Pituitary Gland Disorders

Pituitary Gland.The pituitary is located at the base of the brain, in a small depression of the sphenoid bone (sella turcica). Purpose: control the activity of many other endocrine glands. Master glandHas two lobes, the anterior & posterior lobes.

AnatomyAnterior lobe: glandular tissue, accounts for 75% of total weight. Hormones in this lobe are controlled by regulating hormones from the hypothalmus (stimulate or inhibit)

Posterior: nerve tissue & contains axons that originate in the hypothalmus. Therefore this lobe does not produce hormones but stores those produced by the neurosecretory cells in the hypothalmus. Release of hormones is triggered by receptors in the hypothalmus.

TermsTrophic hormones: hormones that control the secretion of hormones by other glands. Example: TSH stimulates the thyroid to secrete hormones.Effector hormones: produce an effect directly when secreted. Example ADH stimulates kidneys

Review - HormonesAnterior PituitaryGH: growth hormoneACTH: adrenocorticotropic hormoneTSH: thyroid-stimulating hormonePRL: prolactinFSH: follicle-stimulating hormoneLH: luteinizing hormoneMSH: melanocyte stimulating hormone

Posterior PituitaryADH: anti-diuretic hormone (vasopressin)OT: oxytocin

Anterior Pituitary Secretes:GH: stimulates growth of bone and muscle , promotes protein synthesis and fat metabolism.

ACTH (Adrenocorticotropin ): stimulates adrenal gland cortex secretion of mineralcorticoids (aldosterone) & glucocorticoids (cortisol).

TSH: stimulates thyroid to increase secretion of thyroxine, its control is from regulating hormones in the hypothalmus.

Anterior Pituitary ContdProlactin: stimulates milk production from the breasts after childbirth to enable nursing. Oxytoxin from posterior lobe controls milk ejection.

FSH: promotes sperm production in men and stimulates the ovaries to enable ovulation in women. LH and FSH work together to cause normal function of the ovaries and testes.

LH: regulates testosterone in men and estrogen, progesterone in women.

Posterior PituitaryAntidiuretic hormone or ADH - also called vasopressin, vasoconstricts arterioles to increase arterial pressure; increases water reabsorption in distal tubules.

Oxytocin: stimulates uterus to contract at childbirth; stimulates mammary ducts to contract (milk ejection in lactation).

Anterior Pituitary Disorders

Posterior Pituitary Disorders

Anterior Gland Disorders

Disorders occur most often in the anterior pituitary

The anterior pituitary hormones regulates growth, metabolic activity and sexual development.

Major causes include: tumors, pituitary infarction, genetic disorders.

Pathologic consequences of pituitary disorders are 1) hyperpituitarism, 2) hypopituitarism, 3) local compression of brain tissue by expanding tumor

Hyperpituitarism

HyperfunctionResults in excess production and secretion of one or more hormones such as GH, PRL, ACTH.

Most common cause is a benign adenoma.

Anterior pituitary adenoma, a benign tumor which is classified according to size, degree of invasiveness and the hormone secreted.

Prolactin and GH are the hormones most commonly over-produced by adenomas.

Pituitary Adenoma

Adenomas ContdChanges in neurological function may occur as adenomas compress surrounding tissue.

Manifestations include headaches, visual defects and increased ICP.

Treatment is surgical resection through transphenoidal hypophysectomy

Increased GHIncreased GH: Gigantism & Acromegalya statue of Robert Wadlow, the "Alton Giant," who measured 8 feet 11 inches at the time of his death. Young 12 y/o male standing with his mother

Gigantism is the result of GH hypersecretion before the closure of the epiphyseal plates (childhood).Abnormally tall but body proportions are normal

Acromegaly is over secretion of GH in adulthoodContinued growth of boney, connective tissue leads to disproportionate enlargement of tissue..

