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

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

A. MacLeod, Fall 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

A. MacLeod, Fall 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 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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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A. MacLeod, Fall 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

A. MacLeod, Fall 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

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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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!

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall Cushings syndrome

A. MacLeod, Fall 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)

A. MacLeod, Fall 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

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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall 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

A. MacLeod, Fall Cortisone-nursing considerations w Has both cortisol and mineralocorticoid hormones 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

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

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