte Imbalance Care Plan

Interventions
1. 2. 3. 4. 5. 6.

Monitor for abnormal serum electrolytes, as available Monitor for manifestations of electrolyte imbalance Maintain patent IV access Administer fluids, as prescribed, if appropriate Maintain accurate intake and output record Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate

Electrolyte Imbalance Care Plan

Interventions
7. Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate 8. Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as prescribed, if appropriate 9. Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as appropriate 10. Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and diaphoresis) 11. Institute measures to control excessive electrolyte loss (e.g., by resting the gut, changing type of diuretic, or administering antipyretics), as appropriate

Electrolyte Imbalance Care Plan

Interventions
12. 13. 14.

15.

Irrigate nasogastric tubes with normal saline Minimize the amount of ice chips or oral intake consumed by patients with gastric tubes connected to suction Provide diet appropriate for patient's electrolyte imbalance (e.g., potassiumrich, low-sodium, and low-carbohydrate foods) Instruct the patient and/or family on specific dietary modifications, as appropriate Provide a safe environment for the patient with neurological and/or neuromuscular manifestations of electrolyte imbalance Promote orientation Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate

16. 17.

18.

Electrolyte Imbalance Care Plan

Interventions
19. 20. 21. 22. 23. 24.

25.

Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen Monitor patient's response to prescribed electrolyte therapy Monitor for side effects of prescribed supplemental electrolytes (e.g., GI irritation) Monitor closely the serum potassium levels of patients taking digitalis and diuretics Place on cardiac monitor, as appropriate Treat cardiac arrhythmias, according to policy Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as appropriate

Core Competencies

Safe and Quality Nursing Care Management of Resources and Environment Health Education Legal Responsibility Ethico-Moral Responsibility Personal and Professional Development Quality Improvement Research Records Management Communication Collaboration and Teamwork

Safe and Quality Nursing Care

Demonstrates knowledge based on the health and illness status of individual/groups Provides sound decision making in the care of individuals/groups considering their beliefs and values Promotes safety and comfort Sets priorities in nursing care based on patients needs Ensures continuity of care Administer medications and other health therapeutics Utilizes the nursing process as framework for nursing Formulates a plan of care in collaboration with patients and other members of health team Implements NCP to achieve identified outcomes Evaluates progress toward expected outcomes Responds to the urgency of patients condition

Management of Resources and Environment

Organizes work load to facilitate patient care Utilizes resources to support patient care Ensures the functioning of resources Checks proper functioning of equipment Maintains safe environment

Health Education

Assesses the learning needs of patient and family Develops health education plan based on assessed and anticipated needs Develops learning materials for health education Implements health education plan Evaluates the outcome of health education

Legal Responsibility
Adheres to practices in accordance with the nursing law and other relevant legislation including contracts, informed consent Adheres to organizational policies and procedures, local and national Documents care rendered to patients

Ethico-Moral Responsibility
Respects the rights of individual and groups Accepts responsibility and accountability for own decisions and actions Adheres to national and international code of ethics for nurses

Personal and Professional Development

Identifies own learning needs Pursues continuing education Gets involved in professional organizations and civic activities Projects a professional image of a nurse Possesses positive attitude towards change and criticisms Performs function according to professional standards

Quality Improvement
Gathers data for quality improvement Participates in nursing audits and rounds Identifies and reports variances Recommends solutions to identified problems

Research
Gathers data using different methodologies Recommends actions for implementation Disseminates results of research findings Applies research findings in nursing practice

Records Management
Maintains accurate and updated documentation of patient care Records outcome of patient care Observes legal imperatives in record keeping

Communication

Establishes rapport with patients, significant others and members of the health team Identifies verbal and non-verbal cues Utilizes formal and informal channels Responds to needs of individuals, family, group and community Uses appropriate information technology to facilitate communication

Collaboration and Teamwork

Establishes collaborative relationship with colleagues and other members of the health team Collaborates plan of care with other members of the health team

Suggestion for further Readings:

Potter and Perry CD-ROM http://www.scribd.com/doc/17471570/Nursi ng-Care-Plan-for-Fluid-and-ElectrolyteImbalances http://marniekathleen.multiply.com/journal/ item/65/Fluid_and_Electrolyte_Imbalances