Assessment

Changes in physical appearance and target organ function occur with deficiencies of specific pituitary hormones (Chart 65-1). Gonadotropin (LH and FSH) deficiency results in the loss of or change in secondary sex characteristics in men and women. While assessing the male patient, look for facial and body hair loss. Ask about episodes of impotence and decreased libido (sex drive). Women may report amenorrhea (absence of menstrual periods), dyspareunia (painful intercourse), infertility, and decreased libido. While examining the female patient, check for dry skin, breast atrophy, and a decreased amount or absence of axillary and pubic hair.

Neurologic manifestations of hypopituitarism as a result of tumor growth often first occur as changes in vision. Assess the patient’s visual acuity, especially peripheral vision, for changes or loss. Temporal headaches are a common finding. Other manifestations may include diplopia (double vision) and ocular muscle paralysis, limiting eye movement.

Laboratory findings vary widely with hypopituitarism. Some pituitary hormone levels may be measured directly. Often, however, the effects of the hormones, rather than their actual levels, are assessed. Blood levels of triiodothyronine (T₃) and thyroxine (T₄) from the thyroid, as well as testosterone and estradiol from the gonads, are measured easily. If levels of one or all of these hormones are low or in the low-normal range, further evaluation is necessary. Levels of pituitary gonadotropins (LH and FSH) and TSH are sufficient if function of the target organ is apparent. Function of LH and FSH is assessed by observing for the presence of secondary sexual characteristics. Function of TSH is assessed by measuring circulating levels of thyroid hormones. ACTH levels may be normal or low, and prolactin (PRL) levels are low to high.

Stimulation testing can be useful to evaluate pituitary function. For example, insulin injection in people with normal pituitary function causes an increased release of GH and ACTH. With decreased pituitary function, levels of either of these hormones remain unchanged.

Pituitary problems may cause changes in the sella turcica (the bony nest where the pituitary gland rests) that can be seen with skull x-rays. Changes may include enlargement, erosion, and calcifications as a result of pituitary tumors. Computed tomography (CT) and magnetic resonance imaging (MRI) can more distinctly define bone or soft-tissue lesions. An angiogram may be used to rule out the presence of an aneurysm or other vascular problems in the area before surgery.

Interventions

Management of the adult with hypopituitarism focuses on replacement of deficient hormones. Older patients or those with a chronic disease often require a lower amount of hormone replacement. Men who have gonadotropin deficiency receive sex steroid replacement therapy with androgens (testosterone). The most effective route of androgen replacement is IM, although use of transdermal testoste-rone patches is increasing. Instruct the patient in self-administration. Therapy begins with high-dose testosterone and is continued until virilization (presence of male secondary sex characteristics) is achieved. Maximal effects of treatment include increases in penis size, libido, muscle mass, bone size, and bone strength. Chest, facial, pubic, and axillary hair growth also increases, and the voice deepens. Patients usually report improved self-esteem and body image after therapy is initiated. The dose may then be decreased, but therapy continues throughout life.

Androgen therapy is avoided in men with prostate cancer. Side effects of testosterone therapy include gynecomastia (male breast tissue development), acne, baldness, and prostate enlargement.

Achieving fertility in these patients is difficult and requires additional parenteral testosterone therapy and injections of human chorionic gonadotropin (hCG). Teach the patient about the additional therapy, and provide emotional support because the outcome of fertility treatment is uncertain.

Women who have gonadotropin deficiency receive hormone replacement with a combination of estrogen and progesterone. The risk for hypertension or thrombosis (formation of blood clots in deep veins) is increased with estrogen therapy, especially among women who smoke. Emphasize measures to reduce risk and the need for regular health visits. For women who wish to become pregnant, clomiphene (Clomid) may be given to induce ovulation. Gonadotropin-releasing hormone (GnRH) and hCG are used to stimulate ovulation if therapy with clomiphene fails.

Adult patients with GH deficiency may be treated with injections of GH, although this treatment is rare.

Assessment

The manifestations of hyperpituitarism vary, depending on which hormone is produced in excess. Obtain data about the patient’s age, gender, and family history. Ask about any change in hat, glove, ring, or shoe size. Fatigue and lethargy are common. The patient with high GH levels may have backache and arthralgias (joint pain) from bone changes. Ask specifically about headaches and changes in vision.

The patient with hypersecretion of PRL often reports difficulties in sexual functioning. Ask women about menstrual changes (e.g., amenorrhea, irregular menses, and difficulty in becoming pregnant) and about decreased libido or dyspareunia (painful intercourse). Men may report decreased libido and impotence.

