Fluid electrolyte imbalance ppw

PRESENTED BY
Ankita Roy
1st Year M.Sc Nursing Student
Apollo Gleneagles Nursing College

 Fluid, electrolyte and acid-base balance is
fundamental to the process to the process of life. In the
presence of a severe imbalance, the most perfectly
conditioned heart cannot beat, neurons either cannot
transmit or fire uncontrollably, digestion cannot take
place, and skeletal muscle cannot contract.

 Body Fluid Composition
 body fluid is composed of water and various
dissolved substances.
 Total body water constitutes about 60% of the total
body weight but this amount varies with age, gender
and the amount of fat. Total body water decreases
with aging; in people over 65 years of age, body
water may decrease to 45 to 50% of total body
weight. Fat cells contain comparatively little water.

 Water
 It is the primary component of body fluid. It functions in several
ways to maintain normal cellular functions:
 Provides the medium for transportation and exchange of nutrients.
 Provides a medium for metabolic reactions within the cells
 Assists in regulating body temperature
 Provides insulation and act as a lubricant
 Maintenance of blood volume
 Transport of cellular waste products to the lungs and kidney for
removal
 Lubrication and cushioning
 Hydrolysis of food in the digestive system.

 Body fluid is classified by its location inside or outside the cells.
 Intracellular Fluid
 Intracellular fluid is found within cells. It accounts for
approximately 40% of the total body weight. ICF is essential for
normal cell function, providing a medium for metabolic process
 Extracellular Fluid
 Extracellular fluid is located outside the cells. It accounts for
approximately 20% of total body weight. ECF is classified by
location.
 Interstitial Fluid
 Interstitial fluid is located in the spaces between most of the body. It
accounts for approximately 15% of the total body weight.

 Intravascular Fluid
 Intravascular fluid called plasma is contained within the
arteries, veins and capillaries. It accounts for
approximately 5% of the total body.
 Transcellular Fluid
 Transcellular fluids include urine, digestive secretions,
perspiration and cerebrospinal, pleural, synovial,
intraocular, gonadal and pericardial fluids.
 A trace amount of water is found in bone, cartilage and
other dense connective tissues. This water is not
exchangeable with other body fluids.

 Osmosis
 Osmosis is the movement of solvent molecules through a selectively
permeable membrane into a region of higher solute concentration, aiming
to equalize the solute concentrations on the two sides.
 Diffusion
 Diffusion describes the spread of particles through random motion from the
regions of the higher concentration to the regions of lower concentration.
 Filtration
 Filtration is commonly the mechanical or physical operation which is used
for the separation of solids from fluids by interposing a medium through
which only the fluid can pass
 Active Transport
 Active transport is the movement of substance against its concentration
gradient(from low to high concentration).

 Homeostasis require several organs and regulatory mechanisms as well as processes
to maintain the balance between fluid intake and excretion. These mechanisms affect
the volume distribution, and composition of the body fluids.
 These include:
 Thirst
 Heart and blood vessel functions
 Pituitary functions
 Baroreceptors
 Antidiuretic hormone
 Kidney functions
 Lung functions
 Adrenal function
 Renin-angiotensin-aldosterone system

 The cardinal principle about fluid balance is: “ Fluid
balance can be maintained only if intake equals out.”
 Adult Average Daily Intake And Output Fluids
FLUID INTAKE FLUID LOSSES
Ingested water: 1100-1400 mL Kidneys: 1200-1500 mL
Ingested food: 800-1000 mL Skin
 Insensile loss: 600-900 mL
 Sensible loss: 0-500 mL
Metabolic oxidation: 300mL Lungs: 400mL
Gastrointestinal: 100-200mL
TOTAL: 2200-2700mL TOTAL: 2200-2700mL

 Na+: Most abundant electrolyte in the ECF.
 K+: Essential for normal membrane excitability for nerve
impulse.
 Cl-: Regulates osmotic pressure and assists in regulating acid-
base balance.
 Ca2+: Promotes nerve impulse and muscle
contraction/relaxation.
 Mg2+: Plays role in carbohydrate and protein metabolism,
storage and use of intracellular energy and neural transmission.
Important in the functioning of the heart, nerves, and muscles.

 The fluid volume imbalance is either due to excess or
deficit in fluid volume due to various reasons:
 Fluid volume deficit( Hypovolemia)
 Fluid volume excess(hypervolemia)

Fluid volume deficit is a decrease in intravascular,
interstitial and/or intracellular fluid in the body. Fluid
volume deficit occurs when loss of ECF volume
exceeds the intake of fluid. It occurs when there is
deficiency in the amount of both water and electrolytes
in ECF, but the water and electrolyte proportions remain
near normal. Fluid volume deficit is a relatively
common problem that may exist alone or in
combination with other electrolyte or acid-base balance.

