DISEASE

PROCESS OR
CONDITION

FLUID AND
ELECTROLYTES

ASSESSMENT NANDAS
, SIGNS AND
SYMPTOMS,
AND
COMPLICATI
ONS/RISK
FACTORS

DIAGNOSI
S-LABS
AND
DIAGNOS
TIC TESTS

NURSING
INTERVENTIONS,
TREATMENT, AND
MEDICATIONS

PATIENT EDUCATION

FLUID
VOLUME
DEFICIT
EXCESSIVE
FLUID LOSS
(DEHYDRATION)

MANIFESTATI
ONS:
HYPOVOLEMA
RAPID WEIGHT
LOSS
SKIN TUGOR
DIMINSHED
ORTHOSTATIC
HYPOTENSION
TACHYCARDIA
DECREASED
URINE OUTPUT
PALE COOL
SKIN
(VASOCONSTRI
CTION)
FATIGUE
ASSESSMENT:
HEALTH
HISTORYMEDICATIONS
CHRONIC
RENAL
PROBLEMS
ENDOCRINE
DISEASE
HOT WEATHER
EXTENSIVE
EXERCISE
FEVER,
VOMITTING

Ineffective
TISSUE
PERFUSION
RISK FOR
INJURY
DEFICIENT
FLUID
VOLUME

SERUM
ELECTROLY
TESNA+
K+
SERUM
OSMOLARIT
Yosmolality
increases
and isotonic
fluid loss
HEMOGLOBI
N/HEMATOC
RITElevated
URINE
SPECIFIC
GRAVITY
AND
OSMOLALIT
Yincrease
CENTRAL
VENOUS
PRESSUREAssessing
fluid volume
status

Monitor input and output

Assess vital signs, CVP, and
peripheral pulse every 4
hours
Daily weight
Administer iv fluids
Monitor lab values BUN,
hematocrit, creatinine,
cardiac enzymes
Monitor LOC
Turn every 2 hours
Safety precautions
Reduce orthostatic
hypotension

Teach client and family

members how to prevent
orthostatic hypotension
Maintaining adequate fluid
balance
Replace fluids- such as fruit
juices and bouillon
Alternative sources of fluidgelatin, frozen juices, ice
cream

LACK OF
FLUIDS

FLUID
VOLUME
EXCESS
TOO MUCH
WATER
(EDEMA)

MANIFESTATI
ONS:
Hypervolemia
Circulatory
overload
Edema
Chronic heart
failure
Full bonding
pulse
Orthopnea
Distended neck
and peripheral
veins
Cough
Increased
venous
pressure
Dyspnea
Tachycardia
Hypertension
Reduced
oxygen
saturation
Increased urine
output
Ascites
Altered mental
status and
anxiety

FLUID
VOLUME
EXCESS
RISK FOR
IMPAIRED
SKIN
INTEGRITY
IMPAIRED
GAS
EXCHANGE

Renal and
Liver
function
testscreatinine,
BUN, and
liver
enzymes
Hematocrit
and
Hemoglobi
n-decrease
Electrolyte
s and
osmolality

MEDICATIONS:
LOOP DIURETICS-Lasix,
Edecrin, Bumex, Demadex
THIAZIDE
POTASSIUM-SPARING
DIURECTICS
TREATMENTS:
FLUID MANAGEMENT- fluid
restriction
DIETARY MANAGEMENT- sodium
restricted diet
INTERVENTIONS:
Assess vitals, edema (BACK
SACRAL&LOWER
EXTREMETIES), heart sounds,
volume of peripheral arterie
Daily weight
Administer oral fluids
cautiously
Oral hygiene every 2 hours
Teach client sodium restricted
diet
Assess skin
Reposition every 2 hr
Might need pressure mattress
or heel protectors from
pressure ulcers
Auscultate lung and heart
sounds
Place in Folwers position
Monitor oxygen levels and ABG
levels
Administer oxygen if necessary

