Anatomic and Physiologic Overview

Fig. 42-1
 Posterior Pituitary
• The important hormones secreted by the posterior
lobe of the pituitary gland are vasopressin, also called
antidiuretic hormone (ADH), and oxytocin.
• Vasopressin controls the excretion of water by the
kidney; its secretion is stimulated by an increase in the
osmolality of the blood or by a decrease in blood
pressure.
• Hormon ADH dikeluarkan o/ kelenjar hipofisis
posterior  berfungsi mengatur kecepatan ekskresi
air ke dalam urin dan mengatur konsentrasi air dalam
cairan tubuh
 ADAKAH YANG
TAHU
PERBEDAANNYA???
 DEFINISI
• Diabetes insipidus (DI) is a disorder of the posterior
lobe of the pituitary gland that is characterized by a
deficiency of ADH (vasopressin).
• Excessive thirst (polydipsia) and large volumes of
dilute urine characterize the disorder.
• Physiologically, ADH is released primarily in response
to even small elevations in serum osmolality and
secondarily in reaction to hypovolemia or hypotension.
• Any patient who has head trauma, or resection of a
pituitary tumor, has an increased risk of developing DI.
 Classification
• Diabetes insipidus (DI) results from a group of
disorders in which there is an absolute or relative
deficiency of ADH (called central DI) or an
insensitivity to its effects on the renal tubules
(called nephrogenic DI) (Figure 16-3).
• DI can occur if 1) the hypothalamus produces
insufficient ADH; 2) the posterior pituitary fails to
release ADH; or 3) the kidney nephron is resistant
(unresponsive) to ADH.
• Diabetes insipidus can result in acute fluid and
electrolyte disturbances.
Pathogenesis of DI
 Etiology
• There are many causes of DI (Table 16-12).
• It may occur secondary to head trauma, brain tumor,
or surgical ablation or irradiation of the pituitary gland.
• It may also occur with infections of the central nervous
system (meningitis, encephalitis, tuberculosis) or with
tumors (eg, metastatic disease, lymphoma of the
breast or lung).
• Another cause of DI is failure of the renal tubules to
respond to ADH; this nephrogenic form may be related
to hypokalemia, hypercalcemia, and a variety of
medications (eg, lithium, demeclocycline
[Declomycin]).
Causes of DI
NEPHRON
 Pathophysiology
• Central or neurogenic DI results from damage to the
hypothalamic/pituitary system.
• An absolute deficiency of ADH results in an impaired
ability to concentrate urine, polyuria, and a
subsequent risk for dehydration.
• Patients with head trauma or those who have had
neurosurgery must be watched closely for at least 7 to
10 days after the injury for evidence of DI because DI
does not present for at least 48 to 72 hours after the
initial hypothalamic or hypophyseal (system of blood
vessels that link the hypothalamus and the anterior
pituitary) trauma.
 Pathophysiology
• Nephrogenic DI is characterized by renal
tubule insensitivity to ADH and develops
because of structural or functional changes in
the kidney. This results in impaired urine-
concentrating ability and free water
conservation. Nephrogenic DI is less dramatic
than neurogenic DI in its onset and
appearance.
 Clinical Manifestations
ADH Deficiency
• Polydipsia (if alert)
• Polyuria (5-20 L in 24 hours)
Fluid Volume Deficit
• Orthostatic hypotension
• Weight loss
• Tachycardia
• Decreased CVP,
• Poor skin turgor
• Dry mucous membranes
• hypernatremia and severe dehydration
 Orthostatic hypotension
• Orthostatic hypotension, which occurs when
intravascular fluid volume decreases, is
identified by a drop in systolic blood pressure
of 20 mm Hg or a drop in diastolic blood
pressure of 10 mm Hg when the patient
changes position from lying to standing.
 Clinical Manifestations
Intracellular Brain Volume Depletion:
• Confusion
• Restlessness
• Lethargy
• Irritability
• Seizures
• Coma
 Clinical Manifestations
• Without the action of ADH on the distal
nephron of the kidney, an enormous daily
output of very dilute, waterlike urine with a
specific gravity of 1.001 to 1.005 occurs.
• The urine contains no abnormal substances
such as glucose or albumin.
