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Disorders of the Posterior Pituitary Gland
Diabetes Insipidus (DI)
A. Definition: A hyposecretion of ADH (Vasopressin) from the PG (Pituitary Gland) Deficiency of ADH may be partial / complete DI may be permanent / transient B. Etiologic Factors 1. Primary: Idiopathic 2. Secondary: (Central DI/ Neural DI) o Head Trauma, Neurosurgery, Aneurysm, Infection. Conditions that ↑ ICP. Surgical removal of Posterior Pituitary tumor 3. Nephrogenic DI: Inability of the kidneys to respond to ADH (Renal Disease and Medications) C. Pathophysiology
Topics Discussed Here Are: 1. Disorders of the Posterior Pituitary Gland Diabetes Insipidus SIADH 2. Disorders of the Adrenal Glands Pheocromocytoma Addison’s Disease Cushing’s Syndrome Aldosteronism 3. Adrenalectomy
D. Clinical Manifestations 1. Marked Polyuria of more than 4L of urine/day 2. Polydipsia – Drinks 4 – 40L of fluid and craves for COLD water 3. Signs of Dehydration 4. Muscle pain and weakness 5. Post hypotension and tachycardia 6. Appearance of urine is that of waters
Syndrome is characterized by excessive release of ADH or vasopressin from the PPG or another source B.Surgical operation (Hypothalamus) . Diagnostic Test Test Urinalysis Blood Test - Result Urine specific gravity: Very low. nicotine.006 or less Colorless urine Urine ADH (Absent) Serum Na Levels: High (135 – 145 mEq/L) Serum ADH (Decreased/Absent) Low urine osmolality (50 – 200 mOsm/kg) • DILUTED URINE High plasma osmolality (Above 295 mOsm) Water Deprivation Test: Confirmatory Diagnosis 1st Phase – Withhold Water and measure weight 2nd Phase Test what type of DI: Central Primary Nephrogenic Gives ADH Medical Management • Administration of ADH / Its derivative o Desmopressin acetate (ADH derivative) Administered intra-nasally. infection and hemorrhage . Etiologic Factors . morphine. diuretics) jcmendiola_Achievers2013 .Ectopic Tumors (Lung carcinoma) . 1.E.Brain injury.Hypersecretion of ADH abnormally .Medications (Barbiturates. injection o Chlorpropamide and Clofibrate increases actions of ADH o Nephrogenic DI – Chlorpropamide and Thiazide Diuretics F. Nursing Management o Nursing Diagnosis Deficient fluid volume Risk for deficient fluid volume o Nursing Intervention: Maintains adequate fluid volume Measures fluid intake and output accurately Obtain daily weight Monitor hemodynamic status Provide patient with ample water to drink and administer IV fluids as indicated o Monitor result of: Serum and urine osmolality Serum Na tests o Administer or teach self-administration of medications as prescribed and document client’s response Syndrome of Inappropriate Antidiuretic Hormone A. tablets. Definition: .
Serum Na Levels: ↓ Decreased (135 – 145 mEq/L) .Serum ADH: ↑ Increased Medical Management: Hypertonic Saline Diuretics (Furosemide) Demeclocycline (Declomycin) Blocks the action of ADH in the kidneys F. Diagnostic Test Test Result Urinalysis .Urine specific gravity: High .Urine ADH (Increased ↑) Blood Test .Hyponatremia o Anorexia.Abnormal weight gain .C.Concentrated urine . Pathophysiology D. Clinical Manifestations . Nursing Management: . N/V o Mental Status Changes E.Hypertension .Nursing Diagnosis: o Fluid volume excess .Signs of Hypervolemia .Nursing Intervention: Maintain adequate fluid volume o Measures fluid intake and output accurately jcmendiola_Achievers2013 .
Clinical Manifestations: . Pallor .↑ Secretion of epinephrine and norepinephrine by the Adrenal Medulla B. Definition: .Hyperhydrosis E.Hypertension: Palpitation.Nursing Diagnosis Anxiety related to systemic Risk for injury related to hypertensive .Headache: Severe .Hyperglycemia and Glucosuria . Tachycardia. Pathophysiology D. Nursing Management .Nursing Intervention jcmendiola_Achievers2013 . Diagnostic Test Test Result 24 Hour Urine • ↑ Levels of metabolites of catecholamines Blood Test • ↑ Serum levels of epinephrine and norepinephrine Imaging Studies • MRI and CT Scan Medical Management Surgical Removal of the tumor Stabilization of the blood pressure Alpha-adrenergic blocking agents: Phentolamine Catecholamine Synthesis Inhibitors: Metyrosine F.Cause: Tumor C. Etiologic Factors: .Hypermetabolism: Weight Loss .o o o Obtain daily weight Monitor hemodynamic status Maintain fluid restriction to reduce serum dilution and normalize serum Na Pheocromocytoma A.
