WEEK 7: ENDOCRINE DISORDERS the Autonomic Nervous System (ANS), which secretes
catecholamines (epinephrine/adrenaline and norepinephrine).
Adrenal Gland Disorders: Cushing’s Syndrome & Addison’s Disease • Adrenal glands (one each upper portion of kidney)
• Adrenal medulla (center)
Cushing’s Syndrome • Secretes catecholamines (epinephrine [90%] and
norepinephrine [10%])
Anatomy • Part of the autonomic nervous system
• Stimulated preganglionic sympathetic nerve fibers → release of
the catecholamines → regulate metabolic pathways to promote
catabolism of stored fuels → release of free fatty acids, increase
the basal metabolic rate, and elevate the blood glucose level
• The adrenal cortex is considered to be the outer core of the
adrenal gland, and is subdivided into 3 zones: (1) zona
glomerulosa (2) Zona fasicluata (3) zona reticulari, which
secretes steroid hormones (glucocorticoids, mineralocorcticoids,
adrenal sex hormones).
• Adrenal cortex (outer portion)
• Secretes steroid hormones (glucocorticoids, mineralocorticoids,
and sex hormones)
• Regulated by the hypothalamic– pituitary–adrenal axis
• Release of ACTH from the anterior lobe of the pituitary gland →
adrenal cortex → glucocorticoids → inhibit the inflammatory
response to tissue injury and to suppress allergic manifestations.
• Presence of Angiotensin II in blood or increased Na → release of
• The endocrine system is made up of a network of glands, which aldosterone (mineralocorticoids) → promote sodium
secrete chemicals called hormones in order to regulate many reabsorption by the kidney and the GI tract → restore BP
bodily functions, including growth & metabolism. The endocrine • ACTH → adrenal cortex → secretion of adrenal androgens (sex
system works to regulate internal processes through the hormones)
bloodstream.
• The endocrine system helps control the following processes and Definition
systems: • Is caused by prolonged exposure to elevated levels of either
o Growth and development endogenous glucocorticoids or exogenous glucocorticoids.
o Homeostasis (the internal balance of body systems) Exogenous use of glucocorticoids should always be considered
o Metabolism (body energy levels) and excluded in the etiology of Cushing syndrome.
o Reproduction • Endogenous glucocorticoid overproduction, or hypercortisolism,
o Response to stimuli (stress and/or injury) can be dependent on or independent of adrenocorticotropic
• The endocrine system completes these tasks through its network hormone (ACTH).
of glands, which are small but highly important organs that • Sometimes called hypercortisolism, may be caused by the use of
produce, store, and secrete hormones. These glands produce oral corticosteroid medication
different types of hormones that evoke a specific response in • The condition can also occur when your body makes too much
other cells, tissues, and/or organs located throughout the body. cortisol on its own.
The hormones reach these faraway targets using the
bloodstream. Like the nervous system, the endocrine system is
one of the body’s main communicators, but instead of using
nerves to transmit information, the endocrine system uses blood
vessels to deliver hormones to cells as they are chemical
messengers that carry information and instructions from one set
of cells to another.
• The major glands of the endocrine system are the hypothalamus,
pituitary, thyroid, parathyroids, adrenals, and the reproductive
organs such as ovaries and testes. Although the pancreas is not
a gland, it also belongs to the endocrine system.
• When glands produce an incorrect amount of hormones,
endocrine diseases usually occur and impacts may aspect of life.
• Each person has two adrenal glands, each one is attached to the
upper portion of the kidney and is also termed as “suprarenal
glands”.
• Although adrenal gland appears to be a single organ, each
adrenal gland, however, is in reality, 2 adrenal glands with their
own separate, independent functions.
• The adrenal medulla at the center of the gland is considered to
be the inner core. It is innervated by the sympathetic division of
1
,Risk factors • Moon face • Hypocalcemia
• Buffalo hump • Hypertension
• The main risk factor for developing Cushing’s syndrome is taking • Truncal obesity with • Fragile skin that
high-dose corticosteroids over a long period of time. thin extremities bruises easily
• Other risk factors can include: • Supraclavicular fat • Reddish-purple striae
o Type-2 diabetes that isn’t properly managed pads on the abdomen and
o High blood pressure (hypertension) • Weight gain upper thighs
o Obesity • Hirsutism (masculine
• Some cases of Cushing’s syndrome are due to tumor formation. characteristics in
Although there can be a genetic predisposition to develop females)
endocrine tumors (familial Cushing’s syndrome), there’s no way
to prevent tumors from forming.
