pituitary and adrenal glands - chapter 62

adrenal gland hypofunction

-adrenocortical steroid production may decrease as a result of; -inadequate secretion of adrenocorticotropic hormone (ACTH) -dysfunction of they hypothalamic pituitary control mechanism direct dysfunction of adrenal gland tissue

disorders of the posterior pituitary gland

-also called neurohypophysis -deficiency or excess of the hormone vasopressin (ADH) -adh deficiency causes diabetes insipidus -adh excess causes syndrome of inappropriate antidiuretic hormone. -both types promote issues in fl and electros

assessment and hyper adrenal function

-ask about glucocorticoid therapy because it is a common cause of hypercortisolism -weight gain and increased appetite -changes in activity, sleep pattern, fatigue, muscle weakness -bone pain? osteoporosis is common with hypercortisolism -history of bruising easily -menstrual issues? did it stop?

clinical manifestations and hypo adrenal function

-assess for glucose regulation because low cortisol levels are associated with hypoglycemia -fluid depletion -hyperkalemia can cause heart issues

laboratory assessment and hypercortisolism

-blood, salivary, and urine cortisol levels -in pituitary cushing's ACTH will be elevated -salivary cortisol should be less than 2.0 ng -dexamethasone suppression testing; -cushing's disease not present when the cortisol levels are suppressed by dexamethasone

reduced aldrenal androgen levels

-decrease body, axillary, and pubic hair, especially in women -adrenals produce most of the androgens in females

interventions and hypopituitarism

-focuses on replacement of the deficient hormone -men with gonadotropin deficiency receive sex steroid replacement therapy with androgens -parenteral and transdermal best routes -therapy is done with high dose testosterone and is continued until virilization is achieved -therapy will be slightly decreased when this is achieved but they will need therapy for life -therapy for fertility needs gonadotropin releasing hormone injections in addition to testosterone therapy -androgen therapy is avoided in someone with prostate cancer -s/e include gynecomastia (breast tissue) acne, bald, prostate enlargement -women with gonadotrpin deficiency receive hormone replacements with a combo of estrogen and progesterone -risk for hypertesion and thrombosis is increased with this -inducing pregnancy = clomiphene may trigger ovulation -gonadotropin (hcg) can be used to stimulate ovulation if therapy doesn't work

assessment and pheochromocytoma

-hypertension or attacks that range from minutes to hours -headaches, palpitations, sweating, flushing, sense of doom during these attacks -pain in chest or abdomen with n/v can occur -foods high in tyramine -heat intolerance, weight loss and tremors -diagnostic test is 24 hour urine collection for fractionated metanephrine and catercholamine levels, which are elevated -clonidine suppresion test

hyperaldosteronism

-increased secretion of aldosterone with mineralocorticoid excess -primary hyper = conn's syndrome in adults usually from a adrenal adenoma -secondary hyper = high levels of angiotensin 2 stimulated by high plasma renin levels -some causes include; kidney hypoxia, diabetic nephropathy, use of diuretics -increased aldosterone levels cause fluid and electro issues causing the kidneys to retain sodium and excrete potassium and hydrogen. -hypernatremia, hypokalemia, alkalosis results

adrenal gland issues

-insufficiency of adrenocortical steroids causes problems through the loss of aldosterone and cortisol action -decreased cortisol results in hypoglycemia -glomerular filtration and gastric acid production decrease, leading to reduced urea nitrogen excretion, causing anorexia and weight loss ALDOSTERONE (mineralo) CORTISOL (cortico) ANDROGENS

diabetes insipidus

-is a water loss problem caused by either ADH deficiency or inability of the kidneys to respond to ADH -the result of DI is the excretion of large volumes of dilute urine because kidney tubules do not reabsorb water -this causes polyuria (excessive o2 loss with urine) -dehydration, disturbed fl and electros most commonly sodium levels -dehydration causes plasma osmolarity which stimulates thirst sensation

acute adrenal insufficiency or addisonian crisis

-life threatening event in which the need for cortisol and aldosterone is greater than the supply -often during a stressful event (surgery, trauma, severe infection) especially when adrenal hormone output is already reduced -sodium levels fall and potassium levels raise rapidly as well as hypotension

pituitary gland

-located at the base of the brain -divided into anterior and posterior -anterior pit. secretes hormones tropic hormones that stimulate other endocrine glands. -prolactin has a direct effect on final target tissues -posterior = vasopressin (ADH) and oxytocin are produced in the hypothalamus and delivered to the posterior pit. where they are stored -these hormones are released when needed

incidence and prevalence

-most common cause of cushing's disease is a pituitary adenoma -women more likely than men to develop this

deficiencies in; adrenocorticotropic hormone (ACTH) (corticotropin) thyroid stimulating hormone (TSH) (thyrotropin)

-most life threatening because they decrease secretion of vital hormones from adrenal and thyroid glands

assessment and diabetes insipidus

-most manifestations related to dehydration -increased urination and excessive thirst -surgery, hit your head, drug use -can experience shock from losing fluids -test is the 24 hour fluid intake and output without restrictions -output of more than 4l during this period and is greater than the volume ingested -urine is excreted diluted with a low specific gravity less than 1.005 and low osmalarity 50-200

secondary diabetes insipidus

-most often results from tumors in or near the hypothalamus or pituitary gland, head trauma, infectious process, brain surgery, or metastasis tumors

interventions and diabetes insipidus

-most preferred drug is desmopressin acetate -synthetic form of vasopressin given orally or intranasally in a spray -ADH can also be given IV or IM in severe cases -need to make sure these people stay well hydrated -measure i and o's -drink fluid equal to amount of output -drugs for DI can cause water retention and watch for fluid overload -weigh them daily for weight gain -weight gain of more than 2.2 lbs in 1 day is a sign of water toxicity and you must call 911 -water toxicity = headache and acute confusion. get help. -nasal desomopression = chest tightness a side effect.

