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Adrenal Gland
2 adrenal gland, attached to upper portion of kidney 2 areas: medulla and cortex Medulla catecholamines Cortex steroid hormones Regulated by hypothalamic-pituitaryhypothalamic-pituitaryadrenal axis (negative feedback mech.) CRH ACTH Glucocortecoid hormone (cortisol)
Adrenal Function
Adrenal Medulla
Part of ANS Catecholamines promote catabolism of stored fuels Flight or fight response SNS response
Adrenal Cortex
Adrenocortical secretions make it possible for the body to adapt to stress Produces: glucocorticoids, mineralocorticoids, sex hormones GLUCOCORTICOIDS
Glucose metabolism Hydrocortisone (prototype) Corticosteroid: Inhibit inflammatory response and suppress allergic manifestations S/E: DM, osteoporosis, peptic ulcer, increased protein breakdown leading to muscle wasting and poor wound healing, and redistribution of body fat
A.
B.
MINERALOCORTICOIDS
Electrolye metabolism Renal tubular and G.I. epithelium (Na, K, H) Stimulated by ACTH minimal Angiotensin II main stimulus Also stimulated by hyperkalemia
C.
PHEOCHROMOCYTOMA
Tumor of the chromaffin cells of the adrenal medulla May be extra adrenal (near aorta, ovaries, spleen and other organs) Peak incidence is at 40 50 y.o. Strong familial involvement or predisposition implication? Causes HPN that is curable by surgery
Manifestation of Pheochromocytoma
Depends on the amount of catecholamines secreted implications? HPN (250/ 150) and CV disturbances Tremor, headache, flushing, and anxiety Hyperglycemia implication? Triad:
Headache Diaphoresis Palpitations
Vertigo, blurring of vision, tinnitus, air hunger and dyspnea Polyuria, nausea, vomiting, diarrhea, abdominal pain, feeling of impending doom Postural Hypotension if untreated
Imaging studies 131I-metaiodobenzylguanidine MIBG specific isotope targeting catecholamine producing tissue
Management
Bed rest and elevate HOB during attack Alpha-adrenergic blocking agents (phentolamine Alpha[regitine]) Smooth muscle relaxants (Sodium nitroprusside [Nipride]) quick Phenoxybenzamine (Dibenzyline) long-acting longalphaalpha-blocker Beta-adrenergic Blocker Beta Catecholamine synthesis inhibitors alphaalphamethylmethyl-p-tyrosine (metyrosine) Surgery ADRENALECTOMY
Provide hydration before,during, after surgery Nipride and alpha-blockers during and after surgery alpha-
Nursing Management
Teach client that need for corticosteroid use after surgery provide info. Emphasize need for follow-up check up followand monitoring of BP Emphasize the need for family member to undergo screening
ADDISONS DISEASE
ADRENOCORTICAL INSUFFICIENCY Etiology: 1. Addisons disease: a. autoimmune or idiopathic b. hemorrhage into the gland c. Adrenalectomy d. Neoplasm e. Fungal infection d. Tuberculosis 2. Secondary adrenal insufficiency a. Suppression of the H-P axis from exogenous steroid use Hb. Pituitary destruction or removal c. Inadequate cortisol replacement, esp. during time of stress
Pathophysiology: Deficiencies of adrenocortical hormones. Results to fluid, electrolyte, and metabolic disturbances. - Hypoglycemia - Hyponatremia - Hyperkalemia - Increased WBC
Assessment Findings
1. Clinical manifestation
a. Addisons disease - GI complaints; anorexia, nausea, vomiting, abdominal pain, and diarrhea - Fatigue, muscle weakness, and arthralgias - Decrease alertness and confusion - weight loss - Dry skin, decreased body hair, and possible increased pigmentation with ACTH stimulation
b. Addisons
stress - Hypotension (dehydration & SNS) - Rapid, weak pulse - Rapid respiratory rate - Pallor and extreme weakness - Hyperthermia 2. Laboratory and Diagnostic Findings a. Suggestive finding - Serum blood glucose is decreased - Serum sodium level is decreased - Serum potassium level is increased - White blood cell count is increased b. Definitive findings: - Serum cortisol & ACTH - Stimulation and Suppression tests ex. ACTH and Metyrapone
2. Provide immediate treatment for an addisonian crisis - Hydrocortisone (Solu-cortef) IV (Solu- 5 % dextrose in normal saline 2 function - Vasopressor amine if hypotension persist - Antibiotics - Initiate oral intake as soon as tolerated - Other treatment for shock
