CHII Module 3 Complete

What hormones are produced by the posterior pituitary?

Oxytocin and antidiuretic hormone

What hormones are produced by the anterior pituitary?

ACTH, growth hormone, TSH, FSH, prolactin, and LH

If there is hyperactivity in the anterior pituitary gland, what conditions might happen?

Gigantism, acromegaly, acromegalic gigantism, and Cushing’s disease

If there is hypoactivity in the anterior pituitary gland, what conditions might happen?

Dwarfism, acromicria, and Simmond’s disease

If there is hyperactivity in the posterior pituitary gland, what condition might happen?

Syndrome of inappropriate hypersecretion of ADH (SIADH)

If there is hypoactivity in the posterior pituitary gland, what condition might happen?

Diabetes insipidus (DI)

What are the most threatening hypopituitarism deficiencies?

ACTH and TSH; vital for maintaining a balanced metabolism

What are the manifestations of low ACTH?

Anorexia, malaise, lethargy, low serum cortisol, hypoglycemia, vomiting, and pale/gray complexion

What are the manifestations of low TSH?

Decreased libido, weight gain, low thyroid hormone, cold intolerance, low HR, constipation, and slowed cognition

What are the manifestations of low GH?

Decreased bone density and muscle strength, pathologic fractures

What are the manifestations of low LH and FSH?

Loss of sexual characteristics in males and females like facial/body hair, decreased libido, impotence, amenorrhea; neurologic changes such as loss of visual acuity (peripheral vision is early sign), temporal headaches, diplopia, ocular muscle paralysis, limiting eye movement

How is hypopituitarism diagnosed?

Blood levels of pituitary hormones, hormone stimulation testing, CT scan of head, MRI of head, angiography in brain

What interventions should be implemented if someone has an LH and FSH deficiency?

Androgen therapy and/or female hormone replacement therapy (HRT)

What are the side effects of androgen therapy?

Gynecomastia, acne, baldness, prostate enlargement

What are the contraindications for androgen therapy?

Patients with prostate cancer

What are the adverse side effects of HRT?

DVT and HTN

What interventions are done for growth hormone deficiency?

Human GH injections SQ

What are the interventions for TSH deficiencies?

Replaced with thyroid hormone levothyroxine

What are the interventions for ACTH deficiencies?

Replaced with cortisol

What is an important education point for patients taking replacement hormones?

MAINTAIN REGULATION, teach med adherence

What is the most common cause for hyperpituitarism?

Hyper-secreting pituitary adenoma; usually excess GH, prolactin and ACTH

What are the manifestations of excessive growth hormone?

Broad nose, coarse facial features, excessive sweating, voice deepening, enlarged hands, enlarged organs, HA, changes in vision, fatigue and lethargy, backache and arthralgias

What are the manifestations of hyperprolactinaemia?

Erectile dysfunction, hypogonadism, galactorrhoea, gynecomastia, amenorrhea

What are the manifestations of excess ACTH?

HTN, hyperglycemia, purple striae, abdominal obesity, buffalo hump, moon-shaped face

What is a prolactinoma?

Prolactin secreting tumor, most common; causes decrease in normal levels of sex hormones, loss of libido, infertility and spontaneous milk flow

What is gigantism?

Hyperpituitarism; onset of GH hypersecretion BEFORE puberty, continues into adulthood resulting in abnormal height

What is acromegaly?

Hyperpituitarism; GH hypersecretion AFTER puberty, changes are seen in face, hands, feet and ears, NOT height

How is hyperpituitarism diagnosed?

Hormone levels in blood and urine, CT, MRI, suppression testing

What are some non-surgical management actions for hyperpituitarism?

Encourage patient to express concerns and fears about altered physical appearance and/or sexual dysfunction, drug therapy may be used alone or in combination with surgery or radiation

What medications may be prescribed for hyperpituitarism?

Dopamine agonists to inhibit the release of prolactin and GH (bromocriptine and cabergoline); somatostatin analogs (octreotide and lanreotide) and GH receptor (pegvisomant) blockers are most common and effective for acromegaly

What are some considerations for radiation therapy for excess GH patients?

