ADRENAL EXCESS DISORDER

Overview of Adrenal Gland Adrenal cortex – outer shell Mineralocorticoids – Aldosterone Glucocorticoids – Cortisol Secondary sex hormones – Androgens and estrogens Adrenal medulla – inner core works as part of the sympathetic nervous system Produces epinephrine and norepinephrine

Cushing’s disease & Cushing’s syndrome Cushing’s Disease (endogenous) increased secretion of cortisol caused by increased amounts of ACTH secreted by pituitary gland. Cushing’s syndrome (exogenous) resulting from chronic and excessive production of cortisol by adrenal cortex or administration of large doses Risk Factors: Endogenous (Cushing’s disease) Adrenal hyperplasia Adrenocortical carcinoma Carcinoma of the lungs, GI tract, or pancreas, pituitary carcinoma Exogenous (Cushing’s syndrome) Organ transplant Chemotherapy Autoimmune diseases Asthma Allergies Chronic inflammation diseases

Signs and Symptoms: Moon face Buffalo hump Truncal obesity Weakness Fatigue Back and joint pain Irritability or depression Thin, fragile skin Bruising and petechiae Hypertension Tachycardia Weight gain Dependent edema

Diagnostics: Collaborative care: H&P exam Mental status exam Plasma cortisol levels, Plasma ACTH level CBC, WBC, Blood chemistries for sodium, potassium, glucose Dexamethasone suppression test 24-hr urine for free cortisol CT scan, MRI. Collaborative care: Decrease sodium intake, increase intake of potassium, protein, calcium Monitor intake output, daily weight Assess signs of hypervolemia Skin care, protect against skin breakdown and infection Medications: Aminoglutethimide (Cytadren), ketoconazole (Nizoral) Chemotherapy Hypophysectomy – removal of pituitary gland Adrenalectomy – removal of the adrenal gland

Addison’s Disease Signs and Symptoms: Hyperpigmention Weakness and fatigue Nausea and vomiting Dizziness with orthostatic hypothension Severe hypotension Dehydration Hyperkalemia Hypglycemia hypercalcemia (ATI Nursing Education) Adrenocortical insufficiency caused by damage of the adrenal cortex Decreased aldosterone and cortisol Adrenal crisis (medical emergency) – acute adrenal insufficiency, caused by sepsis, trauma, stress, adrenal hemorrhage, steroid withdrawal Risk Factors: Primary - autoimmune dysfunction, TB, hystoplasmosis, adrenalectomy, cancer Secondary – steroid withdrawal, hypophysectomy, pituitary neoplasm

Diagnostics: Collaborative Care: Medications : H&P exam Plasma cortisol level Urine cortisol and aldosterone levels Serum electrolytes ACTH-stimulate test CT scan, MRI ECG, XRAY, CT http://www.youtube.com/watch?v=qf C2te9Unbw Collaborative Care: Monitor fluid deficits Administer prescribed hydrocortisone, continuous infusion of boluses Treat hypercalemia Treat Hypoglycemia Medications : hydrocortisone (Cortef), Prednisode, cortisone Fludrocortisone (Florinef)

Hyperaldosteronism Risk factors : Characterized by excessive aldosterone secretion. Hallmark disease – hypertension with hypokalemic alkalosis. Primary hyperaldosteronism (PA) – caused by small solitary adrenocortical adenoma. Secondary hyperaldosteronism– occurs in response to a nonaderenal cause and elevated aldosterone levels such as renal artery. Risk factors : Age 30 -50 y.o. renal artery stenosis renin-secreting tumors Chronic kidney disease

Signs and symptoms: Diagnostic: Treatment: CT , MRI Hypernatremia Hypertension Headache Muscle weakness, Fatigue Cardiac dysrhythmias Glucose intolerance Metabolic alkalosis Tetany Diagnostic: CT , MRI 18 hydroxycorticosterone- (50ng/dL) Treatment: Adrenalectomy – 80% control HTN Potassium Calcium channel blocker Potassium sparing diuretic (cytaren) dexamethasone

