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83 Cards in this Set

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Negative Feedback Loop
Hypothalamus
Releasing Factor X
Anterior Pituitary
Hormone A
Target Organ
Hormone B
Biological Effects
Anterior Pituitary
(adenohypophysis)
Growth Hormone (GH)
Targets:
*All body tissue
Function:
*Growth and development of skeletal muscle and long bones
*Affects a persons size and height
*Role in protein, fat and carbohydrate metabolism
Thyroid Stimulating Hormone
(TSH)
Targets:
*Thyroid Gland
Function:
*Stimulates synthesis and release of thyroid hormones
*Stimulates growth and function of thyroid gland
Adrenocorticotropic Hormone
(ACTH)
Targets:
*Adrenal Cortex
Function:
*Fosters growth of adrenal cortex
*Stimulates secretion of corticosteroids
Gonadotropic Hormones
Follicle Stimulating Hormone (FSH)
Lutenizing Hormone (LH)
Targets:
*Reproductive organs
FSH Function
*Stimulates secretion of estrogen
*Development of ova in females
*Development of sperm in males
LH Function:
*Stimulates ovulation in females
*Stimulates sex hormone secretion in both male and female
Prolactin
Targets:
*Ovary and mammary glands in females
Function:
*Stimulates milk production in lactating women
*Increases response of follicles to LH and FSH
*Has unclear function in men
Posterior Pituitary
(neurohypophysis)
*Composed of nerve tissue
*Essentially an extension of the hypothalamus
*Stores antidiuretic hormone and oxytocin until their release is triggered by the appropriate response
Antidiuretic Hormone (ADH)
Targets:
*Renal tubules and the vascular smooth muscle
Function:
*Promotes reabsorption of water
*Vasoconstriction
Oxytocin
Targets:
*Uterus and mammary glands
Function:
*Stimulates milk secretion
*Contraction of uterine smooth muscle
Disorders Associated with the Pituitary Gland
*Acromegaly
*Syndrome of inappropriate Antidiuretic Hormone (SIAH)
*Diabetes Insipidus
Acromegaly
Definition:
Growth Hormone Excess
*Commonly affects middle-aged adults
*Three out of every million adults will be diagnosed each year
*Affects both men and women equally
Pathophysiology
Growth Hormone
*Growth hormone is an anabolic hormone
*Promotes protein synthesis and mobilizes glucose and free fatty acids
*Produced by anterior pituitary
*Regulates growth
Childhood deficiency children=dwarfism
Childhood excess children=giantism
Adult excess=acromegaly
Pathophysiology: Negative Feedback Loop
Hypothalamus: GH-RH
Anterior Pituitary: GH
Liver: Insulin-Like Growth Factor 1 (Somatomedin C) Stimulates growth of bones and soft tissue
Somatostatin
*Helps regulate GH release
*Produced in the hypothalmus
*Acts on the pituitary to inhibit GH release
Pathophysiology
Overproduction of GH
*Overproduction is almost always caused by a benign pituitary adenoma (tumor)
*Pituitary tumor secretes GH despite elevated IGF-1 levels
*Overproduction of GH leads to unwanted growth of bones and other soft tissue
*Overproduction of GH results in hyperglycemia through insulin antagonism
Effects of Overproduction of GH Children
Gigantism
*Excessive secretion of growth hormone during childhood before the closure of the bone growth plates. (Epiphysis)
*Onset early childhood or puberty
*May grow as tall as 8 feet and weigh more than 300 lbs
*Very rare disorder
*Most often caused by a benign pituitary tumor or “underlying medical condition”
Clinical Manifestation
Gigantism
*Excess growth during childhood
*Frontal bossing and prominent jaw
*Thickening of facial features
*Disproportionately large hands and feet
*Increased perspiration
*Weakness
*Fatigue
*Irregular menstruation
*Headache
*Delayed onset of puberty
*Double vision or difficulty with peripheral vision
Effects of Overproduction of GH Adults: Acromegaly
*Unwanted growth of bones and other soft tissue
*Elevated blood glucose
*Cardiomegaly
*Left ventricular hypertrophy
*Hypertension
Clinical Manifestations: Acromegaly
*Abnormal soft tissue growth of hand and feet
*Bony changes alter facial features including spacing of the teeth
*Thick coarse oily skin
*Enlarged lips, nose and tongue