AcromegalyRare condition develops between ages 30-50

Symptoms:Coarsening of facial featuresEnlarged hands & feetCarpel trunnel syndromeExcessive sweating & oily skinHeadachesVision disturbanceSleep apneaGeneral tirednessOligomenorrhea or amenorrheaImpotence (adult males)Decreased libido

DiagnosisHistory & physical examInvestigation includes:GH analysis (glucose tolerance) Normally GH concentarion falls with oral glucose; in acromegaly it does not.Prolactin levels as well as other pituitary function testsMRI or CT & visual field tests to determine size and position of the adenoma.Bone scan

TreatmentSurgery (primary choice)RadiotherapyDrug treatment when surgery is not feasibleCombinations of above

Drug treatment of AcromegalyDopamine agonists: Dopamine agonists work on specialist markers (dopamine receptors) on the surface of the tumor to inhibit GH release from the tumour (Parlodel). Somatostatin: growth hormone receptor antagonist decreases the action of GH on target tissues. (octreocide acetate) Dopamine agonists are taken by mouth but in general are less effective than somatostatin analogues, which have to be injected.

Hypopituitarism

Hypopituitarism- Anterior PituitaryDecreased GH in child: DwarfismCondition of being undersizedThere are many forms of dwarfismDwarfism related to pituitary gland is the result of insufficient GHPituitary dwarfism is successfully treated by administering human growth hormone

Hypopituitarism (Adult)- GHLack of GH leads to:Increased CV diseaseExcessive tirednessAnxietyDepressionReduced quality of lifePossible premature death

HyperprolactemiaProlactin levels are normally high during pregnancy and lactation. Symptoms of hyperprolactemia include;discharge from breasts (galactorrhoea) oligomenorrhoea or amenorrhoea in women reduced libido and potency in men pressure effects (e.g. headache and visual disturbance) - more commonly in men

Treatment is surgery, radiation, or medical therapy with drugs that will suppress the production of prolactinUrgent: deterioration in visionImportant: successful RX. results in restoration of fertilityPatients may be predisposed to problems related to osteoporosisAsk about erectile function & reassure client that it is part of the disease and can be treated.

Increased ACTH:Cushings DiseaseCushing's is a disorder in which the adrenal glands are producing too much cortisol (hypercotisolism).If the source of the problem is the pituitary gland, then the correct name is Cushing's Disease whereas, if it originates anywhere else (adrenal tumors, long term steroid administration) then the correct name is Cushing's Syndrome.Cushings Disease is caused by pituitary hypersecretion of ACTH.

Etiology - HypercortisolismIatrogenic hypercortisolism resulting from medical intervention is most common cause of Cushing Syndrome.Pituitary hyper secretion and pituitary tumors account for 70% of Cushings Disease. Adrenal tumors account for 30%.Ectopic secretion of ACTH by tumors located outside the pituitary gland are rare cause of the syndrome and associated with increased morbidity/mortality (ie oat cell ca).

Symptoms psychiatric disturbance (often characterized by amplification of previous personality traits) moon face - particularly filling in of the temporal fossa weight gain - central obesity muscle wasting and proximal myopathy (patients have difficulty standing from a seated position without use of arms) thin skin * - tendency to bruise hirsutism (caused by androgen excess) violaceous striae

Symptoms: hypercortisolismNeurological: Psychosis, emotional labiality, loss of memory, depressionMusculosketal: muscle weakness, muscle wasting, osteoporosis, buffalo hump, truncal obesityIntegumentary: ecchymosis, purple striae on abdomen, poor wound healing, skin infections, thin skin, acne.

Symptoms ContdCV: HTN GI: peptic ulcersMetabolic: hyppokalemia, hypernatremia, edema, moon face, weight gain.Classic symptoms of Cushings: moon face, buffalo hump, purple straie, truncal obesity.

Advanced Cushings

Diagnosis24 hr urine cortisol levels Serum sodium levelsSerum potassium levelsSerum glucoseSerum ACTH in Cushing DiseaseACTH suppression test to identify causeDexamethasone supression test: cause pituitary or adrenalRadiological exam to reveal pituitary or adrenal tumor

TreatmentTransphenoidal surgery if the condition is due to a pituitary tumorWhere surgery is contraindicated or fails to reduce cortisol levels, adrenalectomy and/or pituitary radiation may be necessary.Adrenocortical Inhibitors: (metapyrone, aminogluthimide) are only effective short-term.Diet: low calorie, carbohydrate & salt. High potassium.

