THE PITUITARY GLAND

Phamela Joy S. Alvarez

Anatomic and Physiologic Overview

 The pituitary gland, or hypophysis is commonly referred to as the master

gland because of the influence it has on the secretion of hormones by other
endocrine glands.
 The round structure, about 1.27 cm (1/2 in) in diameter. It is located on the
inferior aspect of the brain and is divided into anterior and posterior lobes. It is
connecter by the hypothalamus.

ANTERIOR PITUITARY

The major hormones of the anterior pituitary gland are:

1. Follicle-Stimulating Hormone / FSH

- One of the hormones essential to pubertal development and the function of
women's ovaries and men's testes. In women, this hormone stimulates the
growth of ovarian follicles in the ovary before the release of an egg from
one follicle at ovulation. It also increases oestradiol production.
2. Luteinizing Hormone/LH
- This hormone is known as a gonadotropin, and it affects the sex organs in both
men and women. For women, it affects ovaries, and in men, it affects the
testes. LH plays a role in puberty, menstruation, and fertility.
3. Prolactin/PRL
 - It acts on the breast to stimulate milk production during pregnancy and after
breast. The levels of these hormones are normally high for pregnant women
and new mothers.
4. Adrenocorticotropic Hormone/ACTH
- Its key function is to stimulate the production and release of cortisol from the
cortex (outer part) of the adrenal gland.
5. Thyroid-Stimulating Hormone/TSH
- Thyroid stimulating hormone is produced and released into the bloodstream by
the pituitary gland. It controls production of the thyroid hormones, thyroxine
and triiodythyroine, by the thyroid gland by binding to receptors located on
cells in the thyroid gland.
6. Growth Hormone or GH/ Somatotropin
- Most abundant anterior pituitary hormone. Its regulates growth in children and
energy and metabolism. It also increase protein synthesis in many tissues, and
increase the breakdown of fatty acids in adipose tissue and increase blood
glucose levels.

POSTERIOR PITUITARY

The important hormones secreted by the posterior pituitary gland are:

1. Vasopressin
- It controls the excretion of water by the kidney; Its secretion is stimulated by
an increase in the osmolality of the blood or by a decrease in blood pressure.
2. Oxytocin
- Oxytocin secretion is stimulated during pregnancy and at childbirth. It also
facilities milk ejection during lactation and increases the force of uterine
contraction during labor and delivery.

Pathophysiology

 Abnormalities of the pituitary functions are caused by oversecretion or

undersecretion of any hormones produced or released by the glands.
 Abnormalities of the anterior posterior portions of the gland may occur
independently.
  Hypo-function of the pituitary gland (hypopituitarism) can result from disease
of the pituitary gland itself or disease of the hypothalamus.

Anatomy of the Anterior Pituitary Gland

The fleshy, glandular anterior pituitary is distinct from the neural composition of the
posterior pituitary. The anterior pituitary is composed of multiple parts:

 Pars distalis:
This is the distal part that comprises the majority of the anterior pituitary; it is
where most pituitary hormone production occurs.
 Pars tuberalis: This is the tubular part that forms a sheath that extends up from
the pars distalis and wraps around the pituitary stalk. Its function is
understood.
 Pars intermedia: This is the intermediate part that sits between the pars distalis
and the posterior pituitary and is often very small in humans.

THE ANTERIOR PITUITARY

Niña Biasas
The anterior pituitary secretes seven hormones that regulate several physiological
processes, including stress, growth, and reproduction. A major organ of the endocrine
system, the anterior pituitary, also called the adenohypophysis, is the glandular,
anterior lobe of the pituitary gland.

• The anterior pituitary regulates several physiological processes, including

stress, growth, reproduction, and lactation.

• The anterior pituitary gland secretes 7 hormones: follicle -stimulating

hormone, luteinizing hormone, adrenocorticotropic hormone, thyroid
-stimulating hormone, prolactin, endorphins, and growth hormone

• Anterior pituitary gland: A major organ of the endocrine system that regulates
several physiological processes including stress, growth, reproduction, and
lactation.

