Caring for client’s with Endocrine DO.Bakersfield College VN 86 PP #2

Pituitary Gland

• Pituitary disorders less common than other disorders although can cause diverse and serious problems.• Hyperpituitarism- excess production and secretion of

one or more hormones. Commonly causes oversecretion of growth hormone.• Hypopituitarism- lack of production of one or more of

the gland’s hormones• Pituitary tumors usually cause both of these conditions.

Pituitary Gland Anterior

• Growth hormone is produced by the anterior lobe of the pituitary gland. It stimulates growth of the long bones• Excess secretion of GH prior to puberty and the closure

of the epiphyseal plates causes gigantism. These patients can be over 7 foot tall.• Dwarfism occurs when there is an inadequate

production of GH during childhood.• During adulthood bones and connective tissue grow at a

slow rate and cause things like enlarged forehead and protruding jaw. Hypersecretion during adulthood.• Untreated: HTN, DM cardiac enlargement and failure.

Pituitary• DX: MRI and CT show enlargement along with tumor.• Labs show elevated growth hormone levels.

• Pituitary tumor treated with transphenoidal hypophysectomy removal of the pituitary gland

• Irradiation of the pituitary tumor• Drug therapy with Sandostatin (octreotide) decreases growth

hormone production does not reduce tumor size.• Lifelong hormone replacement therapy needed.

Posterior Pituitary Gland• Disorders of the posterior pituitary are caused by too much or

too little antidiuretic hormone (ADH).• ADH regulates total body water by acting on the kidney to

retain or release water.• Receptors in the Hypothalamus control the release of ADH in

response to serum osmolarity. • Remember:• When serum osmolarity increases ADH secretion increases

and renal water is reabsorbed, which decreases urine output.• When serum osmolarity decreases (hyposmolarity)it

suppresses the release of ADH so urine output increases.• Thus:

Diabetes Insipidus• DI results from ADH insufficiency. Two types:• 1. Neurogenic DI- results from damage to the pituitary gland

after head injury or cranial surgery.• 2. Nephrogenic DI- kidneys fail to respond to ADH secretion

due to renal failure.• Deficient supply of ADH causes a urinary output of 5 to 15

liters per day. Client develops polydipsia. If the patient can not replace the water loss dehydration develops.

• Risk for hypernatremia.• See manifestations:

DI

Diabetes insipidus diagnosis is based on presence of CM, risk factors, water deprivation test see textbook.•Treatment:•Replace the water loss IV 0.45 NS•ADH replacement therapy DDAVP or vasopressin•Sodium restriction and thiazide diuretics for nephrogenic DI

SIADH• Syndrome of inappropriate ADH secretion• Results from excess production of ADH.• Caused by lung tumor, head injury, pituitary surgery use of

barbiturates, anesthetics or diuretics.• Excess production of ADH leads to water retention

hyponatremia and serum hyposmolarity.

• CM- decreases urine output and concentrated urine.• Neurologic symptoms- cells in the brain swell as water moves

in.• No edema in body, water is going to the extracellular spaces

SIADH• Treatment- correcting the underlying cause, limit fluid intake so

fluid will go back into the cells.• Diuretics such as lasix, with fluid restriction.• Meds:• Declomycin to promote urine producion• Hypertonic saline.• CM- see text• Why fluid restriction?-prevents further dilution of the plasma and

sodium levels.• Diuretics will help to decrease fluid volume excess• Seizure precautions: low serum sodium levels can lead to seizures.

• Teaching- fluid restriction at home and medications. Video

Adrenal Gland Disorders• Disorders involve either the adrenal cortex- secretes cortisol

and aldosterone.• Or the Adrenal medulla- Releases epinephrine and

norepinephrine.• Can cause physical, psychologic and metabolic alterations that

can be life threatening. Most common d/o are• 1. Cushing’s syndrome, Addison’s disease and

pheochromocytoma.

Cushing’s Syndrome• Chronic disorder in which the adrenal cortex produces

excessive amounts of the hormone cortisol.• More common in women 30-50 yrs. May be caused by:• Adrenal tumors• Tumor of the pituitary gland which increases ACTH release

which stimulates the adrenal cortex to produce cortisol.• Chronic glucocorticoid therapy- Where do we see this?• Increased release of ACTH from certain tumors. Lung,

pancreatic.

Cushing’s Syndrome• Too much cortisol/glucocorticoids result in changes in CHO

metabolism, protein and fat metabolism.• Fat deposits• Buffalo hump• Moon face• Muscle weakness and wasting• Loss of collagen and connective tissue, thus poor wound

healing• Thin skin with striae• DM may occur.• Osteoporosis compression fractures• Hypertension, infection, peptic ulcers, depression, hirsutism.

Cushing’s Syndrome• Treatment:• Surgery radiotherapy or medication• Pituitary adenoma- surgery• Radiation if inoperable tumor• Drug therapy when surgery is contraindicated.• DX test: increased plasma cortisol level / elevated 24 hour

urine test for 17 ketosteroids and 17 hydrocorticosteroids.• Plasma ACTH levels are elevated when caused by pituitary

gland tumor• Serum sodium and glucose levels are elevate in Cushing’s

Syndrome.

Cushing’s Syndrome• If surgery indicated when adrenal cortex tumor.• Usually only one adrenal gland is involved.• If both taken the client will have to take lifelong corticosteroid

and mineralcorticoid replacement therapy.• Addisonian crisis is risk after both glands removed.• Radiation therapy when client has inoperable pituitary tumor

causing Cushing’s syndrome.• Radioactive isotopes implanted into the pituitary gland.

Lifelong replacement of hormones

• See Nursing Care.

Addison’s Disease• Most common form of adrenal cortex insufficiency. • Women under age 60.• Primary- Adrenal cortex hypofunction. Autoimmune response.

Which destroys the client’s own adrenal cortex.• Secondary- Lack of pituitary ACTH.adrenalcorticotropic hormone• DX: decreased serum levels of cortisol, atrophy of adrenal gland on

CT.• Manifestations are slow CM when 90% gland destroyed.• CM are from elevated ACTH levels and decreased aldosterone and

cortisol. Primary complication is Addisonian crisis.• CM- See text• Tx: early diagnosis, cortisol replacement, this can induce Cushing’s

syndrome. See textbook.

Addisonian Crisis• Serious life threatening response to acute adrenal

insufficiency.• Major stressors precipitate the condition.• May occur in clients who abruptly withdraw corticosteroid

medications• CM- hypotension, rapid weak pulse, extreme weakness,

confusion, altered K levels, cardiac dysrhythmias.• TX: IV fluids, glucose, sodium glucocorticoids.

Adrenal Medulla Disorders• Pheochromocytoma- benign tumor of the adrenal medulla.• Middle aged adults• Produces excessive amounts of catecholamines such as

epinephrine or norepinephrine.• This stimulates the sympathetic nervous system which in turn• Leads to dramatic rise in the systolic blood pressure!!• 200/150.• Can lead to stroke and MI• DX: increased catecholamine levels in the blood.• CT or MRI• TX: Surgical removal; laparoscopic adrenalectomy• NR; Blood pressure,adrenal hormone replacement therapy,

hypertension may be a problem chronic.