15.6 Applying the Nursing Process
Open Resources for Nursing (Open RN)
The nursing process is used continuously when caring for individuals who have fluid, electrolyte, or acid-base imbalances, or at risk for developing them because their condition can change rapidly. This systematic approach to nursing care ensures that subtle cues or changes are not overlooked and that appropriate outcomes and interventions are implemented according to the client’s current condition.
Assessment
A thorough assessment provides valuable information about a client’s current fluid, electrolyte, and acid-base balance, as well as risk factors for developing imbalances. Performing a chart review or focused health history is a good place to start collecting data, with any identified gaps or discrepancies verified during the physical assessment. It is also important to consider pertinent life span or cultural considerations that impact a client’s fluid and electrolyte status.
Subjective Assessment
Subjective assessment data is information obtained from the client as a primary source or family members or friends as a secondary source. This information must be obtained by interviewing the client or someone accompanying the client. Some of this information can be obtained through a chart review but should be verified with the client or family member for accuracy.
Subjective data to obtain includes age; history of chronic disease, surgeries, or traumas; dietary intake; activity level; prescribed medications and compliance with taking medications; pain; and bowel and bladder functioning. Subjective assessment data is helpful to determine normal pattern identification and risk identification. For example, a history of kidney disease or heart failure places the client at risk for fluid volume excess, whereas diuretic use places the client at risk for fluid volume deficit and electrolyte and acid-base imbalances. A history of diabetes mellitus also places a client at risk for fluid, electrolyte, and acid-base imbalances. Recognizing these risks helps nurses be prepared for complications that may arise and allows the nurse to recognize subtle cues as problems develop.
Objective Assessment
Objective assessment data is information that the nurse directly observes. This data is obtained through a physical examination using inspection, auscultation, and palpation. A complete head-to-toe assessment should be performed to avoid missing clues to the client’s condition.
Focused assessments such as trends in weight, 24-hour intake and output, vital signs, pulses, lung sounds, skin, and mental status are used to determine fluid balance, electrolyte, and acid-base status.
- Accurate daily weights can provide important clues to fluid balance. Weights must be taken on the same scale, at the same time of day, with the client wearing similar clothing in order to be accurate. A one-kilogram change in weight in 24 hours is considered significant because this represents a one-liter fluid gain or l