Changes in appearance and target organ function occur with excesses of specific anterior pituitary hormones (Chart 65-2). Initial manifestations of GH excess are increases in lip and nose sizes, a prominent brow ridge, and increases in head, hand, and foot sizes. The patient with hyperpituitarism often seeks health care because of dramatic changes in appearance. Assess the impact of these changes on self-image and personal relationships.

In hyperpituitarism, usually only one hormone is produced in excess because the cell types within the pituitary gland are so individually organized. The most common hormones produced in excess are PRL, ACTH, and GH. Tumors producing TSH, luteinizing hormone (LH), or follicle-stimulating hormone (FSH) are rare, and elevations of these hormones warrant evaluation. Elevations of LH and FSH are normal in the postmenopausal woman.

Imaging assessment for hyperpituitarism is the same as for hypopituitarism. Skull x-rays are used to identify abnormalities of the sella turcica. CT scans and MRI can define soft-tissue lesions, and angiography can rule out an aneurysm or vascular malformations.

Suppression testing can help diagnose hyperpituitarism and determine whether the normal negative feedback control mechanisms for hormonal regulation are intact. For example, high blood glucose levels suppress the release of GH. In a suppression test, 100 g of oral glucose or 0.5 g/kg of body weight is given IV. GH levels are measured serially for up to 120 minutes. GH levels that do not fall below 5 ng/mL indicate a positive (abnormal) result.

Interventions

The expected outcomes of management for the patient who has hyperpituitarism are to return hormone levels to normal or near normal, reduce or eliminate headache and visual disturbances, prevent complications, and reverse as many of the body changes as possible.

Nonsurgical Management

Encourage the patient to express concerns about his or her altered physical appearance. Help him or her identify personal strengths and positive characteristics, reinforcing each patient’s uniqueness and importance. Galactorrhea, gynecomastia, and reduced sexual functioning can disturb self-image and personal identity. Reassure the patient that treatment may reverse some of these problems. Encourage the patient to discuss his or her feelings.

Drug therapy may be used alone or in combination with surgery and/or radiation. The most common drugs used are dopamine agonists, including bromocriptine mesylate (Parlodel), cabergoline (Dostinex), and pergolide (Permax) (Melmed & Kleinberg, 2008). These drugs stimulate dopamine receptors in the brain and inhibit the release of GH and PRL. In most cases, small tumors decrease until the pituitary gland is of normal size. Large pituitary tumors usually decrease to some extent. In patients with acromegaly, bromocriptine reduces GH levels and decreases tumor size, especially when GH levels remain high after surgery or before the full effect of radiation therapy has occurred.

Side effects of bromocriptine include orthostatic (postural) hypotension, gastric irritation, nausea, headaches, abdominal cramps, and constipation. Give bromocriptine with a meal or a snack to reduce some of these side effects. Treatment starts with a low dose and is gradually increased until the desired level (usually 7.5 mg/day) is reached. If pregnancy occurs, the drug is stopped immediately.

Other agents used for acromegaly are the somatostatin analogs, especially octreotide (Sandostatin), and a growth hormone receptor blocker, pegvisomant (Somavert). Octreotide inhibits GH release through negative feedback. Pegvisomant blocks growth hormone (GH) receptor activity and production of insulin-like growth factor (IGF). Although these therapies are effective, a disadvantage is that they must be given as an injection on a daily or weekly schedule. A major side effect is gallbladder disease. Pegvisomant may cause an increase in tumor size.

Radiation therapy is not useful in the immediate management of acute hyperpituitarism. These therapy regimens take a long time to complete, and several years may pass before a therapeutic effect can be seen. Side effects of radiation therapy include hypopituitarism, optic nerve damage, and other eye and vision problems. Use of the gamma knife procedure is increasing the accuracy of radiation therapy.

Surgical Management

Surgical removal of the pituitary gland and tumor (hypophysectomy) is the most common treatment for hyperpituitarism.

Preoperative Care

Explain that hypophysectomy decreases hormone levels, relieves headaches, and may reverse changes in sexual functioning. Body changes, organ enlargement, and visual changes are not usually reversible. Explain that because nasal packing is present for 2 to 3 days after surgery, it will be necessary to breathe through the mouth, and a “mustache” dressing (“drip” pad) will be placed under the nose. Instruct the patient not to brush teeth, cough, sneeze, blow the nose, or bend forward after surgery. These activities can increase intracranial pressure (ICP) and delay healing.

