Med Surg: Care of pts with Pituitary and Adrenal Gland Problems

Question 1

What does the hypothalamus do?

Answer 1

Secretes horomones: CRH, TRH, GnRH, GH, Prolactin-releasing horomone

Inhibiting horomones: somatostatin (inhibits GH release) & Prolactin-inhibiting hormone

Question 2

What are the 2 lobes of the pituitary glands?

Answer 2

Anterior: actually release horomones, tropic hormones-control secretion of horomones by other glands (ACTH, FSH, LG, TSH), GH, Prolactin

Posterior: storage area for Oxytocin and antidiuretic hormone also known as Vasopressin which are produced by hypothalamus

Question 3

What is the description of Pituitary gland anterior hypopituitarism?

Answer 3

rare disorder that involves hyposecretion of one or more of the pituitary hormones caued by tumors, trauma, encephalitis, autoimmunity or stroke

Question 4

What are the hormones in the pituitary anterior-hypopituitarism?

Answer 4

GH

Gonadotrop hormones

TSH

Adrenocorticotropic hormone

Anti-diuretic hormone

Question 5

What is the assessment for pituitary gland anterior-hypopituitarism?

Answer 5

S&S vary with degree and speed of onset of pituitary dysfunction (vague)

Symptoms are related to hyposecretion of the target glands

Tumors of the pituitary may also cause headaches, visual defects, loss of smell and seizures

Question 6

What does the GH deficiency of the Pituitary Gland of the anterior-hypopituitarism?

Answer 6

Truncal obesity: metabolism issue

Decreased muscle mass: weak

Decreased energy: decrease carb metabolism

reduced exercise capability

flat affect or appear depressed

impaired psycholgic well-being

Question 7

What do FSH & LH deficiences of the pituitary gland anterior hypopituitarism?

Answer 7

female: menstrual irregularities, diminished libido, chane in secondary sex characteristics (decreased breast size)
male: testicular atrophy, diminished sperm production, loss of libido, impotence, decreased facial hair and muscle mass

Question 8

What is the ACTH and corisol deficiency of the pituitary gland anterior-hypopituitarism?

Answer 8

Weakness and fatigue

headache

dry and pale skin

diminished axillary and pubic hair

postural hypotension to regulate BP

fasting hypoglycemia

diminished tolerance for stress

poor resistence to infection

Question 9

What are the interventions for pituiraty gland anterior-hypopituitarism?

Answer 9

Surgery or irradiation for tumor removal

Provide emotional support to client and family

Encourage client and family to express feelings related to disturbed body image or sexual dysfunction

May need horomone replacement for specific deficient hormones

Education regarding signs and symptoms of hypofunction and hyperfunction related to insufficient or excess horomone replacement

Question 10

What is pituitary gland anterior acromegaly?

Answer 10

Hypersecretion of growth horomone by the anterior pituitary gland in the adult

bones and soft tissues grow thicker

rare-only 3 in 1 million adults in US diagnosed each year

affects genders equally

affects middle-aged adults

Gradual onset so usually 7-9 years between initial onset of symptoms and final diagnosis

Question 11

What is the assessment for anterior-acromegaly?

Answer 11

large hands and feet

thickening and enlargement of bony and soft tissues of face and head

speech diffficulties

sleep apnea

visual disturbances/headaches

thick, leathery and oily skin

peripheral neuropathy

proximal muscle weakness

hypertension

deepening of voice

hyperglycemia

cardiac and respiratory diseases

decrease life expectancy

Question 12

What is the testing for anterior-acromegaly?

Answer 12

GH, IGF levels

Oral glucose tolerance test: give glucose load and see if growth horomone falls

Disgnostic imaging: MRI, CT, tumors present/visable

Question 13

What is treatment of anterior-acromegaly?

Answer 13

surgical-hypophysecromy is treatment of choice

radiation therapy: large tumor or horomone levels remain high

Drug therapy

Encourage client and family to express feeling related to disturbed body image and sexual dysfunction

Provide frequent skin care

Provide pharmacological and nonpharmacological intervention for joint pain

Question 14

What is hypophysectomy?

Answer 14

removal of pituitary tumor via craniotomy or transsphenoidal approach

Also called pituitary adenectomy, transphenodial pituitary surgery

Question 15

What are post-op interventions for hypophysectomy?

Answer 15

craniotomy care

Monior VS, neurological status and LOC any approach

Elevate the HOB 30 degrees at all times

monitor for any postnasal drip or nasal drainage

Instruct client to avoid sneezing, coughing, blowing nose or straining at stool

Monitor electrolyte values for temporary diabetes inspidus or syndrome of inappropiate diuretic horomone

Instruct client in administration of prescribed medications: vasopressin, levothyroxine, gonadotropic horomones, GH, glucocorticoids in gland have been removed

Question 16

What is posterior-diabetes insipidus?