Major Hormones Secreted by the Anterior Pituitary Gland

 Adrenocorticotropic hormone (ACTH), is a polypeptide whose target is the

adrenal gland. The effects of ACTH are upon secretion of glucocorticoid,
mineralocorticoids, and sex corticoids.
 Beta-endorphin is a polypeptide that effects the opioid receptor, whose effects
include the inhibition of the perception of pain.
 Thyroid-stimulating hormone is a glycoprotein hormone that affects the
thyroid gland and the secretion of thyroid hormones.
 Follicle-stimulating hormone is a glycoprotein hormone that targets the
gonads and effects the growth of the reproductive system.
 Luteinizing hormone is a glycoprotein hormone that targets the gonads to
effect sex-hormone production.
 Growth hormone is a polypeptide hormone that targets the liver and adipose
tissue and promotes growth through lipid and carbohydrate metabolism.
 Prolactin is a polypeptide hormone whose target is the ovaries and mammary
glands. Prolactin influences the secretion of estrogen/progesterone and milk
production.

Regulation
  Hormone secretion from the anterior pituitary gland is regulated by hormones
secreted by the hypothalamus. Neuroendocrine neurons in the hypothalamus
project axons to the median eminence, at the base of the brain. At this site,
these neurons can release substances into the small blood vessels that travel
directly to the anterior pituitary gland (the hypothalamus-hypophysial portal
vessels).

Most Common Diseases

Hormone Overproduction Underproduction

Growth hormone Acromegaly (gigantism) Growth

retardation(dwarfism)

ACTH Cushing’s disease Addison’s disease (often,

mineralocorticoid function is
not affected)

TSH Hyperthyroidism Hypothyroidism

LH and FSH Polycystic ovary syndrome, Infertility, amenorrhea,

precocious puberty decreased libido (males)

Prolactin Infertility, amenorrhea, Inability to lactate

decreased libido (males)

Pharmacologic

Somatropin (Nutropin, Saizen, Genotropin, Serostim)

o Drug Name: Nutropin

o Classification: Growth hormone (GH)
o Mode of Action: Immune modulator. Somatropin, a recombinant human
growth hormone (rhGH), is 191 amino acid residues long and is practically
identical to human growth hormone (GH) produced by the pituitary gland.

Bromocriptine

o Drug Name: Bromocriptine

o Classification: dopamine receptor agonists.
 o Mode of Action: inhibits secretion of prolactin and acts as a dopamine
receptor agonist by activating postsynaptic dopamine receptors; improves
glycemic control.

Nursing Assessment

These are the important things the nurse should include in conducting assessment,

history taking, and examination:

 Assess for contraindications or cautions (e.g. history of allergy, pregnancy,

serious infection after open heart surgery, etc.) to avoid adverse effects.
 Assess height, weight, thyroid function tests, glucose tolerance tests, and GH
levels to determine baseline status before beginning therapy and for any
potential adverse effects.   

Nursing Diagnoses And Care Planning

Here are some of the nursing diagnoses that can be formulated:

o Imbalanced nutrition: less than body requirements related to metabolic

changes
o Acute pain related to need for injections

Nursing Implementation

These are vital nursing interventions done in patients who are taking GH agonists:

 Reconstitute the drug following manufacturer’s directions because individual

products vary; administer IM or SQ as ordered for appropriate drug delivery.
 Monitor response closely to determine need for dose adjustment.
 Monitor thyroid function, glucose tolerance, and GH levels periodically to
monitor endocrine changes and to institute treatment as needed.
 Provide comfort measures to help patient cope with the drug effects. 
 Provide patient education (storage, preparation, administration techniques)
about drug effects and warning signs to report to enhance patient knowledge
and to promote compliance.   

Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:

 Monitor patient response to therapy (return of GH levels to normal, growth

and development).
 Monitor for adverse effects (e.g. nutritional imbalance, hypothyroidism).
 Evaluate patient understanding on drug therapy by asking patient to name the
drug, its indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy

POSTERIOR PITUITARY

Lois Anne B. Coronado

 The posterior pituitary is neural tissue and consists only of the distal axons of
the hypothalamic magnocellular neurons that make up the neurohypophysis.
 The primary function of the posterior pituitary is the transmission of
hormones originating from neurons located in hypothalamic brain regions
such as the supraoptic nucleus (SON) and paraventricular nucleus (PVN) for
secretion directly into peripheral circulation.
 In the posterior pituitary, the axon terminals of the magnocellular neurons
contain neurosecretory granules, membrane-bound packets of hormones stored
for subsequent release. The blood for the anterior pituitary is supplied via the
hypothalamic-pituitary portal system, but the posterior pituitary blood supply
is directly from the inferior hypophyseal arteries, which are branches of the
posterior communicating and internal carotid arteries. 
 The hormones of the posterior pituitary, oxytocin and vasopressin, are
synthesized in individual hormone-specific magnocellular neurons.

