ADRENAL DYSFUNCTION Flashcards
Located at the top of Kidneys
Adrenal Gland
Divided into the adrenal cortex and adrenal medulla
Adrenal Gland
Adrenal Cortex is refferred as
Adrenocortical hormones
Adrenal Medulla is referred as
Adrenomedullary Hormones
The Adrenocortical Hormones
Sugar (Glucocorticoids
Salt (Mineralocorticoids
Sex (Sex Hormones)
Adrenomedullary Hormones
Catecholamines
-Epinephrine
-Norepinephrine
Glucocorticoids involves mainly cortisol, what is the function of glucocorticoids?
-Norepinephrine sensitizer
-Increased bone demineralization
-Secretion of gastric acid
-Immunosuppression (anti-inflammatory)
-Glucose elevation
-Adipose redistribution
Mineralocorticoids involves mainly aldosterone, what is the function of mineralocorticoids?
Pro-Sodium, Anti-Potassium
-Retains Sodium
- Excretes potassium and hydrogen
Sex hormones involves mainly androgen, what is the function of sex hormones?
-In females, androgen is responsible for androgen-dependent processes (pubertal growth spurt)
-Growth of axillary and pubic hair
-Development and maintenance of sex drive
Epinephrine involves adrenaline, what is the function of epinephrine?
-(+) chronotropy and inotropy
- Bronchodilation
- Increased metabolism
Norepinephrine function
Vasoconstriction
A tumor of the chromaffin cells of the adrenal medulla (usually benign; 10% malignant)
Pheochromocytoma
What age does the Pheochromocytoma peaks?
40-50 years old
Pheochromocytoma mostly affects
Affects men and women equally
Clinical Manifestations of Pheochromocytoma
-Palpitation
- Headache
- Episodic Sweating
-Sustained or Paroxysmal Hypertension
Means persistently high BP even with maintenance and medications of HTN
Sustained Hypertension
Means on and off BP or rise and fall of BP even with maintenance or meds
Paroxysmal Hypertension
What is the Diagnostic for Pheochromocytoma?
Vanillylmandelic Acid (VCMA) Test
Measures urinary excretion of catecholamine metabolite
Vanillylmandelic Acid (VCMA) Test
Specimen of Vanillylmandelic Acid (VCMA) Test
24-hour urine sample
In Vanillylmandelic Acid (VCMA) Test what foods must be avoided?
Avoid coffee and tea, banana, chocolate, vanilla, and aspirin
Normal Level of Vanillylmandelic Acid (VCMA) Test
1.4-6.5 mg/24 hours
Instructions for Specimen Collection in Vanillylmandelic Acid (VCMA) Test
-Decide with patient on collection start time
- Discard first specimen (collected on start time)
- Collect all subsequent specimens over 24-hour period
- Store collected specimens in refrigerator
-Collect last specimen
Medical Management of Pheochromocytoma
Alpha-Adrenergic Blockers
-Phenoxybenzamine (Dibenzyline)
-Given 10 to 14 days prior to surgery
- S/E: orthostasis, nasal stuffiness, fatigue, retrograde ejaculation
Beta-Adrenergic Blockers
- Propranolol (Inderal)
- Initiated once alpha-adrenergic control is achieved
Calcium-Channel Blockers
-Nifedipine (Adalat)
- Alternative treatment if blood pressure control is inadequate or patient is unable to tolerate side effects
Surgical Management of Pheochromocytoma
Adrenalectomy
-Removal of one or both adrenal glands
-Definitive treatment of pheochromocytoma
Adrenalectomy
Complication of Adrenalectomy
-Hypertensive Crisis (Intra/Post-Op)
- Results from the manipulation of the tumor during surgical excision
What is the pre-operative preparation of adrenalectomy?
Control Blood Pressure
Management for Adrenalectomy if Complication occurs
-Sodium nitroprusside (Nitropress)
- Phentolamine (Oraverse)
Nursing Management of Pheochromocytoma
-Institute bed rest with HOB elevated to promote orthostatic decrease in BP during episodes of hypertension or tachycardia
- is a clinical condition that results from chronic exposure to excessive cortisol
-Affects women>men
Cushing’s Syndrome
What causes of Cushing’s Syndrome?
