Bicol University

College of Nursing

Case Study:
Hyponatremia
Serum sodium level of less than 135 mEq/L

● Sheenarose Escober●
● Francis Angelo Hapa●
BSN 3-C
 Table of Contents

Introduction Medical/Surgical
01 S&S, Causes, and Risk
Factors
06 Interventions

02 Anatomy
07
NCP
Nursing Care Plan

03 Pathophysiology
08 Discharge Plan
04 Treatment Options
Conclusion and
05 Laboratory
Procedure
09 Indication
 Case Vignette
A 49-year-old woman (previous history of childhood
asthma, no medication) presented to the emergency
department with nausea and vomiting that had occurred
for 5 days and slurred speech for 1 day prior to
presentation. The patient denied use of alcohol and illicit
drugs. Physical examination revealed her blood pressure
to be 125/70 mmHg; she had no postural drop and had a
regular pulse of 72 beats/min. She had no fever and no
signs of contracted extracellular fluid volume. Results of
further physical and neurological examination were
unremarkable and revealed no goiter, pigmentation, or
vitiligo. Her laboratory results are shown in Table 1.
Additional diagnostic tests included chest x-ray, abdominal
ultrasound, and brain computed tomography, none of
which revealed abnormalities. The syndrome of
inappropriate antidiuretic hormone secretion (SIADH)1
was suspected. However, fluid restriction (500 mL/day) did
not lead to increased serum sodium.
01 Introduction

Signs and Symptoms,

Causes, and Risk
Factors
Hyponatremia
– Sodium Deficit
– refers to a serum sodium level that is less than
135 mEq/L ( 135 mmol/L)
– Hyponatremia can present as an acute or chronic
form.
● Acute hyponatremia is commonly the result of a
fluid overload in a surgical patient.
● Chronic hyponatremia is seen more frequently in
patients outside the hospital setting, has a longer
duration, and has less serious neurological
sequelae.
 Signs and Symptoms

Poor skin turgor, dry mucosa,

headache, decreased saliva
In general, patients with an acute
production, orthostatic fall in
decrease in serum sodium levels have
blood pressure, nausea, vomiting,
more cerebral edema and higher
and abdominal cramping
mortality rates than do those with
more slowly developing
Altered mental status, status hyponatremia.
epilepticus, and coma, are
probably related to the cellular
swelling and cerebral edema
associated with hyponatremia
 Causes

Occurring Less than 48 hours Loss of Sodium

● May be associated with
brain herniation and
compression of midbrain
structures.
Occurring 48 hours or more
● Can occur in status
epilepticus and other
neurologic conditions
● Certain medications
● Heart, kidney, and liver
problems
● Syndrome of Inappropriate
antidiuretic hormone (SIADH)
● Chronic, severe vomiting or
diarrhea and other causes of
dehydration
● Drinking too much water
● Hormonal Changes
● Recreational Drug (Ecstasy)
 Risk Factors
Age Certain Drugs
Older adults may have Medications that
more contributing increase your risk of
factors for hyponatremia include
hyponatremia, including thiazide diuretics as well
age-related changes, as some antidepressants
taking certain and pain medications. In
medications and a addition, the
greater likelihood of recreational drug
developing a chronic Ecstasy has been linked
disease that alters the to fatal cases of
body's sodium balance. hyponatremia.
Conditions that Intensive physical
decrease water activities
excretion People who drink too
much water while taking
kidney disease,
part in marathons,
syndrome of
ultramarathons,
inappropriate
triathlons and other
antidiuretic hormone
long-distance,
(SIADH) and heart
high-intensity activities
failure
are at an increased risk
of hyponatremia.
02 Anatomy
 Anatomy

Hyponatremia is a lower-than-normal concentration of

sodium, usually associated with excess water accumulation
in the body, which dilutes the sodium. An absolute loss of
sodium may be due to a decreased intake of the ion coupled
with its continual excretion in the urine. An abnormal loss of
sodium from the body can result from several conditions,
including excessive sweating, vomiting, or diarrhea; the use
of diuretics; excessive production of urine, which can occur
in diabetes; and acidosis, either metabolic acidosis or
diabetic ketoacidosis.
 Anatomy

A relative decrease in blood sodium can occur because

of an imbalance of sodium in one of the body’s other fluid
compartments or from a dilution of sodium due to water
retention related to edema or congestive heart failure. At
the cellular level, hyponatremia results in increased entry of
water into cells by osmosis. The excess water causes swelling
of the cells; the swelling of red blood cells—decreasing their
oxygen-carrying efficiency and making them potentially too
large to fit through capillaries—along with the swelling of
neurons in the brain can result in brain damage or even
death.
03 Pathophysiology
Hyponatremia primarily occurs due to an imbalance of
water rather than sodium. The urine sodium value assists
in differentiating renal from non renal causes of
hyponatremia. Low urine sodium occurs as the kidney
retains sodium to compensate for non renal fluid loss (i.e.,
vomiting, diarrhea, sweating). High urine sodium
concentration is associated with renal salt wasting (i.e.,
diuretic use). In dilutional hyponatremia, the ECF volume
is increased without any edema.

