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Chapter 65
Care of Patients with Pituitary and Adrenal Gland Problems
Marion Kreisel MSN, RNNU230 Adult Health 2Fall 2011

Disorders of the Anterior Pituitary Gland
Controls growth, metabolic activity & sexual developmentHormones Produced are on page 1426

Primary pituitary dysfunction: problem within the anterior pituitary gland itselfSecondary pituitary dysfunction: problems in the hypothalamus that change the anterior pituitary functionPituitary hypofunction: under secretion of hormonesPituitary hyperfunction: over secretion of hormones

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

Cause of Hypopituitarism
Benign or malignant tumorsAnorexia nervosaShock or severe hypotensionHead traumaBrain tumors or infectionSheehans syndrome: postpartum hemorrhage

Patient-Centered Collaborative Care
AssessmentInterventions include:Replacement of deficient hormonesAndrogen therapy (testerone) for virilization (presence of male seocndary sex characteristics) gynecomastia can occur (development of breast in male)Estrogens and progesteroneGrowth hormone

Hyperpituitarism
Hormone oversecretion occurs with pituitary tumors or hyperplasiaGenetic considerationsGigantismPituitary adenoma most common cause

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

Acromegaly
Growth hormone hypersecretion after pubertyHands and feet are large compared to the rest of the body

Patient-Centered Collaborative Care
AssessmentNonsurgical management:Drug therapyParlodel, Dostinex, Permax, Sandostatin, SomavertRadiationGamma knife procedure

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

Postoperative Care
Monitor neurologic responseAssess for postnasal dripHOB elevatedAssess nasal drainageAvoid coughing early after surgeryAssess for meningitisHormone replacementAvoid bendingAvoid strain at stoolAvoid toothbrushingNumbness in the area of the incisionDecreased sense of smellVasopressin

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 disorderPrimary: defect in the hypothalamus or pituitary glandSecondary: tumors, trauma, infection, surgeryDrug-related: certain RX drugs

Patient-Centered Collaborative Care
AssessmentMost manifestations of DI are related to dehydrationIncrease in frequency of urination and excessive thirstDehydration and hypertonic saline tests used for diagnosis of the disorderUrine diluted with a low specific gravity ( etc.

Patient-Centered Collaborative Care
AssessmentClinical manifestations

Assessment
Psychosocial assessmentLaboratory testsImaging assessment

Adrenal Gland Hyperfunction
Hypersecretion by the adrenal cortex results in Cushings syndrome/disease, hypercortisolism, or excessive androgen production

Pheochromocytoma
Hyperstimulation of the adrenal medulla caused by a tumorExcessive secretion of catecholaminesSurgical TXAvoid caffeine products

Hypercortisolism (Cushings Disease)
EtiologyIncidence/prevalencePatient-centered collaborative careAssessment:Clinical manifestationsskin changes, cardiac changes, musculoskeletal changes, glucose metabolism, immune changesPsychosocial assessmentLaboratory testsblood, salivary and urine cortisol levels, hyperglycemia & hypokalemiaImaging assessment

Hypercortisolism: Nonsurgical Management
*Patient safetyDrug therapy Nutrition therapyMonitoring

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

Hypercortisolism: Surgical Management
HypophysectomyAdrenalectomy

Community-Based Care
Home care managementHealth teachingHealth care resources

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.

Patient-Centered Collaborative Care
AssessmentMost common issueshypokalemia and elevated blood pressure

Interventions
AdrenalectomyDrug therapyGlucocorticoid replacementWhen surgery cannot be performedspironolactone therapy

Pheochromocytoma
Catecholamine-producing tumors that arise in the adrenal medullaTumors produce, store, and release epinephrine and norepinephrine

Patient-Centered Collaborative Care
AssessmentInterventions:Surgery is main treatment.After surgery, assess blood pressure.

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

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

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?

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

Question 4
Which patient with Cushings disease is at greatest risk for developing heart failure?

42-year-old patient with a serum creatinine level of 3.7 mg/dL59-year-old patient with a history of hypertension32-year-old patient with a history of hepatitis B infection60-year-old patient with pneumonia

Question 5
Which condition resulting from lithium (Lithobid) might you expect to see in the patient with bipolar disorder?

Hypothyroidism Hyperpituitarism Diabetes insipidus Hyperaldosteronism

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Answer: ARationale: These symptoms are indicative of hypercortisolism (Cushings disease). Diagnostic testing should be done to confirm diagnosis.
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Answer: ARationale: Changes in vision are frequently the first and most common symptom associated with hypopituitarism as a result of tumor growth. Changes in weight, hair growth patterns, and secondary sex characteristics should also be assessed.
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Answer: DRationale: Diabetes insipidus (DI) causes the excretion of large volumes of dilute urine, leading to polyuria and dehydration. Replacing fluid volume loss via intravascular hydration is an important nursing intervention in the care of the patient with DI. Other interventions such as close monitoring of intake and output measurements, falls prevention, and seizure precautions are related to fluid and electrolyte shifts that occur with rapid water loss.
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Answer: ARationale: The 42-year-old patient has compromised renal function evidenced by an elevated serum creatinine level. Preventing fluid overload that may quickly lead to pulmonary edema and heart failure is a primary concern for patients with Cushings disease. Any patient with Cushings disease is at risk for developing fluid overload, regardless of age. However, the older adult or one who has co-existing cardiac problems, kidney problems, pulmonary problems, or liver problems is at greater risk.
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Answer: CRationale: Treatment with lithium (Lithobid) may result in drug-induced diabetes insipidus.