diabetes insipidus case study nursing

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Diabetes Insipidus Nursing Diagnosis and Nursing Care Plan

Last updated on December 31st, 2022 at 11:49 am

Diabetes Insipidus Nursing Care Plans Diagnosis and Interventions

Diabetes insipidus is a disorder that causes fluid imbalances in the body, which can lead the patient to have polyuria, large amounts of urine, and polydipsia, which makes them feel very thirsty despite drinking fluids.

A healthy adult usually produces about 1 to 2 liters of urine a day. However, an adult who has severe diabetes insipidus may produce up to 20 liters of urine in 24 hours or may pass urine more than 7 times in a day.

Because of its distinctive signs and symptoms, strict input and output monitoring and accurate fluid management are both required for patients with this uncommon disorder. Diabetes insipidus is believed to be caused by a hormone imbalance of the antidiuretic hormone (ADH), also known as vasopressin or AVP.

Diabetes insipidus is not related to diabetes mellitus, as it does not involve a disturbance in the blood glucose levels compared to the latter.

Signs and Symptoms of Diabetes Insipidus

The following are the signs and symptoms of diabetes insipidus:

• Polydipsia – feeling of extreme thirst despite drinking the usual amounts of fluids
• Polyuria  – passing urine in large amounts and usually pale in color
• Nocturia  – increased urinary frequency at night
• Preference for cold drinks

In infants or young children, the following signs and symptoms of diabetes insipidus may be observed:

• Bed-wetting
• Heavy, wet diapers
• Trouble  sleeping
• Weight loss
• Delayed growth
• Constipation

Causes of Diabetes Insipidus

The fluid part of the blood called plasma is filtered by the kidneys to take away the waste products. After the filtering process, the hormone vasopressin or anti-diuretic hormone (ADH) helps the filtered plasma to return to the bloodstream.

ADH is produced in the hypothalamus and is stored in a small gland called the pituitary gland of the brain. Any deficiency of ADH or blockage of its effect causes an increase in the production of excess urine. Problems with ADH levels can cause imbalances in the fluid levels of the body.

Types of Diabetes Insipidus

There are two main types of diabetes insipidus: central and nephrogenic. The other two rare types include gestational diabetes insipidus and dipsogenic or primary polydipsia. In some cases, the cause could be an autoimmune response that results in unwanted damage to the vasopressin-making cells.

• Central diabetes insipidus . The normal process of producing, storing, and releasing ADH can be affected by any damage to the hypothalamus or the pituitary gland. Conditions such as brain tumors or malignancy, brain infections, head injuries, or even surgery can cause this type of diabetes insipidus. Rarely, the disease can also result from a genetic disorder inherited from the person’s parents.
• Nephrogenic diabetes insipidus . This type of diabetes insipidus is caused by any defect in the parts of the kidneys. When the kidney structures are damaged, the organ will not be able to respond appropriately to ADH. This will result in polyuria and nocturia. The damage can be caused by a chronic or long-term kidney disorder, a genetic disease, and/or the use of certain medications such as some antivirals and the drug lithium.
• Gestational diabetes insipidus. A rare disorder during pregnancy, gestational diabetes insipidus happens when ADH is destroyed by a placenta-produced enzyme.
• Dipsogenic diabetes insipidus . Also called primary polydipsia, this type of diabetes insipidus involves damage to the mechanism that regulates thirst in the hypothalamus. Recent studies relate it to some mental health disorders, such as schizophrenia. It causes the patient to drink very large amounts of fluids and pass huge amounts of diluted, pale urine.

Risk Factors for Diabetes Insipidus

The following are risk factors for the development of diabetes insipidus:

• Genetics . The disease can be hereditary and can develop at birth or shortly after being born. There could be permanent changes in the structures of the kidneys, disabling the baby to concentrate urine.
• Sex. Males are usually affected by nephrogenic diabetes insipidus. However, women may pass the gene to their kids.

