ENDOCRINE SYSTEM
Revised 2013 from Saunders Intro. To Med/Surg Nursing, 5th Ed.
Chapter 44
Pituitary and Adrenal Disorders
Learning Objectives
Identify data to be collected for the nursing assessment of adrenal and pituitary function.
Describe the tests and procedures used to diagnose disorders of the adrenal and pituitary glands.
Describe the pathophysiology and medical treatment of adrenocortical insufficiency, excess
adrenocortical hormones, hypopituitarism, diabetes insipidus, and pituitary tumors.
Assist in developing nursing care plans for patients with selected disorders of the adrenal and
pituitary glands.
Hormone Functions and Regulation
Released in response to body’s needs
Responsible for reproduction, fluid and electrolyte balance, host defenses, responses to stress and
injury, energy metabolism, and growth and development
Endocrine system: maintain homeostasis
 Maintenance of physiologic stability despite constant changes in the environment
Hormone Functions and Regulation
Feedback mechanisms
 Controls regulation of endocrine activity by either stimulating or inhibiting
hormone synthesis and secretion
 Triggered by blood levels of specific substances
 May be positive or negative
The Pituitary Gland
Anatomy and Physiology
Weighs approximately 0.6 g; located in the sella turcica, a small indentation in the sphenoid bone
at the base of the brain
Connected to the hypothalamus by the infundibular (hypophyseal) stalk
Small and oval; diameter of about 1 cm
Anatomy and Physiology
Anterior lobe
 Larger of the two lobes: accounts for 70% to 80% of the gland’s weight
 Called the adenohypophysis
 Secretes
•
Growth hormone (GH), or somatotropic hormone
•
Adrenocorticotropic hormone (ACTH)
•
Thyroid-stimulating hormone or thyrotropic hormone
•
Follicle-stimulating hormone
•
Luteinizing hormone
•
Prolactin, or lactogenic hormone
•
Melanocyte-stimulating hormone
Anatomy and Physiology cont’d
Posterior lobe
 The smaller lobe
 Also called the neurohypophysis
 Secretes
•
Antidiuretic hormone (ADH), or vasopressin
•
Oxytocin
Health History
PUT YOUR THINKING CAPS ON AND CRITICALLY THINK..
QWhat are some problems R/T pituitary function that may bring a patient to seek medical
care?
Health History cont’d
PUT YOUR THINKING CAPS ON AND CRITICALLY THINK…
Q When doing your Review of Systems what should you ask about the patient’s general health
state?
Diagnostic Tests and Procedures
Radiographic studies
 Conventional radiographs
 Computed tomographic (CT) scans
 MRI
 Cerebral angiography
Laboratory studies
 Radioimmunoassay
 Enzyme-linked immunosorbent assay (ELISA)
 Hormone reserve activity also can be measured using a number of “suppression”
or “stimulation” tests
Disorders of the Pituitary Gland
Hyperpituitarism Gigantism or Acromegly
Cause
 Pathologic state caused by excess production of one or more of the anterior
pituitary hormones
 Common factor is presence of a pituitary adenoma
 Growth hormone and prolactin often in excess
•
Overproduction leads to gigantism or acromegaly
•
Overproduction of prolactin causes prolactemia
Hyperpituitarism cont’d
Medical diagnosis
 Radiographic studies
•
CT scans using a water-soluble dye
•
MRI
 Laboratory studies
•
Anterior pituitary hormone levels, esp. GH levels
•
Glucose Tolerance Test
Hyperpituitarism cont’d
Medical treatment
 Drug therapy
•
Many drugs used; Somatostatin analogs, dopamine agonists, GH receptor
antagonists, but Sandostatin is the most common drug
 Radiation
 Surgical management
•
Hypophysectomy: surgical removal of the adenoma or of the pituitary.
This method is the treatment of choice.
