About
Excess Chloride greater than 107 mEq/L.
Assess
Hypervolemia, increased sodium, weakness, lethargy, increased heart rate, rapid respirations, confusion, hypertension
Complications
Arrhythmias, coma, death
Diagnosis
- Risk for injury related to fluid/ electrolyte imbalance
- Fluid volume excess related to hypertonic or isotonic IV infusion.
Goals
- The client will have electrolytes within acceptable ranges.
- The client will remain free from injury.
- The client will state understanding of fluid restriction.
Interventions
- Monitor electrolytes, vital signs, Glasgow coma scale, arterial blood gases.
- Monitor intake and output strictly.
- Teach client about fluid restriction diet and eliminating excess chloride intake from foods.
- Monitor telemetry and respiratory status closely.
- Monitor daily weights.
- Administer antihypertensives as ordered.
- Administer hypotonic solutions as ordered.
- Monitor neuro status every two hours.
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