Risk for Electrolyte Imbalance

Risk for Electrolyte Imbalance 5 Nursing Care Plans

Risk for Electrolyte Imbalance NCLEX Review Care Plans

5 Nursing Care Plans on Risk for Electrolyte Imbalance

Electrolyte Imbalance can be defined as the disproportion of electrolytes in the body which can affect the regulation of many bodily processes such as blood acidity and blood pressure, hydration status, nerve and muscle functions, and rebuilding of damaged tissues.

The imbalance of the electrolytes such as sodium, potassium, calcium, magnesium, chloride and phosphate can have mild to severe effects on the body. The degree of effect of electrolyte imbalance depends on how low or high the levels in the blood.

Nursing Stat Facts

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Nursing Stat Facts

Factors Related to Electrolyte Imbalance

Several factors can affect the occurrence of electrolyte imbalance. These include:

  • Vomiting or diarrhea – may cause electrolyte losses
  • Congestive heart failure – patients with CHF may have irregular potassium and sodium levels
  • Diabetes – diabetic patients may have calcium or magnesium imbalance
  • Hypertension – hypertensive patients may have calcium or magnesium imbalance
  • Injury and trauma – may cause electrolyte losses
  • Parental nutrition – may cause electrolyte losses
  • Suctioning – may cause electrolyte losses
  • Patients on diuretics – may have potassium and magnesium imbalance
  • Thyroid and parathyroid disorders – may have calcium and magnesium imbalance
  • Changes in ADH and aldosterone levels – may contribute to sodium imbalance
  • Diet – high protein diet may cause hypernatremia

Signs and Symptoms of Electrolyte Imbalance

  • Nausea and vomiting
  • Dyspnea or shortness of breath
  • Changes in blood pressure levels
  • Confusion or other acute mental disturbances
  • Fatigue and lethargy
  • Malaise or generalized body weakness
  • Tachycardia or rapid heartbeat
  • Arrhythmia or irregular heartbeat
  • Difficulty moving
  • Changes in the frequency of urination

Electrolyte Normal Values

  • Sodium: 136 to 145 mEq/L
  • Potassium: 3.5 to 5.1 mEq/L
  • Chloride: 98 to 107 mEq/L
  • Total calcium: 9 to 10.5 mg/dL
  • Ionized calcium: 4.6 to 5.1 mg/dL
  • Magnesium: 1.8 to 3 mg/dL
  • Phosphate: 0.8 to 1.5 mEq/L

Nursing Care Plans for Risk for Electrolyte Imbalance

Nursing Care Plan 1

Hypernatremia

Nursing Diagnosis: Risk for Electrolyte Imbalance (Hypernatremia) related to diabetes insipidus

Desired Outcome: Patient will be able to maintain a normal electrolyte and fluid balance as evidenced by normal vital signs and the absence of cognitive impairment and neuromuscular irritability.

InterventionRationale
Obtain a urine sample and blood samples from the patient.Urinalysis – to check for urine concentration by means of measuring urine sodium and osmolality levelsBlood test – Biochemistry is needed to check for the level of sodium (normal serum sodium level is 135-145mEq/L); ADH test – to measure the level of circulating ADH in the body (normal ADH range is 0-5 picograms/mL)  
Monitor vital signs, particularly the blood pressure levels.Hypertension or hypotension may be present, depending on the patient’s fluid status.
Regularly check for the patient’s level of consciousness and muscular movement, strength, and tone.Sodium imbalance such as hypernatremia may cause nerve and muscular irritability as well as changes in mentation. Severe hypernatremia, if left untreated, may result to confusion, seizures, or coma.
 Encourage oral fluid intake Administer intravenous dilute fluids as prescribed.Fluid replacement is needed to lower the sodium level in the bloodstream. It is important to administer fluids slowly to prevent brain damage. 5% D/W or 0.45% saline are usually the fluids of choice for free water replacement in patients with hypernatremia with euvolemia.
Start a strict input and output monitoring.To accurately measure the input and output of the patient in order to check the patient’s fluid status.
Educate the patient about avoiding foods high in sodium, such as canned foods including canned vegetables, processed foods, and condiments. Refer the patient to the nutrition and dietetics team as needed.To lower the risk for hypernatremia and its complications.
Administer medications for symptom relief of vomiting and/or diarrhea.Vomiting and diarrhea promote electrolyte losses and may contribute to hypernatremia.
Advise the patient to perform frequent oral care and avoid using alcohol-containing mouthwash.To prevent the drying of mucous membranes and to promote patient comfort.
Monitor other serum electrolytes while checking the sodium levels.To ensure that other electrolytes do not become imbalanced.

Nursing Care Plan 2

Hypercalcemia

Nursing Diagnosis: Risk for Electrolyte Imbalance (Hypercalcemia) related to renal disease

Desired Outcome: Patient will be able to maintain a normal electrolyte and fluid balance as evidenced by normal vital signs, the absence of cognitive impairment, and the presence of normal muscular strength.

