WK 12 - Endocrine (DI, SIADH, Addison's Disease, and Cushing's)

Anterior Pituitary Hyperfunction - Acromegaly

too much growth hormone produced during adulthood bone thickening with transverse growth and tissue enlargement

Restoring Fluid Volume Balance Interventions - Drug Therapy

use drugs that interfere with ACTH production or cortisol production

Preventing Injury - Pathologic Fractures

use lift sheet instead of grasping him or her remind pt to call for help when walking review walkers, canes if needed teach UAP to use gait belt when walking with pt who has bone density loss high-calorie diet that includes increased amts of calcium and vitamin D - milk, cheese, yogurt, and green leafy and root vegetables avoid caffeine and alcohol which inc risk for GI ulcers and reduce bone density

Characteristics of SIADH

water is retained, resulting in hyponatremia fluid overload

Diabetes insipidus

water loss is caused by either an antidiuretic hormone (ADH) deficiency or an inability of the kidneys to respond to ADH

Hormones of Anterior Pituitary

ACTH GH MSH TSH

Hormones of the Posterior Pituitary Gland

ADH (vasopressin) Oxytocin Prolactin FSH, LH

Adrenal Gland Hypofunction - Adrenal Insufficiency

Addison's Disease (Adrenal Insufficiency) too little or absent cortisol and aldosterone

Clinical Presentation of Diabetes Insipidus

Dehydration High sodium levels Inc thirst

Nursing Consideration for DI

Drug Therapy - desmopressin acetate Early detection of dehydration and maintaining adequate hydration Measure I/Os Check urine specific gravity Record daily weight Urge pt to drink fluids in an amount equal to urine output

Emergency Care of Pt with Acute Adrenal Insufficiency

Hormone Replacement Hyperkalemia Management Hypoglycemia Management

Syndrome of Inappropriate ADH (SIADH)

Inc ADH, resulting in decreased fluid output

Hypophysectomy - Postoperative Care

Monitor patient's neurologic status hourly for first 24 hours and then every 4 hours (changes in vision or mental status, altered LOC, or dec strength of extremities) 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" Teach the patient self-administration of the prescribed hormones Keep HOB elevated

Posterior Pituitary Gland Hyperfunction

Syndrome of Inappropriate ADH (SIADH)

Adrenal Insufficiency Key Features - Skin Symptoms

Vitiligo Hyperpigmentation

Emergency Care of Pt with Acute Adrenal Insufficiency - Hypoglycemia Management

administer IV glucose as prescribed administer glucagon as needed and prescribed maintain IV access monitor blood glucose level hourly

Emergency Care of Pt with Acute Adrenal Insufficiency - Hyperkalemia Management

administer insulin with dextrose in normal saline to shift potassium into cells administer potassium binding and excreting resin (Kayexelate) 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 HR; heart block; tall, peaked T waves; fibrillation; asystole)

Adrenal Gland

adrenal cortex makes cortisol and aldosterone adrenal medulla makes epinephrine and norepinephrine - hyperfunction may lead to pheochromocytoma HTN

Adrenal Insufficiency Key Features - Cardiovascular Symptoms

anemia hypotension hyponatremia hyperkalemia hypercalcemia

Adrenal Insufficiency Key Features - GI Symptoms

anorexia nausea/vomiting abdominal pain constipation or diarrhea weight loss salt craving

Preventing Injury - Skin Injury

assess the skin for reddened areas, excoriation, breakdown, and edema turn pts every 2 hours and pad bony prominences use soft toothbrush and electric shaver keep skin clean and dry thoroughly after washing use adhesives sparingly

Acromegaly - Drug Therapy

control secretion of growth hormone bromocriptine and cabergoline

Cushing's Syndrome/Disease Nursing Interventions

correct fluid and electrolyte imbalances - restrict sodium intake monitor for HF prevent injury - skin injury, pathologic fractures, and GI bleeds prevent infection monitor for hyperglycemia monitor use of steroids

Why are pts with Cushing's at risk for GI bleeds?

cortisol inhibits production of mucus that protects stomach lining, dec blood flow to area, and triggers release of excess hydrochloric acid

Key Features of DI - Neurologic

dec cognition ataxia inc thirst irritability

What causes diabetes insipidus

defect in the hypothalamus or pituitary gland tumors drugs (corticosteroids, alcohol) surgery kidney damage

SIADH - Drug Therapy

demeclocycline - inhibits ADH and is an anitbiotic mannitol 3% saline infusion - to prevent further decrease of sodium

Preventing Injury - GI bleeds

drugs that reduce irritation, protect the GI mucosa, and decrease secretion of hydrochloric acid antacids H2 receptor blockers (cimetidine, famotidine, omeprazole) reduce caffeine and alcohol consumption, smoking, and fasting

Cushing's Disease

endogenous secretion production from adrenal cortex

Restoring Fluid Volume Balance Interventions

ensure patient safety restore fluid and electrolyte balance provide supportive care

Cushing's Syndrome

exogenous administration from treatment with glucocorticoids (asthma, COPD, autoimmune disease, transplant, cancer, allergies)

