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Chapter 65
Care of Patients with Pituitary
and Adrenal Gland Problems
Marion Kreisel MSN, RN
NU230 Adult Health 2
Fall 2011
Disorders of the Anterior Pituitary Gland
• Controls growth, metabolic activity & sexual
development
• Hormones Produced are on page 1426
• Primary pituitary dysfunction: problem within the
anterior pituitary gland itself
• Secondary pituitary dysfunction: problems in the
hypothalamus that change the anterior pituitary
function
• Pituitary hypofunction: under secretion of
hormones
• Pituitary hyperfunction: over secretion of
hormones
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
(adrenocorticotropic hormone) and (Thyroid
Stimulating Hormone) TSH b/c decrease of
vital hormones
• Deficiency of gonadotropins. (sexual
hormones)
• Growth hormone stimulates the liver to
produce substances known as somatomedins
that enhance growth activity. Bone & cartilage
Cause of Hypopituitarism
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Benign or malignant tumors
Anorexia nervosa
Shock or severe hypotension
Head trauma
Brain tumors or infection
Sheehan’s syndrome: postpartum
hemorrhage
Patient-Centered Collaborative
Care
• Assessment
• Interventions include:
• Replacement of deficient hormones
• Androgen therapy (testerone) for
virilization (presence of male seocndary
sex characteristics) gynecomastia can
occur (development of breast in male)
• Estrogens and progesterone
• Growth hormone
Hyperpituitarism
• Hormone oversecretion occurs with
pituitary tumors or hyperplasia
• Genetic considerations
• Gigantism
• Pituitary adenoma most common cause
Gigantism
• Gigantism is the onset of growth hormone hypersecretion
before puberty.
Acromegaly
• Growth hormone hypersecretion after
puberty
• Hands and feet are large compared to
the rest of the body
Patient-Centered Collaborative
Care
• Assessment
• Nonsurgical management:
• Drug therapy—Parlodel, Dostinex,
Permax, Sandostatin, Somavert
• Radiation
• Gamma knife procedure
Surgical Management
Surgical Management: transsphenoidal
surgical approach to the pituitary gland.
Selective adenomectomy leaves normal
pituitary tissue undisturbed
Postoperative Care
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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
Avoid toothbrushing
Numbness in the area of the incision
Decreased sense of smell
Vasopressin
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)
• Without ADH kidney collecting ducts do
not absorb water->polyuria->dehydration.
• Diabetes insipidus is classified as:
• Nephrogenic: inherited disorder
• Primary: defect in the hypothalamus or
pituitary gland
• Secondary: tumors, trauma, infection,
surgery
• Drug-related: certain RX drugs
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)
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
Syndrome of Inappropriate Antidiuretic
Hormone Secretion (SIADH)
• Vasopressin (ADH) 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).
SIADH: Patient-Centered
Collaborative Care
• Assessment:
• Recent head trauma
• Cerebrovascular disease
• Tuberculosis or other pulmonary
disease
• Cancer
• All past and current drug use
SIADH: Interventions
• Fluid restriction
• Drug therapy—diuretics, hypertonic saline,
demeclocycline
• Monitor for fluid overload
• Safe environment
• Neurologic assessment
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
• Acute Adrenocortical insufficiency adrenal
crisis life threatening manifestations
appear without warning
Effect of Insufficiency of
Adrenocortical Steroids
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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
Addison’s Disease or Adrenal Insufficiency
• Primary: Table 65-2 page 1437
• Secondary:
• Sudden cessation of long-term highdose glucocorticoid therapy causing
atrophy of the adrenal cortex
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 such as trauma, surgery, severe
infection.
• Na+ decrease K+ increase rapidly,
hypotension-> etc.
Patient-Centered Collaborative
Care
• Assessment
• Clinical manifestations
Assessment
• Psychosocial assessment
• Laboratory tests
• Imaging assessment
Adrenal Gland Hyperfunction
• Hypersecretion by the adrenal cortex
results in Cushing’s syndrome/disease,
hypercortisolism, or excessive androgen
production
Pheochromocytoma
• Hyperstimulation of the adrenal
medulla caused by a tumor
• Excessive secretion of catecholamines
• Surgical TX
• Avoid caffeine products
Hypercortisolism (Cushing’s Disease)
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Etiology
Incidence/prevalence
Patient-centered collaborative care
Assessment:
• Clinical manifestations—skin changes,
cardiac changes, musculoskeletal
changes, glucose metabolism, immune
changes
• Psychosocial assessment
• Laboratory tests—blood, salivary and
urine cortisol levels, hyperglycemia &
hypokalemia
• Imaging assessment
Hypercortisolism: Nonsurgical
Management
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*Patient safety
Drug therapy
Nutrition therapy
Monitoring
• If pt on large doses of glucocorticoids
and c/o not feeling well, have them get
an exam and lab work to see hormone
levels
Hypercortisolism: Surgical
Management
• Hypophysectomy
• Adrenalectomy
Community-Based Care
• Home care management
• Health teaching
• Health care resources
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.
• Causes hypernatermia, hypokalemia, and
metabolic alkalosis.
Patient-Centered Collaborative
Care
• Assessment
• Most common issues—hypokalemia and
elevated blood pressure
Interventions
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Adrenalectomy
Drug therapy
Glucocorticoid replacement
When surgery cannot be performed—
spironolactone therapy
Pheochromocytoma
• Catecholamine-producing tumors that
arise in the adrenal medulla
• Tumors produce, store, and release
epinephrine and norepinephrine
Patient-Centered Collaborative
Care
• Assessment
• Interventions:
• Surgery is main treatment.
• After surgery, assess blood pressure.
Chapter 65
Care of Patients with
Pituitary and Adrenal Gland
Problems
NCLEX
TIME
Question 1
A female patient who is obese is complaining of bruising
easily, acne, and hair loss. She is concerned about
“stretch marks” on her abdomen, thighs, and upper
arms. What would the nurse expect to happen next?
A.
B.
C.
D.
Diagnostic assessment
Radiation therapy
Surgical intervention
Lifelong hormone replacement
Question 2
What is a priority question to ask a patient
with a hypopituitary tumor?
A. “Do you have any changes in your visual
acuity?”
B. “Have you noticed a change in your
libido?”
C. “Have you experienced a change in
growth of your facial hair?”
D. “Have you had an unexpected weight
loss?”
Question 3
What is a priority nursing intervention in the
care of a patient with diabetes insipidus?
A.
B.
C.
D.
Seizure precautions
Fall precautions
Accurate intake and output measurement
IV fluid hydration
Question 4
Which patient with Cushing’s disease is at
greatest risk for developing heart failure?
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42-year-old patient with a serum
creatinine level of 3.7 mg/dL
59-year-old patient with a history of
hypertension
32-year-old patient with a history of
hepatitis B infection
60-year-old patient with pneumonia
Question 5
Which condition resulting from lithium
(Lithobid) might you expect to see in the
patient with bipolar disorder?
A.
B.
C.
D.
Hypothyroidism
Hyperpituitarism
Diabetes insipidus
Hyperaldosteronism