T3 Pituitary and Adrenal Glands

Question 1

Secrete hormones

Maintain cellular regulation

Answer 1

Pituitary and Adrenal Glands

Question 2

Regulates growth, metabolism, and sexual development

Answer 2

Anterior pituitary*

Question 3

Vasopressin (ADH)

Answer 3

Posterior pituitary*

Question 4

Hormones are life sustaining

Answer 4

Adrenal gland

Question 5

including fluid and electrolyte balance
When too much or too little of one or more hormones is secreted, physical and psychological changes occur

maintains fluid and electrolyte impbalance and is an antidiuretic hormone

Answer 5

Cellular regulation

Vasopressin

Question 6

This hormone Secretes:
Growth hormone (GH)
Thyroid stimulating hormone (TSH)
Corticotropine (adrenocorticotropin hormone ACTH)
Follicle-stimulating hormone (FSH)
Luteinizing hormone (LH)
Melanocyte-stimulating hormone (MSH)
Prolactin (PRL)

Answer 6

Anterior pituitary

Question 7

Deficiency of one or more anterior pituitary hormones
Selective hypopituitarism
Results in metabolic problems, sexual dysfunction

Answer 7

Hypopituitarism

Question 8

—Decreased production of all anterior pituitary hormones and is rare

Answer 8

Panhypopituitarism*

Question 9

Most life-threatening deficiencies

Answer 9

—ACTH and TSH*

Question 10

Deficiency of gonadotropins changes What?

Answer 10

sexual function and sterility/infertility

Question 11

increases rate of bone destruction and leads to osteoporosis

Answer 11

Growth hormone deficiency

Question 12

ACTH, Adrenocorticotropic hormone; TSH, thyroid-stimulating hormone.
Gonadotropins include LH and FSH

Cause of hypo varies?

Answer 12

Can be tumors, malnutrition, shock, head trauma, infection, surgery, AIDS, or can be idiopathic

Question 13

is the most common cause of pituitary infarction

Answer 13

Post partum hemorrhage

Question 14

Hypopituitarism assessment

Answer 14

Assessment* (chart 62-1)
Changes in physical appearance
Organ dysfunction
Decreased libido
Changes is secondary sex characteristics
Menstrual cycle changes
Neuro changes
Visual changes

*Chart 62-1 lists each hormone and signs and symtpoms of deficiency

Question 15

Tx and considerations/risks with Hypopituitarism

Answer 15

Lifelong replacement of deficient hormones

Androgen therapy for virilization; gynecomastia can occur

Estrogens and progesterone

Growth hormone

*Note risk of hypertension and thrombus when taking estrogen especially among smokers

Question 16

Causes of Hyperpituitarism

Answer 16

• Hormone oversecretion occurs with
• Pituitary adenoma is most common cause
• Benign tumor
• Are classified by hormone secreted

*Tumors are most common in cells that produce GH, PRL, and ACTH

Question 17

Onset of growth hormone hypersecretion before puberty

The clinical features of growth hormone (GH) excess.

Robert Wadlow, the “Alton giant,” weighed 9 pounds at birth but grew to 30 pounds by the time he was 6 months old. By his first birthday, he had reached 62 pounds. At the time of his death at age 22 from cellulitis of the feet, he was 8 feet, 11 inches tall and weighed 475 pounds.

Answer 17

Gigantism

Question 18

Growth hormone hypersecretion after puberty

Answer 18

Acromegaly

Question 19

The progression of acromegaly.
Onset?

S/s?

Reversible?