*Deepening of voice: hypertrophy of vocal cords
*Excessive sweating
*Fatigue and weakness
*Headaches
*Impaired vision
*Enlargement of liver, spleen, kidneys and heart
Diagnostic Studies: Acromegaly
*History and Physical Examination
*Plasma GH
*Plasma IGF-1 levels
*IGF binding protein-3 levels
*GH response to an oral glucose challenge
*MRI
*CT scan
*Ophthalmologic examination
Treatment: Acromegaly
Goal is to return GH levels to normal
Medical
-Pharmacological
-Radiation
Surgical
-Transsphenoidal hypophysectomy
-Stereotactic radiosurgery
Pharmacological Treatment: Acromegaly (3 Classifications)
1. Somatostatin analogs
*Octreotide (Sandostatin)
*Ocreotide (Depot, Sandostatin LAR)
*Lanreotide SR (lpstyl)
2. Dopamine Agonists
*Cabergoline (Dostinex)
3. GH receptor antagonists
*Pegvisomant (Somavert)
Pharmacological Therapies Acromegaly: Octreotide
**Most common drug used**
*Sandostatin, Sandostatin LAR Depot
*Most effective in suppressing GH release
Mechanism of action:
-Mimicking the suppressant actions of somatostatin on the pituitary
-Used as primary therapy or as adjunct therapy to surgery or radiation
Pharmacological Therapies Acromegaly: Octreotide
**Most common drug used**
Dosage:
*Sandostatin 100 mcg sc TID
*Sandostatin LAR Depot 10-30 mg IM once a month
Side effects:
*Nausea, cramps, diarrhea, flatulence
-usually subside within 1-2 weeks
*Gallstones develop in 1 year in 25% of patients
Expected Effects:
*Normalization of GH and IGF-1 levels
Pharmacologic Therapies Acromegaly: Pegvisomant
Mechanism of action:
*Binds to the same receptors in the body as growth hormone, and blocks the effect of growth hormone
*Notify physician of latex allergy (top of vial is latex), diabetes, kidney disease or liver disease
Pharmacologic Therapies Acromegaly: Pegvisomant
Dosage:
*1st dose of 40 mg SC, injected by physician then
*10 mg daily SC, injected by patient
*Monitor insulin-like growth factor (IGF-1) and liver function with regularly scheduled blood test
Side Effects:
*Flu-like symptoms, pain at the injection site, nausea or diarrhea
Expected Effects:
*Normalize serum levels of IGF-1
Radiation Therapy
*Considered secondary treatment option after surgery has failed to produce complete remission
*Used in combination with drugs
*Used to reduce size of tumor before surgery
*30-70% successful
*Months-years for GH levels to normalize
Stereotactic Radiosurgery
*Radiation delivered to a single site from multiple angles
*Used to occlude blood vessels feeding the tumor
Transsphenoidal Hypophysectomy
Tumors < 10mm
Immediate post-op care for Transphenoidal Hypophysectomy
*HOB at least 30 degrees (decrease pressure)
*Assess for S&S cerebral edema (increased intracranial pressure
*Incision in upper lip and gingiva
*Hormone replacement for life
*CSF leak - clear fluid check for glucose risk for meningitis
Post Op Nursing Care for Transsphenoidal Hypophysectomy Continued
*Avoid coughing, straining
*Assess for CSF leak, meningitis
*No tooth brush for 2 weeks, oral care
*Assess for decreased ADH, adrenal & thyroid deficits
Nursing Process: Assessment
*Abnormal signs and symptoms of abnormal growth (enlargement of lips, nose, tongue) (polyuria, polydipsia)
*Evaluate changes in physical size of each patient
*Changes in appearance hands, feet
*Give unconditional acceptance
*Consider emotional support
Nursing Diagnosis: Acromegaly
Actual
*Disturbed body image
*Deficient fluid volume (polyuria)
*Disturbed sleep pattern (swelling in tissue)
*Disturbed sensory perceptions (enlarged pituitary gland)
Risk
*Risk for ineffective therapeutic regimen management secondary to expensive medications
Planning
Patient Goals
*Accept and cope effectively with altered body image
*Maintain adequate fluid volume
*Experience restful sleep patterns
*Develop no complications
*Obtain long term follow-up care
Nursing Implementation
*Offer reassurance
*Provide accurate information
*If hormonal replacement is necessary provide explanation
*Monitor for hyperglycemia
*Monitor cardiovascular status; Angina, HTN, CHF
Nursing Implementation Cont.
