Comparison of Fluid Electrolyte Exemplars:
SIADH Diabetes Insipidus
Pathophys SIADH is diagnosed as a collection of
symptoms that take place with
otherwise normal function. This
syndrome is characterized by
hyponatremia, concentration of urine
and dilution of blood. The patient has
an adequate amount of blood, but it is
more dilute than normal. SIADH causes
the body to retain fluid resulting in
decreased electrolyte balance.
("Syndrome of Inappropriate
Antidiuretic Hormone (SIADH) Nursing
Care Plan | NRSNG," 2018)
Etiology SIADH is caused as an effect of other
disorders, often nervous system
disorders such as epilepsy, Guillain-
Barre syndrome or head trauma, or
cancers of the pulmonary, brain, GI and
genitourinary systems. It is caused
when the hypothalamus is stimulated
to produce excess amounts of AVP
(arginine vasopressin) which is an
antidiuretic hormone (ADH) that
triggers the kidneys to retain fluid in
the tubules and excrete sodium. As the
amount of fluid builds up in the cells
and tissues, it creates an imbalance of
electrolytes, specifically sodium,
causing hyponatremia. The excess fluid
dilutes the blood instead of being
excreted causing the urine to become
concentrated.
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Acute Renal Failure
Diabetes insipidus refers to the
condition where the kidneys are
unable to retain water. Even though
the patient may be dehydrated, the
kidneys cannot balance the fluid and
produce large amounts of insipid urine
(dilute and odorless). The kidneys
normally produce 1-2 quarts of urine
per day, but with diabetes insipidus,
they may produce 3 – 20 quarts per
day. This results in the patient feeling
very thirsty and have the urge to drink
large amounts of liquid.
("Diabetes Insipidus Nursing Care Plan
| NRSNG," 2018)
The hypothalamus produces a
hormone called vasopressin, an
antidiuretic hormone (ADH) that tells
the kidneys how much fluid to absorb
from the bloodstream. This normally
results in a lower amount of urine
produced. When there is damage to
the hypothalamus (Central diabetes
insipidus, or CDI) or the kidneys are
not able to respond to the vasopressin
(Nephrogenic diabetes insipidus or
NDI), the kidneys do not know when
to stop removing fluid from the body,
even if the body is already dehydrated.
This results in the patient feeling
extremely thirsty, which prompts them
to drink more fluids, and therefore,
secrete more dilute urine.
Chronic Renal Failure
Also known as acute kidney injury
(AKI), is measured by the buildup of
waste in your body and altered fluid
levels because the kidneys are failing
to do their job. The cause of the renal
failure can also change the
pathophysiology. There are three
main causes: 1) decreased blood flow
to the kidneys, 2) direct injury to the
kidney/tissues, and 3) blockage of
urine excretion. Inflammation to the
kidneys or their structures
(nephrons) can cause the kidneys to
fail. Blockage of urine can cause a
backup in the kidney, not allowing
them to continue to filter out waste
from the body or manage fluid levels.
("Acute kidney failure - Diagnosis and
treatment - Mayo Clinic," 2018)
There are many causes of kidney
failure. For example, low blood
perfusion to the kidneys can cause
acute kidney failure from causes such
as an infection/antibiotic use,
hypotension potentially from blood
loss (hemorrhage) or fluid loss
(vomiting/ diarrhea), or even other
organ failure (heart attack, liver
failure). Another reason for kidney
failure could be direct damage to the
structures of the kidney itself. The
biggest offender of kidney damage is
sepsis, but also anything that can
cause inflammation in the vessels of
the kidneys (Vasculitis) as well as the
attempt to treat it with too many
NSAIDs can cause direct damage to
the kidneys. Lastly, if the urine
cannot be excreted, this can cause
kidney failure.
Chronic kidney failure, describes the
gradual loss of kidney function. Your
kidneys filter wastes and excess fluids
from your blood, which are then
excreted in your urine. When chronic
kidney disease reaches an advanced
stage, dangerous levels of fluid,
electrolytes and wastes can build up in
your body.
In the early stages of chronic kidney
disease, you may have few signs or
symptoms. Chronic kidney disease may
not become apparent until your kidney
function is significantly impaired.
Chronic kidney disease can progress to
end-stage kidney failure, which is fatal
without artificial filtering (dialysis) or a
kidney transplant.
("Chronic Kidney Disease NCLEX Review,"
2017)
Chronic kidney disease occurs when a
disease or condition impairs kidney
function, causing kidney damage to
worsen over several months or years.
Diseases and conditions that cause
chronic kidney disease include:
 Type 1 or type 2 diabetes
 High blood pressure
 Glomerulonephritis
 Interstitial nephritis
 Polycystic kidney disease
 Prolonged obstruction of the
urinary tract
 Vesicoureteral reflux
 Recurrent kidney infection
("Chronic Kidney Disease NCLEX Review,"
2017)
 Kidney stones, enlarged prostates
("Syndrome of Inappropriate ("Diabetes Insipidus Nursing Care Plan and some cancers can present
Antidiuretic Hormone (SIADH) Nursing | NRSNG," 2018) problems for the urinary tract’s
Care Plan | NRSNG," 2018) ability to excrete urine.