Answer 16

Hyposecretion of ADH or decreased renal response of ADH

• Neurogenic: damage to hypothalamus or pituitary from trauma, irradiation or cranial surgery
• Nephrogenic: renal tubules do not react to ADH
• Primary: from excessive water intake

Kidney tubules fail to absorb water

Question 17

What is the assessment of posterior-diabetes insipidus?

Answer 17

polyuria of 4-24L/day

polydipsia of 4-30L/day

Nocturia

Fatigue

Dehydration

Urine chemistry - think DILUTE

• low urinary specific gravity
• decreased urine osmolarity, urine pH, urine sodium, uring potassium

Serium chemistry

• increased serum osmolarity, serum sodium, serum potassium

CNS symptoms

-irritability and mental dullness to coma

Question 18

What are the interventions for posterior diabetes insipidus?

Answer 18

goal is fluid and electrolyte balance

monitor VS, neurological and cardiovascular needs

provide for safe environment, especially if pt has postural hypotension

monitor electrolyte values and dehydration

maintain intake of adequate fluid PO and IV

monitor I&O, weight, serum osmolarity and urine gravity

instruct client to avoid food and liquids that produce diuresis

Chlorpropamide or carbamazepine may be prescribed for mild diabetes insipidus

Vasopressin tannate for ADH deficient severe or chronic

Instruct client in the administration of medicaitons as prescribed

Nephrogenic: low NA+ diet, thiazide diuretics, Indomethacin

Instruct client to waer medic-Alert bracelet

Question 19

What is SIADH?

Answer 19

Syndrome of inappropiate antidiuretic hormone

excess ADH is released by not in response to bodies need

causes include trauma, stroke, malignancies, medications and stress

results in water intoxication and hyponatremia

Question 20

What are the assessments of posterior SIADH?

Answer 20

signs of fluid volume overload

changed in LOC and mental status change

weight gain

dilutional hyponatremaia

hypochloremia

concentrated urine in presence of normal or increased intravascular volume

serum hypoosmolarity

Question 21

What are interventions of posterior SIADH?

Answer 21

goal is to treat underlying cause

Monitor VS, cardiac and neurological status

provide safe environment, particullary for the client with changes to LOC of mental status

monitor I&O, daily weight

monitor fluid and electrolyte balance

monitor serum and urine osmolarity

restrict fluid intake as prescribed 500-1000ml/day

administer diuretics and IV fluids, monitor IV fluids carefully

Demeclocycline may be prescribed

Question 22

What is the adrenal gland?

Answer 22

regulates sodium and electrolyte balance

affects carbohydrate, fat and protein metabolism

Sustains fight or flight response

Question 23

What are the glucocorticoids in adrenal glands?

Answer 23

Cortisol, cortisone, corticosterone

Glucose metabolism

protein metabolism

fluid and electrolyte balance

suppression of inflammatory response to injury

Protective imune response to invasion by infections agents

Resistance to stress

Question 24

What are the mineralcorticoids in the adrenal gland?

Answer 24

Aldosterone

regulation of electrolyte balance by promoting sodium retention and potassium excretion

Question 25

What is Addison’s Disease?

Answer 25

hyposecretion of adrenal cortex horomones

All 3 corticosteriods are reduced

Most commonly from an autoimmune response

Can be from TB, infarction, fungal infections, HIV or metastatic cancer

May be very advanced before diagnosed

Fatal if left untreated.

Question 26

What is the assessment for Addison’s Disease?

Answer 26

Lethargy, fatigue and muscle weakness

GI disturbance/anorexia/N&V/diarrhea

Weight loss

salt craving

Menstrual changes

Hypoglycemia, hyponatremia

Hyperkalemia, hypercalcemia

Postural hypotension

Hyperpigmentation of skin

Question 27

What is intervention for Addison’s Disease?

Answer 27

Monitor VS esp BP, weight and I&O

Monitor blood glucose and potassium levels

Administer glucocorticoid and minteralocorticoid medications as prescribed

Protect from exposure to infection

Protect patient from noise, light and temp extremes

Observe for addisonian crisis caused by stress, infection, trauma and surgery

Question 28

What is client education regarding Addison’s Disease?

Answer 28

Avoid individuals with infections

diet: high protein, high carb and normal sodium intake

avoid strenuous exercise and stressful situations

need lifelong glucocorticoid therapy

Avoid over-the-counter medications

Wear a Medic-Alert bracelet

Signs and symptoms related to over- or under- replacement of horomones

Question 29

What is an Addisonian Crisis?

