1. DISORDERS OF THE ADRENAL GLANDS https://www.youtube.com/watch?v=06jbq3bxKE0 (Adrenal Glands: 33 seconds)https://www.youtube.com/watch?v=06jbq3bxKE0 Cushing’s made Easy (7 mins 26 sec) https://www.youtube.com/watch?v=1osIAtrto2k

2. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) ETIOLOGY/PATHOPHYSIOLOGY – May be caused by: 1. Hyperplasia of adrenal tissue resulting from overstimulation by the pituitary hormone – ACTH 2. Tumor of the adrenal cortex 3. ACTH-secreting tumor outside the pituitary –e.g. oat cell cancer of lung 4. Prolonged or overuse of corticosteroid drugs http://www.youtube.com/watch?v=DCXp4oUeYGU (4 min and 44 seconds) impactful personal cushing’s story

3. CUSHINGS SYNDROME IN TWIN GIRL

4. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) CLINICAL MANIFESTATIONS – The overabundance of glucocorticoids, mineralocorticoids, and sex hormones  Moonface Buffalo hump Thin arms and legs due to muscle wasting Weight gain

5. Cushing’s Syndrome Pictograph

6. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) CLINICAL MANIFESTATIONS cont. – Hypokalemia; proteinuria; hyperglycemia – Increased urinary calcium excretion & renal calculi – Susceptible to infections – Loss of libido – Osteoporosis and kyphosis (due to abnormal Ca++ absorption)

7. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) SUBJECTIVE DATA – Depression – Inability to concentrate – Mood disturbances – ↑ risk for self-harm – Back pain – Concern re: altered body image

8. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) OBJECTIVE DATA: – Ecchymoses and petechiae, fragile skin, slow wound healing – Weight gain, abdominal enlargement (striae) – Back pain – Hirsutism in women – Menstrual irregularities – Deepening of the voice – HTN

9. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) DIAGNOSTIC TESTS – Diagnosis usually based on clinical appearance and lab results – Plasma Cortisol - ↑ – Plasma ACTH - ↑ or ↓ – 24 hr urine for: 17-ketosteroids and 17- hydroxysteroids - ↑ – Blood and urine glucose

10. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) DIAGNOSTIC TESTS cont. – Skull xray – visualize the sella turcicca – Adrenal angiography – Abdominal CT, US, MRI

11. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) MEDICAL MANAGEMENT – Treat the causative factor Adrenalectomy for adrenal tumor Radiation or surgical removal for pituitary tumors Medication: – Lysodren (Mitodane therapy) – alters the peripheral metabolism of cortisol  decreases plasma and corticosteroid level; supresses cortisol production » Also known as a “medical adrenalectomy”

12. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) MEDICAL MANAGEMENT cont. – Low Na+, high K+ diet Low sodium  reduces edema High potassium  correct hypocalemia and stabilize cardiac status ↓ calorie, ↓CHO – If Cushing’s is due to prolonged corticosteroid use: 1. gradually reduce and discontinue steroid therapy 2. reduce dose of steroids 3. convert to alternate-day regimen *KEY NURSING INTERVENTION: gradual reduction of dose

13. NURSING DIAGNOSIS/INTERVENTIONS Deficit knowledge, r/t therapeutic regime Activity Intolerance, r/t weakness and immobility NURSING INTERVENTIONS: – Skin Care – gentle handling; frequent assessment – Encourage ambulation as tolerated – Paticipation in ADL’s – Encourage verbalization of concerns – Skilled observation of s/sx depression/ suicidal-thoughts

14. ADRENAL HYPERFUNCTION (Cushing’s Syndrome) NURSING INTERVENTIONS cont. – Pt. understanding of importance of complying with medication regimen – Medic-Alert bracelet – Avoid exposure to infections – Instruct s/sx Addison’s disease for post-op care PROGNOSIS – If not resolved with tumor removal – major lifestyle changes are needed; ↑risk for complications, probable shortened lifespan

15. ADRENAL HYPOFUNCTION (Addison’s Disease) Etiology/pathophysiology – Adrenocortical Insufficiency Adrenal glands do not secrete adequate amounts of glucocorticoids and mineralocorticoids, and androgens May result from – Primary Addison’s (rare) – Adrenalectomy – Pituitary hypofunction – Long-standing steroid therapy

16. ADRENAL HYPOFUNCTION (Addison’s Disease) ETIOLOGY/PATHOPHYSIOLOGY cont. Most common cause: – Antibodies destroy adrenal cortex (tissue outside) Common cause is autoimmune response – Deficiencies in aldosterone and cortisol  disturbance in CHO, Fat, and Protein metabolism  fluid and electrolyte imbalance, dehydration, water loss, and hypovolemia

17. ADRENAL HYPOFUNCTION (Addison’s Disease) CLINICAL MANIFESTATIONS – Related to imbalances of adrenal hormones, nutrients, and electrolytes (not enough glucocorticoids and mineralocorticoids) – Progressive weakness and fatigue – Nausea; anorexia; craving for salt – Postural hypotension: vertigo, weakness, syncope – Headache – Disorientation – Abdominal pain; lower back pain – Anxiety, apprehension; increase reaction to stress

