MDC2 Chapter 57
In acute adrenocortical insufficiency (adrenal crisis), life-threatening symptoms may appear without ....
warning
The syndrome of inappropriate antidiuretic hormone (SIADH) or Schwartz-Bartter syndrome causes ...
water retention and fluid overload
Massive water loss
... increases plasma osmolarity and serum sodium levels, which stimulate the sensation of thirst. Thirst promotes increased fluid intake and aids in maintaining hydration. If the thirst mechanism is poor or if the adult cannot obtain water independently, dehydration becomes more severe and can lead to death
Primary neurogenic diabetes insipidus
... is caused by a defect in the hypothalamus or pituitary gland, resulting in a lack of ADH production or release.
Hyperaldosteronism
... is diagnosed on the basis of laboratory studies and imaging with CT or MRI. Serum potassium levels are decreased, and sodium levels are elevated. Plasma renin levels are low, and aldosterone levels are high. Hydrogen ion loss leads to metabolic alkalemia (elevated blood pH). Urine has a low specific gravity and high aldosterone levels.
Surgical postoperative care- hyperactive pituatry
-Monitor the patient's neurologic response -document any changes in vision or mental status, altered level of consciousness, or decreased extremity strength. -Observe for complications such as transient diabetes insipidus, cerebrospinal fluid (CSF) leakage, infection, and increased ICP.
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.
Hypercortisolism
.. can result in emotional instability, and patients often say that they do not feel like themselves. Ask about mood swings, irritability, new-onset confusion, or depression. Ask the patient whether he or she has been crying or laughing inappropriately or has had difficulty concentrating. The excess hormones stimulate the central nervous system, heightening the awareness of and responses to sensory stimulation. The patient often reports sleep difficulties and fatigue. All of these changes along with the physical changes strongly suggest ..
Glucocorticoids
.. reduce both the inflammation and the immune responses of immunity , increasing the risk for infection. For the patient who is taking glucocorticoid replacement therapy, the risk is ongoing. For the patient who is recovering from surgery to prevent hypercortisolism, the infection risk continues for weeks after surgery.
Hypokalemia and elevated blood pressure
... are the most common problems that patients with hyperaldosteronism develop. He or she may have headache, fatigue, muscle weakness, dehydration, and loss of stamina. Polydipsia (excessive fluid intake) and polyuria (excessive urine output) occur less frequently. Paresthesias (sensations of numbness and tingling) may occur if potassium depletion is severe.
Pituitary function
... can be impaired by malnutrition or rapid loss of body fat.
Mifepristone
... cannot be used during pregnancy because it also blocks progesterone receptors and would cause termination of the pregnancy
Interventions for SIADH
... focus on restricting fluid intake, promoting the excretion of water, replacing lost sodium, and interfering with the action of ADH
Secondary neurogenic diabetes insipidus
... is not caused by an abnormal posterior pituitary gland but is a result of tumors in or near the hypothalamus or pituitary gland, head trauma, infectious processes, or brain surgery.
Hypertonic saline (i.e., 3% sodium chloride
... is used for SIADH when the serum sodium level is very low. Give IV saline cautiously because it may add to existing fluid overload and promote heart failure. If the patient needs routine IV fluids, a saline solution is prescribed to prevent further sodium dilution.
Fluid retention
... may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each 1 lb (about 500 g) of weight gained (after the first ½ lb) equates to 500 mL of retained water. Weigh the patient at the same time daily (before breakfast), using the same scale. Have the patient wear the same type of clothing for each weigh-in.
Adhesive tape
... often causes skin breakdown. Use tape sparingly and remove it carefully. After venipuncture, the patient may have increased bleeding because of blood vessel fragility. Apply pressure over the site until bleeding has stopped.
Glucocorticoid
... preparations are given before surgery. The patient continues to receive glucocorticoids 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 hormone replacement therapy (HRT).
GH deficiency
... results from decreased GH production, failure of the liver to produce somatomedins, or failure of tissues to respond to the somatomedins. In adults, GH deficiency alters cellular regulation by increasing the rate of bone destructive activity, leading to thinner bones (osteoporosis) and an increased risk for fractures.
Monitor intake and output
...and weight to assess therapy effectiveness. Ensure that assistive personnel (AP) understand that these measurements need to be accurate, not just estimated, because treatment decisions are based on the findings. Schedule fluid offerings throughout the 24 hours. Teach AP to check urine for color and character and to report these findings. Check the urine specific gravity (a specific gravity below 1.005 may indicate fluid overload). If IV therapy is used, infuse only the amount prescribed.
CT and MRI
...are most helpful in determining the cause of pituitary problems leading to adrenal insufficiency. .. can show adrenal gland atrophy, but not its cause.
urine specific gravity
1.005-1.030
hypopituitarism
A deficiency of one and sometimes more than one pituitary hormone Most often only one pituitary hormone is deficient, a condition known as selective hypopituitarism. Decreased production of all of the anterior pituitary hormones (panhypopituitarism) is rare and much more serious
Pasireotide
A drug to manage hypercortisolism resulting from a pituitary adenoma is .... 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. The drug is ineffective for patients whose tumors do not have somatostatin receptors.
acute adrenal insufficiency
A life-threatening event in which the need for cortisol and aldosterone is greater than the body's supply. Also known as adrenal crisis or addisonian crisis.
hypercortisolism
A normal salivary cortisol level is lower than 2.0 ng/mL. Higher levels indicate ....
syndrome of inappropriate antidiuretic hormone (SIADH)
A problem in which vasopressin (antidiuretic hormone [ADH]) is secreted even when plasma osmolarity is low or normal, resulting in water retention and fluid overload. (Also known as Schwartz-Bartter syndrome.)
2 to 4 hours
Perform pulmonary hygiene every .... 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.
an amount equal to urine output
Urge the patient to drink fluids in .... If fluids are given IV, ensure the patency of the access catheter and accurately monitor the amount infused hourly.
An ... is the most definitive test for adrenal insufficiency.
ACTH stimulation (provocative) test
cortisol and aldosterone
Acute adrenal insufficiency (addisonian crisis) is a life-threatening event in which the need for .. is greater than the body's supply.
Disorders of the Adrenal Gland
Adrenal Gland Hypofunction Hypercortisolism Hyperaldosteronism
the sudden cessation of long-term glucocorticoid therapy
Adrenal insufficiency is classified as primary or secondary. common cause of secondary adrenal insufficiency is .... This therapy suppresses production of glucocorticoids through negative feedback and causes atrophy of the adrenal cortex. Glucocorticoid drugs must be withdrawn gradually to allow for pituitary production of ACTH and activation of adrenal cells to produce cortisol.
adrenalectomy
After a bilateral ..., patients require lifelong glucocorticoid and mineralocorticoid HRT, starting immediately after surgery. In unilateral adrenalectomy, HRT continues until the remaining adrenal gland increases hormone production. This therapy may be needed for up to 2 years after surgery.
