Adrenocortical Agents Flashcards
Indications for Use of Adrenal Agents
Widely used to suppress the immune system
Short-term use to relieve inflammation during acute stages of illness
Do not cure any inflammatory disorders
Don’t use these meds for any longer than we need to
Anatomy of the Adrenal Glands
Location
Flattened bodies which sit on top of each kidney
Composition
Adrenal medulla: An inner core; part of the SNS
releases epinephrine and norepinephrine when its stimulated by SNS
Adrenal cortex: An outer shell; produces hormones called corticosteroids
Adrenal Abnormalities
Adrenal Excess
- Cushing Disease
Adrenal Insufficiency
- Addison Disease
Adrenal Excess
Cushing Disease (a cushion of hormone - too much of it) Symptoms- moon-like face, central obesity, HTN, protein breakdown, osteoporosis, hirsutism
Adrenal Insufficiency
Addison Disease (we need to add hormone back in) Symptoms- confusion, hypotension, CV collapse (leads to shock and death), fatigue, limited ability to respond to infection
Adrenocortical Agents: Children
Dose is determined by severity of condition not age or weight
Monitor growth and development; (can lead to growth retardation in children - if we see it severely, we discontinue, if not severe, we just reduce dose) discontinue if severe growth retardation
Protect against infection and injuries
Adrenocortical Agents: Adults
Take in the morning
Taper the medication; do not stop abruptly
Check OTC preparations for corticosteroids (such as cortisol)
Protect against infection and injuries
Cross the placenta and can cause ADE to fetus
avoid use in pregnancy
Enter breastmilk and can cause ADE to baby
find alternative method for feeding
Adrenocortical Agents: Older Adults
More likely experience ADE
Reduce dose and monitor closely
More likely to have conditions that are impacted by corticosteroids (DM, HF, osteoporosis) - monitor those conditions that can be exacerbated by corticosteroid agents
Conditions affected by coticosteroids
DM, HF, osteoporosis
Types of Corticosteroids
Androgens
Male and female sex hormones
Glucocorticoids
Stimulate an increase in glucose levels for energy
Mineralocorticoids
Affect electrolyte levels and homeostasis
helps maintain homeostasis
Causes of Adrenal Insufficiency
A patient does not produce enough ACTH
Adrenal glands are not able to respond to ACTH
Adrenal gland is damaged
Secondary to surgical removal of the gland
Prolonged use of corticosteroid hormones
- when body is given an outside source (exogenous) of a hormone, it stops making the hormone altogether
Actions of Adrenocortical Hormones
Increase blood volume (aldosterone effect)
Cause the release of glucose for energy
Slow rate of protein production (reserves energy)
Block activities of the inflammatory and immune systems (reserves a great deal of energy)
Adrenal Crisis
Signs Physiological exhaustion Hypotension Fluid shift Shock and even death a patient has an insufficiency of adrenal hormone - the extreme addisons disease
Treatment of Adrenal Crisis
Massive infusion of replacement steroids
Constant monitoring and life support procedures
Common Glucocorticoids: Names
Betamethasone Budesonide Cortisone Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone
Glucocorticoids: Actions
Actions
Enter target cells and bind to cytoplasmic receptors
Initiate many complex reactions responsible for anti-inflammatory and immunosuppressive effects
autoimmune disorders
Hydrocortisone, cortisone, and prednisone have some mineralocorticoid activity
Glucocorticoids: Indications
Indications
Short-term treatment of many inflammatory disorders
RA / COPD / Any autoimmune condition
To relieve discomfort
To give the body a chance to heal from the effects of inflammation
Glucocorticoids: Contraindications
Contraindications - Known allergy - Acute infection - Lactation Caution - Diabetes - Acute peptic ulcer
Glucocorticoids: ADE
Adverse Effects
Headache, insomnia, psychosis, GI upset, HF (related to fluid retention), fluid retention, increased blood glucose, osteoporosis, frail skin (skin just rips when you barely touch the skin) , growth retardation (children), diabetes, Cushing syndrome, impaired wound healing, aggravating or masking of infections
teacher sees all of the ADE daily in her practice
put on lowest dose possible and get them off asap
Glucocorticoids: Drug drug
Drug-Drug Interactions
Increase in drug when given with erythromycin, ketoconazole, or troleandomycin
Decrease in drug when given with salicylates, barbiturates, phenytoin, or rifampin
Nursing Considerations for Glucocorticoids: Assess
Assess:
History and physical exam
Known allergies, acute infections, peptic ulcer disease, pregnancy, lactation, endocrine disturbances, and renal dysfunction
Weight (baseline and monitor throughout - to detect fluid retention); temperature (baseline and monitor for infection throughout); orientation and affect (CNS effect); grip strength; eye examination; blood pressure, pulse, peripheral perfusion, and vessel evaluation
Respiration and adventitious breath sounds (we hope glucocorticoid alleviates symptoms such as wheezing); glucose tolerance, renal function, serum electrolytes (sodium / calcium / potassium), and endocrine function tests as appropriate
