NURSING DIAGNOSIS: Altered fluid and electrolyte balance

  1. fluid volume excess related to sodium and water retention associated with an increased aldosterone level resulting from:
    1. inability of the liver to metabolize aldosterone
    2. activation of the renin-angiotensin-aldosterone mechanism as a result of decreased renal blood flow (occurs because of a decrease in intravascular volume that results from vasodilation and from third-spacing and sequestration of fluid in the splanchnic system);
  2. third-spacing related to:
    1. low plasma colloid osmotic pressure associated with hypoalbuminemia (a result of decreased hepatic synthesis of albumin and prolonged inadequate nutrition)
    2. increased pressure in the portal system and hepatic lymph system associated with blood flow backup resulting from structural changes in the liver
    3. a generalized increase in hydrostatic pressure associated with fluid volume excess;
  3. hypokalemia related to excessive potassium loss associated with an increased aldosterone level (aldosterone causes potassium excretion) and diuretic therapy;
  4. hyponatremia related to hemodilution associated with fluid volume excess, sodium loss associated with diuretic therapy, and dietary sodium restriction.
Desired Outcome
The client will experience resolution of fluid imbalance as evidenced by:
  1. decline in weight toward client's normal
  2. B/P and pulse within normal range for client and stable with position change
  3. absence or resolution of S3 heart sound
  4. balanced intake and output
  5. usual mental status
  6. serum sodium returning toward normal range
  7. hand vein emptying time less than 5 seconds
  8. decreased dyspnea, peripheral edema, and neck vein distention
  9. improved breath sounds
  10. resolution of ascites.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report:
    1. signs and symptoms of fluid volume excess:
      1. weight gain of 2% or greater in a short period
      2. elevated B/P (B/P may not be elevated if fluid has shifted out of the vascular space)
      3. development or worsening of S3 heart sound
      4. intake greater than output
      5. change in mental status (may also reflect impending hepatic encephalopathy)
      6. low serum sodium (may also result from diuretic therapy and a low sodium diet)
      7. delayed hand vein emptying time (longer than 5 seconds)
      8. dyspnea, orthopnea
      9. peripheral edema
      10. distended neck veins
      11. crackles (rales), diminished or absent breath sounds
    2. signs and symptoms of third-spacing:
      1. ascites
      2. dyspnea and diminished or absent breath sounds
      3. evidence of vascular depletion (e.g. postural hypotension; weak, rapid pulse; decreased urine output)
    3. chest x-ray results showing pulmonary vascular congestion, pleural effusion, or pulmonary edema
    4. low serum albumin levels (results in fluid shifting out of the vascular space because albumin normally maintains plasma colloid osmotic pressure).
  2. Implement measures to restore fluid balance:
    1. perform actions to reduce fluid volume excess:
      1. restrict sodium intake as ordered
      2. maintain fluid restrictions if ordered
      3. implement measures to promote mobilization of fluid back into the vascular space (see actions in this diagnosis) in order to improve renal blood flow, which increases water excretion and reduces activation of the renin-angiotensin-aldosterone mechanism
      4. administer diuretics if ordered (potassium-sparing diuretics [e.g. spironolactone, amiloride, triamterene] are often used initially)
    2. perform actions to prevent further third-spacing and promote mobilization of fluid back into the vascular space:
      1. implement measures to reduce fluid volume excess (see actions in this diagnosis)
      2. encourage client to rest periodically in a recumbent position if tolerated (lying flat promotes venous return and results in lower venous hydrostatic pressure with subsequent reshifting of fluid into vascular space)
      3. administer albumin infusions if ordered to increase colloid osmotic pressure.
  3. Consult physician if signs and symptoms of fluid imbalance persist or worsen.
Desired Outcome
The client will maintain a safe serum potassium level as evidenced by:
  1. regular pulse at 60-100 beats/minute
  2. B/P within normal range for client and stable with position change
  3. usual muscle tone and strength
  4. absence of nausea and vomiting
  5. soft, nondistended abdomen with normal bowel sounds
  6. normal ECG reading
  7. serum potassium within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of hypokalemia (e.g. cardiac dysrhythmias; postural hypotension; muscle weakness; nausea and vomiting; abdominal distention; hypoactive or absent bowel sounds; ECG reading showing ST segment depression, T wave inversion or flattening, and presence of U waves; low serum potassium level).
  2. Implement measures to prevent or treat hypokalemia:
    1. administer intravenous and oral potassium replacements as ordered (monitor serum potassium and urine output closely when giving supplemental potassium; consult physician if potassium level increases above normal and/or urine output is less than 30 ml/hour)
    2. if client is taking a potassium-depleting diuretic or if signs and symptoms of hypokalemia are present, encourage intake of foods/fluids high in potassium (e.g. bananas, potatoes, raisins, apricots, cantaloupe).
  3. Consult physician if signs and symptoms of hypokalemia persist or worsen.
Desired Outcome
The client will maintain a safe serum sodium level as evidenced by:
  1. absence of nausea, vomiting, and abdominal cramps
  2. usual mental status
  3. usual muscle strength
  4. absence of seizure activity
  5. serum sodium within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of hyponatremia (e.g. nausea, vomiting, abdominal cramps, lethargy, confusion, weakness, seizures, low serum sodium level).
  2. Implement measures to treat hyponatremia:
    1. maintain fluid restrictions if ordered
    2. administer hypertonic saline solutions if ordered (not commonly given until hyponatremia is severe because of the risk of hypernatremia and intravascular volume overload); furosemide may be given concurrently to promote water excretion and reduce the risk for intravascular volume overload.
  3. Consult physician if signs and symptoms of hyponatremia persist or worsen.