Body fluid is composed primarily of water and electrolytes. The body is equipped with homeostatic mechanisms to keep the composition and volume of body fluids within narrow limits. Organs involved in this mechanism include the kidneys, lungs, heart, blood vessels, adrenal glands, parathyroid glands, and pituitary gland. Body fluid is divided into two types: intracellular (within the cells) and extracellular (interstitial or tissue fluid, intravascular or plasma, and transcellular, such as cerebrospinal or synovial fluids).
1. Restore homeostasis.
2. Prevent/minimize complications.
3. Provide information about condition/prognosis and treatment needs as appropriate.
1. Homeostasis restored.
2. Free of complications.
3. Condition/prognosis and treatment needs understood.
4. Plan in place to meet needs after discharge.
Note: Because fluid and electrolyte imbalances usually occur in conjunction with other medical conditions, the following information is offered as a reference. The interventions are presented in a general format for inclusion in the primary plan of care.
Nursing diagnosis for fluid and electrolyte imbalances: Excess Fluid Volume may be related to Excess fluid or sodium intake; and Compromised regulatory mechanism possibly evidenced by Signs/symptoms noted in database.
1. Demonstrate stabilized fluid volume as evidenced by balanced I&O, vital signs within patient’s normal range, stable weight, and absence of signs of edema.
2. Verbalize understanding of individual dietary/fluid restrictions.
3. Demonstrate behaviors to monitor fluid status and prevent/limit recurrence.
Nursing intervention with rationale:
1. Monitor vital signs, also CVP if available.
Rationale: Tachycardia and hypertension are common manifestations. Tachypnea usually present with/without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions, e.g., HF.
2. Auscultate lungs and heart sounds.
Rationale: Adventitious sounds (crackles) and extra heart sounds (S3) are indicative of fluid excess. Pulmonary edema may develop rapidly.
3. Assess for presence/location of edema formation.
Rationale: Edema can be either a cause or a result of various pathological conditions reflecting four competing forces—blood hydrostatic and osmotic pressures, and interstitial fluid hydrostatic and osmotic pressures. The dynamic interaction of these four forces allows fluid to shift from one body compartment to another. Edema may be generalized or localized in dependent areas. Elderly patients may develop dependent edema with relatively little excess fluid. Note: Patients in a supine position can have an increase of 4–8 L of fluid before edema is readily detected.
4. Note presence of neck and peripheral vein distension, along with pitting edema, dyspnea.
Rationale: Signs of cardiac decompensation/HF.
5. Maintain accurate I&O. Note decreased urinary output, positive fluid balance (intake higher than output) on 24-hr calculations.
Rationale: Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.
6. Weigh as indicated. Be alert for acute or sudden weight gain.
Rationale: One liter of fluid retention equals a weight gain of 2.2 lb.
7. Monitor infusion rate of parenteral fluids closely; administer via control device/pump as necessary.
Rationale: Sudden fluid bolus/prolonged excessive administration potentiates volume overload/risk of cardiac decompensation.
8. Maintain semi-Fowler’s position if dyspnea or ascites is present.
Rationale: Gravity improves lung expansion by lowering diaphragm and shifting fluid to lower abdominal cavity.
9. Provide safety precautions as indicated, e.g., use of side rails, bed in low position, frequent observation, soft restraints (if required).
Rationale: Fluid shifts may cause cerebral edema/changes in mentation, especially in the geriatric population. Note: Application of restraints can increase agitation, requiring alternative interventions (e.g., one-on-one monitoring, sedation). Use of side rails may place the elderly confused patient at risk for entrapment injury/death.
10. Administer diuretics: loop diuretic, e.g., furosemide (Lasix); thiazide diuretic, e.g., hydrochlorothiazide
(Esidrix); or potassium-sparing diuretic, e.g., spironolactone (Aldactone).
Rationale: To achieve excretion of excess fluid, either a single diuretic (e.g., thiazide) or a combination of agents (e.g., thiazide and spironolactone) may be selected. The combination can be particularly helpful when two drugs have different sites of action, allowing more effective control of fluid excess.