Unit 2: Diabetes Insipidus

Question 1

Antidiuretic Hormone (ADH)

Answer 1

“Vasopressin”

• produced in hypothalamus
• stored and secreted in posterior pituitary gland
• regulates amount of water in the body and constricts blood vessels
• regulates the water by telling the renal tubules to retain water
• increased ADH = increased water retention
• decreased ADH = decreased water retention (increased urinary output)

Question 2

Antidiuresis

Answer 2

no diuresis

-low urinary output

Question 3

Diabetes Insipidus (DI)

Answer 3

• central or nephrogenic
• decreased ADH
• excretion of water by the kidneys; increased urinary output
• decreased urine specific gravity; urine is like clear water (dilute)
• dehydrated
• receives Vasopressin (need to replace ADH)

Question 4

Central DI

Answer 4

caused by a decreased secretion of antidiuretic hormone (ADH) from the posterior pituitary gland

Question 5

Nephrogenic DI

Answer 5

occurs when the kidneys are resistant to ADH and are unable to concentrate urine
-seen in patients w/ chronic renal insufficiency, hypercalcemia, hypokalemia, and interstitial disease of renal tubules

Question 6

Pathophysiology of DI

Answer 6

• the decrease or absence of ADH results from lack of production in the hypothalamus
• antidiuretic hormone (ADH), stored and released from the posterior pituitary gland, works on the receptor cells in the collecting ducts of the kidney, leading to water reabsorption back into the circulation
• with a lack of ADH, the collecting ducts are less permeable to water, and is excreted in urine
• with DI, lack of ADH leads to excretion of large volumes of very dilute urine

Question 7

Clinical Manifestations of DI

Answer 7

dependent on the significance of water loss
-polyuria (increased U/O)
-polydipsia (increased thirst)
-nocturia (urinating frequently at night)
>excessive loss of water leads to hemoconcentration that is observed w/ elevations in serum sodium and hematocrit
-may present with hypotension and tachycardia secondary to hypovolemia
-decreased urine specific gravity
-other signs of fluid volume deficit including thirst, skin tenting, and fatigue

Question 8

What are the primary clinical manifestations seen in DI?

Answer 8

• polyuria (increased U/O)
• polydipsia (increased thirst)
• nocturia (urinating frequently at night)

Question 9

Causes of DI

Answer 9

DI is a decrease in ADH

• kidney issues
• brain tumor
• develop after intracranial surgery
• head trauma

Question 10

Diagnosis of Diabetes Insipidus

Answer 10

-serum and urine electrolytes
-serum and urine osmolality
-CT or MRI of the head
-Urine-specific gravity of less than 1.005
-Urine Osmolality less than 200 MOsm/Kg
-while losing free water, increases in serum sodium, serum osmolality, and hematocrit develop secondary to hemoconcentration
-water deprivation test
>Diagnosis of DI is made when serum osmolality continues to increase and there is no resultant increase in urine osmolality

Question 11

Fluid Management

Answer 11

Management focused on maintaining adequate fluid volume status

• daily weight and I &Os
• if awake and alert, can replace fluid loss by drinking fluids
• in emergency or unconscious patient, IV fluid
• water losses replace w/ a hypotonic fluid (in relation to serum osmolality) such as dextrose in water
• during IV administration, monitor for hyperglycemia, volume overload, and correction of hypernatremia
• avoid food that promotes diuresis (coffee, watermelon, grapes, lemons)

Question 12

Medication Management: Drug of choice

Answer 12

Desmopressin (DDVAP)
-synthetic analog of ADH
-increases ADH
-subcutaneous, intranasal, and oral preparations
>can also give vasopressin (Pitressin), a less expensive ADH synthetic
>these meds require monitoring of fluid status, serum electrolytes, and urine output

Question 13

Desmopressin (DDVAP)

Answer 13

drug of choice for DI
-synthetic analog of ADH
-replaces ADH
-subcutaneous, intranasal, and oral preparations
>med requires frequent monitoring of fluid status, serum electrolytes, and urine output

Question 14

Laboratory Tests

Answer 14

• Hematocrit
• Serum Sodium
• Urine-Specific Gravity

Question 15

Laboratory Tests: Hematocrit

Answer 15

Male: 43-49%
Female: 38-44%
-volume of red blood cells (RBC) in the body
-hematocrit increased in DI

Question 16

Laboratory Tests: Serum Sodium

Answer 16

135-145 mEq/L

-increased in DI

Question 17

Laboratory Tests: Urine-specific gravoty

Answer 17

1. 005-1.030

- decreased in DI

Question 18

Connection Check: The nurse correlates which laboratory value as an indication that desmopressin is effective in the treatment of DI?
A. Serum sodium of 140 mEq/L
B. Serum osmolality of 305 mOsm/kg
C. Urine-specific gravity of 1.004
D. Serum hematocrit 48%

