Page 29 Complete Your CE Test Online - Click Here ● ● CNS damage. ● ● Bladder distension. ● ● Enlarged calyces. ● ● Hydroureter (distention of the ureter). ● ● Hydronephrosis (collection of urine in the kidney). Various diagnostic tests may help in the diagnosis of diabetes insipidus. Urinalysis reveals [5,11] : ● ● Almost colorless urine. ● ● Low urine osmolality (50 to 200 mOsm/kg of water, less than that of plasma). ● ● Low specific gravity (less than 1.005). Additional diagnostic study results that suggest diabetes insipidus include[5,11] : ● ● Serum osmolality of 300 mOsm/kg. ● ● Serum sodium of 147 mEq/L. Dehydration (or water deprivation) test is performed to differentiate ADH deficiency from other types of polyuria by comparing urine osmolality after dehydration and after ADH administration[5,11] . The dehydration test procedure involves[5,11] : ● ● Baseline vital signs, weight, and urine and plasma osmolalities are obtained. ● ● Patients are deprived of fluids. They must be monitored to be sure that they do not drink any fluids. ● ● Urine output, body weight, urine osmolality, urine specific gravity, and plasma osmolality are measured hourly. ● ● Vital signs are monitored for the duration of the test to detect orthostatic hypotension. ● ● Fluids are withheld until patients lose 3% of their body weight, which indicates severe dehydration. ● ● When urine osmolality fails to increase in three consecutive hourly measurements, patients are given 5 units of aqueous vasopressin (ADH) subcutaneously. ● ● Hourly measurements of urinary output and urine specific gravity continue. Diabetes insipidus is diagnosed if “the increase in urine osmolality after ADH administration exceeds nine percent[11, pg 261] .” Patients with pituitary diabetes insipidus have decreased urinary output and increased urine specific gravity. Patients with nephrogenic diabetes have no response to the vasopressin administration[5,11] . Plasma or urinary evaluation of ADH may also be performed. Fluid restriction or the infusion of hypertonic saline infusion are conducted to establish if the origin of the diabetes insipidus is the result of damage to the posterior pituitary gland (neurogenic) or failure of the kidneys to respond to ADH (nephrogenic). In neurogenic diabetes insipidus ADH levels are decreased. In nephrogenic diabetes insipidus ADH levels are elevated[11] . Treatment and nursing considerations Prognosis for patients with diabetes insipidus is generally good, depending on the underlying cause [5,10]. Mild cases of diabetes insipidus may require no treatment other than fluid replacement. Severe cases require that the underlying cause be identified and corrected or treated satisfactorily. Until this is accomplished, various types of vasopressin or of a vasopressin stimulant are administered to control fluid balance and to prevent dehydration[5,11] . There are several medications that can be used to treat diabetes insipidus, including: ● ● Aqueous vasopressin is used as part of the initial management of diabetes following head trauma or neurological procedure. The drug is administered subcutaneously or intramuscularly several times a day because it is only effective for 2 to 6 hours[5,11] . ● ● Desmopressin acetate (DDAVP) is a synthetic, long-acting vasopressin analogue that is effective for 8 to 20 hours. It is administered via nasal spray and is absorbed through the mucous membranes. DDAVP can also be given subcutaneously, intravenously, or orally in tablet form administered at bedtime or in divided doses[5,11] . ● ● Lypressin is a synthetic vasopressin replacement. It is administered as a short-acting nasal spray. However, there are several side effects associated with the drug that can be problematic. These include nasal congestion, nasal irritation, ulceration of nasal passages, substernal tightness of the chest, coughing, and dyspnea with large doses. Additionally, the drug has a variable absorption rate[11] . Treatment alert! If nephrogenic diabetes insipidus is caused by medication, discontinuing the medication allows the kidneys to recover[5] . The prognosis is good for patients who have uncomplicated diabetes insipidus as long as they receive adequate fluid replacement. But the presence of a serious underlying cause (such as cancer) can alter the prognosis depending on how successful treatment initiatives prove to be[5,11] . Nursing care emphasizes meticulous monitoring of intake and output, patient safety, and patient/family education. It is essential to facilitate fluid intake to prevent severe dehydration. Patients must be weighed daily and vital signs monitored carefully. Nurses must also be alert for the development of signs of hypovolemic shock such as cool, clammy skin, anxiety, confusion, rapid breathing, and generalized weakness [5,11] . Nursing consideration: Patient/family education is very important. Nurses must teach the following patient safety actions and education initiatives including[5] . ● ● Instruct patients/families that patients may be weak and/or dizzy. They should be helped to ambulate as needed and cautioned to change positions slowly, especially when moving from lying to sitting or standing positions. ● ● Provide, and teach patients/families to provide, meticulous skin and mouth care since skin and mucous membranes may become dry and cracked. ● ● Explain that constipation is a possibility. Encourage the addition of more high-fiber foods to the patient’s diet. ● ● Teach patients/families how to monitor patients’ intake and output. ● ● Instruct patients/families to report weight gain since this may indicate the need for a decrease in medication dosage. ● ● Teach patients/families to report any return of polyuria. This may indicate that the dosage of medication is too low. ● ● Teach patients to wear a medical alert bracelet. ● ● Instruct patients to carry their medication with them at all times. ● ● Explain the importance of adhering to prescribed medication regimens. As previously mentioned, instruct patients never to stop taking medication unless told to do so by their HCPs. They also need to be instructed to apprise their HCPs of any medications they are taking including OTC medications, herbs, vitamins, minerals, and weight loss products. ● ● Ask patients/families to demonstrate their knowledge of their medications by having them explain how to take medications, side effects, and what to do if side effects occur. Patients/families should demonstrate how to safely administer their medications. Childhood hypothyroidism Jack and Maura are the proud parents of a baby girl, their first child. Maura gave birth yesterday afternoon and is preparing for discharge. Her obstetrician and the baby’s pediatrician enter her room. They explain that as part of the routine newborn screening program, Maura’s baby has been evaluated for congenital hypothyroidism. Results of the screening, unfortunately, show that the baby has congenital hypothyroidism. Reduced thyroid hormone secretion during the development of the fetus or in early infancy causes congenital (CH) or neonatal hypothyroidism (also referred to as infantile cretinism). If the disease is not recognized or not adequately treated, infants develop persistent jaundice, hoarse crying, and respiratory problems. Older children experience dystrophy of bones and muscles, stunted growth, and mental deficiencies[5] .