Nursing Care of the Client with Cancer

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Nursing Care of the Client with Cancer

• Cancer Background
• A. Definition
• 1. Family of complex diseases
• 2. Affect different organs and organ systems
• 3. Normal cells mutate into abnormal cells that
  take over tissue
• 4. Eventually harm and destroy host
• 5. Historically, cancer is a dreaded disease
• B. Oncology
• 1. Study of cancers
• 2. Oncology nurses specialize in the care,
  treatment of clients with cancer

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Nursing Care of the Client with Cancer

• Incidence and Prevalence
• 1. Cancer accounts for about 25 of death on
  yearly basis
• 2. Males 3 most common types of cancer are
  prostate, lung and bronchial, colorectal
• 3. Females 3 most common types of cancer are
  breast, lung and bronchial, and colorectal

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Nursing Care of the Client with Cancer

• Risk factors for cancer (some are controllable
  some are not)
• 1. Heredity 5 10 of cancers documented with
  some breast and colon cancers
• 2. Age 70 of all cancers occur in persons gt 65
• 3. Lower socio-economic status
• 4. Stress
• a. Leads to greater wear and tear on body in
  general
• 5 Diet certain preservatives in pickled, salted
  foods fried foods high-fat, low fiber foods
  charred foods, high fat foods, diet high in red
  meat
• 6. Occupational risk exposure to know
  carcinogens, radiation, high stress
• 7. Infections, especially specific organisms and
  organ (e.g. papillomavirus causing genital warts
  and leading to cervical cancer)
• 8. Tobacco Use Lung, oral and laryngeal,
  esophageal, gastric, pancreatic, bladder cancers
• 9. Alcohol Use also tied with smoking
• 10. Sun Exposure (radiation) e.g. skin cancer

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Nursing Care of the Client with Cancer

• Nursing role includes health promotion to lower
  the controllable risks
• 1. Routine medical check up and screenings
• 2. Client awareness to act if symptoms of cancer
  occur
• 3. Screening examination recommendations by
  American Cancer Society specifics are made
  according to age and frequencies
• a. Breast Cancer self-breast exam, breast
  examination by health care professionals,
  screening mammogram
• b. Colon and Rectal Cancer fecal occult blood,
  flexible sigmoidoscopy, colonoscopy
• c. Cervical, Uterine Cancer Papanicolaou (Pap)
  test
• d. Prostate Cancer digital rectal exam,
  Prostate-specific antigen (PSA) test

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Nursing Care of the Client with Cancer

• Physiology of Cancer
• A. Background
• 1. Normal Cell Growth includes two events
• a. Replication of cellular DNA
• b. Mitosis (cell division)

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Nursing Care of the Client with Cancer

• 2. Cell cycle is under control of cyclins, and
  suppresor gene products which control process by
  working with enzymes
• cyclins promote cell division
• suppresor gene products limit cell
  division
• 3. Forms the basis of how some chemotherapeutic
  agents work against cancers

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Nursing Care of the Client with Cancer

• Theories of Carcinogenesis (what causes cancer to
  occur)
• 1. Cellular Mutation
• a. Cells begin to mutate (change the DNA to
  unnatural cell reproduction)
• 2. Oncogenes/Tumor Suppressor Genes Abnormalities
• a. Oncogenes are genes that promote cell
  proliferation and can trigger cancer
• b. Tumor suppressor genes normally suppress
  oncogenes but are damaged
• 3. Exposure to Known Carcinogens
• a. Act by directly altering the cellular DNA
  (genotoxic)
• b. Act by affecting the immune system
  (promotional)

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Nursing Care of the Client with Cancer

• 4. Viruses
• viruses break the DNA chain and mutates the
  normal cells DNA
• Epstein-Barr virus
• Human papilloma virus
• Hepatitis virus
• 5. Drugs and Hormones
• a. Sex hormones often affect cancers of the
  reproductive systems (estrogen in some breast
  cancers testosterone in prostate cancer)
• b. Glucocorticoids and steroids alter immune
  system

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• 6. Chemical Agents
• a. Industrial and chemical
• b. Can initiate and promote cancer
• b. Examples hydrocarbons in soot arsenic in
  pesticides chemicals in tobacco
• 7. Physical Agents
• a. Exposure to radiation
• Ionizing radiation found in x-rays, radium,
  uranium
• UV radiation
• Sun, tanning beds
• Immune function
• Protects the body from cancerous cells
• Increased rate of cancer in immunocompromised pts

