NURSING DIAGNOSIS: Altered fluid and electrolyte balance

  1. fluid volume deficit related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of fluid associated with vomiting, nasogastric tube drainage, and/or high-volume ileostomy output;
  2. hypokalemia, hypomagnesemia, and hypochloremia related to loss of electrolytes associated with vomiting, nasogastric tube drainage, decreased oral intake, and/or high-volume ileostomy output;
  3. metabolic alkalosis related to loss of hydrochloric acid associated with vomiting and nasogastric tube drainage;
  4. metabolic acidosis related to loss of bicarbonate ions associated with high-volume ileostomy output (effluent contains bicarbonate ions that would normally be absorbed throughout the large intestine).
Desired Outcome
The client will not experience fluid volume deficit, hypokalemia, hypochloremia, hypomagnesemia, and acid-base imbalance as evidenced by:
  1. normal skin turgor
  2. moist mucous membranes
  3. stable weight
  4. B/P and pulse within normal range for client and stable with position change
  5. capillary refill time less than 3 seconds
  6. balanced intake and output within 48 hours after surgery
  7. urine specific gravity within normal range
  8. return of peristalsis within expected time
  9. usual mental status
  10. absence of cardiac dysrhythmias, twitching, muscle weakness, paresthesias, dizziness, headache, nausea, and vomiting
  11. negative Chvostek's and Trousseau's signs
  12. BUN, serum electrolytes, and blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report:
    1. excessive ileostomy output (after bowel activity returns, expected output may be as high as 2000 ml/day and then in 10-14 days it should begin to gradually decrease to 500-800 ml/day within 2-3 months)
    2. signs and symptoms of fluid volume deficit, hypokalemia, hypochloremia, and metabolic alkalosis (see Standardized Postoperative Care Plan, Diagnosis 4)
    3. signs and symptoms of hypomagnesemia (e.g. anxiousness, irritability, cardiac dysrhythmias, tremors, positive Chvostek's and Trousseau's signs, seizures, low serum magnesium)
    4. signs and symptoms of metabolic acidosis (e.g. drowsiness; disorientation; stupor; rapid, deep respirations; headache; nausea; vomiting; cardiac dysrhythmias; low pH and TCO2).
  2. Refer to Standardized Postoperative Care Plan, Diagnosis 4, for measures to prevent or treat fluid volume deficit, hypokalemia, hypochloremia, and metabolic alkalosis.
  3. Implement additional measures to prevent or treat fluid volume deficit and electrolyte imbalances:
    1. administer additional electrolyte replacements (e.g. magnesium sulfate, sodium bicarbonate) if ordered
    2. as diet advances, perform actions to prevent or control excessive ileostomy output:
      1. instruct client to avoid excessive intake of foods/fluids that may cause diarrhea (e.g. raw fruits and vegetables; prune juice; fatty, spicy, or extremely hot or cold items; coffee)
      2. encourage intake of foods that may thicken effluent (e.g. applesauce, bananas, boiled rice, tapioca, pretzels, pasta)
      3. administer antidiarrheal agents (e.g. loperamide, diphenoxylate hydrochloride) if ordered.
  4. Consult physician if signs and symptoms of fluid volume deficit and electrolyte imbalances persist or worsen.