Fluid and Electrolyte Imbalances

Imbalances in fluid and electrolytes may be due to changes in the total quantity of either substance (deficit or excess), protein deficiencies, or extracellular fluid volume shifts. Older patients and very young patients are particularly susceptible.

Fluid volume deficit (dehydration): mechanism that influences fluid balance and sodium levels; decreased quantities of fluid and electrolytes may be caused by deficient intake (poor dietary habits, anorexia, and nausea), excessive output (vomiting, nasogastric suction, and prolonged diarrhea), or failure of regulatory mechanism that influences fluid balance and sodium levels.

Pathophysiology: water moves out of the cells to replace a significant water loss; cells eventually become unable to compensate for the lost fluid, and cellular dehydration begins, leading to circulatory collapse.
Risk factors:

No fluids available.
Available fluids not drinkable.
Inability to take fluids independently.
No response to thirst; does not recognize the need for fluids.
Inability to communicate need; does not speak same language.
Aphasia.
Weakness, comatose.
Inability to swallow.
Psychological alterations.
Overuse of diuretics.
Increased vomiting.
Fever.
Wounds, burns.
Blood loss.

Assessment:

Subjective data

Thirst.
Behavioral changes: apprehension, apathy, lethargy, confusion, restlessness.
Dizziness.
Numbness and tingling of hands and feet.
Anorexia and nausea.
Abdominal cramps.

Objective data

Sudden weight loss of 5%.
Vital signs:

Decreased BP; postural changes.
Increased temperature.
Irregular, weak, rapid pulse.
Increased rate and depth of respirations.

Skin: cool and pale in absence of infection; decreased turgor.
Urine: oliguria to anuria, high specific gravity.
Eyes: soft, sunken.
Tongue: furrows.
Lab data:

Blood - increased hematocrit and BUN.
Urine - decreased 17-ketosteroids.

Analysis/nursing diagnosis:

Fluid volume deficit related to inadequate fluid intake.

Nursing care plan/implementation:
1. Goal: restore fluid and electrolyte balance - increase fluid intake to hydrate client.
2. Goal: promote comfort.
3. Decreased or inadequate output of urine.
4. Psychogenic polydipsia.
5. Certain medical conditions: tuberculosis; encephalitis; meningitis; endocrine disturbances; tumors of lung, pancreas, duodenum, heart failure.
6. Inadequate kidney function or kidney failure.

Assessment:

Subjective data

Behavioral changes: irritability, apathy, confusion, disorientation.
Headache.
Anorexia, nausea, cramping.
Fatigue.
Dyspnea.

Objective data

Vital signs: elevated blood pressure.
Skin: warm, moist; edema - eyelids, facial, dependent, pitting.
Sudden weight gain of 5 lbs.
Pink, frothy sputum; productive.
Constant, irritating cough.
Crackles in lungs.
Pulse, bounding.
Engorgement of neck veins in sitting position.
Urine: polyuria, nocturia.
Lab data:

Blood - decreasing hematocrit, BUN.
Urine - decreasing specific gravity.

Analysis/nursing diagnosis:

Fluid volume excess related to excessive fluid intake or decreased fluid output.

Nursing care plan/implementation:

Goal: maintain oxygen to all cells.

Position: semi-Fowler’s or Fowler’s to facilitate improved gas exchange.
Vital signs: q4h.
Fluid restriction.
Possible rotating tourniquets as needed (especially for interstitial-to-plasma shift).

Goal: promote excretion of excess fluid.

Medications as ordered: diuretics.
If in kidney failure: may need dialysis; explain procedure.
Assist patient during paracentesis, thoracentesis, phlebotomy.

Monitor vital signs to detect shock.
Prevent injury by monitoring sterile technique.
Prevent falling by stabilizing appropriate position during procedure.
Support patient psychologically.

Goal: obtain/maintain fluid balance.

Daily weights; 1 kg = 1000 mL fluid.
Measure: all edematous parts, abdominal girth, I&O.
Limit: fluids by mouth, IVs, sodium.
Strict monitoring of IV fluids.

Goal: prevent tissue injury.

Skin and mouth care as needed.
Evaluate feet for edema and discoloration when patient is out of bed.
Observe suture line on surgical patients (potential for evisceration due to excess fluid retention).
IV route preferred for parenteral medications; Z track if medications are to be given IM (otherwise injected liquid will escape through injection site).

Goal: health teaching.

Improve nutritional status with lowsodium diet.
Identify cause that put patient at risk for imbalance, methods to avoid this situation in the future.
Desired and side effects of diuretics and other prescribed medications.
Monitor urinary output, ankle edema; report to health care manager when fluid retention is noticed.
Limit fluid intake when kidney/cardiac function impaired.

