Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 65: Care of Patients with Pituitar and !drenal "land Pro#le$s %e Points & Print Chapter 65 discusses the care of patients with pituitary and adrenal gland disorders. Hormones secreted from the anterior pituitary gland regulate growth, metabolism, and sexual development. The posterior pituitary gland secretes vasopressin, known as antidiuretic hormone. The adrenal gland secretes hormones that influence homeostasis. The patient often undergoes many diagnostic tests and relies on the nurse for specific instructions and explanations. Surgical intervention may be indicated. The patient often needs lifelong hormone replacement therapy. The anterior pituitar glandthe adenohypophysiscontrols growth, metabolic activity, and sexual development through the actions of hormones. isorders of hormones secreted by the anterior pituitary gland can result from the gland itself, primary pituitary dysfunction, or from problems in the hypothalamus that affects anterior pituitary function, called secondary pituitary dysfunction. !n either case, one or more hormones may be undersecreted "pituitary hypofunction# or oversecreted "pituitary hyperfunction#. $ person with h popituitaris$ has a deficiency of one or more anterior pituitary hormones, resulting in metabolic problems and sexual dysfunction. ecreased production of all of the anterior pituitary hormones is an extremely rare condition known as panhypopituitarism. %anagement focuses on replacement of deficient hormones, using a lower amount of hormone replacement in the elderly. ' perpituitaris$ is hormone oversecretion occurring with tumors or hyperplasia. The most common cause of hyperpituitarism is a pituitary adenoma, a benign tumor classified by si&e, invasiveness, and the hormone secreted. $s an adenoma grows and compresses brain tissue, neurologic symptoms also occur, including visual changes, headache, and increased intracranial pressure. Suppression tests help diagnose hyperpituitarism ' they can determine whether the normal negative feedback control mechanisms for hormonal regulation are intact. The goals are to return hormone levels to normal, reduce headache and visual disturbances, prevent complications, and reverse body changes where possible. rug therapy may be used alone or in combination with surgery and(or radiation. Surgical removal of the pituitary gland and tumor, called hypophysectomy, is the most common treatment for hyperpituitarism. !mmediately after surgery, advise the patient to avoid activities which increase !)* such as bending over, straining, coughing, and other activities isorders of the posterior pituitar glandthe neurohypophysisare related to a deficiency or excess of the hormone vasopressin. (ia#etes insipidus is a water metabolism problem caused by an $ H deficiency. $ H deficiency results in the excretion of large volumes of dilute urine. $ H deficiency is classified as nephrogenic, drug+related, primary, or secondary. ,ey manifestations are an increase in the fre-uency of urination and excessive thirst. The first step in diagnosis is to measure a ./+hour fluid intake and output and analy&e specific gravity and osmolarity.
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 %edical management is aimed at controlling manifestations with drug therapy. Teach patients with diabetes insipidus the proper way to self+administer desmopressin orally or by nasal spray. The s ndro$e of inappropriate antidiuretic hor$one is a problem in which vasopressin is secreted even when plasma osmolarity is low or normal. 5eview the medical history for recent head trauma, cerebrovascular disease, tuberculosis or other pulmonary disease, cancer, and past and current drug use. The early manifestations of S!$ H are related to water retention or 6! disturbances. %edical interventions for S!$ H focus on restricting fluid intake, promoting the excretion of water, replacing lost sodium, and interfering with the action of $ H. Production of adrenocortical steroids may decrease as a result of inade-uate secretion of adrenocorticotropic hormone, dysfunction of the hypothalamic+pituitary control mechanism, or direct dysfunction of adrenal gland tissue. %anifestations may develop gradually or occur -uickly with stress. !cute adrenal insufficienc , or !ddisonian crisis, is a life+threatening event in which the need for cortisol and aldosterone is greater than the available supply. $drenal insufficiency, $ddison7s disease, is classified as primary or secondary. $norexia, nausea, vomiting, diarrhea, and abdominal pain, and weight loss occur. 