chapter 42-endocrine-and-thyroid-disorder-i
TRANSCRIPT
Chapter 42Assessment and Management of
Patients with Endocrine Disorders
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Endocrine System Effects almost every cell, organ, and function of the
body The endocrine system is closely linked with the
nervous system and the immune systemNegative feedback mechanismHormones
Chemical messengers of the bodyAct on specific target cells
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Location of the major endocrine glands.
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HypothalamusSits between the cerebrum and brainstemHouses the pituitary gland and hypothalamusRegulates:
TemperatureFluid volumeGrowthPain and pleasure responseHunger and thirst
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Hypothalamus HormonesReleasing and inhibiting hormonesCorticotropin-releasing hormoneThyrotropin-releasing hormoneGrowth hormone-releasing hormoneGonadotropin-releasing hormoneSomatostatin-=-inhibits GH and TSH
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Pituitary GlandSits beneath the hypothalamusTermed the “master gland”Divided into:
Anterior Pituitary GlandPosterior Pituitary Gland
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Actions of the major hormones of the pituitary gland.
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Adrenal GlandsPyramid-shaped organs that sit on top of the
kidneysEach has two parts:
Outer CortexInner Medulla
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Adrenal CortexMineralocorticoid—aldosterone. Affects sodium
absorption, loss of potassium by kidney
Glucocorticoids—cortisol. Affects metabolism, regulates blood sugar levels, affects growth, anti-inflammatory action, decreases effects of stress
Adrenal androgens—dehydroepiandrosterone and androstenedione. Converted to testosterone in the periphery.
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Adrenal Medulla
Secretion of two hormonesEpinephrineNorepinephrine
Serve as neurotransmitters for sympathetic systemInvolved with the stress response
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Thyroid GlandButterfly shapedSits on either side of the tracheaHas two lobes connected with an isthmusFunctions in the presence of iodineStimulates the secretion of three hormonesInvolved with metabolic rate management and
serum calcium levels
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Thyroid Gland
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Hypothalamic-Pituitary-Thyroid Axis
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ThyroidFollicular cells—excretion of triiodothyronine (T3)
and thyroxine (T4)—Increase BMR, increase bone and protien turnover, increase response to catecholamines, need for infant G&D
Thyroid C cells—calcitonin. Lowers blood calcium and phosphate levels
BMR: Basal Metabolic Rate
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Parathyroid GlandsEmbedded within the posterior lobes of the thyroid
glandSecretion of one hormoneMaintenance of serum calcium levelsParathyroid hormone—regulates serum
calcium
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PancreasLocated behind the stomach between the spleen
and duodenumHas two major functions
Digestive enzymesReleases two hormones: insulin and glucagon
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Kidney1, 25 dihydroxyvitamin D—stimulates calcium
absorption from the intestineRenin—activates the Renin-Angiotensin System
(RAS)Erythropoietin—Increases red blood cell
production
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OvariesEstrogenProgesterone—important in menstrual cycle,
maintains pregnancy,
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TestesAndrogens, testosterone—secondary sexual
characteristics, sperm production
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ThymusReleases thymosin and thymopoietinAffects maturation of T lymphocetes
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PinealMelatoninAffects sleep, fertility and aging
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Past Medical HistoryHormone replacement therapySurgeries, chemotherapy, radiationFamily history: diabetes mellitus, diabetes insipidus,
goiter, obesity, Addison’s disease, infertilitySexual history: changes, characteristics, menstruation,
menopause
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Physical AssessmentGeneral appearance
Vital signs, height, weightIntegumentary
Skin color, temperature, texture, moistureBruising, lesions, wound healingHair and nail texture, hair growth
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Physical AssessmentFace
Shape, symmetryEyes, visual acuityNeck
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Palpating the thyroid gland from behind the client. (Source: Lester V. Bergman/Corbis)
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Physical AssessmentExtremities
Hand and feet sizeTrunkMuscle strength, deep tendon reflexesSensation to hot and cold, vibrationExtremity edema
ThoraxLung and heart sounds
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Older Adults and Endocrine FunctionRelationship unclearAging causes fibrosis of thyroid glandReduces metabolic rateContributes to weight gainCortisol level unchanged in aging
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Abnormal FindingsAsk the client:
Energy levelFatigueMaintenance of ADLSensitivity to heat or coldWeight levelBowel habitsLevel of appetiteUrination, thirst, salt craving
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Abnormal Findings (continued)Ask the client:
Cardiovascular status: blood pressure, heart rate, palpitations, SOB
Vision: changes, tearing, eye edemaNeurologic: numbness/tingling lips or extremities,
nervousness, hand tremors, mood changes, memory changes, sleep patterns
Integumentary: hair changes, skin changes, nails, bruising, wound healing
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Most Common Endocrine DisordersThyroid abnormalitiesDiabetes mellitus
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Diagnostic TestsGH: fasting, well rested, not physically stressedT3/T4, TSH: no specific preparationSerum calcium/phosphate: fasting may or may not be
requiredCortisol/aldosterone level24 urine collection to measure the level of catacholamines
(epinephrine, norepinephrine, dopamine).