3. Help prevent adrenal crisis - Additional corticosteroid therapy in times of stressful events (illness, procedures, ect.) - Supplementary intake of additional salt in times of GI disturbance and very hot weather 4. Provide client and family teaching - Need for lifelong hormone therapy - Discuss hormone therapy - Preloaded, single-injection syringes of singlecorticosteroid - Medical alert bracelet - Teach signs of under-dosing and over dosing under-
CUSHINGS SYNDROME
Results from excessive adrenocortical activity Primarily cortisol, but also androgen and mineralocorticoids Women > Men Etiology: 1. The most common cause of adrenal insufficiency is bilateral adrenal hyperplasia 2. Adrenal neoplasm 3. Ectopic ACTH production from other organs 4. Glucocorticoid therapy
Pathophysiology
The normal feedback mechanism that control the function of the adrenal cortex become ineffective, and the usual diurnal pattern of cortisol is lost
Assessment Findings
1. Clinical manifestation
a. Weight gain and altered fat metabolism/ redistribution of fat (GH on adipose)
a. Central obesity/ truncal obesity b. Buffalo hump c. Moon face
b. Muscle weakness, proximal muscle wasting, and fatigue c. Frequent infections and poor wound healing d. Symptoms of hyperglycemia e. Mental status changes and mood swings f. Menstrual disturbances such amenorrhea
a. Diminished libido b. Skin changes, such as striae, bruises, bruises, acne, and thinning of scalp HPN c. hair d. Hirsutism ( VIrilization) e. Susceptibility to compression fractures f. edema g. Visual disturbance (ptuitary) h. Sleep pattern disturbance altered diurnal secretion of cortisol
2. Laboratory and Diagnostic study findings a. Serum potassium level is decreased -- / b. Serum glucose level is elevated DM c. WBC reveals depressed eosinophils and lymphocyte counts. d. Diurnal variation plasma levels reveal elevated plasma cortisol and 24 hour urine cortisol result e. Dexamethasone suppression test administration of 1 mg dexa. The night before (11pm 8am test) - normal < 5mg/ dL coortisol f. Plasma ACTH (determine if 1o or 2o)
Medical Management
PRIORITY: HPN & HF 1. Transphenoidal hypophysectomy/ Radiations pros & con pituitary tumors 2. Adrenalectomy tx of choice for primary adrenal hypertrophy - watch for signs of adrenal insufficiency 12 48 hrs p op - may warrant temporary replacement 3. Adrenal enzyme inhibitors ectopic ACTH secretion ex. Metyrapone, aminoglutethimide, mitotane, ketoconazole 4. Reduce or taper dose if cause by administration of corticosteroid --- why not stop? - alternate day dose
Nursing Management
Reduce safety hazards, protect patient from falls, fractures, and other injures to bones and soft tissue ---- Why? Assist patient with ambulation if very weak Provide foods high in CHON, calcium and Vit D, low sodium and low calories Watch for subtle signs of infection. Fever? Avoid unnecessary exposure to others with infection Prepare patient for surgery INSULIN THERAPY ---- why? Give 2 ANTI-ULCER MEDS ---- why? ANTI CBG, OCCULT (before, during and after) Encourage moderate activity in spite of difficulty from weakness, wasting, fatigue, insomnia why???? Avoid using adhesive tape Why??? Provide meticulous skin care--- assess skin and bony prominences care--and change position Give info about Corticosteroid therapy --- but this is Cushings???? Advice patient in wearing Medical alert bracelet
PRIMARY ALDOSTERONISM
Excessive production of aldosterone that occurs in some patient with functioning tumors of the adrenal gland.
Clinical Manifestation
Profound Hypokalemia and decrease in H+
Muscle weakness, cramping, and fatigue Inability of the kidney to acidify or concentrate the urine Polyuria ---- contradictory question anyone? Polydipsia due increase osmolality Increase pH and bicarbonate
Sodium may be normal or elevated depends on amount of water reabsorbed with sodium Hypertension most prominent and universal sign; secondary increase in blood volume Decrease serum Ca due to hypokalemic alkalosis Glucose intolerance due to hypokalemic alkalosis action on pancreas
Management
Surgery removal of the tumor(Adrenalectomy)
Will address the problem of Hypokalemia