post operative care

-neurologic responses -postnasal drip or increased swallowing are not good. CSF leak -keep head up after surgery -a light yellow color at edge of the clear drainage is a halo sign and is CSF -persistent, severe headaches = CSF in the sinus area -avoid coughing early after surgery -bend at the knees, keep them lower than your body to pick stuff up -don't strain for a bm -decreased sense of smell is expected after surgery and usually lasts for about 3-4 months meningitis; -headache, fever, and nuchal (neck) rigidity -lifelong replacement therapy if the entire gland has been removed

most common cause of hyperpituitarism

-pituitary adenoma; a benign tumor of one or more tissues within the anterior pituitary. -adenomas are classified by size, invasiveness, and hormone secreted -if it gets larger brain issues can occur -visual disturbances, headache, increased ICP -prolactin secreting tumors are the most common type of pituitary adenoma -excessive PRL inhibits secretion of gonadotropins and sex hormones in men and women, resulting in galactorrhea (breast milk production), amenorrhea, and infertility

nonsurgical management and hypercortisolism

-prevent fluid overload from becoming worst leading to PE and HF -monitor for signs of fluid overload at least every 2 hours

assessment and SIADH

-recent head trauma? -cerebrovascular disease? -tb or pulmonary disease? -cancer? -all past and current drug use -early manifestations; (r/t h2o retention) gi disturbances (appetite decrease, n/v) weight gain edema may be present -hyponatremia will be present -watch neuro function due to shifts in electros due to the excessive water -lethargy, headache, hostile, disorientation, changes in LOC

interventions and SIADH

-restrict fluid intake and promote excretion -must replace lost sodium -fluid restriction is huge because you can further dilute plasma levels -rinse mouth to prevent dry mucous membrane but you must spit it out -intake can be as low as 500-1000ml day -weigh these patients for excessive gain

nutrition therapy

-restrictions of both fluid and sodium intake to control fluid volume -2g to 4g sodium daily -weight daily for any changes -1lb = 500ml of water

growth hormone over production

-results in acromegaly (too much growth hormone) -onset is gradual with a slow progression and changes can go unnoticed for years -increased skeletal thickness, hypertrophy of the skin, enlargement of many organs like the liver and heart -some changes can be reversed after treatment, but skeletal changes are permanent -bone thinning and bone cell overgrowth occurs slowly -breakdown of cartilage and hypertrophy of ligaments, vocal cord, eustachain tubes are common -nerve entrapment and hyperglycemia are also common

interventions and pheochromocytoma

-surgery is main treatment -one or both glands removed (depending on tumor) -hypertension is the hallmark of the disease -monitor BP regularly action alert; -do not palpate abdomen of a patient with pheochromocytoma -stabilize BP before surgery with a adrenergic blocking agent like phenoxybenzamine 7-10 days before surgery -post op monitor for hypertension or hypo and hypovolemia -hemorrhage and shock is possible -monitor v/s and i and o

surgical management

-surgical removal of the pituitary gland and tumor (hypophysectomy) is the most common treatment for hyper.

surgical management

-surgical treatment of adrenocortical hypersecretion depends on the cause of the disease -adrenal hyper function from pituitary secretion of ACTH, removal of a pituitary adenoma using MIS can be used -total hypophysectomy (removal of the pituitary gland) is needed

deficiency in; gonadotropins (luteinizing hormone) (LH) follicle stimulating hormone (FSH)

-these hormones stimulate the gonads to produce sex hormone -changes sexual function in men and women -in men gonadotropin deficiency causes testicular failure with decreased testosterone production that can cause sterility -in women gonadotropin deficiency results in ovarian failure, amenorrhea, infertility

drug therapy

-tolvaptan (oral) or conivaptan (iv) -used to treat patients with hyponatremia -promote water excretion without causing na loss - tolvaptan black box warning with sodium increases as well as usage over 30 days can cause liver failure -diuretics can also manage SIADH when na levels are normal and heart failure is present -watch for sodium loss -hypertonic solutions can be used when serum sodium is low -watch for fluid overload and HF

drug therapy and hyper adrenal gland function

-use of drugs that interfere with ACTH production or adrenal hormone synthesis for temporary relief metyrapone - aminoglutethimide - ketoconazole -decrease cortisol production cyproheptadine interferes with ACTH production pasireotide -hypercorisolism from a adenoma -watch for hyperglycemia

postoperative care

-usually sent to a critical care unit -assess the patient for shock every 15 minutes -bilateral adrenalectomy = lifelong glucocorticoid and mineralcorticoid replacement starting immediately -unilateral = until the adrenal gland can perform the function by itself. can take up to 2 years

assessment and hyperpituitarism

-vary with the hormone in play -high GH levels = back pain and joint pain from bone changes -headaches or changes in vision? -excess prolactin causes sexual function difficulty. menstrual issues? libido? painful intercourse? trouble getting pregnant? men and libido and impotence -GH excess increases lip and nose sizes, prominent brow ridge, increases hand, head, foot sizes -look for help due to dramatic change in appearance. -usually only 1 hormone is produced in excess because the cell types within the pit. gland are very organized. -most common excess hormone is PRL, ACTH, and GH

adrenal gland

-vascular organs on the top of each kidney -hormones effect throughout the body adrenal cortex; -90% of adrenal gland -mineralocorticoids - help control fl and electros. aldosterone is the main mineralco. -glucocorticoids ("essential for life") -cortisol is the main gluco and affects: response to stress carbs, protein, fat metabolism emotional stability immune function na and o2 balance -small amounts of sex hormones (androgens and estrogens) -in women the adrenal gland is major source of androgens

monitoring a patient with SIADH

-watch for fluid overload -pulmonary edema -heart failure due to overload -older patient at a huge risk -cardiac, kidney, pulmonary issues -bounding pulse, neck vein distention, crackles in lungs, edema, reduce output -120 meq na and a risk for neuro issues is present -watch for muscle twitching, orientation

