Disorder

Imbalances caused by this disorder

Nursing Actions (must relate to specific

imbalance in Column #2)

Rationale (there should be a great deal of

detail in this section. I need to know that you
understand why you are assessing,
monitoring, administering, & teaching)

Heart Failure

Hypo/Hypervolemia

Assess
-edema (pulmonary & peripheral)

-uncontrolled lt sided heart failure results in

pulmonary edema, rt sided peripheral
edema
-may be indicative of right sided HF
-tachycardia may indicate fluid volume
overload

-liver enlargement
-vital signs
Monitor
-I & O

-Weight
-Electrolytes
Administer
-diuretics
-K+ supplements

Acidosis/Alkalosis

Teach
-about prescribed medications
Assess
-Vital Signs
-Medications
-Neuromuscular function
Monitor
-ABG
-I&O
Evaluate Medication
Teach
-Signs and symptoms

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-decreased cardiac output can negatively

impact the kidneys (output reflects kidney
function)
-weight is the most sensitive indicator of fluid
retention
-Nat & K+ levels can drop due to diuretics &
potentiate digoxin toxicity
-to decrease fluid volume overload
-to prevent hypokalemia
-find out what patient knows compliance will
keep the patient out of the hospital
-Increased respirations cause more CO2 to be
blown off
-excessive diuretic use
-lactic acid build up will cause diminished
muscle tone and deep tendon reflexes
-to assess PaCO2, bicarbonate, and pH levels
-Overuse of diuretic will cause an increase in
diluted urine
-May need to adjust (decrease) diuretic
medication
-Teach patient signs and symptoms of
respiratory and metabolic acidosis and
alkalosis, what to do and when to seek help

Hypo/Hyperkalemia
Assess
-Vital signs
-Medications
-Bowel sounds
Monitor
-I&O
-Serum potassium and magnesium levels
Administer
-Supplement

-lead to life threating arrhythmias

-Hypo results from diuretic use without
potassium replacement, Hyper is caused from
potassium-sparing diuretic
-Hyper would have hyperactive bowel sounds,
hypo would have diminished bowel sounds
-Urine output is essential for eliminating
potassium
-Necessary for evaluating treatment,
hypomagnesium occurs with hypokalemia
-May give a potassium supplement or increase
dietary intake it increase potassium levels
-May give to decrease potassium levels

-Kayexalate
Teach
-Signs and symptoms
-Medications

Hyponatremia/Hypochloremia
Assess
-Vital signs
-Neuromuscular function
-LOC
-Medications
Monitor
-Serum electrolyte levels
-I&O, skin turgor
-ABG
Administer
-Supplement
Teach
-Signs and symptoms

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-Teach patient about signs and symptoms of

potassium imbalance, what to do, and when to
seek help
-Teach patient about the different kinds of
diuretics and which one would be right for that
patient
-Respiratory rate and pattern (respirations will
become slow and shallow), orthostatic
hypotension
-assess for tetany, hyperactive DTR, muscle
hypertonicity
-patient may become confused and
disoriented
-imbalance may be caused by excessive
diuretic therapy
-to make sure there isnt another imbalance, to
assess if treatment is working
-May indicate dehydration
-assess for acid-base imbalance
-Sodium and chloride supplements

- Teach patient about signs and symptoms of

potassium imbalance, what to do, and when to

seek help

Study Guides
Disorder

Imbalances

Nursing Actions

Rationale

Respiratory Failure

Hypo/hypervolemia

Assess
-Pulmonary edema
-Vital Signs

-Caused from increased fluid in lungs from

overuse of nebulizer
-Fever would increase metabolic rate which
would increase respiratory rate, which
removes fluid from the lungs, orthostatic
hypotension

Monitor
-I&O
-Daily Weight
-Serum Electrolyte levels

X-ray

-Urine output can indicate hypo/hypervolemia

-Can indicate a fluid imbalance
-Usually causes increase in sodium levels
(hypo), or low potassium (hyper)
-Specific gravity greater than 1.030 could
indicate hypovolemia
-Can show pulmonary congestion

Administer
-Diuretic
-Supplement
-Oxygen
-IV Fluids

-May give diuretic for fluid overload

-May give Sodium or Potassium supplement
-May give supplementary oxygen
-May give IV fluids for dehydration

