Adrenal Glands 2 parts of the Adrenal glands Adrenal Medulla- hormones:increase heart rate, RR, elevate BP ( fight or flight,

response to stress) Epinephrine- increase heart rate, dilates bronchial tubes and stimulates the liver to release glucose from storage reserves Norepinephrine constricts blood vessels and raises BP Adrenal Cortex- hormones: Aldosterone- a mineralocorticoid, helps kidneys conserve sodium and excrete potassium, maintaining BP. Decreases the level of potassium Cortisol- glucocorticoids keeps blood glucose stable, has anti-inflammatory properties. Adrenal sex hormones- Androgen and Estrogen Virilism- excess adrenal androgen secretion in females Feminization- excess adrenal estrogen and progestin Layers of Adrenal Cortex a. Zona glomerulosa: top layer; secretes a group of hormones called mineralocorticoids or Aldosterone b. Zona fasiculata: Middle layer; secretes glucocorticoids or cortisol c. Zona reticularis: Inner layer: secretes sex hormones Cushing's Syndrome Hypersecretion of cortisol, blood glucose remains high, retains too much Na, puffy skin, masculinizing effects in women. Signs and Symptoms personality changes buffalo hump moon face hyperglycemia gynecomastia increase susceptibility in infection osteoporosis Amenorrhea thin skin purple striae bruises and petechiae Na and fluid retention GI distress Hypokalemia

Diagnostic test plasma cortisol levels are elevated ACTH level may be high or low 24 hr urine test for 17 ketosteriods and 17 hydroxysteriods skull x-rays presence of tumor in the pituitary adrenal angiography Abdominal CT scan and Ultrasound Medical Management Adrenalectomy- removal of adrenal tumor Radiation/ transphenoidal- pituitary tumors low Na, High K, reduce calories and decrease Carbs Lysoderm (mitotane) cytotoxic agent which is toxic to adrenal gland (taken for 3 months: watch for hepatotoxicity) Nursing Interventions: prevent skin impairment ( turn frequently, ambulate, elbow and heel protector) encourage verbalization of fears encourage verbalization of altered body image

Addison's disease Hyposecretion of cortisol, decrease in serum Na, dehydration, decrease in BP, increase in pigmentation. Addison's causes: major precipitating factors is STRESS 1. adrenalcortical insufficiency occurs when the adrenal glands do not secrete enough mineralocorticoids and glucose. 2. Deficiencies in aldosterone and cortisol produce disturbances 3. Dehydration It may result from : 1. 2. 3. 4. 5. rare primary function pituitary hypofunction longstanding steroid therapy idiopathic adrenal therapy cancer of the adrenal cortex

Signs and Symptoms: bronze pigmentation changes in hair distribution GI disturbance weakness

hypoglycemia weight loss craving for salt postural hypotension hyponatremic

Addison's crisis decrease in BP Nausea and vomiting increase in Temp Cyanosis vasomotor collapse and death Treatment IV administration of corticosteriods in a solution of saline and glucose Diagnostic test decrease Na, decrease plasma cortisol and aldosterone increase K decrease glucose, glucose tolerance test is abnormal decrease 17 ketosteriods and 17- hydroxysteriods 24 hr urine collection Medical management restore fluid and electrolyte balance replace deficient adrenal hormones drug of choice-FIORINEF ( fludrocortisone) Diet increase Na and decrease K

