disorders of pituitary and adrenal glands

Care of Patients with Pituitary Problems and Adrenal Gland Problems :

Care of Patients with Pituitary Problems and Adrenal Gland Problems Presented by: Karen Larson, MBA/TM, MSN, RN

Major Hormone Secreting Glands of the Endocrine System:

Major Hormone Secreting Glands of the Endocrine System

Disorders Associated Posterior Pituitary:

Disorders Associated Posterior Pituitary Diabetes Insipidus- A deficiency of Antidiuretic Hormone (ADH) Excessive diluted urination Excessive thirst Excessive Fluid intake Syndrome of Inappropriate Antiduretic Hormone (SIADH )- An excess release of Antiduretic Hormone (ADH) Oliguria Fluid volume excess; water intoxication Weight gain without edema

Diabetes Insipidus:

Diabetes Insipidus Etiology and pathophysiology Underproduction or secretion of ADH Neurogenic, Nephrogenic, Psychogenic classifications Clinical manifestations Increased thirst Excretion of large amounts of urine (5-20 L/day) Generalized weakness Weight loss Constipation Hypotension Tachycardia CNS manifestations (irritability to mental dullness to coma)

Diabetes Insipidus:

Diabetes Insipidus Diagnostic studies Complete Hx/physical Water Deprevation Test Collaborative care Treat underlying cause Maintain fluids and electrolytes Hormone replacement DDAVP Vasopressin Low Na+ diet and thiazides for nephrogenic DI

Syndrome of Inappropriate Antidiuretic Hormone:

Syndrome of Inappropriate Antidiuretic Hormone Etiology and pathophysiology Overproduction or sustained secretion of ADH Most common cause is malignancy Clinical manifestations Fluid retention, serum hypoosmolality, concentrated urine, normal or ↑ intravascular volume Muscle cramps Weakness Thirst Dulled sensorium Low urinary output Increased body weight

Syndrome of Inappropriate Antidiuretic Hormone:

Syndrome of Inappropriate Antidiuretic Hormone Clinical Manifestations (cont.) When Na+ levels ↓ 120 mmol/L Vomiting Abdominal cramps Muscle twitching Seizures As plasma osmolality and serum Na+ levels decline, cerebral edema, anorexia, confusion, and coma Diagnostic studies Serum Na+ < 134 mmol/kg Serum Osmolality < 280mOsm/kg Urine specific gravity > 1.005

Syndrome of Inappropriate Antidiuretic Hormone:

Syndrome of Inappropriate Antidiuretic Hormone Collaborative Care Treatment directed at underlying cause Avoid medications that stimulate the release of ADH Fluid restrictions of 800-1000 ml /day Intravenous hypertonic saline solution if Na+ ↓ 125 mEq/L Diuretic (such as Lasix) if serum Na+ is ≥ 125 mEq/L May require replacement of K+, Ca+, Mg Declomycin and Lithium to block effect of ADH on the renal tubules

Nursing Management Syndrome of Inappropriate Antidiuretic Hormone:

Nursing Management Syndrome of Inappropriate Antidiuretic Hormone Frequent VS Frequent I/Os Daily weights Monitor LOC Observe for s/sx of hyponatremina ↓ neuro status, seizures, N/V muscle cramping Monitor heart and lung sounds

Adrenal Glands:

Adrenal Glands Adrenal medulla Functions as part of the autonomic nervous system Catecholamines; epinephrine and norepinephrine Adrenal cortex Glucocorticoids Mineralocorticoids Androgens

Adrenocortical Insufficiency:

Adrenocortical Insufficiency Addison’s disease Primary Secondary: Sudden cessation of long-term high-dose glucocorticoid therapy (result of adrenal suppression by exogenous steroid use) Manifestations include muscle weakness, anorexia, GI symptoms, fatigue, dark pigmentation of skin and mucosa, hypotension, low blood glucose, low serum sodium, high serum potassium, mental changes, apathy, emotional lability, confusion Complication: Addisonian crisis Diagnostic tests; adrenocortical hormone levels, ACTH levels, ACTH stimulation test

