Human body cells are immersed in fluids both inside and outside the cell. The water that is inside accounts for about one-half to two-thirds of an average person’s weight.
Fluid inside the cells is called intracellular fluid (ICF), and fluid outside the cells is called extracellular fluid (ECF). Intracellular fluid contains water and dissolved solutes and proteins. The solutes are electrolytes, which plays an important role in physiologic body functions.
An imbalance in fluids and electrolytes can result in excessive amounts of fluids in the body or dehydration. This can happen as a result of an alteration in body systems, chronic disease, certain medications, or an underlying illness.
Nursing Care Plans
Nursing plan and goals for fluid and electrolyte imbalances include: maintaining fluid volume at a functional level, patient exhibits normal laboratory values, demonstrates appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality, re-establishing and maintaining normal pattern and GI functioning.
Here are ten (10) nursing care plans (NCP) for fluid and electrolyte imbalances, more specifically:
Fluid Balance: Hypervolemia and Hypovolemia
Body fluids have a variety of important functions in the human body: the facilitate transport of nutrients, hormones, proteins, and other molecules into cells; aid in the removal of metabolic waste products; regulate body temperature; lubricates musculoskeletal joints; provide a medium for which cellular metabolism could take place; and act as a component in body cavities.
- Hypervolemia refers to an isotonic volume expansion of the extracellular fluid (ECF) caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF.
- Hypovolemia occurs when loss of extracellular fluid exceeds the intake of fluid.
Excess Fluid Volume (Hypervolemia)
Excess Fluid Volume: Increased isotonic fluid retention
May be related to
- Excess fluid or sodium intake.
- Compromised regulatory mechanism.
Possibly evidenced by
- Aphasia, muscle twitching, tremors, seizures.
- Bounding pulses.
- Changes in the level of consciousness (lethargy, disorientation, confusion to coma).
- Distended neck and peripheral veins.
- Edema variable from dependent
- Elevated central venous pressure.
- Extra heart sounds S3.
- Productive cough.
- Shortness of breath.
- Sudden weight gain, often in excess of 5% of total body weight.
- Tachypnea with or without dyspnea, orthopnea.
- Tachycardia usually present; bradycardia-late sign of cardiac decompensation.
- Client will verbalize understanding of individual dietary and fluid restrictions.
- Client will demonstrate behaviors to monitor fluid status and prevent or limit recurrence.
- Client will demonstrate stable fluid volume as evidenced by stable vital signs, balanced intake and output, stable weight, and absence of signs of edema.
|Monitor vital signs as well as central venous pressure, if available.||Tachycardia and hypertension are common manifestations. Tachypnea usually present with or without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions such as heart failure.|
|Weigh client daily. Observe for sudden weight gain.||One liter of fluid retention equals a weight gain of 1 kilogram (2.2 pounds).|
|Note presence of neck and peripheral vein distention, along with pitting edema, and dyspnea.||Signs of cardiac decompensation and heart failure.|
|Auscultate lung and heart sounds.||Adventitious sounds (crackles) and extra heart sounds (S3) are indicative of fluid excess, possibly returning in the rapid development of pulmonary edema.|
|Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations.||Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.|
|Assess for presence and location of edema formation.||Edema can be either a cause or a result of various pathological conditions reflecting four competing forces: blood hydrostatic and osmotic pressures and interstitial fluid hydrostatic and osmotic pressures. The dynamic interaction of these four forces allows fluid to shift from one body compartment to another. Edema may be generalized or localized in dependent areas. Elderly clients may develop dependent edema with relatively little excess fluid.|
|Monitor infusion rate of parenteral fluids closely; May use infusion pump, as necessary.||Rapid fluid bolus or prolonged excessive administration potentiates volume overload and risk of cardiac decompensation.|
|Administer oral fluids with caution. Do a 24-hour schedule fluid intake if fluids are restricted.||Fluid restrictions, as well as extracellular shifts, can aggravate drying of mucous membranes, and the client may desire more fluids than are prudent.|
|Encourage adequate bed rest.||Limited cardiac reserves result in fatigue and activity intolerance. Rest, particularly lying down, favors diuresis and reduction of edema.|
|Encourage deep breathing and coughing exercises.||Pumonary fluid shifts potentiate respiratory complications.|
|Turn or reposition, and provide skin care at regular intervals.||Decreases pressure and friction on edematous tissue, which is more prone to breakdown than normal tissue.|
|Maintain semi-Fowler’s position if dyspnea or ascites is present.||Gravity improves lung expansion by lowering diaphragm and shifting fluid to lower abdominal cavity.|
|Provide safety measures as indicated:
||Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population.|
|Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gasses (ABGs), as indicated.||Extracellular fluid shifts, sodium and water restriction, and renal function all affect serum sodium levels. Potassium deficit may occur with kidney dysfunction or diuretic therapy. BUN may be increased as a result of renal dysfunction. ABGs may reflect metabolic acidosis.|
|Replace potassium losses, as indicated.||Potassium deficit may occur, especially if the client is receiving potassium-wasting diuretic. This can cause lethal cardiac dysrhythmias if untreated.|
|Provide balanced protein, low-sodium diet. Restrict fluids, as indicated.||If serum proteins are low because of malnutrition or gastrointestinal (GI) losses, intake of dietary proteins can enhance colloidal osmotic gradients and promote a return of fluid to the vascular space. Restriction of sodium or water decreases extracellular fluid retention.|
|Administer diuretics as indicated:||To achieve excretion of excess fluid, either a single thiazide diuretic or a combination of agents may be selected, such as thiazide and spironolactone. The combination can be particularly helpful when two drugs have different sites of action, allowing more effective control of fluid excess.|
|Prepare for and assist with dialysis or ultrafiltration, if indicated.||May be done to rapidly reduce fluid overload, especially in the presence of severe cardiac or renal failure.|
Deficient Fluid Volume (Hypovolemia)
Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.
