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Hyponatremia Integrated Concept Map

BOX 1

Factors

  • Predisposing

-Loss of GI Fluids

-Renal Disease

-Adrenal Insufficiency

-Head trauma

-Oat-cell lung tumor

-Psychogenic Polydipsia

-Heart failure

  • Precipitating

-Use of Diuretics

-Excessive administration of D5W and water supplements for patients receiving hypotonic tube feedings

-Medications associated with water retention (oxytocin and certain tranquilizers

-Hyperglycemia

(Hinkle & Cheever, 2018)

Definition

Refers to serum sodium level that is less than 135 mEq/L (135mmol/L)

Can present as acute or chronic form

Acute Hyponatremia is commonly the result of a fluid overload in a surgical patient.

Chronic Hyponatremia is seen more frequently in patients outside the hospital setting, has a longer duration, and has less serious neurological sequelae.

Exercise-associated hyponatremia occurs during extreme temperatures, because of excessive fluid intake before exercise, or prolonged exercise that results in a decrease in serum sodium.

(Hinkle & Cheever, 2018)

Signs and Symptoms with Rationale

  • Poor skin turgor

-occurs with moderate to severe fluid loss

  • Dry mucosa

-occurs with moderate to severe fluid loss

  • Headache

-due to an osmotic shift of water into brain cells causing edema

  • Decreased saliva production

-due to dehydration

  • Orthostatic fall in blood pressure

-due to low blood volume

  • Nausea

-due to an osmotic shift of water into brain cells causing edema

  • Vomiting

-due to dehydration

  • Abdominal cramping

-due to dehydration

  • Altered mental status, status epilepticus, and coma

- related to the cellular swelling and cerebral edema associated with hyponatremia

  • Anorexia

-Hyponatremia can also be seen in severe restrictive eating disorders due to decreased ability of the kidney to excrete free water as a result of low nutritional intake.

  • Muscle cramps

-due to dehydration

  • Feeling of exhaustion

-related to the cellular swelling and cerebral edema associated with hyponatremia

Incidence

Among hospitalized patients, 15-20% have a serum sodium level of < 135 mEq/L, while only 1-4% have a serum sodium level of less than 130 mEq/L. The prevalence of hyponatremia is lower in the ambulatory setting (Simon, 2019).

BOX 8

BOX 2

Surgical Management

  • Non-applicable

Medical Management

  • Neurologic examination
  • Sodium replacement

- by mouth

- nasogastric tube

- parenteral route

  • Hypertonic saline solution
  • Water restriction

(Hinkle & Cheever, 2018)

Pharmacologic Management

  • Arginine Vasopressin (AVP) antagonists

-Stimulate free water excretion

  • IV conivaptan hydrochloride (Vaprisol)
  • Tolvaptan (Samsca)

(Hinkle & Cheever, 2018)

BOX 7

BOX 3

Nursing Interventions: Hyponatremia

  • Monitor intake and output; Calculate fluid balance. Weigh client daily.
  • Encourage fluids and foods high in sodium such as meat, milk, beets, celery, eggs, and carrots. Use fruit juices and bouillon instead of water.
  • Monitor serum and urine electrolytes and osmolality.
  • Provide or restrict fluids, depending on fluid volume status.
  • Administer medications as ordered by physician

Knowledge

Hyponatremia

  • serum sodium level <135 mEq/L
  • can be acute/chronic

Chronic Hyponatremia

  • sodium levels drop gradually over 48 hours or longer — and symptoms and complications are typically more moderate

Acute Hyponatremia

  • sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in a coma and death

Expected results of medications:

  • Furosemide - a loop diuretic; effective in reducing fluid excess to correct sodium and water balance
  • Arginine Vasopressin - stimulate free water excretion
  • IV Conivaptan - improves urine flow without causing the body to lose too much sodium as the patient urinates
  • Tolvaptan - will induce hypotonic diuresis without significantly influencing the excretion of electrolytes

Evidence-Based Interventions: Hyponatremia

  • A Randomized Controlled Pilot Study of Outcomes of Strict Allowance of Fluid Therapy in Hyponatremic Heart Failure (SALT-HF)

-Currently, fluid restriction recommendations in heart failure (HF) are based on expert opinion. After implementing a 1,000-mL/d fluid restriction for 60 days after discharge, outcomes were examined.The 1,000 mL/d fluid restriction led to improved QoL at 60 days after discharge.