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Nursing Care of the Client with Cancer

• Neoplasms also called tumors (mass of new tissue
  that grows independently of surrounding organs
• 1. Types of neoplasms
• a. Benign
• 1. Localized growths respond to bodys
  homeostatic controls
• 2. Encapsulated
• 3. Stop growing when they meet a boundary of
  another tissue
• 4. Can be destructive
• b. Malignant
• 1. Have aggressive growth, rapid cell division
  outside the normal cell cycle
• 2. Not under bodys homeostatic controls
• 3. Cut through surrounding tissues causing
  bleeding, inflammation, necrosis (death) of tissue

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Nursing Care of the Client with Cancer

• Malignant tumors can metastasize
• a. Tumor cells travel through blood or lymph
  circulation to other body areas and invade
  tissues and organs there.
• 1. Primary tumor the original site of the
  malignancy
• 2. Secondary tumor (sites) areas where
  malignancy has spread i.e. metastasis (metastatic
  tumor)
• 3. Common sites of metastasis are lymph nodes,
  liver, lungs, bones, brain
• 4. 50 60 of tumors have metastasized by time
  primary tumor identified
• b. Cancerous cells must avoid detection by immune
  system

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Nursing Care of the Client with Cancer

• C. Malignant neoplasms can recur after surgical
  removal of primary and secondary tumors and other
  treatments
• D. Malignant neoplasms vary in differentiation.
• a. Highly differentiated are more like the
  originating tissue
• b. Undifferentiated neoplasms consist of immature
  cells with no resemblance to parent tissue and
  have no useful function
• E. Malignant cells progress in deviation with
  each generation and do no stop growing and die,
  as do normal cells
• F. Malignant cells are irreversible, i.e. do not
  revert to normal
• G. Malignant cells promote their own survival by
  hormone production, cause vascular permeability
  angiogenesis divert nutrition from host cells

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The steps of metastasis
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Nursing Care of the Client with Cancer

• Effects of Cancer
• 1. Disturbed or loss of physiologic functioning,
  from pressure or obstruction
• a. Anoxia and necrosis of organs
• b. Loss of function bowel or bladder obstruction
• c. Increased intracranial pressure
• d. Interrupted vascular/venous blockage
• e. Ascites
• f. Disturbed liver functioning
• G. Motor and sensory deficits
• Cancer invades bone, brain or compresses nerves
• Respiratory difficulties
• Airway obstruction
• Decreased lung capacity

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Nursing Care of the Client with Cancer

• 2. Hematologic Alterations Impaired function of
  blood cells
• Secondary to any cancer that invades the bone
  marrow (leukemia)
• May also be caused by the treatment
• a. Abnormal wbcs impaired immunity
• b. Diminished rbcs and platelets anemia and
  clotting disorders
• 3. Infections fistula development and tumors may
  become necrotic erode skin surface
• 4. Hemorrhage tumor erosion, bleeding, severe
  anemia
• 5. Anorexia-Cachexia Syndrome wasting away of
  client
• a. Unexplained rapid weight loss, anorexia with
  altered smell and taste
• b. Catabolic state use of bodys tissues and
  muscle proteins to support cancer cell growth

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Nursing Care of the Client with Cancer

• 6. Paraneoplastic Syndromes ectopic sites with
  excess hormone production
• a. Parathyroid hormone (hypercalcemia)
• b. Ectopic secretion of insulin (hypoglycemia)
• c. Antidiuretic hormone (ADH fluid retention)
• d. Adrenocorticotropic hormone (ACTH)
• 7. Pain major concern of clients and families
• a. Types of cancer pain
• 1. Acute symptom that led to diagnosis
• 2. Chronic may be related to treatment or to
  progression of disease
• b. Causes of pain
• 1. Direct tumor involvement including metastatic
  pain
• 2. Nerve compression
• 3. Involvement of visceral organs

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Nursing Care of the Client with Cancer

• 8. Physical Stress body tries to respond and
  destroy neoplasm
• a. Fatigue
• b. Weight loss
• c. Anemia
• d. Dehydration
• e. Electrolyte imbalances
• 9. Psychological Stress
• a. Cancer equals death sentence
• b. Guilt from poor health habits
• c. Fear of pain, suffering, death
• d. Stigmatized

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Nursing Care of the Client with Cancer

