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Diabetes insipidus

Introduction
Diabetes insipidus (DI) is a condition
which causes frequent urination. The
reduction in production or release of ADH
results in fluid and electrolyte imbalance
caused by increased urinary output.
Depending on the cause, Diabetes
insipidus may be transient or life long
condition. In its clinically significant
forms, diabetes insipidus is a rare
disease.

Definition
Diabetes insipidus (DI) is a group of
conditions associated with a
deficiency of secretion of antidiuretic hormone characterized by
the chronic excretion of abnormally
large volumes (more than 50 mL/kg)
of dilute urine.

Incidence
The true prevalence of DI is
unknown, but it is usually
underdiagnosed because the
symptoms and signs are benign and
many patients ignore them or are
unaware of them. It commonly occur
in older adults.

Types
Central (neurogenic) DI: it occurs when any lesion of the
hypothalamus or posterior pituitary interferes with ADH
synthesis, transport or release.
nephrogenic DI: it results from the decreased renal response
to ADH despite presence of adequate ADH.
Primary polydipsia(dispogenic DI): excessive water intake
caused by structural lesion in thirst center or psychologic
disorder.
Gestational DI.
Causes
Central (neurogenic) DI: Multiple causes include brain tumour,
head injury, brain surgery, CNS infections.
nephrogenic DI: Caused by lithium therapy, renal damage, or
hereditary renal disease.
Primary polydipsia(dispogenic DI): excessive water intake
caused by structural lesion in thirst center or psychologic
disorder.

Pathophysiologi
The decrease in ADH results in fluid and electrolyte
imbalances caused by increased urinary output and
increased plasma osmolality. Tubular reabsorption of water
reduces due to decreased tubular permiabilityto the water.
This results in excessive urination which affects activities of
daily living and interrupts sleep when nocturia occurs.
Distended bladder leads to back flow of urine and
hydronephrosis may develope as a complication. This will
eventually leads to renal insufficiency.
Serum osmolality increases due to excessive urine output.
Serum sodium level elevates in order to compensate for the
fluid loss. severe thirst develops by osmoreceptor
stimulation in response to the hypernatrmia. Patent intakes
fluid to replace the loss. If hypernatremia persists
restlessness, reduction in reflexes and seizures may
develope. Cardiac output decreases and tachycardia
develops if fluid volume is not restored. It will lead to
hypotension and finally to hypovolemic shock.

Clinical Manifestations
Diabetes insipidus is characterized by increased thirst and
increased urination. The primary character of DI is polyuria,
excretion of large quantities of urine ( 5-20L per day)with a very
low specific gravity(less than 1.005) and urine osmolality of <
100mmol/kg. In partial DI urine output may be lower(2-4L per day).
Polydipsia (excessive intke of fluids) is also a characteristic feature
of DI. Patient compensate for fluid loss by drinking great amount of
water. The patient with central DI favours cold or iced drinks.
Nocturia occurs due to frequent tendency to urinate which
interrups sleep of the patient.
Central DI usually occurs suddenly with excessive fluid loss. DI
usually has a triphastic pattern: the acute phase with abrupt onset
of polyuria, an interphase where urine volume apparently
normalizes, and a third phase where DI is permanent.
If fluid loss is not compensated, severe fluid volume de ficit results.
This deficit is manifested by weight loss, hypotension, tachycardia
with decreased cardiac output, poor tissue turgor, irritability,
mental dullness. Hypovolemic shock may develop if fluid volume is
not restored.

Diagnostic Studies
Complete history collection regarding cause
and origin of Diabetes Insipidus. Hourly
intake and output should be recorded.
Physical examination: frequent monitoring
of vital signs, body weight, skin turgor, level
of consciousness are necessary.
Urine specific gravity less than 1.005
indicates Diabetes Insipidus.
Urine osmolality less than 100mmol/kg
indicates Diabetes Insipidus.. Serum
osmolality greater than 295mmol/kg
indicates Diabetes Insipidus.

