Hypernatremia: You are “FRIED”

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    Hypernatremia (an excess of serum sodium) can occur in any patient, regardless of age, medical history or healthcare setting. Here, we’ll review identifying symptoms of this potentially life threatening condition and treatment modalities.

    Hypernatremia: You are “FRIED”

    According the Cleveland Clinic, “Hypernatremia is defined as a serum sodium concentration greater than 145 mmol/L. It is most commonly caused by the loss of water via the skin, urine, or gastrointestinal (GI) tract. In all cases, loss of access to water or impaired thirst sensation is required to maintain the hypernatremic state”. An increase in sodium can cause dehydration. Treatment of this condition includes correcting the high sodium level by replacing fluid volume and treating the underlying cause of the fluid loss (antiemetics for vomiting, etc). Replacing fluids for a hypernatremic patient can be extremely delicate and the rate of IV fluids should be carefully considered and monitored so to avoid cerebral edema and increased intracranial pressure. An imbalanced sodium level affects many body systems on a cellular level leading to a wide range of symptoms, listed below.

    F - Fever & Flushed Skin
    Patients with prolonged fever can be more prone to developing hypernatremia, as it can cause excessive sweating and fluid loss. When circulating water becomes decreased for long periods of time, sodium levels can rise from lack of dilution. Treating the cause of the fever (upper respiratory infection or other) can help to correct the imbalance. Frequent monitoring of vital signs, including temperature can provide insight into patient status and should be incorporated into the nursing care plan.

    A full body assessment can give healthcare providers many clues into the direction in which the patient is headed. Flushed skin can be a major visual cue in determining a diagnosis of hypernatremia. Skin will appear reddened or flushed with poor skin turgor and oral mucosa may appear dry with chapped lips if dehydration is present.

    R - Restless
    Sodium is an important mineral needed for proper neurological function; an excess can lead to signs of restlessness, irritability, agitation and overall mood changes. These symptoms should resolve with prompt correction of serum sodium imbalance. Regular monitoring of mental status (including assessment of general emotional tone and level of consciousness) should be incorporated into nursing rounds.

    I - Increased Fluid Retention
    “Water movement between body fluid compartments is regulated by the effective osmolality of the solutes within each compartment. Sodium is the main determinant of plasma osmolality, and water moves toward body compartments with higher osmolality and away from those with lower osmolality” states the Cleveland Clinic. Keeping this concept in mind, fluid can shift from the intracellular space (where sodium is increased) to the extracellular space (into surrounding tissues), causing swelling of extremities and a decrease in blood pressure.

    E - Edema
    Due to the lopsided shift described above, fluids can leak into tissues, only further exacerbating the dehydration state. Light compression stockings and slight elevation of extremities can help to relieve patient discomfort while still being careful not to overload them. Edema can be monitored by checking patient weight pre & post IVF administration, measuring calf diameter and pressing firmly on bony prominences, such as the ankle, to assess pitting edema.

    D - Decreased Urinary Output & Dry Mouth
    Carefully monitoring all intake (both oral and intravenous) and output (emesis, diarrhea & urine) can provide vital clues into the patient status. Decreased urinary output can be both a diagnostic indicator and cause for hypernatremia. When urinary output is decreased it can be due to dehydration. When a significant imbalance is noted between input and output, checking a serum CMP (comprehensive metabolic panel) and other electrolytes (not included in the panel) should be included in the care of the ill patient. As previously mentioned, when fluid shifts into the peripheral tissues (causing edema) the fluid volume intracellularly can decrease - leading to further sodium imbalances. Replacement of fluids, both orally and through an IV should take priority and will correct the issue. Dry mouth and a rough tongue is a typical finding when assessing a dehydrated patient with excess sodium. Nursing care should include moistened oral swabs, ointment for dry lips, ice chips and encouragement of oral hydration if possible. It is important to report oral intake to covering MD/NP so that the IVF rate and volume can be adjusted (as over dilution is also possible, along with increased demand on the circulatory and cardiac systems).

