Page 26 Complete Your CE Test Online - Click Here being produced because of ACTH deficiency. Corticosteroids are administered orally[5,7] . ● ● Levothyroxine: Levothyroxine (brand names Synthroid, Levoxyl) is administered to replace thyroid hormone caused by low or deficient TSH production[7] . ● ● Sex hormones: For patients of child-bearing age, sex hormone administration may be beneficial. These may include testosterone in men and estrogen or a combination of estrogen and progesterone in women. Testosterone is administered via injection or through the skin with a patch or gel. Estrogen and progesterone can be administered via pills, gel, or patches[7] . Gonadotropins (LH and FSH) can be administered by injection to trigger ovulation in women and sperm production in men[7] . ● ● Growth hormone: GH replacement is recommended for children as well as adults. GH or somatropin is administered as daily subcutaneous injections of one of several recombinant deoxyribonucleic acid GHs. Administration is accompanied by monitoring of serum IGF-1 levels. In children, administration can produce more normal height. In adults, administration of a growth hormone may have some benefit but will not make adults taller [5,7] . There are a number of nursing considerations related to treatment of hypopituitarism, including[4, 5, 6, 7] : ● ● Emphasize the need for life-long hormone replacement. Assess knowledge by having patients and families explain why hormone replacement is necessary, consequences of not taking replacements prescribed, and any possible adverse effects and what to do about them. Have patients/families demonstrate how to accurately take prescribed medications. ● ● Emphasize the importance of keeping HCPs informed of any and all medications the patient is taking in addition to hormone replacement therapy. Explain that this includes not only prescription medications but OTC (OTC) medications, herbal supplements, vitamins, minerals, weight loss products, and other supplements. Any or all of these products can interact with each other and have the potential to cause adverse side effects. ● ● Until hormone replacement therapy is complete, monitor patients for signs of thyroid deficiency (lethargy, bradycardia, dry skin and hair, and constipation), adrenal deficiency (weakness, orthostatic hypotension, fatigue, weight loss, and hypoglycemia), and deficiency of gonadotropins (decreased libido, apathy, and lethargy). ● ● Since anorexia can be a significant problem, initiate a dietary consult to help patients and families develop a diet that patients find appealing. Patients should be monitored for changes in weight. ● ● Since orthostatic hypotension is a possibility, teach the patient to move slowly when changing positions, especially when going from lying to sitting and sitting to standing. ● ● Instruct patients to wear a medical identification bracelet. ● ● Refer the families of children with dwarfism to mental health resources for counseling. This disorder can cause significant stress for patients and families. Nursing consideration: Patient/family education is essential for proper management of hypopituitarism. In particular, the need for life-long hormone replacement must be emphasized. Meticulous education regarding hormone replacement is critical! HYPERPITUITARISM Emily is a registered nurse who works on a busy medical-surgical unit. She attends graduate school two evenings a week. Thanks to her busy schedule she has lost touch with many of her neighbors. As she prepares to leave for school one early-summer evening, she notices her next- door neighbor watering his lawn. As she waves hello she notices that his movements seem slow and painful. Feeling concerned, Emily stops to chat. To her surprise she notices that his facial features seem quite different compared to the last time she saw him. His face seems “bigger” and he seems to be sweating excessively even though the evening is actually rather cool. He tells her that he thinks he must be getting arthritis since his “joints ache.” His voice seems deeper and huskier than Emily recalls, and he mentions that he has made an appointment with “my eye doctor since I don’t see as well as I used to and I am getting awful headaches.” Emily is concerned. She is currently studying endocrine disorders and wonders if her neighbor is suffering from hyperpituitarism. Hyperpituitarism, also known as acromegaly and gigantism, is a chronic, progressive disease characterized by hormonal dysfunction and disturbing skeletal overgrowth[5] . It occurs when the pituitary gland produces excessive amounts of GH[5,8] . It is important to differentiate between acromegaly and gigantism. The defining difference is the age of persons experiencing pituitary over- production. Acromegaly affects adults. In adults, the bones increase in size including those of the hands, feet, and face. In children, excessive growth hormone leads to gigantism characterized by exaggerated bone growth and abnormal increases in height[5,8] . Acromegaly occurs after closure of the epiphyseal (rounded end of long bones). This leads to thickening of the bones, transverse bone growth, and visceromegaly (enlargement of the internal abdominal organs)[5] . Giantism starts before epiphyseal closure and causes proportional excessive growth of all body tissues. As the disease advances, loss of other trophic hormones (e.g., TSH, LH, FSH, and corticotropin) may cause malfunction of their target organs[5] . Patient prognosis depends on the underlying cause of the disease. However, hyperpituitarism usually reduces life expectancy unless it is diagnosed in a timely fashion and prompt treatment is initiated[5] . Incidence and etiology Acromegaly is a rare disorder that affects males and females equally, usually between the ages of 30 and 50. About three to four people per every million are diagnosed annually[5] . Giantism can affect infants as well as children, but, fortunately, it is a very rare disorder with only 100 reported cases to date. Affected patients may reach as much as three times the normal height for their age. Adults may reach a height of more than 80 inches[5] . In adults, the most common cause of excessive GH production is a tumor. Most of these tumors are benign adenomas of the pituitary gland. The tumors themselves secrete excessive amounts of GH leading to clinical signs and symptoms. Neurological signs and symptoms such as headache and vision disturbances are the result of a tumor pressing on brain tissue[5,8] . Occasionally, non-pituitary tumors can cause hyperpituitarism. For example, tumors of the lungs adrenal glands, or pancreas may secrete GH. In some cases, tumors may produce growth hormone-releasing hormone (GH-RH). This hormone stimulates the pituitary to produce more GH[8] . Signs and symptoms Acromegaly develops slowly with early signs not readily apparent. It may take years for signs and symptoms to become evident[5,8] . Acromegaly alert! Since the disease develops so slowly some people may notice physical changes in appearance only by comparing old and current photographs[8] . One of the most common initial signs of acromegaly is enlargement of the hands and feet. Patients may complain that their shoe size has steadily increased and that their rings no longer fit[8] . Symptoms can vary among patients but some general characteristics are evident. Excessive secretion of GH causes[5,8] : ● ● Overgrowth of cartilage and connective tissue, which results in a characteristic hulking appearance, enlarged nose, enlarged feet, thickened lips, tongue, fingers, and ears, changes in the shape of the face such as a protruding lower jaw and brow, and wider spacing between the teeth.