Gonadotropins- Deficiency signs and symptoms -Women (Luteinizing hormone (LH) Follicle-stimulating hormone (FSH)
Amenorrhea Anovulation Low estrogen levels Breast atrophy Loss of bone density Decreased axillary and pubic hair Decreased libido
urine output
Urge the patient to drink fluids in an amount equal to .... If fluids are given IV, ensure the patency of the access catheter and accurately monitor the amount infused hourly.
adrenal glands
Ask whether the patient has had radiation to the abdomen or head. Abdominal radiation could directly damage the ..., whereas cranial radiation could interfere with hypothalamic or pituitary influences on adrenal function. Document medical problems (e.g., tuberculosis or previous intracranial surgery) and all past and current drugs, especially steroids, anticoagulants, opioids, and cancer drugs.
Adrenal Insufficiency
Assess for hypoglycemia (e.g., sweating, headaches, tachycardia, and tremors) and fluid depletion (postural hypotension and dehydration). Hyperkalemia (elevated blood potassium levels) can cause dysrhythmias with an irregular heart rate and result in cardiac arrest. Hyponatremia (low blood sodium levels) leading to hypotension and decreased
overstimulation- SIADH
Assess for subtle changes, such as muscle twitching, increasing irritability, or restlessness, before these progress to seizures or coma. Check orientation to time, place, and person every 2 hours because disorientation or confusion may be present as an early indication. Reduce environmental noise and lighting to prevent ....
pus and with only a low-grade fever
Continually assess the patient for possible infection. Symptoms may not be obvious because excess cortisol suppresses infection indicators caused by inflammation. Fever and pus formation depend on the presence of white blood cells (WBCs). The patient who has reduced immunity may have a severe infection without ...
Excess ACTH overstimulates the adrenal cortex. The result is excessive production of glucocorticoids, mineralocorticoids, and androgens, which leads to the development of ...
Cushing disease or syndrome
An excess of cortisol
Cushing disease or syndrome is a group of clinical problems caused by ...
Symptoms of adrenal hypofunction
lethargy, fatigue, and muscle weakness Include questions about salt intake, because salt craving often occurs with hypofunction.
Handle all patients with bone density loss carefully, using ...whenever possible
lift sheets
Adenoma
Benign tumor
A nurse caring for a client with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem will use which of the following actions to prevent harm?
Using nonadhesive methods to secure an IV access
Adrenal Gland Assessment- Hyperfunction
Low potassium, low calcium, low bicarbonate, normal BUN High sodium, Normal to high glucose (fasting), high cortisol (serum), high cortisol (salivary)
Changes include enlargement, erosion, and calcifications as a result of pituitary tumors, as well as soft-tissue lesions, seen most distinctly with ....
CT and MRI
... include head trauma, brain tumors or infection, radiation or surgery of the head and brain, and the last stage of human immune deficiency virus (HIV) disease, HIV-III (AIDS).
Causes of hypopituitarism
Milk, cheese, yogurt, and green leafy and root vegetables
Collaborate with a registered dietitian nutritionist (RDN) to teach the patient about nutrition therapy. A high-calorie diet that includes increased amounts of calcium and vitamin D is needed. ... add calcium to promote bone density. Advise the patient to avoid caffeine and alcohol, which increase the risk for GI ulcers and reduce bone density.
Adrenal Gland Assessment- Hypofunction
Low sodium, normal to low glucose (fasting), low cortisol (serum), low cortisol (salivary) High potassium, high calcium, high bicarbonate, high BUN
One cause of hyperpituitarism is multiple endocrine neoplasia, type 1 ...., in which there is inactivation of the suppressor gene ...
MEN1
gynecomastia
Male breast tissue development.
4 L
Water loss changes blood and urine tests. The 24-hour fluid intake and output is measured without restricting food or fluid intake. DI is considered if urine output is more than ... during this period and is greater than the volume ingested.
Desmopressin
Management focuses on controlling symptoms using drug therapy with .... This drug, a synthetic form of vasopressin, replaces antidiuretic hormone (ADH) and decreases urination. It is available orally, as a sublingual "melt," or intranasally in a metered spray. The frequency of dosing varies with patient responses. Teach those patients who have mild DI that they may need only one or two doses in 24 hours.
... accurately on patients who have either diabetes insipidus or syndrome of inappropriate antidiuretic hormone (SIADH)
Measure intake and output
Signs and Symptoms of deficiency of Growth hormone (GH) (anterior pituatary hormone)
Decreased bone density Pathologic fractures Decreased muscle strength Increased serum cholesterol levels
Gonadotropins- Deficiency signs and symptoms -Men (Luteinizing hormone (LH) Follicle-stimulating hormone (FSH)
Decreased facial hair Decreased ejaculate volume Reduced muscle mass Loss of bone density Decreased body hair Decreased libido Impotence
Adrenocorticotropic hormone (ACTH)- Deficiency signs and symptoms
Decreased serum cortisol levels Pale, sallow complexion Malaise and lethargy Anorexia Postural hypotension Headache Hypoglycemia Hyponatremia Decreased axillary and pubic hair (women)
loss of appetite, nausea, and vomiting
Early symptoms of SIADH are related to the water-retention causing dilution of serum sodium levels (hyponatremia). GI disturbances, such as ... may occur first Weigh the patient and document any recent weight gain. Use this information to monitor responses to therapy.
4 hours
Ensure that no patient suspected of having Diabetes insipidus- DI is deprived of fluids for more than ... because he or she cannot reduce urine output and severe dehydration can result.
hypercortisolism
Expected outcomes of ... management are the reduction of plasma cortisol levels, removal of tumors, and restoration of normal or acceptable body appearance. When the disorder is caused by pituitary or adrenal problems, cure is possible. When caused by drug therapy for another health problem, the focus is to prevent complications from ....
to breathe through the mouth a "mustache" 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.
Explain that because nasal packing is present for 2 to 3 days after surgery, it will be necessary ... These activities can increase intracranial pressure (ICP) and delay healing.
dilutes plasma sodium levels
Fluid restriction is essential because fluid intake further .... In some cases, fluid intake may be kept as low as 500 to 1000 mL/24 hr.
early detection of dehydration and maintaining adequate hydration
For the hospitalized patient with Diabetes Insipidus-DI, nursing management focuses on .... Actions include accurately measuring fluid intake and output, checking urine specific gravity, and recording the patient's weight daily.
walking
Fragile fractures from bone density loss and osteoporosis are possible for months to years after cortisol levels return to normal. When helping the patient move in bed, use a lift sheet instead of grasping him or her. Remind the patient to call for help when ..... Review the use of walkers or canes, if needed. Teach AP to use a gait belt when walking with a patient who has bone density loss.
hydrochloric acid
GI bleeding 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. Although surgery reduces cortisol levels, the normal mucus and increased blood flow may take weeks to return. Interventions focus on drug therapy to reduce irritation, protect the GI mucosa, and decrease secretion of ...
adrenal hypofunction
GI 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.
What happens alert you hyperfuncioning of pituatury gland (one year period)
Gaining 15 lbs. Decreased libido Occosional dripping of clear liquid from both breasts
Encourage the patient to express concerns about his or her altered physical appearance, such as .... Reassure the patient that treatment may reverse some of these problems.
