Nursing diagnosis – RISK FOR ELECTROLYTE IMBALANCE

RISK  FOR  ELECTROLYTE  IMBALANCE

DEFINITION

At risk for change in serum electrolyte levels that may compromise

health

RISK FACTORS

• 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-

• Diarrhea

drome of inappropriate

• Vomiting

antiduretic hormone (SIADH))

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain electrolyte levels within the normal limits.

• Maintain adequate fluid balance consistent with underlying disease

restrictions.

• 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

well.

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

electrolyte imbalance.

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

imbalance.

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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

in care.

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

Management

Reference

Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled

water. Journal of Perianesthesia Nursing, 23, 267–272.

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