Diabetes Insipidus a Matter of Fluids

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Diabetes insipidus A matter of fluids

Nurses in all clinical areas, from pediatrics to large amounts of dilute urine, increased geriatrics, may encounter this relatively rare thirst, and an increased likelihood of dehydration, this disorder is seen across the disease. Knowing how to identify, monitor, and lifespan, equally among men and treat it can help save patients from potentially women. Diabetes mellitus (DM) and DI life-threatening complications. are neither the same condition, nor are they related. Although they both share By Amanda Perkins, DNP, RN the word diabetes, they are two very different disorders. In patients with DM, blood glucose levels are elevated; this Diabetes insipidus (DI) is a rare condition isn’t the case in individuals with DI. affecting approximately 1 out of 25,000 This article provides a description of

people. Characterized by the passage of DI, including the different types, signs AODAODAODAOD / SHUTTERSTOCK

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The body’s role in fluid balance Relying on a variety of factors, including Anterior Posterior thirst, the kidneys, and the hormone vaso- pituitary pituitary pressin (also known as antidiuretic hormone [ADH]), the maintenance of fluid balance in the body is essential. Vasopres- sin plays a significant role in the regula- tion of urination and, in turn, fluid and electrolyte balance. In addition to being produced by the hypothalamus, vasopressin is also stored in and secreted by the pituitary gland. ADH deficiency When the body senses that it has a low fluid level, vasopressin is released to tell the kidneys to absorb a smaller amount of fluid from the bloodstream, effectively H2O increasing the amount of fluid in the body. In cases of dehydration or instances in Collecting duct which a person has hypotension, increased amounts of ADH are released to increase the amount of fluid in the body. Impairment of water On the flip side, when the body senses reabsorption that it has a high fluid volume, the release of vasopressin is either decreased or stopped Urine completely, resulting in an increased loss of fluid in the form of urine. Basically speaking, Decreased renal water reabsorption vasopressin or ADH controls the amount of water that’s released by the kidneys as urine.

Four types Inappropriately dilute When DI is present, the kidneys are un- urine able to maintain the delicate fluid balance within the body (see The mechanism of DI). An individual with DI makes and passes DI too much urine, which can lead to signifi- Polyuria, polydipsia cant problems including, but not limited to, dehydration and fluid and electrolyte Source: Braun C, Anderson C. Applied Pathophysiology: A Conceptual Approach to the imbalances. The urine of a person with DI Mechanisms of Disease. 3rd ed. Philadelphia, PA: Wolters Kluwer Health; 2017. is said to be insipid, which means dilute and odorless. Normally, an individual will There are four types of DI: central, have a urine output of approximately 1 to nephrogenic, dipsogenic, and gestational. 2 L per day, whereas the individual with DI may pass anywhere from 3 to 20 L per Central DI day. Additionally, these individuals may Central DI is caused by damage to the urinate as often as every 15 to 20 minutes hypothalamus or pituitary gland due to throughout the course of a day. surgery, infection, inflammation, a www.NursingMadeIncrediblyEasy.com May/June 2020 Nursing made Incredibly Easy! 29