Diabetes Insipidus

 Most common disorder related to posterior lobe dysfunction.

 A condition in which abnormally large volumes dilute urine are excreted as a
result of deficient production of vasopressin.
 It may occur following surgical treatment of a brain tumor, secondary to
nonsurgical brain tumors, traumatic brain injury, infections of the nervous
 system, post hypophysectomy, failure of renal tubules to respond to ADH, and
the use of specific medications.

PITUITARY TUMOR

Edelrose D. Lapitan

Definition

 Almost all pituitary tumors are benign.

 The tumors may be primary or secondary and functional (secrete pituitary
hormones) or nonfunctional (do not secrete)
 The location and effects of these tumors on hormone production by target
organs can have life-threatening effects.
 Three Principal types of pituitary tumors represent an overgrowth of:
- Eosinophilic (are a type of white blood cell. They help fight off infections
and play a role in your body's immune response. They can also build up
and cause inflammation.)
- Basophilic cells (are a type of white blood cell. Although they're produced
in the bone marrow, they're found in many tissues throughout your body.
They're part of your immune system and play a role in its proper function.
If your basophil level is low, it may be due to a severe allergic reaction.)
- Chromophobic cells (cells with no affinity for either eosinophilic or
basophilic stains)

Etiology

 The cause of uncontrolled cell growth in the pituitary gland, which creates a
tumor, remains unknown.
 The pituitary gland is a small, bean-shaped gland situated at the base of your
brain, somewhat behind your nose and between your ears. Despite its small
size, the gland influences nearly every part of your body. The hormones it
produces help regulate important functions, such as growth, blood pressure
and reproduction.
  A small percentage of pituitary tumor cases run in families, but most have no
apparent hereditary factor. Still, scientists suspect that genetic alterations play
an important role in how pituitary tumors develop.

Clinical Manifestation

Eosinophilic Tumors: develop early in life result in Gigantism

 The affected person may be more than 7 ft tall and large in all proportion, yet
so weak and lethargic that he or she can hardly stand.
 If the disorder begins during adult life, the excessive skeletal growth occurs
only in the:
- Feet
- Hands Giving rise to clinical picture called
acromegaly.
- Superciliary ridge
(Enlargement involves all tissues and organs
(bony ridge located above the
of the body)
eye sockets )
- Molar eminences
- Nose
- Chin
 Severe Headaches
 Visual disturbances
 Decalcification of the skeleton (the removal or loss of calcium or calcium
compounds (as from bones or soil)
 Muscular weakness
 Endocrine Disturbances (similar to those occurring in patients with
hyperthyroidism)
Basophilic Tumors
 Give rise to Cushing syndrome with features largely attributable to
hyperadrenalism, including:
- Masculinization
- Amenorrhea in female
- Truncal obesity
 - Hypertension
- Oestoporosis
- Polycythemia

Chromophobic Tumors: 90% of pituitary tumors. These tumors usually

produce no hormones but destroy the rest of the pituitary gland, causing
hypopituitarism

 (People with this disease are often) obese and somnolent

 Exhibit fine
 Scanty hair
 Dry, Soft skin
 Pasty complexion
 Small bones
 Headaches
 Loss of libido
 Visual defects progressing to blindness.
 Other signs and symptoms include
- Polyuria
- Polyphagia
- Lowering of the basal metabolic rate
- Subnormal body temperature

Assessment and Diagnostic Findings

 History and physical examination including:

- Central vision and Visual fields: may reveal loss of color, discrimination,
diplopia (double vision), or blindness in a portion of a field of vision.
- CT and MRI scans are used to diagnose the presence and extent of
pituitary tumors.
- Serum levels of pituitary hormones may be obtained along with
measurements of hormones of target organs. (Thyroid, adrenal)

