Adrenal Flashcards
Where are the adrenal glands located?
On top of each kidney
What are the two components of the adrenal gland?
Adrenal medulla
Adrenal cortex
The adrenal cortex secretes 50+ hormones. They are categorized into what 3 groups? (Remember: The 3 S’s)
Glucocorticoids (Sugar)
Mineralocorticoids (Salt)
Androgens (Sex)
What is the most abundant glucocorticoid? (It is necessary for life to continue!)
Cortisol
What does cortisol do?
Stimulates lypolysis in fat tissue
Decreases inflammation
Responds to stress
Maintains fluid volume
What feedback system regulates cortisol?
Negative feedback system (Diurnally)
When are cortisol levels highest?
In the morning
What stimulates cortisol release?
Corticotropin-releasing hormone (CRH) from hypothalamus -> adrenocorticotropic hormone (ACTH) from anterior pituitary -> cortisol from adrenal cortex
What is the primary & most potent mineralocorticoid for maintaining the ECF?
Aldosterone
What does aldosterone do?
Tells kidneys to reabsorb sodium & secrete K+ & H+ ions
What causes aldosterone secretion?
Angiotensin II stimulation (↓ fluid volume/ ↓ BP)
Hyperkalemia
Hyponatremia
What inhibits aldosterone?
Hypokalemia
Atrial natriuretic peptide
What is a disorder of hyperfunction of the adrenal cortex?
Cushing Syndrome
What does hyperfunction of the adrenal cortex mean?
Too much corticosteroids (Cortisol particularly)
What is a disorder of hypofunction of the adrenal cortex?
Addison’s Disease
What does hypofunction of the adrenal cortex mean?
Not enough of all 3 types of corticosteroids
What is the most common cause of Cushing’s?
Iatrogenic (pt took too much corticosteroids – ie Prednisone)
What is the main endogenous cause of Cushings?
Adrenocorticotropic hormone (ACTH) secreting pituitary tumor
What are the main s/s of Cushing’s? (Remember: S/S r/t TOO MUCH STEROID!)
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
What imbalances are expected with Cushing’s?
Hypokalemia
Hyperglycemia
Hypernatremia
When Cushing’s syndrome is suspected, what test is done?
24-hour urine collection for free cortisol (level higher than 120 mcg in 24 hours = Cushing’s)
If results are borderline, what test is done?
Low-dexamethasone suppression test
What is the most important thing to remember about all adrenal gland tests?
Give the test medications at the correct time!
What is the treatment for Cushing’s caused by a tumor?
Adrenalectomy
What is the treatment for Cushing’s caused by steroid use?
Gradual discontinuation of corticosteroids
Reduction of corticosteroid dose
Conversion to alternate-day dosing
What must be done when decreasing or discontinuing corticosteroids?
Gradual tapering (to avoid potentially life-threatening adrenal insufficiency
What nursing mgt needs to be done for Cushing’s?
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
What type of surgery must be done to remove adrenal tumors?
Adrenalectomy (bilateral or unilateral)
If surgery is not possible, what is done?
Drug therapy to suppress cortisol secretion (medical adrenalectomy)
What will be required if a bilateral adrenalectomy is performed?
Life-long steroid replacement
What must be done pre-operatively for adrenalectomy?
Get pt in best possible physical condition (correct FVE & hypokalemia; prevent injury; low carb, low salt, high protein, high potassium diet)
What must be given pre-op & intra-op to prevent adrenal insufficiency?
IV Glucocorticoids
What complications are high risk with an adrenalectomy?
Decreased response to high stress levels
Risk of release of endogenous hormones into circulation during sx
Risk of hemorrhage
What is done to ensure adequate stress responses during & after sx?
Administration of high IV doses of corticosteroids
What is a potential complication of the IV steroids?
Increased risk of infection, delayed wound healing
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?
The endogenous steroids can cause HTN
What is the most critical time frame after adrenalectomy?
1st 24-48 hours
What should you report to the physician post-op?
Any rapid or significant changes in: BP, RR, HR
What must be done post-op until the BP is stable
Bedrest
Because the inflammatory response is suppressed, what must you be alert for?
Subtle signs of infection (be meticulous with all nursing care to prevent infection!)
Once IV steroid administration is discontinued, should you just dc the IV?
