Nursing Care Plan (NCP) for Diabetes Insipidus

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Outline

Pathophysiology

Diabetes insipidus refers to the condition where the kidneys are unable to retain water. Even though the patient may be dehydrated, the kidneys cannot balance the fluid and produce large amounts of insipid urine (dilute and odorless). The kidneys normally produce 1-2 quarts of urine per day, but with diabetes insipidus, they may produce 3 – 20 quarts per day. This results in the patient feeling very thirsty and have the urge to drink large amounts of liquid.

Etiology

The hypothalamus produces a hormone called vasopressin, an antidiuretic hormone (ADH) that tells the kidneys how much fluid to absorb from the bloodstream. This normally results in a lower amount of urine produced.  When there is damage to the hypothalamus (Central diabetes insipidus, or CDI) or the kidneys are not able to respond to the vasopressin (Nephrogenic diabetes insipidus or NDI), the kidneys do not know when to stop removing fluid from the body, even if the body is already dehydrated. This results in the patient feeling extremely thirsty, which prompts them to drink more fluids, and therefore, secrete more dilute urine.

Desired Outcome

Prevent dehydration, manage symptoms and prevent complications

Diabetes Insipidus Nursing Care Plan

Subjective Data:

  • Excessive thirst
  • Polyuria, excessive urination
  • Headache
  • Fatigue
  • Nausea
  • Dry mouth
  • Loss of appetite
  • Muscle cramps
  • Confusion

Objective Data:

  • Dry mucous membranes
  • Tachycardia
  • Weight loss
  • Hypotension
  • Hypernatremia
  • Decreased skin elasticity

Nursing Interventions and Rationales

  • Monitor I & O, daily weights, and polydipsia

 

Weight loss will occur with excessive fluid loss. Thirst can be an indicator of fluid balance.

 

  • Monitor for signs / symptoms of hypovolemia

 

Excess fluid loss results in decreased circulatory volume. Early detection and intervention can prevent hypovolemic shock from occuring.

 

  • Monitor for signs of hypotension and provide education and assistance with ambulation

 

Dehydration and hypernatremia can cause the blood pressure to drop which may result in dizziness or weakness with position changes. Assist patient when standing or walking to prevent falls and injury. Educate patient to make slow changes in position.

 

  • Encourage hydration and provide easy access to fluids; administer IV fluids if necessary
    • Hypotonic-  D5W or 0.45% sodium chloride
    • Isotonic – NS (0.9% sodium chloride) if hemodynamically unstable

 

If the patient has intact thirst, offer plenty of fluids to prevent dehydration. If the patient cannot orally tolerate fluids, initiate IV fluids.

 

  • Monitor labs / electrolyte balance
    • Serum and urine osmolality
    • Serum and urine sodium levels
    • Serum potassium

 

Excess fluid loss results in the body excreting potassium and retaining sodium. This results in too much sodium and too little potassium in the blood.

 

  • Administer medications appropriately
    • Chlorpropamide or carbamazepine – stimulates the release of vasopressin (ADH)
    • Hydrochlorothiazide- may be used for nephrogenic DI
    • Aqueous vasopressin – used for short term DI
    • Pitressin tannate is a long-acting vasopressin

 

Depending on the type of diabetes insipidus, medications may be given to stimulate the production of vasopressin, or it may be given as a supplement. When giving medications, monitor for effectiveness and changes in blood pressure due to changes in fluid balance.

 

  • Provide easy access to bathroom

 

Frequent urination can be frustrating for the patient. Provide easy access for voiding including urinal or bedside commode as appropriate.

 

  • Prevent injury and initiate fall precautions

 

Frequent trips to the bathroom can increase the risk of falls. Provide assistance as needed with ambulation, especially if patient has confusion, muscle cramps or muscle weakness from electrolyte imbalance.

 

  • Assess for skin integrity, apply skin barriers as needed

 

Polyuria may lead to bouts of incontinence and increase the risk of skin breakdown. Apply barriers and precautions as necessary to avoid redness or excoriation.

Writing a Nursing Care Plan (NCP) for Diabetes Insipidus

A Nursing Care Plan (NCP) for Diabetes Insipidus starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey guys, in this care plan, we are going to be discussing diabetes insipidus. What we’re going to look at here is a description of diabetes insipidus. We’re going to look at subjective and objective data associated with it and then we’re going to look at nursing interventions and rationales. 

 

Alright, so diabetes insipidus is a condition where the kidneys are not able to retain water in the way that they should. This means that the kidneys are creating extremely large amounts of dilute and even odorless urine actually, they can have up to 20 quarts a day. So, we’re looking at a very extreme, increased urine output. Normal urine output is about one to two quarts per day and like I said, you can have up to 20 with diabetes insipidus because of this excess urine production. The patient becomes really dehydrated and feels very thirsty and you can get some really abnormal electrolytes. 