Clinical Manifestations
Causes
Ophthalmic • Cataracts
• Cushing’s syndrome is caused by an excess of the hormone
• Glaucoma
cortisol. Your adrenal glands produce cortisol. It helps with a
Cardiovascular • Hypertension
number of your body’s functions, including:
• Heart failure
o Regulating blood pressure and the
Endocrine/Metabolic • Truncal obesity
cardiovascular system
• Moon face
o Reducing the immune system’s inflammatory
• Buffalo hump
response
• Sodium retention
o Converting carbohydrates, fats, and proteins
• Hypokalemia
into energy
• Metabolic alkalosis
o Balancing the effects of insulin
• Hyperglycemia
o Responding to stress
• Menstrual
Complications irregularities
• Impotence
• Heart attack and stroke • Negative nitrogen
• Blood clots in the legs and lungs balance
• Infections • Altered calcium
• Bone loss and fractures metabolism
• High blood pressure • Adrenal suppression
• Unhealthy cholesterol levels
• Depression or other mood changes Immune function • Decreased
• Memory loss or trouble concentrating inflammatory
• Insulin resistance and prediabetes responses
• Type 2 diabetes • Impaired wound
• Although Cushing’s syndrome can usually be cured, it can be healing
fatal if not treated. • Increased
susceptibility to
Prevention infections
• Eat a healthy diet Skeletal • Osteoporosis
o Choose a variety of low-calorie foods that are • Spontaneous
high in protein and calcium. fractures
o Take calcium and vitamin D supplements to • Aseptic necrosis of
decrease bone loss femur
o Limit salt (sodium) in your diet. • Vertebral
• Take good care of yourself compression
o Get regular exercise. fractures
o Avoid falls, which can lead to broken bones and Gastrointestinal • Peptic ulcer
other injuries. • Pancreatitis
o See your doctor regularly to watch for other Muscular • Myopathy
problems such as diabetes, high blood pressure, • Muscle weakness
and osteoporosis. Dermatologic • Thinning of skin
• Taking care to avoid long term use of cortisol-containing • Petechiae
medications • Hirsutism (masculine
characteristics in
Signs and Symptoms females)
• Ecchymoses
• Generalized muscle • Hyperglycemia • Striae
wasting and • Hypernatremia • Acne
weakness • Hypokalemia Psychiatric • Mood alterations
2
, • Psychoses ▪ increase serum sodium and blood glucose
levels
▪ decrease serum potassium
Pathophysiology
▪ decrease eosinophils, lymphocytes, and
basophils
▪ increased neutrophils, monocytes
▪ increased WBC count
▪ increased RBC count
▪ Increased platelet count
• Radioimmunoassay
o A sensitive in vitro assay technique that uses radio-
labeled molecules which is used to measure
concentrations of substances, usually measuring
antigen concentrations by use of antibodies
o Measurement of plasma ACTH level which is used to
identify adrenal causes (AA) of Cushing's syndrome.
• Imaging test to detect abnormalities, such as tumor in pituitary
and adrenal glands
o Computed tomography (CT)
o Magnetic resonance imaging (MRI)
★ Several blood samples are collected to determine whether
the normal diurnal variation in plasma levels is present; this
variation is frequently absent in adrenal dysfunction.
