Primary Nursing Diagnosis

Fluid volume deficit related to fluid loss, inadequate fluid intake, or fluid shifts to the extravas-cular space

OUTCOMES. Electrolyte and acid-base balance; Hydration; Fluid balance; Nutritional status: Food and fluid intake; Knowledge: Health behaviors; Urinary elimination

INTERVENTIONS. Electrolyte management: Hypernatremia; Fluid management; Fluid monitoring; Intravenous insertion; Intravenous therapy: Venous access devices maintenance

U PLANNING AND IMPLEMENTATION Collaborative

The goal is to decrease the total body sodium and replace the fluid loss. Encourage liquids; if the patient cannot tolerate fluids, an intravenous (IV) hypotonic electrolyte solution (0.2% or 0.45% sodium chloride) or salt-free solution is usually ordered. Sometimes these two types of solutions are alternated to prevent hyponatremia. If 5% dextrose in water is ordered, monitor the urine output because this solution encourages diuresis, which can aggravate the hypernatremic condition. Maintain intake and output records and weigh the patient each day to monitor the fluid volume status.

Monitor the patient's serum sodium levels daily as well to determine the effectiveness of IV fluids. Administer the water replacement slowly as prescribed to reduce the serum sodium levels not more than 2 mEq/L per hour. If hypernatremia is corrected too quickly, the ECF shifts into the cells, resulting in cerebral edema and neurological problems. Monitor the patient for signs and symptoms of cerebral edema: headache, lethargy, nausea, vomiting, widening pulse pressure, and decreased pulse rate. Sometimes, diuretic therapy is indicated to increase sodium excretion, along with a decrease of oral sodium intake in the diet. No pharmacologic management is usually required other than IV therapy.

Independent

Offer fluids and water frequently to patients with hypernatremia. Avoid caffeinated fluids and alcohol because they can increase the serum sodium level by causing water diuresis. Notify the physician of any changes in mental status, such as agitation, confusion, and disorientation. If the patient is at risk for seizures, initiate seizure precautions.

Give oral care every 2 hours; avoid using lemon glycerin swabs and alcoholic mouthwashes because they have a drying effect and can cause discomfort. Monitor the condition of the skin, and assist with position changes frequently. Determine the patient's ability to ambulate safely. If the patient is confused and disoriented, maintain the bed in the lowest position and maintain safety measures.

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