KMB Diabetes Insipidus

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    Diabetes insipidus

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    Introduction

    Diabetes insipidus (DI) is a conditionwhich causes frequent urination. Thereduction in production or release of ADH

    results in uid and electrolyte imbalancecaused by increased urinary output.Depending on the cause Diabetesinsipidus may be transient or life longcondition. In its clinically signi!cantforms diabetes insipidus is a raredisease.

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    De!nition

    Diabetes insipidus (DI) is a group ofconditions associated with ade!ciency of secretion of anti"diuretic hormone characteri#ed bythe chronic e$cretion of abnormallylarge %olumes (more than &' m*g)

    of dilute urine.

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    Incidence

    The true pre%alence of DI isun*nown but it is usuallyunderdiagnosed because thesymptoms and signs are benign andmany patients ignore them or areunaware of them. It commonly occur

    in older adults.

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    Types

    + ,entral (neurogenic) DI- it occurs when any lesion of thehypothalamus or posterior pituitary interferes with ADHsynthesis transport or release.

    + nephrogenic DI- it results from the decreased renal responseto ADH despite presence of adequate ADH.

    + rimary polydipsia(dispogenic DI)- e$cessi%e water inta*ecaused by structural lesion in thirst center or psychologicdisorder.

    + /estational DI. ,auses + ,entral (neurogenic) DI- 0ultiple causes include brain tumour

    head in1ury brain surgery ,23 infections. + nephrogenic DI- ,aused by lithium therapy renal damage or

    hereditary renal disease. + rimary polydipsia(dispogenic DI)- e$cessi%e water inta*e

    caused by structural lesion in thirst center or psychologicdisorder.

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    athophysiologi

    The decrease in ADH results in uid and electrolyteimbalances caused by increased urinary output andincreased plasma osmolality. Tubular reabsorption of waterreduces due to decreased tubular permiabilityto the water.

    This results in e$cessi%e urination which a4ects acti%ities ofdaily li%ing and interrupts sleep when nocturia occurs.Distended bladder leads to bac* ow of urine andhydronephrosis may de%elope as a complication. This wille%entually leads to renal insu5ciency.3erum osmolality increases due to e$cessi%e urine output.3erum sodium le%el ele%ates in order to compensate for theuid loss. se%ere thirst de%elops by osmoreceptor

    stimulation in response to the hypernatrmia. atent inta*esuid to replace the loss. If hypernatremia persistsrestlessness reduction in ree$es and sei#ures mayde%elope. ,ardiac output decreases and tachycardiade%elops if uid %olume is not restored. It will lead tohypotension and !nally to hypo%olemic shoc*.

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    ,linical 0anifestations

    Diabetes insipidus is characteri#ed by increased thirst andincreased urination. The primary character of DI is polyuriae$cretion of large quantities of urine ( &"6' per day)with a %erylow speci!c gra%ity(less than 7.''&) and urine osmolality of 87''mmol*g. In partial DI urine output may be lower(6"9 per day).

    olydipsia (e$cessi%e int*e of uids) is also a characteristic feature

    of DI. atient compensate for uid loss by drin*ing great amount ofwater. The patient with central DI fa%ours cold or iced drin*s.2octuria occurs due to frequent tendency to urinate whichinterrups sleep of the patient.

    ,entral DI usually occurs suddenly with e$cessi%e uid loss. DIusually has a triphastic pattern- the acute phase with abrupt onsetof polyuria an interphase where urine %olume apparently

    normali#es and a third phase where DI is permanent. If uid loss is not compensated se%ere uid %olume de !cit results.

    This de!cit is manifested by weight loss hypotension tachycardiawith decreased cardiac output poor tissue turgor irritabilitymental dullness. Hypo%olemic shoc* may de%elop if uid %olume isnot restored.

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    Diagnostic 3tudies

    ,omplete history collection regarding causeand origin of Diabetes Insipidus. Hourlyinta*e and output should be recorded.

    hysical e$amination- frequent monitoringof %ital signs body weight s*in turgor le%elof consciousness are necessary.

    :rine speci!c gra%ity less than 7.''&indicates Diabetes Insipidus.

    :rine osmolality less than 7''mmol*gindicates Diabetes Insipidus.. + 3erumosmolality greater than 6;&mmol*gindicates Diabetes Insipidus.

