Chapter 19

1. Chapter 19 Care of Patients with Pituitary and Adrenal Gland Problems

2. Disorders of the Anterior Pituitary Gland • Target tissue • Thyroid, adrenal cortex, ovary, testes, uterus, mammary glands and kidney • Either excess or deficiency • Pathologic condition within the gland or hypothalmic dysfunction • Two to focus on: • Hyperpituitarism • Hypopituitarism

3. Anterior Pituitary Gland • Hyper-secretion and or secretion • Pituitary Tumor • Pituitary hyperplasia • Benign adenoma (most common) • Pressure on the optic nerve • Excess GH, ACTH, prolactin (PRL) or TSH

4. Hypopituitarism • Deficiency of one or more anterior pituitary hormones results in metabolic problems and sexual dysfunction. • Panhypopituitarism—decreased production of all of the anterior pituitary hormones. • Most life-threatening deficiencies—ACTH and TSH. • Deficiency of gonadotropins. • Growth hormone • Proportionate dwarfism

5. Cause of Hypopituitarism • Benign or malignant tumors • Anorexia nervosa • Shock or severe hypotension • Head trauma • Brain tumors or infection • Congenital

6. Patient-Centered Collaborative Care • Assessment • Interventions include: • Replacement of deficient hormones • Androgen therapy for virilization; gynecomastia can occur • Estrogens and progesterone • Growth hormone

7. Hyperpituitarism • Hormone oversecretion occurs with pituitary tumors or hyperplasia • Genetic considerations • Pituitary adenoma

8. Gigantism • Gigantism is the onset of growth hormone hypersecretion before puberty.

9. Acromegaly • Growth hormone hypersecretion after puberty • Surgical Intervention • Transsphenoidal or transfrontal removal of the pituitary gland • http://www.youtube.com/watch?v=Ebhf1qKVA9A

11. Patient-Centered Collaborative Care • Assessment • Nonsurgical management: • Drug therapy- to reduce GH secretion or the effects on tissues • Somatostatin analogues • Dopamine agonists • Growth hormone antagonist • Radiation • Gamma knife procedure • Usually one time treatment

13. Surgical Management

14. Postoperative Care • Monitor neurologic response • Assess for postnasal drip • HOB elevated • Assess nasal drainage • Avoid coughing early after surgery • Assess for meningitis • Hormone replacement • Avoid bending • Avoid strain at stool

15. Postoperative Care • Avoid toothbrushing • Numbness in the area of the incision • Decreased sense of smell • Vasopressin

16. Posterior Pituitary Disorders

17. Diabetes Insipidus • Water metabolism problem caused by an antidiuretic hormone deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH) • Diabetes insipidus is classified as: • Nephrogenic • Neurogenic

18. Patient-Centered Collaborative Care • Assessment • Most manifestations of DI are related to dehydration • Increase in frequency of urination and excessive thirst • Dehydration and hypertonic saline tests used for diagnosis of the disorder • Urine diluted with a low specific gravity (<1.005)

19. DI: Interventions • Oral chlorpropamide • Desmopressin acetate • Early detection of dehydration and maintenance of adequate hydration • Lifelong vasopressin therapy for patients with permanent condition of diabetes insipidus • Teach patients to weigh themselves daily to identify weight gain

20. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) • Vasopressin is secreted even when plasma osmolarity is low or normal. • Feedback mechanisms do not function properly. • Water is retained, resulting in hyponatremia (decreased serum sodium level).

21. SIADH: Patient-Centered Collaborative Care • Assessment: • Recent head trauma • Cerebrovascular disease • Tuberculosis or other pulmonary disease • Cancer • All past and current drug use

22. SIADH: Interventions • Fluid restriction • Drug therapy—diuretics, hypertonic saline, demeclocycline • Monitor for fluid overload • Safe environment • Neurologic assessment

23. Adrenal Gland Dysfunction

24. Adrenal Gland Hypofunction • Adrenocortical steroids may decrease as a result of inadequate secretion of ACTH • Dysfunction of the hypothalamic-pituitary control mechanism • Direct dysfunction of adrenal tissue

25. Effect of Insufficiency of Adrenocortical Steroids • Loss of aldosterone and cortical action • Decreased gluconeogenesis • Depletion of liver and muscle glycogen • Hypoglycemia • Reduced urea nitrogen excretion • Anorexia and weight loss • Potassium, sodium, and water imbalances

26. Addison’s Disease • Primary • Secondary: • Sudden cessation of long-term high-dose glucocorticoid therapy

27. 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

28. Patient-Centered Collaborative Care • Assessment • Clinical manifestations

29. Assessment • Psychosocial assessment • Laboratory tests • Imaging assessment

30. Adrenal Gland Hyperfunction • Hypersecretion by the adrenal cortex results in Cushing’s syndrome/disease, hypercortisolism, or excessive androgen production

31. Pheochromocytoma • Hyperstimulation of the adrenal medulla caused by a tumor • Excessive secretion of catecholamines

32. Hypercortisolism (Cushing’s Disease) • Etiology • Incidence/prevalence • Patient-centered collaborative care • Assessment: • Clinical manifestations—skin changes, cardiac changes, musculoskeletal changes, glucose metabolism, immune changes

34. Hypercortisolism Cushing’s Disease • Psychosocial assessment • Laboratory tests—blood, salivary and urine cortisol levels • Imaging assessment

35. Hypercortisolism: Nonsurgical Management • Patient safety • Drug therapy • Nutrition therapy • Monitoring

36. Hypercortisolism: Surgical Management • Hypophysectomy • Adrenalectomy

37. Community-Based Care • Home care management • Health teaching • Health care resources

38. Hyperaldosteronism • Increased secretion of aldosterone results in mineralocorticoid excess. • Primary hyperaldosteronism (Conn's syndrome) is a result of excessive secretion of aldosterone from one or both adrenal glands.

39. Patient-Centered Collaborative Care • Assessment • Most common issues—hypokalemia and elevated blood pressure

40. Interventions • Adrenalectomy • Drug therapy • Glucocorticoid replacement • When surgery cannot be performed—spironolactone therapy

41. Pheochromocytoma • Catecholamine-producing tumors that arise in the adrenal medulla • Tumors produce, store, and release epinephrine and norepinephrine

42. Patient-Centered Collaborative Care • Assessment • Interventions: • Surgery is main treatment. • After surgery, assess blood pressure.