Copyright © 2017, Elsevier Inc. All rights reserved.

Adrenal Gland Adrenal cortex Adrenal medulla Each portion has different functions and secretes different hormones. Feedback process of hormone regulation Copyright © 2017, Elsevier Inc. All rights reserved.

Adrenal Gland (Cont.) Adrenal medulla secretes catecholamines. Epinephrine Norepinephrine Adrenal cortex secretes corticosteroids. Glucocorticoids Mineralocorticoids (primarily aldosterone) Copyright © 2017, Elsevier Inc. All rights reserved.

Adrenocortical Hormones
Oversecretion leads to Cushing’s syndrome. Undersecretion leads to Addison’s disease. Copyright © 2017, Elsevier Inc. All rights reserved.

Adrenal Drugs Can be either synthetic or natural Many different drugs and forms Glucocorticoids Topical, systemic, inhaled, nasal Mineralocorticoid Systemic Adrenal steroid inhibitors Copyright © 2017, Elsevier Inc. All rights reserved.

Adrenal Drugs (Cont.) Glucocorticoids adrenocorticotropic hormone betamethasone cortisone dexamethasone hydrocortisone methylprednisolone prednisolone triamcinolone Copyright © 2017, Elsevier Inc. All rights reserved.

Mechanism of Action Most corticosteroids exert their effects by modifying enzyme activity. Glucocorticoids differ in their potency, duration of action, and the extent to which they cause salt and fluid retention. Glucocorticoids inhibit or help control inflammatory and immune responses. Copyright © 2017, Elsevier Inc. All rights reserved.

Indications Adrenocortical deficiency Adrenogenital syndrome Bacterial meningitis Cerebral edema Collagen diseases (e.g., systemic lupus erythematosus) Dermatologic diseases (e.g., exfoliative dermatitis, pemphigus) Endocrine disorders (thyroiditis) Copyright © 2017, Elsevier Inc. All rights reserved.

Indications (Cont.) Gastrointestinal (GI) diseases (e.g., ulcerative colitis, regional enteritis) Exacerbations of chronic respiratory illnesses such as asthma and chronic obstructive pulmonary disease Hematologic disorders (reduce bleeding tendencies) Ophthalmic disorders (e.g., nonpyogenic inflammations) Copyright © 2017, Elsevier Inc. All rights reserved.

Indications (Cont.) Organ transplantation (decrease immune response to prevent organ rejection) Leukemias and lymphomas (palliative management) Nephrotic syndrome (remission of proteinuria) Spinal cord injury Copyright © 2017, Elsevier Inc. All rights reserved.

Administration Glucocorticoids administration By inhalation for control of steroid-responsive bronchospastic states Nasally for rhinitis and to prevent the recurrence of polyps after surgical removal Topically for inflammations of the eye, ear, and skin Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question
The nurse should teach a patient taking an oral corticosteroid to take the medication at what time? 8:00 am 12 noon 5:00 pm 8:00 pm Correct answer: A Rationale: Oral corticosteroids should be taken in the morning to minimize adrenal suppression. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Contraindications Drug allergies Serious infections, including septicemia, systemic fungal infections, and varicella However, in the presence of tuberculous meningitis, glucocorticoids may be used to prevent inflammatory central nervous system (CNS) damage. Copyright © 2017, Elsevier Inc. All rights reserved.

Contraindications (Cont.)
Cautious use in patients with: Gastritis, reflux disease, ulcer disease Diabetes Cardiac, renal, or liver dysfunction Copyright © 2017, Elsevier Inc. All rights reserved.

Adverse Effects Potent effects on all body systems Cardiovascular: heart failure, cardiac edema, hypertension—all caused by electrolyte imbalances (hypokalemia, hypernatremia) CNS: convulsions, headache, vertigo, mood swings, nervousness, insomnia Copyright © 2017, Elsevier Inc. All rights reserved.

A patient is receiving prednisone as part of treatment for severe arthritis. He is also receiving furosemide (a loop diuretic), levothyroxine (for hypothyroidism), and a proton pump inhibitor and antacid (for gastroesophageal reflux disease). Which drug does the nurse identify as most likely to be a concern during the therapy with prednisone? Furosemide Levothyroxine Proton pump inhibitor Antacid Correct answer: A Rationale: Coadministration of a loop diuretic with a corticosteroid may result in hypokalemia because of the potassium loss caused by both drugs. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Adverse Effects (Cont.)
Potent effects on all body systems (Cont.) Endocrine: growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, hypothalamic–pituitary–adrenal axis suppression GI: peptic ulcers, pancreatitis, ulcerative esophagitis, abdominal distension Copyright © 2017, Elsevier Inc. All rights reserved.

Potent effects on all body systems (Cont). Integumentary: fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, hirsutism, urticaria Musculoskeletal: muscle weakness, loss of muscle mass, osteoporosis Copyright © 2017, Elsevier Inc. All rights reserved.

