disorders of the pituitary gland

Medical Management Treated by surgical removal of the pituitary gland or by radiation therapy with consequent destruction of the pituitary..  If the tumor is removed or destroyed by ra

CHAPTER 56

ENDOCRINE SYSTEM

Disorders of the Pituitary Gland

PG 947

 Acromeg aly (Hype rpituitaris m):

 A condition in which an over secretion of GH

(growth hormone) occurs after the epiphyses

of the long bones have sealed

 Results of hyperplasia (increase in the number

of cells) or a tumor of the anterior pituitary

S/S of Acromegaly

 S/S: coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and feet (fig 56-1)

 The heart, liver, and spleen may be enlarged Despite enlarged tissues, muscle weakness is common, and hypertrophied joints may become painful and stiff

 Osteoporosis of the spine and joint pain

develop

Acromegaly

Medical Management

 Treated by surgical removal of the pituitary

gland or by radiation therapy with consequent destruction of the pituitary

 Even if the disease is arrested successfully, physical changes are irreversible

 If the tumor is removed or destroyed by

radiation therapy, replacement therapy with

thyroid hormone, corticosteroids, and sex

hormones is necessary

Simmond’s Disease

(Panhypopituitarism) PG 949

 Simmond’s dis e as e is a rare disorder caused

by destruction of the pituitary gland followed

by an absence of pituitary hormonal activity

 Events such as postpartum emboli, surgery, tumor, and TB can destroy pituitary function

S/S Simmond’s Disease

 The gonads and genitalia atrophy

 S/s of hypothyroidism, hypoglycemia, and adrenal insufficiency are apparent

 The client ages prematurely and becomes extremely cachectic

Medical Management

 Administration of substitute hormones for the glands that depend on the pituitary for

stimulation

 If untreated, the disease is fatal

 Assess the client’s mental status, emotional state, energy level, and appetite

Diabetes Insipidus pg 950

 An endocrine disorder that develops when there

is insufficient antidiuretic hormone (ADH) from the posterior pituitary gland

 Can be caused by head trauma that damages the pituitary and by primary or metastatic brain tumors

 The excretion of urine cannot be controlled by limiting

the intake of fluids

 The need for drinking and voiding frequently limits

activities

 Weakness, dehydration, and weight loss develop.

Medical Management

 Desmopressin (DDAVP) nasal solution and lypressin (Diapid) nasal spray are synthetic drugs with ADH activity that reduce the urine output to 2 to 3 L/24 hours

 IV fluids if unable to take po

Syndrome of Inappropriate

Antidiuretic Hormone Secretion

 SIADH—characterized by renal reabsorption of water rather than its normal excretion

 Causes include lung tumors, central nervous

system disorders, brain tumors, CVA, head

trauma, and drugs such as vasopressin, general anesthetic agents,m oral hypoglycemics, and

tricyclic antidepressants

 Continued release of ADH results in ↑ fluid

volume and hyponatremia

with IV administration of a 3% hypertonic

sodium chloride solution

Nursing Management

 S/s of fluid overload: confusion, dyspnea,

pulmonary congestion, hypertension

 S/s of hyponatremia: weakness, muscle

cramps, anorexia, nausea, diarrhea, irritability,

HA, and weight gain without edema

Disorders of the Thyroid Gland

PG 951

 Thyroid disorders include hyperthyroidism,

thyrotoxic crisis, hypothyroidism, thyroid

tumors, and endemic and multinodulal goiters

 Also called Graves disease, Basedow’s

disease, thyrotoxicosis, or exophthalmic goiter

 May be autoimmune or inherited disease

 Symptoms are from mild to severe

 Restless despite feeling fatigued and weak,

highly excitable, and constantly agitated

 Fine tremors of the hands occur, resulting in unusual clumsiness ( 56-4)

Graves Disease

 Cannot tolerate heat, and experience an

increased appetite with weight loss

 Diarrhea also occurs

 Visual changes, such as blurred or double

vision, can develop

 Exophthalmos, seen in client with sever

hyperthyroidism, is due to enlargement of

muscle and fatty tissue that surrounds the rear & sides of the eyeball

 S/s in Table 56-1 PG 952

Hyperthyroidism

Medical Management

 Antithyroid drugs are given to block the

production of thyroid hormone

 Potassium iodide (Lugol’s solution) is prescribed

in combination with an antithyroid drug

 Antithyroid medications should be avoided

during pregnancy because they can induce

hypothyroidism, or cretinism, in the fetus

Nursing Management

 Monitor heart rate and BP

 Record sleep pattern and daily weight

 May take several weeks before thyroid

medication effective

 If radioactive iodine is used to destroy thyroid tissue, tell the client that it does not seriously affect other tissues