Teach the patient about

medications-adverse
effects, prescribed amount,
and purpose
Manifestations of excess
fluid and when to seek
treatment
Recommend or prescribed
diet- how to read food
items, reducing sodium
intake
Monitoring weight
Ways to decrease
dependent edema-change
position, avoid restrictive
clothing, wear support
hose, elevate legs when
sitting, and avoid crossing
legs when sitting
Use pillows and recliner to
sleep
Buy good fitting shoes and
no barefoot

HYPONATREMI
A *LESS THAN
135

MANIFESTATI
ONS:
Weight loss
Muscle cramps
and weakness
Headache
Anxiety
Lethargy
Stupor and
coma
Anorexia
Nausea and
vomiting
Diarrhea
Hypotension
Shock
Cellular edema
Irritability
Personality
changes

RISK FOR
IMBALANCED
FLUID
VOLUME
RISK FOR
INEFFECTIVE
CEREBRAL
TISSUE
PERFUSION

Sodium labs
and
osmolality
-decrease
24 hour
urine
specimen
evaluate
sodium
excretion
Decrease in
BUN and
hematocrit

Medications:
Loop diuretics
Isotonic Ringers solution
(0.9% NaCl)
IV 3% or 5% NaCl solution
may be given in low sodium
levels (110-115mEq/L)
NO Thiazide diuretics
Treatment:
Fluid restriction
High in sodium diet
Interventions:
Monitor I and O
Daily weight
24 hr fluid balance
Monitor flow rate and client
response when CAREFULLY
delivering iv medications
make sure to use infusion
pump
Fluid restriction- calculate
intake
Monitor labs and report
abnormals
Assess for neurological
changes LOC
Assess muscle tone and
strength and tone, deep
tendon reflexes

Teach client the following:

1. Manifestations of
mild and severe
hyponatremia
2. Importance of
electrolyte
monitoring
3. Types of food and
fluids high in sodium
to replace dietary
needs
4. Older adult risk due
to certain
medications

HYPERNATRE
MIA
*MORE THAN
145

MANIFESTATI
ONS:
Weight gain
Increased thirst
Increased urine
output
Dry skin and
mucous
membranes
Decreased skin
tugor
Furrowed
tongue
Dry mouth
Headache
Restlessness
Seizures and
coma
Tachycardia
Hypotension
Vascular
collapse
*CAN LEAD TO
DEATH*

RISK FOR
INJURY

Sodium
and
osmolality
lab values
are higher
than normal

Medications:
Hypotonic IV fluids-0.45%
NaCl
5 % Dextrose in water
Diuretics
Interventions:
Monitor and maintain fluid
replacement within
prescribed limits
Monitor neurological
function-LOC
Institute safety precautions
if necessary
Orient client to time, place,
and circumstances as
needed-allow family
members to visit

Teach client on how to

respond to thirst
Low sodium diet
Use and effects of
medication
Importance of scheduling
and monitoring electrolyte
balances

HYPOKALEMIA
*LESS THAN
3.5

MANIFESTATI
ONS:
Polyuria
Polydipsia
Dilute urine
Nausea and
vomiting
Anorexia
Diarrhea
Decreased
bowel sounds
Fatigue
Leg cramps
Muscle
weakness
Confusion
Depression
Lethargy
Irregular pulse
Dysrhythmias
Postural
hypotension
EKG
abnormalities
Cardiac arrest

DECREASED
CARDIAC
OUTPUT
ACTIVITY
INTOLERANC
E
RISK FOR
FLUID
IMBALANCED
VOLUME

Potassium
levels
Arterial
Blood Gases
Renal
FunctionBUN and
creatinine

Medications:
Potassium supplements
Potassium chloride is added
to iv fluids
Treatment:
High in potassium foodsbananas, spinach, oranges,
avocadoes, potatoes,
tomatoes, meat, seafood,
milk, and yogart
Interventions:
report any electrolyte
imbalances to provider
monitor potassium levels
monitor vital signs
monitor patients for signs of
toxicity- fatguie, weakness,
confusion, or hypotension
dilute iv potassium
CLOSELY MONITOR on iv
pump and flow rate
monitor skeletal muscle
strength and tone
monitor respiratory rate and
depth, heart rate and rthym,
and blood pressure at
resting and active rate
assist with self-care
activities if needed
monitor I and O
monitor bowel sounds and