Priority Nursing DiagnosesFluid volume excessRisk for infectionRisk for injuryActivity intoleranceAnxietyKnowledge deficitRisk for impaired tissue integrity

Teaching DietMedications Medic alert braceletHormone levels and stressSigns of excessive or deficient adrenal hormones

Post op Care following Transphenoidal Surgery

Post op care for cranial surgery (CSF leak, ICP etc.)Hydrocortisone therapy, some on a long-term basisIf surgery results in hypopituitarism, long-term hormone replacement therapy will be requiredMoods swings and depression may be a serious problem that may take months to treat

Hypopituitarism Addisons DiseaseTo be covered under adrenal dysfunction

Posterior Pituitary Disorders

Diabetes insipidus

SIADHDeficiency or excess of ADH

Posterior Lobe DisordersSIADH & diabetes insipidus are major disorders of the posterior pituitaryhoweverEven if posterior lobe becomes damaged, hormonal deficiencies usually do not develop because??

Hyper Posterior Pituitary

SIADHSyndrome of Inappropriate Anti-Diuretic HormoneToo much ADH produced or secreted. SIADH commonly results from malignancies, CHF, & CVA - resulting in damage to the hypothalamus or pituitary which causes failure of the feedback loop that regulates ADH. Client retains water causing dilutional hyponaetremia & decreased osmolality.Decreased serum osmolality cause water to move into cells

Signs and SymptomsLethargy & weaknessConfusion or changes in neurological statusCerebral edemaMuscle crampsDecreased urine outputWeight gain without edemaHypertension(Note: b/c of the low Na, edema will not accompany the FVE)

AssessmentSerum sodium lowSerum osmolality lowUrine osmolality disproportionately elevated in relation to the serum osmolalityUrine specific gravity elevated Plasma ADH elevated

!!!!!!

Treatment of SIADH Treat underlying causeHypertonic or isotonic IV solutionMonitor for signs of fluid and electrolyte imbalanceMonitor for neurological effectsMonitor in and outWeighRestrict fluid intakeMedic AlertLithium inhibits action of ADH to promote water excretion.

Hypofunction Posterior pituitary

Normal urine production

Diabetes Insipitus (DI)DI is usually insidious but can occur with damage to the hypothalamus or the pituitary. (neurogenic DI)May be a result of defect in renal tubules, do not respond to ADH (nephrogenic DI)Decreased production or release of ADH results in massive water lossLeads to hypovolemic & dehydration.

Clinical ManifestationsPolyuria of more than 3 litres per 24 hours in adults (may be up to 20!)Urine specific gravity lowPolydipsia (excessive drinking)Weight lossDry skin & mucous membranesPossible hypovolemia, hypotension, electrolyte imbalance

Diagnostic TestsSerum sodium Urine specific gravity Serum osmolality Urine osmolality Serum ADH levelsVasopressin test and water deprivation test: increased hyperosmolality is diagnostic for DI.

Management Medical management includes Rehydration IV fluids (hypotonic) Symptom management ADH replacement (vasopressin)For nephrogenic DI: thiazide diuretics, mild salt depletion, prostaglandin inhibitors (i.e. ibuprophen)

NursingMonitor for signs of fluid and electrolyte imbalanceMonitor in and outDaily weightMonitor for excessive thirst or outputAssess serum and urine values (decreased SG, decreased urine osmolality, high serum osmolality are early indicators

POSSIBLE NURSING DIAGNOSISFluid Volume Deficit Risk for Injury r/t altered LOCRisk for Altered Health Maintenance Sleep Pattern Disturbance r/t urinary frequency or anxietyAltered Urinary Elimination r/t excess urinary outputBody ImageAltered sexuality

PanhypopituitarismWhen both the anterior and posterior fail to secrete hormones, the condition is called panhypopituitarism.Causes include tumors, infection, injury, iatrogenic (radiation, surgery), infarction Manifestations dont occur until 75% of pituitary has been obliterated.Treatment involves removal of cause and hormone replacement (adrenaocortical insufficiency, thyroid hormone, sex hormones)

KnowThe what these conditions are & difference b/t a) Cushings Disease & Cushings Syndrome b) Giantism &Acromegalyc) Dwarfismd) Diabetes Insipidus vs. Diabetes Mellitus

Consider Nursing Diagnosis related to these conditions

What role does the pituitary gland play in fluid and electrolyte balance?