18. ADRENAL HYPOFUNCTION (Addison’s Disease) Clinical manifestations cont. Darkly pigmented skin and mucous membranes Weight loss Vomiting/Diarrhea Hypoglycemia and fatigue Abnormally low or high body temperature Hyponatremia, Hyperkalemia  when these are present, you must assess for adrenal crisis

19. ADRENAL HYPOFUNCTION (Addison’s Disease) SUBJECTIVE ASSESSMENT – Patient may c/o: severe headache, disorientation, abdominal pain or lower back pain – c/o anxiety, apprehension; poor tolerance to stress – Assess overall understanding of disease

20. ADRENAL HYPOFUNCTION (Addison’s Disease) OBJECTIVE ASSESSMENT – Observation of skin and mucous membrane color; skin hyperpigmentation – Weight loss – Vomiting, diarrhea – Hypoglycemia, fatigue – ↑ or ↓ body temp – s/sx hypotension – Lab - hyperkalemia

21. ADRENAL HYPOFUNCTION (Addison’s Disease) MEDICAL MANAGEMENT – Treatment Restore fluid and electrolyte balance Replacement of deficient adrenal hormones Diet high in sodium and low in potassium Adrenal crisis – IV corticosteroids in a solution of saline and glucose Medications: Oral Hydrocortisone (has mineralo- and gluco- corticoid properties) Florinef – mineralocorticoid medication

22. ADRENAL HYPOFUNCTION (Addison’s Disease ) DIAGNOSTIC TESTS – Serum: Na+, K+, glucose, and Fasting Plasma cortisol and aldosterone levels with ACTH stimulation test – Urine: 24hr collection – RESULTS: If + for adrenal hypofunction: ↓ Na+, glucose, 17-ketosteroids & 17-hydroxysteroids, aldosterone and cortisol levels ↑ K+ GTT - abnormal

23. ADRENAL HYPOFUNCTION (Addison’s Disease) NURSING DIAGNOSES – Ineffective tissue perfusion, peripheral r/t electrolyte imbalance – Risk for infection r/t altered metabolic process NURSING INTERVENTIONS – Monitor circulatory status/VS, particularly Temp, BP – I&O, daily weight – s/sx dehydration

24. ADRENAL HYPOFUNCTION (Addison’s Disease) NURSING INTERVENTIONS cont. – Safe administration IV meds; oral meds – s/sx adrenal crisis and note triggers (sl. 23) Pt. Teaching – Use and carry IM hydrocortisone (solucortef, solumedrol, etc.) – Adherence to medication regimen – Reporting ALL illnesses to MD

25. ADRENAL HYPOFUNCTION (Addison’s Disease) PROGNOSIS: with long-term steroid treatment, good medical care and follow up - fair

26. Development of Addisonian Crisis Sudden, severe drop in BP; syncope Nausea and vomiting Extremely high temperature Cyanosis progressing to vasomotor collapse and death Treatment: – IV corticosteroids in saline and glucose; IM corticosteroid which patient should carry with them

27. PHEOCHROMOCYTOMA Etiology/pathophysiology – Rare tumor of the adrenal medulla  Causes excessive secretion of epinephrine and norepinephrine (catecholamines)  severe HTN Clinical Manifestations – Hypertension (300/175) fluctuates  stroke, kidney damage, and retinopathy Severe h/a, tachycardia, abdominal or chest pain Cardiac damage  heart failure NF1(neurofibromatosis) an Inherited Gene sometimes assoc with Pheochromocytoma. Picture is Severe in nature. http://www.pinterest.com/pin/498703358708291383

28. PHEOCHROMOCYTOMA SUBJECTIVE DATA: During hypertensive crisis – pt. c/o or may feel: – Severe h.a. – Nervous – Palpitations, dizzy, dyspneic – Nausea, anxiety, heat intolerance – Interview pt. re: stressors or overexertion – Identify coping methods

29. PHEOCHROMOCYTOMA OBJECTIVE DATA: VS – BP, pulse, resp. rate ↑ Presence of: tremors, diaphoresis, dilated pupils, glycosuria, hyperglycemia Response to medications

30. PHEOCHROMOCYTOMA DIAGNOSTIC TESTS – 24 hr urine for catecholamine metabolites + for disease = ↑ values – CT/MRI of adrenal glands – Plasma catecholamine – lab draw, and measured during an ‘attack’.

31. PHEOCHROMOCYTOMA MEDICAL MANAGEMENT – Surgical removal of tumor Pre-op administration of Ca++ channel blockers (eg. Cardene) or alpha-adrenergic blockers (eg. Regitine) to control HTN Beta-blockers (e.g. Inderal) given to reduce tachycardia and dysrhythmias

32. PHEOCHROMOCYTOMA NURSING INTERVENTIONS – Same as for any major surgery – Post-op Adrenalectomy (due to large amounts of hydrocortisone administration) – Monitor for: BP changes; s/sx cardiovascular collapse IV fluid and med administration Administration of vasopressors and corticosteroids Adequate rest and avoidance of stress I & O Diet: avoid stimulants

33. PHEOCHROMOCYTOMA NURSINGDIAGNOSIS – Ineffective tissue perfusion, cp, renal, r/t hypertension – Activity Intolerance, r/t hypertension PROGNOSIS: – If undiagnosed and untreated  DM, cardiomyopathy, and death – After tumor removal - good – Inoperative tumor – depends on adequate medical management of HTN