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Hyponatremia

  • Ddx

    • pseudohyponatremia (serum osm > 295)
      • hyperglycemia
      • hyperlipidemia
      • hyperproteinemia
    • hypovolemic (orthostasis, BUN > 20*Cr)
      • GI loss
        • vomiting
        • diarrhea
        • NG suction
        • pancreatitis
      • skin loss
        • sweating
        • burns
      • renal loss (Urine Na > 20)
        • adrenal insufficiency
        • diuretic
        • salt-losing nephritis (GFR < 10)
        • RTA
        • metabolic alkalosis
    • euvolemic
      • SIADH (urine osm > 100)
        • small cell carcinoma
        • CNS lesion
        • tumor
        • AIDS
        • lung tumor or infections
      • drugs
      • hypothyroidism (TSH)
      • glucocorticoid deficiency (hx of dz requiring chronic steroids)
      • psychogenic polydipsia (low urine osm)
      • pain
    • edematous
      • CHF
      • cirrhosis (low albumin)
      • nephrotic syndrome (proteinuria)
      • renal failure (Cr high)
  • Treatment

      • NS if hypovolemia
      • if Na < 120, give 3% NS at no more than correction of 0.5meq/L/hr. Add furosemide 20-40mg.
  • Admission orders

    • Admit: Floor
    • Diagnosis: Hyponatremia
    • Condition: Stable
    • Vital Signs: Routine, check orthostatic vitals
    • Allergies:
    • Nursing: Strict I/Os, daily weights, seizure precautions
    • Diet:
      • NPO if AMS
      • free water restriction unless hypovolemia
      • low Na if volume overload
    • Activity: Up with assistance
    • Labs:
      • CBC, Chem, serum osmolality
      • consider TSH, AM cortisol
      • urine Na, creatinine and osmolality
    • IV:
      • NS if hypovolemia, otherwise none
      • if Na < 120, give 3% NS at no more than correction of 0.5meq/L/hr. Add furosemide 20-40mg.
    • Special:
    • Medications:
      • d/c offending meds (diuretics, NSAIDs, TCAs, antiepileptics, SSRIs)
  • Criteria

    • Na < 135
  • Sx

    • AMS, seizure when Na < 120

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