NO – saline lock or keep KVO in case emergency admin of steroids is necessary
What should be measured daily to evaluate the effectiveness of sx?
Daily urine cortisol levels (same time early each morning)
What could happen if corticosteroids are tapered off too quickly post-op?
Adrenal insufficiency
What are s/s of adrenal insufficiency (hypocortisolism)?
N/V
Dehydration
Increased weakness
Hypotension
What s/s of corticosteroid use should be reported?
Painful joints, pruritus, peeling skin, emotional disturbances
What must be taught to the patient post-op adrenalectomy?
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
What is a primary disorder of adrenal insufficiency?
Addison’s Disease (all 3 types corticosteroids deficient)
What is a secondary cause of adrenal insufficiency?
Lack of pituitary ACTH secretion (gland itself is not cause)
What is the most common cause of Addison’s Disease?
Autoimmune response (pt own antibodies destroy adrenal cortex)
When can abrupt withdrawal or cessation of exogenous steroids cause Addison’s?
If taken more than 3 weeks or more often than every other day
When do the manifestations of Addison’s become apparent?
Not until 90% of adrenal cortex is destroyed
What are the primary manifestations?
Progressive weakness
Fatigue
Weight loss
Anorexia
What are other manifestations that may be seen with adrenal insufficiency?
Skin hyperpigmentation (joints, palmar creases, pressure points, sun-exposed areas) Orthostatic hypotension, hyponatremia, salt craving, hyperkalemia, N/V/D
Which of the above manifestations don’t occur with secondary adrenal insufficiency
Skin hyperpigmentation
How is a diagnosis of Addison’s made?
Subnormal to no rise over basal levels with an ACTH-stimulation test
What does a rise in levels after administration of an ACTH-stimulation test mean?
The adrenals are working so the problem is most likely pituitary disease
What are the expected abnormal labs with Addison’s?
Hyperkalemia
Hypochloremia, hyponatremia, hypoglycemia, anemia
Increased BUN
Low urine levels of cortisol & aldosterone
What is the mainstay of treatment for adrenocortical insufficiency?
Replacement therapy of corticosteroids
What is the most commonly used form of replacement therapy?
Hydrocortisone
2/3 in morning & 1/3 in late afternoon
Increased dose during times of stress to prevent Addisonian crisis!
What mineralocorticoid replacement is given?
Fludrocortisone (Florinef) – administer daily in the mornings
When mineralocorticoids are given, what must be added to the diet?
Salt
What life-threatening problem are patients with adrenocortical insufficiency at risk for?
Addisonian crisis
What triggers Addisonian crisis?
Stress (infection, sx, trauma, hemorrhage, emotional distress)
Sudden withdrawal from corticosteroid HRT
Post-op adrenelectomy or pituitary gland destruction
What s/s may be see with Addisonian crisis?
Hypotension, tachycardia, dehydration -> shock -> circulatory collapse most dangerous manifestation Hyponatremia, hypoglycemia, hyperkalemia N/V/D Pain in lower back or legs
What is important to know about treatment of hypotension during Addisonian crisis?
Won’t respond to usual blood pressure tx – pt must have hormone replacement!
How is FVD tx in Addisonian crisis?
Rapid infusion of 0.9% NS & 5% Dextrose
How is hyperkalemia tx in Addisonian crisis?
Kayexalate
What is the priority intervention in Addisonian crisis?
IV corticosteroid bolus then q 8 hrs x 24-48 hours
What is the nursing mgt for Addisonian Crisis?
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
What are the possible causes of a secondary adrenal insufficiency?
Chronic glucocorticoid therapy that is abruptly discontinued
Hypopituitarism
Pituitary tumor or infarction
Radiation
Compare Cushings with Addisons.
Cushings = hyper (hypertension, hypervolemia, hyperglycemia, hypokalemia, immunosuppression, osteoporosis) Addisons = hypo (hypotension, hypovolemia, hypoglycemia, hyperkalemia, decreased stress response)
What would you expect corticosteroids to be used for?
Adrenal insufficiency Inflammatory tx of asthma Rheumatoid arthritis Ulcerative colitis Acute allergic reactions (short-term tx) Immunosuppression tx for chronic conditions
What do you think will happen if corticosteroids are stopped abruptly?
