Davao Doctors College

General Malvar St., Davao City

BACHELOR OF SCIENCE IN NURSING

Nursing Management of a patient with

DIABETES INSIPIDUS

A Case Study Presented to the Nursing Clinical Instructors

Of Davao Doctors College

In Partial Fulfillment of the Requirements in

Nursing Care Management 107 - B

Laquindanum, Pamela.; Lumapas, Nicole R.; Mancia,

Sweetcele I.; Manligas, Gladys J.

March 2019
 TABLE OF CONTENTS

A. Objectives 1
B. Introduction 2
C. Definition of Diagnosis 4
D. Patient’s Profile 5
i. Biographic Data 5
ii. Past Health History 6
iii. Present Health History 6
iv. Family History 6
v. Developmental History 7
vi. Nutritional History 8
vii. Immunization 8
E. Review of Anatomy and Physiology 9
F. Comprehensive Health Assessment 21
G. Pathophysiology 33
i. Etiology 33
ii. Symptomatology 34
iii. Schematic Diagram 35
iv. Narrative 36
H. Course in the ward/Treatment/Interventions 38
i. Medical Management 38
1. Doctor’s Progress Notes 38
2. Laboratory/Diagnostic Examinations 43
3. Pharmacology 52
ii. Nursing Management 63
I. Discharge Plan 73
J. Bibliography 75
 A. OBJECTIVES

i. General

The group aims to conduct and present this case in a systemic, analytical way
and be guided by the formulated specific objectives for the enhancement of our
knowledge, skills and attitudes towards nursing care.

ii. Specific

At the end of our case study, the group would be able to:

1. Choose a particular client/case for this study;

2. Ask permission to the patient about the study;

3. Obtain initial data about the client through his records along with a personal
interview;

4. Gather, trace and collate the predisposing and precipitating factors that could
have contributed to the client’s illness;

5. Gather and review the results of the diagnostic exams done to the client;

6. Make a drug study on the discontinued and current prescribed medicines;

7. Identify nursing problems and come up with an appropriate and effective nursing
care plan;

8. Formulate prognosis based on the gathered information; and provide appropriate

health teachings and recommendation for the client, family and community.

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 B. INTRODUCTION

Diabetes Insipidus is a disorder of water metabolism caused by a deficiency of

ADH- either decreased in ADH synthesis or an inability of the kidney to respond
appropriately to ADH. ADH deficiency results in the excretion of large volumes of dilute
urine. Deficiency of ADH severely impairs the permeability of the distal tubules and
collecting ducts of the kidneys to water. An excessive loss of free water occurs, resulting
in polyuria. ADH deficiency can be classified as Nephrogenic, Primary, Secondary, and
Drug-related diabetes insipidus. The Nephrogenic diabetes insipidus is an inherited
defect. The renal tubules do not respond to the actions of ADH, which results in
inadequate water reabsorption by the kidney. The amount of hormone is not deficient.
(Ignatavicius, Workman, and Mishler. Medical-Surgical Nursing: A Nursing Process
Approach Volume 2 (2nd Edition)

Diabetes Insipidus (DI) is a heterogeneous clinical syndrome of disturbance in

water balance, characterized by polyuria (urine output > 4 ml/kg/hr), polydypsia (water
intake > 2 L/m2/d) and failure to thrive. In children, Nephrogenic DI (NDI) is more
common than Central DI (CDI), and is often acquired. The signs and symptoms vary
with etiology, age at presentation and mode of onset. Neonates and infants with NDI are
severely affected and difficult to treat. Diagnosis is based on the presence of high
plasma osmolality and low urinary osmolality with significant water diuresis. Water
deprivation test with vasopressin challenge, though has limitations, is done to
differentiate NDI and CDI and diagnose their partial forms. (Management of diabetes
insipidus in children. Indian J. Endocrinol Metab (2012)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183526/)

DI is uncommon in the United States, with a prevalence of 3 cases per 100,000

population. No significant sex-related differences in central or nephrogenic DI exist, with
male and female prevalence being equal. Similarly, no significant differences in
prevalence among ethnic groups have been found. With both central and nephrogenic
DI, inherited causes account for approximately 1-2% of all cases. An incidence of about
1 in 20 million births for nephrogenic DI caused by AQP2 mutations has been cited.

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(Romesh Khardori, MD, PhD, FACP. (2016). Diabetes Insipidus.
emedicine.medscape.com/article/117648-overview#a6)

In the Philippines, The combined prevalence of cranial DI and nephrogenic DI

combined is estimated at 1 in 25,000. DI can complicate up to 1 in 30,000 pregnancies.
Nephrogenic DI is the most common adverse effect of lithium and occurs in up to 40%
of patients. Inherited causes account for approximately less than 10% of all cases of DI.
(http://patient.info/doctor/diabetes-insipidus-pro)

The group 3 decided to take the case of Patient X in which she was diagnosed
with Nephrogenic Diabetes Insipidus because they would like to have a deeper
understanding about this condition so that they could render the care the patient needed
to arrive with a good prognosis. Management should therefore always be based on
appropriate clinical judgment. They would like to apply the things that they’ve learned
through their lectures for the benefit of their patient and to enhance their skills as well.

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 C. Definition of Diagnosis

1. Diabetes Insipidus (DI) - is an uncommon disorder that causes an imbalance of

water in the body. This imbalance leads to intense thirst even after drinking fluids
(polydipsia), and excretion of large amounts of urine (polyuria)

Reference: Lewis, Bruner and mayo (2012) Medical Surgical Nursing

1. Diabetes Insipidus (DI) - is a disorder of water metabolism caused by a deficiency

of ADH or either a decrease in ADH synthesis or an inability of the kidneys to respond
appropriately to ADH.

Reference: Ignatavicius and Workman (2012) Medical Surgical Nursing: Critical:

thinking for collaborative care

3. Diabetes insipidus (DI) - is a rare disorder that occurs when a person's kidneys
pass an abnormally large volume of urine that is insipid—dilute and odorless. In most
people, the kidneys pass about 1 to 2 quarts of urine a day. In people with diabetes
insipidus, the kidneys can pass 3 to 20 quarts of urine a day. As a result, a person with
diabetes insipidus may feel the need to drink large amounts of liquids.

Reference: Auric & Muchick (2014) Critical Nursing Care

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 D. PATIENT’S PROFILE

i. Biographic Data

Name: Patient X

Age: 5 years old

Sex: Female

Civil status: Child

Birthday: August 30, 2013

Religion: Catholic

Nationality: Filipino

Admitting Physician: Dr. D.E.Chan

Date of admission: February 25, 2019

Time of admission: 6:10 PM

Room #: 4011

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 ii. Past Health History

According to the mother of patient X, she experienced common colds, fever,

diarrhea and cough. No any allergies were known and never been admitted before. The
patients had no history of any surgeries or any serious illness.

iii. Present Health History

2 weeks prior to admission, patient’s mother noticed increased intake of water

(approximately 60 ml every intake), and increased frequency of urination twice within 30
minutes. Wakes up at night (two to three times) to urinate, followed by water intake.
Patient’s mother noticed decrease level of activity and increase distention of patient’s
abdomen. Bedwetting was also noticed. Negative of loose bowel movement and
positive of constipation at times, no change of bowel movement. Persistent condition
prompted consultation and admission.

iv. Family History (with Genogram)

MOTHER FATHER

PATIENT X
LEGENDS:
- Hypertension

- Diabetes Insipidus

- Diagnose as Diabetes
Insipidus

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 Patient x was only child. Both parents don’t have bronchial asthma or cardiac
problem. But it was stated at the chart that hypertension was positive on maternal side
and both grandparents in mother side, Diabetes mellitus was positive on the grandfather
on father side and Diabetes insipidus was positive on paternal side and grandmother on
father side.

v. Developmental History

When the patient was born Makes reflex movements like sucking and startling,
has jerky, uncontrolled arm and leg movements. Starts learning to be comforted by
caregivers, begins getting attached to caregivers. At the age of 3 months she can able
to holds her head up unsupported for a short time, she develops different cries for
different needs (hungry, tired, wet). At the age of 5 moths she moves things from hand
to hand, recognizes and responds to own name. At the age of 7 months she sits without
support. At the age of 9 months she starts to understand no, follows a falling object with
eyes. At the age of 12 months she walks holding on to hands or furniture, may stand
alone, and may take a few steps alone. At the age of 18 months she likes to hand things
to others as play, may have temper tantrums, and may be afraid of strangers. At age of
2 years old she shows more and more independence, shows defiant behavior (doing
what he has been told not to). According to Eric Erickson’s stage of psychological
development she was undergone to, our patient belongs in 3 rd stage which is Initiative
vs. guilt ages 3-6 years old. In this stage she initiates in limitation and suddenly feels
guilt when child developing a conscience feel in competition with the parent (i.e., oedipal
feelings).

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 vi. Nutritional History

Patients was breastfed for 9 months and then she was given formula milk and solid
foods. She eats vegetables, fruits and still into bottle feed. She eats biscuits in snacks
that her mother gives to her.

vii. Immunization

Patient’s mother stated that she was fully immunized with BCG, DPT1, DPT2, DPT3,
Measles, OPV1, OPV2, OPV3, MMR1, Hepatis B1, Hepatis B2, Hepatis B3,
Chickenpox, Hib 1, Hib 2 and Hib 3 according to their age and intervals

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 E. REVIEW OF ANATOMY AND PHYSIOLOGY

Anatomy of Kidney

The kidneys are two bean-shaped organs found on the left and right sides of the
body in vertebrates. They filter the blood in order to make urine, to release and retain
water, and to remove waste. They also control the ion concentrations and acid-base
balance of the blood. Each kidney feeds urine into the bladder by means of a tube
known as the ureter.

