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Maret 11, 2011

NURSING CARE PLAN OF CLIENT WITH FLUID AND ELECTROLYTE IMBALANCE

NURSING CARE PLAN OF CLIENT

WITH FLUID AND ELECTROLYTE IMBALANCE

A. FLUID AND ELECTROLYTE BALANCE

1. Definition of Body Fluid and Electrolyte Balance

The balance of fluid in the body fluid compartment; total body water; blood volume; extra cellular space; intracellular space, etc., maintained by processes in the body that regulate the intake and excretion of water and electrolyte, particularly sodium and, potassium.

(www.find-health-articles.com).

The state of body in relation to the intake and excretion of water and electrolyte, particularly sodium and potassium, it exist in a metabolic balance internally with body fluid compartment, total body water, blood volume, extra cellular space, etc., externally trough sensible and insensible sweating. The hypothalamus controls water balance.

(medical-dictionary. thefreediconary.com).

a. Definition of Body Fluid

1) Water and its dissolved constituents make up the bulk of your body; and determine the nature of nearly every physiological process (physioweb.med.uvm.edu).

2) Total body water, contained principally in blood plasma and n intracellular and interstitial fluids.

(medical-dictionary.thefreedictionary.com)

b. Distribution of Body Fluid

Body fluid are distributed in the district compartments :

1) Intra Cellular Fluid (ICF)

ICF comprises all the fluid within body cells, this fluids contains dissolved solutes approximately 40 percents of body weight is ICF.

2) Extra cellular fluid (ECF)

ECF is all fluid outside cell, which is derived in to two smaller compartment.

a) Interstitial fluid is between the cells and outside the blood vessels.

b) Intravascular fluid is blood plasma.

c. Competition of Body Fluid

1) Electrolyte

An electrolyte is an element or compound that melted or dissolved in the water or another solvents, separates into ions and is able to carry on electrical current.

a) Cations are positive charged electrolyte.

b) Anions are negative charged electrolyte.

2) Minerals

Minerals which are ingested as compound are usually referred to by the name a metal, non-metal, radical or phosphate rather than by the name of compound of which they are apart.

3) Cells

Cells are functional basic units of all living tissue, the example of cell within body fluids are Red Blood Cell (RBC) and White Blood Cell (WBC).

d. Movement of Body Fluids

1) Osmosis

Osmosis involves the movement of a pure solvent, such as water through semi permeable membrane from an area of lesser solute concentrations to an area of greater solute concentrations.

a. The actions occur through osmosis :

1) Isotonic is a solution the same osmolality as blood plasma.

2) Hypertonic is a solution of higher osmotic pressure pulls fluid from cells.

3) Hypotonic isotonic of lower osmotic pressure moves fluid into the cells, causing them to enlarge.

b. The osmosis pressure of the blood is affected by plasma proteins, especially albumin; albumin exerts colloid osmotic or oncotic pressure which tends to keep fluid in the intravascular compartment.

2) Diffusion

Diffusion is a movement of a solution (gas or substances) in a solution across a semi permeable membrane from an area of higher concentration to an of lower concentration.

3) Filtration

Filtration is the process by water and diffusible substances that move together in response to fluid pressure.

4) Active Transport

Active Transport requires metabolic activity and expenditure of energy to move materials across cell membranes

e. Regulation of Body fluid

1) Fluid intake

a) Fluid intake is regulated primarily through the thirst mechanism; the thirst control-center is located within the hypothalamus in the brain. Thirst is the conscious desire for water and on of major factors that determine fluid intake (Weldy, 1996, cited in Potter & Perry’s (2001)).

b) The average adult’s intake is about 2200 to 2700 ml per day; oral intake accounts for 1100 to 1400 ml, solid foods about 800 to 1000 ml and oxidative metabolism 300 ml daily (Horne and other, 1997, cited in Potter & Ferry’s (2001)).