Answer 29

Life threatening disorder caused by acute adrenal insufficiency

Question 30

What is Addisonian crisis precipitated by?

Answer 30

Stress

Sudden withdrawal of exogenous corticosteriod horomone replacement therapy

Adrenal surgery

Sudden pituitary gland destruction

Question 31

What is the assessment for Addisonian Crisis?

Answer 31

Tachycardia

Dehydration

Hyponatremia

Hyperkalemia

Hypogycemia

Fever

Weakness

Confusion

Question 32

What are manifestations of Addisonian Crisis?

Answer 32

Hypotension may lead to shock

Circulatory collapse may not respond to vasopressors and fluid replacement

GI: severe vomitting, diarrhea, pain in abdomen

Pain in lower back and legs

Question 33

What are interventions for Addisonian Crisis?

Answer 33

Prepare to administer glucocorticoids IV as prescribed

After crisis resolves: PO glucocorticoids and mineralocorticoids

Monitor VS especially BP

Monitor neuro status noting irritability and confusion

Monitor I&O

Monitor lab values: sodium, postassium and glucose

Administer IV fluids and prescribed to restore electrolyte imbalance

Protect client from infection

Bedrest and quiet environment

Question 34

What is Cushings Disease?

Answer 34

Hypersection of glucocorticoids from the adrenal cortex

Cushings disease: metabolic disorder by abnormally increased secretions of cortisol

Cushings syndrome: metabolic disorder resulting from chronic and excessive production of cortisol by the adrenal cortx or by administration of glucocorticoids in large doses for several weeks or longer

Question 35

What is the assessment of Cushings disease?

Answer 35

General muscle wasting and weakness

Moon face, buffalo hump

Truncal obesity with thin extremities, supraclavicular fat pads, weight gain

Hirsutism

Hyperglycemia, hypernatremia

Hypokalemia, hypocalcemia

Hypertension

Fragile skin that bruises easily, poor wound healing

Red-purple striae on abdomen and upper thighs

Question 36

What are interventions for Cushing disease?

Answer 36

Monitor VS especially BP

Monitor I&O, weight

Monitor lab values: WBC, serum glucose, Na+, K+, Ca+

Diet: decrease sodium, increase protein, K, Calcium

Provide meticulous skin care

Allow client to discuss feelings about body apperance

Administer chemotherapeutic agents as prescribed for inoperable adrenal tumors, radiation for pituiatary adenoma, hypophysectomy or adrenalextomy

Question 37

What is Phenochromocytoma?

Answer 37

Catecholamine-producing tumor usually found in the adrenal medulla

Excessive amounts of epinephrine and norepinephrine are secreted

Diagnostic tests include 24 hour urine collection for anillymandelic acid

Question 38

What is the assessment for Pheochromocytoma?

Answer 38

Sustained hypertension

Severe, pounding headaches

Tachycardia with palpitations

Flushing and profuse diaphoresis

Pain in the chest or abdomen with N/V

Question 39

What are the triggers of pheochromocytoma?

Answer 39

Medications-antihypertensives

opiods

X-ray contrast media

tricyclic antidepressants

Question 40

What are interventions of pheochromocytoma?

Answer 40

Monitor VS, BP and HR

Hypertensive crisis complications (stroke, cardiac dysrhythmias, MI)

Stimuli that can precipitate hypertensive crisis

Instruct not to smoke, drink caffeine-containing beverages or change position suddenly

Administer antihypertensives as ordered

Promote rest and nonstressful environment

Diet: high in calories, minerals and vitamins

Prepare for adrenalextomy

Question 41

What is adrenalectomy?

Answer 41

Surgical removal of an adrenal gland

Lifelong glucocorticoid and mineralcoricoid replacement therapy if removed

Temporary glucocorticoid replacement after unilateral adrenalectomy

Catecholamine levels drop which can result in cardio collapse, hypotension and shock

Hemorrhage may occur because of the high vascularity of adrenal glands

Question 42

What are the postoperative interventions of Adrenalectomy?

Answer 42

Monitor VS

Monitor I&O, <30ml/hr: renal failure and impending shock

Daily weight

Monitor electrolyte and serum glucose levels

Monitor for shock and hemorrhage, check dressing

Monitor for paralytic ileus

Administer: IV fluids, glucocorticoids, mineralocorticoids, analgestics as prescribed

Pulmonary toilet

Instruct client on hormone replacement therapy

Instruct client on need to wear Medic-Alert bracelet