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 controlcenter 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

Calcium (Ca

), and Magnesium (Mg

), Potassium (K

) ,

).

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

phosphate (PO

) and

) 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
5%-10% loss
1%-15%loss
15-20& loss

Mild Fluid volume deficit

(FVD)
Moderate FVD

2%-gain loss
5% - gain loss
8% - gain loss

Severe FVD
Death FVD
Mild fluid volume exeess (FVE)
Moderate FVE
Severe FVE

Head

FVD metabolic or respiration

History
Headache
Dizziness

Observation:
Irritability
Lethargy
Confusion , disorientation

acidosis , metabolic alkalosis

FVD respiratory acidosis or
alkalosis , hyponatremia
Metabolic or respiration acidosis
,hypernatremia , hypokalemia
FVD metabolic alkalosis,
respiratory acidosis ,
hypercalcemia
FVD hypomagnesaemia ,
metabolic acidosis hypokalemia

Eyes:

FVD

Inspection

FVE

Sunken dry conjuntiva

FVE

decreased or absent tearing

Periorbital oedema
papelleoedema

History
Blurred vision

Throat and mouth

FVD hypernatremia

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

Cardiovascular system

FVD

Inspection

FVE

Flack neck vein

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

Palpation
Oedema Dependent body
part : legs, sacrum,back
Increase pulse rate
Decrease pulse rate
Weak pulse
Decrease capillary filling
Bounding pulse

Auscultation
Blood pressur low or without
orthostatic changes

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

Third heart sound

Hypertension

Respiratory systems

FVE

FVE, Metabolic alkalosis,

respiratory acidosis

Inspection
FVE
Increase rate
Dysnoea

FVE

Auscultation
Grackles

Gastro intestinal system

Metabolic acidosis

History

Metabolic acidosis

Anorexia
Abdominal cramps

FVD
Third space syndrome

Inspection
Sunken abdomen

FVD, hyponatremia,
hyperkalaemia
Hyponatremia

Distended abdomen

FVD, hypokalaemia

Vomiting
Diarrhea
Auscultation
Hyperperistaltisis with
diarrhea

Renal systems

FVD, FVE

Inspection

FVE

Oliguria or anuria
Diuresis

Neuromuscular system
Inspection :
Numbness, tingling
Muscle cramps,
tetany

Metabolic alkalosis,
hypocalaemia, potassium
imbalances
Hypocalaemia, metabolic or
respiratory Alkalosis
Hyperosmolar or hypoosmolar

Coma

Imbalances hyponatremia

Tremors

Respiratory acidosis,
hypomagnesaemia

Palpation :
Hypotonocity
Hypertonocity

Hypokalaemia,hypercalaemia
Hypocalaemia,
hypomagnesaemia,metabolic

Percussion :

alkalosis

Decreased or absent deep

tendon reflexes
Increased or hyperactive
deep tendon reflexes

Skin

Hypercaleaemia,
hypermagnesaemia
Hypocalceaemia,
hypomagnesaemia

Hypernatremia,Metabolic
acidosis

Body temperature
FVD
Increase

Hypernatremia, FVD, Metabolic

acidosis

Decreased

Inspection

FVD

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

22.00-

06.00-

14.00-

24hr

Total

06.00

P.O. Intake

14.00

22.00

Intake

Tube feeding

Hyperalimentation

I.V. Primary

I.V.P.B

Blood/blood
Products

Output

Urine

Output

Emesis

G.I. Suction

Drainage

Chest Tube

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

1.

Serum electrolyte levels are measure to determine the hydration status (blood plasma)

2.
The complete blood count is determination of number and type of red and white blood cells per
cubic millimeter
3.

Blood creatinine levels are useful in measure kidney function

4.

BUN : Creatin ratio may be a better indicator of renal function (normal10:1)

5.

Arterial blood gas analysis provides information on the status of acid balance

Fluid/Electrolyte

Normal Value

Kalium Serum

3.5 5.0 mEq/l,

Natrium Serum

135 145 mEq/l,

Clourida Serum

98 100

Calsium Serum

9 10.5 mg/dl

Fosfat Serum

2.8 4.5 mg/dl

Magnesium Serum

1.8 3.0 mg/dl

Glucose Serum

70-100 mg/dl

Hematocrit

Male : 44% - 52%

Female : 39% - 47%

Blood Urea Nitrogen

10 20 mg/dl
0.7 1.5 mg/dl

Creatinin

Serum Osmolality

280 295 mOsmol/kg

Posm = 2 x [Na] + Glucose

18
= 2 x [Na]

Serum Protein

Total

6.8 8.0 g/dl

Albumin

3.5 5.5 g/dl

Globulin

2.0 3.5 g/dl

Urea Examination :

100 200 mEq/24 hr (40 mEq/l)

Natrium Urine

2. Nursing Diagnose
a. Fluid Volume Deficit
Decreased intravascular interstitial and or intracellular fluids. This refers to dehydration (water
loss alone without change in sodium)
Defining Characteristic:
1. Change in mental status
2. Decrease blood pressure
3. Decrease pulse pressure
4. Decrease skin turgor

