COLEGIO de KIDAPAWAN

Paramedical Department
Bachelor of Science in Nursing
First Semester SY: 2022-2023

RLE: FINAL

WATER INTOXICATION SECONDARY TO SYNDROME OF INAPPROPRIATE ANTI

DIURETIC HORMONE

Submitted by:
Bonado, Rosalie
Brato, Nathaniel
Cubelo, Darlene Clarice O.
Elian, Samera
Emba, Ramla
Enal, Dick

Submitted to:
Ana C. Lagdameo, RN

DECEMBER 2022

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TABLE OF CONTENTS
Title Page …………………………………………………………………………… i
Table of Contents ………………………………………………………………… ii
Acknowledgement …………………………………………………………………. iii

I. Introduction ………………………………………………………………. 1

II. Objectives…………………………………………………………………... 2
III. Patient’s Data ……………………………………………………………… 3

IV. Family Background/Health History ……………………………….…… 4

V. Developmental Data …………………………………………………...…. 6
VI. Definition of Complete Diagnosis ……………………………………. 6
VII. Physical Assessment …………………………………………………… 7
VIII. Anatomy and Physiology………………………………………………. 9
IX. Etiology and Symptomatology…………………………………………. 11
X. Pathophysiology…………………………………………………………... 15
XI. Doctor’s Order……………………………………………………………... 17
XII. Diagnostic Exam…………………………………………………………... 19
XIII. Drug Study…………………………………………………………………. 23
XIV. Surgical Procedure (if any) ………………………………………………. 31
XV. Nursing Theories …………………………………………………………. 32
XVII. Nursing Care Plan ………………………………………………………… 33
XVII. Discharge Plan……………………………………………………………. 46
XIX. Recommendation……………………………………………………….…. 48
X. Prognosis ………………………………………………….…………………. 49
XXI. References …………………………………………………………………. 50

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 ACKNOWLEDGEMENT

This work would not be possible without the help of people who made valuable
effort and contribution that serve as encouragement in finishing this research study.

The researchers would like to extend their deepest and sincere gratitude to the
following people who made this study a success.

First of all, our creator, Almighty God for the gift of wisdom and knowledge in its
endless love, compassion, and guidance that he poured to us every day.

To Mrs. Fe B. Estampa RN. RM. MN, Dean of College of Nursing for her full
support, assistance, and understanding.

To our beloved Clinical Instructor, for their endless patience and knowledge that
they impart unto us. It was great privilege and honor to gain information and study under
their guidance.

Lastly, we give thanks to the beloved family of the researchers for their deep
consideration for finances and undying support, encouragement, moral and spiritual
support and as well for the love they give to us.

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 INTRODUCTION
Water intoxication is known as water poisoning, it is a disruption of the brain
function caused by drinking too much water. It is a rare case but there have been
numerous medical reports of death due to excessive water intake. Mostly, affects
people participating in sporting events or endurance training, or people who have
various mental health conditions. Water is just like other substances considered as
poison when over consumed in a short period of time. This occurs when water is being
consumed in a high quantity without adequate electrolyte intake and it can lead to
Syndrome of inappropriate anti- diuretic hormone (SIADH). It is a disorder of impaired
water excretion caused by the inability to suppress the secretion of anti-diuretic
hormone (ADH).
In USA, according to Boscoe, Paramore & Verbalis the prevalence estimates for
Hyponatremia ranged from 3.2 million to 6.1 million persons in the U.S on an annual
basis. Water intoxication with hyponatremia is a rare condition that originated from over
hydration. The causes of this water intoxication include psychiatric disorder, forced
water intake as a form of child abuse and iatrogenic infusion of excessive hypotonic
fluid. Water constitutes up to 75% of a human body’s composition during infancy, and
although this percentage decline to 45% in old age, it is a still a large component of the
body mass (Hall et al.,) Additionally, Water intoxication is usually observed in psychiatric
patients, child abuse victims, and iatrigenic cases.
According to Adriane Seitz, MS, RD, LDN (2020). Water intoxication is particularly
common among endurance athletes. It can happen if a person drinks a lot of water
without correctly accounting for electrolytes losses. As the authors study out of 488
participants in the Boston Marathon 13% had hyponatremia symptoms, and 0.06% had
critical hyponatremia, with sodium level less than 120mmol/l.
According to another report of one medical report, three soldiers died due to
hyponatremia and cerebral edema. This death was associated with drinking more than
5 litters of water in just a few hours.
In Philippines, water intoxication related Syndrome of Inappropriate anti- diuretic
hormone (SIADH) is rare but common in cases in athletes which reported and doesn’t
recognize, lack research resources about (SIADH).
We, as a group 2, choose this study because we find it interesting knowing that
studying Syndrome of inappropriate anti- diuretic hormone, we can gain more
knowledge about it and apply those learning in our future clinical practices since this
topic not yet totally recognize and the researchers doesn’t have resources. We are also
much eager to share the information that we able to get during our study to our fellow
student and to whoever may read this.

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 OBJECTIVE
GENERAL
The researcher from Paramedical Department under the curriculum of Bachelor of
science in Nursing- Third year level aims to identify the cause and effects of water
intoxication secondary to (SIADH) and as well as, the nursing process and management
to treat this condition.

SPECIFIC
The researchers from the bachelor of science in Nursing in Third Year Level aims to
identify the following:
Cognitive
Identify the main cause and effects of having water intoxication secondary to
syndrome of inappropriate anti- diuretics hormone.
Synthesize some ideas or drugs that will help to decrease the risk of water
intoxication secondary to syndrome of inappropriate anti-diuretics hormone.
Establish the nursing theories that are applicable towards the case of the client.
Psychomotor
Observe the proper ways on how to deal with water intoxication through nursing
management.
Explore the ideas or knowledge on what are the internal organs and external
part of the body that can affected of water intoxication secondary to Syndrome of
inappropriate anti- diuretics (SIADH) will occur.
Construct a nursing management through nursing care plan.
To have better grasp of the client’s case, create a pathophysiology diagram.
Affective
Discuss the proper way on how to deal with water intoxication secondary to
(SIADH) through normal water intake and output.
Encourage to be productive on changes in lifestyle, eating habits and practices
necessary for the prognosis of hyponatremia.

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 PATIENT’S DATA

Medical Notes:
Patient’s Data:
 Name: patient X
 Age: 25 years old
 Date of Birth: 20 January 1997
 Height: 167cm
 Weight: 44kgs
 Gender: Male
 Civil Status: single
 Nationality: Filipino

Chief Complaint/s: Nausea and vomiting, consciousness disturbance, restlessness,

confusion, slurred speech and tonic convulsions.

VS upon admission (December 2, 2022 at 1:00 pm)

BP: 140/90 mmHg
HR: 60 bpm
RR: 22 bpm
T: 36.8 °C
O2 sat: 94%

Clinical Findings:
 high-intensity signals in the peri lateral ventricular region
 brain white matter consistent with the development of brain edema
 Muscle rigidity was slightly enhanced in the proximal portion of his extremities
 Severe hyponatremia (120 mmol/l)

Comorbidities:
(–) smoking
(–) alcoholism
(–) hypertension
(–) diabetes
(–) allergies

Diagnosis: Water Intoxication Secondary to Syndrome of Inappropriate Anti-

diuretic Hormone.

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 Family Background/Health History (Genogram)

A 25 years old man who was a delivery rider joined a game with his workmates.
One punishment of the game is that the loser will drink a cup of water in each game. It
is estimated that a cup of water was 300 ml. That day, the patient had repeatedly lost
the game, as a result he had drink 20 cups of water during 25 set of games in total for
the 3 hours game. It is expected that the patient had drank about 6000 ml of water or 6
Liters of water in just three hours.
For about three and a half hours after the game had ended, he was rushed to the
hospital as he was already showing signs and symptoms of water intoxication such as,
restlessness, consciousness disturbance, fatiguability. Soon after, he started having
nausea and vomiting even tonic convulsion. The doctor had given him a dose of 100mg
phenobarbital intramuscularly however the patient condition does not yet improve as he
had showed systemic convulsions again and was administered phenytoin, and the
convulsion disappeared. On the third day, his consciousness had improved and there
was a significant increase in the serum sodium concentration of (123 mmol/l) and urine
myoglobin (372.1 ng/ml) as well as muscle pain, which were consistent with
rhabdomyolysis resulting from the recurrent convulsions and hyponatremia. Following
the improvement of the hyponatremia, those abnormalities also disappeared by the 5th
day. After confirmation of the disappearance of the brain high-intensity signals by MRI
and the normalization of the disturbed free water clearance on the 5th day, the patient
was discharged and he returned to the detention facility with no significant clinical signs
on the 6th day.
The genogram presented below determine the family’s history of past
illness from the third generation. The patients mother has history of SIADH. His father
has history of being hypertensive and diabetic (type2). Both of her grandparent in
maternal sides has unknown disease which was not emphasized. However, on paternal
sides, grandmother has unknown illness and grand father has history of hypothyroidism.

