hyponatremia question- please help!

Nurses General Nursing

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Hi everyone,

I have a question related to hyponatremia. I had a patient a few days ago who came in with hyponatremia and her sodium level was 116. They started her on fluids- 0.9% normal saline- and fluid restriction. Around 1 am they rechecked her sodium and it was up to 120. Then, the doctor ordered a sodium level in the morning and it came back at 128. The PA with nephrology saw the patient and ordered a medication called tolvaptan, which I looked up before giving it, and found that it increases the serum sodium levels by increasing water excretion in the body. She may have not seen the sodium level of 128, as it came back at 8:45, and she may have just seen the pt a few minutes prior and based it off of the level of 120 from 1 am. She also ordered the IV fluids and fluid restriction to be discontinued. A sodium level recheck around 2 pm was ordered to be drawn. I gave the medication around 11:30 or 12. The nephrologist came later in the day to see the patient, and asked me if she had received the tolvaptam, and I said yes. He said that she probably hadn't needed it, and asked me to call him with the 2 pm level, which came back at 132, and he told me to start her on D5W. I realize that replacing the sodium level too fast can be dangerous. Was I wrong to have given the medication? Should I have made sure with nephrology to see if they still wanted the medication to be given with the sodium level up to 128? Please help. your advice is much appreciated.

I am just a nursing student, but when I read this, I am as flabbergasted as you. The normal sodium level is 135-145. If it's 128 or 132 whatever it was, it is still low. Why is the nephrologist ordering D5W? It will lower the sodium level. I was a tech once and was helping take care of a patient that had hyponatremia and fluid restriction. It's SIADH and we gave chicken soup in addition to the 0.9% NS. They also need seizure precautions. I am confused as you on the order of D5W, is there something you are leaving out? If not, I would have questioned the order. But, that's just opinion. I am still a student, so maybe I am wrong.

Oh, and I would have given that medication too because it excretes fluid and increases the sodium level. But, even after that, if it was only 132, then I would try chicken soup. Not much fluid, but ton of sodium.

Thanks for your response, wish_me_luck! Sorry, I should have clarified! I am wondering if I was wrong to give the Tolvaptan (the med to increase the sodium level). I actually called the nephrologist back to confirm that it was really D5W that he wanted given. I guess I am just worried that the tolvaptan shouldn't have been given since he said something to me about it and it can be dangerous to replace sodium too fast...The only reason I can think of that he ordered the D5W was to prevent the sodium from increasing further....116 to 132 in less than 24 hours is a huge increase! I appreciate your responses.

oh, okay. I am not sure about that one. Sorry :( I am wanting to keep updated on this post because I am sure this will come up with me sometime. Some of the questions posted here make me think and try and look up the answer. Well, keep us posted if someone knows the answer.

the nephrologist orderedd d5w on the na+ of 132 because although that's low for you and me, it was a pretty rapid change for someone who was at 116 so recently. rapid change needs to be rapidly repaired; slow change should be repaired slowly or bad things can result. so, oreocookie, you are correct on that point.

i think it would have been a good idea to call the doc that ordered the tolvaptan to say, "we have a more recent serum sodium and i thought you would want to know before i gave it."

thank you for your response, GrnTea. Is this considered an error? I feel terrible that something could have happened :(

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

It's not an errror. The better habit to get into is the one Grtea suggests......a phone call (although it may get you yelled at sometimes....like I care) The lastest lab is blah,blah,blah do you still want xyz given. The reality that we can cause harm every second is a huge responsiblity develop good habits now and that will save you in the future.

Thank you, Esme. My supervisors have told me that I am very thorough...I think sometimes overly so....All the more reason why I am beating myself up for not calling about this. :(

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

It's a learning curve.....you have the obsessiveness that plagues us all. You'll be OK! :hug:

Specializes in I/DD.

The number of times a doctor has thanked me for one of my "just in case" phone calls definitely trumps the number of times doctors have yelled at me for it.

I will now go look up what happens when you replete sodium too quickly. Learning new things every day!

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