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. tumor, or a head injury. To review, the kidneys concentrate urine, leading to hypothalamus makes vasopressin, a large amounts of dilute urine. hormone responsible for increasing or decreasing urine output, and the pitu- Dipsogenic DI itary gland stores and releases vasopres- Dipsogenic DI is caused by a defect of sin. Damage to these areas of the brain the thirst mechanism within the hypo- will lead to difficulty with the produc- thalamus. Individuals with this type of tion, storage, and release of vasopressin. DI are very thirsty, and this increased With central DI, the body has lower- thirst correlates with an increase in fluid than-normal amounts of vasopressin, intake. When fluid intake is increased, which can lead to too much fluid be- we see a suppression in vasopressin se- ing removed from the body in the cretion and increased urinary output. form of urine. In many cases, fluid is This condition typically has the following rapidly lost from the body, leading to three phases: polydipsia and polyuria, dehydration. hyponatremia, and water intoxication. The signs and symptoms of water intoxi- Nephrogenic DI cation are nausea, vomiting, delirium, Nephrogenic DI is caused by kidneys ataxia, seizures, and coma. that are unable to concentrate urine. The Disorders associated with dipsogenic kidneys don’t respond appropriately to DI include chronic meningitis, granuloma- vasopressin, resulting in too much fluid tous disease (immune system disorder in being removed from the body. In individ- which phagocytes don’t work properly), uals with this condition, urine production multiple sclerosis, and mental health dis- can be as high as 12 L per day, with uri- orders. When dipsogenic DI is caused by a nation occurring as often as every hour. mental health disorder, it may be referred Children with nephrogenic DI have a to as psychogenic polydipsia or compul- congenital form, whereas adults present sive drinking. Schizophrenia, compulsive with an acquired form. behaviors, affective disorders, psychosis, Causes of nephrogenic DI include an personality disorders, and stress have been inherited gene, gene mutations, chronic associated with psychogenic polydipsia. kidney disease, medications, decreased Although seen in a variety of mental health serum potassium levels, increased serum disorders, this condition is most commonly calcium levels, and/or a blockage in the seen in patients with schizophrenia. In urinary tract. Lithium is the drug most some cases, the medications used to treat commonly associated with the condition. psychiatric disorders can cause dry mouth, In addition, the antiviral medication foscar- leading to an increased intake of fluids. net and the antipsychotic drug clozapine Note that this type of DI can lead to hypo- have been associated with nephrogenic DI. natremia instead of hypernatremia. When Glucocorticoids and alcohol use may also hyponatremia develops, it can worsen lead to its development. mental health symptoms for the patient. Medications associated with nephrogenic DI can cause damage to kidney Gestational DI cells, which leads to the cells not respond- Gestational DI typically occurs during ing to vasopressin. Individuals taking lith- the third trimester of pregnancy, affecting ium should have kidney function tests 2 to 6 women out of 100,000. The most every 3 months. As is the case with lithi- common signs and symptoms of gesta- um, hypercalcemia can lead to kidney tional DI are polyuria and polydipsia, damage, resulting in nephrogenic DI. both of which are common in pregnancy, Hypokalemia may alter the way that the making diagnosis a challenge in many

