Module 5: Problems of Endocrine/Regulatory Function Flashcards
Pituitary Gland: Functions (7)
- Growth
- Metabolism
- Response to Stress
- Fluid and Electrolyte Balance
- Reproduction
- Lactation
- Labor
NOTE: Hormones maintain hemostasis of cellular function through negative feedback mechanism; signaling to endocrine glands to secrete hormones in response to body change.
Anterior Pituitary Gland: Hormones Secreted (think: “TP FLAG” – TSH, Prolactin, FSH, LH, FSH, ACTH, GH) + MSH
~ Corticotropin – Adrenocorticotropic Hormone (ACTH)
- Stimulates ADRENALS to make cortisol(!!); adrenals are located on top of each kidney
- Glucocorticoids –> Cortisol
- “Stress Hormone”
- Maintain BP
- Regulate blood glucose
- Decrease inflammation
- Promote and regulate metabolism
- Resistance to stress
- Fluid regulation
- Mineralocorticoids –> Aldosterone
- Fluid and Electrolyte Balance
- Catecholamines –> Epi and Norepi
~ Growth Hormone (GH)
- Stimulates GROWTH; Target –> ALL cells
- Children: Overall growth (i.e. height)
- Adults: Maintain muscle, bone, and fat distribution; role in metabolism
~ Thyrotropin – Thyroid Stimulating Hormone (TSH)
- Stimulates THYROID to produce thyroid hormones:
- Thyroxine (T4) and Triiodothyronine (T3))
- Metabolism
- Energy levels
- Nervous system (HR, temp,..)
- Thyrocalcitonin (TCT or Calcitonin)
- Regulates calcium levels
~ Follicle-Stimulating Hormone (FSH)
- Gonadotrophic hormone
- Reproductive glands
~ Luteinizing Hormone (LH)
- Gonadotrophic hormone
- Target ovaries and testes
~ Prolactin (PL)
- Target breasts
~ Mylenocyte Stimulating Hormone (MSH)
- Unknown role in humans at this time.
- Target?
Posterior Pituitary Gland: Hormones Secreted (think: “ANy Other” – ADH, oxytocin)
~ Antidiuretic Hormone (ADH) – or, Vasopressin
- Target –> Kidneys
- Regulates water balance
- Regulates Na levels
~ Oxytocin
- Target –> uterus and breast
(NOTE: Hypothalamus makes, posterior lobe of pituitary STORES.)
What is HYPOpituitarism?
A: Deficiency of ONE or MORE pituitary hormone
- Selective Hypopituitarism
- Only one hormone deficiency; most common(!!)
- Panhypopituitarism
- All hormones deficient
- Or, somewhere in the middle
NOTE: most serious are deficiencies of thyroid and adrenal(!!)
HYPOpituitarism: Causes
- Pituitary tumor – benign or malignant; compress or destroy pituitary tissue
- Malnutrition, Rapid Wt Loss
- Shock – Hypotension, Ischemia to pituitary tissue
- Head Trauma
- Brain Tumor
- Brain Infection
- Radiation of head or brain
- Surgery of head or brain
- Final stages HIV
- Idiopathic hypopituitarism – unknown cause
- Sheehan Syndrome – Infarction
HYPOpituitarism: Assessment
- Manifestation –> Under-secretion(!!)
- Changes in target organs
If pituitary tumor:
- Visual changes
- Headache
- Limited eye movement
- Reduced Cognition
Gonadotropic deficiency (LH, FSH)
- Reproductive organs
- Hair loss
- Decreased libido
- Changes in sex characteristics
- Amenorrhea
- Testicular failure
- Ovarian failure
- Infertility
Growth Hormone (GH)
- Child – Short Stature (child)
- Adult – Reduced bone density (adult) – Osteoporosis, Fractures; Reduced muscle mass; Weight gain; Sensitivity Heat or Cold; Lethargy, fatigue
HYPOpituitarism: Interventions
Hormone replacement therapy
Testosterone
- IM injection, patch, pill, or gel
- Contraindicated with prostate cancer(!!)
- May cause gynecomastia, prostate enlargement, and baldness
Estrogen
- Patch, gel, pill or implant
- Risk: Thrombosis and HTN
Progesterone
- Clomid
Gonadotropin releasing hormone (GnRH)
Growth Hormone Deficiencies
- Subq injection
HYPERpituitarism: Overivew + Causes
Oversecretion of pituitary hormones(!!)
Causes:
a) Tumors (Pituitary Adenomas) – most common cause of hyperpituitarism!!
- Classified by hormone they secrete
- Prolactin secreting tumors are most common.
- Growth Hormone
- Adrenocorticotropic Hormone
- As they grow they can compress brain tissue
- Neuro changes
- Vision changes
- Headache
- Increased ICP
b) Hyperplasia
- An enlargement of an organ or tissue caused by an increase in the amount of organic tissue that results from cell proliferation.
HYPERpituitarism: Acromegaly
- Overproduction of Growth Hormone (GH)
- Slow, gradual progression
- Enlargement of hands, feet, face.