Medical Management

Stereotactic radiation therapy

  Requires the use of a neurosurgery-type stereotactic frame.
 Used to deliver external-beam radiation therapy precisely to the pituitary
tumor with minimal effect on normal tissue

Pharmacologic Therapy

Drug name MOA Indication and Adverse effect Nursing

Contraindication responsibilities
Bromocriptin Inhibits Indication CNS: dizziness, -Instruct patient to
e: Parlodel secretion of -Parkinson Disease headache, fatigue, take drug with
Drug prolactin and (not cycloset) seizures, stroke, meals
class:Dopam acts as a -Amenorrhea and mania, light- -Tell patient to use
ine receptor dopamine galactorrhea from headedness, take cycloset
antagonist receptor hyperprolactinemia; drowsiness, within 2 hours of
agonist by hypogonadism, depression walking in the
activating infertility (not EENT: blurred morning
postsynaptic cycloset) vision, nasal -Advise patient to
dopamine -Acromegaly (not congestion, avoid dizziness
receptors; cycloset) rhinitis, dry mouth and fainting by
improves Contraindication GI: nausea, rising slowly to an
glycemic -Hypersensitive to abdominal cramps, upright position
control ergot derivatives constipation and and avoiding
and in those with diarrhea, vomiting sudden position
uncontrolled HTN, and anorexia changes.
severe ischemic GU: urine -Advise patient to
disease, hereditary retention avoid alcohol
galactose Metabolic: while taking drugs.
intolerance hypoglycemia
Skin: coolness and
pallor of fingers
and toes.

Octreotide: Mimics Indication CNS: anxiety, -Monitor patient

Sandostatin action of -Flushing and confusion, closely for signs
Drug class: naturally diarrhea from dizziness, fatigue, and symptoms of
Somatostin occurring carcinoid tumors. headache, light- glucose imbalance.
Analog somastostati -Watery diarrhea headedness, -Monitor baseline
n from vasoactive weakness, thyroid function
intestinal depression tests
polypeptide- CV: arrhythmias, -Advise patient
secreting tumors bradycardia, chest that drug may
Contraindication pain, conduction restore fertility in
-Hypersensitive to abnormalities, some women with
drug or its peripheral edema acromegaly and
components EENT: blurred that she should use
-Use cautiously in vision effective birth
elderly patients, GI: abdominal control if
who may be more pain, diarrhea and pregnancy isn’t
sensitive to drug. constipation, desired.
flatulence, nausea -Stress importance
and vomiting of the need for
GU: UTI periodic lab testing
Skin: alopecia, octreotide therapy.
erythema or pain
in injection site,
flushing, and hair
loss
Lanreotide: It works by Indication Blurred vision -Ask patient about
Somatuline decreasing -Treatment of Abdominal pain any other
Depot the amounts neuroendocrine Lightheadedness, medications that
Somatostatin of certain tumors and dizziness, or they’re taking
analog natural acromegaly fainting -Do not breast feed
substances Contraindication Pounding in the while taking
produced by -Use cautiously in ears lanreotide
the body patients with Recurrent fever -Avoid sun
underlying cardiac Troubled breathing exposure. Wear
disease or with exertion SPF(or higher)
preexisting sunblock and
bradycardia protective
 clothing.

Surgical Management

HYPOPHYSECTOMY (surgical removal of pituitary gland)

 Treatment of choice in patients with Cushing syndrome resulting from

excessive production of ACTH (Adrenocorticotropic hormone) by a pituitary
tumor.
 May also be performed on occasion as a palliative measure to relieve bone
pain secondary to metastasis of malignant lesions of the breast and prostate.
 Several approached used to remove or destroy the pituitary gland, including
Surgical removal by
- Transfrontal
- Subcranial
- Oronasal-transsphenoidal approaches (is the usual treatment); irradiation;
and cryosurgery
 The Transsphenoidal approach (page-1995)
- Offers direct access to the sella turcica with minimal risk of trauma and
hemorrhage.

Nursing Management (Preoperative)

- The patient is educated in deep breathing techniques before surgery

- The patient is instructed that after the surgery, they will need to avoid
vigorous coughing, blowing the nose, sucking through a straw, or
sneezing. (because these actions may place increased pressure at the
surgical site and cause a CSF leak.)