How BV is regulated:

When the HYPOTHALMUS senses a decrease in serum sodium or increase in serum potassium, it sends a message to the PITUITARY to release adenocorticotropic hormone (ACTH). ACTH stimulates ADRENAL CORTEX to release ALDOSTERONE. It regulates water balance by facilitating sodium reabsorption in renal tubules. As sodium is reabsorbed potassium is excreted by kidneys. As sodium reabsorbed, the circulating blood volume increases through water reabsorbtion resulting in increased BV and Increased BP.

Endocrine system and sodium balance?

Sodium BalanceMaintained by ADH secreted from posterior pituitaryDepends what is ingested & how it is absorbedIncreased sodium intake leads to increased extracellular fluid volumeDecreased sodium intake leads to decreased extracellular fluid volumeIncreased sodium levels leads to increased thirst, release of ADH, retention of water by kidneys & dilution of bloodDecreased sodium levels leads to suppression of thirst, suppression of ADH secretion, & excretion of water by kidneys

Abdominal crampsAltered LOCMuscle twitching, weakness NauseaDry mucous membraneBP alterations depending on depletional or dilutional hyponatremia Poor skin turgor, weight changes r/t fluidTachycardia

Potassium is responsible for:a) Neuromuscular excitability and muscle contractionb) Important in glycogen formation and protein synthesisc) Correction of imbalances of acid-base metabolism

A slight decrease has profound implications for neuromuscular and cardiac function.Prolonged gastric , recent ileostomy, villous adenoma, inadequate intake, excess output, drugs such as diuretics, corticosteroids, insulin, some antibiotics like Pen K, as well as diseases causing any of the above.Foods high in potassium: chocolate, dried fruit, nuts & seeds, oranges, bananas, apricots, cantaloupes, potatoes, mushrooms, tomatoes, carrots

Potassium: HypokalemiaWatch for: (SUCTION)Skeletal muscle weaknessU wave- Electrocardiogram changesConstipation/ileusToxic effects of digoxin (hypocalemia)Irregular weak pulseOrthostatic hypotensionNumbness (paraesthesia)

Neuromuscular signs & symptoms of hypokalemia include:a) confusion & irritabilityb) diminished deep tendon reflexesc) Parkinsonian type tremors

Questions to ask when assessing potassium imbalance in clientsIs client taking antacids? - may interfereIs clients renal status worsening?Is the client taking meds that could raise or lower potassium?Was the blood sample valid? (IV site)How is fluid intake/output

If you were walking across the Sahara Desert with no water. The amount of ADH hormone secreted would be:a) Increasedb) Decreasedc) Stay the same

Giving a hypertonic IV solution to a client may cause too much fluid to be:a) pulled from cells into the bloodstreamb) pulled out of the bloodstream into the cellsc) pushed out of the bloodstream into extravascular space

ThirstEating highly salty foods and losing fluids lead to an increase in extracellular fluid osmolality. This leads to drying of mucous membrane, which stimulates the thirst center in hypothalamus. This mechanism is less effective in elderly, thus they are more prone to dehydration. Also it takes a while for this response to occur. Anticipate!

Great web sitehttp://www.emc.maricopa.edu/faculty/farabee/BIOBK/BioBookENDOCR.html

Pituitary = hypophysisAnterior lobe called the adenohypophysisPosterior lobe called the neurohypophysis

The secretion from these hormones is controlled by releasing secreted by the hypothalmus.

Effector Hormones: produce an effect when secreted (ADH, oxytocin)Trophic hormones: stimulate other glands to release hormones ( ACTH, TSH, LH, FSH)Example:Hypothalmus stimulates anterior pituitary to release ACTH which stimulates adrenal cortex.

