Med Surg: Care of pts with Pituitary and Adrenal Gland Problems Flashcards
What does the hypothalamus do?
Secretes horomones: CRH, TRH, GnRH, GH, Prolactin-releasing horomone
Inhibiting horomones: somatostatin (inhibits GH release) & Prolactin-inhibiting hormone
What are the 2 lobes of the pituitary glands?
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
What is the description of Pituitary gland anterior hypopituitarism?
rare disorder that involves hyposecretion of one or more of the pituitary hormones caued by tumors, trauma, encephalitis, autoimmunity or stroke
What are the hormones in the pituitary anterior-hypopituitarism?
GH
Gonadotrop hormones
TSH
Adrenocorticotropic hormone
Anti-diuretic hormone
What is the assessment for pituitary gland anterior-hypopituitarism?
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
What does the GH deficiency of the Pituitary Gland of the anterior-hypopituitarism?
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
What do FSH & LH deficiences of the pituitary gland anterior hypopituitarism?
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
What is the ACTH and corisol deficiency of the pituitary gland anterior-hypopituitarism?
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
What are the interventions for pituiraty gland anterior-hypopituitarism?
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
What is pituitary gland anterior acromegaly?
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
What is the assessment for anterior-acromegaly?
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
What is the testing for anterior-acromegaly?
GH, IGF levels
Oral glucose tolerance test: give glucose load and see if growth horomone falls
Disgnostic imaging: MRI, CT, tumors present/visable
What is treatment of anterior-acromegaly?
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
What is hypophysectomy?
removal of pituitary tumor via craniotomy or transsphenoidal approach
Also called pituitary adenectomy, transphenodial pituitary surgery
What are post-op interventions for hypophysectomy?
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
What is posterior-diabetes insipidus?
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
What is the assessment of posterior-diabetes insipidus?
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
What are the interventions for posterior diabetes insipidus?
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
What is SIADH?
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
What are the assessments of posterior SIADH?
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
What are interventions of posterior SIADH?
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
What is the adrenal gland?
regulates sodium and electrolyte balance
affects carbohydrate, fat and protein metabolism
Sustains fight or flight response
What are the glucocorticoids in adrenal glands?
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
What are the mineralcorticoids in the adrenal gland?
Aldosterone
regulation of electrolyte balance by promoting sodium retention and potassium excretion
What is Addison’s Disease?
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.
What is the assessment for Addison’s Disease?
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
What is intervention for Addison’s Disease?
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
What is client education regarding Addison’s Disease?
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
What is an Addisonian Crisis?
Life threatening disorder caused by acute adrenal insufficiency
What is Addisonian crisis precipitated by?
Stress
Sudden withdrawal of exogenous corticosteriod horomone replacement therapy
Adrenal surgery
Sudden pituitary gland destruction
What is the assessment for Addisonian Crisis?
Tachycardia
Dehydration
Hyponatremia
Hyperkalemia
Hypogycemia
Fever
Weakness
Confusion
What are manifestations of Addisonian Crisis?
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
What are interventions for Addisonian Crisis?
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
What is Cushings Disease?
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
What is the assessment of Cushings disease?
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
What are interventions for Cushing disease?
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
What is Phenochromocytoma?
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
What is the assessment for Pheochromocytoma?
Sustained hypertension
Severe, pounding headaches
Tachycardia with palpitations
Flushing and profuse diaphoresis
Pain in the chest or abdomen with N/V
What are the triggers of pheochromocytoma?
Medications-antihypertensives
opiods
X-ray contrast media
tricyclic antidepressants
What are interventions of pheochromocytoma?
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
What is adrenalectomy?
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
What are the postoperative interventions of Adrenalectomy?
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
