14 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
3
Slide 32
Diabetes Insipidus (cont.)
• Medical treatment
• Intravenous fluid volume replacement and vasopressors often required to maintain
adequate blood pressure
• Neurogenic DI
TALKING POINTS:
• When is short-term therapy subcutaneous injections of aqueous vasopressin indicated?
4
Slide 33
Diabetes Insipidus (cont.)
• Assessment
• Thirst, change in urine appearance or volume, dizziness, weakness, fainting, and
palpitations
• Hydration, including skin turgor, moisture of mucous membranes, pulse rate and
quality, blood pressure, and mental status
• Intake and output, daily weights, urine specific gravity
• Interventions
• Anxiety
• Disturbed body image
3
Slide 34
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
• Cause
• Water imbalance related to an increase in ADH synthesis or secretion, or both
• Factors which may cause/contribute: brain trauma, surgery, tumors, infection;
vasopressin, general anesthesia, oral hypoglycemic agents, tricyclic antidepressants
TALKING POINTS:
• What factors may cause or contribute to the development of SIADH?
• There are several types of SIADH with various patterns of abnormal ADH secretion.
Slide 35
Syndrome of Inappropriate Antidiuretic Hormone (cont.)
• Signs and symptoms
• Weakness, muscle cramps or twitching, anorexia, nausea, diarrhea, irritability,
headache, and weight gain without edema
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
2
&
3
Slide 36
Syndrome of Inappropriate Antidiuretic Hormone (cont.)
• Medical diagnosis
• Laboratory tests of serum and urine electrolytes and osmolality
• Radiographic studies of brain and lungs detect causative factors
TALKING POINTS:
3
Slide 37
Syndrome of Inappropriate Antidiuretic Hormone (cont.)
• Medical treatment
• Acutely ill: hypertonic saline, very slowly over 4– to 6-hour period
• Restrict fluids to 800 to 1000 mL/day with high intake of dietary sodium
4
Slide 38
Syndrome of Inappropriate Antidiuretic Hormone (cont.)
• Assessment
• Anorexia, nausea, vomiting, diarrhea, headache, irritability, and muscle cramps and
weakness
• History of cancer, pulmonary disease, nervous system disorders, hypothyroidism, or
lupus erythematosus
• Note prescription drugs the patient is taking
• Describe mental status
Slide 39
Syndrome of Inappropriate Antidiuretic Hormone (cont.)
• Interventions
• Risk for injury
• Excess fluid volume
• Ineffective self-health management
1
Anatomy and Physiology
• A pair of small, highly vascularized triangular-shaped organs
16 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Slide 41
Anatomy and Physiology (cont.)
• Medulla
• Constitutes 20% of the gland and contains sympathetic ganglia with secretory cells
• Stimulation of sympathetic nervous system
• Medulla secretes two catecholamines: norepinephrine (noradrenaline) and
Slide 42
Anatomy and Physiology (cont.)
• Cortex
• Comprises80% of adrenal gland; the outer portion
• Considered part of the endocrine system
• Essential for maintaining many life-sustaining physiologic activities
Slide 43
Function of the Adrenal Glands
• Mineralocorticoids
• Produced by the zona glomerulosa
• Key in maintaining adequate extracellular fluid volume
• Renin, angiotensin, and aldosterone
• Renin produced by juxtaglomerular cells of renal afferent arterioles
• Release 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
TALKING POINTS:
• How is the secretion of aldosterone regulated?
Slide 44
Function of the Adrenal Glands (cont.)
• Glucocorticoids
• Produced by the zona reticularis and zona fasciculata
• Most abundant and potent is cortisol
• 92% of circulating cortisol bound to a plasma protein
• Cortisol has a permissive effect on other physiologic processes: the glucocorticoid
TALKING POINTS:
• How does glucocorticoid control carbohydrate, lipid, and fat metabolism, regulation of
antiinflammatory and immune responses, and control of emotional states?
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Slide 45
Function of the Adrenal Glands (cont.)
• Sex hormones
• Adrenal androgens: class of steroids produced in the zona fasciculata and zona
reticularis
• Primary function is masculinization
Slide 46
Health History
• Present illness
• Decreased energy, mental changes (depression, anxiety, nervousness, confusion),
sexual dysfunction, gastrointestinal disturbances, and abnormal skin pigmentation
• Medical history
Slide 47
Health History (cont.)
