adrenal cortex Flashcards
CUSHING SYNDROME AND CUSHING DISEASE- cause - just extra steroids
Cushion syndrome occurs with excess corticosteriods
cushing syndrome - Glucocorticoid (cortisol) related - symptoms - face
Weight gain from fat deposit in the trunk, face and cervical areas resulting in “ truncal obesity, moon face, buffalo hump”
CUSHING SYNDROME: CLINICAL MANIFESTATION - Mineralocorticoid (aldosterone) - what happens when Na is too high? (cushy but high up)
HTN secondary to Na and water retention
CUSHING SYNDROME: CLINICAL MANIFESTATION - men and women
Severe acne
Virilization (male hormones) in women
Hirsutism (male pattern hair growth on women)
Feminization, gynecomastia and impotence in men
cushings - tests - test for what?
Labs
24 urinary cortisol test
Salivary cortisol level
Interprofessional Care (1 of 2) - cushings
Normalize hormone secretion
Treatment depends on cause
Surgical removal or irradiation of pituitary adenoma
Adrenalectomy for adrenal tumors or hyperplasia
Removal of ACTH-secreting tumors
what med? - cushings (cushions needs roids)
If cause is prolonged, use of corticosteroids
Gradually discontinue therapy
Decrease dose
Convert to an alternate-day dosing
Dose must be tapered gradually
ADRENOCORTICAL INSUFFICIENCY- which disease is primary? (addy is small)
Primary adrenal insufficiency (Addison’s disease)
Deficiency of the adrenal cortex
All 3 adrenal hormones are depressed
80% of Addison’s disease d/t autoimmune response
Other causes include: TB, adrenal infarction, chemo, AIDS, neoplasms, bilateral adrenalectomy
ADRENAL INSUFFICIENCY: is it fast, or slow? (adrienne is insideous)
Slow insidious onset (up to 90% of adrenal cortex destroyed before symptoms appears)
ADDISONIAN CRISIS (ACUTE ADRENAL INSUFFICIENCY) - is it an emergency?
Acute drop in adrenocortical hormones: A life-threatening emergency
ADRENAL INSUFFICIENCY - what diagnostic test?
Diagnosis:
ACTH stimulation test
Baseline ACTH and cortisol levels drawn
Then give synthetic ACTH (cosyntropin)
ACTH and cortisol rechecked in 30-60min
Normal response is ↑ cortisol levels
Cortisol level remains low = Addison’s Disease
Hyperkalemia, hyponatremia, hypoglycemia, anemia, hypochloremia
Imaging with MRI or CT
Treatment and Nursing Management - adrenal insufficiency (just put hydrocortisone on it)
Hormone therapy
Hydrocortisone has both glucocorticoid and mineralocorticoid properties
Fludrocortisone a mineralocorticoid
Patient Education - adrenal insufficiency
Do not stop steroid therapy suddenly; could lead to Addisonian crisis and death
HYPERALDOSTERONISM (Conn’s Syndrome)- what type of alkylosis?
Excessive secretion of aldosterone leading to Na+ retention, K+ and H+ excretion → HTN and hypokalemic alkalosis
HYPERALDOSTERONISM: TREATMENT- surgery and what? (you take it, think K+)
Adrenalectomy preferred treatment
Nursing care
Treat with a potassium sparing diuretic (Spironolactone or Eplerenone)
Normalize BP before for surgery
Treat hypokalemia
Frequent monitoring of BP pre and post-op
Vigilant assessment of fluid, electrolyte and cardiovascular status
Hyperaldosteronism Treatment (1 of 2)
Adrenalectomy to remove adenoma
Preoperative
Potassium-sparing diuretics
Antihypertensives
Oral potassium supplements
Sodium restrictions
Hyperaldosteronism Treatment (2 of 2)
Bilateral adrenal hyperplasia
Potassium-sparing diuretic
Calcium channel blockers to control BP
Dexamethasone to decrease adrenal hyperplasia
PHEOCHROMOCYTOMA - what is it? and where? (medusa has a phenomonenal tumor)
A rare condition caused by tumor in the adrenal medulla
PHEOCHROMOCYTOMA = Diagnosis (meta is a phenom)
Diagnosis:
24 hr urine metanephrine test(catecholamine metabolites)
CT and MRI
cushing syndrome = Exogenous
Exogenous: Chronic administration of exogenous corticosteroids e.g. prednisone
cushing syndrome - Endogenous (2 types)
Cortico-tropic dependent
Cortico-tropic independent
cushings - Cortico-tropic dependent (acho is dependent)
Cortico-tropic dependent
85% of Cushing Syndrome is from an ACTH secreting pituitary adenoma (Cushing disease)
cushings - Cortico-tropic independent (independent of adrenal glands)
Cortico-tropic independent
15-20% from adrenal tumors and ectopic ACTH producing tumors from lung or pancreas
cushings - glucocorticoid related symptoms (cushions makes me lose muscle)
Protein wasting caused by catabolism of peripheral tissues → muscle loss and weakness
cushings - glucocorticoid related symptoms (cushions love sugar)
Glucose intolerance due to insulin resistance and gluconeogenesis
cushings - glucocorticoid related symptoms (think what cortisol does to the bones) a
(cushion breaking my butt bone)
Osteoporosis due to ↑ bone resorption and ↓ intestinal Ca+ absorption
cushings - glucocorticoid (cortisol) - skin
(purple cushions)
Ecchymosis, thin fragile skin
Purple striae on breast, abdomen and buttocks
cushings - glucocorticoid related symptoms - immune system?