Answer 19

Onset may be gradual with slow progression
Early detection is essential
Signs include enlargement of face, hands, and feet, increased skeletal thickness, enlarged organs.
May be reversible if caught early (skeletal changes are permanent)

Question 20

Assessment*: Hyperpituitarism: Acrogmegaly/increased hormones

Answer 20

Chart 62-2
Ask about changes in hat, glove, shoe size
Headaches
Changes in appearance
MRI is best imaging

Question 21

Acrogmegaly tx :

Expected outcomes:

Answer 21

Expected outcomes: return to normal or near normal hormone levels and reduce symptoms

Nonsurgical management

Drug therapy (Parlodel, Dostinex, Permax, Sandostatin, Somavert)

Radiation -isn’t instant treatment. May take months or years to see benefits

Gamma knife procedure

Drug therapy can be used in combination with surgery and/or radiation

Question 22

Acromegaly surgical management

Answer 22

The transsphenoidal surgical approach to the pituitary gland. Called hypophysectomy

Selective adenomectomy leaves normal pituitary tissue undisturbed.

Question 23

Post op care for hypophysectomy

Patient teaching?

Answer 23

Monitor neurologic response

Assess for postnasal drip

Elevate head of bed

Assess nasal drainage
-Halo sign

Assess for meningitis

Numbness in the area of the incision

Decreased sense of smell

Level of consciousness, visual changes
Observe for CSF leak by salty taste to postnasal drip or halo sign

Avoid coughing
Avoid bending
Avoid straining at stool
Avoid toothbrushing
Vasopressin and hormone replacment

Keep HOB elevated
No straws
Drink to thirst

Question 24

Water metabolism problem caused by an ADH deficiency *(either decrease in ADH synthesis or inability of kidneys to respond to ADH)
Results in large volumes of dilute urine *

Distal kidney tubules and collectin ducts do not reabsorb water

Classifications
Nephrogenic
Primary
Secondary
Drug-related

Answer 24

DIABETES insipidus

Question 25

Classifications of DI

Answer 25

``` Classifications Nephrogenic Primary Secondary Drug-related ```

Question 26

DI Assessment/ s/s

Answer 26

Symptoms of dehydration Increase in frequency of urination and excessive thirst Urine diluted with low specific gravity (<1.005) Urine output may be anywhere from 4-30 L/24 hours (up to 1250 ml/hr) Water loss increases plasma osmolality and increases sodium levels. Thirst mechanism is essential. Must have access to water

Question 27

DI interventions Lab to monitor? Pt teaching? Drugs?

Answer 27

Management focuses on managing symptoms with drug therapy. If weight gain is more than 2.2 lbs along with other symtpoms such as headache, confusion, nausea, vomiting, patient should go to ER Desmopressin acetate* is preferred drug Early detection of dehydration and maintenance of adequate hydration* DDAVP can be given IV, oral, nasal Lifelong vasopressin therapy with permanent condition Wear medic alert bracelet Teach patients to weigh themselves daily to identify weight gain.* In hospital: monitor spec grav lab

Question 28

Which statements made by a client who has diabetes insipidus indicates to the nurse that more teaching is needed? A: If I gain more that 2 lb in a day I’ll limit my fluid intake B: If I become thirstier, I’ll take another dose of the drug C: I’ll avoid aspirin and aspirin containing substances D: I’ll stop taking the drug for 24 hours before I have any dental work performed E: I’ll limit by intake of salt and sodium to no more than 2 g daily F: I’ll wear my medical alert bracelet at all times

Answer 28

A,C,D,E

Question 29

Vasopressin secretes even when plasma osmolarity is low or normal. Feedback mechanisms do not function properly. Water is retained, results in hyponatremia (decreased serum sodium level) and fluid overload.*

Answer 29

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)*

Question 30

Causes of SIADH

Answer 30

``` Recent head trauma Cerebrovascular disease Tuberculosis or other pulmonary disease Cancer Drug use ```

Question 31

S/s of SIADH?

Answer 31

Related to water retention and dilution of serum sodium* Gi disturbances -Loss of appetite, N/V With extreme low sodium* (<115 meq/L) -Lethargy, headaches, decreased level of consciousness, seizures, and coma Bounding pulse Hypothermia -caused by central nervous system dysfunction Increased urine spec grav*

Question 32

SIADH interventions

Answer 32

Fluid restriction -500-1000 mL/24 hr Drug therapy (diuretics, hypertonic saline, demeclocycline) Monitor for fluid overload -Daily weightslllkpc/l/l. Safe environment Neurologic assessment

Question 33

Adrenocortical steroids may decrease from inadequate secretion of ACTH*. Dysfunction of hypothalamic-pituitary control mechanism Direct dysfunction of adrenal tissue Addisonian crisis vs. Addison’s disease*

Answer 33

Adrenal gland hypofunction

Question 34

One hormone in the pituitary is ???? This stimulates the adrenal glands. Insufficiency of the hormones leads to ???