FOR WHICH CLIENT DOES THE NURSE QUESTION THE PRESCRIPTION FOR ANDROGEN REPLACEMENT THERAPY?

a man with a history of prostate cancer

drug therapy for other issues

acromegaly - somatostatin analogs; octreotide and lanreotide growth hormone receptor blocker; pegvisomant and octreotide

primary adrenal insufficiency

autoimmune disease tb metastatic cancer AIDs hemorrhage gram negative sepsis adrenalectomy abdominal radiation therapy drugs (mitotane) and toxins

categories of DI

nephrogenic (kidney lacks a response) drug related (lithium carbonate) primary (lack of either production or utilization of adh) secondary (tumor, surgery, trauma)

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---------------------PRACTICE QUESTIONS BEGIN----------------

RANDOM INFO (hypopituitarism section)

-LH and FSH stimulate the gonads to produce sex hormones and sexual dysfunction is present when low -GH reduction = indirectly from reduced somatomedin which affects bone and cartilage leading to osteoporosis and fractures -postpartum hemorrhage is the most common cause of pituitary infarction=sheehan's syndrome -eye issues from a tumor = first sign of a neuro problem -men with gonadotropin issues = testosterone replacement. parenteral or transdermal -therapy to become fertile = GnRH and can also stimulate ovulation -clomiphene = trigger ovulation -GH deficiency = subcutaneous injections of human GH. given at night to mimic normal GH release

operative procedure

-MIS transnasal approach is used -results in less damage to nasal structures -general anesthesia -muscle graft is taken after the gland is removed to support the area and prevent leakage of fluid -craniotomy may be needed

deficiency in; growth hormone (GH)

-changes tissue growth patterns indirectly as a result of reduced liver production of somatomedins (type of GH hormone) -these substances, especially somatomedin C triggers growth and maintenance activity in bone, cartilage, and other tissues -GH deficiency can be from decreased production, failure to produce somatomedins by the liver -in children this can make them short and general growth retardation -deficiency in adults does not affect height but increases rate of bone destructive activity (thinning bones), increased fracture risk

hyperpituitarism

-hormone over secretion that occurs with pituitary tumors or tissue hyperplasia (overgrowth) -tumors occur most often in anterior pituitary cells that produce GH, prolactin, adrenocorticotropic hormone

POSTERIOR PITUITARY (SIADH)

-schwartz bartter syndrome -can be caused by cancer therapy, SSRI, fluoroquinoline antibiotics -hyponatremia and fluid overload -free water (not salt) is retained and dependent edema is not usually present, even tough water is being retained -sodium below 115 watch CNS function -deep tendon reflexes decreased, change in LOC, lethargy, hostility, disorientation -elevated urine gravity above 1.030 -restrict fluid intake, promote excretion, replace sodium = interventions -2.2 lbs = 1000mL of water -TOLVAPTAN and CONIVAPTAN most common drugs. used with hyponatremia. promote excretion of water without the loss of sodium. TOLVAPTAN is oral and CONIVAPTAN is IV. TOLVAPTAN black box water for sodium retention. used for more than 30 days risk for liver failure and death. used only in a hospital setting to monitor sodium levels. -diuretics when sodium is near normal and heart failure is present (overload) -saline solutions rather than water solutions. (salt) -monitor these people for heart failure. bounding pulses, htn, neck distention, pulmonary edema occurs quickly and is fatal. -serum sodium below 120 = seizure risk. watch for a muscle twitch before it becomes a coma -change in LOC check on them q hour -reduce noises and stimulation

RANDOM INFO (hyperpituitarism)

-tumors = GH PRL ACTH most often produced in excess -neuro changes occur from enlarged tumor -prolactin secreting tumor = most common -prolactin = galactorrhea, amenorrhea, infertility and inhibits release of gonadotropins -GH overproduction = acromegaly, face hand feet and skin changes. skeletal thickness, hypertrophy of the skin, enlarged organs. bone thinning and bone cell overgrowth -excess ACTH = overproduction in the adrenal cortex. excess gluco, mineralocort, adrogens leading to cushing's disease and issues with fl and electro -hypothalamic problems can cause excessive releasing hormones leading to overstimulation -GH levels = back/joint pain, things are tight?, headaches or changes in vision? -PRL = sexual function difficulty. menstrual changes, fertility issues, painful sex, issues becoming pregnant. men = libido/impotence -GH increase = help my appearance is changing -suppression testing= hyperpituitarism test. high glucose levels suppress release of GH. give these people 100g of glucose followed by GH measurement. GH levels that don't fall below 5ng-which they should- is a sign of a positive test. -BROMOCRIPTINE and CABERGOLINE are the most common drugs. they stimulate dopamine receptors and inhibit release of GH and PRL BROMOCRIPTINE s/e = orthostatic hypotension, gastric irritation, n/abd cramps. take with meal or snack. treatment starts at a low dose. if you become pregnant = STOP. -radiation therapy is not immediate. several years may pass before effect can be seen. -surgical removal of the pituitary gland (hypophysectomy) most common treatment -muscle graft often from the thigh is used to support the area post surgery and prevent leakage of CSF -craniotomy = can't be reached -monitor for any neuro issues post op -postnasal drip or increased swallowing = csf leak is possible -CSF in sinus area = persistent severe headache -don't brush teeth = about 2 weeks. don't strain for a BM. don't bend at your back. mouthwash and daily flossing. a decreased sense of smell is normal for 3-4 months. -anterior portion removed = cortisol, thyroid, and gonadal hormone replacements (you took away the gland making ACTH, TSH, LSH, FSL)