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. cases. The risk of gestational DI rises A closer look at hypovolemic shock with an increased placental mass, such as occurs with multiple fetuses. Potential In severe cases, DI can lead to hypovolemic causes of gestational DI are hemolysis shock—a loss of fluid so severe that the heart with elevated liver enzymes and low is unable to pump enough blood to perfuse the body. Hypovolemic shock is a medical platelet count, or HELLP syndrome; pre- emergency and must be identified and treated eclampsia; and acute fatty liver of preg- early. Signs and symptoms include: nancy. Gestational DI may also be caused • hypotension • decreased urine because prostaglandin produced during • decreased output pregnancy can reduce the kidney’s sensi- temperature • confusion tivity to vasopressin. • rapid, thready • weakness With this disorder, the enzyme vaso- pulse • anxiety pressinase made in the placenta can break • tachypnea • agitation down the mother’s vasopressin. Dur- • pallor • loss of ing pregnancy, trophoblasts (cells that • cool, clammy skin consciousness. develop into a major part of the placenta) produce large amounts of the enzyme prevents this risk by sending signals that vasopressinase, which inactivates ADH. the person is thirsty. Polydipsia as a result Interestingly, vasopressinase activity of thirst is another key feature of DI; it can increases 40- to 50-fold during pregnancy. be so significant that the patient drinks as The liver’s ability to degrade this enzyme much as 20 L per day. The polyuria and increases fourfold and the release of ADH polydipsia that occur with DI occur both also increases. Although gestational DI day and night, which is a distinguishing can be problematic, this condition is usu- feature. Due to diuresis, patients with DI ally mild with minimal symptoms and can develop hypernatremia, which can resolves spontaneously 2 to 3 weeks after ultimately lead to confusion. Dehydra- delivery. tion and hypernatremia may lead to the development of weakness, fatigue, hypo- Signs and symptoms tension, tachycardia, and a decreased A variety of signs and symptoms are LOC. In addition to dehydration, you’ll associated with DI. Some of the more see increased serum osmolality or concen- common signs and symptoms include: trated blood. Individuals with DI are also • polyuria at risk for hypovolemic shock (see A closer • polydipsia look at hypovolemic shock). • dehydration Young children may experience severe • hypernatremia dehydration, vomiting, constipation, • dizziness fever, irritability, sleep disturbances, poor • weakness growth, excessive crying, and failure to • nocturia thrive. Older children may wet the bed, • fatigue have a decreased appetite, and be • hypotension fatigued. Children may also develop • tachycardia hypernatremia with inappropriately • decreased level of consciousness (LOC). dilute urine. Children with DI should be As discussed previously, a key feature monitored closely because they have an of DI is the production of large amounts increased risk of poor outcomes associat- of urine that’s dilute and light in color. ed with fluid loss. We know that when an individual passes DI can significantly impact an individ- large amounts of urine, he or she is at ual’s quality of life, negatively affecting risk for becoming dehydrated. The body school, work, and social life. In many www.NursingMadeIncrediblyEasy.com May/June 2020 Nursing made Incredibly Easy! 31

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. cases, these individuals report that they • urine volume greater than 150 mL/kg/ feel generally unwell and struggle with 24 hours at birth feelings of fatigue, irritability, and poor • urine volume greater than 100 to 110 mL/ concentration. Ask patients about their kg/24 hours up to age 2 years quality of life and provide assistance and • urine volume greater than 50 mL/kg/ support as needed. 24 hours in older children and adults. For example, a patient who weighs Diagnosis 150 lb (68.2 kg) would need a urinary When caring for a patient with suspected output of 3,410 mL or higher to confirm DI, an accurate diagnosis is essential be- polyuria. When caring for adults, it’s cause the treatment plan will differ de- considered reassuring when the 24-hour pending on the type of DI identified. The urine volume is less than 2.5 L. Through- diagnosis of DI is made based on medi- out the diagnostic process, the patient’s cal history, family history, a physical urine is monitored for output and how exam, urinalysis, blood tests, fluid depri- dilute it is. vation tests, and MRI. When completing With DI in mind, we measure osmolali- the nursing history, ask about medica- ty in the urine and blood. To review, osmo- tions used because some medications lality refers to the number of particles in a have adverse reactions that mimic DI fluid. You’ll typically see increased serum and others can cause kidney damage, osmolality and decreased urine osmolality which increases the risk of DI develop- (hypotonic urine). Basically, the patient’s ment. An MRI may be able to detect blood becomes more concentrated and his problems with the hypothalamus or pitu- or her urine becomes less concentrated. itary gland. Additional testing may be Hypotonic urine has an osmolality of less ordered to rule out other diseases. Be than 300 mOsm/kg. A plasma osmolality aware that gestational DI may be under- of 285 mOsm/kg will typically make a diagnosed due to an overlap of symp- person feel thirsty. As the plasma osmolal- toms, such as polyuria and polydipsia, ity increases, so does thirst. which are seen in both DI and during a In addition to osmolality, which only typical pregnancy. measures the number of particles, urine The diagnostic steps for DI are confir- specific gravity may be checked to also mation of polyuria, determination of the measure the concentration of particles. In type of DI, and determination of the general, when urine osmolality is in the underlying etiology. When checking the normal range, urine specific gravity will be patient for polyuria, identify and rule out between 1.003 and 1.030. When monitoring other conditions that can present with urine specific gravity in the patient with DI, similar symptoms, such as urinary urgen- it will often be less than 1.005. Both urine cy, nocturia, incontinence, urinary tract specific gravity and urine osmolality are infection, and prostatic hyperplasia. To relatively easy to measure and noninvasive identify polyuria, a 24-hour urine sample in most cases unless a catheter must be is obtained. If completing this test at used to collect the urine sample. The urine home, educate the patient about the should also be monitored for glucose importance of saving all urinary output. because DM, which can lead to increased When completing this testing in a health- urine output, will result in glucose in the care setting, ensure that all staff members, urine whereas DI won’t. as well as the patient, understand the Serum sodium levels may also be importance of saving all urine. checked in the patient with potential DI. If Polyuria is confirmed with the following the serum sodium levels are elevated, it urinary output: can help identify central or nephrogenic