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GENOGRAM

Paternal Side
Maternal Side

Grand Mother Grand Father Grand Father

Grand Mother

Father
Mother

Son
Legend:

Unknown SIADH

Unknown Hypertensive and Diabetic

Unknown

Hypothyroidism 5
B. History of past Illnesses

 Clinical episodes which can cause SIADH, such as epilepsy, brain surgery
history, head injury or a history of meningoencephalitis, were not seen in his past
history. However, the patient verbalized that he had history of hypothyroidism which
medications has been continued as a result, it affects the inappropriate secretion of
ADH in the body contributing to the development of SIADH.

DEFINITION OF COMPLETE DIAGNOSIS

Water intoxication is a fatal disorder with brain function impairment, defined as

hypo-osmolar syndrome resulting from an excess intake of water, with dilutional
hyponatremia formed principally by (1) the retention of water exceeding renal free water
excretion, or (2) impaired free water excretion from the kidneys. The former situation is
occasionally observed in psychiatric patients with polydipsia, or it may develop as a
result of iatrogenic water overloading. The latter situation results from an inappropriate
secretion of antidiuretic hormone (ADH) to the plasma osmolality. In hypo-osmolar
syndrome, the translocation of a massive amount of extracellular water into the cells
generates an increase in the cellular volume, leading to the development of brain
edema, demonstrating a variety of neurological signs from appetite loss or emesis to
convulsion or consciousness disturbance, depending on the severity and rapidity

Hyponatremia occurs in about 30% of hospitalized patients and syndrome of

inappropriate antidiuretic hormone secretion (SIADH) is a common cause of
hyponatremia. SIADH should be differentiated from other causes of hyponatremia like
diuretic therapy, hypothyroidism and hypercortisolism. Where possible, all attempts
should be made to identify and rectify the cause of SIADH. The main problem in SIADH
is fluid excess, and hyponatremia is dilutional in nature. Fluid restriction is the main stay
in the treatment of SIADH; however, cerebral salt wasting should be excluded in the
clinical setting of brain surgeries, subarachnoid hemorrhage, etc. Fluid restriction in
cerebral salt wasting can be hazardous. Sodium correction in chronic hyponatremia
(onset >48 hours) should be done slowly to avoid deleterious effects in brain.

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 Hyponatremia is the commonest electrolyte abnormality, and syndrome of
inappropriate antidiuretic hormone (SIADH) is the most frequent underlying
pathophysiology. Hyponatremia is associated with
significant morbidity and mortality, and as such appropriate treatment is essential.
Treatment options for SIADH include fluid restriction, demeclocycline, urea, frusemide
and saline infusion, all of which have their limitations. The introduction of the
vasopressin-2 receptor antagonists has allowed clinicians to specifically target the
underlying pathophysiology of SIADH. Initial studies have shown good efficacy and
safety profiles in the treatment of mild to moderate hyponatremia. However, studies
assessing the efficacy and safety of these agents in acute severe symptomatic
hyponatremia are awaited. Furthermore, the cost of these agents at present may limit
their use.

PHYSICAL ASSESSMENT

GENERAL APPEARANCE
The patient is generally having decreased level of consciousness due to her
chief complain of a nausea and vomiting, consciousness disturbance, restlessness,
confusion, slurred speech and tonic convulsions. He appears weak and lifeless, as a
result of his situation. His body movement is limited, seems not aware and
unresponsive to his surroundings. He also experienced series of bradycardia,
tachypnea and hypertension. Her physical appearance appears to be normal and not
too thin with a weight of 44kgs.

VITAL SIGNS
Temperature: 36.8° C
Respiratory rate: 60 bpm
Heart rate: 22 bpm
SpO2: 95%
Blood Pressure: 140/90 mmHg
Height: 167cm
Weight: 47 kg

SKIN
Good skin turgor. No noted skin discoloration. Nail beds are intact with a poor
perfusion due to capillary refill time of three seconds

HEAD
Patient’s head is normocephalic in size and symmetrical. Hair is brittle with
minimal hair loss. No signs of alopecia noted.

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EYES
Pupils are equally round and non-reactive to accumulation and light stimulation.
Eye movement appears a bit sluggish. Has pale conjunctiva. With abnormal-ocular
movements

EARS
Hearing acuity is reduced. Unresponsive to sound stimulation.

NOSE
Both nares are asymmetrical with no discoloration or swelling, and patent. No
presence of mucus secretion.

MOUTH
Uvula is at the midline. Tongue movement is a bit sluggish. Erythematous throat
is noted without tonsillar swelling. Slurred speech is noted.

NECK AND THROAT

Trachea is at the midline. Cervical lymph nodes are smooth, barely perceptible,
and non-tender upon palpation. No jugular vein distended

THORAX, LUNGS AND ABDOMEN

With asymmetrical chest wall expansion with increased expiratory and
inspiratory phase. Slight abdominal distension is noted. Client demonstrate deep and
labored respiration.

CARDIOVASCULAR SYSTEM
ECG shows that heart rhythm is regular. Experienced tachycardia and
tachypnea. Peripheral pulses are in normal range with good pulse quality.

UPPER AND LOWER EXTREMITIES

Limited flexion of the trapezius and sternocleidomastoid muscles is noted. Slight
weakness in muscle strength is noted. Non-existent deep tendon reflexes on the lower
and upper extremities. No presence of edema in both lower and upper limbs.

NEUROMUSCULAR SYSTEM
Unoriented to person, place and time, altered mental status with a Glasgow
coma scale is moderate with a score of 12. Presence of high-intensity signals in the peri
lateral ventricular region. With bilateral distal muscle weakness on both upper and lower
extremities. Muscle rigidity was slightly enhanced in the proximal portion of his
extremities

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GASTROINTESTINAL SYSTEM
With hyperactive bowel sounds

ANATOMY and PHYSIOLOGY

Hypothalamus - a structure deep in your brain, acts as your body's smart

control coordinating center. Its main function is to keep your body in a stable state
called homeostasis. The hypothalamus will produce ADH also known as vasopressin
when the body experience increases in serum osmolarity and decrease in blood
volume. Then the ADH will travel and release in the posterior pituitary gland.

Pituitary Gland - The posterior lobe of the pituitary gland stores and releases
(secretes) only two hormones: Antidiuretic hormone (ADH, or vasopressin): ADH helps
regulate the water balance in your body by controlling the amount of water your kidneys
reabsorb while they're filtering wastes out of your blood. ADH is transported from the
hypothalamus to the posterior pituitary gland then released in the systemic circulation.

Adrenal gland- the adrenal gland, also known as suprarenal glands, are small,
triangular-shaped glands located on top of both kidneys. When ADH is released by the
pituitary gland it stimulates the adrenal gland to produce corticosteroid and aldosterone.
Aldosterone is a hormone that increases blood volume and blood pressure by causing

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kidney reabsorption of water and sodium. The difference with ADH and aldosterone
when it comes to homeostatic activity is that ADH causes reabsorption of only water,
aldosterone is responsible in the reabsorption of both water and sodium in the blood.

Kidney- ADH then travels to the kidneys, where it binds to ADH receptors on the
distal convoluted tubules. The binding of ADH to these receptors causes aquaporin-2
channels to move from the cytoplasm, into the apical membrane of the tubules. These
aquaporin-2 channels allow water to be reabsorbed out of the collecting ducts and back
into the bloodstream. This results in both a decrease in volume and an increase in
osmolality (concentration) of the urine excreted. When it comes to aldosterone in the
kidney is that it binds to receptors in the cells of renal tubules, thus stimulate the
production of ion channels to allow sodium be reabsorbed into the blood as well as
water.

