ADRENAL GLANDS Adrenal Cortex Adrenal Medulla

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ADRENAL CORTEX Sugar Salt Sex

SUGAR concentration - inc thru gluconeogenesis GLUCOCORTICOIDS (regulate metabolism & are critical in stress response) CORTISOL responsible for control and & metabolism of: CHO (carbohydrates) --- Regulation of blood glucose concentration - inc thru gluconeogenesis - dec use during fasting

SUGAR con’t - Cortisol b. FATS-control of fat metabolism - stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism stimulates protein synthesis in liver protein breakdown in tissues

SUGAR con’t Other functions of Cortisol What happens to cortisol levels during stressful times? What does it do to the inflammatory response? What does it do the immune response? Can you name some exogenous corticosteroids?

Exogenous Corticosteroids Common **______________ Betamethasone (Celestone) Budesonide (Entocort EC) Cortisone (Cortone) Prednisolone (Prelone) Triamcinolone (Kenacort, Kenalog)

SALT Mineralocorticoids (F & E balance) Aldosterone Na retention What stimulates aldosterone secretion? What inhibits adlosterone secretion? Na retention Water retention K excretion Hydrogen ion excretion

Question: If your Na level is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion

SEX release of testosterone ANDROGENS hormones which male characteristics release of testosterone

RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ___?___

LET’S LOOK AT ACTH (adrenocorticotropic hormone) Produced where?

ACTH Circulating levels of cortisol levels cause __________ of ACTH think tank: What type of feedback mechanism is this??

AFFECTED BY: Individual biorhythms ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. usually 5AM - 7AM these gradually decrease the rest of day Stress- ____cortisol production & secretion

HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES Too much Too little

HYPERALDOSTERONISM “Conn’s Syndrome” Too much aldosterone secretion Question: What does aldosterone do???? _____________________________ usually caused by adrenal tumor

SIGNS & SYMPTOMS Hyperaldosteronism Na and water retention What is the normal serum K+ level? Usually no edema

DIAGNOSIS Hyperaldosteronism urinary K plasma aldosterone & Na levels with low plasma renin levels BP CT scan EKG changes Labs Presence of hypokalemia with HTN – suspect CONNS

INTERVENTIONS Hyperaldosteronism BP What drugs would you give? Correct hypokalemia/hypernatremia What you would you do? Partial or total adrenalectomy

ADRENALECTOMY PRE-OP Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol levels before or after surgery?

ADRENALECTOMY POST-OP ICU-What type of problems to expect?? IV cortisol for 24 hours IM cortisol 2nd day PO cortisol 3rd day Possible hypo/hyperkalemia If unilateral- steroids weaned

Cushing Syndrome vs Cushing’s Disease

CUSHING’S DISEASE (TOO MUCH CORTISOL!) secretion of cortisol 4X more frequent in females Usually occurs at 20-40 years of age if not related to exogenous factors

ETIOLOGY Cushing’s Cushing’s Disease Cushing Syndrome _____________________ Cushing Syndrome

SIGNS & SYMPTOMS Cushing’s protein catabolism muscle wasting *loss of collagen support poor wound healing

SIGNS & SYMPTOMS Cushing’s Electrolyte imbalances Which ones? s in carbohydrate metabolism Hyperglycemia Why?

SIGNS & SYMPTOMS Cushing’s s in fat metabolism ****abdomen aka: _________ cervical spine ****face

SIGNS & SYMPTOMS More prone to infection resistance to stress immune response More prone to infection resistance to stress

What sign would the nurse identify in each patient?

SIGNS AND SYMPTOMS Cushing’s androgen secretion What would you expect to see? ****excessive hair growth -- aka hirsuitism acne change in voice receding hairline Virulization in women ----- increase male characteristics Ferminization ---- hormonally induced development of female sex characteristics "vellus" and "terminal". Vellus hair is finely textured. Terminal hair is coarse and thick. All women have vellus hair on their face. increased androgens in a woman does not cause hair to grow. The increased androgen converts vellus into terminal hair - the same process that normally occurs in a boy at puberty. Hirsutism is defined as the growth of terminal hair (i.e. androgen stimulated hair) in women in places where it normally does not occur. chin, neck, the skin over the upper breasts (not around the nipples), the skin over the breastbone between the breasts, lower abdomen.