random info (PHEOCHROMOCYTOMA)

-usually a single lesion tumor but can be bilateral or in the abdomen -usually benign but 10% malignant -produce store and release epinephrine. -htn is the hallmark of this. similar to high aldosterone in this way. can also present with severe headache.

preoperative care

-watch fluid and electros prior to surgery -potassium, sodium, and chloride levels -patient with hypercortisolism is at risk for infections and fractures -high calories high protein prior to surgery

The nurse is caring for a client who is prescribed desmopressin (DDAVP) nasal spray for diabetes insipidus. What is a potential side effect of this intranasal drug?

Chest tightness The client may have a sensation of chest tightness as a side effect of desmopressin. Other side effects include ulceration of mucus membranes, allergy, or lung inhalation of the spray. Anuria, drowsiness, and weight gain are signs of water intoxication in clients taking vasopressin, an exogenous form of antidiuretic hormone.

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is receiving IV hypertonic saline. What finding indicates fluid overload in the client?

Crackles in the lungs Crackles in the lungs indicate fluid overload in the client. Pulmonary edema can occur very quickly and lead to death. The nurse must monitor vital signs and assess for subtle neurological changes, like muscle twitching, every 2 hours before seizure or coma occurs. The client with fluid overload will exhibit peripheral edema and decreased urine output following fluid retention.

A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI?

Desmopressin (DDAVP) Desmopressin is the drug of choice for treatment of severe DI. It may be administered orally, nasally, or by intramuscular or intravenous routes. Dopamine hydrochloride is a naturally occurring catecholamine and inotropic vasopressor; it would not be used to treat DI. Prednisone would not be used to treat DI. Tolvaptan is a selective competitive arginine vasopressin receptor 2 antagonist and is not used with DI.

What clinical finding does the nurse expect in a client with reduced aldosterone secretion?

Hyperkalemia

A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first?

Increase fluid intake Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI. This is a serious condition that must be treated rapidly. Encouraging fluids is the initial step, provided the client is able to tolerate oral intake. Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct the dehydration that this client is experiencing. Desmopressin acetate is a synthetic form of antidiuretic hormone (ADH) that is given to reduce urine production; it improves DI and should not be withheld.

What does the nurse identify as a sign of infection for a client who underwent an adrenalectomy?

Increase of 1° F in body temperature An increase of 1° F in body temperature is significant for the client who is immunosuppressed. It indicates infection unless proved otherwise. The client's lungs are assessed every 8 hours for crackles, wheezes, or reduced breath sounds. Pulmonary hygiene must be performed for this client every 2 to 4 hours. The client's mouth must be inspected once every shift for lesions or mucosa breakdown. The immobile client is at a risk for skin breakdown, so the nurse must turn the client every hour. Crackles, wheezes, breakdown of oral mucosa, or skin breakdown are not signs of infection, but can lead to infection if adequate care is not taken.

What manifestation does the nurse expect to find in a client diagnosed with diabetes insipidus (DI)?

Increased urinary frequency The client with DI has a deficiency of antidiuretic hormone (ADH). This results in increased urinary frequency with excretion of large amounts of urine. The urine output may range from 4 to 30L/day. The client has excessive thirst, which may compensate for the urine loss. The client has an increased intake of water and other fluids, which aids in maintaining water homeostasis. The volume of urine is very large so the urine is dilute with a low specific gravity.

ADRENAL INSUFFICIENCY KEY FEATURES

NEURO; muscle weakness fatigue joint/muscle pain GI MANIFESTATIONS; anorexia n/v/abd pain constipation or diarrhea weight loss, salt craving SKIN MANIFESTATIONS; vitiligo hyperpigmentation CARDIO MANIFESTATIONS; anemia hypotension hyponatremia hyperkalemai hypercalcemia

What finding does the nurse expect to assess in a client with deficient growth hormone (GH)?

Pathologic fractures Deficiency of GH leads to decreased muscle mass and decreased bone strength. This increases the risk of pathologic fractures. Weight gain and intolerance to cold are manifestations in the client with decreased thyroid stimulating hormone (TSH). Decreased body hair is found in men with decreased luteinizing hormone.

What changes does the nurse note in a client with hypercortisolism upon physical assessment?

Presence of fat pads on the shoulders The client with hypercortisolism has fat pads on the neck, back, and shoulders due to fat redistribution. The client develops extremely thin and translucent skin following increased blood vessel fragility. Excessive cortisol secretion causes acne; coats of fine hair cover the face and the body. The client develops muscle atrophy or muscle wasting and weakness, especially at the extremities. The client also has truncal obesity following changes in fat distribution.

What skin change does the nurse expect to find in a client with hypercortisolism?