("Acute kidney failure - Diagnosis

and treatment - Mayo Clinic," 2018)

Clinical  irritability  Extreme thirst  Decreased urine output  Nausea

Manifestations  restlessness  Excretion of an excessive  Fluid retention  Vomiting
including  loss of appetite  Shortness of breath  Loss of appetite
amount of diluted urine
Laboratory data  cramps  Fatigue  Fatigue and weakness
(approx. 15L/day)
 nausea and vomiting  Confusion  Sleep problems
 muscle weakness  Nausea  Changes in how much you
 confusion  Weakness urinate
 hallucinations Possible Labs:  Irregular heartbeat  Decreased mental sharpness
 personality changes Serum electrolytes  Chest pain or pressure  Muscle twitches and cramps
 seizures Serum glucose  Seizures or coma in severe  Swelling of feet and ankles
 stupor Urinary specific gravity cases  Persistent itching
Simultaneous plasma and urinary Chest pain
 coma 
osmolality
 Shortness of breath
Plasma antidiuretic hormone Possible Labs:
Possible Labs:  High blood pressure
(ADH) level Urine tests: Urinalysis to find signs
Urine/Serum Osmolarity
24hr Urine collection of kidney failure
Serum Creatinine
Urea and Urate Blood tests: Blood tests will help Possible Labs:
Hematocrit ("Clinical Laboratory Evaluation of find levels of creatinine, urea  a blood test that checks how
Protein the Syndrome of Inappropriate nitrogen phosphorus and well your kidneys are filtering
Albumin Secretion of Antidiuretic potassium should be done in your blood, called GFR. GFR
RBC MCV Hormone," 2008) addition to blood tests for protein stands for glomerular filtration
Serum potassium in order to look at kidney function. rate.
Serum sodium GFR: Your blood test will also help  a urine test to check for
Serum chloride find your GFR (glomerular filtration albumin. Albumin is a protein
Urine specific gravity rate) to estimate the decrease in that can pass into the urine
kidney function when the kidneys are damaged.
("Clinical Laboratory Evaluation of Kidney biopsy: In some situations,  BUN/CRE measures kidney
the Syndrome of Inappropriate a doctor will do a procedure where function
Secretion of Antidiuretic Hormone," a tiny piece of your kidney is  Urinalysis may be done to check
2008) removed and looked at under a for protein, WBC, ketones, etc.
microscope.

