1. ADRENAL GLANDS n Adrenal Cortex n Adrenal Medulla

2. ADRENAL CORTEX n Salt n Sugar n Sex

3. SALT n Mineralocorticoids (F & E balance) –Aldosterone (renin from kidneys controls adrenal cortex production of aldosterone) n Na retention n Water retention n K excretion

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

5. SUGAR n GLUCOCORTICOIDS (regulate metabolism & are critical in stress response) –CORTISOL responsible for control and & metabolism of: a. CHO (carbohydrates) – amt. glucose formed – amt. glucose released

6. CORTISOL b. FATS-control of fat metabolism n stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism –stimulates protein synthesis in liver –protein breakdown in tissues

7. SUGAR n Other fxs of Cortisol – inflammatory and allergic response – immune system therefore prone to infection

8. SEX n ANDROGENS –hormones which male characteristics n release of testosterone n Seen more in women than men

9. RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ______

10. LET’S LOOK AT ACTH (adrenocorticotropic Hormone) n Produced in anterior pituitary gland

11. ACTH n Circulating levels of cortisol – levels cause stimulation of ACTH – levels cause dec. release of ACTH think tank: What type of feedback mechanism is this??

12. AFFECTED BY: n Individual biorhythms –ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. –usually 5AM - 7AM –these gradually decrease rest of day n Stress- cortisol production and secretion

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

14. CATECHOLAMINE RELEASE n Epinephrine n Norepinephrine

15. HYPER AND HYPOFUNCTION ADRENAL CORTEX HORMONES n Too much n Too little

16. I. CUSHING’S DISEASE (TOO MUCH CORTISOL!) n secretion of cortisol from adrenal cortex n 4X more frequent in females n Usually occurs at 35-50 years of age

17. ETIOLOGY Cushing’s n Primary-tumor on the adrenal cortex n Secondary-tumor on the anterior pituitary gland n Ectopic ACTH secreting tumor (lung, pancreas) n Iatrogenic-Steroid administration

18. SIGNS & SYMPTOMS Cushing’s n protein catabolism –muscle wasting –loss of collagen support n thin, fragile skin, bruises easily – poor wound healing

19. SIGNS & SYMPTOMS Cushing’s n s in CHO metabolism –hyperglycemia –Can get diabetes-insulin can’t keep up –Polyuria

21. SIGNS & SYMPTOMS Cushing’s n s in fat metabolism –truncal obesity –buffalo hump –“moon face” – weight but strength

22. SIGNS & SYMPTOMS n immune response –More prone to infection – resistance to stress –Death usually occurs from infection

23. Before

24. After

25. What sign would the nurse identify in each patient?

26. SIGNS AND SYMPTOMS Cushing’s n androgen secretion –excessive hair growth –acne –change in voice –receding hairline

27. SIGNS & SYMPTOMS n mineralocorticoid activity – ________ retention _______ retention – b.p. from ________

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

29. SIGNS & SYMPTOMS n s in hematology n WBCs n lymphocytes n eosinophils

30. DIAGNOSIS of Cushing’s n Serum cortisol levels n What will serum cortisol levels be? Draw AT 8AM AND 8PM n What would you expect? n URINARY LEVELS OF STEROID METABOLITES. n 17-OHCS (hydroxycorticoid steroid) n 17-KS (ketosteroid)

31. TREATMENT of Cushing’s n Surgery transsphenoidal removal of pituitary tumor adrenalectomy-can be unilateral or bilateral n if bilateral, need hormone replacement for life ectopic -try to remove source of ACTH secretion

32. Cushing’s TREATMENT n Radiation to tumors n Palliative drugs –MITOTANE destroys tissue in adrenal cortex

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

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

35. SIGNS & SYMPTOMS Hyperaldosteronism n Na and water retention –H/A, HTN n K+ (hypokalemia) n What is the normal serum K+ level??? n Usually no edema

36. DIAGNOSIS- Hyperaldosteronism n urinary K n plasma aldosterone levels with low plasma renin levels n CT scan n EKG changes

37. INTERVENTIONS Hyperaldosteronism n BP -aldactone=Aldosterone antagonist so what will it do to Na, H2O, and K??? n Correct hypokalemia/hypernatremia –K+ supplements; low Na diet n Partial or total adrenalectomy

38. ADRENALECTOMY PRE-OP n Stabilize hormonally n Correct fluid and electrolytes n Cortisol PM before surgery, AM of surgery and during OR.