Reddish-purple striae The client with hypercortisolism has reddish-purple striae or stretch marks over the abdomen, thighs, and upper arms because of the destructive effect of cortisol on collagen. This client also has thinning "paper-like" skin, especially on the back of the hands. Excessive cortisol secretion causes acne and a fine coating of hair over the face and body. The client also has hyperpigmentation.

LAB VALUES AND ADRENAL GLAND ASSESSMENT

SODIUM; 136-145 hypo: decreased hyper: increased POTASSIUM; 3.5-5.0 hypo: increased hyper: decreased GLUCOSE; 70-110 hypo: norm to decrease hyper: norm to increase CALCIUM; 9-10.5 hypo: increased hyper: decreased CORTISOL; (serum) am: 5-23 pm: 3-13 hypo: decreased hyper: increased

The nurse is assessing the elimination patterns of a client. Which finding needs further evaluation to rule out the possibility of diabetes insipidus (DI)?

The client reports excessive thirst and increased frequency of urination. The client who reports excessive thirst and increased frequency of urination must be evaluated for DI. The client with increased urination frequency will wake up frequently at night to urinate. Normal urine is pale yellow and clear. A client with DI will record a total urine output more than the total fluid intake in 24 hours. The amount of urine may vary from 4 L to 30 L per day, often leading to dehydration. The urine is dilute and the specific gravity is less than 1.005 in a client with DI.

A client with Cushing's disease says that she has lost 1 lb. What does the nurse do next?

Weighs the client. Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment. Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Forcing fluids is not appropriate because usually excess water and sodium reabsorption cause fluid retention in the client with Cushing's disease.

How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)?

Works as an antidiuretic hormone (ADH) in the kidneys Desmopressin is a synthetic form of ADH that binds to kidney receptors and enhances reabsorption of water, thus reducing urine output. Desmopressin does not have any effect on sodium reabsorption. It may cause a slight increase or a transient decrease in blood pressure, but this does not affect urine output. Desmopressin does not increase cardiac output.

posterior pituitary gland

vasopressin (ADH) antidiuretic hormone -problems here cause fl and electro issues

psychosocial assessment and hypercortisolism

-emotional instability -mood swings, irritability, confusion, depression -crying or laughing without reason -change in mental or emotional status

reduced aldosterone secretion

-disturbances of fl and electro balance -especially potassium, sodium, o2 -potassium excretion is decreased, causing hyperkalemia -na and h2o excretion is increased, causing hyponatremia and hypovolemia -k absorption leads to hydrogen ion reabsorption, causing acidosis -aldosterone causes water and Na to stay in the body and secretion of potassium. without this the complete opposite is occurring.

POSTERIOR PITUITARY (DIABETES INSIPIDUS)

-ADH deficiency or kidneys not using it -large amounts of fluid pissed out with a very low dilution rate below 1.005. polyuria, dehydration, disturbed fl and electro occurs. also extreme thirst -DRINK AT LEAST EVERY 4 HOURS. urine output will remain high regardless of how much fl you drink. this can lead to severe dehydration. You drank 2L because you don't feel like drinking but you will pee out 4L. -most manifestations r/t dehydration -diagnostic = 24 hour fl i and o without restrictions. output higher than 4l and is greater than what was ingested. can be from 4l up to 30l a day. -desmopressin most common drug. oral or intranasally. when severe can be given IV. ulcers, chest tightness, lung inhalation of the spray can occur with intransal. use other route if this occurs or with upper resp. infection -weight gain of 2.2lbs or water toxicity (persistent headache, acute confusion) call 911.

adrenal gland hyperfunction

-can be 1 hormone or all -hypercortisolism (cushing's disease) -hyperaldosteronism (excessive mineralo.) (conns syndrome) -or excessive androgen production -hyperstimulation caused by a tumor (pheochromocytoma) results in excessive secretion of catecholamines

primary diabetes insipidus

-caused by a defect in the hypothalamus (makes adh) or posterior pituitary gland (stores adh) resulting in a lack of ADH production or release

interventions and hypo adrenal function

-promote fluid balance, monitor for deficits, and prevent poor glucose control -hyperkalemia can cause heart issues this is a priority for monitoring -assess v/s every 1 to 4 hours -weigh the patient daily, record i and o -monitor lab values -cortisol and aldosterone deficiencies are corrected by replacement therapy -hydrocortisone = glucocorticoid (cortisol) -oral cortisol replacement vary but common drug used is prednisone (prednisolone is not the same, sound alike but very potent) -2/3 in am and 1/3 giving late afternoon to mimic normal release of this hormone mineralcorticoid hormone = (aldosterone) -fludrocortisone may be needed to maintain or restore fl and electro balance

interventions and hyperpituitarism

-return hormones to desired levels -reduce headache or visual disturbances -reverse body changes if possible

imaging assessment and hypo adrenal function

-skull x ray -ct, mri -arteriography

imaging assessment and hyperpituitarism

-skull x ray for abnormalities of the sella turcica -ct scan and mri can show soft tissue issues -angiography for aneurysm

interventions and hyperaldosteronis

-surgery is the most common treatment. -one or both glands can be removed -spironolactone therapy if surgery is not an option -this is a potassium sparring diuretic and must watch for hyperkalemia and also hyponatremia -hyponatremia = dry mouth, thirst, lethargy, drowsiness

operative procedure

-unilateral adrenalectomy = one gland involved -bilateral adrenalectomy = atch producing tumors cannot be treated by other means or both adrenal glands diseased

WHICH URINE PROPERTIES INDICATE TO THE NURSE THAT THE CLIENT WITH SIADH IS RESPONDING TO INTERVENTIONS

-urine output has increased, urine specific gravity has decreased

causes of hypopituitarism

-varies in cause -benign or malignant pituitary tumors can compress and destroy tissue -malnutrition or rapid loss of body fat -shock or severe hypotension reduces blood flow to the pituitary gland (hypoxia) -head trauma -brain tumor or infection -radiation or surgery to the head and brain -AIDs -idopathic hypopituitarism (NKC)

What precautions must a client, who has had a hypophysectomy, take to prevent intracranial pressure (ICP)?