Answer 18

A. Serum sodium of 140 mEq/L

(normal: 135-145)
- sodium will go back to normal because of an increase in ADH from the ADH synthetic medication; ADH would decrease urine output, and allow for more volume of fluid

Question 19

Complications

Answer 19

• develop dehydration and hypovolemia, which will progress to circulatory collapse w/o adequate fluid administration
• patients w/ permanent DI who require daily administration of hormone replacement are at risk for hypovolemia
• hemoconcentration secondary to DI increases risk for hypernatremia

Question 20

Clinical Manifestations of Hypernatremia

Answer 20

r/t central nervous system dysfunction secondary to shrinkage of brain cells
-results in confusion, neuromuscular excitability, seizures, or coma

Question 21

Hemoconcentration

Answer 21

increased concentration of cells and solids in the blood usually resulting from loss of fluid to the tissues

Question 22

Nursing Management: Assessment and Analysis

Answer 22

DI is directly r/t the lack of ADH; there is a loss of free water
>Assessments include:
-polyuria
-urine specific gravity less than 1.005
-low urine osmolality
-secondary to hemoconcentration, lab analysis revels an increase in serum sodium, osmolality, and hematocrit
-changes in BP and HR r/t volume of fluid loss
-patients who are awake and alert with an intake thirst mechanism are usually able to maintain fluid volume by drinking adequate fluids

Question 23

Nursing Diagnoses

Answer 23

• Fluid volume deficit r/t loss of free water secondary to lack of ADH
• Risk for ineffective therapeutic regimen management r/t required administration of desmopressin (DDVAP)
• Sensory perceptual alteration (vision) r/t compression of CN II and III secondary to pituitary tumor

Question 24

Nursing Assessments

Answer 24

• Vital signs
• Intake and Output
• Daily weight
• Visual acuity
• Serum Sodium and Osmolality
• Urine-Specific Gravity

Question 25

Assessments: Vital Signs

Answer 25

lack of ADH leads to excessive water loss with resulting decrease in BP and increase in HR as a compensatory mechanism

Question 26

Assessment: Intake and Output

Answer 26

fluid replacement is dependent on the volume of urine output secondary to lack of ADH

Question 27

Assessments: Daily weight

Answer 27

increased output of dilute urine leads to a decrease in weight

Question 28

Assessment: Serum Sodium and Osmolality

Answer 28

lack of ADH cause an increase in water excretion leading to the concentration of serum sodium (hypernatremia) and an increase in serum osmolality
>Normal sodium (135-145)

Question 29

Assessments: Urine-Specific Gravity

Answer 29

lack of ADH results in the excretion of large volumes of dilute urine

• Urine specific gravity usually less than 1.005
  (1. 005-1.030)

Question 30

Nursing Actions

Answer 30

• Maintain IV access and administer ordered IV solutions
• Administer desmopressin or vasopressin as ordered
• provide adequate oral fluids
• provide mouth care

Question 31

Actions: Administer desmopressin or vasopressin as ordered

Answer 31

synthetic ADH is administered to cause water reabsorption in the kidney

Question 32

Actions: Provide adequate oral fluids

Answer 32

if the patient is alert and awake and has an intact gag reflex, the patient is allowed to drink fluids

Question 33

Actions: Provide mouth care

Answer 33

patient is at risk for fluid volume deficit r/t lack of ADH and require mouth care to minimize complications of dry mucous membranes

Question 34

Nursing Teachings

Answer 34

• Importance of taking medications (ADH replacement) as ordered
• Weigh daily at the same time and on same scale; changes of more than 2 lb./day be reported
• Clinical Manifestations of DI
• Clinical manifestations of fluid overload

Question 35

Connection Check: The patient experiencing diabetes insipidus (DI) is ordered to receive DDAVP. The nurse monitors for which therapeutic effect of these medications
A. increased urine output
B. increased urine-specific gravity
C. increased serum sodium
D. increased serum potassium

Answer 35

B. increased urine-specific gravity

1.005-1.030

Question 36

Evaluating Care Outcomes

Answer 36

DI may be transient after head injury or craniotomy, or permanent disorder

• definitive treatment w/ synthetic ADH replacement results in water reabsorption and normalization of urine output, urine-specific gravity, and serum electrolytes (sodium)
• vital signs are normal
• output proportional to intake
• body weight is stable

Question 37

Safety Alert: Fluid administration after transsphenoidal hypophysectomy

Answer 37

fluid administration must be closely monitored
-administration of hypotonic solutions in post-op patient with a normal serum sodium level increases the risk of fluid shifts and can lead to cerebral edema and an increased in intracranial pressure (ICP)