NUR 149 2nd SEMESTER

A.Y. 2022-2023 PG & TG

DISORDERS OF THE PITUITARY AND THYROID GLANDS

FUNCTIONAL ANATOMY OF PITUITARY GLAND AND PHHYSIOLOGY OF GROWTH HORMONE

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 NORMAL RANGE
• Adrenocorticotropic Hormone (ACTH): 9- Causes:
46pg/mL • Hypersecretion of GH in childhood or in
• Thyroid Stimulating Hormone (TSH): 0.3- pre-adult
5.0uIU/mL • Tumor of acidophilic cells of Anterior
• pituitary (the gland makes more GH than the
• body needs)
• Luteinizing Hormone (LH) & Follicle
stimulating Hormone (FSH): decreased at
menstrual phase.
• Prolactin (PRL): decreased at menstrual
phase
• Growth Hormone (GH) <5.0nanometer/mL
• Melanocyte-stimulating Hormone (MSH)

ANTERIOR PITUITARY
CAUSES OF DISORDERS OF PITUITARY GLAND
Mainly of 2 reasons:
• Hyperactivity
• Hypoactivity
SIGNS AND SYMPTOMS
• Huge stature: 7 or 8 ft height
• Headache due to tumor of pituitary
• Very large hands and feet
• Thick toe and fingers
• A prominent jaw and forehead
• Coarse facial features
• Weakness
• Insomnia and other sleep disorders
• Visual disturbances
• Gigantism ends in hypopituitarism (burning
of cells of anterior pituitary)
• Diabetes insipidus (less secretion of ADH)
• Delayed puberty in both boys and girls
• Irregular menstrual period in girls

DIAGNOSTIC TESTS
• Blood test to measure levels of growth
hormones.
• MRI scan of the gland.
• Insulin-like growth factor 1 (igf-1), which is
a hormone produces by the liver.
• Oral glucose tolerance test: pt will drink a
special beverage containing glucose, a type
of sugar. Blood samples will be taken
before and after the pt drink the beverage.
GIGANTISM In a normal body, growth hormone level
• Pituitary disorder due to will drop after eating or drinking glucose. If
hyperactivity/excessive secretion of growth pt’s levels remain the same, it means his
hormone, which known as somatotropin body is producing too much growth
characterized by: hormone.
• Excess growth of body
• Average ht is approximately 7-8 ft

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 TREATMENT CAUSES
• Treatment for gigantism aim to stop or slow • Hypersecretion of Growth Hormone after
the production of growth hormones. fusion of epiphysis with shaft of the bone.
• Somatostatin analogs such as octreotide • Adenomatous tumor of anterior pituitary
or long-acting lanreotide, which reduce involving the acidophilic cells.
growth hormone release.
SURGERY: SIGNS AND SYMPTOMS
• Hypophysectomy: removing the tumor is
the preferred treatment for gigantism if it’s
• Striking features are protrusion of:
the underlying cause.
o Supraorbital ridges
RADIATION THERAPY:
o Broadening of nose
• Has also been used to bring growth hormone o Thickening of lips
levels to normal if surgery and medical fail. o Thickening and wrinkles formation of
forehead.
o Lower jaw (prognathism)
o Kyphosis: enlargement of hands and
feet with bowing spine
o Scalp is thickened and thrown into folds
o Overgrowth of body hair
o Visceral organs are enlarged
o Thyroid, parathyroid and adrenal
glands show hyperactivity
o Hyperglycemia and glucosuria
o Hypertension
o Headache
o Visual disturbance- Bitemporal
hemianopia (partial blindness where
vision is missing in the outer half of both
the right and left visual field)

Face with these features called as acromegalic or

guerilla face.
PARTS HYPERACTIVITY HYPOACTIVITY
INVOLVE
Anterior 1. Gigantism 1. Dwarfism
Pituitary 2. Acromegaly 2. Acromicria
3. Acromegalic 3. Simmonds
gigantism Disease
4. Cushing’s
disease
Posterior Syndrome of Diabetes
Pituitary inappropriate Insipidus
hypersecretion of
ADH (SIADH)
A&P Dystrophia
Pituitary adiposogenitalis

ACROMEGALY
Anterior pituitary disorder characterized by:
• Ab(n) growth of the hands, feet, and face, cause
by overproduction of growth hormone by the
pituitary gland.
o Enlargement, thickening, and broadening
of bones
o Particularly extremities of the body

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 TREATMENT
o Hypothalamic disorder causing
hypersecretion of corticotropin releasing
• Same as gigantism
hormone.

