ADH

Anotações:

• Deficiency of ADH hormone Responsible of retaining Water in the presence of High Sodium Concentration. In this Case The patient is Loosing Water which increases Sodium Levels. (Hypovolemia Hypernatremia). Increased Sodium Na+ Serum, Increased Serum Osmolality Concentration. Decreased Serum Osmality Concentration. 

1. Signs & Symptoms
   1. Diagnostics
      1. Specific Gravity of Urine Low (<1.005)
      2. Increased Serum Osmality

         Anotações:

         • Less than 100mOsm/Kg
      3. Increase Hgb, Hct & BUN
      4. Increased Sodium
      5. Water Deprivation Test

         Anotações:

         • Before Exam: Body weight and Urine Osmolality volume &amp; Specific Gravity is measured!  The patient is deprived water 8-12hrs and then given Desmopressin acetate Subcutaneously or Nasally. Patient with Central DI will Exibit a drastic increase of urine osmolality from 100 to 600mOsm/Kg and Decrease Urine Volume. Patient with Nephrogenic DI will not be able to increase Urine  Osmolality greater than 300mOsm/Kg
   2. Kidney /Urinary

      Anotações:

      • 2 to 20L a day 
      1. Excessive Urine Output >200ml/hr

         Anotações:

         • Greater than 200ml per hour
      2. Nocturia

         Anotações:

         • Fatigue is due to excessive urination and also causes generalized muscle weakness. 
   3. Neurologic
      1. Irritability
      2. Decreased Cognition
      3. Thirsty
      4. Hyperthermia
      5. Lethargy, Coma, Ataxia
   4. Skin

      Anotações:

      • Fatigue is the result of Nocturia of Frequenctly going to the bathroom. Generalized Weakness can Also Manifest. 
      1. Poor SKin Turgor
      2. Dry Mucous Membranes
   5. Cardiovascular
      1. Weak Peripheral Pulses, easily Obliterated
      2. Tachycardia

         Anotações:

         • Viscosity of Blood is (thicker) so the Heart will compensate to get the tissue oxygenated. 
      3. Hypotension/ Decreased Pulse Pressure
2. Causes

   Anotações:

   • Decreased Water Reabsorption in the Renal Tubules. Which leads to Decreased intravascular Volume. 
   1. Central

      Anotações:

      • Interference with ADH synthesis, Transport or Release. 
      1. Brain Tumor
      2. Head Injury

         Anotações:

         • Usually Self- Limiting 
      3. Brain Surgery

         Anotações:

         • Intercranial Surgery- Triphasic Pattern: Acute excessive polyuria, Interphase Urine Normalizes, Third phase DI permanent (3rd phase 10-14days post-operatively) 
   2. Primary
      1. Structural Lesion in Thirst Center
      2. Psychological Disorder
   3. Nephrogenic

      Anotações:

      • Inadequate Renal Response to ADH 
      1. Renal damage
      2. Drug Therapy (Lithium)
      3. Hereditary Renal Disease
3. Interventions
   1. On-Going Monitoring
      1. Daily Weights
      2. 24hr I&O
      3. Adequate Hydration (Copious) may be given orally or IV (Hypotonic Saline or D5W)
         1. IV Glucose Monitor Hyperglycemia

            Anotações:

            • Hyperglycemia &amp; Glycosuria leads to Osmotic diuresis. This will lead to fluid volume deficit. 
      4. BP, HR (Tachycardia), Urine Output/specific gravity
      5. LOC

         Anotações:

         • alertness, response to stimuli, 
      6. SKin turgor
   2. Central
      1. Desmopressin Acetate (DDAVP): Oral, IV, SC & Nasal Spray

         Anotações:

         • Hormone Replacement Others: Aqueous Vasopressin, Lysine Vasopressin.  *Asssess Response: (Weight gain, Headache, Restlessness, Hyponatremia) 
      2. Chlorpropamide

         Anotações:

         • ADH stimulator  (Synthetic Vasopressin) 
      3. Carbamezapine
   3. Patient Teaching
      1. Teach Patient About Close Follow-Up
   4. Nephrogenic
      1. Low Sodium Diet (no more than 3g)
      2. Thiazide Diuretics

         Anotações:

         • May reduce flow to the ADH distal sensitive distal Nephrons
      3. Indomethacin

         Anotações:

         • Used if Thiazide do not work. NSAID (Helps increase Renal Responsiveness)

Anotações:

• Dilutional Hyponatremia (Euvolemic Hyponatremia) Caused by Overproduction of ADH homormone responsible for retaining water.  Serum Na+ Decreased, Decreased Serum Osmalality Concentration &amp; Increased Serum Osmlality Concentration. 