Water Deprivation Test


Use to find cause of polyuria. All fluids
are withheld for 8 to 16 hours. During the
test patients blood pressure, weight and
urine osmolality are assessed hourly. ADH
is administered IV or subcutaneously and
urine osmolality is measured one hour
later. In central DI the rise in urine
osmolality after vasopressin exceeds 9%.
In nephrogenic DI there is no response to
ADH.

Treatment
Goal: maintenance of fluid and
electrolyte balance.

Pharmacological
Management

Fluid replacement: hypotonic saline


is administered intravenously. For
central diabetes Insipidus.

Hormone Replacement
Desmopressin acetate(DDAVP) can
be administered orally,intravenously
or as nasal spray.
Aqueous vasopressin( pitressin)
Vasopressin tenate
Chlorpropamide( diabinese)
Carbamazepine (tegretol)

For Nephrogenic Diabetes


Insipidus

Dietary measures: limiting sodium


intake to less than 3 g per day help
to reduce urine output.
Thiazide diuretics: they are able to
slow glomerular filtration rate and
allows the kidney to reabsorb more
water. E.g. hydrochlorothiazide
(hydroDiuril), chlorothiazide (Diuril).
Indomethacin (indocin).

Nursing Diagnosis
1. Fluid volume deficit related to excessive urinary output as
manifested by increased thirst and weight loss.
2. Sleeping pattern disturbances, insomnia related to nocturia as
manifested by verbalization of patient about interrupted sleep
3. Activity intolerance related to fatigue and frequent urination as
manifested by weakness and fatigue of the patient.
4. Anxiety related to course of disease and frequent urination as
manifested by verbalization of anxious questions.
5. Ineffective coping related to frequent urination as manifested
by verbalization of negative feeling by the patient.
6. Risk for complications related to excessive loss of fluid from the
body as manifested by hypotension and weight loss.
7. Knowledge deficit regarding management of diabetes insipidus
as manifested by verbalization of doubts by the patient.

Interventions
1. Fluid volume deficit related to
excessive urinary output as manifested
by increased thirst and weight loss.
Assess the fluid level of the patient
Monitor vital signs frequently
Restrict oral fluid intake.
Administer hypotonic saline
intravenously.
Administer medications if ordered.

Interventions
2. Disturbed sleeping pattern, insomnia
related to nocturia as manifested by
verbalization of patient about
interrupted sleep.
Assess the sleeping pattern of the
patient
Give psychological support.
Advice the patient to restrict oral
fluids
Provide calm and quiet environment.

Interventions
3. Activity intolerance related to
fatigue and frequent urination as
manifested by fatigue and weakness
of the patient.
Assess the activity status of the
patient
Give psychological support to the
patient.

Interventions
4. Anxiety related to course of disease and
frequent urination as manifested by
verbalization of anxious questions.
Assess the anxiety level of the patient.
Explain the patient about the disease
and treatment.
Provide calm and quiet environment.
Divert the attention of the patient by
talking about different matter.

Interventions
5. Ineffective coping related to
frequent urination as manifested by
verbalization of negative feeling by
the patient.
Assess the coping ability of the
patient
Explain the patient about the
disease and treatment
Give psychological support.

Interventions
6. Risk for complications related to excessive
loss of fluid from the body as manifested
by hypotension and weight loss.
Assess the fluid volume of the patient
Monitor vital signs frequently.
Take immediate measures to restore
fluid volume such as IV fluid therapy
Administer medications as ordered.

Interventions
7. Knowledge deficit regarding
management of diabetes insipidus
as manifested by verbalization of
doubts by the patient
Assess the knowledge level of the
patient.
Explain the management of
diabetes insipidus to the patient.

Summary
Diabetes insipidus cause frequent
urination, even at night, which can
disrupt sleep. Patient feels excessive
thirst by the stimulation of osmoreceptor
response. Because of the excretion of
abnormally large volumes of dilute urine,
patient may quickly become dehydrated
if do not drink enough water. It can be
treated with fluid replacement and
hormone replacement therapy.

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