hyponatremia replacement

[OreoCookie3]

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.

[nurse2033, MSN, RN]

Well, it sounds like there was no adverse effect to the patient so that kind of answers your question. However, any time you have doubts or are uncomfortable giving a medication, I would always double check, either with the physician, or at least a charge nurse or someone with experience with that medication.

[follybaby]

Hi,

I think the best thing to do next time is to ensure the physician knows the recent value and still confirm from him if you should continue with the medication order. And always inform the nurse in- charge once in doubt.

[Esme12, ASN, BSN, RN]

This was answered on your other posting.

https://allnurses.com/general-nursing-discussion/hyponatremia-question-please-678902.html

[Vespertinas]

"The serum sodium concentration is the primary determinant of the serum osmolality. The fall in serum osmolality in patients with true hyponatremia promotes water movement into the brain and, if the hyponatremia is acute and severe, can lead to cerebral edema and neurologic symptoms. In response to hyponatremia, the brain makes adaptations that lower the cerebral volume toward normal and reduces the likelihood of these complications. The mechanisms responsible for this cerebral adaptation are discussed elsewhere. (See 'Brain adaptation to hyponatremia' below and "Manifestations of hyponatremia and hypernatremia", section on 'Osmolytes and cerebral adaptation to hyponatremia'.)

However, brain adaptations that reduce the risk of cerebral edema make the brain vulnerable to injury if chronic hyponatremia is corrected too rapidly. The neurologic manifestations associated with overly rapid correction have been called the osmotic demyelination syndrome (ODS, formerly called central pontine myelinolysis). As will be described below, almost all patients who develop ODS present with a serum sodium concentration of 120 meq/L or less."

source: uptodate.com

article

Osmotic demyelination syndrome and overly rapid correction of hyponatremia

Author Richard H Sterns, MD

Section Editor Michael Emmett, MD

Deputy Editor John P Forman, MD, MSc