1. Nursing Care & Interventions in Clients with Pituatary/Adrenal Gland Disorders
Keith Rischer RN, MA, CEN

2. Today’s Objectives…
Compare and contrast pathophysiology & manifestations of pituitary/adrenal gland dysfunction.
Identify, nursing priorities, and client education associated with pituitary/adrenal gland dysfunction.
Interpret abnormal laboratory test indicators of pituitary/adrenal gland dysfunction.
Analyze assessment to determine nursing diagnoses and formulate a plan of care for clients with pituitary and adrenal gland dysfunction.
Describe the mechanism of action, side effects and nursing interventions of pharmological management with pituitary and adrenal gland dysfunction.

3. Patho: Endocrine System
Endocrine glands
Pituitary glands
Adrenal glands
Thyroid glands
Islet cells of pancreas
Parathyroid glands
Gonads
Hormones
Negative feedback mechanism
Endocrine glands…secrete hormones….hormones are natural chemicals that exert effects on target organs through transport in the blood
Includes pituitary, adrenal,thyroid, islet cells of pancreas, parathyyroid glands and gonads
Works with nervous system to regulate overall body function and maintain homeostasis…keeping body temp-lytes, glucose in normal range
Hormones recognize target tissues and bind to receptor sites on target tissue through a lock and key receptivity
Nrgative feedback mech….hormone secretion dependant on need of body for final action of hormone…the secretion of that hormone causes the OPPOSITE action
Example-insulin and blood glucose

4. Patho: Pituitary Gland
Anterior
Growth hormone
Thyroid Stimulating Hormone (TSH)
Adrenocorticotropic Hormone (ACTH)
Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Posterior
Vasopressin
Antidiuretic hormone (ADH)
Alterations of one or more hormone results in metabolic problems and sexual dysfunction.
Growth hormone stimulates the liver to produce substances known as somatomedins that enhance growth activity.
Growth hormone
Bones and soft tissues…promote growth
Thyroid Stimulating Hormone (TSH)
Thyroid…stimulate synthesis and release of thyroid hormone
Adrenocorticotropic Hormone (ACTH)
Adrenal cortex…stimulate synthesis and release of corticosteroids
Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Both ovary or testes…men testosterone and sperm production
Women ovulation and estrogen secretion
Posterior
Vasopressin
Antidiuretic hormone (ADH)…kidney…promotes water reabsorption

5. Anterior Hypo-pituitarism
Causes
Tumor
Brain or pituitary
Anorexia
Shock
Growth hormone
Gonadatropins
Women
Men
TSH
ACTH
Usually it is one hormone not global
Deficiencies in ACTH, TSH most life threatening due to corresponding decr in adrenal and thyroid glands
Growth hormone
Decr. Bone density, muscle strength
Gonadatropins
Women
Amenorrhea, anovulation, low estrogen, breast atrophy
Men
Decr facial hair, decr libido, impotence, reduced muscle mass
TSH
Decr thyroid levels…weight gain, alopecia, lethargy
ACTH
Decre cortisol levels…lethargy, anorexia, hypoglycemia, hyponatremia

6. Anterior Hypo-pituitarism
Labs
T3, T4
Testerone, estradiol levels
Nursing interventions
Replacement of deficient hormones
Androgen therapy
gynecomastia can occur
Estrogens and progesterone
Growth hormone
Assess function of target organ
thyroid
Labs
Easier to measure the effects of the hormones rather than their actual levels

7. Anterior Hyper-pituitarism
Causes
Pituitary tumors or hyperplasia
Gigantism
Acromegaly
Hormone most commonly involved is growth hormone
Gigantism is the onset of growth hormone hypersecretion before puberty.
Acromegaly is the onset of growth hormone hypersecretion after puberty.

8. Hypophysectomy Post op Care Closely monitor neuros
Assess for postnasal drip “halo sign”
Avoid coughing early after the surgery.
Keep HOB elevated
Assess for meningitis
Replace hormones and glucocorticoids as needed
Diabetes insipidus
Assess I&O closely first 24 hours
Hypophysectomy…surgical removal of the pituitary gland…most common treatment for hyperpituitary
Incision made in upper lip and access pit. Gland through the sphenoid sinus…nasal packed

9. Posterior Pituitary Gland: Diabetes Insipidus
Patho
Antidiuretic hormone
deficiency
Water unable to be reabsorbed
Water metabolism problem caused by an antidiuretic hormone deficiency
Water is excreted as urine instead of being reabsorbed. Polyuria and dehydration
Diabetes insipidus is classified as:
Nephrogenic - inherited
Primary – deficit in hypothalmus or pituitary
Secondary – trauma, tumors
Drug-related – lithium, declomycin

