Urine Insipidis Observation

The patient in “The Red Hat Hikers” scenario is suffering from hyponatremia. Hyponatremia is defined as a serum sodium level of less than 136mEq/L. Sodium is an electrolyte that is found predominately in the extracellular fluid, and it is the chief regulator of water in the body. Sodium is also important for muscle contraction, nerve impulses, acid-base balance and chemical reactions that occur inside the cell (McCance & Huether, 2014). Normal sodium levels in the body are maintained by the kidneys and the hormone aldosterone. Aldosterone is secreted by the adrenal cortex at the completion of the renin-angiotensin-aldosterone system, and it helps stimulate the proximal tubules of the kidneys to reabsorb sodium and water. The anti-diuretic hormone (ADH) also indirectly affects sodium levels because it regulates water balance in the body (McCance & Huether, 2014).

Joint Commission released national patient safety goals for hospitals in January of 2016. These patient safety goals were “established to help accredited organizations address specific areas of concern in regards to patient safety” (Facts about the National Patient Safety Goals, 2015). National patient safety goal 07.06.01 focuses on the prevention of catheter associated urinary tract infections (CAUTI) in hospitalized patients. Evidence based practice should be implemented to stop these common infections occurring in patients nationwide. Indwelling urinary catheters are only recommended in certain patients, for example to prevent further breakdown of sacral wounds or pressure ulcers in incontinent patients, for comfort in end of life care

4. B.J. receives subcutaneous 1-deamino-8-d-arginine vasopressin (ddAVP) to manage his high urine output. What is the rationale for this therapy? How can effectiveness be assessed?

The most relevant theory in this situation is the preservation of integrity for the patient and in my practice. In order to preserve integrity and social justice I want to attain a respectful nurse-patient relationship. The nurse-patient relationship in high acuity as written in Module 1 BCIT High Acuity course “is one of the central aspects of high acuity nursing practice” (Bungay, 2005, p. 40). I feel confident this theory is the central aspect of all nursing practice. All patients, including the one I’m referring to in this journal, has her own unique beliefs, history, and experience. On top of these, the patient is now, due to critical illness, experiencing an actual or potential physiological crisis (Bungay, 2005, p. 42). It would useful and respectful of me to acknowledge that on top of her present concerns, all concerns she had prior admission still exist. I did not give her the opportunity to express her concerns. I never asked her if she had a cat she was concerned about, was missing Saturday’s farmer’s market, wanted a Sherry, missed her friend, or disliked men. There could be a myriad of things that may be concerning her at the time. All real and potential factors support or challenge having a positive relationship with the patient (Bungay, 2005, p. 41).

On august 13, 2016 I was assigned to follow one of the ICU Nurse. It was a very calm day. She had two patient one was more critical than the other. Both patients were on the ventilator because they had to be intubated the night before. The lady is obese and had gastric bypass surgery two years ago and suffering from severe sleep apnea, but the patient is non-compliance to the CPAP treatment. That was her second time being intubated. She was admitted for seizure monitoring because she was constantly having seizures the day before while she was at home. Due to the fact that she did not want to wear her CPAP machine while in the hospital, after pain medication was administered she was found unresponsive, that was the reason for her intubation the night before. Patient was on intermittent suctioning, she has sinus tachycardia . I had the opportunity to observe some of her daily care. The patient was on fentanyl but when the Dr. try to wean her out of the ventilator she stop breathing, therefore, the DR. discontinue the fentanyl temporarily in other to retest her later.

Polydipsia: increased fluid intake. It is due to high blood glucose that raises the osmolality of blood and makes it more concentrated. With frequent urination, increase water intake becomes necessary. Severe dehydration and electrolyte imbalance can occur. Diabetes may cause blood glucose levels to rise which can lead to increased glucose levels that cause one’s body to pull fluid from cells into the bloodstream and deliver the increased load to the kidneys. This can cause one’s kidneys to over work and produce more urine than normal.

The cause of the high urine output postop is due to diabetes insipidus. “Diabetes insipidus (DI) is a common complication following pituitary surgery” (Schreckinger, Szerli & Mittal, 2012). There are two subsets within Diabetes insipidus, nephrogenic and neurogenic. “Neurogenic (or central) DI occurs when there is inadequate secretion of AVP from the hypothalamus. This can be hereditary, idiopathic, or due to injury to the

1. I think that the patient misunderstood the nurse’s intentions when he was moved from the ICU to the other places in the hospital because there was limited communication letting the know what will be happening. It seems that the patient was not familiar with the hospital, procedures and the people and because of that, the patient felt that all the interventions were to harm him. Even before the surgery, the surgeon visited the patient very quickly and told the patient this was a routine surgery. Although it may be routine, I think that it would be good to educate the patient about what will be occurring in each of the processes. In addition, when the patient was going for exams, the patient had to wonder what exam

Diabetes insipidus is a disorder that causes an imbalance of water in the body because the kidneys are not functioning correctly (cite). It is caused by a lack of antidiuretic hormone (ADH) which prevents dehydration. Individuals with this disorder produces excessive urination and polydipsia (cite). Although diabetes insipidus and mellitus sound related, they are not. Diabetes mellitus type 1 and type 2 are more common forms of diabetes (cite). To diagnose diabetes insipidus, a doctor could use the fluid /water deprivation test or an MRI scan. The fluid/water deprivation test involves allowing an individual to reframe from drinking fluids for a number of hours to become extremely dehydrated while collecting blood and urine samples. An MRI scan of the head can be used to observe abnormalities in the hypothalamus and pituitary gland (cite).