Consume high-fiber foods and drink plenty of fluids. The client who has undergone a hypophysectomy should consume high-fiber foods and drink plenty of fluids to increase peristaltic movement and reduce the risk of ICP by straining during bowel movements. The client should avoid bending from the waist to pick things up because this position increases ICP; the client can seek assistance or bend the knees and lower the body. The client must not cough, sneeze, or blow the nose; these activities increase ICP and the risk of cerebrospinal fluid leakage. Deep breathing does not affect ICP, rather it prevents pulmonary problems.

A client with acromegaly is prescribed bromocriptine mesylate (Parlodel) therapy. What does the nurse tell the client about this treatment?

The drug must be stopped during pregnancy. Bromocriptine therapy must be stopped during pregnancy to prevent adverse consequences. A client on bromocriptine therapy does not experience diarrhea; side effects of this drug include orthostatic hypotension, gastric irritation, nausea, headaches, abdominal cramps, and constipation. The drug is given with a meal or a snack to reduce some of these side effects. Treatment starts with a low dose and is gradually increased until the desired level (usually 7.5 mg/day) is reached.

syndrome of inappropriate antidiuretic hormone

-problem in which vasopressin is over secreted -a decrease in plasma osmolarity usually inhibits ADH production and secretion -in SIADH, ADH continues to be released even when plasma is hypo-osmolar -this leads to fluid disturbances -water is retained, which results in hyponatremia and fluid overload -excessive ADH sends a signal to the kidneys that water must stay in the blood. so this causes little urine with a high concentration and water stays behind in your body.

laboratory findings and hypopituitarism

-vary widely -lab assessment of some hormones involves measuring the effects of the hormones rather than measuring actual hormone levels -for example, t3 and t4, testosterone can be easily measured from the blood -changes in sella turcica (bony nest where glands rest) and skull x ray can be used

HYPERCORTISOLISM (CUSHING'S DISEASE) KEY FEATURES

general appearance; moon face buffalo hump truncal obesity weight gain cardiovascular manifestations; hypertension edema bruising petechiae musculo manifestations; muscle atrophy osteoporosis pathological fractures decreased height skin manifestations; thinning skin striae and increased pigmentation immune system manifestations; increased risk for infection decreased immune function decreased inflammatory process manifestations of an infection hidden

ANTERIOR PIT. GLAND HORMONES

growth hormone thyrotropin (thyroid stimulating hormone) corticotropin (adrenocorticotropic hormone) follicle stimulating hormone luteinizing hormone melanocyte stimulating hormone prolactin

PITUITARY HYPOFUNCTION CHART

growth hormone; -decreased bone density, fractures -decreased muscle strength -increased serum cholesterol levels gonadotropins (LH and FSH); WOMEN; -amenorrhea, anovulation, low estrogen levels, breast atrophy, loss of bone density, axillary and pubic hair decrease, libido lost MEN; -less facial hair, less ejaculate volume, reduced muscle mass, bone density lessened, decreased body hair, loss of libido, impotence thyroid stimulating hormone (thyrotropin) (TSH) -weight gain -intolerance to cold -scalp alopecia -menstrual issues -decreased libido -slowed cognition -lethargy adrenocorticotropic hormone (corticotropin) -decreased serum cortisol levels -pale, sallow complexion -malaise and lethargy -anorexia -postural hypotension -headache -hypoglycemia, hyponatremia -decreased axillary and pubic hair in women vasopressin (ADH) from the post. pit. -increased output -low urine gravity less than 1.005 -hypotension, dehydration -increased osmalarity -thirst

secondary adrenal insufficiency

pituitary tumors postpartum pituitary necrosis hypophysectomy high dose pituitary or whole brain radiation -sudden cessation of long term glucocorticoid therapy is a common cause

ANTERIOR PITUITARY HYPERFUNCTION

prolactin (PRL); -hypogonadism (loss of 2ndary sexual char.) -decreased gonadotropin levels -galactorrhea -increased body fat increased serum prolactin levels growth hormone (GH) -thick lips, coarse facial features, big head -jaw protrusion -enlarged hands and feet -joint pain, back pain -barrel shaped chest -hyperglycemia -sleep apnea -enlarged heart, lungs, liver adrenocorticotropic hormone (ACTH); -cushing's disease (adrenal) -weight gain, trunk obesity -moon face, muscle wasting -loss of bone density -hypertension, hyperglycemia -striae and acne thyrotropin (thyroid stimulating hormone) TSH -elevated plasma tsh and thyroid levels -weight loss, increased appetite -tachycardia and dysrhythmias -heat intolerance -increased GI motility -fine tremors

anterior pituitary gland:

regulates; growth metabolism sexual development

RANDOM INFO (HYPO ADRENAL GLAND)

