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CNC - Intervention Example (NIC)



Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormal or undesired serum electrolyte levels

- Monitor for abnormal serum electrolytes, as available

- Monitor for manifestations of electrolyte imbalance

- Maintain patent IV access Administer fluids, as prescribed, if appropriate

- Maintain accurate intake and output record

- Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate

- Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate

- Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate

- Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as prescribed, if appropriate

- Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as appropriate

- Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and diaphoresis)

- Institute measures to control excessive electrolyte loss (e.g., by resting the gut, changing type of diuretic, or administering antipyretics), as appropriate

- Irrigate nasogastric tubes with normal saline

- Minimize the amount of ice chips or oral intake consumed by patients with gastric tubes connected to suction

- Provide diet appropriate for patient's electrolyte imbalance (e.g., potassium-rich, low-sodium, and low-carbohydrate foods)

-Instruct the patient and/or family on specific dietary modifications, as appropriate

- Provide a safe environment for the patient with neurological and/or neuromuscular manifestations of electrolyte imbalance

-Promote orientation

- Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate

- Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen

- Monitor patient's response to prescribed electrolyte therapy

- Monitor for side effects of prescribed supplemental electrolytes (e.g., GI irritation)

- Monitor closely the serum potassium levels of patients taking digitalis and diuretics

- Place on cardiac monitor, as appropriate

- Treat cardiac arrhythmias, according to policy

- Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as appropriate

1st edition 1992; Revised 5th edition

BACKGROUND READINGS: American Association of Critical Care Nurses. (2006). Core curriculum for critical care nursing (6th ed.) [J. G. Alspach, Ed.]. Philadelphia: W. B. Saunders.

Banker, D., Whittier, G. C., & Rutecki, G. (2003). Acid-base disturbances: 5 rules that can simplify diagnosis. Consultant, 43(3), 381-384, 399-400.

McCance, K. L., & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults and children. St. Louis, MO: Mosby.

Price, S. A., & Wilson, L. M. (2003). Pathophysiology: Clinical concepts of disease processes (6th ed.). St. Louis, MO: Mosby.