An understanding in nursing sensitive indicators in this case could have solved a couple problems that arrived during this patient’s stay. One of the issues was that the patient’s back was reddened due to restraints being placed and the patient not being turned properly to prevent pressure ulcers. If this would have been recognized when the restraints were applied, the patient would have been turned every two hours by placing a pillow under the sides of the patient so that he would not be on his back constantly. Due to him being confused, he may have been moving around a lot and pushed the pillows out, but there is also the case he should be getting rounded on hourly at the minimum. If this understanding would have been understood and the nurse knew what could have happened, she would have been turning the patient to ultimately decrease the hospital stay.

The nurse’s on any ICU are under an enormous amount of stress to add to it I learned today that each day nurse has a day where they are in charge of responding to all the codes. The nurse I shadowed today was Nicole. She showed me a lot of what I learned last semester and helped put it into perspective for me. She first taught me that no matter what ALWAYS take report at the bedside. She taught me her whole routine: take report, adjusts her parameters, she would suction if need, always ensure there is an ambu bag and suction working in the room and ensure all the alarms work then document. We had two patients on the floor the first was post-op day three and the second patient was a CIWA patient. The first patient we checked was the CIWA

Diabetic Nephropathy often begins with hyperglycemia due to an increase of osmotic pressure (William & Hopper, 2011). It then leads to cell expansion and an increase in glomerular filtration rate or (GHR) (William & Hopper, 2011). Thus, kidneys will then receive less blood supply due to atherosclerosis of blood vessels (William & Hopper, 2011). Protein then will leak into the urine due to the capillaries in the glomerular thickining (William & Hopper, 2011). Theses patients most often have problems completely emptying the bladder of urine (William & Hopper, 2011). Most often they will report massive edema and nephrotic syndrome due to the high levels of protein in the urine (William & Hopper, 2011). The patient at this

“Diabetes Insipidus (DI) is a disorder of insufficient activity of ADH, leading to polyuria (frequent urination) and polydipsia (frequent drinking)” (Huether & McCance, 2012, P.449). There are two forms, neurogenic or central DI can occur with injury or some drug to posterior pituitary gland interferes with abnormalities in ADH secretion. Second nephrogenic is failure of the renal tubes to concentrate urine in respond to ADH. In DI the individual has difficulty concentrating urine whether partial or total. The lack of ADH allows filtered water to be excreted in the urine instead of reabsorbed. Results in excretion of large volumes of dilute urine, leading to increase plasma osmolality. The disorder triggers excessive urination and thirst and fluid intake. Urine output can range from 1 to 2 liter/day averaging 8 to 12 liter/day with low specific gravity. Loss of fluid output without replacement the individual can rapidly develop dehydration. The individual that is unable to maintain the appropriate water balance hypernatremia and hyperosmolality will occur. Laboratory test a 24hour urine, serum electrolyte and glucose level. Urine

My day in the intensive care unit, ICU started out very challenging. Upon arrival I entered into my patient’s room to find him covered in blood. He had taken out his IV, stripped from his gown, and was attempting to pull out his Foley catheter. He had arrived to the ER the previous night after being found at his hotel in only his underwear. He was admitted to the ICU to be closely monitored due to the fact that he has diabetes type 2 and his blood sugar level were critically high. His blood sugar levels were ranging from the 800’s and had even gotten as high as 1,098. To regulate his blood sugar level his physician ordered hourly finger sticks as well as a drip of 100 units of regular insulin via IV every 12 hours. His blood sugar level dropped

This 64-year-old male patient presented to the hospital with a four-day history of diplopia, dizziness and an unsteady gait. It was concluded that he had a left thalamic infarct. This resulted in right upper and lower limb weakness, difficulties with coordination and vision problems. This was the second stroke for John (pseudonym) as he was incompliant with taking his medications because they were not organic. Aside from his stroke, John was having problems voiding urine and urinary retention. On multiple occasions he had post void volumes of 800-900mLs in his bladder. A prostate specific antigen test was then done resulting in a level of 10ng/ml, which is significantly above normal for his age (website below). Thus an indwelling catheter (IDC) was inserted and a urology referral completed.