A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?
A.Monitor daily sodium intake.
B.Measure ankle circumference.
C.Obtain serum creatinine levels daily.
D.Ensure client takes a diuretic every morning.
The correct answer and explanation is:
The correct answer is B. Measure ankle circumference.
Explanation:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition in which there is excessive release of antidiuretic hormone (ADH), leading to water retention and dilution of blood sodium levels. The main issue in SIADH is water retention rather than sodium retention, which can lead to fluid overload.
In this client, the significant weight gain of 4.4 lbs (2 kg) over 24 hours, along with elevated blood pressure, are indicative of fluid retention, a common complication of SIADH. The first priority in managing a patient with fluid retention and potential overload is to monitor for signs of edema, which can lead to complications like pulmonary edema if not addressed promptly.
Measuring ankle circumference is a key intervention to assess the extent of peripheral edema, which is a common sign of fluid retention in SIADH. By measuring ankle circumference regularly, the nurse can track the progression of edema and determine if the fluid retention is worsening. This helps in timely intervention to prevent complications associated with fluid overload.
The other options are less urgent for the immediate management of fluid overload:
- A. Monitor daily sodium intake: While sodium intake is important, it is less critical in the immediate management of fluid overload, especially when the issue is primarily water retention rather than sodium balance.
- C. Obtain serum creatinine levels daily: This might be necessary for monitoring kidney function in certain cases, but it is not the first priority in a client with fluid retention due to SIADH.
- D. Ensure client takes a diuretic every morning: While diuretics may be used in the management of fluid retention, they must be carefully administered in SIADH cases because the underlying issue is water retention rather than sodium retention. Overuse of diuretics could exacerbate electrolyte imbalances.
By focusing on measuring ankle circumference, the nurse can directly assess the fluid retention, which is the most immediate concern.