Urinary bladder, ureter and urethra- These organs are part of urinary system
responsible for the transportation of urine formation in the nephron to be excreted down
and outside the body through urination, since water is reabsorbed back in circulation
more concentrated urine will be exerted to prevent for proper hydration maintaining
normal body homeostasis.
The extra water that has been
reabsorbed re- enters the
circulatory system, reducing the
serum osmolality. This reduction in
serum osmolality is detected by the
hypothalamus and results in
decreased production of
ADH.

SYNDROME OF
INAPPROPRIATE SECRETION
OF ANTIDIURETIC
HORMONE (SIADH)
SECRETION

Deranged physiology in
SIADH

The important difference between normal physiology and what occurs in SIADH
is the lack of an effective negative feedback mechanism. This results in continual ADH
production, independent of serum osmolality. Ultimately this leads to abnormally low

10
levels of serum sodium and relatively high levels of urinary sodium, giving rise to the
characteristic clinical features associated with SIADH.

ETIOLOGY AND SYMPTOMATOLOGY

ETIOLOGY
PREDISPOSING FACTORS

Factors Remarks Rationale Significance

 Mutated gene of vasopressin The patient’s

FAMILY HISTORY receptor (V2R) from parents mother has
OF SIADH increase risk of inheriting it. The history of
mutated gene unlike the normal nephrogenic
V2R in which acts as vasopressin syndrome of
receptors allows water to be more inappropriate
permeable in the collecting anti diuretic
tubules thus reabsorbed it back in hormone due
systemic circulation. If mutated to mutated
genes become defected, there is (V2R)
a constant signaling of the V2R receptors. As a
altering the function in maintaining result, there’s
homeostasis. As a result, a higher risk of
constant signal of this receptors inheriting this
despite low serum level lead to disease that
excessive water reabsorption and predisposed
hyponatremia. the patient to
develop
hyponatremia
secondary to
SIDH
secretion.
HISTORY OF  Low thyroid hormone secretion The patient
HYPOTHYROIDSM had a significant relationship of had history of
ADH level. If there’s a decrease in hypothyroidism
cardiac output due to and as a
inappropriate release of thyroid result, it
hormone which is responsible for predisposed

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 effective muscle and cell him to
functioning, any decrease in blood developing
volume induces the release of SIADH.
ADH. And we know that ADH
retains water in the blood causing
sodium and other electrolytes to
become more diluted. As a result,
free water excretion is affected
causing a decrease in serum
osmolality and decreasing sodium
level.

PRECIPITATING FACTOR

Factors Remarks Rationale Significance

 Excessive drinking of The total water

EXCESSIVE water cause blood to be more input of the
DRINKING OF diluted. Normally, a healthy patient exceed
WATER individual will excrete for about way beyond
800-2000 ml of water every day. what a normal
If the amount of water taken in healthy individual
the short period of time exceeds in a day can
way beyond what a normal urine excrete. This
output can a healthy individual means that the
excrete in a day, significantly blood is too
affect the homeostasis of the diluted and it
body. More water in the body means low
means the serum osmolality is sodium level
decreased. Serum osmolality is causing the
the concentration of solutes in the patient to
blood, decreased serum experience water
osmolality level means the diluted intoxication.
is more diluted. Water is too
much that it dilutes other solutes
such as sodium, calcium and etc.
in the blood. If excess water is in
the blood will lead to
hyponatremia also known as

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 water intoxication because of
decreased amount of sodium
level. Normally with
unconcentrated blood, it tends to
increase blood volume thus any
increase in blood volume signals
the hypothalamus to release ADH
in the blood to help excrete all
those excess water through
urination. But with SIADH, more
water is retained because more
water is reabsorbed in the
bloodstream causing urine
osmolality to increase.

SYMPTOMATHOLOGY
FACTORS RATIONALE SIGNIFICANCE
ACTUA
L
NAUSEA AND  Excess fluid due to too much The patient
VOMITING water in the blood increases the experience
chance of accumulation in the nausea and
gastro-intestinal tract, as a result vomiting as one
the abdomen swells and become of chief complain
distended increasing pressure on after more than 3
the adjacent organ causing hours of
nausea and vomiting. It may also overhydration.
due to the fact that the patient
experience cerebral edema,
increasing intracranial pressure
lead to nausea and vomiting.
TONIC  Excess fluid that accumulate in The brain
CONVULSION the brain cause cerebral edema, magnetic
increasing intracranial pressure resonance
will lead to brainstem shows high
compression and herniation intensity signal in
leading to seizure as symptoms the peri lateral
of severe hyponatremia due to ventricular region
water intoxication. therefore it is
evident that the
patient suffers
from brain
edema as a

13
 result, he suffers
neurologic
disturbances
such as seizures.
SLURRED  Affected left frontal lobe which is The patient has
SPEECH responsible for the language and slurred speech
speech control in the brain cause due to cerebral
poorly articulated words due to edema
the excess accumulation of water increasing
in the brain causing cerebral intracranial
edema. This increase pressure in pressure in the
the affected part of the brain affected part of
affecting the speech ability of the the brain.
person.
RESTLESSNESS  Too much water cause cell to The patient was
swell and lyse because it mostly restless due to
accumulates inside the cell in an his condition
attempt to maintain homeostasis
with low sodium. Cell that swell
can lead to restlessness, inability
to focus and etc.
CONFUSION  Same effect with neurologic The patient is
disturbances due to cerebral confused and
edema causes confusion. unoriented with
what was
happening in his
surroundings.
CONSCIOSNESS  Due to increased intracranial The patient was
DISTURBANCE pressure of the brain weak and
compressing the braincells and unresponsive to
tissues, affect the person’s surrounding and
consciousness. Also due to the making limited
small arteries are being basic reflex.
compressed with it, insufficient
oxygen supply is limited affecting
the level of consciousness of the
patient.

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 PATHOPHYSIOLOGY

PREDISPOSING FACTORS PRECIPITATING FACTORS

FAMILY HISTORY HYPOTHYROIDSM

OVERHYDRATION

Mutated gene of V2R Low thyroid hormone has Excessive drinking of 6 liters of water
receptors been linked in increase ADH in short amount of time will lead to
level more excess water in the blood

Since V2r receptor is

responsible for water With low cardiac output With too much water in the blood
absorption in the kidney, and low blood volume, due dilutes solutes and other
mutated gene will cause to hypothyroidism, it electrolytes in the blood
constant signaling of signals the hypothalamus
receptor leading to to produce more ADH thus
allowing more water to be Diluted blood decreases serum
excessive reabsorption of osmolality which means blood
water in systemic reabsorbed.
becomes unconcentrated but the
circulation urine osmolality is increased making it
more concentrated.

With too much water in the systemic circulation it increases blood volume. Increase blood volume and
decrease plasma osmolality will signal the brain to no longer produce ADH hormone. No ADH will be
secreted by the posterior pituitary gland in the circulation. The kidney then gets no ADH and will not
reabsorb water in the collecting tubules in the nephrons, thus, excess water will be excreted in the
urine. Osmotic balance in the body then is maintained.

With SIADH, there’s an inappropriate production of Anti-Diuretic Hormone, in the hypothalamus despite
the decrease in serum osmolality and an increase in blood volume. Therefore, the posterior pituitary
gland keeps on releasing ADH as a result, more water is reabsorbed in the kidney thus retaining excess
water in the blood. Too much water dilutes other electrolytes and solutes most importantly the sodium
which significantly dropping its level beyond normal.

Low sodium in the blood will cause water in extracellular space to move into intracellular space. Too
much accumulation of water in the cell will lead to swelling and bursting.

AFFECTED SYSTEM 15
There’s a possible swelling Pulmonary edema, SOB, low BP,
CARDIOVASCULAR in the cells and extra fluid arrythmia, tachypnea,
SYSTEM bradycardia, tachycardia
 There’s a possible Leg and hands edema,
MUSCUSKELETAL
swelling in the cells and muscle pain, muscle
SYSTEM
extra fluid cramps, muscle spasm,
fatigue, lack of energy

Cerebral edema, headache,

There’s a possible decrease level of
NEUROSYSTEM
swelling in the cells and consciousness, confusion,
extra fluid agitation, stupor, seizure,
coma, slurred speech, high
blood pressure.