Complications of Diabetes Insipidus

• Dehydration. Diabetes insipidus may result in dehydration if left untreated. A dehydrated patient may have increased fatigue, thirst, dryness of the mouth, and poor skin elasticity or skin turgor.
• Electrolyte imbalance. Diabetes insipidus can affect the balance of the electrolytes, particularly serum sodium and potassium, which are the two main electrolytes involved in fluid balance. An imbalance of these electrolytes can result in muscular weakness and cramps, acute confusion, loss of appetite, nausea, and/or vomiting.

Diagnosis of Diabetes Insipidus

• Water deprivation test. In this exam, the patient will be subjected to oral fluid cessation for a few hours. The nurse should measure the changes in the urine output, body weight, and concentration of blood and urine while the body is deprived of water and other fluids. The test aims to check if the body’s production of ADH is adequate and to assess the response of the kidneys to ADH. The physician may order the administration of synthetic ADH during the water deprivation test.
• Magnetic resonance imaging (MRI). To check for any abnormalities in the pituitary gland, an MRI of the head may be ordered. An MRI can help see detailed images of the brain tissues in and around the pituitary gland through the non-invasive method of using radio waves in a magnetic field.
• Genetic testing. The doctor may order a genetic screening procedure if the patient’s family members also suffer from excessive urine production or polyuria.

Treatment for Diabetes Insipidus

The type of diabetes insipidus determines the treatment required, which may include the following:

• Central diabetes insipidus. The physician may prescribe a synthetic replacement for ADH called desmopressin, which can help reduce urination. It is usually available in tablet form, but can also be given by injection or as a nasal spray. The drug may result in unwanted water retention and hyponatremia or low sodium levels if taken too much, so the amount of desmopressin may vary depending on the ADH level in the body. Another type of medication is one that can help increase the availability of ADH in the body.
• Nephrogenic diabetes insipidus. This type of D.I. is usually treated with a low-sodium diet to facilitate the reduction of urine that is produced by the kidneys. The doctor may prescribe a diuretic called hydrochlorothiazide to improve polyuria. The patient will also be encouraged to drink adequate amounts of water daily. Desmopressin will not be helpful in this type of D.I.
• Gestational diabetes insipidus. Synthetic hormone desmopressin is usually the treatment of choice in pregnant women with D.I.
• Dipsogenic diabetes insipidus. The physician will instruct the patient to decrease oral fluid intake. As this type of D.I. can be strongly related to an underlying mental health condition, treating the specific mental health disorder may have a positive effect on primary polydipsia.
• Lifestyle changes. The patient will be instructed to take measures to prevent dehydration and electrolyte imbalance, which are the two most common complications of diabetes insipidus. The patient should carry water wherever they go and must never stop the prescribed medication abruptly or on their own. It is also recommended to carry a medical alert card in their wallet or wear a medical alert bracelet which can help if the patient has a medical emergency.

Nursing Diagnosis for Diabetes Insipidus

Diabetes insipidus nursing care plan 1.

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to lack of understanding of the condition and its treatment regimen and unfamiliarity with the complications secondary to diabetes insipidus as evidenced by asking numerous questions and verbal expression of misconceptions about the illness

Desired Outcome: The patient will verbally express their complete comprehension of diabetes insipidus and the medications used in the treatment.

Diabetes Insipidus Nursing Care Plan 2

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume related to endocrine regulatory mechanism dysfunction, hypophysectomy, impairment of the neuro-hypophyseal, and hypopituitarism secondary to diabetes insipidus as evidenced by polyuria, polydipsia, and rapid weight loss

Desired Outcome: The patient will have average fluid volume, as evidenced by the noticeable lack of thirst, a standard blood sodium level, and an unchanging weight.

Diabetes Insipidus Nursing Care Plan 3

Risk for Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity related to urinary recurrence, large volume output, and the possibility of incontinence secondary to diabetes insipidus

Desired Outcome: The patient’s skin will be intact and remain undamaged.