A deficiency of aldosterone, as occurs in adrenal

insufficiency, also predisposes to sodium deficiency. In
addition, the use of certain medications, such as
anticonvulsants (i.e., carbamazepine [Tegretol],
oxcarbazepine (Trileptal), levetiracetam [Keppra]), SSRis
(fluoxetine [Prozac], sertraline [Zoloft], paroxetine
[Paxil]), or desmopressin acetate (DDAVP), increases the
risk of hyponatremia.
SIADH is seen in hyponatremia as well as
hypematremia. The physiologic
disturbances include excessive ADH
activity, with water retention and
dilutional hyponatremia, and
inappropriate urinary excretion of sodium
in the presence of hyponatremia. SIADH
can be the result of either sustained
secretion of ADH by the hypothalamus or
production of an ADH-like substance from
a tumor (aberrant ADH production).
Conditions affecting the central nervous
system are associated with SIADH.
04 Treatment
Options
There is no curative treatment for hyponatremia, only symptomatic.

In general, hyponatremia is treated with

● Fluid restriction (euvolemia)
● Isotonic saline (hypovolemia), and
● Diuresis (hypervolemia).
A combination of these therapies may be needed based
on the presentation. Hypertonic saline is used to treat
severe symptomatic hyponatremia. Medications such as
vaptans may have a role in the treatment of euvolemic
and hypervolemic hyponatremia. The treatment of
hypernatremia involves correcting the underlying cause
and correcting the free water deficit.
If you have moderate, chronic hyponatremia due to your diet, diuretics or drinking
too much water, your doctor may recommend temporarily cutting back on fluids.
He or she may also suggest adjusting your diuretic use to increase the level of
sodium in your blood.

If you have severe, acute hyponatremia, you'll need more-aggressive treatment.

Options include:
● Intravenous fluids. Your doctor may recommend IV sodium solution to slowly
raise the sodium levels in your blood. This requires a stay in the hospital for
frequent monitoring of sodium levels as too rapid of a correction is
dangerous.
● Medications. You may take medications to manage the signs and symptoms of
hyponatremia, such as headaches, nausea and seizures.
05 Laboratory
Procedure
Lab procedures given,
Normal values,
Abnormal values
 Procedure Indication

Urine osmolality Urine osmolality helps differentiate between conditions associated

with impaired free-water excretion and primary polydipsia. A urine
osmolality greater than 100 mOsm/kg indicates impaired ability of the
kidneys to dilute the urine.

Serum osmolality Serum osmolality readily differentiates between true hyponatremia

and pseudohyponatremia. The latter may be secondary to
hyperlipidemia or hyperproteinemia, or may be hypertonic
hyponatremia associated with elevated glucose, mannitol, glycine
(posturologic or postgynecologic procedure), sucrose, or maltose
(contained in IgG formulations).

Urinary sodium Urinary sodium concentration helps differentiate between

hyponatremia secondary to hypovolemia and syndrome of
concentration inappropriate antidiuretic hormone secretion (SIADH). With SIADH
(and salt-wasting syndrome), the urine sodium is greater than 20-40
mEq/L. With hypovolemia, the urine sodium typically measures less
than 25 mEq/L. However, if sodium intake in a patient with SIADH (or
salt-wasting) happens to be low, then urine sodium may fall below 25
mEq/L.
06 Medical/
Surgical
Interventions
Medical Interventions

● Demeclocycline
(Declomycin)
● Samsca
● Ure-Na
● Tolvaptan
● Urea
● Sodium Acetate
07 NCP