-ACTH is related to adrenal gland function. if you don't have a good pituitary gland = adrenal gland issues. can also be issues in the adrenal gland itself or hypothalamus-pituitary dysfunc. -adrenal crisis = life threatening -decreased cortisol levels = hypoglycemia -aldosterone is a hormone that normally promotes the excretion of potassium, keep fluid and sodium normally for a BP compensation. -reduced aldosterone = hyperkalemia, hyponatremia and hypovolemia. complete opposite of what it normally does. acidosis is also an issue with hyperkalemia hydrogen ions. SALT CRAVINGS -low androgen levels = decreased body hair especially in women because it is there source of most androgen. -in addison's syndrome, potassium is rising and sodium is decreasing rapidly. severe hypotention occurs from blood volume depletion. -common cause of 2ndary adrenal insufficiency is sudden cessation of gloco therapy -lethargy, fatigue, muscle weakness often present with hypo adrenal function -salt cravings -anorexia, n/v/d and abd pain occur. weight loss -hyperpigmentation is a big sign -ACTH stimulation (provocation test) most definitive test for adrenal insufficiency. ACTH 0.25-1mg given IV. plasma cortisol should respond. with deficiency, cortisol response is absent or decreased. in secondary insufficiency, it is increased -cardiac function is a priority (hyperkalemia from low aldosterone). as well as fl and electro balance and hypoglycemia. -PREDNISONE most common cortisol replacement therapy. 2/3 in am 1/3 in pm.

pheochromocytoma

-catecholamine producing tumor that arises in the adrenal medulla -usually occur as a single lesion in 1 gland -can be bilateral or in the abdomen -usually benign -these tumors produce, store, and release epinephrine and norepinephrine. -these excess hormones stimulate adrenergic receptors and can have wide range effects on the autonomic nervous system -cause unknown but can be from; neurofibromatosis, multiple endocrine neoplasia, von hippel lindau disease, pheochromocytoma paragangliona syndrome

assessment and hypo adrenal function

-change in activity due to lethargy, fatigue and muscle weakness is common -salt cravings occur with hypofunction -GI issues like pain, n/v, abd pain -radiation to the abdomen or head -b or intracranial surgery?

assessment and hypopituitarism

-changes in appearance and target organ function occurs depending on the hormones gonadotropin (LH and FSH); -loss or change in sex characteristics -male = facial and body hair loss. impotence and lack of libido. -women = amenorrhea, dyspareunia (painful sex), infertility, decreased libido also check for dry skin, breast atrophy, axillary and pubic hair neurologic manifestations from a tumor; -first changes occur in vision -assess acuity, peripheral vision esp. for changes -headaches, diplopia (double vision), limited eye movement are common

etiology

-cushing's disease or syndrome is a group of clinical problems caused by excessive cortisol -when the anterior pituitary gland over secretes adrenocorticotropic hormone (ACTH) it causes hyperplasia of the adrenal cortex in both glands and excess of most hormones -this process is known as pituitary cushing's disease because it is caused by the pituitary -can also be caused by a problem in the adrenal cortex like a benign tumor this is called adrenal cushing's disease and usually occurs in just 1 gland -when it is caused by glucocorticoid excess from drug therapy, it is known as cushing's syndrome. see this with someone with asthma and chronic intake of steroids.

hypopituitarism

-deficiency in 1 or more anterior pituitary hormones -if only 1 hormone is affected, this is known as selective hypopituitarism -decreased production of all hormones is known as panhypopituitarism and is rare -most often 1 hormone is reduced in secretion and all other hormones reduce to a lesser degree

psych assessment and hypo adrenal function

-depends on the degree of imbalances -lethargic -depressed -confused, psychotic -assess orientation of the patient

radiation therapy

-does not have immediate effects in reducing pituitary hormone excesses, can actually take years -use of a gamma knife to have a precise method of giving radiation to reduce size

hypercortisolism (cushing's disease)

-excess secretion of cortisol from the adrenal cortex causing many issues -problem in the adrenal cortex -problem in anterior pituitary gland -problem in the hypothalamus -also can be caused by glucocorticoid therapy -this affects metabolism of all body systems - increase in body fat from slow turnover of plasma fatty acids- trunk, buffalo hip, moon face -decreased muscle mass, strength, thin skin, fragile capillaries, bone density loss from n increase in the breakdown of tissue protein -high levels of coricosteroids kill lymph and shrink organs containing lymphocytes like the spleen and lymph nodes. -wbc production decreased -protection of inflammatory and immune processes are reduced -increased androgen production causes; acne hirsutism (increased body hair) clitoral hypertrophy in women -decreasing ovary production of estrogen and progesterone -oligomenorrhea (scan or infrequent menses)

physical assessment / clinical manifestations and hyper function

-fat distribution to the neck, back and shoulders (buffalo hump) enlarged trunk with thin arms and legs. a round face (moon face) -muscle wasting and weakness -skin changes; increased blood vessel fragility and bruising easily, thin or translucent skin, wounds that don't heal -reddish purple striae (strech marks) occur on the abd, thighs, upper arms -acne and fine coating of hair occur over the face and body -cardiac changes; disturbed fl and electros can cause cardio issues -watch sodium and water musculoskeletal changes; occur as a result of nitrogen depletion and mineral loss. muscle mass decrease, arms and legs especially glucose regulation; high becuase the liver releases glucose and the insulin receptors are less sensitive, glucose does not move easily into these tissues immune changes; excess cortisol results in immunosuppresion and increased infection risk -cortisol in excess reduces lymphs and a lack of body reaction to an infection

RANDOM INFO (ADRENAL HYPERFUNCTION)