Takes a long time to achieve therapeutic effect (years), not recommended for acromegaly; side effects are hypopituitarism, optic nerve damage, and other eye and vision problems

What are some surgical management interventions for hyperpituitarism?

Hypophysectomy, most common long-term treatment for hyperpituitarism

What is a hypophysectomy?

Surgical removal of pituitary gland along with tumor, minimally invasive trans-nasal or trans-sphenoidal; causes HYPOpituitarism, so they need lifelong multiple hormone therapies

What are some pre-op care actions for a hypophysectomy?

Explain the goal of the treatment, explain that certain changes made by the hormones are NOT reversible (GH)

What are some post-op care actions for a hypophysectomy?

Nasal packing for 2-3 days after surgery and mustache dressing, breathe through mouth; decrease sense of smell for 3-4 months after procedure; tell patient not to brush teeth, blow nose, cough, sneeze, or bend forward after surgery (increases ICP and delays healing); monitor neuro hourly for 24 hours, monitor I&O, observe for complications, prevent increased ICP, perform oral rinses and apply moisturizers over lips, teach about self-administration of prescribed hormones

What are some possible complications of a hypophysectomy?

DI, CSF leakage, infection, increase ICP, meningitis

How do you identify a CSF leak?

Assess nasal drainage for presence of glucose, halo sign, persistent severe headaches; most CSF leaks heal themselves but the provider must be notified promptly

What is Diabetes Insipidus (DI)?

Water metabolism problem caused by an ADH deficiency OR inability of kidneys to respond to ADH

What are some causes of DI?

Brain tumors, head trauma, or other causes of cerebral edema

What is Arginine vasopressin deficiency (AVP-D)?

Classification of DI, central DI; problem in the hypothalamus or pituitary gland; lack of ADH production or release

What is Arginine vasopressin resistance (AVP-R)?

Classification of DI, nephrogenic DI; renal tubes do not respond to ADH (severe kidney injury); can be drug related, LITHIUM and DEMECLOCYCLINE interfere with kidney response to ADH

What is the cardinal sign of DI?

Excretion of large amounts of very DILUTE urine with excessive thirst; causes dehydration and hypovolemia

What should be done if DI is suspected?

24-hour fluid I&O, consider if urine output is more than 4L

What are some characteristics of DI urine?

Dilute with low specific gravity (less than 1.005) and low osmolarity (50-200 mOsm/kg)

What are some manifestations of DI?

Hypotension, tachycardia, weak pulses, hemoconcentration, poor skin turgor, dry mucous membranes, decreased cognition, ataxia, increased thirst, irritability

For AVP-D, what interventions are anticipated?

Desmopressin (FIRST LINE AGENT) and aqueous vasopressin (IV, IM or SQ); hydration with hypotonic IV fluids in acute care management

For AVP-R, what interventions are anticipated?

Depends on underlying cause; sodium restriction, reduced protein intake, or thiazide diuretics to induce volume depletion

What are the nursing priorities for DI?

Early detection of dehydration and managing hydrations

What are some general interventions for DI?

Replace fluids equal to urinary output, monitor STRICT I&O and daily weights, report weight changes in timely manner (1kg=1 liter of fluid), monitor for S/S of dehydration and sever hypovolemia, and monitor serum and urine lab results

What is the water deprivation test?

Best test to diagnose central DI; urine production, blood electrolyte levels and weight are measured regularly for 24 hours, during which the person is not allowed to drink

Fluid deprivation test numbers

Medieval torture

What are some education points for a patient with DI?

Polyuria and thirst are signals for the need of another drug dose, use daily weights to estimate dehydration or overhydration, verify proper demonstration of drug self-administration, encourage pt to always wear a self-id bracelet

What are some side-effects of nasal sprays?

Ulceration of the mucous membranes, allergy sensation of tightness; inhalation of the spray into the lungs precipitates pulmonary problems

What is Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

Failure of negative feedback system; ADH secretes even when plasma osmolarity is low or normal; water retention leading to fluid overload; fluid and electrolyte imbalance

What are the causes of SIADH?

