Ch. 41 Diabetes Insipidus (exam 3)

Acromegaly/Gigantism

-Hypersecretion of the pituitary GH over a long period of time *Etiology*: secondary to a benign tumor of the pituitary gland. *Patho*: pituitary tumor secrete GH & prolactin; stim growth of bones *Clinical Manifestations*: vision changes, oily skin, hirsutism, difficulty speaking, larger tongue, feet grow, galactorrhea, gynecomastia *Diagnostic Tests*: serum GH, Somatomedin C (SM-C), Xray, MRI *Planning & Implementation*: Give Octreotide (Sandostatin) 20 mg IM Q4Weeks

The nurse is concerned about high sodium levels in her patient experiencing diabetes insipidus. Which is the priority nursing action? 1-Supplement the reciprocal hypokalemia. 2-Complete hourly neurological assessments. 3-Provide safety precautions for seizures. 4-Monitor hourly urine output.

3

ACTH

Adrenocorticotropic hormone - decreased glucocorticoids leads to: hypoglycemia, decreased cortisol levels, and decreased ability to handle stress - decreased mineralocorticoids leads to: Hyponatremia, hypotension, hyperkalemia

1. On review of Ms. Andrews' admission clinical presentation, which clinical manifestations are most related to excessive growth hormone?' A. Headache B. Enlarged hands C. Visual changes D. Nausea

B An excess of growth hormone in adults does not affect bone length because of closure of the epiphyses but does affect bone density, and acromegaly (thickening of bones, particularly of the hands, feet, and facial bones) may develop.

2. Ms. Andrews is ordered to receive bromocriptine mesylate (Parlodel) for the treatment of her tumor. The nurse correlates which rationale for this medication? A. Decreases serum glucose levels B. Decreases water reabsorption in the kidneys C. Decreases secretion of growth hormone D. Decreases secretion of A D H

C Dopamine agonists (bromocriptine mesylate [Parlodel]) inhibit the release of anterior pituitary hormones. Medications that inhibit release of growth hormone include somatostatin analogs and growth hormone receptor blockers.

nursing diagnoses for DI

Fluid volume deficit related to loss of free water secondary to lack of A D H Risk for ineffective therapeutic regimen management related to required administration of desmopressin (DDAVP) Sensory perceptual alteration (vision) related to compression of CN II and III secondary to pituitary tumor

The nurse is caring for a patient after a transsphenoidal hypophysectomy. Which assessment changes are most concerning? 1- Heart rate is increased. 2- Pulse is full and bounding. 3- Blood pressure is increased. 4- Serum osmolality is decreased.

Heart rate is increased. Rationale: Diabetes insipidus is associated with the removal of the posterior pituitary gland. It is caused by decreased secretion of antidiuretic hormone. In such condition, heart rate is increased.

actions for hypopituitarism

Implement safety measures — Risk of injury related to falls and pathologic fractures increases secondary to decreased secretion of growth hormone. Increase vitamin D and calcium intake — Treats osteoporosis secondary to decreased growth hormone; vitamin D promotes absorption of calcium in the gastrointestinal tract. Hormone replacement — Supplementation of sex hormones may be administered to treat hypofunction of the gonads. Collaborate with physical therapy to maximize mobility — Osteoporosis increases the risk for falls, and the physical therapist can provide input into safe transfers from bed to chair and measures to decrease the incidence of falls.

Lutenizing (LH)

Stimulates ovulation; testosterone synthesis

assessments for hypopituitarism

Vital signs — Hypotension and tachycardia develop secondary to decreased secretion of A C T H, leading to decreased secretion of glucocorticoid and mineralocorticoid, resulting in sodium and water loss. Changes in fertility — Decreased testosterone may lead to sterility in males. Decreased LH or FSH may lead to amenorrhea and infertility in females. Signs of decreased bone density — A lack of growth hormone in adults affects bone density, and the patient is at risk for osteoporosis.

To resolve fluid volume deficits and correct plasma osmolality, what type of fluid would be used in the treatment of diabetes insipidus? a. Hypotonic fluid such as 5% dextrose in water b. Isotonic fluid such as Ringer's lactate c. Colloid fluid such as albumin d. Isotonic fluid such as 5% dextrose in water

a. Hypotonic fluid such as 5% dextrose in water Rationale: Water losses are replaced with a hypotonic fluid (in relation to the patient's serum osmolality) such as dextrose in water. During IV administration, the patient is monitored for hyperglycemia, volume overload, and correction of hypernatremia. Decreasing the serum sodium by 0.5 mmol/L every hour minimizes the chances of overly rapid correction of hypernatremia.

The physician may order a replacement antidiuretic hormone such as desmopressin. How can this be administered? Select all that apply. a. It can be administered via intranasal route. b. It can be given orally. c. It can be given in an IV. d. It can be given subcutaneously.

a. It can be administered via intranasal route. b. It can be given orally. d. It can be given subcutaneously.

