Question

John is a 23-year-old white Caucasian male, diagnosed with Syndrome of Inappropriate Anti-diuretic Hormone. Prepare a NURSING CARE PLAN.

Answer 1

Fluid electrolyte imbalance related to ADH increase in our body evidence by edema

subjective Data:

Nausea

Muscle cramps

Depression, irritability

Fatigue

Objective Data:

Vomiting

Hypothermia

Tremors

Confusion

Seizures

Coma

Edema

Signs of Volume Overload

Nursing Interventions and Rationales

Monitor I & O, daily weights

Patients may be on fluid restrictions to help balance intake and output. Monitor for retention through calculated intake and output and with daily weights at the same time on the same scale each day.

Continuous ECG monitoring

Changes in electrolyte balance can disrupt the electrical conduction in the heart causing dysrhythmias.

Assess and monitor vital signs every 1-2 hours

Fluid shifts can occur quickly causing changes in blood pressure and heart rate. Most often patients will experience hypotension.

Assess and monitor respiratory status; note changes in respiration, auscultate lungs

Excess fluid volume can settle in and around the lungs and heart. Monitor for signs of congestion, difficulty breathing. SIADH can also be triggered by pneumonia, so monitor for the underlying cause as well.

Administer medication and electrolyte supplements appropriately

Electrolyte supplements (potassium)

Demeclocycline or lithium – stops the kidneys from responding to extra ADH

Supplements may be given to regulate electrolyte imbalance. Carefully administer supplements to avoid overloading too quickly

Monitor lab / diagnostic values

Serum potassium

Serum sodium

Serum chloride

Serum osmolality (concentration)

Urine specific gravity

Hyponatremia is the hallmark of SIADH. Monitor lab values to determine if treatment is effective.