Nursing Diagnosis/Intervention for Hyponatremia

There are many nursing diagnosis for hyponatremia.  With two types of hyponatremia (depletional and dilutional), there are different interventions and nursing diagnosis for the sodium deficit.  In this blog, I will give some associated nursing diagnosis for hyponatremia and will analyze the "deficient fluid volume r/t diuresis" nursing diagnosis for it's interventions as well. 

1.Deficient fluid volume related to fluid loss, leading to hyponatremia. (Actual for depletional hyponatremia)

- This is due to the patient losing too much sodium through urination.  The sodium is excreted through the urine, diarrhea, sweat, etc.  This will cause depletional hyponatremia.  This is very apparent, especially in patients in the hospital with Clostridium dificile (C. Diff) infections, leading to diarrhea and excess fluid/sodium excretion.  This is also very common in athletes who lose too much water and salt through sweat, which can lead to hyponatremia. 

Interventions:
-Administer IV isotonic solution as ordered
-Restrict free water intake. 

Monitor for(2): 
-Vital signs hourly and I/O
-Monitor serum sodium levels. 
-Fluid Monitoring.  

2. Excess fluid volume related to hyponatremia.  

-This would be dilutional hyponatremia, where the fluid volume in the body is so high that it will dilute the sodium in the body, making the concentration lower, thus affecting bodily functions such as nerve transmission and causing confusion/muscle cramps (3).  The symptoms will be the same as well for depletional hyponatremia.  

3. Disturbed energy field related to increased intercranial pressure from hyponatremia.

-This mostly relates to dilutional hyponatremia, where the fluid volume excess shows up in the brain, along with an increased intercranial pressure(1).  The increased intercranial pressure may cause many problems with mental status and may be very serious. 

4. Acute confusion related to hyponatremia. 

-This could be related to one of two things.  One is that the lowered sodium levels in the blood affects the nerve transmissions in the brain, causing confusion. Another factor that could play a large part in confusion is the increased intercranial pressure related to hyponatremia as well, which "cramps" the brain, causing mental function to decline.  With the decline of mental function in certain areas of the brain, it can cause confusion of the individual.  

5. Activity intolerance related to hyponatremia as evidenced by muscle spasms/weakness. 

-With less sodium in the muscle, the nerves will not function as effectively, which can cause muscle spasms or weakness.  This may cause much discomfort and may put the patient at a risk for falls.  This is especially dangerous in geriatric patients, as falls are much more dangerous to that particular population.  

Works Cited:

1. McGill University. (2013, August 20). A new role for sodium in the brain.ScienceDaily. Retrieved May 18, 2015 from www.sciencedaily.com/releases/2013/08/130820113931.htm

2.Nursing-Nurse.Com. (2007). Retrieved May 18, 2015, from http://www.nursing-nurse.com/medical-and-nursing-management-of-sodium-deficit-hyponatremia-serum-sodium-466/

3. Antipuesto, J. (2010, December 15). Fluid and Electrolyte Imbalance: Hyponatremia | Nursing Crib. Retrieved May 18, 2015, from http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-nursing/fluid-and-electrolyte-imbalance-hyponatremia/

Nursing Care of Individuals with Hyponatremia

Nursing care for hyponatremia, an electrolyte imbalance of sodium in the body is a lot trickier than one may think. "How may that be so?  Just pump some sodium or normal saline into their body!" Well, it can be just as easy as that, depending on the type of hyponatremia one presents with. Also, there is another very important factor that one must consider.  Many times, there are other underlying causes of hyponatremia, such as congestive heart failure, diarrhea, liver failure, etc.  Management of the serum sodium level is still very much a very important part of the treatment of hyponatremia of course.  Nursing care for patients are focused on safe serum sodium levels, which are evidenced by: absence of n/v and cramps, no altered mental status, usual muscle strength, absence of seizures, and serum sodium levels within the normal range (1).  In order to detect any changes in the patient's normals, however, part of the nursing care involves assessments of signs and symptoms of hyponatremia.  These signs and symptoms include: nausea, vomiting, abdominal cramps, lethargy, confusion, weakness, seizures,and low serum sodium levels) (1). Nursing interventions to treat hyponatremia include: maintaining fluid restrictions (if ordered) and consulting physician about changes in dose of diuretic and temporary discontinuation of dietary sodium restriction if sodium level is significantly reduced (1). For hypovelemic hyponatremia, isotonic saline should be administered in order to replace the contracted intravascular volume (2).  For nursing care, many times, for hyponatremia, it is just managing the symptoms of hyponatremia while treating the low sodium in the blood.  The following tables and charts will make it easier to understand what is being done for hyponatremia:

  

Medical Management / Nursing Interventions:
- Electrolyte management: Hyponatremia
- Cerebral edema management
- Delirium management
- Fluid monitoring
- Fluid management
- Seizure precautions
- Monitor level of consciousness
- Institute safety measures for seizures
- Administer IV isotonic solution (e.g. 0.9% NaCl) as ordered
- Restrict free water intake (e.g. 1.2 L/24 hr)
- Monitor vital signs hourly and I&O (ECF excess, restrict fluids and  administer diuretics)
- Monitor serum sodium levels. Teach patient about adequate intake of sodium, side effects of diuretics and other causes for hyponatremia.

Works Cited:

1)  EHS: Nursing Care Planning Guides - Care Planner: Diagnosis: Altered fluid and electrolyte balance. (2012). Retrieved May 14, 2015, from http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=131|132|

2)  Simon, E. (2015, March 1). Hyponatremia Treatment & Management. Retrieved May 14, 2015, from http://emedicine.medscape.com/article/242166-treatment

3)  Sarikonda, K., & Watson, R. (2009, October 11). Hyponatremia. Retrieved May 14, 2015, from http://nihlibrary.ors.nih.gov/jw/POC/eepHyponatremia.htm

4) Nursing-Nurse.Com. (2007). Retrieved May 14, 2015, from http://www.nursing-nurse.com/medical-and-nursing-management-of-sodium-deficit-hyponatremia-serum-sodium-466/

Hyponatremia Treatment 

Hyponatremia....the deficit of sodium in the blood.  "How hard could it be to treat?  Just add some sodium in the blood." you may think.  In truth, it is a little more complicated than that.  There are two modes to treating hyponatremia: pharmacologic and fluid/electrolyte balancing by infusing IV solution, such as normal saline. Since hypotonic hyponatremia accounts for most clinical cases of hyponatremia, the first step is to evaluate the degree of hypotonic hyponatremia to determine whether emergency therapy is needed (1).  Treatment is guided by three factors: Patient's volume status, duration and magnitude of the hyponatremia, and degree and severity of clinical symptoms (1).   For asymptomatic patients there are a few treatments depending on the severity of the hypponatremia. For hypovolemic hyponatremia, there are a few options for treatment: administer isotonic saline to patients to replace intravascular volume (1).  Patients who have hyponatremia secondary to diuretics may also need K+ repletion, which is osmotically active just like sodium.  By correcting the volume repletion, the stimulus to ADH secretion is turned off.  A large water diuresis may be caused, which may lead to a much more rapid correction of hyponatremia that may cause other complications, so a hypotonic fluid such as D5 1/2 normal saline may be administered (1).  For hypervolemic hyponatremia, patients are treated with salt and fluid restrictions, loop diuretics, and correction of the underlying condition that may be causing hypervolemic hyponatremia (1).  For euvolemic (normal volume) asymptomatic hyponatremic patients, free water restrictions is the treatment of choice (1).  Below, I have included a chart that helps (and helped me a lot) in visualizing what each type of hyponatremia is and what treatment we should give.  