 Fluid volume deficient(dehydration) results from excessive loss of water
electrolytes from extracellular fluid.
 POSSIBLE CAUSES
 Excessive fluid loss through secretions or excretions.
 Insufficient intake of water and electrolytes.
 OTHER CAUSES
 Excessive renal losses of water and sodium from diuretic therapy and renal
disorders.
 Water and sodium lose during sweating from excessive exercise or
increased environmental temperature.
 Hemorrhage.
 Chronic use of laxatives or enemas.


decreased fluid intake
abnormal fluid loss
loss of body fluids
That causes fluid volume deficit

 MUCOUS MEMBRANES
1. Dry, may be sticky
2. Decreased tongue size
3. Increase longitudinal furrows
 NEUROLOGIC
1. Altered sensorium
2. Anxiety, restlessness
3. Diminished alertness
4. Possible coma
 INTEGUMENTARY SYSTEM
1. Diminished skin turgor
2. Dry skin
3. Pale, cool extremities

 MUSCULOSKELETAL SYSTEM
1. Fatigue
2. Decrease urinary output
3. Oliguria
4. Increased specific gravity

 CARDIOVASCULAR SYSTEM
1. Tachycardia
2. Orthostatic hypotension
3. Falling systolic/ diastolic pressure
4. Flat neck vein
5. Decrease venous filling
6. Decrease capillary refill
7. Decrease hematocrit
 POTENTIAL COMPLICATION
1. Hypovolemic shock

 Fluid management
 Correct with oral fluid replacement
 Oral rehydration therapy: solution containing glucose and
electrolytes.
 Isotonic solution- 0.9% NaCL , NA+ 154Meq/L, CL- 154mEq/L
 Hypotonic solution-0.45% NaCL, NA+ 77mEq/L, CL- 77mEq/L,
 Hypertonic solution- 3% NaCL Or 5% NaCL Solution
 Colloid solution- dextrose in NS OR 5% D5
 Antiemetic drugs
 Antidiarrheal drugs
 Treatment may include replacement of fluids and electrolytes by IV,
oral or entral routes.

ASSESSMENT
 SUBJECTIVE DATA:
Mr. x said that “ I’m feeling very weak, thirsty and my head is
reeling”
 OBJECTIVE DATA:
Excessive sweating, Vomiting, Diarrhea , Thirst , Weakness,
sunken eye , dry mucous membrane, flat neck veins, weak rapid
pulse, postural hypotension, increase specific gravity, Skin
trauma, Burns Draining wounds, Hyperglycemia, Excessive
laxative use.

 NURSING DIAGNOSIS
Deficient Fluid Volume related to Active fluid loss-burns,
diarrhea, fistulas, gastric intubation, hemorrhage, wounds may be
evidence by Abdominal distention, Confusion, restlessness, Dark
concentrated urine, Decreased urine volume, Flattened neck
veins, Hypotension, Pale, moist, clammy skin, Tachycardia,
Tachypnea, Weak pulses.

 GOAL
To maintain fluid balance in the body.
 PLANNING
- To do Weigh daily and compare with 24-hour intake and
output.
- To do Monitor vital signs and CVP. Observe for temperature
elevation and orthostatic hypotension.
- To do Monitor urine output. Measure or estimate fluid losses
from all sources such as diaphoresis, wound drainage, and
gastric losses.
- To do Palpate peripheral pulses; Observe for skin color,
temperature, and capillary refill.

- To do Monitor for a sudden or marked elevation of blood pressure, dyspnea,
basilar crackles, frothy sputum, moist cough, and restlessness.
- To Provide skin and mouth care. Bathe every other day using mild soap. Apply
lotion, as indicated.
- To Administer IV solutions, as indicated:
1. Colloids:
 Albumin or Plasmanate.
 Dextran.
 Hetastarch(Hespan)
2. Isotonic solutions:
 0.9% NaCl (normal saline).
 5% dextrose/water.
 3. 0.45% NaCl and lactated Ringer’s solution.

 EXPECTED OUTCOME
Patient may improve some health condition and knowledge.

 Fluid volume excess may result from excessive intake of fluids,
abnormal retention of fluids, or interstitial to plasma fluid shift.
Although shifts in fluid between the plasma and interstitium do
not alter the overall volume of the ECF , these shifts do result in
changes in the intravascular volume.

Increased fluid volume intake
Fluid overload or diminished function of homeostatic mechanisms responsible for regulating
fluid balance.
Consumption of excessive amounts of sodium salts.
Excessive administration of sodium containing fluids impaired regulatory mechanisms may
predispose to body.
Serious fluid volume excess.

 swelling, also called edema, most often in the feet, ankles,
wrists, and face
 discomfort in the body, causing cramping, headache, and
stomach bloating
 high blood pressure caused by excess fluid in the bloodstream
 shortness of breath caused by extra fluid entering lungs and
reducing your ability to breathe normally
 heart problems, because excess fluid can speed up or slow
heart rate, harm heart muscles, and increase the size of heart.

