Transcript ADRENAL GLAND

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
How much per day?
SUGAR
con’t
 Other
functions of Cortisol
– What does it do to the inflammatory
response?
– What does it do the immune response?
Exogenous Corticosteroids
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**______________
**______________
**______________
**______________
______________
______________
______________
______________
______________
SALT

Mineralocorticoids (F & E balance)
What stimulates aldosterone
secretion?
What inhibits adlosterone
secretion?
Na retention
Water retention
K excretion
Hydrogen 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
ESTROGENS
 ANDROGENS

– hormones which
characteristics
 release
male
of testosterone
Do women produce androgens?
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 rest of day

Stress- ____cortisol production & secretion
HYPER & HYPO
FUNCTION
ADRENAL CORTEX HORMONES
 Too
much
 Too
little
II.
HYPERALDOSTERONISM
“Conn’s Syndrome”
 Too
much aldosterone secretion
 Question:
– What does aldosterone do????
_____________________________
 usually caused by adrenal tumor
SIGNS & SYMPTOMS
Hyperaldosteronism

Na and water retention
– What s/s would you expect?

What is the normal serum K+ level?
– What s/s would you expect?

Usually no edema
– Why?
DIAGNOSISHyperaldosteronism

urinary K
CT scan
 EKG changes


plasma
aldosterone &
Na levels with
low plasma
renin levels
INTERVENTIONS
Hyperaldosteronism

BP
– What drugs would you give?

Correct hypokalemia/hypernatremia
– What you would you do?

Partial or total adrenalectomy
ADRENALECTOMY
PRE-OP
 Stabilize
hormonally
 Correct fluid and electrolytes
 Would you need to replace cortisol
levels before or after surgery?
ADRENALECTOMY
POST-OP

ICU-What type of problems to expect??
– IV cortisol for 24 hours
– IM cortisol 2nd day
– PO cortisol 3rd day

Possible hypo/hyperkalemia
– What are some s/s of this?
– What would an ekg look like for hypokalemia?

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

ETIOLOGY
Cushing’s

Cushing’s Disease
– _____________________

Cushing Syndrome
– _____________________
– _____________________
– _____________________
SIGNS & SYMPTOMS
Cushing’s

protein catabolism
– muscle wasting
– ****loss of collagen support
– poor wound healing
SIGNS & SYMPTOMS
Cushing’s
 Electrolyte
imbalances
– Which ones?

s in CHO metabolism
– Hyperglycemia
 Why?
SIGNS & SYMPTOMS
Cushing’s

s in fat metabolism
– ****abdomen
 aka:
_________
– cervical spine
 aka:
_________
– ****face
 aka:
_________
SIGNS & SYMPTOMS
immune response

– More prone to infection
–
resistance to stress
Common cause of death?
Before
After
What sign would the nurse
identify in each patient?
SIGNS & SYMPTOMS

mineralocorticoid activity
– ________ retention
_______ retention
– What happens to blood pressure?
SIGNS & SYMPTOMS
MENTAL 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

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 pts

Serum cortisol levels
– What will serum cortisol levels be?
– Draw AT 8AM AND 8PM

What would you expect?
High Dose
Dexamethasone Suppression Test
ACTH
Cortisol
Low/undectable
Not
suppressed
Adrenal Cushing syndrome is likely.
NormalVery 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

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
Eosinopenia
Glycosuria
Osteoporosis
Alkalosis
CT & MRI
– Of what?
– Looking for what?
- Lymphopenia
- Hyperglycemia
- Hypercalcemia
- ****Hypokalemia
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
destroys tissue
in adrenal cortex
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





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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 DISEASE
hypofunction 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
atrophy
–autoimmune condition
Antibodies attack against own
adrenal cortex
–90% of tissue destroyed
ETIOLOGY of Addison’s
 Malignancy
 TB
 Fungal
infections
(histoplasmosis)
 AIDS
 Iatrogenic causes
– adrenalectomy, chemo, anticoagulant tx
SIGNS & SYMPTOMS
Addison’s Disease



fatigue, weight loss, anorexia
– Why? think of cortisol fx
Changes in skin pigment
– small black freckles
– Why?
Muscular weakness
– Why?
SIGNS & SYMPTOMS
Addison’s

Fluid & electrolyte imbalances
– WHY?

b.p.
– WHY?
Hyponatremia-why?
 Hyperkalemia-why?
 Hypoglycemia-why?

SIGNS & SYMPTOMS
Addison’s

androgens
– hair loss,

sexual fx
mental disturbances
– anxiety, irritability, etc.

salt craving-why?
DIAGNOSIS-Addison’s
 ____serum
cortisol
 ____urinary 17-OHCS and 17 KS
 ____K
 ____Na
 ____serum glucose
 ____plasma ACTH
 ____urine free cortisol
INTERVENTIONS
Addison’s Disease

Life long hormone replacement
– primary-need_______________
20-25mgs in AM & 10-12mg in PM
 Why different doses?

– 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
INTERVENTIONS
Addison’s Disease
 Keep
parenteral glucocorticoids
at home for injection during
illness
 Avoid infections/stress
COMPLICATIONS
Addison’s Disease
 Adrenal
crisis
 Electrolyte imbalance
 Hypoglycemia
ADDISON’S CRISIS
 Sudden
decrease or absence of
adrenal cortex hormones which
are:
__________________
__________________
__________________
CAUSES

Name 4 causes
– 1. __________________________
– 2. __________________________
– 3. __________________________
– 4. __________________________
SIGNS & SYMPTOMS
Addisonian Crisis
DehydrationNa, K,
BP
N/V,diarrhea, wt. loss
 Weakness
 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?

TREATMENT
Addisonian 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

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 SYMPTOMS
Pheochromocytoma
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 & SYMPTOMS
Pheochromocytoma
Deep breathing
 Pounding heart
 Headache
 Moist cool hands & feet
 Visual disturbances

DIAGNOSIS
Pheochromocytoma
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-PRE-OP

Adrenergic blocking agents
– Minipress to

Beta blocking agents
– Inderal to

bp
hr, b.p., & force of contraction
Diet
– high in vitamin, mineral,calorie, no caffeine

Sedatives
INTERVENTIONS
 Monitor
b.p.
 Eliminate attacks
 If attack- complete bedrest
and HOB 45 degrees
Laparoscopic Adrenalectomy/
Open abdominal Incision
DURING SURGERY
GIVE REGITINE AND
NIPRIDE TO PREVENT
HYPERTENSIVE CRISIS
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?
Now Let’s
Practice Some
Questions….