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Hypernatremia Integrated Concept Map

BOX 1

Definition

Is a serum sodium level higher than 145 mEq/L (145 mmol/L)

Caused by gain of sodium in excess of water or by a loss of water in excess of sodium

(Hinkle & Cheever, 2018)

Factors

Predisposing

  • Fluid deprivation in patients who cannot respond to thirst
  • Diabetes insipidus
  • Salt water near-drowning victims

Precipitating

  • Hypertonic tube feedings without adequate water supplements
  • Hyperventilation
  • Watery diarrhea
  • Burns
  • Diaphoresis
  • Heat stroke
  • Excess corticosteroid, sodium bicarbonate and sodium chloride administration

(Hinkle & Cheever, 2018)

Incidence

Although the incidence of hypernatremia on admission to the hospital has been estimated at 0.12-1.4%, a review by Tsipotis et al of 19,072 unselected hospitalized adults found that community-acquired hypernatremia occurred in 21% (Lukitsch, 2018)

Signs and Symptoms with Rationale

  • Dehydration

- due to an impaired thirst mechanism or limited access to water

  • Mental status and behavioral changes

- rapid decrease in intracellular water content and brain volume caused by an osmotic shift of free water out of the cells.

  • Increase in body temperature
  • Thirst – primary characteristic
  • Swollen dry tongue

- due to shift of fluids

  • Sticky mucous membranes

- due to less water, more sodium

  • Lethargy

- rapid decrease in intracellular water content and brain volume caused by an osmotic shift of free water out of the cells

  • Dizziness

- rapid decrease in intracellular water content and brain volume caused by an osmotic shift of free water out of the cells

  • Restlessness

- due to the effect to the central nervous system and stem from a loss of water content from brain cells

  • Irritability

- due to the effect to the central nervous system and stem from a loss of water content from brain cells

  • Simple partial or tonic-clonic seizures

- due to the effect to the central nervous system and stem from a loss of water content from brain cells

  • Pulmonary edema

- shift of fluids due to volume overload

  • Hyperreflexia

- rapid decrease in intracellular water content and brain volume caused by an osmotic shift of free water out of the cells.

  • Twitching

- rapid decrease in intracellular water content and brain volume caused by an osmotic shift of free water out of the cells.

  • Nausea

- associated with dehydration

  • Vomiting

- associated with dehydration

  • Anorexia

- Hypernatremia is an unusual manifestation in anorexia nervosa. It is caused by net water loss (increased loss or decreased intake) or, rarely, sodium gain

  • Increased Pulse

- possibly due to increased blood volume

  • Increased BP

- possibly due to increased blood volume

  • Increased urine specific gravity and urine osmolality

- due to changes in concentration

  • Dilute urine – in patients with nephrogenic or central diabetes

BOX 2

BOX 3

Surgical Management

N/A

Medical Management

  • Infusion of a hypotonic electrolyte solution

- e.g. 0.3% sodium chloride

  • Infusion of isotonic nonsaline solution

- e.g. dextrose in 5% water (D5W)

(Hinkle & Cheever, 2018)

Evidence-Based Interventions: Hypernatremia

Pathogenesis and Treatment of Hypernatremia

  • In treating hypernatremia, the speed of correction is important because the volume regulation mechanisms restore the brain volume to normal when hypernatremia is chronic. Accurate prediction of the fluid volume requirement demands the knowledge of urine output and its electrolyte content, but when the information is not available, urine may be assumed to be isotonic in its electrolyte content.

Hypernatremia Due to Hypodipsia and Elevated Threshold for Vasopressin Release — Effects of Treatment with Hydrochlorothiazide, Chlorpropamide and Tolbutamide

  • Long-term administration of hydrochlorothiazide has kept the serum sodium within normal limits, primarily by limiting renal free water clearance. Chlorpropamide and tolbutamide also proved to be strikingly effective in correcting the hypernatremia, by markedly increasing urinary osmolality. It is speculated that the sulfonylureas increase the concentration of cyclic adenosine monophosphate in the renal medulla as well as in the pancreatic beta cells, and that this accounts for their effects on urinary concentration and insulin secretion.

Risk factors for hypernatremia in patients with short- and long-term tolvaptan treatment

  • The long-term efficacy of tolvaptan, a vasopressin V2 receptor antagonist, has been reported. However, the safety of long-term treatment remains to be fully elucidated. We assessed the safety profile of tolvaptan with respect to hypernatremia. A daily dosage of 7.5 mg or less was recommended to prevent hypernatremia in short- as well as long-term tolvaptan treatment, and mainly elderly patients were at risk for hypernatremia.

Nursing Interventions: Hypernatremia

  • Monitor level of consciousness and muscular strength, tone, and movement.
  • Monitor intake and output and specific gravity. Assess the presence and location of edema. Weigh client daily.
  • Assess skin turgor, color, and temperature and mucous membrane moisture.
  • Provide safety and seizure precaution as indicated:

- Bed in a low position.

- Use of padded side rails.

  • Teach the client to avoid foods high in sodium such as regular canned vegetables and vegetable juices, processed foods, snack foods, and condiments.
  • Encourage increase oral and IV fluid intake.
  • Monitor serum electrolytes, osmolality, and arterial blood gasses, as indicated.
  • Restrict sodium intake and administer diuretics as indicated.