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    hours. During thetest patient?s blood pressure weight and

    urine osmolality are assessed hourly. ADHis administered [email protected] or subcutaneously andurine osmolality is measured one hourlater. In central DI the rise in urine

    osmolality after %asopressin e$ceeds ;.In nephrogenic DI there is no response toADH.

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    Treatment

    /oal- maintenance of uid andelectrolyte balance.

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    harmacological

    0anagement Bluid replacement- hypotonic salineis administered intra%enously. Borcentral diabetes Insipidus.

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    Hormone Ceplacement

    Desmopressin acetate([email protected]) canbe administered orallyintra%enouslyor as nasal spray.

    Aqueous %asopressin( pitressin)

    @asopressin tenate

    ,hlorpropamide( diabinese) ,arbama#epine (tegretol)

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    Bor 2ephrogenic Diabetes

    Insipidus Dietary measures- limiting sodiuminta*e to less than g per day helpto reduce urine output.

    Thia#ide diuretics- they are able toslow glomerular !ltration rate andallows the *idney to reabsorb more

    water. E.g. hydrochlorothia#ide(hydroDiuril) chlorothia#ide (Diuril).

    Indomethacin (indocin).

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    2ursing Diagnosis

    7. Bluid %olume de!cit related to e$cessi%e urinary output asmanifested by increased thirst and weight loss.

    6. 3leeping pattern disturbances insomnia related to nocturia asmanifested by %erbali#ation of patient about interrupted sleep

    . Acti%ity intolerance related to fatigue and frequent urination asmanifested by wea*ness and fatigue of the patient.

    9. An$iety related to course of disease and frequent urination asmanifested by %erbali#ation of an$ious questions.

    &. Ine4ecti%e coping related to frequent urination as manifestedby %erbali#ation of negati%e feeling by the patient.

    >. Cis* for complications related to e$cessi%e loss of uid from thebody as manifested by hypotension and weight loss.

    F. Gnowledge de!cit regarding management of diabetes insipidusas manifested by %erbali#ation of doubts by the patient.

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    Inter%entions

    7. Bluid %olume de!cit related toe$cessi%e urinary output as manifestedby increased thirst and weight loss.

    Assess the uid le%el of the patient 0onitor %ital signs frequently Cestrict oral uid inta*e. Administer hypotonic salineintra%enously. Administer medications if ordered.

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    Inter%entions

    6. Disturbed sleeping pattern insomniarelated to nocturia as manifested by%erbali#ation of patient about

    interrupted sleep. Assess the sleeping pattern of thepatient /i%e psychological support.

    Ad%ice the patient to restrict oraluids ro%ide calm and quiet en%ironment.

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    Inter%entions

    . Acti%ity intolerance related tofatigue and frequent urination asmanifested by fatigue and wea*ness

    of the patient. Assess the acti%ity status of thepatient

    /i%e psychological support to thepatient.

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    Inter%entions

    9. An$iety related to course of disease andfrequent urination as manifested by%erbali#ation of an$ious questions.

    Assess the an$iety le%el of the patient.

    E$plain the patient about the diseaseand treatment.

    ro%ide calm and quiet en%ironment. Di%ert the attention of the patient bytal*ing about di4erent matter.

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    Inter%entions

    &. Ine4ecti%e coping related tofrequent urination as manifested by%erbali#ation of negati%e feeling by

    the patient. Assess the coping ability of thepatient

    E$plain the patient about thedisease and treatment /i%e psychological support.

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    Inter%entions

    >. Cis* for complications related to e$cessi%eloss of uid from the body as manifestedby hypotension and weight loss.

    Assess the uid %olume of the patient 0onitor %ital signs frequently. Ta*e immediate measures to restoreuid %olume such as [email protected] uid therapy

    Administer medications as ordered.

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    Inter%entions

    F. Gnowledge de!cit regardingmanagement of diabetes insipidusas manifested by %erbali#ation of

    doubts by the patient Assess the *nowledge le%el of thepatient.

    E$plain the management ofdiabetes insipidus to the patient.

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    3ummary

    Diabetes insipidus cause frequenturination e%en at night which candisrupt sleep. atient feels e$cessi%e