Post Op Nursing Care
 Assessment
•
Neurologic status and vision must be monitored closely with particular
attention to level of consciousness, pupil size and equality, and vital signs
•
Strict Intake and output WHY?
•
Inspect nasal packing  WHY ?
•
Signs and symptoms of infection
Nursing Diagnosis and related Interventions
Critically Think Now… What are your nursing interventions related to these Nursing Diagnosis?
•
Anxiety
•
Acute Pain and Impaired Oral Mucous Membrane
•
Risk for Injury
•
Risk for Infection
Hypopituitarism
Dwarfism
 Inadequate secretion of growth hormone during preadolescence
 Attainment of a maximum height 40% below normal
 Causes hereditary or related to damage to the anterior portion of the pituitary
gland
Panhypopituitarism
 Growth has been completed and some pathologic process impairs the function of
the pituitary
Hypopituitarism
Signs and symptoms
 Depends on the stage of life which hormones are deficient
 Dwarfism
•
Occurs early; person as short as 36 inches but with proportional physical
characteristics
•
Often have delayed or absent sexual maturation
•
Accelerated pattern of aging, thus shorter life span
Hypopituitarism cont’d
Signs and symptoms
 Panhypopituitarism ( growth is completed but some pathologic process impairs
the function of the pituitary gland )
•
Simmonds cachexia develops:
 Muscle and organ wasting and disruptions of both digestion and
metabolism
•
Absence of ACTH affects ability to cope with stress
•
Thyroid-stimulating hormone is depleted
•
Decreased pigmentation of the skin
•
Gonads may become atrophied
Hypopituitarism cont’d
Medical diagnosis
 Health history
 Physical examinationwith dwarfism findings are diagnostic
 X-rays and CT scans to detect tumors
 Cerebral angiography
 Serum levels of pituitary hormones
Medical and surgical treatment
 Deficient hormones are replaced as needed
 If caused by tumor, surgery, or radiation
Important Interventions
 Education important: disturbances in body image, sexual function, nutritional
status, and fluid balance can be improved if patient follows the prescribed therapy
 Acknowledge patient’s feelings and encourage expression of concerns; refer to a
mental health counselor if patient has difficulty dealing with the effects of the
disease
Posterior Pituitary Disorders
Characterized by deficient or excess amounts of ADH ( Anti diuretic hormone ) or “vasopressin”
ADH helps to maintain fluid balance
^ ADH levels  low urine output or fluid retention
Low ADH levels  more water passes through the kidneys than normal
Diabetes Insipidus
 Results from underproduction of ADH
 Char by large volumes of dilute urine (polyuria)
 Urine will be very dilute
Signs & Symptoms
Copious amounts of very dilute urine, may exceed 30 liters/day
Dehydration
Thirst
Hypotension, tachycardia, dizziness, weakness and fainting
Medical Diagnosis and Trmt
Diagnosis Based on health history, PE, 24 hr. urine output of > 4 L
Treatment IV fluid volume replacement and vasopressors are required to maintain BP. Most
common drug is DDAVP (Desmopressin)
Nursing Interventions
I&O 
IV fluid replacement
Fall precautions
VS   
Mon. thirst & weight
Compensate for fluid loss
Monitor for dizziness, weakness
Monitor for palpitations
Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
Cause
 Water imbalance related to an increase in ADH synthesis or secretion, or both
Pathophysiology
 When ADH is elevated despite normal or low serum osmolality, kidneys retain
excessive water
 Plasma volume expands, causing the blood pressure to rise. Body sodium is
diluted (hyponatremia), and water intoxication develops
Syndrome of Inappropriate
Antidiuretic Hormone cont’d
Signs and symptoms
 Weakness, muscle cramps or twitching, anorexia, nausea, diarrhea, irritability,
headache, and weight gain without edema
 When the central nervous system is affected by water intoxication, the level of
consciousness deteriorates
 Patient may have seizures or lapse into a coma
Syndrome of Inappropriate
Antidiuretic Hormone cont’d
Medical diagnosis
 Laboratory tests of serum and urine electrolytes and osmolality
 Urine osmolality is high ( very concentrated ) and serum osmolality is low ( very
dilute )
 Radiographic studies of brain and lungs may be done to try to detect causative
factors
Medical Treatment
Intended to correct the cause
There are several approaches to therapy ( all are patient sensitive )
The focus is to promote elimination of excess water & keep Na & K+ levels balanced
Lithium Carbonate or demeclocycline (blocks the effect of ADH)
Strict fluid restrictions to 800-1000ml/day with a high Na diet ( ? cardiac patients )
Medical Treatment ( cont’d )
Hypertonic NS (3%) pulls Na out of the intracellular space and into the extracellular space thus ^
serum Na levels.