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Thyroid DisordersCretinism HypothyroidismHyperthyroidismThyroiditisGoiter Thyroid cancer
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HYPOTHYRODISM
Hypothyroidism is the disease state caused by insufficient production of thyroid hormone by the thyroid gland.
INCEDENCE • 30-60 yrs of age• Mostly women (5 times more than men)
CausesAutoimmune disease (Hashimoto's
thyroiditis, post–Graves' disease)Atrophy of thyroid gland with agingTherapy for hyperthyroidism
Radioactive iodine (131I)Thyroidectomy
MedicationsRadiation to head and neck
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Clinical Manifestations:
1. Fatigue.
2. Constipation.
3. Apathy
4. Weight gain.
5. Memory and mental impairment and decreased
concentration.
6. masklike face.
7. Menstrual irregularities and loss of libido.
8. Coarseness or loss of hair.
9. Dry skin and cold intolerance.10. Menstrual disturbances 11. Numbness and tingling of
fingers. 12. Tongue, hands, and feet
may enlarge 13. Slurred speach 14. Hyperlipidemia. 15. Reflex delay. 16. Bradycardia. 17. Hypothermia. 18. Cardiac and respiratory
complications .
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LABORATORY ASSESSMENT T3 T4 TSH
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TREATMENT
LIFELONG THYROID HORMONE REPLACEMENT levothyroxine sodium (Synthroid, T4, Eltroxin) IMPORTANT: start at low does, to avoid hypertension,
heart failure and MITeach about S&S of hyperthyroidism with replacement
therapy
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MYXEDEMA DEVELOPS
Rare serious complication of untreated hypothyroidismDecreased metabolism causes the heart muscle to become
flabby Leads to decreased cardiac outputLeads to decreased perfusion to brain and other vital organsLeads to tissue and organ failureLIFE THREATENING EMERGENCY WITH HIGH
MORTALITY RATEEdema changes client’s appearanceNonpitting edema appears everywhere especially around the
eyes, hands, feet, between shoulder blades Tongue thickens, edema forms in larynx, voice husky
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PROBLEMS SEEN WITH MYXEDEMA COMAComaRespiratory failureHypotensionHyponatremiaHypothermiahypoglycemia
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TREATMENT OF MYEXEDEMA COMA
Patent airwayReplace fluids with IV.Give levothyroxine sodium IVGive glucose IVGive corticosteroidsCheck temp, BP hourlyMonitor changes LOC hourlyAspiration precautions, keep warm
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Hyperthyroidism
Clinical Manifestations (thyrotoxicosis):1. Heat intolerance.2. Palpitations, tachycardia, elevated systolic BP.3. Increased appetite but with weight loss.4. Menstrual irregularities and decreased libido.5. Increased serum T4, T3.6. Exophthalmos (bulging eyes) 7. Perspiration, skin moist and flushed ; however,
elders’ skin may be dry and pruritic 8. Insomnia.9. Fatigue and muscle weakness10. Nervousness, irritability, can’t sit quietly. 11. Diarrhea.
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Hyperthyroidism
Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus.
Graves' disease: the most common type of hyperthyroidism, results from an excessive output of thyroid hormones.
May appear after an emotional shock, stress, or an infection
Other causes: thyroiditis and excessive ingestion of thyroid hormone
Affects women 8X more frequently than men (appears between second and fourth decade)
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Medical Management of Hyperthyroidism
Radioactive 131I therapy Medications
Propylthiouracil and methimazoleSodium or potassium iodine solutionsDexamethasoneBeta-blockers
Surgery; subtotal thyroidectomy Relapse of disorder is commonDisease or treatment may result in hypothyroidism
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ThyroiditisInflammation of the thyroid gland. Can be acute, subacute, or chronic (Hashimoto's
Disease)Each type of thyroiditis is characterized by
inflammation, fibrosis, or lymphocytic infiltration of the thyroid gland.
Characterized by autoimmune damage to the thyroid.May cause thyrotoxicosis, hypothyroidism, or both
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Thyroid Tumors
Can be being benign or malignant. If the enlargement is sufficient to cause a visible
swelling in the neck, referred to as a goiter.Some goiters are accompanied by hyperthyroidism, in
which case they are described as toxic; others are associated with a euthyroid state and are called nontoxic goiters.
