Mod 8 Info to Know

Question 1

Signs and symptoms of decreased antidiuretic hormone (ADH)? (ADH is a hormone which tells your kidneys how much water to conserve)

Answer 1

• Greatly increased urine output
• Low urine specific gravity (<1.005)
• Hypotension
• Dehydration
• Increased plasma osmolarity
• Increased thirst
• Output does not decrease when fluid intake decreases

Question 2

​What disease is associated with decreased ADH?

​

Answer 2

Diabetes insipidus: central diabetes insipidus

Question 3

​Diabetes insipidus: central diabetes insipidus

​What are the key assessment findings/lab values of this disease?

Answer 3

Cardiovascular Symptoms • Hypotension • Tachycardia • Weak peripheral pulses •
Hemoconcentration Kidney/Urinary Symptoms • Increased urine output • Dilute, low specific gravity Skin Symptoms • Poor turgor • Dry mucous membranes
Neurologic Symptoms • Decreased cognition* • Ataxia* • Increased thirst • Irritability*
*Occurs when access to water is limited and rapid dehydration results.
Lab values: Water loss changes blood and urine tests. The 24-hour fluid intake and output is measured without restricting food or fluid intake. DI is considered if urine output is more than 4 L during this period and is greater than the volume ingested. The amount of urine excreted in 24 hours by patients with DI may vary from 4 to 30 L/day. Urine is dilute with a low specific gravity (less than 1.005) and low osmolarity (50 to 200 mOsm/kg) or osmolality (50 to 200 mOsm/L).

Question 4

2. Signs and symptoms of increased antidiuretic hormone (ADH)?

Answer 4

Early symptoms of SIADH are related to the water-retention dilution of serum sodium levels (hyponatremia).
GI disturbances, such as loss of appetite, nausea, and vomiting, may occur first.

Weigh the patient and document any recent weight gain. Use this information to monitor responses to therapy.

In SIADH, free water (not salt) is retained; and dependent edema is not usually present, even though water is retained.

Water retention, hyponatremia, and fluid shifts affect central nervous system function, especially when the serum sodium level is below 115 mEq/L (mmol/L).

The patient may have lethargy, headaches, hostility, disorientation, and a change in level of consciousness. Lethargy and headaches can progress to decreased responsiveness, seizures, and coma.
Assess deep tendon reflexes, which are usually decreased.
Vital sign changes include full and bounding pulse (caused by the increased fluid volume) and hypothermia (caused by central nervous system disturbance

other findings that occur with hyponatremia.

Water retention causes urine volume to decrease and urine osmolarity to increase. At the same time, plasma volume increases, and plasma osmolarity decreases. Elevated urine sodium levels and specific gravity reflect increased urine concentration. Serum sodium levels are decreased, often as low as 110 mEq/L (mmol/L), because of fluid retention and sodium loss.

Question 5

What disease is associated with increased ADH?

​

Answer 5

Malignancies
• Small cell lung cancer • Pancreatic, duodenal, and GU carcinomas • Thymoma • Hodgkin’s lymphoma • Non-Hodgkin’s lymphoma

CNS Disorders
• Trauma • Infection • Tumors (primary or metastatic) • Strokes • Porphyria • Systemic lupus erythematosus

Pulmonary Disorders
• Viral and bacterial pneumonia • Lung abscesses • Active tuberculosis • Pneumothorax • Chronic lung diseases • Mycoses • Positive-pressure ventilation

Drugs
• Exogenous ADH • Chlorpropamide • Vincristine • Cyclophosphamide • Carbamazepine • Opioids • Tricyclic antidepressants • General anesthetics • Fluoroquinolone antibiotics

Question 6

What are the key assessment findings/lab values of this disease?
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Answer 6

Hyponatremia, fluid overload, elevated urine osmolarity over 100 -(fluid restriction)