Galactorrhea- excessive or inappropriate milk production Gynecomastia- breast growth in men Reduced sexual functioning
hypercortisolism
He or she may report weight gain and an increased appetite. Ask about changes in activity or sleep patterns, fatigue, and muscle weakness. Ask about bone pain or a history of fractures, because osteoporosis results from hypercortisolism. Ask about a history of frequent infections and easy bruising. Women often stop menstruating. GI problems include ulcer formation from increased hydrochloric acid secretion and decreased production of protective gastric mucus.
hyperpituitarism
Hormone oversecretion that occurs with anterior pituitary tumors or tissue hyperplasia (tissue overgrowth)
Prednisone
Hydrocortisone corrects glucocorticoid deficiency. Oral cortisol replacement regimens and dosages vary. The most common drug used for this purpose is ... In general, divided doses are given, with two-thirds given on arising in the morning and one-third at 6:00 p.m. to mimic the normal release of this hormone.
Disorders of the Pituitary Gland
Hypopituitarism Hyperpituitarism Diabetes Insipidus Syndrome of inappropriate Antidiuretic Hormone
melanocytes
In patients with primary insufficiency (problem with adrenal gland function), plasma ACTH and melanocyte-stimulating hormone (MSH) levels are elevated in response to the adrenal-hypothalamic-pituitary feedback system. (Both ACTH and MSH are made from the same prehormone molecule. Anything that stimulates increased production of ACTH often also leads to increased production of MSH.) Elevated MSH levels result in areas of increased pigmentation (Fig. 57.2). In primary autoimmune disease, patchy areas of decreased pigmentation (vitiligo) may occur because of destruction of skin .... Body hair may also be decreased. In secondary adrenal insufficiency (problem in the hypothalamus or pituitary gland leading to decreased ACTH and MSH levels), skin pigmentation is not changed.
Impotence
Inability to reach erection or orgasm
aldosterone
Increased ... levels cause disturbances of fluid and electrolyte balance , which then trigger the kidney tubules to retain sodium and excrete potassium and hydrogen ions. Hypernatremia, hypokalemia, and metabolic alkalosis result. Sodium retention increases blood volume, which raises blood pressure, increasing the risk for strokes, heart attacks, and kidney damage.
hyperaldosteronism
Increased secretion of aldosterone with mineralocorticoid excess
NSAIDs and drugs that contain aspirin or other salicylates
Instruct the patient to reduce alcohol or caffeine consumption, smoking, and fasting because these actions cause gastric irritation. ...can cause gastritis and intensify GI bleeding. These should be avoided or limited.
Prednisone- Adrenal Hypofunction
Instruct the patient to report illness because the usual daily dosage may not be adequate during periods of illness or severe stress.
Hydrocortisone- Adrenal Hypofunction
Instruct the patient to report signs or symptoms of excessive drug therapy (e.g., rapid weight gain, round face, fluid retention), which indicate Cushing syndrome and a possible need for a dosage adjustment.
Cortisone- Adrenal Hypofunction
Instruct the patient to take the drug with meals or a snack to avoid gastric irritation.
Decreased
Insufficiency of adrenocortical steroids causes problems through the loss of aldosterone and cortisol action. .. cortisol levels result in hypoglycemia. Gastric acid production and glomerular filtration decrease. Decreased glomerular filtration leads to excessive blood urea nitrogen (BUN) levels, which cause anorexia and weight loss.
surgery, trauma, severe infection
It often occurs in response to a stressful event (e.g., ...), especially when the adrenal hormone output is already reduced.
Hypercortisolism (Cushing's syndrome)
Laboratory tests include blood, salivary, and urine cortisol levels. These are high in patients with any type of hypercortisolism
decrease
Low adrenal androgen levels ... body, axillary, and pubic hair, 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.
2 hours
Monitor for indicators of fluid overload (bounding pulse, increasing neck vein distention, lung crackles, increasing peripheral edema, reduced urine output) at least every ... Pulmonary edema can occur quickly and lead to death. Notify the primary health care provider of any change that indicates fluid overload either is not responding to therapy or is worse.
ECG
Monitor the patient for response to drug therapy, especially weight loss and increased urine output. Observe for symptoms of problems with fluid and electrolyte balance , especially changes in ... patterns. Assess laboratory findings, especially sodium and potassium values, whenever they are drawn.
Fludrocortisone- Adrenal Hypofunction
Monitor the patient's blood pressure to assess for the potential side effect of hypertension. Instruct the patient to report weight gain or edema because sodium intake may need to be restricted.
8 hours
Monitor the patient's daily complete blood count (CBC) with differential WBC count, especially neutrophils. Inspect the mouth during every shift for lesions and mucosa breakdown. Assess the lungs every... for crackles, wheezes, or reduced breath sounds. Assess all urine for odor and cloudiness. Ask about any urgency, burning, or pain on urination.
pulmonary edema and heart failure
Monitor the patient's response to therapy to prevent the fluid overload from becoming worse, leading to ..... Any patient with SIADH, regardless of age, is at risk for these complications. The older adult or one who also has cardiac, kidney, pulmonary, or liver problems is at greater risk.
Nephrogenic diabetes insipidus
Nephrogenic diabetes insipidus is a problem with the kidney's response to ADH rather than a problem with ADH production. A severe kidney injury can reduce the ability of the kidney tubules to respond to ADH. Then 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.
vision
Neurologic symptoms of hypopituitarism as a result of tumor growth often first occur as changes in .... Assess for changes in the patient's vision, especially peripheral vision. Headaches, diplopia (double vision), and limited eye movement are common.
hypercortisolism and fluid overload
Nonsurgical interventions focus on patient safety, drug therapy, nutrition therapy, and monitoring; these interventions are the basis of nonsurgical action for ...
15 minutes for shoc
Postoperative care after adrenalectomy includes monitoring in an ICU. Immediately after surgery, assess the patient every...(e.g., hypotension; a rapid, weak pulse; and a decreasing urine output) resulting from insufficient glucocorticoid replacement. Monitor vital signs, central venous pressure, pulmonary wedge pressure, intake and output, daily weights, and serum electrolyte levels.
... is the most common cause of pituitary infarction, which results in decreased hormone secretion. This clinical problem is known as Sheehan syndrome.
Postpartum hemorrhage
True
Prednisone and prednisolone are soundalike drugs, and care is needed not to confuse them. Although they are both corticosteroids, they are not interchangeable because prednisolone is more potent than prednisone. (T/F)
virilization
Presence of male secondary sex characteristics
GI ulcers
Priority nursing interventions for prevention of injury focus on skin assessment and protection, coordinating care to ensure gentle handling, and patient teaching regarding drug therapy for prevention of ...
sodium levels fall, and potassium levels rise rapidly.
Problems are the same as those of chronic insufficiency but are more severe. However, unless intervention is initiated promptly, ...
most common type of pituitary adenoma
Prolactin (PRL)-secreting tumors
The patient with hypersecretion of ... often reports sexual function difficulty. Ask women about menstrual changes, decreased libido, painful intercourse, and any difficulty in becoming pregnant. Men may report decreased libido and impotence.
Prolactine (PRL)
Usually only one hormone is produced in excess because the cell types within the pituitary gland are so individually organized and distinct. The most common hormones produced in excess with hyperpituitarism are ...
Prolactine PRL Adrenocorticotropic hormone ACTH Growth Hormone GH
saline instead of water
Use ... to dilute tube feedings, irrigate GI tubes, and give drugs by GI tube.
aldosterone
Severe hypotension results from the blood volume depletion that occurs with the loss of ...