-Urine

Teach
-Fluid imbalances
-Medications

Hypo/Hyperkalemia

Assess
-Vital signs
-Medications
-Bowel sounds
Monitor
-I&O
-Serum potassium levels and other electrolyte

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- Teach patient about signs and symptoms of

fluid imbalance, what to do, and when to seek
help
-If patient prescribed medication teach patient
about that medication and how important it is
to take regularly
-Increased/Decreased respiratory rate,
hypotension, orthostatic hypotension
-May be caused by diuretics
-Decreased bowel sounds could indicate
hypokalemia, increased bowel sounds could
indicate hyperkalemia
-Want to make sure there is adequate output
for potassium excretion
-To assess severity of the imbalance and to

levels

assess if something else may be causing the

imbalance

-ABG

-To assess for acidosis (from hyperkalemia) or

alkalosis (from hypokalemia)

Administer
-Supplement

-Potassium supplement if hypokalemic

-Kayexalate

-Given if potassium levels are too high

Teach
-Signs and symptoms
-Medications

-About potassium imbalance, what to do , and

when to seek help
-If prescribed medications, make sure patient
knows what the medication is for, how to take
it and side effects it may cause

Assess
-Vital Signs

-Respiratory rate: hypoventilation can cause

respiratory acidosis, hyperventilation can
cause respiratory alkalosis, hypoxia can cause
metabolic acidosis
Increased lactic acid (from hypoxia) will cause
diminished muscle tone and deep tendon
reflexes

Acidosis/Alkalosis

-Neuromuscular function
Monitor
-ABG
-Serum electrolyte levels

- to assess PaCO2, bicarbonate, and pH levels

-acidosis may cause hyperkalemia

Administer
-Oxygen

-May give supplement oxygen

Teach
-Signs and symptoms
-Medications

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-Of hyper/hypoventilation and hypoxia,

breathing techniques and when to seek help
-Teach patient about any medications
administered, what it is for, when to take it and
any side effects it may cause

Disorder

Imbalances

Nursing Actions

Excessive GI fluid loss

Hypovolemia

Assess
-Vitals
-Skin Turgor/Capillary refill
-Temperature/Color of skin
Monitor
-Daily weight
-I&O

-Increased heart rate, orthostatic hypotension

-Tenting skin turgor and delayed capillary refill
are signs of hypovolemia
-Skin will be pale and cool

-LOC
-Serum electrolyte levels
-H&H levels
-BUN and Creatinine
-Breath sounds

-Weight loss can indicate rapid fluid loss

-Output may be decreased and urine may be
concentrated
-May become confused due to volume loss
-Sodium levels may become elevated
-Assess blood volume
-May be increased, kidney function
-Crackles, may indicate fluid overload

Administer
-Fluids
-Plasma proteins (albumin)
-Oxygen
-Antiemetic
-Antidiarrheal

-Replaces fluid that has been lost

-To increase serum osmolality
-To ensure sufficient tissue perfusion
-For nausea and vomiting
-For diarrhea

Teaching
-Fluids
-Signs and symptoms

Hypo/kalemia, magnesemia,
natremia, chloremia

Rationale

Assess
-Vitals

Monitor
-Serum electrolyte levels
Administer

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-Teach patient to drink plenty of fluids

-Teach patient about signs and symptoms of
hypovolemia and when to seek help, also
teach signs and symptoms of fluid overload
and when to seek help
-May or may not have changes in vitals,
depending on which imbalance they are
having, would likely have increased heart rate
and decreased BP
-Making sure they are returning to normal after
treatment starts

-Supplements
-Fluids

-Will depend on which electrolyte levels are

low
-Oral or IV replacement

Teaching
-Supplements

-Teach about increasing dietary electrolytes to

help return balance

-Signs and symptoms

-Teach signs and symptoms of electrolyte

imbalances, and when to seek help
-Make sure patient knows about the opposite
imbalances to prevent other problems

-Hyper/kalemia, magnesemai, natremia,

chloremia

Metabolic acidosis/alkalosis

Assess
-Vital signs

-Neurologic status
Monitor
-ABG
-Serum electrolyte levels
-I&O
Administer
-Fluids
-Antiemetic
-Antidiarrheal
-Supplements
Teach
-Signs and symptoms
-Medications