Diagnostic procedures
Medical/Surgical Management
• If the results of all three tests are normal, the patient likely does
HYPOPHYSECTOMY
not have Cushing syndrome (but may have a mild case, or the
manifestations may be cyclic). a. Description
• Can falsely elevate cortisol levels; stress, obesity, depression,
and medications such as anticonvulsant agents, estrogen (during • Hypophysectomy is the surgical removal of the pituitary gland to
pregnancy or as oral medications), and rifampin (Rifadin) treat cancerous or benign tumors. It is a high-risk surgical
procedure, and the approach is carefully selected to manage risk
• Serum cortisol levels and maximize benefit.
o Usually higher in the early morning (6 to 8 am) • The surgery is carried out under general anesthetic, and it takes
and lower in the evening (4 to 6 pm). This 1-2 hours to complete.
variation is lost in patients with Cushing
b. Purpose of the Surgery
syndrome
• Urinary cortisol test • To prevent the possible malignant tumor from spreading to
• Requires a 24-hour urine collection. other parts of the body. To cease the overproduction of the
• If the results of the urinary cortisol test are three times the upper hormone cortisol which is the contributing factor of Cushing’s
limit of the normal range and one other test is abnormal, Cushing disease.
syndrome can be assumed.
• Dexamethasone suppression test/ Overnight dexamethasone c. Indications
suppression test
o Widely used and most sensitive screening test for • Diabetic patients whose vision is threatened by neovascular
diagnosis of pituitary and adrenal causes of changes characterizing proliferative retinopathy.
Cushing syndrome. • Advancing breast cancer for postmenopausal (natural or
o Can be performed on an outpatient basis induced) patients who have received two trials of hormonal
o Dexamethasone (1 mg or 8 mg) is given orally late therapy
in the evening or at bedtime, and a plasma • Advancing prostate cancer
cortisol level is obtained at 8 am the next • Cushing’s Syndrome
morning. • Benign or malignant tumor in the pituitary gland
o Suppression of cortisol to less than 5 mg/dL • Biopsy of midline spheno clival lesions (e.g. chordoma,
indicates that the hypothalamic–pituitary– aspergilloma, meningioma etc.)
adrenal axis is functioning properly d. Contraindications
• Other tests that help indicate Cushing syndrome
o CBC with differentials and other blood test • The main limitation of a hypophysectomy, especially the
transsphenoidal approach, is when the operative corridor is
3
, narrow and lateral tumor is difficult to resect. For instance, when • Fluids are usually given after nausea ceases, and the
the epicenter of the tumor is lateral to the carotid artery. patient then progresses to a regular diet.
• Instruct the patient that after the surgery he or she
e. Types of Pituitary Gland Removal Approaches will need to avoid vigorous coughing, blowing the
nose, sucking through a straw, or sneezing, because
• Transfrontal - This approach invades the cranial cavity. The these actions may place increased pressure at the
approach begins by performing a complete ethmoidectomy. This surgical site and cause a CSF leak.
is followed by identification and dissection of the frontal recess. • For transsphenoidal approach:
This area is then widened via a modified endoscopic procedure • Keep the head of the patient’s bed raised
to provide a panoramic exposure of the posterior table of the to decrease pressure on the sella turcica
frontal sinus. and to promote normal drainage.
• Subcranial - It is a technique in which the anterior skull base is • Check the nasal packing inserted during
approached directly by disarticulating the nasal root and glabella surgery for blood or CSF drainage.
to directly access the frontal and ethmoid sinuses and the • Oral care is provided every 4 hours or
more frequently. Use warm saline mouth
anterior fossa.
rinses. Avoid brushing teeth until the
• Oronasal–transsphenoidal - The usual choice of approach for
incision above the teeth has healed.
the procedure. Incision is made beneath the upper lip to gain • Because of the anatomic proximity of the
access into the nasal cavity and into the sella turcica and pituitary gland to the optic chiasm, visual
pituitary region. This is often done with the assistance of either acuity and visual fields are assessed at
a surgical microscope or an endoscopic camera. regular intervals.
• Cryo Hypophysectomy - It is a transseptal-transsphenoidal • 3-4 days after surgery, have the packing
hypophysectomy using a cryogenic probe that produces a cold removed and only then can the area
injury to reduce the release of growth hormone. around the nares be cleaned with the
• Irradiation Hypophysectomy - It is a neurosurgical procedure in prescribed solution to remove crusted
which focused, high-dose radiation therapy is targeted at the blood and moisten the mucous
membranes.
pituitary gland. This procedure is done collaboratively with
Pharmacology with Nursing Considerations
radiation oncologists. This procedure does not require any
anesthesia or implants, and does not involve directly lesioning Ketoconazole
the brain or spinal cord. It relieves symptoms, but it is not a cure Classification: Antifungal
and long-term efficacy is not as reliable. Therefore, this is usually Action: inhibits synthesis of ergosterol, damaging the
reserved for patients with severe pain cell membrane and resulting loss of essential
intracellular material. Also inhibits biosynthesis of
Nursing Care triglycerides and phospholipids and inhibits oxidative
and preoxidative enzyme activity.