... reduces blood flow to the pituitary gland, leading to hypoxia, infarction, and reduced hormone secretion.
Shock or severe hypotension
2 hours and pad bony prominences
Skin injury is a continuing risk even after surgery has corrected the cortisol excess because the changes induced in the skin and blood vessels remain for weeks to months. Assess the skin for reddened areas, excoriation, breakdown, and edema. If mobility is decreased, turn the patient every ...
Omeprazole and esomeprazole
Some agents block the H2 receptors in the gastric mucosa. When histamine binds to these receptors, a series of actions release hydrochloric acid. Drugs that block the H2-receptor site include cimetidine, famotidine, and nizatidine. ... inhibit the gastric proton pump and prevent the formation of hydrochloric acid.
... can help diagnose hyperpituitarism
Suppression testing
hyperaldosteronism
Surgery is a common treatment for ..., and one or both adrenal glands may be removed. The patient's potassium level must be corrected before surgery. Drugs used to increase potassium levels include spironolactone, a potassium-sparing diuretic and aldosterone antagonist. Potassium supplements may be used to increase potassium levels before surgery.
hypophysectomy
Surgical removal of the pituitary gland
hyperpituitarism
Surgical removal of the pituitary gland (hypophysectomy) along with any tumor is the most common treatment for .... Successful surgery decreases hormone levels, relieves headaches, and may reverse changes in sexual functioning.
hour or as prescribed
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 2 to 4 hours may be sufficient. For the patient who has had a change in level of consciousness, perform neurologic checks at least every .... Inspect the environment every shift, making sure that basic safety measures, such as side rails being securely in place, are observed.
pituitary adenoma
The most common non-drug therapy-related cause of Cushing disease is a ... Women are more likely than men to develop Cushing disease. Cushing syndrome from chronic use of exogenous corticosteroids is more common because these drugs are often used to control serious chronic inflammatory conditions.
10 times
The parenteral form of desmopressin is ... stronger than the oral form, and the dosage must be reduced.
skin breakdown
The patient is at risk for injury from ..., bone fractures, and GI bleeding. Prevention of these injuries is a major nursing care focus.
urine volume to decrease and urine osmolarity to increase
Water retention causes .... At the same time, plasma volume increases, and plasma osmolarity decreases. Elevated urine sodium levels and specific gravity reflect increased urine concentration. Serum sodium levels decrease, sometimes to as low as 110 mEq/L (mmol/L), because of fluid retention and sodium loss.
selective serotonin reuptake inhibitors
a group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters
acromegaly
abnormal enlargement of the extremities
In the pituitary, excessive production of growth hormone occurs and leads to ....
acromegaly
Deficiencies of .... are the most life threatening because they cause a decrease in the secretion of vital hormones from the adrenal and thyroid glands.
adrenocorticotropic hormone (ACTH) thyroid-stimulating hormone (TSH)
amenorrhea
an abnormal absence of mensturation
An ... can help rule out an aneurysm or any other vascular problems in the area before surgery.
angiogram
Scalp alopecia
areas of boldness on the head hair
Teach the patient and family about the symptoms of ... and when to seek medical advice
infection
Most often hyperpituitarism is caused by a ... within one pituitary cell type
benign tumor (adenoma)
galactorrhea
breast milk production
Instruct patients taking ... to seek medical care immediately if chest pain, dizziness, or watery nasal discharge occurs
bromocriptine
hyperpituatirism drug therapy- inhibit the release of Growth Hormone-GH and Prolactine-PRL
bromocriptine and cabergoline (dopamine agonists)
Excessive Prolactin (PRL)-secreting tumors
inhibits the secretion of gonadotropins and sex hormones in men and women, resulting in galactorrhea (breast milk production), amenorrhea, and infertility.
common causes of The syndrome of inappropriate antidiuretic hormone (SIADH)
cancer therapy pulmonary infection or impairment specific drugs-including selective serotonin reuptake inhibitors
Teach the patient with diabetes insipidus the indicators of ...
dehydration
Pulmonary Disorders- Conditions Causing the Syndrome of Inappropriate Antidiuretic Hormone
• Viral and bacterial pneumonia • Lung abscesses • Active tuberculosis • Pneumothorax • Chronic lung diseases • Mycoses • Positive-pressure ventilation
Skin Symptoms- Adrenal Insufficiency
• Vitiligo or • Hyperpigmentation
Preoperative
... care starts with correcting disturbances of fluid and electrolyte balance before surgery. Continue to monitor blood potassium, sodium, and chloride levels. Dysrhythmias from potassium imbalance may occur, and cardiac monitoring is needed. Hyperglycemia is controlled before surgery. The patient with hypercortisolism is at risk for complications of infections and fractures. Prevent infection with handwashing and aseptic technique. Decrease the risk for falls by raising top side rails and encouraging the patient to ask for assistance when getting out of bed. A high-calorie, high-protein diet is prescribed before surgery.
Nutrition therapy
... for the patient with hypercortisolism may involve restrictions of both fluid and sodium intake to control fluid volume. Often sodium restriction involves only "no added salt" to ordinary table foods when fluid overload is mild. For more pronounced fluid overload, the patient may be restricted to anywhere from 2 g/day to 4 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. Explain to the patient and family the reason for any fluid restriction and the importance of adhering to the prescribed restriction.
Surgical management of adrenocortical
... hypersecretion depends on the cause of the problem. When adrenal hyperfunction is due to increased pituitary secretion of ACTH, removal of a pituitary adenoma using minimally invasive techniques may be attempted. Sometimes a total hypophysectomy (surgical removal of the pituitary gland) is needed. (See earlier discussion of Hypophysectomy in the Hyperpituitarism section.) If hypercortisolism is caused by an adrenal tumor, an adrenalectomy (removal of the adrenal gland) may be needed.
hypercortisolism (cushing disease)
...is the excess secretion of cortisol from the adrenal cortex, causing many problems. The disorder can be caused by a problem in the adrenal cortex itself, a problem in the anterior pituitary gland, or a problem in the hypothalamus. In addition, one of the most common causes of hypercortisolism is glucocorticoid therapy.
The priority problems for patients with Cushing disease or Cushing syndrome are:
1. Fluid overload due to hormone-induced water and sodium retention 2. Potential for injury due to skin thinning, poor wound healing, and bone density loss 3. Potential for infection due to hormone-induced reduced immunity
Ensure that no patient suspected of having DI is deprived of fluids for more than ..
4 hours
-neurogenic (primary or secondary)- insafficiant production of ADH -nephrogenic- production of ADH is ok but kidneys are not functioning -drug related
ADH deficiency is classified as ..., 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.
Cause of hyperpituitarism
Adenoma (Benign Tumor) within one pituitary cell type
... are classified by the hormone secreted. As an ... gets larger and compresses brain tissue, neurologic changes, as well as endocrine problems, may occur. Symptoms may include vision changes, headache, and increased intracranial pressure (ICP)
Adenomas
only in the hospital
Administer tolvaptan or conivaptan .. setting so serum sodium levels can be monitored closely for the development of hypernatremia and other complications.
