ADRENAL GLANDS Adrenal Cortex Adrenal Medulla

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ADRENAL CORTEX Sugar Salt Sex

SUGAR GLUCOCORTICOIDS (regulate metabolism & are critical in stress response) CORTISOL responsible for control and & metabolism of: CHO (carbohydrates) --- Regulation of blood glucose concentration - inc thru gluconeogenesis - dec use during fasting

SUGAR con’t - Cortisol b. FATS-control of fat metabolism - stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism stimulates protein synthesis in liver protein breakdown in tissues How much per day?

SUGAR con’t Other functions of Cortisol What does it do to the inflammatory response? What does it do the immune response?

Exogenous Corticosteroids **______________ ______________

SALT Mineralocorticoids (F & E balance) Na retention Water retention What stimulates aldosterone secretion? What inhibits adlosterone secretion? Na retention Water retention K excretion Hydrogen ion secretion

Question: If your Na level is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion

SEX ESTROGENS ANDROGENS release of testosterone hormones which male characteristics release of testosterone Do women produce androgens?

RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ______

LET’S LOOK AT ACTH (adrenocorticotropic hormone) Produced where?

ACTH Circulating levels of cortisol levels cause __________ of ACTH think tank: What type of feedback mechanism is this??

AFFECTED BY: Individual biorhythms ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. usually 5AM - 7AM these gradually decrease rest of day Stress- ____cortisol production & secretion

HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES Too much Too little

II. HYPERALDOSTERONISM “Conn’s Syndrome” Too much aldosterone secretion Question: What does aldosterone do???? _____________________________ usually caused by adrenal tumor

SIGNS & SYMPTOMS Hyperaldosteronism Na and water retention What s/s would you expect? What is the normal serum K+ level? Usually no edema Why?

DIAGNOSIS-Hyperaldosteronism urinary K plasma aldosterone & Na levels with low plasma renin levels CT scan EKG changes

INTERVENTIONS Hyperaldosteronism BP What drugs would you give? Correct hypokalemia/hypernatremia What you would you do? Partial or total adrenalectomy

ADRENALECTOMY PRE-OP Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol levels before or after surgery?

ADRENALECTOMY POST-OP ICU-What type of problems to expect?? IV cortisol for 24 hours IM cortisol 2nd day PO cortisol 3rd day Possible hypo/hyperkalemia What are some s/s of this? What would an ekg look like for hypokalemia? If unilateral- steroids weaned

Cushing Syndrome vs Cushing’s Disease

CUSHING’S DISEASE (TOO MUCH CORTISOL!) secretion of cortisol from adrenal cortex 4X more frequent in females Usually occurs at 20-40 years of age

ETIOLOGY Cushing’s Cushing’s Disease Cushing Syndrome _____________________ Cushing Syndrome

SIGNS & SYMPTOMS Cushing’s protein catabolism muscle wasting ****loss of collagen support poor wound healing

SIGNS & SYMPTOMS Cushing’s Electrolyte imbalances Which ones? s in CHO metabolism Hyperglycemia Why?

SIGNS & SYMPTOMS Cushing’s s in fat metabolism ****abdomen aka: _________ cervical spine ****face

SIGNS & SYMPTOMS immune response More prone to infection resistance to stress Common cause of death?

Before

After

What sign would the nurse identify in each patient?

SIGNS AND SYMPTOMS Cushing’s androgen secretion What would you expect to see?

SIGNS & SYMPTOMS mineralocorticoid activity _______ retention What happens to blood pressure?

SIGNS & SYMPTOMS MENTAL CHANGES Mild to severe depression Psychosis Poor concentration and memory Sleep disorders Mood swings Euphoria Depression Anxiety

SIGNS & SYMPTOMS s in hematology WBCs lymphocytes eosinophils

DIAGNOSIS of Cushing’s 24 hr urine collection for ‘free cortisol’ How do you do this? What levels would diagnosis Cushing? (When results are borderline…..dexamethasone suppression test) Dexamethasone suppression test --------------------------------------false positive can occur in depressed pts Serum cortisol levels What will serum cortisol levels be? Draw AT 8AM AND 8PM What would you expect?

DIAGNOSIS of Cushing’s Plasma ACTH levels Low, normal or elevated? Other labs associated with Cushing’s Leukocytosis - Lymphopenia Eosinopenia - Hyperglycemia Glycosuria - Hypercalcemia Osteoporosis - ****Hypokalemia Alkalosis CT & MRI Of what? Looking for what?

TREATMENT of Cushing’s Primary goal: What do you think? Treatment related to underlying cause!!!!!

