Diabetes Insipidus

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. 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 (1).

Nursing Care Plans

1. Deficient Fluid Volume

Common Related Factors Defining Characteristics
Compromised endocrine regulatoryPolyuria
mechanism
Output exceeds intake
Neurohypophyseal dysfunction
Polydipsia (increased thirst)
Hypopituitarism
Sudden weight loss
Hypophysectomy
Urine specific gravity less than 1.005
Nephrogenic DI
 Urine osmolality less than 300 mOsm/L

Hypernatremia (sodium greater than 145

mEq/L)

Altered mental status

Requests for cold or ice water

Common Expected Outcome NOC Outcomes

Patient experiences normal fluid volume asFluid Balance; Electrolyte and Acid-Base
evidenced by absence of thirst, normalBalance
serum sodium level, and stable weight.
NIC Interventions

Fluid Monitoring; Fluid Management;

Electrolyte Management

Ongoing Assessment

Actions/Interventions Rationale
Monitor intake and output. Report urineWith DI, the patient voids large urine
volume greater than 200 mL for each of 2volumes independent of the fluid intake.
consecutive hours or 500 mL in a 2-hourUrine output ranges from 2 to 3 L/day with
period. renal DI to greater than 10 L/day with central
DI.
Monitor for increased thirst (polydipsia). If the patient is conscious and the thirst
center is intact, thirst can be a reliable
indicator of fluid balance. Polyuria and
polydipsia strongly suggest DI. Also, the DI
patient prefers ice water.
Weigh daily. Weight loss occurs with excessive fluid loss.
Monitor urine specific gravity. This may be 1.005 or less.
Monitor serum and urine osmolality. Urine osmolality will be decreased and
serum osmolality will increase.
Monitor urine and serum sodium levels. The patient with DI has decreased urine
sodium levels and hypernatremia.
Monitor serum potassium. Hypokalemia may result from the increase in
urinary output of potassium.
Monitor for signs of hypovolemic shockFrequent assessment can detect changes early
(e.g., tachycardia, tachypnea, hypotension). for rapid intervention. Polyuria causes
decreased circulatory blood volume.
Therapeutic Interventions
Actions/Interventions Rationale
Allow the patient to drink water at will. Patients with intact thirst mechanisms may
maintain fluid balance by drinking huge
quantities of water to compensate for the
amount they urinate. Patients prefer cold or
ice water.
Provide easily accessible fluid source,This encourages fluid intake.
keeping adequate fluids at bedside.
Administer intravenous (IV) fluids: IV fluids are indicated if the patient cannot
take in sufficient fluids orally.
• 5% dextrose in water or 0.45%Hypotonic IV fluids provide free water and
sodium chloride help lower serum sodium levels gradually.
• 0.9% sodium chloride Isotonic fluids may be indicated for the
patient who has sustained significant fluid
loss and is hemodynamically unstable. Once
circulatory volume has been restored,
hypotonic IV fluids can be given.
Administer medication as prescribed. Aqueous vasopressin is usually used for DI
of short duration (e.g., postoperative
neurosurgery or head trauma). Pitressin
tannate (vasopressin) in oil (the longer-acting
vasopressin) is used for longer-term DI.
Patients with milder forms of DI may use
chlorpropamide (Diabinese), clofibrate
(Atromid), or carbamazepine (Tegretol) to
stimulate release of ADH from the posterior
pituitary and enhance its action on the renal
tubules. Hydrochlorothiazide
(HydroDIURIL) may also be used for
nephrogenic DI.
If vasopressin is given, monitor for waterOvermedication can result in volume excess.
intoxication or rebound hyponatremia.

