Nursing Diagnosis & Care Plan for Fluid and Electrolyte Imbalance- Student’s Guide
Introduction
Fluid imbalance occurs when the body contains an abnormal amount of fluid or does not contain enough fluid. An imbalance can be due to dehydration, excess drinking, kidney disease, heart failure (HF), or other conditions.
This guide is meant to educate nursing students about fluid imbalance. As you read, keep in mind that our top writers are ready to help in case you get stuck or cannot complete your nursing assignment due to other reasons such as a busy schedule. All you need to is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Fluid Imbalance
Causes of fluid imbalance include:
• Dehydration- Occurs when a person does not drink enough fluid to balance the amount lost through urination, sweat, and bowel movements. Dehydration can occur in hot weather or during heavy exercise.
• Excess drinking- Occurs when a person drinks more fluid than the body can use.
• Heart failure (HF)- Heart failure causes salt and water to be retained in the blood vessels of the lungs and kidneys, leading to fluid accumulation.
– Cardiomyopathy- The heart muscle weakens due to a change in its structure or a decrease in its function.
– Cardiac arrhythmias- Cardiac arrhythmias are irregular heartbeats that can cause the heart to beat too slowly or quickly, leading to fluid buildup in the lungs and abdomen.
• Kidney disease– Decreased kidney functioning leads to accumulation of sodium and water (edema) in the body.
• Diabetes mellitus- The sugar level in a person with diabetes is too high, resulting in excess fluid building up in the blood vessels and tissues.
• Nephrotic syndrome- This disorder occurs when protein leaks out of healthy kidneys into the urine. Red blood cells get smaller and weaker as this process occurs, causing fluid to stay in the blood.
Signs and symptoms of fluid imbalance
A patient experiencing fluid imbalance may show the following signs and symptoms.
• Increased thirst and urination— may occur as a result of increased fluid intake or the body’s attempt to eliminate excess fluids.
• Oliguria— A decrease in urination; may be a sign of kidney failure.
• Weight gain— Occurs when water is retained. The patient will feel full after eating, and sleepiness, nausea, and vomiting are common with fluid retention.
• Weight loss— Occurs when dehydration occurs. Signs of dehydration may include dry mouth and tongue, decreased urine output, low blood pressure, rapid heart rate, and cool skin that is slow to return to normal temperature after being exposed to the heat.
• Shortness of breath— May occur if there is an abnormal accumulation of fluid in the lungs.
• Chest pain and palpitations— May occur if there is excess fluid in the heart or lungs.
• Headache, confusion, and irritability— Often occur with increased sodium concentration.
• Confusion, decrease alertness, and inappropriate behavior— Occurs if a person has too much water in the body (congestive heart failure, nephrotic syndrome, or diabetes).
• Muscle cramps— May occur if a person with dehydration becomes very active.
Fluid imbalance risk factors
A patient experiencing fluid imbalance is at risk of developing the following complications:
• Cardiovascular strain— If there is excess fluid in the body, blood volume increases, and heart function may be compromised. The resulting strain can damage blood vessels and increase the risk of a heart attack.
• Liver dysfunction— If a fluid imbalance occurs due to kidney disease, increased pressure on the liver can cause cirrhosis or failure.
• Neurological complications— Inadequate hydration can result in neurological complications such as confusion or seizures. This is most commonly seen in infants and those with psychiatric disorders.
• Edema— The accumulation of fluid in the tissues increases pressure in the veins and impairs circulation.
Nursing diagnosis for fluid imbalance
The following nursing diagnoses are related to fluid imbalance:
• Risk for impaired gas exchange related to inadequate intake or loss of fluid and electrolytes
• Deficient knowledge [impaired] regarding the assessment of own hydration status
• Noncompliance [related to disease process, complex treatment regimen, sick role], related to insufficient information about the need to drink fluids, fatigue from illness, etc.