Interactions Multiple drug interactions, including: Non–potassium-sparing diuretics (e.g., thiazides, loop diuretics) can lead to severe hypocalcemia and hypokalemia. Aspirin, other nonsteroidal antiinflammatory drugs (NSAIDs), and other ulcerogenic drugs produces additive GI effects and an increased chance of gastric ulcer development. Anticholinesterase drugs produce weakness in patients with myasthenia gravis. Copyright © 2017, Elsevier Inc. All rights reserved.

Interactions (Cont.) Immunizing biologics inhibit the immune response to the biologic. Antidiabetic drugs may reduce the hypoglycemic effects of the latter and result in elevated blood glucose levels. Others Copyright © 2017, Elsevier Inc. All rights reserved.

When administering aminoglutethimide (Cytadren) to a patient, it is most important for the nurse to monitor serum electrolytes. cardiac enzymes. liver enzymes. arterial blood gases. Correct answer: C Rationale: Aminoglutethimide therapy may cause hepatotoxicity, so it is important to monitor liver enzymes. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Prednisone Most commonly used oral glucocorticoid for antiinflammatory or immunosuppressant purposes Also used to treat exacerbations of chronic respiratory illnesses Inadequate for the management of adrenocortical insufficiency (Addison’s disease) Copyright © 2017, Elsevier Inc. All rights reserved.

Methylprednisolone (Solu-Medrol)
Most commonly used injectable glucocorticoid drug Primary use: antiinflammatory or immunosuppressant drug Usually administered intravenously Available in a long-acting (depot) formulation Most injectable formulations contain a preservative (benzyl alcohol) that cannot be given to children younger than 28 days of age. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications Perform a physical assessment to determine baseline weight, height, intake and output status, vital signs (especially blood pressure), hydration status, and immune status. Obtain baseline laboratory studies. Assess for edema and electrolyte imbalances. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.)
Assess for contraindications to adrenal drugs, especially the presence of peptic ulcer disease. Assess for drug allergies and potential drug interactions (prescription and over-the-counter drugs). Be aware that these drugs may alter serum glucose and electrolyte levels. Copyright © 2017, Elsevier Inc. All rights reserved.

Systemic forms may be given by oral, intramuscular, intravenous, or rectal routes (not subcutaneous). Prepare and administer according to manufacturer’s directions. Oral forms should be given with food or milk to minimize GI upset. Copyright © 2017, Elsevier Inc. All rights reserved.

For topical applications, follow instructions about use and type of dressing, if any, to apply. Clear nasal passages before giving a nasal corticosteroid. Copyright © 2017, Elsevier Inc. All rights reserved.

After using an orally inhaled corticosteroid, instruct patients to rinse their mouths to prevent possible oral fungal infections. Teach patients taking corticosteroids to avoid contact with people with infections and to report any fever, increased weakness, lethargy, or sore throat. Copyright © 2017, Elsevier Inc. All rights reserved.

A patient is taking an inhaled corticosteroid for asthma. After the patient takes a dose of the inhaler, the nurse’s priority should be to listen to the patient’s breath sounds. have the patient rinse his mouth with warm water. instruct the patient to cough and deep breathe. take the patient’s apical pulse for 1 minute. Correct answer: B Rationale: The patient should rinse his mouth with water immediately after taking an inhaled corticosteroid to avoid oral fungal infections and other oral irritations. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Patients should be taught to take all adrenal medications at the same time every day, usually in the morning, with meals or food. Patients should not take adrenal medications with alcohol, aspirin, or NSAIDs. Copyright © 2017, Elsevier Inc. All rights reserved.

Sudden discontinuation of these drugs can precipitate an adrenal crisis caused by a sudden drop in serum levels of cortisone. Doses are usually tapered before the drug is discontinued. Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response Question
Which of the following should the nurse include when teaching a patient about glucocorticoid therapy? Do not abruptly stop taking the drug. Take the medication on an empty stomach. Avoid use of antiulcer medications when taking glucocorticoids. When used long term, alternate-day dosing of glucocorticoids will help minimize thyroid suppression. Correct answer: A Rationale: With oral and all other forms of glucocorticoids that are given short or long term, abrupt withdrawal must be avoided. Abrupt withdrawal of adrenal drugs (e.g., prednisone, methylprednisolone) may lead to a sudden decrease in, or no production of, endogenous glucocorticoids, resulting in adrenal insufficiency. It is recommended that oral dosage forms be given with a snack or meal to help minimize GI upset. An order for an H2 receptor antagonist or a proton pump inhibitor may be prescribed to minimize GI upset and to minimize ulcer formation because these drugs are ulcerogenic. In long-term therapy, alternate-day dosing of glucocorticoids, if possible, will help minimize the adrenal suppression. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.

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