Acute Adrenal Insufficiency/Addisonian Crisis:

Acute Adrenal Insufficiency/ Addisonian Crisis Life-threatening event in which the need for cortisol and aldosterone is greater than the available supply Usually occurs in a response to a stressful event

Nursing Process: The Care of the Patient with Adrenocortical Insufficiency— Assessment:

Nursing Process: The Care of the Patient with Adrenocortical Insufficiency— Assessment Level of stress; note any illness or stressors that may precipitate problems Fluid and electrolyte status VS and postural blood pressures Note signs and symptoms related to adrenocortical insufficiency such as weight changes, muscle weakness, and fatigue Medications Monitor for signs and symptoms of Addisonian crisis

Nursing Process: The Care of the Patient with Adrenocortical Insufficiency— Diagnoses:

Nursing Process: The Care of the Patient with Adrenocortical Insufficiency— Diagnoses Risk for fluid volume deficit monitor for signs and symptoms of fluid volume deficit, encourage fluids and foods, select foods high in sodium, administer hormone replacement as prescribed Activity intolerance and fatigue avoid stress and activity until stable, perform all activities for patient when in crisis, maintain a quiet nonstressful environment, measures to reduce anxiety Knowledge deficit Teaching

Adrenocortical Excess/Cushing’s Syndrome:

Adrenocortical Excess/Cushing’s Syndrome Due to excessive adrenocortical activity or corticosteroid medications Manifestations include hyperglycemia which may develop into diabetes, weight gain, central type obesity with “buffalo hump,” heavy trunk and thin extremities, fragile thin skin, ecchymosis, striae, weakness, lassitude, sleep disturbances, osteoporosis, muscle wasting, hypertension, “moon-face”, acne, increased susceptibility to infection, slow healing, virilization in women, loss of libido, mood changes, increased serum sodium, decreased serum potassium (See Chart 42-11) Dexamethasone suppression test

Cushing’s Syndrome:

Cushing’s Syndrome

Nursing Process: The Care of the Patient with Cushing’s Syndrome—Assessment:

Nursing Process: The Care of the Patient with Cushing’s Syndrome—Assessment Activity level and ability to carry out self-care Skin assessment Changes in physical appearance and patient responses to these changes Mental function Emotional status Medications

Nursing Process: The Care of the Patient with Cushing’s Syndrome—Diagnoses:

Nursing Process: The Care of the Patient with Cushing’s Syndrome—Diagnoses Risk for injury Risk for infection Self-care deficit Impaired skin integrity Disturbed body image Disturbed thought processes

Interventions (Cushing’s):

Interventions (Cushing’s) Decrease risk of injury; establish a protective environment; assist as needed; encourage diet high in protein, calcium, and vitamin D. Decrease risk of infection; avoid exposure to infections, assess patient carefully as corticosteroids mask signs of infection. Plan and space rest and activity. Meticulous skin care and frequent, careful skin assessment. Explanation to the patient and family about causes of emotional instability. Patient teaching.

Collaborative Problems/Potential Complications:

Collaborative Problems/Potential Complications Bone loss (osteoporosis), which can result in unusual bone fractures, such as rib fractures and fractures of the bones in the feet High blood pressure (hypertension) Diabetes Frequent or unusual infections Loss of muscle mass and strength

Corticosteroid Therapy:

Corticosteroid Therapy Widely used drugs to treat adrenal insufficiency, suppress inflammation and autoimmune response, control allergic reactions, and reduce transplant rejection Common corticosteroids (See Table 42-5) Patient teaching Timing of doses Need to take as prescribed, tapering required to discontinue or reduce therapy Potential side-effects and measures to reduction of side-effects (See Table 42-6)

Pheochromocytoma :

Pheochromocytoma Catecholamine-producing tumors that arise in the adrenal medulla Tumors produce, store, and release epinephrine and norepinephrine Assessment Interventions: Surgery is main treatment. After surgery, assess blood pressure.