Endocrine DIsorders

Question 1

pituitary gland

Answer 1

■ Master gland
■ Anterior
– Regulates growth, metabolism, and sexual development
– Amongst other things
■ Posterior
– Secretes vasopressin
 ADH
– Amongst other things
■ Problems with the pituitary gland
can cause over- or under- secretion

Question 2

what does ADH do

Answer 2

control urinary output
manage fluids
ADH regulates & balances the amount of water in your blood

Question 3

SIADH

Answer 3

Excessive secretion of ADH  significant
water retention and dilutional hyponatremia  brain edema and increased ICP

Question 4

causes of SIADH

Answer 4

– Cancers (lung, GI, GU, lymphoma)
– Decrease in serum sodium levels
– Pulmonary disorders (severe pneumonia,
lung CA, active TB, positive pressure
ventilation)
– CNS disorders (head injury, brain
surgery/tumor, stroke, subdural
hematoma, and infection)
– Drugs (thiazide diuretics, chlorpropamide, vincristine, phenothiazines, anticonvulsants, nicotine, opioids, tricyclic antidepressants)

Question 5

assessment of SIADH

Answer 5

Findings are most associated with water
retention and low sodium
– Decreased U/O
– Increased weight
– Headache, weakness
– Water retention s/s
– Severe hyponatremia
■ Confusion, decreased LOC
■ Lethargy, irritability
■ Depressed DTRs
■ Myoclonus (cramps and twitching)
■ Asterixis
■ Generalized seizures
■ Coma

Question 6

diagnostics for SIADH

Answer 6

Serum testing: THINK DILUTE
■ Sodium level (less than 135; less
than 120 is dangerous)
■ Serum osmolality < 280mOsm/kg
■ Low BUN and uric acid levels
■ As blood volume increases, blood
osmolarity decreases
Urine testing: THINK CONCENTRATED
■ Increased urine osmolality (shows
kidneys inability to dilute urine) >100
mOsm/kg
■ Urine specific gravity >1.030
■ Urine sodium level >20 mEq/L
■ As urine volume decreases, urine
osmolarity increases.
Labs to r/o other causes

Question 7

nursing management of SIADH

Answer 7

– Fluid restriction
– Monitor I&Os and daily weights
– Observe for hyponatremia s/s, FVO, heart failure/pulmonary edema
– Seizure, safety, and fall precautions
– Reduce environmental stimuli
– Oral care and ice chips
– Assess for neurological changes
– Use 0.9% sodium chloride, instead of water, to flush enteral tubes, and to mix medications or dilute enteral feedings
– Avoid central pontine myelinolysis (rapid rise in sodium changes in serum osmo fluid pulled from brain damage of myelin sheath)

Question 8

medical management of SIADH

Answer 8

– Goal: Promote excretion of water,
Replace low sodium, & identifying/eliminating cause
– Stops meds increasing ADH (listed in causes)
– Restricting fluid intake (<1000 mL)
– Drug therapy
■ Conivaptan
■ Hypertonic saline (3% NaCl) in small, slow amounts via central line and pump; treatment of severe hyponatremia (<120)
■ Diuretics
■ Demeclocycline

Question 9

treatment of choice for pituitary tumor

Answer 9

hypophysectomy

Question 10

how is a hypophysectomy performed

Answer 10

Done through transsphenoidal approach (incision beneath the upper lip) or endonasal (incision through nasal cavity)
– Transsphenoidal has less complications and more visualization of structures
– If both approaches don’t work, craniotomy is done

Question 11

preop for hypophysectomy

Answer 11

– Endocrine tests; general preop labs, informed consent
– Funduscopic and visual field exams
– Assess for sinus infection (contraindication for procedure)
– Corticosteroids before, during, and after surgery to prevent an abrupt drop in cortisol level
– Octreotide to shrink tumor and decrease GH production
– Client teaching

Question 12

post-op hypophysectomy care

Answer 12

■ Monitor VS, cardiac, resp status and CSF leak (halo test, clear drainage)
■ Assess for meningeal irritation
■ Assess visual acuity and fields
– Worsening indicates expanding hematoma
■ HOB 15-30 degrees with midline position
■ Assess electrolytes and I&O, urine specific gravity, daily weight
■ Clear fluids then advance as tolerated
■ IV ABX
■ Check nasal packing for blood and CSF
– Monitor mustache dressing
– Removed 3-4 days postop then it can be cleaned with prescribed solution
■ Oral care Q4 hours
– For sublabial approach, do not brush teeth until healed
– Warm saline mouth rinses
– Mist vaporizer
– Lip balm
– Room humidifier