Suppression of the immune system → ↑ infection and delayed wound healing
cushings - glucocorticoid related symptoms - hair and skin? (cushions make hair thin and break out)
Thinning of the hair, acne
Hyperpigmentation of skin and mucous membrane due to melanotropic effect of ACTH
cushings - ACTH levels - for hypothalamus and adrenal
Serum ACTH level (↑ or normal = related to hypothalamus/pituitary dz, ACTH ↓or undetectable and ↑cortisol = adrenal etiology)
cushings - what test?
(dax tests the cushions)
Dexamethasone suppression test with simultaneous measurement of ACTH and Cortisol
Positive Cushing syndrome or disease will show ↑ cortisol level
MRI and CT for tumor localization
ACTH - what does it regulate? (andro cortisol makes me sneeze)
Adrenocorticotropic hormone (ACTH) is a tropic hormone produced by the anterior pituitary. The hypothalamic-pituitary axis controls it. ACTH regulates cortisol and androgen production.
adrenal insufficiency - symptoms- what’s the most concerning symptom?
Weakness, anorexia, weight loss, nausea, abd pain, skin hyperpigmentation, joint pain, headache
Hypotension most concerning → shock especially during stress
addisonian crisis - causes (addy is stressing me out)
Manifestations:
Stress
Sudden withholding of corticosteroid hormone therapy
Adrenal surgery
Sudden pituitary gland destruction
addisonian crisis - symptoms- heart, sugar, sodium? (addy is low)
Symptoms:
Vomiting, abd pain, tachycardia, dehydration, hyponatremia, hypoglycemia, fever, confusion, severe hypotension leading to shock
addison’s - interventions (just corticocids)
Medi-alert bracelet for patient’s with Addision’s disease in case of profound circulatory collapse
Intervention requires glucocorticoids; not just vasopressors and fluid replacement
adrenal insufficiency - meds (Adrienne needs DHEA and salt)
DHEA an androgen replacement
Increase salt intake
adrenal insufficiency - note changes in what?
Complete medication hx (Oral hypoglycemics, oral contraceptives, cardiac meds, anticoagulants and NSAIDs may interfere w/drug therapy)
Minimize exposure to infection
Note changes in BP and weight
when to take corticosteriods? and why?
(steroids need food)
Corticosteroids taken > a week should be tapered slowly
Take early in morning with food to minimize gastric irritation
Take Ca supplements, Vit D, alendronate when patient on long-term steroid therapy
Participate in low impact exercise
hyperaldosteronism - Primary
Primary: Caused by solitary adrenocortical adenoma
hyperaldosteronism - Secondary - think what happens when your kidneys don’t work
Secondary: Nonadrenal related e.g. renal artery stenosis, renin-secreting tumors and CKD
hyperaldosteronism - s/sx (sodium up, potassium down)
Sx: HTN, headache, symptoms of hypokalemia (muscle weakness, dysrhythmia, tetany)
hyperaldosteronism - treatments
Treatments include management of HTN and hypokalemia, surgery to remove tumor
PHEOCHROMOCYTOMA - s/sx (phenonmenal nervous headache)
Anxiety, palpitations
Severe episodic hypertension accompanied by:
Severe pounding headache
Tachycardia with palpitation
Profuse sweating
Unexplained abd and chest pain
Pheochromocytoma (tumor in adrenal gland) crisis - cause (phenom gets high)
direct trauma, pressure on tumor, stress or meds (opioids, contrast dye, anti-htn, tricyclic antidepressants).
Pheochromocytoma crisis - how long does it last?
May last minutes to hours.
Pheochromocytoma - treatments (just surgery)
Treatments:
Tumor removal resolves HTN
Pre-op: ⍺ and β blockers to prevent hypertensive crisis intraop
If not a surgical candidate use metyrosine (Demser) to reduce catecholamine production by tumor
aldosterone is a
mineralcorticoid
secondary adrenal insufficiency - causes (seconds for acho)
Secondary adrenal insufficiency
Lack of pituitary ACTH secretion
Caused by pituitary disease or exogenous corticosteroids
Usually only cortisol and androgen depressed (rarely aldosterone)
addison’s - high or low cortisol?
(addy is low)
low
PHEOCHROMOCYTOMA causes excess secretion of what?
(phenomenal epi)
leading to excess secretion of catecholamines (epinephrine and norepinephrine)
