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Nursing Adult I > Adrenal > Flashcards

Adrenal Flashcards

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1
Q

Where are the adrenal glands located?

A

On top of each kidney

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2
Q

What are the two components of the adrenal gland?

A

Adrenal medulla

Adrenal cortex

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3
Q

The adrenal cortex secretes 50+ hormones. They are categorized into what 3 groups? (Remember: The 3 S’s)

A

Glucocorticoids (Sugar)
Mineralocorticoids (Salt)
Androgens (Sex)

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4
Q

What is the most abundant glucocorticoid? (It is necessary for life to continue!)

A

Cortisol

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5
Q

What does cortisol do?

A

Stimulates lypolysis in fat tissue
Decreases inflammation
Responds to stress
Maintains fluid volume

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6
Q

What feedback system regulates cortisol?

A

Negative feedback system (Diurnally)

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7
Q

When are cortisol levels highest?

A

In the morning

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8
Q

What stimulates cortisol release?

A

Corticotropin-releasing hormone (CRH) from hypothalamus -> adrenocorticotropic hormone (ACTH) from anterior pituitary -> cortisol from adrenal cortex

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9
Q

What is the primary & most potent mineralocorticoid for maintaining the ECF?

A

Aldosterone

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10
Q

What does aldosterone do?

A

Tells kidneys to reabsorb sodium & secrete K+ & H+ ions

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11
Q

What causes aldosterone secretion?

A

Angiotensin II stimulation (↓ fluid volume/ ↓ BP)
Hyperkalemia
Hyponatremia

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12
Q

What inhibits aldosterone?

A

Hypokalemia

Atrial natriuretic peptide

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13
Q

What is a disorder of hyperfunction of the adrenal cortex?

A

Cushing Syndrome

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14
Q

What does hyperfunction of the adrenal cortex mean?

A

Too much corticosteroids (Cortisol particularly)

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15
Q

What is a disorder of hypofunction of the adrenal cortex?

A

Addison’s Disease

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16
Q

What does hypofunction of the adrenal cortex mean?

A

Not enough of all 3 types of corticosteroids

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17
Q

What is the most common cause of Cushing’s?

A

Iatrogenic (pt took too much corticosteroids – ie Prednisone)

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18
Q

What is the main endogenous cause of Cushings?

A

Adrenocorticotropic hormone (ACTH) secreting pituitary tumor

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19
Q

What are the main s/s of Cushing’s? (Remember: S/S r/t TOO MUCH STEROID!)

A

Weight gain (esp. trunk, cervical spine [buffalo hump], moon face)
Hypertension
Hyperglycemia; unexplained Hypokalemia
Osteoporosis (RISK of pathological fx)
Thin skin; easy bruised; depressed purple red striae
Delayed wound healing

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20
Q

What imbalances are expected with Cushing’s?

A

Hypokalemia
Hyperglycemia
Hypernatremia

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21
Q

When Cushing’s syndrome is suspected, what test is done?

A

24-hour urine collection for free cortisol (level higher than 120 mcg in 24 hours = Cushing’s)

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22
Q

If results are borderline, what test is done?

A

Low-dexamethasone suppression test

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23
Q

What is the most important thing to remember about all adrenal gland tests?

A

Give the test medications at the correct time!

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24
Q

What is the treatment for Cushing’s caused by a tumor?

A

Adrenalectomy

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25
Q

What is the treatment for Cushing’s caused by steroid use?

A

Gradual discontinuation of corticosteroids
Reduction of corticosteroid dose
Conversion to alternate-day dosing

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26
Q

What must be done when decreasing or discontinuing corticosteroids?

A

Gradual tapering (to avoid potentially life-threatening adrenal insufficiency

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27
Q

What nursing mgt needs to be done for Cushing’s?

A

Risk for fluid retention!
Monitor vital signs Q 4 for hypertension
Urine output q shift
Daily weight
Glucose levels
S/S infection (decreased stress response)
S/S thrombosis (sudden chest pain, dyspnea, tachypnea)
Risk for pathologic fracture! Assist pt w/ activities.
Provide emotional support r/t physical changes
Reassure patient that changes will resolve with tx

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28
Q

What type of surgery must be done to remove adrenal tumors?

A

Adrenalectomy (bilateral or unilateral)

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29
Q

If surgery is not possible, what is done?

A

Drug therapy to suppress cortisol secretion (medical adrenalectomy)

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30
Q

What will be required if a bilateral adrenalectomy is performed?

A

Life-long steroid replacement

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31
Q

What must be done pre-operatively for adrenalectomy?

