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 care 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.
Potassium (K) Imbalances: Hyperkalemia and Hypokalemia
Potassium (K) is a major cation in intracellular fluid (ICF). Potassium is important in regulating the osmolarity of ECF by exchanging with sodium. It also maintains the transmembrane electrical potential that exists between the ICF and ECF. Potassium also maintains normal neuromuscular contraction by participation in the sodium-potassium pump.
The normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L.
- Hyperkalemia is definied as serum potassium level above 5.0 mEq/L.
- Hypokalemia is defined as serum potassium level below 3.5 mEq/L.
Risk For Electrolyte Imbalance (Hyperkalemia)
May be related to
- Renal disease.
- Treatment-related side effects such as cytotoxic drugs, NSAIDs, diuretics, potassium-containing medications, massive transfusion with banked blood.
Possibly evidenced by
- [not applicable].
- Client will display heart rate, blood pressure, and laboratory results within the normal limit and absence of paresthesia, muscle weakness, and cognitive impairment.
|Monitor heart rate and rhythm. Be aware that cardiac arrest can occur.||Potassium excess depresses myocardial conduction. Bradycardia can progress to cardiac fibrillation and arrest.|
|Monitor respiratory rate and depth. Encourage deep breathing and coughing exercise. Elevate the head of the bed.||Clients may hypoventilate and retain carbon dioxide resulting in respiratory acidosis. Muscular weakness can affect respiratory muscles and lead to respiratory complications.|
|Assess the level of consciousness and neuromuscular function, including sensation, strength, and movement.||The client is usually conscious and alert; however, muscular paresthesia, weakness, and flaccid paralysis may occur.|
|Monitor urine output.||In kidney failure, potassium is retained because of improper excretion. Potassium is contraindicated if oliguria or anuria is present.|
|Identify client at risk or the cause of the hyperkalemia such as excessive intake of potassium or decreased excretion.||Early identification and intervention can avoid complications.|
|Encourage frequent rest periods; assist with daily activities, as indicated.||General muscle weakness decreases activity tolerance.|
|Stress importance of the client’s notifying future caregivers when chronic condition potentiates the development of hyperkalemia, such as oliguric renal failure.||May help prevent hyperkalemia recurrences.|
|Teach and assist the client with range-of-motion (ROM) exercises, as tolerated.||Improves muscle tone and reduces muscle cramps and pain.|
|Encourage intake of carbohydrates and fats and low potassium food such as pineapple, plums, strawberries, carrots, cauliflower, corn, and whole grains.||Reduces exogenous sources of potassium and prevents metabolic tissue breakdown with the release of cellular potassium.|
|Instruct client in use of potassium-containing salts or salt substitutes, taking potassium supplements safely.||Prevention of hyperkalemia can be managed with diet, supplements, and other medications.|
|Identify and discontinue dietary sources of potassium, such as beans, dark leafy greens, potatoes, squash, yogurt, fish, avocados, mushrooms, and bananas.||Facilitates the reduction of potassium levels and may prevent recurrence of hyperkalemia.|
|Review drug regimen for medications containing potassium or affecting potassium excretion such as spironolactone (Aldactone), hydrochlorothiazide (Maxzide), amiloride (Midamor), and penicillin G.||Requires regular monitoring of potassium levels and may require alternate drug choices or changes in the dosage or frequency.|
|Monitor laboratory results, such as serum potassium and arterial blood gasses, as indicated.||Evaluate therapy needs and effectiveness.|
|Administer medications, as indicated:|
|Promotes renal clearance and potassium excretion.|
|Administration of nebulization has been helpful in clients receiving hemodialysis and may also attenuate the hypoglycemic effect of insulin administration.|
|Temporary stopgap measure that antagonizes toxic potassium depressant effects on the heart and stimulates cardiac contractility.|
|Short term emergency measure to move potassium into the cell, thus reducing toxic serum level.|
|Resin removes potassium by exchanging potassium for sodium or calcium in the GI tract. Sorbitol enhances evacuation.|
|Provide fresh blood or washed red blood cells (RBCs), if transfusion is indicated.||Fresh blood has less potassium than banked blood because the breakdown of older RBCs releases potassium.|
|Infuse potassium-based medication or solutions slowly.||Prevents administration of concentrated bolus, allows time for kidneys to clear excess free potassium.|
|Prepare for and assist with dialysis.||May be required when more conservative methods fail or are contraindicated such as severe heart failure.|
Risk For Electrolyte Imbalance (Hypokalemia)
May be related to
- Diarrhea, vomiting.