• Review of systems
• Patient’s perception of his/her general state of health
• Changes in skin color, especially bronzed or smoky pigmentation, and increased
facial hair in women. Note changes in weight and appetite
• Headache, lightheadedness with position changes, muscle weakness, nausea,
vomiting, abdominal pain, anorexia, menstrual dysfunction, erectile dysfunction
• Functional assessment
• Usual diet and activity patterns; disruptions in lifestyle
Slide 48
Physical Examination
• Height, weight, and vital signs
• Note patient’s responses and ability to follow instructions
• Skin: bronzed/smoky pigmentation, bruising, petechiae, vitiligo, pallor
• Inspect the face of the female patient for excess facial hair
• Examine the oral mucous membranes for color changes
Slide 49
Age-Related Changes
• Under normal circumstances, adrenal function remains adequate in older person
• Some decline in cortisol secretion, but this is balanced by decrease in cortisol metabolism
such that blood levels remain normal
• Secretion of aldosterone and plasma renin activity decline, thus abilities to conserve
sodium and adapt to position changes less efficient
18 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
3
Slide 50
Adrenal Hypofunction
• Cause
• Primary adrenal insufficiency
• Also called Addison disease
• Destructive disease process affecting the adrenal glands; results in deficiencies of
cortisol and aldosterone
• Secondary adrenal insufficiency
TALKING POINTS:
• What is the most common cause of Addison disease?
the adrenal glands’ intrinsic activity.
Slide 51
Adrenal Hypofunction (cont.)
• Pathophysiology
• Insufficiency of adrenocortical steroids: defects associated with the loss of
mineralocorticoids and glucocorticoids
• Skin hyperpigmentation
Adrenal Hypofunction (cont.)
• Acute adrenal crisis (addisonian crisis)
• A life-threatening emergency
TALKING POINTS:
• What stressors may initiate an adrenal crisis?
Slide 53
Adrenal Hypofunction (cont.)
• Acute adrenal crisis (addisonian crisis)
• Manifestations include symptoms of mineralocorticoid and glucocorticoid deficiency
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
2
&
3
Slide 54
Adrenal Hypofunction (cont.)
• Medical diagnosis
• Laboratory studies
• Low serum and urinary cortisol level, decreased fasting glucose, hyponatremia,
hyperkalemia, and increased BUN
3
Slide 55
Adrenal Hypofunction (cont.)
• Medical treatment
• Replacement therapy with glucocorticoids and mineralocorticoids
4
Adrenal Hypofunction (cont.)
• Assessment
• Weight loss, salt craving, nausea and vomiting, abdominal cramping and diarrhea,
Slide 57
Adrenal Hypofunction (cont.)
• Interventions
• Ineffective tissue perfusion
• Risk for injury
3
Slide 58
Adrenal Hypersecretion (Cushing Syndrome)
• Cause
• Production of excess amounts of corticosteroids, particularly glucocorticoid
• Overproduction: endogenous (internal) as well as exogenous (external)
Slide 59
Adrenal Hypersecretion (Cushing Syndrome): Pathophysiology
• Clinical manifestations affect most body systems; excess levels of circulating
corticosteroids
• Produces marked changes in personal appearance, including obesity, facial redness,
hirsutism, menstrual disorders, hypertension of varying degrees, muscle wasting of
20 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Slide 60
Adrenal Hypersecretion (Cushing Syndrome): Pathophysiology(cont.)
• Findings that lead to diagnosis
• Truncal obesity
• Protein wasting
• Hypokalemia of uncertain cause
2
&
3
Slide 61
Adrenal Hypersecretion (Cushing Syndrome)
• Medical diagnosis
• Laboratory studies
• 24-hour urine collection for free cortisol
• Low-dose dexamethasone suppression test
cortisol
• Radiographic studies
3
Adrenal Hypersecretion (Cushing Syndrome) (cont.)
• Medical treatment
• Drug therapy
TALKING POINTS:
• If Cushing syndrome is caused by administration of synthetic glucocorticoids, the provider
may gradually withdraw them.
4
Slide 63
Adrenal Hypersecretion (Cushing Syndrome) (cont.)
• Assessment
• Detailed history and physical examination
• Onset of symptoms, prior treatments, drug allergies, and current medications
• Interventions
• Risk for infection
• Disturbed thought processes
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Slide 64
Preoperative Care of the Adrenalectomy Patient
• Correct any electrolyte imbalances
• Strict handwashing and observance of aseptic technique to prevent infections in these
susceptible patients
• Preoperative education involves a discussion of glucocorticoid replacement therapy,
including dosage, side effects, and complications
Postoperative Care of the Adrenalectomy Patient
• Vital signs for signs and symptoms of impending shock (evident as hypotension), weak or
TALKING POINTS:
• After adrenalectomy, patients are sent to a critical care unit for at least 1 to 2 days for
close observation and assessment.
Postoperative Care of the Adrenalectomy Patient (cont.)
• Protect patient by using strict aseptic technique for wound care and invasive procedures
TALKING POINTS:
• What symptoms of adrenal insufficiency should be assessed for?
• High doses of cortisol are given intravenously during and for several days after surgery to
enable the patient to deal with the physical stress of surgery.