 Diagnostic Tests
The most common tests are serum sodium concentration,
serum osmolality, and urine osmolality (Table 33-6).
• Water deprivation test
• Serum sodium > 145 mEq/L
• Serum osmolality > 295 mOsm/kg/L
• Urine osmolality inappropriately low with high serum
osmolality (< 150 mOsm/kg/L)
• Urine specific gravity decreased (less than 1.005)
• BUN and creatinine increased (hemoconcentration)
 Medical Management
• Treatment goals include restoration of
circulating fluid volume, pharmacologic ADH
replacement, and treatment of the underlying
condition.
 Volume Restoration
• Fluid replacement is provided in the initial
phase of the treatment to prevent circulatory
collapse by oral or hypotonic IV solutions are
infused
• Carefully monitored to restore the
hemodynamic balance.
 Pharmacologic Therapy
• Desmopressin (DDAVP), a synthetic
vasopressin without the vascular effects of
natural ADH
• It is administered intranasally; One or two
administrations daily (ie, every 12 to 24 hours)
(Tierney, McPhee & Papadakis, 2005)
• Desmopressin acts on the distal tubules and
collecting ducts of the kidney to increase
water reabsorption.
 Nursing Management
• Nursing management of the patient with DI
incorporates a variety of nursing diagnoses
(Box 33-16).
• Nursing management is directed toward
administration of prescribed fluids and
medications, evaluation of response to
therapy, and provision of patient education.
 Administration of Fluids and
Medications
• Rapid IV fluid replacement requires the use of
a volumetric pump.
• Initially, a hypotonic IV solution is used to
replace fluids lost and lower the serum
hyperosmolality.
• ADH replacement is accomplished with
extreme caution in the patient with a history
of heart disease, because ADH may cause
hypertension and overhydration.
 Fluid Volume Replacement (1)
• Administer hypotonic volume, such as
dextrose 5% in water, quarter-strength or half-
strength saline, IV as prescribed to restore the
hypotonic fluid lost through osmotic diuresis.
• The administration of normal saline to replace
volume is usually contraindicated because it
presents an added renal load, promoting
osmotic diuresis and worsening dehydration.
 Fluid Volume Replacement (1)
• In severe DI, where large amounts of fluid
replacement are required, the IV intake is
usually titrated to urine output; for example,
400 mL of urine output for 1 hour is replaced
with 400 mL IV fluid the next hour.
• A good rule of thumb is to reduce serum
sodium by 0.5 mEq/L every hour but no more
than 12 mEq/L per day.
 Fluid Volume Replacement (2)
• Monitor fluid status: Hourly urine outputs along
with measurements of urine specific gravity every
1-2 hours should be done along with daily weight
and strict intake and output.
• Monitor for signs of continuing fluid volume
deficit.
• If the serum Na is > 155 mEq/L, rehydration
should occur over 48 hours.
• A serum Na + > 170 necessitates ICU care.
• Expected outcomes for the patient with DI are
listed in Table 16-13.
Fluid Volume Replacement (2)
Evaluation of Response to Therapy
• Monitoring of HR, BP, CVP, and pulmonary artery
pressures (if a pulmonary artery catheter is in
place)
• I&O measurement, condition of buccal
membranes, skin turgor, daily weight
measurements, presence of thirst, and
temperature
• Placement of a urinary catheter
• Simultaneous urine and blood specimens for
determination of osmolality, serum sodium and
serum potassium are obtained.
Evaluation of Response to Therapy
• Monitor for overmedication, which may
precipitate hypervolemia.
• Signs and symptoms of fluid volume excess
include dyspnea, hypertension, weight gain, and
angina.
• Hyponatremia is another serious consequence
and if it develops rapidly can cause extreme
cerebral edema and osmotic demyelination
syndrome. Therefore, close monitoring of serum
sodium is necessary.
 Patient Education
• Educating the patient and the family about the
disease process and how it affects thirst,
urination, and fluid balance encourages patients
to participate in their care and reduces the
feelings of hopelessness (Box 33-17).
• the signs and symptoms of dehydration and
overhydration and procedures for accurate daily
weight and urine specific gravity measurements.
 SEMOGA
BERMANFAAT