A client is suspected of having diabetes insipidus and is admitted to the medical-surgical nursing unit. Which diagnostic tests does the nurse anticipate the physician will order? Select all that apply. - Serum and urine electrolytes - CT scan - Osmolality - Urine-specific gravity - Lumbar puncture

a. Serum and urine electrolytes c. Osmolality d. Urine-specific gravity

The nursing is admitting a patient from home. Which presenting symptom causes the nurse to be concerned that the patient has developed diabetes insipidus (DI)? 1-Hypertension 2-Bradycardia 3-Polyuria 4-Decreased serum sodium

3

The patient presents to the emergency department with 1-week symptoms of polyuria, polydipsia, hypernatremia, and tachycardia. The patient has an elevate serum osmolality. A malfunction in which area of the brain is most likely causing these symptoms? 1- Hypothalamus 2- Anterior lobe of the pituitary 3- Posterior pituitary gland 4- Sella turcica

3

Follicle-stimulating hormone (FSH)

secreted by the pituitary gland to stimulate maturation of the egg cell (ovum)

Adrenocorticotropic hormone

stimulates the growth and secretions of the adrenal cortex

thyroid-stimulating hormone

stimulates thyroid gland (TSH)

evaluating care outcomes for hyperpituitarism

•Suppression of excess hormone secretion •Removal of hypersecreting tumor •Neurologically intact Normal fluid and electrolyte imbalance The patient with hyperpituitarism may achieve normal function through the administration of medications that suppress excess hormone secretion, particularly growth hormone. Removal of a hypersecreting tumor of the anterior pituitary with no associated injury to the gland usually results in normal function. Changes in bone structure will not return to normal, but there is no further growth in bone secondary to excessive growth hormone in the adult. After transsphenoidal hypophysectomy, the patient should be neurologically intact with normal fluid and electrolyte balance.

medical diagnostics for all hypopituitarism types

- ACTH stimulation test - TSH, FSH, LH, prolactin, and growth hormone tests - CT scan - MRI Hormonal studies conducted to assess for hypopituitarism include the A C T H (Cortrosyn) stimulation test and measurements of T S H, FSH, LH, prolactin, and growth hormone provocative tests. If a tumor of the brain or pituitary is suspected, a head computed tomography (C T) or M R I may be completed. A battery of serum studies related to effects on target glands or cells is also performed to assist in a definitive diagnosis based on physical presentation. With suspected abnormalities in growth hormone, manifested by complaints of weakness or pathologic bone fractures, diagnostic evaluation often focuses on ruling-out other causes. Direct measurement of growth hormone is difficult because the levels change throughout the course of a day

growth hormone hypopituitarism

- decreased bone density - decreased muscle strength - increased risk of bone fractures

TSH hypopituitarism

- decreased levels of T3 and T4 - decreased metabolic rate - weight gain - thinning of hair - decreased libido

pathophysiology of hypopituitarism

- deficiency of one of the anterior pituitary hormones results in changes in metabolic or sexual function, dependent on which hormone level is decreased. - the increase in one or more of the anterior pituitary hormones determines the patho of hypopituitarism

signs and symptoms of acromegaly

- headache - supraorbital bulging - thickening and broadening of bone - broadened nose - enlarged tongue and lips - coarse features - thyroid gland hypertrophy - cardiomegaly - increased perspiration - galactorrhea - hepatomegaly - splenomegaly - carpal tunnel syndrome - enlarged colon - enlarged hands - osteoarthritis - enlarged feet (breadth)

ACTH hyperpituitarism

- increased glucocorticoids (hyperglycemia and increased cortisol level) - increased mineralcorticoids (hypernatremia, hypertension, hypokalemia)

hypopituitarism

- rare, affecting fewer than 200,000 individuals in the US. - anterior pituitary dysfunction is often secondary to a pituitary tumor or damage to the hypothalamus. - increased itracranial pressure secondary to head trauma, CNS infections like meningitis, or brain tumors may also affect perfusion of the hypothalamus and result in damage. - postpartum hemorrhage, resulting in large blood loss and corresponding hypotension, may lead to severe hypo perfusion and infarction of anterior pituitary. - gradual onset, occurs after 70-90% of the anterior pituitary is nonfunctional or destroyed.

The nurse is providing discharge instructions to a patient and his family after a diagnosis of diabetes insipidus (DI). Which instructions should be included? Select all that apply. 1- "Check body weight daily at the same time and on the same scale." 2- "Report weight changes of more than 5 pounds per day." 3- "Drink plenty of fluids." 4- "Maintain adequate mouth care." 5- "Know that overuse of desmopressin may lead to dehydration."

