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Hyperpituitarism and Hypopituitarism

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Kelsey Clark

on 2 March 2014

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Transcript of Hyperpituitarism and Hypopituitarism

Collaborative Care
Treatment goal: return patient's GH back to normal range
Surgery
:
hypophysectomy
--best chance for a cure and produces an immediate reduction in GH. With removal of entire gland, hormone therapy will be given.
Radiation Therapy
: when surgery fails or if patient is a poor candidate for surgery. May also be given to shrink the tumor prior to surgery.
Drug Therapy
: Primary drug is octreotide (Sandostatin) that reduces GH levels to normal in many patients. Given by subcutaneous injection 3 times a week. GH measured every 2 weeks to determine dosing and effectiveness.
Anterior Pituitary Hormones
Growth Hormone
(GH) affects growth and development of all body tissues
Prolactin
stimulates breast development necessary for lactation
Tropic Hormones: hormones that control the secretion of hormones by other glands
:
Thyroid Stimulation Hormone
(TSH)
Adrenocorticotropic Hormone
(ACTH) stimulates the adrenal cortex to secrete corticosteroids
Follical Stimulating Hormone
(FSH) stimulates secretion of estrogen and development of ova in women and sperm in men
Luteinizing Hormone
(LH) stimulates ovulation in women and secretion of sex hormones in both men and women

Transsphenoidal Hypophysectomy
Hyperpituitarism
Disorders
Acromegaly
--overproduction of GH
Mean age of diagnosis: 40-45 yrs old
CAUSE: benign pituitary tumor resulting in overgrowth of soft tissues and bones in the hands, feet and face
Because the epiphyseal plates are already closed, they don't get longer, they get thicker
Diagnostic Studies
Patient history and physical exam
Lab tests:
Insulin-like growth factor 1 (IGF-1): As GH levels rise, so does IGF-1.
Oral glucose tolerance test (OGTT): specific test for acromegaly. GH is normally inhibited by glucose so they obtain two baseline GH levels. Then administer 75 or 100 grams of oral glucose and obtain glucose levels at 30, 60, 90, and 120 minutes. Normally, GH falls during OGTT. With acromegaly, the levels do not fall and can even rise.
MRI or CT scan with contrast used to detect pituitary tumors.
What is the Pituitary Gland?
Hyperpituitarism and Hypopituitarism

Kelsey Clark

Signs and Symptoms of Acromegaly
Enlargement of hands and feet with joint pain (mild to crippling)
Carpal tunnel syndrome may be present
Thickening and enlargement of the bony and soft tissue on the face, feet, and head
Enlargement of tongue (speech difficulties)
Hypertrophy of vocal cords (deepened voice)
Upper airway narrows (sleep apnea)
Skin becomes thick, leathery and oily
May have peripheral neuropathy and muscle weakness
Visual changes due to pressure on optic nerve
Headaches
Manifestations of diabetes mellitus, increased thirst and increased urination (GH antagonizes action of insulin resulting in hyperglycemia)
Increases free fatty acid levels in blood predisposing for atherosclerosis (GH mobilizes stored fat for energy)
Posterior Pituitary Hormones
These hormones are produced in the hypothalamus and travel down nerve tracks into the posterior pituitary gland for storage:
Antidiuretic Hormone
(ADH) which regulates fluid volume by stimulating reabsorption of water in the renal tubules and is also a potent vasoconstrictor
Oxytocin
stimulates ejection of milk into mammary ducts during lactation and stimulates contraction of the uterus
Nursing Assessment
Assess patient for S/S of abnormal tissue growth and evaluate changes in physical size.
Question patients about increases in hat, glove and shoe sizes.
Older pictures may be helpful in evaluating changes, as they happen slowly and the patient may not be aware
Nursing Interventions
Postoperative care after a
transsphenoidal hypophysectomy
:
Elevate the bed at all times to 30 degrees [avoids pressure on the removal site and decreases headaches]
Monitor pupillary response, speech patterns, and extremity strength to detect neurological complications
Perform mouth care every 4 hours to keep the surgical area clean
Avoid tooth brushing for at least 10 days to protect suture line
Observe for signs of bleeding
Instruct patient to avoid vigorous coughing, sneezing and straining at stool to prevent CSF leakage
Notify surgeon and send any clear nasal drainage to lab to be tested for glucose (a high glucose level could indicate CSF leakage increasing risk of meningitis)
Nursing Interventions
After stereotactic radiosurgery (radiation therapy):
Patient usually moved from the specialized radiation center to the neurosurgical nursing unit for overnight observation
Patient will be wearing a stereotactic head frame which is attached to the skull with pins (Used to keep head as still as possible while radiation is happening)
Monitor V/S, neurological status and fluid volume status
Possible complications include: increased headache, seizures, nausea, and vomiting
Stereotactic Head Frame
Nursing Interventions
Observe patients for transient diabetes insipidus due to loss of ADH in the posterior pituitary gland or due to cerebral edema from surgery
Closely monitor urine output and serum and urine osmolarity
Hormone therapy will be necessary to replace ADH, cortisol and thyroid hormone
Teach patients about the need for lifelong therapy
Periodic photos showing a decrease in symptoms may be helpful in encouraging patient
Surgery may result in permanent loss of FSH and LH which can decrease fertility
Assist the patient in working through the grieving process associated with those losses
Other Hyperpituitarism
Disorders
Hyperthyroidism (excessive thyroid stimulating hormone)
Syndrome of inappropriate antidiuretic hormone (SIADH) (excessive ADH)
Cushing's disease (excessive adrenocorticotropic hormone)
Hyperprolactinemia (excessive prolactin hormone)
Hypopituitarism
Rare disorder involves decrease in one of more of the pituitary hormones
PRIMARY CAUSE: pituitary tumor
Other causes: autoimmune disorders infections, pituitary infarction or destruction of the gland due to trauma, radiation or surgical procedures
A deficiency of only one hormone is called
selective hypopituitarism
Total failure of the pituitary gland results in absence of all hormones, called
panhypopituitarism

Most common hormone deficiencies involve GH and the gonadotropins (LH and FSH)
These deficiencies can be life threatening leading to organ failure or shock
S/S of Hypopituitarism
Early manifestations:
headaches
visual changes (decreased visual acuity or decreased peripheral vision)
loss of smell
nausea and vomiting
seizures
Diagnostic Studies
Patient history and physical examination
MRI and CT to identify tumor
Lab tests to directly measure levels of pituitary hormones
Nursing and Collaborative Management
Treatment:
surgery
or
radiation therapy
followed by
lifelong hormone therapy
(same as for hyperpituitarism)
Somatropin
, recombinant human GH, is used for long-term GH deficiency resulting in patients experiencing increased energy, increased lean body mass, a feeling of well-being and improved body image
Sex hormone therapy is offered to improve sexual function. Estrogen and progesterone replacement for women and testosterone for men.

NCLEX Question
During preoperative teaching for a patient scheduled for transsphenoidal hypophysectomy for treatment of a pituitary adenoma, the nurse instructs the patient about the need to

a. remain on bed rest for the first 48 hours after the surgery.
b. avoid brushing the teeth for at least 10 days after the surgery.
c. cough and deep-breathe every 2 hrs postoperatively.
d. be positioned flat with sandbags at the head postoperatively.
B
R: To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

NCLEX Question
A patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

a. "Have you had a recent head injury?"
b. "Do you have to wear larger shoes now?"
c. "Is there any family history of acromegaly?"
d. "Are you experiencing tremors or anxiety?"
B
Rationale: Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly
Thank you
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