InterventionRationale
Obtain blood sample from the patient.Blood test – Biochemistry is needed to check for the level of calcium (normal serum calcium levels: Total calcium: 9 to 10.5 mg/dL Ionized calcium: 4.6 to 5.1 mg/dL  
Monitor vital signs, particularly the cardiac rate and rhythm.Hypercalcemia may result to the overstimulation of cardiac muscles which can cause ineffective cardiac contraction and dysrhythmias. Sinus bradycardia may be observed in patients with hypercalcemia. This also puts the patient at risk for cardiac arrest.
Regularly check for the patient’s level of consciousness and muscular movement, strength, and tone.Calcium imbalance such as hypercalcemia may cause nerve and muscular weakness as well as changes in mentation. The patient may also experience lethargy and fatigue due to high calcium levels in the blood. The patient may also Severe hypercalcemia, if left untreated, may result to convulsion or coma.
Encourage oral fluid intake Administer intravenous isotonic fluids as prescribed. If kidney stones are present, encourage drinking acid-ash juices such as prune and cranberry juice.Fluid replacement is needed to lower the calcium level in the bloodstream by promoting urinary flow and clearance. It is important to administer fluids to prevent dehydration and stone formation.
Start a strict input and output monitoring.To accurately measure the input and output of the patient in order to check the patient’s response to interventions.
Educate the patient about avoiding foods high in calcium, such as eggs, dairy products, and spinach. Calcium-containing antacids should also be avoided. Refer the patient to the nutrition and dietetics team as needed.To lower the risk for hypercalcemia and its complications.
Administer medications for the treatment of hypercalcemia as prescribed.Calcitonin may be given to promote the movement of calcium from the blood into the bones. Diuretics may be prescribed to promote the elimination of calcium from the body. Glucocorticoids may be given to stop the absorption of calcium in the intestines.
Reposition the patient frequently. Encourage physical activity and range-of-motion (ROM) exercises. Refer to the physiotherapy team as required.To exercise the muscles which may reduce or prevent the shifting of calcium from the bones to the bloodstream.
Review the patients’ current medications, looking for any calcium-elevating drugs.Some drugs may further elevate calcium levels and might need to be dose adjusted or changed to an alternative medication.
Monitor other serum electrolytes (i.e., magnesium and phosphate) while checking the calcium levels.To ensure that other electrolytes do not become imbalanced.

Nursing Care Plan 3

Hypocalcemia

Nursing Diagnosis: Risk for Electrolyte Imbalance (Hypocalcemia) related to diarrhea

Desired Outcome: Patient will be able to maintain a normal electrolyte and fluid balance as evidenced by normal vital signs, the absence of respiratory impairment and neuromuscular irritability.

InterventionRationale
Obtain blood sample from the patient.Blood test – Biochemistry is needed to check for the level of calcium (normal serum calcium levels: Total calcium: 9 to 10.5 mg/dL Ionized calcium: 4.6 to 5.1 mg/dL  
Monitor vital signs, particularly the respiratory rate, cardiac rate and rhythm. Ensure that a tracheostomy set is prepared at the bedside.Hypocalcemia puts the patient at risk for laryngeal stridor, which may result to respiratory arrest. Hypocalcemia may result to the under-stimulation of cardiac muscles which can cause irregular cardiac contraction and dysrhythmias. Tachycardia may be observed in patients with hypocalcemia. This also puts the patient at risk for ventricular arrythmias.
Assess for the patient’s neuromuscular movement, tone, and strength as well as reflexes. Observe for the presence of Chvostek’s sign and Trousseau’s sign.Hypocalcemia is evidenced by neuromuscular irritability and weakness. Chvostek’s sign – the twitching of the ipsilateral facial muscles upon percussion, indicating increased irritability of the facial nerveTrousseau’s sign – carpopedal spasm of the hand and wrist when a blood pressure cuff is inflated
Administer intravenous calcium gluconate as prescribed.To rapidly treat acute hypocalcemia, especially in patients with convulsion or tetany.
Educate the patient to eat foods high in calcium and vitamin D, such as eggs, dairy products, sardines, yogurt oranges, green beans, and spinach. Oral calcium and vitamin D supplements should be advised. Calcium-containing antacids can be taken by the patient. Refer the patient to the nutrition and dietetics team as needed.
Avoid phosphorus-rich foods such as whole wheat, barley, bran, nuts, and chocolate.
To improve calcium levels in the body. Vitamin D helps in the intestinal absorption of calcium. Phosphorus reacts in an opposite way to calcium in the body. It may compete with calcium in terms of intestinal absorption.
Administer medications for symptom relief of diarrhea.Diarrhea promotes electrolyte losses and may contribute to hypocalcemia.
Teach the patient some stress-reduction activities and relaxation techniques. Refer to the complementary therapy team as required.Stress can trigger hypocalcemic tetany.
Review the patients’ current medications, looking for any magnesium-lowering drugs.Some drugs may decrease magnesium levels which can indirectly reduce calcium levels.
Monitor other serum electrolytes (i.e., magnesium and phosphate) while checking the calcium levels.To ensure that other electrolytes do not become imbalanced.