Potassium rich foods

Potassium supplements
Using salt substitutes to
increase potassium intake
Monitor potassium levels
Manifestations of potassium
imbalance

any abdominal distention

HYPERKALEMI
A
*MORE THAN
5.0

MANIFESTATI
ONS:
Thirst
Decreased
urine output
Increase urine
specific gravity
Dry skin, dry
mucous
membranes
Increased
tongue furrows
Decreased
salivation
Headache
Restlessness
Seizures
Coma
Tachycardia
Pulse weak and
thread
Decreased
blood pressure

RISK FOR
DECREASED
CARDIAC
OUTPUT
RISK FOR
ACTIVITY
INTOLERANC
E

SERUM
ELECTROLY
TES
ABGS
EKG

Medications:
Diuretics
Insulin
Hypertonic dextrose
Sodium bicarbonate
Calcium gluconate
Calcium chloride
Sorbitol
Sodium polystyrene
sulfonate (Kayexalate)
Treatment:
Dialysis
Interventions:
Closely monitor the
response to IV calcium
gluconate
Monitor skeletal muscle
strength and tone
Monitor respiratory depth
and rate
Assess lung sounds
Assist with self-care needs

Diet restrictions
Medications to be avoided

EKG changes
Vascular
collapse

HYPOCALCEMI
A
*LESS THAN
8.5

Manifestation
s:
Numbness and
tingling
Muscle
cramping
Hyperactive
reflexes
Tetany
Carpopedal and
laryngeal
spasms
Positive
chvostek and
trousseau signs
Bone pain
Fractures
Decreased
blood pressure
Complications
:
Airway
obstruction
Respiratory
arrest

RISK FOR
INJURY

Total serum
calcium
Serum
albumin
Serum
magnesium
Serum
phosphate
Parathyroid
hormone
EKG

Medications:
Calcium supplementscalcium salts
Calcium via IV prevents
airway obstruction
Carefully administer calcium
chloride-irritates veins and
can cause necrosis and
cause bradycardia
Nutrition:
High in calcium foods:
Dairy products
Canned salmon
Broccoli
Spinach
Tofu
Interventions:
check for signs of chvostek
and trousseau signs
Vitals
Apical pulse
Presence of convulsions
Monitor airway and
respiratory status
Monitor cardiovascular
status-heart rate and

Teach the client:

1. Medications and
calcium supplements
2. List of high in
calcium foods-might
need vitamin D foods
as well
3. Manifestations to
report to the health
provider
4. Stress the
importance of
following up care

Ventricular
dysrhythmias
Prolonged QT
intervals
Cardiac arrest
Heart failure
Convulsions

HYPERCALCE
MIA
*MORE THAN
10

Manifestation
s:
Increased thirst
and urine
output
Anorexia
Nausea and
vomiting
Constipation
Muscle
weakness
Increased blood
pressure
muscle
weakness
fatigue
confusion
lethargic
behavior or
personality

rhythm, pulse. And blood

pressure
Monitor EKG when patient is
receiving calcium IV
preparations and if client is
receiving digitalis.
If experiencing tetanyprovide seizure precautions
and quiet environment (side
rails may be established)
RISK FOR
INJURY
RISK FOR
FLUID
VOLUME
EXCESS

Calcium
levels are
high
Parathyroid
levels
EKG
changes
Bone
density
scans

Medications:
Lasix
Calcitonin
Bisphosphonates
Mithramycin-IV
Glucocorticoids
Fluid Therapy:
Isotonic saline
Interventions:
safety precautions
monitor LOC
monitor digitalis toxcitityvision changes, anorexia,
and changes in heart rate
promote fluid hydration
maintain dilute urine-have
client drink prune, cranberry
juice (help maintain acidic
urine)
use caution when turning,