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DI; if the serum sodium levels are normal At the completion of the fluid depriva- or low, dipsogenic DI is suspected. tion test, desmopressin may be used for Fluid deprivation tests involve the patients who have continued dilute urine restriction of fluid intake while measuring to help differentiate between nephrogenic changes in body weight and urine concen- DI and central DI. Patients who have cen- tration. The two types of fluid deprivation tral DI should be able to concentrate urine tests that may be carried out are the short after the administration of desmopressin, test and the formal fluid deprivation test. whereas those with nephrogenic DI won’t Before either of these tests, electrolyte be able to. abnormalities must be identified and cor- An additional test that may be carried rected. Additionally, medications that can out is the hypertonic saline infusion test. affect urinary output should be discontin- Depending on the facility, nurses may find ued for 24 hours before the test. that some healthcare providers prefer the For the short test, the patient stops drink- hypertonic saline test over the fluid depri- ing liquids at a specified time, a urine sam- vation test. In fact, some research studies ple is collected at a different specified time, have shown that the hypertonic saline and the concentration of the sample is tested. infusion test is a more effective way of The formal fluid deprivation test is per- testing for DI. This test is conducted in formed in the hospital setting. The patient a healthcare setting, typically lasting needs to be monitored closely for adverse 3 hours or less. As with the fluid depriva- reactions such as dehydration. The patient tion test, medications affecting output is weighed and his or her urine is tested at need to be stopped 24 hours before the

Accurate diagnosis is essential because the treatment plan will differ depending on the type of DI identified. Diagnostic steps include confirmation of polyuria and determination of the underlying etiology. specified intervals, in some cases as often test. Baseline blood testing will be com- as every hour. The test will be stopped if pleted for copeptin (an arginine vasopres- one or more of the following occurs: hypo- sin surrogate), sodium, glucose, urea, and tension or tachycardia, weight loss of 5% plasma osmolality. or more, and/or urine concentration At the start of this test, hypertonic increase in two to three consecutive tests. saline is given as a 250 mL bolus over 10 to At the completion of the test, serum sodi- 15 minutes and then slowed and adminis- um, vasopressin levels, and urine concen- tered as a continuous infusion. Serum tration are checked. In patients who don’t sodium and osmolality are measured have DI (excepting dipsogenic DI), the every 30 minutes for the duration of the increase in plasma osmolality that occurs test. Once the serum sodium levels are due to decreased intake stimulates the greater than or equal to 150 mOsm/L, the release of vasopressin, effectively causing test is terminated. At the completion of the the urine to become more concentrated, test, the patient is asked to drink water at with increased urine osmolality. In 30 mL/kg over 30 minutes followed by an patients who have DI, this process doesn’t infusion of dextrose 5% (D5) at 500 mL/h happen, and the urine will remain dilute. for 1 hour. After the infusion of D5, the www.NursingMadeIncrediblyEasy.com May/June 2020 Nursing made Incredibly Easy! 33