When should patients taking bromocriptine seek medical care immediately?

experiencing chest pain, dizziness, or watery nasal discharge because of possibility of serious side effects including cardiac dysrhythmias, coronary artery spasms, and CSF leakage

SIADH - Fluid Restriction

fluid intake further dilutes plasma sodium levels may be limited to 500 to 1000 mL/24hr

Cushing's Disease/Syndrome Priority Problems

fluid overload due to hormone-induced water and sodium retention potential for injury due to skin thinning, poor wound healing, and bone density loss potential for infection due to hormone-induced reduced immunity potential for acute adrenal insufficiency

Endoscopic Pituitary Surgery Post Op Complications

headaches (most common) bleeding diabetes insipidus

How is Cushing's Syndrome diagnosed?

high saliva, blood and urine cortisol levels increase ACTH levels, when caused from pituitary decreased ACTH levels, when caused by adrenal gland/chronic steroid use hyperglycemia hypernatremia hypocalcemia hypokalemia imaging tests (CT, MRI, ultrasound) to detect a tumor

Addison's Disease Treatment

hydrocortisone

Cushing's Disease/ Syndrome Key Features - Cardiovascular Symptoms

hypertension frequent dependent edema bruising petechiae

Clinical Presentation of SIADH

hyponatremia loss of appetite, nausea, and vomiting inc weight oliguira (low concentrated urine output) lethargy headache hostility disorientation change in LOC dec responsiveness, seizures, and coma full and bounding pulse hypothermia

Acromegaly - Surgical Management

hypophysectomy to dec hormone levels, relieve headaches, and reverse changes in sexual functioning

Key Features of DI - Cardiovascular

hypotension tachycardia weak peripheral pulses hemoconcentration

Endocrine System

hypothalamus communicates with the pituitary gland secretions released into the blood stream that regulate distant functions controls and coordinates metabolism, respirations, secretion, and reproduction

Causes of Adrenal Gland Dysfunction

inadequate secretion or over secretion of ACTH by pituitary gland dysfunction of the hypothalamus dysfunction of adrenal gland tissue glucocorticoid therapy

Cushing's Disease/ Syndrome Key Features - Immune System Symptoms

inc risk for infection reduced immunity dec inflammatory responses signs and symptoms of infection/inflammation possibly masked

Key Features of DI - Kidney/Urinary

inc urine output dilute, low specific gravity

Adrenal Gland Hyperfunction

increased ACTH, increased cortisol loss of normal diurnal pattern of release of cortisol (endogenous secretion or exogenous administration)

SIADH Lab Findings

increased sodium in urine increased urine specific gravity decreased serum osmolarity decreased serum sodium level

Prednisone Nursing Implications

instruct the patient to report illness because the usual daily dosage may not be adequate during periods of illness or severe stress

Hydrocortisone Nursing Implications

instruct the pt 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 weight gain round face fluid retention

Addison's Disease Clinical Picture

lethargy, fatigue (extreme) GI disturbances weight loss hypoglycemia hyponatremia hyperkalemia (may lead to dysrhythmias) hypercalcemia hyperpigmentation of skin (bronzed) impotence (men); menstrual changes (women)

Acute Adrenal Insufficiency (Addisonian Crisis)

life-threatening event in which the need for cortisol and aldosterone is greater than the body's supply occurs in response to a stressful event (surgery, trauma, or severe infection)

CSF Indications

light yellow color at the edge of the clear drainage - halo sign persistent, severe headaches

Addison's Disease Diagnosis

low saliva, blood and urine cortisol levels hypoglycemia hyponatremia hypercalcemia hyperkalemia imaging tests (CT, MRI, ultrasound) to determine cause of adrenal insufficiency

Acromegaly - Radiation Therapy

may take several years for effect

Restoring Fluid Volume Balance Interventions - Monitoring

monitor intake and output and weight to assess therapy effectiveness schedule fluid offerings throughout 24hrs teach UAP to check urine for color and character and to report these findings rapid weight gain is the best indicator of fluid overload and retention

Nursing Assessment

monitor patient weights, I&Os monitor vitals, particularly BP monitor labs (expect to see hypernatremia, hyperglycemia, and hypokalemia) educate patient s/sx; treatments skin care nutritional intake mental status watch for emotional lability, including mood swings, irritability, confusion, and depression

Cushing's Disease/ Syndrome Key Features - General Appearance

moon face buffalo hump truncal obesity weight gain

Cushing's Disease/ Syndrome Key Features - Musculoskeletal Symptoms

muscle atrophy (most apparent in extremities) osteoporosis (bone density loss) pathological fractures decreased height with vertebral collapse aseptic necrosis of the femur head slow or poor healing of bone fractures

Adrenal Insufficiency Key Features - Neuromuscular Symptoms

muscle weakness fatigue joint/muscle pain

Transnasal Transphenoidal Hypophysectomy Preoperative Care

nasal packing present for 2 to 3 days after surgery - necessary to breathe through the mouth Avoid brushing teeth, sneeze, blowing nose, or bending forward after surgery - increase ICP