GASTRO-INTESTINAL There’s a possible

N&V, weight gain,
SYSTEM swelling in the cells and
abdominal distension,
extra fluid
shortness of breath

DIAGNOSTIC EXAM: CBC (sodium level), Urine analysis (serum and osmolality),
Imaging test like MRI, Blood gas analysis, Urine biochemistry and renal function test,
Endocrinology

WATER INTOXICATION SECONDARY TO SYNDROME OF

INAPPROPRIATE ANTI-DIURETIC HORMONE SECRETION
IF TREATED IF NOT TREATED

MEDICAL NURSING COMPLICATION

MANAGEMENT MANANGEMENT

PULMONARY AND
Furosemide 1.) Excess fluid volume HEART CONGESTION
Dexamethasone 2.) Altered thought process BRAIN DAMAGE
Phenytoin 3.) Fluid and electrolyte DEATH
Lithium carbonate imbalance
Vasopressin 4.) Risk for injury
Ranitidine 5.) Risk for imbalance
nutrition less than body
requirement

16

GOOD PROGNOSIS
 PHYSICIAN ORDER SHEET

Patient name: PATIENT X B-day:01/20/1997 Room no.: 29a

Attending Physician: Dr. ENAL Allergies: None

Date/ Time Progress notes Order
NOVEMBER 22, 2022 Please admit under the service of Dr. ENAL (AP)
@ 3:00pm and Dr. CUBELO for co- management

Cleared by Dr. EMBA (IDS). Advised to be on

contact precaution, one watcher only; RT-PCR
BP: 140/90 mmHg result to follow
HR: 60 bpm
RR: 22 bpm
T: 36.8 °C Secure consent to care
O2 sat: 94%

(+) nausea and vomiting

(+) slurred speech Strick I and O monitoring with fluid restriction to
(+) tonic convulsion 500ml/day
(+) restlessness
(+) confusion VSq2 then q2 after 24hrs, I/O q shift
(+) consciousness disturbance

(+) history of hypothyroidism Monitor episodes of frequent episode of tonic

convulsions
Na: 120 mmol/l

Place on protective environment

Weigh daily

Refer to ICU if symptoms worsen/episodes of deep

state of unconsciousness.

17
 IVF: 0.9 NS 1L @400cc/hr.
O2: Oxygen saturation of 2 L/minutes
Labs: Relay results once in

CHEST PA
CBC,
Blood chemistry test
CBG now
UA
BLOOD GAS ANALYSIS
ENDOCRINOLOGY TEST
URINE BIOCHEMESTRY AND RENAL
FUNCTION
MRI (brain)

Conferred with Dr.ENAL– to see patient later

Start:
Furosemide 40 gm IVTT now, then BID

Dexamethasone 6.6 mg IVTT OD

Phenytoin IV 15mg/ml (slow) for 50mg/min THEN

and 100mg q 8 * PRN

Lithium carbonate 300 mg PO TID (slow release)

Vasopressin antagonist (tolvaptan) 15 mg PO OD.

Then 30mg) OD for the next 24 hours
NOVEMBER 22, 2021
Ranitidine hydrochloride 150 mg PO B.I.D

Urea 40g/150 ml IVTT

Please facilitate MRI of the brain

Encourage to limit fluid intake

Regularly turn/reposition q 2hrs

Monitor VS closely

Watch out for signs of pulmonary and heart

NOVEMBER 23, 2021
congestion
@ 3:00 pm
Limit visitors
18
 Rounds with Dr. Enal

Cont. Vital signs monitoring

Cont. Limit fluid intake to 500mg/day

Encourage increase dietary intake rich in protein

and sodium

On a strict I and O monitoring

DIAGNOSTIC EXAM

FIGURE1: Changes in the laboratory data and clinical signs of a 25-year-old male who drank

approximately 6 liters of water over a 3-hour period

19
FINDINGS: high-intensity signals in the peri lateral ventricular region and brain
white matter consistent with the development of brain edema 

Laboratory findings on admission

DATE TEST NORMAPATIENT CLINICAL NURSING

L VALUE
RESULTS SIGNIFICANCE RESPONSIBILITIES
NOVEMBER Physician have Encourage to avoid
22,2022 at their baseline stress if possible
3:00 P.M. on possible because altered
PERIPHERAL BLOOD CELL medication or physiologic status
COUNT treatment for influence and
White blood 4.8-11.0 13,700 the patient changes normal
cell count / illness as hematologic values
ul evidence by the
Red blood 4.5-6.1 450 laboratory
cell count, showing that
104 / ul peripheral blood
Hemoglobin, 14-18 14.1 count is on
g/dl normal range
Hematocrit, 42.52 41.6
%
Platelets, x 150-450 19.0
104 / ul

DAT TEST NORMA PATIENT CLINICAL NURSING

E L VALUE RESULT SIGNIFICANC RESPONSIBILITIE
S E S
NOVEMBER 22,2022 at 3:00 P.M. This kind of test Safe keep the
BLOOD CHEMISTRY also gives the documents for future
Total protien 6.0-8.3 7.8 physician an references of for
g/dl insight on client medication
Albumin,g/dl 3.4-5.4 5.1 condition for concerns.
Blood urea 6-24 11 treating the
nitrogen,mg/dl illness and also Tell the patient to
Creatinine, 0.74-1.35 0.65 measure other eat healthy foods
mg/dl substance that
Uric acid, mg/dl 3.5-7.2 2.2 help show how Tell the patient to be
Soduim, mmol/l 136-145 120 well the kidneys more active like a
Potassium, 3.6-5.2 4.2 are working and combination of
mmol/l how well the moderate and
Chloride,mmol/ 95-105 83 body is vigorous exercise.
l absorbing.
Take medication as
Calcuim, mg/dl 8.5-102 9.9
In the evidence needed.
Triglyceride, 150 36
shown the FBS
mg/dl
is above the
Total 200-239 207 normal value
cholesterol,

20
 mg/dl and it indicates
Fasting blood 99 121 that he/she
sugar, mg/dl have
C-reactive 0.3-1.0 0.6 prediabetes
protien, mg/dl

DATE TEST NORMAL PATIENT CLINICAL NURSING

VALUE RESULTS SIGNIFICANCE RESPONSIBILITIES
NOVEMBER 22,2022 at 3:00 P.M. It is used to Collect and label
URINALYSIS detect and specimen for analysis
Specific 1.000- 1.007 manage a wide and to ensure their
Gravity 1.060 range of delivery to the lab.
pH 7.35-7.45 6.2 disorders, such
Protein 4.5-8.0 - as urinary tract
Sugar 99 - infections,
Red blood 4 0-1 kidney and
cells count/ diabetes.
HPF
White 2-5 0-1
blood cell
count/HPF

DATE TEST NORMA PATIENT CLINICAL NURSING

L RESULTS SIGNIFICANCE RESPONSIBILITI
VALUE ES
NOVEMBER 22,2022 at 3:00 P.M. The doctor may ask for Keep the patient
BLOOD GAS ANALYSIS (ROOM an arterial blood gas warm and dry.
AIR) test to: check for severe Encourage the
pH 7.35- 7.502 breathing and lung patient to deep
7.45 problem such as slow breathe into
pCO2,m 35-45 25.6 asthma, etc, a brown paper
m HG bag. Monitor the
PO2, 75-100 100.8 vital signs
mm HG
HCO3, 22-26 20.2
mmol/l

DATE TEST NORMAL PATIENT CLINICAL NURSING

VALUE RESULTS SIGNIFICANC RESPONSIBILITIES
E
NOVEMBER 22,2022 at 3:00 P.M. This kind of test Tell the patient to
ENDOCRINOLOGY shows the limiting salt taking
ADH, pg/ ml 0.9-4.6 6.4 plasma medicine and taking
Plasma renin 06-4.3 <0.1(0.3- aldosterone is medicine may
activity, 5.4) on above the control symptoms
ng/ml/h normal value it without surgery.
Plasma 3-28 59 (30-159) leads to fluid

21
 aldosterone, retention and
pg/ml increase blood
Plasma 5-25 32.6 pressure,
cortisol, ug/ dl wakness and
TSH, uIU/ml 0.5-5 0.59 period of
Free T4, ng /dl 0.9-2.3 1.07 paralysis