Nursing Diagnosis and related Interventions
Critically Think Now… What are your nursing interventions related to these Nursing Diagnosis?
 Risk for Injury
 Excess Fluid Volume
 Ineffective Therapeutic Regimen Management
The Adrenal Glands
Anatomy and Physiology
A pair of small, highly vascularized triangular-shaped organs
Located in the retroperitoneal cavity on the superior poles of each kidney, lateral to the lower
thoracic and upper lumbar vertebrae
Two parts: an outer portion called the cortex and an inner portion called the medulla
Anatomy and Physiology cont’d
Cortex  secretes steroid hormones (mineralocorticoids & glucocorticoids ) also androgens and
estrogen
Medulla  secretes epinephrine & norepinephrine
Aldosterone
Most important mineralocorticoid
Regulates Na and K +
Keeps blood volume balanced
Renin, Angiotensin & Aldosterone
Mineralocorticoids
 Are Key in maintaining adequate extracellular fluid volume
Renin, angiotensin, and aldosterone
 Renin release is stimulated by decrease in extracellular fluid volume
 Renin acts on plasma proteins to release angiotensin I, which is catalyzed in the
lung to angiotensin II
 Angiotensin II stimulates the secretion of aldosterone, which results in sodium
and water retention
Cortisol
Most important glucocorticoid
Has anti-inflammatory response
Immune response
Controls emotional state
ACTH
ADRENAL CORTICOIDTROPIC HORMONE
Sent to adrenals by Pituitary
Stimulates production of adrenal
Serum ACTH levels are checked to see if Pituitary gland is sending messages to the adrenals
Health History
Critically think about these 3 areas?
Present illness
Past medical history
Review of Systems & PE
Adrenal Hypofunction/Addison’s Disease
Most often caused by:
•
autoimmune disease process affecting the adrenal glands; results in
deficiencies of cortisol and aldosterone
•
Occurs in 1 per 100,000 people
•
Decrease of ACTH production ( is a secondary cause )
•
TB and fungal infections
•
Also abrupt withdrawal of exogenous steroids ( could cause Addison’s
disease )
Signs & Symptoms
Weakness, lethargy and malaise
Skin hyperpigmentation (looks sun tanned )
Light headedness upon rising
Due to hypovolemia (orthostatic hypotension)
Have pt. move slowly, help getting out of bed
Decrease tolerance to minor stress
Variety of GI complaints
Salt craving (due to hyponatremia )
Adrenal Hypofunction cont’d
Acute adrenal crisis (Addisonian crisis)
 A life-threatening emergency bec. Of fluid and electrolyte imbalances
 Cause from abrupt withdrawal of steroid therapy
 Stress ( infections, illness, trauma, emotional disturbances )
 Other precipitating factors are adrenal surgery, or pituitary destruction
Adrenal Hypofunction cont’d
Acute adrenal crisis (Addisonian crisis)
 Manifestations include symptoms of mineralocorticoid and glucocorticoid
deficiency but are more severe: hypotension, tachycardia, dehydration, confusion,
hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia
 If untreated, fluid and electrolyte imbalances can lead to circulatory collapse,
cardiac arrhythmias, cardiac arrest, coma, and death
Adrenal Hypofunction cont’d
Medical diagnosis is made by:
Clinical signs and symptoms discussed
Variety of lab findings
•
Low serum cortisol level, low glucose, hyponatremia, hyperkalemia
•
Plasma ACTH concentration (ACTH stimulation test )
•
If high  Adrenals at fault; if low  pituitary at fault
 EKG
 X-rays
Adrenal Hypofunction cont’d
Medical treatment
 Replacement therapy with glucocorticoids and mineralocorticoids
 Hydrocortisone is drug of choice because it contains both gluco and
mineralocorticoids
Nursing Dx & related Interventions
Critically thinking time… put those caps on and FOCUS….