  • The Treatment of Hyponatremia

-Accordingly, we suggest therapeutic goals of 6 to 8 mmol/L in 24 hours, 12 to 14 mmol/L in 48 hours, and 14 to 16 mmol/L in 72 hours. Inadvertent overcorrection owing to a water diuresis may complicate any form of therapy, including the newly available vasopressin antagonists. Frequent monitoring of the serum sodium concentration and urine output are mandatory. Administration of desmopressin to terminate an unwanted water diuresis is an effective strategy to avoid or reverse overcorrection.

  • Treatment of Symptomatic Hyponatremia

-In patients with asymptomatic hyponatremia, slow correction is the appropriate approach. When patients are overtreated, neurologic damage can be prevented by relowering the serum sodium (SNa) so that the daily increase in SNa remains below 10 mmol/L/24 hours. Frequent measurements of SNa during the correction phase of SNa are mandatory to avoid overcorrection. The use of urea to treat hyponatremia represents an advantageous alternative to hypertonic saline.

Hyponatremia

Evaluation

  • Assess LOC and neurologic response of patient because sodium deficit can result in the decreased mentation to the point of coma as well as generalized muscle weakness, cramps and convulsions.
  • Monitor patient’s labs - serum and urine electrolytes, osmolality
  • Monitor patients’ vital signs

Standards

  • patient’s vital signs
  • patient’s labs
  • patient’s neurological assessment
  • document patient’s response to medications administered
  • health teaching for both client and significant others
  • Acknowledgment slip for the health teaching plan implementation

BOX 4

BOX 6

Nursing Diagnosis:

  • Risk for electrolyte imbalance r/t excessive fluid

  • Deficient Fluid Volume: verbalization of thirst related to decrease in sodium levels. (Hypovolemic Hyponatremia)

Nursing Assessment:

Objective Cues:

  • Poor skin turgor
  • Dry mucosa
  • Decreased saliva production
  • Orthostatic fall in blood pressure
  • Vomiting
  • Abdominal cramping
  • Altered mental status, status epilepticus, and coma
  • Anorexia
  • Muscle cramps

Subjective Cues:

  • Headache
  • Nausea
  • Feeling of exhaustion

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. 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.

  • 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.

  • Provide skin and mouth care.

- To prevent further dryness of the mucous membrane.

  • 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

  • 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

Priority Nursing Problem:

  • Risk for electrolyte imbalance
  • Deficient Fluid Volume (Hypovolemic Hyponatremia)
  • Risk for Injury

BOX 5

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 :

1. Achieve a heart rate within normal ranges

2. Attain normalized blood pressure

3. Display laboratory results within normal limits

4. Display absence of muscle weakness and neurological irritability

Nursing Actions:

  • Monitor I&O. Calculate fluid balance and weight daily

- indicators of fluid balance are important because either fluid excess or deficit may occur with hyponatremia

  • Assess LOC and neuromuscular response

- Sodium deficit may result in decreased mentation to the point of coma, as well as generalized muscle weakness, cramps, or convulsions.

  • Maintain quiet environment; provide safety and seizure precautions

- reduces CNS stimulation and risk of injury from neurological complications such as seizures

  • Monitor serum and urine electrolytes and osmolality

- Evaluates therapy needs and effectiveness

  • Administer loop diuretics e.g., furosemide (Lasix) as indicated by physician

- effective in reducing fluid excess to correct sodium and water balance

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