A nurse is planning care for a client who has a new diagnosis of diabetes insipidus

Diabetes insipidus is a rare condition where you pee a lot and often feel thirsty.

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Cranial diabetes insipidus
Nephrogenic diabetes insipidus
Nursing Care Plans

Diabetes insipidus is not related to type 1 diabetes or type 2 diabetes (also known as diabetes mellitus), but it does share some of the same signs and symptoms.

The 2 main symptoms of diabetes insipidus are:

extreme thirst (polydipsia)
peeing a lot, even at night (polyuria)

In very severe cases of diabetes insipidus, a person can pee up to 20 litres of urine in a day.

Find out more about the symptoms of diabetes insipidus

You should always see your GP if you're feeling thirsty all the time.

Although it may not be diabetes insipidus, it should be investigated.

Also see your GP if you're:

peeing more than normal – most healthy adults pass urine 4 to 7 times in a 24-hour period
needing to pee small amounts at frequent intervals – sometimes this can occur along with the feeling that you need to pee immediately

Children tend to pee more frequently because they have smaller bladders.

But seek medical advice if your child pees more than 10 times a day.

Your GP will be able to carry out a number of tests to help determine what's causing the problem.

Find out more about diagnosing diabetes insipidus

Diabetes insipidus is caused by problems with a hormone called vasopressin (AVP), also called antidiuretic hormone (ADH).

AVP plays a key role in regulating the amount of fluid in the body.

It's produced by specialist nerve cells in a part of the brain known as the hypothalamus.

AVP passes from the hypothalamus to the pituitary gland, where it's stored until needed.

The pituitary gland releases AVP when the amount of water in the body becomes too low.

It helps retain water in the body by reducing the amount of water lost through the kidneys, making the kidneys produce more concentrated urine.

In diabetes insipidus, the lack of production of AVP means the kidneys cannot make enough concentrated urine and too much water is passed from the body.

In rare cases, the kidneys do not respond to AVP. This causes a specific form of diabetes insipidus called nephrogenic diabetes insipidus.

People feel thirsty as the body tries to compensate for the increased loss of water by increasing the amount of water taken in.

Find out more about the causes of diabetes insipidus

Diabetes insipidus affects about 1 in 25,000 people in the general population.

Adults are more likely to develop the condition, but it can occur at any age.

In rarer cases, diabetes insipidus can develop during pregnancy, known as gestational diabetes insipidus.

There are 2 main types of diabetes insipidus:

cranial diabetes insipidus
nephrogenic diabetes insipidus

Cranial diabetes insipidus

Cranial diabetes insipidus occurs when there's not enough AVP in the body to regulate urine production.

Cranial diabetes insipidus is the most common type of diabetes insipidus.

It can be caused by damage to the hypothalamus or pituitary gland – for example, after an infection, operation, brain tumour or head injury.

In about 1 in 3 cases of cranial diabetes insipidus there's no obvious reason why the hypothalamus stops making enough AVP.

Nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus occurs when there's enough AVP in the body but the kidneys fail to respond to it.

It can be caused by kidney damage or, in some cases, inherited as a problem on its own.

Some medications, particularly lithium (used to help stabilise mood in some people with specific mental health conditions, such as bipolar disorder), can cause nephrogenic diabetes insipidus.

Treatment is not always needed for mild cases of cranial diabetes insipidus.

You just need to increase the amount of water you drink to compensate for the fluid lost through urination.

If necessary, a medication called desmopressin can be used to replicate the functions of AVP.

Nephrogenic diabetes insipidus is often treated with medications called thiazide diuretics, which reduce the amount of urine the kidneys produce.

Find out more about treating diabetes insipidus

As diabetes insipidus increases water loss in the urine, the amount of water in the body can become low. This is known as dehydration.

Rehydration with water can be used to treat mild dehydration. Severe dehydration will need to be treated in hospital.

Find out more about the complications of diabetes insipidus

Page last reviewed: 13 October 2022
Next review due: 13 October 2025

Diabetes insipidus (DI) is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst. It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or “bedwetting”). Urine output is increased because it is not concentrated normally.

Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measured concentration (osmolality or specific gravity) is low.

Nursing Care Plans

Here are three (3) nursing care plans for diabetes insipidus.

1. Deficient Fluid Volume

May be related to

Compromised endocrine regulatory mechanism
Neurophypophyseal dysfunction
Hypopituitarism
Hypophysectomy
Nephrogenic DI

Defining Characteristics

Polyuria
Output exceeds intake
Polydipsia (increased thirst)
Sudden weight loss
Urine specific gravity less than 1.005
Urine osmolality less than 300 mOsm/L
Hypernatremia
Altered mental status
Requests for cold or ice water

Desired outcomes

Patient experiences normal fluid volume as evidenced by absence of thirst, normal serum sodium level, and stable weight.

