Sodium (Na) abnormal, Hypernatremia, Hyponatremia
Also Consider: Abnormal lab test, Mental status change
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Decreased Level (hyponatremia)
Symptoms: memory loss, confusion, lethargy, fatigue, irritability, falls, poor appetite, headache, muscle weakness/cramps, seizures, coma
Common causes: heart failure, liver failure, kidney disease, medications, pneumonia, stroke
Increased Level (hypernatremia)
Symptoms: lethargy, weakness, irritability, seizures, coma
Common causes: dehydration, inadequate fluid intake, diarrhea, uncontrolled diabetes
1. Take Vital Signs
Temperature:
Blood Pressure lying:
Blood Pressure standing:
Heart Rate lying:
Heart Rate standing:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
Not eating or drinking as much as usual
Fainting, dizziness or lightheadedness when standing up
Acute decline in ADL abilities
Thirst, signs of dehydration
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress
Cardiovascular: edema
GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds
GU: New or worsened incontinence
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)
Very low urinary output (<30cc/hr)
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Sodium less than 125
Sodium greater than 155
Any high or low sodium level with change in mental status
Notify medical staff & resident representative within the next 16 hours.
Na greater than 150 or less than 128
Notify medical staff on the next business day
All other abnormal sodium levels
SBAR Report
Situation: (High) (Low) "Sodium level of ___” (associated with) (acute symptoms)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
Reason the test was done
Abnormal vital signs or changes with lying and standing
History of heart failure, liver failure, kidney disease
Recent illness,fever, medication changes, head injury
General observation of patient condition
Diet restrictions, fluid restriction, thickened liquids
On medication that decreases sodium level: Diuretics such as furosemide/Lasix, torsemide, hydrochlorothiazide, metolazone, bumetanide, chlorthalidone; fludrocortisone; antidepressants; valproic acid; ACE-inhibitors, carbamazepine
Blood glucose, if elevated
Abnormal findings on lung, cardiovascular, abdomen, or neurologic observations.
Tube feeding rate, water flush orders, residual measurements, recent changes
Availability of IV or clysis hydration (i.e., PICC line)
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with diff, BMP/Chem8, TSH, Drug levels
When to repeat sodium level
“Hold” parameters for medicines that lower blood pressure
IV or SC (clysis) fluids
Increase tube feed water flushes
Change fluid restriction orders
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs every 4-8 hrs for 2-3 days
Offer fluids frequently if sodium is high
Oral, IV, or subcutaneous fluids if needed for hydration
Place on Intake & Output monitoring
Monitor meal acceptance
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative daily or with any changes
Update advance directives if appropriate
2025-04-27
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