ADH

Annotations:

• 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

         Annotations:

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

         Annotations:

         • 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

      Annotations:

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

         Annotations:

         • Greater than 200ml per hour
      2. Nocturia

         Annotations:

         • 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

      Annotations:

      • 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

         Annotations:

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

   Annotations:

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

      Annotations:

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

         Annotations:

         • Usually Self- Limiting 
      3. Brain Surgery

         Annotations:

         • 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

      Annotations:

      • 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

            Annotations:

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

         Annotations:

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

         Annotations:

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

         Annotations:

         • 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

         Annotations:

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

         Annotations:

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

Annotations:

• 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

      Annotations:

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

      Annotations:

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

      Annotations:

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

      Annotations:

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

         Annotations:

         • Most Common!!!
2. Signs & Symptoms

   Annotations:

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

      Annotations:

      • 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

         Annotations:

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

      Annotations:

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

      Annotations:

      • 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

         Annotations:

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

      Annotations:

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

      Annotations:

      • 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

      Annotations:

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

      Annotations:

      • 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

      Annotations:

      •  Euvolemic Hyponatremia Medication Treatments
      1. Tolvaptan
      2. Conivaptan

Annotations:

• Anitdiuretic Hormone is produced from the Hypothalamus.

1. Posterior Pituitary

   Annotations:

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