Nursing Care Plan 4

Hypermagnesemia

Nursing Diagnosis: Risk for Electrolyte Imbalance (Hypermagnesemia) related to chronic diarrhea

Desired Outcome: Patient will be able to maintain a normal electrolyte and fluid balance as evidenced by normal vital signs, normal muscular strength, and the absence of respiratory impairment.

InterventionRationale
Obtain blood sample from the patient.Blood test – Biochemistry is needed to check for the level of magnesium. Normal serum Mg levels: 1.8 to 3 mg/dL 
Monitor vital signs, particularly the respiratory rate, cardiac rate and rhythm, and blood pressure.Hypermagnesemia puts the patient at risk for respiratory muscular weakness which may lead to apnea. It may also result to slow cardiac contraction as manifested by bradycardia or heart block. This also puts the patient at risk for cardiac arrest.
Unexplained hypotension may be an early sign of magnesium toxicity.
Assess for the patient’s level of consciousness, as well as his/her neuromuscular movement, tone, reflexes, and strength. Regularly check for patellar reflexes.Hypermagnesemia is evidenced by neuromuscular and CNS depression which can manifest as confusion or drowsiness. This can lead to coma or flaccid paralysis. Absence of reflexes may indicate hypermagnesemia.
Administer intravenous calcium gluconate, thiazide diuretics, and intravenous fluids as prescribed.Calcium gluconate – to rapidly treat magnesium toxicity or hypermagnesemia.  Thiazide diuretics and IV fluids – to facilitate renal clearance of magnesium
Educate the patient to avoid eating foods high in magnesium, such as whole grains, bran, nuts, and seeds. To prevent any further increase in magnesium levels in the body.
Administer medications for symptom relief of diarrhea.Diarrhea promotes electrolyte losses and may contribute to hypermagnesemia.
Encourage bed rest. Teach the patient some stress-reduction activities and relaxation techniques. Refer to the complementary therapy team as required.Lethargy and muscular weakness due to hypermagnesemia may be observed, thus the patient needs plenty of rest. Stress can worsen chronic diarrhea, which is the related factor to hypermagnesemia in this case.
Advise the patient to avoid magnesium-containing antacids.These drugs may further increase serum magnesium levels.
Monitor other serum electrolytes (i.e., calcium and phosphate) while checking the magnesium levels.To ensure that other electrolytes do not become imbalanced.

Nursing Care Plan 5

Hypomagnesemia

Nursing Diagnosis: Risk for Electrolyte Imbalance (Hypomagnesemia) related to malnutrition

Desired Outcome: Patient will be able to maintain a normal electrolyte and fluid balance as evidenced by normal vital signs, normal muscular strength, and the absence of neuromuscular irritability

InterventionRationale
Obtain blood sample from the patient.Blood test – Biochemistry is needed to check for the level of magnesium. Normal serum Mg levels: 1.8 to 3 mg/dL 
Monitor vital signs, particularly the respiratory rate, cardiac rate and rhythm. Assess swallowing and signs of dysphagia. Prepare a tracheostomy set at bedside.Hypomagnesemia puts the patient at risk for laryngeal stridor, which may result to respiratory arrest. Hypomagnesemia may result to the under-stimulation of cardiac muscles which can cause irregular cardiac contraction and dysrhythmias.
Assess for the patient’s neuromuscular movement, tone, and strength as well as reflexes. Observe for the presence of Chvostek’s sign and Trousseau’s sign.Hypomagnesemia is evidenced by neuromuscular irritability and weakness. Chvostek’s sign – the twitching of the ipsilateral facial muscles upon percussion, indicating increased irritability of the facial nerveTrousseau’s sign – carpopedal spasm of the hand and wrist when a blood pressure cuff is inflated  
Administer oral magnesium supplement and/or intravenous magnesium as prescribed.To facilitate the replacement of magnesium.
Educate the patient to eat foods high in magnesium, such as whole grains, bran, nuts, and seeds. To increase in magnesium levels in the body.
Encourage physical activity, particularly range of motion (ROM) exercises. Refer to the physiotherapy team as required.To improve muscular strength and tone.
Advise the patient to take magnesium-containing antacids if needed.These drugs may further increase serum magnesium levels.
Monitor other serum electrolytes (i.e., calcium and phosphate) while checking the magnesium levels.To ensure that other electrolytes do not become imbalanced.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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