Question 7

3. Signs and symptoms of increased growth hormone

Answer 7

Acromegaly • Thickened lips • Coarse enlarged facial features • Increasing head size • Lower jaw protrusion • Enlarged hands and feet • Joint pain • Barrel-shaped chest • Hyperglycemia • Sleep apnea • Enlarged heart, lungs, and liver. Sweating, oily skin, skin tags, muscle weakness
Anterior Pituitary Hyperfunction Prolactin (PRL) • Hypogonadism (loss of secondary sexual characteristics) • Decreased gonadotropin levels • Galactorrhea • Increased body fat • Increased serum prolactin levels Growth Hormone (GH) Acromegaly • Thickened lips • Coarse facial features • Increasing head size • Lower jaw protrusion • Enlarged hands and feet • Joint pain • Barrel-shaped chest • Hyperglycemia • Sleep apnea • Enlarged heart, lungs, and liver Adrenocorticotropic Hormone (ACTH) Cushing’s Disease (Pituitary) • Elevated plasma cortisol levels • Weight gain • Truncal obesity • “Moon face” • Extremity muscle wasting • Loss of bone density • Hypertension • Hyperglycemia • Striae and acne Thyrotropin (Thyroid-Stimulating Hormone [TSH]) • Elevated plasma TSH and thyroid hormone levels • Weight loss • Tachycardia and dysrhythmias • Heat intolerance • Increased GI motility • Fine tremors Gonadotropins (Luteinizing Hormone [LH], Follicle-Stimulating Hormone [FSH]) Men: • Elevated LH and FSH levels • Hypogonadism or hypergonadism Women: • Normal LH and FSH levels

Question 8

What diseases are caused by increased growth hormone?

Answer 8

The most common cause of hyperpituitarism is a pituitary adenoma—a benign tumor of one or more tissues within the anterior pituitary

Adenomas are classified by the hormone secreted. As an adenoma gets larger and compresses brain tissue, neurologic changes, as well as endocrine problems, may occur. Symptoms may include visual disturbances, headache, and increased intracranial pressure.

-Prolactin (PRL)-secreting tumors are the most common type of pituitary adenoma. Excessive PRL inhibits the secretion of gonadotropins and sex hormones in men and women, resulting in galactorrhea (breast milk production),
amenorrhea, and infertility.

Overproduction of GH in adults results in -acromegaly.The onset may be gradual with slow progression, and changes may remain unnoticed for years before diagnosis of the disorder. Early detection and treatment are essential to prevent irreversible enlargement of the face, hands, and feet. Other changes include increased skeletal thickness, hypertrophy of the skin, and enlargement of many organs such as the liver and heart. Some changes may be reversible after treatment, but skeletal changes are permanent.

• Gonadotropins (Luteinizing Hormone [LH], Follicle-Stimulating Hormone [FSH]) Men: • Elevated LH and FSH levels • Hypogonadism or hypergonadism Women: • Normal LH and FSH levels
• Thyrotropin (Thyroid-Stimulating Hormone [TSH]) • Elevated plasma TSH and thyroid hormone levels
• Adrenocorticotropic Hormone (ACTH) Cushing’s Disease (Pituitary) • Elevated plasma cortisol levels
• Anterior Pituitary Hyperfunction Prolactin (PRL)

Question 9

4. Signs and symptoms of decreased Adrenocorticotropic hormone

Answer 9

Insufficiency of adrenocortical steroids causes problems through the loss of aldosterone and cortisol action. Decreased cortisol levels result in hypoglycemia.

Gastric acid production and glomerular filtration decrease. Decreased glomerular filtration leads to excessive blood urea nitrogen levels, which cause anorexia and weight loss. Reduced aldosterone secretion causes disturbances of FLUID AND ELECTROLYTE BALANCE. Potassium excretion is decreased, causing hyperkalemia. Sodium and water excretion are increased, causing hyponatremia and hypovolemia. Potassium retention also promotes reabsorption of hydrogen ions, which can lead to acidosis. Low adrenal androgen levels decrease the body, axillary, and pubic hair, especially in women, because the adrenals produce most of the androgens in females. The severity of symptoms is related to the degree of hormone deficiency. Hypotension.

Adrenal Insufficienc:y Neuromuscular Symptoms • Muscle weakness • Fatigue • Joint/muscle pain Gastrointestinal Symptoms • Anorexia • Nausea, vomiting • Abdominal pain • Constipation or diarrhea • Weight loss • Salt craving Skin Symptoms • Vitiligo • Hyperpigmentation Cardiovascular Symptoms • Anemia • Hypotension • Hyponatremia • Hyperkalemia • Hypercalcemia
​What disease is caused by decreased ACTH?
Addison’s disease- unless intervention is initiated promptly, sodium levels fall, and potassium levels rise rapidly. Severe hypotension results from the blood volume depletion that occurs with the loss of aldosterone.