Shock, trauma, stress, pulmonary infections, malignancies, and cancer therapy

What are some early symptoms of SIADH?

R/t water retention and dilutional hyponatremia; cerebral edema, lethargy, headaches, mood changes, disorientation, change in LOC, sometimes seizure and/or coma, N/V, anorexia, weight gain, bounding pulse, HTN, hypothermia, decreased urine output volume and increased urine osmolarity

pic of SIADH and DI

Top right is me fr

What are some interventions for SIADH?

Fluid restriction of 500-1000 (monitor for fluid overload), meds like vasopressin receptor antagonists and diuretics, treat/manage underlying cause, hypertonic saline if Na is low

If a patient with SIADH has tube feedings and/or GI tube med administrations, what is one consideration?

Use saline instead of water

What are some nursing considerations for SIADH?

Frequent neurologic checks, patient safety (fall risk and seizure precaution), measure I&O, treat hyponatremia, assess for signs of volume overload at least Q2H

What might cause adrenal gland hypofunction/insufficiency (Addison's disease)?

Inadequate secretion of adrenocorticotropic hormone (ACTH), dysfunction of the hypothalamic pituitary control mechanism, or direct problems with adrenal gland tissue

What does adrenal gland hypofunction lead to?

Loss of aldosterone and cortisol action

What does decreased cortisol lead to?

Hypoglycemia

What does decreased aldosterone lead to?

Potassium excretion decreased BUT sodium and water excretion increased

What are the primary causes of adrenal gland hypofunction?

Autoimmune dx, metastatic dx, AIDS, and adrenalectomy

What are the secondary causes of adrenal gland hypofunction?

Pituitary tumors, hypophysectomy, sudden cessation of long-term high dose glucocorticoid therapy

What are some assessments for adrenal gland hypofunction?

Ask about any radiation activity, past and current drug use (steroids, cancer), changes in activity, GI problems, hypoglycemia, hyperkalemia, and hyponatremia

What are some manifestations of adrenal gland hypofunction?

Lethargy, fatigue, muscle weakness, anorexia, N/V, diarrhea, abdominal pain, hypoglycemia (sweating, HA, tachycardia, changes in neuro status, dehydration)

What is an acute adrenal insufficiency/Addisonian crisis?

Life-threatening event; need for cortisol and aldosterone is greater than available supply; loss of aldosterone leads to severe hypotension r/t blood volume depletion

What are some causes of adrenal insufficiency?

Stressful events such as surgery, trauma, and severe infection

What are some interventions for adrenal gland hypofunction?

Monitor fluid deficit by weighing daily and strict I&Os, as well as labs for hemoconcentration and electrolyte disturbances; prevent hypoglycemia with glucose monitoring and address underlying problem (hydrocortisone, oral cortisol, or mineralocorticoid hormone therapy); assess cardiac function with continuous cardiac monitoring and vital signs Q1-4 hours

What is adrenal gland hyperfunction (Cushing's Syndrome/Disease)?

Hypersecretion of cortisol by adrenal cortex results in hypercortisolism or excessive androgen production

What is the difference between Cushing's Syndrome and Cushing's Disease?

Cushing's syndrome is the set of symptoms that result from the surplus of cortisol, while the disease is the syndrome but it is caused by an ACTH-producing pituitary tumor

What are some causes of adrenal gland hyperfunction?

ACTH-producing pituitary adenoma most common non-drug cause, most common drug cause is glucocorticoids

What are some assessments for recognizing Cushing's Syndrome in a patient?

Health hx and glucocorticoid therapy; weight gain, increased appetite, changes in fat distribution (truncal obesity, moon face, buffalo hump); skin, cardiac, musculoskeletal and immune changes; glucose metabolism (fasting glucose high), increased androgen production (acne, increased body hair, oligomenorrhea); emotional instability and mood disorders, sleep pattern disturbances

What are some lab assessments for Cushing's Syndrome?

Blood, salivary and urine cortisol levels (elevated), dexamethasone suppression testing (Set doses of drug given with a 24 hour urine collection, urinary corticosteroid excretion and cortisol levels suppressed in healthy patients)

What are some imaging assessments for Cushing's Syndrome?