Treatments for Different Types of Hyponatremia

Works Cited

1.  Simon, E. (2015, March 15). Hyponatremia Treatment & Management. Retrieved May 6, 2015, from http://emedicine.medscape.com/article/242166-treatment

Signs and Symptoms of Hyponatremia

Having hyponatremia can be really troublesome, so it is very crucial to recognize the signs and symptoms.  Since sodium helps with muscle and nerve conduction, many of the symptoms are related to defects in that specific area. According to Medline, common signs and symptoms of hyponatremia include: confusion, convulsions, fatigue, headache, irritability, loss of appetite, muscle spasms or cramps, muscle weakness, nausea, restlessness, and vomiting.  Complications from rapidly evolving and severe hyponatremia are more neurologic. and much more serious.  The symptoms include: seizures, coma, permanent brain damage, respiratory arrest, brain-stem herniation, and in the worst case scenario: death (3).  For acute severe hyponatremia (sodium concentration of <115mm), patients usually always present with symptoms.  Acute severe hyponatremia usually presents with neurologic symptoms that include drowsiness and disorientation to coma, grand mal seizures, and respiratory arrest (2).  These symptoms can be very dangerous and should be corrected immediately.  Chronic severe hyponatremia is a slightly different story.  The symptoms of hyponatremia are usually involves mild to moderate symptoms.  In chronic hyponatremia, brain volume regulation is intact, so thus neurologic symptoms are not apparent (there is no evidence of brain swelling) (2). Severe chronic hyponatremia is commonly observed in the advanced stages of he inappropriate secretion of antidiuretic hormone, cardiac failure, and liver cirrhosis.  It does not appear to case major problems by itself (2).  In a study done by physicians in the Journal of the Association of Physicians of India, the most common presenting symptoms were: Lethargy, irrelavant speech, and drowsiness (4).  This is very apparent in the graph below:

Patients Admitted to the Hospital With Symptoms Attributable to Hyponatremia

Prevalence of Hyponatremia Types 

Various Causes of Hyponatremia

Works Cited

1 . Dugdale, D. (2014, April 14). Hyponatremia: MedlinePlus Medical Encyclopedia. Retrieved April 29, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000394.htm

2. Gross, P., Reimann, D., Henschkowski, J., & Damian, M. (2001). Treatment of Severe Hyponatremia: Conventional and Novel Aspects. Journal of the American Society of Nephrology, 12, S10-S14. Retrieved April 29, 2015, from http://jasn.asnjournals.org/content/12/suppl_1/S10.full

3. Hospital-associated hyponatremia is an important predictor of morbidity and mortality1. (2014, June 1). Retrieved May 3, 2015, from http://www.hyponatremiaupdates.com/serious-threat.aspx

4.Rao, M., Sudhir, U., Kumar, A., Saravanan, S., Mahesh, E., & Punith, K. (2010). Hospital-Based Descriptive Study of Symptomatic Hyponatremia in Elderly Patients. Journal of the Association of Physicians of India, 58. Retrieved April 30, 2015, from http://www.japi.org/november_2010/article_03.html

