Endocrine – Adrenal Gland Part 1

Adrenal Gland Description – AKA Suprarenal gland – Location On top of each kidney – Composed of: Adrenal cortex Adrenal Medulla

Hormone & Function Adrenal Cortex – Mineralocortioids Aldosterone – Function Regulates electrolyte & fluid homeostasis

Hormone & Function Adrenal Cortex – Glucocorticoids Cortisol Hydrocortisone – Function Stim. gluconeogenesis &  blood glucose Anti-inflammatory Anti-immunity Anti- allergy

Hormone & Function Adrenal Cortex – Androgen Sex hormones – Function Female – Stim. Sex drive Men – Negligible

Hormone & Function Adrenal Medulla – Epinephrine Adrenaline – Function Prolong &  SNS (sympathetic nervous system) response to stress

Hormone & Function Adrenal Medulla – Norepinephrine – Function Prolong &  SNS (sympathetic nervous system) response to stress

Effects of Epinephrine & Norepinephrine a.  cardiac output b.  metabolic rate c.Vasoconstriction d.  respiratory rate

Adrenal Cortex The cortex synthesizes & secretes 30+ different steroids. – Glucocorticoids – Mineralocorticoids – Androgens

Learning Tip SALT, SUGAR & SEX Aldosterone = promotes salt retention Cortisol= sugar Androgens = sex hormones

Negative feedback loop Stress  Hypothalamus  Stimulates Anterior Pituitary  Secretes ACTH  target cell  Adrenal cortex  Secretes Cortisol  specific action  metabolic activity  Helps manage stress

Cushing disease/ syndrome Description – Cortisol excess

Cushing disease/ syndrome Pathyophysiology – Diurnal rhythm  in AM – Normal secretion of cortisol  in times of stress – In Cushing's, cortisol is hypersecreted without regard to stress or time of day.

Cushing disease/ syndrome Etiology –  secretions ACTH – Pituitary CA – Lung tumor – **#1 prolonged use of glucocorticoid meds for inflammatory disorders Rheumatoid arthritis COPD

Cushing disease/ syndrome Etiology – Iatrogenic Caused by treatment or diagnostic procedure – Females > Male

Cushing disease/ syndrome Signs & Symptoms – Adiposity Deposits of adipose tissue in the face, neck & trunk Moon shaped face Buffalo hump

Cushing disease/ syndrome S&S – Weight gain – Na & H20 retention – K+ is lost Hypokalemia – Purple striae on the abdomen – Hirsutism

Cushing disease/ syndrome S&S – This extremities d/t muscle wasting – Boys = early onset of puberty – Girls = masculine characteristics – C/O fatigue, muscle weakness, sleep disturbance, amenorrhea,  libido, irritability, emotional labiality

Cushing disease/ syndrome S&S – Could be: Petechiae Eccymoses  wound healing Swollen ankles

Cushing disease/ syndrome Complications  calcium reabsorption from the bone leading to osteoporosis & pathologic fractures Cortisol causes insulin resistance and ↑ hepatic gluconeogenesis and insulin resistance Leads to glucose intolerance and diabetes mellitus

Cushing disease/ syndrome Complications Frequent infections & slow wound healing – Suppressed inflammatory response can mask severe infections – Cortisol is an immunosuppressive Deceased ability to handle stress – Psych problems i.e. mood swings

Cushing disease/ syndrome Diagnosis – Plasma Corticol level – ACTH level – Adrenalangiography

Cushing disease/ syndrome Medical management Early dectection key #1 goal = restore hormonal balance Usually meds.

Cushing disease/ syndrome Med. Management Tx based on causative factor If adrenal cancer  – Surgery If caused by steroid meds  – Change regiment – Risk to benefit analysis

Cushing disease/ syndrome Surgical management If pituitary gland  – Hypophysectomy If adrenal tumor  – Adrenalectomy

Cushing disease/ syndrome Aminoglutethimide (cytadren) – Action Inhibits synthesis of adrenal steroids – S/E Dizziness or drowsiness – Nrs. Instruct to avoid activities that need mental alertness

Cushing disease/ syndrome Ketoconazole (Nizoral) – Action Antifungal Inhibits adrenal steroidogenesis

Cushing disease/ syndrome Diet High in protein High K+ Low sodium Reduces carbs & calories

Cushing disease/ syndrome Nursing Management Rx history VS Lung auscultation – Crackles Edema Skin integrity Glucose levels S&S of infection

Adrenalectomy Pre-op – Electrolyte imbalance – Hyperglycemia – Prevent adrenal crisis Administer glucocorticoids! Sudden drop in hormones  crisis

Adrenalectomy Post-op – Fluid & electrolyte changes – Replace glucocorticoids, mineralocorticoids for life – Bilateral???