SIGNS AND SYMPTOMS

ACROMEGALIC GIGANTISM
1. Disproportionate distribution of body fat
• Rare disorder results:
• Due to hypersecretion of GH in children, before • Moon face: fat accumulation and
fusion of epiphysis with the shaft of bones retention of water and salt.
results in gigantism. • Torso: fat accumulation in chest and
• If hypersecretion of GH is continued after the abdomen but slim legs and arms.
Acromegaly also appear • Buffalo hump: fat deposit on the back
of neck and shoulder.
CAUSES, SYMPTOMS & TEATMENT • Pot belly: fat accumulation in upper
abdomen.
• Same as gigantism and acromegaly

CUSHING’S DISEASE
• Rare disease characterized by obesity

CAUSES 2. Purple striae: reddish purple stripes on

abdomen due to mainly three reasons:
• Hypersecretion of glucocorticoids mainly • Stretching of abdominal wall by
cortisol excess subcutaneous fat.
• Either pituitary origin (Cushing’s dse) or • Rupture of subdermal tissues due to
adrenal origin (Cushing’s syndrome) stretching.
• High stress levels in the final trimester of • Deficiency of collagen fibers due to
pregnancy protein depletion.
• Athletic training
• Malnutrition
• Alcoholism
• Depression or panic disorders
• Use of corticosteroid medications (like 3. Thinning of extremities
prednisone) in high doses for a long period 4. Thinning of skin and subcutaneous tissues
of time. 5. Acanthosis: Darkening of skin on neck i.e.
– diffuse epidermal hyperplasia.
PITUITARY ORIGIN 6. Pigmentation of skin
7. Facial redness (problem plethora)
• Increased secretion of ACTH 8. Weakening of muscle
(Adrenocorticotropic Hormone) leads to
hyperplasia and adrenal cortex therefore,
hypersecretion of glucocorticoids takes place.
• ACTH is increased by:
o Tumor in pituitary cells (basophilic cells)

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 9. Facial hair growth (Hirsutism)
10. Bone resorption leads to osteoporosis.
11. Hyperglycemia due to gluconeogenesis
leads adrenal diabetes and glycosuria.
12. Hypertension
13. Immunosuppression resulting in
susceptibility for infection
14. Poor healing

DIAGNOSTIC EVALUATION
• Plasma cortisol level – increase (Morning 5- REPLACEMENT THERAPY POSTOPERATIVELY
23 micrograms per deciliter (mcg/dL,
Afternoon 3-16 mcg/dL) • Adrenalectomy pts require a lifelong
• Blood glucose level – increased. replacement therapy with the following:
• Serum potassium level – decreased (3.5 - A glucocorticoid – cortisone
5.2 milliequivalents per liter (mEq/L) A mineralocorticoid – fludrocortisones
• Eosinophils – decreased (0-5%) After pituitary irradiation or
• Plasma ACTH increased in pt. with pituitary hypophysectomy, pt may require adrenal
tumor. replacement, plus thyroid, posterior
• Plasma ACTH level low in pt. with adrenal pituitary, and gonadal replacement
tumor. therapy.
• X-ray of the skull to detect erosion of the After transsphenoidal adenomectomy,
sella turcica by a pituitary tumor. patient require hydrocortisone
• C.T. scan and ultrasonography to detect the replacement therapy for periods of 12 –
location of tumor. 18 months

MANAGEMENT MEDICAL TREATMENT

• Surgical and Radiation: - Tumor (adrenal
and pituitary) is removed or treated with • If patient cannot undergo surgery, cortisol
irradiation. synthesis inhibiting medications may be
used:
• Transsphenoidal adenomectomy: remove
Mitotane: an agent toxic to the adrenal
a tumor (adenoma) of the pituitary gland is
cortex – known as medical
carried out through the nasal cavity.
adrenalectomy,, nausea, vomiting,
• Transfrontal craniotomy: may be
diarrhea, somnolence and depression
necessary when pituitary tumor has enlarged
may occur with use of this medication.
beyond sella turcica.
Metiprone: to control steroid
• Bilateral adrenalectomy: in case of hypersecretion in patients who do not
hyperplasia of adrenals. respond to mitotane therapy.
Aminoglutethimide: block cholesterol
conversion to pregnenolone, effectively
blocking cortisol production.

COMPLICATIONS
TRANSSPHENOIDAL
ADENOMECTOMY
TRANSFRONTAL
CRANIOTOMY
• Possible reoccurrence in pts with adrenal
carcinoma

BILATERAL ADRENALECTOMY DWARFISM

• It is an effective last resort if other measures fail • Pituitary disorder in children characterized by
to control the disease stunted growth.
• The patient will need hydrocortisone
(cortisol) replacement therapy after surgery,
and possibly continued throughout life.