Radioactive Iodine

Thyrotoxic Crisis

 An abrupt form of hyperthyroidism that is a threatening event

life- Thought to be triggered by extreme stress,

infection, diabetic ketoacidosis, trauma,

toxemia of pregnancy, or manipulation of a

hyperactive thyroid gland during surgery or

physical examination

Thyrotoxic Crisis

 S/S: Temperature may be as high as 106 F

 Pulse rate is rapid, and cardiac arrhythmias are common

 Persistent vomiting

 Extreme restlessness with delirium

 Chest pain

 dyspnea

Thyrotoxic Crisis

 Me dic al Manage me nt: immediate treatment

is necessary

 Antithyroid drugs are used to block the

synthesis of thyroid hormones

 A corticosteroid may be given IV to replace depletion that results from overstimulation of the adrenals during the hypermetabolic state

Thyrotoxic Crisis

 IV sodium iodide prevents the release of

thyroid hormones by the thyroid gland

 Inderal, a beta blocker, reduces the effect of thyroid hormones on the cardiovascular

system

 Supportive therapy includes IV fluids,

antipyretic measures, and oxygen therapy

Thyrotoxic Crisis

 Nurs ing Manag e me nt: Pt is ac utely ill!!

 Monitor V/S esp the temperature (may require measures other than antipyretics such as

cooling blankets or the application of ice)

Hypothyroidism pg 954

 Occurs when the thyroid gland fails to secrete

an adequate amount of thyroid hormones

 May originate within the thyroid (primary) or within the pituitary, in which case insufficient TSH is secreted

 Regardless, results in a slowing of all

metabolic processes (s ee Table 56-1)

 Severe hypothyroidism is called myxedema

 Advanced, untreated myxedema can progress

Myxedema

 Opposite in many respects to those of

hyperthyroidism

 The metabolic rate and physical and mental

activity are SLOWED!!

 Lethargic, lacks energy, dozes frequently during the day, is forgetful, and has chronic headaches

 The face takes on a mask like unemotional

expression, yet the client often is irritable

 The tongue may be enlarged and the lips

swollen, and there may be edema of the eyelids

 The temperature and pulse rate are decreased, and there is an intolerance to cold

 The weight increase despite a low caloric intake

 The skin is dry, and hair characteristically is

coarse and sparse and tends to fall out

 Menstrual disorders are common

 Constipation may be severe

 The voice is low pitched and hoarse, and

speech is slow

 Hearing may be impaired

 There may be numbness or tingling in the arms

or legs that is unrelieved by position change

 Can go untreated for years because of the

vague symptoms

Medical Management

 Treated with thyroid replacement therapy (s ee

Table 56-1)

 Thyroid hormone in the form of desiccated

thyroid extract, or with one of the synthetic

products, such as synthroid or cytomel, are

oral thyroid preparations

Nursing Management

 Observed for the adverse effects of thyroid

replacement therapy

 Dyspnea, rapid pulse rate, palpitations,

precordial pain, hyperactivity, insomnia,

dizziness, and GI disorders—in other words, signs of hyperthyroidism—may be seen if the dose of thyroid hormone is too high

 Once replacement therapy has begun, a

dramatic change may be seen in a few weeks

 Often found on routine physical exam

 As the tumor enlarges, may notice a swelling in the neck—malignant tumors can cause voice

changes, hoarseness, and difficulty swallowing

Medical Management

 Surgical removal of the lesion is considered if

it results in s/s as difficulty swallowing and

noticeable swelling in the neck

 A thyroidectomy (total or subtotal) is typically performed

 After removal hormone replacement therapy is needed for life

Nursing Management

 Thyroidectomy -AIRWAY! AIRWAY! AIRWAY!!!!!!!!!!

Endemic & Multinodular Goiters

pg 961

 The word GOITER refers to an enlargement of

the thyroid gland

 Caused by a deficiency of iodine in the diet, by the inability of the thyroid to use iodine, or by relative iodine deficiency caused by increasing body demands for thyroid hormones

Nontoxic Goiter

 Nontoxic goiter (also called simple or colloid

goiter) is an enlargement of the thyroid, usually without symptoms of thyroid dysfunction

 Nodular goiters contain one or more areas of hyperplasia

 This type of goiter appears to develop for

essentially the same reasons as an endemic goiter

Medical Management

 Depends on the cause

 Foods high in iodine if caused by a

deficiency -such as seafood or iodized salt

 Sometimes –a thyroidectomy is recommended

Nursing Management

 Closely observe the respiratory status

 Elevate the head of the bed to relieve

respiratory symptoms

 Provide a diet high in iodine and use iodized salt

 Iodine content is highest in seafood's and in

variable amounts in bread, milk, eggs, meat,

and spinach

 Soft diet may be necessary

Thyroiditis pg 961

 Inflammation of the thyroid gland, can be acute, subacute, or chronic

 Acute—more common in children, appears to

be the result or a bacterial infection of the gland

 Subacute thyroiditis –can follow an upper

respiratory viral infection and is relatively rare

 More common is Has himotos ’ thyroiditis , a

chronic form of thyroiditis It is believed to be an autoimmune disorder

 Acute: high fever, malaise, and tenderness and swelling of the thyroid gland

 Subacute: swollen and painful gland, chills,

fever, and malaise approx, 2 weeks after a viral infection

 Has himoto’s thyroiditis : enlargement of the thyroid and, in some cases, symptoms of

hypothyroidism

Medical Management

 Acute: antibiotics

 Subacute: symptomatic and includes

analgesics for pain and discomfort

 Corticosteroid medication also may be

prescribed to reduce inflammation

 Has himoto’s : thyroid hormone replacement therapy Surgery is required if the gland

becomes excessively large

 Show the client how to support his or her head when rising from bed to avoid straining the

neck incision (sit-ups)

 Inform the client that a dressing will be applied

to the front of the neck

Care plan

 Nursing Care plan: on your own!!!!!

