RISK FOR ELECTROLYTE IMBALANCE
At risk for change in serum electrolyte levels that may compromise
• Fluid imbalance (e.g., dehydra-
• Renal dysfunction
tion, water intoxication)
• Endocrine dysfunction
• Treatment-related side effects
• Impaired regulatory mechanisms
(e.g., medications, drains)
(e.g., diabetes insipidus, syn-
drome of inappropriate
antiduretic hormone (SIADH))
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Physical regulation
The patient will
• Maintain electrolyte levels within the normal limits.
• Maintain adequate ﬂuid balance consistent with underlying disease
• Identify health situations that increase risk for electrolyte
imbalance and verbalize interventions to promote balance.
• Verbalize signs and symptoms that require immediate intervention
by healthcare provider.
• Remain safe from injury associated with electrolyte imbalance.
SUGGESTED NOC OUTCOMES
Electrolyte & Acid–Base Balance, Fluid Balance
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s ﬂuid status. Patients who demonstrate
ﬂuid volume alterations are likely to have electrolyte alterations as
Monitor patient for physical signs of electrolyte imbalance. Many
cardiac, neurological, and musculoskeletal symptoms are indicative
of speciﬁc electrolyte abnormalities.
Perform: Collect and evaluate serum electrolyte results as ordered to
allow for prompt diagnosis and treatment of any abnormalities.
Treat underlying medical condition. Correction of the underlying
cause of electrolyte imbalance is the ﬁrst step in correcting
Inform: Educate patient and family regarding risks for electrolyte dis-
turbances associated with their particular medical condition and pos-
sible interventions if symptoms occur. Early identiﬁcation and inter-
vention may prevent life-threatening complications of electrolyte
Attend: Provide support and encouragement to patient and family in
their efforts to participate in the management of the condition. Pos-
itive feedback will increase self-conﬁdence and feeling of partnership
Manage: Coordinate care with other members of the healthcare team
to provide safe environment. Electrolyte imbalances can cause poor
coordination, weakness, and altered gait.
SUGGESTED NIC INTERVENTIONS
Electrolyte Management, Electrolyte Monitoring, Fluid–Electrolyte
Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled
water. Journal of Perianesthesia Nursing, 23, 267–272.