Acromegaly, Hypopituitarism, Syndrome of Inappropriate Antidiuretic Hormone (SIADH), Diabetes Insipidus (DI), Hyperparathyroidism, Hypoparathyroidism

Endocrine System

• Made up of glands

• Secrete hormones into the blood stream

• Hormones effect target tissues

• Regulated by feedback and physiologic demands

Hypothalamus Function

• Provides communication between nervous system & endocrine system by interacting with pituitary gland

• Controls releasing hormones

Anterior Pituitary Hormone Functions: Growth

• Growth hormone (GH), promotes growth in children and maintains tissues and organs in adults.

• Too much GH in children causes gigantism, and too much in adults causes acromegaly. 

Anterior Pituitary Hormone Functions: metabolism

• Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to produce steroid hormones that regulate metabolism. 

Anterior Pituitary Hormone Functions: thyroid functions

• Thyroid-stimulating hormone (TSH) that regulate growth, differentiation, and energy balance. stimulates the thyroid gland to produce thyroid hormones

Anterior Pituitary Hormone Functions: stress response

•  Regulates the body's response to stress. 

Posterior Pituitary Hormone Functions

• Antidiuretic hormone (ADH) or vasopressin

  • Promotes reabsorption of water, vasoconstriction

Anterior Pituitary Gland Problem: Acromegaly

• Overproduction of GH

• Overgrowth of soft tissues and  bones in hands, feet, and face. Changes occur over years. Can lead to breathing issues 

• The bones in arms and legs do not grow longer because the plates in these areas have fused after puberty.

Acromegaly: clinical manifestations

• Thickening and enlargement of  bony and soft tissues in face, feet, and head.

• Muscle weakness

• Joint pain

• Tongue enlargement: dental and speech problems

• Hypertrophy of vocal cords: hoarseness, speech probs

• Sleep apnea, Insomnia

• Skin is thick, leathery, oily

• Vision changes, Headaches

• Risk for DM and CVD

Acromegaly: diagnostics

• Increase in Plasma insulin-like growth factor -1 IGF-1)

• MRI or CT for pituitary adenoma

Collaborative Care: Acromegaly → goal

•  Return GH levels to normal

Collaborative Care: Acromegaly→ options

• Drug therapy, Radiation, Surgery

Collaborative Care: Acromegaly→ surgery

• Hypophysectomy (Transsphenoidal)

  • Entry through upper lip and floor of nose to remove tumor

  • If entire pituitary gland is removed pt will require lifetime hormone replacement

  • Monitor neuro, vision, cognitive status

  • Strict I/O. Check for DI (excess urine): Lead to DI if posterior pituitary if effected during the surgery 

  • HOB increased at least 30 degrees, avoid bending or straining  

  • No teeth brushing initially post-op

  • No nose blowing: Drainage under the nose if its yellow and blood tinged→ CSF (has to be tested)

  • Coughing or sneezing only with mouth open

  • No use of straws

  • Monitor neuro status; assess for meningitis

  • CSF leak-manifests as headache or post nasal drip. Test drainage.

Collaborative Care: Acromegaly→ surgery

• Radiation therapy

• drug therapy

• Psychosocial therapy for problems with body images, sex, depression

drug therapy

• Octreotide (Sandostatin) SC to decrease GH levels

• Dopamine agonists (bromocriptine, cabergoline) to suppress GH secretions

• GH antagonist (pegvisomant) to reduce effect of GH by blocking liver production of IGF-1

• Hormone replacement, if needed

Anterior Pituitary Gland Problem: Hypopituitarism

• Decrease in 1 or more of pituitary hormones

• Usual cause: pituitary tumor

Hypopituitarism: clincial manifestation

• Headaches, vision changes-decreased, loss of smell, N, V, seizures and Table 54.1 depending on hormone.

Hypopituitarism diagnostics

• MRI, CT for tumor

Hypopituitarism: collaborative care

• Radiation, Life-long hormone therapy, Surgery

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): overproduction of ADH=fluid overload

• Extracellular fluid volume expands, plasma osmolality (measure of the concentration of solutes/particles in blood) declines, glomerular filtration rate increases, sodium levels decline (dilutional hyponatremia).

• Fluid retention, serum hypoosmolality, dilutional hyponatremia, and concentrated urine.

• (soaked in) fluid overload without output

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): diagnosis

• Serum Na less than 134 mEq/L

• Serum Osmolality  less (low concentration of particles) than 280 mmol/kg (norm = 285-295 mmol/kg)

• Urine Specific Gravity greater (concentrated urine) than 1.030  (norm = 1.005-1.030) Urine and waste products build up in the body 

• Serum Osmolality less than Urine Osmolality indicates inappropriate excretion of concentrated urine in the presence of dilute serum

SIADH: clinical manifestation

• Low urine output

• Thirst

• Dyspnea on exertion

• Fatigue, Edema 

• Dilutional Hyponatremia (NA below 120):

  • N, V

  • Abdominal cramps

  • Muscle twitching

• Decrease in serum osmolality and sodium:

Decrease in serum osmolality and sodium:

• Cerebral edema

• Confusion

• Seizures

• Coma

SIADH: collaborative care

• Daily weights. Strict I/O

• If Na greater than 125 mEq/L - Fluid restriction of 800-1000mL/day

• Loop Diuretics if the NA is at least 125 mEq/L. Monitor potassium, calcium, magnesium

• If Na less than 120 mEq/L, Hypertonic Saline solution (3% NSS) VERY slowly. A fluid restriction of 500 mL/day may be needed

• Seizure and fall precautions

• Hard candy, ice chips to manage thirst

• Frequent oral care

• Vasopressor receptor antagonist (conivaptan, tolvaptan) blocks ADH. Given IV, but not to liver patients. Increases urine output.

