Hyponatremia
Hypo: “under/beneath”
Natr: Prefix for Sodium
Emia: blood
Meaning of Hyponatremia: low sodium in the
blood
Normal sodium levels: 135 to 145 mEq/L
(<135 = hyponatremia)
Role of sodium in the body: An important
electrolyte that helps regulate water inside
and outside of the cell. Remember that water
and sodium loves each other and where ever
sodium goes so does water.
Types of Hyponatremia
Euvolemic Hyponatremia is where the
water in the body increases but the
sodium stays the same. The causes
include: SIADH (Syndrome of
inappropriate antidiuretic hormone
secretion) which is due to the increased
amount of secretion of antidiuretic
hormone. This hormone retains water in
the body which dilutes sodium. Other
causes: diabetes insipidus, adrenal
insufficiency, Addison’s disease etc.
Hypovolemic Hyponatremia is where
the patient has lost a lot of fluid and
sodium. Causes: vomiting, diarrhea, NG
suction, diuretic therapy , sweating
Hypervolemic Hyponatremia is where
the body has increased in fluid and
sodium. However, sodium decreases due
to dilution and because total body water
and sodium are regulated independently
in the body. Causes: congestive heart
failure, kidney failure, IV infusion of saline,
liver failure etc.
Causes of Hyponatremia
Remember “NO Na+”
Na+ excretion increased with renal
problems, NG suction (GI system rich in
sodium), vomiting, diuretics, sweating,
diarrhea, decreased secretion of
aldosterone (diabetes insipidus) (wasting
sodium)
Overload of fluid with congestive heart
failure, hypotonic fluids infusions, renal
failure (dilutes sodium)
Na+ intake low through low salt diets or
nothing by mouth
Antidiuretic hormone over secreted
**SIADH (syndrome of inappropriate
antidiuretic hormone secretion…
remembers retains water in the body and
this dilutes sodium)
Signs & Symptoms of Hyponatremia
Remember “SALT LOSS”
Seizures & Stupor
Abdominal cramping, attitude changes
(confusion)
Lethargic
Tendon reflexes diminished, trouble
concentrating (confused)
Loss of urine & appetite
Orthostatic hypotension, overactive
bowel sounds
Shallow respirations (happens late due to
skeletal muscle weakness)
Spasms of muscles
Nursing Interventions for
Hyponatremia
Watch cardiac, respiratory, neuro, renal,
and GI status
Hypovolemic Hyponatremia: give IV
sodium chloride infusion to restore
sodium and fluids (3% Saline hypertonic
solution….harsh on the veins…given in
ICU usually through central line very
slowly…must watch for fluid overload)
Hypervolemic Hyponatremia: Restrict
fluid intake and in some cases administer
diuretics to excretion the extra water
rather than sodium to help concentrate the
sodium. If the patient has renal
impairment they may need dialysis.
Caused by SIADH or antidiuretic hormone
problems: fluid restriction or treated with
an antidiuretic hormone antagonists
called Declomycin which is part of the
tetracycline family (don’t give with food
especially dairy or antacids…bind to
cations and this affect absorption).
If patient takes Lithium remember to
monitor drug levels because lithium
excretion will be diminished and this can
cause lithium toxicity.
Instruct to increase oral sodium
intake and some physicians may
prescribe sodium tablets. Food rich in
sodium include: bacon, butter canned
food, cheese, hot dogs, lunch meat,
processed food, table salt
Hypernatremia
Hyper: “excessive”
Natr: Prefix for Sodium
Emia: blood
Meaning of Hypernatremia: excessive
sodium in the bloodisotonic, hypotonic,
and hypertonic tonicity.
Normal sodium levels: 135 to 145
mEq/L (>145 sodium is hypernatremic)
Hypernatremia is a water problem rather
than a sodium problem. This is because
when the body collects sodium it causes a
lot of water retention and this is what
causes the patient problems.
Role of sodium in the body: It’s an
important electrolyte that helps regulate
the amount of water inside and outside of
the cell (water and sodium loves each
other).
Where ever sodium goes, so does water.
Watch my video on hypotonic, hypertonic,
and isotonic tonicity.
For example, in hypernatremia there is a
lot of sodium outside the cell and this
attracts the water from inside the cell
which will cause water to move outside
the cell and dehydrate the cell. Sodium
also plays a role in muscle, nerves, and
organ function.
Causes of Hypernatremia
Remember the phrase “HIGH SALT”
Hypercortisolism (Cushing’s Syndrome),
hyperventilation
Increased intake of sodium (oral or IV
route)
GI feeding (tube) without adequate water
supplements
Hypertonic solutions
Sodium excretion decreased (body
keeping too much sodium) and
corticosteroids
Aldosterone overproduction
(Hyperaldosteronism)
Loss of fluids (dehydrated) infection
(fever), sweating, diarrhea, and diabetes
insipidus
Thirst impairment
Signs & Symptoms of Hypernatremia
Remember: “No FRIED foods for you!”
(too much salt)
Fever, flushed skin
Restless, really agitated
Increased fluid retention
Edema, extremely confused
Decreased urine output, dry mouth/skin

