ADRENAL GLANDSAdrenal CortexAdrenal Medulla

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ADRENAL CORTEX SugarSaltSex

SUGARGLUCOCORTICOIDS (regulate metabolism & are critical in stress response)CORTISOL responsible for control and & metabolism of:

CHO (carbohydrates)--- Regulation of blood glucose concentration- inc thru gluconeogenesis- dec use during fasting

SUGAR cont- Cortisolb. FATS-control of fat metabolism- stimulates fatty acid mobilization from adipose tissue

c. PROTEINS-control of protein metabolismstimulates protein synthesis in liverprotein breakdown in tissues

SUGARcontOther functions of CortisolWhat 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 CorticosteroidsCommon**______________**______________**______________**______________

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

SALTMineralocorticoids (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

SEXESTROGENSANDROGENShormones which male characteristicsrelease of testosterone

RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ___?___

LETS LOOK AT ACTH(adrenocorticotropic hormone)Produced where?

ACTHCirculating levels of cortisol levels cause __________ of ACTH

levels cause __________ of ACTH

think tank: What type of feedback mechanism is this??

AFFECTED BY:Individual biorhythmsACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING.usually 5AM - 7AMthese gradually decrease the rest of dayStress- ____cortisol production & secretion

HYPER & HYPOFUNCTION ADRENAL CORTEX HORMONES

Too much

Too little

Too much aldosterone secretionQuestion: What does aldosterone do????_____________________________usually caused by adrenal tumor

HYPERALDOSTERONISMConns Syndrome

SIGNS & SYMPTOMSHyperaldosteronismNa 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 scanEKG changesLabs

Presence of hypokalemia with HTN suspect CONNS

INTERVENTIONSHyperaldosteronism BP What drugs would you give?

Correct hypokalemia/hypernatremiaWhat you would you do?

Partial or total adrenalectomy

ADRENALECTOMYPRE-OP

Stabilize hormonallyCorrect fluid and electrolytesWould you need to replace cortisol levels before or after surgery?

ADRENALECTOMYPOST-OPICU-What type of problems to expect??IV cortisol for 24 hoursIM cortisol 2nd dayPO cortisol 3rd dayPossible hypo/hyperkalemiaIf unilateral- steroids weaned

Cushing Syndrome vs Cushings Disease

CUSHINGS DISEASE(TOO MUCH CORTISOL!) secretion of cortisol 4X more frequent in femalesUsually occurs at 20-40 years of age if not related to exogenous factors

ETIOLOGYCushingsCushings Disease_____________________

Cushing Syndrome_______________________________________________________________

SIGNS & SYMPTOMS Cushings protein catabolismmuscle wasting

*loss of collagen support

poor wound healing

SIGNS & SYMPTOMSCushingsElectrolyte imbalancesWhich ones? s in carbohydrate metabolismHyperglycemiaWhy?

SIGNS & SYMPTOMSCushings s in fat metabolism****abdomenaka: _________cervical spineaka: _________****face aka: _________

SIGNS & SYMPTOMS immune response

More prone to infection

resistance to stress

What sign would the nurse identify in each patient?

SIGNS AND SYMPTOMSCushings androgen secretionWhat would you expect to see?

SIGNS & SYMPTOMS mineralocorticoid activity ________ retention_______ retention

What happens to blood pressure?

SIGNS & SYMPTOMSMENTAL CHANGESMood swingsEuphoriaDepressionAnxietyMild to severe depressionPsychosisPoor concentration and memorySleep disorders

SIGNS & SYMPTOMS s in hematology

WBCs

lymphocytes

eosinophils

DIAGNOSIS of CushingsClinical presentation is the first indication:truncal obesitymoon facies with plethorapurplish red striaehirsutismmenstrual disordershypertensionunexplained hypokalemia

DIAGNOSIS of Cushings24 hr urine collection for free cortisolHow do you do this?What levels would diagnosis Cushing?

(When results are borderline..dexamethasone suppression test)

Dexamethasone suppression testfalse positive can occur in depressed or overly stressed pts

Serum cortisol levelsWhat will serum cortisol levels be? Draw AT 8AM AND 8PMWhat would you expect?

High DoseDexamethasone Suppression Test

ACTHCortisolLow/undectableNot suppressedAdrenal Cushing syndrome is likely.Normal-Very HighLack of suppressionEctopic 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 ACTHNormal - ElevatedIs suppressedCushings disease should be considered. A pituitary MRI would be needed to confirm

Markers of Adrenal Cortex function

Urinary17-hydroxycorticosteroids (17-OHCS)

17-ketosteroid sulfates (17-KS-S)

DIAGNOSIS of CushingsPlasma ACTH levelsLow, normal or elevated?Other labs associated with CushingsLeukocytosis- LymphopeniaEosinopenia- HyperglycemiaGlycosuria- HypercalcemiaOsteoporosis- ****HypokalemiaAlkalosisCT & MRI Of what?Looking for what?

TREATMENT of Cushings

Primary goal:What do you think?

Treatment related to underlying cause!!!!!

TREATMENT of CushingsSurgerytranssphenoidal -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 CushingsRadiation to tumorsWhy would one choose radiation?

Palliative drugsGoal of drug therapy?MITOTANE directly suppresses adrenal cortex fxOthers: Metyrapone blocks cortisol synthesis & Ketocenozole blocks cortisol sysnthesis

TREATMENT of Cushings

What if Cushing Syndrome is result of exogenous corticosteroids?

REVIEW:WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHINGS?