SIGNS & SYMPTOMS mineralocorticoid activity _______ retention What happens to blood pressure?

SIGNS & SYMPTOMS MENTAL CHANGES Mild to severe depression Psychosis Poor concentration and memory Sleep disorders Mood swings Euphoria Depression Anxiety

SIGNS & SYMPTOMS s in hematology WBCs lymphocytes eosinophils

DIAGNOSIS of Cushing’s Clinical presentation is the first indication: truncal obesity “moon facies” – with plethora purplish red striae hirsutism menstrual disorders hypertension unexplained hypokalemia

DIAGNOSIS of Cushing’s 24 hr urine collection for ‘free cortisol’ How do you do this? What levels would diagnosis Cushing? (When results are borderline…..dexamethasone suppression test) Dexamethasone suppression test false positive can occur in depressed or overly stressed pts Serum cortisol levels What will serum cortisol levels be? Draw AT 8AM AND 8PM What would you expect?

High Dose Dexamethasone Suppression Test ACTH Cortisol Low/undectable Not suppressed Adrenal Cushing syndrome is likely. Normal- Very High Lack of suppression Ectopic ACTH syndrome is likely. If an adrenal tumor is not apparent, a chest CT and abdominal CT is indicated to rule out a different tumor secreting ACTH Normal - Elevated Is suppressed Cushing’s disease should be considered. A pituitary MRI would be needed to confirm

Markers of Adrenal Cortex function Urinary 17-hydroxycorticosteroids (17-OHCS) 17-ketosteroid sulfates (17-KS-S) increased

DIAGNOSIS of Cushing’s Plasma ACTH levels Low, normal or elevated? Other labs associated with Cushing’s Leukocytosis - Lymphopenia Eosinopenia - Hyperglycemia Glycosuria - Hypercalcemia Osteoporosis - ****Hypokalemia Alkalosis CT & MRI Of what? Looking for what?

TREATMENT of Cushing’s Primary goal: What do you think? Treatment related to underlying cause!!!!!

TREATMENT of Cushing’s Surgery transsphenoidal -removal of pituitary tumor ectopic ACTH secreting tumor -try to remove source of ACTH secretion adrenalectomy -can be unilateral or bilateral -if bilateral, need hormone replacement for life -Laproscopic vs Open Surgical

TREATMENT of Cushing’s Radiation to tumors Why would one choose radiation? Palliative drugs Goal of drug therapy? MITOTANE directly suppresses adrenal cortex fx Others: Metyrapone blocks cortisol synthesis & Ketocenozole blocks cortisol sysnthesis

TREATMENT of Cushing’s What if Cushing Syndrome is result of exogenous corticosteroids?

REVIEW: WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHING’S?

Nursing Diagnosis Risk for infection Imbalanced nutrition more than requirements Risk for injury…inc muscle wasting Disturbed body image Impaired skin integrity Fluid volume excess

ADDISON’S DISEASE hypofunction of adrenal cortex What hormones will you have too little of??? glucocorticoids or _______ mineralocorticoids or _______ androgens or ____________

Trivia Question: Which famous President had Addison’s Disease???

ETIOLOGY of Addison’s Idiopathic atrophy autoimmune condition antibodies attack against own adrenal cortex 90% of tissue destroyed

ETIOLOGY of Addison’s Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes Iatrogenic causes ----- anticoagulant ---- cause Adrenal hemmorage

SIGNS & SYMPTOMS Addison’s Disease Fatigue, weight loss, anorexia Changes in skin pigment small black freckles Muscular weakness

SIGNS & SYMPTOMS Addison’s Fluid & electrolyte imbalances b.p. Hyponatremia Hyperkalemia Hypoglycemia

SIGNS & SYMPTOMS Addison’s androgens hair loss, sexual fx mental disturbances anxiety, irritability, etc. salt craving