• Collaborative Care
• A. Diagnostic Tests used to diagnose cancer
• 1. Determine location of cancer
• a. Xrays
• b. Computed tomography
• c. Ultrasounds
• d. Magnetic resonance imaging
• e. Nuclear imaging
• f. Angiography
• 2. Diagnosis of cellular type of can be done
  through tissue samples from biopsies, shedded
  cells (e.g. Papanicolaou smear) washings
• a. Cytologic Examination tissue examined under
  microscope
• b. Identification System of Tumors
  Classification Grading -- Staging

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Nursing Care of the Client with Cancer

• 1. Classification according to the tissue or
  cell of origin, e.g. sarcoma, from supportive
• 2. Grading
• a. Evaluates degree of differentiation and rate
  of growth
• b. Grade 1 (least aggressive) to Grade 4 (most
  aggressive)
• 3. Staging
• a. Relative tumor size and extent of disease
• b. TNM (Tumor size Nodes lymph node
  involvement Metastases)

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Nursing Care of the Client with Cancer

• 3. Tumor markers specific proteins which
  indicate malignancy
• a. PSA (Prostatic-specific antigen) prostate
  cancer
• b. CEA (Carcinoembryonic antigen) colon cancer
• c. Alkaline Phosphatase bone metastasis
• 4 Direct Visualization
• a. Sigmoidoscopy
• b. Cystoscopy
• c. Endoscopy
• d. Bronchoscopy
• e. Exploratory surgery lymph node biopsies to
  determine metastases

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Nursing Care of the Client with Cancer

• Other non-specific tests
• a. CBC, Differential
• b. Electrolytes
• c. Blood Chemistries (liver enzymes alanine
  aminotransferase (ALT) aspartate
  aminotransferase (AST) lactic dehydrogenase (LDH)

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Nursing Care of the Client with Cancer

• Treatment Goals depending on type and stage of
  cancer
• A. Cure
• 1. Recover from specific cancer with treatment
• 2. Alert for reoccurrence
• 3. May involve rehabilitation with physical and
  occupational therapy
• B. Control of symptoms and progression of cancer
  
• 1. Continued surveillance
• 2. Treatment when indicated (e.g. some bladder
  cancer, prostate cancer)
• C. Palliation of symptoms may involve terminal
  care if clients cancer is not responding to
  treatment

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Nursing Care of the Client with Cancer

• Treatment Options (depend on type of cancer)
  alone or with combination
• A. Chemotherapy
• 1. Effects are systemic and kills the metastatic
  cells
• 2. Often combinations of drugs in specific
  protocols over varying time periods
• Much more effective then a single agent
• Consider the timing of the nadir of each drug
• The time when the bone marrow activity and WBC
  counts are at their lowest levels after chemo
• Different times for different drugs

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• 3. Cell-kill hypothesis with each cell cycle a
  percentage of cancerous cells are killed but some
  remain repeating chemo kills more cells until
  those left can be handled by bodys immune system

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Nursing Care of the Client with Cancer

• B. Classes of Chemotherapy Drugs
• 1. Alkylating agents
• 1. Action create defects in tumor DNA
• 2. Examples Nitrogen Mustard, Cisplatin
• 2. Antimetabolites
• 1. Action similar to metabolites needed for
  vital cell processes
• Counterfeit metabolites interfere with cell
  division
• 2. Examples Methotrexate 5 fluorouracil
• 3. Toxic Effects nausea, vomiting, stomatitis,
  diarrhea, alopecia, leukopenia
• 3. Antitumor Antibiotics
• 1. Action interfere with DNA
• 2. Examples Actinomycin D, Bleomycin
• 3. Toxic Effect damage to cardiac muscle

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Nursing Care of the Client with Cancer

• 4. Antimiotic agents
• 1. Action Prevent cell division
• 2. Examples Vincristine, Vinblastine
• 3. Toxic Effects affects neurotransmission,
  alopecia, bone marrow depression
• 5. Hormone agonist
• 1. Action large amounts of hormones upset the
  balance and alter the uptake of other hormones
  necessary for cell division
• 2. Example estrogen, progestin, androgen

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• 6. Hormone Antagonist
• 1. Action block hormones on hormone-binding
  tumors (breast, prostate, endometrium cause
  tumor regression
• Decreasing the amount of hormones can decrease
  the cancer growth rate
• Does not cure, but increases survival rates
• 2. Examples Tamoxifen (breast) Flutamide
  (prostate)
• 3. Toxic Effects altered secondary sex
  characteristics

