Adult Nursing Concepts

Specific Disorders of the Pituitary Gland Hypopituitarism General information Hypofunction of the anterior pituitary gland resulting in deficiencies of both the hormones secreted by the anterior pituitary gland and those secreted by the target glands May be caused by tumor, trauma, surgical removal, or irradiation of the gland; or may be congenital (See Pituitary Dwarfism, in Unit 5) Medical management: specific treatment depends on cause Tumor: surgical removal or irradiation of the gland Regardless of cause, treatment will include replacement of deficient hormones: e.g., cortico-steroids, thyroid hormone, sex hormones, gonadotropins (may be used to restore fertility). Assessment findings Tumor: bitemporal hemianopia, headache Varying signs of hormonal disturbances depending on which hormones are being undersecreted (e.g., menstrual dysfunction, hypothyroidism, adrenal insufficiency) Retardation of growth if condition occurs before epiphyseal closure Diagnostic tests Skull x-ray, CT scan may reveal pituitary tumor Plasma hormone levels may be decreased depending on specific hormones undersecreted Nursing interventions Provide care for the client undergoing hypophysectomy or radiation therapy if indicated. Provide client teaching and discharge planning concerning Hormone replacement therapy Importance of follow-up care Hyperpituitarism General information Hyperfunction of the anterior pituitary gland resulting in oversecretion of one or more of the anterior pituitary hormones Overproduction of the growth hormone produces acromegaly in adults and gigantism in children (if hypersecretion occurs before epiphyseal closure); see Hyperpituitarim (Gigantism), in Unit 5. Usually caused by a benign pituitary adenoma Medical management: surgical removal or irradiation of the gland Assessment findings Tumor: bitemporal hemianopia; headache Hormonal disturbances depending on which hormones are being excreted in excess Acromegaly caused by oversecretion of growth hormones: transverse enlargement of bones, especially noticeable in skull and in bones of hands and feet; features become coarse and heavy; lips become heavier; tongue enlarged Diagnostic tests Skull x-ray, CT scan reveal pituitary tumor Plasma hormone levels reveal increased growth hormone, oversecretion of other hormones Nursing interventions Monitor for hyperglycemia and cardiovascular problems (hypertension, angina, CHF) and modify care accordingly. Provide psychologic support and acceptance for alterations in body image. Provide care for the client undergoing hypophysectomy or radiation therapy if indicated. Hypophysectomy General information Partial or complete removal of the pituitary gland Indications: pituitary tumors, diabetic retinopathy, metastatic cancer of the breast or prostate, which may be endocrine dependent Surgical approaches Craniotomy: usually transfrontal Transphenoidal: incision made in inner aspect of upper lip and gingiva; sella turcica is entered through the floor of the nose and sphenoid sinuses Nursing care In addition to pre-op care of the craniotomy client, explain post-op expectations. In addition to post-op care of the craniotomy client, observe for signs of target gland deficiencies (diabetes insipidus, adrenal insufficiency, hypothyroidism) due to total removal of the gland or to post-op edema. Perform hourly urine outputs and specific gravities; alert physician if urine output is greater than 800-900 ml/2 hours or if specific gravity is less than 1.004. Administer cortisone replacement as ordered. If transphenoidal approach used Elevate the head of the bed to 30° to decrease headache and pressure on the sella turcica. Administer mild analgesics for headache as ordered. Perform frequent oral hygiene with soft swabs to cleanse the teeth and mouth rinses; no toothbrushing. Observe for and prevent CSF leak from surgical site. warn the client not to cough, sneeze, or blow nose. observe for clear drainage from nose or postnasal drip (constant swallowing); check drainage for glucose; positive results indicate that drainage is CSF. if leakage does occur elevate head of bed and call the physician. most leaks will resolve in 72 hours with bed rest and elevation. may do daily spinal taps to decrease CSF pressure. administer antibiotics as ordered to prevent meningitis. Provide client teaching and discharge planning concerning Hormone therapy if gland is completely removed, client will have permanent diabetes insipidus (see below) cortisone and thyroid hormone replacement replacement of sex hormones testosterone: may be given for impotence in men estrogen: may be given for atropy of the vaginal mucosa in women human pituitary gonadotropins: may restore fertility in some women Need for lifelong follow-up and hormone replacement Need to wear Medic-Alert bracelet If transphenoidal approach was used avoid bending and straining at stool for 2 months post-op no toothbrushing until sutures are removed and incision heals (about 10 days) Diabetes Insipidus General information Hypofunction of the posterior pituitary gland resulting in deficiency of ADH Characterized by excessive thirst and urination Caused by tumor, trauma, inflammation, pituitary surgery Assessment findings Polydipsia (excessive thirst) and severe polyuria with low specific gravity Fatigue, muscle weakness, irritability, weight loss, signs of dehydration Tachycardia, eventual shock if fluids not replaced Diagnostic tests Urine specific gravity less than 1.004 Water deprivation test reveals inability to concentrate urine Nursing interventions Maintain fluid and electrolyte balance. Keep accurate I&O. Weigh daily. Administer IV/oral fluids as ordered to replace fluid losses. Monitor vital signs and observe for signs of dehydration and hypovolemia. Administer hormone replacement as ordered. Vasopressin (Pitressin) and vasopressin tannate (Pitressin tannate in oil); given by IM injection warm to body temperature before giving. shake tannate suspension to ensure uniform dispersion. Lypressin (Diapid): nasal spray Provide client teaching and discharge planning concerning Lifelong hormone replacement; lypressin as needed to control polyuria and polydipsia Need to wear Medic-Alert bracelet 1. Which assessment is most important for the nurse to make when monitoring a client with a pituitary tumor that secretes ACTH?