 Management of fluid volume excess is directed at the causes, and if
related to excessive administration of sodium-containing fluids,
discontinuing the infusion may be all that is needed. Symptomatic
treatment consists of administering diuretics and restricting fluids and
sodium.
 Pharmacologic therapy- thiazide diuretics block sodium
reabsorption in distal tube,where only 5% to 10% of filtered sodium
is reabsorbed. Loop diuretics, such as furosemide(Lasix),
bumetanide (bumex), or torsemide (demadex), can cause a greater
loss of both sodium and water because they block sodium
reabsorption in the ascending limb of the loop of henle, where 20%
to 30% of filtered sodium is normally reabsorbed.

 Dialysis- if renal function is so severely impaired that
pharmacologic agent cannot act efficiently, other modalities
are considered to remove sodium and fluid from the body.
Hemodialysis or peritoneal dialysis may be used to remove
nitrogenous wastes and control potassium and acid-Base
balance and to remove sodium and fluid.
 Nutritional therapy: treatment of fluid volume excess usually
involves dietary restriction of sodium. An average daily diet
not restricted in sodium contains 6 to 15 g of salt, where low-
sodium diets can range from mild restriction to as little as 250
mg of sodium per day depending on the patients needs.

ASSESSMENT
 SUBJECTIVE DATA
 Mr. x said that “ My head is reeling. I can’t walk properly for
swelling leg, abdomen get increased and can’t breath properly ”
 OBJECTIVE DATA
Ascites, Aphasia, muscle twitching, tremors, seizures, Changes in
the level of consciousness ,lethargy, disorientation, confusion to
coma), Distended neck and peripheral veins, Edema
,Hypertension, Productive cough, Shortness of breath,

Excess Fluid Volume related to Excess fluid or sodium
intake and compromised regulatory mechanism as
evidence by Ascites, Distended neck and peripheral
veins, Edema, Hypertension, Shortness of breath.
 GOAL
To maintain fluid volume in the body.

 PLANNING
- To do Monitor vital signs as well as central venous pressure, if available.
- To do Weigh client daily. Observe for sudden weight gain.
- To do Auscultate lung and heart sounds.
- To do Monitor intake and output. Note decreased urinary output and positive fluid
balance on 24-hour calculations.
- To do Assess for presence and location of edema formation.
- To do Administer oral fluids with caution. To do a 24-hour schedule fluid intake if
fluids are restricted.
- To Encourage adequate bed rest.
- To do Encourage deep breathing and coughing exercises.
- To Maintain semi-Fowler’s position if dyspnea or ascites is present.
- To Administer diuretics as indicated:
- Loop diuretics such as furosemide (Lasix).
- Potassium-sparing diuretics such as spironolactone (Aldactone).
 Thiazide diuretics such as hydrochlorothiazide (Microzide).

- To do Assess for presence and location of edema formation.
- To do Administer oral fluids with caution. To do a 24-hour schedule fluid intake if
fluids are restricted.
- To Encourage adequate bed rest.
- To do Encourage deep breathing and coughing exercises.
- To Maintain semi-Fowler’s position if dyspnea or ascites is present.
- To Administer diuretics as indicated:
- Loop diuretics such as furosemide (Lasix).
- Potassium-sparing diuretics such as spironolactone (Aldactone).
- Thiazide diuretics such as hydrochlorothiazide (Microzide).

 Expected Outcome
Patient May improve some health condition and knowledge.

 Hyponatremia may results from loss of sodium-
containing fluids, from water excess or a combination of
both. Hyponatrmia causes hypoosmolality with a shift
of water into the cells.

Imbalanceofwaterratherthansodium
Theurinesodiumassistsindifferentiatingrenalfromnonrenal
Hypernatremiaoccurs

 Hyponatremia signs and symptoms may include:
 Nausea and vomiting
 Headache
 Confusion
 Loss of energy, drowsiness and fatigue
 Restlessness and irritability
 Muscle weakness, spasms or cramps
 Seizures
 Coma
 Decrease serum and urine sodium
 Decrease urine specific gravity and osmolality.

1. sodium replacement.
2. Water restriction
3. Pharmacologic therapy

 ASSESSMENT
OBJECTIVE DATA
Nausea and vomiting, Headache, Confusion, Loss of energy, drowsiness
and fatigue, Restlessness and irritability, Muscle weakness, spasms or
cramps, Seizures, Coma, Decrease serum and urine sodium, Decrease
urine specific gravity and osmolality.
Risk For Electrolyte Imbalance (Hyponatremia) related to Diarrhea,
vomiting, Renal dysfunction, Treatment-related side effect such as
medications, gastric suctioning, electrolyte-free intravenous (IV)
solutions Water intoxication.

 GOAL
To maintain fluid electrolyte balance in the body.
 PLANNING
- To do Monitor respiratory rate and depth.
- To Monitor intake and output; Calculate fluid balance. Weigh
client daily.
- To Assess level of consciousness and neuromuscular response.
- To Identify patient ar risk for hyponatremia and the specific
cause such as sodium loss or fluid excess.
- To Provide safety and seizure precautions. Maintain a calm,
quiet environment.