Postoperative Period

 Complications associated with: hemorrhage,

airway obstruction, paralysis of the recurrent

laryngeal nerve (responsible for speech),

hypoparathyroidism, and hypothyroidism

 Hypothyroidism—may not be apparent for

several days of weeks after surgery

 Rarely, thyrotoxic crisis occurs as a result of

excessive manipulation of the gland during

surgery It may be seen within the first 12 hours after surgery

Care of the Pt after Thyroid

Surgery

 Immediately on return from surgery, take vital signs, assess the client for a patent airway, and inspect the dressing for bleeding or drainage

 Ask the client to say a few words to check the voice for tone, pitch, and hoarseness

 Minor voice changes are normal after thyroid

surgery

Post-op Care

 An infrequent postoperative complication is

tetany (muscle hypertonia with spasm and

tremor) which is caused by a low concentration

of calcium resulting from the accidental removal

of the parathyroid glands during thyroidectomy

 The client may complain of muscle cramps and numbness and tingling of the arms and legs

Disorders of the Parathyroid

Hyperparathyroidism pg 962

 Can be a primary or secondary condition

 Most common cause of primary is an adenoma

of one of the parathyroid glands

 Secondary—the parathyroid glands secrete an excessive amount of parathormone in response

to hypocalcemia, which may be caused by

vitamin D deficiency, chronic renal failure, large doses of thiazide diuretics, and excessive use of laxatives and calcium supplements

 Excessive calcium in the blood depresses the responsiveness of the peripheral nerves,

accounting for fatigue and muscle weakness

 The muscles become hypotonic (low of or

decrease in muscle tone)

 Cardiac arrhythmias may develop

 Skeletal tenderness and pain on bearing weight

 Bones may break with little or no trauma

 N/V, or constipation

Medical Management

 Secondary—managed by correcting the cause (eg, vitamin D therapy, correction of renal

failure, calcium restricted diet)

 Primary—only treatment is surgical removal of hypertrophied gland tissue or of an individual

tumor of one of the parathyroid glands

 One or more of the parathyroids are left in place because they are necessary for calcium and

phosphorus metabolism

Nursing Management

 I & O

 Observe for signs of urinary calculi from

hypercalcemia, flank pain, and decreasing

urinary stream

 Encourage a large volume of fluid to keep the urine dilute

Hypoparathyroidism pg 963

 A deficiency of parathormone that results in

hypocalcemia

 Parathormone regulates calcium balance by

increasing absorption of calcium from the GI

tract and bone reabsorption of calcium

 Hypocalcemia affects neuromuscular functions

 It causes hyperexcitability, resulting in spastic

muscle contractions and paresthesias (abnormal sensations)

 The main symptom of acute, sudden

hypoparathyrodism is tetany

 May report numbness and tingling in the

fingers or toes or around the lips

 A voluntary movement may be followed by an involuntary jerking spasm

 Chvostek’s sign & Trousseaus sign may be elicited

 Laryngeal spasm can occur in the larynx,

causing dyspnea, with long, crowing respirations

as air tries to get past the constriction

 Cyanosis may be present and the client is in

danger of asphyxia and cardiac arrhythmias

 N/V, abdominal pain, and seizures can develop

Medical Management

 Tetany and severe hypoparathyroidism are

treated immediately by the administration of an

IV calcium salt, such as calcium gluconate

 ET and mechanical ventilation may be

necessary if acute resp distress occurs

 Bronchodilators also are used

 Parathyroid replacement therapy is not the usual treatment because of its associated incidence of allergic reactions If used, drug resistance

develops in approx 2 weeks

Medical Management

 Long-term treatment after trauma to or

inadvertent removal of the parathyroids includes administration of oral calcium, vitamin D, or

vitamin D2 (calciferol), which increases the

serum calcium level

 The dose is R/T the degree of hypocalcemia,

which is determined by frequent monitoring of serum and urine calcium levels

 A diet high in calcium and low in phosphorus is recommended

Nursing Management

 Be alert for signs of tetany

 Be prepared to administer IV calcium salt.—observe for adverse effects, such as flushing, cardiac arrhythmia (usually a bradycardia),

tingling in the arms and legs, and a metallic taste

 Local tissue necrosis may occur if the IV fluid escapes into surrounding tissues