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 & Perrys (2001)). b) The average adults 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 & Ferrys(2001)). 2) Hormonal Regulation a.) Antidiuretics Hormone (ADH) ADH is stored in posterior pituitary gland and its 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 & Perrys. (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 & Perrys (2001)).
2. 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 ofhypokalemia 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 & Perrys. 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 trosseaus sign (corpopedal spasm with hypoxia) 5. Positive chvosteks 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 chvosteks sign and trousseaus 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 Potters and Perrys (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 infants 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 bodys 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 bodys surface burned, the greater the fluid loss. The burned client loses bodys 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 & perrys.(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 Mild Fluid volume deficit (FVD) 5%-10% loss Moderate FVD 1%-15%loss 15-20& loss Severe FVD 2%-gain loss

5% - gain loss 8% - gain loss

Death FVD Mild fluid volume exeess (FVE) Moderate FVE Severe FVE FVD metabolic or respiration acidosis , metabolic alkalosis FVD respiratory acidosis or alkalosis , hyponatremia Metabolic or respiration acidosis ,hypernatremia , hypokalemia FVD metabolic alkalosis, respiratory acidosis ,

Head History

Headache Dizziness

Observation:

Irritability

hypercalcemia Lethargy Confusion , disorientation FVD hypomagnesaemia , metabolic acidosis hypokalemia FVD FVE FVE

Eyes: Inspection

Sunken dry conjuntiva decreased or absent tearing Periorbital oedema papelleoedema History

Blurred vision FVD hypernatremia

Throat and mouth Inspection

Sticky, dry mucous membranes ,dry cracked lips decreased salivation Longitudinal tongue furrows Cardiovascular system Inspection

FVD FVE FVD FVE Metabolic alkalosis, respiratory acidosis hyponatremia Metabolic alkalosis, hypokalemia FVD, hypokalemia FVD

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

FVE FVD,hyponatremia, hypokalemia,hypermagnesaemia FVE FVE

Auscultation

Blood pressur low or without orthostatic changes Third heart sound

Hypertension FVE, Metabolic alkalosis, respiratory acidosis FVE

Respiratory systems Inspection

Increase rate FVE Dysnoea

Auscultation

Grackles Metabolic acidosis Metabolic acidosis FVD Third space syndrome

Gastro intestinal system History

Anorexia Abdominal cramps

Inspection Sunken abdomen Distended abdomen Vomiting Diarrhea Auscultation Hyperperistaltisis with diarrhea Renal systems FVD, hyponatremia, hyperkalaemia Hyponatremia FVD, hypokalaemia

FVD, FVE

Inspection Oliguria or anuria Diuresis Neuromuscular system Inspection : Numbness, tingling Muscle cramps, tetany Coma Tremors Palpation :

FVE

Metabolic alkalosis, hypocalaemia, potassium imbalances Hypocalaemia, metabolic or respiratory Alkalosis Hyperosmolar or hypoosmolar Imbalances hyponatremia Respiratory acidosis, hypomagnesaemia Hypokalaemia,hypercalaemia

Hypotonocity Hypertonocity

Percussion :

Hypocalaemia, hypomagnesaemia,metabolic alkalosis Hypercaleaemia, hypermagnesaemia Hypocalceaemia, hypomagnesaemia Hypernatremia,Metabolic acidosis FVD

Decreased or absent deep tendon reflexes Increased or hyperactive deep tendon reflexes Skin Body temperature

Increase Decreased Hypernatremia, FVD, Metabolic acidosis FVD

Inspection Dry,flushed Palpation Inelastic skin turgor

,Cold, Clammy skin 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

22.0006.00

06.0014.00

14.0022.00

24hr

Total

Output

P.O. Intake Tube feeding Hyperalimentation I.V. Primary I.V.P.B Blood/blood Products Urine Emesis G.I. Suction Drainage Chest Tube

Intake

Output

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 Kalium Serum Natrium Serum Clourida Serum Calsium Serum Fosfat Serum Magnesium Serum Glucose Serum Hematocrit Blood Urea Nitrogen Creatinin Serum Osmolality Posm = 2 x [Na] + Glucose 18 = 2 x [Na] Serum Protein Total Albumin Globulin Urea Examination : Natrium Urine 2. Nursing Diagnose a. Fluid Volume Deficit

Normal Value 3.5 5.0 mEq/l, 135 145 mEq/l, 98 100 9 10.5 mg/dl 2.8 4.5 mg/dl 1.8 3.0 mg/dl 70-100 mg/dl Male : 44% - 52% Female : 39% - 47% 10 20 mg/dl 0.7 1.5 mg/dl 280 295 mOsmol/kg

6.8 8.0 g/dl 3.5 5.5 g/dl 2.0 3.5 g/dl 100 200 mEq/24 hr (40 mEq/l)

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 Assess and document Accurate assessment amount, color and enable the nurse to develop appropriate Experience a reduction or characteristic of vomitus, diarrhea and plans for fluid alleviation of the drainage from wounds or replacement therapy causative fluid loss tube factor, as evidenced by decrease in amount or Medications such as of absence of emeses, Assess vital signs, weight antiemetics or diarrhea, or wound and skin turgor antidiarrheals may be drainage necessary to reduce or eliminate fluid losses Administer medication as ordered to prevent further fluid loss Has a balance fluid intake Measure and Measuring intake and output (averaging document fluid and output 2500 ml per day) for 3 intake and output allows the days nurse to Encourage oral determine fluid fluid intake as balance or permitted. Manifests clinical signs of extent of Schedule adequate hydration : imbalance amounts to be a. Normal vital ingested during Scheduling 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 specificgravi ty (1.101 to 1.025) g. Stable weight

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 clients 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

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

 Has serum osmolality, hemoglobin, hematocrite within normal limits Identifies reason for fluid deficit and the amounts type of food and fluids to consume to prevent a recurrence

Monitor serum osmolality, hemoglobin, and hematocrite levels Asses knowledge base of client/family Provide information about causes of fluid volume deficit, reason for prescribed therapy and prevention of recurrences

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 An increased serum osmolality and an elevated hemoglobin and hematocrite are indicative Client understanding of condition and preventive measures may facilitate necessary follow-up care

b. Nursing diagnosis : fluid volume excess Outcome criteria The client

Has a balance fluid intake and output (averaging 2500 ml/day )

Nursing intervention Measure and document fluid intake and output

Restricted fluid

Rationale Measuring intake and output enables the nurse to determine fluid balance or the extent

for 3 days

intake as ordered

of imbalances

Administer diuretic as ordered

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 Monitoring homodynamic status every 1 or 2 hours or as the clients 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

A gradual in weight accompanies a reduction in fluid retention 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 documentatio n of edema are essential to evaluate

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

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

effects of therapy

Maintains skin integrity over edematous areas

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

Has electrolyte levels within normal limits

Monitor serum electrolyte, hemoglobin and hematocrite

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 lowsalt 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?