Question 10

Name two medications used to treat this disease - decreased Adrenocorticotropic hormone

Answer 10

Hormone Replacement • Start rapid infusion of normal saline or dextrose 5% in normal saline. • Initial dose of hydrocortisone sodium (Solu-Cortef) is 100 to 300 mg or dexamethasone 4 to 12 mg as an IV bolus.
• Administer additional 100 mg of hydrocortisone sodium by continuous IV infusion over the next 8 hours.
• Give hydrocortisone 50 mg IM concomitantly with hydration every 12 hours. • Initiate an H2 histamine blocker (e.g., ranitidine) IV for ulcer prevention.
Hyperkalemia Management • Administer insulin (20 to 50 units) with dextrose (20 to 50 mg) in normal saline to shift potassium into cells.
• Administer potassium binding and excreting resin (e.g., Kayexalate).
• Give loop or thiazide diuretics. • Avoid potassium-sparing diuretics, as prescribed. • Initiate potassium restriction.
• Monitor intake and output. • Monitor heart rate, rhythm, and ECG for signs and symptoms of hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole). Hypoglycemia Management
• Administer IV glucose as prescribed. • Administer glucagon as needed and prescribed. • Maintain IV access. • Monitor blood glucose level hourly.

Question 11

What is the significance of glucose monitoring in this disease?

decreased Adrenocorticotropic hormone

Answer 11

Assess for hypoglycemia (e.g., sweating, headaches, tachycardia, and tremors) and fluid depletion (postural hypotension and dehydration). Hyperkalemia (elevated blood potassium levels) can cause dysrhythmias with an irregular heart rate and result in cardiac arrest. Hyponatremia (low blood sodium levels) leading to hypotension and decreased cognition is often one of the first indicators of adrenal insufficiency

Question 12

What important electrolyte lab value should be monitored?

decreased Adrenocorticotropic hormone

Answer 12

Laboratory findings include low serum and low salivary cortisol levels, low fasting blood glucose, low sodium, elevated potassium, and increased blood urea nitrogen (BUN) levels (Chart 62-8). In primary disease, the eosinophil count and ACTH level are elevated. Plasma cortisol levels do not rise during provocation tests

Question 13

5. Signs and symptoms of increased adrenocorticotropic hormone

Answer 13

Hypercortisolism (Cushing’s Disease/Syndrome) General Appearance • Moon face • Buffalo hump • Truncal obesity • Weight gain Cardiovascular Symptoms • Hypertension • Frequent dependent edema • Bruising • Petechiae Musculoskeletal Symptoms • Muscle atrophy (most apparent in extremities) • Osteoporosis (bone density loss) • Pathologic fractures • Decreased height with vertebral collapse • Aseptic necrosis of the femur head • Slow or poor healing of bone fractures Skin Symptoms • Thinning skin • Striae and increased pigmentation Immune System Symptoms • Increased risk for infection • Reduced IMMUNITY • Decreased inflammatory responses • Signs and symptoms of infection/inflammation possibly masked

Question 14

​What disease is caused by increased ACTH?
​

Conditions Causing Increased Cortisol Secretion Endogenous Secretion (Cushing’s Disease)

Answer 14

• Bilateral adrenal hyperplasia* • Pituitary adenoma increasing the production of ACTH (pituitary Cushing’s disease) • Malignancies: carcinomas of the lung, GI tract, pancreas • Adrenal adenomas or carcinomas Exogenous Administration (Cushing’s Syndrome) • Therapeutic use of ACTH or glucocorticoids—most commonly for treatment of: • Asthma • Autoimmune disorders • Organ transplantation • Cancer chemotherapy • Allergic responses • Chronic fibrosis

Question 15

​What lab test is done to diagnose this disease? Increased acth

Answer 15

Laboratory tests include blood, salivary, and urine cortisol levels.
These are high in patients with any type of hypercortisolism. Plasma ACTH levels vary, depending on the cause of the problem. In pituitary Cushing’s disease, ACTH levels are elevated. In adrenal Cushing’s disease or when Cushing’s syndrome results from chronic steroid use, ACTH levels are low. Salivary cortisol levels may be used to detect hypercortisolism because these levels accurately reflect blood levels, especially late-night specimens (Elias et al., 2014; Raff, 2015). A normal salivary cortisol level is lower than 2.0 ng/mL. Higher levels indicate hypercortisolism. Urine is tested to measure levels of free cortisol and the metabolites of cortisol and androgens (17-hydroxycorticosteroids and 17-ketosteroids). In Cushing’s disease, levels of urine cortisol and androgens are all elevated in a 24-hour specimen. Cortisol-to-creatinine ratios in the first specimen of the day can replace the 24-hour test for screening. A ratio greater than 25 nmol/mmol is a positive test (Stewart & Newell-Price, 2016) Dexamethasone suppression testing can screen for hypercortisolism and may take place overnight or over a 3-day period. Set doses of dexamethasone are given. A 24-hour urine collection follows drug administration. When urinary 17-hydroxycorticosteroid excretion and cortisol levels are suppressed by dexamethasone, Cushing’s disease is not present. Additional laboratory findings that accompany hypercortisolism include:
• Increased blood glucose level
• Decreased lymphocyte count
• Increased sodium level
• Decreased serum calcium level

