Adrenal Gland

Cortex
Glucocorticoids
Cortisol
Affects carbohydrate metabolism (raises blood sugar in times of stress)

Mineralocorticoids
Aldosterone
Maintains normal salt and water balance by action on the kidneys

Androgens
Sex hormones

Disorders of the Adrenal Gland

adrenal medulla epinephrine and norepinephrine adrenal cortex mineralocorticoids, glucocorticoids, adrogens stimulated by ACTH by the anterior pituitary gland
2

Notes
stress importance of ACTH

adrenal cortex
mineralocorticoids aldosterone secreted when blood pressure is low it moves sodium and water from renal tubules to the blood this increases blood pressure and blood volume

Notes
potassium is excreted regulates water and sodium balance

adrenal cortex
glucocorticoids cortisol-most prevalent breaks down stored glycogen and increases the amount of glucose in the blood. strong anti-inflammatory affect

Notes
cortisol is given and known as steroids. these can mimic the effects of glucocorticoids.

adrenal cortex
androgens male sex hormones

Adrenal Gland
Cushings syndrome
Disorder of adrenal cortex
Produces excessive amounts of cortisol Affects women more than men Ages 20-50

Notes
overstimulation of ACTH or by prolonged administrations of corticoids,

Cushings
Causes
Adrenal tumors
Increase production of cortisol

Tumor of pituitary gland

Increases ACTH release which stimulates adrenal cortex to produce cortisol

Chronic glucocorticoid therapy Increased ACTH release from lung or pancreatic tumors

Notes
ACTH comes from anterior pituitary. Glucocorticoids are drugs such as prednisone, it is frequently prescribed for resp. pats. To decrease inflammation, also for transplant pts. Or rheumatoid arthritis. hypersecretion

Cushings
With increased (hyper) secretion of cortisol
Fat deposits in abdomen, under clavicle, buffalo hump over the upper back, round moon face Altered protein metabolism
Muscle weakness, wasting in extremities

Stress hormone

Notes
Pts. Gain weight. Weight gain is seen in trunk and face. Limbs are generally spared excess sweating, thinning of the skin. Which causes bruising and dryness and mucous membranes. Purple stiae (weight gain stretches the skin and is becomes thin and weakened it then has small capillaries hemorrhage. Can develop hypercalcemia which can lead to skin necrosis. Hypercalcemia leads to osteoporosis and compression fractures. Cortisol can affect other endocrine systems such as mineralocorticoid and adrogen. This result in sodium and water retention, which can lead to hypertension. Increase in adrogens can reslut in amenorrhoea and infertility. High blood sugar from insulin resistance. Which can result in diabetes mellitus. Untreated it can lead to heart disease. Think of cortisol as a stress hormone. So it impairs wound healing and depresses inflammatory response. See page 349 Burke. Excess cortisol secretions result in sodium and water retention. This causes fluid volume excess and wt gain. Sodium and water retention causes htn, bounding rapid pulse. Dependent edema, wheezes crackles. arms and legs become thin as a result of muscle waste hyperglycemia due to glucose intolerance susceptible to infections but the symptoms may be masked .

Cushings
If left untreated can result in hypertension hypernatremia, hypokalemia, elevated blood sugar, heart failure

Notes
Hypertension from increased cortisol and stress. Heart failure again from stress affects. Hypernatremia from affects on mineralocorticoid, hypokalemia from affect of mineralocorticoid. Htn from increased water and sodium retention.

Cushings
Diagnosis
Increased plasma cortisol level and elevated 24 hour urine test for 17-ketosteroids, and 17hydroxycortiocosteroids. Plasma ACTH levels are elevated when Cushings is caused by pituitary tumor Serum glucose and sodium levels are elevated.

Cushings
Medications
Used when cushings syndrome is caused by inoperable pituitary or adrenal tumor
Mitotane (Lysodren) suppresses activity of the adrenal cortex Metyrapone and aminoglutethimide (Cytadren) inhibit cortiosol synthesis by the adrenal cortex

Notes
diet low in sodium for hypernatremia, reduced calories and carbohydrates for hyperglycemia,

Cushings syndrome
Nursing considerations
Body image, infection, injury, fluid and electrolyte imbalance.

Cushings
Monitor for side effects of medications caused by decreased adrenal function such as anorexia, nausea, vomiting, and diarrhea Severe side effects include hypotension and tachycardia Client is at risk for severe infections related to suppressed immunity.

Notes
Also patient is at risk for severe infections can be life threatening.

Cushings
Treatment
If caused by tumor and adenalectomy is done
Usually only one adrenal gland is involved if both are removed the client is required to take lifelong corticosteroid and mineralocorticoid replacement therapy. ICU
Monitor for Addisons

Cushings
Surgical removal of pituitary gland is indicated when the disease is caused by pituitary tumor.
Hypophysectomy

Radiation therapy
If inoperable brain tumor causing Cushings
Radioactive isotopes implanted

Notes
do not abruptly discontinue corticoids as this can lead to addisons

Addisons disease
Primary
Adrenal Cortex undersecretion (hypofunction)

Secondary
Undersecretion of pituitary ACTH

Addisons disease
Occurs more frequently in women under the age of 60
Primary addisons is an automimmune response destroys clients own adrenal cortex
Leads to reduced glucocorticoids, mineralcorticoids, and androgens Slow onset and manifestations occur when more than 90% of your gland is destroyed.

Addisonian Crisis
Aka adrenal crisis
Serious life threatening response to acute adrenal insufficiency.
Major stressors precipitate this condition
Surgery, trauma, severe infections

Abrupt withdrawal of corticosteroid medications

Addisonian Crisis
Monitor client for hypotension, rapid weak pulse, extreme weakness, confusion resulting from circulatory collapse and shock. Client is managed in ICU for IV fluids, glucose, NA and glucocorticoids.
Keep warm and quiet.

Notes
K levels can reach dangerously high levels. This can lead to cardiac dysrhytmias. Client has fluid volume deficit, resulting from water and NA loss from bvomiting and diarrhea. This can lead to hypovolemic shock. Increase oral fluids. Pt is hyponatremic.

Addisons disease
Treatment
Cortisol replacement
Can induce Cushings syndrome

Mineralocorticoid replacement
Fludrocortisone (Florinef)

Hydrocortisone is given PO to replace cortisol During crisis (surgery, serious illness, or trauma) may need increased corticosteroids or mineralocorticoids.

Adrenal Medulla
Pheochromocytoma
Benign tumor of the adrenal medulla
Adults 40-50 years of age Erratically produces excessive amounts of catecholomines
Stimulate SNS

Pheochromocytoma
Increased SNS
B/P 200-300 systolic and a diastolic greater than 150. Pounding headache Tachycardia Profuse sweating Flushing Palpitations

Pheochromocytoma
If left untreated can lead to MI and stroke
Pt. in ICU Life threatening

Notes
Bring down the b/p. Hemodynamic monitoring, iv antihypertensive

Pheochromocytoma
Diagnosis
Increased catecholamine levels in blood or urine CT scan MRI

Pheochromocytoma
Treatment to remove tumor
May need adrenal hormone replacement therapy May require antihypertensives

Review
What clinical manifestation can the nurse expect with Addisons disease?
Multiple bruises Postural hypotension Peripheral edema SOB

Notes
With lack of mineralocorticoid aldosterone, blood volume and blood pressure are lower which results in postural hypotension. Multiple bruises are noted in Cushings peripheral edema and SOB are not found in addisons.