Bromocriptine Side Effects and Nursing Considerations

orthostatic hypotension headaches nausea abdominal cramps constipation give with food to reduce GI effects

Acromegaly Clinical Presentation

overgrowth of bone and cartilage carpal tunnel thick, oily skin enlarged lips, tongue and nose deep voice snoring excessive sweating fatigue weakness headache, impaired vision abnormal menses impotence in men enlarged organs (heart, liver, spleen, kidney)

Glands of the Endocrine System

pancreas pituitary gland hypothalamus thyroid parathyroid adrenals pineal gland

Cushing's Disease/Syndrome Key Features S&S

personality changes red face inc susceptibility to infection hyperglycemia CNS irritability fat round "moon face" fluid retention (edema) thin extremities gynecomastia fat deposition on abdomen and back of neck ("buffalo hump") osteoporosis (inc risk of fractures) GI distress - inc acid purple striae amenorrhea, hirsutism thin skin bruises and petechiae

Key Features of DI - Skin

poor turgor dry mucous membranes

Restoring Fluid Volume Balance Interventions - Ensure Patient Safety

prevent fluid overload from becoming worse, leading to pulmonary edema and HF S&S of fluid overload (crackles, bounding pulse, inc neck vein distention, inc peripheral edema, red urine output) at risk for skin breakdown - use pressure-reducing or pressure-relieving overlay on the mattress prevent pathologic fractures (daily weight bearing exercises to drive calcium back into the bones; vitamin D to aid in absorption of calcium) prevent GI bleed w/ regularly schedule H2 receptor blocker)

Endoscopic Pituitary Surgery

prevent inc ICP avoid trauma assess for CSF leakage monitor for fluid balance self-administration of hormones

Addison's Disease Nursing Interventions

promote fluid balance monitor for fluid deficit prevent hypoglycemia monitor lab values (K, Na, Ca, Glucose) monitor vitals, I/Os administer glucocorticoid as prescribed (hydrocortisone, prednisone)

Preventing Injury

pt is at risk for injury from skin breakdown, bone fractures, and GI bleeding

How do high level of corticosteroids inc risk of infection

reduces lymphocyte production and shrinks organs containing lymphocytes, such as the spleen and lymph nodes WBC cytokine production is decreased

Surgical Treatment for Cushing's

removal of tumor - hypophysectomy or adrenalectomy

Restoring Fluid Volume Balance Interventions - Nutrition Therapy

restrict fluid and sodium intake

Nursing Interventions for SIADH

restrict fluid intake promote excretion of water replace lost sodium measure I/Os and daily weights assess for inc BP, bounding pulse, crackles, dyspnea, inc peripheral edema, reduced urine output assess neuro status (lethargy, change in LOC) --> seizures monitor serum sodium levels monitor sodium levels

Hyposecretion of ADH

results in diabetes insipidus

Hyposecretion of TSH

results in hypothyroidism, obesity, fatigue, and hypotension

Hyposecretion of FSH

results in infertility and sexual dysfunction

Hyposecretion of LH

results in infertility and sexual dysfunction

Hyposecretion of ACTH

results in infertility, sexual dysfunction, fatigue, and hypotension

Hyposecretion of GH

results in obesity, decreased cardiac output, fatigue, and hypotension

Addisonian Crisis Key Symptoms

severe headaches abdomen, leg, back pain hypotension hyponatremia, hyperkalemia, hypoglycemia shock

Addisonian Crisis Pathophysiology

sodium levels fall, and potassium levels rise rapidly severe hypotension results from the blood volume depletion that occurs with the loss of aldosterone

Emergency Care of Pt with Acute Adrenal Insufficiency - Hormone Replacement

start rapid infusion of normal saline or dextrose 5% in normal saline initial dose of hydrocortisone sodium is 100 to 300 mg or dexamethasone 4 to 12 mg as an IV bolus administer additional 100 mg of hydrocortisone sodium by continuous IV infusion over the next 8 hours give hydrocortisone 50 mg IM concomitantly with hydration every 12 hours initiate an H2 histamine blocker IV for ulcer prevention

Nursing Considerations for Acromegaly

support for patient with changes in appearance - promote positive self image

Preventing Acute Adrenal Insufficiency

teach patients who are taking steroids for more than a week to taper off gradually

Acromegaly Key Features

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

Cushing's Disease/ Syndrome Key Features - Skin Symptoms

thinning skin striae and inc pigmentation acne fine coating of hair over the face and body women - hirsutism, clitoral hypertrophy, male pattern balding

Preventing Infection

thorough hand-washing wearing a mask strict aseptic technique when performing dressing changes or any invasive procedures avoid crowds or others with infections have yearly flu vaccine continually assess for S&S of infection monitor CBC with differential WBC count - inspect mouth during every shift for lesions and mucosa breakdown, assess lungs every 8 hours for crackles, wheezes, or reduced breath sounds, assess all urine for odor and cloudiness