Preoperative
Indication: indicated for treatment of candidiasis,
• Gather preoperative assessment of baseline data.
chronic mucocutaneous candidiasis, candiduria,
• Ensure patient’s and family’s understanding of and
histoplasmosis, chromomycosis, oral thrush,
reactions to the anticipated surgical procedure and
blastomycosis, coccidioidomycosis,
its possible effects by explaining what to expect
paracoccidioidomycosis, onychomycosis, CNS fungal
during and after surgery.
infection, and Cushing’s syndrome.
• Make sure an Informed consent is secured.
Contraindication: Patients with hypersensitivity and
• Acquire the necessary imaging tests and lab tests
fungal meningitis. Contraindicated with pregnancy.
before procedure.
Cautiously with hepatic failure.
• Funduscopic examination and visual field
determinations are performed, because the most Adverse Effects:
serious effect of pituitary tumor is localized • Nausea and Vomiting
pressure on the optic nerve or chiasm. • Headache
• Explain the use of general anesthesia and its • Abdominal pain
possible effects. • Diarrhea
• Explain that the existing features and symptoms of • Hepatotoxicity
the Cushing’s disease will remain unaffected after • Somnolence
surgery. • Fever
• Chills
Postoperative
• Suicidal Tendencies
General Considerations
• Thrombocytopenia
• Monitor and manage vital signs especially blood
• Leukopenia
pressure and central venous pressure.
• Pruritus
• Morphine sulfate may be used in the management
• Gynecomastia
of postoperative pain in patients who have
• Urticaria
undergone a craniotomy.
• Anaphylaxis
• Measure I/O to guide fluid-electrolyte
replacement. Nursing Consideration
4
catecholamines (epinephrine/adrenaline and norepinephrine).
Adrenal Gland Disorders: Cushing’s Syndrome & Addison’s Disease • Adrenal glands (one each upper portion of kidney)
• Adrenal medulla (center)
Cushing’s Syndrome • Secretes catecholamines (epinephrine [90%] and
norepinephrine [10%])
Anatomy • Part of the autonomic nervous system
• Stimulated preganglionic sympathetic nerve fibers → release of
the catecholamines → regulate metabolic pathways to promote
catabolism of stored fuels → release of free fatty acids, increase
the basal metabolic rate, and elevate the blood glucose level
• The adrenal cortex is considered to be the outer core of the
adrenal gland, and is subdivided into 3 zones: (1) zona
glomerulosa (2) Zona fasicluata (3) zona reticulari, which
secretes steroid hormones (glucocorticoids, mineralocorcticoids,
adrenal sex hormones).
• Adrenal cortex (outer portion)
• Secretes steroid hormones (glucocorticoids, mineralocorticoids,
and sex hormones)
• Regulated by the hypothalamic– pituitary–adrenal axis
• Release of ACTH from the anterior lobe of the pituitary gland →
adrenal cortex → glucocorticoids → inhibit the inflammatory
response to tissue injury and to suppress allergic manifestations.
• Presence of Angiotensin II in blood or increased Na → release of
• The endocrine system is made up of a network of glands, which aldosterone (mineralocorticoids) → promote sodium
secrete chemicals called hormones in order to regulate many reabsorption by the kidney and the GI tract → restore BP
bodily functions, including growth & metabolism. The endocrine • ACTH → adrenal cortex → secretion of adrenal androgens (sex
system works to regulate internal processes through the hormones)
bloodstream.