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 CAUSE OF DWARFISM and decrease in gonadotropin
hormone
• Reduction in the GH in infancy or early
childhood
• Deficiency of GH releasing hormone from ACROMICRIA
hypothalamus
• Atrophy or acidophilic cells in the - Rare disease in adults characterized by the
adenohypophysis atrophy of the extremities of the body.
• Tumor of chromophobes: nonfunctioning
tumor, compresses and destroys the (n) cells
• Panhypopituitarism

SIGNS AND SYMPTOMS

• Stunted skeletal growth CAUSES OF ACROMICRIA
• Maximum ht approximately 3ft
• Head becomes slightly larger in relation of • Deficiency of GH in adults
body • Secretion of GH decreases in the ff
• Mental activity is (n) without any deformity conditions:
• Reproductive system is not affected due to Deficiency of GH releasing hormone
lack of GH but in panhypopituitarism puberty Atrophy of acidophilic cells in the
is not obtained due to lack of gonadotropic anterior pituitary
hormone. Tumor o chromophobes
Panhypopituitarism
TYPES OF DWARFISM
SIGNS AND SYMPTOMS
• Laron dwarfism: ab(n) GH secretagogue
receptors in liver • Atrophy and thinning of extremities (major
• Psychogenic dwarfism: stress dwarfism symptoms)
• Dwarfism in dystrophia adiposogenitals • Associated with hypothyroidism
• Hyposecretion of adrenocortical hormone
1. LARON DWARFISM • Person becomes lethargic and obese
Genetical disorder • Loss of sexual function
Called as GH insensitivity
Occurs due to presence of ab(n) GH SIMMOND’S DISEASE
secretagogue receptors in liver
GHS becomes ab(n) due to mutation in
• Rare pituitary disease: weakness and wasting
genes responsible for receptor
Doesn’t depend on amount of GH of the body due to severe chronic illness.
secretion, hormone can’t stimulate the • Also called cachexia
growth due to ab(n) GHS • Occurs mostly in Panhypopituitarism
• Atrophy (shrinks and reduced function) of the
2. PSYCHOGENIC DWARFISM cells and organs that are normally stimulated bu
Due to extreme emotional deprivation or pituitary hormones.
stress
Deficiency of GH CAUSES
Also called as psychosocial dwarfism or
Stress dwarfism • Tumor
• Presses on the optic nerve and surrounding
3. DWARFISM IN DYSTROPHIA brain structures.
ADIPOSOGENETALIS • Complication of pregnancy.
Called as Frohlich syndrome Postpartum hypopituitarism or
Rare childhood disorder postpartum pituitary gland necrosis,
Characterized by: (decreased functioning of the pituitary
o Obesity gland), caused by ischemic necrosis due to
o Growth retardation blood loss and hypovolemic shock during
o Retarded development of genital and after childbirth.
organs
o Associated with tumors of
hypothalamus – increased appetite

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 SIGNS AND SYMPTOMS CAUSES
• Developing senile decay: due to deficiency • Develops due to the deficiency of ADH
of hormone from target glands of anterior which occurs in the following conditions:
pituitary e.g., thyroid gland, adrenal cortex, Lesion (injury) or degradation of
and gonads. supraoctic and paraventricular nuclei of
• Loss of hair hypothalamus.
• The skin on face becomes dry and wrinkled. Lesion in hypothalamo-hypophyseal
(Most common) tract
Atrophy of posterior pituitary
Inability of renal tubules to give response
to ADH hormone. Called as Nephrogenic
diabetic Insipidus.

SIGNS AND SYMPTOMS

POSTERIOR PITUITARY 1. POLYURIA
• Excretion of large quantity of dilute urine with
increased frequency of voiding is called
SYNDROME OF INAPPROPRIATE HYPERSECRETION polyuria.
OF ANTIDIURETIC HORMONE • Daily output is >4litres.
• Due to absence of ADH, the epithelial cells
of distal convoluted tubule in the nephron
• Disease characterized by loss of sodium and the collecting duct of the kidney
through urine due to hypersecretion of ADH becomes impermeable to water.

CAUSES 2. POLYDIPSIA
• Intake of excess water
• Due to cerebral tumors, lung tumors, and • Because of polyuria, thirst center in
lung cancers because the tumor cells hypothalamus results in intake of large
secrete ADH. quantity of water.
• Normal secretion of ADH makes the plasma
hypotonic. 3. DEHYDRATION – in some cases, the thirst
• Hypotonic solution inhibits the ADH center in the hypothalamus is also affected by
secretion and restoration of plasma the lesion. Therefore, water intake decreases in
osmolarity takes place. these pts and, the loss of water through urine is
• But in SIADH, secretion of ADH from tumor not compensated.
is not inhibited by hypotonic plasma. • Dry mouth
• Changes in skin elasticity
SIGNS AND SYMPTOMS • Low BP (hypotension)
• Elevated blood Sodium (hypernatremia)
• Fever
• Loss of Appetite
• Headache
• Weight Loss
• N/V • Electrolyte imbalance
• Headache
• Muscle weakness, spasm and cramps TESTS AND DIAGNOSIS
• Fatigue
• Restlessness and irritability • Genetic Testing: genetic testing is used to
detect altered genes that may cause illness
In severe conditions pt die because of coma and or dse. Although genetic testing an offer
convulsion. important health information, it has
limitations.
•
DIABETES INSIPIDUS MRI: uses a magnetic field and radio waves
to create detailed images of the organs and
tissues within the body.
• Posterior pituitary disorder characterized by • URINALYSIS: can be used to assess
excess excretion overall health, detect wide range of