Question 13

client teaching for hypophysectomy

Answer 13

■ Deep breathe, NO COUGHING!!
■ NO COUGHING, SNEEZING, BLOWING THE NOSE, SUCKING THROUGH A STRAW, BEND AT WAIST, NO STRAINING  increased pressure on surgical site  CSF leak
■ Avoid measures that increase ICP
– High fiber diet
– Others
■ Breathe through mouth and not nose
■ Notify the provider of increased swallowing, postnasal drip, drainage that makes a halo (yellow on the edge and clear in the middle), headache, excessive bleeding, confusion
■ Continuous nursing assessments and teaching
■ Post-op care
■ Monitor for complications

Question 14

diabetes insipidus

Answer 14

ADH deficiency from posterior pituitary (neurogenic) or inability of kidneys to respond to ADH (nephrogenic)
Diabetes insipidus, Decreased ADH, Diuresis

■ Causes excretion of large volumes of dilute urine because water is not reabsorbed
■ Leads to polyuria, increased thirst, dehydration, and disturbed F&E balance (increased sodium)

Question 15

Central (neurogenic)

Answer 15

interference with ADH synthesis, transport, and release; brain tumor, head injury, brain surgery, CNS infections

Question 16

Nephrogenic

Answer 16

inadequate renal response to ADH; hypokalemia, hypercalcemia, renal
damage

Question 17

Psychogenic

Answer 17

excess water intake; lesion in thirst center, psychological disorder

Question 18

clinical manifestations of DI

Answer 18

■ Symptoms of fluid volume deficit (weight loss, hypotension, tachycardia, poor skin turgor, dry mucous membranes)
■ Increased urination (U/O of 3-20 L/day) and excessive thirst; nocturia
■ Urine testing: Think DILUTE
– Decreased urine specific gravity (<1.005)
– Decreased urine osmolality (<200 mOsm/L)
– Decreased urine sodium
– As urine volume increases, urine osmo
decreases
■ Blood testing: Think CONCENTRATED
– Increased blood osmolality (>300 mOsm/L)
– Increased blood sodium (>145): irritability, mental status change, coma
– As blood volume decreases, the blood osmo increases

Question 19

assessment of DI

Answer 19

■ 24-hour urine collection
■ Measure level of ADH after synthetic DH
administration
– Central DI: ADH causes elevation in urine
osmo by 50%
– Nephrogenic: small/no increase in urine
osmo
■ Water deprivation test
– Deprive client of water for 8-12 hours
– Then can give DDAVP SQ
– If the urine becomes more concentrated
following vasopressin injection, it is
neurogenic DI; if little to no change, it is
either nephrogenic DI or psychogenic
polydipsia (a compulsive behavior related
to excessive fluid intake).
– Contraindicated if serum Na is elevated

Question 20

DI medical management

Answer 20

■ Goals: replace ADH, adequate fluid replacement,
identify and treat cause
■ DDAVP
– Orally, intranasally (spray or calibrated tube)
■ Can cause conjunctivitis and rhinitis
■ IM vasopressin (if intranasal not available)
■ For nephrogenic, thiazide diuretics (reduce flow to
ADH sensitive nephrons), chlorpropamide,
Indomethacin to decrease renal responsiveness to
ADH
– But can cause SIADH
■ Treatment for psychogenic
– Prevent water intoxication
■ Do not withhold fluids
■ IV Therapy hydration
■ Avoid fluids and foods that have a diuretic effect
(caffeine)
■ Lifelong vasopressin therapy with permanent condition

Question 21

DI nursing management

Answer 21

■ Maintain adequate fluid volume
■ Monitor weight, VS, I&O
■ Administer vasopressin
– Avoid with cardiac conditions
– Demonstrate how to administer meds
■ Wear a medical alert bracelet and carry med admin
■ Fall precautions
■ Sodium limits of <3 g/day
■ Provide skin and mouth care using a soft toothbrush
and mild mouthwash to avoid trauma to the oral
mucosa.
■ Use alcohol‑free skin care products,