Disorders of Adrenal Cortex and Adrenal Medulla

Question 1

Adrenal Medulla

Answer 1

makes epinephrine and norepinephrine

Question 2

Adrenal Cortex

Answer 2

makes corticosteroids: Glucocorticoids, mineral corticoids, androgens

Question 3

Glucocorticoids

Answer 3

Cortisol

Regulates metabolsim, Increased BS, Regulates body’s stress response

Question 4

Mineralcorticoids

Answer 4

Aldosterone

Regulate Fluid and Electrolyte balance
excess amounts = low K, elevated BP, fluid retention

Question 5

Androgens

Answer 5

Sex Hormones: estrogen, testosterone, andosterone

regulate growth and development in both genders, regulate sexual activity in women

Question 6

Hormones of Adrenal Cortex: ACTH

Answer 6

Anterior Pituitary releases ACTH, ACTH fosters growth of adrenal cortex, stimulates secretion of corticosteroids

Once appropriate levels are reaches, ACTH stops corticosteroids from being released

Question 7

Cushing Syndrome

Answer 7

Most common cause: Administration of exogenous corticosteroids

Too much corticosteroids; no specific etiology

other causes: adrenal tumors and actinic ACTH production by a tumor outside of hypothalamic-pituitary-adrenal axis

Question 8

Exogenous corticosteroids

Answer 8

an outside source; too many steroids for too long

Question 9

Endogenous corticosteroids

Answer 9

ACTH secreting pituitary tumor (Cushing’s Disease)

Question 10

Cushing Syndrome Clinical Manifestations

Answer 10

Primarily r/t excess glucocorticoids; excess androgens and mineralcorticoids may be present:

Truncal Obesity, “Moon Face”, “Buffalo Hump”, purple striae on abdomen, breasts, buttock; acne, hirsutism and menstrual irregularities in women

Lack of muscle tone/bone breakdown
HTN, unexplained hypokalemia, hyperglycemia
Prolonged healing time of wounds (suppressed inflammation which is needed for healing)

Question 11

Cushing Syndrome: Dx studies

Answer 11

24hr urine collection for free cortisol (needs to be started after the first urination in the morning)

Dexamethasone suppression test
Plasma cortisol levels
CT/MRI of pituitary and adrenal glands
Plasma ACTH
Serum Electrolytes (BS, K, Na)

*Cortisol levels are highest in the morning but vary during the day depending on time and whats going on (stress)

Question 12

Cushing Syndrome Collaborative Care

Answer 12

Goal: return hormone levels to w/in normal limits!

tx depends on underlying cause

Question 13

Pituitary Adenoma collaborative care

Answer 13

Transsphenoidal approach hypophysectomy
- meningitis concern, do not brush teeth (suture line in gums), cannot sneeze, cough b/c of ICP

Radiation Therapy

Question 14

Ectopic ACTH - secreting tumor collaborative care

Answer 14

Treat primary neoplasm

Treat cancer!

Question 15

Adrenal Tumors collaborative Care

Answer 15

Adrenalectomy (complex procedure)

• May need to perform bilaterally
• Laparoscopic procedure unless tumor is malignant

Pharmacologic Therapy - Medical Adrenalectomy (treat w/ meds)

• Ketaconazole “Azole”
• Aminoglutethimide
• May be used in addition to surgery or if surgery is contraindicated

Question 16

Azoles for Adrenal Tumors

Answer 16

High does of antifungals can cause adrenal cortex injury

Question 17

Prolonged exogenous corticosteroids collaborative care

Answer 17

discontinue by tapering dose (b/c the adrenal cortex will need to start producing it’s own steroids again)

reduce dose
convert to alternating day regimen (every other day)

Question 18

Cushing Syndrome nursing dx

Answer 18

Risk for infection
Disturbed self-image
Impaired skin integrity (risk for wounds)
Risk for imbalanced fluid volume

Question 19

Cushing Syndrome Nursing Management

Answer 19

monitor CV function, manage DM, closely monitor s/s of infection (fever and inflammation will be masked - look for pain and change in mentation)

• d/c care varies depending on client
• educate to wear MEDICAL ALERT BRACELET
• avoid temp. extremes, infections, emotional stress

Reassure client physical changes will resolve once hormone levels return to normal

Question 20

Open and Laparoscopic Adrenalectomy Nursing Management

Answer 20

• high risk of hemorrhage
• manipulation may release large amounts of hormones
• carefully monitor BP, F&E status post op
• IV corticosteroids post-op (to replace everything that was taken away)
• fall risk post-op if hypotension develops from hypocorticolism
• morning urine cortisol levels evaluate surgery effectiveness

