DEFINITON

Diabetes insipidus is a disorder of the posterior pituitary gland and is defined as inadequate
production, release or use of anti-diuretic hormone(ADH)

TYPES

1) NEUROGENIC DIABETES INSIPIDUS

 Results from inadequate amounts of anti‐diuretic hormone (ADH) being produced by
hypothalamus or released by the pituitary gland.

2) NEPHROGENIC DIABETES INSIPIDUS

 Results from ineffective action of vasopressin in the kidney.
 It can be the distal tubules and collecting ducts itself are insensitive to the action of
anti-diuretic hormone.

PATHOPHYSIOLOGY

1. anti-diuretic hormone(ADH) facilitates concentration of the urine by stimulating

reabsorption of water from the distal tubule of the kidney.
2. When the production, release or use of ADH is inadequate, the tubules do not resorb,
leading to polyuria (passage of a large volume of urine in a given period).
3. Therefore, the body is unable to conserve water, resulting in severe dehydration and
the child will become more thirsty.

ETIOLOGY

1) NEUROGENIC DIABETES INSIPIDUS

 Idiopathic- the cause of 20% to 50% of cases of neurogenic diabetes insipidus is
unknown.
 Midline central nervous system malformations
  Anoxic encephalopathy- brain damage due to lack of oxygen
 Cerebral edema
 Traumatic brain injury- such as road traffic accidents, falls and domestic abuse.
 Brain tumours
 Central nervous system infection- meningitis and encephalitis.

2) NEPHROGENIC DIABETES INSIPIDUS

 CONGENITAL
 More than 90% of paediatric patients with nephrogenic diabetes insipidus have
an X-linked defect of the vasopressin receptor. Not as common as the acquired
type, but its presentation is more severe.

 ACQUIRED
 Obstructive uropathy- is defined as the blockage of urine drainage from the
kidney, ureter or bladder. This will increased collecting duct pressure cause
damage to the tubular epithelium and resulting in insensitivity to the action of
ADH
 Chronic kidney disease
 Prolonged metabolic imbalances- specifically as low levels of potassium in the
blood (hypokalemia) or high levels of calcium in the blood (hypercalcemia).
 Use of certain drugs- lithium or antiviral medications such as foscarnet
(Foscavir).
CLINICAL MANIFESTATION

CENTRAL DIABETES INSIPIDUS NEPHROGENIC DIABETES INSIPIDUS

1. Polyuria 1. Polyuria
 Is excessive urination due to  Tubules do not resorb due to
inadequate ADH causes tubules to inadequate ADH.
not resorb.
2. Dehydration
2. Dehydration  Because the body is unable to
 Because the body is unable to conserve water.
conserve water.
3. Polydipsia
3. Polydipsia  Due to dehydration.
 Is excessive thirst due to dehydration.
4. Hypernatremia in neonatal period
4. Enuresis  Sodium intake should be monitored
 Is an involuntary urination that is .
common in children at night. 5. Fever

5. Constipation 6. Vomiting
 Due to dehydration and lack of water
in the body. 7. Mental status changes

6. Nocturia
 Is a urination during night due to high
fluid intake or bladder obstructions.

7. Irritable
 If fluids withheld.
8. Fever

DIAGNOSTIC TEST

1. Serum electrolyte
 Serum osmolality is elevated greater than 300 mOsm/kg.
 Serum sodium is elevated greater than 145 mEq/L.

2. Urinalysis
 Urine osmolality is decreased less than 300 mOsm/kg.
 Urine specific gravity is decreased less than 1.005.

3. CT scan
 To visualize the pituitary gland to detect a tumor.

4. MRI
 To visualize the pituitary gland to detect a tumor.

5. Fluid deprivation test

 To evaluate the level of ADH.
 Helps to confirm the diagnosis.
TREATMENT
 MEDICAL TREATMENT
CENTRAL DIABETES INSIPIDUS
1. Intranasal or oral desmopressin acetate
(DDAVP)
 Helps reduces urinary output
 Enabling the child to live a more normal
life with a decrease in thirst, urinary
output and nocturia.
 Dose is based on route administration,
age and response to therapy.
 NON-MEDICAL TREATMENT
NEPHROGENIC DIABETES INSIPIDUS
1. Thiazide diuretics
 Reduce extracellular sodium content.
 Stimulate the proximal tubule to
reabsorb water.
 Take the solution with a syringe.
2. Indomethacin
 To have an additive effect on decreased
water excretion.
 In capsule form and should be taken
with food.
3. Amiloride
 To reduce urinary potassium losses.
 Take medication by mouth with food.
4. Prostaglandin inhibitor
 Successfully used to treat nephrogenic
DI but not recommended in long-term
use.
5. Placement on a low sodium formula
 To reduce solute intake and resultant
obligate water loss associated with
solute excretion.
1. Restrict intake and monitor sodium and potassium level.
 To prevent hypernatremia and hypokalemia.