- Increased skeletal thickness
- Hypertrophy of skin
- Enlargement of organs
- Bone cell overgrowth
- Breakdown of cartilage
- Hypertrophy of ligaments, vocal cords, eustachian tubes
- Hyperglycemia
- Reversible vs. Permanent
HYPERpituitarism: Diagnostics
- Suppression Testing(!!): Give glucose (to induce hyperglycemia) and measure GH levels.
- High glucose levels suppress release of GH.
- High levels of GH, greater than 1ng/mL or unchanged are positive for hyperpituitarism(!!)
Others:
- Skull x-ray
- CT scan
- MRI
- Labs, to check hormone levels
HYPERpituitarism: Interventions
Drug Therapy
- Dopamine agonists (i.e., Bromocriptine, Cabergoline) – stimulate dopamine receptors in the brain and slows release of GH and Prolactin.
- Side Effects (know these!!):
- Orthostatic hypotension
- GI irritation; given with food!
- HAs
- Dysrhythmias (rare)
- CSF leakage (rare)
- Somatostatin Analogs (i.e., Ocreotide, Lanreotide) – inhibits GH release
- GH receptor blocker (i.e., Pegvisomant) – blocks GH receptor activity; weekly injections(!!)
Radiation Therapy
- May take months to years
- Not recommended for acromegaly
- Side effects may be noted.
Surgery
- Hypophysectomy
- Most common intervention for hyperpituitarism
- Surgical removal of pituitary and tumors.
- Post Op:
- Nasal packing, drip dressing
- Special oral care
- NOTHING to increase ICP (no coughing, sneezing, bending, lifting, etc.)
- Observe for complications, such as: diabetes insipidus (DI), CSF leak, infection, increased ICP, meningitis(!!)
(NOTE: If entire pituitary removed, will require life-long HRT!)
Posterior Pituitary Disorder: SIADH (Soaked Inside; drowning in ADH!!)
SIADH: General Overview
- Excess ADH (vasopressin)
- Water retention
- Low Na
- Fluid Overload
- ADH is secreted despite osmolarity being low or normal. (note: normally, decrease in osmolarity –> decrease in ADH)
SIADH: Causes
- Cancer therapy
- Pulmonary infection or impairment
- Certain drugs (SSRIs….)
SIADH: Key Features
- Water retention
- Fluid OVERLOAD
- Neuro (i.e., Lethargy, Headache, Restlessness, Disoriented, Decreased LOC, Decreased DTR, May lead to unresponsive, coma, seizures!!)
- Cardiac (i.e., Bounding pulse, Hypothermia, NO dependent edema (d/t water retention + sodium loss))
- GI (i..e, Loss appetite, N/V)
- GU (i..e, Low UOP, Concentrated urine)
SIADH: Interventions
- General:
- Restrict fluid intake (500-1000 mL/24 hours; STRICT I&O(!!))
- Replace Sodium
- Daily Weights
- Mouth care
- Monitor for Fluid Overload (s/s – JVD)
- Drug Therapy
- Vasopressin antagonists (Low Sodium Levels) – “Vaptans” (i..e, Tolvaptan PO, Conivaptan IV); promote water excretion, retain sodium!!; SE: rapid increase Na, liver failure, death (YIKES!)
- Diuretics (Normal sodium levels) – Used less often(!!); increases sodium loss…used primarily with HF with “normal” levels of Na.
- Hypertonic saline–3% NaCl (low sodium levels) – used when sodium levels are VERY low; can cause HF and preexisting overload worse; SE: Pulmonary edema, HF, Overload.
EXTRA: Lil’ Tid Bit of Info r/t Na Levels:
- Hyponatremia can be very dangerous (Na < 120 can lead to seizures!!), but, correcting sodium too quickly can, too!; never correct the sodium too quickly (8mmol/L per 24hours)
- WHY? – Rapid correction of severe hyponatremia can result in serious neurologic complications, including osmotic demyelination(!!)
- Considerations:
- Frequent neuro assessments
- Create safe environment
- Reduce stimulation, noise, dim lights,
- Fall precautions
Posterior Pituitary Disorder: Diabetes Insipidus (think: Dry Inside; not enough ADH!)
Diabetes Insipidus (DI): General Overview
- Disorder of the POSTERIOR pituitary
- Antidiuretic Hormone (ADH) deficiency or inability of kidneys to respond to ADH.
- Excess fluid loss
- High UOP
- Dilute urine
- Dehydration
- Fluid and electrolyte imbalances
DI: Causes
- Pituitary
- Head injury
- Surgery
- Certain medications
DI: Classified as
- Neurogenic
- Nephrogenic – Kidneys fail to respond to ADH
- Drug Related – Lithium & demeclocycline interfere with kidney’s ability to respond to ADH.
DI: Primary or Secondary
- Primary –> Lack of ADH production or release
- Secondary –> not caused by pituitary abnormality.
