Risk factors may include
Treatment-related side effects such as gastric suctioning, electrolyte free intravenous (IV) solutions, medications
Possibly evidenced by
(Not applicable, presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Electrolyte & Acid/Base Balance
Display heart rate, BP, and laboratory results within normal limits (WNL) for client; absence of muscle weakness; and neurological irritability.
Nursing intervention with rationale:
1. Identify client at risk for hyponatremia and the specific cause such as sodium loss or fluid excess.
Rationale: 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 promptly.
2. Monitor intake and output (I&O). Calculate fluid balance. Weigh daily.
Rationale: Indicators of fluid balance are important because either fluid excess or deficit may occur with hyponatremia.
3. Assess level of consciousness (LOC) and neuromuscular response.
Rationale: Sodium deficit may result in decreased mentation to the point of coma, as well as generalized muscle weakness, cramps, or convulsions.
4. Maintain quiet environment; provide safety and seizure precautions.
Rationale: Reduces CNS stimulation and risk of injury from neurological complications such as seizures.
5. Note respiratory rate and depth.
Rationale: Co-occurring hypochloremia may produce slow and shallow respirations as the body compensates for metabolic alkalosis.
6. Encourage foods and fluids high in sodium such as milk, meat, eggs, carrots, beets, and celery. Use fruit juices and bouillon instead of plain water.
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.
7. Irrigate nasogastric (NG) tube (when used) with normal saline instead of water.
Rationale: Isotonic irrigation will minimize loss of gastrointestinal (GI) electrolytes.
8. Observe for signs of circulatory overload, as indicated.
Rationale: Administration of sodium-containing IV fluids in presence of HF increases risk.
9. Provide or restrict fluids, depending on fluid volume status.
Rationale: In presence of hypovolemia, volume losses are replaced with isotonic saline (e.g., normal saline), or, on occasion, hypertonic solution (3% NaCl) when hyponatremia is life threatening. In the presence of fluid volume excess, or SIADH, fluid restriction is indicated. Note: Too rapid or excessive administration of hypertonic solutions can be lethal.
10. Prepare for/assist with dialysis as indicated.
Rationale: May be done to restore sodium balance without increasing fluid level when hyponatremia is severe or response to diuretic therapy is inadequate.