1. A. MacLeod, Fall 20021 Disturbances of the Adrenal Gland Semester V RN Fall 2002 Ann MacLeod, RN, BScN, MPH

2. A. MacLeod, Fall 20022 Agenda w Test Take Up w Understand Disturbances of the Adrenal Gland w Assessment of w Nursing diagnoses w Nursing care

3. A. MacLeod, Fall 20023 Disturbance in Adrenal Hormones w Over view: A&P: adrenal glands- 2 small structures which cap the top of the kidneys w each composed of 2 structures with its own function w inner core: adrenal medulla w outer shell: adrenal cortex

4. A. MacLeod, Fall 20024 Functions of Adrenal Medulla: w Adrenal medulla: releases epinephrine and norepinepherine which convert glycogen to glucose to increase cardiac output w Fight or flight response w nor-epinephrine produces vascular constriction which increases BP

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6. 6 Hyposecretion of the adrenal medulla w Assessment  plasma and urine catacholamines, epinephrine and norepinephrine low BP, little fight or flight response uncommon w management supplement with catacholamines

7. A. MacLeod, Fall 20027 Adrenal Medulla (hypertrophy)  epinephrine & norepinephrine w Pheochromocytoma: tumor of the adrenal gland Assessment can be life-threatening headache, vertigo, blurred visiontinnitus dyspnea, palpitations, tachycardia hyperglycemia, glucosuria hypertension very high (and postural hypotension) nervousness, anxiety, tremors indigestion, nausea, vomiting, abdominal pain fatigue, exhaustion

8. A. MacLeod, Fall 20028 Pheochromocytoma: tumor of the adrenal gland Assessment cont’d w  plasma & urine epinephrine and norepinephrine (catecholamines) w clonidine ( Catapres) suppression test blocks sympathetic stimulation & will not suppress if the gland is over producing epinephrine w CT Scan, MRI, MIBG tagged x-ray, ultrasound

9. A. MacLeod, Fall 20029 Pheochromocytoma: tumor of the adrenal gland: Management w Pharmacologic tx to treat symptoms alpha adrenergic blockers (phentolamine) beta adrenergic blockers (propranolol) catacholamine synthesis inhibitors (metyrosine) w Surgical removal: adrenalectomy then supplement catacholamines andn corticosteroids monitor BP, BS, ECGs

10. A. MacLeod, Fall 200210 Adrenal Cortex w Hypothalamus  Corticotropin Releasing Hormone  Post. Pituitary releases Adrenocorticotropin hormone ( ACTH)  stimulate adrenal cortex to release hormones: Glucocorticoids ( cortisol): stimulates  blood glucose, anti- inflammation Mineralocorticoids (aldosterone) : regulates electrolyte balances Sex hormones (s/a estrogen, androgens) : sexual dev’p

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12. A. MacLeod, Fall 200212 Glucocorticoids- cortisol w Regulate blood sugar by conserving body glucose and promoting gluconeogenesis w regulates protein, fat and CHO metabolism w stress response w anti- inflammatory and immune response

13. A. MacLeod, Fall 200213 Mineralocorticoids-Aldosterone w promotes Na+ retention and K+ excretion w targets kidney tubules w only responsible for increases in blood volume of 5-10 % offset by increased Glomerular Filtration Rate w (ADH is more responsible) w low K+ muscle weakness, lowered membrane potential, therefore more easily excited  cramping and become weak

14. A. MacLeod, Fall 200214 Sex Hormones Androgens w small amount of estrogens w sexual development

15. A. MacLeod, Fall 200215 Hyposecretion of the Adrenal Cortex - Addison’s Disease w may be primary or secondary w Primary: as a result of atrophy or autoimmune destruction, tumors or suppressed pit. Function w secondary: insufficient ACTH from pituitary gland

16. A. MacLeod, Fall 200216 Glucocorticoid hyposecretion  cortisol w Wide spread metabolic imbalances w decreased gluconeogenesis  blood sugar (pt. Weak, exhausted, wt, loss, nausea, vomiting) w decreased resistance to stress, infection and inflammation

17. A. MacLeod, Fall 200217 Decreased aldosterone: w Na+ channels in Kidney tubule do NOT open  Na+ and H20 stay in the urine w Dehydration, hypotension, decreased Cardiac output, circulatory collapse w K+ cannot get into urine  hyperkalemia  K+  decreased muscle contractility  arrthymias  death

18. A. MacLeod, Fall 200218 Assessment: w Blood  K+,  WBC w Blood  Glucose,  Na+,  aldosterone w  Muscular weakness, anorexia, GI upset w fatigue, wt. Loss w decreased BP w chronic dehydration w ACTH fails to  cortisol

