Ch. 62 Care of Patients with Pituitary and Adrenal Gland Problems

Sx of adrenal crisis

confusion severe hypotension hypovolemia shock metabolic acidosis (high K+) low Na+ (seizures) cardiac dsyrhtymias

Sx of hypoglycemia

cool/clammy skin, anxiety, irritable, headaches, tremos, and tachycardia

Nursing care after a hypophysectomy

-Monitor the patient's neuro status hourly for first 24 hours and then q4h -Monitor fluid balance, especially for output greater than intake -Encoruage thepatient to perfrm deep breathing exercises -Instruct patient not to cough blow nose, or sneeze -Instruct the patient to use dental flss or oral moth rinses rather than toothbrushing -Montior the nasal drip pad for the type and amount of drainge -Teach the patient methods to avoid constipation and subsent "straining" -Teach the patient self-administration of prescribed hormones

sx of cushings disease

-moon face -buffalo hump -weight gain -hyperglycemia -truncal obesity -hypertension, edema, brusing -striae, acne, scalp balding -muscle atrohpy, loss of bone density -slow healing -decreased immunity -hirsutism -bounding pulse

sx of adrenal insufficiency

-weakness and fatigue -joint/muslce pain -anorexia, N/V, abdonminal pain -weight loss -salt craving -constipation or diarrhea -hyperpigementation -hyponatremia, hyperkalemia, hypercalcemia -orthostatic hypotension

nasal packing will be present for

2-3 days post op following hypophysectomy

bromocriptine and carbegoline

inhibit the release of GH and PRL

Causes of DI

Central (failure to produce ADH in brain), Nephrogenic (insensitivity of the kidney) AKI, head injury, lithium, infection, brain surgeyr, netasitc tumors

excessive ACTH results in

Cushings disease

SIADH treatment

Fluid restriction, IV hypertonic saline, conivaptan/tolvaptan, demeclocycline use diuretics caustiolsy (may increase K+ levels)

Side effect of Androgen therapy

Gynecomastia (male breast tissue development), acne, baldness, and proste enlagement

Excessive PRL secretion

Inhibits gonadotropins resulting in galactorrhea (breast milk production), amenorrhea and infertility

low urine osmolarity

less than 100

hypophysectomy

Surgical removal of the pituitary gland and tumor

Causes of Adrenal Insufficiency

TB Autoimmune disease HIV/AIDS infection hemorrhage adrenalectomy abrupt stop of long term glucocorticoid therapy radiation therapy cancer tumors

Causes of SIADH

TBI, strokes, infection, SLE, cancer, tumors, sepsis, excess DDVP, COPD exacerbation, pneumothorax, pneumonia, carbamazepine, TCAs, opiods

Which statements made by a client who has diabetes insipidus indicate to the nurse that more teaching is needed? (Select all that apply.) a. If I gain more than 2 lbs (1 kg) in a day, I will limit my fluid intake. b. If I become more thirsty, I will take another dose of the drug. c. I will avoid aspirin and aspirin-containing substances. d. I will stop taking the drug for 24 hours before I have any dental work performed. e. I will limit my intake of salt and sodium to no more than 2 g daily. f. I will wear my medical alert bracelet at all times.

a, c, d, and e

The nurse and nursing student are caring for a client with pheochromocytoma who is admitted for surgery. Which of these statements by the student requires immediate intervention by the nurse? a. "When performing the gastrointestinal assessment, I need to palpate the client's abdomen." b. "I will review the chest x-ray results for pulmonary edema." c. "I will initiate a 24-hour urine collection now." d. "I have requested the client be placed with a roommate for distraction."

a. "When performing the gastrointestinal assessment, I need to palpate the client's abdomen."

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a serum sodium level of 105 mEq/L (105 mmol/L). Which request by the health care provider does the nurse carry out first? a. Administer infusion of 150 mL of 3% NaCl over 3 hours. b. Draw blood for hemoglobin and hematocrit (H&H). c. Insert an indwelling catheter and monitor urine output. d. Weigh the client on admission and daily thereafter.

a. Administer infusion of 150 mL of 3% NaCl over 3 hours.

A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L (130 mmol/L), K+ 6.6 mEq/L (6.6 mmol/L), and glucose 72 mg/dL (4 mmol/L). Which prescription will the nurse implement first? a. Administer insulin with dextrose in normal saline. b. Give spironolactone (Aldactone) orally. c. Initiate ulcer prophylaxis protocol with a histamine2 (H2) blocker d. Obtain arterial blood gases.

a. Administer insulin with dextrose in normal saline.