Nursing Considerations for Glucocorticoids: Diagnosis
Nursing Diagnoses
Altered cardiac output related to fluid retention
Excess fluid volume related to water retention
Disturbed sensory perception
Risk for infection related to immunosuppression
Ineffective coping related to body changes caused by the drug
Deficient knowledge regarding drug therapy
Imbalanced nutrition: more than body requirements related to metabolic changes
Nursing Considerations for Glucocorticoids: Implementation
Implementation
- Administer drug daily at 8 to 9 am
- Space multiple doses evenly throughout the day
- Use the minimal dose for the minimal amount of time
- Taper doses when discontinuing from high doses or from long-term therapy
- Arrange for increased dose when the patient is under stress
- Use alternate-day maintenance therapy with short-acting drugs
- Do not give live virus vaccines when the patient is immunosuppressed
live virus not good when immunosuppressed
- Protect the patient from unnecessary exposure to infection and invasive procedures
- teach need to be vigilant with monitoring glucose levels in diabetic patients
Nursing Considerations for Glucocorticoids: Evaluation
Evaluation
Monitor patient response to the drug (relief of signs and symptoms of inflammation, return of adrenal function to within normal limits)
Monitor for adverse effects (increased susceptibility to infections, skin changes, endocrine dysfunctions, fatigue, fluid retention, peptic ulcer, psychological changes)
Evaluate the effectiveness of the teaching plan
Prednisone: Prototype Glucocorticoids: Indications
- Indication: replacement therapy in adrenal cortical insufficiency, short-term management of various inflammatory and allergic disorders, hypercalcemia associated with cancer, hematological disorders, ulcerative colitis (an autoimmune condition) , acute exacerbations of multiple sclerosis, palliation in some leukemias, trichinosis with systemic involvement
Prednisone: Prototype Glucocorticoids : Actions
Actions: enters target cells and binds to intracellular corticosteroid receptors, initiating many complex reactions responsible for its anti-inflammatory and immunosupportive effects
Prednisone: Prototype Glucocorticoids: ADE
ADE: vertigo, HA, hypotension, shock, sodium and fluid retention, amenorrhea, increased appetite, weight gain, immunosuppression, aggravation or masking of infections, impaired wound healing
Common Mineralocorticoids: Names
Cortisone
Fludrocortisone
Hydrocortisone
All have effect on electrolytes - they act like aldosterone - very similar
Common Mineralocorticoids: Actions
Actions
Holds sodium, and with it, water in the body
Causes the excretion of potassium by acting on the renal tubule
Mineralocorticoids: Indications
Indications
Replacement therapy in primary and secondary adrenal insufficiency
Mineralocorticoids: Contraindications
Contraindications
- Known allergy
- Hypertension
- CHF
- Cardiac disease
Caution
- Pregnancy
- Presence of any infection
- High sodium intake
Mineralocorticoids: ADE
Adverse Effects
Increase fluid volumes, hypokalemia
Mineralocorticoids: Drug drug interactions
Drug-Drug Interactions
Decrease effectiveness with salicylates, barbiturates, hydantoins, rifampin, and anticholinesterases
Nursing Considerations for Mineralocorticoids: Assess
Assess:
History and physical exam
Known allergy
Heart failure, hypertension, or infections; high sodium intake; lactation; and pregnancy
Nursing Considerations for Mineralocorticoids: Diagnosis
Nursing Diagnoses
Imbalanced nutrition: more than body requirements related to metabolic changes
Excess fluid volume related to sodium retention
Impaired urinary elimination related to sodium retention
Deficient knowledge regarding drug therapy
Nursing Considerations for Mineralocorticoids
Implementation
Implementation
Use only in conjunction with appropriate glucocorticoids
to maintain electrolyte balance
Increase dose in times of stress
Monitor for hypokalemia (weakness, serum electrolytes)
retain sodium and excrete potassium
Discontinue if signs of overdose (excessive weight gain, edema, hypertension, cardiomegaly)
Provide thorough patient teaching
ADE, follow ups, blood tests, teach about signs and symptoms of hypokalemia, daily weights, when to contact health care provider with dramatic weight gain
Nursing Considerations for Mineralocorticoids: Evaluation
Evaluation
Monitor patient response to the drug (maintenance of electrolyte balance)
Monitor for adverse effects (fluid retention, edema, hypokalemia, headache)
Evaluate the effectiveness of the teaching plan
Monitor compliance with the regimen
Prototype Mineralocorticoids: Fludocortisone: Indications
Indications: partial replacement therapy in cortical insufficiency conditions, treatment of salt-losing adrenogenital syndrome; off-label use: treatment of hypotension
used a lot in clinical setting when can’t figure out why blood pressure is low
Prototype Mineralocorticoids: Fludocortisone: Actions
Actions: increases sodium reabsorption in the renal tubules and increases potassium and hydrogen excretion, leading to water and sodium retention
