Sodium Imbalances main cation & primary determinant of ECF osmolality (Na+ is ECF): p.

325
 Hyponatremia – Na+ Less than 135

 Less than normal Na+ in blood (serum) (norm. Na+ [] is 135 to 145 mEq/L)

 Causes:

 1) Na loss (increase Na excretion) or inadequate Na intake &

 2) water excess (dilution of Na w/ fluid excess, retention) or 3) a combination of both.

 Symptoms are related to cellular swelling and are first manifested in the CNS, excess water lowers plasma
osmolality, shifting fluid into brain cells, causing irritability, apprehension, confusion, seizures, and even coma
 Occurs frequently in seriously ill clients, surgery or major trauma, during administration of fluids in patients with
renal failure, or in patients with psychiatric disorders associated with excessive water intake Na in the ECF
becomes diluted!

 NANDA’s for Hyponatremia:

 Risk for injury related to altered sensorium and decreased level of consciousness secondary to abnormal CNS
function

 •Potential complication: severe neurologic changes

Treatment for hyponatremia caused by water excess: fluid restriction is often all that is needed to treat the problem. If
severe symptoms (seizures) develop, small amounts of IV hypertonic saline solution (3% NaCl) are given to restore the
serum sodium level while the body is returning to a normal water balance.

Treatment of hyponatremia caused by abnormal fluid loss: includes fluid replacement with sodium-containing solutions.

 Hypernatremia- Higher [] of Na+ (greater than 145mEq/L) in the ECF.

 Causes: excessive H2O LOSS or overall excessive intake of Na (Fluid moves out of the cell, H2O loss in excess of
H2O)

 Can be caused by increase in aldosterone secretionSodium is retained and potassium is excreted

 S&S (dry, sticky tongue, thirst,) (causes hyperosmolality- causes a shift of water out of the cells, which leads to
cellular dehydration.) (Hypernatremia 2nd to water deficiency is often the result of an impaired level of
consciousness or an inability to obtain fluids.)

 When hypernatremia occurs, the body attempts to conserve as much water as possible through renal reabsorption

 Patient education- food’s that are high in Na+ (canned soups, processed meats, condiments)
 NANDA’s for Hypernatremia:

 •Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function

 •Potential complication: seizures and coma leading to irreversible brain damage

* * Treatment: For primary water deficit, continued water loss must be prevented and water replacement must be provided. If
NPO, IV of 5% dextrose in water or hypotonic saline given initially. Na levels must be reduced gradually to prevent too rapid
a shift of H2O back into the cells. Overly rapid correction of hypernatremia can result in cerebral edema.
**Treatment: For sodium excess- dilute the Na [] w/sodium-free IV fluids, such as 5% dextrose in water, and to promote
excretion of the excess sodium by administering Thiazide (HCTC) diuretics. Dietary sodium intake will also be restricted to
no more than 3mg a day to decrease urine output
TABLE 17-5 Sodium Imbalances: Causes and Clinical Manifestations