- To Encourage fluids and foods high in sodium such
as meat, milk, beets, celery, eggs, and carrots. Use
fruit juices and bouillon instead of water.
- To Provide or restrict fluids, depending on fluid
volume status.
EXPECTED OUTCOME
Patient May improve some knowledge.

 Hypernatremia is a serum sodium level higher than
145 mEq/L. it can be caused by a gain of sodium in
excess of water or by a loss of water in excess of
sodium

Fluid deprivation in unconscious patients who cannot perceive, respond to, or communicate
their thirst
Administration of hypertonic enteral feedings without adequate water supplements.
Decreased ability to concentrate urine due to a defect in the kidney tubules that interferes with
water reabsorption .
Leads to hypernatremia, as does watery diarrhea and greatly increased insensible water loss

 Thirst
 Elevated body temperature
 Swollen dry tongue
 Sticky mucous membranes
 Hallucinations
 Lethargy
 Restlessness
 Irritability
 Focal or grand mal seizure
 Pulmonary edema
 Increase pulse
 Increase blood pressure
 Increase serum sodium
 Decrease urine sodium
 Increase specific gravity and osmolality
 Decrease CVP

 Treatment of hypernatremia consists of a gradual lowering of
the serum sodium level by the infusion of a hypotonic
electrolyte solution or an isotonic non-saline solution.

 Assessment
 OBJECTIVE DATA :
Thirst, Elevated body temperature, Swollen dry tongue , Sticky
mucous membranes, Hallucinations, Lethargy, Restlessness,
Irritability, Focal or grand mal seizure, Pulmonary edema,
Increase pulse, Increase blood pressure, Increase serum sodium,
Decrease urine sodium,Increase specific gravity and osmolality,
Decrease CVP.

 DIAGNOSIS
Risk For Electrolyte Imbalance (Hypernatremia) related to
Diarrhea, vomiting, Diabetes insipidus, renal disease, Fever,
profuse sweating, High-protein diet Side effects of medication
such as osmotic diuretics.
 GOAL
To maintain fluid –electrolyte balance in the body

 PLANNING
- To do Monitor respiratory rate and depth.
- To do Monitor blood pressure.
- To do Monitor level of consciousness and muscular strength,
tone, and movement.
- To Monitor intake and output and specific gravity. Assess the
presence and location of edema. Weigh client daily.
- To Assess skin turgor, color, and temperature and mucous
membrane moisture.

- To Provide safety and seizure precaution as indicated:
 Bed in a low position.
 Use of padded side rails.
- To Encourage meticulous skin care and frequent
repositioning.
- To Teach the patient to avoid foods high in sodium such
as regular canned vegetables and vegetable juices,
processed foods, snack foods, and condiments.
- To Provide frequent oral care. Avoid the use of
mouthwash containing alcohol.
 To Encourage increase oral and IV fluid intake.

 Hypokalemia (low serum potassium) can result from
abnormal losses of potassium from a shift of potassium
from ECF To ICF, or rarely from deficit of dietary
potassium intake. Hypokalemia (below 3.5 mEq/L).

Abnormal losses of potassium
From a shift of potassium from ECF to ICF
Rarely from deficient dietary potassium intake.
Abnormal losses occur when the patient elevated aldosterone level,it released when the
circulating blood volume is low
It causes sodium retention in the kidneys
Hypokalemia occurs

 Fatigue
 Anorexia
 Muscle weakness
 Polyuria
 Decreased bowel motility
 Leg cramps
 Decrease blood pressure
 Abdominal distention
 Flattened T waves
 Prominent U waves
 ST Depression
 Prolong PR Interval

 If hypokalemia cannot be prevented by conventional
measures such as increased intake in the daily diet or by
oral potassium supplements for deficiencies, then it is
treated cautiously with IV replacement therapy.
Potassium loss must be corrected daily, administration
of 40 to 80 mEq/day of potassium is adequate in the
adult if there are no abnormal losses of potassium.

 ASSESSMENT
OBJECTIVE DATA
Thirst, elevated body temperature, swollen dry tongue, sticky
mucous membranes, lethargy, restlessness, irritability, nausea and
vomiting, muscle weakness, leg cramps, decrease blood pressure
Risk For Electrolyte Imbalance(hypokalemia) related to Diarrhea,
vomiting, Diabetic acidosis, renal failure, High-sodium diet,
starvation, Profuse sweating

 GOAL
 PLANNING
- To do Monitor respiratory rate, depth, and effort. Encourage
deep breathing and coughing exercise. Encouraged frequent
re-positions.
- To do Monitor heart rate and rhythm.
- To do Monitor level of consciousness and neuromuscular
function, noting movement, strength, and sensation.
- To Monitor gastric, urinary, and wound losses accurately.