Question 16

​Name at least two priority problems for this disease

Increased acth

Answer 16

The priority collaborative problems for patients with Cushing’s disease or Cushing’s syndrome are:

1. Fluid overload due to hormone-induced water and sodium retention
2. Potential for injury due to skin thinning, poor wound healing, and bone density loss
3. Potential for infection due to hormone-induced reduced IMMUNITY
4. Potential for acute adrenal insufficiency

Question 17

Care of patient following hypophysectomy

Answer 17

Monitor the patient’s neurologic response and document any changes in vision or mental status, altered level of consciousness, or decreased strength of the extremities. Observe the patient for complications such as transient diabetes insipidus (discussed later in this chapter), cerebrospinal fluid (CSF) leakage, infection, and increased ICP. Teach the patient to report any postnasal drip or increased swallowing, which may indicate leakage of CSF. Keep the head of the bed elevated after surgery. Assess nasal drainage for quantity, quality, and the presence of glucose (which indicates that the fluid is CSF). A light yellow color at the edge of the clear drainage on the dressing is called the halo sign and indicates CSF. If the patient has persistent, severe headaches, CSF fluid may have leaked into the sinus area. Most CSF leaks resolve with bedrest, and surgical intervention is rarely needed. Teach the patient to avoid coughing early after surgery because it increases pressure in the incision area and may lead to a CSF leak. Remind him or her to perform deep-breathing exercises hourly while awake to prevent pulmonary problems. Patients may have mouth dryness from mouth breathing. Instruct the patient to rinse the mouth frequently and to apply a lubricating jelly to dry lips. Assess for indications of infection, especially meningitis, such as headache, fever, and nuchal (neck) rigidity. The surgeon may prescribe antibiotics, analgesics, and antipyretics. If the entire pituitary gland has been removed, replacement of thyroid hormones and glucocorticoids is lifelong. Best practices for care after surgery are listed in.
Assess cardiovascular status: • Vital signs, including apical pulse, pulse pressure, presence or absence of orthostatic hypotension, and the quality/rhythm of peripheral pulses Assess cognition and mental status Assess condition of operative site: • Observe nasal area for drainage: • If present, note color, clarity, and odor • Test clear drainage for the presence of glucose Assess neuromuscular status: • Reactivity of patellar and biceps reflexes • Oral temperature • Handgrip strength • Steadiness of gait • Distant and near visual acuity • Pupillary responses to light Assess kidney function: • Observe urine specimen for color, odor, cloudiness, and amount • Ask about: • Headaches or visual disturbances • Ease of bowel movements • 24-hour fluid intake and output • Over-the-counter and prescribed drugs taken Assess patient’s understanding of illness and adherence with treatment: • Symptoms to report to health care provider • Drug plan (correct timing and dose)
After a hypophysectomy, advise the patient to avoid activities that might interfere with healing or increase intracranial pressure (ICP). Teach him or her to avoid bending over from the waist to pick up objects or tie shoes because this position increases ICP. Teach the patient to bend the knees and then lower the body to pick up fallen objects. ICP also increases when the patient strains to have a bowel movement. Suggest techniques to prevent constipation, such as eating high-fiber foods, drinking plenty of fluids, and using stool softeners or laxatives. Teach the patient to avoid toothbrushing for about 2 weeks after transsphenoidal surgery. Frequent mouth care with mouthwash and daily flossing provide adequate oral hygiene. A decreased sense of smell is expected after surgery and usually lasts 3 to 4 months. Hormone replacement with vasopressin may be needed to maintain fluid balance (see discussion of Interventions in the Diabetes Insipidus section). If the anterior portion of the pituitary gland is removed, instruct the patient in cortisol, thyroid, and gonadal hormone replacement.

Question 18

​What safety considerations should patients be taught? For hypophysectomy

Answer 18

• Monitor the patient’s neurologic status hourly for the first 24 hours and then every 4 hours. • Monitor fluid balance, especially for output greater than intake. • Encourage the patient to perform deep-breathing exercises. • Instruct the patient not to cough, blow the nose, or sneeze. • Instruct the patient to use dental floss and oral mouth rinses rather than toothbrushing until the surgeon gives permission. • Instruct the patient to avoid bending at the waist to prevent increasing intracranial pressure. • Monitor the nasal drip pad for the type and amount of drainage. • Teach the patient methods to avoid constipation and subsequent “straining.” • Teach the patient self-administration of the prescribed hormones.

