1. ADRENAL GLANDS n Adrenal Cortex n Adrenal Medulla

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4. ADRENAL CORTEX n Sugar n Salt n Sex

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

6. 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?

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

8. Exogenous Corticosteroids n **______________ n ______________

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

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

11. SEX n ESTROGENS n ANDROGENS –hormones which male characteristics n release of testosterone Do women produce androgens?

12. RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ______

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

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

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

16. HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES n Too much n Too little

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

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

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

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

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

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

23. Cushing Syndrome vs Cushing’s Disease

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

25. ETIOLOGY Cushing’s n Cushing’s Disease –_____________________ n Cushing Syndrome –_____________________

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

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

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

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

30. Before

31. After

32. What sign would the nurse identify in each patient?

33. SIGNS AND SYMPTOMS Cushing’s n androgen secretion –What would you expect to see?

34. SIGNS & SYMPTOMS n mineralocorticoid activity – ________ retention _______ retention –What happens to blood pressure?

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

37. SIGNS & SYMPTOMS n s in hematology n WBCs n lymphocytes n eosinophils

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

39. High Dose Dexamethasone Suppression Test ACTHCortisol Low/undectableNot suppressed Adrenal Cushing syndrome is likely. Normal- Very High Lack of suppression Ectopic ACTH syndrome is likely. If an adrenal tumor is not apparent, a chest CT and abdominal CT is indicated to rule out a different tumor secreting ACTH Normal - ElevatedIs suppressed Cushing’s disease should be considered. A pituitary MRI would be needed to confirm

40. Markers of Adrenal Cortex function n 17-hydroxycorticosteroids (17-OHCS) n 17-ketosteroid sulfates (17-KS-S)

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

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

43. TREATMENT of Cushing’s n 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

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

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

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

47. Nursing Diagnosis n Risk for infection n Imbalanced nutrition more than requirements n Risk for injury…inc muscle wasting n Disturbed body image n Impaired skin integrity n Fluid volume excess

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

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

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

52. ETIOLOGY of Addison’s n Malignancy n TB n Fungal infections (histoplasmosis) n AIDS n Iatrogenic causes –adrenalectomy, chemo, anticoagulant tx

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

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

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

56. DIAGNOSIS-Addison’s n ____serum cortisol n ____urinary 17-OHCS and 17 KS n ____K n ____Na n ____serum glucose n ____plasma ACTH n ____urine free cortisol

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

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

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

60. COMPLICATIONS Addison’s Disease n Adrenal crisis n Electrolyte imbalance n Hypoglycemia

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

62. CAUSES n Name 4 causes –1. __________________________ –2. __________________________ –3. __________________________ –4. __________________________

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

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

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

66. TREATMENT n Try to anxiety n May have to give vasopressors –Dopamine or Epinepherine n Avoid additional stress

67. Adrenal Medulla

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

70. CATECHOLAMINE RELEASE n Epinephrine n Norepinephrine

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

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

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

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

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

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

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

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

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

80. Now Let’s Practice Some Questions….