DIAGNOSIS-Addison’s ____serum cortisol ____urinary 17-OHCS and 17 KS ____serum glucose ____plasma ACTH ____urine free cortisol

INTERVENTIONS Addison’s Disease Life long hormone replacement primary-need_______________ 20-25mgs in AM & 10-12mg in PM When might one need to increase the dose? also need mineralocorticoid-(FLORINEF)

INTERVENTIONS Salt food liberally Do not fast or omit meals Eat between meals and snack Eat diet high in carbs and proteins Wear medic-alert bracelet kit of 100mg hydrocortisone IM

INTERVENTIONS Addison’s Disease Keep parenteral glucocorticoids at home for injection during illness Do you need to avoid infections/stress?

COMPLICATIONS Addison’s Disease Adrenal crisis Electrolyte imbalance Hypoglycemia

ADDISON’S CRISIS Sudden decrease or absence of adrenal cortex hormones which are: __________________

Addison’sCAUSES Name 4 causes 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________

SIGNS & SYMPTOMS Addisonian Crisis Dehydration- Na, K, BP N/V,diarrhea, wt. loss Weakness & fatigue Confusion, headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH

Question If an EKG were performed on a client in Addisonian Crisis, what would you expect to see?

TREATMENT Addisonian Crisis Rapid infusion of IV fluids What IV fluids will be used? Check VS & UO frequently Why? Monitor EKG Treat hyperkalemia How? Give Solu-Cortef IV Q6 hours until S & S disappear

TREATMENT Try to anxiety May have to give vasopressors Dopamine or Epinepherine Avoid additional stress

Adrenal Medulla

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ADRENAL MEDULLA Fight or flight What is released by the adrenal medulla?

CATECHOLAMINE RELEASE Epinephrine Norepinephrine Be sure to know what each does.

Epinephrine Regulates HR & BP inc. blood glucose stimulate ACTH stimulate glucorticoids inc. rate & force of cardiac contractions constricts blood vessels in skin, mucous membranes, & kidneys dilates blood vessels in skeletal muscles, coronary & pulmonary arteries

Norepinephrine Increases HR & force of contractions Constricts blood vessels throughout the body

Hyperfunction of the Adrenal Medulla PHEOCHROMOCYTOMA rare, benign tumor of the adrenal medulla oh no...what are we going to see a hypersecretion of????

SIGNS AND SYMPTOMS Pheochromocytoma What do you think is the hallmark sign? Paroxymal attacks**** NE and Epinepherine released sporadically Attacks may be provoked by meds antihypertensives, opioids, contrast media If untreated  DM, cardiomyopathy, death Why?

SIGNS & SYMPTOMS Pheochromocytoma Deep breathing Pounding heart Headache Moist cool hands & feet Visual disturbances

DIAGNOSIS Pheochromocytoma Often missed 24 hour urine fractionated metanephrines fractionated cathecholamines creatinine Are these increased or decreased? Plasma catecholamines When are these drawn? CT to locate tumor

Interventions/Treatment Pheochromocytoma Primary goal? Primary treatment? Pre - op Calcium channel blockers Cardene Sympathetic blocking agents Minipress (watch for orthostatic hypotension) Beta blocking agents Inderal Primary goal ========decrease blood pressure Primary treatment ==== tumor removal Sympathetic === teach to change positions slowly Bblockers === dec. HR, BP & force of contraction

INTERVENTIONS Monitor b.p. Eliminate attacks If attack- complete bedrest and HOB 45 degrees

Interventions/Treatment Pheochromocytoma Diet high in vitamins, minerals, calories, no caffeine Sedatives

give REGITINE & NIPRIDE to prevent hypertensive crisis Laparoscopic Adrenalectomy/ Open abdominal incision DURING SURGERY give REGITINE & NIPRIDE to prevent hypertensive crisis

POST-OP b.p. may be initially, Volume expanders Vasopressors BUT CAN BOTTOM OUT Volume expanders Vasopressors Hourly I and O Observe for hemorrhage

QUESTION?? What if you are not a candidate for surgery? Demser (drug which inhibits catecholamine synthesis) Avoid opiates, histamines, Reglan, anti-depressants. Why?