Operative Procedures

Depending on tumor size and other patient factors, a minimally invasive endoscopic transnasal approach may be used instead of the more traditional transsphenoidal approach (Fig. 65-2). Although both procedures are less invasive than a craniotomy, the endoscopic approach uses smaller diameter instruments and results in less damage to nasal structures (Graham et al., 2009). Both procedures are performed with the patient in a semi-sitting position. For the transsphenoidal approach, the surgeon makes an incision just above the upper lip and reaches the pituitary gland through the sphenoid sinus. After the gland is removed, a muscle graft is taken, often from the thigh, to support the area and prevent leakage of cerebrospinal fluid (CSF). Nasal packing is inserted after the incision is closed, and a mustache dressing is applied. If the tumor cannot be reached by either the endoscopic transnasal approach or the transsphenoidal approach, a craniotomy may be indicated (see Chapter 47).

FIG. 65-2 The transsphenoidal surgical approach to the pituitary gland. Selective adenomectomy leaves normal pituitary tissue undisturbed.

Postoperative Care

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 on pp. 1378-1380), CSF leakage, infection, and increased ICP.

Teach the patient to report any postnasal drip or increased swallowing, which might 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. If the CSF leak persists, the physician may perform a spinal tap to reduce CSF pressure. Surgical intervention is rarely necessary.

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 the patient to perform deep-breathing exercises hourly while awake to prevent pulmonary problems. Patients may have mouth dryness from mouth breathing. Perform frequent oral rinses, and apply a lubricating jelly to dry lips.

Infection can occur after surgery. Specifically assess for manifestations of 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 Chart 65-3.

Chart 65-3 Best Practice For Patient Safety & Quality Care

The Patient After Hypophysectomy

• 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, because transient diabetes insipidus can occur.

• Encourage the patient to maintain pulmonary hygiene through deep-breathing exercises.

• Instruct the patient to not cough, blow the nose, or sneeze.

• Instruct the patient to use dental floss and oral mouth rinses, because brushing the teeth is not permitted until the incision heals sufficiently.

• Instruct the patient to avoid bending at the waist for any reason, because this position increases intracranial pressure.

• Monitor the nasal drip pad for the type and amount of drainage. The presence of the halo sign may indicate a CSF leak.

• Monitor bowel movements to prevent constipation and subsequent “straining.”

• Teach the patient self-administration of the prescribed hormones.

CSF, Cerebrospinal fluid.

After surgery, the patient needs daily self-management regimens and frequent checkups. He or she may need strategies to reduce stress. The home care nurse performs a focused assessment during any home visit to a patient who has undergone a hypophysectomy (Chart 65-4). Review drug regimens and manifestations of infection and cerebral edema with the family.

Chart 65-4 Home Care Assessment

The Patient Who Has Undergone Transsphenoidal or Endoscopic Nasal Hypophysectomy for Hyperpituitarism

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:

• Level of consciousness

• Orientation to time, place, and person

• Accurate reading of a seven-word sentence containing no words longer than three syllables

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

• Visual fields

• 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

• 24-hour diet recall

• 24-hour activity recall

• Over-the-counter and prescribed drugs taken

Assess patient’s understanding of illness and adherence with treatment:

• Signs and symptoms to report to health care provider

• Drug plan (correct timing and dose)

After a transsphenoidal hypophysectomy, advise the patient to avoid activities that might interfere with healing. 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. Activities that increase ICP should be avoided for up to 2 months after surgery.

Teach the patient to avoid toothbrushing for about 2 weeks after surgery until the incision has healed. Frequent mouth care (every 4 to 6 hours) with mouthwash and daily flossing provide adequate oral hygiene. Numbness in the area of the incision and a decreased sense of smell are expected after surgery and usually last 3 to 4 months. Advise the patient to use a mirror to check the gums for bleeding, because reduced sensation increases the risk for injury.

After a hypophysectomy, hormone replacement with vasopressin may be needed to maintain fluid balance. (See discussion of Interventions on pp. 1378-1380 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. Teach the patient to report the return of any symptoms of hyperpituitarism immediately to the primary health care provider.

 Nclex Examination Challenge

Safe and Effective Care Environment

The nurse notes that the mustache dressing of a client who is 12 hours postoperative from a transsphenoidal hypophysectomy is wet. What is the nurse’s best action?

A. Reapply a dry dressing and document this expected response.

B. Ask the client whether other symptoms of a cold are present.

C. Notify the surgeon or the Rapid Response Team.

D. Test the drainage for the presence of glucose.