DI: Key Features
Cardiac:
- Hypotension
- Tachycardia
- Weak peripheral pulse
- Hemoconcentration
Renal:
- Increased UOP
- Diluted urine
Skin:
- Poor skin turgor
- Dry mucous membranes
Neuro:
- Decreased cognition
- Ataxia
- Increased thirst
- Irritability
Diabetes Insipidus: Assessment
Fluid balance
- I&O
- UOP
- Daily weights
- Hypovolemic Shock
- Increased thirst – Watch for water toxicity (s/s: change in LOC, confusion, weight gain, etc.)
Electrolyte imbalances
- Serum Osmo (320s – high; normal 280)
- Na
- Urine Osmo (low; gettin’ rid of ONLY H2O - holdin’ on to salt)
DI: Diagnostics
Blood tests
- Serum Osmolarity (>300)
- Serum Na (>145)
Urine tests
- Specific gravity (Less than 1.005)
24 hour I&O
- DI if >4L UOP and > ingested oral intake
- DI can be 4L-30L output/day
Diabetes Insipidus: Interventions
General:
- EARLY detection(!!)
- Maintaining hydration
- Encouraging oral intake of fluids (note: ff unable to take PO, then IV)
- DI can be a permanent
- DI can be FATAL
Drug Therapy:
- Desmopressin (DDAVP) – Synthetic form of vasopressin (antidiuretic hormone)
- IV Fluids – Assess hydration status; I&Os
If permanent, education!! (i.e., daily weights, s/s of dehydration, addt’l doses(?), etc.)
Adrenal Disorder: Adrenal Gland HYPERfunction – Cushing’s Disease
Cushing’s Disease: General Overview
- EXCESS Cortisol and Aldosterone
- Caused by a problem with adrenal cortex, pituitary, or hypothalamus
Common causes
- Pituitary adenoma = Cushing’s Disease (a specific type of Cushing syndrome!)
- Glucocorticoid therapy (i.e., prednisone) = Cushing’s Syndrome
Cushing’s Disease: Assessment
- Presence of glucocorticoids affects metabolism
- Increased body fat, due to slow turnover of plasma fatty acids.
- Truncal obesity
- Buffalo Hump
- Moon face
- Weight gain
- Decreased muscle mass, due to breakdown of tissue protein
- Decreased strength
- Bone density loss – osteoporosis, fractures, muscle atrophy
- Thin skin, striae, increased pigmentation
- Fragile capillaries
- Decreased Immunity
- Decreased lymphocyte production – decreased spleen size and lymph nodes
- Decreased WBC production – increased infection risk(!!)
- Increased androgen production
- Acne
- Increased body hair
- Altered menses
- Decrease progesterone and estrogen
- Additional Features:
- Fatigue, weakness
- Hyperglycemia – can’t move glucose into cells
- F&E imblanaces; HTN, bounding pulse, dependent edema, bruising/petechiae
- Increase in hydrochloric production – Ulcers?
- Mood swings, sleep disturbances, depression, confusion, may not “feel” like themselves
Cushing’s Disease: Diagnostics
- Cortisol Levels – Blood, Saliva, and Urine
- ACTH levels (varies d/t culprit)
- Pituitary –> increased
- Adrenal –> decreased
- Cushing’s Syndrome –> decreased
- Dexamethasone suppression testing(!!)
- Given dose of dexamethasone –> collect urine for 24 hours (Normal: dexamethasone suppresses cortisol and corticosteroid secretion(!!))
- Other Labs:
- Glucose: Hyperglycemia
- Sodium: Hypernatremia
- Calcium: Hypocalcemia
- Lymphocytes: Reduced Lymphocytes
- CT, MRI, Arteriogram: Looking for lesions
Cushing’s Disease: Interventions (GOAL = Reduction of cortisol)
Manage Fluid and Electrolytes!!)
- Monitor Electrolytes
- Monitor and prevent fluid overload
- Normotensive
- I&O
- UOP
- Weight(!!)
Nutrition
- Restrict fluids
- Sodium restrictions
- High vit D
Normal Body Weight(?) – Body Image disturbances
Skin assessment
- Breakdown prevention
- Barrier creams, lotion
- Avoid tapes or remove as soon as possible
Fractures
- Fall Prevention
- Mobility aids
GI bleeds
- PUD prophy
- Avoid NSAIDS
- Antiacid use
Infection prevention
- Handwashing
- Monitor labs (WBC, CBC…)
- Fever
- UTI S&S
- Pulmonary Hygiene
- Aseptic technique
MS
- Rehab/PT/OT
- Assistance with ADL’s
- May need home health or rehab
Drug Therapy (monitor drug response!!)
- Goal is to inhibit or interfere with ACTH
- Steroidogenesis inhibitors
Surgery
- Pituitary Adenoma (i.e., Hypophysectomy, removal pituitary)
- Adrenal adenoma (i.e., Adrenalectomy, can be removal of one or both) – If both adrenals, will require lifelong gluco & mineralocorticoids; In unilateral, HTR until single adrenal increases hormone production, may take up to 2 years.
Radiation