Preoperative Care
*Installation of antibiotic nose drops
*Discussion of mouth breathing
*Mouth care
*Ambulation
*Pain control
*Activity
*Hormone replacement
*Avoid straining at stool (valsalva maneuver), vigorous coughing, and sneezing
Nursing Implementation Cont.
Postoperative Care after transsphenoidal approach
*HOB elevated 30 degrees (prevent post-op HA
*Monitor neurological status
*Monitor for any clear nasal drainage and send to laboratory for glucose testing (CSF leak) risk for meningitis
*Assess pain level
*Provide mouth care
Nursing Implementation Cont.
Postoperative care after stereotactic radiosurgery
*Monitor vital signs
*Neurologic status
*Fluid volume status
*Monitor for possible complications (HA, seizures, N/V)
*Provide pin site care
*Monitor level of pain
*Assess for Diabetes Insipidus
Nursing Implementation
*Management of care
*Patient teaching
-Hormone replacement (medications taken for life)
Nursing Implementation
Psychosocial Integrity
*Unexpected body image changes
*Grieving process
Evaluation (pt w/ GH excess) Expected Outcomes
*Experience no postoperative complications
*Know how and when to take hormone replacement (if indicated)
*State symptoms requiring immediate attention and appropriate actions
*State the importance of long-term follow-up
*Have a follow-up medical appointment
Syndrome of Inappropriate Antidiuretic Hormone SIADH
2nd disorder of pituitary hormone
Definition:
*Overproduction or over secretion of ADH
*ADH is also referred to as arginine vasopressin
*Vasopressin
-Synthesized in hypothalmus
-Stored in posterior pituitary
-regulation of water balance and osmolarity
Causes of SIADH
*Malignant tumors (Small cell lung cancers)
*Central Nervous System Disorders
*Drug Therapy
*Hypothyroidism
*Lung Infection (pneumonia, TB)
*COPD
*Positive Pressure Mechanical Ventilation
Clincal Manifestations of SIADH
*Muscle cramps and weakness
*Low urine output
*Increased body weight
Clincal Manifestations of SIADH: Sodium levels below 120mEq/L
(Normal sodium levels 135-145 mEq/L)
*Vomiting
*Abdominal cramping
*Muscle twitching
*Seizures
Clinical Manifestations
*As plasma osmolality and serum sodium levels continue to decline
-Lethary
-Anorexia
-Confusion (Cerebral Edema)
-Headache
-Seizures
-Coma
Diagnostic Studies
*Simultaneous measurements of urine and serum osmolality
*Dilutional hyponatremia is indicated by a serum sodium less than 134 mEq/L
*Serum osmolality less than 280 mOsm/kg
*Urine specific gravity greater than 1.003
*Decreased BUN, creatinine clearance, hemoglobin and hematocrit
Treatment
Immediate goal is to restore normal fluid volume and osmolality
*Directed at underlying cause
-Surgical removal of tumor
-Avoid or discontinue medications that stimulate the release of ADH
Treatment
Serum Sodium is greater than 125 mEq/L and symptoms are mild
*Restrict fluids to 800-1000 ml per day
*Restriction should lead to a gradual daily reduction in weight
*Progressive rise in serum sodium concentration and osmolality
*Symptomatic improvement
Treatment: Severe Hyponatremia Serum Sodium Levels less than 120 mEq/L
*IV hypertonic saline solution 3%-5% (seizures)
-slow infusion with a pump
*Lasix (only if sodium is at least 125 mEq/L) K supplement may be needed
*Fluid restriction of 500 ml/day
Treatment: Chronic SIADH
*Water restriction of 800-1000 mL/day
*Declomycin (block effects of ADH on renal tubules)
*Lithium (block effects of ADH on renal tubules)
Nursing Process: Assessment
