Med-Surg: Chapter 42: Adrenal Cortex Hyperfunction

Question 1

What is Adrenal Cortex Hyperfunction a result of?

Answer 1

may be secondary to excessive secretion of glucocorticoids (hypercortisolism) or excessive secretion of aldosterone (hyperaldosteronism)

Question 2

Hypercortisolism

Answer 2

categorized as primary (adrenal cortex disorder), secondary (anterior pituitary gland disorder), or tertiary (hypothalamic etiology)
-Cushing’s

Question 3

Cushing’s

Answer 3

used to describe hyperfunction of the adrenal cortex

Question 4

Cushing’s Disease

Answer 4

condition caused by excessive hormone production from an anterior pituitary tumor producing excessive ACTH or excessive hormone secretion from a primary tumor of the adrenal cortex

Question 5

Cushing’s Syndrome

Answer 5

broad term
-used to describe an excess of hormone production (CRH, ACTH, glucocorticoids), or administration of exogenous corticosteroid medications

Question 6

Hyperaldosteronism (Conn’s Syndrome)

Answer 6

because the primary action of aldosterone is sodium and water reabsorption and potassium excretion, hypertension and hypokalemia develop

Question 7

Pathophysiology

Answer 7

• excessive circulating glucocorticoid (cortisol) is the pathological process associated with primary hypercortisolism
• excessive secretion of ACTH from the anterior pituitary gland leads to hypercortisolism through its effects on the adrenal cortex

Question 8

Clinical Manifestations

Answer 8

related to hypersecretion of these hormones
-hyperglycemia
-fluid retention
-hypokalemia
-abnormal fat distribution
-decreased muscle mass
>the maldistribution of fats and changes in muscle are related to the effects that glucocorticoids have on fat and protein metabolism

> in females,

• virilization (male sexual characteristics developing)
• breast atrophy
• vocal changes (deepening)
• amenorrhea

> overproduction of cortisol also affects the immune system by decreasing inflammatory and immune responses
-lymphocytes are destroyed secondary to high levels of circulating cortisol; risk for infection

> hyperaldosteronism, usually secondary to a hypersecreting tumor of the adrenal cortex, or hyperplasia, results in increased aldosterone production

• secondary to the action of aldosterone, sodium and water reabsorption are increased; elevated blood pressure is associated with the sodium and water retention
• cardiac irregularities (atrial or ventricular tachyarrhythmias or U waves) secondary to hypokalemia (b/c there is an excess of potassium secretion with hyperaldosteronism)

Question 9

Diagnosis of Hypercortisolism

Answer 9

• assessment of cortisol levels, results of suppression tests, and serum electrolytes
• b/c aldosterone secretion results in both sodium and water reabsorption, there may not be an increase in serum sodium (secondary to water reabsorption)
• patient presents with hyperglycemia (secondary to glucocorticoid activity)
• presents with hypokalemia
• measurement of urinary free cortisol (measures in a 24-hour period)
• overnight dexamethasone suppression test

Question 10

Overnight Dexamethasone Suppression Test

Answer 10

evaluate hypercortisolism, specifically whether the administration of exogenous glucocorticoid (dexamethasone) inhibits the secretion of ACTH, that, in turn, decreases stimulation of cortisol release

> dexamethasone, 1 mg, is administered 11 pm followed by the collection of serum cortisol level at 8 am; results are based on whether suppression of cortisol secretion’s occur secondary to the administration of exogenous glucocorticoid

> Results:
-if the morning level is less than 2 to 3 mg/dL, normal functioning of the hypothalamic-pituitary adrenal axis is determined

Question 11

Medical Management of Hypercortisolism

Answer 11

focuses on preventing complications associated with fluid overload, changes in immune status, changes in skin integrity, and changes in body structure
-medications that interfere with ACTH and glucocorticoid production are used

> Aminoglutethimide; interferes with cortisol production in the adrenal cortex
Cyproheptadine; impacts ACTH production
-with both meds, monitor for signs of adrenal suppression (hypoglycemia and hyponatremia)

> Pasireotide (Signifor), subcutaneous somatostatin analog, used to inhibit release of corticotropin in patients with Cushing’s disease secondary to pituitary adenoma

Question 12

Aminoglutethimide

Answer 12

interferes with cortisol production in the adrenal cortex

-monitor for adrenal suppression (hypoglycemia, hyponatremia)

Question 13

Cyproheptadine

Answer 13

impacts ACTH production

-monitor for adrenal suppression (hypoglycemia, hyponatremia)

Question 14

Surgical Management of Hypercortisolism

Answer 14

based on etiology

• if a pituitary tumor = transsphenoidal hypophysectomy
• with hypersecreting tumors of the adrenal cortex = adrenalectomy (removal of adrenal gland)
• stereotactic radiosurgery of the pituitary gland = can be used in management of tumors of the pituitary gland

Question 15

Diagnosis of Hyperaldosteronism

Answer 15

evaluation of serum electrolytes and imaging studies

• elevated serum aldosterone levels
• hypokalemia
• hypernatremia
• b/c hyperaldosteronism is usually secondary to hypersecreting tumors or hyperplasia, CT, or MRI may demonstrate enlargement or changes of the adrenal cortex

Question 16

Medical Management Of Hyperaldosteronism

Answer 16

focus on controlling hypertension, managing hypokalemia, and determining the etiology of hyperaldosteronism