Secondary: Pituitary hypofunction. weakness. especially glucocorticoids and mineralocorticoids B. Definition: .Primary: Auto-immune response. 3. lethargy. 8.↓ Secretion of adrenal cortex hormones. weight loss ↓ Serum Sodium ↑ Serum Potassium jcmendiola_Achievers2013 . 2. 6. infection and idiopathic atrophy of the adrenal glands . Pathophysiology Addison’s Disease Auto-immune Response Primary Infection Idiopathic Atrophy Secondary Surgery Pituitary Hypofunction ↑ ACTH Levels Destruction of Adrenal Cortical Cells Adrenal Atrophy Hyperpigmentation Decreased Mineralocorticoids Low ALDOSTERONE Decreased Glucocorticoids Low Plasma Cortisol Levels Disturbance in Na.1. Etiologic Factors . surgery C. Monitor VS especially BP Monitor for Hypertensive crisis Prepare Phentolamine for hypertensive crisis Avoid stimulation that can cause ↑ BP Teach importance of avoiding foods and beverages with caffeine Monitor blood glucose and urine glucose Provide adequate rest and sleep periods Provide HIGH CALORIE foods and Vitamins / Minerals supplements Prepare client for possible surgery Disorders of the Adrenal Glands Adrenal Cortex: Aldosterone Cortisol Androgen Addison’s Disease A. 4. 7. 5. K Water Metabolism Decreased Gluconeogenesis ↓ CHON Metabolism Insulin Insensitivity ↓ Anti-inflammatory response ↓ Stress response GI Disturbance ↓ Renal Water Reabsorption Hypoglycemia Water Loss Dehydration Hyponatremia Hyperkalemia HYPOVOLEMIA Fatigue.
↑ Skin pigmentation (Primary type) E. Water loss. avoidance of strenuous activities.Adrenal Cortex Carcinoma . WEAKNESS. Nursing Management .Adrenal Cushing’s Syndrome . N/V. Etiologic Factors . Definition: .Ectopic: Extra pituitary tumors secreting ACTH jcmendiola_Achievers2013 . HIGH CARBOHYDRATE and ↑ Na intake 5. GI disturbance (anorexia. weakness. Hyponatremia and Hyperkalemia 2. ↑ Oral Fluid Intake (OFI) Glucocorticoid Deficit Treatment Hydrocortisone Prednisone Mineralocorticoid Deficient Treatment Fludrocortisone Cushing’s Syndrome A. COMA & DEATH Medical Management Restore Fluid and electrolyte balance ↑ Na and ↓ K. Hypoglycemia 4.D. Monitor electrolyte levels 4.A condition resulting from the HYPERSECRETION of GLUCOCORTICOIDS from the adrenal cortex B. proper pacing of ADLs 6.Pituitary Adenoma / Hyperplasia . LETHARGY. fatigue 5. irritability. Assess Intake and Output.Pituitary Cushing’s Syndrome (Cushing’s Disease) . Monitor vital signs especially blood pressure 3. anxiety 7. Clinical Manifestations: 1. hypovolemia 3. Weight loss. Diagnostic Test Test Blood Chemistry Result ↑ Potassium (K) ↓ Sodium (Na) and Glucose ↓ Cortisol and Aldosterone Level ↑ ACTH ↑ White Blood Cells (WBC) MRI and CT-Scan Complete Blood Count Imaging Studies Nursing Diagnosis Fluid volume deficit related to renal losses of sodium and water Activity intolerance related to decreased Cortisol production Risk for infection related to ineffective stress response F. N/V) 6. WOF: Addisonian Crisis Severe HYPOTENSION. stress and monitoring for infection 7. dehydration. Educate the patient regarding hormone therapy. Provide a HIGH PROTEIN. obtain daily weight 2. Mental status changes: Depression. Assist in performing ADLs.Nursing Interventions: 1.
