Chapter 19Care of Patients with

Pituitary and Adrenal Gland Problems

Disorders of the Anterior Pituitary Gland

Target tissueThyroid, 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:HyperpituitarismHypopituitarism

Anterior Pituitary GlandHyper-secretion and or secretion

Pituitary TumorPituitary hyperplasiaBenign adenoma (most common)

Pressure on the optic nerve

Excess GH, ACTH, prolactin (PRL) or TSH

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 hormoneProportionate dwarfism

Cause of HypopituitarismBenign or malignant tumors

Anorexia nervosa

Shock or severe hypotension

Head trauma

Brain tumors or infection

Congenital

Patient-Centered Collaborative Care

Assessment

Interventions include:Replacement of deficient hormonesAndrogen therapy for virilization; gynecomastia

can occurEstrogens and progesteroneGrowth hormone

Hyperpituitarism Hormone oversecretion occurs with pituitary

tumors or hyperplasia

Genetic considerations

Pituitary adenoma

GigantismGigantism is the onset of growth hormone

hypersecretion before puberty.

AcromegalyGrowth hormone hypersecretion after puberty

Surgical InterventionTranssphenoidal or transfrontal removal of the

pituitary gland

http://www.youtube.com/watch?v=Ebhf1qKVA9A

Patient-Centered Collaborative Care

Assessment

Nonsurgical management:Drug therapy- to reduce GH secretion or the

effects on tissues Somatostatin analoguesDopamine agonistsGrowth hormone antagonist

RadiationGamma knife procedure

Usually one time treatment

Surgical Management

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

Postoperative Care Avoid toothbrushing

Numbness in the area of the incision

Decreased sense of smell

Vasopressin

Diabetes InsipidusWater 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:NephrogenicNeurogenic

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 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 traumaCerebrovascular diseaseTuberculosis or other pulmonary diseaseCancerAll past and current drug use

SIADH: InterventionsFluid 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

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

Addison’s DiseasePrimary

Secondary:Sudden cessation of long-term high-dose

glucocorticoid therapy

Acute Adrenal Insufficiency/Addisonian

CrisisLife-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

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

Hypercortisolism (Cushing’s Disease)

Etiology

Incidence/prevalence

Patient-centered collaborative care

Assessment:Clinical manifestations—skin changes, cardiac

changes, musculoskeletal changes, glucose metabolism, immune changes

Hypercortisolism Cushing’s Disease

Psychosocial assessmentLaboratory tests—blood, salivary and urine cortisol

levels Imaging assessment

Hypercortisolism: Nonsurgical Management

Patient safety

Drug therapy

Nutrition therapy

Monitoring

Hypercortisolism: Surgical Management

Hypophysectomy

Adrenalectomy

Community-Based CareHome 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.

Patient-Centered Collaborative Care

Assessment

Most common issues—hypokalemia and elevated blood pressure

Interventions 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.