- Diabetic acidosis, renal failure.
- High-sodium diet, starvation.
- Profuse sweating.
- Treatment-related side effects such as diuretics, TPN, some antibiotics.
Possibly evidenced by
- [not applicable].
- Client will display heart rhythm and laboratory results within the normal limit for client and absence of paresthesias, muscle weakness, and cognitive impairment.
|Monitor respiratory rate, depth, and effort. Encourage deep breathing and coughing exercise. Encouraged frequent re-positions.||Respiratory muscle weakness may progress to paralysis leading to respiratory arrest.|
|Monitor heart rate and rhythm.||Abnormalities in heart conduction and contractility are associated with hypokalemia. Tachycardia may develop as well as potentially life-threatening atrial and ventricular dysrhythmias–AV blocks, AV dissociation, ventricular tachycardia and PVCs.|
|Note for signs of metabolic alkalosis such as tachycardia, dysrhythmias, hypoventilation, tetany, and changes in mentation.||These are usually associated with hypokalemia.|
|Monitor level of consciousness and neuromuscular function, noting movement, strength, and sensation.||Tetany, paresthesia, apathy, drowsiness, irritability, and coma may occur.|
|Monitor gastric, urinary, and wound losses accurately.||Guide for calculating fluid and potassium replacement needs.|
|Observe for absence or changes in bowel sounds.||Paralytic ileus commonly follows gastric losses through vomiting, gastric suction, or protracted diarrhea.|
|Discuss preventable causes of the condition such as nutritional choices and the proper use of laxatives.||Provides an opportunity for the client to prevent a recurrence. In addition, dietary control is more palatable than oral replacement medications.|
|Encourage high potassium diet such as oranges, bananas, tomatoes, coffee, red meat, and dried fruits. Discuss the use of potassium chloride salt substitutes for a client receiving long-term diuretics.||Potassium may be replaced and level maintained through the diet when the client is allowed oral food and fluids. Dietary replacement of 40 to 60 mEq/L/day is usually sufficient if no abnormal losses are happening.|
|Monitor rate of IV potassium administration using micro drop set or infusion pump. Observe for side effects, provide ice pack, as indicated.||Ensures controlled delivery of medication to prevent bolus effect and reduce associated discomfort such as burning sensation at IV site. When a solution cannot be administered via central vein and slowing of rate is not possible or effective, applying an ice pack to the infusion site may help relieve discomfort.|
|Review medication regimen for potassium-wasting drugs such as:||If alternative drugs such as potassium-sparing diuretics (e.g., Aldactone, Midamor) cannot be administered or when high-dose sodium drugs are administered (e.g., carbenicillin), close monitoring and replacement of potassium are important.|
|Observe for signs of digoxin toxicity when used: reports if blurred vision, vomiting, nausea, increasing atrial dysrhythmias, and heart block.||Hypokalemia enhances the effect of digoxin, slowing cardiac conduction.|
|Monitor laboratory results as indicated.|
|Correction of metabolic alkalosis raises serum potassium level and decreased replacement needs. Correction of acidosis drives potassium back into the cells, resulting in reduced serum levels and increased replacement needs.|
|Frequent regular checking of serum potassium should be done during replacement therapy especially in the presence of insufficient renal function.|
|Administer potassium orally or intravenously.||May be required to correct deficiencies when changes in medication, therapy, and dietary intake are inadequate.|
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Endocrine and Metabolic Care Plans
Nursing care plans related to the endocrine system and metabolism:
- Acid-Base Balance
- - Respiratory Acidosis Nursing Care Plan
- - Respiratory Alkalosis Nursing Care Plan
- - Metabolic Acidosis Nursing Care Plan
- - Metabolic Alkalosis Nursing Care Plan
- Addison's Disease | 3 Care Plans
- Cushing’s Disease | 6 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Diabetes Mellitus Type 2 | 13+ Care Plans
- Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) | 4 Care Plans
- Eating Disorders: Anorexia & Bulimia Nervosa | 7 Care Plans
- Fluid and Electrolyte Imbalances | 10 Care Plans
- - Fluid Balance: Hypervolemia & Hypovolemia
- - Potassium (K) Imbalances: Hyperkalemia and Hypokalemia
- - Sodium (Na) Imbalances: Hypernatremia and Hyponatremia
- - Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia
- - Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperthyroidism | 7 Care Plans
- Hypothyroidism | 3 Care Plans
- Obesity | 4 Care Plans
- Thyroidectomy | 5 Care Plans