39. ADRENALECTOMY POST-OP n ICU-What type of problems to expect?? n IV cortisol for 24 hours n IM cortisol 2nd day n PO cortisol 3rd day n Poor wound healing n If unilateral- steroids weaned –other adrenal takes over 6-12 months

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

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

43. ETIOLOGY of Addison’s n Idiopathic atrophy –autoimmune condition Antibodies attack against own adrenal cortex –90% of tissue destroyed

44. ETIOLOGY of Addison’s n TB/fungal infections (histoplasmosis) n Iatrogenic causes –adrenalectomy, chemo, anticoagulant tx

45. SIGNS & SYMPTOMS Addison’s Disease n fatigue, weight loss, anorexia –Why? think of cortisol fx n Changes in skin pigment –small black freckles – cortisol -- ACTH-- MSH n Muscular weakness –cortisol helps muscles maintain contraction and avoid fatigue

46. SIGNS & SYMPTOMS Addison’s n Fluid & electrolyte imbalances –WHY??? n b.p. –WHY??? n Hyponatremia-why? n Hyperkalemia-why? n Hypoglycemia-why?

47. SIGNS & SYMPTOMS Addison’s n androgens –hair loss, sexual fx n mental disturbances –anxiety, irritability, etc. n salt craving-why?

48. DIAGNOSIS-Addison’s n serum cortisol n urinary 17-OHCS and 17 KS n K, n Na n serum glucose

49. INTERVENTIONS Addison’s Disease n Life long hormone replacement –primary-need oral cortisone 20- 25mgs in AM and 10-12mg in PM –change dose PRN for stress –also need mineralocorticoid- (FLORINEF)

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

51. INTERVENTIONS Addison’s Disease n Keep parenteral glucocorticoids at home for injection during illness n Avoid infections/stress

52. COMPLICATIONS Addison’s Disease n Adrenal crisis n Electrolyte imbalance n Hypoglycemia

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

54. CAUSES n Pt. with Addison’s who doesn’t respond to tx or has stress without dose n Pt. with Addison’s but undiagnosed who is exposed to stress n Pt. on steroids that are dc’d without tapering n Pt. with Addison’s not controlled

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

56. TREATMENT Addisonian Crisis n Rapid infusion of IV fluids n Check VS and urine output frequently n Monitor EKG n Give solu-cortef IV Q6 hours until S & S disappear

57. TREATMENT n Try to anxiety n May have to give vasopressors –Dopamine or Epinepherine n Avoid additional stress

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

59. SIGNS AND SYMPTOMS n Hallmark is hypertension-200/150 or greater n “Spells”-paroxymal attacks –bladder distension,emotional distress, exposure to cold. n NE and Epinepherine released sporadically

60. SIGNS & SYMPTOMS n Deep breathing n Pounding heart n Headache n Moist cool hands & feet n Visual disturbances

61. DIAGNOSIS n 24 hour urine-VMA (metabolite of Epinepherine) n Plasma catecholamines n CT to locate tumor

62. INTERVENTIONS-PRE-OP n Adrenergic blocking agents –Minipress to bp n Beta blocking agents –Inderal to hr, b.p., & force of contraction n Diet – high in vitamin, mineral,calorie, no caffeine n Sedatives

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

64. DURING SURGERY GIVE REGITINE AND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS

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

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

67. Now Let’s Practice Some Questions….