Hyponatremia (Na+ <135 mEq/L [mmol/L]) Hypernatremia (Na+ >145 mEq/L [mmol/L])
Causes
Excessive sodium loss: Excessive sodium intake:
IV fluids: hypertonic NaCl, excessive isotonic NaCl, IV sodium
Gl losses: diarrhea, vomiting, fistulas, NG suction
bicarbonate
+
Renal losses: diuretics, adrenal insufficiency, Na
Hypertonic tube feedings without water supplements
wasting renal disease
Skin losses: burns, wound drainage Near-drowning in salt water
Inadequate water intake: unconscious or cognitively impaired
Inadequate sodium intake: fasting diets
individuals
Excessive water loss (↑ sodium concentration): ↑ insensible water loss
Excessive water gain (↓ sodium concentration):
(high fever, heatstroke, prolonged hyperventilation), osmotic diuretic
excessive hypotonic IV fluids, primary polydipsia
therapy, diarrhea
Disease states: SIADH, heart failure, primary Disease states: diabetes insipidus, primary hyperaldosteronism, Cushing
hypoaldosteronism syndrome, uncontrolled diabetes mellitus
Clinical Manifestations
Hyponatremia with Decreased ECF Volume (Na+
Hypernatremia with Decreased ECF Volume (due to H2O loss)
loss)
Irritability, apprehension, confusion, dizziness, Restlessness, agitation, twitching, seizures, coma
personality changes, tremors, seizures, coma Intense thirst; dry, swollen tongue, sticky mucous membranes
Dry mucous membranes Postural hypotension, ↓ CVP, weight loss
Postural hypotension, ↓ CVP, ↓ jugular venous
filling (flattened neck veins), tachycardia, thready Weakness, lethargy
pulse
Cold and clammy skin
Hyponatremia with Normal/Increased ECF
Hypernatremia with Normal/Increased ECF Volume (due to Na gain)
Volume
Headache, apathy, confusion, weakness, muscle
Restlessness, agitation, twitching, seizures, coma
spasms, seizures, coma
Nausea, vomiting, diarrhea, abdominal cramps,
Intense thirst, flushed skin
distended neck veins
Weight gain, ↑ BP, ↑ CVP Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
BP, Blood pressure; CVP, central venous pressure; ECF, extracellular fluid; Gl, gastrointestinal; IV, intravenous; NG,
nasogastric; SIADH, syndrome of inappropriate antidiuretic hormone

SODIUM- (Na+ normal value: 135-145) Main Cation of ECF

Has osmolar property & is important in the movement of H2O, Na+ drawls fluid in & impacts osmolality
Functions: CNS!! Skeletal muscle contraction, cardiac contraction, nerve impulse transmission, ECF osmolarity & volume,
urine [] r/t renal fxn

HYPONATREMIA (<135mEq/L)
Pathology: low Na deficit OR H2O excess that gets PULLED into cell, which swells & burst
Cause:
 1) loss from GI, NG tub, skin, or kidney
 2) adrenal or pituitary disorder (SIADH)
 3) dilutional hyponatremia caused by water excess- inappropriate use of sodium free or hypotonic solutions (NOTE:
SIADH = abnormal retention of water)
Symptoms:
 1)MANY manifestations b/c of cellular SWELLINGCNS symptoms 1st , confusion, irritability, seizures, spasms
 2) Weakness, LOW DTR (hypoactive reflexes) deep tendon reflexes (bc Na is imp in neuromuscular transmission),
increased intestinal motility  cramps & diarrhea
Management:
 In water excess situation: fluid restriction or hypertonic solution (3% NaCl)
In Na deficit situation: give fluid replacement w/ sodium containing solutions
NANDA’s: Risk for injury; Altered MS; Altered GI r/t diarrhea

HYPERNATREMIA >145mEq/L in the plasma bed, so cell shrinks!

Pathology: increase Na intake OR massive loss of H2O

Cause: 1)defective thirst center in (hypothalamus) posterior pituitary gland-ADH

2) increase Na intake in fluids/foods
3)osmotic diuresis- from hyperosmolar tube feed , DM pt’s that loose a lot of H2O & Na+ level goes up
4)clinical states (Nephrogenic Diabetes Insipidus) or (ADH disorder)
5)tumor of the adrenal glands (hyperaldosterone disorder- accumulate Na+)
6)excessive sweating
 symptoms: thirst!!! is triggered & you drink if A&Ox3, not a new, or deseased system, Lethargy, seizures,
neuromuscular, coma, postural hypotension, weight loss b/c H2O defecit), decreased skin turgor

management:
1) Identify cause (H2O loss, or high Na+ [] from intake) Check plasma osmolality, urine specimen foe specific gravity
2) In H2O loss situation: give hypotonic solution!!!!! D5W b/c body state is hyperosmolar
3) In high sodium situation: give diuretics to get rid of Na w/ THIAZIDE
NOTE: Don’t give hypotonic solution rapidly, could cause cerebral edema by inducing H2O rapidly!
Nanda: Risk for injury r/t CNS deficit