Nursing Case Study On Hyponatremia

Upon evaluation of the patient, who is a 19 years old female admitted to Emergency Department complaining of headache and confusion due to increased ingestion of water during a pledging a sorority. In clustering and analyzing the data in the scenario such as the laboratory result: Sodium122mEq (low), Potassium 3.6 mEq/L, Calcium 10 mg/dL, Magnesium 2 mg/dL, Chloride: 100 mEq/L, Phospate: 2 mEq/L, (Treas & Willkinson, 2014), assessment of the patient on objective data she has poor skin turgor, dry mucous membranes, and orthostatic hypotension as well as complaining of headache, abdominal cramping a subjective data

After clustering the information and the assessment a nursing diagnoses of Hyponatremia related excessive intake of hypotonic fluid

as evidence by changes in serum electrolyte levels, which may compromise her health was identified. (Ladwig, Ackley, & Makic Flynn, 2014). As the RN monitoring this patient for potential problems will be to assess for and report signs and symptoms of:
-Change in mental status
-Seizures
-Muscle cramps or twitching
-Monitor client's behavior for restlessness, anxiety, confusion, sleepiness
- Poor motor coordination
- Convulsions or hyperventilation
-Assess vital signs and breath sounds every 4 hours report changes such as signs of increased intra-cerebral pressure
- Slow pulse
- Increased SBP (more than 10 mm Hg)
- Decreased DBP (more than 10 mm Hg)
-Review laboratory data as ordered and report deviations to provider
- Implement fluid restriction as ordered, especially since serum sodium is low
(Treas & Willkinson, 2014)
The analysis used and rationale for this choice of hyponatremia was base on laboratory result and the patient initial chief complain in the scenario of water intoxication.

Excessive intake of hypotonic solutions, such as water can present with neurological symptoms due to the shifting of water into brain tissues causing a resultant dilution of sodium in the vascular space (Treas & Willkinson, 2014)

Reference

Ladwig, G. B., Ackley, B. J., & Makic Flynn, M. B. (2014). Mosby's Guide to Nursing Diagnosis (Early Diagnosis in Cancer). St. Louis, Missouri: Elsevier Health Sciences.

Treas, L., & Willkinson, J. (2014). Basic Nursing Concepts, Skills & Reasoning. Philadephia, PA: F A.

Davis.