DATE TEST NORMAL PATIENT CLINICAL NURSING

VALUE RESULTS SIGNIFICANC RESPONSIBILITIES
E
NOVEMBER 22,2022 at 3:00 P.M. The urine Tell the client to
URINE BIOCHEMISTRY AND RENAL biochemistry driink 2 to 3 L of fluid
FUNCTION and renal daily to report any
Creatine, mg/dl 53 26.7 function shows decrease in urine
Urea nitrogen, 6-24 12-20 that the Uric output.
mg/dl acid is above
Uric acid, mg/dl 3.5-7.2 2.7-5.4 the normal level Teach the client
Sodium, mmol/l 65 40-220 about dietary
Potassium,mmol/ 15-20 15.7 This test can modification to limit
l have an foods high in purine.
Chloride, mmol/l 96-106 52 important
Creatine 88-128 88.4 adjuvant role in
clearance, ml/min the diagnosis
and evaluation
Urine Osmolality, 50-1200 305
of a number of
mosm/kg H2O
clinical
Plasma 275-295 247
problems
osmolality, mosm
/ kg H2O
TcH2O, ml/ min 1.73 1.73
(Free water 1.73 -1.73)
clearance, ml/min
FENa, % 1 1.32
FEUA, % - 20.0

22
DRUG STUDY
DRUG NAME INDICATION CONTRAIN ADVERSE NURSING
DICATION EFFECTS RESPONSIBILITIES
Generic Lithium Lithium is Headache. - Establish rapport
names: carbonate is not Nausea or and get patient trust
lithium indicated in the recommende vomiting. upon giving
carbonate treatment of d in patients Diarrhea. medication
manic episodes with renal Rationale: to prevent
Brand name: of Bipolar impairment. Dizziness awkwardness and
Lithium Disorder. It is also not or enhance compliance
Carbonate Bipolar recommende drowsiness in taking medication
Tablets Disorder, Manic d in patients Changes in
(DSM-IV) is with appetite. - Monitor for S&S of
Classifications: equivalent to cardiovascul Hand lithium toxicity (e.g.,
Antimanic Manic ar disease. tremors. vomiting, diarrhea,
Agents Depressive Lithium lack of coordination,
Dry mouth.
illness, Manic, causes drowsiness,
Route/ Increased muscular weakness,
in the older reversible T
frequency thirst. slurred speech when
DSM-II wave
Oral Route level is 1.5–2.0
terminology. changes and
300mg mEq/L; ataxia,
Lithium can unmask
450mg blurred vision,
carbonate is Brugada
also indicated syndrome. A giddiness, tinnitus,
as a cardiology muscle twitching,
maintenance consult is coarse tremors,
treatment for necessary if polyuria when >2.0
individuals with a patient mEq/L).
a diagnosis of experiences Rationale: To be
Bipolar unexplained able to know any
Disorder. palpitations occurrence of
Maintenance and adverse effect thus
therapy syncope. reducing risk of more
reduces the fatal complication to
frequency of arise
manic episodes
and diminishes * For any occurrence
the intensity of of lithium toxicity,
those episodes withhold one dose
which may and immediately call
occur. physician. Drug
should not be
stopped abruptly.

23
 Rationale: To be
able to limit
occurrence of serious
complications and so
that doctor will adjust
this said medication
for safety

- Instruct patient to
not chew medication
as this is extended
release
Rationale: Chewing
this medication will
cause stomach upset

-Advice the patient to

not take any
beverages containing
caffeine
Rationale: caffeine
containing beverages
is contraindicated
with this medication
as it interferes with
drug action

Drug name Mechani Indication Contraindi Adverse Nursing

sm of cation effect Responsibilities
Action
-Inhibits - Contraindic nausea or -Check doctor's
reabsorpti Furosemid ated with vomiting, order.
on of e is allergy to stomach R: to make sure
sodium indicated furosemide, cramping, if it is right
and for the sulphonami feeling like patient and right
chloride treatment des, allergy you or the medication.
from the of edema to room is
proximal associate tartrazine, spinning, -Assess allergy
and distal d with anuria, dizziness, to furosemide,
tubules congestiv severe blurred sulfonamides,
Brand name: and e heart renal vision, tartrazine.
Lasix ascendin failure, failure; itching or R: To support
Generic g limb of cirrhosis hepatic rash, early recognition
name: the loop of the coma; increased and treatment of

24
Furosemide of Henle, liver, and pregnancy; urination, symptoms of
Dosage: leading to renal lactation feeling of drug allergy to
40mg/ml a sodium- disease, thirst, improve patient
Classification: rich including weakness, outcomes and to
Loop dieresis. the drowsines ensure adverse
Diuretics nephrotic s, drug reactions
Route: syndrome, restlessne are reported
IVTT in adults ss, appropriately.
and muscle
pediatric pains or -Check the
patients. cramps, patency of the IV
urinating site and IV line.
less, R: Check IV
fast or insertion site for
abnormal signs and
heartbeat, symptoms of
severe phlebitis or
nausea or infection. Check
vomiting for fluid leaking,
redness, pain,
tenderness, and
swelling.

-Administer the
right dose at the
right time.
R: To avoid any
complication in
giving the
medication.

-Measure and
record weight to
monitor fluid
changes.
R: to know if the
fluid intake and
output is
increase or
decrease

-Monitor blood
glucose levels
R: It can help
you to monitor
the effect of
diabetes

25
 medications on
blood sugar
levels. Identify
blood sugar
levels that are
high or low.

-Arrange to
monitor serum
electrolytes,
hydration, liver
and renal
function.
R: to find out if
your body has a
fluid imbalance
or an imbalance
in acid and base
levels.

-document and
record
R: promotes
patient safety
and quality of
care.

DRUG ACTION INDICATI CONTRAI ADVERSE NURSING

NAME ON NDICATIO EFFECTS RESPONSIBILITIES
N
Tolvaptan is an Concomita -Monitor signs of
is a aquaretic nt use of Nausea, nausea and
competitiv drug that strong Thirst, vomiting, fatigue,
e functions CYP3A Dry mouth, diarrhea and etc.
antagonis as a inhibitors Pollakiuria, R: to serve as
t at selective, Hypersensi Urinary baseline data in
vasopres competitiv tivity (eg, frequency/ determining any
sin V2 e anaphylacti output abnormalities and
receptors. vasopres c shock, increased, occurrence of
Its major sin generalize Increased adverse reaction
Brand action is receptor 2 d rash) urination,
Name: in the antagonis Anuria Fatigue, - Advice to report
Samsca, renal t used to Inability of Diarrhea, these signs to the
Jynarque collecting treat patient to Dizziness, physician
ducts to hyponatre sense or GI immediately
Generic reduce mia appropriate bleeding R: to prevent

26
Name(S): water associate ly respond with situation from
Tolvaptan reabsorpti d with to thirst preexisting worsening
on and congestiv Hypovolem cirrhosis,
Classificat produce e heart ic Weakness, -Monitor signs of
ions: aquaresis failure, hyponatre Constipatio allergic reactions
Vasopressi without cirrhosis, mia n, and anaphylaxis,
n sodium and the . Hyperglyce including pulmonary
antagonist loss, thus syndrome mia, symptoms
increasin of Anorexia, (laryngeal edema,
Route/ g free inappropri Pyrexia, wheezing, cough,
Dosage: water ate dyspnea) or skin
15 mg PO clearance antidiureti reactions (rash,
OD. Then and c pruritus, urticaria).
30mg) OD correcting hormone R: to be able to
for the next dilutional prevent any
24 hours hyponatra occurrence of
emia. adverse reaction
that delay
improvement of
health status

- monitor signs for

right upper
abdominal
discomfort, dark
urine or jaundice
should discontinue
treatment
R: to prevent any
worsening of
situation as this
indicate liver injury
for the
discontinuation of
treatment.

* Encourage to
notify physician
immediately if these
reactions occur.
R: To prevent this
from happening as
this require
immediate medical
attention

27
Drug name Mechanis Indication Contraindi Adverse Nursing
m of cation reaction Responsibilities
Action
- It It is indicated Contraindic Cns: * Monitor vital
thought to for the ated with headache, signs
limit management allergy to fatigue, R: To serve as
seizure of status phenytoin dizziness, baseline data in
activity by epilepticus content, weakness, determining any
promoting and as well hypersensi ataxia, occurrence of
sodium as tivity to the insomnia, symptoms
effuse generalized drug, sinus twitching, related to
from tonic-clonic bradycardi nervousness adverse reaction
neurons in and complex a, CV:
Brand motor partial sinoatrial Vasodilation, *Advice the
name: cortex and seizures. block, edema, chest patient to notify
Dilatin reducing second- or pain, physicians if any
activity in third- tachycardia, signs and
Generic brainstem degree hypotension symptoms of
name: s centers atrioventric EENT: adverse reaction
Phenytoin responsibl ular block, diplopia, eye is felt
e for tonic Adams pain,
Dosage: -clonic stroke photophobia, R: To be able to
15mg/ml seizures. syndrome sinusitis, provide
(slow) for rhinitis, adjustment when
50mg/min pharyngitis, it comes to the
THEN and GI: nausea dosage and
100mg q 8 and vomiting, administration to
diarrhea, prevent situation
Classificati from worsening
constipation,
on: .
dry mouth
Anticonvuls * Closely monitor
GU: pink
ant liver and kidney
urine or
reddish function test
Route: even the CBC
IVTT brown
R: To monitor
whether there is
any abnormality
that might cause
severe damaging
effect

*Inform patient
that this drug can
make your urine
become
discolored and
that its normal

28
 R: To enhance
patient
understanding
and relieve
anxiety

* Instruct the
patient to
practice dental
and oral care
R: to prevent
occurrence of
gingival
hyperplasia

* caution the
patient to not
stop the drug
therapy abruptly
without doctor’s
approval
R: stopping
medication
abruptly might
cause severe
adverse effect
and complication

*Caution to
patient not to
take any
beverages
containing
alcohol
R: alcohol can
interact with
medication
causing
interruption in its
therapeutic
action.