1. Causes
   1. MIscellaneous

      Anotações:

      • Hypothyroidism, Lung infection, COPD, Positive pressure mechanical ventilation, HIV, Adrenal Insufficiency. 
   2. Drug Therapy

      Anotações:

      • Carbamazepine, Chlorpropamide, General Anasthetics, Opioids, Oxytocin, Thiazide Diuretics, SSRI &amp; antidepressants, Tricyclic Antidepressants, Chemotherapy drugs, (Vincristine, Vinblastine, Cyclophosphamide)
   3. CNS disorders

      Anotações:

      • Head injury, stroke, brain tumor, Infection (Encephalitis, meningitis), Cerebral Atrophy, Guillain Barre Syndrome, Systemic Lupus Erythematosus
   4. Malignant Tumors

      Anotações:

      • pancreatic cancer, Lymphoid cancer, Thymus Cancer, Prostate Cancer, Colorectal Cancer
      1. Small Cell Lung Cancer

         Anotações:

         • Most Common!!!
2. Signs & Symptoms

   Anotações:

   • ADH increases Premeability at the Renal Distal Tubule &amp; Collecting Duct which leads to Reabsorption of Water into the Circulation. 
   1. Increased Body Weight

      Anotações:

      • Without Edema 
   2. > 1.025 Urine Specific Gravity (Low Urine Output)
   3. Diagnostics
      1. Na+ Declines
      2. ECF expands
      3. GFR increases
      4. Plasma Osmality Decline

         Anotações:

         • &lt;240mEq/L
   4. Pulmonary Edema
   5. Muscle Cramps & Generalized Weakness, Hyperreflexia
   6. Increased BP
   7. Cerebral Edema

      Anotações:

      • This can Occur symptoms would include: Lethargy, confusion Headache, seizure, coma 
   8. Restless, Irritable, Apprehension

      Anotações:

      • Headache 
   9. Anorexia, N&V, irritability, Thirst, Dyspnea on exertion & Fatigue 1st signs
3. Interventions
   1. Fluid Restriction NO more than 100mL a day
      1. Oral Care due to Discomfort of Oral Restriction
         1. Gum, Ice Chips Decrease Thirst
      2. Declomycin

         Anotações:

         • The drug blocks effects on  the renal Tubules. 
   2. Strict I&O
   3. Daily Weight
   4. Neurologic Checks

      Anotações:

      • Seizure Precautions
   5. Increase HOB no more than 10 degrees

      Anotações:

      • Increase Venous return to the Heart &amp; Increase Left atrial filling Pressure.  Reducing the Release of ADH? 
   6. d/c Drugs that increase ADH production

      Anotações:

      • Chlorpropamide, carbamezapine, oxytocin, thiazide, diuretics, SSRI antidepressants &amp; Some Chemo Drugs.
   7. Diuretics (125mEq/L)

      Anotações:

      • If below the patient may loose sodium ions with the water which is increased risk for seizure. Also causes loss of K+, Ca+ &amp; Mg2+ loss may need supplements. 
      1. Furosemide
   8. Severe Hyponatremia (Seizures)
      1. 3% Hypertonic Saline
   9. Pharmalogical Therapy

      Anotações:

      •  Euvolemic Hyponatremia Medication Treatments
      1. Tolvaptan
      2. Conivaptan

Anotações:

• Anitdiuretic Hormone is produced from the Hypothalamus.

1. Posterior Pituitary

   Anotações:

   • Anitdiuretic Hormone Stored &amp; Produced in the Posterior Pituitary.