Nursing Management (Postoperative)

- Vital signs are measured to monitor hemodynamic, cardiac, and

ventilatory status.
- Visual acuity and visual fields are assessed at regular intervals. (because of
the anatomic proximity of the pituitary gland to the optic chiasm) (one
method is to ask the patient to count the number of fingers held up by the
 nurse): Evidence of decreasing visual acuity suggests an expanding
hematoma.
- The head of the bed is raised to decrease pressure on the sella turcica and
to promote normal drainage.
- The patient is cautioned against blowing the nose or engaging in any
activity that raises ICP. (such as bending during urination or defecation)
- Intake and output (are measured as a guide to fluid and electrolyte
replacement and to assess for diabetes insipidus)
- Measure urine-specific gravity after each voiding
- Daily weight is monitored. (fluids are usually given after nausea ceases,
and the patient then progresses to a regular diet)
- Nasal packaging inserted during surgery is checked frequently for blood or
CSF drainage.
- Oral care is provided every 4 hours or more frequently. (teeth is not
usually brush used of warm saline mouth rinses and cool mist vaporizer
are helpful). Use of petrolatum to soothe the lips.
 Features or symptoms of acromegaly are unaffected by surgical removal of the
tumor.
 The absence of the pituitary gland alters the function of many body systems.
Menstruation ceases and infertility occurs after total or near-total ablation of
the pituitary gland.
 Replacement therapy with corticosteroids and thyroid hormone is necessary.

Nursing Diagnosis

 Risk for acute confusion (Associated with hypernatremia/hyponatremia due to

diabetes insipidus
 Risk for bleeding (associated endoscopic endonasal transsphenoidal approach)
 Deficient knowledge (about the disease process, treatment methods and
results, discharge and home care.
 Risk for aspiration (associated with pituitary surgery)
 Risk for impaired skin integrity (associated with changes in hormone levels,
sweating and immobility after surgical intervention)

Planning
 Health Promotion & Health Maintenance and Restoration

 Lifestyle changes such as

- staying at a healthy weight
- quitting smoking
- But pituitary tumors have not been linked with any known outside risk
factors. As a result, there is no known way to prevent these tumors at this
time.

Nursing Intervention

 Fluid balance is monitored, the patient’s environment is arranged by forming a

non-complex medium, and the patient will be communicated to support the
patient’s sense of integrity.
 Intracranial pressure increase may cause nose bleeding (the patient and his/her
family should be informed and recommended to avoid activities that may lead
to ICP)
 The importance of home care is emphasized/ A written education plan for
discharge training is developed and possible complications after surgery and
signs and symptoms of the disease are explained to the patients and relatives.
 Respiratory rate, rhythm, breath sounds and spO2 are evaluated at regular
intervals. The patient is supported for mobilization usually on the second day
after pituitary surgery
 Skin care, cleaning and moisturization are provided. Adequate and balanced
feeding is supported.

Evaluation

 The patient is expected not to develop any confusion and participate in daily
life activities
 The patient and his/her family are aware of the risk of bleeding and clinically
no bleeding event occurs.
 The patient and his/her family well understood and can express the disease
process, treatment methods and results, discharge plan and home care.
 Patient should be able to breathe easily and not experience aspiration
 Applying preventive measures and achievement of maintaining skin integrity
 DIABETES INSIPIDUS

Jillian Louise D. Pelayo

- Is the most common disorder of the posterior lobe of the pituitary gland and is
characterized by deficiency of ADH. This imbalance leads you to produce
large amounts of urine. It also makes you extremely thirsty (polydipsia) even
if you have something to drink. It may occur secondary to head trauma, brain
tumor, or surgical ablation or irradiation of pituitary gland. It may also occur
with infections of the nervous system (meningitis, encephalitis, tuberculosis)
or with tumors (e.g. metastatic disease, lymphoma of the breast or lung).
There's no cure for diabetes insipidus. But treatments can relieve your thirst
and decrease your urine output and prevent dehydration.