The kidneys regulate the balance of ions known as electrolytes in the blood,
along with maintaining acid base homeostasis. They also move waste products out of
the blood and into the urine, such as nitrogen-containing urea and ammonium. Kidneys
also regulate fluid balance and blood pressure. They are also responsible for the
reabsorption of water, glucose, and amino acids. The kidneys also produce hormones
including calcitriol and erythropoietin. The kidneys also make an important enzyme,
renin, which affects blood pressure through negative feedback.

Located at the rear of the abdominal cavity in the retroperitoneal space, the
kidneys receive blood from the paired renal arteries, and drain into the paired renal
veins.

Location

In humans, the kidneys

are located high in the
abdominal cavity, one on
each side of the spine, and
lie in a retroperitoneal
position at a slightly oblique
angle. The asymmetry within
the abdominal cavity, caused
by the position of the liver,

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typically results in the right kidney being slightly lower and smaller than the left, and
being placed slightly more to the middle than the left kidney. The left kidney is
approximately at the vertebral level T12 to L3, and the right is slightly lower. The right
kidney sits just below the diaphragm and posterior to the liver. The left sits below the
diaphragm and posterior to the spleen. On top of each kidney is an adrenal gland. The
upper parts of the kidneys are partially protected by the 11th and 12th ribs. Each kidney,
with its adrenal gland is surrounded by two layers of fat: the perinephric fat present
between renal fascia and renal capsule and paranephric fat superior to the renal fascia.

Structure

The kidney has a bean-shaped structure with a convex and a concave border. A
recessed area on the concave border is the renal hilum, where the renal artery enters
the kidney and the renal vein and ureter leave. The kidney is surrounded by tough
fibrous tissue, the renal capsule, which is itself surrounded by perirenal fat (adipose
capsule), renal fascia, and pararenal fat (paranephric body). The anterior (front) surface
of these tissues is the peritoneum, while the posterior (rear) surface is the transversalis
fascia.

The superior pole of the right kidney is adjacent to the liver. For the left kidney, it
is next to the spleen. Both, therefore, move down upon inhalation.

In adult males, the kidney weighs between 125 and 170 grams. In females the
weight of the kidney is between 115 and 155 grams.[7] A Danish study measured the
median renal length to be 11.2 cm (4.4 in) on the left side and 10.9 cm (4.3 in) on the
right side in adults. Median renal volumes were 146 cm3 on the left and 134 cm3 on the
right.

The substance, or parenchyma, of the kidney is divided into two major structures:
the outer renal cortex and the inner renal medulla. Grossly, these structures take the
shape of eight to 18 cone-shaped renal lobes, each containing renal cortex surrounding
a portion of medulla called a renal pyramid (of Malpighi). Between the renal pyramids
are projections of cortex called renal columns (or Bertin columns). Nephrons, the urine-
producing functional structures of the kidney, span the cortex and medulla. The initial

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filtering portion of a nephron is the renal corpuscle which is located in the cortex. This is
followed by a renal tubule that passes from the cortex deep into the medullary pyramids.
Part of the renal cortex, a medullary ray is a collection of renal tubules that drain into a
single collecting duct.

The tip, or papilla, of each pyramid empties urine into a minor calyx; minor
calyces empty into major calyces, and major calyces empty into the renal pelvis. This
becomes the ureter. At the hilum, the ureter and renal vein exit the kidney and the renal
artery enters. Hilar fat and lymphatic tissue with lymph nodes surrounds these
structures. The hilar fat is contiguous with a fat-filled cavity called the renal sinus. The
renal sinus collectively contains the renal pelvis and calyces and separates these
structures from the renal medullary tissue.

Blood Supply

The renal circulation supplies the blood to the kidneys via the renal arteries, left
and right, which branch directly from the abdominal aorta. Despite their relatively small
size, the kidneys receive approximately 20% of the cardiac output.

Each renal artery branches into segmental arteries, dividing further into interlobar
arteries, which penetrate the renal capsule and extend through the renal columns
between the renal pyramids. The interlobar arteries then supply blood to the arcuate
arteries that run through the boundary of the cortex and the medulla. Each arcuate
artery supplies several interlobular arteries that feed into the afferent arterioles that
supply the glomeruli.

The medullary interstitium is the functional space in the kidney beneath the
individual filters (glomeruli), which are rich in blood vessels. The interstitium absorbs
fluid recovered from urine. Various conditions can lead to scarring and congestion of
this area, which can cause kidney dysfunction and failure.

After filtration occurs, the blood moves through a small network of venules that
converge into interlobular veins. As with the arteriole distribution, the veins follow the
same pattern: the interlobular provide blood to the arcuate veins then back to the

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interlobar veins, which come to form the renal vein exiting the kidney for transfusion for
blood.

Innervation

The kidney and nervous system communicate via the renal plexus, whose fibers
course along the renal arteries to reach each kidney. Input from the sympathetic
nervous system triggers vasoconstriction in the kidney, thereby reducing renal blood
flow. The kidney also receives input from the parasympathetic nervous system, by way
of the renal branches of the vagus nerve (cranial nerve X); the function of this is yet
unclear. Sensory input from the kidney travels to the T10-11 levels of the spinal cord
and is sensed in the corresponding dermatome. Thus, pain in the flank region may be
referred from corresponding kidney.

Functions

 Excretions of waste

The kidneys excrete a variety of waste products produced by metabolism into the
urine. These include the nitrogenous wastes urea, from protein catabolism, and uric
acid, from nucleic acid metabolism. The ability of mammals and some birds to
concentrate wastes into a volume of urine much smaller than the volume of blood from
which the wastes were extracted is dependent on an elaborate countercurrent
multiplication mechanism. This requires several independent nephron characteristics to
operate: a tight hairpin configuration of the tubules, water and ion permeability in the
descending limb of the loop, water impermeability in the ascending loop, and active ion
transport out of most of the ascending limb. In addition, passive countercurrent
exchange by the vessels carrying the blood supply to the nephron is essential for
enabling this function.

 Reabsorption

Location of Reabsorbed nutrient Notes

Reabsorption

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Early proximal Glucose (100%), amino  PTH will inhibit phosphate
tubule acids (100%), reabsorption.
bicarbonate (90%),  AT II stimulates Na+, H2O and
Na+ (65%), Cl−, HCO3−reabsorption.
phosphate and H2O
(65%)
Thin descending H2O  Reabsorbs via medullary
loop of Henle hypertonicity and makes urine
hypertonic.
+
Thick ascending Na (10–20%), K, + −
Cl ;  This region is impermeable to
loop of Henle indirectly induces para H2O and the urine becomes
cellular reabsorption of less concentrated as it
2+ 2+
Mg , Ca ascends.
Early distal Na+, Cl−  PTH causes Ca2+ reabsorption.
convoluted
tubule
Collecting Na+(3–5%), H2O  Na+ is reabsorbed in exchange
tubules for K +, and H +, which is
regulated by aldosterone.
 ADH acts on the V2 receptor
and inserts aquaporins on the
luminal side

 Acid-Base Homeostasis

Two organ systems, the kidneys and lungs, maintain acid-base homeostasis,
which is the maintenance of pH around a relatively stable value. The lungs contribute to
acid-base homeostasis by regulating carbon dioxide (CO2) concentration. The kidneys
have two very important roles in maintaining the acid-base balance: to reabsorb and
regenerate bicarbonate from urine, and to excrete hydrogen ions and fixed acids
(anions of acids) into urine.

 Osmolality Regulation

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 Maintaining water and salt level of the body. Any significant rise in plasma
osmolality is detected by the hypothalamus, which communicates directly with the
posterior pituitary gland. An increase in osmolality causes the gland to secrete
antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an
increase in urine concentration. The two factors work together to return the plasma
osmolality to its normal levels.

ADH binds to principal cells in the collecting duct that translocate aquaporins to
the membrane, allowing water to leave the normally impermeable membrane and be
reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the
body.

There are two systems that create a hyperosmotic medulla and thus increase the
body plasma volume: Urea recycling and the 'single effect.'

Urea is usually excreted as a waste product from the kidneys. However, when
plasma blood volume is low and ADH is released the aquaporins that are opened are
also permeable to urea. This allows urea to leave the collecting duct into the medulla
creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the
nephron and be excreted or recycled again depending on whether ADH is still present
or not.

The 'Single effect' describes the fact that the ascending thick limb of the loop of
Henle is not permeable to water but is permeable to NaCl. This allows for a
countercurrent exchange system whereby the medulla becomes increasingly
concentrated, but at the same time setting up an osmotic gradient for water to follow
should the aquaporins of the collecting duct be opened by ADH.

 Blood Pressure Regulation

Although the kidney cannot directly sense blood, long-term regulation of blood
pressure predominantly depends upon the kidney. This primarily occurs through
maintenance of the extracellular fluid compartment, the size of which depends on the
plasma sodium concentration. Renin is the first in a series of important chemical
messengers that make up the renin-angiotensin system. Changes in renin ultimately

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alter the output of this system, principally the hormones angiotensin II and aldosterone.
Each hormone acts via multiple mechanisms, but both increase the kidney's absorption
of sodium chloride, thereby expanding the extracellular fluid compartment and raising
blood pressure. When renin levels are elevated, the concentrations of angiotensin II and
aldosterone increase, leading to increased sodium chloride reabsorption, expansion of
the extracellular fluid compartment, and an increase in blood pressure. Conversely,
when renin levels are low, angiotensin II and aldosterone levels decrease, contracting
the extracellular fluid compartment, and decreasing blood pressure.

