Iggy Chapter 62: Care of Patients With Pituitary and Adrenal Gland Problems

glucocorticoids

A common cause of secondary adrenal insufficiency is the sudden cessation of long-term glucocorticoid therapy. This therapy suppresses production of _______ through negative feedback by causing atrophy of the adrenal cortex.

Hemoconcentration

A condition in which the concentration of blood cells is increased in proportion to the plasma

Smell

A decreased sense of _____ is expected after hypophysectomy and usually lasts 3 to 4 months.

pasireotide

A drug to manage hypercortisolism resulting from a pituitary adenoma is _____ (Signifor). This subcutaneous drug binds to somatostatin receptors on the adenoma and inhibits tumor production of corticotropin. Lower levels of corticotropin lead to lower levels of cortisol production in the adrenal glands

2

A normal salivary cortisol level is lower than ____ ng/mL. Higher levels indicate hypercortisolism.

Porphyria

A sunlight sensitivity disorder which causes its victims to be allergic to UV rays

2.2, 1000

A weight gain of _____ lb (1 kg) or more per day or a gradual increase over several days is cause for concern. A _____-lb (1-kg) weight increase is equal to a ______-mL fluid retention (1 kg = 1 L)

Neurogenic, nephrogenic, drug

ADH deficiency is classified as _____ (primary or secondary), ________, or ______-related, depending on whether the problem is caused by insufficient production of ADH or an inability of the kidney to respond to the presence of ADH.

Increased, decreased, increased, decreased

Additional laboratory findings that accompany hypercortisolism include: • _______ blood glucose level • ________ lymphocyte count • _________ sodium level • _______ serum calcium level

Muscle weakness, fatigue, joint pain

Adrenal insufficiency Neuromuscular symptoms

Anemia, hypotension, hypoglycemia hyponatremia, hyperkalemia, hypercalcemia

Adrenal insufficiency cardio symptoms

Vitiligo, hyperpigmentation

Adrenal insufficiency skin symptoms

Cortisol, pale, lethargy, anorexia, postural hypotension, hypo, hypo, decreased

Adrenocorticotropic hormone (ACTH) DEFICIENCY signs and symptoms Decreased serum _____ levels _____, sallow complexion Malaise and _____ _______ _______ ______ Headache ______-glycemia _____-natremia ________ axillary and pubic hair (women)

15

After an adrenalectomy, the patient is monitored in an ICU. Immediately after surgery, assess the patient every ___ minutes for shock (e.g., hypotension; a rapid, weak pulse; and a decreasing urine output) resulting from insufficient glucocorticoid replacement.

Somatostatin analogs

Agents to treat GH excess (acromegaly) also include _________ ______, especially _______ (Sandostatin) and ________ (Somuline)

Cortisol, primary, secondary

An ACTH stimulation (provocation) test is the most definitive test for adrenal insufficiency. ACTH 0.25 to 1 mg is given IV, and plasma ______ levels are obtained at 30-minute and 1-hour intervals. In _______ insufficiency, the cortisol response is absent or very decreased. In _________ insufficiency, it is increased. When acute adrenal insufficiency is suspected, treatment is started without stimulation testing

ACTH stimulation (provocation)

An ______ _______ test is the most definitive test for adrenal insufficiency.

Adrenal crisis

An acute, life-threatening state of profound adrenocortical insufficiency requiring immediate medical management. It is characterized by glucocorticoid deficiency, a drop in extracellular fluid volume, hyponatremia, and hyperkalemia.

selective hypopituitarism

An adult with hypopituitarism usually has a deficiency of one pituitary hormone, a condition known as _______ _______

prostate

Androgen therapy is avoided in men with _____ cancer to prevent enhancing tumor cell growth.

Muscle atrophy, osteoporosis, pathologic fractures, decrease height, aseptic necRosis of femur head, slow/poor bone healing

MS symptoms of Cushing's

osteoporosis, bruising

Ask about bone pain or a history of fractures, because _________ is common in hypercortisolism. Ask about a history of frequent infections and easy ______. Women often stop menstruating.

Head, TB, cancer

Ask the patient about his or her medical history, which may reveal conditions that can cause SIADH. Information about these conditions should be obtained: • Recent _____ trauma • Cerebrovascular disease • _____ or other pulmonary disease • _______ • All past and current drug use

meningitis

Assess for indications of infection, especially ________, such as headache, fever, and nuchal (neck) rigidity. The surgeon may prescribe antibiotics, analgesics, and antipyretics.

Lung, GU, thymoma, lymphoma

Malignant conditions causing SIADH: • Small cell _____ cancer • Pancreatic, duodenal, and ____ carcinomas • _______ • Hodgkin's & Non-Hodgkin's ______

Community

Management of patients with chronic DI occurs in the ________ unless acute problems develop. Also, whenever patients are in an acute care setting for other health problems, care must include continuing DI management.

hyponatremia

In SIADH, ADH continues to be released even when plasma is hypo-osmolar, leading to disturbances of FLUID AND ELECTROLYTE BALANCE. Water is retained, which results in dilutional _________ (a decreased serum sodium level) and fluid overload. The increase in blood volume increases the kidney filtration and inhibits the release of renin and aldosterone, which increase urine sodium loss and lead to greater ___________.

GH

In adults _____ deficiency alters CELLULAR REGULATION by increasing the rate of bone destructive activity, leading to thinner bones (osteoporosis) and an increased risk for fractures.

gonadotropin

In men, _______ deficiency results in testicular failure with decreased testosterone production that may cause sterility. In women, __________ deficiency results in ovarian failure, amenorrhea, and infertility.