Evaluation/outcome criteria:

Fluid balance obtained.
No respiratory, cardiac complications.
Vital signs within normal limits.
Urinary output improved, no evidence of edema.

Common electrolyte imbalances: electrolytes are taken into the body in foods and fluids; normally lost through sweat and urine. May also be lost through hemorrhage, vomiting, and diarrhea. Electrolytes have major influences on: body water regulation and osmolality, acid-base regulation, enzyme reactions, and neuromuscular activity. Clinically important electrolytes are:

Sodium (Na⁺): normal 135-145 mEq/L.| Most prevalent cation in extracellular fluid. Controls osmotic pressure; essential for neuromuscular functioning and intracellular chemical reactions. Aids in maintenance of acid-base balance. Necessary for glucose to be transported into cells.

Hyponatremia - sodium deficit, resulting from either a sodium loss or water excess. Serum-sodium level below 135 mEq/L; symptoms usually do not occur until below 120 mEq/L unless rapid drop.
Hypernatremia - excess sodium in the blood, resulting from either high sodium intake, water loss, or low water intake. Serum-sodium level above 145 mEq/L,

Potassium (K⁺):normal 3.5-5.0 mEq/L Direct effect on excitability of nerves and muscles. Contributes to intracellular osmotic pressure and influences acid-base balance. Major cation of the cell. Required for storage of nitrogen as muscle protein.

Hypokalemia - potassium deficit related to dehydration, starvation, vomiting, diarrhea, diuretics. Serum-potassium level below 3.5 mEq/L; symptoms may not occur until below 2.5 mEq/L.
Hyperkalemia - potassium excess related to severe tissue damage, renal disease, excess administration of oral or IV potassium. Serumpotassium level above 5 mEq/L; symptoms usually occur when above 6.5 mEq/L.

Calcium (Ca²⁺): normal 4.5-5.5 mEq/L.| Essential to muscle metabolism, cardiac function, and bone health. Controlled by parathyroid hormone; reciprocal relationship between calcium and phosphorus.

Hypokalemia - potassium deficit related to dehydration, starvation, vomiting, diarrhea, diuretics. Serum-potassium level below 3.5 mEq/L; symptoms may not occur until below 2.5 mEq/L.
Hyperkalemia - potassium excess related to severe tissue damage, renal disease, excess administration of oral or IV potassium. Serumpotassium level above 5 mEq/L; symptoms usually occur when above 6.5 mEq/L.

Magnesium (Mg²⁺): normal 1.5-2.5 mEq/L.| Essential to cellular metabolism of carbohydrates and proteins.

Hypomagnesemia - magnesium deficit related to impaired absorption from GI tract, excessive loss through kidneys, and prolonged periods of poor nutritional intake. Hypomagnesemia leads to neuromuscular irritability. Serum-magnesium level below 1.5 mEq/L.
Hypermagnesemia - magnesium excess related to renal insufficiency, overdose during replacement therapy, severe dehydration, repeated enemas with Mg²⁺ sulfate (epsom salts). Serum-magnesium level above 2.5 mEq/L.