("Acute kidney failure - Diagnosis ("Chronic Kidney Disease NCLEX Review,"

and treatment - Mayo Clinic," 2017)
2018)

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Interventions 1. Monitor I & O, daily weights
o Patients may be on
fluid restrictions to help balance
intake and output. Monitor for
retention through calculated
intake and output and with daily
weights at the same time on the
same scale each day.
2. Continuous ECG monitoring
o Changes in
electrolyte balance can disrupt
the electrical conduction in the
heart causing dysrhythmias.
3. Assess and monitor vital signs
every 1-2 hours
o Fluid shifts can occur
quickly causing changes in blood
pressure and heart rate. Most
often patients will experience
hypotension.
4. Assess and monitor
respiratory status; note changes
in respiration, auscultate lungs
o Excess fluid volume
can settle in and around the lungs
and heart. Monitor for signs of
congestion, difficulty breathing.
SIADH can also be triggered by
pneumonia, so monitor for the
underlying cause as well.
5. Administer medication and
electrolyte supplements
appropriately: Electrolyte
supplements (potassium),
Demeclocycline or lithium - stops
the kidneys from responding to
extra ADH
o Supplements may be
given to regulate electrolyte
imbalance. Carefully administer
supplements to avoid overloading
too quickly
6. Monitor lab / diagnostic
values: Serum potassium, Serum
sodium, Serum chloride, Serum
osmolality (concentration), Urine
specific gravity
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1. Monitor I & O, daily weights,
and polydipsia
o Weight loss will
occur with excessive fluid loss.
Thirst can be an indicator of fluid
balance.
2. Monitor for signs /
symptoms of hypovolemia
o Excess fluid loss
results in decreased circulatory
volume. Early detection and
intervention can prevent
hypovolemic shock from
occuring.
3. Monitor for signs of
hypotension and provide
education and assistance with
ambulation
o Dehydration and
hypernatremia can cause the
blood pressure to drop which
may result in dizziness or
weakness with position changes.
Assist patient when standing or
walking to prevent falls and
injury. Educate patient to make
slow changes in position.
4. Encourage hydration and
provide easy access to fluids;
administer IV fluids if necessary:
Hypotonic- D5W or 0.45%
sodium chloride, Isotonic - NS
(0.9% sodium chloride) if
hemodynamically unstable
o If the patient has
intact thirst, offer plenty of fluids
to prevent dehydration. If the
patient cannot orally tolerate
fluids, initiate IV fluids.
5. Monitor labs / electrolyte
balance: Serum and urine
osmolality, Serum and urine
sodium levels, Serum potassium
o Excess fluid loss
results in the body excreting
potassium and retaining sodium.
This results in too much sodium
1. Strict intake and output
measurement
o It is important if
the kidney’s are not functioning
to measure the patient’s I&Os.
Notify the physician if there is a
deficit greater than 5-10%.
2. Medications to watch:
Statins, NSAIDS, Aspirin
o Be mindful of
medications that can become
toxic when the kidneys aren’t
functioning at their prime.
3. Statins NSAIDS Aspirin
Acetaminophen Insulin Some
antibiotics Herbal supplements
o Be mindful of
medications that can become
toxic when the kidneys aren’t
functioning at their prime.
Try to limits these drugs, watch
labs and antibiotic troughs.
Look out for signs and
symptoms of overdose.
4. Monitor lung sounds and
edema
o You want to make
sure fluid balance is carefully
monitored. A backup in the
lungs would cause crackles and
a back up systemically would
cause pitting edema in the legs.
5. Diuretic administration:
Furosemide (Lasix) Bumetanide
(Bumex) Spironolactone
(Aldactone)
o This is very
important… diuretics are going
to make the patient PEE… lots
and lots of PEE. Do not under
any circumstances administer a
diuretic without a bathroom
plan. And a word to the wise,
have a backup plan. Meaning if
you have a walkie talkie patient
with functioning arms and a
strong call light finger, I still
1. Monitor vitals
o Maintain reasonable
blood pressure to help protect the
kidneys from further damage
2. Monitor and manage blood
sugar
o Keeping blood sugar in
the optimal range if diabetic can help
reduce the stress on the kidneys
3. Assess cardiopulmonary
system: Auscultate heart and lungs
for abnormal sounds
o Fluid retention from
improper glomerular filtration may
collect in the myocardium resulting
in stress on the heart and in the
lungs. Listen for friction rub and
pulmonary crackles or congestion
4. Monitor lab/diagnostic studies:
Glomerular Filtration Rate (GFR) <60
indicates kidney disease, <15
indicates kidney failure, CT /
Ultrasound Kidney biopsy (if
necessary), Chest x-ray - if indicated
o GFR- is a blood test
that can show the degree of kidney
function available. It is a calculation
of creatinine levels, race, age, gender
and other factors.
Albumin- urine albumin test- healthy
kidneys do not allow albumin into
the urine. Albumin in the urine may
indicate decreased kidney function.
CT / Ultrasound- this imaging may be
helpful to view the kidneys to
determine if there are tumors or
other unusual characteristics of the
kidneys
5. Evaluate mental status
o Notice changes in
mental status and confusion.
Cerebral edema and stroke are
possible complications.