 Hormone Secretion

The kidneys secrete a variety of hormones, including erythropoietin, and the

enzyme renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at
tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood
cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal
absorption of calcium and the renal reabsorption of phosphate. Part of the renin–
angiotensin–aldosterone system, renin is an enzyme involved in the regulation of
aldosterone levels.

What urine is made of?

Urine is made of water, urea, electrolytes, and other waste products. The exact
contents of urine vary depending on how much fluid and salt you take in, your
environment and your health. Some medicines and drugs are excreted in urine and can
be found in the urine.

 94% water  .25% phosphate

 3.5% urea  .25% sulfate

 1% sodium*  .15% creatinine

 .5% chloride*  .1% uric acid

 .25% potassium*  *Electrolytes

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Anatomy of the Pituitary Gland

The fully developed pituitary gland is pea-sized and weighs approximately 0.5 g.
The adenohypophysis constitutes roughly 80% of the pituitary and manufactures an
array of peptide hormones. The release of these pituitary hormones is mediated by
hypothalamic neurohormones that are secreted from the median eminence (a site
where axon terminals emanate from the hypothalamus) and that reach the
adenohypophysis via a portal venous system.

Unlike the adenohypophysis, the neurohypophysis is not glandular and does not
synthesize hormones. Instead, it is a site where axons project from neuronal cell bodies
in the supraoptic and paraventricular nuclei of the hypothalamus. These hypothalamic
cell bodies produce hormones that undergo axonal transport through the pituitary stalk
and into terminal axons within the neurohypophysis. The hormones are then stored and
released directly into the systemic vasculature.

The pituitary gland is enveloped by dura and sits within the sella turcica of the
sphenoid bone. The sella turcica is a saddle-shaped depression that surrounds the
inferior, anterior, and posterior aspects of the pituitary. The superior aspect of the
pituitary is covered by the diaphragma sellae, which is a fold of dura mater that
separates the cerebrospinal fluid–filled subarachnoid space from the pituitary. The
infundibulum pierces the diaphragma sellae in order to connect the pituitary to the
hypothalamus.

The lateral aspects of the pituitary are adjacent to the cavernous sinuses (see
the image below). From superior to inferior, the cavernous sinus contains cranial nerves
III (oculomotor), IV (trochlear), VI (abducens), V1 (ophthalmic branch of trigeminal
nerve), and V2 (maxillary branch of trigeminal nerve). The internal carotid artery also
courses through the cavernous sinus, medial to these nerves.

Blood Supply

The adenohypophysis receives the majority of its blood supply from the paired
superior hypophyseal arteries, which arise from the medial aspect of the internal carotid
artery, within the ophthalmic segment. The superior hypophyseal artery commonly

16
emerges within 5 mm distal to the origin of the ophthalmic artery and eventually
forms the primary capillary network found in the median eminence.

The neurohypophysis is supplied by the inferior hypophyseal arteries.

These vessels are terminal branches of the meningohypophyseal trunk, which
arises from the cavernous portion of the internal
carotid artery.

The hypophyseal portal veins drain the

primary capillary plexus formed by the superior
hypophyseal arteries, which deliver blood to the
pars distalis. The pars distalis in turn houses the
secondary capillary plexus. Thus, a portal
venous system allows delivery of hypothalamic
prohormones to the adenohypophysis, and the
neurohypophysis secretes hormones directly
into the venous draining system of the pituitary.

Hormones

The anterior pituitary synthesizes and secretes hormones. All releasing

hormones (-RH) referred to, can also be referred to as releasing factors (-RF).

 Somatotrophins:

Human growth hormone (HGH), also referred to as 'growth hormone'

(GH), and also as somatotropin, is released under the influence of hypothalamic
growth hormone-releasing hormone (GHRH), and is inhibited by hypothalamic
somatostatin

 Thyrotrophins:

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 Thyroid-stimulating hormone (TSH), is released under the influence of
hypothalamic thyrotropin-releasing hormone (TRH) and is inhibited by
somatostatin.

 Corticotropins:

Adrenocorticotropic hormone (ACTH), and Beta-endorphin are released

under the influence of hypothalamic corticotropin-releasing hormone (CRH).

 Lactotrophins:

Prolactin (PRL), also known as 'Luteotropic' hormone (LTH), whose

release is inconsistently stimulated by hypothalamic TRH, oxytocin, vasopressin,
vasoactive intestinal peptide, angiotensin II, neuropeptide Y, galanin, substance
P, bombesin-like peptides (gastrin-releasing peptide, neuromedin B and C), and
neurotensin, and inhibited by hypothalamic dopamine.

 Gonadotropins:

Luteinizing hormone (also referred to as 'Lutropin' or 'LH').

Follicle-stimulating hormone (FSH), both released under influence of

Gonadotropin-Releasing Hormone (GnRH)

These hormones are released from the anterior pituitary under the
influence of the hypothalamus. Hypothalamic hormones are secreted to the
anterior lobe by way of a special capillary system, called the hypothalamic-
hypophysial portal system.

Intermediate

The intermediate lobe synthesizes and secretes the following important

endocrine hormone:

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 Melanocyte–stimulating hormone (MSH). This is also produced in the
anterior lobe. When produced in the intermediate lobe, MSHs are sometimes
called "intermedins".

Posterior Lobe

The posterior pituitary stores and secretes (but does not synthesize) the
following important endocrine hormones:

 Magnocellular Neurons:

Antidiuretic hormone (ADH, also known as vasopressin and arginine

vasopressin AVP), the majority of which is released from the supraoptic nucleus
in the hypothalamus.

Oxytocin, most of which is released from the paraventricular nucleus in the

hypothalamus. Oxytocin is one of the few hormones to create a positive feedback
loop. For example, uterine contractions stimulate the release of oxytocin from the
posterior pituitary, which, in turn, increases uterine contractions. This positive
feedback loop continues throughout labour.

 Antidiuretic Hormone or Vasopressin

Vasopressin, also known as antidiuretic hormone (ADH), is a

neurohypophysial hormone found in most mammals. In most species it contains
arginine and is thus also called arginine vasopressin (AVP) or argipressin. Its two
primary functions are to retain water in the body and to constrict blood vessels.
Vasopressin regulates the body's retention of water by acting to increase water
reabsorption in the kidney's collecting ducts, the tubules which receive the very
dilute urine produced by the functional unit of the kidney, the nephrons.

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 Vasopressin is a peptide hormone that increases water permeability of the
kidney's collecting duct and distal convoluted tubule by inducing translocation of
aquaporin-CD water channels in the plasma membrane of collecting duct cells. It
also increases peripheral vascular resistance, which in turn increases arterial
blood pressure. It plays a key role in homeostasis, by the regulation of water,
glucose, and salts in the blood. It is derived from a preprohormone precursor that
is synthesized in the hypothalamus and stored in vesicles at the posterior
pituitary.

Most of vasopressin is stored in the posterior pituitary to be released into

the bloodstream. However, some AVP may also be released directly into the
brain, and accumulating evidence suggests it plays an important role in social
behavior, sexual motivation and pair bonding, and maternal responses to stress.
It has a very short half-life between 16–24 minutes.

One of the most important roles of AVP is to regulate the body's retention
of water; it is released when the body is dehydrated and causes the kidneys to
conserve water, thus concentrating the urine and reducing urine volume. At high
concentrations, it also raises blood pressure by inducing moderate
vasoconstriction.

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 F. Comprehensive Health Assessment

Physical Assessment

Integument

● Skin: The client’s skin is light brown and uniform in color, unblemished
and no presence of any foul odor. He has a good skin turgor and skin’s
temperature is within normal limit.
● Hair: The hair of the client is thick, silky hair is evenly distributed and
has a variable amount of body hair. There are also no signs of infection
and infestation observed.
● Nails: The client has a light brown nail and has the shape of convex
curve. It is smooth and is intact with the epidermis. When nails pressed
between the fingers (Blanch Test), the nails return to usual color in less
than 2-3 seconds.
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Head

● Head: The head of the client is rounded; normocephalic and

symmetrical.
● Skull: There are no nodules or masses and depressions when
palpated.
● Face: The face of the client appeared smooth and has uniform
consistency and with no presence of nodules or masses.

Eyes and Vision

● Eyebrows: Hair is evenly distributed. The client’s eyebrows are

symmetrically aligned and showed equal movement when asked to
raise and lower eyebrows.
● Eyelashes: Eyelashes appeared to be equally distributed and curled
slightly outward.
● Eyelids: There were no presence of discharges, no discoloration and
lids close symmetrically with involuntary blinks approximately 15-20
times per minute.
● Eyes
○ The Bulbar conjunctiva appeared transparent with few
capillaries evident.
○ The sclera appeared white.
○ The palpebral conjunctiva appeared shiny, smooth and pink.
○ There is no edema or tearing of the lacrimal gland.
○ Cornea is transparent, smooth and shiny and the details of
the iris are visible. The client blinks when the cornea was
touched.
○ The pupils of the eyes are black and equal in size which is
2mm diameter. The iris is flat and round. PERRLA (pupils
equally round respond to light accommodation), illuminated
and non-illuminated pupils constrict. Pupils constrict when
looking at near object and dilate at far object. Pupils converge
when object is moved towards the nose.
22
 ○ When assessing the peripheral visual field, the client can see
objects in the periphery when looking straight ahead.
○ When testing for the Extraocular Muscle, both eyes of the
client coordinately moved in unison with parallel alignment.

Ears and Hearing

● Ears: The Auricles are symmetrical and has the same color with his
facial skin. The auricles are aligned with the outer canthus of eye.
When palpating for the texture, the auricles are mobile, firm and not
tender. The pinna recoils when folded. During the assessment of Watch
tick test, the client was able to hear ticking in both ears.

