Nursing Management of Patients with Adrenal Disorders

Question 1

Adrenal Insufficiency

Answer 1

Primary: Addison’s Disease
May be hereditary; Lack of:
Glucocorticoids
Mineralocorticoids
Androgens

Secondary
Lack of pituitary ACTH
Lack of:
Glucocorticoids
Androgens

Clinical symptoms
Headache
Progressive weakness, Mild fatigue & Irritability
Weight loss
Anorexia, N / V
Orthostatic hypotension
Hyperkalemia
Hyponatremia
Abdominal pain, Diarrhea
Salt craving
Joint pain

Insidious onset; Often advanced before diagnosed
Usually 90% loss of adrenal cortices at time of diagnosis

Question 2

Addison’s Disease Diagnostic Testing

Answer 2

Labs:
Hyperkalemia
Hyponatremia
Hypoglycemia
Anemia
Increased BUN

Imaging studies:
Localize tumor, identify adrenal calcification or enlargement
X-ray
CT scan
MRI

ACTH Stimulation Test
Baseline: Cortisol & ACTH
Synthetic ACTH given IVP
Levels rechecked after 30 & 60 minutes
Elevated Cortisol normal
Little or no increase in Cortisol (Addison’s disease)
High ACTH (Primary adrenal insufficiency)

CRH (Corticotrophin-releasing hormone) Stimulation Test Secreted by hypothalamus; central driver stress hormone system (hypothalamic–pituitary–adrenal axis)
Abnormal ACTH Test response
Synthetic CRH given IVP
Levels checked after 30 & 60 minutes
High ACTH levels with no Cortisol (Addison’s disease)
Absence of ACTH or delayed response (Secondary)

Question 3

Treatment:Addison’s Disease

Answer 3

Glucocorticoid: Hydrocortisone (Gluco & Mineralo-corticoid properties)
2/3 total daily dose in AM
1/3 total daily dose in PM
Must be increased during times of stress to prevent Addisonian Crisis

Carry Emergency Kit at all times
100 mg Hydrocortisone IM syringes
Instructions for use

Mineralocorticoid: Fludrocortisone (Florinef)
Once daily in AM
Androgens (For women): Dehydro-epi-androsterone (DHEA)

Increase dietary salt intake

Question 4

Acute Adrenal Insufficiency(Addisonian Crisis)

Answer 4

Sudden, penetrating pain in back, abdomen, legs
Severe vomiting
Diarrhea
Hypotension & Tachycardia
Hypo-natremia
Hyper-kalemia
Hypo-glycemia
Dehydration
Fever
Weakness
Confusion

Treatment
Management of shock; Volume expansion with
0.9% Saline
D5W
Correct electrolyte imbalance
Kayexalate
High-dose Hydrocortisone replacement:
100 mg IV bolus, then
100 mg IV every 8-hours x 24 hours
IV tapered to PO doses

Question 5

Addison’s Disease:Nursing Interventions

Answer 5

Medication history

Frequent assessment:
Vital signs
Fluid & electrolyte status
Monitor mental status
Daily weight

Watch for signs of Cushing syndrome

Infection prevention

Assist with daily hygiene

Protect from stress & extremes
Light
Noise
Temperature

Question 6

Addison’s Disease:Patient Teaching

Answer 6

Life-long Therapy; Medication dosing to reflect normal circadian rhythm & decrease side effects
Glucocorticoids in divided doses
Mineralocorticoids once in the morning
Take with food to decrease gastric distress
Need to increase corticosteroids during times of stress
Emergency Kit
Medical Alert Bracelet

Question 7

Effects of Corticosteroid Therapy

Answer 7

Expected:
Anti-inflammatory action
Immunosuppression
Maintenance of normal BP
↓ Potassium & calcium
↑ Glucose & B/P
Delayed healing

Potential complications:
Peptic ulcer disease
Muscle atrophy / weakness
Mood & behavior changes
Moon Facies
Truncal obesity
Protein depletion
Decreased K+ & Ca+
Increased glucose & BP
Delayed healing
Susceptibility to infection
Suppressed immune response
Risk for acute Adrenal Crisis if therapy stopped abruptly