A

Get pt in best possible physical condition (correct FVE & hypokalemia; prevent injury; low carb, low salt, high protein, high potassium diet)

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32
Q

What must be given pre-op & intra-op to prevent adrenal insufficiency?

A

IV Glucocorticoids

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33
Q

What complications are high risk with an adrenalectomy?

A

Decreased response to high stress levels
Risk of release of endogenous hormones into circulation during sx
Risk of hemorrhage

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34
Q

What is done to ensure adequate stress responses during & after sx?

A

Administration of high IV doses of corticosteroids

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35
Q

What is a potential complication of the IV steroids?

A

Increased risk of infection, delayed wound healing

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36
Q

Because the glands are highly vascular, there is increased risk of hemorrhage. How can that risk be increased by excess release of hormones during the surgery?

A

The endogenous steroids can cause HTN

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37
Q

What is the most critical time frame after adrenalectomy?

A

1st 24-48 hours

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38
Q

What should you report to the physician post-op?

A

Any rapid or significant changes in: BP, RR, HR

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39
Q

What must be done post-op until the BP is stable

A

Bedrest

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40
Q

Because the inflammatory response is suppressed, what must you be alert for?

A

Subtle signs of infection (be meticulous with all nursing care to prevent infection!)

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41
Q

Once IV steroid administration is discontinued, should you just dc the IV?

A

NO – saline lock or keep KVO in case emergency admin of steroids is necessary

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42
Q

What should be measured daily to evaluate the effectiveness of sx?

A

Daily urine cortisol levels (same time early each morning)

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43
Q

What could happen if corticosteroids are tapered off too quickly post-op?

A

Adrenal insufficiency

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44
Q

What are s/s of adrenal insufficiency (hypocortisolism)?

A

N/V
Dehydration
Increased weakness
Hypotension

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45
Q

What s/s of corticosteroid use should be reported?

A

Painful joints, pruritus, peeling skin, emotional disturbances

46
Q

What must be taught to the patient post-op adrenalectomy?

A

Must wear Medic-Alert bracelet AT ALL TIMES
Avoid extreme temperatures
Avoid infections
Avoid stress / emotional disturbances
Bilat adrenalectomy – NEED life-long HRT which should be adjusted to stress levels (fever, flu, teeth extractions, rigorous physical activity) – Best to err on side of over replacement!
STRESS that the patient MUST be compliant or complications will occur!
S/S of over-medicated & under-medicated

47
Q

What is a primary disorder of adrenal insufficiency?

A

Addison’s Disease (all 3 types corticosteroids deficient)

48
Q

What is a secondary cause of adrenal insufficiency?

A

Lack of pituitary ACTH secretion (gland itself is not cause)

49
Q

What is the most common cause of Addison’s Disease?

A

Autoimmune response (pt own antibodies destroy adrenal cortex)

50
Q

When can abrupt withdrawal or cessation of exogenous steroids cause Addison’s?

A

If taken more than 3 weeks or more often than every other day

51
Q

When do the manifestations of Addison’s become apparent?

A

Not until 90% of adrenal cortex is destroyed

52
Q

What are the primary manifestations?

A

Progressive weakness
Fatigue
Weight loss
Anorexia

53
Q

What are other manifestations that may be seen with adrenal insufficiency?

A 
Skin hyperpigmentation (joints, palmar creases, pressure points, sun-exposed areas)
Orthostatic hypotension, hyponatremia, salt craving, hyperkalemia, N/V/D
54
Q

Which of the above manifestations don’t occur with secondary adrenal insufficiency

A

Skin hyperpigmentation

55
Q

How is a diagnosis of Addison’s made?

A

Subnormal to no rise over basal levels with an ACTH-stimulation test

56
Q

What does a rise in levels after administration of an ACTH-stimulation test mean?

A

The adrenals are working so the problem is most likely pituitary disease

57
Q

What are the expected abnormal labs with Addison’s?

A

Hyperkalemia
Hypochloremia, hyponatremia, hypoglycemia, anemia
Increased BUN
Low urine levels of cortisol & aldosterone

58
Q

What is the mainstay of treatment for adrenocortical insufficiency?

A

Replacement therapy of corticosteroids

59
Q

What is the most commonly used form of replacement therapy?

A

Hydrocortisone
2/3 in morning & 1/3 in late afternoon
Increased dose during times of stress to prevent Addisonian crisis!

60
Q

What mineralocorticoid replacement is given?

A

Fludrocortisone (Florinef) – administer daily in the mornings

61
Q

When mineralocorticoids are given, what must be added to the diet?