Nose and Sinus

● Nose: The nose appeared symmetric, straight and uniform in color.

There was no presence of discharge or flaring. When lightly palpated,
there were no tenderness and lesions
● Mouth:
○ The lips of the client are uniformly pink; moist, symmetric and
have a smooth texture. The client was able to purse his lips
when asked to whistle.
○ Teeth and Gums: There are no discoloration of the enamels,
no retraction of gums, pinkish in color of gums
○ The buccal mucosa of the client appeared as uniformly pink;
moist, soft, glistening and with elastic texture.
○ The tongue of the client is centrally positioned. It is pink in
color, moist and slightly rough. There is a presence of thin
whitish coating.
○ The smooth palates are light pink and smooth while the hard
palate has a more irregular texture.

23
 ○ The uvula of the client is positioned in the midline of the soft
palate.
● Neck:
○ The neck muscles are equal in size. The client showed
coordinated, smooth head movement with no discomfort.
○ The lymph nodes of the client are not palpable.
○ The trachea is placed in the midline of the neck.
○ The thyroid gland is not visible on inspection and the glands
ascend during swallowing but are not visible.

Thorax, Lungs, and Abdomen

● Lungs / Chest: The chest wall is intact with no tenderness and

masses. There’s a full and symmetric expansion and the thumbs
separate 2-3 cm during deep inspiration when assessing for the
respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.
● Heart: There were no visible pulsations on the aortic and pulmonic
areas. There is no presence of heaves or lifts.
● Abdomen: The abdomen of the client has an unblemished skin and is
uniform in color. The abdomen has a symmetric contour. There were
symmetric movements caused associated with client’s respiration.
○ The jugular veins are not visible.
○ When nails pressed between the fingers (Blanch Test), the
nails return to usual color in less than 2-3 seconds.

Extremities

● Muscles: The muscles are not palpable with the absence of tremors.
Patient was noted with coordinated movement while standing. The
patient appears weak, Hypokalemia noted on labs.

24
 ● Bones: There were no presence of bone deformities, tenderness and
swelling.
● Joints: There were no swelling, and tenderness. Only at the right side
of the body that has no joint movements.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

● Skin When skin is pinched it goes to

previous state immediately (2 seconds).

With light brown complexion.

With dry skin

● Hair Evenly distributed hair.

With short, black and shiny hair.

● Nails Smooth and has intact epidermis

With short and clean fingernails and

toenails.

Convex and with good capillary refill

time of 2-3 seconds.

Skull Rounded, normocephalic and

symmetrical, smooth and has uniform
consistency. Absence of nodules or
25
 masses.

Face Symmetrical facial movement, palpebral

fissures equal in size, symmetric
nasolabial folds.

Eyes and Vision

● Eyebrows Hair evenly distributed with skin intact.

Eyebrows are symmetrically aligned

and have equal movement.

● Eyelashes Equally distributed and curled slightly

outward.

● Eyelids Skin intact with no discharges and no

discoloration.

Lids close symmetrically and blinks

involuntary.

● Bulbar conjunctiva Transparent with capillaries slightly

visible

● Palpebral Conjunctiva Shiny, smooth, pink

● Sclera Appears white.

26
 ● Lacrimal gland, Lacrimal sac, No edema or tenderness over the
Nasolacrimal duct lacrimal gland and no tearing.

Cornea

● Clarity and texture Transparent, smooth and shiny upon

inspection by the use of a penlight
which is held in an oblique angle of the
eye and moving the light slowly across
the eye.

Has [brown] eyes.

● Corneal sensitivity Blinks when the cornea is touched

through a cotton wisp from the back of
the client.

Pupils Black, equal in size with consensual

and direct reaction, pupils equally
rounded and reactive to light and
accommodation, pupils constrict when
looking at near objects, dilates at far
objects, converge when object is moved
toward the nose at four inches distance
and by using penlight.

27
Visual Fields When looking straight ahead, the client
can see objects at the periphery which
is done by having the client sit directly
facing the nurse at a distance of 2-3
feet.

The right eye is covered with a card and

asked to look directly at the student
nurse’s nose. Hold penlight in the
periphery and ask the client when the
moving object is spotted.

Visual Acuity Able to identify letter/read in the

newsprints at a distance of fourteen
inches.

Patient was able to read the newsprint

at a distance of 8 inches.

Ear and Hearing

● Auricles Color of the auricles is same as facial

skin, symmetrical, auricle is aligned with
the outer canthus of the eye, mobile,
firm, non-tender, and pinna recoils after
it is being folded.

● External Ear Canal Without impacted cerumen.

● Hearing Acuity Test Voice sound audible.

28
 ● Watch Tick Test Able to hear ticking on right ear at a
distance of one inch and was able to
hear the ticking on the left ear at the
same distance

Nose and sinuses

● External Nose Symmetric and straight, no flaring,

uniform in color, air moves freely as the
clients breathes through the nares.

● Nasal Cavity Mucosa is pink, no lesions and nasal

septum intact and in middle with no
tenderness.

Mouth and Oropharynx Symmetrical, pale lips, brown gums and

able to purse lips.

● Teeth With dental caries and decayed lower

molars

● Tongue and floor of the mouth Central position, pink but with whitish
coating which is normal, with veins
prominent in the floor of the mouth.

● Tongue movement Moves when asked to move without

difficulty and without tenderness upon
palpation.

Uvula Positioned midline of soft palate.

29
Gag Reflex Present which is elicited through the
use of a tongue depressor.

Neck Positioned at the midline without

tenderness and flexes easily. No
masses palpated.

Head movement Coordinated, smooth movement with no

discomfort, head laterally flexes, head
laterally rotates and hyperextends.

Muscle strength With has equal strength.

Lymph Nodes Non-palpable, non tender

● Thyroid Gland Not visible on inspection, glands ascend

but not visible in female during
swallowing and visible in males.

Thorax and lungs

Posterior thorax Chest symmetrical

● Spinal alignment Spine vertically aligned, spinal column

is straight, left and right shoulders and
hips are at the same height.

Breath Sounds With wheezing sounds upon

auscultation without dyspnea.

30
 ● Anterior Thorax Quiet, rhythmic and effortless
respiration

Abdomen Unblemished skin, uniform in color,

symmetric contour, not distended.

Abdominal movements Symmetrical movements cause by

respirations.

● Auscultation of bowel sounds With audible sounds of 23 bowel

sounds/minute.

Upper Extremities Barely moves arms on its own.

Lower Extremities Presence of body malaise due to

Hypokalemia as seen on labs.

Muscles Equal in size both sides of the body,

with coordinated movements.

Bones and Joints No deformities or swelling, joints move

smoothly.

Mental Status The patient responds well.

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or

time.

Attention span Able to concentrate as evidence by

answering the questions appropriately.

31
Level of Consciousness A total of 15 points indicative of
complete orientation and alertness.

Motor Function

Gross Motor and Balance

● Walking gait Coordinated movements, has no activity

intolerance

Standing on one foot with eyes closed Able to stand on its own but bosy
weakness is noted.

Heel toe walking Able to do heel toe walking.

Toe or heel walking Able to do toe and heel walking.

Fine motor test for Upper Extremities Able to move on its own.

Finger to nose test Repeatedly and rhythmically touches

the nose on left side of the hand only.

Alternating supination and pronation of Can alternately supinate and pronate

hands on knees hand at rapid pace at left hand only.

Finger to nose and to the nurse’s finger Perform with coordinating and rapidity
at left and right fingers.

Fingers to fingers Perform with accuracy and rapidity at

left and right fingers.

Fingers to thumb Rapidly touches each finger to thumb

with left and right hand.

32
Fine motor test for the Lower Able to stand and move its own.
Extremities

Pain sensation Able to discriminate between sharp and

dull sensation when touched with
needle and cotton.

G. Pathophysiology

i. Etiology

Etiology Present Justification

33
Predisposing: - Congenital diabetes
 A genetically- inherited  insipidus is present at birth. It
disease. is a result of a defect passed
down through families.
(medical-surgical nursing by
Precipitating: Brunner and Suddart’s 12th
 Decrease potassium edition,2013,pg.1245)
level in blood serum 
(hypokalemia) of 2.28 - a condition where there
mmoL/L (3.6-5.1) isn't enough potassium in the
blood (all the cells in the
body, including kidney cells,
 High calcium level or require potassium to function
hypercalcemia properly)
(medical-surgical nursing by

 Pyelonephritis (kidney Brunner and Suddart’s 12th

infection edition,2013,pg.1245)

 Ureteral obstruction

ii. Symptomatology

Signs and Symptoms Present Justification

34
Signs: - Show signs of asking fluid
as means of baby talk (As
 Extreme thirst 
observed by the student
(polydipsia) nurse)
 Excretion of large 
- Patient has a total of 190 cc
amount of urine excreted during water
deprivation test (patient’s
(polyuria) chart)

- Patient’s weight during
 Weight loss water deprivation test is from
10.6 to 10.65 then back to
 10.6 (patient’s chart)
Symptoms:
 Body weakness
- Mother verbalize that she
 notice patient has less
activity or energy. (interview
 Trouble sleeping with the mother)

- Mother verbalize that

patient has difficulty in
 sleeping due to waking up at
 Extreme thirst
night just to urinate.
(polydipsia) (interview with the mother)

- Shortly after urinating the

patient mother notice
immediate intake or asking
of fluids.(interview with the
mother)

35
iii. Schematic Diagram

36
iv. Narrative

Hypothalamus produces antidiuretic hormone and then sends it to the

posterior pituitary gland to be stored. Posterior pituitary gland then releases
adequate vasopressin (ADH) to the bloodstream then goes to the kidney to
command to pass out less water in the urine. ADH receptor does not receive or
respond to the ADH because of genetically defected kidney tubules. Kidney

37
decreases its permeability to promote water reabsorption. Which results in
increased urine output, which now leads to diabetes insipidus.