Drug name Mechanis Indication Contrain Adverse Nursing

m of dication reaction Responsibilities

29
 Action
- increase This osmotic Contraindi CNS: * Monitor vital
osmotic diuretic cated with headache, signs
pressure medication is allergy to fatigue, R: To serve as
of indicated for urea dizziness, baseline data in
glomerula the content, weakness, determining any
r filtrate, treatment of hypersens agitation, occurrence of
inhibits hyponatremi itivity to nervousness symptoms related
tubular a and for the the drug, drowsiness to adverse
reabsorpti increase several CV: capillary reaction
on of intracranial renal bleeding,
water and pressure or impairmen cardiotoxicity * Check the label
electrolyte intraocular ts, marked Tachycardia, and dosage.
and pressure. dehydratio hypotension R: To properly
elevates n, active GI: nausea administer
Brand plasma intracrania and medications and
name: osmolality l bleeding, vomiting, prevent medication
Ure-na , hepatic GU: oliguria error
increasing failure, Metabolic:
Generic water infusion hypervolemi * Instruct patient to
name: influx into into lower a notify physician for
Urea cellular leg in Skin: any bothersome or
fluid elderly irritation or prolonged side
Dosage patient necrotic effects
and sloughing R: to be able to
frequency: with prevent any
40g/150 ml extravasatio worsening of signs
IVTT n and symptoms of
Other: pain, adverse reaction.
Classificati thrombosis,
on: * Explain the drug
chemical
Osmotic therapy to the
phlebitis,
diuretic patient
hypothermia,
R: to promote
infection at
Route: knowledge and
injection site
IVTT understanding
about medication
and promote
active participation
in medicine
administration

* Ensure proper
intake and output
is accurately
measured
R: to know

30
 whether the drug’s
therapeutic action
had already taken
effect. Also, to
know the hydration
status of the
patient to prevent
dehydration

* Instruct the
patient that this
medication may
affect many body
systems therefore
it is necessary to
immediately report
symptoms such as
headache or
confusion
R: any occurrence
of signs and
symptoms of this
drug should be
known
immediately so
considerations will
be made

*Perform the rights

in administering
medication
R: to ensure
patient
understanding and
compliance thus
reducing error.

SURGICAL PROCEDURE
There is no intended surgical procedure for the treatment of water intoxication
secondary to SIADH because it can be managed with appropriate medication and
nursing management ensuring fluid restriction, proper I and O monitoring, diuretics,
anticonvulsant and anti-inflammatory drug management.
NURSING THEORY

31
Theorist Theory
Virginia Virginia Henderson developed
Henderson the Nursing Need Theory to
define the unique focus of
nursing practice. The theory
focuses on the importance of
increasing the patient's
independence to hasten their
progress in the hospital.
Henderson's theory
emphasizes the basic human
needs and how nurses can
meet those needs.
Florence Environmental Theory “The
Nightingale act of utilizing the environment
of the patient to assist him in
his recovery.” It involves the
nurse’s initiative to configure
environmental settings
appropriate for the gradual
restoration of the patient’s
health, and that external factor
associated with the patient’s
surroundings affect life or
biologic and physiologic
processes, and his
development.
IDA JEAN This theory emphasized the
ORLANDO reciprocal relationship
between
patient and nurse and viewed
nursing’s professional function
as finding out and meeting the
patient’s immediate need for
help. Her theory allows nurses
to
create an effective nursing
care
plan that can also be easily
adapted when and if any
complications arise with the
32
Application to the case
The nursing needs theory is
applicable in our case because as
a nurse we need to provide the
needs of our clients and care for
patients until they can care for
themselves once again.
This is applicable to our patient
because, we, the student nurses
as well as the staff nurse shall
provide a good and clean
environment so that the patient
will have a good stay in the
hospital while treating the illness.
This is also applicable to our
patient because as a nurse we
need to practice the cleanliness to
provide a good and clean
environmental for the patient
safety and recovery
This theory is applicable to our
patient because as a nurse we
need to build relationship in our
patient to approach their need
or compliant, because a patient
cannot state the nature and
meaning of his or her distress
without the nurses help or him
or her first having established a
helpful.
 patient.

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Evaluation
Subjective: Fluid volume Within 8 INDEPENDENT Goal partially
‘’Nakainon excess related hours of met.
sya ng to water nursing * Monitor Input and After 8 hours
maraming tubig intoxication intervention output of nursing
biilang parusa secondary to the patient’s appropriately intervention,
sa laro nila SIADH as fluid volume R: the patient’s
kanina” as evidenced by will be To know the fluid volume
verbalized by restlessness. stabilized as amount of the extra was
significant consciousness evidenced by fluid is un the body stabilized as
other. disturbance increased through exertion evidenced by
and level of increased
Objective: decreased serum * Strictly monitor level of
*Restlessness sodium level. concentration intake and output serum
*Consciousnes for about 135 of the patient concentration
s disturbance Rationale: mol/l and R: To prevent any for about 125
with a Glasgow Water vital signs further mol/l and
coma scale of intoxication will be complications of vital signs
12 due to SIADH maintained hyponatremia will be
* Decreased will lead to within normal associated to more maintained
sodium excess range of electrolyte within normal
concentration in reabsorption 120/80 imbalances and to range of
the blood of of water in the mmHg. know the amount of 130/90
120 mol/l kidney back in urine excreted in a mmHg.
* Nausea and the circulation day to evaluate
vomiting as a result, whether his
* Abdominal plasma situation was
distention osmolality is improving
decreased
causing * Encourage for
V/S taken as patient to high sodium and
follows: experience protein diet.
T:36.8°C decreased R:
P:60bpm sodium level, Sodium in a diet
R:22bpm restlessness favors renal
BP: and excretion of excess
140/90mmHg consciousness fluid thus protein
O2 sat: 94% disturbance helps muscle
regeneration from
cell damage

*Monitor and

33
 record the patients’
blood pressure and
heart regularly.
R:
To help prevent
occurrence of
pulmonary
congestion as one
serios complication
of hyponatremia

* Educate the pt.

And the family
about the medical
condition by
explaining the
cause, signs and
symptoms, and
management.
R:
Having knowledge
will allow the pt.
and the family to
fully understand the
treatment plan and
will be able to
participate in
resolving the case.

* Encourage to
take medication as
order by doctor.
(Ex. Diuretics)
R:
Diuretics aids in the
excretion of
excess body fluids.

* Ensure to stick to
a limited fluid
intake of 500ml of
water in a day as
indicated
R: Fluid restriction
is essential to
prevent further
ingestion of water

34
 leading to more
lower sodium level

* Encourage a
complete bed rest
R: To promote
relaxation and limit
too much exertion
of effort

DEPENDENT:
* Administer
medications as
prescribed such as
urea and
furosemide as
prescribed by
physician
R: this medication
is essential to
induce water loss
through excretion.