Diabetes Insipidus Nursing Care Plan 4

Disturbed Sleep Pattern

Nursing Diagnosis: Disturbed Sleep Pattern related to an increase in urinary frequency and anxiety about the condition secondary to diabetes insipidus, as evidenced by discontentment with sleeping habits, waking up earlier or later than desired, general fatigue, and sleep disruption.

Desired Outcome: The patient will get an adequate amount of sleep, as demonstrated by a refreshed appearance, verbalization of feeling relaxed, and an improvement in sleeping habits.

Diabetes Insipidus Nursing Care Plan 5

Nursing Diagnosis: Nausea related to disparities in minerals in the blood, such as potassium and sodium (electrolytes), which preserve the body’s fluid equilibrium secondary to diabetes insipidus as evidenced by dizziness and lethargy.

Desired Outcome: The patient will report less severe or complete elimination of nausea.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

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3 Diabetes Insipidus Nursing Care Plans

Diabetes insipidus (DI) is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst. It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or “bedwetting”). Urine output is increased because it is not concentrated normally.

Table of Contents

1. deficient fluid volume, 2. risk for impaired skin integrity, 3. deficient knowledge.

Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measured concentration (osmolality or specific gravity) is low.

Nursing Care Plans

Here are three (3) nursing care plans for diabetes insipidus.

May be related to

• Compromised endocrine regulatory mechanism
• Neurophypophyseal dysfunction
• Hypopituitarism
• Hypophysectomy
• Nephrogenic DI

Defining Characteristics

• Output exceeds intake
• Polydipsia (increased thirst)
• Sudden weight loss
• Urine specific gravity less than 1.005
• Urine osmolality less than 300 mOsm/L
• Hypernatremia
• Altered mental status
• Requests for cold or ice water

Desired outcomes

• Patient experiences normal fluid volume as evidenced by absence of thirst, normal serum sodium level, and stable weight.

Risk factors

• Urinary frequency with high volume output and the potential for incontinence

Desired outcome

• Patient’s skin remains intact.
• New condition
• Unfamiliarity with the disease and treatment

Defining characteristics

• Questioning
• Requests for more information
• Verbalization of misconceptions or misinterpretations
• Patient verbalizes correct understanding of DI and the medications used in treatment

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Diabetes Insipidus (DI) NCLEX Review for Nursing Students + Free Download

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Understanding Diabetes Insipidus (DI) is Important for Nursing Students 

Endocrine Disorder: Diabetes insipidus is a rare but important endocrine disorder characterized by excessive thirst and urination due to the inability to regulate water balance. Nurses should be knowledgeable about its pathophysiology, clinical presentation, and management. Potentially Life-Threatening: Severe cases of diabetes insipidus can lead to dehydration, electrolyte imbalances, and complications such as hypovolemic shock. Nurses need to understand the potential severity of this condition and how to provide appropriate care. Assessment Skills: Nurses should be skilled in assessing patients for signs of diabetes insipidus, including excessive thirst, polyuria, and signs of dehydration.

Fluid and Electrolyte Imbalance: Diabetes insipidus can lead to significant fluid and electrolyte imbalances. Nurses need to understand the implications of these imbalances and how to address them. Diagnostic Tests: Nurses should be familiar with the diagnostic tests used to confirm diabetes insipidus, such as water deprivation tests and urine osmolality measurements. Medication Management: Understanding the medications used to manage diabetes insipidus, such as desmopressin, and their administration is important for nurses. Fluid Replacement: In cases of severe dehydration, nurses need to understand fluid replacement protocols to address the increased water loss associated with diabetes insipidus. Documentation: Accurate documentation of signs, symptoms, interventions, and patient education is crucial for tracking the patient's condition and providing continuity of care. NCLEX Preparation: The NCLEX exam may include questions related to diabetes insipidus, its pathophysiology, assessment, interventions, and patient education. A solid understanding of this topic is essential for answering these questions accurately. Overall, understanding diabetes insipidus equips nursing students to provide safe, patient-centered care to individuals affected by this condition. It ensures that nursing students are prepared to address the unique challenges and needs of patients with diabetes insipidus and contribute to positive patient outcomes.