2, 3, mouth, mustache, ICP

Before the hypophysectomy, explain that nasal packing will be present for ___ to ___ days after surgery. The patient must breath through ______ and a "_______" dressing (drip pad) will be placed under the nose. Instruct the patient not to brush teeth, cough, sneeze, blow the nose, or bend forward after surgery. These activities can increase ______ and delay healing.

Strokes, porphyria, lupus

CNS Disorders causing SIADH: • Trauma • Infection • Tumors (primary or metastatic) • _______ • ________ • Systemic _______ erythematosus

Hypertension, frequent dependent edema, bruising, petechiae

Cardio symptoms of cushing's

Tumor, malnutrition, rapid weight loss, shock, sever hypotension, head trauma, infection, radiation, head/brain surgery, and AIDS

Causes of hypopituitarism:

Somatostatin anaglog, pegvisomant

Combination therapy with monthly injections of a _________ ________ and weekly injections of _________ has provided good control of acromegaly.

Morning, Snacks, Stress

Cortisol Replacement Therapy • Take your medication in divided doses, as prescribed (e.g., the first dose in the _______ and the second dose between 4 PM and 6 PM). • Take your medication with meals or ______. • Weigh yourself daily and keep a record to show your primary health care provider. • Increase your dosage as directed by your primary health care provider for increased physical ______ or severe emotional _______ • Never skip a dose of medication. If you have persistent vomiting or severe diarrhea and cannot take your medication by mouth for 24 to 36 hours, call your physician. If you cannot reach your primary health care provider, go to the nearest emergency department. You may need an injection to take the place of your usual oral medication. • Always wear your medical alert bracelet or necklace. • Make regular visits for health care follow-up. • Learn how to give yourself an intramuscular injection of hydrocortisone.

Meal, snack

Cortisone - Instruct the patient to take the drug with _____ or a ______ to avoid gastric irritation.

Hypercortisolism

Cushing's syndrome

Elevated, pigmentation

In patients with primary insufficiency (problem with adrenal gland function), plasma ACTH and melanocyte-stimulating hormone (MSH) levels are ________ in response to the adrenal-hypothalamic-pituitary feedback system. Elevated MSH levels result in areas of increased ________

Decreased

In primary autoimmune disease, patchy areas of decreased pigmentation may occur because of destruction of skin melanocytes. Body hair may also be ________

ACTH, TSH

Deficiencies of _______ or _____ are the most life threatening because they cause a decrease in the secretion of vital hormones from the adrenal and thyroid glands

Thirst

Dehydration from massive water loss increases plasma osmolarity and serum sodium levels, which stimulate the sensation of ______. ______ promotes increased fluid intake and aids in maintaining hydration.

Posterior

Diabetes insipidus (DI) is a disorder of the __________ pituitary gland in which water loss is caused by either an antidiuretic hormone (ADH) deficiency or an inability of the kidneys to respond to ADH.

Increased urine output, dilute, low spg

DI Kidney/urinary symptoms

Decreased cognition, ataxia, increased thirst, irritability

DI Neurological Symptoms

Hypotension, tachycardia, weak peripheral pulses, hemoconcentration

DI cardiovascular symptoms

Poor turgor, dry mucous membranes

DI skin symptoms

Hypo

Decreased cortisol levels result in ______glycemia.

BUN

Decreased glomerular filtration leads to excessive _____ levels, which cause anorexia and weight loss.

Abdomen

Do not palpate the _______ of a patient with a pheochromocytoma , because this action could stimulate a sudden release of catecholamines and trigger severe hypertension.

Hot

Dosage adjustment may be needed, especially in _____ weather when more sodium is lost because of excessive perspiration. Salt restriction or diuretic therapy should not be started without considering whether it might lead to an adrenal crisis.

Tolvaptan (Oral), conivaptan (IV)

Drug therapy with vasopressin receptor antagonists (vaptans), such as _______ (Samsca) or _________ (Vaprisol), is used to treat SIADH when hyponatremia is present in hospitalized patients. These drugs promote water excretion without causing sodium loss.

Lithium carbonate, demeclocycline

Drug-related diabetes insipidus is usually caused by _______ ______ (Eskalith, Lithobid, Carbolith ) and _________ (Declomycin). These drugs can interfere with the response of the kidneys to ADH.

Phenytoin (Dilantin)

Drug: Increase effects of cimetidine, isoniazid, chloramphenicol; decrease effects with folic acid, calcium, antacids, sucralfate, vinblastine, cisplatin. Decrease effects of anticoagulants, oral contraceptives, antihistamines, corticosteroids, theophylline, cyclosporin, quinidine, dopamine, rifampin. Food: Decreased effects of folic acid, calcium, and vitamin D

ADH, opioids, tricyclic antidepressants, anesthetics, antibiotics

Drugs causing SIADH: • Exogenous _______ • Chlorpropamide • Vincristine • Cyclophosphamide • Carbamazepine • ________ • ________ ____________ • General _________ • Fluoroquinolone __________

pheochromocytoma

Drugs such as tricyclic antidepressants, droperidol, glucagon, metoclopramide, phenothiazines, and naloxone can induce a hypertensive crisis in the patient with _______

spironolactone

Drugs used to increase potassium levels include ________ (Aldactone, Spirono, Sincomen ), a potassium-sparing diuretic and aldosterone antagonist. Potassium supplements may be prescribed to increase potassium levels before surgery. The patient may also benefit from a low-sodium diet before surgery.

