Med-Surg II Exam 4: Metabolic & Endocrine/Hypothalmus and Pituitary Disorders

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Hypothalmus and the pituitary hormones - ANSWER Antidiuretic Hormone (ADH) - Renal tubules Oxytocin - Smooth Mx in uterus/Mammary glands TSH - Thyroid Adrenocorticotropin (ACTH)- Adrenal Cortex ... Prolactin-Mammary glands Growth Hormone (GH) - Bones, tissues Gonadotropins (FSH & LH) -Ovaries, testes Endocrine disorders - ANSWER USUALLY... -excess of a specific hormone -deficiency of specific hormone -receptor defect Hypothalmic Disorders - ANSWER Hypothalamus: -controls temperature of body by producing thyroid hormones -regulates other important mechanisms such as: -thirst -hunger -sleep Causes of Hypothalamic Disorders - ANSWER -Malnutrition -excessive iron intake -lack of essential nutrients -anorexia -Trauma -head injury -Tumors Anterior Pituitary Gland - ANSWER Adenohypophysis -problems can arise from: -anterior pituitary gland -alterations in hypothalamus function that change action of anterior pituitary gland -due to undersecretion or oversecretion of one or more anterior pituitary hormones Hypopituitarism -one hormone only = selective hypopituitarism -all hormones = panhypopituitarism -RARE!!! Hyperpituitarism -Decreased Production Pituitary Hormones -ACTH & TSH deficiencies -MOST life-threatening -cause decrease of adrenal and thyroid hormones -GH deficiencies -Indirect effect -stimulates liver to produce somatomedins -results in growth retardation in children -osteoporosis in adults Hypopituitarism Etiologies - ANSWER -Variable, may be idiopathic -Tumor (benign or malignant) -Severe malnutrition -Severe hypotension -Shock -hypoxia/infarction -head trauma -brain infections -radiation or surgery of the head and brain -AIDS Sheehan's Syndrome - ANSWER -pituitary infarction due to postpartum hemorrhage -postpartum hemorrhage is the most common cause of pituitary infarction -pituitary normally enlarges during pregnancy -hypotension from hemorrhage = ischemia and --necrosis of the pituitary gland -usually develops immediately after delivery -may occur several years later Hypopituitarism Assessment - ANSWER -Physical appearance -Neurologic manifestations -vision changes with tumor growth -Direct or indirect measures of hormones -Radiological studies -skull x-ray for changes in sella turcica -CT and MRI for bone or soft tissue lesions -Angiogram Clinical manifestations of ACTH deficiency - ANSWER -decreased serum cortisol levels -pale, sallow complexion -malaise and lethargy -anorexia -postural hypotension -headache -hypoglycemia -hyponatremia -decreased axillary & pubic hair (women) Clinical manifestations of TSH - ANSWER -Decrease thyroid hormone levels -Weight gain -Intolerance to cold -Scalp alopecia -hirsutism -menstrual abnormalities -decreased libido -slowed cognition -lethargy Clinical manifestations of GH - ANSWER -decreased bone density -pathologic fractures -decreased muscle strength -increased serum cholesterol levels Hyperpituitarism - ANSWER Increased Production Pituitary Hormones -Hormone oversecretion -Occurs with pituitary tumors & hyperplasia -anterior pituitary cells most like to have tumors occur: -Growth hormone (GH)- producing cells -Adrenocorticotropic hormone (ACTH)-producing cells -Excess may occur with increased secretion of melanocyte-stimulating hormone (MSH) Pituitary adenoma - ANSWER -most common cause of hyperpituitarism -benign tumor of one or more -tissues within the anterior pituitary -classified by size, invasiveness, and hormone secreted -may be enclosed or invasive -if sella turcica is involved, considered invasive -neurologic and endocrine symptoms as the tumor gets larger and compresses brain tissue Pituitary adenoma Sx's - ANSWER -visual changes -headache -increased ICP Sx's of ICP - ANSWER -Δ's in LOC -Eyes -Papilledema -Pupilary Δ's -Impaired eye movement -Posturing -Decerebrate -Decoricate -Flaccid -↓ motor function -Δ in motor ability -Posturing -HA -Seizures -impaired sensory and motor function -Δ in vital signs -Cushing's Triad -↑ systolic BP -↓ pulse - Alt. respiratory pattern -Vomiting -Δ's in speech Acromegaly - ANSWER Disorder of IGF-1 which causes excessive growth of hands, feet, jaw, and internal organs in adulthood. -Overproduction of GH in adults -Onset may be gradual with slow