ADRENAL GLANDS

Adrenal Cortex Adrenal Medulla

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ADRENAL CORTEX

Sugar Salt Sex

SUGAR 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

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

SUGARcon’tOther functions of Cortisol

What happens to cortisol levels during stressful times?

What does it do to the inflammatory response? What does it do the immune response? Can you name some exogenous

corticosteroids?

Exogenous Corticosteroids

Common **______________ **______________ **______________ **______________

Betamethasone (Celestone) Budesonide (Entocort EC) Cortisone (Cortone) Prednisolone (Prelone) Triamcinolone (Kenacort, Kenalog)

SALT

Mineralocorticoids (F & E balance)

AldosteroneWhat stimulates aldosterone secretion?What inhibits adlosterone secretion?

Na retention Water retentionK excretionHydrogen ion excretion

Question:If your Na level is low, will aldosterone secretion

or

If your serum K+ level is high, will aldosterone secretion

or

SEX

ANDROGENS hormones which male characteristics

release of testosterone

RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ___?___

LET’S LOOK AT ACTH(adrenocorticotropic hormone)

Produced where?

ACTH

Circulating levels of cortisol levels cause __________ of ACTH

levels cause __________ of ACTH

think tank:

What type of feedback mechanism is this??

AFFECTED BY:

Individual biorhythms ACTH LEVELS ARE HIGHEST 2 HOURS

BEFORE AND JUST AFTER AWAKENING. usually 5AM - 7AM these gradually decrease the rest of day

Stress- ____cortisol production & secretion

HYPER & HYPOFUNCTION ADRENAL CORTEX HORMONES

Too much

Too little

Too much aldosterone secretion Question:

What does aldosterone do????

_____________________________ usually caused by adrenal tumor

HYPERALDOSTERONISM“Conn’s Syndrome”

SIGNS & SYMPTOMSHyperaldosteronism Na and water retention

What is the normal serum K+ level?

Usually no edema

DIAGNOSISHyperaldosteronism urinary K

plasma aldosterone & Na levels with low plasma renin levels

BP

CT scan EKG changes Labs

Presence of hypokalemia with HTN – suspect CONNS

INTERVENTIONSHyperaldosteronism

BP What drugs would you give?

Correct hypokalemia/hypernatremia What you would you do?

Partial or total adrenalectomy

ADRENALECTOMYPRE-OP

Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol

levels before or after surgery?

ADRENALECTOMYPOST-OP ICU-What type of problems to expect??

IV cortisol for 24 hours IM cortisol 2nd day PO cortisol 3rd day

Possible hypo/hyperkalemia If unilateral- steroids weaned

Cushing Syndrome

vs

Cushing’s Disease

CUSHING’S DISEASE(TOO MUCH CORTISOL!)

secretion of cortisol 4X more frequent in females Usually occurs at 20-40 years of age if not related to exogenous factors

ETIOLOGYCushing’s Cushing’s Disease

_____________________

Cushing Syndrome _____________________ _____________________ _____________________

SIGNS & SYMPTOMS Cushing’s protein catabolism

muscle wasting

*loss of collagen support

poor wound healing

SIGNS & SYMPTOMSCushing’s Electrolyte imbalances

Which ones?

s in carbohydrate metabolism Hyperglycemia

Why?

SIGNS & SYMPTOMSCushing’s s in fat metabolism

****abdomen aka: _________

cervical spine aka: _________

****face aka: _________

SIGNS & SYMPTOMS

immune response

More prone to infection

resistance to stress

What sign would the nurse identify in each patient?

SIGNS & SYMPTOMS

mineralocorticoid activity ________ retention

_______ retention

What happens to blood pressure?

SIGNS & SYMPTOMSMENTAL CHANGES

Mood swings Euphoria Depression Anxiety

Mild to severe depression

Psychosis Poor concentration and

memory Sleep disorders

SIGNS & SYMPTOMS

s in hematology

WBCs

lymphocytes

eosinophils

DIAGNOSIS of Cushing’s

Clinical presentation is the first indication: truncal obesity “moon facies” – with plethora purplish red striae hirsutism menstrual disorders hypertension unexplained hypokalemia

DIAGNOSIS of Cushing’s 24 hr urine collection for ‘free cortisol’

How do you do this? What levels would diagnosis Cushing?

(When results are borderline…..dexamethasone suppression test)

Dexamethasone suppression test false positive can occur in depressed or overly stressed pts

Serum cortisol levels What will serum cortisol levels be? Draw AT 8AM AND 8PM

What would you expect?

High DoseDexamethasone Suppression Test

ACTH Cortisol

Low/undectable Not 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 - Elevated Is suppressed Cushing’s disease should be considered. A pituitary MRI would be needed to confirm

Markers of Adrenal Cortex function

Urinary 17-hydroxycorticosteroids (17-OHCS)

17-ketosteroid sulfates (17-KS-S)

DIAGNOSIS of Cushing’s Plasma ACTH levels

Low, normal or elevated? Other labs associated with Cushing’s

Leukocytosis - Lymphopenia Eosinopenia - Hyperglycemia Glycosuria - Hypercalcemia Osteoporosis - ****Hypokalemia Alkalosis

CT & MRI Of what? Looking for what?