Pheochromocytoma Signs and symptoms: Risk factors: A tumor of the center of the adrenal gland and medulla Excessive catecholamines (epinephrine, norepinephrine 10% - malignant Severe hypertension Risk factors: Neurofibromatosis Multiple endocrine neoplasia syndrome Age 40 – 60 y,o Signs and symptoms: Pain in chest/abdominal Hypertension Headaches Diaphoresis Palpitations Heat intolerance Tremors Apprehension

Diagnostic procedures: Treatments: Laboratory test: Vanillymandelic acid (VMA) testing – 24 hr. urine collection VMA normal level 2 to 7 mg/24hr. Diagnostic procedures: Clonidine suppression test Administration of phenotolamine (Regitine) Treatments: Alpha adrenergic blockers – prazosin, phenoxybenzmine Beta blockers – metoprolol (Lopressor) Glucocorticoids – Prednisone (Deltasone) Adrenalectomy surgery – complications of hypertensive crisis

NCLEX QUESTION #1 A client is diagnosed with pheochromocytoma. A nurse prepares a plan of care for the client; while planning, the nurse understand that pheochromocytoma is a condition that: 1. causes profound hypotension 2. is manifested by severe hypoglycemia 3. is not curable and is treated symptomatically 4. causes the release of excessive amounts of catecholamines

Answer: 4 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver.

NCLEX QUESTION #2 A nurse is providing discharge instructions to a client who has Cushing’s syndrome. Which client statement indicates that instructions related to the dietary management are understood? 1. “I can eat food that have a lot of potassium in them.” 2. “I will need to limit the amount of protein in my diet.” 3. “I am fortunate that I can eat all the salty foods I enjoy.” 4. “I am fortunate that I do not need to follow any special diet.”

Answer: 1 Rationale: A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing’s syndrome. Such diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.

NCLEX QUESTION #3 A nursing instructor asks a student to be describe the pathophysiology that occurs in Cushing’s disease. Which statement by the student indicates and accurate understanding of this disorder? 1. “Cushing’s disease results from an oversecretion of corticotropic hormones.: 2. “Cushing’s disease results from an undersecretion of mineralocorticoid hormones.” 3. “Cushing’s disease results from an undersecretion of mineralocorticoid hormones.” 4. “Cushing disease results from an increased pituitary secretion of adrenocorticotropic hormone.”

Answer: 4 Rationale: Cushing’s disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison’s disease is hypo secretion of adrenal cortex hormones from the adrenal gland.

NCLEX QUESTION #4 A nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. IN the preoperative period, the priority nursing action would be to monitor: 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

Answer: 4 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches.

NCLEX QUESTION #5 A nurse is performing an assessment on a client with pheochromocytoma. Which of the following assessment data would indicate a potential complication associated with this disorder? 1. A coagulation time of 5 minutes 2. A urinary output of 50 mil per hour 3. A blood urea nitrogen level of 20 mg/dL 4. A heart rate that is 90 beats/min and irregular

Answer: 4 Rationale: the complications associated with pheochromocytoma include hypertensive retinopathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias or dissection aortic aneurysm.

References http://www.youtube.com/watch?v=qfC2te9Unbw Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical- surgical nursing, assessment and management of clinical problems. (8th ed., Vol. 2, pp1430-1433 &1276-1284). St. Louis, MO: Mosby Inc. RN Adult Medical Surgical Nursing Review Module Edition 8.0 pages 1066-1091 Silvestri, L. A., (2012). Saunders Q&A review for the NCLEX-RN examination. (5th ed.)St. Louis, MO: Elsevier Inc. Vicennati, V., Repaci, A., di Dalmazi, G., Rinaldi, E., Golfieri, R., Giampalma, E., & ... Pasquali, R. (2012). Combined Aldosterone and Cortisol Secretion by Adrenal Incidentaloma. International Journal Of Surgical Pathology, 20(3), 316-319. doi:10.1177/1066896911427036 Terzolo, M. M., Pia, A. A., & Reimondo, G. G. (2012). Subclinical Cushing's syndrome: definition and management. Clinical Endocrinology, 76(1), 12-18. doi:10.1111/j.1365-2265.2011.04253.x http://www.youtube.com/watch?v=qfC2te9Unbw