 

Okay, so let’s think a little bit about how this actually may happen. So, the hypothalamus in the brain is actually what secretes a hormone called vasopressin, which is an antidiuretic hormone. So, this antidiuretic hormone is actually what tells the kidneys how much fluid they need to absorb. So, usually vasopressin is released from the hypothalamus when the body needs to retain fluid for some reason. So maybe, they’ve lost blood but for some reason, the body needs more fluid. Now, if the hypothalamus isn’t able to release vasopressin because it’s been damaged, you get something called central diabetes insipidus or CDI. If the kidneys aren’t able to respond to vasopressin that is in the body, you get something called nephrogenic diabetes, insipidus or NDI. So, those are the two different types of diabetes insipidus to be aware of. Either way, what happens is that the kidneys won’t know when to stop removing fluid from the body and the patient is going to have excess urine production. When you have this, you may see diabetes insipidus. 

 

The desired outcome for a patient who has this diagnosis is to prevent dehydration, manage symptoms and prevent complications. Often the complications are about those abnormal electrolytes that I mentioned. Okay, so let’s get into the care plan. 

 

The subjective data that you’re going to see with diabetes insipidus are excessive thirst, polyuria, excessive urination, headache, fatigue, nausea, dry mouth, loss of appetite, muscle cramps and confusion. 

 

The objective data that you will see with this diagnosis are again, dry mucous membranes, tachycardia, weight loss, hypotension, hypernatremia and decreased skin elasticity. Also, you can see how with both of these, they’re directly linked to fluid abnormalities and electrical abnormalities.

 

Your first nursing intervention here is to keep a super close eye on the patient’s eyes, nose, weight and their level of thirst. Now, it’s important, so important that we know exactly what the patient is taking in. So, their intake and what their output is. We need to know every time they go to the bathroom and we need to know exactly how much they’re urinating. Also, remember that weight loss can occur with excessive fluid loss, and extreme thirst may be a clue that the patient’s fluid loss has actually worsened in extreme cases. If the dehydration becomes severe enough, the patient may actually show signs and symptoms of hypovolemia and possibly even shock in really severe cases. So, if this happens, you’re going to notice changes in vital signs. So, you’re going to notice an increased heart rate. You’re going to notice tachypnea as well, so increased respiratory rate and a decrease in blood pressure. So, we just mentioned that you might see a drop in blood pressure. If they’ve got low volume, if this happens, it’s really important to provide education and assistance with ambulation. You want to be looking for signs like dizziness and then really, you want to educate patients on how to make sure that we can avoid falls as much as possible, and then they may need assistance with their ambulation.

 

Okay, this next innovation intervention is super important. These patients are going to need fluids. So, we’ve got to encourage hydration and make sure that patients have access to fluids. Sometimes IV fluids are going to be necessary if they become hemodynamically unstable. Alright, so we’ve been talking about fluid balance a lot, but next we need to pay really close attention to the patient’s electrolyte balance. The way that we keep a close eye on this is to check urine and serum osmolality as well as our sodium and potassium levels. When the body is losing an excess amount of fluid, you’re going to see potassium excreted excessively as well. So, you’re going to end up with hypokalemia, but the opposite of that is going to happen with your sodium because your body’s going to retain the sodium and you’re going to end up with hypernatremia. So, when you’re looking at these electrolytes, you want to look for hypernatremia and hypokalemia. 

 

The next thing we may need to do is actually to give medications. I’ve listed the really important ones here for you to see. So, the chlorpropamide may be given to stimulate the release of vasopressin. Hydrochlorothiazide may be given to treat nephrogenic diabetes insipidus, which again, remember is when the kidneys can’t respond to the vasopressin that’s already circulating in the body. Aqueous vasopressin may be given to treat short-term diabetes insipidus and the Pitressin tannate is a long-acting vasopressin. Now, remember, anytime you give your medication, it’s really important to monitor for the effectiveness of that medication. So, we want to be looking for changes in blood pressure and changes in fluid balance okay? Remember, these patients are at risk for hypotension, dizziness and electrolyte imbalances. So, it’s really important to include this in your nursing intervention, how to prevent injury and reduce the risk of falls. This means providing assistance to the bathroom and easy, easy access to the bathroom as well. Lastly, here, because of the frequent urination, some patients may actually experience incontinence. If that happens, they’re at increased risk for skin breakdown, therefore it’s essential that we continually assess skin integrity and apply skin barriers as needed. 

 

Alright, that’s it for our lesson on diabetes insipidus. We love you guys. Now, go out and be your very best self today and as always, happy nursing!

 

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