Electrolyte Imbalances

Disorder and Related Conditions	Assessment		Analysis/Nursing Diagnosis	Nursing Care Plan/ Implementation	Evaluation/Outcome Criteria
	Subjective Data	Objective Data
Hyponatremia Addison’s disease Starvation Gi suction Thiazide diuretics Excess water intake, enemas Fever Fluid shifts Ascites Bums Small-bowel obstruction Profuse perspiration	Apathy, apprehension, mental confusion. delirium Fatigue Vertigo, headache Anorexia, nausea Abdominal and muscle cramps	Pulse: rapid and weak BP: postural hypotension Shock, coma GI: weight loss, diarrhea, loss through NG tubes Muscle weakness	Diarrhea Fluid volume excess Altered nutrition, less than body requirements Sensory-perceptual alteration (kinesthetic)	Obtain normal sodium level: identify cause of deficit, increase sodium intake PO (salty foods). IVs - hypertonic solu- tions Prevent further sodium loss: irrigate NG tubes with saline; hourly I&O to monitor kidney output Prevent injury related to shock, dizziness, decreased sensorium; dangle before ambulation Skin care	No complications of shock present Return of muscle strength Alert, oriented Limits intake of plain water
Hypernatremia High sodium intake Low water intake Diarrhea High fever with rapid respirations Impaired renal functions Acute tracheobronchitis	Lethargy Restlessness, agitation Confusion	BP and temperature elevated Neuromuscular: diminished reflexes Skin: flushed; firm turgor GI: mucous membrane dry, sticky GU: decreased output	Fluid volume deficit Fluid volume excess Altered nutrition, less than body requirements Sensory-perceptual alteration	Obtain normal sodium level: de- w crease sodium intake I&O to recognize signs and symp- toms of complications, e.g., heart failure, pulmonary edema	No complaint of thirst Alert, oriented Relaxed in appearance Identifies high-sodium foods to avoid
Hypokalemia Decreased intake: Poor potassium food intake Excessive dieting Nausea Alcoholism IV fluids without added potassium Increased loss: GI suctioning, vomiting, diarrhea Ulcerative colitis Drainage: ostomy, fistulas Medications: potassium-losing diuretics,digoxin, cathartics Increased aldosterone production Renal disorders	Apathy, lethargy, fatigue, weakness Irritability, mental confusion Anorexia, nausea Leg cramps	Muscles: weakness, paralysis, paresthesia, hyporeflexia Respirations: shallow to respiratory arrest Cardiac decreased BP; elevated, weak, irregular pulse; arrhythmias ECG: low, flat T waves; prolonged ST segment: elevated U wave; potential arrest GI: vomiting, flatulence, constipation; decreased motility - distention - paralytic ileus GU: urine not concentrated; polyuria, nocturia; kidney damage Speech: slow	Decreased cardiac output Fatigue Altered cardiopulmonary tissue perfusion Ineffective breathing patterns Constipation Bathing/hygiene self-care deficit Impaired home maintenance management Sensory-perceptual alteration (gustatory)	Replace lost potassium: increase potassium in diet (see Unit 9); liquid PO potassium medications dilute in juice to aid taste; give potassium only if kidneys functioning Prevent injury to tissues: prevent infiltration, pain, tissue damage Prevent potassium loss: irrigate NG tubes with saline, not water	Identifies cause of imbal- ance Lists foods to include in diet Lists signs and symptoms of imbalance Return of muscle strength No cardiac arrhythmias
Hyperkalemia Burns Crushing injuries Kidney disease Excessive infusion or ingestion of K * Adrenal insufficiency Mercurial poisoning	Irritability Weakness, muscle cramps Nausea, intestinal cramps	Musc/ex paresthesia, flaccid muscle paralysis (later) Cardiac: irregular pulse; arrhythmias; bradycardia - asystole ECG: high T waves; depressed ST segment, widened QRS complex; diminished or absent P waves; ventricular fibrillation GI: explosive diarrhea; hyper- active bowel sounds Kidney: scanty to no urine	Decreased cardiac output Altered urinary elimination Activity intolerance Ineffective breathing patterns Diarrhea Impaired home maintenance management	Decrease amount of potassium in body; identify and treat cause of imbalance; give foods low in K"; avoid drugs or IV fluids containing K* If kidney failure present, may need to prepare for dialysis [K- 3^5.0 rntyr ]	No complications (e.g., arrhythmias, acidosis, respiratory failure)
Hypocalcemia Acute pancreatitis Diarrhea Peritonitis Damage to parathyroid during thyroidectomy Hypothyroidism Bums Pregnancy and lactation Iow vitamin D intake Multiple blood transfusions Renal disorders Massive infection	Fatigue Tingling/numbness; fingers and circumoral Abdominal cramps Palpitations Dyspnea	Muscle spasms: tonic muscles, carpopedal, laryngeal Neuromuscular: grimacing, hy- perirritable facial nerves Tetany - convulsions Orthopedic: osteoporosis - fractures Cardiac: arrhythmias - arrest GL diarrhea	Pain Diarrhea Altered nutrition, less than body requirements Risk for injury Sensory-perceptual alteration (gustatory)	Prevent tetany (medical emer- 40 gency): calcium gluconate IV, 2.5-5.O ml. 10% solution; re- peated qlOmin to maximum dose of 30 mL Prevent tissue injury due to hy- poxia and sloughing; adminis- ter slowly; avoid infiltration Prevent injury related to medica- tion administration. Caution: drug interaction with carbon- ate, phosphate, digitalis; avoid hypercalcemia In less acute condition: increase ten calcium intake—calcium glu- conate or lactate	No signs of tetany Absent Trousseau's and Chvostek's signs List foods high in vitamin D and calcium
Hypercalcemia Parathyroid glands: overactive, tumor Increased immobility Decreased renal function Bone cancer Increased vitamin D and calcium intake Milk-alkali syndrome - self-administration of antacids; increased milk in diet to relieve GI symptoms	Pain: flank, deep bone, shin splints Muscle weakness, fa- tigue Anorexia, nausea Headache Thirst —» polyuria	Muscles: relaxed GU: kidney stones GI: increased milk intake, con- stipation. dehydration Neurological: stupor - coma	Decreased cardiac output Constipation Activity intolerance Altered urinary elimination Pain	Reduce calcium intake: decrease m foods high in calcium; identify cause of imbalance; give steroids, diuretics as ordered; isotonic saline IV Prevent injury: prevent pathological fractures (e.g., advanced cancer); prevent renal calculi by increasing fluid intake	No pain reported No fractures/calculi seen on x-ray exam
Hypomagnesemia Impaired GI absorption Prolonged malnutrition or starvation Alcoholism Excess loss of magnesium through kidneys. related to increased aldosterone production Prolonged diarrhea Draining Gl fistulas	Agitation Depression Confusion Paresthesia	Muscles: irritable, tremors, spasticity, tetany —» convul- sions Cardiac: arrhythmias, tachycardia		Risk for injury related to seizure activity Decreased cardiac output	Provide safety: prevent injury to disoriented patient; administer magnesium salts PO or IV Health teaching: prevention; diet - high-magnesium foods: fruits, green vegetables, whole grain cereals, milk, meats, nuts
Hypermagnesemia Renal failure Diabetic ketoacidosis Severe dehydration Antacid therapy	Drowsiness, lethargy	Neuromuscular: loss of deep- tendon reflexes Respiratory: depression Cardiac: arrest, hypotension	Ineffective breathing pattern Decreased cardiac output Fluid volume deficit Fluid volume excess Altered cardiopulmonary tissue perfusion	Obtain norma! magnesium level: IV calcium; fluids; possible dialysis	No complications (e,g„ respiratory depression, arrhythmias) Identifies magnesium-based antacids (e.g., Gclusil) Deep-tendon reflexes 2+