Clinical Manifestation

Without the action of ADH on the distal nephron of the kidney, an enormous daily
output (greater than 250ml per hr) of very dilute urine with a specific gravity of 1.001
to 1.005 occurs. The urine contains no abnormal substances such as glucose or
albumin. Because of the intense thirst, the patient tends to drink 2 to 20L of fluid daily
and craves cold water. In adults, the onset of DI may be insidious or abrupt.

The disease cannot be controlled by limiting fluid intake, because the high-
volume loss of urine continues even without fluid replacement. Attempts to restrict
fluid cause the patient to experience an insatiable craving for fluid and to develop
hypernatremia and severe dehydration.

● Being extremely thirsty

● Producing large amounts of pale urine
● Frequently needing to get up to urinate during the night
● Preferring cold drinks

An infant or young child with diabetes insipidus may have the following signs and
symptoms:

● Heavy, wet diapers

● Bed-wetting
● Trouble sleeping
● Fever
● Vomiting
● Constipation
● Delayed growth
● Weight loss

Diabetes insipidus occurs when your body can't properly balance the body's fluid
levels.

Your kidneys filter the fluid portion of your blood to remove waste products. The
majority of the fluid is returned to the bloodstream while the waste and a smaller
amount of fluid make up urine. Urine is excreted from your body after being
temporarily stored in your bladder.

A hormone called antidiuretic hormone (ADH), or vasopressin, is needed for the fluid
that's filtered by the kidneys to go back into the bloodstream. ADH is made in a part
of the brain called the hypothalamus and stored in the pituitary gland, a small gland
found in the base of the brain. Conditions that cause a deficiency of ADH or block the
effect of ADH result in production of excess urine.
If you have diabetes insipidus, your body can't properly balance fluid levels. The
cause depends on the type of diabetes insipidus you have.

Types of Diabetes Insipidus

● Central diabetes insipidus. Damage to the pituitary gland or hypothalamus

from surgery, a tumor, head injury or illness can cause central diabetes
insipidus by affecting the usual production, storage and release of ADH. An
inherited genetic disease also can cause this condition.
● Nephrogenic diabetes insipidus. Nephrogenic diabetes insipidus occurs when
there's a defect in the structures in your kidneys that makes your kidneys
unable to properly respond to ADH.
The defect may be due to an inherited (genetic) disorder or a chronic kidney disorder.
Certain drugs, such as lithium or antiviral medications such as foscarnet (Foscavir),
also can cause nephrogenic diabetes insipidus.

● Gestational diabetes insipidus. Gestational diabetes insipidus is rare. It

occurs only during pregnancy when an enzyme made by the placenta destroys
ADH in the mother.
● Primary polydipsia. Also known as dipsogenic diabetes insipidus, this
condition can cause production of large amounts of diluted urine from
drinking excessive amounts of fluids.
Primary polydipsia can be caused by damage to the thirst-regulating mechanism in the
hypothalamus. The condition has also been linked to mental illness, such as
schizophrenia.

Sometimes, there's no obvious cause of diabetes insipidus. However, in some people,

the disorder may be the result of an autoimmune reaction that causes the immune
system to damage the cells that make vasopressin.

Risk factors

Nephrogenic diabetes insipidus that's present at or shortly after birth usually has an
inherited (genetic) cause that permanently changes the kidneys' ability to concentrate
urine. Nephrogenic diabetes insipidus usually affects males, though women can pass
the gene on to their children.
Complications

● Dehydration
Diabetes insipidus may lead to dehydration. Dehydration can cause:

❖ Dry mouth
❖ Changes in skin elasticity
❖ Thirst
❖ Fatigue
● Electrolyte imbalance
Diabetes insipidus can cause an imbalance in minerals in your blood, such as sodium
and potassium (electrolytes), that maintain the fluid balance in your body. Symptoms
of an electrolyte imbalance may include:

❖ Weakness
❖ Nausea
❖ Vomiting
❖ Loss of appetite
❖ Muscle cramps
❖ Confusion
Assessment and Diagnostic Findings

The fluid deprivation test is carried out by withholding fluids for 8-12hrs or
until 3% to 5% of the body weight is lost.

● The patient is weighed frequently during the test.

