[NURSING CARE FOR A PATIENT UNDERGONE ENDONASAL ENDOSCOPIC APPROACH PITUITARY SURGERY]. / Cuidados de enfermería a paciente sometido a cirugía hipofisaria MEDIANTE ABORDAJE ENDOSCÓPICO ENDONASAL.

The pituitary gland is an endocrine gland that releases different hormones responsible for controlling the production of hormones in other glands, and maintaining the body's homeostasis. This tiny gland is located in a bone cavity known as the sellaturcica. Anomalous growth of some cells produces pituitary adenomas, which represent between 10 and 15% of intracranial tumors. In the majority of cases, the cause is unknown, but they are usually benign tumors with a slow growth rate. Due to the wide range of functions of the pituitary gland, it can present a wide variety of symptoms which tend to present once the adenoma has reached a certain size. The most commonly used currently access to the pituitary gland is the transphenoidal endoscopic approach. We present here the case of a 28 year old man diagnosed with a non-functioning pituitary macroadenoma, describing the health education, monitoring and emotional support provided during his hospital stay and the recommendations made on his discharge from hospital. It is important to emphasise the role of nursing in order to avoid complications and ensure that care is adapted to the needs of the individual at all times.

Managing the patient with transsphenoidal pituitary tumor resection.

Patients who undergo transsphenoidal pituitary tumor resection require a multidisciplinary team approach, consisting of a neurosurgeon, an endocrinologist, and nurses. Successful transsphenoidal surgery needs expert nursing care for early identification and prompt treatment of pituitary dysfunction and neurosurgical complications. Pituitary dysfunction includes adrenal insufficiency, diabetes insipidus, syndrome of inappropriate antidiuretic hormone, and cerebral salt wasting syndrome. Neurosurgical complications may include visual disturbance, cerebrospinal fluid leak, subdural hematoma, and epistaxis.

Pharmacological management of secreting pituitary tumors.

Because pituitary adenomas can present in many ways, nurses need to be aware of the signs and symptoms of different hormone-secreting tumors and their related pharmacologic treatment. Although long-term medical management of secreting tumors and their hormonal complications is usually carried out on an outpatient basis, diagnosis often occurs during inpatient care. Consequently, nurses in both settings need to be knowledgeable about medications used, outcomes expected, and adverse effects experienced. Patient care should be centered around education and management of complications as patient compliance is increased with knowledge.

Craniopharyngiomas.

Craniopharyngiomas are rare, benign, suprasellar brain tumors that account for 1%-3% of all intracranial tumors. Pituitary gland involvement causes loss of pituitary function, which makes endocrine evaluation necessary before and after surgery. Symptoms of intracranial mass effect, including visual field loss, obstructive hydrocephalus, and extraocular palsy of the cranial nerves, may occur. Lifelong follow-up is crucial because of the risk of recurrence and the need for ongoing hormone replacement therapy. Surgical resection is the primary therapy. However, radiotherapy may be indicated. Nurses play a major role in caring for patients with a craniopharyngioma by preventing and identifying complications, educating patients and families about the importance of long-term follow-up, and collaborating with multidisciplinary teams.

Caring for the patient undergoing transsphenoidal surgery in the acute care setting: an alternative to critical care.

Patients undergoing transsphenoidal surgery have complex needs that require expert care and the coordination of a multidisciplinary team of healthcare professionals. In general, patients requiring this surgery are cared for in intensive care units. An innovative program at the University of Virginia, developed 11 years ago, enables these patients to be cared for on an acute care unit for the entirety of their hospitalization. The success of this program is evident in positive clinical and financial outcomes.

Endoscopic resection of pituitary lesions through the nostril.

The endoscope has been used in paranasal sinus surgery for many years. More recently, cooperation between neurosurgeons and ear, nose, and throat (ENT) surgeons has resulted in an extension of use of the endoscope to resection of lesions in the sella turcica region. The procedure described herein involves insertion of the endoscope and surgical instruments through one nostril to provide improved visualization of the pituitary gland and an economy of perioperative trauma. As compared with the traditional sublabial, transseptal approach, endonasal pituitary tumor resection is more direct, less traumatic, and allows excellent exposure of the tumor. These improvements result in reduced morbidity, shorter length of stay, and greater patient satisfaction.

