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DIABETES INSIPIDUS (DI) The opposite of SIADH; *Salty blood, watery urine*; Dec production or secretion of ADH or poor response to ADH by renal tubules; Acute or Chronic Types of DI (1) -Neuro:ADH production or release altered; Head related issues, CNS infections, surgery; -Psycho: Excessive thirst, water intake; Lesion in thirst center or psychological diagnosis Types of DI (2) -Nephro: Response from renal tubules altered despite adequate ADH present; Drugs (lithium), renal damage; -Gestational DI Clinical Manifestations Polydipsia & polyuria; Serum Na level; Low USG -<1.005; Elevated serum osmolality; Fluid volume deficit (Weight loss; Tenting; Hypotension; Tachycardia; Shock) DI Assessment Strict I & O; Daily labs: Na; Collect urine sample; Collect serum osmolality per MD order; Assessment:Daily weight, Vital signs, Skin turgor DI Diagnosis Identify the cause of alterations in blood work and urine or to account for presenting S&S; Central vs. Nephrogenic DI-->Water deprivation test Water deprivation test Used to assess if DI is caused by neuro or nephro: Withhold fluids for 8-16 hours, draw ADH levels before and during. Central D.I. Care Fluid Replacement: Hypotonic NSS or D5W; Hormone Replacement: Desmopressin (DDAVP), Carbamazepine (Tegretal- For a Partial D.I.) Nephrogenic D.I. Care Low salt (Na) diet (<3 grams/day); Thiazide diuretics: slow the GFR allowing increased water reabsorption in tubules; Indocin: used if thiazide diuretics aren't effective Nursing care of DI 1 Fluid volume status(I & O, daily weights) Medication administration-DDAVP: increase dose if urine output increases while specific gravity is low Nursing care of DI 2 Teaching-Med administration: DDAVP can cause HA, nausea, vomiting, signs of hyponatremia; Home maintenance; Daily weight; Regular blood work Thyroid Gland Controls how quick body uses energy, makes proteins, and controls sensitivity to other hormones; Produces thyroxine (T4), triiodothyronine (T3), calcitonin; pituitary and hypothalamus control it Goiter Enlargement of the thyroid gland; Excess TSH stimulation, Lack of circulating thyroid hormones, Goitrogens (food/drugs with thyroid inhibiting substances) Palpable thyroid gland "Nodular goiter" - small, discrete, autonomously functioning nodules that secrete thyroid hormones. Single or multiple nodules; If associated with hyperthyroidism - it is termed "toxic" Goiter Diagnosis and treatment Physical assessment:Palpable thyroid gland?; Labs: TSH, T3, T4, Free T3 & T4; Surgery:Thyroidectomy (*airway); Medications:Thyroid hormone replacement therapy Graves Disease: Hyperthyroidism Unknown etiology; Autoimmune process; Thyroid enlarges and marked increase in secretion of thyroid hormones noted; Women > Men; Usually affects persons aged 20-40 yrs Graves Disease: Hyperthyroidism Clinical Manifestations Weight loss, Nervousness (early),Tachycardia; Angina; Fatigue; Insomnia; Inc appetite; Diarrhea; Diaphoresis, *Goiter, *Exophthalmos, Intolerance to heat, Menstrual irregularities, Graves Diagnosis TSH (low); T4, T3; Free T3 & T4 (high), Radioactive iodine uptake (35-95% uptake); Thyroid scan; EKG:Tachycardia, A-fib, change in P & T waves; Ophthalmologic exam Graves Care & Mgt *GOAL-Decrease adverse effects of thyroid hormones & stop oversecretion; Antithyroid Meds; Radioactive Iodine Therapy(Ablation); Subtotal Thyroidectomy; Nutritional Support Graves Meds - Thiomides PTU & Tapazole-Inhibit the synthesis of thyroid hormones; Blocks peripheral conversion of T4 to T3;*Young, pregnant, need to achieve euthyroid state before surgery* Graves Meds - Iodine Large doses given prior to surgery (+PTU)-Dec size of thyroid gland; Dec vascularity of thyroid gland; Inhibits synthesis of T3 & T4; Blocks release of T3 & T4 Graves Meds: Iodine Toxicity Toxicity of this med for Graves causes swelling of buccal mucosa, excess salivation, nausea, vomiting, & skin reactions Graves Treatment;: Radiation Therapy: Using radioactive iodine-Limits thyroid hormone secretion by damaging thyroid tissue; Non-pregnant pts only; Delayed response; Complication: hypothyroidism; Requires life long thyroid replacement Graves Treatment: Subtotal Thyroidectomy: Do this if they suspect thyroid malignancy, allergic to iodone; Only portion of thyroid removed. Allows regeneration. Attempt to avoid prolonged hypothyroid state Graves Treatment: Total Thyroidectomy: Do this if they suspect thyroid malignancy, allergic to iodone; Entire thyroid gland removed. Life long thyroid hormone replacement needed Complications of Thyroidectomy Hypothyroidism; Hemorrhage; Damage/removed parathyroid gland; Infection; Damage to laryngeal nerve; Thyrotoxic Crisis Graves: Thyroidectomy Surgical info Pre-Op Medical preparation-Thiomides, Iodine Teaching:Incision, ROM/Activity restrictions, Dietary restrictions. Vocal changes, Consent: Informed Graves: Thyroidectomy Surgical info Post-Op Room prep:Humidified O2, Suction, Trach tray for emergency Vital signs, AIRWAY!**, Musculoskeletal: tetany; Semi-fowlers, Avoid neck flexion Graves: Thyroidectomy Surgical info Post-Op 2 Meds:Pain, Synthroid (if needed); Diet-Once gag reflex returns, Thin liquids & soft foods; Surgical Incision-Remove sutures, Steri-strips, Drain maybe Graves Care and Mgt: Nutritional Support R/T increased metabolic rates; 4000-5000 calories/day 6 meals + snacks; Include Vitamin A, B6, C, Thiamine; Avoid spicy foods & caffeine