5. Decrease pulse volume

6. Decrease tongue turgor
7. decrease urine output
8. Decrease venous filling
9. Dry mucous membrane
10. Dry skin
11. Elevated hematocrite
12. Increase body temperature
13. Increase pulse rate
14. Increase urine concentration
15. Sudden weight loss ( except in third spacing )
16. Thirst
17. Weakness
Related Factors :
1. Active fluid volume loss related to excessive diaphoresis, vomiting, diarrhea, wound
drainage or suction
2. Failure of regulatory mechanism related to neurohypophyseal impairment diabetes
insipidus or pancreatic impairment
b. Fluid Volume Excess
Definition : Increase isotonic fluid retention and edema .
Defining characteristic :
1. Adventitious breath sounds
2. Altered electrolyte
3. Anasarca

4. Anxiety
5. Azotemia
6. Blood pressure change
7. Change in mental status
8. Change in respiratory pattern
9. Decrease hematocrite
10. Decrease hemoglobin
11. Dypsnea
12. Edema
13. Increase central venous pressure
14. Intake exceeds output
15. Jugular vein distention
16. Oliguria
17. Orthopnea
18. Pleura effusion
19. Positive hepatonary reflex
20. Pulmonary artery pressure change
21. Pulmonary congestion
22. Restlessness
23. Specific gravity change
24. S3 heart sounds
25. Weight gain over short period of time
Related factors :

a. Compromised regulatory mechanism

b. Excess fluid intake
c. Excess sodium intake
d. Increased loss decrease intake of protein.
e. Specific drug therapy.
3. Planning
a. Nursing diagnosis : fluid volume deficit

Outcome criteria

Nursing Intervention

Rationale

Assess and document

Accurate assessment
amount, color and
enable the nurse to
characteristic
of
develop appropriate
Experience a reduction or
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
Measure and
Measuring intake
Has a balance fluid intake
document fluid
and output
intake and output
allows the
and output (averaging
nurse to
2500 ml per day) for 3
Encourage oral
determine fluid
days
fluid intake as
balance or
permitted.
extent of
Manifests clinical signs of
Schedule
imbalance
amounts to be
adequate hydration :
Scheduling
ingested during
a. Normal vital
each shift
specific
signs for
amounts for
age,sex and
Provide at the
each shift helps
health status
beside oral fluid
the client
b. Good skin
that the client
achieve short
turgor and
prefers
The client

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

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

term goals.
Fluid intake may
be greater when
desired fluids
are provided
This rate of
output may not
be sufficient to
excrete
required
metabolic
wastes and to
sustain life. It
may reflect
decreased
blood volume
flow to kidneys
Hypotension and
increased pulse
rate are
indicative of
intravascular
fluid deficit
Poor skin turgor,
tissue dryness
and presence of
thirst are
indications of
dehydration
Dark
concentrated
urine and an
elevated
specific gravity
are indicative
of fluid deficit
with releases
antidiuretics
hormone
(ADH)
These parameters
measure the
extent of
regulatory
mechanism
failure (in this

case, pancreatic
function
associated with
diabetes
mellitus)
A stable body
weight is
measure of
body fluid
balance
Has serum
osmolality,
hemoglobin,
hematocrite
within normal
limits

Monitor serum
osmolality,
hemoglobin, and
hematocrite
levels

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

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

Asses knowledge
base of
client/family

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

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

b. Nursing diagnosis : fluid volume excess

Outcome criteria

Nursing intervention
Measure and

The client

document fluid intake and

output

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

Has a balance fluid

intake and output
(averaging 2500 ml/day )
for 3 days

Restricted fluid
intake as ordered
Administer diuretic
as ordered

or the extent of
imbalances
Restricted
intake prevents as
increase in signs
associated with fluid
retention (e.g. dyspnea,
and circulatory
overload)
Diuretics are
given to promote urine
output and fluid loss

Loses specified
amount body weight within
1 week and then maintains
stable body weight
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

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)

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

c. Gradual
reduction in
edema

Measure
circumference of
ankle edema

effects of
therapy

Document location
and degree of
edema on scale of
+1 to +4
Maintains skin
integrity over
edematous areas

Provide pillow
supports to
edematous
extremities and
elevate
edematous
extremities above
heart level
whenever
possible
Provide proper skin
care to edematous
areas (use,
thoroughly. Rinse
soap from skin
and apply lotions
to skin)

Has electrolyte
levels within
normal limits

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

Inspects the skin for

redness and
blanching

These sign
indicate
impaired
blood
circulation

Monitor serum
electrolyte,
hemoglobin and
hematocrite

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

retention.
Serum sodium
may be
decreased
with
excessive
fluid retention
Identifies reasons
for fluid excess
and the amount
and types of food
and fluid to
consume to
prevents food and
fluid to consume
to prevents

Assess knowledge
of condition
Provide information
about causes of
volume excess,
reason for
prescribed
therapy, and how
to prevent
recurrence (e.g.,
by eating a 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?