GH: stimulates growth; promotes active transport of amino acids into cell & influences the rate at which CHO and fats are catabolized. Stimulates growth in childhood, is important for maintaining a healthy body composition and well-being in adults. In adults it is important for maintaining muscle mass as well as bone mass. It also plays a role in maintenance of constant blood sugar levels (through conversion of conversion of glycogen to glucose)ACTH (Adrenocorticotropin ): stimulates adrenal gland cortex secretion of mineralcorticoids (aldosterone) & glucocorticoids (cortisol). Cortisol, a so-called "stress hormone" is vital to survival. It helps maintain blood pressure and blood glucose levels. Aldosterone maintain electrolyte/water balance.TSH: stimulates thyroid to increase secretion of thyroxine, regulates the body's metabolism, energy, growth and development, and nervous system activity- vital to survivalProlactin: stimulates milk production from the breasts after childbirth to enable nursing; controlled by regulating hormones from hypothalmus.can FSH: promotes sperm production in men and stimulates the ovaries to enable ovulation in women. LH and FSH work together to cause normal function of the ovaries and testes.LH: regulates testosterone in men and estrogen in womenADH & oxytocin are called EFFECTOR hormones b/c they produce an effect when secreted.Whereas:Hypothalmic hormones stimulate the posterior pituitary to release TROPHIC (gland-stimulating) hormones.Trophic hormones: stimulate another gland. i.e. ACTH, TSH, FSH, LH.

Major causes of pituitary disease include tumors, pituitary infarction, genetic disorders and trauma.Pituitary tumors produce local (increased pressure in the cranium visual field abnormalities, headaches and somnolence) and systemic effects from over or under production of hormones..

Treatment involves removal of pituitary tumors.GH is a hormone necessary for growth, regulates cell division, synthesis of protein. It exerts metabolic effects on organs, skin, muscle and connective tissue.

GH is a peptide anterior pituitary hormone essential for growth. GH-releasing hormone stimulates release of GH. GH-inhibiting hormone suppresses the release of GH. The hypothalamus maintains homeostatic levels of GH. Cells under the action of GH increase in size (hypertrophy) and number (hyperplasia). GH also causes increase in bone length and thickness by deposition of cartilage at the ends of bones. During adolescence, sex hormones cause replacement of cartilage by bone, halting further bone growth even though GH is still present. Too little or two much GH can cause dwarfism or gigantism, respectively.

Acromegaly is a very rare condition and usually develops between the ages of 30 and 50. If the condition develops before a person has stopped growing (which usually occurs between the ages of 15 to 17 years of age), it causes gigantism because growth hormone promotes growth of bones in the body.

ProghathismHistory: note change in hat, glove, shoe or ring size.Report fatigue and lethargyBackache & arthralgiaVisual defects and headaches

Laboratory Analysis

In hyperpituitarism, usually only one hormone is produced in excess, most common being PRL, ACTH, GH

Physical ExamChanges in facial features; in head, hand & foot sizeArthritic type changesVision changes from compression on optic nervesHTNOrganomegaly (cardiac or hepatic)Deepened voiceDysphagia from enlarged toungue

Acromegaly may be treated by operating on the pituitary gland, by radiotherapy, by drug treatment, or a combination of these. The aim of all treatments is to reduce growth hormone levels to normal as this is associated with the disappearance of symptoms and improvement of your general wellbeing.

Transphenoidal pituitary surgery and removal of adenoma. Surgery is the gold standard of treatment in clients who are acceptable surgical risks.

Radiation is indicated in clients where surgery failed to bring GH down to normal levels or in poor surgical candidates. There is a higher risk of panhypopituitarism with this. However neurologic complications are possible such as visual loss, weakness and memory impairment.Drug TreatmentOctreocert acetate: SomavertDopamine agonist: Parlodel

Medical treatment: Octreotide causes tumor shrinkage; Dostinex & Parlodel (dopamine agonists) lower GH secretion; Somavert blocks the action of GH

New developmentsPegvisomant (Somavert) is a completely new way of treating acromegaly. All current forms of treatment attempt to lower the amount of GH released by the pituitary gland. Pegvisomant is a blocker of the action of GH. It does not try to inhibit the release of GH from the pituitary into the blood but instead stops the GH leaving the blood to stick to cells throughout the body. This should block all the unwanted effects of GH and studies in patients with acromegaly suggest it is very effective. It is hoped it will be available in the near future.

