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

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.

3. 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.

4. 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.

5. 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:

6. 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:

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.