-hyper secretion of the adrenal cortex results in hypercortisolism (cushing's disease). hyperaldosteronism. and excessive androgen production. -pheochromocytoma is the result of hyper stimulation of the adrenal gland causing an excess in catecholamines (fight or flight) -hypercortisolism (cushing's disease) causes many problems. can be a problem in the adrenal gland, pituitary gland (acth) or the hypothalamus (stimulation hormones) -increase in fat in face, shoulders, buffalo hip, moon face. breakdown of proteins causing muscle loss. thin skin. bone density loss (osteoporosis) -high cortisol levels = inflammation and immune system decrease -increased androgen = acne, hirsuitism (body hair growth) clitoral hypertrophy. disrupt normal ovarian feedback mechanism, decreasing ovary production of estrogen and progesterone. oligomenorrhea results. -pituitary cushing's disease = caused by acth -adrenal cushing's disease = caused by adrenal -cushing's syndrome = drug therapy for something else (steroids for asthma) -most common cause of cushing's = pituitary adenoma -syndrome more common than disease due to the chronic use of corticosteroids for asthma, respiratory problems RA, etc. -weight gain, always hungry, fatigue, muscle weakness, bone pain or fractures as osteoporosis is common. infections and bruising easily. women stop menstruating. GI issues. SODIUM RETENTION AND HTN. -neck, back and shoulder fat "buffalo hump". enlarged trunk with thin arms and legs. round face called moon face. muscle wasting and weak. bruising easily from blood vessel fragility. thin skin. wounds not healing. reddish striae on abdomen, thigh and upper arms. acne and fine coating of hair on face and body. water and sodium is retained. hypervolemia. edema formation. blood pressure elevated. high blood glucose levels. immune and inflammatory responses decreased. high risk for infection. mood swings. irritable, confused, depression. -METYRAPONE, AMINOGLUTETHIMIDE, KETOCONAZOLE use different pathways to decrease cortisol production. -adrenalectomy is the removal of the adrenal gland and may be indicated with hypercortisolism. -gluco preparations given before surgery. adrenal crisis post surgery is possible from a sudden drop so you begin therapy right away. -after surgery assess for shock every 15 minutes from no cortisol therapy. -with bilateral surgery they need replacement therapy right after surgery. with unilateral, hormone replacement occurs until remaining gland can increase production. can take up to 2 years. -skin changes from hyper cortisol remain for weeks to months. assess the skin. osteoporosis lingers for months to years watch for fractures. use a lift sheet. GI bleeding is common with hypercortisolism. GI function takes weeks to return to normal. watch for infection from immune and inflammatory destruction.

random info (high aldosterone)

-hyperaldosteronism. primary is called conn's syndrome. -secondary is caused by high levels of angio tensin 2 stimulated by high plasma renin levels. -disturbances in fluid and electro occurs. -retain sodium and fluid while getting rid of potassium is the main issue. hypertension occurs. alkalaosis also occurs. -hypokalemia and elevated BP most common problem -surgery most common treatment -hormones given prior to treatment to prevent a crisis. -spironolactone therapy is used for someone who can't have this surgery. it is a potassium sparring diuretic.

assessment and hyperaldosteronism

-hypokalemia and elevated BP most common issue -headache, fatigue, muscle weakness, dehydration and loss of stamina can occur -polydipsia and polyuria occur less frequently -paresthesias (numb and tingling) with severe K depletion

drug related diabetes insipidus

-lithium carbonate demeclocycline -these drugs interfere with the response of the kidneys to ADH

diagnostic assessment and hypo adrenal function

-low serum cortisol -low fasting blood flucose -low sodium -elevated potassium -increased BUN levels -ACTH stimulation test most definitive test for adrenal insufficiency -ACTH 0.25 to 1mh give IV -in primary insufficiency, cortisol response is absent or very low -secondary, it is increased

drug therapy and hyperpituitarism

-may be alone or in combination with surgery and radiation -dopamine agonists; bromocriptine mesylate (parlodel) -s/e include gastric irritation, n, headache, abd cramps, constipation -take with meal or snake to reduce s/e -treatment starts at a low dose and increases -if you become pregnant, stop taking this cabergoline (dostinex) -stimulate dopamine receptors in the brain and inhibit release of GH and PRL

PATIENT AFTER A HYPOPHYSECTOMY

-monitor neuro status q hour first 24 hrs -fluid balance, especially output -encourage deep breathing -do not cough, blow nose, sneeze -dental floss and oral mouth rinses, do not brush teeth -don't bend at the waist -monitor for nasal drip

pre op care

-nasal packing will be present for 2 to 3 days and you need to breathe from your mouth -"mustache dressing" or a drip pad will be placed under the nose -do not brush teeth, blow your nose, or bend forward after surgery

corticotropin (adrenocorticotropic hormone) (ACTH) over production

-overstimulates the adrenal cortex -excessive glucocorticoids, mineralocorticoids, and androgens, which leads to development of cushing's disease and problems with fl and electro balance

preventing injury

-patient with hypercortisolism is at risk for skin breakdown, bone fractures, and GI bleeding skin injury; -continued risk post surgery from changes to skin and vessels for weeks to months. assess the skin regularly for red or broken areas pathological fractures; bone density loss and osteoporosis is possible for months to years after cortisol levels go back to normal -use a lift sheet, call for help when ambulating. GI bleeding; common with hypercortisolism -may take weeks to go back to normal -reduce irritation, protect GI mucus, decrease secretion of hydrochloric acid preventing infection; -patient with hypercortisolism (glucocorticoid) have a reduced inflammation and immune response, increasing risk for infection -protect this patient from infection -can be a lack of symptoms due to lack of inflammation -monitor daily CBC and WBC, neutrophils -watch v/s, lungs, change in temps