May be related to
- Active fluid loss-burns, diarrhea, fistulas, gastric intubation, hemorrhage, wounds.
- Regulatory failure- diabetes insipidus, diabetic ketoacidosis (DKA), adrenal disease, systemic infections, recovery phase of acute renal failure.
Possibly evidenced by
- Abdominal distention.
- Confusion, restlessness.
- Dark concentrated urine.
- Decreased urine volume.
- Decreased central venous pressure.
- Flattened neck veins.
- Pale, moist, clammy skin.
- Weak pulses.
- Client will verbalize understanding of causative factors and purpose of therapeutic interventions.
- Client will demonstrate behaviors to monitor and correct deficit, as appropriate.
- Client will maintain fluid volume at a functional level as evidenced by stable vital signs, good skin turgor, good capillary refill, moist mucous membranes and adequate urinary output with normal specific gravity.
|Weigh client daily and compare with 24-hour intake and output.||Although fluid intake and weight gain greater than output may not accurately reflect intravascular volume, these measurements provide useful data for comparison.|
|Monitor vital signs and CVP. Observe for temperature elevation and orthostatic hypotension.||Tachycardia is present along with a varying degree of hypotension, depending on the degree of fluid deficit. CVP measurements are helpful in determining the degree of fluid deficit and response to replacement therapy. Fever increases metabolism and exacerbates fluid loss|
|Monitor urine output. Measure or estimate fluid losses from all sources such as diaphoresis, wound drainage, and gastric losses.||Fluid replacement needs are based on the correction of current deficits and ongoing losses. A decreased urinary output may indicate hypovolemia, insufficient renal perfusion or polyuria can be present, requiring more aggressive fluid replacement.|
|Investigate reports of sudden or sharp chest pain, cyanosis, restlessness, increased anxiety, and dyspnea.||Hemoconcentration and increased platelet aggregation may result in systemic emboli formation.|
|Palpate peripheral pulses; Observe for skin color, temperature, and capillary refill.||Conditions that contribute to extracellular fluid deficit can result in inadequate organ perfusion to all areas and may cause circulatory collapse and shock.|
|Monitor for a sudden or marked elevation of blood pressure, dyspnea, basilar crackles, frothy sputum, moist cough, and restlessness.||Too rapid correction of fluid deficit may compromise the cardiopulmonary system, especially if colloids are used in general fluid replacement.|
|Evaluate client’s ability to manage own hydration.||Impaired gag and swallow reflexes, anorexia, oral discomfort, nausea, and changes in mentation are among factors that affect client’s ability to replace fluids orally.|
|Provide skin and mouth care. Bathe every other day using mild soap. Apply lotion, as indicated.||Skin and mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water. Daily bathing may increase dryness.|
|Ascertain client’s beverage preferences, and set up a 24-hour schedule for fluid intake. Encourage foods with high fluid content.||Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.|
|Provide safety precautions, as indicated, such as the use of side rails when appropriate, bed in low position, frequent observation, and soft restraints if required.||Decreased cerebral perfusion frequently results in changes in mentation or altered thought process, requiring protective measures to prevent client injury.|
|Turn frequently, gently massage skin, and protect bony prominence.||Tissues are susceptible to breakdown because of vasoconstriction and increased cellular fragility.|
|Monitor laboratory studies, as indicated.||Depending on the degree of fluid loss, differing electrolyte and metabolic imbalances may be present and require correction.|
|Provide tube feedings, including free water, as appropriate.||Enteral replacement can provide proteins and other needed elements in addition to meeting general fluid replacements when swallowing is not intact.|
|Administer IV solutions, as indicated:|
||Corrects plasma protein concentration deficits.|
|2. Isotonic solutions:
||Crystalloids provide prompt circulatory improvement, although the benefit may be transient because of increased renal clearance.|
|3. 0.45% NaCl and lactated Ringer’s solution.||As soon as the client is normotensive, a hypotonic solution (0.45% NaCl) may be used to provide both electrolytes and free water for renal excretion of metabolic wastes. Buffered crystalloids are used with caution because they may potentiate the risk of metabolic wastes.|