2. Risk for Impaired Skin Integrity

Common Risk Factor
Urinary frequency with high volume output
and the potential for incontinence
Common Expected Outcome NOC Outcomes

Patient’s skin remains intact. Tissue Integrity: Skin and Mucous

 Membranes; Risk Control; Risk Detection

NIC Interventions

Skin Surveillance; Skin Care: Topical

Treatments

Ongoing Assessment

Actions/Interventions Rationale
Inspect skin; document condition andEarly detection and intervention may prevent
changes in status. occurrence or progression of impaired skin
integrity. Fluid loss from polyuria
contributes to decreased skin turgor and
dryness.
Assess for continence or incontinence.Excessive moisture on the skin increases the
Evaluate need for an indwelling urinaryrisk of skin breakdown.
catheter.
Assess other factors that may risk theExcessive moisture from urinary
patient’s skin integrity (e.g., immobility,incontinence can add to the risk for skin
nutritional status, altered mental status). breakdown from other sources.

Therapeutic Interventions

Actions/Interventions Rationale
Provide easy access to the bathroom, urinal,Both polyuria and polydipsia disrupt the
or bedpan. patient’s normal activities (including sleep).
Easy access to void will decrease
inconvenience and frustration.
Use skin barriers as needed. These prevent redness or excoriation from
urinary frequency.
Keep bed linen clean, dry, and wrinkle-free. This prevents shearing forces.

3. Deficient Knowledge
Common Related Factors Defining Characteristics
New condition Questions

Unfamiliarity with disease and treatment Requests for more information

Verbalized misconceptions or
misinterpretation
Common Expected Outcome NOC Outcomes

Patient verbalizes correct understanding ofKnowledge: Disease Process; Knowledge:

DI and the medications used in treatment. Medication

NIC Interventions

Teaching: Disease Process; Teaching:

Prescribed Medication

Ongoing Assessment

Actions/Interventions Rationale
Assess level of knowledge of DI cause andAn individualized teaching plan is based on
treatment. the patient’s current knowledge and desire
for additional information.
Assess readiness to learn. Rapid fluid loss from polyuria can lead to
impaired cognitive function. This change in
mental status can limit the patient’s ability to
learn new information.

Therapeutic Interventions

Actions/Interventions Rationale
Give written information concerning the
diagnosis and treatment of DI:
• Water deprivation ADH stimulationThis test may be done to differentiate
test nephrogenic causes from neurogenic causes
of DI. The patient is instructed to take
nothing by mouth (NPO) for 12 hours before
a blood sample is drawn to measure ADH
levels. The ADH level is increased in
nephrogenic DI and decreased in neurogenic
(central) DI. Vasopressin may be given to
evaluate renal response. There is no response
to the drug in nephrogenic DI.
• Computed tomography scan orThese scans may be ordered if a pituitary
magnetic resonance imaging tumor is suspected.
• Desmopressin acetate (DDAVP) This is the drug of choice for the
management of DI. This medication is a
synthetic form of ADH and is administered
intranasally.
• Aqueous form of ADH (vasopressin) This drug has a shorter half-life than
DDAVP and therefore requires more
 frequent daily administration. Vasopressin is
usually given parenterally and is not
recommended for the long-term management
of chronic DI.
• Other drugs used in combination toThese secondary drugs work on the kidney or
manage DI, includingthe posterior pituitary gland to increase
chlorpropamide (Diabinese),pituitary release of ADH or increase renal
clofibrate (Atromid), carbamazepineresponse to ADH.
(Tegretol), and hydrochlorothiazide
Teach the patient the necessity of closelyThis assists the patient in monitoring the
monitoring fluid balance, including dailycondition so that adjustments can be made
weights (same time of day with sameaccordingly, helping prevent undertreatment
amount of clothing), fluid intake and output,or overtreatment with the medication,.
and measurement of urine specific gravity.
Discuss when to seek further medicalPatients with chronic disease need to be able
attention (at signs of underdosage orto recognize important changes in their
overdosage of medications). condition to avert complications and possible
hospitalization.
Instruct the patient to wear a medical alertThis allows for prompt intervention in the
bracelet, listing DI and the medications thatevent of an emergency.
the patient is using.