Blood Gas Variations with Acid-Base Imbalances

Acid-base balance: concentration of hydrogen ions in extracellular fluid is determined by the ratio of bicarbonate to carbonic acid. The normal ratio is 20:1. Even when arterial blood gases are abnormal, if the ratio remains at 20:1, no imbalance will occur.

Causes of blood gas abnormalities:
Types of acid-base imbalance:

Acidosis: hydrogen ion concentration increases and pH decreases.
Alkalosis: hydrogen ion concentration decreases and pH increases.
Metabolic imbalances: bicarbonate is the problem. In primary conditions, the level of bicarbonate is directly proportional to pH.

Metabolic acidosis: excessive acid is produced or added to the body, bicarbonate is lost, or acid is retained due to poorly functioning kidneys. Deficit of bicarbonate.
Metabolic alkalosis: excessive acid is lost or bicarbonate or alkali is retained. Excess of bicarbonate.
As compensatory mechanism, Pco₂ will be low in metabolic acidosis, as the body attempts to eliminate excess carbonic acid and elevate pH. Pco₂ will become elevated in metabolic alkalosis.

Respiratory imbalances: carbonic acid is the problem. In primary conditions, Pco₂ is inversely proportional to the pH.

Respiratory acidosis: pulmonary ventilation decreases, causing an elevation in the level of carbon dioxide or carbonic acid. Excess of Pco₂.
Respiratory alkalosis: pulmonary ventilation increases, causing a decrease in the level of carbon dioxide or carbonic acid. Deficit of Pco₂.
As a compensatory mechanism, the level of bicarbonate will increase in respiratory acidosis and decrease in respiratory alkalosis.

Assessment: Acid-Base Imbalances.
Analysis/nursing diagnosis:

Impaired gas exchange related to hyperventilation.
Ineffective breathing pattern related to decreased thoracic movements.
Ineffective airway clearance related to retained secretions.
Risk for injury related to poorly functioning kidneys.
Altered renal tissue perfusion related to dehydration.
Altered urinary elimination, related to renal failure.
Fluid volume excess related to altered kidney function.
Fluid volume deficit related to diarrhea or dehydration.
Knowledge deficit related to self-administration of antacid medications.

Nursing care plan/implementation: Acid-Base Imbalances.
Evaluation/outcome criteria: Acid-Base Imbalances.