Hormone replacement, hyperkalemia management, and hypoglycemia Management

Emergency Care of the Patient With Acute Adrenal Insufficiency includes....

NOT

In secondary adrenal insufficiency (problem in the hypothalamus or pituitary gland leading to decreased ACTH and MSH levels), skin pigmentation is ______ changed.

Hyperplasia

Endogenous Secretion (Cushing's Disease) • Bilateral adrenal ________* • Pituitary adenoma increasing the production of ACTH (pituitary Cushing's disease) • Malignancies: carcinomas of the lung, GI tract, pancreas • Adrenal adenomas or carcinomas

4

Ensure that no patient suspected of having DI is deprived of fluids for more than ____ hours because he or she cannot reduce urine output and severe dehydration can result.

Cushing's disease

Excess ACTH overstimulates the adrenal cortex. The result is excessive production of glucocorticoids, mineralocorticoids, and androgens, which leads to the development of _______ ________

Gonadotropins (Luteinizing Hormone [LH], Follicle-Stimulating Hormone [FSH])

Excess _____ results in Men: • Elevated LH and FSH levels • Hypogonadism or hypergonadism Women: • Normal LH and FSH levels

Thyrotropin (thyroid releasing hormone (TRH))

Excess ______ results in • Elevated plasma TSH and thyroid hormone levels • Weight loss • Tachycardia and dysrhythmias • Heat intolerance • Increased GI motility • Fine tremors

GH (acromegaly)

Excess ______ results in • Thickened lips • Coarse facial features • Increasing head size • Lower jaw protrusion • Enlarged hands and feet • Joint pain • Barrel-shaped chest • Hyperglycemia • Sleep apnea • Enlarged heart, lungs, and liver

ACTH (Cushing's Disease)

Excess _______ results in • Elevated plasma cortisol levels • Weight gain • Truncal obesity • "Moon face" • Extremity muscle wasting • Loss of bone density • Hypertension • Hyperglycemia • Striae and acne

Prolactin

Excess ________ results in • Hypogonadism (loss of secondary sexual characteristics) • Decreased gonadotropin levels • Galactorrhea • Increased body fat • Increased serum prolactin levels

glucocorticoids

Exogenous Administration (Cushing's Syndrome) • Therapeutic use of ACTH or _________—most commonly for treatment of: • Asthma • Autoimmune disorders • Organ transplantation • Cancer chemotherapy • Allergic responses • Chronic fibrosis

Hypertension, sodium

Fludrocortisone (Florinef) Monitor the patient's blood pressure to assess for the potential side effect of __________. Instruct the patient to report weight gain or edema because sodium intake may need to be __________.

1, 500

Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload.Each __ lb (about _____ g) of weight gained (after the first half pound) equates to 500 mL of retained water.

tyramine

Foods or beverages high in _______ (e.g., aged cheese, red wine) also induce hypertension

virilization

For men who have gonadotropin deficiency, therapy begins with high-dose testosterone and is continued until _______ (presence of male secondary sex characteristics) is achieved, with responses that include increases in penis size, libido, muscle mass, bone size, and bone strength.

demeclocycline

For milder SIADH, ___________ (Declomycin), an oral antibiotic, may help reach FLUID AND ELECTROLYTE BALANCE, although the drug is not approved for this problem.

2, 4

For more pronounced fluid overload, the patient may be restricted to anywhere from __ g/day to ___ g/day of sodium. When sodium restriction is ongoing, teach the patient and family how to check food labels for sodium content and how to keep a daily record of sodium ingested.

renin

In secondary hyperaldosteronism, excessive secretion of aldosterone is caused by the high levels of angiotensin II that are stimulated by high plasma _____ levels. Some causes include kidney hypoxia, diabetic nephropathy, and excessive use of some diuretics.

cyproheptadine, Mitotane, mifepristone

For patients with hypercortisolism resulting from increased ACTH production, _________ (Periactin) may be used because it interferes with ACTH production. ________ (Lysodren) is an adrenal cytotoxic agent used for inoperable tumors causing hypercortisolism. For adults with increased ACTH production who have type 2 diabetes and who do not respond to other drug therapies, another drug is _________ (Korlym), which is a synthetic steroid that blocks glucocorticoid receptors.

dehydration

For the hospitalized patient with DI, nursing management focuses on early detection of _________ and maintaining adequate hydration. Interventions include accurately measuring fluid intake and output, checking urine specific gravity, and recording the patient's weight daily

Pegvisomant (Somavert)

GH receptor blocker medication

Bleeding

GI ____________ is common with hypercortisolism. Cortisol (1) inhibits production of the thick, gel-like mucus that protects the stomach lining, (2) decreases blood flow to the area, and (3) triggers the release of excess hydrochloric acid.

Reassure

Galactorrhea (fluid leakage from the breast), gynecomastia(breast enlargement in men), and reduced sexual functioning can disturb self-image and personal identity. _________ the patient that treatment may reverse some of these problems.

Moon face, buffalo hump, truncal obesity, weight gain

General appearance of Cushing's syndrome

gradually

Glucocorticoid drugs must be withdrawn ________ to allow for pituitary production of ACTH and activation of adrenal cells to produce cortisol.