Assessment Diagnosis Planning Intervention Evaluation

Subjective Electrolyte Within 6-8 Independent: After 6-8
data: Imbalance hours of - Frequently monitor hours of
"Pirme na (Hyponatremia) nursing serum electrolyte levels. nursing
lang man ko related to water intervention R: The levels of intervention
maluya intoxication the client electrolytes in the body the goal was
ma'am murag secondary to will display can become too low or partially met.
walay kusog SIADH heart rate, too high. Early detection The patient
akong mga as evidenced by blood of abnormality in serum was able to
kalawasan" confusion, pressure electrolyte levels allows display heart
as verbalized muscle and prompt initiation of rate and
by the weakness and laboratory measures to prevent laboratory
patient. restlessness results further imbalances. results
Objective within the within
data: normal limit -Monitor respiratory rate normal limit
-Muscle Rationalization with and depth. for the client
weakness : absence of R: Co-occurring as
- An electrolyte muscle hypochloremia may evidenced
Restlessness imbalance weakness; produce slow and by HR:89
and irritability occurs when and shallow respiration as bpm, blood
-Confusion you have too neurological the body compensates pressure is
unoriented to much or not irritability. for metabolic alkalosis. partially
surrounding enough of decreased

35
and stimuli certain minerals -Monitor intake and to 130/100
in your body. output; Calculate fluid and there is
V/S: This imbalance balance. Weigh client absence of
BP: 140/90 may be a sign of daily. muscle
mmHg a problem like R: Fluid balance weakness;
HR: 60 bpm kidney disease. indicators are important and
RR: 22 bpm Electrolytes are since either fluid excess improved
Temp.: 36.8 minerals that or deficit may occur with neurological
°C give off an hyponatremia condition.
O2 sat: 94% electrical charge - Provide a quite and
when they peaceful environment to
dissolve in fluids improve consciousness
like blood and and neuromuscular
urine that’s why response.
the body will R: A deficit in sodium
experience levels may lead in
confusion, decreased mentation to
muscle coma, as well as
weakness and generalized muscle
restlessness weakness, cramps, or
convulsions.

-Encourage fluids and

foods high in sodium
such as meat, milk,
beets, celery, eggs, and
carrots.
R: Unless sodium
deficit causes serious
symptoms requiring
immediate IV
replacement, the client
may benefit from slower
replacement by oral
method or removal of
previous salt restriction.
-Provide or restrict
fluids, depending on
fluid volume status and
as prescribed by the
doctor
R: In the presence of
fluid excess or SIADH,
fluid restriction is
indicated while in the
presence of
hypovolemia, volume
36
 losses are replaced with
isotonic saline, or, on
occasion, hypertonic
solution when
hyponatremia is life-
threatening

Dependent:
-Administer Furosemide
(Lasix).
R: Useful in reducing
fluid excess to correct
sodium and water
balance.
-Call the doctor if there
is any problem with the
medication so that it will
not be worsen.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Activity Within 8 hours Independent: Goal met.

“Wala akong intolerance of nursing - Established After 4 hours of
lakas gumalaw with a intervention report to the nursing
man lang dahil functional the patient will family during intervention,
nananakit at level be able to rounds the patient was
nanghihina ang classification
demonstrate Rationale: able to
aking of IV relateddecrease in For better demonstrate
kalamnan” as to muscle physiological compliance and decrease in
verbalized by weakness signs of patient physiological
the patient secondary to intolerance by understanding signs of
SIADH as maintain the intolerance by
Objective data: evidenced respiration, * Provide peace maintain the
- Shortness of by muscle oxygen and respiration,
breath weakness, saturation and balance activity oxygen
- Deep and fatigue and blood with periods of saturation and
labored shortness of pressure rest; allow for un blood pressure
respiration breath within the interrupted within the
- muscle normal range sleep. normal range of
weakness Rationale: of 18 bpm. Rationale: To 18 bpm. 120/80
- fatigue With water 120/80 mmHg better promote mmHg and
- decrease level intoxication and 98% relaxation and rest 98%
of secondary to respectively. to help easily respectively.
consciousness SIADH there regain energy back.
is muscle

37
Vital signs: weakness - Assist in a range
BP: 140/90 and fatigue of motion exercise
mmHg due to cell and excretion of
HR: 60 bpm swelling as a minimal effort such
RR: 22 bpm result, as walking a few
Temp.: 36.8 °C patient will steps with rest in
O2 sat: 94% not able to between and the
complete the opportunity to
desired sit down as
activity tolerated by the
patient.
Rationale: to
improve muscle
strength, mood and
energy

* Provide relaxation
technique such as
deep breathing
exercises
Rationale: to help
improve the
breathing pattern of
the patient

* Encourage to
practice healthy
eating habits rich in
protein, salt and
other nutrients
Rationale: to help
improve the
general status of
the patient as
nutrient such as
protein improve
muscle strength
and healing.

Dependent:

* Administer
medication as
prescribed by
physician

Rationale: to help

38
 manage the
disease and
improve the status
of the patient for
easy recovery

* Administer
oxygen therapy
regulated in an
accurate way as
indicated by the
doctor
Rationale:
Oxygenation supply
is necessary to
help improve
oxygen level in the
blood thus helps
with improving the
heart rate,
breathing and even
fatigue

Assessment Diagnosis Planning Intervention Evaluation

SUBJECTIVE Risk for injury Within 8 hours INDEPENDENT Goal Met.
DATA: related to of nursing : -Provide
changes in intervention, assistive After 8 hours
"Hindi na ako physiological the patient will devices for of nursing
makakilos state within CNS be free from walking such as intervention,
masyado secondary to injury and cane, crutches the patient was
ma'am SIADH as modify and wheelchair free from injury
nanghihina na evidence by environment to for the patient and modify
katawan ko" as enhance support to environment to
verbalized by Rationale: safety. move. enhance
the patient. With SIADH due R: To enhance safety
to overhydration safety and free
OBJECTIVE excess fluid will of injury
DATA: accumulate in
the brain causing -Instruct the
- Decrease cerebral edema. patient to ask
level of And if it for help when
consciousness accumulated in needed to
- Confusion the cell, it will prevent from
- Electrolyte cause to swell falling on bed.
imbalance

39
such as low and lyse. Due to R: To aid in
sodium in the this, increase doing activities
blood of 120 intracranial and will limit risk
mmol/l pressure lead to of accidents
- Muscle decrease level of
weakness consciousness, -Ask the
-Decreased confusion and significant
strength in confusion. For others to stay
lower affected cells in with the patient
extremities the muscle always.
cause muscle R: To closely
weakness. If this watch the
Vital signs are persist, it patient to
as follows: predisposes the ensure safety at
patient to be all times and
BP: 140/90 susceptible/pron also emotional
mmHg e to accidents, and physical
HR: 60 bpm injury and fall. support with
RR: 22 bpm love once can
Temp.: 36.8 °C improve the
O2 sat: 94% health status
easily

- Advice patient
for a complete
bed rest
R: to have
adequate rest
necessary to
regain energy

- Provide safety
precautions
ensuring safety
such as raise
side rails and
avoid scattered
rugs
R: To prevent
chances of
getting accident
from
accidentally
falling

- Keep the

40
 personal
possessions
within safe
reach
R: To prevent
reaching out of
objects that can
potentially
contribute to
falls.

- Ensure that
there’s
adequate room
lighting
especially at
night
R: To help
increase
visibility of the
patient in case
of reaching out
objects to
reduce chances
of falling.

DEPENDENT:
- Administer
medications
such as
Dexamethasone
to the patient
appropriately
according to
doctor’s order
R: to treat
cerebral edema
and any form of
inflammation of
the brain due to
excess water in
order to improve
physiological
status of the
patient
ASSESSMEN DIAGNOSIS PLANNING INTERVENTIO EVALUATION
T N

41
Subjective: Risk for Within 8 hours Independent: Goal partially
“Pagkatapos Imbalanced of nursing - Monitor the Met:
nya pong nutrition less intervention daily weight of After 8 hours
uminom ng than body the the patient of nursing
maraming requirements patient will be Rationale: intervention
tubig ay related able to display To know the patient
nagsusuka na electrolyte normalization significant displayed not
po siya” imbalances of laboratory increase of normalization
as verbalized secondary to result as decrease in of laboratory
by the SIADH as evidenced by weight as result as
significant evidenced by increased indicative of evidenced by
other muscle serum sodium imbalanced increased
weakness, level of nutrition serum sodium
Objective: fatigue and 135mmol/l, level of
- severe nausea and urine chloride - Explain to the 125mmol/l,
hyponatremia vomiting level of patient the urine chloride
with low level 100mmol/l and relation of level of
of sodium of Rationale: Due free symptoms SIADH to 85mmol/l. But
120mmol/l to the disease of malnutrition nausea and the patient
- electrolyte process of water symptoms vomiting and displayed free
imbalance with intoxication such as loss of appetite symptoms of
low level of secondary to improved Rationale: malnutrition
chloride of SIADH result to appetite, level - To help the symptoms
52mmol/l muscle of patients such as
-fatigue weakness, consciousness understand why improved
-muscle fatigue and , and absence nausea and appetite, level
weakness nausea and of muscle vomiting of
- loss of vomiting. This weakness and. associated with consciousness
appetite contributes to the loss of appetite , and absence
- decreased loss of appetite is one of the of muscle
level of and electrolyte signs of SIADH. weakness and
consciousness imbalances
increasing the - Create a daily
Vital sign risk of imbalance weight chart and
taken: nutrition less a food and fluid
T: 36.8 °C than body chart.
RR:22 cpm requirements Rationale
PR: 60 bpm - To effectively
BP: monitory the
140/90mmHg patient’s daily
SPO2: 95% nutritional intake

-Help the patient

to select
appropriate
dietary choices
to follow a high

42
 caloric diet.
Rationale
- To increases
the caloric
intake of the
patient that can
be used by the
body to increase
energy levels
and be able to
perform ADLs.

