Pituitary and Adrenal Gland Problems/Care, Ch. 57 (Iggy) Flashcards
-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
REASON for Pituitary Gland Malfunction
**Pituitary gland is close to the optic nerve=Visual changes are 1st SX noticed
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
CLINICAL MANIFESTATIONS:
Hypopituitarism
Hormone Specific
*Can be subtle, nonspecific findings
S/SX: Truncal obesity, osteoporosis, LOW muscle mass and strength, weakness, fatigue, depression/flat affect
MANIFESTATIONS:
Hypopituitarism
*Growth Hormone (GH)
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
MANIFESTATIONS:
Hypopituitarism
*Follicle-Stimulating Hormone (FSH) &
Luteinizing Hormone (LH)
Involves CORTISOL deficit: Weakness, fatigue, headache, dry/pale skin, diminished axillary/pubic hair, LOW resistance to infection, fasting hypoglycemia
MANIFESTATIONS:
Hypopituitarism
*Adrenocorticotropic Hormone (ACTH)
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
Hypopituitarism:
Gonadotropin (LH and FSH) Deficiency
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
B. Wash hands before entering the room
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.
SURGICAL INTERVENTION:
*Transsphenoidal Hypophysectomy
** ^ 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
SURGICAL INTERVENTION:
Hypophysectomy
Lovenox-anticoagulant prevent blood clots (Low molecular wt. heparin)
Laxatives-Prevent Constipation r/t decrease intracranial pressure
Compression Pumps on Legs
MEDS: Post-Op
Transsphenoidal Hypophysectomy
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.
POST-OP CONSIDERATIONS:
Hypophysectomy
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
PATHO: Hyperpituitarism
Hypersecretion of GH happens BEFORE the epiphyseal closure @ puberty.
–Very tall (ex: 8ft; die early around 22)
Hyperpituitarism
Gigantism
^^ 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
Hyperpituitarism-
Acromegaly
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)
CLINICAL MANIFESTATION:
Hyperpituitarism
Acromegaly
–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
CLINICAL MANIFESTATIONS
Acromegaly
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
MEDS: Acromegaly
Somatostatin analogs, dopamine agonists, and/or GH antagonists.
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?
False
–Smoother skin can happen
–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.
DIAGNOSTIC TESTING
Acromegaly
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.
SURGICAL INTERVENTION:
Acromegaly=Hypophysectomy
- ^^ADH
- ^^ water reabsorption in RENAL tubules
- ^^ INTRAvascular (outside cell-into body=dehydration=edema) fluid volume
- Dilutional Hyponatremia and LOW serum Osmolality (LOW urine output)
PATHO:
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
“SI”= soaked inside
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
CLINICAL MANIFESTATION:**
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
Serum LOW/ Urine HIGH
S/SX:***
Increased thirst
Lethargy
Headaches
Confusion
Can progress to irritability, muscle twitching, n/v, decreased responsiveness, seizures, coma, and death
S/SX: SIADH
***
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
INTERVENTIONS
SIADH
- LOW ADH
- LOW water reabsorption in RENAL tubules
- LOW intravascular fluid volume= ^^Serum osmolality/ hypernatremia & ^^urine output
PATHO:
Diabetes Insipidus (DI)
–>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
TYPES of DI
** Central or Neurogenic DI=most common=brain injury**
–^^ 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
CLINICAL MANIFESTATIONS
DI
^^^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.
PATHO:
Cushing’s Disease/Syndrome
**Common cause long-term use of corticosteroids
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
CLINICAL MANIFESTATION
Cushing’s DZ
*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
PATHO:
Primary Adrenal Cortex Insufficiency (Addison’s disease)
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**
CLINICAL MANIFESTATIONS
Addison’s DZ
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.
Addisonian Crisis