Question 8

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Answer 8

Release of ADH despite low / normal plasma osmolarity
Fluid retention
Low urine output
Weight gain without edema
Serum hypo-osmolarity
Dilutional hyponatremia
Concentrated urine with normal or increased intra-vascular volume

Interventions
Fluid restriction: 800 – 1000 mL / day
Frequent oral care
Distraction
Furosemide (Lasix) with Na+ > 125
Seizure / fall precautions
HOB flat or 10-degrees
IV Conivaptan (Vapriosol)
PO Tolvapan (Samsca)

Question 9

Cushing’s Syndrome

Answer 9

Excess Corticosteroids

Question 10

Adrenal Cortex Hormones(Corticosteroids)

Answer 10

Glucocorticoids
Regulate metabolism
Increase blood glucose
Critical in physiologic stress response
Mineralocorticoids
Regulate sodium & potassium balance
Androgens
Involved in growth & development
Sexual development in women

Question 11

Cushing SyndromeEtiology & Pathophysiology

Answer 11

Chronic exposure to excess Glucocorticoids
Iatrogenic: Administration of exogenous corticosteroids (Prednisone)
ACTH-secreting pituitary adenoma
(85%; Cushing Disease)
Adrenal tumors
Ectopic production of ACTH by other tumors (Lung or Pancreas)

Question 12

Cushing SyndromeManifestations: Excess Glucocorticoids

Answer 12

Weight gain
Truncal & general obesity
Moon face
Buffalo hump
Purplish, red striae
Loss of collagen
Thin skin
Easy bruising

Hyperglycemia
Glucose intolerance
Increased gluconeogenesis
Muscle wasting
Osteoporosis & back pain
Delayed wound healing

Question 13

Cushing SyndromeManifestations: Excess Mineralocorticoids & Androgens

Answer 13

Excess Mineralocorticoids

Hypokalemia

Hypertension

Excess Androgens
Severe acne

Virilization in women
Increased body hair (Hirsutism)
Menstrual disorders

Feminization in men
Gynecomastia
Impotence

Question 14

Cushing Syndrome Providing Emotional Support

Answer 14

Remain sensitive to patient feelings

Offer respect & unconditional acceptance

Offer reassurance that physical changes & emotional lability will resolve when hormone levels return to normal

Question 15

Cushing SyndromeDiagnostic Studies

Answer 15

Late night, or midnight plasma or salivary cortisol
24-hour urine collection for free cortisol
Elevated (Above 100 mcg / 24-hours)
Low-dose Dexamethasone suppression test
CT or MRI to detect tumor
Plasma ACTH levels
High or normal with Cushing disease (pituitary etiology)
Low, normal, or high with Cushing syndrome
Hypokalemia & alkalosis; With ectopic ACTH syndrome & Adrenal cancer

Question 16

Cushing SyndromeExample Nursing Diagnosis & Outcome

Answer 16

Disturbed body image
r/t Alteration in body function d/t disease; change in appearance from disease process
AEB avoidance of mirrors, withdrawal from previously valued social experiences, & verbalization of negative feelings about personal appearance
Outcome: Client will be willing to use mirrors for personal hygiene, will resume involvement in at least one, weekly social activity, & will be able to verbalize positive feelings about their appearance within 1-month

Question 17

Cushing SyndromeInterventions for Health Promotion

Answer 17

Identify patients at risk
Long-term exogenous cortisol therapy is major risk factor
Teach patients about medication use & how to monitor for side effects

Question 18

Cushing SyndromeCollaborative Care

Answer 18

Goal: Normalize hormone secretion
Treatment depends on cause
Surgical removal or irradiation of pituitary adenoma
Surgical Adrenalectomy for adrenal tumors or hyperplasia
Removal of ectopic ACTH-secreting tumors (lung/pancreas)
Medical Adrenalectomy; Used cautiously; doses needed to suppress cortisol often toxic
Ketoconazole (Nizoral)
Aminoglutethimide (Cytadren)
Mitotane (Lysodren)
Hydrocortisone or Prednisone PRN to prevent adrenal insufficiency

