Post on 24-Dec-2015
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ADRENAL GLANDS
Adrenal Cortex Adrenal Medulla
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ADRENAL CORTEX
Sugar Salt Sex
SUGAR GLUCOCORTICOIDS (regulate metabolism &
are critical in stress response) CORTISOL responsible for control and &
metabolism of:
a. 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
SUGARcon’tOther 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)
AldosteroneWhat stimulates aldosterone secretion?What inhibits adlosterone secretion?
Na retention Water retentionK excretionHydrogen ion excretion
Question:If your Na level is low, will aldosterone secretion
or
If your serum K+ level is high, will aldosterone secretion
or
SEX
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
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 & HYPOFUNCTION ADRENAL CORTEX HORMONES
Too much
Too little
Too much aldosterone secretion Question:
What does aldosterone do????
_____________________________ usually caused by adrenal tumor
HYPERALDOSTERONISM“Conn’s Syndrome”
SIGNS & SYMPTOMSHyperaldosteronism Na and water retention
What is the normal serum K+ level?
Usually no edema
DIAGNOSISHyperaldosteronism urinary K
plasma aldosterone & Na levels with low plasma renin levels
BP
CT scan EKG changes Labs
Presence of hypokalemia with HTN – suspect CONNS
INTERVENTIONSHyperaldosteronism
BP What drugs would you give?
Correct hypokalemia/hypernatremia What you would you do?
Partial or total adrenalectomy
ADRENALECTOMYPRE-OP
Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol
levels before or after surgery?
ADRENALECTOMYPOST-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
ETIOLOGYCushing’s Cushing’s Disease
_____________________
Cushing Syndrome _____________________ _____________________ _____________________
SIGNS & SYMPTOMS Cushing’s protein catabolism
muscle wasting
*loss of collagen support
poor wound healing
SIGNS & SYMPTOMSCushing’s Electrolyte imbalances
Which ones?
s in carbohydrate metabolism Hyperglycemia
Why?
SIGNS & SYMPTOMSCushing’s s in fat metabolism
****abdomen aka: _________
cervical spine aka: _________
****face aka: _________
SIGNS & SYMPTOMS
immune response
More prone to infection
resistance to stress
What sign would the nurse identify in each patient?
SIGNS & SYMPTOMS
mineralocorticoid activity ________ retention
_______ retention
What happens to blood pressure?
SIGNS & SYMPTOMSMENTAL CHANGES
Mood swings Euphoria Depression Anxiety
Mild to severe depression
Psychosis Poor concentration and
memory Sleep disorders
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 DoseDexamethasone 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)
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 DISEASEhypofunction 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 atrophyautoimmune condition
antibodies attack against own adrenal cortex
90% of tissue destroyed
ETIOLOGY of Addison’s
Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes
SIGNS & SYMPTOMSAddison’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 ____K ____Na ____serum glucose ____plasma ACTH ____urine free cortisol
INTERVENTIONSAddison’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
INTERVENTIONSAddison’s Disease Keep parenteral glucocorticoids at
home for injection during illness Do you need to avoid
infections/stress?
COMPLICATIONSAddison’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 & SYMPTOMSAddisonian 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?
TREATMENTAddisonian 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 SYMPTOMSPheochromocytoma 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 & SYMPTOMSPheochromocytoma Deep breathing Pounding heart Headache Moist cool hands & feet Visual disturbances
DIAGNOSISPheochromocytoma
Often missed 24 hour urine
fractionated metanephrines fractionated cathecholamines creatinine Are these increased or decreased?
Plasma catecholamines When are these drawn? Are these increased or decreased?
CT to locate tumor
Interventions/TreatmentPheochromocytoma Primary goal? Primary treatment? Pre - op
Calcium channel blockers Cardene
Sympathetic blocking agents Minipress (watch for orthostatic hypotension)
Beta blocking agents Inderal
INTERVENTIONS
Monitor b.p.Eliminate attacksIf attack- complete bedrest and
HOB 45 degrees
Interventions/TreatmentPheochromocytoma
Diet high in vitamins, minerals, calories, no caffeine
Sedatives
DURING SURGERY
give REGITINE & NIPRIDE to prevent hypertensive crisis
Laparoscopic Adrenalectomy/Open abdominal incision
POST-OP
b.p. may be initially, 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?