Endocrine Disorders usually develop from...

• Excess of a specific hormone
• Deficiency of a specific hormone
• Receptor defect

• Hypopituitarism - selective or pan
• Hyperpituitarism

Most life threatening = ACTH & TSH deficiencies (cause decrease in adrenal and thyroid hormones)

Hypopituitarism

Causes

• Head trauma
• Radiation or surgery of the head and brain

• Pituitary infarction due to postpartum hemorrhage
• Usually immediate but can occur several years later
• Hx is IMPORTANT - birth in the last few years?
• Pituitary naturally gets larger during pregnancy

Hypopituitarism

Assessment

Neurologic Manifestations - VISION changes with tumor growth

Skull x-ray for changes in sella turcica (where pituitary gland sits)

Hypopituitarism

Clinical Manifestations

ACTH deficiency:

• Decreased serum cortisol
• Hyponatremia
• Hypoglycemia
• Trouble maintaining BP

TSH deficiency:

• Decreased serum thyroid hormone
• Decreased libido
• (Hypothyroidism s/s)

GH deficiency:

• Decreased bone density

Hyperpituitarism

Pituitary adenoma

Most common cause of hyperpituitarism

A benign tumor in one or more tissues w/in anterior pituitary

May be enclosed or invasive (if sella turcica involved)

PRL-secreting tumors = most common type of pituitary adenoma

Hyperpituitarism

GH

Acromegaly

Early detection essential

Some changes reversible with tx - skeletal changes are permanent

Hyperpituitarism

Excess ACTH

Overstimulates adrenal cortex - sugar, salt, sex

Leads to dvlpmt of Cushing's disease:

• Moon face
• Extremity muscle wasting
• Loss of bone density
• HTN
• Hyperglycemia
• Hyperpigmentation

Hyperpituitarism

PRL

Occurs in both sexes; think pregnancy?

CMs:

• Hypogonadism
• Decreased gonadotropin lvls
• Galactorrhea
• Increased body fat
• Increased serum prolactin

Hyperpituitarism

Excess TSH

Increased metabolism

S/S of hyperthyroidism

Hyperpituitarism

Assessment

• Skull x-rays for sella turcica changes
• Suppression testing
• Determines functioning of neg feedback control (ex - high blood glucose levels suppress release of GH - if they do not drop, abnormal test)

Hyperpituitarism

Interventions

• Radiation therapy - not useful immediately, may take several years
• Dopamine agonists - catecholamines will try to reset neg. feedback system
• Hypophysectomy - most common tx
• Pt in semi-sitting position
• Endoscopic transnasal approach
• Transsphenoidal approach
• Craniotomy - if tumor can't be reached using either approach

Hyperpituitarism

Transsphenoidal surgical approach

Hyperpituitarism

Care after hypophysectomy

• Neuro checks
• I/O - b/c we've messed with ADH (posterior pituitary)
• Deep breathing - NO coughing!
• Do NOT blow nose or sneeze
• No brushing teeth until incision heals (use dental floss or mouth wash)
• No bending at waist for any reason
• Monitor nasal drip pad - watch for CSF
• Prevent constipation and any straining
• Teach self admin of prescribed hormones

• Disorders usually r/t deficiency or excess of ADH
• Independent of anterior pituitary problems
• Diabetes insipidus - ADH deficiency
• SIADH - ADH excess

Hypopituitarism (Posterior)

Diabetes Insipidus

Insufficient ADH

Lg volumes of dilute urine (3-6 L)

Drug induced poss - Lithium carbonate

Output does NOT decrease with intake decrease

Diabetes Insipidus

Assessment

• Polydipsia, polyuria
• 24 I/O - don't restrict fluid
• If greater than 4 L and greater than volume ingested

DI

Interventions

• Partial ADH deficiency = Diabinese PO
• Increases action of existing ADH
• Severe ADH deficiency = DDAVP
• Oral or nasal
• Severe dehydration - IV or IM
• IV form 10X stronger than oral form

DI

Pt Education

• Permanent DI patients on lifelong DDAVP or vasopressin therapy
• Daily weights
• S/S of water toxicity - persistent h/a, acute confusion, seizures
• Weight gain or water toxicity - CALL 911
• Med alert bracelet

Hyperpituitarism (Posterior)

SIADH

• Excess ADH
• Water retained = dilutional hyponatremia & fluid overload

SIADH

Assessment

• Water retention - NO dependent edema
• Hypothermia
• Radioimmunoassay of ADH
• Hyponatremic

SIADH

Interventions

• Restrict fluid intake (as low as 500-600 mL/24 hrs)
• Monitor for fluid overload
• Seizure precautions
• Neuro checks
• Administer SAMSCA (PO) - vasopressin antagonist, excretes water w/o sodium loss
• ONLY administere in hospital!!!