Answer 34

ACTH (adrenocorticotropic hormone). loss of aldosterone and cortisol.

Question 35

Adrenal Insufficiency: life threatening* Need for cortisol and aldosterone is greater than supply* Response to stress* Surgery Trauma Infection Unless treated sodium falls and potassium rises rapidly Problems are the same as with chronic insufficiency but are more sever Unless intervention is initiated promptly, sodium levels fall and potassium levels rise rapidly. Severe hypotension results

Answer 35

Addisons crisis

Question 36

Assesment of Addison’s

Answer 36

``` Muscle weakness Fatigue Joint pain a/n/v Salt cravings Hyperpigmentation Hypotension Hypoglycemia Hyponatremia Hyperkalemia ``` Decreased cortisol results in hypoglycemia Gastric acid production decreases Glomerular filtration rate decreases leading to excessive BUN Potassium excretion is decreased causing hyperkalemia.

Question 37

Addisons dx/ labs?

Answer 37

``` Lab findings: Low serum and salivary cortisol* Low fasting blood sugar Low sodium High potassium High BUN ```

Question 38

Addisons interventions

Answer 38

Promote fluid balance Monitor for fluid deficit Prevent hypoglycemia* Assess cardiac function Weigh patient daily Hormone replacement* - Prednisone - Fludrocortisone (Florinef)

Question 39

Hypersecretion by adrenal cortex results in Cushing’s syndrome/disease, hypercortisolism, or excessive androgen production.*

Answer 39

Adrenal gland hyper function

Question 40

Adrenal gland hyper function cause

Answer 40

Can be caused by adrenal cortex itself, problems in anterior pituitary, or problem in hypothalamus. Glucocorticoid use can cause hypercortisolism

Question 41

S/s of Cushing’s syndrome

Answer 41

Sign and symptoms*—skin changes, buffalo hump, moon face, acne, striae, hirsutism cardiac changes, musculoskeletal changes, glucose metabolism, immune changes Increase in body fat, truncal obesity Muscle wasting and weakness Cardiac changes from sodium and water retention leading to hypervolemia and edema, high BP, and full and bounding pulses Glucose is high because liver release glucose and insulin receptors are less sensitive. Reduced immunity: excess cortisol reduces the number of circulating lymphocytes Patient may not have fever or redness Emotional instability, mood swings, irritability, depression

