1. ADRENAL EXCESS DISORDER

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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
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Collaborative Care:
Monitor fluid deficits
Administer prescribed hydrocortisone, continuous infusion of boluses
Treat hypercalemia
Treat Hypoglycemia
Medications :
hydrocortisone (Cortef), Prednisode, cortisone
Fludrocortisone (Florinef)

8. 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 y.o.
renal artery stenosis
renin-secreting tumors
Chronic kidney disease

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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.”

15. 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.

16. 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.”

17. 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.

18. 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

19. 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.

20. 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

21. 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.

22. 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, pp & ). St. Louis, MO: Mosby Inc.
RN Adult Medical Surgical Nursing Review Module Edition 8.0 pages
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), doi: /
Terzolo, M. M., Pia, A. A., & Reimondo, G. G. (2012). Subclinical Cushing's syndrome: definition and management. Clinical Endocrinology, 76(1), doi: /j x