• Deficient community health related to lack of access to adequate nutrition
• Impaired skin integrity related to inadequate fluid intake and altered tissue perfusion
• Risk for constipation [activity intolerance] related to limited physical activity as a result of pain or weakness caused by cardiac failure or hypoalbuminemia
• Potential for infection [related to decreased perfusion of mucous membranes], related to lack of skin turgor, dry mouth and nasal passages, lethargy, sunken eyeballs
• Altered fluid volume related to diabetes mellitus with resultant glucose intolerance or nephrotic syndrome
• Alteration in comfort [disturbed] related to thirst and dry mouth
• Potential impaired gas exchange if the fluid imbalance is severe enough or prolonged enough.
Nursing care plans for patients with fluid imbalance
Plan of care for patients with fluid imbalance: The care plan for patients experiencing fluid imbalance includes the following interventions.
• Teach the patient the signs and symptoms of dehydration, including decreased urine output, dry mouth, and tongue, and decreased blood pressure.
• Treatment consists of restoring fluid balance and electrolyte (sodium, potassium, chloride) levels to normal. Cool fluids with added sugar can be given to the patient orally or through a nasogastric tube when oral intake is impossible. The patient may need intravenous solutions for rehydration if he has a disorder damaging the small intestine (Crohn disease, celiac disease) or if swelling in the gastrointestinal tract impairs normal absorption. Monitoring of vital signs and urine output is necessary to ensure patient safety.
• When adequate intake cannot be maintained, explain to the family that total parenteral nutrition may be required (TPN). Instruct them to call the physician if they have questions.
• When adequate intake can be maintained, encourage a diet of foods high in potassium and salt (cured meats, eggs) and low in sodium (fresh fruits, vegetables).
Plan of care for patients with altered fluid volume: Patients with altered fluid volume may need individualized care plans. The plan of care for the following patients with fluid volume imbalances emphasizes monitoring vital signs and includes interventions that ensure safety for these patients:
• Patients with diabetes mellitus and those who have undergone gastric bypass surgery or pancreatoduodenectomy are at risk for hypokalemia (low blood levels of potassium). Monitor potassium levels often and provide oral or parenteral supplements as prescribed.
• Patients with liver failure or those taking diuretic medications are at risk for hypovolemic hyponatremia (low blood levels of sodium).
• Hypervolemic hyponatremia may be seen in patients with low urine volume (such as those with chronic kidney failure) and in individuals taking certain diuretics. Monitor profoundly obese individuals for hypovolemic hyponatremia.
• Patients with heart failure are at risk for hypervolemic hyponatremia; monitor sodium levels closely in these patients.
• Patients who have been receiving prolonged TPN are at risk for hypervolemic hyponatremia.
You may also check Nursing Diagnosis, Care Plans, and Interventions for Hypovolemic Shock
Treatment for fluid imbalance
Treating fluid imbalance may include the following:
• Restoring fluid volume when it is low and preventing further overload when present. This can be accomplished with electrolyte-containing solutions given through a nasogastric tube or by intravenous administration.
• When hypernatremia (high blood levels of sodium) is the result of fluid overload, treating the cause is the first priority.
• Treating underlying disease conditions such as liver and heart failure is essential for correcting fluid balance problems. Even changes in diet to include more fluids may be necessary to restore normal levels to kidneys or other organs.
Electrolyte Imbalance
A disorder characterized by the lack of or excess amount of certain electrically charged particles (ions) in the blood plasma and body fluids. For example, disorders such as dehydration and diarrhea can cause sodium, potassium, chloride, calcium, and magnesium imbalances. Electrolyte imbalance is also associated with the use of diuretics or laxatives.
Importance of electrolytes in the body
Electrolytes are important in the body for the conduction of nerve impulses, the transmission of messages between nerves and muscles, regulation of heartbeat and contraction of the heart muscle, maintenance of fluid balance in the body, acid-base balance (pH), production of urine by the kidneys, and kidney function.
Causes of electrolyte imbalance
Electrolyte imbalances can occur in the following conditions:
• Dehydration resulting from inadequate intake or excessive loss of body fluids may result from profuse sweating, vomiting, diarrhea, burns, and extensive blood loss.
• Diseases that affect the kidneys include diabetes mellitus and glomerulonephritis (inflammation of the membrane surrounding kidney tubules). With these conditions, excessive amounts of water and electrolytes are lost in the urine.