HRT (hormone replacement therapy)
After bilateral adrenalectomy, lifelong .. is needed to prevent adrenal insufficiency. Without the adrenal glands the patient completely depends on the exogenous drug. If the drug is stopped, even for a day or two, no other glands produce the glucocorticoids and the patient develops acute adrenal insufficiency, a life-threatening condition. Management of this problem is described in the Adrenal Gland Hypofunction section. Teach the patient and family about adherence to the drug regimen and its side effects as
adrenal crisis
An additional mineralocorticoid hormone, such as fludrocortisone, may be needed to maintain or restore fluid and electrolyte balance (especially sodium and potassium). Dosage adjustment may be needed, especially in hot 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 ...
not usually present, even though water is retained
In SIADH, free water (not salt) is retained and dependent edema is ...
Management of hypopituitarism focuses on replacement of all deficient hormones to ensure appropriate ...
cellular regulation
antidiuretic hormone (ADH) deficiency or an inability of the kidneys to respond to ADH
Diabetes insipidus (DI) is a disorder of the posterior pituitary gland in which water loss is caused by either an ... 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 polyuria (excessive water loss through urination), dehydration, and disturbed fluid and electrolyte balance .
endocrine neoplasia
endocrine abnormal formation of tissue growth
Psychosocial Assessment
Depending on the degree of imbalance, patients may appear lethargic, depressed, confused, and even psychotic. Assess the patient's orientation to person, place, and time. Families may report that the patient has wide mood swings and is forgetful.
Thyroid-stimulating hormone (TSH, thyrotropin)- Deficiency signs and symptoms
Decreased thyroid hormone levels Weight gain Intolerance to cold Scalp alopecia Hirsutism Menstrual abnormalities Decreased libido Slowed cognition Lethargy
Antidiuretic hormone (ADH, vasopressin)- Posterior Pituitary Hormones
Diabetes insipidus: Greatly increased urine output Low urine specific gravity (<1.005) Hypotension Dehydration Increased plasma osmolarity Increased thirst Increased plasma electrolyte levels, especially sodium Urine output does not decrease when fluid intake decreases
diabetes insipidus (DI)
Disorder of the posterior 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.
fluid overload
Drug therapy for Diabetes Insipidus- DI induces water retention and can cause .... Teach patients to weigh themselves daily 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 and type of clothing.
Metyrapone aminoglutethimide ketoconazole mitotane etomidate
Drug therapy involves the use of drugs that interfere with adrenocorticotropic hormone (ACTH) production or adrenal hormone synthesis for temporary relief and are categorized as steroidogenesis inhibitors. ... use different pathways to decrease cortisol production.
tolvaptan or conivaptan
Drug therapy with vasopressin receptor antagonists (vaptans), such as ..., is used to treat SIADH when hyponatremia is present in hospitalized patients. These drugs promote water excretion without causing sodium loss.
lithium carbonate and demeclocycline
Drug-related diabetes insipidus is most often caused by .... These drugs can interfere with the response of the kidneys to ADH.
go immediately to the emergency department or call 911
If weight gain of more than 2.2 lb (1 kg) along with other signs of water toxicity occurs (e.g., persistent headache, acute confusion, nausea, vomiting), instruct him or her to ...
CT scans, MRI, and arteriography
Imaging for hypercortisolism includes ... These images can identify lesions of the adrenal or pituitary glands, lung, GI tract, or pancreas
inadequate
Immediately after returning home, the patient may need a support person to stay and provide more attention than could be given by a visiting nurse or home care aide. Contact with the interprofessional health care team is needed for follow-up and identification of potential problems. The patient taking corticosteroid therapy may have symptoms of adrenal insufficiency if the dosage is ..... Suggest that the patient obtain and wear a medical alert bracelet listing the condition and the drug replacement therapy.
1000-mL
Measure intake, output, and daily weights to assess the degree of fluid restriction needed. A weight gain of 2.2 lb (1 kg) or more per day or a gradual increase over several days is cause for concern. A 2.2-lb (1-kg) increase is equal to a ... fluid retention (1 kg = 1 L). Prevent mouth dryness with frequent oral rinsing (warn patients not to swallow the rinses).
Gonadotropins (Luteinizing Hormone [LH], Follicle-Stimulating Hormone [FSH]) - Hyperfunction
Men • Elevated LH and FSH levels • Hypogonadism or hypergonadism Women • Normal LH and FSH levels
bounding pulse, increasing neck vein distention, lung crackles, dyspnea (difficulty breathing), increasing peripheral edema, reduced urine output
Monitor for increased fluid overload (...) at least every 2 hours. Pulmonary edema can occur very quickly and can lead to death. Notify the primary health care provider of any change that indicates the fluid overload is not responding to therapy or is worse.
acromegaly
Octreotide inhibits GH release through negative feedback. Pegvisomant blocks GH receptor activity and blocks production of insulin-like growth factor (IGF). Combination therapy with monthly injections of a somatostatin analog and weekly injections of pegvisomant has provided good control of the disease.
Operative
Operative procedures include a unilateral adrenalectomy when one gland is involved or a bilateral adrenalectomy when ACTH-producing tumors cannot be treated by other means or when both adrenal glands are diseased. Surgery is most often performed by laparoscopic adrenalectomy, a minimally invasive surgical approach (DiDalmazi & Reincke, 2018). If necessary, an open surgery through the abdomen or the lateral flank can be performed.
Prednisone
Oral cortisol replacement regimens and dosages vary. The most common drug used for this purpose is. In general, divided doses are given, with two-thirds given on arising in the morning and one-third at 6:00 p.m. to mimic the normal release of this hormone.
pulmonary edema and heart failure
Patient safety includes preventing fluid overload from becoming worse, leading to .... Any patient with fluid overload, regardless of age, is at risk for these complications. The older adult or one who has coexisting cardiac problems, kidney problems, pulmonary problems, or liver problems is at greater risk.
Adrenal glands insuffiency- Nursing interventions
Promoting fluid balance Monitoring for fluid deficit Preventing hypoglycemia Because hyperkalemia can cause dysrhythmias with an irregular heart rate and result in cardiac arrest, assessing cardiac function is a nursing priority. Assess vital signs every 1 to 4 hours, depending on the patient's condition and the presence of dysrhythmias or postural hypotension. Weigh the patient daily and record intake and output. Monitor laboratory values to identify hemoconcentration (e.g., increased hematocrit or BUN).
reduced immunity
Protect the patient with ... from infection. All personnel must use extreme care during all nursing procedures. Thorough handwashing is important. Anyone with an upper respiratory tract infection who enters the patient's room must wear a mask. Observe strict aseptic technique when performing dressing changes or any invasive procedure.
Stress
Protecting the patient with reduced immunity from infection at home is important. Urge him or her to use proper hygiene and social distancing and to avoid crowds or others with infections. Encourage the patient and all people living in the same home with him or her to have yearly influenza vaccinations. ... that the patient should immediately notify the primary health care provider if he or she has a fever or any other sign of infection.
neurologic changes and seizures
Providing a safe environment is needed when the serum sodium level falls below 120 mEq/L (mmol/L). The risk for ... increases as a result of osmotic fluid shifts into brain tissue. Observe for and document changes in the patient's neurologic status.
aldosterone
Reduced .. secretion causes disturbances of fluid and electrolyte balance . Potassium excretion is decreased, causing hyperkalemia. Sodium and water excretion are increased, causing hyponatremia and hypovolemia. Potassium retention also promotes reabsorption of hydrogen ions, which can lead to acidosis.