- To Observe for absence or changes in bowel sounds
- To Discuss preventable causes of the condition such as
nutritional choices and the proper use of laxatives.
- 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.
EXPECTED OUTCOME

 Hyperkalemia (greater than 5.0mEq/L) seldom occurs
in patients with normal renal function.
 Pathophysiology
Massive intake of potassium
Impaired renal excretion
Shift potassium from the ICF to ECF
Leads to hyperkalemia

 Muscle weakness
 Tachycardia to bradycardia
 Dysrhythmias
 Flaccid paralysis
 Paresthesis
 Intestinal colic
 Cramps
 Abdominal distention
 Irritability
 Anxiety
 Tall tented T waves
 Prolonged PR interval
 Absent P waves
 ST depression

1. Restriction of Dietary potassium intake.
2. Emergency pharmacologic therapy
3. Monitoring vital signs
4. Iv administration of sodium bicarbonate.
5. Diuretic therapy
6. Continue EKG monitoring
7. Hemodialysis

ASSESSMENT
 OBJECTIVE DATA
Muscle weakness, Tachycardia to bradycardia , Dysrhythmias, Flaccid
paralysis, Paresthesis, Intestinal colic Cramps, Abdominal distention,
Irritability, Anxiety, Tall tented T wave,s Prolonged PR interval, QRS
duration, Absent P waves, ST depression.
Risk For Electrolyte Imbalance (Hyperkalemia) related to Renal
disease.Treatment-related side effects such as cytotoxic drugs,
NSAIDs, diuretics, potassium-containing medications, massive blood
transfusion.

 GOAL
To maintain fluid electrolyte balance in the body
 PLANNING
- To do Monitor heart rate and rhythm. Be aware that cardiac arrest
can occur.
- To do Monitor respiratory rate and depth. Encourage deep breathing
and coughing exercise. Elevate the head of the bed.
- To do Assess the level of consciousness and neuromuscular
function, including sensation, strength, and movement.
- To Monitor urine output
- To Encourage frequent rest periods; assist with daily activities, as
indicated.

- To Encourage intake of carbohydrates and fats and
low potassium food such as pineapple, plums,
strawberries, carrots, cauliflower, corn, and whole
grains.
- To Instruct patient in use of potassium-containing
salts or salt substitutes, taking potassium supplements
safely.

Hypocalcemia (serum values lower than 8.6mg/dl ) occurs in a
variety of clinical situations. A patient may have a total body
calcium deficit but a normal serum calcium level.
Pathophysiology
Decrease in extracellular Ca ++
The membrane potential on the outside becomes less negative
Less amount of depolarization is required to initiate action potential
Increased excitability of muscle and tissue

 Numbness
 Tingling of fingers, toes.
 Positive trousseau’s sign
 Chvostek’s sign
 Seizures
 Hyperactive deep tendon reflexes
 Irritability
 Anxiety
 Impaired clotting time
 Diarrhea
 Decrease blood pressure
 Prolonged QT interval and lengthened ST

1. Symptomatic treatment
2. IV administration of calcium salts
3. Increasing dietary intake of calcium to at least 1000
to 1500 mg/day
4. Vitamin-D therapy may be instituted to increase
calcium absorption from the GI tract.

 ASSESSMENT
OBJECTIVE DATA
 Neuromuscular, irritability, Positive trousseau’s and chvostek’s signs,
Insomnia, Mood exchanges, Anorexia,Vomiting, Increased tendon
reflexes, Increase blood pressure, Flat or inverted T waves, Depressed
ST segment, Prolonged PR interval, Widened QRS.
Risk For Electrolyte Imbalance (Hypocalcemia) related to
Chronic laxative abuse,Diarrhea, Renal failure,Treatment-
related side effects of medications such as antibiotics,
anticonvulsants, corticosteroids, diuretics.

 GOAL
 PLANNING
- To Monitor respiratory rate, effort, and rhythm. Place tracheostomy
set at the bedside
- To Monitor heart rate and rhythm.
- To Assess for areas of possible bleeding. Observe for petechiae and
ecchymosis.
- To Discuss the use of antacids and laxatives.
- To Assess neuromuscular strength, tone, movement, and reflexes;
observe for Trousseau’s and Chvostek’s sign.
- ToMaintain a safe, quiet environment and seizure precaution.

- To Encourage relaxation and stress-reduction measures
such as deep-breathing exercise, guided imagery, and
visualizations.
- To Encourage to eat foods high in calcium such as dark
leafy greens, cheese, low-fat milk, yogurt, eggs, oranges,
green beans, and sardines. Avoid intake of phosphorus-
rich foods such as bran, chocolates, nuts, whole wheat,
and barley.
Patient May improve some knowledge.S

 Hypercalcemia (greater than 10.2 mg/dl) is a
dangerous imbalance when severe, in fact
hypercalcemia crisis has a mortality rate as high as 50%
if not treated promptly.

the excessive PTH secretion
hyperparathyroidism
increased release of calcium from the bones
increase intestinal and renal absorption of calcium
calcifications of soft tissue occur when the calcium phosphorus product
exceeds 70mg/dl

 Muscular weakness
 Constipation
 Anorexia
 Polyuria and polydipsia
 Dehydration
 Hypoactive deep tendon reflexes
 Lethargy
 Deep bone pain
 Pathologic fractures
 Flank pain
 Calcium stones
 Hypertension
 Shortened ST segment and QT interval
 Bradycardia
 Heart blocks

 Monitor intake and output.
 Encourage fluid intake to prevent stone formation.
 Encourage fiber to prevent constipation.
 Eliminate calcium supplements and limit calcium-
based antacids.
 Renal dialysis may be required.