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. patient’s serum sodium levels are checked may be performed. Baseline and post-op to ensure that they’ve returned to normal. neurologic assessments should be complet- Throughout the course of the hyperton- ed. Patient education includes the avoid- ic saline infusion test, the patient must be ance of activities that can put pressure on closely monitored, particularly frequent the site, such as coughing, sneezing, blow- vital signs assessment. A benefit to this test ing the nose, straining for a bowel move- is that it doesn’t require urine to be collect- ment, and bending at the waist. Although ed and tested. When reviewing the lab this surgery can be used to treat DI, it can results, a plasma copeptin level of less than also cause DI. The post-op patient should 4.9 pmol/L is indicative of central DI and a be monitored for signs and symptoms of level greater than or equal to 4.9 pmol/L DI and appropriate treatments initiated if it indicates primary polydipsia. A baseline develops. copeptin value of greater than 21.4 pmol/L With nephrogenic DI, it’s important to is indicative of nephrogenic DI. identify and treat the cause because treating

Astute assessment skills will help you identify signs and symptoms of DI and complications if they develop. Knowing what to look for can save your patient’s life.

Treatment the cause may cure the condition. If neph- Patients with diagnosed or suspected rogenic DI is caused by a medication that’s DI may be referred to a nephrologist or damaged the kidneys, the medication may endocrinologist. The type of treatment need to be discontinued and kidney func- varies, depending on the type of DI. tion monitored. In some cases, stopping With central DI, the hormone desmo- the medication will be enough to address pressin will be prescribed to replace vaso- the problem. When electrolyte abnor- pressin in the body. This medication can malities are identified as a potential cause, be administered via injection, nasal spray, those abnormalities should be treated and or pill. Desmopressin has been shown to reversed. In some instances, such as when be a safe medication, but it can cause the ADH is lacking, a thiazide diuretic may be following adverse reactions: headache, prescribed because it paradoxically reduces upset stomach, congestion, runny nose, urine production. When used for central and/or nosebleeds. Taking too much of and nephrogenic DI, thiazide diuretics this medication or drinking too much fluid allow for water and sodium reabsorp- while taking it can lead to fluid overload, tion at the proximal tubules, which causes which results in headaches, dizziness, decreased urine output. Adverse reactions bloating, and hyponatremia. Signs and associated with thiazide diuretics include symptoms of hyponatremia include head- orthostatic hypotension, indigestion, sen- ache, confusion, and nausea/vomiting. sitive skin, and/or erectile dysfunction. Although desmopressin can help control Additionally, aspirin and ibuprofen may the patient’s symptoms, this treatment reduce urine production when used in isn’t curative. conjunction with thiazide diuretics. If a pituitary tumor is present, a hypo- Treatment for dipsogenic DI can be physectomy (pituitary gland removal) challenging; in many cases, there’s no