TREATMENT of Cushing’s Primary goal:

What do you think?

Treatment related to underlying cause!!!!!

TREATMENT of Cushing’s 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

TREATMENT of Cushing’s Radiation to tumors

Why would one choose radiation?

Palliative drugs Goal of drug therapy? MITOTANE

directly suppresses

adrenal cortex fx

Others: Metyrapone blocks cortisol synthesis &

Ketocenozole blocks cortisol sysnthesis

TREATMENT of Cushing’s

What if Cushing Syndrome is result of exogenous corticosteroids?

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

Nursing Diagnosis

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

ADDISON’S DISEASEhypofunction of adrenal cortex What hormones will you have too little of???

glucocorticoids or _______

mineralocorticoids or _______

androgens or ____________

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

ETIOLOGY of Addison’s

Idiopathic atrophyautoimmune condition

antibodies attack against own adrenal cortex

90% of tissue destroyed

ETIOLOGY of Addison’s

Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes

SIGNS & SYMPTOMSAddison’s Disease Fatigue, weight loss, anorexia

Changes in skin pigment small black freckles

Muscular weakness

SIGNS & SYMPTOMS Addison’s Fluid & electrolyte imbalances

b.p.

Hyponatremia Hyperkalemia Hypoglycemia

SIGNS & SYMPTOMS Addison’s

androgens hair loss, sexual fx

mental disturbances anxiety, irritability, etc.

salt craving

DIAGNOSIS-Addison’s

____serum cortisol ____urinary 17-OHCS and 17 KS ____K ____Na ____serum glucose ____plasma ACTH ____urine free cortisol

INTERVENTIONSAddison’s Disease Life long hormone replacement

primary-need_______________ 20-25mgs in AM & 10-12mg in PM

When might one need to increase the dose? also need mineralocorticoid-

(FLORINEF)

INTERVENTIONS

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

INTERVENTIONSAddison’s Disease Keep parenteral glucocorticoids at

home for injection during illness Do you need to avoid

infections/stress?

COMPLICATIONSAddison’s Disease Adrenal crisis Electrolyte imbalance Hypoglycemia

ADDISON’S CRISIS

Sudden decrease or absence of adrenal cortex hormones which are:

__________________

__________________

__________________

Addison’sCAUSES

Name 4 causes 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________

SIGNS & SYMPTOMSAddisonian Crisis Dehydration- Na, K, BP

N/V,diarrhea, wt. loss Weakness & fatigue Confusion, headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH

Question

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

TREATMENTAddisonian Crisis

Rapid infusion of IV fluids What IV fluids will be used?

Check VS & UO frequently Why?

Monitor EKG Treat hyperkalemia

How? Give Solu-Cortef IV Q6 hours until S & S

disappear

TREATMENT

Try to anxiety May have to give vasopressors

Dopamine or Epinepherine

Avoid additional stress

Adrenal Medulla

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ADRENAL MEDULLA

Fight or flight What is released by the adrenal medulla?

CATECHOLAMINE RELEASE Epinephrine Norepinephrine

Be sure to know what each does.

Epinephrine

Regulates HR & BP inc. blood glucose stimulate ACTH stimulate glucorticoids inc. rate & force of cardiac contractions constricts blood vessels in skin, mucous

membranes, & kidneys dilates blood vessels in skeletal muscles,

coronary & pulmonary arteries

Norepinephrine

Increases HR & force of contractions

Constricts blood vessels throughout the body

Hyperfunction of the Adrenal Medulla

PHEOCHROMOCYTOMA

rare, benign tumor of the adrenal medulla oh no...what are we going to

see a hypersecretion of????

SIGNS AND SYMPTOMSPheochromocytoma What do you think is the hallmark sign? Paroxymal attacks****

NE and Epinepherine released sporadically Attacks may be provoked by meds

antihypertensives, opioids, contrast media If untreated DM, cardiomyopathy, death

Why?

SIGNS & SYMPTOMSPheochromocytoma Deep breathing Pounding heart Headache Moist cool hands & feet Visual disturbances

DIAGNOSISPheochromocytoma

Often missed 24 hour urine

fractionated metanephrines fractionated cathecholamines creatinine Are these increased or decreased?

Plasma catecholamines When are these drawn? Are these increased or decreased?

CT to locate tumor

Interventions/TreatmentPheochromocytoma Primary goal? Primary treatment? Pre - op

Calcium channel blockers Cardene

Sympathetic blocking agents Minipress (watch for orthostatic hypotension)

Beta blocking agents Inderal

INTERVENTIONS

Monitor b.p.Eliminate attacksIf attack- complete bedrest and

HOB 45 degrees

Interventions/TreatmentPheochromocytoma

Diet high in vitamins, minerals, calories, no caffeine

Sedatives

DURING SURGERY

give REGITINE & NIPRIDE to prevent hypertensive crisis

Laparoscopic Adrenalectomy/Open abdominal incision

POST-OP

b.p. may be initially, BUT CAN BOTTOM OUT

Volume expanders Vasopressors Hourly I and O Observe for hemorrhage

QUESTION??

What if you are not a candidate for surgery? Demser

(drug which inhibits catecholamine synthesis)

Avoid opiates, histamines, Reglan, anti-depressants. Why?