• Diseases that affect the adrenal glands include Addison’s disease and Cushing’s syndrome (excessive production of steroids by the adrenal cortex). With these conditions, significant potassium loss occurs through the kidneys.
• Gastrointestinal disorders such as peptic ulcers, non-steroidal anti-inflammatory drug (NSAID) ulcers, Crohn’s disease, and others where there is a loss of electrolytes in the stools.
• Metabolic diseases such as hyperthyroidism (excessive production of thyroid hormones), diabetes mellitus, kidney failure, adrenal insufficiency, malnutrition, and severe burns.
• Nutritional disorders such as anemia (reduced number of red blood cells due to low levels of iron), sickle cell disease, pernicious anemia (reduced activity of the enzyme needed for the production of vitamin B12), kwashiorkor, and marasmus (protein deficiency diseases), and bulimia.
• Potassium depletion may result from high-dose diuretic therapy, parenteral feeding with no potassium supplementation, diarrhea, vomiting, excessive sweating, and aldosterone deficiency (rare).
• Sodium depletion may occur during chronic diarrhea and in patients on low-sodium diets for hypertension (high blood pressure).
• Thirst and increased water drinking may lead to deficits in other electrolytes such as potassium, magnesium, calcium, and chloride.
Clinical manifestations of electrolyte imbalance
The following are some of the clinical signs of electrolyte imbalances:
• Cardiovascular symptoms include arrhythmias (irregular heartbeat), decreased heart muscle contractility, and congestive heart failure.
• Central nervous system symptoms include a disturbance in mental status, weakness, convulsions, personality changes, depression, apathy, coma, irritability, agitation, or anxiety.
• Gastrointestinal symptoms include nausea and vomiting.
• Musculoskeletal symptoms include muscle cramps, weakness, and paralysis.
• Skin signs may include dry skin, discoloration of the face due to poor blood flow (cyanosis), and a tingling or pins-and-needles sensation caused by nerve damage. In severe cases, swelling or muscle breakdown (rhabdomyolysis) can occur with the release of muscle contents into the bloodstream.
Nursing diagnosis of electrolyte imbalance
An electrolyte imbalance refers to the imbalanced sodium, potassium, calcium, magnesium, and chloride concentrations in the body fluids. It manifests symptoms such as nausea, muscle cramps, weakness, polyuria (increased frequency of urination), increased thirst, cardiac arrhythmias (irregular heartbeat), seizure activity, etc. The nursing diagnosis with this article are as follows:
1. Deficient Knowledge related to electrolyte imbalance and its factors that contribute towards it – sodium, potassium, calcium, etc.
2. Risk for Injury related to muscle weakness and constipation
3. Anxiety, related to the changes of clinical status (changing values in laboratory results)
4. Constipation, related to the deficits of potassium
5. Altered Nutrition: Less than Body Requirements related to nausea and vomiting etc.
6. Deficient Fluid Volume related to polyuria (increased frequency of urination) due to mineral imbalance
7. Risk for activity intolerance, related to the changes in clinical status
8. Threatened Self-esteem, related to the possible complications of electrolyte imbalance, etc.
Nursing care plan for the prevention and management of electrolyte imbalance
-Nursing Diagnosis: Deficient Fluid Volume related to polyuria (increased frequency of urination)
Plan: Administer IV fluids using normal saline solution at a rate of 150 mL × 3/day, in addition to oral fluids at a rate of 200-300 mL per day.
• Teaching: Explain the rationale for IV administration and monitor urine output. Monitor skin turgor and mucous membranes using normal saline flush to check the level of hydration. Monitor cardiac status by checking liver enzymes such as AST, ALT, and LDH levels. If the patient experiences significant muscle weakness or hypotension, administer B-complex vitamins to correct for possible deficiencies.
• Patient Teaching: Explain that polyuria is likely due to mineral imbalances in the body fluid and may be remedied by taking oral fluids regularly and IV fluids using normal saline solution.
-Nursing Diagnosis: Imbalanced Nutrition, less than Body Requirements related to nausea and vomiting
Plan:
- Encourage the patient to eat small portions of low-sugar foods such as toast or crackers.