*Hourly vital signs
*Hourly I&O
*Hourly measurement of urine specific gravity
*Daily weights
*Level of consciousness
*Observe for signs of hyponatremia (seizures, N/V, muscle cramping
*Monitor heart and lung sounds
Nursing Diagnosis
Actual
*Fluid/Volume imbalance
*Imbalanced nutrition
Risk
*Risk for injury r/t decreased LOC
Planning Patient Goals
*Fluid volume and osmolality is restored
*Electrolyte imbalance is restored
*Provide safe effective care
*Address health maintenance/promotion issues
*Establish outcomes
Nursing Implementation: Acute Onset SIADH
*Fluid restriction of 1000 mL/day
*HOB flat or no more than 10 degrees (Venous return to heart)
*Protect from injury (side rails up)
*Seizure precautions
*Frequent turning, positioning and ROM exercises if pt bedridden
*Frequent oral hygiene (Fluid restriction)
*Provide distractions to decrease the discomfort of thirst r/t fluid restriction
Nursing Implementation: Chronic SIADH
*Patient teaching to self management
-Fluid restriction of 800-1000 mL/day
-Sucking on ice chips or hard candy (decrease thirst)
-Planning fluid intake
-Supplemental NA and K if diuretic prescribed
-Symptoms of fluid and electrolyte imbalance
-Close follow-up care if treated with Declomycin (Nephrotoxic S/E Fungal infections)
Evaluation: Expected Outcomes
*Maintain fluid and electrolyte balance
*State symptoms requiring immediate attention and appropriate actions
*State the importance of long-term follow-up care
Diabetes Insipidus
Definition:
*Group of conditions associated with underproduction or undersecretion of ADH or a decreased renal response to ADH
Pt may experience nocturia
Classifications of Diabetes Insipidus
*Central Diabetes Insipidus
*Nephrogenic Diabetes Insipidus
*Dispogenic Diabetes Insipidus
S/S Fluid Volume Deficit
Central Diabetes Insipidus
Definition:
Any organic lesion of the hypothalmus, infundibular stem or posterior pituitary interferes with ADH synthesis, transport or release
Cause: Brain tumor, head injury, brain surgery, CNS infection
Nephrogenic Diabetes Insipidus
Definition:
There is adequate ADH but there is a decreased response to ADH in the kidney
Cause: Drug therapy (lithium), renal damage, hereditary renal disease
Dispogenic Diabetes Insipidus
Definition:
Associated with excessive water intake
Cause: Structural lesion in thirst center or psychological disorder
Clinical Manifestations
*Increased thirst (polydipsia)
*Increased urination (polyuria)
*Urine output 5-20 L/day
*Urine specific gravity less than 1.005
*Urine osmolality less than 100 mOsm/kg
*Serum osmolality is usually greater 295 mOsm/kg
Clinical Manifestations
Fluid volume deficit manifested by:
*Weight loss
*Constipation
*Poor skin turgor
*Hypotension
*Tachycardia
*Shock
*CNS manifestations
-Irritability
-Mental dullness
-Coma
Clinical Manifestations of Central DI After Intracranial Surgery Triphasic pattern;
Acute Phase:
-Abrupt onset of polyuria (w/in 24 hrs)
Interphase:
-Urine volume normalizes (2-5 days
Third Phase:
-Central DI is permanent
-Apparent within 10-14 days postop
Diagnostic Studies
*Identify cause first
*H&P (History & Physical)
*Waster deprivation test
DI following cranial surgery is usually permanent
Water Deprivation Test
*Obtain baseline:
-Weight
-Pulse
-B/P
-Urine and plasma osmolalities
-Urine specific gravity
*All fluids are held for 8-16 hours
*Reassure patient throughout test
*Assess B/P, weight and urine osmolality hourly
Water Deprivation Test cont.