A

Salt

62
Q

What life-threatening problem are patients with adrenocortical insufficiency at risk for?

A

Addisonian crisis

63
Q

What triggers Addisonian crisis?

A

Stress (infection, sx, trauma, hemorrhage, emotional distress)
Sudden withdrawal from corticosteroid HRT
Post-op adrenelectomy or pituitary gland destruction

64
Q

What s/s may be see with Addisonian crisis?

A 
Hypotension, tachycardia, dehydration -> shock -> circulatory collapse        
most dangerous manifestation
Hyponatremia, hypoglycemia, hyperkalemia
N/V/D
Pain in lower back or legs
65
Q

What is important to know about treatment of hypotension during Addisonian crisis?

A

Won’t respond to usual blood pressure tx – pt must have hormone replacement!

66
Q

How is FVD tx in Addisonian crisis?

A

Rapid infusion of 0.9% NS & 5% Dextrose

67
Q

How is hyperkalemia tx in Addisonian crisis?

A

Kayexalate

68
Q

What is the priority intervention in Addisonian crisis?

A

IV corticosteroid bolus then q 8 hrs x 24-48 hours

69
Q

What is the nursing mgt for Addisonian Crisis?

A

Monitor vital signs & FVD q 30 minutes to 4 hrs prn
Daily weight
Diligent corticosteroid administration
Protect against noise, light, extreme temperatures
Educate same as for adrenal insufficiency
Plus teach s/s crisis
Carry emergency kit at all times

70
Q

What are the possible causes of a secondary adrenal insufficiency?

A

Chronic glucocorticoid therapy that is abruptly discontinued
Hypopituitarism
Pituitary tumor or infarction
Radiation

71
Q

Compare Cushings with Addisons.

A

Cushings = hyper (hypertension, hypervolemia, hyperglycemia, hypokalemia, immunosuppression, osteoporosis)
Addisons = hypo (hypotension, hypovolemia, hypoglycemia, hyperkalemia, decreased stress response)

72
Q

What would you expect corticosteroids to be used for?

A 
Adrenal insufficiency
Inflammatory tx of asthma
Rheumatoid arthritis
Ulcerative colitis
Acute allergic reactions (short-term tx)
Immunosuppression tx for chronic conditions
73
Q

What do you think will happen if corticosteroids are stopped abruptly?

A

Acute adrenal insufficiency (s/s weakness, hypotension, hyponatremia, , hypoglycemia, hyperkalemia)

74
Q

What should the pt be taught about minimizing the adverse effects of a steroid (ie. Prednisone)?

A

Take it with food or milk

75
Q

What additional medication might the pt take to decrease the occurrence of GI distress?

A

H2 Blockers

76
Q

What are some of the main side effects of corticosteroids?

A

Hypokalemia (increases K+ excretion)
Hyperglycemia (glucose intolerance)
Cushingoid characteristics (i.e. moon face)
Delayed wound healing (decreased immune response)
Increased risk of infection (decreased immune response)
Osteoporosis (calcium loss); Pathologic fx

77
Q

What nursing mgt should occur for pts taking corticosteroids?

A 
Prevent osteoporosis 
Increase Ca+ & Vit D intake; promote activity
Diet
High protein, Ca+, & K+; Low fat & CHO
If edema occurs, restrict Na+
Monitor glucose levels
Avoid exposure to illness
78
Q

What are some things that need to be reported to the physician when a pt is taking corticosteroids?

A 
Missed doses
S/S infection
Weight gain > 5LB
Pedal edema
Any other problems due to insufficiency or overuse (i.e. weakness, fatigue, electrolyte imbalances, v/s changes)
79
Q

What should pts avoid when taking corticosteroids?

A

Caffeine, alcohol, aspirin-containing products

80
Q

What are the corticosteroids?

A

Hydrocortisone (IM/PO) [Cortisol, Hydrocortone, Cortef, Solu-Cortef]
Dexamethasone (IV/IM) [Decadron]
Betamethasone [Celestone]
Methulprednisone (IM/PO) [Medrol, Solu-Medrol, Depo-Medrol]
Prednisone (PO) [Delatsone}
Prednisolone (PO) [Prelone, Predalone]
Triamcinolone (cream) [ Arstocort, Kenalog]
Beclomethasone (inhaled) [Beconase, Vanceril, Beclovent]

81
Q

What is Hyperaldosteronism?

A

Too much aldosterone (mineralocorticoid)

82
Q

What is the primary Hyperaldosteronism called?

