Pituitary and Adrenal Gland Problems/Care, Ch. 57 (Iggy)

Question 1

-PITUITARY ADENOMAS are slow-growing, benign tumor
—>commonly in adults 40-60 yr
***EARLY SX=Visual Changes
–HYPERsecretory pituitary adenomas secrete an excess of a particular hormone
—>prolactin, GH, or ACTH; the SX will match the Hormone

Answer 1

REASON for Pituitary Gland Malfunction

**Pituitary gland is close to the optic nerve=Visual changes are 1st SX noticed

Question 2

Headaches
EARLY S: Visual changes (LOW visual acuity or LOW peripheral vision)
Loss of sense of smell
Nausea and vomiting
LATE S: Seizures
**S/SX assoc. w/ hyposecretion of the target glands vary widely depending on the affected hormones

Answer 2

CLINICAL MANIFESTATIONS:
Hypopituitarism

Hormone Specific

Question 3

*Can be subtle, nonspecific findings
S/SX: Truncal obesity, osteoporosis, LOW muscle mass and strength, weakness, fatigue, depression/flat affect

Answer 3

MANIFESTATIONS:
Hypopituitarism
*Growth Hormone (GH)

Question 4

WOMEN: Menstrual irregularities, LOW libido, changes in secondary sex characteristics: decreased breast size/axillary/pubic hair.

MEN: Testicular atrophy, LOW ejaculate volume, LOW libido, impotence, decreased facial hair, LOW bone density/muscle mass

Answer 4

MANIFESTATIONS:
Hypopituitarism
*Follicle-Stimulating Hormone (FSH) &
Luteinizing Hormone (LH)

Question 5

Involves CORTISOL deficit: Weakness, fatigue, headache, dry/pale skin, diminished axillary/pubic hair, LOW resistance to infection, fasting hypoglycemia

Answer 5

MANIFESTATIONS:
Hypopituitarism
*Adrenocorticotropic Hormone (ACTH)

Question 6

TX: Life-long ANDROGEN (testosterone) THERAPY
-Begin w/ high dose until Virilization has occurred then dose is reduced
Virilization S: ^ penis size/ libido/beard thickness/hair growth/ muscle mass/ bone strength, and deepening of voice
TEACH: How to inject/ rotate sites at PM; Disposing of sharps; Prevent infection; Has to be life-long; Routine LAB work; REPORT when sx improve so dose can be lowered

Answer 6

Hypopituitarism:
Gonadotropin (LH and FSH) Deficiency

Question 7

A nurse provides care to a patient diagnosed with adrenocorticotropic hormone (ACTH) deficiency. What is the nurse’s first priority action?
A. Assess temperature for signs of infection
B. Wash hands before entering the room
C. Wear gloves when touching the patient
D. Apply lotion to dry skin

Answer 7

B. Wash hands before entering the room

Question 8

For hypo/hyperpituitarism
Need routine LAB visits
–Entire pituitary gland is removed = permanent loss of all pituitary hormones.
The pt. will require lifelong replacement of GH, TSH, sex hormones, and glucocorticoids.

Answer 8

SURGICAL INTERVENTION:
*Transsphenoidal Hypophysectomy

Question 9

** ^ HOB at all times to a 30-degree angle (high Fowler’s)
–Gentle mouth care q4hr (essential to keep the surgical area clean and free of debris)
AVOID brushing teeth for at >10 days=protect the suture line.
-**AVOID anything that ^ intracranial pressure like: Don’t hold it in
Blowing the nose, Vigorous coughing, Sneezing, Straining with stools (Valsalva maneuver)
**CHECK any CLEAR drainage from the nose (A.K.A postnasal drips; HALO S) with a URINE DIPSTICK for glucose and protein.
**Glucose >30 mg/dL indicates CSF leakage from an open connection with the brain R/T RISK for MENINGITIS

Answer 9

SURGICAL INTERVENTION:
Hypophysectomy

Question 10

Lovenox-anticoagulant prevent blood clots (Low molecular wt. heparin)
Laxatives-Prevent Constipation r/t decrease intracranial pressure
Compression Pumps on Legs

Answer 10

MEDS: Post-Op
Transsphenoidal Hypophysectomy

Question 11

Complaints of a persistent or severe headache, frequent swallowing, and feeling of a runny noise= pos. CSF LEAKAGE into the sinuses.
**Look for clear drainage (halo sign) on the mustache dressing.
Any sign of a CSF leak= REPORT to HCP ASAP.
–A CSF leak usually resolves within 72 hours when treated with head ^ and bed rest.
–If the leak persists, daily spinal taps may be done to reduce pressure to below-normal levels.