Transsphenoidal resection of pituitary adenoma: using a critical pathway.

The use of a transsphenoidal critical pathway can be a vital tool for critical care nurses in anticipating complications and improving patient outcomes. Complications such as diabetes insipidus and cerebrospinal fluid leak associated with posttranssphenoidal patients may result in prolonged hospitalization and worsened functional outcome. Implementing a transsphenoidal critical pathway for these patients can guide their care and alert critical care nurses to potential complications and their prevention and/or treatment.

Management of the patient with a pituitary tumor resection.

The resection of a pituitary tumor represents a challenging diagnosis for the critical care nurse. There are important nursing assessments that can assist in identifying post-surgical complications. Detailed teaching instructions by the critical care nurses will also assist in minimizing the patient's postoperative complications.

Transsphenoidal adenomectomy.

The pituitary gland is a complex organ controlling many of the body's hormonal and metabolic functions. The gland's complexity and location in the brain have a serious impact on the diagnosis and treatment of pituitary pathology. Several surgical approaches are available to treat pituitary tumors; however, the transsphenoidal approach allows the surgeon to remove the tumor with minimal damage to surrounding intracranial structures. Perioperative nurses should be knowledgeable about pituitary pathology (ie, mass effect, hormonal involvement), patient treatment options, surgical approaches, and possible postoperative complications to provide quality nursing care.

Case management of the patient with pituitary tumor.

Many medical-surgical nurse case managers will care for patients with pituitary tumors at some point in their careers. These patients present multiple challenges throughout their courses of treatment. Using astute assessment and intervention skills, the nurse case manager can positively influence the outcomes of therapy for these patients, whether they are in the diagnostic, treatment, or follow-up phase of care. Nursing management can indeed make a difference in the costs of money, time, and functional disabilities experienced by patients with pituitary tumors.

Prolactinoma: a review and case study.

Prolactinomas are often characterized by a slow, insidious onset of symptoms. This case study highlights the need for a thorough understanding of the endocrine system and reinforces the importance of history taking and detailed nursing assessment.

Nursing care of pituitary surgery: an example of advanced clinical practice.

Because we have one of the leading pituitary surgeons in Canada, Dr. Harley Smyth, on our neurosurgical service we have nursed over 53f cases of pituitary tumor resection at the Wellesley Hospital. This series of patients represents a major ongoing international research project in Endocrinology and Neurosurgery and involves close teamwork between these two services and the nursing service. The paper gives a brief overview of pituitary surgery from its beginnings with Sir Victor Horsley in 1904 and details major breakthroughs since the 1960's. The three principal clinical groups of pituitary problems treated at the Wellesley are then outlined. The preoperative work-up on the endocrinology ward delineating clinical symptoms and precise hormonal values, the operation with the new anatomical approach developed by Dr. Smyth, and postoperative care with precise monitoring of fluid and electrolyte balance, methods of nasal packing, treatment of cerebrospinal fluid leaks and tracking of hormone levels are all examined in detail. We explain new developments such as the move to less steroid coverage and the better understanding of the ultrastructure and functional microbiology of pituitary tumors. We conclude by pointing out the excellent management of these patients, with a short hospital stay and much of the preoperative work-up done on an outpatient basis. As well these patients are an extremely satisfying group to nurse because of the high correction rate achieved. Finally, as nursing protocols constantly change and as we continually learn more from this research project, we emphasize the need for the flexibility and knowledge of the advanced nursing practitioner.

Complications of transsphenoidal surgery.

Transsphenoidal surgery has many advantages in providing access to the sella turcica. It is associated with relatively low morbidity and mortality but it should be recognized that it is not without risk. Often, signs and symptoms of complications from transsphenoidal surgery are observed by the nurse. With early detection and prompt management, patients need not suffer the serious disabilities that may ensue.