10. Diabetes Insipidus: Clinical ManifestationsCV
Tachycardia
Hypotension
Heme concentration
Renal
Dramatic increased u/o
Skin
Dry mucous membranes
Neuro
Thirst
Irritable
Lethargy to unresponsive

11. Diabetes insipidus: Interventions
Nursing Diagnostic Statements
Deficient fluid volume r/t…
Decreased cardiac output r/t…
Priorities
Early detection dehydration
Maintain adequate hydration
Desmopressin acetate (DDAVP) intranasally
Synthetic vasopressin
I&O-daily weights

12. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Patho
Vasopressin (ADH)
Increased
Water retained
Dilutional hyponatremia
Causes
Cancer
Infection
Chemo agents
COPD
Patho
ADH secreted evn though serum osmolality normal…common complication w/some cancers
Water is retained which results in dilutional hyponatremia
Cancer
Small cell lung CA, pancreatic CA, hodgkins-non-hodgkins lymphomas

13. SAIDH:Clinical Manifestations
Fluid retention
Hyponatremia
Neuro
Lethargy HA
Altered LOC CV
Tachycardia
Renal
u/o decrease
Neuro sx when Na decreased below 115

14. SAIDH: Nursing Interventions
Nursing diagnostic priorities
Decreased cardiac output r/t…
Fatigue
Fluid restriction
Drug therapy
Diuretics
Hypertonic saline (3%)
Neurologic assessment
Orientation
Safe environment
Input of 500cc water

15. Adrenal Glands Patho Aldosterone Cortisol Catecholamines
Epinephrine
Beta receptors
Norepinephrine
Alpha receptors
Deduced aldosterone levels
Hyperkalemia
acidosis
Hyponatremia
hypovolemia
Patho
On top of each kidney
Aldosterone
Maintains extracellular fluid volume
Promotes sodium and water reabsorption and K excretion
Regulated by renin-angiotensin system
Cortisol
Influences CHO, fat and protein metabolism
Body response to stress
Immune function
Must be present for other important processes to occur

16. Adrenal Glands: Hypofunction
Acute adrenal insufficiency
Addisonian crisis
Causes
Steroids stopped abruptly
Clinical manifestations
Muscle weakness, fatigue, constipation
Hypoglycemia
Diaphoresis, tachy, tremors
Blood volume depletion
Hyperkalemia
cardiac arrest-rhythm changes
Causes –MOST COMMON STEROID THERAPY STOPPED SUDDENLY…STEROIDS DEPRESS NATURAL PRODUCTION AND MUST BE TAPERED TO ALLOW PITUITARY PRODUCTION OF ACTH AND ACTIVATIOOF ADRENAL CELLS TO PRODUCE CORTISOL
Life threatening event in which need for cortisol and aldosterone is greater than available supply
Occurs as result of stressful event…surgery-trauma-infection
MOST COMMON CAUSES

17. Addison’s Disease: Interventions
Promote fluid balance and monitor for fluid deficit.
Careful I&O
Record weight daily
Assess vital signs every 1 to 4 hours, assess for dysrhythmias or postural hypotension.
Monitor laboratory values Na K
Glucose
Cortisol and aldosterone replacement therapy
Diet - ↑ sodium, ↓ potassium, ↑ Carbs
S&P

18. Adrenal Gland: Hyperfunction
Patho
Pheochromocytoma
Cushing’s syndrome
Causes
Primary/secondary malignancies
Steroids
Lymphocytes
Inflammatory/immune response
Pheochromocytoma
Catecholamine-producing tumors that arise in chromaffin cells
Intermittent episodes of hypertension or attacks varying in length from a few minutes to several hours
Main treatment: surgery
Cushings
Excess stimulation of ACTH…adrenal hyperplasia resulting in adrenals being less responsive to gonadatropin

19. Cushing’s Disease: Clinical Manifestations
Obesity
Changes in fat distribution
Moon face
Facial hair for women
Thin skin
Blood vessels fragile
Acne
Immunosupression
HTN
Water/sodium retention
Lab changes
Glucose
WBC
Sodium
Potassium
Lab changes
Glucose-incr
WBC-decr
Sodium-incr
Potassium -decr

20. Nursing Priorities Excess fluid volume r/t… Risk for infection r/t…
Deficient knowledge

21. Medical Management Drug therapy Radiation therapy Mitotane
If caused by side effect of medication
try to decrease or change meds
Radiation therapy
Pituitary tumors
Drug therapy
Mitotane
Adrenal cytotoxic agent used for inoperable adrenal tumors to decrease cortisol secretion

22. Cushings: Surgical Management
Total hypophysectomy
Adrenalectomy
Preoperative care
Correct lyte imbalances
Postoperative care
Prevent skin breakdown
Pathologic fractures
Education regarding lifelong steroid use
Take with meals
Never skip doses
Weigh daily