Question 42

Cushing s labs dx

Answer 42

``` Lab Values Blood, salivary, and urine cortisol levels will be high* Late night salivary cortisol Hyperglycemia Decreased lymphocytes Increased sodium Decreased calcium ```

Question 43

Cushing s disease priority

Answer 43

The priority problems for patients with Cushing’s disease or Cushing’s syndrome are* - -Fluid overload due to hormone-induced water and sodium retention -Potential for injury due to skin thinning, poor wound healing, and bone density loss -Potential for infection due to hormone-induced reduced immunity -Potential for acute adrenal insufficiency

Question 44

Tx and nursing interventions for cushings

Answer 44

Restore fluid balance Reduce skin breakdown Meds to decrease cortisol -Metyrapone, ketoconazole, periactin Nutrition: fluid restriction, sodium restriction, -high calorie* Daily weights* Surgical: hypophysectomy or adrenalectomy -Hormone replacement if pituitary or adrenals are removed

Question 45

Catecholamine-producing tumors arising in the adrenal medulla Usually occur in one adrenal gland but can be bilateral or in the abdomen Tumors produce, store, and release epinephrine and norepinephrine.* Usually benign Cause is unknown Although they are benign, they must be removed to prevent life threatening complications

Answer 45

Pheochromocytoma

Question 46

Pheochromocytoma s/s or assessment

Answer 46

Intermittent episodes of hypertension-HTN can range from few minutes to several hours Severe headaches Palpitations Diaphoresis and flushing Sense of impending doom Chest pain N/V

Question 47

What can induce HTN in Pheochromocytoma

Answer 47

Increased abdominal pressure, defecation, vigorous abdominal palpation can provoke hypertensive crisis* Drugs such as tricyclic antidepressants, glucoagon, metoclopramide, naloxone can induce hypertensive crisis Tyramine (found in aged cheese and wine, etc) can also induce hypertension

Question 48

Interventions for Pheochromocytoma

Answer 48

Surgery is the main treatment* Adrenalectomy Monitor for blood pressure changes Monitor for hypovolemia If inoperable: alpha and beta adrenergic blockers

Question 49

A 56-year-old woman is admitted to the ED with a blood pressure of 168/92 and reports of fatigue and muscle weakness. She has bruising on her arms and 2+ swelling in her ankles. Her weight has gone from 150 to 185 lbs over the past 6 months. Assessment reveals that she has truncal obesity and thin extremities. Which diagnosis does the nurse suspect? Hyperpituitarism (acromegaly) Hypercortisolism (Cushing’s disease) Hyperaldosteronism (Conn’s syndrome) Adrenal insufficiency (Addison’s disease)

Answer 49

ANS: B The patient’s manifestations of elevated blood pressure, fatigue, muscle weakness, bruising, dependent edema, weight gain, and truncal obesity with thin extremities are all key features of hypercortisolism, or Cushing’s disease. Other manifestations of Cushing’s disease include “moon face,” “buffalo hump,” osteoporosis, and thinning skin with striae.

Question 50

The patient is admitted to the acute medical care unit for a workup for Cushing’s disease. When she is assessed, she is found sitting at the bedside crying. She states, “I just don’t know what to do. I feel so confused and down in the dumps.” What is the nurse’s best response? “Would you like to speak with a pastor or priest?” “Have you experienced this kind of confusion before?” “It’s going to be fine. We’ll find out what’s wrong and take care of it.” “Have you noticed if your mood goes quickly from happy to sad?”

Answer 50

ANS: D Hypercortisolism can result in emotional lability, including mood swings, irritability, confusion, and depression. Asking this question helps in performing a psychosocial assessment of the patient.

Question 51

The student nurse is creating a care plan for the patient. Which priority problems should be the focus of the care plan? (Select all that apply.) ``` Fatigue Fluid overload Sleep deprivation Potential for infection Predisposition to injury ```

Answer 51

ANS: B, D ,E Fluid overload, risk for injury, and inadequate nutrition are common problems in patients with Cushing’s disease. Sleep deprivation and fatigue are additional possible focus areas, but not as essential as the other three.

Question 52

During evening shift, the patient’s MRI reveals the presence of a pituitary adenoma. The following day, surgery is performed to remove the tumor. What is the nurse’s priority concern for the patient postoperatively? Airway management Assessing for systemic infection Monitoring for neurologic changes Development of transient diabetes mellitus

Answer 52

ANS: C Removal of a pituitary adenoma is completed by a transsphenoidal hypophysectomy. Postoperatively, it is essential to monitor the patient for neurologic response, documenting changes in vision, mental status, level of consciousness, or decreased strength in the extremities.

Question 53

Which key interventions should be implemented postoperatively for the patient after undergoing a hypophysectomy? (Select all that apply.) Report any postnasal drip. Keep the head of the bed elevated. Have the patient avoid coughing soon after surgery. Monitor for a light-yellow color at the edge of clear drainage. Instruct the patient to take thyroid and glucocorticoid replacement for at least 6 months.

Answer 53

ANS: A, B, C, D After hypophysectomy, the patient will need thyroid and glucocorticoid replacement for the rest of her life.