Nursing Care Plan

 Nursing Intervention
Monitor intake and output and
specific gravity. Assess the presence
and location of edema. Weigh client
daily.
Assess skin turgor, color, and
temperature and mucous membrane
moisture.
Assess level of consciousness and
neuromuscular response.
Rationale
These parameters are variable, depending on the fluid
status, and are indicators of therapy needs and
effectiveness.
Depending on the fluid status, hypertension or hypotension
may be present. The presence of postural hypotension may
affect activity tolerance.
A deficit in sodium levels may lead in decreased mentation to
coma, as well as generalized muscle weakness, cramps, or
convulsions.
 Nursing Intervention
Note for signs of circulatory
overload, as indicated
Identify client’s risk for
hyponatremia and the specific cause
such as sodium loss or fluid excess.
Provide safety and seizure
precautions. Maintain a calm, quiet
environment.
Irrigate nasogastric tube (when used)
with normal saline instead of water.
Rationale
Administration of sodium-containing IV fluids in the
presence of heart failure increases risk.
Provides clues for early intervention. Hyponatremia is a
common imbalance, especially in the elderly, and may range
from mild to severe. Severe hyponatremia can cause
neurological damage or death if not treated properly.
Decreases CNS stimulation and risk of injury from
neurological complications such as seizures.
The use of isotonic solution during irrigation decreases
gastrointestinal electrolyte losses.
 Nursing Intervention
Encourage fluids and foods high in
sodium such as meat, milk, beets,
celery, eggs, and carrots. Use fruit
juices and bouillon instead of water.
Monitor serum and urine
electrolytes and osmolality.
Provide or restrict fluids, depending
on fluid volume status.
Rationale
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.
Evaluates therapy needs and effectiveness.
In the presence of fluid excess or SIADH, fluid restriction is
indicated while in the presence of hypovolemia, volume
losses are replaced with isotonic saline, or, on occasion,
hypertonic solution when hyponatremia is life-threatening.
 Nursing Intervention Rationale

Administer Captopril (Capoten). May be used in combination with a loop diuretic

medications as (e.g., Lasix) to correct fluid volume excess,
especially in the presence of heart failure.
indicated:
Demeclocycline Helpful in treating chronic SIADH, or when
(Declomycin). severe water restriction may not be tolerated.

Furosemide (Lasix). Useful in reducing fluid excess to correct sodium

and water balance.

Potassium chloride. Used to correct potassium deficit, especially

during diuretic therapy.

Sodium chloride. Used to replace deficits in the presence of chronic

or ongoing losses.

Prepare for/assist with dialysis as indicated. May be done to restore sodium balance without
increasing fluid level when hyponatremia is
severe or response to diuretic therapy is
inadequate.
08 Discharge
Plan
Anticipating healthcare
needs after
hospitalization
 Discharge Plan
To help prevent hyponatremia:
Home Care
● Limit your intake of fluids. Drink only the
amounts directed by your healthcare
provider.
● Ask your healthcare provider what you
should use to replace fluids if you are
throwing up.
● Keep all follow-up appointments. Your
provider needs to watch your condition
closely.
● Take all medicines exactly as directed.
Certain medicines can lower blood sodium
levels.
● If you have done something that makes you
sweat a lot, drink fluids that contain salt
and other electrolytes.
● Tell all healthcare providers what
medicines you take. Mention all
prescription and over-the-counter drugs
and herbs.
● Have your sodium levels checked often.
This is vital if you take a diuretic (medicine
that helps your body get rid of water).
Follow Up
● Follow up as advised.

When to call Healthcare Provider

Call your provider right away if you have any of
the following:
● Severe tiredness
● Fainting
● Dizziness
● Loss of appetite
● Nausea or vomiting
● Confusion or forgetfulness
● Muscle spasms, cramping, or twitching
● Seizures
● Gait disturbances
09 Conclusion
& Indication
Conclusion & Indication
Hyponatremia is the most common
electrolyte disorder present in
hospitalized patients. Acute and severe
hyponatremia can cause significant
morbidity and mortality. Hyponatremia is
a condition where sodium levels in the
blood are lower than normal. Sodium is
an essential electrolyte that helps
maintain the balance of water in and
around your cells. It's important for
proper muscle and nerve function. It also
helps maintain stable blood pressure
levels.
 References
● Severe Hyponatremia with High Urine Sodium and Osmolality. AACC. (n.d.).
https://www.aacc.org/science-and-research/clinical-chemistry/clinical-case-studies/2009/severe-hypon
atremia-with-high-urine-sodium-and-osmolality.

● Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of medical-surgical nursing (Edition 13.).
Wolters Kluwer Health/Lippincott Williams & Wilkins.

● Mayo Foundation for Medical Education and Research. (2020, May 23). Hyponatremia. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/hyponatremia/symptoms-causes/syc-20373711.

● Idris, F. (2020, December 5). 10 Fluid And Electrolyte Imbalances Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/3/.

● Eric E Simon, M. D. (2021, April 3). Hyponatremia. Practice Essentials, Pathophysiology, Epidemiology.
https://emedicine.medscape.com/article/242166-overview#a1.