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• 7. Hormone inhibitors
• Aromatase inhibitors (Arimidex, Aromasin)
• Prevents production of aromatase which is needed
  for estrogen production
• Used in post menopausal women
• Side effects
• Masculinizing effects in women
• Fluid retention

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Nursing Care of the Client with Cancer

• Effects of Chemotherapy
• a. Tissues (fast growing) frequently affected
• b. Examples mucous membranes, hair cells, bone
  marrow, specific organs with specific agents,
  reproductive organs (all fetal toxic, impair
  ability to reproduce).
• Administration of chemotherapeutic agents
• a. Trained and certified personnel, according to
  established guidelines
• b. Preparation
• 1. Protect personnel from toxic effects
• Drugs absorbed through skin and mucous membranes
• Protective clothing and extreme care
• 2. Extreme care for correct dosage double check
  with physician orders, pharmacists preparation
• c. Proper management clients excrement

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Nursing Care of the Client with Cancer

• d. Routes
• 1. Oral
• 2. Body cavity (intraperitoneal or intrapleural)
• 3. Intravenous
• Use of vascular access devices because of threat
  of extravasation (leakage into tissues) and
  long-term therapy
• If the drug is a vessicant it may result in pain,
  infection and tissue loss

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• e. Types of vascular access devices
• 1. PICC lines (peripherally inserted central
  catheters)
• 2. Tunnelled catheters (Hickman, Groshong)
• 3. Surgically implanted ports (accessed with 90o
  angle needle

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Hickman Catheter
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Portacath
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PICC Line
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Nursing Care of the Client with Cancer

• Managing side effects of chemotherapy
• A. Nausea and vomiting
• 80 of patients will develop it
• Antiemetics such as Zofran, Tigan, Compazine as
  well as Ativan to control the symptoms
• Monitor for dehydration and need for IV fluids

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• B. Bone marrow suppression
• Decreased number of RBC
• Leads to hypoxia, fatigue
• Hgb 9.5-10 gm/dl require oral iron supplements
• Hgb below 8 gm/dl require transfusion
• May use Epogen to stimulate RBC production

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• Decrease number of WBC (normal 4,500-11,000
  mm3) especially neutrophils (normal 3,000-7,000
  cells/cc)
• Neutropenia-count below 2000
• Pt at extreme risk for infection
• May order granulocyte colony stimulating factor
  (leukine) to stimulate bone marrow to increase
  WBC count
• Neutropenic precautions
• Private room
• Good handwashing
• Monitor temp q 4 hours, monitor for chills, UTI,
  pneumonia
• Limit visitors to healthy adults
• No flowers or plants
• Monitor neutrophil count

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• Thrombocytopenia
• Drop in platlet count (normal 150,000-400,000/mm3)
  below 100,000
• Test pt for bleeding in stool and urine
• Avoid punctures for IV or IM
• Handle pt gently
• Use electric razor
• Avoid placing foley or rectal thermometers
• Avoid oral trauma with soft bristle brushes,
  avoid flossing, avoid hard candy
• Watch for ALOC, pupil changes that might indicate
  intracranial bleeds
• Stool softeners to avoid straining

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• C. Mucocitis
• Inflammation and ulceration of mucous membranes
  and entire GI tract
• Rinse mouth with ½ normal saline and ½ peroxide
  every 12 hours
• Topical analgesic medication
• Avoid mouthwashes with alcohol
• Avoid spicy or hard food
• Watch nutritional status

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• D. Alopecia
• Hair loss
• 2-3 weeks after treatment is started
• Affects all the hair, including eyebrows,
  eyelashes
• Within 4-8 weeks after treatment hair begins to
  grow back
• Before hair loss, have the pt pick out a wig that
  is similar to hair color

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• E. Peripheral neuropathy
• Numbness and tingling to fingers and toes in a
  glove and sock pattern
• May cause gait and possible fall problems
• F. Provide emotional and spiritual support to
  patient and families

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Nursing Care of the Client with Cancer

