E
Risk for electrolyte Imbalance
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Monitor vital signs at least three times a day, or more frequently as needed. Notify provider of significant deviation from baseline. Electrolyte imbalance can lead to clinical manifestations such as respiratory failure, arrhythmias, edema, muscle weakness, and altered mental status (Buckley, LeBlanc, & Cawley, 2010).
Monitor cardiac rate and rhythm. Report changes to provider. Hyperkalemia can result in ECG changes that can lead to cardiac arrest, and ventricular dysrhythmias (Lee, 2010). Magnesium imbalances also can cause cardiac arrhythmias (Buckley, LeBlanc, & Cawley, 2010). Low serum magnesium (≤2 mEq/L) is associated with hypokalemia and ECG changes (Metheny, 2009).
• Monitor intake and output and daily weights. Weight gain is a sensitive and consistent sign of fluid volume excess (Metheny, 2009).
• Monitor for abdominal distention and discomfort. Gastric emptying rate is generally accelerated by the total volume of fluids consumed (Popkin, D’Anci, & Rosenberg, 2010).
• Monitor the client’s respiratory status and muscle strength. Phosphorus is an essential element in cell structure, metabolism and maintenance of acid-base processes. Consequences of hypophosphatemia include cardiac and respiratory failure (Geerse et al, 2010).
• Assess cardiac status and neurological alterations. Hypophosphatemia can cause myocardial dysfunction, hematological dysfunction, and neurological changes. Causes of neurological changes are not well documented. Hyperphosphatemia is associated with hypocalcemia, causing tetany, muscle spasms, and cardiac arrhythmias (Geerse et al, 2010).
• Review the client’s medical and surgical history for possible causes of altered electrolytes. Periods of excess fluid loss can lead to dehydration and resulting loss of electrolytes; fluid can be lost through gastrointestinal illness, renal failure, hyperthermia, blood loss, and perspiration due to strenuous exercise (Popkin, D’Anci, & Rosenberg, 2010). Additional causes of electrolyte imbalances include burns, trauma, sepsis, diabetic ketoacidosis, extensive surgeries, and changes in acid-base balance (Yee, 2010).
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective. Symptoms of electrolyte imbalance and dehydration can include muscle cramps, paresthesias, abdominal cramps, skin manifestations, cardiac arrhythmias, and tetany (Lee, 2010).
Monitor the effects of ordered medications such as diuretics and heart medications. Medications can have adverse effects on electrolyte balance, particularly chemotherapeutic agents, amphotericin B, aminoglycosides, phosphate ingestion loop diuretics, and vitamin D (Buckley, LeBlanc, & Cawley, 2010).
Administer parenteral fluids as ordered and monitor their effects. Rapid resuscitation with fluids can cause adverse effects such as water retention and electrolyte imbalance. Administration of fluids should be done in order to impact the plasma electrolytes and pH in a predictable fashion to prevent adverse consequences (Kaplan & Kellum, 2010).
Geriatric:• Monitor electrolyte levels carefully, including sodium levels and potassium levels, with both increased and decreased levels possible. Elderly are prone to electrolyte abnormalities because of failure of regulatory mechanisms associated with heart and kidney disease, a decrease in the ability to reabsorb sodium and a loss of diluting capacity in the kidneys. Many elderly clients are receiving selective serotonin reuptake inhibitors for treatment of depression, which can result in hyponatremia (Schlanger & Bailey, 2010).
Client/Family Teaching and Discharge Planning:
• Teach client/family the signs of low potassium and the risk factors. Signs and symptoms of low potassium include muscle weakness, nausea, vomiting, constipation, and irregular pulse (Lee, 2010).
• Teach client/family signs of high potassium and the risk factors. Signs and symptoms of high potassium include restlessness, muscle weakness, slow heart rate, diarrhea, and cramping (Metheny, 2009).
• Teach client/family the signs of low sodium and the risk factors. Early signs of low sodium include nausea, muscle cramps, disorientation, and confusion and may mimic those of dehydration (Lee, 2010).
• Teach client/family the signs of high sodium and the risk factors. Signs of high sodium include thirst, dry mucous membranes, rapid heartbeat, low blood pressure, and cool extremities. Symptoms can progress to confusion, delirium, and seizures (Lee, 2010).
• Teach client/family the importance of hydration during exercise. Dehydration occurs when the amount of water leaving the body is greater than the amount consumed. The body can lose large amounts of fluid when it tries to cool itself by sweating (Wedro, 2008).
• Teach client/family the warning signs of dehydration. Early signs of dehydration include thirst and decreased urine output. As dehydration increases, symptoms may include dry mouth, muscle cramps, nausea and vomiting, lightheadedness, and orthostatic hypotension. Severe dehydration can cause confusion, weakness, coma, and organ failure (Schwellnus, 2009).
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Diuretic use remains a primary cause of low serum potassium levels (Lee, 2010).
Instruct the client to report any adverse medication side effects to his/her provider. Assessing and instructing clients about medications and focusing on important details can help prevent client medication errors (Buckley, LeBlanc, & Cawley, 2010).
References
Buckley, M.S., LeBlanc, J.M., Cawley, M.J. Electrolyte disturbances associated with commonly prescribed medications in the intensive care unit. Crit Care Med. 2010;38(6):S253–S264.
Geerse, D.A., et al. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care. 2010;14(4):R147.
Kaplan, L.J., Kellum, J.A. Fluids, pH, ions and electrolytes. Curr Opin Crit Care. 2010;16(4):323–331.
Lee, J.W. Fluid and electrolyte disturbances in critically ill patients. Electrolyte Blood Press. 2010;8(2):72–81.
Metheny, N.M. Fluid and electrolyte balance: nursing considerations. Sudbury, MA: Jones & Bartlett Learning; 2009.
Popkin, B.M., D’Anci, K.E., Rosenberg, I.H. Water, hydration, and health. Nutr Rev. 2010;68(8):439–458.
Schlanger, L.E., Bailey, J.L., Sands, J.M. Electrolytes in the aging. ACKD. 2010;17(4):308–319.
Schwellnus, M.P. Cause of exercise-associated muscle cramps (EAMC)—altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med. 2009;43(6):401–408.
Wedro, B., Dehydration, 2008 Retrieved March 24, 2009, from http://www.medicinenet.com/dehydration/article.htm
Yee, A.H. Neurologic presentations of acid-base imbalance, electrolyte abnormalities and endocrine emergencies. Neurol Clin. 2010;28(1):1–16.
Disturbed energy Field