-Steroid Use (Exogenous Source
- Cushing’s Disease (ACTH- producing pituitary adenoma)
- Adrenal Hyperplasia
-Malignancies
Clinical Manifestations of Cushing’s Syndrome
-“Moon Face”
-Skinny arms and legs
-Amenorrhea
-Depression
-Hypertension and hyperglycemia
-Infections (Often recurrent)
-Purpura and peptic ulcers
-Osteoporosis
-Non-healing wound
Diagnostic Test of Cushing’s Syndrome
Dexamethasone Suppression Test
Assesses adrenal gland function by measuring changes in the body’s ACTH and cortisol level in response to oral doses of dexamethasone
Dexamethasone Suppression Test
Screening Test for Crushing’s Syndrome
Low-Dose Suppression
(Dexamethasone 1 mg)
Procedure
1. Low- dose Dexamethasone PO at 11 PM
2. Plasma cortisol is measured at 9AM of the following day
Interpretation
Low plasma cortisol – Normal
Normal/High plasma cortisol – Cushing’s syndrome
Determines Etiology or Causes of Cushing’s Syndrome
High-dose Suppression
(Dexamethasone 8 mg)
Procedure
High- dose Dexamethasone PO at 11 PM
Plasma cortisol is measured at 9AM of the following day
Interpretation
Low plasma cortisol – Cushing’s Disease
Normal/High plasma cortisol, check ACTH
ACTH is low – Adrenal Cushing
ACTH is high – Ectopic ACTH source
Medical-Surgical Management of Cushing’s Syndrome
-Transsphenoidal hypophysectomy
-Done if cause is a pituitary tumor
-Adrenalectomy (Laparoscopic)
-Done if cause is adrenal hyperplasia
Post operative care of Adrenalectomy (Laparoscopic)
-Symptoms of adrenal insufficiency may appear 12 to 48 hours after surgery
-Hydrocortisone is given for several months
Dose reduction
-Done if cause of syndrome is the administration of corticosteroids
-Dose is tapered to the minimum dosage needed to treat underlying disease process
Key Nursing Interventions of Cushing’s Syndrome
- Institute safety/fall precautions
- Adhere to infection prevention and control measures
- Provide meticulous skin and wound care
- Encourage verbalization of concerns
- Monitor vital signs and blood glucose frequently. Intervene as needed
Primary Adrenal Insufficiency
Addison’s Disease
Occurs when the adrenal glands are damaged and cannot secret adrenocortical hormones
Addison’s Disease
Causes of Addison’s Disease
-Autoimmune
- Adrenal gland destruction (commonly from tuberculosis)
Clinical Manifestations of Addison’s Disease
-Progressive weakness
-Fatigue
-Anorexia
-Weight loss
-Nausea and vomiting
-Occasional diarrhea
-Salt cravings
-Orthostatic hypotension
-Impotence
-Decreased libido
-Amenorrhea
Eternal tan of Addison’s Disease
Hyperpigmentation
-Usually generalized but commonly affects the sun- exposed areas.
-Involves the skin and mucous membranes
-It is caused by the stimulant effect of excess adrenocorticotrophic hormone (ACTH) on the melanocytes to produce melanin.
Hyperpigmentation
-white patchy areas
-Commonly associated with Addison’s disease having an autoimmune etiology
Vitiligo
Diagnostic Test for Addison’s Disease
ACTH Stimulation Test
assesses the functional capacity of the adrenal cortex to synthesize cortisol.
ACTH Stimulation Test
ACTH stimulation Test Procedure & Interpretation
Procedure:
- Baseline cortisol and aldosterone levels are obtained
- Synthetic ACTH is administered IM or IV
- Cortisol and aldosterone levels are checked 30 or 60 minutes after
Interpretation
-Normal: elevation of cortisol and aldosterone levels to twice the baseline level
-Addison’s disease: little or no response to ACTH stimulation
Due to low cortisol levels
Hypoglycemia
Due to low aldosterone levels
Hyponatremia
Due to low aldosterone levels
Hyperkalemia
Medical Management of Addison’s Disease
-Hydrocortisone (Solu- cortef)
-Drug of choice for Addisonian crisis and daily maintenance
-Possesses both glucocorticoid and mineralocorticoid properties
-Fludrocortisone (Florinef)
-Has a more potent mineralocorticoid property
-Used when patient needs to be weaned off hydrocortisone
Key Nursing Interventions of Addison’s Disease
- Instruct to increase salt intake during hot weathers
- Provide diet that is high in sodium but low in potassium
- Caution about condiments that uses potassium citrate as salt substitute
- Encourage to increase fluid intake
- Provide small, frequent feedings especially if with anorexia
- Educate on stress management and avoidance of infection, crowded places, and extremes of temperatures
What triggers Addisonian Crisis?
- Stress (infection, trauma, surgery, emotional turmoil)
- Failure to increase steroid during anticipated stress
- Bilateral adrenal hemorrhage (Meningococcal/Pseudemona complication, pregnancy)
Clinical Manifestations of Addisonian Crisis
- Nausea and vomiting
- Hypotension
- Rapid but weak pulse
- Decreasing mental status (initially restlessness, confusion)
- Cyanosis
6.vHyperpyrexia (T>38.5) - Abdominal pain, if with adrenal hemorrhage
Medical Management of Addisonian Crisis
-Priority: restore volume deficit and correct hypotension
-Infuse 0.9% Sodium Chloride (PNSS)
-Glucose supplementation, if hypoglycemic
-D50W via IV Push
-Identify and correct precipitating cause
-Steroid replacement
-Hydrocortisone 100mg continuous infusion
-Tapered down as the condition improves
Key Nursing Interventions of Addisonian Crisis
- Start an IV line using a large- bore IV catheter
- Closely monitor vital signs, glucose, and neurologic status
- Use an infusion pump to administer hydrocortisone infusion
- Provide supportive care