Overview of Diabetes Insipidus

Hyposecretion or failure to respond to antidiuretic hormone (ADH) from the posterior pituitary, which leads to excess water loss

General Information forDiabetes Insipidus

1. Urine output → 4L to 30L in a 24 hour period 2. Excessive dehydration 3. Causes        a. Neurogenic→ stroke, tumor       b. Infection       c. Pituitary surgery (pituitary gland secretes ADH)

Assessment for Diabetes Insipidus

1. Polyuria → Excessive urine output→ dilute urine, Urine Specific Gravity <1.006 2. Polydipsia (extreme thirst) 3. Hypotension leading to cardiovascular collapse 4. Tachycardia 5. Hypernatremia, neurological changes

Therapeutic Management for Diabetes Insipidus

1. Water replacement         a. PO Free Water (plain water)         b. D5W if IV replacement required 2. Hormone replacement→ DDAVP (Desmopressin/ Vasopressin) → Synthetic ADH 3. Monitor urine output hourly (Report UO >200mL/ hour), monitor urine specific gravity 4. Daily weight monitoring

Nursing Case Study for Diabetes Insipidus

Patient Profile: Lucas Carter, a 10-year-old boy, is admitted to the pediatric unit with complaints of excessive thirst and urination. His parents report that he has been drinking large amounts of water and needing to use the bathroom frequently, even during the night. Assessment: Upon assessment, Lucas appears alert and oriented but slightly dehydrated. He reports feeling thirsty and requests water frequently. His urine output is significantly increased, and his urine appears dilute. His serum electrolyte levels are within normal range, but his serum osmolality is low.

• Collaborate with the healthcare provider to initiate fluid replacement to address Lucas's dehydration and maintain adequate fluid balance.
• Collaborate with the healthcare provider to order diagnostic tests, such as water deprivation tests and urine osmolality measurements, to confirm the diagnosis of diabetes insipidus.
• Collaborate with the healthcare provider to initiate desmopressin therapy, a synthetic form of antidiuretic hormone, to manage Lucas's symptoms and help regulate his fluid balance.
• Monitor Lucas's vital signs regularly, especially his blood pressure and heart rate, to ensure he remains hemodynamically stable.
• Perform neurological assessments to monitor Lucas's level of consciousness and cognitive function, as electrolyte imbalances or dehydration can affect neurological status.
• Educate Lucas and his family about the condition, the importance of adhering to medication therapy, and the signs of dehydration to watch for.
• Collaborate with the healthcare team to monitor Lucas's fluid intake and output, as well as his serum electrolyte levels, to prevent imbalances.
• Provide emotional support to Lucas and his family, addressing their concerns and helping them cope with the challenges of managing a chronic condition.
• Schedule regular follow-up appointments to monitor Lucas's response to treatment, adjust medication doses as needed, and provide ongoing support.

Outcome:  With comprehensive care and proper management, Lucas's condition improves. His excessive thirst and urination subside as he receives desmopressin therapy. His fluid balance is maintained, and he is educated about his condition to actively participate in self-management.

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A Case of Diabetes Insipidus

By David F. Dean (rr)

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“Amanda Richards,” a 20-year-old junior in college, is majoring in biology and hopes to be a pediatrician one day. For about a month, she has been waking up frequently at night to go to the bathroom. Most recently, she has noticed that she needs to go to the bathroom during the day more often, almost hourly. Students read about these symptoms and then answer a set of directed questions designed to teach facts and principles of physiology using reference books, textbooks, the Internet, and each other as sources of information. The case has been used in a sophomore-level course in human anatomy and physiology as well as in senior-level course in general physiology.