Diagnosis/Progress of Hyponatremia

There are three different types of hyponatremia, and based on the amount of fluid in the cells, we can differentiate between the different types of hyponatremias.  The three types that we can diagnose are all a type of hypotonic hyponatremia.  They are: hypovolemic, euvolemic, and hypervolemic hyponatremia (1).  In all of theses cases, the blood level of sodium decreases to below 135 mEq/L (which is below the normal range of serum sodium).  Hypovolemic hyponatremia is presented with a depletion of ECF (extracellular fluid).  Since this is not easily detectable, the best way to detect hypovolemic hyponatremia is through patient history, physical examination, and laboratory results (1).  The symptoms that the patient may have include vomiting, diarrhea, orthostatic blood pressure decrease, increased pulse, and signs of dehydration (decreased skin turgor and dry mucous membranes) (1).  Laboratory signs include elevations of BUN, creatinine, and uric acid (1).   However, the laboratory signs are non-specific and can apply to other diseases.  Euvolemic hyponatremia occurs because of the high prevalence of SIADH.  It is diagnosed primarily from the patient's history, physical examination, and laboratory results (1).  Laboratory results that are indicative of euvolemic hyponatremia include a low BUN and a low serum uric acid level.  Measuring urine sodium is the most helpful in diagnosing euvolemic hyponatremia.  Hypervolemic hyponatremia is a detectable increased ECF volume.  This is usually caused by the inability of the body to excrete fluid.  With the buildup of fluid in the body, the body can be volume overloaded, thus causing hypo-osmolarity.  The diagnosis of fluid excess from hypervolemic hyponatremia is made through the patients history, physical examination, and laboratory results.  Physical examination can help detect patients with signs of fluid overload (edema, ascites, and pulmonary edema).  Laboratory results to detect hypervolemic hyponatremia include elevation of plasma levels of brain natriuretic peptide and a low urine of fractional sodium excretion due to the activation of the renin-angiotensin-aldosterone system.  In acute hyponatremia, one of the deadliest complications is brain herniation. Symptoms can progress from headache, nausea, vomiting, or confusion to seizures, respiratory arrest, and/or death.  They can also progress to a permanent vegatative state as a complication from severe cerebral edema (1).  These symptoms happen the most to postoperative patients, patients with water intoxication brought on by endurance exercises (like marathons), or use of drugs such as eccstasy (1).  Who knew hyponatremia could be so scary?

Brain Herniation 

Works Cited

1)  Verblis, J., Goldsmith, S., Greenberg, A., Korzelius, C., Schrier, R., Sterns, R., & Thompson, C. (2013). Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. The American Journal of Medicine, 126(10), S1-S42. Retrieved April 22, 2015, from http://www.amjmed.com/article/S0002-9343(13)00605-0/fulltext

Hyponatremia Etiology/Pathophysiology

Hyponatremia's etiology and pathophysiology are very interesting.  First of all, I will talk about the etiology of hyponatremia (how it's caused).  Before that though, I must reiterate from my previous blog post:  there are two types of hyponatremia; dilutional and depletional hyponatremia.  Dilutional hyponatremia is just what it sounds like.  There is too much fluid in your blood, which decreases the concentration of sodium in the blood to less than 135 mEq/L.  This is much like the effect of pouring distilled water into salt water, making the water less "salty".  Depletional hyponatremia is when the body loses too much sodium via fluid loss.  Prime examples include urine and sweat.  People who are most at risk of this are people who exercise too much, losing too much sodium through sweat.  Most people with hyponatremia have resided/reside in a healthcare setting.  "Surely, it must be some kind of disease that causes the sodium level to go down" you may think.  That is not the case at all.  One of the biggest causes of hyponatremia is iatragenic (caused by the healthcare professional).  Many times, there are co-morbidities associated with hyponatremia.  Hyponatremia serves as a marker for heart and liver diseases.  It is also associated with kidney injury, brain tumors, and brain hemorrhaging (1). In a study, the hospital mortality rate for patients with hyponatremia was 6.1% as compared to 2.3% with non-hyponatremic patients (1).

Mortality vs. Serum Sodium

With the chart shown above, we can see that mortality percentage peaks at patients with serum sodium at 115 to 124 mEq/L.  Several points of evidence suggests that hyponatremia is rarely a cause of death, but rather a marker for  the severity of the underlying disease (1).  "(1) once sNa falls below 120 mEq/L, mortality rate does not seem to increase as the severity of hyponatremia worsens; in fact the trend is in the opposite direction; (2) deaths in patients with sNa <120 mEq/L were associated with serious comorbidities and were mostly attributable to conditions other than hyponatremia; (3) neurologic symptoms attributable to hyponatremia were uncommon among fatal cases, and deaths attributable to neurologic complications were rare. (1)"

Fatal cases with uncorrected hospital-acquired or hospital-aggravated hyponatremia