3
Slide 67
Pheochromocytoma
• Usually benign tumor of adrenal medulla causes excessive catecholamine secretion
• Hypertension, hypermetabolism, hyperglycemia
• Episodes triggered by emotional distress, exercise, manipulation of the tumor, postural
TALKING POINTS:
• What are the classic clinical findings with pheochromocytoma?
Slide 68
Question 1
• Which of the following is not an ingredient of a hormone?
A. Somatotropin
B. Amine
C. Peptide
D. Steroid
22 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Slide 69
Question 2
• All of the following are hormones secreted by the anterior lobe of the pituitary gland
except __________.
A. somatotropic hormone
B. oxytocin
C. prolactin
D. follicle-stimulating hormone
TALKING POINTS:
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the anatomy and physiology of the
endocrine system.
• Discuss the age-related changes in the older
adult.
PRACTICE
• Divide the class into two groups. Assign one
group the adrenal gland and the other the
pituitary gland. Have the groups list the
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Refer to Box
46-1(p. 1008). For selected items listed
under the Health History and Physical
Examination sections, identify the rationales
for collecting this information. Ask students
to provide constructive comments on each
other’s posts.
2
DISCUSS
• Discuss the diagnostic tests and procedures
used to diagnose endocrine disorders.
PRACTICE
• Divide the class into small groups, and
assign each group a diagnostic test or
procedure from Table 46-2 (pp. 1009-1010).
POST AND COMMENT
• Post the following discussion topic online
and have students comment. For selected
diagnostic tests, prepare and post a video of
a nurse providing patient/family instructions
relevant to the diagnostic test. Ask students
to provide constructive comments on each
other’s videos.
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
3
DISCUSS
• Discuss the pathophysiology and medical
treatment of adrenocortical insufficiency,
PRACTICE
• Divide the class into small groups. Assign
each group one of the following topics:
growth disorders, adrenocortical
insufficiency, excess adrenocortical
hormones, hypopituitarism, diabetes
insipidus, and pituitary tumors. Have each
group discuss the pathophysiology and
medical treatment of the disease and then
present its information to the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss your
complication would be most frightening? If
you had this disorder, what would you want
your health care provider and nurses to
teach, and what care would you want
provided? Ask students to provide
constructive comments on each other’s
posts.
4
DISCUSS
• Discuss the nursing care of patients with
endocrine disorders.
PRACTICE
• Divide the class into small groups. Have
each group refer to the Nursing Diagnoses,
Goals, and Outcome Criteria: Diabetes
Insipidus and identify two nursing
interventions with rationales for each nursing
diagnosis, goal, and outcome. Then have
each group present its information to the
class for discussion.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
type of patient/family education needed for
selected endocrine disorders. Ask students
to post constructive comments on each
other’s posts.
24 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 46.1
Critical Thinking Question
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?
Discussion Guidelines: The nurse should collect data about weight loss, salt cravings, nausea,
Instructor Notes/Student Feedback
____________________________________________________ Chapter 46Pituitary and Adrenal Disorders 25
46
Assessments for
Pituitary and Adrenal Disorders
CHAPTER OBJECTIVES
Lesson 46.1:
2. Describe the tests and procedures used to diagnose disorders of the adrenal and pituitary glands.
4. Assist in developing nursing care plans for patients with selected disorders of the adrenal and
pituitary glands.
Assessments by Lesson & Objective
Lesson 46.1
1
Study Guide
• Part IA: 1, 8-10, 13-15 (pp. 303-304)
• Part IE: 1-12 (pp. 305-306)
• Part IH: A-G (p. 307)
• Part II I: 1, 3, 4, 12, 21, 23, 29 (pp. 308-310)
• Part IIIK: 8 (p. 311)
2
Study Guide
• Part IG: 1-7 (p. 306)
• Part II I: 11, 27, 35 (pp. 308-310)
Evolve Instructor Resources
• Test Bank: 1, 11
• Open Book Quiz: 1, 9
3
Study Guide
• Part IA: 2-7, 11-15 (pp. 303–304)
• Part IB: 1-5 (p. 304)
• Part IC: 1-8 (pp. 304-305)
• Part ID: 1-14 (p. 305)
Evolve Instructor Resources
• Test Bank: 3-6, 8-10, 13-16, 18, 21, 25-31
• Open Book Quiz: 2, 3, 5-8, 10
Evolve Student Resources
• NCLEX Review: 1, 4, 5, 8, 9
• Prioritization: 1-5
26 Chapter 46Pituitary and Adrenal Disorders _____________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
4
Study Guide
• Part II I: 10, 28, 30, 32 (pp. 309-310)
Evolve Instructor Resources
• Test Bank: 2, 7, 12, 17, 19, 20, 22-24, 32
• Open Book Quiz: 4
Evolve Student Resources
• NCLEX Review: 2, 3, 6, 7, 10
• Prioritization: 6
Instructor’s Notes/Student Feedback