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-Signs of hyperventilation/hypoventilation,
Blood pressure will drop/increase, cardiac
output will eventually decrease
-May show diminished muscle tone and DTR,
or hyperactive reflexes, both lead to
confusion, stupor, and coma
-pH levels, bicarbonate level, and the PaCO2
level
-Can cause hypokalemia, hypochloremia,
hypocalcemia, hyperkalemia
-Poly-uria
-Replaces fluid that has been lost
-For nausea and vomiting
-For diarrhea
-May administer potassium, chloride or
calcium supplement
-Teach about signs and symptoms of
metabolic acidosis/alkalosis, what to do to
prevent it, and when to seek help
-Teach about the medications given, make
sure patient knows what they are for and how
they will prevent/help them with the imbalance

Hyper/magnesemia, phosphatemia,
natremia

Assess
-Vitals
-Medications

-Assess for signs and symptoms of these

electrolyte imbalances
- Assess what the patient is currently taking,
excessive GI loss can be caused by excessive
use of enemas and laxatives

Monitor
-I&O

-because giving fluids want ot prevent fluid

overload

Administer
-Fluids

-To replace fluids lost, and to dilute blood

volume, encourage electrolyte excretion

Teach
-Medications

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-Must teach patient about the negative effects

of over use of laxatives and enemas, they will
encourage fluid loss out of the GI tract but
also some contain magnesium, phosphate,
and sodium which may cause an electrolyte
imbalance

Disorder

Imbalances

Nursing Actions

Rationale

Renal Failure

Hypo/hypervolemia

Assess
-Vital signs
-Lung sounds
-Edema

-Hypertension, hypotension, cardiac output

changes
-Crackles may indicate hypervolemia
-Edema results from urinary output less than
fluid intake

Monitor
-Daily weight
-I&O

-Serum electrolyte levels

-Weight can indicate a fluid imbalance

-Intake should be almost equal to output, can
indicate a problem
-Fluid volume, high hematocrit could indicate
dehydration
-to rule out an electrolyte imbalance

Administer
-Fluids
-Diuretics
-Supplements

-If needed, watch for fluid overload

-If renal failure is not severe
-If there is an electrolyte imbalance

-H&H

Teach
-Medication

-Signs and symptoms

-Daily weight

Hyper/kalemia, phosphatemia,
natremia, magnesemia

Assess
-Vitals
-ECG
Monitor

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-Teach about medications prescribed, also

important for patient to know where their
medications are being excreted, if the kidneys
are not working medications could become
toxic
-Teach about signs and symptoms of
medication toxicity and hypo/hypervolemia,
what to do and when to seek help
-Teach patient about how daily weight can be
the first sign of fluid overload, teach patient to
notify HCP if greater than 2lb in one day
-Respiratory rate, Blood pressure, heart rate
(tachypnea, arrhythmias, hypertension)
-Can indicate hyperkalemia
-Renal failure can cause electrolyte

-Serum electrolyte levels

-BUN, Creatinine levels
-Daily weight
Administer
-Medications
-Diet
Teach
-Signs and symptoms
-Medications
-Diet

Hypo/calcemia, natremia
Assess
-Vitals
-Edema
-I&O
Monitor
-Serum electrolyte levels

-GFR

imbalances, to evaluate imbalance and

severity
-Can indicate a worsening condition
-Can indicate fluid retention
-administer medications for the imbalance that
is present (Kayexalate)
-Restrict patients diet, high in calories, low
protein, and no sodium added
-Teach patient about the signs and symptoms
of these imbalances and when to seek help
-How to take them and what the side effects
are and when to report them
-Teach patient about the high calorie, low
protein and no sodium diet, provide a dietitian
if needed
-May indicate imbalance
-May indicate fluid retention caused by
hyponatremia
-Can indicate decreased renal function, also
could indicate fluid retention
-Can indicate the imbalance and the severity
of the imbalance, also may indicate
hyperphosphatemia which can cause
hypocalcemia
-Decrease in GFR levels can cause
hyponatrema
-Can indicate fluid retention

-Daily weight
Administer
-Supplement
-Diuretic
-Dialysis
Teach
-Medication
-Signs and symptoms
-Diet
-Proper care for shunt, fistula or VAD

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-May need supplement for Vitamin D, calcium,

or sodium
-For excess fluid
-If diuretic is not working or contraindicated
-About the medication, side effects
-Teach signs and symptoms of imbalances
and when to seek help
-Avoid foods high in sodium and high in
potassium
-If needed for dialysis, must know proper way
to take care of it