• The endocrine system helps control the following processes and Definition
systems: • Is caused by prolonged exposure to elevated levels of either
o Growth and development endogenous glucocorticoids or exogenous glucocorticoids.
o Homeostasis (the internal balance of body systems) Exogenous use of glucocorticoids should always be considered
o Metabolism (body energy levels) and excluded in the etiology of Cushing syndrome.
o Reproduction • Endogenous glucocorticoid overproduction, or hypercortisolism,
o Response to stimuli (stress and/or injury) can be dependent on or independent of adrenocorticotropic
• The endocrine system completes these tasks through its network hormone (ACTH).
of glands, which are small but highly important organs that • Sometimes called hypercortisolism, may be caused by the use of
produce, store, and secrete hormones. These glands produce oral corticosteroid medication
different types of hormones that evoke a specific response in • The condition can also occur when your body makes too much
other cells, tissues, and/or organs located throughout the body. cortisol on its own.
The hormones reach these faraway targets using the
bloodstream. Like the nervous system, the endocrine system is
one of the body’s main communicators, but instead of using
nerves to transmit information, the endocrine system uses blood
vessels to deliver hormones to cells as they are chemical
messengers that carry information and instructions from one set
of cells to another.
• The major glands of the endocrine system are the hypothalamus,
pituitary, thyroid, parathyroids, adrenals, and the reproductive
organs such as ovaries and testes. Although the pancreas is not
a gland, it also belongs to the endocrine system.
• When glands produce an incorrect amount of hormones,
endocrine diseases usually occur and impacts may aspect of life.
• Each person has two adrenal glands, each one is attached to the
upper portion of the kidney and is also termed as “suprarenal
glands”.
• Although adrenal gland appears to be a single organ, each
adrenal gland, however, is in reality, 2 adrenal glands with their
own separate, independent functions.
• The adrenal medulla at the center of the gland is considered to
be the inner core. It is innervated by the sympathetic division of
1
,Risk factors • Moon face • Hypocalcemia
• Buffalo hump • Hypertension
• The main risk factor for developing Cushing’s syndrome is taking • Truncal obesity with • Fragile skin that
high-dose corticosteroids over a long period of time. thin extremities bruises easily
• Other risk factors can include: • Supraclavicular fat • Reddish-purple striae
o Type-2 diabetes that isn’t properly managed pads on the abdomen and
o High blood pressure (hypertension) • Weight gain upper thighs
o Obesity • Hirsutism (masculine
• Some cases of Cushing’s syndrome are due to tumor formation. characteristics in
Although there can be a genetic predisposition to develop females)
endocrine tumors (familial Cushing’s syndrome), there’s no way
to prevent tumors from forming.
Clinical Manifestations
Causes
Ophthalmic • Cataracts
• Cushing’s syndrome is caused by an excess of the hormone
• Glaucoma
cortisol. Your adrenal glands produce cortisol. It helps with a
Cardiovascular • Hypertension
number of your body’s functions, including:
• Heart failure
o Regulating blood pressure and the
Endocrine/Metabolic • Truncal obesity
cardiovascular system
• Moon face
o Reducing the immune system’s inflammatory
• Buffalo hump
response
• Sodium retention
o Converting carbohydrates, fats, and proteins
• Hypokalemia
into energy
• Metabolic alkalosis
o Balancing the effects of insulin
• Hyperglycemia
o Responding to stress
• Menstrual
Complications irregularities
• Impotence
• Heart attack and stroke • Negative nitrogen
• Blood clots in the legs and lungs balance
• Infections • Altered calcium
• Bone loss and fractures metabolism
• High blood pressure • Adrenal suppression
• Unhealthy cholesterol levels
• Depression or other mood changes Immune function • Decreased
• Memory loss or trouble concentrating inflammatory
• Insulin resistance and prediabetes responses
• Type 2 diabetes • Impaired wound
• Although Cushing’s syndrome can usually be cured, it can be healing
fatal if not treated. • Increased
susceptibility to
Prevention infections
• Eat a healthy diet Skeletal • Osteoporosis
o Choose a variety of low-calorie foods that are • Spontaneous
high in protein and calcium. fractures
o Take calcium and vitamin D supplements to • Aseptic necrosis of
decrease bone loss femur
o Limit salt (sodium) in your diet. • Vertebral
• Take good care of yourself compression
o Get regular exercise. fractures
o Avoid falls, which can lead to broken bones and Gastrointestinal • Peptic ulcer
other injuries. • Pancreatitis
o See your doctor regularly to watch for other Muscular • Myopathy
problems such as diabetes, high blood pressure, • Muscle weakness
and osteoporosis. Dermatologic • Thinning of skin
• Taking care to avoid long term use of cortisol-containing • Petechiae
medications • Hirsutism (masculine
characteristics in
Signs and Symptoms females)
• Ecchymoses
• Generalized muscle • Hyperglycemia • Striae
wasting and • Hypernatremia • Acne
weakness • Hypokalemia Psychiatric • Mood alterations
2
, • Psychoses ▪ increase serum sodium and blood glucose
levels
▪ decrease serum potassium
Pathophysiology
▪ decrease eosinophils, lymphocytes, and
basophils
▪ increased neutrophils, monocytes
▪ increased WBC count
▪ increased RBC count
▪ Increased platelet count
• Radioimmunoassay
o A sensitive in vitro assay technique that uses radio-
labeled molecules which is used to measure
concentrations of substances, usually measuring
antigen concentrations by use of antibodies
o Measurement of plasma ACTH level which is used to
identify adrenal causes (AA) of Cushing's syndrome.
