Di+Siadh,Irwan

8/13/2019 Di+Siadh,Irwan

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Diabetes Insipidusby : Irwan Subekti,SKep,Ners


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Posterior Pituitary

Antidiuretic

hormone(ADH) (Also

called vasopressin)

Disorders/diseases

resulting from

dysfunction

Excess:Syndrome of

Inappropriate ADH

secretion (SIADH)

Deficiency:

Diabetes Insipidus


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Pathophysiology of

Diabetes InsipidusInjury to hypothalamus orpituitary gland

Free water excreted in urineExtracellular dehydration

Hypotension

Hypovolemic shock

Hypernatremia

Decreased cerebral perfusion


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DI: Pathogenesis

Inability to concentrate urine Central

ADH deficiency from hypothalamo-neurohypophyseal damage or atrophy,

ADH mutations Nephrogenic

Renal inability to respond to ADHsecondary to disturbance of

corticomedullary osmotic gradient,defect of ADH-cAMP system, orosmotic diuresis.

Psychogenic polydipsia physiologic ADH inhibition


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Diabetes Insipidus : Etilogy

Familial oridiopathic

Head injury

Neuorsurgery

Damage to thehypothalamicareas thatproduce ADH

Cause

Lesion ofhypothalmusinterferes with ADH

synthesis/transport/release

brain tumour

pituitary/cranialsurgery

head trauma

CNS infection

vascular disease.


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4Types of Diabetes Insipidus 1) Neurogenic-also known as

central hypothalamic

pituitary

neurohypophyseal

Caused by a deficiency of the

Antidiuretic hormone,

vasopressin

2) Nephrogenic-also knownas

Vasopressin - resistant Caused by insensitivity of

the kidneys to the effect of

the antidiuretic hormone,

vasopressin

3) Gestagenic-also

known as

Gestestional

Caused by a deficiency

of the antidiuretic

hormone, vasopressin,

that occurs only during

pregnancy

4) Dipsogenic, a form

of primary polydipsis

Caused by

Abnormal thirst and the

Excessive intake of water

or other liquids


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Diagnosis & RxDiabetes Insipidus

Diagnosis D.I.

History and

examination

Water deprivation test

Vasopressin challenge

test 24 hours urine

Highsod iumin

blood MRI of pituitary,

hypothalmus and skull

to see damaged areas

Treatment

Intravenous fluids

Hypertonic saline IV-

Extracellular solution topull fluid from outside

the cell to inside the cell

Vasopressin SC/IM/IV,

nasal prep Long term DDAVP

(Desmopression) nasal

prep. (analog ADH)


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Diagnosis - Fluid Deprivation Test(To identify cause of polyuria)

Baseline VS, then check hourly-allows RN todetect changes, esp postural hypotensin &

tachycardia

Deprive pt of fluid-Observe for compliance withfluid restriction

Hourly- urinary output, specific gravity, &

osmololity

Urine test results determine whether testing

can proceed.

Testing can proceed if urinary osmolality

stabilized for 3 samples and 3% wt loss is noted


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Dx- Vasopressin challenge

Order for 5 Units of aqueous vasopressin sc Continue hourly urinary measurements

Vasopressin triggers and ongoing assessment

detects Changes in urinary specific gravity andosmolality

Specific gravity & osmolality decrease with

primary and secondary diabetes insipidus No response is seen with nephrogenic diabetes

insipidue


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Diabetes insipidus treatment

Vasopressin (Pitressin) : is ADH

Classification: Hormone (antidiuretic)

Uses: Treatment of central diabetes insipidus sue to

deficient antidiuretic hormone.

Route/Dose: IM, sc, nasal spray Nsg Implications:

replace fluid: saline and glucose

monitor I & O

check specific gravity

observe electrolytes

Monitor adverse reactions-abdominal cramps, angina,

MI


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Diabetes insipidus treatment

Desmopressin (DDAVP)

Classification: Hormone (andiuretic)

Indication: Management of primary nocturnal eneuresis

unresponsive to other treatment modalities

po, sc, IV, Intranasal

Action: An anologue of naturally occuring vasopressin

(antiuretic hormone). Primary action is enhanced reabsorptionof water in the kidneys

Therapeutic Effects: Prevention of nocturnal enuresis.

Maintenace of appropriate body water content in diabetes

insipidus. Nsg Implication: Monitor urine & plasma osmola l i ty& urine

vo lumefrequently. Assess pt for symptoms of dehydrat ion

(excessive thirst, dry skin & mucous membranes, tachycardia,

poor skin turgor) Weigh pt daily & assess for edema


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Nursing Issues Fluid and electrolyte imbalance:

R/T >diuresis,

monitor urine and plasma osmolarity

monitor specific gravity (usually will be low with >diuresis)

monitor urine volume (usually will be high 5-10L in 24 hr)

Therapy successful when urine output and specific gravitybegin to return to normal

monitor s/s dehydration

weight pt daily & assess for edema

Fluid vo lume def ic it

Nurse will monitor for hypotension, constipation, shock

Sleeping problems: R/T nocturia & increasedthirst

Education:


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Medical Management

Immediate managementRestoration of circulation fluid

volumePharmacologic ADH replacement

Medications to manage central DIVasopressin (Pitressin)DDAVP (Desmopressin)

Medications to manage nephrogenicDI

Thiazide diuretics

Diagnose and treat cause of DI


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Nursing Management

Nursing priorities in the care of the

patient with DI are directed toward:

Administering fluids and medications.

Evaluating response to therapy.

Maintaining surveillance for complications.

Providing patient and family education.


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Actions/Interventions Rationale

Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance

by drinking huge quantities of water to compensate for the amount

they urinate. Patients prefer cold or ice water.

Provide easily accessible fluid source, keeping adequate fluids at

bedside.

This encourages fluid intake.

Administer intravenous (IV) fluids: IV fluids are indicated if the patient cannot take in sufficient fluids

orally.

5% dextrose in water or 0.45% sodium chloride Hypotonic IV fluids provide free water and help lower serum sodium

levels gradually.

0.9% sodium chloride Isotonic fluids may be indicated for the patient who has sustained

significant fluid loss and is hemodynamically unstable. Once

circulatory volume has been restored, hypotonic IV fluids can be

given.

Administer medication as prescribed. Aqueous vasopressin is usually used for DI of short duration (e.g.,

postoperative neurosurgery or head trauma). Pitressin tannate(vasopressin) in oil (the longer-acting vasopressin) is used for

longer-term DI. Patients with milder forms of DI may use

chlorpropamide (Diabinese), clofibrate (Atromid), or carbamazepine

(Tegretol) to stimulate release of ADH from the posterior pituitary

and enhance its action on the renal tubules. Hydrochlorothiazide

(HydroDIURIL) may also be used for nephrogenic DI.

If vasopressin is given, monitor for water intoxication or rebound

hyponatremia.

Overmedication can result in volume excess.

TherapeuticInterventions


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