ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Risk for electrolyte Short Term Goal: -Establish rapport -To gain patients Short Term
No verbalization imbalance (excess After 4 hours of trust Goal:
from the patient fluid volume) nursing intervention Goal not met the
related to the the patient will -Monitor Na+ (Sodium ion) level, -In presence of a patient has
Objective Data: compromised increase in output to weight and notify health care syndrome of expired
Temperature 39.4 regulatory 30ml/hr. provider in case of significant inappropriate
mechanism with an findings. ADH secretion Long Term
Heart rate 91 bpm increase in Anti- Long Term Goal: (SIADH), the Goal:
diuretic hormone After 8 hours of Patient has Goal not met the
Respiratory rate (ADH) as nursing intervention inappropriate patient has
connected to evidenced by the patient’s urine urinary expired
mechanical decrease in urine specific gravity will concentration
ventilator specific gravity be at 1.010-1.030 causes excessive
water retention.
Blood pressure If the Na+ level
130/80 mmHg reaches below
118 mEq/L there
02 saturation 97% may be seizure
activity.
-Fluid intake may be restricted to
500ml-1000ml per 24 hrs. -Fluid restriction
helps to achieve
homeostasis.
-Free use of Na+(Sodium
ion) may be advised. -It normalizes
Na+ levels.

-Elevate the head of the bed to 10-

20 degrees, in case of
hypervolemia is present. -It promotes
 venous return and
reduces ADH
release.
-The regular specimen should be
sent for evaluating electrolytes
levels especially Na+. -To check the
improvement in
Na+ level due to
- Administer electrolyte-binding treatment.
medications
-Medications,
such as
Kayexalate for
hyperkalemia, as
- Administer IV fluids prescribed.

-To promote renal

excretion of
excess electrolyte
levels, as
- Educate the patient and family prescribed.
members about dietary choices
corresponding to the specific
electrolyte imbalance. - Provide
information about
monitoring for
potential
electrolyte
imbalances at
home resulting
from their
medications.