A client with iatrogenic Cushing's disease is a resident in a long-term care facility. Which nursing action included in the plan of care is most appropriate to delegate to unlicensed assistive personnel (UAP)? a. Assist with personal hygiene and skin care. b. Develop a plan of care to minimize risk for infection. c. Instruct the client on the reasons to avoid overeating. d. Monitor for signs and symptoms of fluid retention.

a. Assist with personal hygiene and skin care.

After receiving change-of-shift report about these four clients, which client does the nurse attend to first? a. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L) b. Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due c. Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L (3.4 mmol/L) d. Client with pituitary adenoma who is reporting a severe headache

a. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L)

The nurse is teaching a client about the expected outcome for treatment of syndrome of inappropriate antidiuretic hormone (SIADH). What does the nurse tell the client to look for? a. Decrease in difficulty in breathing b. Dry mucous membranes c. Increasing heart rate d. Muscle spasms

a. Decrease in difficulty in breathing

The nurse is planning to administer medications to a client with diabetes insipidus (DI) who has dry lips and mucous membranes and poor skin turgor. Which intervention will the nurse provide first? a. Encourage oral fluid intake b. Offer lip balm c. Perform a 24-hour urine test d. Withhold desmopressin acetate (DDAVP)

a. Encourage oral fluid intake

A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. The client has a prescription for Desmopressin (DDAVP). Which outcome indicates a positive response to treatment? a. Urine output of 60-80 mL/hour b. Blood glucose level of 110 mg/dL (6.1 mmol/L) c. Ability to sit quietly and read a magazine d. Potassium level within expected range

a. Urine output of 60-80 mL/hour

overproduction of GH

acromegaly large nose and forehead thickened lips, hands, and feet skeletal thickenss hypertrophy of skin enlargement of liver, heart, lungs increasing head size lower jaw protrusion joint pain hyperglycemia sleep apnea

hypotension and decreed LOC is often the first indicators of

adrenal insufficiency

When reviewing the laboratory values of a client who has chronic obstructive pulmonary disease and pneumonia, the nurse observes these findings. Which one does the nurse report to the provider immediately? a. International normalized ratio (INR) 2.1 b. Serum chloride 96 nEq/L (mmol/L) c. Serum sodium 117 mEq/L (mmol/L) d. pH 7.28

c. Serum sodium 117 mEq/L (mmol/L)

Adverse effects of bromocriptine

cardiac dysrhytmias CSF leakage coronary artery spams

The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? a. Anxiety b. Headache c. Nausea d. Weight loss

b. Headache

A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? a. Encourage the client to cough and deep-breathe. b. Instruct the client not to strain during a bowel movement. c. Instruct the client to blow the nose if there is any postnasal drip. d. Place the client in the Trendelenburg position.

b. Instruct the client not to strain during a bowel movement.

A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8°F oral. Which nursing intervention is the highest priority for this client? a. Administering furosemide (Lasix) b. Providing isotonic fluids c. Replacing potassium losses d. Restricting sodium

b. Providing isotonic fluids

The nurse is providing discharge instructions to a client receiving spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? a. "I must call the primary health care provider if I am more tired than usual." b. "I need to increase my salt intake." c. "I will eat a banana every day." d. "This drug will not control my heart rate."

c. "I will eat a banana every day."

A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? a. "Don't mind this. The disease is causing this." b. "I need to check the client's cortisol level." c. "The disease can sometimes affect emotional responses." d. "Medication is available to help with this."

c. "The disease can sometimes affect emotional responses."

The nurse is assessing a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires immediate notification to the primary health care provider? a. Dry lips and oral mucosa on examination b. Nasal drainage that tests negative for glucose c. Client report of a headache and stiff neck d. Urine specific gravity of 1.016

c. Client report of a headache and stiff neck

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH) admitted with change in mental status. To determine whether fluid restrictions have been effective, for which of these outcomes will the nurse monitor? a. Decreased hematocrit b. Decreased serum osmolality c. Increased serum sodium d. Increased urine specific gravity

c. Increased serum sodium

hypopituitarism as a result of tumor growth often first occur as

changes in vision

In the preoperative holding area, the client who is scheduled to have an adrenalectomy for hypercortisolism is prescribed to receive cortisol by intravenous infusion. What is the nurse's best action? a. Request a "time-out" to determine whether this is a valid prescription. b. Ask the client whether he or she usually takes prednisone. c. Hold the dose because the client has a high cortisol level. d. Administer the drug as prescribed.

d. Administer the drug as prescribed.