 ASSESSMENT
 OBJECTIVE DATA
Flushing, Hypotension, Muscle weakness, Drowsiness,
Hypoactive reflexes, Depressed respirations, Cardiac arrest and
coma, Tachycardia to bradycardia, Prolong PR interval and QRS,
Peaked T waves.
 Risk For Electrolyte Imbalance (Hypercalcemia) related to
Hyperparathyroidism, Hyperthyroidism, Renal disease, Treatment-related side
effects of medications such as anticancer drugs, theophylline, lithium, thiazide
diuretics.

 GOAL
To maintain fluid –electrolyte balance in the body.
 PLANNING
- To Assess the level of consciousness and neuromuscular
status, including muscle tone, strength, and movement.
- To Auscultate bowel sounds.
- To Monitor cardiac rate and rhythm. Be aware that cardiac
arrest can occur in a hypercalcemic crisis.
- To Monitor intake and output; calculate fluid balance.
- To do Strain urine if flank pain occurs.
- To Provide safety measures, including gentle handling when
moving client.

- To Maintain bulk in diet
- To Encourage fluid intake of 3 to 4 liters per day,
including sodium-containing fluids (within cardiac
tolerance) and use of acid-ash juices such as cranberry
and prune, if kidney stones present or suspected.
- To Encourage frequent repositioning and range-of-motion
(ROM) and/or muscle-setting exercises with caution.
Promote ambulation as tolerated.
Patient May improve some knowledge

 Hypomagnesemia refers to below-normal serum
magnesium concentration (1.3mg/dl) and is
frequently associated with hypokalemia and
hypocalcemia.

High serum calcium
Increased acetylcholine release
Increased neuromuscular irritability
Increased sensitivity to acetylcholine at the myoneural junction
Diminished threshold of excitation for the motor nerve
Enhancement of myofibril contraction
High serum calcium
Excretion of magnesium by the GI tract

 Neuromuscular irritability
 Positive trousseau’s and chvostek’s signs
 Insomnia
 Mood exchanges
 Anorexia
 Vomiting
 Increased tendon reflexes
 Increase blood pressure
 Flat or inverted T waves
 Depressed ST segment
 Prolonged PR interval

 Monitor intake and output
 Encourage foods high in magnesium
 Avoid alcohol intake
 If client is taking digoxin, monitor pulse and observe
for toxicity
 Institute safety precautions

 ASSESSMENT
 OBJECTIVE DATA
Neuromuscular irritability, Positive trousseau’s and chvostek’s signs,
Insomnia, Mood exchanges, Anorexia, Vomiting, Increased tendon
reflexes, Increase blood pressure, Flat or inverted T waves, Depressed
ST segment, Prolonged PR interval, Widened QRS.
Risk For Electrolyte Imbalance (Hypomagnesemia) related to Diabetic
ketoacidosis, hyperaldosteronism, Excessive losses, Malnutrition, Renal disease.
,Treatment-related side effects of medications such as antifungals,
aminoglycosides, chemotherapy agents, diuretics.

 GOAL
To maintain fluid –electrolyte balance in the body.
 PLANNING
- To Auscultate bowel sounds.
- To do Assess the client’s airway and swallowing.
- To Monitor heart rate and rhythm; Monitor ECG changes.
- To Assess level of consciousness and neuromuscular strength, tone,
movement, and reflexes; observe for Trousseau’s and Chvostek’s sign.
- To Encourage range-of-motion (ROM) exercises, as tolerated
- To Provide safety and seizure precaution as indicated:
 Bed in a low position.
 Frequent observation.
 Use of padded side rails.

- To Provide a quiet environment and subdued lighting.
- To Encourage intake of dairy products, meat, fish,
green leafy vegetables, and whole grains.

 Hypermagnesemia (serum levels over 2.3 mg/dL) is
rare electrolyte abnormality, because the kidneys
efficiently excrete magnesium

Release of cellular magnesium that cannot be excreted because of profound fluid volume
depletion and resulting oliguria.
A surplus of magnesium can also result from excessive magnesium administration to treat low
hypomagnesemia
that decrease GI motility
Decreased elimination of magnesium
increased absorption due to intestinal hypomotility
Can contribute to hyper-magnesemia

 Flushing
 Hypotension
 Muscle weakness
 Drowsiness
 Hypoactive reflexes
 Depressed respirations
 Cardiac arrest and coma
 Prolong PR interval and QRS
 Peaked T waves

 Monitor vital signs and airway
 Monitor reflexes
 Avoid magnesium-based antacids and laxatives
 Restrict dietary intake of foods
 High in magnesium

 Assessment
OBJECTIVE DATA
Flushing, Hypotension, Muscle weakness, Drowsiness,
Hypoactive reflexes, Depressed respirations, Cardiac arrest and
coma, Tachycardia to bradycardia, Prolong PR interval and QRS.
 Nursing diagnosis
Risk For Electrolyte Imbalance (Hypermagnesemia) related to
Chronic diarrhea, Diabetic ketoacidosis, Renal dysfunction,
Treatment-related side effects of such as medications containing
magnesium, dialysis with hard water, diuretic abuse.