1,3,4

Which interventions should the nurse implement when caring for the patient who has undergone a transsphenoidal hypophysectomy? Select all that apply. 1- Conduct a neurological assessment. 2- Maintain the head of the bed at a 30° angle. 3- Provide frequent mouth care. 4- Monitor the nasal drainage pad. 5- Obtain urine-specific gravity every hour.

1,3,4,5

The nurse is caring for a client at risk for developing diabetes insipidus. What is the initial assessment change the nurse should anticipate? - Polyuria - Hypotension - Polydipsia - Polyphagia

1- polyuria

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Urine-Specific Gravity 1- 1.000 2- 1.030

1.000 Urine-specific gravity is less than 1.005 in patients who have DI. The urine is dilute from the loss of water.

The nursing is caring for a patient with newly diagnosed idiopathic diabetes insipidus (DI). Which of the following should the nurse include in patient teaching? 1-Pineal tumor is commonly the cause. 2-Destruction of the cells of the hypothalamus lead to the condition. 3-Traditional craniotomy is the reason for this. 4-Head trauma often causes the condition.

2

The nursing student asks the nurse how central diabetes insipidus (DI) is different from nephrogenic DI. How should the nurse respond? 1- Central DI occurs because the kidneys are resistant to ADH. 2- Central DI is caused by decreased secretion of ADH. 3- Central DI is observed in patients with chronic renal insufficiency. 4- Central DI occurs when the kidneys are unable to concentrate urine.

2

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Urine Osmolality 1- > 200 milliosmole/Kilogram 2- < 200 milliosmole/ Kilogram

2- < 200 milliosmole/ Kilogram Decreased urine osmolality of less than 200 mOsm/kg is a key indicator of DI. This is a result of the water eliminated in the urine.

The nurse is receiving hand-off reports for four patients. Which patient presents with a serum sodium level consistent with diabetes insipidus (DI)? Patient A -- 148 Patient B -- 140 Patient C -- 136 Patient D -- 128

A

5. The nurse monitors for which therapeutic effect as a result of the administration of Pitressin? A. Decreased urine output B. Decreased blood pressure C. Decreased serum glucose D. Decreased thirst

A : Pitressin (form of antidiuretic hormone) works by increasing reabsorption of water in the kidneys and is manifested by a decrease in urine output. Other therapeutic effects include normalizing blood pressure (which may be decreased with DI). Pitressin has no effect of serum glucose level. Thirst may decrease as fluid balance is reestablished.

decrease is adrenocorticotropic hypopituitarism

A decrease in adrenocorticotropic hormone (A C T H) leads to a decrease in release of the mineralocorticoids (aldosterone) and glucocorticoids (cortisol) from the adrenal cortex. - decrease in thyroid hormones d/t decreases secretion of TSH from anterior pituitary gland hypopituitarism - . Alterations in sexual and reproductive functioning are caused by decreased secretion of the gonadotropins, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). There is also a decrease in growth hormone that presents differently according to the age of the patient. In children before the closure of the epiphyses, dwarfism (small stature) develops. A lack of growth hormone in adults does not affect bone length but does affect bone density, and osteoporosis (reduction in bone density) may develop.

actions for hyperpituitarism

Administer dopamine agonists — Inhibit release of anterior pituitary hormones Administer somatostatin analogs — Inhibit release of growth hormone Administer hormone supplements — Replacement of sexual hormones is required to facilitate normal function and conception.

nursing management for hyperpituitarism

Administer humidified oxygen as ordered — The surgical approach (via the sphenoid) does not allow the patient to breathe through the mouth. The patient is an obligate mouth breather, and humidification facilitates maintaining moist mucous membranes. Maintain IV access and administer ordered IV solutions — In patients with a decrease in level of consciousness, IV fluids are usually indicated. The solution ordered is based on the serum sodium level Administer desmopressin or vasopressin as ordered — Synthetic ADH is administered to cause water reabsorption in the kidneys. Maintain head of the bed at 45 to 60 degrees — Facilitates ease of breathing by dropping diaphragm, and promotes outflow via jugular veins to minimize changes in intracranial pressure Provide adequate oral fluids — If the patient is alert and awake, the patient is allowed to drink fluids. Provide mouth care — The patient is at risk for fluid volume deficit related to lack of ADH and requires mouth care to minimize complications of dry mucous membranes.

assessment and analysis for DI

Because DI is directly related to the lack of A D H, there is loss of free water. Assessment findings include polyuria, urine-specific gravity less than 1.005, and low urine osmolality (especially in relation to serum osmolality). Secondary to hemoconcentration, laboratory analyses reveal an increase in serum sodium, osmolality, and hematocrit. Changes in blood pressure and heart rate are related to the 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