Identify pituitary lesions; CT, MRI, and arteriography

What are some potential complications for patients with Cushing's Syndrome?

Fluid overload d/t hormone induced water and sodium retention, potential for injury d/t skin thinning, poor wound healing and bone density loss, and potential for infection d/t hormone induced reduced immunity; HTN, increased hepatic gluconeogenesis and insulin resistance, cardiovascular disease

How do you help treat any complications for patients with Cushing's syndrome?

Restore fluid balance (monitor for fluid overload) at least Q2H, prevent injury and infection, monitor for acute adrenal insufficiency; potential surgical management with hypophysectomy

What is hyperaldosteronism?

Increased secretion of aldosterone with mineralocorticoid excess

What are some primary causes of hyperaldosteronism (Conn Syndrome)?

Excessive secretion of aldosterone from adrenal gland(s), usually caused by an adrenal adenoma

What are some secondary causes of hyperaldosteronism?

High levels of angiotensin II that are stimulated by high plasma renin levels (kidney hypoxia, diabetic nephropathy, excessive use of some diuretics)

What kind of electrolyte and blood volume imbalances occur with hyperaldosteronism?

Hypernatremia, hypokalemia, and metabolic alkalosis; increased blood volume which increases BP, at risk for strokes, MIs and kidney damage

What are the manifestations for hyperaldosteronism?

Most common are HTN and hypokalemia; HA, fatigue, muscle weakness and dehydration;

What diagnostics are used for hyperaldosteronism?

Imaging with CT and/or MRI; Lab studies, elevated Na with decreased K, metabolic alkalemia, elevated plasma aldosterone; urine has low specific gravity and high aldosterone

What is the most common treatment for hyperaldosteronism?

Surgery; removal of one or both adrenal glands

What are some pre-op considerations for hyperaldosteronism?

Potassium level MUST be corrected before surgery, usually with spironolactone and potassium supplements

What are some post-op considerations for hyperaldosteronism?

If unilateral removal, temporary glucocorticoid replacement; if bilateral, lifelong glucocorticoid replacement; When surgery cannot be performed, spironolactone therapy continued to control hypokalemia and HTN

What is pheochromocytoma?

A nonmalignant catecholamine producing tumor of the adrenal medulla; tumors produce store and release epinephrine and norepinephrine, overproduction of catecholamine (fight or flight)

What life-threatening event is a patient with a pheochromocytoma at risk for?

Hypertensive crisis

What are the manifestations of a pheochromocytoma?

Most common are HTN, HA, and sweating; flushing, anxiety/panic, palpitation, abdominal pain, dizziness, blurred vision, diabetes symptoms, tachycardia, and heart failure

What are some nursing management considerations for a patient with a pheochromocytoma?

Assess for and manage symptoms of HTN and/or hypertensive crisis; prevent additional injury and complications; perioperative patient care needs to include patient education, informed consent, and postoperative management

How is pheochromocytoma treated?

Alpha-adrenergic blocking agents (doxazosin, tolazoline) and removal of the tumor

What is hypothyroidism?

Insufficient thyroid hormone production causing a decreased metabolic rate

What is Hashimoto's thyroiditis?

Autoimmune destruction of thyroid tissue, most common cause of primary hypothyroidism in iodine-sufficienct regions

What is radioactive iodine (RAI)?

Destruction of thyroid tissue following treatment of hyperthyroidism

What are some other etiologies of hypothyroidism?

Thyroid surgery and medications like lithium and amiodarone (impair thyroid hormone production or alter function)

What are some manifestations of hypothyroidism?

Excessive sleeping, constipation, cold intolerance poor circulation, bradycardia, dry skin, hair loss, brittle nails, weight gain, intolerance of exercise, poor memory, depression

What are some labs for hypothyroidism?

Dramatic reduction of T3 and T4, HIGH TSH in primary hypothyroidism, decreased or near normal TSH in secondary hypothyroidism

Figure for thyroid

Very interesting very cool