2) Hormonal Regulation

a.) Antidiuretics Hormone (ADH)

ADH is stored in posterior pituitary gland and it’s released in response to charges in blood osmolality.

b) Aldosterone

Aldosterone is released by the adrenal cortex in response to increase plasma potassium levels or as a part of rennin – angiotensin – aldosterone mechanism to counteract hypovolemia.

c) Rennin

Rennin is a proteolytic enzyme that secreted by the kidneys, response to decrease renal perfusion secondary to a decrease in extra cellular volume; rennin acts to produce angiotensin 1, which cause to vasoconstriction.

3) Fluid Output Regulation

a) Kidneys

Kidneys are the major regulatory organs of fluid balance, they received approximately 180 liters of plasma to filter each day and produce 1400 until 1500 ml of urine.

b) Skin

Water loss from the skin is regulated by the sympathetic nervous system which is sweat glands; water loss from the skin can be a sensible or insensible loss; an average of 500 to 600 ml of sensible or insensible fluids is lost via the skin each day.

c) Lungs

The lungs expire 300 – 400 ml of water daily; this insensible water loss may increase in response to charges in respiratory rate and depth.

d) GI Tract

GI Tract plays a vital role in fluid regulation, approximately 3 to 6 liters of isotonic fluid is moved into the GI Tract. Under normal conditions, the average adult loses only 100 to 200 ml of the 3 to 6 liters each day through fasces.

f. Regulation of Electrolytes

1) Cations

Major cations within the body fluids include sodium (Na), Potassium (K) , Calcium (Ca), and Magnesium (Mg).

a) Sodium

Sodium is the most abundant cation (90%) in ECF; sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulses transmission, regulation of acid-base balance and participation in cellular chemical reactions.

b) Potassium

Potassium regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction.

c) Calcium

Calcium is stored in bone, plasma and body cells, 99% of calcium is located in bone and only 1% calcium is in ECF; approximately 50% of calcium in the plasma is bound to protein, primarily albumin and 40% is free ionized calcium. Calcium is necessary for bone and teeth formation, blood clotting, hormone secretions, cell membrane integrity, cardiac conduction, transmission of nerve impulses and muscle contractions.

d) Magnesium

Magnesium is essential for enzyme activities, neurochemical activities, on a cardiac and skeletal muscle excitability. Plasma concentration of magnesium range from 0,7 – 0,95 mmol/L. About 50% to 60% of body magnesium is contained within the ECF compartment, the rest is located inside the cell (Beare and Myers, 1998, citied in Potter & Perry’s. (2001)).

2) Anions

Three major anions of body fluids are chlorine (x-), bicarbonate (HCO) and phosphate (PO) ions.

a) Chlorine is the major anion in ECF, normal concentration of chlorine range from 98-106 mmol/L.

b) Bicarbonate is found in ECF and ICF, normal arterial

Bicarbonate levels range between 23-32 mmol/L; venous bicarbonate is measure as carbon dioxide concert and the normal value is 24-34 mmol/L.

c) Phosphorus

Nearly all phosphorus in the form of phosphate (PO), phosphate also promotes normal neuromuscular action and participates in carbohydrate metabolism.

g. Regulation of Acid- Base Balance

1) Chemical Regulation

The largest chemical buffer in ECF is the carbonic acid and bicarbonate buffer system.

2) Biological Regulation

Biological buffering occurs when hydrogen ions are absorbed or released by cells.

3) Physiological Regulations

Two physiological buffer in the body are :

a) Lungs

The lungs adapt rapidly to an acid-base imbalance, they act to return the normal pH before the action of the biological buffers.

b) Kidneys

Kidneys take few hours to several days to regulate acid-base imbalance; they reabsorb bicarbonate in cases of acid excrete and it in cases of acid deficit. The kidneys use the ammonia mechanism certain amino acids are chemically changed within the renal tubulus into ammonia, which in the presence of hydrogen ions ammonium and is excreted in the urine (Beare and Myers, 1998, cited in Potter & Perry’s (2001)).

  1. Pathophysiology of Body Fluids

a. Electrolyte Imbalances

1) Sodium Imbalances

a) Hyponatremia is a lower than normal concentration of sodium in the blood (serum) which can occur with net sodium loss or water excess.