Metabolic acidosis, alkalosis

Assess
-Vital signs
Monitor
-ABG
-Serum electrolyte levels

-Signs of hypo/hyperventilation, pulse, Blood

pressure
-pH levels, bicarbonate level, and the PaCO2
level
-Can cause hypokalemia, hypochloremia,
hypocalcemia, hyperkalemia
-Polyuria

-I&O
Administer
-Fluids
-Supplements
-Medications

-If renal function can tolerate

-For electrolyte imbalances
-Sodium bicarbonate,

Teach
-Signs and symptoms

-Signs and symptoms of metabolic acidosis

and alkalosis, what to do and when to seek
help
-Teach patients about any medications given,
side effects and when to report them to HCP

-Medications

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Disorder

Imbalances

Nursing Actions

Rationale

Burns

Hypo/hypervolemia

Assess
-Vitals

-Increased respirations may indicate a

blockage or damage to the lungs, third-space
shift may cause diminished pulses in
extremities
-Due to third-space shift, also pulmonary
(assess lung sounds for crackles)

-Edema
Monitor
-I&O

-H&H levels
-Bowel sounds

-Kidneys may retain water due to release of

stress hormones
-Signs of fluid retention
-Electrolyte imbalances can cause similar
signs and symptoms, rule out other
imbalances
-Will indicate an fluid imbalance
-hypovolemia can cause paralytic ileus

Administer
-Fluids
-Diuretics
-Oxygen

-If ordered for fluid replacement

-If ordered for fluid retention
-If oxygen supplement is needed

-Daily weight
-Serum electrolyte levels

Teach
-Plan
-Medications
-Signs and Symptoms

Hyper/kalemia, natremia

Assess
-Vital signs
-ECG results
Monitor
-I&O

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-Teach patient about their own plan of

treatment
-Inform patient about medications, when they
are ineffective, side effects and when to seek
help
-Signs and symptoms of hypo/hypervolemia
and when to seek help
-Irregular heart rate, lung sounds, temperature
-Arrhythmias
-Diminished kidney perfusion may cause
kidneys to retain sodium and water
(decreasing urine output)

-Daily weight
-Serum electrolyte levels
-BUN, Creatinine levels

-Indication of fluid retention

-To determine severity of the imbalance
-To evaluate the kidney function

Administer
-Fluids

-IV fluids to encourage excretion of extra

electrolytes
-If fluids are contraindicated may give diuretic
or Kayexalate to eliminate extra sodium and
potassium

-Medications
Teach
-Signs and symptoms
-Medications
-Plan
-Diet

Hypo/natremia, calcemia, kalemia

Assess
-Vital signs
Monitor
-I&O
-Daily weight
-Serum electrolyte balance
-ABG
Administer
-Medications
-Supplements
Teach
-Signs and symptoms
-Medications
-Diet

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-Signs and symptoms of imbalances (hyper

and hypo), when to seek help
-Teach about medications if administered
-Teach patient about their plan of treatment
-Diet low in potassium and salt
-Assess for signs and symptoms of the
electrolyte imbalances
-Hyponatremia can be caused by increased
diuresis
-First sign of fluid retention
-To evaluate the severity of the imbalance
-Metabolic acidosis can occur from
hyponatremia
-May be given an antidiuretic to help retain
fluids (if needed)
-May be given a sodium, calcium, or
potassium supplement or increase dietary
intake if able
-Signs and symptoms of imbalances and
when to seek help
-Teach patient about medications, side effects,
and when to seek help
-May need to increase dietary intake of
sodium, calcium, and potassium if able

Metabolic acidosis

Assess
-Vitals

-Monitor for changes and assess cardiac

rhythm, breathing rate, hypotension

Monitor
-I&O
-Daily weight
-ABG

-To monitor renal function

-To monitor fluid retention
-For severity of the imbalance, also to monitor
changes, typically lab results for metabolic
acidosis are: pH below 7.35, Paco2 less than
35 mmHg
-Potassium levels are usually high, watch for
hyperkalemia

-Serum electrolyte balance

Administer
-Medications
-Dialysis
Teach
-Signs and symptoms
-Medications

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-possible medication ordered sodium

bicarbonate, vasopressor
-If needed
-Teach signs and symptoms of metabolic
acidosis and when to seek help
-Teach patient about medications, any side
effects from medications and when to seek
help

S 2013 NURS 2992 14