4. In providing care to Ms. Andrews after she undergoes a transsphenoidal hypophysectomy, the nurse prioritizes which intervention? A. Maintaining the patient in a flat, supine position B. Instructing the patient to cough and deep breathe C. Monitoring for clear fluid drainage from the nose D. Limiting exposure to bright lights

C Clear fluid drainage from the nose in the patient after transsphenoidal hypophysectomy may indicate a cerebrospinal fluid (CSF) leak that can lead to meningitis. The patient is usually placed with the head of bed elevated 45°, and coughing is minimized to avoid pressure on the operative site. Bright lights may be limited to decrease environmental stimuli, but this is not as high of a priority as monitoring for a CSF leak.

overview of symptoms for hyperpituitarism

Clinical manifestations observed in the patient with hyperpituitarism are directly related to specific hormone excesses. Common findings may include: Hyperglycemia related to increased secretion of A C T H, resulting in increased secretion of cortisol Hypernatremia and hypertension secondary to increased secretion of aldosterone Hypokalemia secondary to increased secretion of aldosterone Increased bone density secondary to increased secretion of growth hormone

general signs and symptoms of hypopituitarism

Clinical manifestations observed in the patient with hypopituitarism are directly related to the specific hormone deficiency. Common findings may include: Hypoglycemia related to decreased secretion of A C T H, resulting in decreased secretion of cortisol Decreased ability to cope with stress secondary to decreased secretion of cortisol Hyponatremia and hypotension secondary to decreased aldosterone secretion Hyperkalemia secondary to decreased aldosterone secretion Decreased bone density secondary to decreased growth hormone secretion

3. Which laboratory result does the nurse correlate with a diagnosis of diabetes insipidus (D I)? A. Serum osmolality, 285 mOsm/kg B. Serum sodium, 132 mEq/L C. Hematocrit 32% D. Urine-specific gravity, 1.001

D The clinical presentation of the patient with DI is dependent upon the significance of water loss. Due to the lack of A D H, the patient excretes large volumes of dilute urine with a low specific gravity. Serum sodium and osmolality levels are increased in DI secondary to hemoconcentration.

medications for diabetes insipidus

Desmopressin (DDAVP), a synthetic analog of A D H, is the drug of choice in patients with DI and is available in subcutaneous, intranasal, and oral preparations. There is also a synthetic vasopressin (Pitressin) used to treat DI that is less expensive than desmopressin. Patients receiving either of these medications require frequent monitoring of fluid status, serum electrolytes, and urine output.

Review the events within the health record below. Select the priority request by the nurse when performing a Situation, Background, Assessment, Recommendation (SBAR) communication with the provider. 1-IV D5 and 0.45% NaCl at 200 mL/hr 2-Desmopressin 0.05 mg orally no 3-Daily weight 4-High sodium diet

Desmopressin 0.05 mg orally no Rationale: This medication is a synthetic analog of antidiuretic hormone and highly effective in the treatment of acute diabetes insipidus.

evaluating care outcomes for DI

Diabetes insipidus may be transient after head injury or craniotomy, or it may be a permanent disorder. Definitive treatment with synthetic A D H replacement results in water reabsorption and normalization of urine output, urine-specific gravity, and serum electrolytes. Vital signs are normal, output is proportional to intake, and body weight is stable in patients with well controlled DI

diagnosis for hyperpituitarism

Diagnostic evaluation of hyperpituitarism focuses on the particular hormone and target cells/glands affected by the excess of tropic hormone. Hormonal studies conducted to assess for hyperpituitarism include the A C T H (Cortrosyn) stimulation test and measurements of T S H, FSH, LH, prolactin, and growth hormone provocative tests. If a hypersecreting tumor of the brain or pituitary is suspected, a head C T or M R I may be completed. A battery of serum studies associated with effects on target glands or cells is also performed to assist in a definitive diagnosis based on physical presentation. With suspected increases in growth hormone, the patient presents with increases in the size of the hands and feet and broadening of the facial bones.

pathophysiology of hyperpituitarism

Hyperpituitarism secondary to hypersecretion of hormones leads to specific dysfunction related to the hormone involved. An excess of one of the anterior pituitary hormones results in changes in metabolic or sexual function that are dependent on which hormone level is elevated. The effects of an increase in one or more of the anterior pituitary hormones determine the pathophysiology of hyperpituitarism. An increase in A C T H leads to an increase in release of the mineralocorticoids and glucocorticoids from the adrenal cortex. Likewise, there is an increase in thyroid hormone released secondary to the increased secretion of T S H from the anterior pituitary gland. Alterations in sexual and reproductive functioning are caused by increased secretion of the gonadotropins (LH and FSH). There is also an increase in growth hormone that presents differently according to the age of the patient. In children before the closure of the epiphyses, gigantism (large stature) develops. An excess of growth hormone in adults does not affect bone length because of closure of the epiphyses but does affect bone density, and acromegaly (thickening of bones, particularly of the hands, feet, and facial bones) may develop (Fig. 41.1).