• Surgery
• 1. Diagnosis, staging, and sometimes treatment of
  cancer
• 2. May be prophylaxis or removal of at risk
  tissue or organ prior to development of cancer
  (breast cancer)
• 3. Involves removal of body part, organ,
  sometimes with altered functioning (e.g.
  colostomy)
• 4. Debulking (decrease size of) tumors in
  advanced cases
• 5. Reconstruction and rehabilitation (e.g. breast
  implant post mastectomy)
• 6. Palliative surgery to improve the quality
  of life
• Removal of tumor tissue that is causing pain or
  obstruction
• 5. Psychological support to deal with surgery as
  well as cancer diagnosis

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Nursing Care of the Client with Cancer

• Radiation Therapy
• 1. Treatment of choice for some tumors to kill
  or reduce tumor, relieve pain or obstruction
• Destroy cancer cells with minimal exposure to
  normal cells
• Cells die or are unable to divide
• 2. Delivery
• a. Teletherapy (external) radiation delivered in
  uniform dose to tumor
• Beam radiation
• b. Brachytherapy delivers high dose to tumor and
  less to other tissues radiation source is placed
  in tumor or next to it in the form of seeds
• Radiation source within the patient so pt emits
  radiation for a period of time and is a hazard to
  others
• c. Combination

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• 3. Goals
• a. Maximum tumor control with minimal damage to
  normal tissues
• b. Caregivers must protect selves by using
  shields, distancing and limiting time with
  client, following safety protocols
• Private room
• Caution sign on the door for radioactive material
• Dosimeter film badge by staff
• No pregnant staff
• Limit visitors to ½ hour per day and keep them at
  least 6 ft from the source

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Nursing Care of the Client with Cancer

• 4. Treatment Schedules
• a. Planned according to radiosensitivity of
  tumor, tolerance of client
• b. Monitor blood cell counts
• 5. Side Effects
• a. Skin (external radiation) blanching,
  erythema, sloughing, breakdown
• Use mild soak
• Dry skin with a patting motion, not rubbing
• Dont use powders or lotions unless prescribed by
  radiologist
• Wear soft clothing over the site
• Avoid the sun and heat

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• b. Ulcerated mucous membranes pain, lack of
  saliva (xerostoma)
• c. Gastrointestinal nausea and vomiting,
  diarrhea, bleeding, sometimes fistula formation
• d. Radiation pneumonitis
• 1-3 months after treatment
• Cough, SOB, fever
• Treated with steroids to decrease inflammation

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Nursing Care of the Client with Cancer

• Monoclonal antibodies (inoculate animal with
  tumor antigen and retrieve antibodies against
  tumor for human)
• Antibodies target specific substances needed by
  the cancer cell for growth (Herceptin for breast
  cancer)

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• Gene therapy
• experimental
• May insert gene into the tumor cells to make them
  more susceptible to being killed by antiviral
  agents
• May insert genes for cytokines that increase
  their effectiveness in killing cancer cells

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• Angiogenesis inhibitor drugs
• prevent new blood vessels from forming and
  delivering blood to the tissue

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Nursing Care of the Client with Cancer

• F. Bone Marrow Transplantation and Peripheral
  Blood Stem Cell Transplantation
• 1. Stimulation of nonfunctioning marrow or
  replace bone marrow
• 2. Common treatment for leukemias
• G. Pain Control
• 1. Includes pain directly from cancer, treatment,
  or unrelated
• 2. Necessary for continuing function or comfort
  in terminally ill clients
• 3. Goal is maximum relief with minimal side
  effects
• 4. Multiple combinations of analgesics (narcotic
  and non-narcotic) and adjuvants such as steroids
  or antidepressants includes around the clock
  (ATC) schedule with additional medications for
  break-through pain
• 5. Multiple routes of medications
• 6. May involve injections of anesthetics into
  nerve, surgical severing of nerves radiation
• 7. May need to progress to stronger pain
  medications as pain increases and client develops
  tolerance to pain medication

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Nursing Care of the Client with Cancer

• Nursing Diagnoses for Clients with Cancer
• A. Anxiety
• 1. Therapeutic interactions with client and
  family community resources such as American
  Cancer Society, I Can Cope
• 2. Availability of community resources for
  terminally ill (Hospice care in-patient, home
  care)
• B. Disturbed Body Image
• 1. Includes loss of body parts (e.g.
  amputations) appearance changes (skin, hair)
  altered functions (e.g. colostomy) cachexic
  appearance, loss of energy, ability to be
  productive
• 2. Fear of rejection, stigma
• C. Anticipatory Grieving
• 1. Facing death and making preparations for
  death will be consideration
• 2. Offer realistic hope that cancer treatment may
  be successful