● Plasma and urine osmolality studies are performed at the beginning and the
end of the test.
● The inability to increase specific gravity and osmolality of the urine is
characteristic of DI.
● The patient continues to excrete large volumes of urine with low specific
gravity and experiences weight loss, increasing serum osmolality, and elevated
serum sodium levels.
● The patient’s condition needs to be monitored frequently during the test, and
the test is terminated if tachycardia, excessive weight loss, or hypotension
develops.
Other diagnostic procedures include concurrent measurements of plasma levels of
ADH and plasma and urine osmolality as well as a trial of desmopressin (synthetic
vasopressin) therapy and intravenous infusion of hypertonic saline solution. If the
diagnosis is confirmed and the cause is not obvious the patient is carefully assessed
for tumors that may be causing the disorder.

Medical Management

The objectives of therapy are

1. To replace ADH (which is usually a long term therapeutic program)

2. To ensure adequate fluid replacement
3. To identify and correct the underlying intracranial pathology.
Nephrogenic causes require different management approach

Vasopressin Replacement

● Desmopressin (DDAVP), administered intranasally, 1 or 2 administrations

daily to control symptoms
● Lypressin (Diapid), absorbed through nasal mucosa into blood; duration may
be short for patients with severe disease
● Intramuscular administration of ADH (vasopressin tannate in oil) every 24 to
96 hours to reduce urinary volume (shake vigorously or warm; administer in
the evening; rotate injection sites to prevent lipodystrophy)

Pharmacologic Therapy

Drug name Drug class Administration Standard Dose Side effects

and OTC/RX Route
DDAVP synthetic Intravenously, 0.05 mg (1/2 of Infrequently, large
(desmopressi analogue of 8- subcutaneously, the 0.1 mg doses of the
n acetate) arginine orally tablet) two intranasal
vasopressin times a day formulations of
RX DDAVP
(desmopressin acetate
tablets)
 Injection have
produced transient
headache, nausea,
flushing and mild
abdominal cramps.
These symptoms
have disappeared
with reduction in
dosage.
DIABINESE Sulfonylureas orally 100 mg and 250 Dizziness and
(chlorpropam hypoglycemic mg tablets. headache.
ide) agent
RX Gastrointestinal
disturbances are the
most common
reactions; nausea has
been reported in less
than 5% of patients,
and diarrhea,
vomiting.

Nursing Diagnosis

● Deficient Fluid Volume

May be related to

● Compromised endocrine regulatory mechanism

● Neurohypophyseal dysfunction
● Hypopituitarism
● Hypophysectomy
● Nephrogenic DI
Nursing Interventions

● Monitor vital signs and neurological and cardiovascular status.

 ● Provide a safe environment, particularly for the client with a change in level of
consciousness or mental status.
● Monitor electrolyte values and for signs of dehydration.
● Monitor intake and output, weight, and specific gravity of urine.
● Maintain the intake of adequate fluids, and monitor for signs of dehydration.
● Instruct the client to avoid foods or liquids that produce diuresis.
● Administer chlorpropamide (Diabinese) if prescribed for mild diabetes
insipidus.
● Administer vasopressin tannate (Pitressin) or desmopressin acetate
(DDAVP,Stimate) as prescribed; these are used when the ADH deficiency is
severe or chronic.
● Instruct the client in the administration of medications as prescribed (DDAVP
may be administered by injection, intranasally, or orally).
● Instruct the client to wear a Medic-Alert bracelet.

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE

SECRETION

Allia Daphne P. Veriadiano

The syndrome of inappropriate antidiuretic hormone (SIADH) secretion includes

excessive ADH secretion from the pituitary gland even in the face of subnormal
serum osmolality. Patients with SIADH cannot excrete a dilute urine, retain fluids,
and develop a sodium deficiency known as dilutional hyponatremia. SIADH is often
of nonendocrine origin; for instance, the syndrome may occur in patients with
bronchogenic carcinoma in which malignant lung cells synthesize and release ADH.
SIADH has also occurred in patients with severe pneumonia, pneumothorax, and
other disorders of the lungs, as well as malignant tumors that affect other organs
(Kaiser & Ho, 2016; Porth, 2015).

Disorders of the central nervous system, such as head injury, brain surgery or tumor,
and infection, are thought to produce SIADH by direct stimulation of the pituitary
gland (Kaiser & Ho, 2016). Some medications (e.g., vincristine [Oncovin],
phenothiazines, tricyclic antidepressants, thiazide diuretics) and nicotine have been
implicated in SIADH; they either directly stimulate the pituitary gland or increase the
sensitivity of renal tubules to circulating ADH.