Signs and symptoms are polydipsia, polyuria, hypokalemia, weight loss,

body weakness, and trouble sleeping. If not treated, it may lead to brain damage,
impaired renal function, intellectual disability, and restlessness; which may
eventually lead to death. If treated, increased oral-fluid intake, encourage low-salt
low-fat diet, administer medicines as prescribed by the attending physician, or
may have some modified ADH medications to do it at home; which may lead to
full recovery.

38
 H. Course in the Ward/Treatment/Interventions

i. Medical Interventions

1.) Doctor’s Progress Notes

February 25, 2019

5:00pm

 Pls. admit Cassandra Diez 5 y.o female under my service to 4A

 PNI: Diabetes Insipidus
 Diet for age
 Labs:
-S. Na, K, BUN, Crea
- Urinalysis
- For cranial MRI of contrast under sedation c/o Dr. Palabyab
 Insert IV heplock
 Monitor vs q4
 Intake and ouput q4 cc/cc; pls measure and record
 Pls. inform me once the patient is admitted

6:00pm

 Carry out Doctor’s order

 Admit under the service of Dr. Du
 Intake and ouput strictly monitoring q4 cc/cc; pls provide bedside
monitoring sheet ( w/o fail!)
 AP aware of admission
 Pls. prepare Water Deprivation Challenge Test Form
 Pls. secure DDAVP 60 mcg melt

7:00pm
39
  Conferred w/ AP
 Secure DDAVP 50 mg

9:35pm

 Patient seen and examined

 History and PE reviewed
 Pls. facilitate other labs and refer result
 Pls. measure Intake and Output cc/cc
 For MRI tomorrow 8am (NPO 4am)
 D5IMB 500 + 15 meqs KCL @ 45ml/hr
 Refer accordingly

10:20pm

AROD Pre-Op Orders

 NPO orders as follows: (Pls. label chart)

- Solids until 2am
- Milk until 4am
- Clear liquids until 5am
- NPO thereafter (5am onwards)

- VS 1 hr prior to OR/ procedure

 Continue IVF check patency

 Pls. prepare the following for cranial MRI procedures:
- Propostol 20 ml amp. #1
- Midazolam amp. #1
- Fentanyl amp. #1
- Atropine amp. #1
- 1 ml syringe #1
- 3 ml syringe #1
- 5 ml syringe #1
 Bring the above supplies with the patient when transporting to MRI
 Conferred with Dr. Palabyab:
- Repeat K (serum) at 4am
- For ABG at 5am
 Inform OR/AROD once cleared and approval
 Refer accordingly

10:40pm

AROD
40
  Conferred with Dr. Palabyab
 Hold cranial MRI tomorrow and resched to 2/27/19 at 7am
 Inform Pedia ROD and MRI dept. for changes in sched
 Hold repeat Serum K
 Hold ABG
 Hold NPO orders
 Refer accordingly

February 26, 2019

12:00am

 AP aware of changes in MRI schedule

 Continue monitoring
 Refer`

5:45am

 Continue monitoring
 Pls. facilitate urinalysis
 Maintain IVF and incorporate KCL @ 40meqs/hr
 Monitor I/O
 Refer

6:30am

 Conferred w/ AP
 Start Cefuroxime 350mg IVTT q8 ANST
 Refer

10:40am

Rounds w/ AP

 On NPO
 Baseline weight
 IVF to KSS
 Maintain on heplock
 Strict I/O monitoring ml/ml q hourly
 For Water Deprivation Test
 Get patients weight every after urination
 Get the volume every urination
41
  Once weight is 10kg, for STAT S. Na, K, Ca, Phosphorus, BUN, and urine
SG

1:00pm

Rounds w/ AP

 Refer to Dr. Manalaysay for co-management

 Defer MRI of cranium
 Include ABG, urine calcium, and urine Crea
 Collect above once with urine output
 May discontinue water deprivation test

4:00pm

 Start K Citrate 1tab TID x 3 doses

 Refer

February 27, 2019

6:45am

Rounds w/ AP

 Follow up lab result and relay please

 Meds c/o Dr. Manalaysay
 Allow watcher to have photocopy of all labs
 Advised

5:45pm

 Rounds with Dr. Manalaysay

 For Bone Aging study
 Start Na Bicarbonate 650 mg 1tab – disregard
 Start Vit. D (Rocatriol) 0.25 mg/cap, 1 cap OD after breakfast
 Start Hydrochlorthiazide 12.5 mg/tab, ¼ tab 2x a day (am-pm)
 For CT stonogram

1:00am

 Start NaCO3 650 mg/tab, 450 mg/paper tab once a day PO

5:00am
42
  Follow up official result of Bone Aging study and CT stonogram
 Continue meds and monitoring
 Refer

2.) Laboratory/ Diagnostic Examinations

Davao Doctors Hospital

Patient name: PATIENT X Age:5Y

Patient No: 00419938 Ward/Rm #: 4A

Physician: Dr. Chan

PROCEDURE& NORMAL RESULT IMPLICATIONS

PURPOSE RANGE
Urinalysis Physical LYTYLW

Draw Date Examination:

&Time: February Color
Character Clear
25, 2019
Reaction 7.5
7:15 pm Specific 1.010
A urine tests is Gravity
Chemical Negative A negative test result
43
 used to assess Examination: means that there is no
bladder or kidney Albumin detectable amount of
protein in the urine at the
infections,
time of testing.
diabetes, https://labtestsonline.org
dehydration and /understanding/analytes/
urine-protein/tab/test/
preeclampsia by Sugar Negative A positive urine glucose
screening for high test would indicate that
levels of sugars, the blood glucose level
is very high, and a
proteins, ketones
negative urine glucose
and bacteria. test could mean that the
High levels of level is low, normal, or
slightly elevated.
sugars may
http://www.diabetesself
suggest management.com/diabe
gestational tes-
resources/definitions/uri
diabetes, which
ne-glucose-test/
may develop Urine Flow 0-17 7
around the 20th Cytometry:
week of WBC
pregnancy. * 0-3 1
RBC 0-11 0
* 0-2 0
Epithelial 0-17 2
Cells
* 0-3 0
CAST 0-1 0
* 0-3 0
Bacteria 0-278 8
* 0-50 1
Sodium 136-144 138
Draw Date & Time: February 25,
2019 7:38 pm
A sodium blood test is used to
detect abnormal concentrations of
44
 sodium, including low sodium
(hyponatremia) and high sodium
(hypernatremia). It is often used as
part of an electrolyte panel or basic
metabolic panel for a routine health
checkup.
Blood Urea Nitrogen 2.9-9.3 4.57
Draw Date & Time: February 25,
2019 7:38 pm
A blood urea nitrogen (BUN) test
measures the amount of nitrogen in
your blood that comes from the
waste product urea.
Potassium 3.6-5.1 2.72 L In hypokalemia, the level
of potassium in blood is
Draw Date & Time: February 25,
too low. A low potassium
2019 7:38 pm level has many causes
but usually results from
This test measures the amount of
vomiting, diarrhea,
potassium in the fluid portion adrenal gland disorders,
or use of diuretics. A low
(serum) of the blood. Potassium
potassium level can
(K+) helps nerves and muscles make muscles feel
weak, cramp, twitch, or
communicate. It also helps move
even become paralyzed,
nutrients into cells and waste and abnormal heart
rhythms may develop.
products out of cells.
http://www.mayoclinic.or
g/symptoms/low-
potassium/basics/cause
s/sym-20050632
Creatinine 40-60 31 L Low blood creatinine
levels can be caused by
Draw Date & Time: February 25,
a diet very low in protein,
2019 7:38 pm severe liver disease, a
low muscle mass due to
The creatinine blood test is used to
a disease or aging, or
assess kidney function. It measures pregnancy, according to
WebMD.
45
the level of creatinine in the blood. https://www.reference.co
m/health/causes-low-
creatinine-levels-
b59133a5500f3d16#
ABG (I-STAT) RR - 30
FiO2 - 21
Exam Date:
pH 7.35-7.45 7.401
February 26, pCO2 35-45 32
2019 pO2 - 106
Base Excess - -5
Result Date: Bicarbonates - 19.9
February 26, O2 Sat 80-100 98

2019
An arterial blood
gas (ABG) test
measures the
acidity (pH) and
the levels of
oxygen and
carbon dioxide
in the blood from
an artery. This
test is used to
check how well
your lungs are
able to move
oxygen into the
blood and
remove carbon
dioxide from the
blood.
Calcium Time Urine 2.5-7.5 1.47 L If calcium levels in the
urine are abnormally low
Draw Date & Time: February 26,
it may be a sign of:

46
 2019 2:43 pm  malabsorption
disorders—such
A test for calcium in urine is a 24-
as vomiting or
hour test that checks the amount of diarrhea because
the food nutrients
calcium that is passed from the
have not been
body in the urine. properly digested
 vitamin D
deficiency
 hypoparathyroidis
m—a disease in
which the
parathyroid does
not produce
enough of a
hormone to keep
the calcium and
phosphorus levels
at proper levels
 use of thiazide
diuretics
http://www.healthline.
com/health/calcium-
urine#Results5