Facial hair, ejaculate volume, muscle, bone, hair, libido, impotence

Gonadotropins (luteinizing hormone [LH], follicle-stimulating hormone [FSH]) DEFICIENCY signs and symptoms Men: • Decreased ______ ______ • Decreased ______ _______ • Reduced _______ mass • Loss of _______ density • Decreased body ______ • Decreased _____ • ________

amenorrhea, anovulation, low, atrophy, bone, hair, libido

Gonadotropins (luteinizing hormone [LH], follicle-stimulating hormone [FSH]) DEFICIENCY signs and symptoms Women: • ________ • __________ • _____ estrogen levels • Breast ______ • Loss of ______ density • Decreased axillary and pubic ___ • Decreased ____

Bone, fractures, strength, cholesterol

Growth hormone (GH) DEFICIENCY signs and symptoms: Decreased ______ density Pathologic ________ Decreased muscle _______ Increased serum ________ levels

Somatomedins

Growth hormone (GH) deficiency changes tissue growth patterns by reducing liver production of ___________. These substances, especially _______ C, trigger growth and maintain bone, cartilage, and other tissues throughout life.

IMMUNITY

High levels of corticosteroids reduce lymphocyte production and shrink organs containing lymphocytes, such as the spleen and the lymph nodes. White blood cell cytokine production is decreased. These changes reduce _______ and increase the risk for infection.

NS, D5W, hydrocortisone sodium, dexamethasone, hydrocortisone sodium, hydrocortisone, H2 histamine blocker

Hormone replacement for patient with Acute Adrenal Insufficiency: • Start rapid infusion of _______ or _____ • Initial dose of _______ ________ (Solu-Cortef) is 100 to 300 mg or ___________ 4 to 12 mg as an IV bolus. • Administer additional 100 mg of ______ _________ by continuous IV infusion over the next 8 hours. • Give _________ 50 mg IM concomitantly with hydration every 12 hours. • Initiate an ___ ________ ______ (e.g., ranitidine) IV for ulcer prevention.

Weight gain, round

Hydrocortisone (Cortef, Hycort) Instruct the patient to report the following signs or symptoms of excessive drug therapy, which indicate Cushing's syndrome and a possible need for a dosage adjustment: • Rapid _______ _______ • ________ face • Fluid retention

Insulin, kayexalate, loop, thiazide, ECG

Hyperkalemia management for patient with Acute Adrenal Insufficiency: • Administer _________ (20 to 50 units) with dextrose (20 to 50 mg) in normal saline to shift potassium into cells. • Administer potassium binding and excreting resin (e.g., ________). • Give _____ or _______ diuretics. • Avoid potassium-sparing diuretics, as prescribed. • Initiate potassium restriction. • Monitor intake and output. • Monitor heart rate, rhythm, and ____ for signs and symptoms of hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole).

Decreased, increased, decreased, increased, increased, increased, decreased

Hypofunction of the adrenal gland: sodium potassium glucose calcium bicarbonate BUN cortisol

Glucose, glucagon, hourly

Hypoglycemia management for patient with Acute Adrenal Insufficiency: • Administer IV _____ as prescribed. • Administer _______ as needed and prescribed. • Maintain IV access. • Monitor blood glucose level ______.

hyperaldosteronism

Hypokalemia and elevated blood pressure are the most common problems that patients with _______ develop.

Cortisol, thyroid, gonadal, hyperpituitarism

If the anterior portion of the pituitary gland is removed, instruct the patient in ______, ______, and _______ hormone replacement. Teach the patient to report the return of any symptoms of ________ immediately to the primary health care provider.

2.2

If weight gain of more than ______ lb (1 kg) along with other signs of water toxicity occur (e.g., persistent headache, acute confusion, nausea, vomiting), instruct the patient or family that the patient must go to the emergency department or call 911. Instruct him or her to wear a medical alert bracelet identifying the disorder and drugs.

Increased risk for infection, reduced immunity, decreased inflammatory response, infection S&S masked

Immune symptoms of Cushing's

hirsutism, Oligomenorrhea

In Cushing's, increased androgen production also occurs and causes acne, ________ (increased body hair growth), and occasionally clitoral hypertrophy. Increased androgens disrupt the normal ovarian hormone feedback mechanism, decreasing the ovary's production of estrogens and progesterone. _________ (scant or infrequent menses) occurs as a result.

500, 1000, saline

In some cases, with SIADH fluid intake may be kept as low as ____ to ______ mL/24 hr. Dilute tube feedings with ______ rather than water and use ______ to irrigate GI tubes. Mix drugs to be given by GI tube with _______.

D

In the preoperative holding area, the client who is scheduled to have an adrenalectomy for hypercortisolism is prescribed to receive cortisol by IV 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.

2

In unilateral adrenalectomy, hormone replacement continues until the remaining adrenal gland increases hormone production. This therapy may be needed for up to ___ years after surgery.

androgen

In women, look for the presence of hirsutism, clitoral hypertrophy, and male pattern balding related to _______ excess.

Salt

Include questions about _____ intake, because ____ craving often occurs with adrenal hypofunction.

Hypernatremia, hypokalemia, metabolic alkalosis

Increased aldosterone levels cause disturbances of FLUID AND ELECTROLYTE BALANCE, which then trigger the kidney tubules to retain sodium and excrete potassium and hydrogen ions. ______, _______, and ______ ______ result. Sodium retention increases blood volume, which raises blood pressure, increasing the risk for strokes, heart attacks, and kidney damage.

NSAIDs

Instruct the patient to reduce alcohol or caffeine consumption, smoking, and fasting because these actions cause gastric irritation. _______ and drugs that contain aspirin or other salicylates can cause gastritis and intensify GI bleeding. These should be avoided or limited.