Nursing interventions Assess circulatory status keep accurate I & O monitor daily weight check skin turgor and offer fluids frequently keep free from stressful environment Adrenal Medulla Disorders PHEOCROMOCYTOMA chromaffin cell tumor, found in the adrenal medulla causes excessive secretion of EPI and NOREPINEPHRINE only 10% are malignant occur between 20 to 60 years old Signs and Symptoms

primary manifestations is HYPERTENSION with BP fluctuating widely with potential HYPERTENSIVE CRISIS severe headache dilated pupils palpitations diaphoresis tachycardia heart failure Diagnostic Test confirmatory if increase Vanillmadelic acid test in 24 hr urine collection or VMA in urine Total catecholamine test in 24 hr urine test increase CT scan with IVP to locate tumor Management surgical removal of the tumor or adrenal Post-op administration of alpha adrenergic blocking agent REGITINE DIBENZYLINE to control the hypertension Demser ( metyrecine) inhibits catecholamine production Nursing intervention post OP BP monitoring Avoid stress adequate rest- provide sedatives Monitoring of I and O Vasopresin and corticosteriods are given ( DEXAMETHASONE AND PREDNISONE) Diet should be free from stimulants like caffeine or coffee monitor signs of infection and delayed wound healing Drug interactons with corticosteriods / diuretics enhance the loss of Kwarfarin may increase or decrease effects close monitoring is needed because of potentiation effects oral hyperglycemic agents may need adjustments PARATHYROID Functions CHON hormone that regulates the Ca and phosphorous metabolism. Parathormone tends to lower the blood phosphorous level Normal serum Calcium level is 8.5 to 10.2 mg/ dL Hyperparathyroidism a condition resulting to overactivity of one or more of the parathyroid glands Assesments X-ray will show decalcification of bones. Elevated serum calcium, PTH and alkaline phosphates levels

Hypercalcemia can also be caused by excessive intake of thiazide diuretics, Vitamin D, or Calcium supplements Primary Hyperparathyroidism enlargement of the parathyroid glands Increase secretions of PTH Increase serum Ca levels Most common cause: Adenoma, genetics, multiple endocrine disorders Signs and Symptoms increase calcium in blood apathy muscle weakness irritability formation of kidney stones demineralization of bones bone tumors shortening of body structures Diagnostic findings increase calcium levels increase parathormone levels double antibody parathyroid hormone test UTZ, MRI, Thalium Scan- to elevate the glands

Hypercalcemic crisis extreme elevation of Ca ( 15 mg/dL or 3-7 mmol ) life threatening cardio, neuro, renal symptoms Treatment rehydration with large volumes of IVF Diuretics Phosphates theraphy Cytotoxic agents ( mythramycin) Dialysis calcitonin combination of calcitonin and corticosteriods (increase bone deposit of calcium and decrease serum calcium) give biphosphates ( etidronate, didronel, pamironate) fosomax prevent loss of bone mass Nursing Management health educational hydration mobility

 diet and medication improve calcium intake ( thiazide diuretics are avoided, low appetite) monitor for tetany after surgery and hypocalcemia

Hypoparathyroidism Causes: 1. inadequate amount of PTH after interruption of blood supply 2. surgical removal of parathyroid Absence of parathormone results to : decrease intestinal absorption of dietary Ca decrease resorption of Ca from bone and renal tubules Signs and Symptoms Tetany- chief symptoms Anxiety Irritability Depression Delirium tetany develops at serum Ca levels of 5-6 mg/ dL or lower xray of bones show increase in density calcification is detected Management goal is to raise the calcium levels to 9 10 mg /dL administration of Calcium gluconate TIV for tetany hypocalcemia-; if not effective give pentobarbital parenteral parathormone monitor for allergic reaction and serum Ca Level reduce stimulation ( noise and bright lights and sudden movements) Tracheostomy / mechanical ventilation along with bronchodilators Therapy for chronic hypoparathyroidism administration increase Ca, decrease phosphorous diet avoid milk and milk producst and eggs due to phosphates avoid spinach contains oxalates can cause kidney stones Oral Ca gluconate or calcium salts Aluminum hydroxide gel or aluminum carbonate to bind phosphates and to promote its excretion through GIT Post Op Hypoparathyroid monitor for early signs of hypocalcemia Tetany, seizures, respirator dysfunction Keep Calcium gluconate at bed side and administer with slowly with caution due to dysrhythmias

 Ca and digitalis = increase systolic contraction and potentiate each other educate on high calcium and low phosphates intake.