A Mac Leod Fall 2002 Disturbances of the

A. Mac. Leod, Fall 2002 Disturbances of the Adrenal Gland Semester V RN Fall 2002 Ann Mac. Leod, RN, BSc. N, MPH 1

Agenda w w w Test Take Up Understand Disturbances of the Adrenal Gland Assessment of Nursing diagnoses Nursing care A. Mac. Leod, Fall 2002 2

Disturbance in Adrenal Hormones 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 w A. Mac. Leod, Fall 2002 3

Functions of Adrenal Medulla: 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 w A. Mac. Leod, Fall 2002 4

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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. Mac. Leod, Fall 2002 6

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. Mac. Leod, Fall 2002 7

Pheochromocytoma: tumor of the adrenal gland Assessment cont’d 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 w A. Mac. Leod, Fall 2002 8

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. Mac. Leod, Fall 2002 9

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 A. Mac. Leod, Fall 2002 10

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Glucocorticoids- cortisol 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 w A. Mac. Leod, Fall 2002 12

Mineralocorticoids-Aldosterone w w w promotes Na+ retention and K+ excretion targets kidney tubules only responsible for increases in blood volume of 5 -10 % offset by increased Glomerular Filtration Rate (ADH is more responsible) low K+ muscle weakness, lowered membrane potential, therefore more easily A. Mac. Leod, Fall 2002 excited cramping and become weak 13

Sex Hormones Androgens small amount of estrogens w sexual development w A. Mac. Leod, Fall 2002 14

Hyposecretion of the Adrenal Cortex - Addison’s Disease 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 w A. Mac. Leod, Fall 2002 15

Glucocorticoid hyposecretion cortisol Wide spread metabolic imbalances w decreased gluconeogenesis blood sugar (pt. Weak, exhausted, wt, loss, nausea, vomiting) w decreased resistance to stress, infection and inflammation w A. Mac. Leod, Fall 2002 16

Decreased aldosterone: Na+ channels in Kidney tubule do NOT open Na+ and H 20 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 w A. Mac. Leod, Fall 2002 17

Assessment: w w w w Blood K+, WBC Blood Glucose, Na+, aldosterone Muscular weakness, anorexia, GI upset fatigue, wt. Loss decreased BP chronic dehydration ACTH fails to cortisol A. Mac. Leod, Fall 2002 18

Addisonian Crisis When subject to stress, infection, trauma and surgery. (could be fatal) w headache, nausea, vomiting, fever, abd. Pain, severe hypotension w vascular collapse>>>SHOCK w A. Mac. Leod, Fall 2002 19

Management: w w w Immed. Tx. To combat shock and administer fluids IV solucortef, vasopressin to increase BP antibiotics to combat infection if present Increase NA+, Decrease K+ diet life long admin. Of corticosteroids and mineralocortoids A. Mac. Leod, Fall 2002 20

Pharmacotherapy 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! w A. Mac. Leod, Fall 2002 21

Nursing Diagnoses/ Process w Fluid vol. deficit Daily wt. I+O, assessment of mucous membranes w monitor BP freq. w Diet: carb, protein, Na+, increased fluids w pharmcotherapy w monitor excessive A. Mac. Leod, Fall 2002 22 sweating w

Nursing Process w Activity intolerance w Knowledge Deficit Avoid stressful activity, quiet environ. Complete bedrest, help with bathing, turning w rationale for steroid replacements, medic alert, diet, wt, injectable hormones w A. Mac. Leod, Fall 2002 23

Hypersecretion of Adrenal Cortex: Cushing’s Syndrome Usually secondary to hypersecretion of the of ACTH by the pituitary due to tumours w Hypercorticism: steroid hormone replacement w A. Mac. Leod, Fall 2002 24

Cushings syndrome A. Mac. Leod, Fall 2002 25

Glucocorticoid Excess w w w Gluconeogenesis- Breakdown of fats and proteins to increase blood sugar distrubution of adipose tissue in the abd. and behind shoulders (buffalo hump) protein loss thin skin, weak blood vessels, osteoporosis, decreased immunity ( IGg) hyperglycemia diabetes vasoconstrictor (anti-inflammatory) A. Mac. Leod, Fall 2002 26

Aldosterone Excess 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 w A. Mac. Leod, Fall 2002 27

Androgen Excess Women more masculin w hair on head thins w abnormal facial hair w A. Mac. Leod, Fall 2002 28

Assessment for Cushing’s Disease 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 w A. Mac. Leod, Fall 2002 29

Management: 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 w A. Mac. Leod, Fall 2002 30

Nursing Diagnoses w w w w Risk for injury due to weakness Self Care Deficit imp. Skin integrity high risk for infection body image disturbance fluid vol. Excess pt. Teaching and followup A. Mac. Leod, Fall 2002 31

Adrenalectomy Nursing Care: Post-op: vital signs q 1 -4 hrs 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 w A. Mac. Leod, Fall 2002 32

Corticosteroid treatment w w w w Either for Addisons, or post op adrenalectomy actions: gluconeogenesis ( breakdown, fat & proteins) inhibits prostoglandin formation inflammatory process complement system, and permeability, cytokines blocked &B lymphocytes not activated immune response vasoconstriction & Na +retention BP bone absorption into blood stabilize mast cells therefore less broncho. A. Mac. Leod, Fall 2002 33 constriction

Cortisone-nursing considerations w w w w Has both cortisol and mineralocorticoid hormones 15 -30 mg PO daily Taper Doses, give with or after meals monitor blood counts and glucose, Na+ K+ monitor mood changes, skin for lesions or acne, stretch marks, menstrual changes monitor signs of infection many drug contraindications monitor weight loss, skin hyperpigmentation A. Mac. Leod, Fall 2002 34

Cushings Syndrome Non-surgical maintenance Monitor emotions & support systems w skin care & hygiene w Diet hi K+, low Na+ and calories w A. Mac. Leod, Fall 2002 35

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