Amenorrhea 6. E. General muscle weakness and wasting 2. menstruation ACNE Abnormal Fat Mobilization ↑ Gluconeogenesis ↑ Antiinflammatory Effect ↑ Vascular sensitivity to catecholamine Truncal Obesity Moon Face Buffalo Hump ↑ CHON Metabolism ↑ Serum Glucose PRONE to infection Vasoconstriction WEIGHT GAIN Muscle Wasting Osteoporosis ↓ Collagen Hypertension Skin thinning Easy bruising More visible capillaries Purple striae D. Pathophysiology Cushing’s Syndrome Ineffective Feedback mechanism of Adrenocortical function Excessive production of adreno-cortical Hormones ↑ Mineralocorticoids ↑ Androgens ↑ Glucocorticoids Blood Volume Women: Virilism Hirsutism Breast atrophy Enlarged clitoris Masculine voice Loss of libido. Hirsutism 8. ↓ K Reduced Eosinophils MRI and CT-Scan Complete Blood Count Imaging Studies F. Clinical Manifestations 1. Osteoporosis 11. Easy bruisability Reddish-purplish Striae on the abdomen and thighs 7.. Hyperglycemia 10.Iatrogenic: Exogenous Glucocorticoid Administration C. Moon face 4. Nursing Management Nursing Diagnosis Impaired Self-care deficit Altered body image Risk for infection Disturbed body image jcmendiola_Achievers2013 . Truncal obesity 3. HTN 9. Buffalo hump 5. Diagnostic Tests Test Blood Test Result Excessive Cortisol level ↑ Glucose ↑ Na.
Pathophysiology 1. Administer prescribed medications like 5. Headache / N/V 5. Etiologic Factors . Pituitary Tumor .Secondary Hyperaldosteronism • Sustained elevation of renin and activation of Angiotensin II C. Glucose. Protect patient from infection 7. Provide a LOW CARBOHYDRATE. Clinical Manifestations: 1. Definition: .G. Hypernatremia 4. 4. 3. LOW Na and HIGH PROTEIN Diet Aldosteronism / Conn’s Disease A. Weight and VS 2.Primary Hyperaldosteronism (Conn’s Disease) • Tumor. Na and Ca 3. Hypertension 3.Hypersecretion of Aldosterone from the adrenal cortex B. Visual Changes jcmendiola_Achievers2013 . Function of Mineralocorticoid Sodium Retention Secondary Water Retention Potassium Excretion Functions of Androgen: Hair Growth Exaggerated Effects Hypernatremia Hypervolemia – HTN Hypokalemia Hirsutism D. 2. Nursing Intervention 1. Provide meticulous skin care 4. Symptoms of Hypokalemia 2. Prepare client for surgical management – Pituitary surgery and adrenalectomy 6. Monitor laboratory values. Monitor Intake and Output. Improve body image 8.
↑ Urinary K 5. Prepare patient for possible surgical interventions Medical Management 1. I&O. Monitor serum K and Na 3. meticulous care is given to protect the client from infection and from other complications that could cause adrenal crisis Serum electrolytes and blood pressure are monitored “Buti pa ung ihi sweet dahil sa diabetes…” XD jcmendiola_Achievers2013 . Diuretics: Spironolactone 3.Cushing’s Syndrome . includes: o Frequent checking of VS o Assessing hemorrhage o Turning o Coughing IV Hydrocortisone (Solu-cortet) is given as directed to prevent adrenal crisis Non stressful environment is maintained. Muscle weakness. Na Restriction: NO SALINE ↓ Na Diet 4. urine specific gravity 2. Serum K: VERY LOW 4. because at least one adrenal gland will be removed POSTOPERATIVE MANAGEMENT Usual postop care for abdominal surgery. Provide K rich foods and supplements 4.Adrenal tumors . rest is promoted. Fatigue and Nocturia E. ↑ Serum and Urinary Aldosterone F. Urine specific gravity: LOW – Due to Polyuria 2. Surgical removal of tumor 2.Hyperaldosteronism Accomplished through abdominal / flank incision • PREOPERATIVE MANAGEMENT Blood Pressure and Fluid Volume are optimized and frequently assessed Surgery and Nursing care are explained to the client Glucocorticoids will be given to cover period of stress (Surgery). Administer prescribed diuretics – Spironolactone 5. Monitor VS. Maintain Na Restricted Diet 6.6. Serum Na: HIGH (Above 145) 3. Nursing Intervention Nursing Diagnosis o Fluid volume excess Nursing Intervention 1. K Supplementation 5. Diagnostic Test 1. Anti-Hypertensive therapy Adrenalectomy • • Unilateral or Bilateral removal of adrenal glands Indications: .