.b) Hypernatremia is a greater than normal contrentation of sodium in ECF that can be caused by excess water loss or an overall sodium excess.

2) Potassium Imbalance

a. Hypokalemia is one of the most common electrolyte imbalance, in which an in adequate amount of potassium circulates in ECF. The most common cause of hypokalemia is use of potassium easting diuretic such as thiazide and loop diuretics.

b. Hyperkalemia is a greater than normal amount of potassium in the blood, the primary cause of hyperkalemia is renal failure, because any decrease In renal function diminishes the amount of potassium the kidney can excrete.

3) Calcium Imbalances

a. Hypocalcemia represent drop in serum and ionized calcium, it can result from several illness, renal insufficiently.

b. Hypercalcemia is an increase in the total serum concentration, it calcium and ionized calcium. Hyoercalcemia is frequently symptom of an underlying disease resulting in excess bone resorption with release of calcium.

4) Magnesium Imbalances

a. Hypomagnesaemia, a dropin serum magnesium, occurs with malnutrition and with mal absorption disordes and signs and symptom are directly related to the neuromuscular system.

b. Hypermagnesaemia is an increase in serum magnesium levels.

5. Chloride Imbalances

a) Hypochloraemia occurs when the serum chloride levels falls bellow normal.

b) Hyperchloraemia occurs when the serum chloride level rises above normal.

  • Fluid Disturbances

The basic types of fluid imbalances are isotonic and osmolar, isotonic deficit and excess exists when the water and electrolyte are gained or loss in equal proportion. In contrast, osmolar imbalances are losser or excesses of only water so that the concentration (osmolality) of the serum is affected.

  • Acid Imbalances

1. Respiratory acidosis is marked by an increased arterial carbon dioxide concentration (PaCO2), excess carbonic acid (H2CO3) and an increased hydrogen ion concentration (decreased pH).

2. Respiratory alkalosis result is marked by decreased PaCO3 and increase pH.

3. Metabolic acidosis result because of the high acid content of the blood, which also causes a less of sodium bicarbonate, the alkaline half of the carbonate buffer system (Weldy, 1996. Cited in Potter & Perry’s. 2001)

4. Metabolic alkalosis is marked by the heavy loss of acid from the body or by increased levels of bicarbonate; the most common cause are vomiting and gastric sunction.

3. Clinical Manifestation

a. Hyponatremia

1. Apprehension

2. Diarrhea

3. Abdominal ramping

4. Postural hypotention

b. Hypernatremia

1. Thirst

2. Agitation

3. Restlessness and irritability

4. Dry and flushed skin

c. Hypokalemia

1. Irregular pulse

2. Ventricular dsyrhytmia

3. Decreased muscle tone

4. Weakness and fatigue

5. Intestinal distention

d. Hyperkalemia

1. Diarrhea

2. Abdominal cramps

3. Weakness

4. Anxiety

5. Paraesthesia

6. Dsyrhytmias

e. Hypocalcemia

1. Tetany

2. Hyperactive reflexes

3. Muscle cramps and pathological fracture (chronic hypocalcemia)

4. Positive trosseau’s sign (corpopedal spasm with hypoxia)

5. Positive chvostek’s sign (concentration of facial muscles when facial nerve is tapped)

6.Tingling and numbness of finger and circumoral region

f. Hypercalcemia

1. Anorexia

2. Weakness

3. Nausea and vomiting

4. Low back pain

5. Lethargy

6. Decrease level conciousness

g. Hypimagnesaemia

1. Muscular tremor

2. Positive chvostek’s sign and trousseau’s sign

3. Dsyrhytmias

4. Confusion and disorientation

h. Hypermagnesaemia

1. Flushing

2. Hypotention

3. hypoactive deep tendon reflexes

4. Decreased depth and race of respiration

i. Respiration Acidosis

1. Confusion

2. Ventricular dsyrhytmias

3. Dizziness

j. Respiration Alkalosis

1. Dizziness

2. convulsions

3. Confusion

k. Metabolic Acidosis

1. Headache

2. Confusion

3. Tachypnoea with deep respiration

l. Metabolic Alkalosis

1. Tingling and numbness of extremities

2.Dizziness

3. Tetany

4. Muscles cramps

5. Dsyrhytmias

4.Treatment

a. Health Promotion

Health promotion activities in the area of fluid, electrolyte, and acid base imbalance focus on primarily in client teaching. For examples client with renal failure must avoid excess of intake of fluid, sodium, potassium and phosphorus. Though diet education these clients learn the types of food to avoid and suitable volume of fluid they are permitted daily.