Urine Creatinine - 1227

Draw Date & Time: February 26,
2019 2:43 pm
A creatinine urine test measures
the amount of creatinine in your
urine. Creatinine is a chemical
waste product produced by muscle
metabolism. When your kidneys are
functioning normally, they filter
creatinine and other waste products
out of your blood. These waste
products are removed from your
body through urination.
47
 Sodium 136-144 137
Draw Date & Time: February 26,
2019 2:51 pm
A sodium blood test is used to
detect abnormal concentrations of
sodium, including low sodium
(hyponatremia) and high sodium
(hypernatremia). It is often used as
part of an electrolyte panel or basic
metabolic panel for a routine health
checkup.
A sodium blood test is used to
detect abnormal concentrations of
sodium, including low sodium
(hyponatremia) and high sodium
(hypernatremia). It is often used as
part of an electrolyte panel or basic
metabolic panel for a routine health
checkup.
Blood Urea Nitrogen 2.9-9.3 3.16
Draw Date & Time: February 26,
2019 2:51 pm
2019 7:38 pm
A blood urea nitrogen (BUN) test
measures the amount of nitrogen in
your blood that comes from the
waste product urea.
Potassium 3.6-5.1 2.28 L In hypokalemia, the level
of potassium in blood is
Draw Date & Time: February 26,
too low. A low potassium
2019 2:51 pm level has many causes
but usually results from
48
 This test measures the amount of vomiting, diarrhea,
adrenal gland disorders,
potassium in the fluid portion
or use of diuretics. A low
(serum) of the blood. Potassium potassium level can
make muscles feel
(K+) helps nerves and muscles
weak, cramp, twitch, or
communicate. It also helps move even become paralyzed,
and abnormal heart
nutrients into cells and waste
rhythms may develop.
products out of cells. http://www.mayoclinic.or
o/symptoms/low-
potassium/basics/cause
c/sym-20050632
Calcium 2.2-2.6 2.05 L A low calcium level may
result from a problem
Draw Date & Time: February 26,
with the parathyroid
2019 2:51 pm glands, as well as from
diet, kidney disorders, or
A blood calcium test is ordered to
certain drugs.
screen for, diagnose, and monitor a http://www.merckmanual
s.com/home/hormonal-
range of conditions relating to the
and-metabolic-
bones, heart, nerves, kidneys, and disorders/electrolyte-
balance/hypocalcemia-
teeth. The test may also be ordered
low-level-of-calcium-in-
if a person has symptoms of a the-blood
parathyroid disorder,
malabsorption, or an overactive
thyroid
Phosphorus 0.81-1.49 1.14
Draw Date & Time: February 26,
2019 2:51 pm
Phosphorus tests are most often
ordered along with other tests, such
as those for calcium, parathyroid
hormone (PTH), and/or vitamin D,
to help diagnose and/or monitor
treatment of various conditions that

49
 cause calcium and phosphorus
imbalances.

ULTRASOUND – KIDNEYS & UB

Date performed: February 25, 2019
Result Date: February 26, 2019

Length (cm) Width (cm) Height (cm) Parenchymal

Right Kidney 7.6 4.0 4.0 1.1
Left Kidney 7.9 4.0 4.0 1.1

Both kidneys show echogenic renal pyramids which are most pronounced
towards the papillae. The cortical parenchyma shows a normal homogenous
echotexture. Central echo complex shows normal echogenicity and no
separation of the calyces or renal pelvis. No solid masses or cysts are seen.

The urinary bladder is fully distended. Its wall is smooth and of normal
thickness. No internal echoes seen.

IMPRESSION:
~MEDULLARY NEPHROCALCINOSIS, CONSIDERATIONS ARE DISTAL
RENAL TUBULAR ACIDOSIS, DISORDERS OF CALCIUM METABOLISM.

CHEST P.A. LATERAL (PEDIA)

Date/Time Performed: February 25, 2019
50
Result Date: February 26, 2019

Heart size is within normal limits. Its configuration is unremarkable. Pulmonary

vascularity is normal. Parahilar and peribronchial infiltrates are not noted
bilaterally. Rest of the lungs are clear. The lateral costophrenic sinuses are sharp.
Hili are not enlarged. Visualized osseous structures are normal.

IMPRESSION:
~ SUGGESTIVE OF AN INFLAMMATORY LUNG DISEASE COMPATIBLE WITH
PNEUMONIA OF INTERSTITIAL PATTERN.

WATER DEPRIVATION TEST

Purpose: to identify the cause of polyuria

Time Weight (kg) Urine Volume(mL)

10:40 am 10.6 kg 50 cc

11:55 am 10.65 kg 80 cc

1:20 pm 10.6 kg 60 cc

51
52
 3) Pharmacology

BRAND NAME MECHANISM OF SIDE EFFECTS CONTRAINDICATIONS DOSAGE NURSING MANAGEMENT

ACTION
Citrocarbonate Antacids reduce CNS: tetany. --Contraindicated in 650 mg/tab --To avoid risk of alkalosis, obtain
the total acid CV: edema. patient’s with metabolic or PO 3 tablets blood pH, partial pressure of arterial
load in the GI GI: gastric respiratory alkalosis and in in AM TID carbon dioxide,, and electrolyte
tract and distention, those with hypocalcemia in *Dissolve in levels. Tell prescriber laboratory
elevate gastric belching, which alkalosis may juice results.
pH to reduce flatulence. produce tetany, --Tell significant others not to take
Generic pepsin activity. Metabolic: hypertension, seizures, or drug with milk because doing so
Name:
They also hypokalemia, heart failure. many cause high levels of calcium in
Sodium
bicarbonate strengthen the metabolic --Contraindicated in patients the blood, abnormally high alkalinity
gastric mucosal alkalosis, losing chloride because of in tissues and fluids, or kidney
barrier and hypernatremia, vomiting or continuous GI stones.
increase hyperosmolarit suction and in those --Do not use sodium bicarbonate as
esophageal y with receiving diuretics that is antacid. A non-absorbable OTC
spinchter tone. overdose. contraindicated for acute alternative for repeated use is safer.
Skin: pain and ingestion of strong mineral --Do not take antacids longer than 2
irritation at acids. wk except under advice and
injection use. supervision of a physician. Self-
medication with routine doses of
sodium bicarbonate or soda mints
may cause sodium retention and

53
 alkalosis, especially when kidney
function is impaired.
--Be aware that commonly used OTC
antacid products contain sodium
bicarbonate: Alka-Seltzer, Bromo-
Seltzer, Gaviscon

BRAND NAME MECHANISM SIDE EFFECTS CONTRAINDICATIONS DOSAGE NURSING MANAGEMENT

OF ACTION

54
Hytaz Increases CNS: dizziness, --Contraindicated in 12.5 mg/tab --Monitor fluid intake and output,
sodium and vertigo, patients with anuria and ¼ tab PO weight, blood pressure, and
water headache, patients hypersensitive to 2x a day electrolyte levels.
paresthesia,
excretion by other thiazides or other --Watch for signs and symptoms of
weakness,
inhibiting sulfonamide derivatives. hypokalemia, such as muscle
restlessness.
sodium and --Use cautiously in weakness and cramps.
CV: orthostatic
Generic Name: chloride children and in patients --Drug may be used with potassium-
hypotension,
hydrochlorothiazid
reabsorptio allergic
with severe renal disease, sparing diuretic to prevent potassium
e
n in distal myocarditis, impaired hepatic function, loss.
segment of vasculitis. or progressive hepatic --Instruct significant others to take
the GI: pancreatitis, disease. drug with food to minimize GI upset.
nephron. anorexia, nausea, --Advise patient to take drug in
epigastric morning to avoid need to urinate at
distress, vomiting, night; if patient needs second dose,
abdominal pain,
have him take it in early afternoon.
diarrhea,
--Consult physician before using OTC
constipation.
drugs. Many contain large amounts of
GU: renal failure,
sodium as well as potassium.
polyuria, frequent
urination, --Monitor weight daily.

interstitial --Note: Diabetic patients need to

nephritis. monitor blood glucose closely. This
Hematologic: drug causes impaired glucose

55
aplastic anemia, tolerance.
agranulocytosis, --Report signs of hypokalemia to
leucopenia, physician.
thrombocytopenia
--Change positions slowly; avoid hot
, hemolytic
baths or showers, extended exposure
anemia.
to sunlight, and sitting or standing still
Hepatic: jaundice.
for long periods.
Musculoskeletal:
muscle pain.
Respiratory:
respiratory
distress,
pneumonitis.
Skin: dermatitis,
photosensitivity
reactions, rash,
purpura, alopecia.
Other:
anaphylactic
reactions,
hypersensitivity
reactions, gout.