Nursing Interventions for Hypernatremia

Restrict sodium intake! Know foods high
in salt such as bacon, butter, canned food,
cheese, hot dogs, lunch meat, processed
food, and table salt.
Keep patient safe because they will be
confused and agitated.
Doctor may order to give isotonic or
hypotonic solutions such as 0.45%
NS (which is hypotonic and most
commonly used). Give hypotonic fluids
slowly because brain tissue is at risk due
to the shifting of fluids back into the cell
(remember the cell is dehydrated with
hypernatremia) and the patient is at risk
for cerebral edema. In other words, the
cell can lyse if fluids are administered too
quickly.
Educate patient and family about sign and
symptoms of high sodium level and
proper foods to eat.
. A patient has a sodium level of 123
and presents with confusion. The doctor
diagnoses the patient with Syndrome of
Inappropriate Antidiuretic Hormone
Secretion (SIADH). Which type of
hyponatremia is this?
A. Hypovolemic
B. Euvolemic
C. Hypervolemic
D. Antivolemic
The answer is B: Euvolemic
2. A patient with a sodium level of 112 is
taking Lithium. Which of the following is
a nursing priority?
A. Hold further doses of Lithium
B. Monitor Lithium drug level due to risk
of toxicity
C. Monitor potassium level due to
increased risk of toxicity
D. No priority is need. 112 is a normal
sodium level
The answer is B: Monitor Lithium drug
level due to risk of toxicity
3. A patient with a sodium level of 178 is
ordered to be started on 0.45% Saline.
What is the most IMPORTANT nursing
intervention for this patient?
A. Maintain patent IV
B. Give rapidly to ensure fluids levels
are shifted properly
C. Clarify doctor’s order because 0.45%
saline is contraindicated in
hypernatremia
D. Give slowly and watch for signs and
symptoms of cerebral edema
The answer is D: Give slowly and watch
for signs and symptoms of cerebral
edema. The most important intervention
is to give slowly and watch for S&S of
cerebral edema because a hypotonic
solution can cause rapid swelling of the
cell. Maintain a patent IV is correct but
not the most important option in this
scenario.
4. You have completed diet teaching
with a patient who has hypernatremia.
Which statement by the patient causes
concern?
A. “I will buy fresh vegetables and fruits.”
B. “I will avoid eating canned foods.”
C. “I’m glad I can still eat sandwiches
with bologna.”
D. “I will avoid cooking with butter.”
The answer is C: “I’m glad I can still eat
sandwiches with bologna.”
5. A patient with Cushing’s Syndrome
has been experiencing an infection and
has a fever of 102’F. On assessment,
you find the patient to be confused,
restless, has dry mucous membranes,
and flushed skin. Which finding below
correlates with the presentation of this
patient?
A. Sodium level of 144
B. Sodium level of 115
C. Sodium level of 170
D. Sodium level of 135
The answer is C: Sodium level of 170
6. Which patient below is considered
hypernatremic?
A. A patient with a sodium level of 155
B. A patient with a sodium level of 145
C. A patient with a sodium level of 120
D. A patient with a sodium level of 136
The answer is A: A patient with a
sodium level of 155
7. A patient with a sodium level of 115 is
ordered to start Declomycin. Which
statement is NOT true about this
medication?
A. “Declomycin is an antidiuretic
hormone antagonist that treats SIADH.”
B. “Declomycin is part of the tetracycline
family.”
C. “Declomycin is to be taken with food,
preferably, milk.”
D. “Declomycin is contraindicated in
children and pregnant/nursing women.”
The answer is C: “Declomycin is to be 11. A patient has a sodium level of 130.
taken with food, preferably, milk.” What is this condition called?
Declomycin binds to cations (calcium) A. Hyponatremia
and this affects GI absorption…it should B. Hypernatremia
be given without food. C. Normal Sodium Level
D. Hypercalcemia
8. A patient with hypovolemic The answer is A: Hyponatremia
hyponatremia is started on IV fluids.
Which of the following fluids do you
expect the patient to be started on?
A. 0.45% Saline
B. 3% Saline
C. D5W
D. 0.33% Saline
The answer is B: 3% Saline Patients
with hypovolemic hyponatremia are
started on a hypertonic solution (the
circulatory system is dehydrated & and
the cells are swollen…so a hypertonic
solution will shrink the cells and increase
fluid volume) and 3% Saline is the only
hypertonic solutions. The other options
are either hypotonic or isotonic.