Addison’s Disease Description –  corticol – Adrenal hypofunction – Adrenal insufficiency – Adrenalcortical insufficiency

Addison’s Disease Pathophysiology – 90% of adrenal gland destroyed – Autoimmune disease – Primary ACTH may be high – Secondary ACTH will be low

Addison’s Disease Etiology Primary – Bilateral adrenalectomy Secondary –  ACTH from pituitary –  hypothalamus stimulation

Addison’s Disease Etiology Prolonged use of coticosteroid Rx   ACTH   hormonal release from adrenal gland *** esp. at risk if drugs abruptly DC’ed – Taper dose

Addison’s Disease: Signs & Symptoms Hypotension – Lack of aldosterone  – Na+ & H2O loss – K+ reabsorption  Tachycardia Orthostatic hypotension

Addison’s Disease: Signs & Symptoms Bronze coloration of skin Hypoglycemia Vitiglio Fatigue, muscle weakness Weight loss Crave salty foods

Addison’s Disease: Signs & Symptoms  tolerance for stress – Anxious – Irritable – Confused Pulse – Weak GI upset – N/V – Anorexia

Addison’s disease: Complications Adrenal crisis – Acute Addison’s dis – May occur Trauma Surgery Stress Abrupt withdrawl of cortisone meds

Addison’s disease: Complications Adrenal Crisis – S&S Na+ & H20 loss Hypotension Dehydration Tachycardia – IV & administer hydrocortisone

Addison’s disease: Medical Management Restore fluid and electrolyte balance Replacement of deficient adrenal hormones – Glucocorticoids (hydrocortisone) – Mineralocorticoids (fludrocortisone)

Addison’s disease: Pharmacological Lifetime steroids Glucocorticoids – Hydrocortisone (hydrocortone) Mineralocorticoids – Fludrocortisone acetate (Florinef) Diurnal rhythm – 2/3 AM – 1/3 PM

Addison’s disease: Diet High in Na+ Low in K+

Addison’s disease: Nursing Management Diagnosis??? Fluid volume deficit – r/t  Na+ level Vomiting  renal losses – A.M.B. Poor skin turgor Weight loss Orthostatic hypotension

Addison’s disease: Nursing Management qDay wts I&O Glucose K+ & Na+ Skin turgor Orthostatic hypotension

HypofunctionHyperfunction Disorder Addison’s disease Cushing syndrome S&S Na+ & H20 loss Hypotension Hypoglycemia Fatigue Hyperkalemia Na+ & H20 retention Wt. gain Hyperglycemia Buffalo hump Moon face Hypokalemia

HypofunctionHyperfunction Usual tx Glucocorticoids Meneralocorticoid Restore fluid Alter steroid Rx Surgery Nrs Dx Fluid volume deficitFluid volume excess Glucose intolerance Diet  Na+  K+  Na+  K+

Pheochromocytoma: Description AKA chromaffin cell tumor Rare disease Characterized by paroxysmal or sustained hypertension – d/t excess secretion of epi and norepi

Pheochromocytoma: Pathophysiology Caused by a tumor – Usually Rt. adrenal Etiology – Idiopathic Stress can bring on an attack

Pheochromocytoma: Signs & Symptoms HTN – > 115 mmHG diastolic – Intermittent – Unstable Tachycardia Unrelenting H/A Profuse diaphoresis Palpitations

Pheochromocytoma: Signs & Symptoms Visual disturbances N/V Feeling of apprehension Elevated blood glucose levels

Pheochromocytoma: Complications Stroke Retinopathy Heart disease Kidney damage

Pheochromocytoma: Medical Management / Surgical Treatment of choice is… – Surgery Stable a surgery Adrenal gland removed BP

Pheochromocytoma: Pharmacological Phentolamine mesylate (Regitine) Nitroprusside sodium (Nipride) – HTN

Pheochromocytoma: Diet  protein Avoid caffeine

Pheochromocytoma: Nursing Management Monitor BP VS Na+ levels