Acute adrenal insufficiency (s/s weakness, hypotension, hyponatremia, , hypoglycemia, hyperkalemia)
What should the pt be taught about minimizing the adverse effects of a steroid (ie. Prednisone)?
Take it with food or milk
What additional medication might the pt take to decrease the occurrence of GI distress?
H2 Blockers
What are some of the main side effects of corticosteroids?
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
What nursing mgt should occur for pts taking corticosteroids?
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
What are some things that need to be reported to the physician when a pt is taking corticosteroids?
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)
What should pts avoid when taking corticosteroids?
Caffeine, alcohol, aspirin-containing products
What are the corticosteroids?
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]
What is Hyperaldosteronism?
Too much aldosterone (mineralocorticoid)
What is the primary Hyperaldosteronism called?
Conn’s Disease
What is the hallmark of Conn’s disease (hyperaldosteronism)?
Hypertension with hypokalemic alkalosis
What is primary hyperaldosteronism usually due to?
Adrenal gland lesion causing increased secretion
What is secondary hyperaldosteronism usually due to?
Conditions causing non-adrenal activation of the renin-angiotensin system (i.e. cirrhosis, chronic kidney disease, laxative or diuretic abuse)
What does aldosterone do?
Causes Na+ retention, & K+ H+ excretion
If you have sodium retention, what will this lead to?
Water retention -> increased thirst -> stimulation of ADH -> FVE -> HYPERTENSION
What are the expected manifestations of excessive aldosterone?
HYPERnatremia HYPERvolemia Polyuria & Polydipsia HYPOkalemia Metabolic Alkalosis
Due to hypernatremia & hypertension, what do you expect the pt may complain of?
Headache
What test is used to confirm hyperaldosteronism?
Saline infusion test
What is the necessary tx for primary hyperaldosteronism?
Adrenalectomy
What is the tx for secondary hyperaldosteronism?
Treat the cause (as is usually always the case with any secondary disorders)
What medical mgt should occur for hyperaldosteronism?
Spirinolactone (Aldactone) to decrease BP
Monitor for hyperkalemia
Decrease sodium in diet; Increase K+ if not on Aldactone
Inspra (eplerenone)
What hormones are secreted by the adrenal medulla?
Catecholamines
Epinephrine (adrenaline)
Nor-epinephrine (noradrenaline)
Dopamine
What are type of hormones are catecholamines?
Neurotransmitter hormones
What are catecholamines ESSENTIAL for?
The body’s response to stress
What is pheochromocytoma ?
Excessive release of catecholamines from the adrenal medulla
What is the MOST DANGEROUS immediate effect of pheochromocytoma?
SEVERE HTN
What may cause an acute attack?
Emotional stress, physical exertion, displaced abd organs, valsalva maneuver, rapid position change, meds that trigger catecholamine release (beta blockers, histamines, glucagon, nicotine)
What are the manifestations of pheochromocytoma?
Pounding headache Profuse diaphoresis Severe hypertension Tachycardia with palpatations Dilated pupils Emotional instability; agitation; feeling of doom Unexplained chest or abd pain Cold extremities
What are some long-term complications of pheochromocytoma?
Intractable HTN à vision changes to blindness
Cardiac disease (CHF, pulmonary edema)
Impaired glucose tolerance; diabetes mellitus
Renal failure
Weight loss
What test is 90% accurate to dx pheochromocytoma?
Urine catecholamine (will be elevated)
What other test may be done but can have false negative results?
VMA – vanillylmandelic acid
What tx is usually curative for pheochromocytoma?
Adrenalectomy
What are these pts at risk for intra-operatively?
Increased risk of HTN and arrhythmias r/t manipulation of the gland or stress from the sudden release of hormones
What is a possible post-operative complication?
Significant BP drop
What must occur with the pt for 2 weeks prior to sx?
Must be normotensive (NORMAL BP)
Give meds to decrease BP & reduce s/s of excess catecholamines
Prior to surgery, what should the pt dx with pheochromocytoma do to prevent attacks?
Plenty of rest Decrease stress Increase calories, vitamins, & minerals in diet Take sedatives prn NO CAFFEINE
What post-op monitoring should the nurse do?
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
What are the functions of cortisol
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
What are the functions of aldosterone
Regulation of electrolyte balance by promoting sodium retention and potassium excretion