The test continues until:
*Urine osmolality stabilizes
*Body weight declines by 5%
*Orthostatic hypotension develops
ADH is then given
Urine osmolality is measured 1 hour later
*In Central DI-the rise in urine osmolality after vasopressin exceeds 9%
Treatment
*Goal is to maintain fluid & electrolyte balance
*Determine and treat primary cause
Medical
*Pharmacological
*Nutritional
Pharmacological Treatment Central DI
Acute Phase
*Hypotonic Saline IV titrated to replace urinary output
*Hormone replacement: Desmopressin acetate (DDAVP)
*ADH Replacement:
-Aqueous vasopressin (Pitressin)
-Vasopressin tannate
-Lysine vasopressin (Diapid)
*Carbamazepine (Tegretol)
*Chlorpropamide (Diabinese)
*Clofibrate (Atromid)
Pharmocological Therapy: Desmopressin (Drug of choice in treating Central DI)
*DDAVP, Stimate
*Drug of choice when treating DI d/t prolonged effect, convenient route, decreased side effects (especially vasoconstriction)
Mechanism of action:
*Acts on the kidneys to reduce the flow of urine which increases the urine osmolality
Pharmacological Therapy: Desmopressin (Drug of choice in treating Central DI)
Dosage:
*Adults: 0.1mL intranasally BID or 0.25-0.5mL SC or IV BID
*Children: 0.05-0.3mL intranasally daily either in single dose or in 2 doses
Side Effects:
*Stuffy or runny nose
*Upset stomach
Pharmacological Therapy: Desmopressin
Side Effects:
*Water intoxication (excessive water retention
-Early signs-drowsiness, listlessness, headache
-Late signs-convulsions and terminal coma
Expected Effects:
*Normalization of urinary water excretion
Pharmacological Therapy: Vasopressin
*Identical in structure to naturally occurring ADH
*Powerful vasoconstrictor
Mechanism of action:
*Acts on the kidneys to reduce the flow of urine which increases the urine osmolality
Pharmacological Therapy: Vasopressin
Dosage:
*5-10 units IM or SC 3-4 times/day
Side Effects:
*Water intoxication
-Early signs-drowsiness, listlessness, headache
-Late signs-convulsions and terminal coma
Pharmacological Therapy: Vasopressin
*Cardiovascular Effects (In patients with coronary insufficiency)
-Angina pectoris
-Myocardial Infarction
-Gangrene
Expected Effects:
*Normalization of urinary water excretion
Nutritional Treatment: Nephrogenic DI
*Low Sodium Diet (decrease urine output)
*Thiazide diuretics
-Slows glomerular filtration rates which allows the kidneys to reabsorb more water in the Loop of Henle and distal tubules
-Hydrochlorothiazide (HydroDiuril)
-Chlorothiazide (Diuril)
*Indocin (NSAID)
Nursing Process: Assessment
*Weight (daily)
*Pulse
*B/P
*I&O
*Urine Specific Gravity
*Urine Glucose
Nursing Diagnosis
Actual
-Fluid volume imbalance
-Disturbed sleep pattern
-Impaired concept
Risk
-Risk for ineffective management of therapeutic regimen
Nursing Management: Planning, Patient Goals
*Early detection
*Maintenance of adequate hydration
*Experience restful sleep patterns
*Patient teaching for long-term management
*Obtain long term follow-up care
Nursing Implementation
*Administer fluids IV or PO
*Administer hormone replacement
*Keep adequate fluid at bedside
*Maintain accurate I&O
*Assess for fluid volume deficit frequently
Nursing Implementation
*Provide support and reassurance
*Management of care (early detection)
*Patient teaching to self management
Evaluation: Expected Outcomes
*State symptoms requiring immediate attention and appropriate action
*Know how and when to take hormone replacement (if indicated)
*State the importance of long-term follow-up
*Have a follow-up appointment