• Imaging test to detect abnormalities, such as tumor in pituitary
and adrenal glands
o Computed tomography (CT)
o Magnetic resonance imaging (MRI)
★ Several blood samples are collected to determine whether
the normal diurnal variation in plasma levels is present; this
variation is frequently absent in adrenal dysfunction.
Diagnostic procedures
Medical/Surgical Management
• If the results of all three tests are normal, the patient likely does
HYPOPHYSECTOMY
not have Cushing syndrome (but may have a mild case, or the
manifestations may be cyclic). a. Description
• Can falsely elevate cortisol levels; stress, obesity, depression,
and medications such as anticonvulsant agents, estrogen (during • Hypophysectomy is the surgical removal of the pituitary gland to
pregnancy or as oral medications), and rifampin (Rifadin) treat cancerous or benign tumors. It is a high-risk surgical
procedure, and the approach is carefully selected to manage risk
• Serum cortisol levels and maximize benefit.
o Usually higher in the early morning (6 to 8 am) • The surgery is carried out under general anesthetic, and it takes
and lower in the evening (4 to 6 pm). This 1-2 hours to complete.
variation is lost in patients with Cushing
b. Purpose of the Surgery
syndrome
• Urinary cortisol test • To prevent the possible malignant tumor from spreading to
• Requires a 24-hour urine collection. other parts of the body. To cease the overproduction of the
• If the results of the urinary cortisol test are three times the upper hormone cortisol which is the contributing factor of Cushing’s
limit of the normal range and one other test is abnormal, Cushing disease.
syndrome can be assumed.
• Dexamethasone suppression test/ Overnight dexamethasone c. Indications
suppression test
o Widely used and most sensitive screening test for • Diabetic patients whose vision is threatened by neovascular
diagnosis of pituitary and adrenal causes of changes characterizing proliferative retinopathy.
Cushing syndrome. • Advancing breast cancer for postmenopausal (natural or
o Can be performed on an outpatient basis induced) patients who have received two trials of hormonal
o Dexamethasone (1 mg or 8 mg) is given orally late therapy
in the evening or at bedtime, and a plasma • Advancing prostate cancer
cortisol level is obtained at 8 am the next • Cushing’s Syndrome
morning. • Benign or malignant tumor in the pituitary gland
o Suppression of cortisol to less than 5 mg/dL • Biopsy of midline spheno clival lesions (e.g. chordoma,
indicates that the hypothalamic–pituitary– aspergilloma, meningioma etc.)
adrenal axis is functioning properly d. Contraindications
• Other tests that help indicate Cushing syndrome
o CBC with differentials and other blood test • The main limitation of a hypophysectomy, especially the
transsphenoidal approach, is when the operative corridor is
3
, narrow and lateral tumor is difficult to resect. For instance, when • Fluids are usually given after nausea ceases, and the
the epicenter of the tumor is lateral to the carotid artery. patient then progresses to a regular diet.