1. Blood pressure. 2. Height. 3. Pulse rate. 4. Output.

Answer :1 Rationale: 1. ACTH-secreting tumors can cause Cushing's syndrome, which can elevate the blood pressure to dangerously high levels. 2. Growth hormone-secreting tumors can stimulate the growth of long bones and increase height, but ACTH-secreting tumors do not affect height. 3. TSH-secreting tumors can cause hyperthyroidism, with resulting tachycardia. ACTH-secreting tumors do not increase the pulse rate. 4. The syndrome of inappropriate ADH (SIADH) can diminish urinary output, but ACTH-secreting tumors do not alter output substantially.

2. The nurse is caring for a client who underwent surgical hypophysectomy. Which of the following assessments is most essential for the nurse to make immediately post-op?

1. Blood pressure. 2. Serum calcium levels. 3. Breath sounds. 4. Bowel sounds.

Answer 1 Rationale: 1. Hypophysectomy (removal of the pituitary gland) interferes with the secretion of both glucocorticoids and antidiuretic hormone, both of which are essential to maintain fluid balance and blood pressure. Careful monitoring of blood pressure is essential to ensure that hormone replacement therapy is adequate. 2. Removal of the pituitary gland does not substantially affect serum calcium levels. The pituitary gland does not stimulate the parathyroid glands, which regulate serum calcium. 3. Although assessment of breath sounds is routinely carried out in the immediate post-op period, this is not the most essential assessment for the nurse to make. 4. Although assessment of bowel sounds is routinely carried out post-op, this is not the most essential assessment for the nurse to make.

Mr. P. has had a hypophysectomy with a complete removal of the pituitary gland. Which of the following statements represents to the nurse the most complete understanding of follow-up care?

1. I will need to have lifelong follow-up, to take hormone replacement therapy for the rest of my life, and to wear a Medic-Alert bracelet. 2. I will need to wear a Medic-Alert bracelet. 3. I will need to take hormone replacements for the next two months. 4. I will need to wear a Medic-Alert bracelet and take hormone replacements for the next year.

Answer Rationale: 1. Hormone replacement and follow-up care are needed for the rest of his life because the pituitary gland has been removed. This is the master gland that secretes trophic hormones that stimulate target glands to produce their hormones. A Medic-Alert bracelet is needed to alert others of his condition.

A 62-year-old female is admitted with a posterior pituitary tumor and is experiencing diabetes insipidus, a complication of that tumor. The nursing diagnosis most appropriate for this client is

1. fluid volume deficit. 2. fluid volume excess. 3. incontinence, bowel. 4. diarrhea.

Answer 1 Rationale: 1. Diabetes insipidus is characterized by polydipsia and polyuria. It occurs with lesions of the hypothalamus and pituitary. Because antidiuretic hormone synthesis is affected, the client is at high risk for dehydration, which is life-threatening. 2. Fluid volume excess is an appropriate diagnosis for a client experiencing the syndrome of inappropriate antidiuretic hormone (SIADH).