Aldosterone, cortisol

Insufficiency of adrenocortical steroids causes problems through the loss of _________ and ________ action.

polyurea, polydipsia

Key symptoms of DI

Easily

Laboratory findings vary widely. Some pituitary hormone levels may be measured directly. For example, blood levels of triiodothyronine (T3) and thyroxine (T4) from the thyroid, testosterone and estradiol from the gonads, and prolactin levels are measured ________

Hair

Low adrenal androgen levels decrease the body, axillary, and pubic _____, especially in women, because the adrenals produce most of the androgens in females. The severity of symptoms is related to the degree of hormone deficiency.

Androgens

Men who have gonadotropin deficiency receive sex steroid replacement therapy with ________ (testosterone).

calcium

Milk, cheese, yogurt, and green leafy and root vegetables add ______ to promote bone density.

bedrest

Most CSF leaks resolve with _______, and surgical intervention is rarely needed.

Desmopressin acetate (DDAVP)

Most preferred medication for DI

nitrogen

Musculoskeletal changes occur in Cushing's as a result of ______ depletion and mineral loss.

X, males, autosomal

Nephrogenic diabetes insipidus can be a genetic disorder in which the ADH receptor has a defect that prevents kidney tubules from interacting with ADH. This problem is most commonly inherited as an ___-linked recessive disorder in which the AVPR2 gene coding for the ADH receptor is mutated and only ______ are affected. There is also an ________ form of the disorder in which the AQP2 gene is mutated and both males and females are affected.

Vision

Neurologic symptoms of hypOpituitarism as a result of tumor growth often first occur as changes in _______.

hypoglycemia

Nursing interventions for addison's disease focus on promoting fluid balance, monitoring for fluid deficit, and preventing _______ Because hyperkalemia can cause dysrhythmias with an irregular heart rate and result in cardiac arrest, assessing cardiac function is a nursing priority

Fluid, sodium

Nutrition therapy for the patient with hypercortisolism may involve restrictions of both ______ and ______ intake to control fluid volume.

hat, glove, ring, shoe vision

Obtain the patient's age, gender, and family history. Ask about any change in _____, _____, ______, or ______ size and the presence of fatigue. The patient with high GH levels may have backache and joint pain from bone changes. Ask specifically about headaches and changes in v_____

MEN1

One cause of hyperpituitarism is multiple endocrine neoplasia, type 1 (MEN1), in which there is inactivation of the suppressor gene _______... MEN1 has an autosomal-dominant inheritance pattern and may result in a benign tumor of the pituitary, parathyroid glands, or pancreas. In the pituitary, this problem causes excessive production of growth hormone and acromegaly.

prednisone

Oral cortisol replacement regimens and dosages vary. The most common drug used for this purpose is ________. Generally, divided doses are given, with two thirds given on arising in the morning and one third at 6:00 PM to mimic the normal release of this hormone.

Skeletal

Other acromegaly changes include increased skeletal thickness, hypertrophy of the skin, and enlargement of many organs such as the liver and heart. Some changes may be reversible after treatment, but ________ changes are permanent.

acromegaly

Overproduction of GH in adults results in ________ (Fig. 62-1). The onset may be gradual with slow progression, and changes may remain unnoticed for years before diagnosis of the disorder. Early detection and treatment are essential to prevent irreversible enlargement of the face, hands, and feet.

Lifelong

Patients with hypopituitarism often require _____ hormone replacement therapy (HRT). Such patients can be found in the community and in any care setting. It is important that HRT continues when they are admitted to an acute care setting for any reason.

Epi and NE

Phenochromocytoma produce, store, and release ______ and ______ This stimulate adrenergic receptors and can have wide-ranging adverse effects mimicking the action of the sympathetic nervous system.

elevated, low

Plasma ACTH levels vary, depending on the cause of the problem. In pituitary Cushing's disease, ACTH levels are _________. In adrenal Cushing's disease or when Cushing's syndrome results from chronic steroid use, ACTH levels are ______.

illness

Prednisone (Winpred)Instruct the patient to report _______ because the usual daily dosage may not be adequate during periods of illness or severe stress.

prednisolone

Prednisone and ______ are sound-alike drugs, and care is needed not to confuse them. Although they are both corticosteroids, they are not interchangeable because _________ is several times more potent than prednisone and dosages are not the same.

autoimmune disease, TB, cancer, AIDS, hemorrhage, garm-negative sepsis, adrenalectomy, Abdominal radiation therapy, drugs

Primary causes of Addison's disease (Adrenal Insufficiency)

Adrenal

Primary hyperaldosteronism (Conn's syndrome)diagnosed in adults results from excessive secretion of aldosterone from one or both ______ glands, usually caused by an adrenal adenoma.

Pneumonia, TB, chronic, positive-pressure ventilation

Pulmonary Disorders causing SIADH: • Viral and bacterial ______ • Lung abscesses • Active ________ • Pneumothorax • _______ lung diseases • Mycoses • ______-______ _______

hyperkalimia, hyponatremia, acidosis

Reduced aldosterone secretion causes disturbances of FLUID AND ELECTROLYTE BALANCE. Potassium excretion is decreased, causing __________. Sodium and water excretion are increased, causing __________ and hypovolemia. Potassium retention also promotes reabsorption of hydrogen ions, which can lead to _________.

late-night

Salivary cortisol levels may be used to detect hypercortisolism because these levels accurately reflect blood levels, especially ____-____ specimens

Cessation of long term corticosterioid drug therapy, pituitary tumors, PP pituitary necrosis, hypophysectomy, high dose pituitary radiation

Secondary Causes of Addisons disease (Adrenal Insufficiency)

gynecomastia

Side effects of Androgen therapy include _________ (male breast tissue development), acne, baldness, and prostate enlargement.

hypotension, constipation, meal, snack

Side effects of bromocriptine include orthostatic (postural) _______, headaches, nausea, abdominal cramps, and ________. Give bromocriptine with a _____ or a _____ to reduce GI side effects. Treatment starts with a low dose and is gradually increased until the desired level is reached. If pregnancy occurs, the drug is stopped immediately.