b. Daily Weight Intake and Output Measurements

Clients with fluid and electrolyte alternation should be weighed daily; daily weight is the single most important indicator of fliud status/(Horne and others,1997, cited in potter and perry;s, 2001). Weight should be determined at the some time each day with the some scale after the clients voids; the scale should be calibrated each day or routinely. Intake and Output records provide additional information about fluid balance; intake and output measurements when examined for trends can indicate whether excretion of fluid through the kidneys has diminished.

c. Enteral Replacement Of Fluids

Oral replacement of fluids and electrolytes is appropiates as long as that client not so physiologically unstable that oral fluid can not be replaced rapidly.

d. Restriction Of Fluids

Client who retain fluids and have fluid volume oxcers (EVE) require restricted fluid intake.

e. Parenteral Replacement Of Fluid and Electrolytes

Fluid and infusion may be replaced through infusion directly into blood rather than via the digestive system; parenteral replacement includes total parenteral nutrition (TPN), IV fluid and electrolyte theraphy (Crystalloid), and blood complement (colloid) administration.

B. NURSING CARE CONCEPT

This concept of nursing care plan for client with fluid and electrolyte imbalance is based on literature review cited from Potter’s and Perry’s (2001) and Kozier & Erbs (1991).

1. Assessment

a. Nursing History

The nursing assessment begins with a client history, which is designed to reveal any risk factors or preexisting condition that may cause or contribute to a disturbances of hold, electrolyte, and acid base balances.

1. Age

An infant’s proportioning of total body water is greater than that of the children or adult. Infants are not protected from fluid loss because they ingest and excrete to relatively grater daily volume than adults. (Horne and other, 1997). Therefore they are at a greater risk for fluid deficites (FVDs) and hyperosmolar imbalance because body water loss is proportionately grater per kilogram of weigh.

2. Acute Illness

Recent surgery, held and chest trauma, shocck and second or third degree burns are condition that place clients at high risk for fluid, electrolyte and acid base alteration.

a. Surgery

The more extensive the surgery and hold loss during the surgical procedure, the greater the body’s response to the surgical trauma. In addition, after surgery clients can exhibit many acid base changes. The client who is reluctant to breathe deeply and caugh may develop respiratory acidosis due to retained PaCO2.

b. Burns

The greater the body’s surface burned, the greater the fluid loss. The burned client loses body’s fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. It accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudates. Third, water vapor and heat are lost in proportion to the amount of skin that is burned away. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Last, sodium and water shift into the cells, further compromising extra cellular fluid volume.

3. Chronic Illness

a. Cancer

The types of fluid and electrolyte imbalances that are observed in a client with cancer depend on the type and progresion of the cancer, client with cancer at risk for fluid and electrolyte imbalances related to the side effects, e.g. diarrhea, and anorexia of their chemoterapeutic and radiological treatments.

b. Cardiovascular disease

In the client with cardiovascular disease a diminished cardiac output reduces kidney perfusion, causing the client to experience decease in urinary output. The client will retrain sodium and water , resulting in circulatory over load, and run the risk of developing pulmonary edema.

c. Renal disorders

Kidney disease alters fluid and electrolyte balance by tile abnormal retention of sodium. Chloride, potassium and water extra cellular compartment. Metabolic acidosis result when hydrogen ions are retained due to decreased renal function.

d. Gastrointestinal disturbances

Gastrointestinal an nasogastric suctioning result in a loss of fluid, potassium, and chloride ions.