TREATMENT of Cushing’s Surgery transsphenoidal -removal of pituitary tumor ectopic ACTH secreting tumor -try to remove source of ACTH secretion adrenalectomy -can be unilateral or bilateral -if bilateral, need hormone replacement for life -Laproscopic vs Open Surgical

TREATMENT of Cushing’s Radiation to tumors Why would one choose radiation? Palliative drugs Goal of drug therapy? MITOTANE destroys tissue in adrenal cortex

TREATMENT of Cushing’s What if Cushing Syndrome is result of exogenous corticosteroids?

REVIEW: WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHING’S?

ADDISON’S DISEASE hypofunction of adrenal cortex What hormones will you have too little of??? glucocorticoids or _______ mineralocorticoids or _______ androgens or ____________

Trivia Question: Which famous President had Addison’s Disease???

ETIOLOGY of Addison’s Idiopathic atrophy autoimmune condition Antibodies attack against own adrenal cortex 90% of tissue destroyed

ETIOLOGY of Addison’s Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes adrenalectomy, chemo, anticoagulant tx Iatrogenic causes ----- anticoagulant ---- cause Adrenal hemmorage

SIGNS & SYMPTOMS Addison’s Disease fatigue, weight loss, anorexia Why? think of cortisol fx Changes in skin pigment small black freckles Why? Muscular weakness

SIGNS & SYMPTOMS Addison’s Fluid & electrolyte imbalances WHY? b.p. Hyponatremia-why? Hyperkalemia-why? Hypoglycemia-why?

SIGNS & SYMPTOMS Addison’s androgens hair loss, sexual fx mental disturbances anxiety, irritability, etc. salt craving-why?

DIAGNOSIS-Addison’s ____serum cortisol ____urinary 17-OHCS and 17 KS ____serum glucose ____plasma ACTH ____urine free cortisol

INTERVENTIONS Addison’s Disease Life long hormone replacement primary-need_______________ 20-25mgs in AM & 10-12mg in PM Why different doses? When might one need to increase the dose? also need mineralocorticoid-(FLORINEF)

INTERVENTIONS Salt food liberally Do not fast or omit meals Eat between meals and snack Eat diet high in carbs and proteins Wear medic-alert bracelet kit of 100mg hydrocortisone IM

INTERVENTIONS Addison’s Disease Keep parenteral glucocorticoids at home for injection during illness Avoid infections/stress

COMPLICATIONS Addison’s Disease Adrenal crisis Electrolyte imbalance Hypoglycemia

ADDISON’S CRISIS Sudden decrease or absence of adrenal cortex hormones which are: __________________

CAUSES Name 4 causes 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________

SIGNS & SYMPTOMS Addisonian Crisis Dehydration- Na, K, BP N/V,diarrhea, wt. loss Weakness Confusion,headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH

Question If an EKG were performed on a client in Addisonian Crisis, what would you expect to see?

TREATMENT Addisonian Crisis Rapid infusion of IV fluids What IV fluids will be used? Check VS & UO frequently Why? Monitor EKG Treat hyperkalemia How? Give Solu-Cortef IV Q6 hours until S & S disappear

TREATMENT Try to anxiety May have to give vasopressors Dopamine or Epinepherine Avoid additional stress

Adrenal Medulla

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ADRENAL MEDULLA Fight or flight What is released by the adrenal medulla?

CATECHOLAMINE RELEASE Epinephrine Norepinephrine

Hyperfunction of the Adrenal Medulla PHEOCHROMOCYTOMA rare, benign tumor of the adrenal medulla oh no...what are we going to see a hypersecretion of????

SIGNS AND SYMPTOMS Pheochromocytoma What do you think is the hallmark sign? Paroxymal attacks**** NE and Epinepherine released sporadically Attacks may be provoked by meds antihypertensives, opioids, contrast media If untreated  DM, cardiomyopathy, death Why?

SIGNS & SYMPTOMS Pheochromocytoma Deep breathing Pounding heart Headache Moist cool hands & feet Visual disturbances

DIAGNOSIS Pheochromocytoma Often missed 24 hour urine fractionated metanephrines fractionated cathecholamines creatinine Are these increased or decreased? Plasma catecholamines When are these drawn? CT to locate tumor

INTERVENTIONS-PRE-OP Adrenergic blocking agents Minipress to bp Beta blocking agents Inderal to hr, b.p., & force of contraction Diet high in vitamin, mineral,calorie, no caffeine Sedatives

INTERVENTIONS Monitor b.p. Eliminate attacks If attack- complete bedrest and HOB 45 degrees

Laparoscopic Adrenalectomy/ Open abdominal Incision DURING SURGERY GIVE REGITINE AND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS

POST-OP b.p. may be initially, Volume expanders Vasopressors BUT CAN BOTTOM OUT Volume expanders Vasopressors Hourly I and O Observe for hemorrhage

QUESTION?? What if you are not a candidate for surgery? Demser (drug which inhibits catecholamine synthesis) Avoid opiates, histamines, reglan, anti-depressants. Why?

Now Let’s Practice Some Questions….