o Hyponatremia is the
hallmark of SIADH. Monitor lab
values to determine if treatment
is effective.
("Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
Nursing Care Plan | NRSNG,"
2018)
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and too little potassium in the
blood.
6. Administer medications
appropriately: Chlorpropamide
or carbamazepine - stimulates
the release of vasopressin
(ADH), Hydrochlorothiazide-
may be used for nephrogenic DI,
Aqueous vasopressin - used for
short term DI, Pitressin tannate
is a long-acting vasopressin
o Depending on the
type of diabetes insipidus,
medications may be given to
stimulate the production of
vasopressin, or it may be given
as a supplement. When giving
medications, monitor for
effectiveness and changes in
blood pressure due to changes in
fluid balance.
7. Provide easy access to
bathroom
o Frequent urination
can be frustrating for the patient.
Provide easy access for voiding
including urinal or bedside
commode as appropriate.
8. Prevent injury and initiate
fall precautions
o Frequent trips to the
bathroom can increase the risk
of falls. Provide assistance as
needed with ambulation,
especially if patient has
confusion, muscle cramps or
muscle weakness from
electrolyte imbalance.
9. Assess for skin integrity,
apply skin barriers as needed
o Polyuria may lead to
bouts of incontinence and
increase the risk of skin
breakdown. Apply barriers and
would set up a bedside
commode just.in.case. I walk
them to the bathroom or assist
them in any way needed, but it
is possible that they do not
know how urgent their situation
is and I can clean up pee, but
you can’t clean up that patients
dignity.
6. Monitor Potassium
Potassium (K+) Normal range:
3.5 - 5.0 mEq/L
o As Furosemide is
the front line and best
treatment for kidney failure,
nurses must be careful to watch
the patient’s potassium levels
(Remember: Furosemide is
potassium wasting).
7. Diet changes and control
Fluid restriction Salt restriction
o Educating the
patient on decreased sodium
intake as well as strict fluid
intake is vital when in any sort
of kidney failure.
8. Monitor Kidney Labs Blood
Urea Nitrogen (BUN) Normal
Range: 7-20 mg/dL Creatinine
(Cr) Normal Range: 0.7-1.4
mg/dL
o This measures how
well treatment is working, you
want the labs to be moving
back to normal limits.
Blood Urea Nitrogen (BUN):
measures the amount of urea in
the blood. When protein is
broken down ammonia is
formed. Ammonia is converted
to urea in the liver and is
eventually excreted in the
kidneys.
Creatinine (Cr): is a byproduct
of creatine metabolism, and it is
excreted by the kidneys.
6. Monitor I & O
o Monitor kidney
function and calculate fluid
retention.
Daily weights at the same time each
day on the same scale can also help
determine amount of fluid being
retained.
Measure for decreased output <400
mL/24 hr period may be evidenced
by dependent edema
7. Insert indwelling catheter as
appropriate
o To help monitor fluid
balance and characteristics of urine
8. Palpate abdomen
o To assess for fluid
retention
9. Restrict fluids
o Closely monitor fluid
intake to prevent overload and help
reduce retention and promote
emptying of the bladder.
10. Nutrition education
o A renal diet is low in
protein and sodium. The kidneys are
compromised and unable to remove
the waste produced by processing
proteins (BUN).
Choose foods low in saturated and
trans fat to prevent and lower fat
deposits in the blood vessels.
Choose lower potassium foods to
avoid hyperkalemia caused by excess
potassium retention.
("Chronic Kidney Disease Nursing
Care Plan | NRSNG," 2018)
 precautions as necessary to ("Nursing Care Plan for Acute
avoid redness or excoriation. Renal Failure | NRSNG," 2017)