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Thyroid Cancer
Much less prevalent than other forms of cancer; however, it accounts for 90% of endocrine malignancies.
Diagnosis: thyroid hormone, biobsyManagement
The treatment of choice surgical removal. Total or near-total thyroidectomy is performed if possible. Modified neck dissection or more extensive radical neck dissection is performed if there is lymph node involvement.
After surgery, radioactive iodine.Thyroid hormone supplement to replace the hormone.
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ThyroidectomyTreatment of choice for thyroid cancerPreoperative goals include the reduction of stress and anxiety
to avoid precipitation of thyroid storm (euothyroid)Iodine prep (Lugols or K iodide solution) to decrease size
and vascularity of gland to minimize risk of hemorrhage, reduces risk of thyroid storm during surgery
Preoperative teaching includes dietary guidance to meet patient metabolic needs and avoidance of caffeinated beverages and other stimulants, explanation of tests and procedures, and demonstration of support of head to be used postoperatively
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Postoperative Care
Monitor dressing for potential bleeding and hematoma formation; check posterior dressing
Monitor respirations; potential airway impairmentAssess pain and provide pain relief measuresSemi-Fowler’s position, support headAssess voice but discourage talking Potential hypocalcaemia related to injury or removal of
parathyroid glands; monitor for hypocalcaemia
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POST-OP THYROIDECTOMY NURSING CARE
1. VS, I&O, IV2. Semifowlers3. Support head4. Avoid tension on sutures5. Pain meds, analgesic lozengers6. Humidified oxygen, suction7. First fluids: cold/ice, tolerated best, then soft diet8. Limited talking , hoarseness common9. Assess for voice changes: injury to the recurrent
laryngeal nerve
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POSTOP THYROIDECTOMY NURSING CARE
CHECK FOR HEMORRHAGE 1st 24 hrs:
Look behind neck and sides of neck
Check for c/o pressure or fullness at incision site
Check drain REPORT TO MD
CHECK FOR RESPIRATORY DISTRESS
Laryngeal stridor (harsh hi pitched resp sounds)
Result of edema of glottis, hematoma,or tetany
Tracheostomy set/airway/ O2, suction
CALL MD for extreme hoarseness
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Complication of operation:
HemorrhageLaryngeal nerve damage.HypoparathyrodismHypothyroidismSeptesisPostoperative infection
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Parathyroid Four glands on the posterior thyroid glandParathormone regulates calcium and phosphorus
balanceIncreased parathormone elevates blood calcium by
increasing calcium absorption from the kidney, intestine, and bone.
Parathormone lowers phosphorus level.
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Parathyroid Glands
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Hyperparathyroidism
Primary hyperparathyroidism is 2–4 X more frequent in women.Manifestations include elevated serum calcium, bone
decalcification, renal calculi, apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, cardiac dysrhythmias, psychological manifestations
TreatmentParathyroidectomyHydration therapyEncourage mobility reduce calcium excretionDiet: encourage fluid, avoid excess or restricted calcium
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QuestionIs the following statement True or False?
The patient in acute hypercalcemic crisis requires close monitoring for life-threatening complications and prompt treatment to reduce serum calcium levels.
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HypoparathryoidismDeficiency of parathormone usually due to surgeryResults in hypocalcaemia and hyperphosphatemiaManifestations include tetany, numbness and tingling
in extremities, stiffness of hands and feet, bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability, depression, delirium, ECG changesTrousseau’s sign and Chvostek’s sign
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Management of Hypoparathyroidism
Increase serum calcium level to 9—10 mg/dL Calcium gluconate IVMay also use sedatives such as pentobarbital to
decrease neuromuscular irritabilityParathormone may be administered; potential allergic
reactionsEnvironment free of noise, drafts, bright lights, sudden
movementDiet high in calcium and low in phosphorusVitamin D Aluminum hydroxide is administered after meals to
bind with phosphate and promote its excretion through the gastrointestinal tract.