Answer 11

POST-OP CONSIDERATIONS:
Hypophysectomy

Question 12

Hormone ^ excretion r/t anterior pituitary tumors or tissue hyperplasia
–^^ GH in adults results in ACROMEGALY
–>Bones length of the arms and legs Average b/c the problem occurs AFTER epiphyseal closure (after puberty)
—>Before= Gigantism
DX: 40-45 years old
–>Thickening and enlargement of soft tissues and bones in the hands, feet, and face

Answer 12

PATHO: Hyperpituitarism

Question 13

Hypersecretion of GH happens BEFORE the epiphyseal closure @ puberty.
–Very tall (ex: 8ft; die early around 22)

Answer 13

Hyperpituitarism
Gigantism

Question 14

^^ GH after puberty
S/SX: No nose bridge, Prominent chin/ frontal bone “Planting Forehead”/box-like jaw bone, Leathery skin, Generalized course/ thick
Hard IV access=Need larger bore needle

Answer 14

Hyperpituitarism-
Acromegaly

Question 15

DX: Evaluation of plasma insulin-like growth factor (IGF-1) lvls and GH response to ORAL glucose tolerance TEST
S/SX: KEEP GROWING PAST PUBERTY
^ BP, Diaphoresis, Hyperglycemia (insulin resistant= need insulin), Thickened (course) Skin,
Deep voice, mood swings, headaches
enlarged hands and feet
Enlarged Lips/spleen, Increased foot/shoe size(KEY sx), Kyphosis (hump-back)

Answer 15

CLINICAL MANIFESTATION:
Hyperpituitarism
Acromegaly

Question 16

–Short life expectancy.
–S/SX: Proximal muscle weakness and joint pain; enlargement of lips/ tongue, Deep voice, thick and leathery skin.
–other S/SX acne, visual changes r/t pressure on the optic nerve, and headaches.
–^ Risk: cardiovascular disease; DM (Polydipsia and polyuria); colorectal cancer; carpal tunnel syndrome; peripheral neuropathy; dental problems; speech difficulties; sleep apnea; glucose intolerance

Answer 16

CLINICAL MANIFESTATIONS
Acromegaly

Question 17

MEDS: Somatostatin analogs, dopamine agonists, and/or GH antagonists.
Stop meds if pregnant
–Somatostatin analogs: Reduces GH levels to normal.
ADMIN SubQ injection 3qwk
–>Long-acting somatostatin analogs
Octreotide; Pasireotide; Lanreotide SR*
IM injections 1q4wk
GH levels LABS q2wk=guide drug dosing, then q6mnth until the desired response is achieved
**Serial photographs: showing improvement in appearance may be helpful to the pt. recovery r/t dec. anxiety/ smoother skin/ ^ self image

Answer 17

MEDS: Acromegaly

Somatostatin analogs, dopamine agonists, and/or GH antagonists.

Question 18

If a patient with acromegaly is well controlled, manifestations such as joint pain and bone deformities often improve or go away after treatment.
Is this True or False?

Answer 18

False
–Smoother skin can happen

Question 19

–EVALUATION of plasma insulin-like growth factor (IGF-1) levels and GH response to an oral glucose tolerance test
–MRI or CT scan with contrast media can detect pituitary adenomas.
–**If tumor is detected: A complete eye exam, including visual field test R/T a tumor may cause pressure on the optic chiasm or optic nerves.

Answer 19

DIAGNOSTIC TESTING
Acromegaly

Question 20

TX of choice.
–Best chance for a cure and optimal symptom management.
–Immediate reduction in GH levels followed by a drop in IGF-1 levels within a few weeks.
–LARGE TUMORS or GH levels >45 ng/mL may require adjuvant radiation or drug therapy.

Answer 20

SURGICAL INTERVENTION:
Acromegaly=Hypophysectomy

Question 21

1. ^^ADH
2. ^^ water reabsorption in RENAL tubules
3. ^^ INTRAvascular (outside cell-into body=dehydration=edema) fluid volume
4. Dilutional Hyponatremia and LOW serum Osmolality (LOW urine output)

Answer 21

PATHO:
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)

“SI”= soaked inside

Question 22

Serum (plasma) findings:
*labs all low
Water retention
LOW: hyponatremia (serum)/ serum (plasma) osmolarity/
Serum (plasma) specific gravity

Urine findings:
*labs all ^
LOW: urine output
^^ urine osmolarity/ urine specific gravity (r/t concentrated urine)/ sodium in the urine

Answer 22

CLINICAL MANIFESTATION:**
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)

Serum LOW/ Urine HIGH

Question 23

S/SX:***
Increased thirst
Lethargy
Headaches
Confusion
Can progress to irritability, muscle twitching, n/v, decreased responsiveness, seizures, coma, and death