Question 21

Adrenocortical Insufficiency

Answer 21

Primary Cause: Addison’s Disease; usually from autoimmune response

Secondary Cause: Lack of ACTH secretion by pituitary; may be from pituitary disease or result of exogenous administration of corticosteroids

Question 22

Adrenocortical Insufficiency Clinical Manifestations

Answer 22

Generally 90% of adrenal cortex destroyed before symptoms present; significantly delays dx, insidious onset, manifestations for primary and secondary similar

Weakness, fatigue weightless, anorexia, skin hyper pigmentation (primary only)
Orthostatic hypotension, hyponatremia, hyperkalemia
N/V/D, irritability and depression, hypoglycemia

Question 23

Acute Adrenal Insufficiency

Answer 23

Addisonian Crisis

life-threatening emergency; insufficient corticosteroid or rapid decrease in corticosteroids

• Stress related (infection, surgery, trauma, psychological stress)
• sudden withdrawal of exogenous corticosteroid therapy

Question 24

Addisonian Crisis Manifestations

Answer 24

hypotension, tachycardia, dehydration, GI symptoms (N/V/D), hyponatremia
hyperkalemia
Hypoglycemia
Shock
Circulatory collapse usually unresponsive to fluid replacement and vasopressors

Need to give Steroids!!

Question 25

Adrenocortical Insufficiency Dx Studies

Answer 25

ACHT stimulation test (normal response to this test: cortisol levels should go up, but if they have Addison's disease -nothing will happen) ``` CT/MRI Serum Electrolytes (need to watch) ```

Question 26

Adrenocortical Insufficiency Collaborative Care

Answer 26

treat underlying cause Corticosteroid replacement therapy: Hydrocortisone

Question 27

Hydrocortisone

Answer 27

Drug of choice: has glucocorticoid and mineral corticoid properties Doses INCREASED in times of STRESS!! - moderate stress (test) - double dose - severe stress (death) - triple dose

Question 28

Fludrocortisone acetate (Florinef)

Answer 28

mineralcorticoid replacement therapy for adrenocortical insufficiency increased salt in diet during periods of heat/humidity replaces aldosterone

Question 29

Addisonian Crisis Collaborative Care

Answer 29

manage shock High dose IV hydrocortisone replacement Large volume boluses of IV 0.9% NSS and D5%

Question 30

Adrenocortical Insufficiency Nursing Dx

Answer 30

risk for imbalanced fluid volume ineffective tissue perfusion ineffective therapeutic regimen management

Question 31

Adrenocortical Insufficiency Nursing Management

Answer 31

carefully monitor CV status, fluid and electrolyte status protect from noise, light, environmental temp. extremes Pharmacologic management: - glucocorticoids: daily dose divided: 2/3 morning, 1/3 afternoon - mineralcorticoids: once daily in morning

Question 32

Adrenocortical Insufficiency Teaching

Answer 32

importance of maintaining daily corticosteroid replacement therapy appropriately increasing dose during stress s/s of corticosteroid deficiency and excess medical alert bracelet Home BP monitoring Emergency IM hydrocortisone kit for acute insufficiency state

Question 33

early sign of Addisonial Crisis

Answer 33

Nausea and Vomiting

Question 34

Pheochromocytoma

Answer 34

Rare condition caused by adrenal medulla tumor causing excess release of catecholamines (epinephrine and norepinephrine) occurs in both genders and at any age Usually benign bilateral tumors occasional Untreated: may cause DM, cardiomyopathy and death Happens in Waves! secondary HTN

Question 35

Pheochromocytoma Clinical Manifestations

Answer 35

``` severe, pounding headache tachycardia palpitations diaphoresis chest/abdominal pain anxiety ``` provoked by meds: antihypertensives, opioids, radiologic contrast media, TCA's

Question 36

Pheochromocytoma Dx Studies

Answer 36

Secondary cause of HTN Should be considered in clients that don't respond to antihypertensive agents -urine fractionated metanephrines - urine fractionated catecholamines and creatinine - plasma catecholamines -CT/MRI

Question 37

Pheochromocytoma Collaborative Care

Answer 37

Surgery: open or laparoscopic (Adrenalectomy) Preop: alpha adrenergic blockers and beta adrenergic blockers Monitor BS Avoid smoking, Caffeine Do Not palpate abdomen HTN usually resolves w/ tumor removal HTN may persist after removal - treat HTN w/ routine hypertensive meds Med: Metyrosine

Question 38

Adrenalectomy Collaborative Care

Answer 38

life-long steroid replacement, falls precaution