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Understanding iso-, hypo-, and hypertonic solutions Isotonic: The concentration Hypotonic: The concentration Hypertonic: The concentra- of dissolved solutes in two of dissolved solutes in two tion of dissolved solutes in two environments is equal. 0.9% environments is unequal, with environments is unequal, with sodium chloride is an isotonic the hypotonic solution having the hypertonic solution having solution. When administered less dissolved solutes than more dissolved solutes than to patients, 0.9% sodium chlo- other solutions. 0.45% sodium other solutions. 3% sodium ride solution won’t cause any chloride is a hypotonic solu- chloride is a hypertonic solu- fluid shifts. tion. When administered to tion. When administered to patients, 0.45% sodium chlo- patients, 3% sodium chloride ride solution will cause fluid to solution will cause fluid to shift shift from the bloodstream and from the cells and move into move into the cells. the bloodstream. effective treatment. If a mental health dis- treatment, the patient with DI should be order is a cause, treating the psychiatric closely monitored and educated about the illness may be beneficial. If medications disease and how to manage it. are identified as causing dry mouth for the patient, it may be possible to explore Complications different medications. If it isn’t possible to The two main complications associated alter medications causing dry mouth, with DI are dehydration and electrolyte interventions such as dry mouth tablets, imbalances. Signs and symptoms of mouthwashes, and sprays may be used to dehydration include: help with symptom control. Treatment • thirst may also include fluid restriction and • dry skin, mouth, and lips psychosocial care. • sunken features When a patient has gestational DI, des- • fatigue mopressin, which has been shown to be • dizziness safe during pregnancy, may be prescribed. • lightheadedness Note that the placenta doesn’t destroy • confusion desmopressin like it destroys vasopressin. • headache In some cases, no treatment is necessary. • muscle cramps The patient will be encouraged to drink • decreased urine output extra fluid and monitored closely. If treat- • concentrated urine ment is started, it will typically be stopped • syncope after delivery because symptoms usually • nausea resolve within a few weeks. • tachycardia In general, the patient with DI must • tachypnea. drink enough liquid to prevent dehydra- Mild dehydration can lead to changes tion and the associated complications. In in BP, heart rate, and temperature. Severe mild cases of DI, the individual may only dehydration can present with weakness need to drink more water. Additionally, and confusion, progressing to brain dam- hypotonic I.V. fluids, such as 0.45% sodi- age, kidney damage, and death if left um chloride solution, may be given to untreated. replace fluids without increasing sodium Dehydration must be monitored levels. (For more information on hypoton- when it occurs. Be mindful that dehy- ic fluids, see Understanding iso-, hypo-, dration, vomiting, fever, sweating, and and hypertonic solutions.) Regardless of the hot weather can increase the risk of or www.NursingMadeIncrediblyEasy.com May/June 2020 Nursing made Incredibly Easy! 35

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. sodium, each facility uses its own ranges. key points Defer to your facility’s ranges when Priority nursing assessments caring for patients with serum sodium When caring for a patient with DI, priority abnormalities. Patients with hyperna- nursing assessments include the following: tremia must be monitored and receive • Obtain a health history, including medica- treatment to decrease their serum sodium tions taken, history of pregnancy, family levels. In instances in which a fluid history of DI, kidney disease, and mental imbalance accompanies hypernatremia, health disorders. the fluid imbalance should be corrected, • Monitor for polyuria, polydipsia, nocturia, followed by a serum sodium level check and signs and symptoms of dehydration. to determine if the corrected fluid balance • Assess skin turgor, vital signs trends, daily also corrected the hypernatremia. If the weights, and intake and output. patient continues to have elevated serum • Closely observe urinary output, including sodium levels, I.V. fluid replacement amount, color, and clarity of urine. without sodium may be enough to correct • Monitor all requested labs, paying close the problem. Lastly, the patient may be attention to serum sodium levels and kidney placed on a sodium-restricted diet. function tests. Nursing interventions worsen dehydration. If any of these Nurses play an essential role when caring risk factors develop, be ready to com- for patients with DI, including assessing municate your findings and treat the daily weights, intake and output, skin identified cause. For mild cases of dehy- turgor, mucous membranes, vital signs, dration, I.V. fluids or increased fluid changes in LOC, and labs. When com- intake may be prescribed. Electrolytes pleting daily weights, it’s necessary to may need to be replaced to prevent fur- obtain the patient’s weight at the same ther complications. time each day on the same scale. All staff The most common electrolyte imbalance members caring for the patient, in addi- that develops in patients with DI is hyper- tion to the patient and his or her family/ natremia, or an elevated serum sodium level. caregivers, should be educated about the Serum sodium concentration is controlled importance of accurate intake and output by water homeostasis. Thirst, vasopressin/ measurement. Assess skin turgor and ADH, and the renin-angiotensin-aldosterone mucous membranes for dryness because system all play a role in water homeostasis. these two assessments provide important When a patient develops hypernatremia, information about the patient’s hydration the first symptom that typically develops is status. Vital signs should be monitored, increased thirst. The patient may also pres- being mindful of a decrease in BP and in- ent with mental status changes, such as agi- creased pulse. Also monitor for changes tation, confusion, and personality changes. in LOC in addition to agitation, anxiety, He or she may experience muscle twitches, and restlessness. Be aware of all lab tests unusual muscle contractions, skeletal mus- ordered and ensure that the results are cle weakness, nausea, vomiting, lethargy, reviewed and reported to the healthcare irritability, spasticity, seizures, and in provider as needed. severe cases, coma. When polyuria is occurring, encourage Normal serum sodium levels are 135 to increased fluid intake. If the patient is tak- 145 mEq/L. With hypernatremia, serum ing medications such as desmopressin, sodium levels are above 145 mEq/L. encourage decreased fluid intake. Be Although some facilities recognize 135 to mindful of patients who have a dimin- 145 mEq/L as the normal range for serum ished thirst mechanism or those who can’t