Question 19

What critical assessment finding should be reported to the provider immediately?

For hypophysectomy

Answer 19

Teach the patient to report any postnasal drip or increased swallowing, which may indicate leakage of CSF.
Teach the patient to report the return of any symptoms of hyperpituitarism immediately to the primary health care provider.

Question 20

What is a pheochromocytoma?

Answer 20

It is a catecholamine-producing tumor of the adrenal medulla.

These tumors usually occur in one adrenal gland, although they can be bilateral or in the abdomen. Pheochromocytomas are usually benign, but about 10% are malignant (Young, 2016). The tumors produce, store, and release epinephrine and norepinephrine (NE). Excessive epinephrine and NE stimulate adrenergic receptors and can have wide-ranging adverse effects mimicking the action of the sympathetic nervous system.

Question 21

​What are the signs and symptoms of a pheochromocytoma “episode”

Answer 21

The patient often has intermittent episodes of hypertension or attacks that range from a few minutes to several hours. During these episodes, the patient has severe headaches, palpitations, profuse diaphoresis, flushing, apprehension, or a sense of impending doom. Pain in the chest or abdomen, with nausea and vomiting, can also occur. Increased abdominal pressure, defecation, and vigorous abdominal palpation can provoke a hypertensive crisis. Drugs such as tricyclic antidepressants, droperidol, glucagon, metoclopramide, phenothiazines, and naloxone can induce a hypertensive crisis in the patient with pheochromocytoma.
Foods or beverages high in tyramine (e.g., aged cheese, red wine) also induce hypertension. The patient may also report heat intolerance, weight loss, and tremors. The most common diagnostic test is blood and 24-hour urine collection for fractionated metanephrine and catecholamine levels, all of which are elevated in the presence of a pheochromocytoma.

Question 22

What is the treatment for pheochromocytoma?

Answer 22

Surgery is the main treatment for a pheochromocytoma. One or both adrenal glands are removed (depending on whether the tumor is bilateral).
After surgery, nursing interventions focus on promoting adequate tissue perfusion, nutritional needs, and comfort measures.
Hypertension is the main sign of the disease and the most common complication after surgery.
Monitor the blood pressure regularly and place the cuff consistently on the same arm, with the patient in lying and standing positions.
Teach the patient not to smoke, drink caffeine-containing beverages, or change position suddenly, which can stimulate blood pressure changes.
Provide a diet rich in calories, vitamins, and minerals.

Question 23

​List a key safety alert for this diagnosis?

Answer 23

Do not palpate the abdomen of a patient with a pheochromocytoma, because this action could stimulate a sudden release of catecholamines and trigger severe hypertension.

Question 24

Practice Questions:
A client complains of weight gain, has thin extremities, a “buffalo hump,” and a protruding abdomen. The nurse realizes that this client is most likely to be diagnosed with which disease process?
A. Addison’s disease
B. Cretinism
C. Cushing’s syndrome
D. Pheochromocytoma

Answer 24

C. Cushing’s syndrome**

Question 25

Emergency care of the client in addisonian crisis includes which one of the following interventions?
A. Dextrose 25 gm. IVP
B. Potassium chloride IVPB
C. Desmopressin IV
D. Hydrocotisone sodium (Solu-Cortef) IV bolus*

Answer 25

D. Hydrocotisone sodium (Solu-Cortef) IV bolus*

Question 26

A client tells the nurse he is “so thirsty” that he has already consumed four pitchers of water. The client’s urine output is 3500 mL in an 8-hour period. The client is recovering from surgery on the pituitary gland. Serum glucose is 140 gm/dl. What endocrine disorder is the client most likely experiencing?
A. Diabetes insipidus*
B. Diabetes mellitus
C. Myxedema
D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH).

Answer 26

A. Diabetes insipidus*

Question 27

The client has the syndrome of inappropriate antidiuretic hormone (SIADH) and has a sodium level of 123 mEq/L. Which of the following should the nurse anticipate in planning the client’s care?
A. An IV of 0.45% sodium chloride
B. Restrict fluid intake to 1000 mL per day*
C. Provide a diet containing 2 grams of sodium per day
D. Administer desmopressin acetate 0.2 mg orally

Answer 27

B. Restrict fluid intake to 1000 mL per day*