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