1. Avoid excess intake

of calcium rich foods
and antacids
2. Discuss dose, use,
desired and possible
adverse effects
3. Increase fluid intake
3 to 4 quarts per day
4. Increase acid ash
foods-meats, fish,
poultry, eggs,
cranberries, plums,
and prunes
5. Increase dietary fiber
and fluid intake
6. Maintain weight
bearing physical
activity

changes
dysthymias and
EKG changes
Complications
:
Peptic ulcer
disease
Kidney stones
Pancreatitis
Hypercalcemic
crisis

HYPOMAGNES
EMIA
*LESS THAN

1.6

Manifestation
s:
Changes in
personality
Nystagmustwitching of the
eyeballs
Positive
Babinski,
chvostek, and
trousseau signs
Hypertension
Tachycardia
Cardiac
dysrhythmias
tetany
depression
seizures
agitation

positioning , transferring,
and ambulating client if
bone reabsorption occurs.
Strict I and O
Assess vital signs,
respiratory status, and heart
sounds
Place in folwers positionlung expansion

RISK FOR
INJURY

Monitor
electrolyte
imbalances

Interventions:
Monitor serum electrolytesmagnesium, potassium, and
calcium
Monitor GI function bowel
sounds and abdominal
distention
Initiate cardiac monitoring,
reporting and treating, EKG
changes and dysrhythmias
Asses deep tendon reflexes
frequently during iv
magnesium infusions and
prior to IM dose
Maintain a quiet darkened
environment
Seizure precautions

High in magnesium foods

Alcohol treatment options
(if necessary)
Stress importance of well
-balanced diet

hallucinations
*DEATH CAN
OCCUR

HYPERMAGNES
EMIA
*MORE

2.6

THAN

Confusion
Lethargy
Hypotension
Cardiac
dysrhythmias
Coma
Cardiac arrest
Hypotension
Flushing and
sweating
Bradydysrhyth
mias
Nausea and
vomiting
Weakness
Drowsiness
Weak or deep
tendon reflexes
Respiratory
depression
Heart block

DECREASED
CARDAIC
OUPUT
INEFFECTIVE
BREATHING
PATTERN
RISK FOR
INJURY
RISK FOR
INEFFECTIVE
HEALTH
MAINTENECE

Monitor
electrolyte
imbalances

Treatment:
All medications and
procedures are withheld that
contain magnesium
With a patient with renal
failure-hemodialysis or
peritoneal dialysis will
remove excess magnesium
in the body
Calcium gluconate is
administered IV
Mechanical ventilation may
be necessary
Pacemaker

Teach
1.
2.
3.

client:
Manifestations
Medications
Hemodialysis or
dialysis procedures

HYPOPHOSPHA
TEMIA
*LESS

THAN

2.5

HYPERPHOSPHAT
EMIA

*MORE THAN
4.5

Manifestation
s:
Tremors
Paresthesias
Confusion
Stupor
Bone pain
Joint stiffness
Bleeding
disorders
Impaired white
blood cell
function
Seizures
Manifestation
s:
Paresthesias
Muscle
weakness
Nausea and
vomiting
Dysphagia
Tetany
Decreased
blood pressure

IMPAIRED
PHYSCIAL
MOBILITY
DECREASED
CARDIAC
OUTPUT
RISK FOR
INJURY

Monitor
phosphorou
s levels

Treatment:
Main treatment is
prevention
Improve diet and provide
oral supplements
IV phosphate can be used
when less than 1.0
Interventions:
Monitor electrolyte
imbalances

Teach
1.
2.
3.

Monitor
calcium
levels
Monitor
phosphorou
s levels

Treatment:
Dialysis
IV normal saline
Calcium antacids
Phosphate foods will be
restricted (organ meats and
dairy products)
Interventions:
Monitor laboratory datahigh in phosphorous and low
in calcium

Teach
1.
2.
3.

client:
Manifestations
Medications
Well-balanced diet

client:
Manifestations
Medications
Restriction of high in
phosphate foods
4. Laxatives and
enemas

Cardiac
dysrhythmias
Muscle spasms

Monitor for hypocalcemia