Age/Gender	Admission SNa (mEqL)	Lowest SNa (mEq/L)	SNa at Death (mEq/L)	Day of Death	Clinical Course	Comfort Care?	Charlson Score
66/M	145	114	114	27	Metastatic carcinoma, cardiac arrest, respiratory failure, anoxic brain damage, acute kidney injury, refractory shock. First SNa <120 mEq/L 4 days before death	Yes	11
67/M	139	115	115	163	Sepsis with several months in hospital with irreversible multiorgan failure; first sNa <120 mEq/L on day 155, 8 days before death	Yes	5
63/M	138	117	117	16	Metastatic carcinoma, acute kidney injury, acute respiratory failure. First SNa <120 mEq/L 1 day before death	Yes	11
87/M	136	118	123	24	ESRD. Comfort care on admission.	Yes	4
65/M	132	118	118	11	End-stage liver disease, sepsis, multiorgan failure. First sNa <120 mEq/L on day of death	Yes	5
65/M	131	119	119	11	Cardiogenic shock. First sNa <120 mEq/L 1 day before death	Yes	4
55/M	124	119	122	12	End-stage heart disease, acute kidney injury	No	7
54/F	124	119	122	4	End-stage lung disease	Yes	3
83/M	120	118	123	7	End stage heart disease	No	8
63/M	121	119	122	2	Advanced lung cancer	No	7

As you can see from this table, almost all patients who had hyponatremia died of an underlying progressive illness (1).  We can conclude that many cases of hyponatremia can be directly linked to or tied to another disease.  Sure, it's possible to die from hyponatremia, but most of the time, it's more complicated than that. 

Works Cited:

1) Chawla, A., Sterns, R., Nigwekar, S., & Cappuccio, J. (2011). Mortality and Serum Sodium: Do Patients Die from or with Hyponatremia? Clinical Journal of the American Society of Nephrology, 960-965. Retrieved April 17, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3087791/#B18

Epidemiology of Hyponatremia 

Hyponatremia in reality is not too common of a disease, especially in the U.S.  With the abundance of nutrients and food, there is one place where hyponatremia is extremely prevalent, and that is in the healthcare setting (e.g hospitals, retirement homes, etc.). In the hospital setting, the incidence of hyponatremia lies at around 15% of patients.  67% of cases of hyponatremia are iatrogenic, which means that the state of hyponatremia was brought on by the healthcare workers themselves (1).  The risk of hyponatremia increases with age (1).  Incidences have been reported from 7-51% in geriatric patients, with many of them occuring in long term care centers (2).  Why is this even important?  Sodium plays an important role in the body's water regulation along with many other important bodily functions such as muscle and nerve function.  Without sodium, the body will not be able to properly function.  It is also important to note that there is an association between hyponatremia, heart failure, pulmonary tuberculosis, child diarrhea, and heart attacks (1).  This is important because even though it doesn't seem like hyponatremia is as life-threatening as something.... say like cancer, aids, or heart attack, it is still very important to monitor serum sodium levels.  Even slight hyponatremia increases the risk of death, so with immediate intervention, lives can be saved.

Hypnatremia and Hospital Mortality

Hyponatremia occurs in the hospital setting the most often and does not have a race/ethnicity preference. Outside of the hospital however, hyponatremia is prevalent in people who are participating in physical activity and sweat a lot.  Examples include marathon runners who lose lots of water, along with salt (sodium and chloride).  To remedy this, it is important to drink fluid with electrolytes (such as gatorade), along with not overdrinking water.  Just drinking the right amount is enough.  Always be careful to take everything in moderation, including water!

Works Cited 

1) Blevins, L. (2013, March 5). Hyponatremia: The Endocrinologist's Role in Improving Patient Outcomes. Retrieved April 9, 2015, from https://www.aace.com/sites/all/files/blevins_hyponatremia_ss2013AM.pdf

2) Verbalis, J., Goldsmith, S., Greenberg, A., Korzelius, C., Schrier, R., Sterns, R., & Thompson, C. (2013). Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. American Journal of Medicine, 126(10), 42-42. Retrieved April 8, 2015, from http://www.amjmed.com/article/S0002-9343(13)00605-0/abstract