9. A patient has a sodium level of 119.

Which of the following is NOT related to
this finding?
A. Over secretion of ADH (antidiuretic
hormone)
B. Low salt diet
C. Inadequate water intake
D. Hypotonic fluid infusion (overload)
The answer is C: Inadequate water
intake

10. Which patient below is at risk for

experiencing Hypovolemic
Hyponatremia?
A. Patient with congestive heart failure
B. Patient with cirrhosis of the liver
C. Patient on IV saline at 250 cc/hr
D. Patient with nasogastric tube suction
experiencing diarrhea
The answer is D: Patient with
nasogastric tube suction experiencing
diarrhea
Hypokalemia
You will learn the following:
 Causes (easy mnemonics to
remember it)
 Signs & Symptoms (tricks on how
to easily remember)
 Nursing Intervention…things that
NCLEX and lecture exams look for
Hypo= low
Kal= root word for potassium….. don’t
get it confused with cal= calcium
Emia=blood
Meaning of hypokalemia: Low
Potassium in the Blood
Normal Potassium Level 3.5-5.1 (2.5
or less is very dangerous)
Most of the body’s potassium is found in
the intracellular part of the cell
compared to the extracellular which is
where sodium is mainly found. Blood
tests measure potassium levels via the
outside of the cell (extracellular fluid).
Causes of Hypokalemia
“Your Body is trying
to DITCH potassium”
Drugs (laxatives, diuretics,
corticosteroids)
Inadequate consumption of Potassium
(NPO, anorexia)
Too much water intake (dilutes the
potassium)
Cushing’s Syndrome (during this
condition the adrenal glands produce
excessive amounts of cortisol (if cortisol
levels are excessive enough, they will
start to affect the action of the Na+/K+
pump which will have properties like
aldosterone and cause the body to
retain sodium/water but waste
potassium)…hence hypokalemia
Heavy Fluid Loss (NG suction, vomiting,
diarrhea, wound drainage, sweating)
(Other causes: when the potassium
moves from the extracellular to the
intracellular with alkalosis or
hyperinsulinism (this is where too much
insulin in the blood and the patient will
have symptoms of hypoglycemia)
Signs & Symptoms of
Hypokalemia
Try to remember everything is going to
be SLOW and LOW. Don’t forget
potassium plays a role in muscle and
nerve conduction so muscle systems
are going to be messed up and effect
the heart, GI, renal, and the breathing
muscles for the lungs.
 Weak pulses (irregular and
thread)
 Orthostatic Hypotension
  Depression ST, flat or inverted T
wave and prominent u-wave
 Shallow respirations with
diminished breath sounds….due to
weakness of accessory muscle
movement to breath)
 Confusion, weak
 Flaccid paralysis
 Decrease deep tendon reflexes
 Decreased bowel sounds
Easy way to Remember 7 L’s
1. Lethargy (confusion)
2. Low, shallow respirations (due to
decreased ability to use accessory
muscles for breathing)
3. Lethal cardiac dysrhythmias
4. Lots of urine
5. Leg cramps
6. Limp muscles
7. Low BP & Heart
Nursing Interventions for
Hypokalemia
Watch heart rhythm (place on cardiac
monitor…most are already on
telemetry), respiratory status, neuro, GI,
urinary output and renal status (BUN
and creatinine levels)
Watch other electrolytes like Magnesium
(will also decrease…hard to get K+ to
increase if Mag is low), watch glucose,
sodium, and calcium all go hand-in-hand
and play a role in cell transport
Administer oral Supplements for
potassium with doctor’s order: usually