Answer 23

S/SX: SIADH
***

Question 24

Common r/t SMALL CELL LUNG CANCER
**PRIORITY: Infuse hypertonic (EX: 3% NaCl) Infusion SLOWLY Never bolus or rapidly infuse.
–STRICT fluid restriction: May be as low as 500 ml in 24 hours.
**Vasopressin receptor antagonists= promote water excretion w/out NA loss
**Lasix and K Supp = ONLY if serum NA is <125mEq/l
Only used if serum sodium is at least 125 mEq/L
–HOB NOT ^ >10 degrees. R/T
Maximizing venous return helps AVOID stimulating stretch receptors in the heart that signal more ADH

Answer 24

INTERVENTIONS
SIADH

Question 25

1. LOW ADH
2. LOW water reabsorption in RENAL tubules
3. LOW intravascular fluid volume= ^^Serum osmolality/ hypernatremia & ^^urine output

Answer 25

PATHO:
Diabetes Insipidus (DI)

Question 26

–>Central or Neurogenic DI
**common; interference with ADH synthesis, transport, or release
Ex: (Past or Present )Brain tumor, head injury, brain surgery, CNS infections
–>Nephrogenic DI
Inadequate renal response to ADH despite the presence of adequate ADH
Ex: Drug therapy (especially **lithium), renal damage, hereditary renal disease
–>Primary DI
caused by ^^ water intake
Ex: Structural lesion in thirst center, psychologic disorder

Answer 26

TYPES of DI

** Central or Neurogenic DI=most common=brain injury**

Question 27

–^^ Serum hypernatremia
Polydipsia (increased thirst)
Polyuria (increased urinary output) up to 20L/day; >200mL/hr
–LOW urinary specific gravity (<1.005)
—LOW urine osmolality of <100 mOsm/kg (100 mmol/kg)
—^^serum osmolality (usually >295 mOsm/kg) because of hypernatremia
S/SX: Fatigue r/t nocturia
UnTX hypernatremia=brain shrinkage and intracranial bleeding

Answer 27

CLINICAL MANIFESTATIONS
DI

Question 28

^^^cortisol levels
CAUSE: (Common) ** long-term use of corticosteroids (e.g., prednisone).
(Not common) adrenal tumors and ectopic ACTH production by tumors (in lung or pancreas).
–**DX: more common in 20- to 40-year-old women.
**^^ RISK for infection.
TEACH: **Proper handwashing, avoid crowds and sick people
Wear Medical Alert bracelet
Must tapper off corticoids (steroids). NEVER abruptly stop.

Answer 28

PATHO:
Cushing’s Disease/Syndrome

**Common cause long-term use of corticosteroids

Question 29

Buffalo hump
Striae (stretch marks)
Thin, fragile skin= ^RISK for shear and friction tears
Moon face/ Red Face
Thin extremities
Truncal obesity/ fluid retention
Weight gain
Risk for infection
Personality Changes/ CNS irritability
Hirsutism (^ abnormal hair growth)
Bruises and Petechiae
Osteoporosis (^ RISK of fractures)
Hyperglycemia
GI distress= ^ acid

Answer 29

CLINICAL MANIFESTATION
Cushing’s DZ

Question 30

*hyposecretion of adrenal cortex hormones
Glucocorticoids, mineralocorticoids, and androgen
—R/T stop of long-term high-dose glucocorticoid therapy
–Fatal if left unTX
-Pt. needs lifelong replacement of glucocorticoids
—>** ^^ dose in times of stress
-**PROTECT pt. from noise, bright light, and environmental temperature extremes (cannot cope with stress b/c corticosteroids cannot be produced and can trigger Addisonian crisis)
**DIET: High protein/carb diet
Wear Medical Alert bracelet

Answer 30

PATHO:
Primary Adrenal Cortex Insufficiency (Addison’s disease)

Question 31

Hyper pigmentation of the skin (bronze skin)
Muscle weakness
Fatigue
Weight loss
Menstrual changes
Hirsutism
Hypoglycemic
Postural Hypotension
^^RISK of Addisonian Crisis if stop taking therapy**

Answer 31

CLINICAL MANIFESTATIONS
Addison’s DZ

Question 32

Extremely LOW cortisol levels; **life-threatening emergency requiring aggressive management.
S/S: Severe abdominal pain, dehydration, hyperkalemia (dysrhythmias), hyponatremia (Coma/seizures), and hypotension, renal failure
**TX: shock management and high-dose IV hydrocortisone (methylprednisolone) replacement.
–STAT admin of large volumes of ISOTONIC fluids. w/bolus
(0.9% saline solution and 5% dextrose) =reverse hypotension and electrolyte imbalances until BP returns to normal.

Answer 32

Addisonian Crisis