Pharmacologic Management

  • Desmopressin acetate
  • Synthetic ADH to treat Diabetes Insipidus if it is the cause of hypernatremia

(Hinkle & Cheever, 2018)

BOX 8

BOX 4

Hypernatremia

Priority Nursing Problem:

  • Risk for electrolyte imbalance
  • Deficient Fluid Volume
  • Fluid Volume Overload

Nursing Diagnosis:

  • Risk for electrolyte imbalance r/t total body water deficit

  • Deficient Fluid Volume: verbalization of thirst related to ineffective regulatory mechanism in response to thirst.

Nursing Assessment:

Objective Cues:

  • Dehydration
  • Mental status and behavioral changes
  • Increase in body temperature
  • Swollen dry tongue
  • Sticky mucous membranes
  • Restlessness
  • Irritability
  • Simple partial or tonic-clonic seizures
  • Pulmonary edema
  • Hyperreflexia
  • Twitching
  • Vomiting
  • Anorexia
  • Increased Pulse
  • Increased BP
  • Increased urine specific gravity and urine osmolality
  • Dilute urine – in patients with nephrogenic or central diabetes

Subjective Cues:

  • Thirst
  • Lethargy
  • Nausea
  • Dizziness

BOX 5

BOX 7

Evaluation

  • monitor patient’s vital signs
  • monitor patient’s labs - electrolytes, osmolality and arterial blood gas
  • assess patients’ skin turgor, color and temperature

Standards

  • patient’s vital signs
  • physical exam
  • skin turgor
  • color
  • temperature
  • mucous membrane moisture
  • monitor patient’s electrolytes, osmolality and arterial blood gas
  • document patient’s response to medications administered
  • implementation of health teaching plan
  • Acknowledgment slip for the health teaching plan implementation

Knowledge

Hypernatremia

  • serum sodium level >145 mEq/L
  • caused by:
  • gain of sodium in excess of water
  • loss of water in excess of sodium

Expected results of Medications:

  • Desmopressin acetate - Desmopressin acetate as a common therapeutic agent of central diabetes insipidus proved to be an effective treatment for essential hypernatremia.
  • Patients should be given intravenous 5% dextrose for acute hypernatremia or half-normal saline (0.45% sodium chloride) for chronic hypernatremia if unable to tolerate oral water. - to correct the extracellular fluid depletion

Goal: After 4 days of holistic nursing care, the client will be able to: Normalize vital signs and laboratory results

Objective: After 8 hours of student nurse - client interaction, the client will be able to :

  • Achieve a heart rate within normal ranges
  • Attain normalized blood pressure
  • Display laboratory results within normal limits
  • Display absence of neuromuscular irritability and cognitive impairment

Nursing Actions:

  • Monitor BP

- either hypertension or hypotension may be present depending on the fluid status

  • Identify client at risk for hypernatremia and likely causes such as water deficit or sodium excess

- early identification and intervention prevents serious complications

  • Maintain safety and seizure precautions such as bed in low position and use of side rails, as indicated

- Sodium excess and cerebral edema increases risks of convulsions

  • Assess skin turgor, color and temperature and mucous membrane moisture
  • Water-deficit hyponatremia manifests
  • Provide and encourage meticulous skin care and frequent repositioning
  • maintains skin integrity
  • Provide frequent oral care.
  • Promotes comfort
  • Discourage the use of mouthwash that contain alcohol
  • prevents further drying of mucous membranes
  • Monitor serum electrolytes, osmolality, and arterial blood gases as indicated
  • Evaluates therapy needs and effectiveness
  • Increase oral and IV fluid intake
  • replacement of total body water deficit will gradually restore sodium and water balance
  • Restrict sodium intake and administer diuretics as indicated by physician
  • restriction of sodium intake while promoting renal clearance lowers serum sodium levels in the process of extracellular fluid excess

BOX 6

Goal: After 4 days of holistic nursing care, the client will be able to:

manifest no signs of dehydration as evidenced by maintained fluid volume.

Objective: After 8 hours of student - nurse client interaction, the client will be able to:

maintain fluid volume at a functional level as evidenced by stable vital signs, good skin turgor, good capillary refill, moist mucous membranes and adequate urinary output with normal specific gravity.

Nursing Actions: measures to promote balanced fluid volume

Monitor urine output.

1. Measure or estimate fluid losses from all sources such as diaphoresis, wound drainage, and gastric losses.

  • Fluid replacement needs are based on the correction of current deficits and ongoing losses.

2. Evaluate client’s ability to manage own hydration

  • Impaired gag and swallow reflexes, anorexia, oral discomfort, nausea, and changes in mentation are among factors that affect client’s ability to replace fluids orally.

3. Provide skin and mouth care.

  • To prevent further dryness of the mucous membrane.

4. Provide safety precautions, as indicated, such as the use of side rails when appropriate, bed in low position, frequent observation, and soft restraints if required

  • Decreased cerebral perfusion frequently results in changes in mentation or altered thought process, requiring protective measures to prevent client injury

5. Administer IV solutions, as indicated (Isotonic solution such as 0.9% NaCl)

  • helps restore water levels in the body, saline water helps in the treatment of symptoms such as lightheadedness and other dehydration related symptom
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