4. Environmental factor

The nurse should also include certain environmental factors in nursing history, client have a participated in vigorous exercise or who have become exposed to extremes may have clinical sign of fluid and electrolyte . loss fluid from sweating varies and reach amaximal rate of 21/hour (ignativiciuos, workman and mishler,1999),cited in potter perrys.(2001)

5. Diet

Dietary intake of fluids ,salt, potassium, calcium, magnesium, necessary carbohydrate and protein help maintain normal fluids , electrolyte and acid base status .recent changed in apatite or the ability to chew and swallow can affect nutritional status and fluid hydration.

6. Life style

If a client already has preexisting medical risk ,such as a history of smoking or alcohol consumption ,they can further impair the client ability to adapt to fluid, electrolyte and acid base alteration .

7. Medication

The nurse will assess the client knowledge of side effect and adherence to medication schedule and the client knowledge of potential side effect over . the counter medication on fluids electrolyte and acid base balance. (Beare and Myers ,1998,cited in potter & perry’s.(2001))

b. Physical assessment

A trough examination is necessary, because fluid and electrolyte imbalance or acid base disturbance can affect all body system.

Physical and Behavioral Nursing Assessment For Fluid, Electrolyte ,and Acid -Base Imbalance

Assessment

imbalance

Weight(change)

  • 2% -5% loss

  • 5%-10% loss
  • 1%-15%loss
  • 15-20& loss
  • 2%-gain loss

  • 5% - gain loss
  • 8% - gain loss

Mild Fluid volume deficit (FVD)

Moderate FVD

Severe FVD

Death FVD

Mild fluid volume exeess (FVE)

Moderate FVE

Severe FVE

Head

History

  • Headache

  • Dizziness

Observation:

  • Irritability

  • Lethargy

  • Confusion , disorientation

FVD metabolic or respiration acidosis , metabolic alkalosis

FVD respiratory acidosis or alkalosis , hyponatremia

Metabolic or respiration acidosis ,hypernatremia , hypokalemia

FVD metabolic alkalosis, respiratory acidosis , hypercalcemia

FVD hypomagnesaemia , metabolic acidosis hypokalemia

Eyes:

Inspection

  • Sunken dry conjuntiva decreased or absent tearing
  • Periorbital oedema papelleoedema

History

  • Blurred vision

FVD

FVE

FVE

Throat and mouth

Inspection

  • Sticky, dry mucous membranes ,dry cracked lips decreased salivation
  • Longitudinal tongue furrows

FVD hypernatremia

Cardiovascular system

Inspection

  • Flack neck vein
  • Distended neck vein
  • Dependent body part : legs, sacrum,back slow venous

Palpation

  • Oedema Dependent body part : legs, sacrum,back
  • Increase pulse rate

  • Decrease pulse rate

  • Weak pulse
  • Decrease capillary filling
  • Bounding pulse

Auscultation

  • Blood pressur low or without orthostatic changes
  • Third heart sound

  • Hypertension

FVD

FVE

FVD

FVE

Metabolic alkalosis, respiratory acidosis hyponatremia

Metabolic alkalosis, hypokalemia

FVD, hypokalemia

FVD

FVE

FVD,hyponatremia, hypokalemia,hypermagnesaemia

FVE

FVE

Respiratory systems

Inspection

  • Increase rate

  • Dysnoea

Auscultation

  • Grackles

FVE, Metabolic alkalosis, respiratory acidosis

FVE

FVE

Gastro intestinal system

History

  • Anorexia
  • Abdominal cramps

Inspection

· Sunken abdomen

· Distended abdomen

· Vomiting

· Diarrhea

Auscultation

· Hyperperistaltisis with diarrhea

Metabolic acidosis

Metabolic acidosis

FVD

Third space syndrome

FVD, hyponatremia, hyperkalaemia

Hyponatremia

FVD, hypokalaemia

Renal systems

Inspection

· Oliguria or anuria

· Diuresis

FVD, FVE

FVE

Neuromuscular system

Inspection :

· Numbness, tingling

· Muscle cramps, tetany

· Coma

· Tremors

Palpation :

  • Hypotonocity
  • Hypertonocity

Percussion :

