1. ADRENAL GLANDS
Adrenal Cortex
Adrenal Medulla

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4. ADRENAL CORTEX
Sugar
Salt
Sex

5. 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

6. 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

7. 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?

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

9. 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

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

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

12. RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ___?___

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

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

15. 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

16. HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES
Too much
Too little

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

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

19. 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

20. INTERVENTIONS HyperaldosteronismBP
What drugs would you give?
Correct hypokalemia/hypernatremia
What you would you do?
Partial or total adrenalectomy

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

22. 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

23. Cushing Syndrome vs
Cushing’s Disease

24. 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

25. ETIOLOGY Cushing’s Cushing’s Disease Cushing Syndrome
_____________________
Cushing Syndrome

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

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

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

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

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

31. 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.

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

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

34. SIGNS & SYMPTOMS
s in hematology
WBCs
lymphocytes
eosinophils

36. 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

37. 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?

38. 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

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

40. 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?

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

42. 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

43. 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

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

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

46. 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

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

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

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

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

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

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

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

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

55. 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)

56. 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

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

58. COMPLICATIONS Addison’s Disease
Adrenal crisis
Electrolyte imbalance
Hypoglycemia

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

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

61. 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

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

63. 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

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

65. Adrenal Medulla

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

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

69. 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

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

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

72. 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?

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

74. 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

75. 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

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

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

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

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

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