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Disturbances of the Adrenal Gland Semester V RN Fall 2002

Disturbances of the Adrenal Gland Semester V RN Fall 2002. Ann MacLeod, RN, BScN, MPH. Agenda. Test Take Up Understand Disturbances of the Adrenal Gland Assessment of Nursing diagnoses Nursing care. Disturbance in Adrenal Hormones.

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Disturbances of the Adrenal Gland Semester V RN Fall 2002

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  1. A. MacLeod, Fall 2002 Disturbances of the Adrenal GlandSemester V RN Fall 2002 Ann MacLeod, RN, BScN, MPH

  2. Agenda • Test Take Up • Understand Disturbances of the Adrenal Gland • Assessment of • Nursing diagnoses • Nursing care A. MacLeod, Fall 2002

  3. Disturbance in Adrenal Hormones • Over view: A&P: adrenal glands- 2 small structures which cap the top of the kidneys • each composed of 2 structures with its own function • inner core: adrenal medulla • outer shell: adrenal cortex A. MacLeod, Fall 2002

  4. Functions of Adrenal Medulla: • Adrenal medulla: releases epinephrine and norepinepherine which convert glycogen to glucose to increase cardiac output • Fight or flight response • nor-epinephrine produces vascular constriction which increases BP A. MacLeod, Fall 2002

  5. A. MacLeod, Fall 2002

  6. Hyposecretion of the adrenal medulla • Assessment •  plasma and urine catacholamines, epinephrine and norepinephrine • low BP, little fight or flight response • uncommon • management • supplement with catacholamines A. MacLeod, Fall 2002

  7. Adrenal Medulla (hypertrophy)  epinephrine & norepinephrine • Pheochromocytoma: tumor of the adrenal gland Assessment • can be life-threatening • headache, vertigo, blurred visiontinnitus • dyspnea, palpitations, tachycardia • hyperglycemia, glucosuria • hypertension very high (and postural hypotension) • nervousness, anxiety, tremors • indigestion, nausea, vomiting, abdominal pain • fatigue, exhaustion A. MacLeod, Fall 2002

  8. Pheochromocytoma: tumor of the adrenal gland Assessment cont’d •  plasma & urine epinephrine and norepinephrine (catecholamines) • clonidine ( Catapres) suppression test blocks sympathetic stimulation & will not suppress if the gland is over producing epinephrine • CT Scan, MRI, MIBG tagged x-ray, ultrasound A. MacLeod, Fall 2002

  9. Pheochromocytoma: tumor of the adrenal gland: Management • Pharmacologic tx to treat symptoms • alpha adrenergic blockers (phentolamine) • beta adrenergic blockers (propranolol) • catacholamine synthesis inhibitors (metyrosine) • Surgical removal: adrenalectomy • then supplement catacholamines andn corticosteroids • monitor BP, BS, ECGs A. MacLeod, Fall 2002

  10. Adrenal Cortex • Hypothalamus  Corticotropin Releasing Hormone  Post. Pituitary releases Adrenocorticotropin hormone ( ACTH)  stimulate adrenal cortex to release hormones: • Glucocorticoids ( cortisol): stimulates  blood glucose, anti- inflammation • Mineralocorticoids (aldosterone) : regulates electrolyte balances • Sex hormones (s/a estrogen, androgens) : sexual dev’p A. MacLeod, Fall 2002

  11. A. MacLeod, Fall 2002

  12. Glucocorticoids- cortisol • Regulate blood sugar by conserving body glucose and promoting gluconeogenesis • regulates protein, fat and CHO metabolism • stress response • anti- inflammatory and immune response A. MacLeod, Fall 2002

  13. Mineralocorticoids-Aldosterone • promotes Na+ retention and K+ excretion • targets kidney tubules • only responsible for increases in blood volume of 5-10 % offset by increased Glomerular Filtration Rate • (ADH is more responsible) • low K+ muscle weakness, lowered membrane potential, therefore more easily excited  cramping and become weak A. MacLeod, Fall 2002

  14. Sex Hormones Androgens • small amount of estrogens • sexual development A. MacLeod, Fall 2002

  15. Hyposecretion of the Adrenal Cortex - Addison’s Disease • may be primary or secondary • Primary: as a result of atrophy or autoimmune destruction, tumors or suppressed pit. Function • secondary: insufficient ACTH from pituitary gland A. MacLeod, Fall 2002

  16. Glucocorticoid hyposecretion  cortisol • Wide spread metabolic imbalances • decreased gluconeogenesis blood sugar (pt. Weak, exhausted, wt, loss, nausea, vomiting) • decreased resistance to stress, infection and inflammation A. MacLeod, Fall 2002

  17. Decreased aldosterone: • Na+ channels in Kidney tubule do NOT open  Na+ and H20 stay in the urine • Dehydration, hypotension, decreased Cardiac output, circulatory collapse • K+ cannot get into urine  hyperkalemia K+ decreased muscle contractility  arrthymias  death A. MacLeod, Fall 2002