Iatrogenic cause
Gradually decrease dose of glucocorticoids & discontinue therapy
Convert to alternate-day regimen
Dose must be tapered gradually to prevent adrenal insufficiency / crisis

Assess & monitor
Vital signs
Daily weight
Glucose
Signs & symptoms of inflammation & infection
Signs & symptoms of thromboembolism

Question 19

Cushing SyndromePre-operative Care

Answer 19

Optimize physical condition
Control hypertension & hyperglycemia
Correct hypokalemia
High-protein diet (Correct protein depletion)
Patient teaching
Informed consent
Baseline neurological tests
Baseline visual acuity tests

Transphenoidal Hypophysectomy
Vaseline gauze or balloon-tipped catheter in sphenoid sinus
1 - 3 days
Moustache dressing

Adrenalectomy
NG tube
Urinary catheter
IV therapy
CVP monitoring
SCD’s

Question 20

Cushing SyndromeAdrenalectomy – Postoperative Care

Answer 20

Large release of hormones
Labile B/P, F & E imbalance
Bed rest until BP stabilized
High dose IV corticosteroids during & several days after surgery
Increased risk for:
HTN & hemorrhage
Infection & delayed wound healing

Monitor for infection; Meticulous care to prevent
Report signs of adrenal insufficiency:
N/V
Increased weakness
Dehydration
Hypotension
Painful joints
Pruritus
Peeling skin
Emotional lability

Question 21

Trans-sphenoidal Hypophysectomy

Answer 21

Surgical removal of Pituitary gland
Permanent loss of all Pituitary hormones when entire gland removed
Incision through upper lip & gingiva, Stella turcica entered through floor of nose & sphenoid sinuses

Question 22

Trans-sphenoidal Hypophysectomy:Post-Operative Assessment

Answer 22

Neuro checks every hour for 24-hours, then every 4-hours
HR, rhythm & BP
Intake & output
Assess for symptoms of DI (Hypo-pituitarism)
Polydipsia
Polyuria
Serum electrolytes
N / V, Urinary retention, Constipation

Potential Complications
CSF Leakage
Infection
Bleeding
Visual impairment
Incomplete tumor removal

Glucocorticoids to avoid drop in cortisol level
Analgesia for HA
HOB 30-degrees
Avoid increased ICP & decrease headaches
Prevent CSF leakage – Teach & assist patient to avoid:
Vigorous coughing, sneezing
Valsalva maneuver
Oral care every 4-hours; No teeth brushing for 7 to 10-days

Question 23

Trans-sphenoidal Hypophysectomy:Risk for Infection

Answer 23

Abscess formation
Notify Provider for:
Periorbital pain
Abnormal protrusion or displacement of eye
Visual disturbances
Obtain X-ray or CT
Return to surgery

Meningitis
Notify Provider for:
High fever
Stiff neck
N/V
Sensitivity to light
Blood tests
X-ray or CT
Lumbar puncture

Question 24

Trans-sphenoidal Hypophysectomy:Risk for Bleeding

Answer 24

Patient teaching:
Avoid bending & straining for 2-months
Stool softeners to ease/avoid straining
Avoid coughing
No toothbrushes for 7-10 days post-op
Monitor platelet count
150,000 - 400,000 / mm3 (150 – 400)
Notify Provider

Question 25

Transient, Central, Diabetes Insipidus

Answer 25

Polydipsia & Polyuria
Monitor for acute dehydration
Accurate I/O
U. O. 2 – 20 L / day
Daily weight
Low URINE specific gravity
Hypernatremia
Blood pressure & HR
Level of consciousness

Treatment
Fluid replacement (PO or IV)
D5W or Hypotonic saline
Titrated to urine output
Desmopressin (DDAVP); Hormone replacement of choice
Vasopressin (Pitressin); Alternative ADH Replacement
Medications to control thirst:
Chlorpropamide (Diabenese)
Carbamazepine (Tegretol)

Assess need for transfer to higher level of care

Question 26

Nephrogenic Diabetes Insipidus

Answer 26

Low-sodium diet (Less than 3 Grams/day)
Thiazide diuretics
Hydrocholorthiazide (HCTZ)
Chlorothiazide
NSAIDs
Indomethacin (Indocin)