 GOAL
To maintain fluid-electrolyte balance in the body.
 PLANNING
- To do Monitor respiratory rate and depth. Encourage deep
breathing and coughing exercise. Elevate the head of the bed.
- To Monitor blood pressure.
- To Monitor urinary output and 24-hour fluid balance.

- To Assess the level of consciousness and neuromuscular
status, including reflexes, muscle movement, tone, and
strength.
- To Check patellar reflexes regularly.
- Encourage bed rest; assist with personal activities, as needed.
- To Encourage increased fluid intake, if appropriate.
Patient May improve some knowledge

 Hypophosphatemia is indicated by value below 2.5
mg/dl. Although it often indicates phosphorus
deficiency.

Deficiency of cellular ATP or 2,3-diphosphoglycerate
An enzyme in RBCs that facilitates oxygen delivery to the tissues
Because of phosphorus is needed for formation of ATP and 2,3 DPG
Its deficit results in impaired cellular energy and oxygen delivery
Mild to moderate hypophosphatemia is often asymptomatic

 Paresthesias
 Muscle weakness
 Drowsiness
 Hypoactive reflexes
 Decreased respirations
 Cardiac arrest and coma
 Diaphoresis
 Prolonged PR interval and QRS,
 Peaked T waves

 Monitor serum phosphate level
 Monitor calcium levels as phosphate is replaced
 Start TPN slowly to avoid drops in phosphate.

 ASSESSMENT
 OBJECTIVE DATA
Paresthesias, Muscle weakness, Drowsiness, Hypoactive reflexes, Decreased
respirations, Cardiac arrest and coma, Diaphoresis, Tachycardia to bradycardia,
Prolonged PR interval and QRS, Peaked T waves.
Risk For Electrolyte Imbalance (Hypophosphatemia) related to alcohol
withdrawal, diabetic ketoacidosis, respiratory acidosis
 GOAL
To maintain electrolyte balance in the body

 PLANNING
- To Monitor respiratory rate, effort, and rhythm. Place tracheostomy set at
the bedside
- To Assess the level of consciousness and neuromuscular status, including
muscle tone, strength, and movement.
- To Encourage relaxation and stress-reduction measures such as deep-
breathing exercise, guided imagery, and visualizations.
- To Encourage frequent repositioning and range-of-motion (ROM) and/or
muscle-setting exercises with caution. Promote ambulation as tolerated.
- To Monitor intake and output; calculate fluid balance
 To Monitor intake and output; calculate fluid balance
Patient may improve some knowledge

 Hyperphosphatemia is a serum phosphorus level that
exceeds 4.5 mg/dL in adults.
Pathophysiology
Renal disease
Decrease phosphate excretion
Calcium phosphate deposition and decrease vitamin D
Soft tissue calcification
Hyperphosphatemia occur

 Tetany
 Tachycardia
 Anorexia
 Muscle weakness
 Sign and symptoms of hypocalcemia
 Hyperactive reflexes

 Monitor serum phosphate
 Monitor for tetany
 If severe, administer aluminum hydroxide with meals
to bind phosphorus

 ASSESSMENT
OBJECTIVE DATA
Tetany, Tachycardia, Anorexia, Nausea and vomiting, Muscle weakness, Sign
and symptoms of hypocalcemia, Hyperactive reflexes, Soft tissue calcifications
in lungs.
Risk For Electrolyte Imbalance (Hyper phosphatemia) related to renal failure,
hyperthyroidism, chemotherapy, excess use of phosphate-bases laxative.
 GOAL

 PLANNING
- To Monitor respiratory rate, effort, and rhythm. Place tracheostomy set at the
bedside
- To Assess for areas of possible bleeding. Observe for petechiae and
ecchymosis.
- To Discuss the use of antacids and laxatives.
- To Assess neuromuscular strength, tone, movement, and reflexes; observe for
Trousseau’s and Chvostek’s sign.
- To Maintain a safe, quiet environment and seizure precaution.
- To Encourage relaxation and stress-reduction measures such as deep-breathing
exercise, guided imagery, and visualizations.
- To Encourage to eat foods high in calcium such as dark leafy greens, cheese,
low-fat milk, yogurt, eggs, oranges, green beans, and sardines. Avoid intake of
phosphorus-rich foods such as bran, chocolates, nuts, whole wheat, and barley.
Patient may improve some knowledge.