• Hypertension treated with Spironolactone (Aldactone), a potassium sparing diuretic; potassium and sodium levels are monitored while on this medication
• potassium supplementation may also be required b/c of loss of potassium caused by elevated aldosterone

Question 17

Medications for Hypertension in Hyperaldosteronism

Answer 17

Spironolactone (Aldactone)
-potassium-sparing diuretic

> monitor sodium and potassium levels on this medication

Question 18

Surgical Management of Hyperaldosteronism

Answer 18

adrenalectomy to remove hypersecreting tumors of the adrenal cortex

Question 19

Complications of Hypercortisolism

Answer 19

at risk for complications associated with excessive cortisol levels

• Osteoporosis: relative to the effects of cortisol on bone density and can increase the risk of pathological fractures
• In patients with hypercortisolism secondary to exogenous corticosteroid therapy, acute adrenal crisis may result with abrupt withdrawal of medication
• elevated serum glucose may complicate management of diabetes mellitus
• gastrointestinal bleeding may develop as a result of decreased mucus production in the GI tract, decreased blood flow, and release of hydrochloric acid secondary to the effects of cortisol

Question 20

Safety Alert: Patients on Exogenous Corticosteroids

Answer 20

patients receiving exogenous cortico-steroids (for their inflammatory actions) are often prescribed medications that serve as gastrointestinal prophylaxis
-b/c of the effects of corticosteroids on the GI tract, the patient must be assessed for complaints of gastrointestinal distress and GI bleeding

Question 21

Complications of Hyperaldosteronism

Answer 21

complications related to hypertension and severe hypokalemia

• untreated hypertension leads to damage to other organs including the heart, vasculature, kidneys, and eyes
• uncontrolled BP increases the risk for acute myocardial infarction and acute stroke (cerebrovascular accident)
• cardiac dysrhythmias are associated with severe hypokalemia

Question 22

Nursing Management: Assessment and Analysis

Answer 22

the clinical manifestations in the patient with adrenal cortex hyperfunction are related to elevated circulating levels of cortisol or aldosterone

> Hypercortisolism: (excessive cortisol)

• hypertension
• hyperglycemia
• dependent edema
• thin, friable skin
• fat maldistribution (truncal obesity, “moon face”, and “buffalo hump”)
• loss of bone density
• decreased inflammatory process
• increased risk of infection

> Hyperaldosteronism:

• hypertension
• hypernatremia
• hypokalemia
• headache

Question 23

Nursing Diagnoses For Hypercortisolism

Answer 23

• Fluid volume excess associated with increased sodium and water reabsorption secondary to excess glucocorticoid secretion
• Body image disturbance associated with development of truncal obesity and fat deposition secondary to excess glucocorticoid secretion
• Risk for infection associated with immunosuppression
• Deficient knowledge associated with diagnosis of hypercortisolism

Question 24

Nursing Diagnosis For Hyperaldosteronism

Answer 24

• Fluid volume excess associated with increased sodium and water reabsorption secondary to excess aldosterone secretion
• Risk for decreased cardiac output associated with cardiac dysrhythmias secondary to hypokalemia
• Deficient knowledge associated with management of hyperaldosteronism

Question 25

Nursing Interventions: Assessment

Answer 25

> Vital Signs:

• suppressed immune function secondary to hypercortisolism increases the risk of infection
• small increases in body temperature may be significant, and signs of infection may be masked b/c of immune suppression
• blood pressure and heart rate may increase secondary to fluid retention

> Intake and Output

• monitoring is important to evaluate trends once treatment has been started
• urine output should increase and signs of fluid overload should decrease if treatment is effective

> Serum Glucose, Potassium

• glucose levels rise secondary to increased secretion of glucocorticoid
• Potassium levels also fall secondary to increased excretion via the kidneys secondary to glucocorticoid and mineralocorticoid activity

> Daily Weight

• weight gain occurs secondary to fluid retention secondary to sodium and water reabsorption
• peripheral edema may develop

> Skin
-thinning skin and increased friability develop secondary to excess cortisol

> Fat Distribution
-actions of glucocorticoid affect fat metabolism, leading to maldistribution of fat including truncal obesity, moon face, and buffalo hump

> Muscle Mass
-muscle atrophy develops secondary to altered protein metabolism

> Wound healing
-delayed wound healing occurs associated with suppressed inflammatory response

Question 26

Nursing Actions

Answer 26

> Administer medications that interfere with production/ secretion of cortisol
-decreases secretion of cortisol

> Head of the Bed Elevated 45 Degrees
-decreases work of breathing that may develop secondary to fluid retention

> Turn patient frequently and protect the skin from injury
-thinning of the skin along with increased friability of the skin accompanied by fluid retention increase the chances of skin injury caused by pressure or friction

Question 27

Teaching

Answer 27

> Overview of the Disease process
-important to detect early signs of both hypercortisolism and adrenal insufficiency

> Importance of taking prescribed medications
-medications that interfere with cortisol production are key to disease management

> Modify Salt in Diet as directed
-excessive salt intake may further exacerbate fluid retention

Question 28

Evaluating Care Outcomes

Answer 28

• if etiology is a hypersecreting tumor of the pituitary gland or adrenal cortex, surgical intervention (transsphenoidal hypophysectomy, adrenalectomy, stereotactic radiosurgery) is indicated
• be closely monitored postoperatively and may require lifelong corticosteroid replacement on the basis of the surgical outcome
• stable vital signs and fluid volume status, serum electrolytes within normal limits, and intact skin are expected outcomes with treatment of hyperfunction of the adrenal cortex