Chapter 65

1. Chapter 65 Care of Patients with Pituitary and Adrenal Gland Problems Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011

2. Disorders of the Anterior Pituitary Gland • Controls growth, metabolic activity & sexual development • Hormones Produced are on page 1426 • Primary pituitary dysfunction: problem within the anterior pituitary gland itself • Secondary pituitary dysfunction: problems in the hypothalamus that change the anterior pituitary function • Pituitary hypofunction: under secretion of hormones • Pituitary hyperfunction: over secretion of hormones

3. Hypopituitarism • Deficiency of one or more anterior pituitary hormones results in metabolic problems and sexual dysfunction. • Panhypopituitarism—decreased production of all of the anterior pituitary hormones. • Most life-threatening deficiencies—ACTH (adrenocorticotropic hormone) and (Thyroid Stimulating Hormone) TSH b/c decrease of vital hormones • Deficiency of gonadotropins. (sexual hormones) • Growth hormone stimulates the liver to produce substances known as somatomedins that enhance growth activity. Bone & cartilage

4. Cause of Hypopituitarism • Benign or malignant tumors • Anorexia nervosa • Shock or severe hypotension • Head trauma • Brain tumors or infection • Sheehan’s syndrome: postpartum hemorrhage

5. Patient-Centered Collaborative Care • Assessment • Interventions include: • Replacement of deficient hormones • Androgen therapy (testerone) for virilization (presence of male seocndary sex characteristics) gynecomastia can occur (development of breast in male) • Estrogens and progesterone • Growth hormone

6. Hyperpituitarism • Hormone oversecretion occurs with pituitary tumors or hyperplasia • Genetic considerations • Gigantism • Pituitary adenoma most common cause

7. Gigantism • Gigantism is the onset of growth hormone hypersecretion before puberty.

8. Acromegaly • Growth hormone hypersecretion after puberty • Hands and feet are large compared to the rest of the body

9. Patient-Centered Collaborative Care • Assessment • Nonsurgical management: • Drug therapy—Parlodel, Dostinex, Permax, Sandostatin, Somavert • Radiation • Gamma knife procedure

10. Surgical Management Surgical Management: transsphenoidal surgical approach to the pituitary gland. Selective adenomectomy leaves normal pituitary tissue undisturbed

11. Postoperative Care • Monitor neurologic response • Assess for postnasal drip • HOB elevated • Assess nasal drainage • Avoid coughing early after surgery • Assess for meningitis • Hormone replacement • Avoid bending • Avoid strain at stool • Avoid toothbrushing • Numbness in the area of the incision • Decreased sense of smell • Vasopressin

12. Diabetes Insipidus • Water metabolism problem caused by an antidiuretic hormone deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH) • Without ADH kidney collecting ducts do not absorb water->polyuria->dehydration. • Diabetes insipidus is classified as: • Nephrogenic: inherited disorder • Primary: defect in the hypothalamus or pituitary gland • Secondary: tumors, trauma, infection, surgery • Drug-related: certain RX drugs

13. Patient-Centered Collaborative Care • Assessment • Most manifestations of DI are related to dehydration • Increase in frequency of urination and excessive thirst • Dehydration and hypertonic saline tests used for diagnosis of the disorder • Urine diluted with a low specific gravity (<1.005)

14. DI: Interventions • Oral chlorpropamide • Desmopressin acetate • Early detection of dehydration and maintenance of adequate hydration • Lifelong vasopressin therapy for patients with permanent condition of diabetes insipidus • Teach patients to weigh themselves daily to identify weight gain

15. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) • Vasopressin (ADH) is secreted even when plasma osmolarity is low or normal. • Feedback mechanisms do not function properly. • Water is retained, resulting in hyponatremia (decreased serum sodium level).