  18. Assessment: • Blood K+, WBC • Blood Glucose,  Na+, aldosterone • Muscular weakness, anorexia, GI upset • fatigue, wt. Loss • decreased BP • chronic dehydration • ACTH fails to  cortisol A. MacLeod, Fall 2002

  19. Addisonian Crisis • When subject to stress, infection, trauma and surgery. (could be fatal) • headache, nausea, vomiting,fever, abd. Pain, severe hypotension • vascular collapse>>>SHOCK A. MacLeod, Fall 2002

  20. Management: • Immed. Tx. To combat shock and administer fluids • IV solucortef, vasopressin to increase BP • antibiotics to combat infection if present • Increase NA+, Decrease K+ diet • life long admin. Of corticosteroids and mineralocortoids A. MacLeod, Fall 2002

  21. Pharmacotherapy • Florinef: mineralocorticoid • cortisone, cortisol, prednisone, betamethesone} glucococorticoids • corticosteroids may cause S/E: moonface, wt. Gain, edema., K+ loss, Increased urination, nocturia, masking of s/s infection • Steroids must be tapered! A. MacLeod, Fall 2002

  22. Fluid vol. deficit Daily wt. I+O, assessment of mucous membranes monitor BP freq. Diet: carb,protein,Na+, increased fluids pharmcotherapy monitor excessive sweating Nursing Diagnoses/ Process A. MacLeod, Fall 2002

  23. Activity intolerance Knowledge Deficit Avoid stressful activity, quiet environ. Complete bedrest, help with bathing, turning rationale for steroid replacements, medic alert, diet, wt,injectable hormones Nursing Process A. MacLeod, Fall 2002

  24. Hypersecretion of Adrenal Cortex: Cushing’s Syndrome • Usually secondary to hypersecretion of the of ACTH by the pituitary due to tumours • Hypercorticism: steroid hormone replacement A. MacLeod, Fall 2002

  25. Cushings syndrome A. MacLeod, Fall 2002

  26. Glucocorticoid Excess • Gluconeogenesis- Breakdown of fats and proteins to increase blood sugar • distrubution of adipose tissue in the abd. and behind shoulders (buffalo hump) • protein loss  thin skin, weak blood vessels, osteoporosis, decreased immunity ( IGg) • hyperglycemia  diabetes • vasoconstrictor (anti-inflammatory) A. MacLeod, Fall 2002

  27. Aldosterone Excess • Kidney tubules opens Na+ channels  Na+ and water retention in blood  edema, elevated BP • K+ is excreted in urine  blood depletion  hypokalemia K+muscle excitability  cramps, fatigue A. MacLeod, Fall 2002

  28. Androgen Excess • Women more masculin • hair on head thins • abnormal facial hair A. MacLeod, Fall 2002

  29. Assessment for Cushing’s Disease • 24 hr. urine: free cortisol increased • DST Dexamethesone Suppression Test: 1 mg. Of dexamethesone is given po the night before. This should suppress plasma cortisol levels at 0800 the next day to 50% of baseline • Blood tests:  Glucose,  K+, Na+ • CT or MRI : adrenal mass or pit. tumor A. MacLeod, Fall 2002

  30. Management: • Surgical removal of the tumor of the pituitary gland is Rx. Of choice • adrenalectomy • may have radiation • often causes hyposecretion so must assess for this and monitor supplements of hormones A. MacLeod, Fall 2002

  31. Nursing Diagnoses • Risk for injury due to weakness • Self Care Deficit • imp. Skin integrity • high risk for infection • body image disturbance • fluid vol. Excess • pt. Teaching and followup A. MacLeod, Fall 2002

  32. Post-op: vital signs q 1-4hrs especially BP I+O observe for hemorrhage (area is highly vascular) monitor serum electrolytes (may cause insufficiency Be alert for s/s adrenal insufficency IV corticosteroids dressing change prn observe for s/s infection and delayed wound healing Adrenalectomy Nursing Care: A. MacLeod, Fall 2002

  33. Corticosteroid treatment • Either for Addisons, or post op adrenalectomy • actions: • gluconeogenesis ( breakdown, fat & proteins) • inhibits prostoglandin formation inflammatory process complement system, and permeability, • cytokines blocked &B lymphocytes not activatedimmune response • vasoconstriction & Na +retention  BP • bone absorption into blood • stabilize mast cells therefore less broncho- constriction A. MacLeod, Fall 2002

  34. Cortisone-nursing considerations • Has both cortisol and mineralocorticoid hormones 15-30 mg PO daily • Taper Doses, give with or after meals • monitor blood counts and glucose, Na+ K+ • monitor mood changes, skin for lesions or acne, stretch marks, menstrual changes • monitor signs of infection • many drug contraindications • monitor weight loss, skin hyperpigmentation A. MacLeod, Fall 2002

  35. Cushings Syndrome Non-surgical maintenance • Monitor emotions & support systems • skin care & hygiene • Diet hi K+, low Na+ and calories A. MacLeod, Fall 2002

  36. A. MacLeod, Fall 2002

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