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.
Sodium (Na) Imbalances: Hypernatremia and Hyponatremia
Sodium (Na) is a major extracellular fluid cation. The balance of sodium is important for many physiologic functions that include facilitating impulse transmission in nerve and muscle fibers by participating in the sodium-potassium pump; assists in acid-base balance by combining with bicarbonate and chloride.
The normal serum sodium concentration ranges from 135 to 145 mEq/L.
- Hypernatremia is defined as serum sodium levels above 145 mEq/L.
- Hyponatremia is defined as serum sodium levels below 135 mEq/L.
Risk For Electrolyte Imbalance (Hypernatremia)
May be related to
- Diarrhea, vomiting.
- Diabetes insipidus, renal disease.
- Fever, profuse sweating.
- High-protein diet.
- Side effects of medication such as osmotic diuretics.
Possibly evidenced by
- [not applicable].
- Client will display heart rate, blood pressure, and laboratory results within the normal limit and absence of neuromuscular irritability and cognitive impairment.
|Monitor respiratory rate and depth.||Metabolic acidosis secondary to hyperchloremia may result in deep, labored breathing with air hunger, which can lead to a cardiopulmonary arrest if left untreated.|
|Monitor blood pressure.||Depending on the fluid status, hypertension or hypotension may be present. The presence of postural hypotension may affect activity tolerance.|
|Monitor level of consciousness and muscular strength, tone, and movement.||Sodium imbalances may cause changes that vary from irritability and confusion to seizures and coma. In the presence of a water deficit, rapid rehydration may cause cerebral edema.|
|Monitor intake and output and specific gravity. Assess the presence and location of edema. Weigh client daily.||These parameters are variable, depending on the fluid status, and are indicators of therapy needs and effectiveness.|
|Assess skin turgor, color, and temperature and mucous membrane moisture.||Water-deficit hyponatremia manifest by signs of dehydration.|
|Provide safety and seizure precaution as indicated:||Cerebral edema and sodium excess increase the risk of convulsions.|
|Allow debilitated client fluids at regular intervals. Provide free water to a client receiving enteral feedings.||May prevent hypernatremia in a client who is unable to perceive or respond to thirst.|
|Encourage meticulous skin care and frequent repositioning.||Maintains the integrity of the skin.|
|Teach the client to avoid foods high in sodium such as regular canned vegetables and vegetable juices, processed foods, snack foods, and condiments.||Decreases the risk of sodium associated complications such as stroke, heart disease, and heart failure.|
|Provide frequent oral care. Avoid the use of mouthwash containing alcohol.||Promotes comfort and prevent further drying of mucous membranes.|
|Identify the client at risk for hypernatremia and likely cause such as sodium excess or water deficit.||Early identification and intervention prevent serious complications associated with this problem.|
|Encourage increase oral and IV fluid intake.||Replacement of total body water deficit will gradually restore sodium and water balance.|
|Monitor serum electrolytes, osmolality, and arterial blood gasses, as indicated.||This will evaluate the therapy needs and effectiveness.|
|Restrict sodium intake and administer diuretics as indicated.||Sodium intake restriction while promoting renal clearance decreases serum sodium levels in the presence of extracellular fluid excess.|
Risk For Electrolyte Imbalance (Hyponatremia)
May be related to
- Diarrhea, vomiting.
- Renal dysfunction.
- Treatment-related side effect such as medications, gastric suctioning, electrolyte-free intravenous (IV) solutions.
- Water intoxication.
Possibly evidenced by
- [not applicable].
- Client will display heart rate, blood pressure and laboratory results within the normal limit for the client; absence of muscle weakness; and neurological irritability.
|Monitor respiratory rate and depth.||Co-occurring hypochloremia may produce slow and shallow respiration as the body compensates for metabolic alkalosis.|
|Monitor intake and output; Calculate fluid balance. Weigh client daily.||Fluid balance indicators are important since either fluid excess or deficit may occur with hyponatremia.|
|Assess level of consciousness and neuromuscular response.||A deficit in sodium levels may lead in decreased mentation to coma, as well as generalized muscle weakness, cramps, or convulsions.|
|Note for signs of circulatory overload, as indicated||Administration of sodium-containing IV fluids in the presence of heart failure increases risk.|
|Identify client ar risk for hyponatremia and the specific cause such as sodium loss or fluid excess.||Provides clues for early intervention. Hyponatremia is a common imbalance, especially in the elderly, and may range from mild to severe. Severe hyponatremia can cause neurological damage or death if not treated properly.|
|Provide safety and seizure precautions. Maintain a calm, quiet environment.||Decreases CNS stimulation and risk of injury from neurological complications such as seizures.|
|Irrigate nasogastric tube (when used) with normal saline instead of water.||The use of isotonic solution during irrigation decreases gastrointestinal electrolyte losses.|
|Encourage fluids and foods high in sodium such as meat, milk, beets, celery, eggs, and carrots. Use fruit juices and bouillon instead of water.||Unless sodium deficit causes serious symptoms requiring immediate IV replacement, the client may benefit from slower replacement by oral method or removal of previous salt restriction.|
|Monitor serum and urine electrolytes and osmolality.||Evaluates therapy needs and effectiveness.|
|Provide or restrict fluids, depending on fluid volume status.||In the presence of fluid excess or SIADH, fluid restriction is indicated while in the presence of hypovolemia, volume losses are replaced with isotonic saline, or, on occasion, hypertonic solution when hyponatremia is life-threatening.|
|Administer medications, as indicated:|
|May be used in combination with a loop diuretic (e.g., Lasix) to correct fluid volume excess, especially in the presence of heart failure.|
|Helpful in treating chronic SIADH, or when severe water restriction may not be tolerated.|
|Useful in reducing fluid excess to correct sodium and water balance.|
|Used to correct potassium deficit, especially during diuretic therapy.|
|Used to replace deficits in the presence of chronic or ongoing losses.|
|Prepare for/assist with dialysis as indicated.||May be done to restore sodium balance without increasing fluid level when hyponatremia is severe or response to diuretic therapy is 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