Thinning, Bruising, striae and increased pigementation, excess hair, acne

Skin symptoms of Cushing's

hyperpituitarism, GH

Suppression testing can help diagnose ___________. High blood glucose levels usually suppress the release of ______. Giving 100 g of oral glucose or 0.5 g/kg of body weight is followed by serial _____ level measurements. _____ levels that do not fall below 5 ng/mL (mcg/L) indicate a positive (abnormal) result.

GH excess

Symptoms of ____ _______ are increases in lip and nose sizes, a prominent brow ridge, and increases in head, hand, and foot sizes. The patient often seeks health care because of these dramatic changes in appearance.

daily

Teach all patients taking these drugs to weigh themselves ______ to identify weight gain. Stress the importance of using the same scale and weighing at the same time of day while wearing a similar amount of clothing.

chest pain, dizziness, watery nasal discharge

Teach patients taking bromocriptine to seek medical care immediately if _____ ______, ______, or _____ _____ _____ occurs because of the possibility of serious side effects, including cardiac dysrhythmias, coronary artery spasms, and cerebrospinal fluid leakage.

swallowing

Teach the patient to report any postnasal drip or increased _______, which may indicate leakage of CSF. Keep the head of the bed elevated after surgery. Assess nasal drainage for quantity, quality, and the presence of glucose (which indicates that the fluid is CSF).

4, 4, 30

The 24-hour fluid intake and output is measured without restricting food or fluid intake. DI is considered if urine output is more than ____ L during this period and is greater than the volume ingested. The amount of urine excreted in 24 hours by patients with DI may vary from ____ to _____ L/day

Skin breakdown

The patient with fluid volume excess and dependent edema is at risk for ____ _______. Use a pressure-reducing or pressure-relieving overlay on the mattress. Assess skin pressure areas, especially the coccyx, elbows, hips, and heels, daily for redness or open areas.

Hourly, 4, output, input, cough, toothbrushing, bend, drainage, constipation

The Patient After Hypophysectomy • Monitor the patient's neurologic status _______ for the first 24 hours and then every ____ hours. • Monitor fluid balance, especially for ______ greater than ________. • Encourage the patient to perform deep-breathing exercises. • Instruct the patient not to _______, blow the nose, or sneeze. • Instruct the patient to use dental floss and oral mouth rinses rather than ___________ until the surgeon gives permission (TWO WEEKS) • Instruct the patient to avoid _________ at the waist to prevent increasing intracranial pressure. • Monitor the nasal drip pad for the type and amount of __________. • Teach the patient methods to avoid __________-_ and subsequent "straining." • Teach the patient self-administration of the prescribed hormones.

syndrome of inappropriate antidiuretic hormone (SIADH)

The ______ ___ ______ ______ _______ or Schwartz-Bartter syndrome is a problem in which vasopressin (antidiuretic hormone [ADH]) is secreted even when plasma osmolarity is low or normal. A decrease in plasma osmolarity normally inhibits ADH production and secretion.

parenteral

The ________ form of desmopressin (DDAVP) is 10 times stronger than the oral form, and the dosage must be reduced.

Mood, Forgetful

With Addison's disease, assess the patient's orientation to person, place, and time. Families may report that the patient has wide ______ swings and is _______.

2, 4, hour

The frequency of neurologic checks depends on the patient's status. For the patient being treated for SIADH who is hyponatremic but alert, awake, and oriented, checks every ___ to ____ hours may be sufficient. For the patient who has had a change in level of consciousness, perform neurologic checks at least every ______ or as prescribed. Inspect the environment every shift, making sure that basic safety measures, such as side rails being securely in place, are observed.

adenoma

The most common cause of hyperpituitarism is a pituitary ________—a benign tumor of one or more tissues within the anterior pituitary

elevated

The most common diagnostic test is blood and 24-hour urine collection for fractionated metanephrine and catecholamine levels, all of which are ________ in the presence of a pheochromocytoma

Parenteral, transdermal

The most effective routes of androgen replacement are _____ and _______

Drug

The patient most at risk for acute adrenal insufficiency is the one who has Cushing's syndrome as a result of glucocorticoid ____ therapy.

phenoxybenzamine

The patient's blood pressure is stabilized with adrenergic blocking agents such as _______ (Dibenzyline) starting 7 to 10 days before surgery because of the increased risk for severe hypertension during surgery. Drug dosages are adjusted until blood pressure is controlled and hypertensive attacks do not occur. The blood volume expands, and blood pressure in the supine position returns to normal.

Enlarges

The pituitary gland normally _____ during pregnancy; and, when hypotension during delivery results from hemorrhage, ischemia and necrosis of the gland occur.

truncal obesity

The presence of excess glucocorticoids, regardless of the cause, affects metabolism and all body systems. An increase in total body fat results from slow turnover of plasma fatty acids. This fat is redistributed, producing _____ ______, "buffalo hump," and "moon face"

Fluid, injury, infection, insufficiency

The priority collaborative problems for patients with Cushing's disease or Cushing's syndrome are: 1. _______ overload due to hormone-induced water and sodium retention 2. Potential for ______ due to skin thinning, poor wound healing, and bone density loss 3. Potential for _______ due to hormone-induced reduced IMMUNITY 4. Potential for acute adrenal _______

polyuria

The result of DI is the excretion of large volumes of dilute urine because the distal kidney tubules and collecting ducts do not reabsorb water; this leads to _______ (excessive water loss through urination), dehydration, and disturbed FLUID AND ELECTROLYTE BALANCE.