The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? a. Client who is receiving IV hydrocortisone for an Addisonian crisis b. Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer c. Client being discharged after a unilateral adrenalectomy to remove a pheochromocytoma d. Client with Cushing's syndrome who requires frequent glucose monitoring and administration of insulin

d. Client with Cushing's syndrome who requires frequent glucose monitoring and administration of insulin

When caring for a client with hypercortisolism the nurse notices that the phlebotomist, who plans to draw blood from the client, displays symptoms of a cold. What would the nurse do? a. Request another phlebotomist be sent from the laboratory. b. Monitor the client for cold-like symptoms. c. Refuse to allow the phlebotomist to enter the client's room. d. Ensure the phlebotomist wears a facemask.

d. Ensure the phlebotomist wears a facemask.

A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? a. Assess skin turgor and mucous membranes for hydration status. b. Discuss the dietary restrictions for 24-hour urine testing. c. Plan ways to control the environment that will avoid stimulating the client. d. Remind the client to not order coffee with meals

d. Remind the client to not order coffee with meals

A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? a. Document symptoms of incisional infection or meningitis. b. Give over-the-counter laxatives if the client is constipated. c. Set up medications as prescribed for the day. d. Test any nasal drainage for the presence of glucose.

d. Test any nasal drainage for the presence of glucose.

A client with Cushing's disease says that she has lost 1 pound (0.5 kg) What does the nurse do next? a. Auscultate the lungs for crackles. b. Check urine for specific gravity. c. Check the blood pressure. d. Weigh the client.

d. Weigh the client.

Sx of GH deficiency

decreased bone density patholgoical fractures decresad muscle strength increased cholesterol levels

Sx of ACTH Deficiency

decreased serum cortisol levels pale, sallow complexion maliase and lethargy anorexia postural hypotenstion headache hypoglycemia hyponatremia

low specific gravity

dilute urine (less than 1.005)

Treatment of acromegaly

dopamine agonists bromocriptine and carbegoline

DI nursing interventions

encourage patient to drink lots of fluids monitor I&Os daily weights montiro electrlyte balances and VS montior pt's heart rhythym via tele fall precautions

SIADH nursing interventions

fluid restrictions strict I&Os daily weights seizure precuations monitor electrolytes and VS assess heart rhyhtym via tele fall precautions frequently listen to lung sounds

a deficiency in gonadotropins (FSH & LH)

loss in secondary sex characteristcs and libido dyspareunia (painful intercourse) women: ovairian failure, amenorrhea, and infertility men: sterility

side effects of fludrocortisone

mineralocorticoid hormone causes hypotension and weight gain

Sx of SIADH

oliguria hyperkalemia metabolic acidosis hyponatremia (decrease in LOC, confusion, hostile, lethargy, seizures) decreased DTR hypothermia fluid overload (JVD, edmea, bouding pulse, dyspnea) lung crackles hypotension weight gain GI upset

Tolvaptan and Conivaptan

only used in hospital setting so serum sodium levels can be closely monitored for developement of hypernatremia

side effects of bromocriptine

orthostatic hypotension headaches, N/V, abnominal cramps, constipation give with meal to reduce GI upset class X (NO pregnacny)

decrease producition of all the anterior pituitary hormones

panhypopituitarism

The most common cause of hyperpitiuitarism

pituitary adenoma a begingn tumor of one or more tissues wihtin the anterior pituitary gland

Sheehan's syndrome

postpartum pituitary necrosis

deficiency of one pituitary hormone

selective hypopituitarism

Treatment of DI

synthetic ADH (DDAVP) manage electrolytes IV fluids

Sx of Diabetes Insipidus

tachycardia, weak/thready pulses decresadcongnition high urine output, dilute urine, low specific gravity increased hematocrit and hemoglobin hypernatremia hypokalemia irritable increased thirst ataxia decresad cognition poor skin turgor dry mucous membranes

Causes of hypopituitarism

tumors malnutrition or rapid weight loss severe hypotension or shock head trauma infection radiation or surgery of head/brain AIDS

Sx of hypothyroidism

weight gain intolerence to cold scalp alopecia hirsutism menstural abnormalities decreased libido slowed cognition lethargy/fatigue

Sx of Cushing's disease

weight gain truncal obesity moon face extremity muscle wasting loss of bone density striae and acne hyperglycemia hypertension buffalo hump

sx of hyperthyroidism

weight loss tachycardia and dsyrhythmias heat intoerance incrsed GI motility fine tremors elevated TSH, T3 and T4 levels