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 disorders, or monitor a medical condition or NURSING ASSESSMENT
treatment.
• Prevent dehydration
• Observe the shape and size of the body
• Wear a medical alert bracelet or carry a measuring weight and height, observe the
medical alert car in hand. shape and size of the breast, axillary and
pubic hair growth in male clients, observe
DYSTROPHIA ADIPOSOGENITALIS also growth of facial hair.
• Ability of clients to meet their basic needs
• Characterized by obesity and hypogonadism • Palpation of the skin, the woman usually
affecting mainly adolescent boys becomes dry and rough.
• Also known as Frohlich syndrome or
hypothalamic eunichism NURSING DIAGNOSIS
DEFINITION • Disturbed body image related to:
• Adiposogenital Dystrophy, also called Frolich’s enlargement of body parts as manifested by
syndrome rare childhood metabolic disorder enlarged hands, fee and jaw.
characterized by obesity, growth retardation, • Ineffective coping related to change in
and retarded development of the genital organs. appearance as manifested by verbalization
It is usually associated with tumors of the of negative feeling about the change in
hypothalamus, causing increased appetite and appearance.
depressed secretion and gonadotropin. • Disturbed sensory perception related to
enlarged pituitary gland as manifested by
protrusion of eye balls.
• Risk for Decreased Cardiac Output related
to Uncontrolled hyperthyroidism,
hypermetabolic state.
• Disturbed sleeping pattern related to soft
tissue swelling as manifested by
verbalization of the patient about insomnia.
• Fluid volume deficit related to polyuria as
manifested by excessive thirst of the patient.
• Anxiety related to change in appearance
and treatment as manifested by verbalization
of the patient about body appearance.
• Knowledge deficit regarding development
CAUSES of disease and treatment as manifested by
repeated questions by the patient regarding
• Hypoactivity of both anterior and posterior disease and treatment.
pituitary
• Tumor in pituitary gland and hypothalamic NURSING RESPONSIBILITIES
regions concerned with food intake and
gonadal development
• Reduce metabolic demands and support
• Injury or atrophy of pituitary gland
cardiovascular function
• Genetic inability of hypothalamus to secrete
• Provide psychological support.
luteinizing hormone.
• Prevent complications
• Provide information about disease
SYMPTOMS process/prognosis and therapy needs.

• Obesity (common feature)

• Sexual infantilism (failure to develop NURSING INTERVENTIONS
secondary sexual characters)
• Dwarfism occurs if disease starts in growing
• Monitor BP lying, sitting, and standing, if
age
able. Note widened pulse pressure.
• Called as infantile or prepubertal type of
• Investigate reports of chest pain or angina.
Frohlich syndrome (in children) and adult
• Assess pulse and heart rate while patient is
type of Frohlich’s syndrome (in adult)
sleeping.
• Other features are loss of vision and
• Auscultate heart sounds, note extra heart
diabetes
sounds, development of gallops and systolic
murmurs.

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• Monitor ECG, noting rate and rhythm.
Document dysrhythmias.
• Administer medications as indicated
• Provide comfort measures: touch therapy or
massage, cool showers. Patient with
dyspnea will be most comfortable sitting in
high Fowler’s position.
• Provide for diversional activities that are
calming e.g., reading television.
• Administer medication as needed:
Sedatives: phenobarbital (Luminal),
Antianxiety agents: chlordiazepoxide
(Librium)
• Assess thinking process. Determine
attention span, orientation to place, person,
or time.
• Note changes in behavior.
• Assess level of anxiety.
• Provide quiet environment; decreased
stimuli, cool room, dim lights. Limit
procedures and/or personnel.
• Provide clock, calendar, room with outside
window; alter level of lighting to stimulate day
or night.
• Provide safety measures. Pad side rails,
close supervision, applying soft restraints as
last resorts as necessary.
• Monitor daily food intake. Weigh daily and
report losses.
• Encourage patient to eat and increase
number of meals and snacks. Give or
suggest high-calorie foods that are easily
digested.
• Avoid food that increases peristalsis and
fluids that cause diarrhea.

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