("Diabetes Insipidus Nursing Care

Plan | NRSNG," 2018)

Possible In severe cases, low sodium can lead Dehydration
Complications to: Except for primary polydipsia, which
 Decreased consciousness, causes you to retain too much water,
hallucinations or coma diabetes insipidus can cause your body
 Brain herniation to retain too little water to function
 Death properly, and you can become
dehydrated.
(Ignatavicius, Workman, & Rebar, 2017) Electrolyte imbalance
Diabetes insipidus can also cause an
electrolyte imbalance. Electrolyte
imbalance can cause symptoms, such
as:
 Fatigue or lethargy
 Nausea
 Loss of appetite
 Muscle cramps
 Confusion
(Ignatavicius, Workman, & Rebar,
2017)
 Fluid buildup. Acute kidney
failure may lead to a buildup of
fluid in your lungs, which can
cause shortness of breath.
 Chest pain. If the lining that
covers your heart (pericardium)
becomes inflamed, you may
experience chest pain.
 Muscle weakness. When
your body's fluids and
electrolytes — your body's blood
chemistry — are out of balance,
muscle weakness can result.
 Permanent kidney
damage. Occasionally, acute
kidney failure causes permanent
loss of kidney function, or end-
stage renal disease. People with
end-stage renal disease require
either permanent dialysis — a
mechanical filtration process used
to remove toxins and wastes from
the body — or a kidney transplant
to survive.
 Death. Acute kidney failure
can lead to loss of kidney function
and, ultimately, death.
 Fluid retention
 A sudden rise in potassium
levels
 Heart and blood vessel disease
 Weak bones and an increased
risk of bone fractures
 Anemia
 Decreased sex drive, erectile
dysfunction or reduced fertility
 Damage to your CNS
 Decreased immune response
 Pericarditis
 Pregnancy complications
 Irreversible damage to your
kidneys (end-stage kidney disease).
("Chronic Kidney Disease NCLEX Review,"
2017)

("Acute Kidney Injury (AKI),"

2017)

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 References

Acute kidney failure - Diagnosis and treatment - Mayo Clinic. (2018, June 23). Retrieved from https://www.mayoclinic.org/diseases-conditions/kidney-failure/diagnosis-treatment/drc-

20369053

Acute Kidney Injury (AKI). (2017, February 3). Retrieved from https://www.kidney.org/atoz/content/AcuteKidneyInjury

Chronic Kidney Disease NCLEX Review. (2017, July 24). Retrieved from https://www.registerednursern.com/chronic-kidney-disease-nclex-review/

Chronic Kidney Disease Nursing Care Plan | NRSNG. (2018, November 1). Retrieved from https://www.nrsng.com/care-plan/chronic-kidney-disease/#nursing-interventions

Clinical Laboratory Evaluation of the Syndrome of Inappropriate Secretion of Antidiuretic Hormone. (2008, July 1). Retrieved from https://cjasn.asnjournals.org/content/3/4/1175#sec-4

Diabetes Insipidus Nursing Care Plan | NRSNG. (2018, November 1). Retrieved from https://www.nrsng.com/care-plan/diabetes-insipidus/

Diabetes Insipidus Workup: Approach Considerations, Water Deprivation Testing, Pituitary Studies. (2018, April 27). Retrieved from https://emedicine.medscape.com/article/117648-

workup

Ignatavicius, D. D., Workman, M. L., & Rebar, C. (2017). Medical-Surgical Nursing: Patient-Centered Collaborative Care, 2-Volume Set. Philadelphia, PA: Saunders.

Nursing Care Plan for Acute Renal Failure | NRSNG. (2017, June 26). Retrieved from https://www.nrsng.com/care-plan/acute-renal-failure/

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Nursing Care Plan | NRSNG. (2018, November 9). Retrieved from https://www.nrsng.com/care-plan/syndrome-of-inappropriate-

antidiuretic-hormone-siadh/

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