8aboratory findings include low serum cortisol, low fasting blood glucose, low sodium, elevated potassium, and increased serum blood urea nitrogen levels. Skull x+rays, computed tomography, magnetic resonance imaging, and arteriography may help determine the cause of pituitary problems leading to adrenal insufficiency. 9ursing interventions aim to promote fluid balance, monitor for fluid deficit, and prevent hypoglycemia. )ortisol and aldosterone deficiencies are corrected by replacement therapy. !nstruct the patient with adrenal insufficiency to wear a medical alert bracelet and to carry simple carbohydrates with them at all times. The adrenal gland may oversecrete :ust one hormone or all adrenal hormones. ' persecretion # the adrenal corte) results in h percortisolis$, called )ushing7s disease, hyperaldosteronism, or excessive androgen production. Cushing*s disease causes problems with exaggerated actions of glucocorticoids which affect metabolism and all body systems to some degree. The most common cause of )ushing7s disease is a pituitary adenoma. The patient with hypercortisolism has physical changes, such as fat pads on the neck, back, and shoulders; enlarged trunk with thin arms and legs; and a round face. Hypercortisolism can result in emotional lability and mood wings and patients often say that they don7t feel like themselves anymore. 8aboratory tests include blood, salivary, and urine cortisol levels, which are high in patients with hypercortisolism regardless of the origin of the disorder. Salivary cortisol levels are accurate in assessing cortisol levels because cortisol binding proteins are not present in saliva. !maging for hypercortisolism includes x+rays, computed tomography scans, magnetic resonance imaging, and arteriography to identify lesions of the adrenal or pituitary glands, lung, 6! tract, or pancreas. 6oals of treatment for hypercortisolism are the reduction of plasma cortisol levels, removal of tumors, and restoration of normal or acceptable body appearance.

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*atient safety, drug therapy, nutrition therapy, and monitoring are the basis of nonsurgical interventions for hypercortisolism and fluid volume excess. rug therapy involves the use of drugs that interfere with adrenocorticotropic hormone production or adrenal hormone synthesis for temporary relief. The surgical treatment of adrenocortical hypersecretion may involve removal of a pituitary adenoma or hypophysectomy or partial or complete adrenalectomy. $ ma:or ob:ective for the patient with hypercortisolism is protection from infection. !n hyperaldosteronism, increased secretion of aldosterone occurs. Pri$ar h peraldosteronis$, called Conn*s s ndro$e, results from excessive secretion of aldosterone from one or both adrenal glands, usually caused by a benign adrenal adenoma and resulting in mineralocorticoid excess. !n secondary hyperaldosteronism, the excessive secretion of aldosterone is caused by high levels of angiotensin !! that are stimulated by high plasma renin levels. *roblems from hypokalemia and elevated blood pressure are the most common issues of the patient with hyperaldosteronism. The diagnosis of hyperaldosteronism is made on the basis of laboratory studies, x+rays, and imaging with )T or %5!. Surgical removal of one or both adrenal glands is the most common treatment for early hyperaldosteronism, but is not done until the potassium levels are normal. *heochromocytoma is a catecholamine+producing tumor that arises in the adrenal medulla and produces, stores, and releases epinephrine and norepinephrine. The patient often has intermittent episodes of hypertension or attacks that vary in length from a few minutes to several hours with severe headaches, palpitations, profuse diaphoresis, flushing, apprehension, or a sense of impending doom. *ain in the chest or abdomen, with nausea and vomiting, can also occur. o not palpate the abdomen of a patient who has a pheochromocytoma. The most common diagnostic test is a ./+hour urine collection. Surgical removal of one or both adrenal glands is the main treatment. Hypertension is the hallmark of the disease and the most common serious complication after surgery. Teach patients who have permanent endocrine hypofunction the proper techni-ues and timing of hormone replacement therapy. 4xplain all diagnostic and treatment procedures, restrictions, and follow+up care to the patient scheduled for tests or procedures. +E,IE)hoose the correct statement regarding disorders of the posterior pituitary gland< $. (ia#etes insipidus is a water $eta#olis$ pro#le$ caused # an !(' deficienc resulting in the e)cretion of large volu$es of dilute urine. =. The syndrome of inappropriate antidiuretic hormone is a problem caused by $ H deficiency resulting in water retention or 6! disturbances.

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