16. SIADH: Patient-Centered Collaborative Care • Assessment: • Recent head trauma • Cerebrovascular disease • Tuberculosis or other pulmonary disease • Cancer • All past and current drug use

17. SIADH: Interventions • Fluid restriction • Drug therapy—diuretics, hypertonic saline, demeclocycline • Monitor for fluid overload • Safe environment • Neurologic assessment

18. Adrenal Gland Hypofunction • Adrenocortical steroids may decrease as a result of inadequate secretion of ACTH • Dysfunction of the hypothalamic-pituitary control mechanism • Direct dysfunction of adrenal tissue • Acute Adrenocortical insufficiency adrenal crisis life threatening manifestations appear without warning

19. Effect of Insufficiency of Adrenocortical Steroids • Loss of aldosterone and cortical action • Decreased gluconeogenesis • Depletion of liver and muscle glycogen • Hypoglycemia • Reduced urea nitrogen excretion • Anorexia and weight loss • Potassium, sodium, and water imbalances

20. Addison’s Disease or Adrenal Insufficiency • Primary: Table 65-2 page 1437 • Secondary: • Sudden cessation of long-term high-dose glucocorticoid therapy causing atrophy of the adrenal cortex

21. Acute Adrenal Insufficiency/Addisonian Crisis • Life-threatening event in which the need for cortisol and aldosterone is greater than the available supply • Usually occurs in a response to a stressful event such as trauma, surgery, severe infection. • Na+ decrease K+ increase rapidly, hypotension-> etc.

22. Patient-Centered Collaborative Care • Assessment • Clinical manifestations

23. Assessment • Psychosocial assessment • Laboratory tests • Imaging assessment

24. Adrenal Gland Hyperfunction • Hypersecretion by the adrenal cortex results in Cushing’s syndrome/disease, hypercortisolism, or excessive androgen production

25. Pheochromocytoma • Hyperstimulation of the adrenal medulla caused by a tumor • Excessive secretion of catecholamines • Surgical TX • Avoid caffeine products

26. Hypercortisolism (Cushing’s Disease) • Etiology • Incidence/prevalence • Patient-centered collaborative care • Assessment: • Clinical manifestations—skin changes, cardiac changes, musculoskeletal changes, glucose metabolism, immune changes • Psychosocial assessment • Laboratory tests—blood, salivary and urine cortisol levels, hyperglycemia & hypokalemia • Imaging assessment

27. Hypercortisolism: Nonsurgical Management • *Patient safety • Drug therapy • Nutrition therapy • Monitoring • If pt on large doses of glucocorticoids and c/o not feeling well, have them get an exam and lab work to see hormone levels

28. Hypercortisolism: Surgical Management • Hypophysectomy • Adrenalectomy

29. Community-Based Care • Home care management • Health teaching • Health care resources

30. Hyperaldosteronism • Increased secretion of aldosterone results in mineralocorticoid excess. • Primary hyperaldosteronism (Conn's syndrome) is a result of excessive secretion of aldosterone from one or both adrenal glands. • Causes hypernatermia, hypokalemia, and metabolic alkalosis.

31. Patient-Centered Collaborative Care • Assessment • Most common issues—hypokalemia and elevated blood pressure

32. Interventions • Adrenalectomy • Drug therapy • Glucocorticoid replacement • When surgery cannot be performed—spironolactone therapy

33. Pheochromocytoma • Catecholamine-producing tumors that arise in the adrenal medulla • Tumors produce, store, and release epinephrine and norepinephrine

34. Patient-Centered Collaborative Care • Assessment • Interventions: • Surgery is main treatment. • After surgery, assess blood pressure.

35. Chapter 65 NCLEX TIME Care of Patients with Pituitary and Adrenal Gland Problems

36. Question 1 A female patient who is obese is complaining of bruising easily, acne, and hair loss. She is concerned about “stretch marks” on her abdomen, thighs, and upper arms. What would the nurse expect to happen next? • Diagnostic assessment • Radiation therapy • Surgical intervention • Lifelong hormone replacement

37. Question 2 What is a priority question to ask a patient with a hypopituitary tumor? • “Do you have any changes in your visual acuity?” • “Have you noticed a change in your libido?” • “Have you experienced a change in growth of your facial hair?” • “Have you had an unexpected weight loss?”

38. Question 3 What is a priority nursing intervention in the care of a patient with diabetes insipidus? • Seizure precautions • Fall precautions • Accurate intake and output measurement • IV fluid hydration

39. Question 4 Which patient with Cushing’s disease is at greatest risk for developing heart failure? • 42-year-old patient with a serum creatinine level of 3.7 mg/dL • 59-year-old patient with a history of hypertension • 32-year-old patient with a history of hepatitis B infection • 60-year-old patient with pneumonia

40. Question 5 Which condition resulting from lithium (Lithobid) might you expect to see in the patient with bipolar disorder? • Hypothyroidism • Hyperpituitarism • Diabetes insipidus • Hyperaldosteronism