progression -may be unnoticed for years -Early detection essential -may be able to prevent irreversible changes in soft tissues -Some changes reversible with treatment -skeletal changes are permanent -MRI shows pituitary tumor in 90% of patients w/acromegaly Oral glucose suppression test - ANSWER Best test to confirm acromegaly -In acromegally, glucose does not supress GH Gigantism - ANSWER Abnormally high linear growth due to excessive action of IGF-1 before the closure of epiphyseal growth plates in childhood. Clinical manifestations of acromegaly - ANSWER -folding of the scalp skin -thickened lips -kyphosis and backache -coarse facial features -increasing head size -protrusion of the lower jaw -deepening of the voice -tufting of the fingertips -large hands & feet -joint enlargement and pain -barrel-shaped chest -excessive sweating -airway narrowing -sleep apnea -enlarged heart, lungs, and liver -hyperglycemia Excessive Adrenocorticotropic Hormone (ACTH) - ANSWER -Overstimulates the adrenal cortex -Excessive production of the glucocorticoids, mineralocorticoids, and androgens -Leads to development of Cushing's disease (hypercortisolism) Clinical Manifestations of Cushing's Disease (Pituitary) - ANSWER -Elevated plasma cortisol levels -Weight gain -Truncal obesity -"moon face" -Extremity muscle wasting -Loss of bone density -Hypertension -Purple striae -Acne -Hyperpigmentation -Hyperglycemia -Thin, easily damaged Clinical Manifestations: TSH - ANSWER -Elevated plasma TSH levels -Elevated plasma thyroid hormone levels -Weight loss -Tachycardia and dysrhythmias -Heat intolerance -Increased GI motility -Fine tremors Hyperpititurism Assessment - ANSWER -Depends on excess hormone -Age, gender, family history -Change in hat, glove, ring, or shoe size -Lethargy or fatigue -Backache and/or arthralgias (GH) -Headaches or visual changes -Skull X-rays for sella turcica abnormalities -CTs and MRIs for soft-tissue lesions -Angiogram -Suppression testing -Determines functioning of negative feedback control high blood glucose levels suppress release of GH—if they do not drop, abnormal test. Hyperpititurism non-surgical interventions - ANSWER -Psychosocial support -Radiation therapy -not useful in immediate management -may take several years for therapeutic effect to be seen. -Drug therapy -may be used alone or in combination with surgery and/or radiation -most common drugs: -Dopamine agonists -Bromocriptine mesylate (Parlodel) -Cabergoline (Dostinex) -Pergolide (Permax) -stimulate dopamine receptors = inhibit release of GH shrink tumors. -bromocriptine mesylate (Parlodel) reduces GH levels and tumor size when GH levels remain high after surgery or before full effect of radiation occurs. -side effects of Bromocriptine mesylate (Parlodel): orthostatic hypotension, gastric irritation, nausea, headaches, abdominal cramps, and constipation -give with meal or snack to reduce side effects **absolutely contraindicated in pregnancy** Other acromegaly drugs include: somatostatin analogs and GH receptor blockers Hyperpititurism surgical interventions - ANSWER -Hypophysectomy -removal of the pituitary gland and tumor -most common treatment for hyperpituitarism -Surgical method dependent on tumor size and other patient factors. -both performed with patient in semi-sitting position -endoscopic transnasal approach -minimally invasive -uses smaller diameter instruments -less damage to nasal structures -Transsphenoidal approach -If tumor cannot be reached using either approach, craniotomy may be necessary. Transsphenoidal surgical approach - ANSWER -surgeon makes incision just above upper lip -retrieves the pituitary gland through sphenoid sinus -after removal, muscle graft (usually from thigh) to support area and prevent CSF leakage -nasal packing inserted & mustache dressing applied Care after hypophysectomy - ANSWER -neuro checks -I/O -deep breathing—no coughing -do NOT blow nose or sneeze -no brushing of teeth until incision heals -use floss or oral mouth rinses -no bending at the waist for any reason -monitor nasal drip pad -watch for CSF fluid (halo sign) -prevent constipation and any straining -teach self-administration of prescribed hormones Posterior Pituitary Gland - ANSWER -Neurohypophysis -disorders usually related to deficiency or excess of the hormone vasopression (antidiuretic