A

Conn’s Disease

83
Q

What is the hallmark of Conn’s disease (hyperaldosteronism)?

A

Hypertension with hypokalemic alkalosis

84
Q

What is primary hyperaldosteronism usually due to?

A

Adrenal gland lesion causing increased secretion

85
Q

What is secondary hyperaldosteronism usually due to?

A

Conditions causing non-adrenal activation of the renin-angiotensin system (i.e. cirrhosis, chronic kidney disease, laxative or diuretic abuse)

86
Q

What does aldosterone do?

A

Causes Na+ retention, & K+ H+ excretion

87
Q

If you have sodium retention, what will this lead to?

A

Water retention -> increased thirst -> stimulation of ADH -> FVE -> HYPERTENSION

88
Q

What are the expected manifestations of excessive aldosterone?

A 
HYPERnatremia
HYPERvolemia
Polyuria & Polydipsia
HYPOkalemia
Metabolic Alkalosis
89
Q

Due to hypernatremia & hypertension, what do you expect the pt may complain of?

A

Headache

90
Q

What test is used to confirm hyperaldosteronism?

A

Saline infusion test

91
Q

What is the necessary tx for primary hyperaldosteronism?

A

Adrenalectomy

92
Q

What is the tx for secondary hyperaldosteronism?

A

Treat the cause (as is usually always the case with any secondary disorders)

93
Q

What medical mgt should occur for hyperaldosteronism?

A

Spirinolactone (Aldactone) to decrease BP
Monitor for hyperkalemia
Decrease sodium in diet; Increase K+ if not on Aldactone
Inspra (eplerenone)

94
Q

What hormones are secreted by the adrenal medulla?

A

Catecholamines
Epinephrine (adrenaline)
Nor-epinephrine (noradrenaline)
Dopamine

95
Q

What are type of hormones are catecholamines?

A

Neurotransmitter hormones

96
Q

What are catecholamines ESSENTIAL for?

A

The body’s response to stress

97
Q

What is pheochromocytoma ?

A

Excessive release of catecholamines from the adrenal medulla

98
Q

What is the MOST DANGEROUS immediate effect of pheochromocytoma?

A

SEVERE HTN

99
Q

What may cause an acute attack?

A

Emotional stress, physical exertion, displaced abd organs, valsalva maneuver, rapid position change, meds that trigger catecholamine release (beta blockers, histamines, glucagon, nicotine)

100
Q

What are the manifestations of pheochromocytoma?

A 
Pounding headache
Profuse diaphoresis
Severe hypertension
Tachycardia with palpatations
Dilated pupils
Emotional instability; agitation; feeling of doom
Unexplained chest or abd pain
Cold extremities
101
Q

What are some long-term complications of pheochromocytoma?

A

Intractable HTN à vision changes to blindness
Cardiac disease (CHF, pulmonary edema)
Impaired glucose tolerance; diabetes mellitus
Renal failure
Weight loss

102
Q

What test is 90% accurate to dx pheochromocytoma?

A

Urine catecholamine (will be elevated)

103
Q

What other test may be done but can have false negative results?

A

VMA – vanillylmandelic acid

104
Q

What tx is usually curative for pheochromocytoma?

A

Adrenalectomy

105
Q

What are these pts at risk for intra-operatively?

A

Increased risk of HTN and arrhythmias r/t manipulation of the gland or stress from the sudden release of hormones

106
Q

What is a possible post-operative complication?

A

Significant BP drop

107
Q

What must occur with the pt for 2 weeks prior to sx?

A

Must be normotensive (NORMAL BP)

Give meds to decrease BP & reduce s/s of excess catecholamines

108
Q

Prior to surgery, what should the pt dx with pheochromocytoma do to prevent attacks?

A 
Plenty of rest
Decrease stress
Increase calories, vitamins, & minerals in diet
Take sedatives prn
NO CAFFEINE
109
Q

What post-op monitoring should the nurse do?

A 
Watch for S/S of shock
Could be due to hemorrhage
Could be due to lowered catecholamine levels
Monitor for hypotension 1st 24-48 hours
Watch urine output every hour
Check dressing often
Watch for s/s adrenal insufficiency
110
Q

What are the functions of cortisol

A

Responsible for glucose metabolism, protein metabolism, f/e balance, suppression of inflammatory response to injury, protective immune response to infectious agents, and resistance to stress

111
Q

What are the functions of aldosterone

A

Regulation of electrolyte balance by promoting sodium retention and potassium excretion

Nursing Adult I (6 decks)

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