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. report thirst, such as infants or patients Fenske W, Refardt J, Chifu I, et al. A copeptin-based approach in the diagnosis of diabetes insipidus. N Engl J who are confused. These patients are at a Med. 2018;379(5):428-439. much higher risk for complications associ- Gubbi S, Hannah-Shmouni F, Koch CA, Verbalis JG. ated with polyuria if they’re unable to Diagnostic Testing for Diabetes Insipidus. South Dartmouth, receive adequate amounts of fluid. It may MA: Endotext; 2019. Kalra S, Zargar AH, Jain SM, et al. Diabetes insipidus: the be beneficial to educate the patient about other diabetes. Indian J Endocrinol Metab. 2016;20(1):9-21. wearing a medical-alert bracelet stating MedlinePlus. Diabetes insipidus—central. 2020. https:// that he or she has DI. medlineplus.gov/ency/article/000460.htm. MedlinePlus. Hypovolemic shock. 2020. https://medline plus.gov/ency/article/000167.htm. At the ready National Health Service. Diabetes insipidus. 2019. Astute assessment skills will help you www.nhs.uk/conditions/diabetes-insipidus. identify signs and symptoms of DI and National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes insipidus. 2015. www.niddk.nih.gov/ complications if they develop. Knowing health-information/kidney-disease/diabetes-insipidus. what to look for can save your patient’s University of Rochester Medical Center. Dehydration. life. ■ 2020. www.urmc.rochester.edu/encyclopedia/content.asp x?contenttypeid=85&contentid=P00828. Williams LS, Hopper PD. Understanding Medical-Surgical REFERENCES Nursing. 6th ed. Philadelphia, PA: F.A. Davis; 2019. Belzile M, Pouliot A, Cumyn A, Côté AM. Renal physi- Zain MA, Raza A, Hanif MO, et al. Double trouble— ology and fluid and electrolyte disorders in pregnancy. severe hypernatremia secondary to central diabetes Best Pract Res Clin Obstet Gynaecol. 2019;57:1-14. insipidus complicated by hypercalcemic nephrogenic Bhatia MS, Goyal A, Saha R, Doval N. Psychogenic diabetes insipidus: a case report. Am J Case Rep. 2018;19: polydipsia—management challenges. Shanghai Arch 973-977. Psychiatry. 2017;29(3):180-183. Amanda Perkins is an Associate Professor of Nursing at Vermont Bockenhauer D, Bichet DG. Pathophysiology, diagnosis Tech in Randolph, Vt., and a Nursing made Incredibly Easy! Editorial and management of nephrogenic diabetes insipidus. Board Member. Nat Rev Nephrol. 2015;11(10):576-588. The author and planners have disclosed no potential conflicts of Cleveland Clinic. Diabetes insipidus. 2017. https:// interest, financial or otherwise. my.clevelandclinic.org/health/diseases/16618-diabetes- insipidus. DOI-10.1097/01.NME.0000658172.72738.c2

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