Estrogen

The risk for hypertension or thrombosis(formation of blood clots in deep veins) is increased with _______ therapy, especially among smokers.

GnRH

Therapy for men with gonadotropin deficiency to increase fertility requires _____ injections, rather than testosterone therapy

Thyroid, gain, cold, alopecia, hirsutism, menstrual, cognition, lethargy

Thyroid-stimulating hormone (thyrotropin) (TSH) DEFICIENCY signs and symptoms: Decreased ____ hormone levels Weight ______ Intolerance to _____ Scalp _______ _________ ______ abnormalities Decreased libido Slowed ______ ________

BROmocriptine, cabergoline

To treat hyperpituitarism, common drugs include _______ and ________ which are dopamine agonists, stimulating the brain to inhibit the release of GH and PRL

Fluid restriction, demeclocycline

Treatment of SIADH

GH, PRL, ACTH

Tumors occur most often in the anterior pituitary cells that produce ______, _____, and ______

elevated, 25

Urine is tested to measure levels of free cortisol and the metabolites of cortisol and androgens (17-hydroxycorticosteroids and 17-ketosteroids). In Cushing's disease, levels of urine cortisol and androgens are all _______ in a 24-hour specimen. Cortisol-to-creatinine ratios in the first specimen of the day can replace the 24-hour test for screening. A ratio greater than ___ nmol/mmol is a positive test (Stewart & Newell-Price, 2016)

2, 4

With Cushing's perform pulmonary hygiene every __ to ___ hours. Listen to the lungs for crackles, wheezes, or reduced breath sounds. Urge the patient to deep breathe or use an incentive spirometer every hour while awake.

hypothalamic

Usually hyperpituitarism is caused by benign tumors (adenomas) from one pituitary cell type. It can also be caused by a _______ problem of excessive production of releasing hormones, which then overstimulate a normal pituitary gland

Increased, low, hypo, dehydration, increased increased, output

Vasopressin (antidiuretic hormone [ADH]) DEFICIENCY signs and symptoms: Diabetes insipidus: • Greatly ________ urine output • _____ urine specific gravity (<1.005) • _____tension • _______ • ________ plasma osmolarity • _______ thirst • _______ does not decrease when fluid intake decreases

adrenal Cushing's disease

When excess glucocorticoids are caused by an actual problem in the actual adrenal cortex, usually a benign tumor (adrenal adenoma), the problem is called _____ _____ _____ (or primary Cushing's disease) and usually occurs in only one adrenal gland.

Cushing's syndrome

When glucocorticoid excess results from drug therapy for another health problem, it is known as ____ _____ (also called secondary Cushing's syndrome).

C

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 mEq/L (mmol/L) C. Serum sodium 117 mEq/L (mmol/L) D. pH 7.28

pituitary Cushing's disease

When the anterior pituitary gland oversecretes adrenocorticotropic hormone (ACTH), this hormone causes hyperplasia of the adrenal cortex in both adrenal glands and an excess of glucocorticoid production This problem is _____ _____ _____ because the tissue causing the problem is the pituitary, not in the adrenal gland.

A, C, D, E

Which statements made by a client who has diabetes insipidus indicates to the nurse that more teaching is needed? Select all that apply. A. If I gain more than 2 lb (1 kg) in a day, I'll limit my fluid intake. B. If I become thirstier, I'll take another dose of the drug. C. I'll avoid aspirin and aspirin-containing substances. D. I'll stop taking the drug for 24 hours before I have any dental work performed. E. I'll limit my intake of salt and sodium to no more than 2 g daily. F. I'll wear my medical alert bracelet at all times.

GI

With Addison's diSease, _____ problems, such as anorexia, nausea, vomiting, diarrhea, and abdominal pain, often occur. Ask about weight loss during the past months. Women may have menstrual changes related to weight loss, and men may report impotence.

Ulceration, chest, lung

With DDAVP, ________ of the mucous membranes, allergy, a sensation of _______ tightness, and ______ inhalation of the spray may occur with use of the intranasal preparations. If side effects occur or if the patient has an upper respiratory infection, oral or subcutaneous vasopressin is used.

120

With SIADH Providing a safe environment is needed when the serum sodium level falls below ____ mEq/L (mmol/L). The risk for neurologic changes and seizures increases as a result of osmotic fluid shifts into brain tissue.

2, reduce

With SIADH, assess for subtle changes, such as muscle twitching, increasing irritability, or restlessness before they progress to seizures or coma. Check orientation to time, place, and person every _____ hours because disorientation or confusion may be present. _______ environmental noise and lighting to prevent overstimulation.

Hyperglycemia

With acromegaly, breakdown of joint cartilage and hypertrophy of ligaments, vocal cords, and eustachian tubes are common. Nerve entrapment and _________ (elevated blood glucose levels) are common.

Peripheral

With hypopituitarism, assess the patient's visual acuity, especially _________ vision, for changes or loss. Headaches, diplopia (double vision), and limited eye movement are common.