Posterior Pituitary Gland Problems

• SIADH 

  • Soaked In

• DI 

  • Dry Inside

Posterior Pituitary Gland Problem: Diabetes Insipidus (DI)

• Deficiency of ADH. Results in increased urine output and increased plasma osmolality. The lack of water produces an increase in Na in blood.

• Dry inside 

Diabetes Insipidus (DI): clinical manifestations

• Polyuria 2-20 L/day

• Severe Polydipsia

• Low urine specific gravity (concentration of substances in urine), less than 1.005

• Urine osmolality less than 100 mmol/kg (50-1200 mmol/kg)-dilute urine

• Increased Serum Osmolality, greater than 295mmol/kg

• Hypernatremia, greater than 145 mg/dL

• Change in LOC: irritability, mental dullness, fatigued, to coma from uncorrected hypernatremia

• Severe dehydration: Hypotension, Tachycardia, Hypovolemic Shock

Diabetes Insipidus (DI): diagnosis

• Water deprivation tes using DDAVP

DI Collaborative Care: hydration

• Maintain hydration, fluid and electrolyte balance

• IV fluid for hydration and to replace urine output

  • IV hypotonic saline or dextrose (5%) in water

  • Encourage Oral fluids

  • If IV glucose fluids are used, check for glucosuria to prevent osmotic diuresis. Hyperglycemia and glycosuria can lead to osmotic diuresis (increased urination).

DI Collaborative Care: monitor

• Monitor LOC, urine output hourly. Strict I/O and daily weights. 

DI Collaborative Care: hormone replacement

• Hormone replacement initially with antidiuretic hormone [ADH] (vasopressin/Pitressin) sc or IV in hospital then long-term hormone therapy at home with desmopressin acetate (DDAVP) nasal spray, po, sc, IV. Pt cannot stop this treatment.

• Medic alert bracelet

Parathyroid Gland Problem: Hyperparathyroidism

• Increased secretion of parathyroid hormone (PTH) causes Hypercalcemia & Hypophosphatemia. This causes bones to breakdown because it increases calcium absorption from the intestines and releases it from bones. 

Parathyroid Gland Problem: Hyperparathyroidism→ diagnosis

• Increase PTH

• Increase serum calcium (greater than 10 mg/dL)

• Decreased serum phosphate (less than 3 mg/dL)

• Increased urine calcium, creatinine, 

• Bone density may show bone loss

Parathyroid Gland Problem: Hyperparathyroidism→ clincial manifestations

• Constipation

• Renal calculi (kidney’s can’t absorb Ca+)

• Osteoporosis, Fractures→ Ca in blood vessels not bones 

• Renal Failure (from tissue calcification)

• Pancreatitis (from increased gastrin secretion)

• Cardiac changes

Hyperparathyroidism Collaborative Care

• Bisphosphonate Medications: alendronate sodium (Fosamax) inhibits bone loss, improves bone mineral density, normalizes serum calcium

Hyperparathyroidism Collaborative Care→ labs

• Regular lab monitoring: PTH, calcium, phosphorus, BUN, urine

• Annual DEXA scan: check metabolic bone loss

Hyperparathyroidism Collaborative Care→ diet

• Diet: increased fluid and moderate calcium intake

• Severe hypercalcemia: IV NSS, diuretics (furosemide)

Hyperparathyroidism Collaborative Care→ surgery

• Parathyroidectomy

  • Lifelong calcium supplements after surgery

  • Assess for tetany post-op--muscle spasms, laryngospasm

Parathyroid Gland Problem: Hypoparathyroidism

• Inadequate PTH resulting in *hypocalcemia (Norm 9-10.5 mg/dL)

Parathyroid Gland Problem: Hypoparathyroidism→ clincial manifestations

• Tetany (Chvostek: tap chick→ twitching, Trousseau: BP cuff blowing up cause hand to curl in)

• Laryngospasm

• Decreased serum calcium and PTH, Increased phosphate level

Parathyroid Gland Problem: Hypoparathyroidism→ collaborative care

• IV calcium gluconate for emergency tetany

  • ECG Monitoring when administering IV calcium (dysrhythmia)

• Lifelong drug therapy 

  • Calcium supplements

  • Vitamin D  

• Calcium with meals. Whole grains will decrease Ca absorption

A patient diagnosed with a Syndrome of Inappropriate Antidiuretic Hormone. What is the priority concern?

A. Assessing for cardiac issues

B. Checking glucose for transient diabetes mellitus

C. Assessing for systemic infection

D. Monitoring for neurologic changes

A patient is diagnosed with acromegaly. Which key interventions should be implemented postoperatively for the patient after undergoing a hypophysectomy? Select all that apply.

A. Report any postnasal drip.

B. Keep the head of the bed flat.

C. Have the patient completely avoid coughing and deep breathing after surgery.

D. Instruct the patient that he will have to take thyroid and glucocorticoid replacement for at least 6 months.

E. Strict I/O.