teachings for hyperpituitarism

Disease process and importance of adherence to prescribed medications — Because of the complexity of the disease process and possible side effects of medications (that may decrease secretion of other anterior pituitary hormones), the patient and family need to understand the specific changes to be reported to the healthcare provider. Collaborate with the pharmacist for medication teaching. Signs of meningitis — The surgical approach increases the risk of meningitis, and the nurse needs to monitor for elevated temperature, nuchal rigidity (stiff neck), and photophobia. Signs and symptoms of DI: Instruct patient to notify his or her healthcare provider for increased urine output and excessive thirst. Signs and symptoms of fluid overload: Instruct patient to notify his or her healthcare provider for weight gain. — The patient must understand the pathophysiology of this disorder and the importance of fluid volume balance. Overcorrection of DI with DDAVP or Pitressin may lead to fluid overload. Use a soft toothbrush after transsphenoidal hypophysectomy — Decreases potential to damage incision line after transsphenoidal activity Avoid activities (coughing, sneezing, bending at the waist) after transsphenoidal hypophysectomy — These activities can put strain on the surgical site. Report any increase in drainage of clear fluid from the nose after transsphenoidal hypophysectomy — Clear drainage from the nose may indicate a CSF leak that increases risk of meningitis.

Hyperpituitarism

Hyperpituitarism is usually related to a hypersecreting tumor. The incidence of these types of tumors is higher in females, but there are no differences based on race or ethnicity. These types of tumors may present in children or adults, and there is a genetic association with the tumor development. The patient presentation is consistent with clinical manifestations associated with the oversecreted hormone, and the tumor itself may lead to headaches or visual changes secondary to compression of the optic nerve (CN II) and other structures in the central nervous system

surgical management for hyperpituitarism

Hypersecreting tumors of the pituitary gland are surgically removed by a transsphenoidal hypophysectomy. The sublabial transseptal approach to a pituitary tumor involves an incision made under the top lip, with entry to the nasal cavity made through the floor of the nose. The nasal septum is moved to the side, and the sphenoid sinus is opened to access the sella turcica and the pituitary gland. Smaller pituitary tumors may also be removed via an endoscopic approach, which poses fewer postoperative complications than the sublabial transseptal approach. This surgical procedure gains access to the pituitary tumor through a fiberoptic device inserted through an incision in the lining of the nose. Stereotactic radiosurgery, a minimally invasive procedure, is another surgical approach that may be indicated for residual or recurrent pituitary tumors after surgical resection. Delivering high-dose radiation to a precisely targeted area of the brain, the goal is eradication of the tumor with minimal effects to adjacent normal brain tissue.

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Blood pressure a. HYPERTENSION b. HYPOTENSION

Hypotension With polyuria and dehydration, blood pressure will decrease.

teachings for DI

Importance of taking medications (A D H replacement) as ordered — Taking the medications (Vasopressin/Pitressin) at the same time daily mimics normal release and supports water reabsorption in the kidneys. Weigh daily at same time and on same scale — Weight is directly associated with water loss or gain, and changes of more than 2 lb per day should be reported to the healthcare provider. Clinical manifestations of DI — The patient must understand the pathophysiology of this disorder and the importance of fluid volume balance. Clinical manifestations of fluid overload — Overcorrection of DI with DDAVP or Pitressin may lead to fluid overload.

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Thirst 1- Increased 2- Decreased

Increased DI results in intravascular dehydration, which activates the thirst mechanism.

actions for DI

Maintain IV access and administer ordered IV solutions — In patients with a decrease in level of consciousness, IV fluids are usually indicated. The solution ordered is based on serum sodium level. It is important to maintain vascular access because placement of an IV catheter in a profoundly hypotensive patient is difficult. Administer desmopressin or vasopressin as ordered — Synthetic A D H is administered to cause water reabsorption in the kidney. Provide adequate oral fluids — If the patient is alert and awake and has an intact gag reflex, the patient is allowed to drink fluids. Provide mouth care — The patient is at risk for fluid volume deficient related to lack of A D H and requires mouth care to minimize complications of dry mucous membranes.

treatment for diabetes insipidus

Management of DI is focused on maintaining adequate fluid volume status. Most patients who are awake and alert are able to replace water loss by drinking fluids. In an emergency or in the unconscious patient, IV fluid administration is indicated. Water losses are replaced with a hypotonic fluid (in relation to the patient's serum osmolality) such as dextrose in water. During IV administration, the patient is monitored for hyperglycemia, volume overload, and correction of hypernatremia. Decreasing the serum sodium by 0.5 mmol/L every hour minimizes the chances of overly rapid correction of hypernatremia.

