1. ADRENAL GLANDS
Adrenal Cortex
Adrenal Medulla

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4. ADRENAL CORTEX
Sugar
Salt
Sex

5. SUGAR
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
How much per day?

7. SUGAR con’t Other functions of Cortisol
What does it do to the inflammatory response?
What does it do the immune response?

8. Exogenous Corticosteroids
**______________
______________

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

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

11. SEX ESTROGENS ANDROGENS release of testosterone
hormones which male characteristics
release of testosterone
Do women produce androgens?

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 rest of day
Stress- ____cortisol production & secretion

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

17. II. 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 s/s would you expect?
What is the normal serum K+ level?
Usually no edema
Why?

19. DIAGNOSIS-Hyperaldosteronism
urinary K
plasma aldosterone & Na levels with low plasma renin levels
CT scan
EKG changes

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
What are some s/s of this?
What would an ekg look like for hypokalemia?
If unilateral- steroids weaned

23. Cushing Syndrome vs
Cushing’s Disease

24. CUSHING’S DISEASE (TOO MUCH CORTISOL!)
secretion of cortisol from adrenal cortex
4X more frequent in females
Usually occurs at 20-40
years of age

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 CHO metabolism
Hyperglycemia
Why?

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

29. SIGNS & SYMPTOMS immune response More prone to infection
resistance to stress
Common cause of death?

30. Before

31. After

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

33. SIGNS AND SYMPTOMS Cushing’s
androgen secretion
What would you expect
to see?

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

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

37. SIGNS & SYMPTOMS
s in hematology
WBCs
lymphocytes
eosinophils

38. 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 pts
Serum cortisol levels
What will serum cortisol levels be?
Draw AT 8AM AND 8PM
What would you expect?

39. 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?

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

41. 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

42. TREATMENT of Cushing’s
Radiation to tumors
Why would one choose radiation?
Palliative drugs
Goal of drug therapy?
MITOTANE
destroys tissue
in adrenal cortex

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

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

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

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

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

49. ETIOLOGY of Addison’s Malignancy TB Fungal infections (histoplasmosis)
AIDS
Iatrogenic causes
adrenalectomy, chemo, anticoagulant tx
Iatrogenic causes anticoagulant ---- cause Adrenal hemmorage

50. SIGNS & SYMPTOMS Addison’s Disease
fatigue, weight loss, anorexia
Why? think of cortisol fx
Changes in skin pigment
small black freckles
Why?
Muscular weakness

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

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

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

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

55. 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

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

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

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

59. CAUSES Name 4 causes 1. __________________________
2. __________________________
3. __________________________
4. __________________________

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

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

62. 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

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

64. Adrenal Medulla

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

67. CATECHOLAMINE RELEASE
Epinephrine
Norepinephrine

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

69. 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?

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

71. 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

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

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

74. Laparoscopic Adrenalectomy/ Open abdominal Incision DURING SURGERY
GIVE REGITINE AND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS

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

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

77. Now Let’s Practice Some Questions….