for levels 2.5-3.5…give with food can
cause GI upset
IV Potassium for levels less 2.5 (NEVER
EVER GIVE POTASSIUM via IV push or
by IM or subq routes)
-Give according to the bag instruction
don’t increase the rate…has to be given
slow…patients given more than 10-20
meq/hr should be on a cardiac monitor
and monitored for EKG changes
-Cause phlebitis or infiltrations
Don’t give LASIX, demadex , or
thiazides (waste more Potassium) or
Digoxin (cause digoxin toxicity) if
Potassium level low…notify md for
further orders)
Physician will switch patient to a
potassium sparing diuretic
Spironolactone (Aldactone), Dyazide,
Maxide, Triamterene
Instruct patient to eat
Potassium rich foods
Remember POTASSIUM to help you
remember the foods
 Potatoes, pork
 Oranges
 Tomatoes
 Avocados
  Strawberries,
 Spinach
 fIsh
 mUshrooms
 Musk melons: cantaloupe
Also included are: (carrots, raisins,
bananas)
Hyperkalemia
You will learn the following:
 Causes (easy mnemonics to
remember it)
Signs & Symptoms (tricks on how
to easily remember)
Nursing Intervention…things that
NCLEX and lecture exams look for
Hyper= excessive
Kal= root word for potassium
Emia=blood
Meaning of hyperkalemia: excessive
potassium in the blood
Normal Potassium is 3.5 to 5.1.
Anything higher 7.0 or higher is very
dangerous!
Most of the body’s potassium is found in
the intracellular part of the cell
compared to the extracellular which is
where sodium is mainly found. Blood
tests that measure potassium levels are
measuring the potassium outside of the
cell in the extracellular fluid.
Remember that potassium is
responsible for nerve impulse
conduction and muscle contraction.
Causes of Hyperkalemia
Remember the phrase “The
Body CARED too much about
Potassium”
Cellular Movement of Potassium from
Intracellular to extracellular (burns,
tissue damages, acidosis)
Adrenal Insufficiency with Addison’s
Disease
Renal Failure
Excessive Potassium intake
Drugs (potassium-sparing drugs:
spironolactone), Triamterene, ACE
inhibitors, NSAIDS)
Signs & Symptoms of
Hyperkalemia
Remember the word MURDER
Muscle weakness
Urine production little or none (renal
failure)
Respiratory failure (due to the
decreased ability to use breathing
muscles or seizures develop)
Decreased cardiac contractility (weak
pulse, low blood pressure)
Rhythm changes: Tall peaked T waves,
flat p waves, Widened QRS and
prolonged PR interval
Nursing Interventions for
Hyperkalemia
 Monitor cardiac, respiratory,
neuromuscular, renal, and GI
status
 Stop IV potassium if running and
hold any PO potassium
supplements
 Initiate potassium restricted diet
and remember foods that are high
in potassium
 Remember the word
POTASSIUM for food rich in
potassium
Potatoes, pork
Also included are carrots, cantaloupe,
raisins, bananas.

o Prepare patient for ready
for dialysis. Most patient are
renal patients who get
dialysis regularly and will
have high potassium.
o Kayexalate is sometimes
ordered and given PO or via
enema. This drug promotes
GI sodium absorption which
causes potassium excretion.
o Doctor may order
potassium wasting drugs like
Lasix or Hydrochlorothiazide
o Administer a hypertonic
solution of glucose and
regular insulin to pull the
potassium into the cell

Oranges

Tomatoes

Avocados

Strawberries,

Spinach

fIsh

mUshrooms

Musk Melons: cantaloupe

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