Disturbances of the Adrenal Gland Semester V RN Fall 2002

Disturbances of the Adrenal Gland
Semester V RN Fall 2002
Ann MacLeod, RN, BScN, MPH
 Test Take Up
Understand Disturbances of the Adrenal Gland
Assessment of
Nursing diagnoses
Nursing care
Disturbance in Adrenal Hormones
 Over view: A&P: adrenal glands- 2 small structures which cap the top of the kidneys
 each composed of 2 structures with its own function
 inner core: adrenal medulla
 outer shell: adrenal cortex
Functions of Adrenal Medulla:
 Adrenal medulla: releases epinephrine and norepinepherine which convert glycogen to
glucose to increase cardiac output
 Fight or flight response
 nor-epinephrine produces vascular constriction which increases BP
Hyposecretion of the adrenal medulla
 Assessment
•  plasma and urine catacholamines, epinephrine and norepinephrine
• low BP, little fight or flight response
• uncommon
 management
• supplement with catacholamines
Adrenal Medulla (hypertrophy)
 epinephrine & norepinephrine
 Pheochromocytoma: tumor of the adrenal gland Assessment
• can be life-threatening
• headache, vertigo, blurred visiontinnitus
• dyspnea, palpitations, tachycardia
• hyperglycemia, glucosuria
• hypertension very high (and postural hypotension)
• nervousness, anxiety, tremors
• indigestion, nausea, vomiting, abdominal pain
• fatigue, exhaustion
Pheochromocytoma: tumor of the adrenal gland Assessment cont’d
  plasma & urine epinephrine and norepinephrine (catecholamines)
 clonidine ( Catapres) suppression test blocks sympathetic stimulation & will not
suppress if the gland is over producing epinephrine
 CT Scan, MRI, MIBG tagged x-ray, ultrasound
Pheochromocytoma: tumor of the adrenal gland: Management
 Pharmacologic tx to treat symptoms
• alpha adrenergic blockers (phentolamine)
• beta adrenergic blockers (propranolol)
• catacholamine synthesis inhibitors (metyrosine)
 Surgical removal: adrenalectomy
• then supplement catacholamines andn corticosteroids
• monitor BP, BS, ECGs
Adrenal Cortex
 Hypothalamus  Corticotropin Releasing Hormone  Post. Pituitary releases
Adrenocorticotropin hormone ( ACTH)  stimulate adrenal cortex to release
• Glucocorticoids ( cortisol): stimulates  blood glucose, anti- inflammation
• Mineralocorticoids (aldosterone) : regulates electrolyte balances
• Sex hormones (s/a estrogen, androgens) : sexual dev’p
Glucocorticoids- cortisol
 Regulate blood sugar by conserving body glucose and promoting gluconeogenesis
 regulates protein, fat and CHO metabolism
 stress response
 anti- inflammatory and immune response
 promotes Na+ retention and K+ excretion
 targets kidney tubules
 only responsible for increases in blood volume of 5-10 % offset by increased
Glomerular Filtration Rate
 (ADH is more responsible)
 low K+ muscle weakness, lowered membrane potential, therefore more easily excited
 cramping and become weak
Sex Hormones Androgens
 small amount of estrogens
 sexual development
Hyposecretion of the Adrenal Cortex - Addison’s Disease
 may be primary or secondary
 Primary: as a result of atrophy or autoimmune destruction, tumors or suppressed pit.
 secondary: insufficient ACTH from pituitary gland
Glucocorticoid hyposecretion
 cortisol
 Wide spread metabolic imbalances
 decreased gluconeogenesis blood sugar (pt. Weak, exhausted, wt, loss, nausea,
 decreased resistance to stress, infection and inflammation
Decreased aldosterone:
 Na+ channels in Kidney tubule do NOT open  Na+ and H20 stay in the urine
 Dehydration, hypotension, decreased Cardiac output, circulatory collapse
 K+ cannot get into urine  hyperkalemia K+  decreased muscle contractility 
arrthymias  death
 Blood K+, WBC
 Blood Glucose,  Na+, aldosterone
 Muscular weakness, anorexia, GI upset
 fatigue, wt. Loss
 decreased BP
 chronic dehydration
 ACTH fails to  cortisol
Addisonian Crisis
 When subject to stress, infection, trauma and surgery. (could be fatal)
 headache, nausea, vomiting,fever, abd. Pain, severe hypotension
 vascular collapse>>>SHOCK
 Immed. Tx. To combat shock and administer fluids
 IV solucortef, vasopressin to increase BP
 antibiotics to combat infection if present
 Increase NA+, Decrease K+ diet
 life long admin. Of corticosteroids and mineralocortoids
 Florinef: mineralocorticoid
 cortisone, cortisol, prednisone, betamethesone} glucococorticoids
 corticosteroids may cause S/E: moonface, wt. Gain, edema., K+ loss, Increased
urination, nocturia, masking of s/s infection
 Steroids must be tapered!