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• Learn about the similarities and dissimilarities between diabetes insipidus and diabetes mellitus.
• Understand the basic differences between the four types of diabetes insipidus.
• Be able to define and describe excessive thirst and urination in adults.
• Understand the methods by which diabetes insipidus is diagnosed and treated.
• Learn about other conditions which produce symptoms similar to those produced by diabetes insipidus.
• Be able to describe the physiological effects of antidiuretic hormone other than the maintenance of body water balance.

Pituitary diabetes insipidus; diabetic; antidiuretic hormone; ADH; vasopressin; osmoreceptors; osmolarity; polyuria; polydipsia; supraoptic nuclei; kidney function

Subject Headings

EDUCATIONAL LEVEL

Undergraduate lower division, Undergraduate upper division

TOPICAL AREAS

TYPE/METHODS

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Case study: a patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse.

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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• Ris (Zotero)
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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1  

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11  

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

    • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

    • Limited exercise

    • High carbohydrate intake

    • No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14  

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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ICEECE2012 Poster Presentations Clinical case reports - Pituitary/Adrenal (58 abstracts)

Central diabetes insipidus: about two clinical cases

C. nogueira 1, , m. matos 1, , c. esteves 1, , g. jorge 1 , j. couto 2 , c. neves 1, , j. queirós 1 , e. vinha 1 , i. bernardes 1 & d. carvalho 1,.

1 Centro Hospitalar São João, Porto, Portugal; 2 Instituto Português de Oncologia, Porto, Portugal; 3 University of Porto, Porto, Portugal.

Introduction: Central diabetes insipidus (CDI) is produced by the destruction of the magnocellular neurons of the hypothalamic supraoptic and paraventricular nuclei which results in decreased arginine vasopressin (AVP) synthesis and secretion.

Case report 1: Forty-five year old female, previously healthy, was observed in April 2011 complaining of polydipsia, polyuria, nocturia and weight loss since January. Diabetes mellitus (DM) was excluded and she was admitted for study of possible diabetes insipidus. Water deprivation test was suggestive of CDI. Magnetic resonance imaging (MRI) showed infundibular hypophysitis and no hyperintense signal in the neurohypophysis. Autoimmune diseases, infections and infiltrative diseases were excluded. Imaging (chest x-ray, abdominal ultrasound, mammography, breast ultrasound and thoracoabdominal CT) was normal. No other pituitary deficits were shown. She started therapy with oral desmopressin with clinical improvement.

Case report 2: Fourty-three year old man, previously healthy, was seen in August 2011 complaining of polydipsia, polyuria and nocturia during the previous 3 months. DM was excluded. Water deprivation test was positive for CDI. Pituitary MRI was normal, with normal signal of high intensity in the neutohypophysis. He had no other hormonal deficits. Autoimmune and infectous diseases were excluded. After initiation of oral desmopressin the symptoms disappeared.

Discussion: In both cases it was not determined the etiology of CDI, as it may occur in 20–50% of CDI cases. In our institution is not possible to determine antibodies towards vasopressin secretory cells, which does not allow the diagnosis of this autoimmune form of CDI. The infundibular hypophysitis, observed in the first case, can occur in about 50% of idiopathic cases and more frequently in women. The lymphocytic hypophysitis can be diagnosed by pituitary biopsy, but it’s a very aggressive procedure and almost never performed. These cases highlight the difficulty of the etiologic diagnosis of CDI. However, proper treatment allows the symptoms control.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

15th International & 14th European Congress of Endocrinology

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Treating nephrogenic diabetes insipidus: a case study

Affiliation.

• 1 St. Michael's Hospital, Toronto, Ontario, Canada. [email protected]
• PMID: 12042694
• DOI: 10.1097/00003465-200205000-00005

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