Nursing DiagnosisRisk for infectionImbalanced nutrition more than requirements Risk for injuryinc muscle wastingDisturbed body imageImpaired skin integrityFluid volume excess

ADDISONS DISEASEhypofunction of adrenal cortexWhat hormones will you have too little of???

glucocorticoids or _______

mineralocorticoids or _______

androgens or ____________

Trivia Question: Which famous President had Addisons Disease???

ETIOLOGY of AddisonsIdiopathic atrophyautoimmune condition antibodies attack against own adrenal cortex90% of tissue destroyed

ETIOLOGY of AddisonsMalignancyTBFungal infections (histoplasmosis)AIDSIatrogenic causes

SIGNS & SYMPTOMSAddisons DiseaseFatigue, weight loss, anorexia

Changes in skin pigmentsmall black freckles

Muscular weakness

SIGNS & SYMPTOMS AddisonsFluid & electrolyte imbalances

b.p.

HyponatremiaHyperkalemiaHypoglycemia

SIGNS & SYMPTOMS Addisons

androgenshair loss, sexual fxmental disturbancesanxiety, irritability, etc.salt craving

DIAGNOSIS-Addisons____serum cortisol____urinary 17-OHCS and 17 KS____K____Na____serum glucose____plasma ACTH ____urine free cortisol

INTERVENTIONSAddisons DiseaseLife long hormone replacementprimary-need_______________20-25mgs in AM & 10-12mg in PM

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

INTERVENTIONSSalt food liberallyDo not fast or omit mealsEat between meals and snackEat diet high in carbs and proteinsWear medic-alert braceletkit of 100mg hydrocortisone IM

INTERVENTIONSAddisons DiseaseKeep parenteral glucocorticoids at home for injection during illnessDo you need to avoid infections/stress?

COMPLICATIONSAddisons DiseaseAdrenal crisisElectrolyte imbalanceHypoglycemia

ADDISONS CRISISSudden decrease or absence of adrenal cortex hormones which are: __________________ __________________ __________________

AddisonsCAUSESName 4 causes1. __________________________2. __________________________3. __________________________4. __________________________

SIGNS & SYMPTOMSAddisonian CrisisDehydration- Na, K, BP N/V,diarrhea, wt. lossWeakness & fatigueConfusion, headacheHypovolemic shock, comaPallor, Inc. HR,RR, hypoglycemiaRenal shut-down-DEATH

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

TREATMENTAddisonian CrisisRapid infusion of IV fluidsWhat IV fluids will be used?Check VS & UO frequentlyWhy?Monitor EKGTreat hyperkalemiaHow?Give Solu-Cortef IV Q6 hours until S & S disappear

TREATMENTTry to anxietyMay have to give vasopressorsDopamine or EpinepherineAvoid additional stress

Adrenal Medulla

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ADRENAL MEDULLAFight or flightWhat is released by the adrenal medulla?

CATECHOLAMINE RELEASEEpinephrineNorepinephrine

Be sure to know what each does.

EpinephrineRegulates HR & BPinc. blood glucosestimulate ACTHstimulate glucorticoidsinc. rate & force of cardiac contractionsconstricts blood vessels in skin, mucous membranes, & kidneysdilates blood vessels in skeletal muscles, coronary & pulmonary arteries

NorepinephrineIncreases HR & force of contractions

Constricts blood vessels throughout the body

Hyperfunction of the Adrenal Medulla

PHEOCHROMOCYTOMArare, benign tumor of the adrenal medullaoh no...what are we going to see a hypersecretion of????

SIGNS AND SYMPTOMSPheochromocytomaWhat do you think is the hallmark sign? Paroxymal attacks****NE and Epinepherine released sporadicallyAttacks may be provoked by medsantihypertensives, opioids, contrast mediaIf untreated DM, cardiomyopathy, deathWhy?

SIGNS & SYMPTOMSPheochromocytomaDeep breathingPounding heartHeadacheMoist cool hands & feetVisual disturbances

DIAGNOSISPheochromocytoma

Often missed24 hour urinefractionated metanephrinesfractionated cathecholaminescreatinineAre these increased or decreased?Plasma catecholaminesWhen are these drawn?Are these increased or decreased?CT to locate tumor

Interventions/TreatmentPheochromocytomaPrimary goal?Primary treatment?Pre - opCalcium channel blockersCardeneSympathetic blocking agentsMinipress (watch for orthostatic hypotension)Beta blocking agentsInderal

INTERVENTIONSMonitor b.p.Eliminate attacksIf attack- complete bedrest and HOB 45 degrees

Interventions/TreatmentPheochromocytomaDiet 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 OUTVolume expandersVasopressorsHourly I and OObserve 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?

****excessive hair growth -- aka hirsuitismacnechange in voicereceding hairlineVirulization in women ----- increase male characteristicsFerminization ---- hormonally induced development of female sex characteristics

"vellus" and "terminal". Vellus hair is finely textured. Terminal hair is coarse and thick. All women have vellus hair on their face.

increased androgens in a woman does not cause hair to grow. The increased androgen converts vellus into terminal hair - the same process that normally occurs in a boy at puberty.

Hirsutism is defined as the growth of terminal hair (i.e. androgen stimulated hair) in women in places where it normally does not occur. chin, neck, the skin over the upper breasts (not around the nipples), the skin over the breastbone between the breasts, lower abdomen.

increased

Iatrogenic causes ----- anticoagulant ---- cause Adrenal hemmorage

Primary goal ========decrease blood pressure

Primary treatment ==== tumor removal

Sympathetic === teach to change positions slowly

Bblockers === dec. HR, BP & force of contraction