Nursing Diagnoses/ Process
 Fluid vol. deficit
 Daily wt. I+O, assessment of mucous membranes
 monitor BP freq.
 Diet: carb,protein,Na+, increased fluids
 pharmcotherapy
 monitor excessive sweating
Nursing Process
 Activity intolerance
 Knowledge Deficit
 Avoid stressful activity, quiet environ. Complete bedrest, help with bathing, turning
 rationale for steroid replacements, medic alert, diet, wt,injectable hormones
Hypersecretion of Adrenal Cortex: Cushing’s Syndrome
 Usually secondary to hypersecretion of the of ACTH by the pituitary due to tumours
 Hypercorticism: steroid hormone replacement
Cushings syndrome
Glucocorticoid Excess
 Gluconeogenesis- Breakdown of fats and proteins to increase blood sugar
 distrubution of adipose tissue in the abd. and behind shoulders (buffalo hump)
 protein loss  thin skin, weak blood vessels, osteoporosis, decreased immunity ( IGg)
 hyperglycemia  diabetes
 vasoconstrictor (anti-inflammatory)
Aldosterone Excess
 Kidney tubules opens Na+ channels  Na+ and water retention in blood  edema,
elevated BP
 K+ is excreted in urine  blood depletion  hypokalemia K+muscle excitability
 cramps, fatigue
Androgen Excess
 Women more masculin
 hair on head thins
 abnormal facial hair
Assessment for Cushing’s Disease
 24 hr. urine: free cortisol increased
 DST Dexamethesone Suppression Test: 1 mg. Of dexamethesone is given po the night
before. This should suppress plasma cortisol levels at 0800 the next day to 50% of
 Blood tests:  Glucose,  K+, Na+
 CT or MRI : adrenal mass or pit. tumor
 Surgical removal of the tumor of the pituitary gland is Rx. Of choice
 adrenalectomy
 may have radiation
 often causes hyposecretion so must assess for this and monitor supplements of
Nursing Diagnoses
 Risk for injury due to weakness
 Self Care Deficit
 imp. Skin integrity
 high risk for infection
 body image disturbance
 fluid vol. Excess
 pt. Teaching and followup
Adrenalectomy Nursing Care:
 Post-op: vital signs q 1-4hrs especially BP
 I+O
 observe for hemorrhage (area is highly vascular)
 monitor serum electrolytes (may cause insufficiency
 Be alert for s/s adrenal insufficency
 IV corticosteroids
 dressing change prn
 observe for s/s infection and delayed wound healing
Corticosteroid treatment
 Either for Addisons, or post op adrenalectomy
 actions:
 gluconeogenesis ( breakdown, fat & proteins)
 inhibits prostoglandin formation inflammatory process complement system, and
 cytokines blocked &B lymphocytes not activatedimmune response
 vasoconstriction & Na +retention  BP
 bone absorption into blood
 stabilize mast cells therefore less broncho- constriction
Cortisone-nursing considerations
 Has both cortisol and mineralocorticoid hormones 15-30 mg PO daily
 Taper Doses, give with or after meals
 monitor blood counts and glucose, Na+ K+
 monitor mood changes, skin for lesions or acne, stretch marks, menstrual changes
 monitor signs of infection
 many drug contraindications
 monitor weight loss, skin hyperpigmentation
Cushings Syndrome Non-surgical maintenance
 Monitor emotions & support systems
 skin care & hygiene
 Diet hi K+, low Na+ and calories