  • Decreased or absent deep tendon reflexes
  • Increased or hyperactive deep tendon reflexes

Metabolic alkalosis, hypocalaemia, potassium imbalances

Hypocalaemia, metabolic or respiratory Alkalosis

Hyperosmolar or hypoosmolar

Imbalances hyponatremia

Respiratory acidosis, hypomagnesaemia

Hypokalaemia,hypercalaemia

Hypocalaemia, hypomagnesaemia,metabolic alkalosis

Hypercaleaemia, hypermagnesaemia

Hypocalceaemia, hypomagnesaemia

Skin

Body temperature

  • Increase

  • Decreased

Inspection

· Dry,flushed

Palpation

· Inelastic skin turgor ,Cold, Clammy skin

Hypernatremia,Metabolic acidosis

FVD

Hypernatremia, FVD, Metabolic acidosis

FVD

c. Measuring fluid intake and output

Measuring and recording all liquid intakes an output during 24 hour period is an important part of the client assessment database for liquid and electrolyte balance oral intake include all liquid taken by mouth, such as gelatin, ice ,cream and water.

Output include urine diarrhea ,vomit, gastric suction drainage from post surgical, wound or other tubes .

Ambulatory client urinary output is recorded after each trip to the bathroom ,the client has instruction to measure and record their own output. When a client has an indwelling Foley cateter ,drainage tube suction that output is recorded at the end of each nursing shift or more frequently.

Intake

Date

22.00-06.00

06.00-14.00

14.00-22.00

24hr

Total

P.O. Intake

Intake

Tube feeding

Hyperalimentation

I.V. Primary

I.V.P.B

Blood/blood Products

Output

Urine

Output

Emesis

G.I. Suction

Drainage

Chest Tube

d. Laboratory Studies

These test include serum and urinary electrolyte levels BUN levels urine specific gravity, ABG reading.

  1. Serum electrolyte levels are measure to determine the hydration status (blood plasma)
  2. The complete blood count is determination of number and type of red and white blood cells per cubic millimeter
  3. Blood creatinine levels are useful in measure kidney function
  4. BUN : Creatin ratio may be a better indicator of renal function (normal10:1)
  5. Arterial blood gas analysis provides information on the status of acid balance

Fluid/Electrolyte

Normal Value

Kalium Serum

3.5 – 5.0 mEq/l,

Natrium Serum

135 – 145 mEq/l,

Clourida Serum

98 – 100

Calsium Serum

9 – 10.5 mg/dl

Fosfat Serum

2.8 – 4.5 mg/dl

Magnesium Serum

1.8 – 3.0 mg/dl

Glucose Serum

70-100 mg/dl

Hematocrit

Male : 44% - 52%

Female : 39% - 47%

Blood Urea Nitrogen

10 – 20 mg/dl

0.7 – 1.5 mg/dl

Creatinin

Serum Osmolality

Posm = 2 x [Na] + Glucose

18

= 2 x [Na]

280 – 295 mOsmol/kg

Serum Protein

Total

6.8 – 8.0 g/dl

Albumin

3.5 – 5.5 g/dl

Globulin

2.0 – 3.5 g/dl

Urea Examination :

100 – 200 mEq/24 hr (40 mEq/l)

Natrium Urine

2. Nursing Diagnose

a. Fluid Volume Deficit

Decreased intravascular interstitial and or intracellular fluids. This refers to dehydration (water loss alone without change in sodium)

Defining Characteristic:

1. Change in mental status

2. Decrease blood pressure

3. Decrease pulse pressure

4. Decrease skin turgor

5. Decrease pulse volume

6. Decrease tongue turgor

7. decrease urine output

8. Decrease venous filling

9. Dry mucous membrane

10. Dry skin

11. Elevated hematocrite

12. Increase body temperature

13. Increase pulse rate

14. Increase urine concentration

15. Sudden weight loss ( except in third spacing )

16. Thirst

17. Weakness

Related Factors :

1. Active fluid volume loss related to excessive diaphoresis, vomiting, diarrhea, wound drainage or suction

2. Failure of regulatory mechanism related to neurohypophyseal impairment diabetes insipidus or pancreatic impairment

b. Fluid Volume Excess

Definition : Increase isotonic fluid retention and edema .