 Hypochloremia is a serum chloride level below 97 mEq/L
Pathophysiology
Low sodium intake
Decrease serum sodium level
Metabolic alkalosis , massive blood transfusion, diuretic therapy, burns, fever
May cause hypochloremia

 Agitation
 Irritability
 Tremors
 Muscle cramps
 Hyperactive deep tendon reflexs
 Slow shallow respirations
 Seizures
 Dysrhythmias
 Coma
 Decrease serum chloride
 Decrease serum sodium
 Increase pH
 Increase serum bicarbonate
 Decrease serum potassium
 Decrease urine chloride level

 Treatment involves correcting the cause of hypochloremia and the
contributing electrolyte and acid base imbalances.normal saline or half-
strength saline solution is administered by IV to replace the chloride. If the
patient is receiving a diuretic , it may be discontinued or another diuretic
prescribed.

 ASESSMENT
 OBJECTIVE DATA
Agitation, Irritability, Tremors, Muscle cramps, Hyperactive deep tendon reflexs,
Slow shallow respirations, Seizures, Dysrhythmias, Coma, Decrease serum
chloride, Decrease serum sodium, Increase pH, Increase serum bicarbonate,
Decrease serum potassium, Decrease urine chloride level, Increase carbon dioxide .
Risk For Electrolyte Imbalance (Hypochloremia) related to low sodium intake,
decreased serum sodium levels, metabolic alkalosis, massive blood transfusions.
 GOAL

PLANNING
 To do Monitor respiratory rate and depth.
 To Monitor intake and output; Calculate fluid balance. Weigh client daily.
 To Assess level of consciousness and neuromuscular response.
 To Identify patient ar risk for hyponatremia and the specific cause such as sodium
loss or fluid excess.
 To Provide safety and seizure precautions. Maintain a calm, quiet environment.
 To Encourage fluids and foods high in sodium such as meat, milk, beets, celery,
eggs, and carrots. Use fruit juices and bouillon instead of water.
 To Provide or restrict fluids, depending on fluid volume status.
EXPECTED OUTCOME

 Hyperchloremia exists when the serum level of chloride exceeds 107
mEq/L. Hypernatremia, bicarbonate loss, and metabolic acidosis can occur
with high chloride levels.
 Pathophysiology
Loss of bicarbonate ions via the kidney or the GI tract with a corresponding increase in chloride
ions
Chloride ions in the form of acidifying salts accumulate
acidosis occurs with a decrease in bicarbonate ions
Head trauma ,increased perspiration, excess adrenocortical hormone production,
Decreased glomerular filteration can lead to a high serum chloride level.

 Tachypnea
 Lethargy
 Weakness
 deep rapid respiration
 decline in cognitive status
 decrease cardiac output
 dyspnea
 tachycardia
 pitting edema
 dysrhythmias
 coma
 increase serum chloride
 increase serum potassium and sodium
 decrease serum pH
 decrease serum bicarbonate
 increase urinary chloride level

 Monitor vital signs
 Monitor arterial blood gas values
 Maintain intake and output chart
 Hypotonic solution may be given
 Lactated Ringer’s solution may be given.

 ASESSMENT
 OBJECTIVE DATA
Tachypnea, Lethargy, Weakness, deep rapid respiration, decline in cognitive status,
decrease cardiac output, Dyspnea, tachycardia, pitting edema, dysrhythmias, coma,
increase serum chloride, increase serum potassium and sodium, decrease serum
pH, decrease serum bicarbonate, increase urinary chloride level.
Risk For Electrolyte Imbalance (Hyperchloremia) reletd to head trauma, excess
adrenocortical hormone production, decreased glomerular filteration.
 GOAL
To improve fluid electrolyte balance in the body.

PLANNING
 To do Monitor heart rate and rhythm. Be aware that cardiac arrest can occur.
 To do Monitor respiratory rate and depth. Encourage deep breathing and coughing
exercise. Elevate the head of the bed.
 To do Assess the level of consciousness and neuromuscular function, including sensation,
strength, and movement.
 To Monitor urine output
 To Encourage frequent rest periods; assist with daily activities, as indicated.
 To Encourage intake of carbohydrates and fats and low potassium food such as pineapple,
plums, strawberries, carrots, cauliflower, corn, and whole grains.
 To Instruct patient in use of potassium-containing salts or salt substitutes, taking
potassium supplements safely.
EXPECTED OUTCOME

Electrolyte imbalance, or water-electrolyte imbalance, is
an abnormality in the concentration of electrolytes in the
body. Electrolytes play a vital role in maintaining
homeostasis in the body. They help to regulate heart and
neurological function, fluid balance, oxygen delivery,
acid–base balance and much more.so we have to intake
sufficient fluid for our body.

1. Sharma K.Suresh & Madhavi S.Brunner And
Suddarth’s. Textbook Of Medical Surgical
Nursing.volume 1.Wolters Kluwer;264-293
2. Lewis.Dirksen.Heitkemper.Bucher.Chintamoni.Mrina
lini Mani.Lewis’s Medical-Surgical Nursing.Volume
1.Elsevier.
3. Perry’s and potter. Fundamentals of nursing.Elsevier.

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