Diabetes Insipidus PDF

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Diabetes Insipidus ...

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Diabetes Insipidus 1. Discriminate among elements of clinical decision making for the registered nurse for patients with diabetes insipidus and alterations. 2. Integrate health promotion, specialized modalities and pharmacological agents for patients with Diabetes Insipidus and alterations. 3. Distinguish clinical manifestations and diagnostic findings for patients with Diabetes Insipidus and alterations. 4. Prioritize nursing interventions for patients with Diabetes Insipidus and alterations. Diabetes insipidus ● Diabetes insipidus results from a deficiency of ADH, which is secreted by the posterior lobe of the pituitary gland (neurohypophysis). ● Decreased ADH reduces the ability of the distal renal tubules in the kidneys to collect and concentrate urine, resulting in excessive diluted urination, excessive thirst, electrolyte imbalance, and excessive fluid intake. TYPES of Diabetes Insipidus Primary: A lack of ADH production or release; caused by defects in the hypothalamus or pituitary gland. Secondary: A lack of ADH production or release; caused by infection, tumors in or near the hypothalamus or pituitary gland, head trauma, or brain surgery. Nephrogenic: Inherited; renal tubules do not react to ADH Drug-induced: Lithium carbonate or demeclocycline can alter the way the kidneys respond to ADH. ASSESSMENT Risk Factors: ● Clients who have a head injury, tumor or lesion, surgery or irradiation near or around the pituitary gland, or infection (meningitis, encephalitis) ● Clients who are taking lithium carbonate or demeclocycline ● Older adult clients are at higher risk for dehydration due to lower water content of the body, decreased thirst response, decreased ability of the kidneys to concentrate urine, increased use of diuretics, swallowing difficulties, or inadequate food intake. Expected Findings: ● Polyuria (abrupt onset of excessive urination, urinary output of 4 to 30 L/day of dilute urine): failure of the renal tubules to collect and reabsorb water ● Polydipsia (excessive thirst, consumption of 2 to 20 L/day) ● Nocturia ● Fatigue ● Dehydration, as evidenced by extreme thirst, weight loss, muscle weakness, headache, constipation, and dizziness PHYSICAL ASSESSMENT FINDINGS ● Sunken eyes ● Tachycardia ● Hypotension ● Loss or absence of skin turgor ● Dry mucous membranes ● Weak, poor peripheral pulses ● Decreased cognition Laboratory Test: Electrolyte imbalances: such as increased sodium Urine chemistry: Think DILUTE. ● Decreased urine specific gravity (less than 1.005) ● Decreased urine osmolality (less than 200 mOsm/L) ● Decreased urine pH ● Decreased urine sodium ● Decreased urine potassium ● As urine volume increases, urine osmolality decreases. Serum chemistry: Think CONCENTRATED. ● Increased serum osmolality (greater than 300 mOsm/L) ● Increased serum sodium ● Increased serum potassium ● As serum volume decreases, the serum osmolality increases.

Diagnostic Procedures: Water deprivation test (ADH stimulation test) ● This is an easy and reliable diagnostic test. Dehydration is induced by withholding fluids. ● A subcutaneous injection of vasopressin produces urine output with an increased specific gravity and osmolality. ● The test is positive for DI if the kidneys are unable to concentrate urine despite increased plasma osmolarity. NURSING ACTIONS ● Obtain baseline weight, vital signs, serum electrolytes and osmolarity, and urine specific gravity and osmolarity. ● Monitor hourly vital signs, urine specific gravity, osmolarity, and body weight.  Discontinue the test and rehydrate the client for a loss of more than 2 kg in body weight. ● Monitor for severe dehydration.  Early indications of dehydration can be postural hypotension, tachycardia, and dizziness. Be prepared to discontinue the test if these indicators develop. CLIENT EDUCATION ● Explain the test procedure to the client. ● Advise the client to report any dizziness, headache, or nausea. Vasopressin test A subcutaneous injection of vasopressin produces urine output with an increased specific gravity if the client has central diabetes insipidus. This differentiates central from nephrogenic diabetes insipidus. NURSING ACTIONS: Administer vasopressin subcutaneously and obtain a urine sample for osmolality 30 to 60 min after administration. CLIENT EDUCATION: Explain the test procedure to the client. Advise the client to notify the nurse of any dizziness, headache, or nausea. PATIENT-CENTERED CARE NURSING CARE ● Monitor vital signs, urinary output, central venous pressure, I&O, specific gravity, and laboratory studies (potassium, sodium, BUN, creatinine, specific gravity, osmolarity). ● Weigh the client daily. ● Promote the prescribed diet (regular diet with restriction of foods that exert a diuretic effect, such as caffeine). ● IV therapy: Hydration (I&O must be matched to prevent dehydration) and electrolyte replacement. ● Promote safety: Keep bedside rails up while client is in bed, and provide assistance with ambulation due to dizziness or muscle weakness. Ensure easy access to a bathroom or bedpan. ● Add bulk foods and fruit juices to the diet if constipation develops. A laxative might be needed. ● Assess skin turgor and mucous membranes. ● Provide skin and mouth care, and apply a lubricant to cracked or sore lips. Use a soft toothbrush and mild mouthwash to avoid trauma to the oral mucosa. Use alcohol-free skin care products, and apply emollient lotion after baths. ● Encourage the client to drink fluids in response to thirst. MEDICATIONS ADH replacement agents ● Desmopressin, which is a synthetic ADH, or aqueous vasopressin administered intranasally, orally, or parenterally ● Results in increased water absorption from kidneys and decreased urine output NURSING CONSIDERATIONS ● Monitor vital signs, urinary output, central venous pressure, I&O, specific gravity, and laboratory studies (potassium, sodium, BUN, creatinine, specific gravity, osmolarity). ● Dose can be adjusted depending on urine output. ● Give vasopressin cautiously to clients who have coronary artery disease because the medication can cause vasoconstriction. ● Monitor for headache, confusion, or other indications of water intoxication. CLIENT EDUCATION ● Educate the client regarding lifelong self-administration of vasopressin therapy. ● For an intranasal dose, teach the client to clear nasal passage and sit upright prior to inhalation. ● Instruct the client to monitor weight daily and notify the provider of a gain greater than 0.9 kg (2 lb) in 24 hr. ● Instruct the client to restrict fluids if directed and notify the provider of headache or confusion. INTERPROFESSIONAL CARE Home assistance for fluid, medication, and dietary management might be required.

CLIENT EDUCATION ● Instruct client on medications for home use. ● Instruct the client to weigh daily, eat a high-fiber diet, wear a medical alert wristband, and monitor fluid I&O. ● Teach the client to monitor for indications of dehydration (weight loss; dry, cracked lips; confusion; weakness). ● Advise the client to restrict fluids as prescribed to prevent water intoxication and avoid consumption of alcohol. COMPLICATIONS Untreated DI can cause hypovolemia, hyperosmolarity, hypernatremia, circulatory collapse, unconsciousness, central nervous system damage, and seizures. Excessive urine output causing severe dehydration can lead to these complications. NURSING ACTIONS: Monitor fluid balance and prevent dehydration by providing proper fluid intake. CLIENT EDUCATION: Advise the client to seek early medical attention for any indications of DI and follow care instructions....