56
BRAND NAME MECHANISM OF SIDE EFFECTS CONTRAINDICATIONS DOSAGE NURSING MANAGEMENT
ACTION

57
Tascit Potassium Patients with hyperkalemia ● Explain to the significant others the
Some patients 1 tab PO
citrate works (or who have conditions purpose of the medication and the
may develop TID
by restoring predisposing them to need to take as directed, especially
minor x 3 doses
naturally hyperkalemia), as a further when concurrent digoxin or diuretics
gastrointestinal
occurring rise in serum potassium are taken. A missed dose should be
complaints eg,
chemicals in concentration may produce taken as soon as remembered within
GENERIC NAME abdominal
the urine that cardiac arrest. Such 2 hr; if not, return to regular dose
K Citrate discomfort,
stop crystals conditions include: Chronic schedule. Do not double dose.
vomiting,
from forming, renal failure, uncontrolled ● Emphasize correct method of
diarrhea, loose
and also diabetes mellitus, acute administration. GI irritation or
bowel
inhibits the dehydration, strenuous ulceration may result from chewing
movements or
formation of physical exercise in enteric-coated tablets or insufficient
nausea. These
the 2 most unconditioned individuals, dilution of liquid or powder forms.
symptoms are
common adrenal insufficiency, ● Instruct to the significant others to
due to the
types of extensive tissue avoid salt substitutes or low-salt milk
irritation of the
kidney breakdown, or in the or food unless approved by health
gastrointestinal
stones, administration of care professional. Patient should be
tract and may
calcium potassium-sparing agent advised to read all labels to prevent
be alleviated
oxalate and (eg, triamterene), excess potassium intake.
by taking the
uric acid obstruction or stricture or ● Advise significant others regarding
dose with
stones. In those taking anticholinergic sources of dietary potassium.
meals or
numerous medication. Because of its Encourage compliance with
snack, or by

58
 studies, ulcerogenic potential, recommended diet.
reducing the
patients potassium citrate should ● Instruct significant others to report
dosage.
treated with not be given to patients dark, tarry, or bloody stools;
Patients may
Kaitrate have with peptic ulcer disease. weakness; unusual fatigue; or tingling
find intact
demonstrated Potassium citrate is of extremities. Notify health care
matrices in
significantly contraindicated in patients professional if nausea, vomiting,
feces.
lower rates of with renal insufficiency diarrhea, or stomach discomfort
kidney stone (glomerular filtration rate persists. Dosage may require
formation. In <0.7 mL/kg/min), because adjustment.
many of danger of soft tissue ● Emphasize the importance of
patients, new calcification and increased regular follow-up exams to monitor
stones do not risk for the development of serum levels and progress.
form at all. hyperkalemia.

BRAND NAME MECHANISM OF SIDE EFFECTS CONTRAINDICATIONS DOSAGE NURSING MANAGEMENT

ACTION

59
Rocaltrol Vit. D The two Tell your doctor right away if Rocaltrol should 0.25m --Lab tests: Determine baseline and
known sites any of these unlikely but not be given to cg/Cap periodic levels of serum calcium,
of action of c serious side effects occur: patients 1 cap phosphorus, magnesium, alkaline
alcitriol are loss of appetite, with hypercalcemi PO phosphatase, creatinine; measure
intestine and back/bone/joint/muscle a or evidence daily urinary calcium and phosphorus
bone. pain, constipation, dry of vitamin D after levels q24h.
Generic Name: A calcitriol mouth, eye toxicity. Use of breakf --Effectiveness of therapy depends
Calcitriol receptor- pain/redness/sensitivity to Rocaltrol in ast. on an adequate daily intake of
binding light, headache, patients with calcium and phosphate. The
protein fast/slow/irregular known hypersensi physician may prescribe a calcium
appears to heartbeat, nausea/vomiting/ tivity to Rocaltrol supplement on an as-needed basis.
exist in the diarrhea, (or drugs of the --Monitor for hypercalcemia (see
mucosa of sleepiness, stomach/abdomi same class) or any Signs & Symptoms, Appendix F).
human nal pain, increased thirst, of the inactive During dosage adjustment period,
intestine. signs of kidney problems ingredients is monitor serum calcium levels
Additional (such as change in the contraindicated. particularly twice weekly to avoid
evidence amount of urine), weakness. hypercalcemia.
suggests A very serious allergic --If hypercalcemia develops, withhold
that calcitriol reaction to this drug is calcitriol and calcium supplements
may also act unlikely, but seek immediate and notify physician. Drugs may be
on the kidney medical attention if it occurs. reinitiated when serum calcium
and the Symptoms of a returns to normal.

60
parathyroid serious allergic
glands. reaction may
include: rash, itching/swellin
g (especially of the
face/tongue/throat),
severe dizziness, trouble
breathing.

61
BRAND NAME MECHANISM OF SIDE EFFECTS CONTRAINDICATIONS DOSAGE NURSING MANAGEMENT
ACTION
Caltrate Calcium carbonate Constipation, Patients with Ca 1tablet --Note number and consistency of stools.
can neutralize flatulence; renal calculi or PO If constipation is a problem, physician
gastric acid rapidly hypercalcemia history of renal QID may prescribe alternate or combination
and effectively. ; metabolic calculi; therapy with a magnesium antacid or
However, it may alkalosis; milk- hypercalcemia; advice patient to take a laxative or stool
adversely activate alkali hypophosphataemia. softener as necessary.
Ca dependent syndrome, Patients with --Lab tests: Determine serum and urine
Generic
processes, leading tissue- suspected digoxin calcium weekly in patients receiving
Name:
to secretion of calcification. toxicity. prolonged therapy and in patients with
Calcium-Acid
gastric and Gastric renal dysfunction.
hydrochloric acid. hypersecretion --Record amelioration of symptoms of
It can induce and acid hypocalcemia
rebound acid rebound (with --Observe for S&S of hypercalcemia in
secretion and, prolonged patients receiving frequent or high doses,
prolonged high use). or who have impaired renal.
doses may cause
hypercalcemia,
alkalosis and milk-
alkali syndrome.

62
BRAND NAME MECHANISM OF ACTION SIDE EFFECTS CONTRAINDI DOSAGE NURSING MANAGEMENT
CATIONS
Zinacef Semisynthetic second-  Body as a Hypersens --Determine history of hypersensitivity
Heplock
generation cephalosporin Whole: Thrombo itivity to reactions to cephalosporins, penicillins,
flushing
antibiotic with structure similar phlebitis (IV site); cephalosp and history of allergies, particularly to
350mg
to that of the penicillins. pain, burning, orins and drugs, before therapy is initiated.
Resistance against beta- cellulitis (IM site); related --Lab tests: Perform culture and sensitivity
2 ml
lactamase-producing strains superinfections, antibiotics; tests before initiation of therapy and
GENERIC IVTT Q8
NAME exceeds that of first generation positive Coombs' pregnancy periodically during therapy if indicated.
Cefuroxime cephalosporins. Antimicrobial test. (category Therapy may be instituted pending test
spectrum of activity resembles GI: Diarrh B), results. Monitor periodically BUN and
that of cefonicid. Preferentially ea, nausea, lactation. creatinine clearance.
binds to one or more of the antibiotic- --Inspect IM and IV injection sites
penicillin-binding proteins associated frequently for signs of phlebitis.
(PBP) located on cell walls of colitis. --Report onset of loose stools or diarrhea.
susceptible organisms. This  Skin: Ras Although pseudomembranous colitis (see
inhibits third and final stage of h, pruritus, Signs & Symptoms, Appendix F) rarely
bacterial cell wall synthesis, urticaria. occurs, this potentially life-threatening
thus killing the bacterium.  Urogenita complication should be ruled out as the
Partial cross-allergenicity l: Increased cause of diarrhea during and after
between other beta-lactam serum creatinine antibiotic therapy.
antibiotics and cephalosporins and BUN, --Monitor for manifestations of
has been reported. decreased hypersensitivity. Discontinue drug and

63
creatinine report their appearance promptly.
clearance. --Monitor I&O rates and pattern: Especially
important in severely ill patients receiving
high doses. Report any significant
changes.

64
 ii.Nursing Management
Assessment NSG. SCIENTIFIC Nursing
Diagnosis BASIS Goals/Objecti Interventions RATIONALE EVALUATION
ves
Subjective: Fluid and Low potassium After 8 hours Independent - provide critical After 8 hours of nursing
“Parati siyang Electrolyte (hypokalemia) of nursing > Monitor vital information about interventions, the
umiihi kasabay ng Imbalance refers to a lower care, the signs. a patient's state of patient’s
panghihina.” As related to than normal patient’s health. significant others were
verbalized by the active fluid potassium level significant >Assess skin turgor - signs of able to verbalize
patient’s mother. loss in your others will be and oral mucous dehydration are understanding of
secondary bloodstream. able to: membranes for also detected causative factors and
Objectives: to low Potassium is a signs of through the skin. purpose of individual
 Frequent levels of chemical A.Verbalize dehydration. therapeutic
urination potassium (electrolyte) that understandin interventions and
 Body
and is critical to the g of causative > Monitor fluid - verifying if the medications and
weakness
calcium. proper factors and status in relation to patient is on a fluid demonstrated lifestyle
 Irritability
 Fatigue functioning of purpose of dietary intake. restraint is changes to avoid
 Potassium
nerve and individual necessary progression of
level of 2.28
muscles cells, therapeutic > Encourage the - oral fluid dehydration as
mEq/L (3.6-
particularly interventions patient to increase replacement is evidenced by
5.1 mEq/L)
heart muscle and oral fluid intake. indicated for mild good skin turgor and
 Calcium
cells. Calcium is medications. fluid deficit and is a stable vital signs.
level of 8.20
one of the cost-effective
mg/dl (8.8-

65
10.4 mg/dl) body's electrolyt B. method for
es, which Demonstrate replacement
are minerals tha lifestyle treatment.
t carry an changes to
electric charge avoid >Aid the patient if - dehydrated
when dissolved progression she is unable to eat patients may be
in body fluids of without assistance, weak and unable
such as blood. A dehydration. and encourage the to meet prescribed
low calcium family to assist with intake
level may result feedings as independently.
from a problem necessary.
with the
parathyroid > Emphasize - promotes interest
glands, as well importance of oral in drinking and
as from diet, hygiene reduces discomfort
kidney of dry mucous
disorders, or membranes.
certain drugs. Dependent:
-Calcium
>Administered
carbonate can
Calcium-Acid as
neutralize gastric
prescribed by the
acid rapidly and
physician
effectively.