HRT

Women who have gonadotropin deficiency receive ______ with a combination of estrogen and progesterone

PRL

_____-secreting tumors are the most common type of pituitary adenoma. Excessive ______ inhibits the secretion of gonadotropins and sex hormones in men and women, resulting in galactorrhea (breast milk production), amenorrhea, and infertility.

Hyperaldosteronism

______ is an increased secretion of aldosterone with mineralocorticoid excess.

MRI

______ is the best imaging assessment for diagnosis of hyperpituitarism (Melmed & Kleinberg, 2016). Skull x-rays may be used to identify abnormalities of the sella turcica.

PPH, Sheehan's syndrome

______ is the most common cause of pituitary infarction, which results in decreased hormone secretion. This clinical problem is known as ______ _____

Mifepristone

_______ (Korlym) cannot be used during pregnancy because it also blocks progesterone receptors and would cause termination of the pregnancy.

Antacids

_______ buffer stomach acids and protect the GI mucosa. Teach the patient that these drugs should be taken on a regular schedule rather than on an as-needed basis.

Hydrocortisone

_______ corrects glucocorticoid deficiency

Nephrogenic

_______ diabetes insipidus is a problem with the kidney's response to ADH rather than a problem with ADH production or release. Any severe kidney injury can reduce the ability of the kidney tubules to respond to ADH. In this situation, as long as the kidney is able to continue to produce urine, DI results. In some cases, a mutation in the gene responsible for producing the ADH receptor interferes with kidney response to ADH.

Tolvaptan

_______ has a black box warning that rapid increases in serum sodium levels (those greater than a 12-mEq/L [mmol/L] increase in 24 hours) have been associated with central nervous system demyelination that can lead to serious complications and death. In addition, when this drug is used at higher dosages or for longer than 30 days, there is a significant risk for liver failure and death

Octreoctide

_______ inhibits Gh release through negative feedback.

Secondary neurogenic

________ ________ diabetes insipidus is not caused by a direct problem with the posterior pituitary but is a result of tumors in or near the hypothalamus or pituitary gland, head trauma, infectious processes, brain surgery, or metastatic tumors.

Women

________ are more likely to develop Cushing's disease. Cushing's syndrome from chronic use of exogenous corticosteroids is more common because these drugs are often used to control serious chronic inflammatory conditions.

Primary neurogenic

_________ ________ diabetes insipidus is caused by a defect in the hypothalamus or pituitary gland, resulting in a lack of ADH production or release.

Acute adrenal insufficiency (Addisonian crisis)

_________ __________ is a life-threatening event in which the need for cortisol and aldosterone is greater than the body's supply. It often occurs in response to a stressful event (e.g., surgery, trauma, severe infection), especially when the adrenal hormone output is already reduced.

Cushing's

_________ disease is the excess secretion of cortisol from the adrenal cortex, causing many problems. It is caused by a problem in the adrenal cortex itself, a problem in the anterior pituitary gland, or a problem in the hypothalamus. In addition, glucocorticoid therapy can cause hypercortisolism.

Flow

_________ sheets recording neurologic assessments and laboratory data are helpful in detecting neurologic trends.

Glucocorticoids

__________ preparations are given before surgery. The patient continues to receive _________- during surgery to prevent adrenal crisis because the removal of the tumor results in a sudden drop in cortisol levels. Before surgery, discuss the need for long-term drug therapy.

Phenochromocytoma

___________ is a catecholamine-producing tumor of the adrenal medulla. These tumors usually occur in one adrenal gland, although they can be bilateral or in the abdomen.

Dexamethasone

___________ suppression testing can screen for hypercortisolism and may take place overnight or over a 3-day period. Set doses of dexamethasone are given. A 24-hour urine collection follows drug administration. When urinary 17-hydroxycorticosteroid excretion and cortisol levels are suppressed by _________, Cushing's disease is not present.

hyperpituitarism

_______________ is hormone oversecretion that occurs with anterior pituitary tumors or tissue hyperplasia (tissue overgrowth).

Catecholamine

a class of amines that includes the neurotransmitters dopamine, norepinephrine, and epinephrine

Moon face

a round (moon-shaped) face

Anorexia, N&S, ab pain, constipation or diarrhea, weight loss, salt craving

adrenal insufficiency GI symptoms

Very Nice Drugs (verapamil, nifedipine, diltiazem)

calcium channel blockers

Vasopressin (ADH)

desmopressin acetate (DDAVP), a synthetic form of _____ given orally, as a sublingual "melt," or intranasally in a metered spray

Galactorrhea

discharge of milk

Night

dult patients with GH deficiency may be treated with subcutaneous injections of human GH (hGH). Injections are given at _______ to mimic normal GH release

Increased, decreased, increased, decreased, decreased, normal, increased

hyperfunction of the adrenal gland: sodium potassium glucose calcium bicarbonate BUN cortisol

Ataxia

lack of muscle coordination

hypertensive

pheochromocytomas increased abdominal pressure, defecation, and vigorous abdominal palpation can provoke a ________ crisis.

hypertension

pheochromocytomas often has intermittent episodes of ________ or attacks that range from a few minutes to several hours. During these episodes, the patient has severe headaches, palpitations, profuse diaphoresis, flushing, apprehension, or a sense of impending doom.

hypophysectomy

removal of the pituitary gland (most common treatment of hyperpituitarism

Adrenalectomy

surgical removal of one or both adrenal glands

buffalo hump

the accumulation of fatty tissue at the base of the neck

panhypopituitarism

total pituitary impairment that brings about a progressive and general loss of hormone activity