Defining characteristic :

1. Adventitious breath sounds

2. Altered electrolyte

3. Anasarca

4. Anxiety

5. Azotemia

6. Blood pressure change

7. Change in mental status

8. Change in respiratory pattern

9. Decrease hematocrite

10. Decrease hemoglobin

11. Dypsnea

12. Edema

13. Increase central venous pressure

14. Intake exceeds output

15. Jugular vein distention

16. Oliguria

17. Orthopnea

18. Pleura effusion

19. Positive hepatonary reflex

20. Pulmonary artery pressure change

21. Pulmonary congestion

22. Restlessness

23. Specific gravity change

24. S3 heart sounds

25. Weight gain over short period of time

Related factors :

a. Compromised regulatory mechanism

b. Excess fluid intake

c. Excess sodium intake

d. Increased loss decrease intake of protein.

e. Specific drug therapy.

3. Planning

a. Nursing diagnosis : fluid volume deficit

Outcome criteria

Nursing Intervention

Rationale

The client

· Experience a reduction or alleviation of the causative fluid loss factor, as evidenced by decrease in amount or of absence of emeses, diarrhea, or wound drainage

· Assess and document amount, color and characteristic of vomitus, diarrhea and drainage from wounds or tube

· Assess vital signs, weight and skin turgor

· Administer medication as ordered to prevent further fluid loss

· Accurate assessment enable the nurse to develop appropriate plans for fluid replacement therapy

· Medications such as antiemetics or antidiarrheals may be necessary to reduce or eliminate fluid losses

· Has a balance fluid intake and output (averaging 2500 ml per day) for 3 days

· Manifests clinical signs of adequate hydration :

a. Normal vital signs for age,sex and health status

b. Good skin turgor and color

c. Moist mucous membrane

d. Absence of thirst

e. Orientation of time place and person

f. Normal urine color, characteristic and specific gravity (1.101 to 1.025)

g. Stable weight

· Measure and document fluid intake and output

· Encourage oral fluid intake as permitted. Schedule amounts to be ingested during each shift

· Provide at the beside oral fluid that the client prefers

· Report and document an output under 30 to 60 ml/h

· Monitor vital signs every 1 to 2 hours or as the client’s condition indicates

· Assess skin and mucous membrane moisture, skin color and turgor, present of thirst and mental status

· Measuring specific gravity of urine q2h or as the client indicates

· If fluid loss is related to failure of a regulatory mechanism, assess urine for sugar and acetone and monitor serum glucose and plasma volumes as indicated

· Weight the client at the same time each day with the same amount of clothing

· Measuring intake and output allows the nurse to determine fluid balance or extent of imbalance

· Scheduling specific amounts for each shift helps the client achieve short term goals.

· Fluid intake may be greater when desired fluids are provided

· This rate of output may not be sufficient to excrete required metabolic wastes and to sustain life. It may reflect decreased blood volume flow to kidneys

· Hypotension and increased pulse rate are indicative of intravascular fluid deficit

· Poor skin turgor, tissue dryness and presence of thirst are indications of dehydration

· Dark concentrated urine and an elevated specific gravity are indicative of fluid deficit with releases antidiuretics hormone (ADH)

· These parameters measure the extent of regulatory mechanism failure (in this case, pancreatic function associated with diabetes mellitus)

· A stable body weight is measure of body fluid balance

· Has serum osmolality, hemoglobin, hematocrite within normal limits

· Monitor serum osmolality, hemoglobin, and hematocrite levels

· An increased serum osmolality and an elevated hemoglobin and hematocrite are indicative

· Identifies reason for fluid deficit and the amounts type of food and fluids to consume to prevent a recurrence

· Asses knowledge base of client/family

· Provide information about causes of fluid volume deficit, reason for prescribed therapy and prevention of recurrences