Women who have gonadotropin deficiency receive HRT with a combination of ...
estrogen and progesterone
transsphenoidal/ endoscopic transnasal
Surgical removal of the tumor at pituatiry
diabetes insipidus
Symptoms include an increase in urination and excessive thirst. Ask about a history of recent surgery, head trauma, or drug use (e.g., lithium). Although increased fluid intake prevents serious volume depletion, the patient who is deprived of fluids or who cannot increase oral fluid intake may develop shock from fluid loss. Symptoms of dehydration (e.g., poor skin turgor, dry or cracked mucous membranes) may be present.
Full and bounding pulse (caused by the increased fluid volume) Hypothermia (caused by central nervous system disturbance) Delusional Hyponatremia No depending edema Increase urine osmolority
Symptoms of SIADH
4 hours
Take vital signs at least every .. to assess for fever. A temperature elevation of even 1°F (or 0.5°C) above baseline is significant for a patient who has reduced immunity , and indicates infection until otherwise proven.
avoid coughing
Teach the patient to .... early after surgery because it increases pressure in the incision area and may lead to a CSF leak. Remind him or her to perform deep-breathing hourly while awake to prevent pulmonary problems. Instruct the patient to rinse the mouth frequently and to apply a lubricating jelly to dry lips to manage the dryness from mouth breathing.
postnasal drip or increased swallowing
Teach the patient to report any ..., which may indicate leakage of cerebrospinal fluid (CSF). Keep the head of the bed elevated. Assess nasal drainage for quantity, quality, and the presence of glucose (present in CSF). A light yellow color at the edge of the clear drainage on the dressing is called the halo sign and indicates CSF. If the patient has persistent, severe headaches, CSF fluid may have leaked into the sinus area. Most CSF leaks resolve with bedrest, and surgical intervention is rarely needed.
hypercortisolism
The patient with hypercortisolism is expected to avoid injury.
less than 1.005
The amount of urine excreted in 24 hours by patients with DI may vary from 4 to 30 L/day. Urine is dilute with a low specific gravity (...) and low osmolarity (50 to 200 mOsm/kg) or osmolality (50 to 200 mOsm/L).
.... regulate growth, metabolism, and sexual development
The anterior pituitary hormones
pituitary gland
The endocrine system's most influential gland. Under the influence of the hypothalamus, the pituitary regulates growth and controls other endocrine glands.
hypercortisolism (Cushing disease)
The excess secretion of cortisol from the adrenal cortex, causing many problems.
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. For patients receiving oxygen by mask or nasal cannula, check the skin around the mask, nares, and ears and under the elastic band. Help the patient change positions every 2 hours or ensure that others assigned to perform the intervention are diligent in this action.
exogenous glucocorticoids
The patient taking .... who is discharged to home remains at continuing risk for impaired fluid and electrolyte balance , especially fluid volume excess. Teach him or her and the family to monitor and record the patient's weight daily to show the primary health care provider at any checkups. Also instruct the patient to call the primary health care provider for weight gain of more than 3 lb in a week or more than 1 to 2 lb in a 24-hour period.
glucocorticoid
The patient who has undergone a unilateral adrenalectomy may need temporary ... replacement; replacement is lifelong when both adrenal glands are removed. Glucocorticoids are given before surgery to prevent adrenal crisis.
hypercortisolism
The patient with ... is expected to remain free from infection and avoid situations that increase the risk for infection.
Hypersecretion of Prolactine- PRL
The patient with ... often reports sexual function difficulty. Ask women about menstrual changes, decreased libido, painful intercourse, and any difficulty in becoming pregnant. Men may report decreased libido and impotence.
hypercortisolism
The patient with ... usually has muscle weakness and fatigue for some weeks after surgery and remains at risk for falls and other injury. These problems may necessitate one-floor living for a short time; and a home health aide may be needed to assist with hygiene, meal preparation, and maintenance.
polyuria and polydipsia
The patient with permanent DI requires lifelong drug therapy. Check his or her ability to assess symptoms, and adjust dosages as prescribed for changes in conditions. Teach that .. indicate the need for another dose.
.... function to secrete hormones that affect the cellular regulation of the entire body, including fluid and electrolyte balance .
The pituitary and adrenal glands
...., vasopressin (antidiuretic hormone [ADH]), helps maintain fluid and electrolyte balance
The posterior pituitary hormone
excess glucocorticoids- cushing disease
The presence of ..., 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 truncal obesity, "buffalo hump," and "moon face". Increases in the breakdown of tissue protein result in decreased muscle mass and muscle strength, thin skin, and fragile capillaries. Effects on minerals lead to bone density loss.
Antiduretic hormone (ADH)
This hormone from the posterior pituitary gland decreases the amount of urine by making collecting tubules permeable to water. If there is none present, the tubules are practically impermeable to water and more water is lost from the body as urine (Diabetes insipidus)
serum sodium levels
Tolvaptan is an oral drug, and conivaptan is given IV. Tolvaptan has a black box warning that rapid increases in ... (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. When this drug is used at higher dosages or for longer than 30 days, there is a significant risk for liver failure and death
If the entire pituitary gland has been removed, replacement of thyroid hormones and glucocorticoids is lifelong.(T/F)
True
Teach patients who have permanent ... the proper techniques and timing of hormone replacement therapy
endocrine hypofunction
dilutional hyponatremia (a decreased serum sodium level) and fluid overload
Water retention results in .... The increase in blood volume increases the kidney filtration and inhibits the release of renin and aldosterone, which increase urine sodium loss and results in greater hyponatremia.
115 mEq/L (mmol/L)
Water retention, hyponatremia, and fluid shifts affect central nervous system function, especially when the serum sodium level is below ... The patient may have lethargy, headaches, hostility (unfriendliness), disorientation, and a change in level of consciousness. Lethargy and headaches can progress to decreased responsiveness, seizures, and coma. Assess deep tendon reflexes, which are usually decreased.
spironolactone therapy
When surgery cannot be performed, ... is continued to control hypokalemia and hypertension. Because spironolactone is a potassium-sparing diuretic, hyperkalemia can occur in patients who have impaired kidney function or excessive potassium intake. Advise the patient to avoid potassium supplements and foods rich in potassium, such as meat, fish, and many (but not all) vegetables and fruits. Hyponatremia can occur with spironolactone therapy, and the patient may need increased dietary sodium. Instruct patients to report symptoms of hyponatremia, such as muscle weakness, dizziness, lethargy, or drowsiness. Instruct them to report any additional side effects of spironolactone therapy, including gynecomastia, diarrhea, headache, rash, urticaria (hives), confusion, erectile dysfunction, hirsutism, and amenorrhea. Additional drug therapy to control hypertension is often needed.
Urine output volume decreased; urine specific gravity increased
Which urine characteristics indicate to the nurse that the client being managed for diabetes insipidus is responding appropriately to interventions?