- Offer frequent small meals instead of 3 large meals per day.
- Use antacids to relieve heartburn symptoms.
- Administer antiemetic agents, such as ondansetron and promethazine to relieve nausea.
• Teaching: Explain that the emetic drugs will help alleviate vomiting symptoms by blocking receptors in the brain that trigger vomiting. Emphasize the importance of taking antiemetics with food and not on an empty stomach.
• Patient Teaching: Instruct the patient to eat small portions of low-sugar foods like toast or crackers. Instruct the patient to take antiemetics with food and not on an empty stomach.
-Nursing Diagnosis: Impaired Skin Integrity related to decreased blood flow (cyanosis) and a tingling or pins-and-needles sensation caused by nerve damage
Plan:
- Administer oxygen by nasal cannula or face mask.
- Encourage the patient to elevate the lower extremities to relieve pressure on the inferior vena cava, resulting in inadequate circulation and cyanosis of the skin.
- Monitor capillary refill using pulse oximetry (SpO2) readings. If cyanosis (blue tint to the skin) becomes severe, use a cardiopulmonary bypass machine and intravenous vasoactive drugs (drugs that act on the blood vessels) depending on the severity of symptoms.
-Nursing Diagnosis: Deficient Knowledge related to the rationale for administering oxygen and capillary refill
Plan:
- Explain that oxygen is administered since respiratory failure is a possible fluid and electrolyte imbalance complication.
- Monitor blood pressure, heart rate, temperature, and capillary refill using pulse oximetry (SpO2) readings to ensure adequate circulation.
- Explain the rationale for administering oxygen by nasal cannula or face mask and the importance of monitoring for signs of cyanosis such as pallor, blueness, or a tingling sensation in the hands and feet.
- Discuss the rationale for elevating lower extremities to relieve pressure on the inferior vena cava, resulting in inadequate circulation and cyanosis of the skin.
• Teaching: Explain that cardiac status should be monitored using capillary refill and pulse oximetry (SpO2) readings if symptoms worsen despite oxygen administration. Explain that cardiac status can be monitored by measuring liver enzymes such as AST, ALT, and LDH levels. If the patient experiences significant muscle weakness or hypotension, administer B-complex vitamins to correct for possible deficiencies.
• Patient Teaching: Instruct the patient to monitor blood pressure, heart rate, temperature, and capillary refill using pulse oximetry (SpO2) readings if oxygen is administered. Instruct the patient to elevate lower extremities to relieve pressure on the inferior vena cava, resulting in inadequate circulation and cyanosis of the skin.
Referral: Consult with dietitian and pharmacist for possible dietary and drug interventions.
Ensure that the patient understands how to monitor their own blood pressure and temperature using a thermometer and aneroid cuff or sphygmomanometer.
• Patient Teaching: Instruct the patient to measure and compare vital signs such as blood pressure, heart rate, temperature, and capillary refill using pulse oximetry (SpO2) readings at home and report significant changes.
-Nursing Diagnosis: Impaired Gas Exchange related to a decrease in CO2 level causing respiratory alkalosis (due to excess loss of H+ ions) and hypoxia (lack of oxygen delivery to tissues)
Plan:
- Administer high flow O2 (at least 6 L/min) to the patient.
- Consider using a portable CO2 absorber (alkalinizing agent) and administer IV potassium gluconate to increase pH levels in the blood, which could help reduce metabolic acidosis.
- Ensure that urine output is adequate because the decreased renal function can result in various clinical problems such as dehydration, electrolyte imbalances, and hyperkalemia (elevated blood potassium levels).
• Teaching: Instruct the patient to monitor capillary refill using pulse oximetry (SpO2) readings. If SpO2 reading is low, inform the patient that oxygen is being administered and provide reassurance.
• Patient Teaching: Instruct the patient to monitor capillary refill using pulse oximetry (SpO2) readings. If SpO2 reading is low, instruct the patient to notify the health care provider immediately because oxygen is being administered and provide reassurance.
• Referral: Consult with dietitian and pharmacist for possible dietary and drug interventions.