2. Cold fluids
 Is preferred to relieve thirst.

3. High fluid intakes.

 To prevent dehydration during an illness.

COMPLICATIONS

1. Hypernatremia and hypokalemia

 Hypernatremia may be developed if diabetes insipidus is left untreated.

 During the initial diagnostic test, an elevated serum sodium can be seen which
the result could be greater than 145 mEq/L.
 It is due to the deficit water in the body which causes the sodium electrolyte to
increase as a result.

2. Brain damage

 Dehydration is one of the signs and symptoms of diabetes insipidus.

 Most of the time, children get enough water from eating and drinking to replace
the fluids they lose.
 But in some cases such as diabetes insipidus, a child can lose more water than
normal.
 This child might experience hypovolemic shock where the body is not able to
make enough blood (inadequate oxygen) to send to the vital organs.
 It causes a drop in blood pressure and leads to brain damage and eventually
death.

3. Impaired mental function

  Electrolytes such as sodium helps to carry signals from cell to cell.
 If electrolytes are imbalanced, the normal electrical messages can be mixed up
where this can lead to involuntary muscle contractions and sometimes loss
consciousness.
 The same goes to children whom are having severe dehydration, they may
develop mental confusion and disorientation as well as potential to experience
seizures

4. Poor growth

 Poor growth is another possible complication of diabetes insipidus in a child.

 This is caused by one of the signs and symptoms of poor feeding as they tend
to feel more thirsty rather than hungry.
 Nutrition is the main factor for a child’s growth.
 As they lack nutrition due to poor feeding, they may experience a stalled
growth.

5. Restlessness

 There is a condition called hypertonic dehydration, imbalance of water and salt

in the body.
 Newborns may also get the condition when they are first learning to nurse, or if
they are born early and underweight.
 This dehydration caused by diabetes insipidus can result in restlessness in
children.
 Deficiency of water can cause eyes and cheeks to take on sunken appearance
where areas around eyes become dark and shadowed.
 These are signs and symptoms of restlessness which are common in young
children and babies.

HEALTH PROMOTION
 1. Educate parents about making fluids available to the child as needed such as
bringing water bottles together during outing or going to school.
2. Educate parents to obtain and record daily weight as well as measuring intake and
output.
Parents may need to weigh diapers to monitor urine output in infants
3. Educate parents on signs of dehydration such as cracked lips, dry skin or having a
dark yellow urine.
4. Offer water every few hours to the child. Aware the parents that cold fluid is preferred
and helps to relieve thirst.
5. Educate parents on the correct procedure to prepare and administer drugs such as
time to administer and their amount.
6. The child with chronic diabetes insipidus should always wear a medical alert
identification such as tag or bracelet to indicate the presence of the disorder
7. Advice parents to partner with school officials to make arrangements to provide the
child unrestricted access to toilet facilities and water.

NURSING DIAGNOSIS
1. Fluid volume deficit.

Nursing Interventions Rationale

1. Monitor patient’s intake and output. To detect abnormalities. Urine output greater
than 500ml in two hours should be reported.

2. Monitor for increased thirst Thirst can be a reliable indicator of fluid balance.
(polydipsia).

3. Monitor signs of hypovolemic shock Polyuria causes decreased circulatory blood

such as tachycardia, tachypnea, volume. Frequent assessment can detect
and hypotension. changes early for rapid intervention.

4. Weight patient daily. Weight loss occurs with excessive fluid loss.

5. Allow the patient to drink water at So the patient can maintain fluid balance by
will. drinking huge quantities of water to compensate
for the amount they urinate.

6. Provide easy access to the Easy access to void will decrease inconvenience

bathroom or urinal. and frustration.

7. Provide easily accessible fluid To encourage fluid intake.

sources.

8. Administer intravenous fluids, such Hypotonic IV fluids help lower serum sodium
as dextrose 5% and sodium levels, while isotonic fluids are indicated for those
chloride 0.45%, or sodium chloride who are hemodynamically instable.
0.9%.
2. Deficient knowledge related to low developmental age

Nursing Interventions Rationale

1. Identify the learner: the patient, Patients who are really young are dependent on
family, or caregiver. their caregiver, hence the caregiver will be
receiving the health education instead.

2. Assess the learner’s ability to learn So an appropriate teaching plan can be outlined.
or perform desired health-related
care.

3. Perform teaching sessions in a quiet A calm environment allows the patient to

and comfortable place. concentrate and focus more completely.

This technique aids the learner make adjustments

4. Help the learner in integrating
in daily life that will result in the desired change in
information into daily life.
behaviour.

5. Provide clear, thorough, and

Patients are better able to ask questions when
understandable explanations and
they have basic information about what to expect.
demonstrations.

Visual aid provide better understanding

 6. Give information with the use of
media. Use visual aids like
diagrams, pictures and videotapes.

Allows verification of understanding of given

7. Encourage questions
information.

8. Ask the learner to teach-back the To evaluate the learner’s understanding and
information using their own words. correct any misunderstandings.

REFERENCES

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