Hypopituitarism Hormone deficiency caused by the inadequate secretion of one or more of the hormones normally secreted by the pituitary, is known as hypopituitarism. It may be caused by compression of the normal tissue by a developing tumour, surgery, or radiotherapy. If hypopituitarism is caused by tumour compression, function may be partially or fully recovered after surgery or medical therapy to reduce the size of the tumour.Surgically-induced hypopituitarism may occur in some cases, particularly if the tumour is large, but this can be transitory and some or all of the function may recover. Hypopituitarism may also develop after several years of treatment of a pituitary tumour by radiotherapy.

Dwarfism, condition of being undersized, or less than 127 cm (50 in) in height. Some dwarfs have been less than 64 cm (24 in) tall when fully grown. The term midget is usually applied to physically well-proportioned dwarfs. The term pygmy is applied to people whose shortness of stature is a racial trait and not caused by disease.Cretinism, a result of a disease of the thyroid gland, is the cause of most dwarfism in Europe, Canada, and the United States . Other causes of dwarfism are Down syndrome, a congenital condition with symptoms similar to those of cretinism; achondroplasia, a disease characterized by short extremities resulting from absorption of cartilaginous tissue during the fetal stage; hypochondroplasia, a milder form of achondroplasia; spinal tuberculosis; and deficiency of the secretions of the pituitary gland or of the ovary. Geneticists have recently found the gene responsible for achondroplasia and hypochondroplasia, the most common forms of dwarfism.Treatment of cretinism with thyroxine or thyroid extract early in infancy results in normal growth and development. Pituitary dwarfism is successfully treated by administering human growth hormone.Complete lack of GH is not fatal in adults as would be the case with some hormones, but it can have major detrimental effects that may cause disease some years earlier than might otherwise have been the case. Studies have shown that patients with underactive pituitary glands (hypopituitarism) replaced with all hormones except GH have an increased risk of dying prematurely, possible because of cardiovascular disease. Lack of GH causes changes in blood cholesterol concentrations (and also a number of other chemicals involved in blood clotting) which, in other studies, have been associated with an increased risk of heart disease. GH deficient adults have been shown to suffer from excessive tiredness, anxiety, depression and generally feeling unwell, as well as having feelings of social isolation and a tendency to be easily upset. This can be severe enough to lead to an inability to work or to maintain a basic acceptable lifestyle. These factors have led most studies to conclude that GH deficiency results in reduced 'quality of life'. Symptoms of Hormone Deficiency Symptoms Deficient Hormone Growth retardation in children, excessive tiredness, muscle weakness GH Hypogonadism - reduced body hair, low libido, impotence in men; menorrhoea, dyspareunia and hot flushes in women FSH/LH: Weight gain, decreased energy, sensitivity to cold, constipation, dry skinTSHPale appearance, weight loss, low blood pressure, dizziness, tiredness ACTH thirst and polyuriaAVP Acute hypopituitarism - sudden headache, collapse, hypothermia, hypoglycaemia and hypotension. This may be a life-threatening emergency.

Increased levels caused by:prolactin-secreting pituitary tumorA non-secreting tumor that prevents dopamine (PRIH) from reaching normal prolactin-producing cells.Transphenoidal hypophysectomy anterior pituitaryTransphenoidal neurophysectomy posterior pituitary.Cushing's disease. This is a problem arising in the pituitary gland caused by a tumour which overproduces a hormone called ACTH. This in turn stimulates the adrenal glands to overproduce the steroid hormone cortisol. Cushing's syndrome can also be caused by a small growth in one, or both, of the adrenal glands.Cushing's is rare and is more often found in women than in men. It can affect all age groups, but the peak incidence is in middle age.Typical symptomsbehaviourial changes, depression and mood swings, occasionally psychological problems can be severe face tends to be rounder (moon face) and redder weight gain around the trunk (central obesity) muscle wasting and proximal myopathy (patients have difficulty standing from a seated position without use of arms) tendency to bruise easily appearance of red 'stretch marks' on the abdomen, similar to those which occur during pregnancy irregular periods (oligomenorrhoea) or loss of normal menstrual function (amenorrhoea) - females impotence - males reduced fertility decrease in sex drive increase in hair growth on the face and body (hirsutism) increase in blood pressure development of mild diabetes mellitus Because Cushing's progresses slowly and gradually in most cases, it can go unrecognised for some time.Medical intervention long term use of glucocorticoids.