Gonadotropin (LH and FSH) deficiency
changes secondary sex characteristics in men and women. Men may have facial and body hair loss. Ask about impotence and decreased libido (sex drive). Women may report amenorrhea, dyspareunia (painful intercourse), infertility, and decreased libido. Women may also have dry skin, breast atrophy, and a decrease or absence of axillary and pubic hair
Teach patients taking bromocriptine to seek medical care immediately if occurs ...from the result of cardiac dysrhythmias, coronary artery spasms, and cerebrospinal fluid leakage.
chest pain, dizziness, or watery nasal discharge
Instruct patients who are taking a ... for more than a week not to stop the drug suddenly
corticosteroid
If the anterior portion of the pituitary gland is removed, instruct the patient in ... hormone replacement. Teach the patient to report the return of any symptoms of hyperpituitarism immediately to the primary health care provider.
cortisol, thyroid, and gonadal
Teach patients with diabetes insipidus the proper way to self-administer ... orally or by nasal spray
desmopressin
Hirsutism
excessive hair growth over the body or face especially women
galactorrhea
excessive or inappropriate production of milk
polydipsia
excessive thirst
The risk ....is increased with estrogen therapy, especially among smokers and those who use nicotine in any form.
for hypertension or thrombosis (formation of blood clots in deep veins)
Adults with GH deficiency may be treated with subcutaneous injections of human growth hormone (hGH). Injections are ... to mimic normal GH release
given at night
... results in testicular failure with decreased testosterone production that may cause sterility
gonadotropin deficiency
Men who have ... receive replacement therapy with androgens (testosterone), usually by the parenteral or transdermal route
gonadotropin deficiency
Therapy to increase fertility requires ... injections, not testosterone therapy
gonadotropin-releasing hormone (GnRH)
Tumors occur most often in the anterior pituitary cells that produce ...
growth hormone (GH) prolactin (PRL) adrenocorticotropic hormone (ACTH)
Side effect of Androgen therapy
gynecomastia (male breast tissue development) acne baldness prostate enlargement
The expected outcomes of management for hyperpituitarism are to return hormone levels to normal or near normal, reduce or eliminate .... and reverse as many of the body changes as possible.
headache visual disturbances prevent complications
Symptoms of hyperpituitarism vary with the hormone produced in excess. Obtain the patient's age, gender, and family history. Ask about any change in hat, glove, ring, or shoe 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 vision
The pituitary gland normally enlarges during pregnancy; if hemorrhage and hypotension occur during delivery, ..... can occur.
hemorrhage with ischemia and necrosis of the gland
Ensure that ... replacement drugs are given as close to the prescribed times as possible
hormone
Patients with hypopituitarism require lifelong ..... It is important that ... continues when they are admitted to an acute care setting for any reason.
hormone replacement therapy (HRT)
follicle-stimulating hormone [FSH]—
hormones that stimulate the gonads to produce sex hormones
During the immediate period after a hypophysectomy, teach the patient to avoid activities that increase intracranial pressure (e.g., bending at the waist, straining to have a bowel movement, coughing).
hypophysectomy
Impotence
inability to reach erection or orgasim
Hyperaldosteronism
is an increased secretion of aldosterone with mineralocorticoid excess. Primary hyperaldosteronism (Conn syndrome) in adults results from excessive secretion of aldosterone from one or both adrenal glands, usually caused by an adrenal adenoma. In secondary hyperaldosteronism, excessive secretion of aldosterone is caused by the high levels of angiotensin II that are stimulated by high plasma renin levels. Some causes include kidney hypoxia, diabetic nephropathy, and excessive use of some diuretics.
Adrenal Gland Hypofunction- Diagnostic Assessment
low serum sodium low salivary cortisol levels low fasting blood glucose elevated potassium increased blood urea nitrogen (BUN) levels In primary disease, the eosinophil count and ACTH level are elevated. Plasma cortisol levels do not rise during provocation tests
Assess for indications of infection, especially ..., such as headache, fever, and nuchal (neck) rigidity. The surgeon may prescribe antibiotics, analgesics, and antipyretics.
meningitis
acromegaly treatment
octreotide and lanreotide- somatostatin analog pegvisomant- growth hormone (GH) receptor blocker
Side effects of bromocriptine include
orthostatic (postural) hypotension headaches nausea abdominal cramps constipation
dyspareunia
painful intercourse
Hyperpituitarism is hormone oversecretion that occurs with anterior ...
pituitary tumors or tissue hyperplasia (tissue overgrowth)
Androgen therapy is avoided in men with ...
prostate cancer to prevent enhancing tumor cell growth
Laboratory findings vary widely. Some pituitary hormone levels may be measured directly. Laboratory assessment of some pituitary hormones involves measuring the effects of the hormones ... For example, blood levels of triiodothyronine (T3) and thyroxine (T4) from the thyroid, testosterone and estradiol from the gonads, and prolactin levels are measured easily. If levels of any of these hormones are low, further pituitary evaluation is necessary.
rather than the actual hormone levels
libido
sex drive
High levels of corticosteroids reduce lymphocyte production and shrink organs containing lymphocytes, such as the ... White blood cell (WBC) cytokine production is decreased. These changes reduce immunity and increase the risk for infection.
spleen and the lymph nodes (shrinking)
Give bromocriptine with a meal or a snack 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.
Adrenal cortex production of steroid hormone may decrease as a result of inadequate secretion of adrenocorticotropic hormone (ACTH), dysfunction of the hypothalamic-pituitary control mechanism, or direct problems of adrenal gland tissue (Cole, 2018). Symptoms may develop gradually or occur quickly with ...
stress
hyperplasia
tissue overgrowth
Instruct the patient with adrenal insufficiency to wear a medical alert bracelet and ....
to carry simple carbohydrates with him or her at all times
Teach the patient to avoid toothbrushing for about 2 weeks after .. surgery. Frequent mouth care with mouthwash and daily flossing provide adequate oral hygiene. A decreased sense of smell is expected after surgery and usually lasts 3 to 4 months.
transsphenoidal
Therapy begins with high-dose testosterone and is continued until ... (presence of male secondary sex characteristics) is achieved. Positive responses include increases in penis size, libido, muscle mass, bone size, and bone strength, as well as increases in facial and body hair.
virilization
Emergency Management of the Patient With Acute Adrenal Insufficiency-Hypoglycemia Management
• Administer IV glucose as prescribed. • Prepare to administer glucagon as needed and prescribed. • Maintain IV access. • Monitor blood glucose level hourly.
Emergency Management of the Patient With Acute Adrenal Insufficiency- Hyperkalemia Management
• Administer insulin in units equal to the same number of mg of extra dextrose in normal saline intravenously to shift potassium into cells. • Give potassium binding and excreting resin. • Give loop or thiazide diuretics. • Avoid potassium-sparing diuretics, as prescribed. • Initiate potassium restriction. • Monitor intake and output. • Monitor heart rate, rhythm, and ECG for signs and symptoms of hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole).
