GROUP

2
M AG A L L O N , B U E N AV E N T U R A
S A L L A B E R G E R , J AY R A H N I C O L E
A G L I A M , J E S S I C A M AY
D I Ñ O , F O R T U N AT O
TOPIC
FLUID AND/OR
ELECTROLYTE
IMBALANCE
• Electrolytes are ions that can have either a negative or positive
charge. Electrolytes and the levels of electrolytes play roles that are
essential to life.
• Body fluids have a variety of important functions in the human
body: the facilitate transport of nutrients, hormones, proteins, and
other molecules into cells; aid in the removal of metabolic waste
products; regulate body temperature; lubricates musculoskeletal
joints; provide a medium for which cellular metabolism could take
place; and act as a component in body cavities.
• Fluid and electrolyte imbalances can result from excessive losses
through these routes.
WHAT ARE ELECTROLYTE DISORDERS?
• An electrolyte disorder occurs when the levels of electrolytes in
your body are either too high or too low. Electrolytes are naturally
occurring elements and compounds in the body. They control
important physiologic functions.
• Examples of electrolytes include:
– calcium
– chloride
– magnesium
– phosphate
– potassium
– sodium
1. SYMPTOMS OF ELECTROLYTE DISORDERS
MI L D FOR MS OF E L ECT ROLY TE DI SOR DE R S MAY NOT C AUSE ANY
SY MPTOMS. SUCH DI SOR DE R S C AN G O UNDE T E CT ED UNT I L T H E Y AR E
DI SCOV E R ED DUR I NG A ROUT I NE B L OOD T E ST. SY MP TOMS USUAL LY
START TO APPE AR ONCE A PART I CUL AR DI SOR DE R B E COMES MOR E
SE V E R E .
COMMON SY MPTOMS OF AN E L E CT ROLY T E DI SOR DE R I NCL UDE :

• Irregular heartbeat • Abdominal cramping

• Fast heart rate • Muscle weakness
• Lethargy • Muscle cramping
• Fatigue • Irritability
• Convulsions or Seizures • Confusions
• Nausea • Headaches
• Vomiting • Numbness and Tingling
• Diarrhea or Constipation
2. NURSING DIAGNOSIS
• Hypervolemia refers to an isotonic volume expansion of the extracellular fluid (ECF) caused by the
abnormal retention of water and sodium in approximately the same proportions in which they normally
exist in the ECF.

Possibly evidenced by:

• Ascites.
• Aphasia, muscle twitching, tremors, seizures.
• Bounding pulses.
• Changes in the level of consciousness (lethargy, disorientation, confusion to coma).
• Crackles.
• Distended neck and peripheral veins.
• Edema variable from dependent
• Elevated central venous pressure.
• Extra heart sounds S3.
• Hypertension.
• Productive cough
• Shortness of breath.
• Sudden weight gain, often in excess of 5% of total body weight.
• Tachypnea with or without dyspnea, orthopnea.
• Tachycardia usually present; bradycardia-late sign of cardiac decompensation.
• Hypovolemia occurs when loss of extracellular fluid exceeds the intake of fluid.

Possibly evidenced by:

• Abdominal distention.
• Confusion, restlessness.
• Dark concentrated urine.
• Decreased urine volume.
• Decreased central venous pressure.
• Flattened neck veins.
• Hypotension.
• Pale, moist, clammy skin.
• Tachycardia.
• Tachypnea.
• Weak pulses.
3. PLAN
Hypervolemia

Nursing Interventions:
• Monitor vital signs as well as central venous pressure, if available.
• Weigh client daily. Observe for sudden weight gain.
• Note presence of neck and peripheral vein distention, along with pitting edema, and dyspnea.
• Auscultate lung and heart sounds.
• Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations.
• Assess for presence and location of edema formation.
• Monitor infusion rate of parenteral fluids closely; May use infusion pump, as necessary.
• Administer oral fluids with caution. Do a 24-hour schedule fluid intake if fluids are restricted.
• Encourage adequate bed rest.
• Encourage deep breathing and coughing exercises.
• Turn or reposition, and provide skin care at regular intervals.
• Maintain semi-Fowler’s position if dyspnea or ascites is present.
• Provide safety measures as indicated: (Bed in a low position, frequent observation, soft restraints, use of side rails)
• Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gasses (ABGs), as indicated.
• Replace potassium losses, as indicated.
• Provide balanced protein, low-sodium diet. Restrict fluids, as indicated.
Hypovolemia

Nursing Interventions:
• Weigh client daily and compare with 24-hour intake and output.
• Monitor vital signs and CVP. Observe for temperature elevation and orthostatic hypotension
• Monitor urine output. Measure or estimate fluid losses from all sources such as diaphoresis, wound drainage, and gastric losses.
• Investigate reports of sudden or sharp chest pain, cyanosis, restlessness, increased anxiety, and dyspnea.
• Palpate peripheral pulses; Observe for skin color, temperature, and capillary refill.
• Monitor for a sudden or marked elevation of blood pressure, dyspnea, basilar crackles, frothy sputum, moist cough, and restlessness.
• Evaluate client’s ability to manage own hydration.
• Provide skin and mouth care. Bathe every other day using mild soap. Apply lotion, as indicated.
• Ascertain client’s beverage preferences, and set up a 24-hour schedule for fluid intake. Encourage foods with high fluid content.
• Provide safety precautions, as indicated, such as the use of side rails when appropriate, bed in low position, frequent observation, and
soft restraints if required.
• Turn frequently, gently massage skin, and protect bony prominence.
• Monitor laboratory studies, as indicated.
• Provide tube feedings, including free water, as appropriate.
4. WHAT ARE THE MEASURES TO
MAINTAIN LEVEL OF WELNESS?
• Eat Whole Foods
The best way to get all the nutrients your body needs is to eat whole foods the majority of the
time. That means avoiding junk foods that have little or no nutritional value. Eating a balanced
diet full of fresh produce, lean protein, healthy fats, and complex carbohydrates will give you all
the nutrients you need to keep your body in balance.
• Hold the Salt
Most processed foods contain an unnecessarily high amount of salt. Salad dressing, sauces,
highly processed desserts, and soda are all major sources of sodium! When you cook your
own food, replace table salt with sea salt or Himalayan salt which are full of important
minerals.
• Drink Water
As long as you’re eating a healthy and balanced diet, using small amounts of salt in your food,
and drinking plenty of water, your fluid balance should be able to manage itself. Water also
helps keep your metabolism and digestive system in check.
• Recover after Exercise
Replenish your electrolyte levels after working out by consuming foods that contain potassium
and sodium. That includes papaya, broth, milk, pickles, sweet potatoes, and coconut water. While
natural sources are ideal, you can also get electrolytes from tablets and supplements. This helps
avoid muscle fatigue after a workout.
• Take an Epsom Salt Bath
Your body actually absorbs magnesium better through your skin than through your digestive
system. If you’re experiencing muscle cramps, troubles sleeping, or anxiety, consider taking
a warm Epsom salt bath since Epsom salt is rich in magnesium.
REFERENCES:
• https://www.nutriliving.com/blog/how-to-achieve-the-perfect-balance-of-electrolytes
• https://www.registerednursing.org/nclex/fluid-electrolyte-imbalances/#identifying-signs-
symptoms-clients-fluid-andor-electrolyte-imbalances
• https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/