 Risk for Injury
 Imbalanced Nutrition: Less Than Body Requirements
 Patient teaching on…..?
Case Study
A 39-year-old construction worker who complains of decreased energy, impotence, and
abdominal pain is being tested for Addison disease. What data should the nurse collect
when obtaining the patient’s health history? What physiologic changes in the body result in
the abnormal symptoms of Addison disease?
Adrenal Hypersecretion
(Cushing’s Syndrome)
Cause
 Production of excess amounts of corticosteroids, particularly glucocorticoid
 Overproduction: endogenous (internal) as well as exogenous (external)
•
Endogenous causes  related to a tumor/neoplasm
•
Exogenous causprolonged administration of high doses of
corticosteroids
Adrenal Hypersecretion (Cushing Syndrome): Pathophysiology
Excess levels of circulating corticosteroids will affect every body system
Produces marked changes in personal appearance, including obesity, facial redness, hirsutism,
menstrual disorders, hypertension of varying degrees, muscle wasting of extremities
Additionally delayed wound healing, insomnia, irrational behavior, and mood disturbances such
as irritability and anxiety
Adrenal Hypersecretion (Cushing Syndrome): Clinical S/S
Hallmark Findings that lead to diagnosis
 Truncal obesity
 Protein wasting, causing arms & legs to be thin
 Facial fullness, often called a “moon face”
 Purple striae on the abdomen, breasts, buttocks, or thighs; very thin friable skin
 Osteoporosis
 Hypokalemia of uncertain cause
 Irritability or mood swings
 ^ BP and easy bruising
Adrenal Hypersecretion
(Cushing Syndrome)
Medical diagnosis
Physical s/s
 Laboratory studies
•
24-hour urine collection for free cortisol
•
Low-dose dexamethasone suppression test
( Should show drop of cortisol & steroid levels when compared to baseline; if not, then
Cushing’s is considered )
 Radiographic studies
•
CT scan and MRI  if tumor is suspected as cause
Adrenal Hypersecretion
(Cushing Syndrome) cont’d
Medical treatment
 Drug therapy
•
Mitotane (Lysodren), ketoconazole (Nizoral), aminoglutethimide
(Cytadren), and metyrapone (Metopirone)
 Radiation
•
Administered externally or internally
 Surgical management
Considerations….
Drug Therapy  Lysodren
There is a risk of acute adrenal crisis when patients are on drugs that suppress adrenal function.
Radiation  is not always effective; requires a long period of treatment and can destroy healthy
tissue.
Review Slide !
Addison’s Disease
Lab values are  Hypoglycemia, hyponatremia and hyperkalemia
Cushing’s Syndrome
Lab values are  Hyperglycemia, hypernatremia and hypokalemia
CRITICALLY THINK NOW !
What are your nursing interventions for this patient and why?
Look closely at this slide. What do you think the relevance is between it and what you’ve learned
thus far pertaining to the Endocrine System???
Are things always as they appear?
Is it wise to jump to conclusions without looking closely at the facts and critically thinking?
You’re half way there to finishing the Endocrine System.
Keep your FOCUS and turn to Chapter 45 for Thyroid and Parathyroid Disorders