Cardiovascular Symptoms- Adrenal Insufficiency
• Anemia • Hypotension • Hyponatremia • Hyperkalemia • Hypercalcemia
Gastrointestinal Symptoms- Adrenal Insufficiency
• Anorexia • Nausea, vomiting • Abdominal pain • Constipation or diarrhea • Weight loss • Salt craving
Causes of Primary and Secondary Adrenal Insufficiency- Primary Causes
• Autoimmune disease a • Tuberculosis • Metastatic cancer • HIV-III (AIDS) • Hemorrhage • Gram-negative sepsis • Adrenalectomy • Abdominal radiation therapy • Drugs (mitotane) and toxins
Conditions Causing Increased Cortisol Secretion- Endogenous Secretion (Cushing Disease)
• Bilateral adrenal hyperplasia (most common cause) • Pituitary adenoma increasing the production of ACTH (pituitary Cushing disease) • Malignancies: carcinomas of the lung, GI tract, pancreas • Adrenal adenomas or carcinomas
Neurologic Symptoms- Diabetes Insipidus
• Decreased cognition • Ataxia • Increased thirst • Irritability
Thyrotropin (Thyroid-Stimulating Hormone [TSH])- Hyperfunction
• Elevated plasma TSH and thyroid hormone levels • Weight loss • Tachycardia and dysrhythmias • Heat intolerance • Increased GI motility • Fine tremors
Adrenocorticotropic Hormone (ACTH): Pituitary Cushing Syndrome- Hyperfunction
• Elevated plasma cortisol levels • Weight gain • Truncal obesity • Moon face • Extremity muscle wasting • Loss of bone density • Hypertension • Hyperglycemia • Striae and acne
Drugs- Conditions Causing the Syndrome of Inappropriate Antidiuretic Hormone
• Exogenous ADH • Chlorpropamide • Vincristine • Cyclophosphamide • Carbamazepine • Opioids • Tricyclic antidepressants • General anesthetics • Fluoroquinolone antibiotics
The anterior pituitary gland (adenohypophysis) secretes the following hormones to maintain homeostasis
• Growth hormone (GH; somatotropin) • Thyrotropin (thyroid-stimulating hormone [TSH]) • Corticotropin (adrenocorticotropic hormone [ACTH]) • Follicle-stimulating hormone (FSH) • Luteinizing hormone (LH) • Melanocyte-stimulating hormone (MSH) • Prolactin (PRL)
Hypercortisolism (Cushing Disease/Syndrome) Cardiovascular Symptoms
• Hypertension • Frequent dependent edema • Bruising • Petechiae
Prolactin (PRL)- Hyperfunction
• Hypogonadism (loss of secondary sexual characteristics) • Decreased gonadotropin levels • Galactorrhea • Increased body fat • Increased serum prolactin levels
Cardiovascular Symptoms- Diabetes Insipidus
• Hypotension • Tachycardia • Weak peripheral pulses • Hemoconcentration
Additional laboratory findings that accompany hypercortisolism include:
• Increased blood glucose level • Decreased lymphocyte count • Increased sodium level • Decreased serum calcium level
Hypercortisolism (Cushing Disease/Syndrome) Immune System Symptoms
• Increased risk for infection • Reduced immunity • Decreased inflammatory responses • Signs and symptoms of infection and inflammation possibly masked
Kidney/Urinary Symptoms- Diabetes Insipidus
• Increased urine output • Dilute, low specific gravity
Evaluate the care of the patient with hypercortisolism based on the identified priority patient problems. The expected outcomes of interventions are that the patient will:
• Maintain fluid and electrolyte balance as indicated by blood pressure at or near the normal range, stable body weight, and normal serum sodium and potassium levels • Remain free from injury as indicated by having intact skin, minimal bruising, absence of bone fractures, and no occult blood in vomitus, stools, or GI secretions • Remain free from infection as indicated by absence of fever, purulent drainage, cough, pain or burning on urination • Participate in infection prevention strategies of social distancing and obtaining appropriate immunizations • Not experience acute adrenal insufficiency
he Patient After Hypophysectomy- removal of pituitary gland
• Monitor the patient's neurologic status hourly for the first 24 hours and then every 4 hours. • Monitor fluid balance, especially for output greater than intake. • Encourage the patient to perform deep-breathing exercises. • Instruct the patient not to cough, blow the nose, or sneeze. • Instruct the patient to use dental floss and oral mouth rinses rather than toothbrushing until the surgeon gives permission. • Instruct the patient to avoid bending at the waist to prevent increasing intracranial pressure. • Monitor the nasal drip pad for the type and amount of drainage. • Teach the patient methods to avoid constipation and subsequent "straining." (prevent constipation, such as eating high-fiber foods, drinking plenty of fluids, and using stool softeners or laxatives.) • Teach the patient self-administration of the prescribed hormones. *Teach him or her to avoid bending over from the waist to pick up objects or tie shoes because this position increases ICP
Hypercortisolism (Cushing Disease/Syndrome) General Appearance
• Moon face • Buffalo hump • Truncal obesity • Weight gain
Hypercortisolism (Cushing Disease/Syndrome) Musculoskeletal Symptoms
• Muscle atrophy (most apparent in extremities) • Osteoporosis with: • Fragile fractures • Decreased height and vertebral collapse • Aseptic necrosis of the femur head • Slow or poor healing of bone fractures
Adrenal Insufficiency- Neuromuscular Symptoms
• Muscle weakness • Fatigue • Joint and/or muscle pain
Causes of Primary and Secondary Adrenal Insufficiency- Secondary Causes
• Pituitary tumors • Postpartum pituitary necrosis • Hypophysectomy • High-dose pituitary or whole-brain radiation • Cessation of long-term corticosteroid drug therapy
Skin Symptoms- Diabetes Insipidus
• Poor turgor • Dry mucous membranes
Malignancies- Conditions Causing the Syndrome of Inappropriate Antidiuretic Hormone
• Small cell lung cancer • Pancreatic, duodenal, and GU carcinomas • Thymoma • Hodgkin lymphoma • Non-Hodgkin lymphoma
Emergency Management of the Patient With Acute Adrenal Insufficiency- Hormone Replacement
• Start rapid infusion of normal saline or dextrose 5% in normal saline. • Initial higher doses of hydrocortisone sodium or dexamethasone is administered as an IV bolus. • Administer additional hydrocortisone sodium by continuous IV infusion over the next 8 hours. • Give an additional dose of hydrocortisone IM concomitantly with hydration every 12 hours. • Initiate an H2 histamine blocker (e.g., cimetidine) IV for ulcer prevention.
Cortisol Replacement Therapy
• Take your medication in divided doses, as prescribed (e.g., the first dose in the morning and the second dose between 4 p.m. and 6 p.m.) for best effects. • Take your medication with meals or snacks to prevent stomach irritation. • 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 stress or severe emotional stress. • 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 primary health care provider. 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 (and have a family member learn) how to give yourself an intramuscular injection of hydrocortisone in case you cannot take your oral drug.
Conditions Causing Increased Cortisol Secretion- Exogenous Administration (Cushing Syndrome)
• Therapeutic use of ACTH or glucocorticoids—most commonly for treatment of: • Asthma • Autoimmune disorders • Organ transplantation • Cancer chemotherapy • Allergic responses • Chronic fibrosis
Growth Hormone (GH), Acromegaly- Hyperfunction
• 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
Hypercortisolism (Cushing Disease/Syndrome) Skin Symptoms
• Thinning skin • Increased facial and body hair • Striae and increased pigmentation
CNS Disorders- Conditions Causing the Syndrome of Inappropriate Antidiuretic Hormone
• Trauma • Infection • Tumors (primary or metastatic) • Strokes • Porphyria • Systemic lupus erythematosus