    Using the acronym FRIED can help you identify your hypernatremic patient. Replacement of fluids is key in correcting this imbalance of vascular osmolality and electrolytes. Nursing care should include close monitoring of patient status through frequent vital signs and full body assessment. Comfort care is also imperative, including mouth care (glycerin swabs & lubricant for lips), documentation of hourly all intake & output and encouragement/availability of oral fluids. Nursing care plans may also include education on sodium content of foods and proper daily oral hydration volume.

    References:
    Edema Overview
    Hypernatremia Signs and Symptoms
    Hyponatremia and Hypernatremia

    STAFF NOTE: Clarification/edits done 09/28/17
    Last edit by Joe V on Oct 20
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    6 Comments

  3. by   ~♪♫ in my ♥~
    Quote from Ashley Hay
    fluid can shift from the intravascular space (venous system - where sodium is increased) to the extravascular space (into surrounding tissues), causing swelling of extremities and a decrease in blood pressure.
    I think you misspoke here. In hypernatremia, the fluid shifts from the intracellular space to the extracellular space where the osmolality is higher. It is this water shift out of the cells and its associated shrinkage of the cells from which the serious complications of hyperosmolar states arise.

    Mount, D. B., Sayegh, M. H., & Singh, A. K. (Eds.). (2013). Core Concepts in the Disorders of Fluid, Electrolytes and Acid-Base Balance. New York, NY: Springer. doi:10.1007/978-1-4614-3770-3
  4. by   mshull
    Quote from ~♪♫ in my ♥~
    I think you misspoke here. In hypernatremia, the fluid shifts from the intracellular space to the extracellular space where the osmolality is higher. It is this water shift out of the cells and its associated shrinkage of the cells from which the serious complications of hyperosmolar states arise.

    Mount, D. B., Sayegh, M. H., & Singh, A. K. (Eds.). (2013). Core Concepts in the Disorders of Fluid, Electrolytes and Acid-Base Balance. New York, NY: Springer. doi:10.1007/978-1-4614-3770-3
    I was just about to ask about this. Current nursing student here and wondering why hypernatremia would cause edema... I would think the high serum concentration would pull fluid into the intravascular space? Just looking for clarification!
  5. by   KelRN215
    This article doesn't address the primary cause of hypernatremia I have encountered throughout my nursing career- complete central diabetes insipidus. These patients definitely don't have the majority of the symptoms listed- no fluid retention (their kidneys can't concentrate urine without anti-diuretic hormone telling them to so they're voiding large amounts of dilute urine), no edema and certainly no decreased urine output- they're urinating liters of water, essentially.

    I also disagree with this statement- "In all cases, loss of access to water or impaired thirst sensation is required to maintain the hypernatremic state"- when it comes to complete DI, especially in children. They can have an intact thirst and unlimited access to water but just not be able to take in enough to keep up with their losses.
  6. by   traumaRUs
    Thanks for your comments - appreciate it and edits have been appropriately made.

    @KelRN2015 - agree that the most common diagnosis I see for hypernatremia is DI. My area of practice is nephrology and this is a common diagnosis that we see.
  7. by   Ashley Hay, BSN, RN
    Quote from ~♪♫ in my ♥~
    I think you misspoke here. In hypernatremia, the fluid shifts from the intracellular space to the extracellular space where the osmolality is higher. It is this water shift out of the cells and its associated shrinkage of the cells from which the serious complications of hyperosmolar states arise.

    Mount, D. B., Sayegh, M. H., & Singh, A. K. (Eds.). (2013). Core Concepts in the Disorders of Fluid, Electrolytes and Acid-Base Balance. New York, NY: Springer. doi:10.1007/978-1-4614-3770-3
    Thank you for catching the mistake! While I was excited to learn about hypernatremia more in depth by writing this article, it is not my area of expertise and I apologize for the mistake. Thanks for reading and for your valuable input!
  8. by   Ashley Hay, BSN, RN
    Quote from mshull
    I was just about to ask about this. Current nursing student here and wondering why hypernatremia would cause edema... I would think the high serum concentration would pull fluid into the intravascular space? Just looking for clarification!
    So sorry for the confusion. When I write the articles (with students in mind) I always do my best to research topics and write as clearly as possible, my apologies. Thanks for reaching out to clarify.

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