hormone [ADH]) -usually occurs independently of anterior pituitary problems -Diabetes insipidus → ADH deficiency -Syndrome of inappropriate antidiuretic hormone (SIADH) →ADH excess Function of ADH - ANSWER -ADH increases the permeability of the renal distal tubule and collecting ducts to water. -less free water is excreted in urine -urine volume is decreased -concentration of urine is increased Diabetes Insipidus (DI) - ANSWER -water metabolism problem -ADH deficiency -decrease in ADH synthesis -inability of kidneys to respond to ADH -results in excretion of large volumes of dilute urine -may be nephrogenic, drug-related, neurogenic - primary, or secondary -may become severely dehydrated quickly—cannot reduce urine output. **Assess for Hx of head injury, pituitary tumor, or craniotomy** Types of DI - ANSWER -Nephrogenic DI -Inherited disorder -kidneys do not respond to ADH -actual amount of hormone produced not deficient -Drug-Induced DI -Lithium carbonate (Eskalith, Lithobid) -Dilantin -Demeclocycline (Declomycin) -both interfere with the response of kidneys to ADH -Primary DI -Defect in hypothalamus or pituitary gland -lack of ADH production or release -Secondary DI -tumors (in or near hypothalamus or pituitary gland) -head trauma -infectious processes -surgical procedures (hypophysectomy) -metastatic tumors -less often: brain hemorrhage, brain disease, or cerebral aneurysm Diabetes Insipidus Signs/Sx - ANSWER -Up to 20 L urine/day -↓ osmolality -↓ specific gravity -Hypovolemia -↑ thirst -Tachycardia -↓ BP ****************************************************************** -greatly increased urine output - polyuria (4 - 30 L/day) - 1st sign -low urine specific gravity (<1.005) -low urine osmolarity (< 100 - 200) -hypovolemia -increased plasma osmolarity (> 300) -increased thirst -polydipsia -output does not decrease when fluid intake decreases Diabetes Insipidus Nursing Care - ANSWER -Monitor fluids -Replace fluids -Assess neuro status -Assess vital signs -Assess mucous membranes DI Treatment - ANSWER Rx: Vasopressin DDAVP DI Assessment - ANSWER -Two of the three Ps of diabetes mellitus -POLYURIA -POLYDIPSIA -Assess for dehydration!!! -may develop shock from fluid loss -fluid I/O for 24 hours -do NOT restrict food or fluid (if not contraindicated) -DI if more than 4 L during this period and greater than volume ingested -amount may vary from 4 to 30 L/day!!! DI Interventions - ANSWER -administer medications -partial ADH deficit -chlorpropamide (Diabinese) PO -increases action of existing ADH -may also stimulate production of ADH in hypothalamus -antidiabetic agent that has some type of unknown mechanism of antidiuresis. -Severe ADH deficit -must replace ADH to maintain water balance -drug of choice is desmopressin acetate (DDAVP) -desmopressin acetate (DDAVP) -synthetic form of vasopressin -given orally or intranasally -severe dehydration, may be given IV or IM -IV form of DDAVP is 10 X stronger than oral form -response should occur within 1 hour of administration. -Vasopression (Pitressin) is an exogenous form of ADH DI Patient Education - ANSWER -Permanent DI patients will be on lifelong desmopressin or vasopressin therapy -Daily weights -same time, same scales, similar clothing -Signs and symptoms of water toxicity -persistent headache, acute confusion, seizures, hyponatremia) -Weight gain or water toxicity → Call 911 -Med-Alert jewelry Syndrome of inappropriate antidiuretic hormone secretion (SIADH) - ANSWER -Schwartz-Bartter syndrome -vasopressin (antidiuretic hormone [ADH]) secreted even when plasma osmolarity is low or normal -occurs with many pathologic conditions and drugs -ADH continues to be released, water is retained dilutional hyponatremia and fluid overload -increase in plasma volume increases GFR and inhibits renin and aldosterone release more sodium loss in urine and more serum hyponatremia SIADH Etiology - ANSWER Malignancies -small oat cell carcinoma of the lung -duodenal, pancreatic, or GU CA -thymoma -Hodgkin's and Non-Hodgkin's lymphoma Pulmonary disorders -viral & bacterial pneumonia -lung abscess -active TB -pneumothorax -chronic lung disease -mycoses -positive-pressure ventilation CNS Disorders -head trauma -infection -stroke -SLE -porphyria -tumor (primary or metastatic) [Show More]

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