• Instruct the patient that after the surgery he or she
e. Types of Pituitary Gland Removal Approaches will need to avoid vigorous coughing, blowing the
nose, sucking through a straw, or sneezing, because
• Transfrontal - This approach invades the cranial cavity. The these actions may place increased pressure at the
approach begins by performing a complete ethmoidectomy. This surgical site and cause a CSF leak.
is followed by identification and dissection of the frontal recess. • For transsphenoidal approach:
This area is then widened via a modified endoscopic procedure • Keep the head of the patient’s bed raised
to provide a panoramic exposure of the posterior table of the to decrease pressure on the sella turcica
frontal sinus. and to promote normal drainage.
• Subcranial - It is a technique in which the anterior skull base is • Check the nasal packing inserted during
approached directly by disarticulating the nasal root and glabella surgery for blood or CSF drainage.
to directly access the frontal and ethmoid sinuses and the • Oral care is provided every 4 hours or
more frequently. Use warm saline mouth
anterior fossa.
rinses. Avoid brushing teeth until the
• Oronasal–transsphenoidal - The usual choice of approach for
incision above the teeth has healed.
the procedure. Incision is made beneath the upper lip to gain • Because of the anatomic proximity of the
access into the nasal cavity and into the sella turcica and pituitary gland to the optic chiasm, visual
pituitary region. This is often done with the assistance of either acuity and visual fields are assessed at
a surgical microscope or an endoscopic camera. regular intervals.
• Cryo Hypophysectomy - It is a transseptal-transsphenoidal • 3-4 days after surgery, have the packing
hypophysectomy using a cryogenic probe that produces a cold removed and only then can the area
injury to reduce the release of growth hormone. around the nares be cleaned with the
• Irradiation Hypophysectomy - It is a neurosurgical procedure in prescribed solution to remove crusted
which focused, high-dose radiation therapy is targeted at the blood and moisten the mucous
membranes.
pituitary gland. This procedure is done collaboratively with
Pharmacology with Nursing Considerations
radiation oncologists. This procedure does not require any
anesthesia or implants, and does not involve directly lesioning Ketoconazole
the brain or spinal cord. It relieves symptoms, but it is not a cure Classification: Antifungal
and long-term efficacy is not as reliable. Therefore, this is usually Action: inhibits synthesis of ergosterol, damaging the
reserved for patients with severe pain cell membrane and resulting loss of essential
intracellular material. Also inhibits biosynthesis of
Nursing Care triglycerides and phospholipids and inhibits oxidative
and preoxidative enzyme activity.
Preoperative
Indication: indicated for treatment of candidiasis,
• Gather preoperative assessment of baseline data.
chronic mucocutaneous candidiasis, candiduria,
• Ensure patient’s and family’s understanding of and
histoplasmosis, chromomycosis, oral thrush,
reactions to the anticipated surgical procedure and
blastomycosis, coccidioidomycosis,
its possible effects by explaining what to expect
paracoccidioidomycosis, onychomycosis, CNS fungal
during and after surgery.
infection, and Cushing’s syndrome.
• Make sure an Informed consent is secured.
Contraindication: Patients with hypersensitivity and
• Acquire the necessary imaging tests and lab tests
fungal meningitis. Contraindicated with pregnancy.
before procedure.
Cautiously with hepatic failure.
• Funduscopic examination and visual field
determinations are performed, because the most Adverse Effects:
serious effect of pituitary tumor is localized • Nausea and Vomiting
pressure on the optic nerve or chiasm. • Headache
• Explain the use of general anesthesia and its • Abdominal pain
possible effects. • Diarrhea
• Explain that the existing features and symptoms of • Hepatotoxicity
the Cushing’s disease will remain unaffected after • Somnolence
surgery. • Fever
• Chills
Postoperative
• Suicidal Tendencies
General Considerations
• Thrombocytopenia
• Monitor and manage vital signs especially blood
• Leukopenia
pressure and central venous pressure.
• Pruritus
• Morphine sulfate may be used in the management
• Gynecomastia
of postoperative pain in patients who have
• Urticaria
undergone a craniotomy.
• Anaphylaxis
• Measure I/O to guide fluid-electrolyte
replacement. Nursing Consideration
4