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Nursing Care of the Client with Cancer

• D. Risk for Infection
• E. Risk for Injury
• 1. Organ obstruction
• 2. Pathological fractures
• F. Altered Nutrition less than body requirements
• 1. Consultation with dietician, lab evaluation of
  nutritional status
• 2. Managing problems with eating anorexia,
  nausea and vomiting
• 3. May involve use of parenteral nutrition
• G. Impaired Tissue Integrity
• 1. Oral, pharyngeal, esophageal tissues (due to
  chemotherapy, bleeding due to low platelet
  counts, fungal infections such as thrush)
• 2. Teach inspection, frequent oral hygiene,
  specific non-irritating products, thrush control

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Nursing Care of the Client with Cancer

• Oncologic Emergencies
• A. Pericaridal Effusion and Neoplastic Cardiac
  Tamponade
• 1. Concern compression of heart by fluid in
  pericardial sac, compromised cardiac output
• 2. Treatment pericardiocentesis

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• B. Superior Vena Cava Syndrome
• 1. obstruction of venous system with increased
  venous pressure and stasis facial and neck edema
  with slow progression to respiration distress
• Late signs are cyanosis, decreased cardiac output
  and hypotension
• 2. Treatment respiratory support decrease tumor
  size with radiation or chemotherapy

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Compression of the superior vena cava in SVC
syndrome
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• C. Sepsis and Septic Shock
• 1. Early recognition of infection
• Patients at risk secondary to low WBC and
  impaired immune system
• 2. Treatment prompt intervention with
  antibiotics and vasopressors

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• D. DIC disseminated intravascular coagulation
• Triggered by severe illness, usually sepsis in
  cancer patients
• Abnormal clotting uses up existing clotting
  factors and platelets quickly then the pt
  hemorrhages
• Mortality rate is 70
• Prevention of sepsis is key

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Nursing Care of the Client with Cancer

• E. Spinal Cord Compression
• 1. Pressure from expanding tumor or vertebral
  collapse can cause irreversible paraplegia
• 2. Back pain initial symptom with progressive
  paresthesia and paralysis
• Paralysis is usually permanent
• 3. Treatment early detection
• High dose corticosteroid to decrease the swelling
• radiation or surgical decompression

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• F. Obstructive Uropathy
• 1. Concern blockage of urine flow undiagnosed
  can result in renal failure
• 2. Treatment restore urine flow

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• G. Hypercalcemia
• 1. High calcium (normal 9-10.5) usually from
  bone metastases
• 2. May also come from cancer of the lung, head,
  neck, kidney and lymph nodes that secrete
  parathyroid hormone that causes the bone to
  release calcium
• 2. Symptoms include fatigue, muscle weakness,
  polyuria, constipation, progressing to coma,
  seizures
• 3. Treatment
• restore fluids with intravenous saline which
  also increases the excretion of calcium
• loop diuretics increase calcium excretion
• Calcium chelators such as mithracin
• Inhibit calcium resorption from the bone with
  calcitonin, diphosphonate

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• H. Tumor Lysis Syndrome
• 1. Occurs with rapid necrosis of tumor cells with
  chemotherapy
• When tumor cells die they release potassium and
  purines
• Potassium (norm 3.5-5.5) elevation causes cardiac
  arrhthymias, muscle weakness, twitching, cramps
• Purines convert to uric acid which causes renal
  failure, flank pain, gout when elevated above 10
  mg/dl
• Hyperphosphatemia with secondary to hypocalcemia
  causes heart block, HTN, renal failure

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• Treatment
• Hydration
• Instruct pt to increase fluid intake before and
  after chemo
• May need IV hydration
• Diuretics to increase urine flow
• Allopurinol to increase uric acid excretion
• May need dialysis

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Nursing Care of the Client with Cancer

• I. SIADH (Syndrome of Inappropriate Antidiuretic
  Hormone Secretion)
• 1. Ectopic ADH production from tumor leads to
  excessive hyponatremia
• 2. holds onto too much fluid which decreases
  sodium level (normal 135-145)
• 3. Symptoms
• Weakness, muscle cramps, fatigue, ALOC, headache,
  seizures
• 2. Treatment restore sodium level
• Fluid restriction
• Increase sodium
• Antibiotic demeclocycline works in opposition to
  ADH
• Limits ADH effect on distal renal tubules so they
  can excrete water