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Adrenal Glands
Adrenal medullaFunctions as part of the autonomic nervous systemCatecholamines; epinephrine and norepinephrine
Adrenal cortexGlucocorticoidsMineralocorticoidsAndrogens
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Adrenal Insufficiency Adrenal cortex function is inadequate to
meet the needs for cortical hormonesPrimary: Addison’s DiseaseSecondaryMay be the result of adrenal suppression by
exogenous steroid use
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Adrenal Crisis
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Manifestations
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Muscle weakness, anorexia, GI symptoms, fatigue, dark pigmentation of skin and mucosa, hypotension, low blood glucose, low serum sodium, high serum potassium, mental changes, apathy, emotional lability, confusion
Addisonian crisis: circulatory collapseDiagnostic tests; adrenocortical hormone levels, ACTH
levels, ACTH stimulation test
Adrenal CrisisMedical Management
ImmediateReverse shockRestore blood circulation
Antibiotics if infectionIdentify causeSupplement
glucocorticoids during stressful procedures or significant illness
Nursing Management
Assess fluid balanceMonitor VS closelyGood skin assessmentLimit activity Provide quiet, non-
stressful environment
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Nursing Process: The Care of the Patient with Adrenocortical Insufficiency
AssessmentLevel of stress; note any illness or stressors that may
precipitate problemsFluid and electrolyte status VS and postural blood pressuresNote signs and symptoms related to adrenocortical
insufficiency such as weight changes, muscle weakness, and fatigue
MedicationsMonitor for signs and symptoms of Addisonian crisis
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Nursing Process: The Care of the Patient with Adrenocortical Insufficiency
DiagnosesRisk for fluid volume deficitActivity intolerance and fatigueKnowledge deficit
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Interventions
Risk for fluid deficit; monitor for signs and symptoms of fluid volume deficit, encourage fluids and foods, select foods high in sodium, administer hormone replacement as prescribed
Activity intolerance; avoid stress and activity until stable, perform all activities for patient when in crisis, maintain a quiet nonstressful environment, measures to reduce anxiety
Teaching(See Chart 42-10)
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Cushing’s SyndromeDue to excessive
adrenocortical activity or corticosteroid medications
Women between the ages of 20 and 40 years are five times more likely than men to develop Cushing's syndrome.
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Cushing’s Syndrome/ManifestationsHyperglycemia which may develop into diabetes,
weight gain, central type obesity with “buffalo hump,” heavy trunk and thin extremities, fragile thin skin, ecchymosis, striae, weakness, lassitude, sleep disturbances, osteoporosis, muscle wasting, hypertension, “moon-face”, acne, increased susceptibility to infection, slow healing, virilization in women, loss of libido, mood changes, increased serum sodium, decreased serum potassium
Diagnosis: Dexamethasone suppression test, ↑ Na+ ↑ glucose, ↓ K+, metabolic alkalosis
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Cushing’s Syndrome
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Cushing’s SyndromeMedical Management
Pituitary tumorSurgical removalradiation
AdrenalectomyAdrenal enzyme
inhibitors Attempt to reduce or
taper corticosteroid dose
Nursing Managment
Prevent injuryIncreased protein, calcium
and vitamin D in dietMedical asepsisMonitor blood glucoseModerate activity with rest
periodsProvide restful
environment
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Nursing Process: The Care of the Patient with Cushing’s Syndrome
AssessmentActivity level and ability to carry out self-careSkin assessmentChanges in physical appearance and patient responses
to these changesMental functionEmotional statusMedications
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Nursing Process: The Care of the Patient with Cushing’s Syndrome—
DiagnosesRisk for injuryRisk for infectionSelf-care deficitImpaired skin integrityDisturbed body imageDisturbed thought processes
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Collaborative Problems/Potential Complications
Addisonian crisisAdverse effects of adrenocortical activity
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Nursing Process: The Care of the Patient with Cushing’s Syndrome
Planning: Goals may include 1. Decreased risk of injury, 2. Decreased risk of infection, 3. Increased ability to carry out self-care activities, 4. Improved skin integrity, 5. Improved body image, 6. Improved mental function, and 7. Absence of complications
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InterventionsDecrease risk of injury; establish a protective environment;
assist as needed; encourage diet high in protein, calcium, and vitamin D.
Decrease risk of infection; avoid exposure to infections, assess patient carefully as corticosteroids mask signs of infection.
Plan and space rest and activity.Meticulous skin care and frequent, careful skin assessment.Explanation to the patient and family about causes of
emotional instability. Patient teaching.
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Diabetes InsipidusA disorder of the posterior lobe of the pituitary gland
that is characterized by a deficiency of ADH (vasopressin). Excessive thirst (polydipsia) and large volumes of dilute urine.
It may occur secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland, infections of the central nervous system or with tumors
Another cause of diabetes insipidus is failure of the renal tubules to respond to ADH
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Medical Management
The objectives of therapy are 1. to replace ADH (which is usually a long-term
therapeutic program), 2. to ensure adequate fluid replacement, and 3. to identify and correct the underlying
intracranial pathology.
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