Fluid and Electrolyte Care Plan Example

Fluid and Electrolyte Care Plan


Susan Smith

Female: 70 years old, 177.80 cm, 72.73 kg

Allergies: No known allergies

Vital signs:

Heart rate-60

Blood pressure-140/88


Temperature-102.4 F


Pain -5

Respiratory system assessment; on auscultation the breath sounds were audible   rhonchi with wheezes in the upper fields, and rhonchi in the bases. The client on observation shows signs of shortness of breath and she is using accessory muscles while   breathing.

Nursing Diagnosis

  1. Acute pain – as evidenced by the patient’s   respiratory distress (shortness of breath) and   audible abnormal breath sounds.

Long term goal

  • The patient will demonstrate    decreased breath sounds andalso opening of the air way.
  • To ensure that the patient understand and verbalize on their dietary and fluid restrictions.
  • To ensure that the patient demonstrates stabilized fluid volume with a balanced fluid intake and output.
  • The patient understands on the importance of medication adherence after discharge and need for regular checkup.

Interventions and rationale

  • Encourage the patient to have adequate bed rest in a quiet and warm environment as this reduces the energy demands and consumption of the patient.
  • Administer vasodilators these medications help in enhancing the blood flow to the myocardium and therefore reducing blood flow to the heart.
  • Elevate the head of the bed and ensure the patient stays in a semi flawless position this will help improve chest expansion and oxygenation which in turn helps opening the client’s airway.
  • Teach and help the patient   basic relaxation techniques to help reduce stress chest pain is mostly associated with emotional stress and can be relieved by simple s relaxation techniques.

Short term goal-

The patient will report of decreased chest pain and also demonstrate some of the pain-relieving techniques.

Maintain the patient’s vital signs within the normal range.

Interventions and rationale

Monitor the patient pain intensity using rating scale and identify the precipitating factors this will help in diagnosis and as well as reduce the intensity.

Monitor the patient   vital signs regularly until the   pain subsidies, increased blood pressure and heart rate is expected as compensatory mechanism in acute pain.

Assess the patient response to medication this helps in   determining the effectiveness of the medications and interventions.

  • Decreased cardiac output – as evidence by the clients increase in heart rate (tachycardia), chest pain and   changes in blood pressure.

Long term goal- the patient will demonstrate adequate cardiac output as evidenced by normal vital signs, no symptoms of heart failure and lack of arrhythmias.

Rationale and intervention

  • Give oxygen as per the patient presentation –supplemental oxygen help relieve symptoms such as pulmonary congestion and dyspnea .it also helps in increasing the oxygen availability in the myocardium.
  • Provide the patient with a peaceful environment for rest and assist in any activities- this helps in   minimizing and controlling stressors that increases the body oxygen demand.
  • Encourage the   client to sleep in a semi recumbent position as this position helps in decreasing the myocardial oxygen demand and consumption.
  • Change the client position every two hours – patients on prolonged bed rest are at risk of developing pressure ulcers and hence it is important to reposition the patient.

 Short term goal  

 The patient will verbalize decreased episodes of shortness of breath

 The patient will demonstrate and participate in   activities that will reduce cardiac overload.

Interventions and rationale

  • Monitor the patient for signs and symptoms of fluid and electrolyte imbalances some medications and fluids can create electrolyte imbalances such as hypokalemia and hyperkalemia.
  • Administerthe drugs as indicated by the clinician this help in ensuring quick recovery. Educate the patient on the need of medical adherence to prevent recurrence.
  • Teach and educate the patient on the pathophysiology of the disease   and the role of each medication given. This information helps in the successful management of the ailment.
  • To monitor the patient oxygen saturation this helps in diagnosis and staging the severity of the heart failure for prompt action to be taken.
  • Monitor the patient’s laboratory findings this will help the nursing practitioner understand the underlying cause of heart failure and hence help initiate treatment immediately.

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