Overview

 Antidiuretic hormone (ADH) is produced by an area of the brain called the

hypothalamus. This hormone is stored in and released by the pituitary gland.
ADH controls how your body releases and conserves water.
 When ADH (also called vasopressin) is produced in excess, the condition is
called syndrome of inappropriate antidiuretic hormone (SIADH). This
overproduction can occur in places other than the hypothalamus.
 SIADH makes it harder for your body to release water. Additionally, SIDAH
causes levels of electrolytes, like sodium, to fall as a result of water retention.
A low sodium level or hyponatremia is a major complication of SIADH and is
responsible for many of the symptoms of SIADH. Early symptoms may be
mild and include cramping, nausea, and vomiting. In severe cases, SIADH can
cause confusion, seizures, and coma.

The Role of Antidiuretic Hormone in the Body

 Antidiuretic hormone is also called arginine vasopressin (AVP). It is produced

in the hypothalamus in the brain.
 ADH has been found to help to regulate the osmotic balance in the body,
which refers to the amounts of electrolytes and non-electrolytes in the cells,
tissues, and interstitial fluid.
 It also regulates sodium levels, blood pressure, and helps the kidneys to
function normally.
 ADH is also responsible for regulating water retention in the body. The more
ADH there is the body, the more water will be retained. Conversely, less water
will be retained if ADH levels are low.

Clinical Manifestation

SIADH makes it difficult for your body to get rid of excess water. This causes a
buildup of fluids as well as abnormally low sodium levels.
Symptoms may be mild and vague at first, but tend to build. Severe cases may involve
these symptoms:

 irritability and restlessness

 loss of appetite

 cramps

 nausea and vomiting

 muscle weakness

 confusion

 hallucinations

 personality changes

 seizures

 stupor

 coma

Causes

A variety of conditions can trigger abnormal ADH production, including:

 brain infections

 bleeding in or around the brain

 head trauma

 hydrocephalus

 Guillian-Barre syndrome

 multiple sclerosis

 infections including HIV and Rocky Mountain spotted fever

 cancers of the lung or gastrointestinal or genitourinary tract, lymphoma,

sarcoma
  lung infections

 asthma

 cystic fibrosis

 medications

 anesthesia

 hereditary factors

 sarcoidosis

Signs And Symptoms

Vital signs

 BP: Increased or may be normal

 HR: tachycardia
 Temperature: decreased or may be normal
Neurologic

 Alert to unresponsiveness
 Seizures
Cardiovascular

 Bounding pulses
Pulmonary

 Crackles may be present

Gastrointestinal

 Cramps
 Decreased bowel sounds
 Vomiting
Muscoloskeletal

 Weakness
 Cramps
 Absent deep tension reflexes

Laboratory
  Serum Sodium
 Serum Osmolality
 Urine specific gravity of the first morning voiding
 Urine Sodium
 Urine Osmolality

Medical Management

Interventions include eliminating the underlying cause, if possible, and restricting

fluid intake (John & Day, 2012). Because retained water is excreted slowly through
the kidneys, the extracellular fluid volume contracts and the serum sodium
concentration gradually increases toward normal. Diuretic agents such as furosemide
(Lasix) may be used along with fluid restriction if severe hyponatremia is present.

Nursing Management

Close monitoring of fluid intake and output, daily weight, urine and blood
chemistries, and neurologic status is indicated for the patient at risk for SIADH.
Supportive measures and explanations of procedures and treatments assist the patient
in managing this disorder.

Nursing Process

Assessment

Subjective Data:

 Nausea
 Muscle Cramps
 Irritability
 Fatigue

Objective Data:

 Vomiting
 Hypothermia
  Tremors
 Confusion
 Seizures
 Coma
 Edema

Diagnosis

 Excess fluid volume related to excessive amount of antidiuretic hormone

secretion.
Intervention

 Monitor I&O, daily weights

 Continuous EKG monitoring
 Assess, monitor vital signs q 1-2 hours
 Assess and monitor respiratory status
 Administer medication supplements
 Monitor lab/diagnostic values