66
 -Potassium citrate
>Administered K works by restoring
Citrate as naturally occurring
prescribed by the chemicals in the
physician. urine that stop
crystals from
forming, and also
inhibits the
formation of the 2
most common
types of kidney
stones, calcium
oxalate and uric
acid stones

67
 Assessment Nsg. Scientific Basis Planning Interventions Rationale Evaluation
Diagnosis
Subjective: Activity Low potassium After 8 hours Independent After 8 hours
“Nanghihina yung intolerance (hypokalemia) refers of nursing > Monitor vital signs -provide critical of nursing
anak ko” As related to to a lower than care, the information about a interventions,
verbalized by the generalized normal potassium patient will be patient's state of the patient
patient’s mother. body level in your able to: health. was able to
weakness bloodstream. > Assess emotional or - stress or participate
secondary Potassium is a A. participate psychological factors depression may willingly in
Objectives: to low levels chemical (electrolyte) willingly in affecting the current increase the effects necessary or
 Body of that is critical to the necessary or situation of an illness desired
weakness potassium proper functioning of desired activities and
 Irritability
and nerve and muscles activities and > Plann care with rest - to reduce fatigue was able to
 Fatigue
 Potassium calcium. cells, particularly report periods between report
level of heart muscle cells. measurable activities increase in
2.28 Calcium is one of the increase in activity
mEq/L body's electrolytes, activity > Provide positive - helps to minimize intolerance.
(3.6-5.1 which intolerance. atmosphere, while frustration,
mEq/L) are minerals that acknowledging difficulty rechannel energy,
 Calcium
carry an electric of the situation for the
level of
charge when patient
8.20 mg/dl
dissolved in body
(8.8-10.4
fluids such as blood. >Assist patient to learn
mg/dl)
A low calcium level and demonstrate - To prevent injuries.
may result from a appropriate safety
problem with the measures
parathyroid glands,
as well as from diet, 68 > Provide information to
kidney disorders, or the patient’s significant - to enhance sense
certain drugs. others about the effect of well being
Assessment Nsg. Scientific Basis Planning Interventions Rationale Evaluation
Diagnosi
s

69
Subjective: Disturbed The most After 8 Independent: After 8 hours
“Paratin siyang Sleeping common signs hours of > Observe or obtain - to determine usual of nursing
umiihii na pati sa Pattern and symptoms nursing care feedback from patient sleep pattern and interventions
gabi nadidistorbo related to of diabetes the patient’s regarding bedtime, routines, provide comparative ,
yung tulog niya.” active insipidus are significant number of hours of sleep, baseline the patient’s
As verbalized by fluid loss. extreme thirst others will time of arising and significant
the patient’s and excretion be able to: environmental needs. others was
mother. of an excessive able to
amount of A. identify >Provide quiet environment -To enhance patient’s identify
Objectives: diluted urine appropriate and comfort measures ability to fall asleep. appropriate
- Frequent depending on intervention Interventions
urination the severity of s to promote > Limit fluid intake in - To reduce need for to promote
- Bed wetting the condition. sleep. evening if nocturia is a nighttime elimination. sleep.
- Frequent Other signs problem
yawning may include
- Expressionless needing to get > Provide child’s sleep time - To prevent injuries.
face up at night to safety
- Less than age- urinate > Recommend midmorning - napping especially in
normed sleep time (nocturia) and nap if one is required. the afternoon can
(8-9 hrs a day) bed-wetting. disrupt normal sleep
patterns.
Assessment Nsg. Scientific Basis Planning Interventions Rationale Evaluation
Diagnosi

70
 s

S >"Pinapawisan Skin is the After 8 >Inspect patient's skin and intervention may After 8hours
siya kunti" as Risk for primary hours of condition and changes in prevent occurrence or of nursing
verbalized by the impaired defense of the nursing status progression of impaired intervention
mother skin body; it intervention skin integrity. Fluid loss Goal is met.
integrity protects the the patient's from polyuria contributes The patient's
O>sweating/
related to body against skin will to decreased skin turgor skin was
diaphoresis
altered infections and remain and dryness. remaining
fluid diseases intact and intact and
>Skin is moisture
status brought about also remain >Assess for continence or >Excessive moisture on has a good
by the invasion good skin incontinence. the skin increases the skin turgor
>Skin turgor of 1-
Ref: of microbes in turgor for 1- risk of the skin as
2sec.
Nursing the body. A 3sec. breakdown. manifested
pocket normal skin is >Assess other factors that by 2 seconds
>Skin is intact.
guide moist and may risk the patient's skin >Excessive moisture only.
Pg.465 - intact; dryness integrity (e.g immobility, from urinary
>Frequent
468 of the skin is nutritional status, altered incontinence can add to
urination
more prone to mental status). the risk breakdown from
friction that other sources.
>Urine output of may result
50-80ml per result to >Provide easy access to the >Both polyuria and
urination. impairment of bathroom, urinal or bedpan. polydipsia disrupt the

71
the skin patient's normal
integrity as activities (including
compared with sleep). Easy access to
a moist skin. void will decreases
inconvenience and
frustration.

Dependent: >These prevent redness

>Use skin barriers as or excoriation from
needed. urinary frequency.

Collaborative: >This prevents shearing

>Instructed the mother to forces and wet linens
keep bed linen clean, dry may source of bacteria
and wrinkle free.

72
Assessment Nursing Scientific Basis Planning Nursing Rationale Evaluation
Diagnosis Interventions
S >" Deficient Cognitive After 8hours of Independent: After 8 hours of
>Assess level of >An individualized
magkatulad knowledge processes are nursing nursing
knowledge of DI teaching plan is based
sila ng sakit ng related to the performance intervention the cause and on the patient’s current intervention goal is
treatment. knowledge and desire
tatay niya pero cognitive of a cognitive patient will be met. The patient
for additional
hanggang limitation. activity or able to identify was able to
information.
ngayon di ko processing and the correct Identify the correct
>Assess
parin movement that understanding readiness to >So that the patient will understanding
learn. be aware about his\her
maintindihan affects the about diabetes condition. Rapid fluid towards her
bakit pati siya mental contents insipidus and loss from polyuria can condition about
lead to impaired
nagkaganito" of a person such can follow Diabetes
cognitive function. This
as verbalized as the process of instructions for change in mental status Insipidus, and will
by the mother. thinking or her treatment. can limit the patient’s able to follow
ability to learn new
the cognitive ope >Assess the level information. instructions for her
of the client’s
O>Irritable ration of treatment as
capabilities and
>To know clients coping
when follow remembering the possibilities of guided by the
situation. ability towards the
instructions Ref: something. It situation. mother.
Nursing encompasses >Determine
pocket client’s previous
>always guide. processes such >Patient with chronic
knowledge or
asking as knowledge, skills related to disease need to be able
his or her to recognize important
questions attention,
diagnosis and the changes in their
about her memory and influence on condition to avert

71
condition working willingness to complications and
learn possible hospitalization.
memory,
>doubtful judgment and Independent:
>Listen carefully > It helps to the client to
evaluation,
to the instructions avoid asking question or
>statement of reasoning and on what is being
said or asked. doubt if she\he know
misconception "computation",
what happening.
problem solving
>agitated and decision
Collaborative:
behavior making, >Discuss when to
seek further >This is the drug of
comprehension
medical attention choice for the
and production (at signs of under
dosage or management of DI.
of language.
overdose of This medication is a
medication).Admi
nistered synthetic form of ADH
medication such and is administered
as Desmopressin
acetate (DDAVP) intranasally.
as ordered by the
physician.

72
 I. Discharge Plan

Medications:

 Instruct the patients significant others to follow and continue if there are home
medications prescribed by the doctor.
 Teach patient or the patients significant others about the proper dosage and the
right time to take the medication.
 Emphasize to the patient’s significant others the importance of following
prescribed meds by the Doctor.
 Instruct the patient’s significant other to contact health care provider if the
medicine is not helping and if there are side effects happening.

Exercise:

 Encourage the patient’s significant others to practice weighing the child daily at
the same time and at the same scale. Rapid weight loss can be a sign of fluid
loss in the body.

Treatment:

 Encourage the patient’s significant others about the need to return for more blood
and urine test to check if the treatments are working.

Health Teachings:

 Instruct the patient or significant others to contact health care provider if the
patient have a dry and cracked lips, headaches and vision changes.
 Instruct the significant others to monitor child’s weight on a daily basis to monitor
fluid levels.
 Encourage the significant others to have a water supply on hand for the child to
prevent dehydration.
 Educate the client to notify primary health care provider of a weight gain greater
than 2 pounds in 24 hours.
 Emphasize to the significant others about the importance of reporting large
amount of urine output.

Outpatient:

73
  Follow up checkup is necessary to check the progress of condition.

Diet:

 Instruct the patients significant others about the need to decrease sodium
or salt intake by the patient. This may help decrease the amount of fluids
you lose.
 Instruct the patients significant others to avoid processed foods and
caffeinated products.
 Instruct the patients significant others to reduce the amount of protein
intake.

Spiritual:

 Encourage the patient’s family to look forward positively for an early

coping of condition.

J. Bibliography
74
(Ignatavicius, Workman, and Mishler. Medical-Surgical Nursing: A Nursing
Process Approach Volume 2 (2nd Edition)

(Management of diabetes insipidus in children. Indian J Endocrinol Metab.

(2012.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183526/)

(Romesh Khardori, MD, PhD, FACP. (2016). Diabetes Insipidus.

emedicine.medscape.com/article/117648-overview#a6)

(http://patient.info/doctor/diabetes-insipidus-pro)

Lewis, Bruner and mayo (2012) Medical Surgical Nursing

Ignatavicius and Workman (2012) Medical Surgical Nursing: Critical: thinking for
collaborative care

Auric & Muchick (2014) Critical Nursing Care

(medical-surgical nursing by Brunner and Suddart’s 12 th edition,2013,pg.1245)

Patient’s Chart

75