- Advice patient
to increase
protein and salt
diet
Rationale: to
help regain
normal serum
sodium level
and for better
energy and
muscle healing

* Encourage a
full bed rest and
as well as
position patient
in a semi
fowler’s position
or desired
position of the
patient
Rationale:
To promote
better relaxation

-Refer the
patient to the
dietitian.
Rationale
-To provide a
more
specialized care
for the patient in
terms of
nutrition and

43
 diet in relation to
newly
diagnosed
SIADH.

Dependent:
* Administer
medications as
prescribed
Rationale:
For easy
recovery of
illness and
prevent
nutritional
imbalance

* Administer O2
therapy as
prescribed
Rationale: O2
therapy is
essential
improving
fatiguability

Collaborative:

- Refer the
patient to the
dietitian.
Rationale:
-To provide a
more
specialized care
for the patient in
terms of
nutrition and
diet in relation to
newly
diagnosed
SIADH.

44
DISCHARGE PLAN (M.E.T.H.O.D.S)

Medication Exercise/ Treatme Health Out- Diet Spiritualit

Environme nt Teachin Patient y
nt g
- Discharged -Provide a -Discuss -Limit -Be -Limiting
medications comfortabl to the fluid sure to water - Advice
such as e and patient intake attend intake, tea, to have
continuation clean about the every all coffee, fate in
drugs as per room. It will importan day as appoint juices and yourself
doctor’s order help the ce of the doctors’ ment or other liquids to
like patient to medicati advice check- that are strengthe
furosemide, relax and on and ups. mostly n
ranitidine, stress free. treatment - Teach - water is emotiona
dexamethason done to patient Remind essential.
- Advice of any l, spiritual
e must be her. the and
taken exactly patient that electroly patient -Encourage
exercise is te fluids and mental
as directed. and health
essential -Advise conservi signific foods high
- Advice for better ng in sodium necessar
the ant y to have
patient to not recovery patient to techniqu others such as
missed a but if he es such meat, milk, positive
take about outlook in
single dose of feels thirsty treatment as the beets,
medication as he must like for
seriously increase importa celery,
easy
this can delay include so that it salt nce in eggs, and
progress. drinking intake if carrots. Use recovery.
will not health -
fluids lead to suspect promoti fruit juices
-Make sure to containing complicat ed for and bouillon Encourag
on e the
follow the salt and ions. hyponat activitie instead of
exact time, electrolyte remia water. patient to
s, strengthe
-Call a
45
dose, route healthcar includin n herself
and medication -Provide e - Teach g health by
to take as safety and provider patient screeni praying
prescribed to seizure if there is to ng. and
avoid any precaution any recogniz asking
complications. s. Maintain unconditi e signs God to
a calm, onal and cure and
-Advise not to quiet happens sympto overcom
take non- environme to you ms of e what
prescribed nt it like hyponat she
medication decreases severe remia to experien
because taking CNS tiredness enhanc cing.
medication that stimulation , e
is not and risk of seizures, underst
prescribed by injury from muscle anding
the physician neurologic spasm, and be
can worsen the al cramping more
condition of the complicatio , or knowled
patient and it ns such as twitching. geable
can cause seizures. on what
complication - Advice actions
and overdose. patient to to take
stick to in case
-Encourage follow up of water
patient to drink schedule intoxicat
this medication and ion
with water but consultati
educate further on
to not
overhydrate -
Encoura
- Ensure ge often
patient sodium
understanding level
about the checked
adverse as to
reaction of this prevent
drug and to electrolyt
consult doctors e
if symptoms imbalanc
persist es since
medicati
ons
encourag
e
diuresis

46
 PPROGNOSIS

Acute water intoxication secondary to SIADH is a medical emergency that need

immediate medical attention and assessment to prevent sever neurological damage.
Several sties had proven that it is associated to mortality if not treated immediately
therefore, a treatment for hyponatremia due to SIADH is essential to promote patient’s
wellbeing and to lessen the risk of serious complications. Accurate diagnosis of SIADH
and the differentiation from other causes of hyponatremia is the first essential step in
determining appropriate treatment. Rapid examination and diagnosis are critical in the
treatment of acute moderate to severe hypotonic hyponatremia in order to avoid illness
progression. It is possible to safely begin correction of low serum sodium concentrations
in the symptomatic ED patient and avoid the potentially life-threatening and irreversible
neurologic sequelae of overcorrection (Rizzuto, 2021).
It is believed that the prognosis of SIADH is reversible or can be cured depends
on that is the cause of it (Cleveland Clinic, 2022). In this case the factors involve are
predisposing and precipitating factors. Predisposing factors are those indirectly cause
SIDH such as hypothyroidism which is believed to associated to increase level of ADH
and family history that includes defected gene of vasopressin 2 receptor. Precipitating
factors that directly cause the disease process to occur is overhydration in a short
period of time. Medication can help treat the disease as prescribed by the doctor.
Nursing and medical management had played a huge role in maintaining the electrolyte

47
balance in the body and as well as treating the symptoms such as cerebral edema,
muscle weakness, nausea and vomiting, and etc. Fluid restriction that case negative
fluid balance must be encourage by the patient. Proper I and O monitoring such as oral,
intravenous and metabolic production must be lowered daily beyond water losses
though skin, respiratory tract, stool and urine.
The prognosis of in this case is good depending on the patient’s level of
participation, proper attitude toward medications and treatment regimen. Also, if the
patient display understanding about the factors that predispose her on having water
intoxication stones and encourage to avoid things that will cause recurrence. As
observed, the financial status of the patient and as well as good emotional and spiritual
motivations and support by all of her family members ensures that water intoxication
secondary to SIADH of the patient i treated and the prognosis is good.

RECOMMENDATION
The nursing students from third year level of Bachelor of Science in Nursing, establish
this case analysis to provide information, knowledge and recommendations
toward the following:

TO THE PATIENT:

 Patient must display good attitude towards treatment regimen

 Be present to the next follow up checkups and follow appropriate
medications as prescribed by physician
 Practice proper eating habits at all times such as nutritious foods for
more muscle regeneration
 Be watchful on doing impulsive things that can have serious effect on
your body such as excessive overhydration

TO THE FAMILY MEMBER

 Assist client always in her activity

 Assist client towards health status and rehabilitation

48
  Provide emotional, financial, spiritual and mental support to the
patient

TO THE PARAMEDICAL STUDENTS:

 Learn and understand the preventive measures to help future patient

with underlying same manifestation of clinical signs and symptoms to
prevent having a Water Intoxication Secondary to Syndrome of
Inappropriate Anti-Diuretic Hormone
 Patient teaching method must be well practiced in providing care and
must involve the patient as always
 Show emotional and physical support to patient at all times

REFERENCESS:

Rizzuto, R. et al. (September 30, 2021) Acute Water Intoxication With Resultant Hypo-
Osmolar Hyponatremia Complicated by Hypotension Secondary to Diffuse Third-
Spacing Retrieved on December 11, 2022

Cleveland Clinic (August 03, 2022) SIADH (Syndrome of Inappropriate Antidiuretic

Hormone Secretion) Retrieved on December 11, 2022

Seitz, A., (May 14, 2020) What happens if you drink too much water? Retrieved on
December 9, 2022

49
Nursing Spectrum Drug Handbook 2010

Doenges M. et. Al (2006) Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions

and
Rationale 11th edition

50