Blood Gas Abnormalities: Causes

Decreased Po₂

Collapsed alveoli (atelectasis)

Airway obstruction

By the tongue
By a foreign body

Failure to take deep breaths

Pain (rib fracture, pleurisy)
Paralysis of respiratory muscles (spinal cord injury, polio)
Depression of the respiratory center (head injury, drug overdose)

Collapse of the whole lung (pneumothorax)

Fluid in the alveoli

Pulmonary edema
Pneumonia
Near-drowning
Chest trauma

Other gases in the alveoli

Smoke inhalation
Inhalation of toxic chemicals
Carbon monoxide poisoning

Respiratory arrest

Elevated Pco₂

Decreased CO₂ elimination (hypoventilation)

Decreased tidal volume

Pain (rib fractures, pleurisy)
Weakness (myasthenia gravis)
Paralysis (spinal cord injury, polio)

Decreased respiratory rate

Head injury
Depressant drugs
Stroke

Increased CO₂ production

Fever
Muscular exertion
Anaerobic metabolism

Acid-Base Imbalances

Disorder and Related Conditions	Assessment		Nursing Care Plan/ Implementation	Evaluation/Outcome Criteria
	Subjective Data	Objective Data
Respiratory Acidosis Acute bronchitis Emphysema Respiratory obstruction Atelectasis Damage to respiratory center Pneumonia Asthmatic attack Drug overdose Drug overdose	Headache Irritability Disorientation Weakness Dyspnea on exertion Nausea	Increased respirations Cyanosis Tachycardia Diaphoresis Dehydration Coma (CO₂ narcosis) Hyperventilation to compensate if no pulmonary pathology present IHCO₂ normal, Paco, elevated, pH <7.5	Assist with normal breathing: encourage coughing; suction airway; postural drainage; pursed-lip B breathing; raise HOB Protect from injury: oxygen at 2 L; encourage fluids; avoid sedation; medica- Health teaching: identify cause, prevent future episodes; increase awareness regarding risk factors and early signs of impending imbalance; encourage compliance	Normal acid-base balance obtained Respiratory rate slows, <30 No signs of pulmonary infection (e.g., sputum colorless, breath sounds clear) Demonstrates breathing exercises (e.g., diaphragmatic breathing)
Metabolic Acidosis Diabetic ketoacidosis Hyperthyroidism Severe infections Lactic acidosis in shock Renal failure - uremia Prolonged starvation diet; low-protein diet Diarrhea, dehydration Hepatitis Burns	Headache Restlessness Apathy weakness Disorientation Thirst Nausea, abdominal pain	Kussmaul’s respirations: deep, rapid air hunger; Ttemperature Vomiting, diarrhea Dehydration Stupor - convulsions - HCO₂ below normal Paco, normal, K+ >5, pH <7.39	Restore normal metabolism: correct underlying problem; sodium bicarbonate PO/IV; sodium lactate; fluid replacement, Ringer’s solution; Prevent complications: regular insulin for ketoacidosis; hourly outputs; prepare for dialysis if in kidney failure Health teaching: identify signs and symptoms of primary illness; prevent complications, cardiac arrest; diet instructions	Normal acid-base balance obtained No rebound respiratory alkalosis following therapy No tetany following return of normal pH Alert, oriented No signs of K+ excess
Respiratory Alkalosis Hyperventilation - CO₂ Fever Metabolic acidosis Increased ICP, encephalitis Salicylate poisoning After intensive exercise Hypoxia, high altitudes	Circumoral paresthesia Weakness Apprehension	Increased respirations Increased neuromuscular irritability; hypereflexia, muscle twitching, tetany, positive Chvostek’s sign Convulsions Unconsciousness Hypokalemia HCO₂ normal, Paco, decreased, pH >7.45	Increase carbon dioxide level: rebreathing into a paper bag; adjusting respirator for CO₂ retention and oxygen inspired Prevent injury: safety measures for those who are unconscious; hypothermia for elevated temper- Health teaching: recognize stressful events; counseling if problem is hysteria	Normal acid-base balance obtained Recognizes psychological and environmental factors causing condition Respiratory rate returns to normal No cardiac arrhyth- Alert, oriented
Metabolic Alkalosis Potassium deficiencies Vomiting GI suctioning Intestinal fistulas Inadequate electrolyte replacement Increased use of antacids Diuretic therapy, steroids Increased ingestion/ injection of bicarbonates	Lethargy Irritability Disorientation Nausea	Respirations: shallow; apnea, decreased thoracic movement; cyanosis Pulse: irregular - cardiac Muscles: twitching - tetany, convulsions G.I.: vomiting, diarrhea, paralytic ileus HCO₂ elevated above 26, Paco; normal, K⁺ <3.5, pH >7.45	Obtain, maintain acid-base balance: irrigate NG tubes with saline; monitor I&O; IV saline, potassium added; isotonic solutions PO; monitor vital signs Prevent physical injury: monitor for potassium loss, side effects of medications Health teaching: increase sodium when loss expected; instructions regarding selfadministration of medications (e.g., baking soda)	Normal acid-base balance obtained No signs of potassium Respiratory rate 16-20 No arrhythmias - pulse regular Lists food sources high in potassium