· Client understanding of condition and preventive measures may facilitate necessary follow-up care

b. Nursing diagnosis : fluid volume excess

Outcome criteria

Nursing intervention

Rationale

The client

  • Has a balance fluid intake and output (averaging 2500 ml/day ) for 3 days

  • Measure and document fluid intake and output

  • Restricted fluid intake as ordered

  • Administer diuretic as ordered

  • Measuring intake and output enables the nurse to determine fluid balance or the extent of imbalances
  • Restricted intake prevents as increase in signs associated with fluid retention (e.g. dyspnea, and circulatory overload)
  • Diuretics are given to promote urine output and fluid loss
  • Loses specified amount body weight within 1 week and then maintains stable body weight
  • Weight the client daily at the same time with the same amount of clothing
  • A gradual in weight accompanies a reduction in fluid retention
  • Regains normal hydration status, as manifested by :

a. Homodynamic status within normal limits for the client (blood pressure, central venous pressure and absence of distention

b. Clear breath sound, respiratory rate within normal limits, regular rhythm, and freedom from dyspnea or shortness of breath

c. Gradual reduction in edema

· Monitoring homodynamic status every 1 or 2 hours or as the client’s condition warrants

· Auscultate the lungs, ask the client about dyspnea and shortness of breath, observe the respiratory rate rhythm an dept, and note the position client assumes for ease of breathing

· Inspect and palpate areas of edema (periorbital, sacral, peripheral)

· Measure circumference of ankle edema

· Document location and degree of edema on scale of +1 to +4

· This allows the nurse to determine desire change (decrease) in blood pressure, central venous

· Abnormal lung sounds shortness of breath and orthopnea are indicative of excess fluid in the lungs

· Accurate assessment and documentation of edema are essential to evaluate effects of therapy

· Maintains skin integrity over edematous areas

· Provide pillow supports to edematous extremities and elevate edematous extremities above heart level whenever possible

· Provide proper skin care to edematous areas (use, thoroughly. Rinse soap from skin and apply lotions to skin)

· Inspects the skin for redness and blanching

· Pillow support reduce pressure on edematous skin. Elevation promotes venous circulation and reduces edema

· Soap has drying effect. Lotion moistens the skin and maintains its resiliency

· These sign indicate impaired blood circulation

· Has electrolyte levels within normal limits

· Monitor serum electrolyte, hemoglobin and hematocrite

· A decreased hemoglobin and hematocrite may indicate intravascular fluid volume excess. An elevated sodium level support retention. Serum sodium may be decreased with excessive fluid retention

· Identifies reasons for fluid excess and the amount and types of food and fluid to consume to prevents food and fluid to consume to prevents

· Assess knowledge of condition

· Provide information about causes of volume excess, reason for prescribed therapy, and how to prevent recurrence (e.g., by eating a low-salt diet ) and side effect of medications

· Client understands of condition and preventive measures may facilitate necessary follow-up care

4. Evaluation

a. Fluid and electrolyte balance can be maintained.

b. Adequate of urine output, blood pressure in stable condition, moist membrane mucous, skin turgor increase.

c. Patient can understand the causes of fluids and electrolyte imbalances. If outcomes are not achieved, the nurse should explore why they are not, asking for example, the following question :

1) Why are fluid intakes and output not it balances?

2) What reason does the client give?

3) Is the client not able to ingest enough fluids orally?

4) Did the nurse fail to help the client establish an appropriate schedule for ingesting the fluids?

5) Is the client feeling nauseated?

6) Are abnormal sources of fluid loss persisting?

7) Are ordered medications affecting fluid intake or output?

REFERENCES

Kozier,B.,Erb,G.,Olievery,R.,1991.Fundamental of Nursing Concepts, Process and Practice.4th Edition.California:Addison-Weasly Company.

Potter,P.A.,And Perry,A.G.2001.Fundamental of Nursing.Sidney:Mosby.

Water electrolyte balance provide in www/find-health-articles.com/msh-water-electrolyte-balance.htm.(accessed April 24,2010)

Water Electrolyte Balance.1998.Provide in http://cancerwebs.nel.ac.uk/cgi_bin/omd?water-electrolyte+balance(assed April 24,2010)

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