19. A. MacLeod, Fall 200219 Addisonian Crisis w When subject to stress, infection, trauma and surgery. (could be fatal) w headache, nausea, vomiting,fever, abd. Pain, severe hypotension w vascular collapse>>>SHOCK

20. A. MacLeod, Fall 200220 Management: w Immed. Tx. To combat shock and administer fluids w IV solucortef, vasopressin to increase BP w antibiotics to combat infection if present w Increase NA+, Decrease K+ diet w life long admin. Of corticosteroids and mineralocortoids

21. A. MacLeod, Fall 200221 Pharmacotherapy w Florinef: mineralocorticoid w cortisone, cortisol, prednisone, betamethesone} glucococorticoids w corticosteroids may cause S/E: moonface, wt. Gain, edema., K+ loss, Increased urination, nocturia, masking of s/s infection w Steroids must be tapered!

22. A. MacLeod, Fall 200222 Nursing Diagnoses/ Process w Fluid vol. deficit w Daily wt. I+O, assessment of mucous membranes w monitor BP freq. w Diet:  carb,  protein,  Na+, increased fluids w pharmcotherapy w monitor excessive sweating

23. A. MacLeod, Fall 200223 Nursing Process w Activity intolerance w Knowledge Deficit w Avoid stressful activity, quiet environ. Complete bedrest, help with bathing, turning w rationale for steroid replacements, medic alert, diet, wt,injectable hormones

24. A. MacLeod, Fall 200224 Hypersecretion of Adrenal Cortex: Cushing’s Syndrome w Usually secondary to hypersecretion of the of ACTH by the pituitary due to tumours w Hypercorticism: steroid hormone replacement

25. A. MacLeod, Fall 200225 Cushings syndrome

26. A. MacLeod, Fall 200226 Glucocorticoid Excess w Gluconeogenesis- Breakdown of fats and proteins to increase blood sugar w distrubution of adipose tissue in the abd. and behind shoulders (buffalo hump) w protein loss  thin skin, weak blood vessels, osteoporosis, decreased immunity ( IGg) w hyperglycemia  diabetes w vasoconstrictor (anti-inflammatory)

27. A. MacLeod, Fall 200227 Aldosterone Excess w Kidney tubules opens Na+ channels   Na+ and water retention in blood  edema, elevated BP w K+ is excreted in urine  blood depletion  hypokalemia  K+  muscle excitability  cramps, fatigue

28. A. MacLeod, Fall 200228 Androgen Excess w Women more masculin w hair on head thins w abnormal facial hair

29. A. MacLeod, Fall 200229 Assessment for Cushing’s Disease w 24 hr. urine: free cortisol increased w DST Dexamethesone Suppression Test: 1 mg. Of dexamethesone is given po the night before. This should suppress plasma cortisol levels at 0800 the next day to 50% of baseline w Blood tests:  Glucose,  K+,  Na+ w CT or MRI : adrenal mass or pit. tumor

30. A. MacLeod, Fall 200230 Management: w Surgical removal of the tumor of the pituitary gland is Rx. Of choice w adrenalectomy w may have radiation w often causes hyposecretion so must assess for this and monitor supplements of hormones

31. A. MacLeod, Fall 200231 Nursing Diagnoses w Risk for injury due to weakness w Self Care Deficit w imp. Skin integrity w high risk for infection w body image disturbance w fluid vol. Excess w pt. Teaching and followup

32. A. MacLeod, Fall 200232 Adrenalectomy Nursing Care: w Post-op: vital signs q 1-4hrs especially BP w I+O w observe for hemorrhage (area is highly vascular) w monitor serum electrolytes (may cause insufficiency w Be alert for s/s adrenal insufficency w IV corticosteroids w dressing change prn w observe for s/s infection and delayed wound healing

33. A. MacLeod, Fall 200233 Corticosteroid treatment w Either for Addisons, or post op adrenalectomy w actions: w  gluconeogenesis ( breakdown, fat & proteins) w inhibits prostoglandin formation  inflammatory process  complement system, and permeability, w cytokines blocked &B lymphocytes not activated  immune response w vasoconstriction & Na +retention   BP w  bone absorption into blood w stabilize mast cells therefore less broncho- constriction

34. A. MacLeod, Fall 200234 Cortisone-nursing considerations w Has both cortisol and mineralocorticoid hormones 15-30 mg PO daily w Taper Doses, give with or after meals w monitor blood counts and glucose, Na+ K+ w monitor mood changes, skin for lesions or acne, stretch marks, menstrual changes w monitor signs of infection w many drug contraindications w monitor weight loss, skin hyperpigmentation

35. A. MacLeod, Fall 200235 Cushings Syndrome Non-surgical maintenance w Monitor emotions & support systems w skin care & hygiene w Diet hi K+, low Na+ and calories

36. A. MacLeod, Fall 200236