evaluating care outcomes for hypopituitarism

Patients with hypopituitarism can achieve relatively normal function by complying with prescribed therapy. Replacement hormone therapy based on the specific hormone is combined with supportive treatment to address end gland/target cell effects. Vital signs within normal limits, improved mobility, stable weight, and normal fluid volume status are indicative of stable anterior pituitary function. With appropriate hormone replacement, fertility and conception may be achieved. During periods of stress, such as invasive procedures, the patient needs to be aware of the signs of adrenal insufficiency and the clinical manifestations they should report to their healthcare provider.

complications of hypopituitarism

Patients with hypopituitarism may develop life-threatening emergencies, particularly with panhypopituitarism. Lack of A C T H with a resultant decrease in glucocorticoids and mineralocorticoids is a life-threatening emergency because the patient is unable to maintain adequate fluid volume status, which may lead to circulatory collapse. Additionally, a lack of T S H, leading to a decrease in thyroid hormone secretion, may result in a severe decrease in metabolism that affects all body functions and is particularly dangerous in relation to metabolism of medications.

teachings for hypopituitarism

Signs and symptoms of acute adrenal insufficiency — Infection, injury, and stress lead to an increased need for A C T H. Because of underlying hypopituitarism, the patient may require exogenous glucocorticoids in the event of stress (physiological or psychological). Importance of taking hormone supplements in the morning — Taking hormone supplements in the morning mimics the normal release of these hormones

pathophysiology of diabetes insipidus

The decrease or absence of A D H in the patient with DI results from lack of production in the hypothalamus. Antidiuretic hormone, 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 A D H, the collecting ducts are less permeable to water, and it is excreted as urine. In patients with DI, the lack of A D H leads to excretion of large volumes of very dilute urine.

endoscopic approach to surgical removal of pituitary tumor

The endoscopic approach gains access to the pituitary tumor through a fiberoptic device inserted into the nostril, and then the sella turcica is entered for tumor removal.

medications for hyperpituitarism

The goals of medical management of hyperpituitarism are aimed at decreasing secretion of the involved hormones and treating clinical manifestations secondary to target gland or cell hyperfunction (hyperglycemia, hypertension, etc.). Dopamine agonists (bromocriptine mesylate [Parlodel]) inhibit the release of anterior pituitary hormones. Medications that inhibit release of growth hormone include somatostatin analogs and growth hormone receptor blockers. In some cases, these medications are used to decrease the size of the tumor in advance of surgical removal.

medications for hypopituitarism

The goals of medical management of hypopituitarism are aimed at restoring target hormone levels to normal levels. Hormone replacement is guided by the specific hormone deficiency. In addition to hormone replacement, supportive therapies such as fluid and electrolyte replacement are the key to managing the patient with hypopituitarism. Hormone replacement may include cortisol, thyroid hormone, testosterone, or estrogen. Management of a decrease in growth hormone is usually focused on the pathophysiological processes associated with decreased bone density and osteoporosis and includes ensuring adequate intake or supplementation with vitamin D and calcium.

sublabial transseptal surgery

The sublabial transseptal approach to a pituitary tumor involves an incision made under the top lip, with entry to the nasal cavity made through the floor of the nose. The nasal septum is moved to the side, and the sphenoid sinus is opened to access the sella turcica and the pituitary gland

assessments for hyperpituitarism

Vital signs — Hypertension may develop secondary to excessive secretion of mineralocorticoid, leading to reabsorption of sodium and water. Neurological assessment, including vision — Pituitary tumors may cause an increase in intracranial pressure. As tumors enlarge and extend beyond the sella turcica, they may compress CN II and CN III. Intake and output — Urinary output may decrease secondary to increased reabsorption of sodium and water. Excessive output of dilute urine may occur if the patient develops diabetes insipidus. Daily weight — Reabsorption of sodium and water secondary to increased mineralocorticoid may lead to increases in weight. Serum electrolytes — Increased secretion of A C T H leads to increased cortisol and aldosterone, leading to sodium retention and potassium loss. Changes in size of hands, feet, and bone structure — Increased secretion of growth hormone leads to thickening of the bones. Neurovascular status — In patients with acromegaly, bone growth may compress peripheral nerves causing numbness, tingling, or pain in the hands and feet.