Adrenal cortex:glucocrticoids: (cortisol) called the stress hormone. Regulates metabolism of carbohydrates, fat and protein, enhances protein synthesis and increasing breakdown of protein and fatty acids, increases blood glucose and is critical in the physiologic stress response.Mineralcorticoids: (aldosterone) regulate Na and h2o balanceAndrogens: growth and development

Disease: ACTH secreting pituitary tumorsSyndrome: problem originates in the adrenal glandSerum cortisol levels: high

Serum sodium levels: hypernatremia

Serum potassium levels: hypokalemia

Serum glucose: elevated24 hr urine show high cortisol in Cushings disease.

ACTH suppression test to identify cause Dexamethasone supression test: cause pituitary or adrenal The client is given 1 mg Dexamethasone at 11 pm the evening before the test. For people without Cushing Disease this should suppress plasma cortisol levels at 8 am. This test excludes Cushing Syndrome. With98% certainty.

Disturbed body imageExcessive: weight gain, thirst, polyuria, easy bruising & muscle weakness.Deficeincy: Fatigue, weight loss and abdominal pain.the hypothalmus continues to produce the ADH & oxytocin.

Excessive production of ADH secreted from posterior pituitary or an ectopic source.Often the result of a carcinoma (i.e. lung oat cell ca), also infections, trauma, drugs.Key features are water retention, hyponatremia and hypo-osmolalityWater intoxicationSerum sodium (hyponatremia) Serum osmolality (low)Urine specific gravity (increased)

Medications: diureticsDiabetes Insipidus Diabetes insipidus (DI) literally means the passage of copious volumes of urine 'lacking taste', in contrast to the 'sweet tasting' urine typical of diabetes mellitus. DI is characterized by the production of large volumes of dilute urine (more than 3 litres per day) and constant thirst. It can have a number of causes but inadequate secretion of AVP (ADH), the pituitary hormone that controls kidney urine flow and concentration, is the most common.Water balance is normally achieved by three mechanisms:adequate vasopressin secretion thirst appreciation and drinking vasopressin-responsive kidneys The hypothalmus normally detects dehydration, sends a message to the pituitary, which in turn releases ADH, and sends it to the kidney.The kidney acts on the collecting and distal tubules to reabsorb to restore fluid balance.With excess fluid balance, the hypothalmus sends a message to the pituitary to inhibit secretion of ADH, promoting excretion of fluid.Trauma, infection or tumor growth in the region of the hypothalamus or pituitary may reduce the secretion of vasopressin. Pituitary surgery can result in transitory DI, but in some cases it may be permanent and may also be accompanied by the loss of other pituitary hormones.

A deficiency of ADH results in inability to conserve water.Vasopression is given in acute phase.

Serum sodium (hypernatremia)Urine specific gravity (low)Serum osmolality (high)Urine osmolality (decreased) Serum ADH levels: decreasedVasopressin test and water deprivation test: increased hyperosmolality is diagnostic for DI.After administering vassopressin normally people will show a concentration of urine but not as pronounced as those with DI.Risk for injury LOC related to degree of hyponatremia causing confusion, lethargy, irritability, seizures and coma. Also related to post-operative complications.Need to monitor for hormonal imbalance, ICP, meningitis, adrenal insufficiency, monitor for CSF drainage.How we test for test serous drainage for CSF?

Others: PC electrolyte imbalance

Because aldosterone and other steroids cause a retention of Na and an increased excretion of potassium, conditions in which hormones are decreased may cause an increased serum K level, For example- in Addisons disease malfunctioning of the adrenal cortex reduces the corticosteroid level. Serum Na levels are decreased, and serum K levels may increase.