Nursing Interventions	Rationale
Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period.	With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI.
Monitor for increased thirst (polydipsia).	If the patient is conscious and the thirst center is intact, thirst can be a reliable indicator of fluid balance. Polyuria and polydipsia strongly suggest DI. Also, the DI patient prefers ice water.
Weigh daily.	Weight loss occurs with excessive fluid loss.
Monitor urine specific gravity.	This may be 1.005 or less.
Monitor serum and urine osmolality.	Urine osmolality will be decreased and serum osmolality will increase.
Monitor urine and serum sodium levels.	The patient with DI has decreased urine sodium levels and hypernatremia.
Monitor serum potassium.	Hypokalemia may result from the increase in urinary output of potassium.
Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension).	Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume.
Allow the patient to drink water at will.	Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water.
Provide easily accessible fluid source, keeping adequate fluids at bedside.	This encourages fluid intake.
Administer intravenous (IV) fluids:	IV fluids are indicated if the patient cannot take in sufficient fluids orally.
5% dextrose in water or 0.45% sodium chloride	Hypotonic IV fluids provide free water and help lower serum sodium levels gradually.
	Isotonic fluids may be indicated for the patient who has sustained significant fluid loss and is hemodynamically unstable. Once circulatory volume has been restored, hypotonic IV fluids can be given.
Administer medication as prescribed.	Aqueous vasopressin is usually used for DI of short duration (e.g., postoperative neurosurgery or head trauma). Pitressin tannate (vasopressin) in oil (the longer-acting vasopressin) is used for longer-term DI. Patients with milder forms of DI may use chlorpropamide (Diabinese), clofibrate (Atromid), or carbamazepine (Tegretol) to stimulate release of ADH from the posterior pituitary and enhance its action on the renal tubules. Hydrochlorothiazide (HydroDIURIL) may also be used for nephrogenic DI.
If vasopressin is given, monitor for water intoxication or rebound hyponatremia.	Overmedication can result in volume excess.

2. Risk for Impaired Skin Integrity

Risk factors

Urinary frequency with high volume output and the potential for incontinence

Desired outcome

Patient’s skin remains intact.

Nursing Interventions	Rationale
Inspect skin; document condition and changes in status.	Early detection and intervention may prevent occurrence or progression of impaired skin integrity. Fluid loss from polyuria contributes to decreased skin turgor and dryness.
Assess for continence or incontinence. Evaluate need for an indwelling urinary catheter.	Excessive moisture on the skin increases the risk of skin breakdown.
Assess other factors that may risk the patient’s skin integrity (e.g., immobility, nutritional status, altered mental status).	Excessive moisture from urinary incontinence can add to the risk for skin breakdown from other sources.
Provide easy access to the bathroom, urinal, or bedpan.	Both polyuria and polydipsia disrupt the patient’s normal activities (including sleep). Easy access to void will decrease inconvenience and frustration.
Use skin barriers as needed.	These prevent redness or excoriation from urinary frequency.
Keep bed linen clean, dry, and wrinkle-free.	This prevents shearing forces.

3. Deficient Knowledge

May be related to

New condition
Unfamiliarity with the disease and treatment

Defining characteristics

Questioning
Requests for more information
Verbalization of misconceptions or misinterpretations

Desired outcomes

Patient verbalizes correct understanding of DI and the medications used in treatment

Nursing Interventions	Rationale
Assess level of knowledge of DI cause and treatment.	An individualized teaching plan is based on the patient’s current knowledge and desire for additional information.
Assess readiness to learn.	Rapid fluid loss from polyuria can lead to impaired cognitive function. This change in mental status can limit the patient’s ability to learn new information.
Give written information concerning the diagnosis and treatment of DI:
Water deprivation ADH stimulation test	This test may be done to differentiate nephrogenic causes from neurogenic causes of DI. The patient is instructed to take nothing by mouth (NPO) for 12 hours before a blood sample is drawn to measure ADH levels. The ADH level is increased in nephrogenic DI and decreased in neurogenic (central) DI. Vasopressin may be given to evaluate renal response. There is no response to the drug in nephrogenic DI.
Computed tomography scan or magnetic resonance imaging	These scans may be ordered if a pituitary tumor is suspected.
Desmopressin acetate (DDAVP)	This is the drug of choice for the management of DI. This medication is a synthetic form of ADH and is administered intranasally.
Aqueous form of ADH (vasopressin)	This drug has a shorter half-life than DDAVP and therefore requires more frequent daily administration. Vasopressin is usually given parenterally and is not recommended for the long-term management of chronic DI.
Other drugs used in combination to manage DI, including chlorpropamide (Diabinese), clofibrate (Atromid), carbamazepine (Tegretol), and hydrochlorothiazide	These secondary drugs work on the kidney or the posterior pituitary gland to increase pituitary release of ADH or increase renal response to ADH.
Teach the patient the necessity of closely monitoring fluid balance, including daily weights (same time of day with same amount of clothing), fluid intake and output, and measurement of urine specific gravity.	This assists the patient in monitoring the condition so that adjustments can be made accordingly, helping prevent undertreatment or overtreatment with the medication.
Discuss when to seek further medical attention (at signs of underdosage or overdosage of medications).	Patients with chronic disease need to be able to recognize important changes in their condition to avert complications and possible hospitalization.
Instruct the patient to wear a medical alert bracelet, listing DI and the medications that the patient is using.	This allows for prompt intervention in the event of an emergency.