hyperpituitarism assessments

Vital signs — Hypotension and tachycardia are seen if the patient develops postoperative DI. Temperature elevation may occur if there is postoperative infection from the surgical incision or secondary to a CSF leak. Neurological status — An increase in intracranial pressure secondary to the surgical procedure may lead to changes in the level of consciousness and papillary changes. Visual field changes may develop secondary to postoperative cerebral edema. Intake and output — Lack of ADH leads to an increase in excretion of large amounts of dilute urine. Mucus membranes and mouth — Because of nasal packing after transsphenoidal hypophysectomy, the patient breathes primarily through the mouth, leading to increased dryness. Urine-specific gravity — Urine-specific gravity decreases, usually less than 1.005 secondary to lack of ADH and subsequent excretion of dilute urine. Serum sodium and osmolality — Serum sodium and osmolality increase because of increased excretion of water secondary to lack of ADH.

nursing interventions for DI

Vital signs — Lack of A D H leads to excessive water loss with resulting decrease in blood pressure and increase in heart rate as a compensatory mechanism. Intake and output — Fluid replacement is largely dependent on the volume of urine output secondary to lack of A D H. Daily weight — Increased output of dilute urine, secondary to lack of A D H, leads to decrease in weight. Visual acuity — Growth of the pituitary tumor may compress CN II or CN III. Serum sodium and osmolality — Lack of A D H causes an increase in water excretion leading to the concentration of serum sodium (hypernatremia) and an increase in serum osmolality. Urine-specific gravity — Lack of A D H results in the excretion of large volumes of dilute urine; specific gravity is usually less than 1.005.

What are the primary clinical manifestations seen in clients with diabetes insipidus? Select all that apply. a. Polyuria b. Nausea and vomiting c. Nocturia d. Fatigue e. Polydipsia

a. Polyuria c. Nocturia d. Fatigue e. Polydipsia Rationale: The clinical presentation of the patient with DI is dependent on the significance of water loss. Polyuria, polydipsia, and nocturia are the primary clinical manifestations seen in patients with DI. The excessive loss of water leads to hemoconcentration that is observed with elevations in serum sodium and hematocrit. The patient may present with hypotension and tachycardia

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Heart rate a. TACHYCARDIA b. BRADYCARDIA

a. TACHYCARDIA Rationale: Dehydration will cause the heart rate to increase.

Regardless of the type of diabetes insipidus, what is the primary pathophysiological mechanism? a. Abnormal glycemic control b. Decreased secretion of antidiuretic hormone c. Increased plaque formation d. Abnormal demyelination

b. Decreased secretion of antidiuretic hormone

Which are consistent with the clinical diagnosis of diabetes insipidus? Select all that apply. BUN: 5Sodium: 152Hematocrit: 56Urin Specific Gravity: 1.001Serum Osmolality: 301 a. Decreased blood urea nitrogen b. Increased serum sodium c. Increased hematocrit d. Decreased urine specific gravity e. Increased serum osmolality

b. Increased serum sodium c. Increased hematocrit d. Decreased urine specific gravity e. Increased serum osmolality Rationale: Urine-specific gravity of less than 1.005 and urine osmolality less than 200 mOsm/kg are key indicators of DI. While the patient loses free water, increases in serum sodium, serum osmolality, and hematocrit develop secondary to hemoconcentration.

A transsphenoidal approach is used to treat pathological etiologies of diabetes insipidus. Which nursing actions would be included in the post-operative plan of care for clients who undergo this procedure? Select all that apply. - Insertion of nasogastric tube to allow for enteral feedings - Providing oxygen therapy as needed - Providing client with cooling blanket to prevent - hyperthermia - Providing oral fluids if client is alert and awake - Maintaining head of bed between 45 and 60 degrees

b. Providing oxygen therapy as neededd. Providing oral fluids if client is alert and awakee. Maintaining head of bed between 45 and 60 degrees

What is the cause of about a third of clinical cases of diabetes insipidus? a. Brain tumors b. Head trauma c. Intracranial surgery d. Idiopathic

d. Idiopathic Rationale: Approximately 30% of cases of DI are idiopathic, whereas 25% are secondary to brain tumors, 20% develop after intracranial surgery, and 16% occur after head trauma. Idiopathic DI develops secondary to destruction of the cells of the hypothalamus that produce ADH and is often an autoimmune process.

What is the basis of fluid therapy replacement for the treatment of diabetes insipidus? - Serum osmolality is decreased as fluids are replaced rapidly. - A fluid challenge is used to restore fluid volume. - Additional fluids are needed in the intravascular space to maintain adequate fluid volume. - Slowly decreasing the serum sodium decreases rapid correction of hypernatremia.

d. Slowly decreasing the serum sodium decreases rapid correction of hypernatremia.

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Antidiuretic hormone (ADH) production 1- increased 2- decreased

decreased ADH secretion is decreased as a result of damage to the posterior pituitary gland. This decrease causes the body to excrete more water.

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Hematocrit 1- hemodilution 2- hemoconcentration

hemoconcentration DI causes a rise in hematocrit levels resulting in hemoconcentration of the blood due to fluid loss.

growth hormone

hormone secreted by anterior pituitary gland that stimulates growth of bones

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Serum sodium a. HYPERNATREMIA b. HYPONATREMIA

hypernatremia As the blood loses water, it becomes more concentrated and the serum sodium level rises.

FSH hypopituitarism

in females: decreased estrogen production and well as decreased ovulation in males: decreased sperm production

lutenizing hormone hypopituitarism

in females: irregular menses or amenorrhea as well as decreased ovulation - in males: decreased testosterone

This or That? For each option, select the correct answer relative to central diabetes insipidus (DI). Serum Osmolality 1- increased 2- Decreased

increased In DI, one would expect to see an increase in serum osmolality from the loss of water in the urine.

Growth hormone hyperpituitarism

‒Increased bone density ‒Coarse facial features ‒Menstrual irregularities

diabetes insipidus

•30% of cases are idiopathic •25% secondary to brain tumors •20% after intracranial surgery •16% after head trauma Diabetes insipidus (DI) is classified as either central or nephrogenic. Central DI is caused by a decreased secretion of antidiuretic hormone (A D H) from the posterior pituitary gland. Nephrogenic DI occurs when the kidneys are resistant to A D H and are unable to concentrate urine, and this type of DI is observed in patients with chronic renal insufficiency, hypercalcemia, hypokalemia, and interstitial disease of the renal tubules. This chapter focuses on central DI. Approximately 30% of cases of DI are idiopathic, whereas 25% are secondary to brain tumors, 20% develop after intracranial surgery, and 16% occur after head trauma. Idiopathic DI develops secondary to destruction of the cells of the hypothalamus that produce A D H and is often an autoimmune process. Primary brain tumors leading to DI include craniopharyngiomas (arising near the pituitary gland) and pineal tumors. Postneurosurgical DI varies by type of surgical procedure. In patients undergoing traditional craniotomy, DI is reported in 60% to 80% of the patients, whereas with the transsphenoidal approach (see Fig. 41.1), only approximately 10% to 20% of the patients develop postoperative DI. In some of these cases, particularly in postoperative DI, the disorder is transient.

complications of diabetes insipidus

•Dehydration •Hypovolemia The patient with DI may develop dehydration and hypovolemia, progressing to circulatory collapse without adequate fluid administration. Patients with permanent DI who require daily administration of hormone replacement are particularly at risk for hypovolemia. Hemoconcentration secondary to DI also increases the risk for hypernatremia. The clinical presentation of hypernatremia is related to central nervous system dysfunction secondary to shrinkage of brain cells and results in confusion, neuromuscular excitability, seizures, or coma.

complications for hyperpituitarism

•Hyperglycemia •Hypertension •Acromegaly •Thyroid storm Patients with hyperpituitarism may develop complications related to excess hormone secretion. Excess A C T H with a resultant increase in glucocorticoids and mineralocorticoids leads to hyperglycemia, hypertension, and acromegaly. Additionally, an excess of T S H leading to an increase in thyroid hormone secretion may result in severe hyperthyroidism and may deteriorate to thyroid storm. After transsphenoidal hypophysectomy, the patient is at risk for CSF rhinorrhea that increases the risk of meningitis (see Evidence-Based Practice). Damage to the posterior pituitary gland may lead to disorders and antidiuretic hormone secretion.

TSH hyperpituitarism

•Increased levels of T3 and T4 ‒Increased metabolic rate ‒Weight loss Exophthalmos

diagnostics for diabetes insipidus

•Serum and urine electrolytes •Serum and urine osmolality •Urine specific gravity CT scan and MRI Diagnostic evaluation of DI includes serum and urine electrolytes, serum and urine osmolality, urine-specific gravity, and C T or M R I of the head. Urine-specific gravity of less than 1.005 and urine osmolality less than 200 mOsm/kg are key indicators of DI. While the patient loses free water, increases in serum sodium, serum osmolality, and hematocrit develop secondary to hemoconcentration. The water deprivation test is also used in the diagnosis of DI. In this test, all water is withheld, and urine osmolality and body weight are measured hourly. During the test, the patient's weight and urine osmolality are evaluated because normally the withholding of water leads to a urine osmolality 2 to 4 times greater than the serum osmolality. The diagnosis of DI is made when serum osmolality continues to increase, and there is no resultant increase in urine osmolality.

signs and symptoms of diabetes insipidus

•Significant water loss •Polyuria, polydipsia, nocturia The clinical presentation of the patient with DI is dependent on the significance of water loss. Polyuria, polydipsia, and nocturia are the primary clinical manifestations seen in patients with DI. The excessive loss of water leads to hemoconcentration that is observed with elevations in serum sodium and hematocrit. The patient may present with hypotension and tachycardia secondary to hypovolemia. Other signs of fluid volume deficit including thirst, skin tenting, and fatigue may also be observed