Endocrine – Adrenal Gland

Endocrine – Adrenal Gland

Part 1

Adrenal Gland

• Description– AKA

• Suprarenal gland

– Location• On top of each kidney

– Composed of:• Adrenal cortex• Adrenal Medulla

Hormone & Function

• Adrenal Cortex– Mineralocortioids

• Aldosterone

– Function• Regulates electrolyte

& fluid homeostasis

Hormone & Function

• Adrenal Cortex– Glucocorticoids

• Cortisol• Hydrocortisone

– Function• Stim. gluconeogenesis

& blood glucose• Anti-inflammatory• Anti-immunity• Anti- allergy

Hormone & Function

• Adrenal Cortex– Androgen

• Sex hormones

– Function• Female

– Stim. Sex drive

• Men– Negligible

Hormone & Function

• Adrenal Medulla– Epinephrine

• Adrenaline

– Function• Prolong & SNS

(sympathetic nervous system) response to stress

Hormone & Function

• Adrenal Medulla– Norepinephrine– Function

• Prolong & SNS (sympathetic nervous system) response to stress

Effects of Epinephrine & Norepinephrine

a. cardiac outputb. metabolic ratec. Vasoconstrictiond. respiratory rate

Adrenal Cortex

• The cortex synthesizes & secretes 30+ different steroids. – Glucocorticoids– Mineralocorticoids– Androgens

Learning Tip

SALT, SUGAR & SEX• Aldosterone =

promotes salt retention

• Cortisol= sugar• Androgens = sex

hormones

Negative feedback loop

• Stress • Hypothalamus • Stimulates Anterior Pituitary • Secretes ACTH target cell • Adrenal cortex • Secretes Cortisol specific action• metabolic activity • Helps manage stress

Cushing disease/ syndrome

• Description– Cortisol excess

Cushing disease/ syndrome

• Pathyophysiology– Diurnal rhythm

• in AM

– Normal secretion of cortisol in times of stress– In Cushing's, cortisol is hypersecreted without

regard to stress or time of day.

Cushing disease/ syndrome

• Etiology– secretions ACTH– Pituitary CA– Lung tumor– **#1 prolonged use of glucocorticoid meds for

inflammatory disorders• Rheumatoid arthritis• COPD

Cushing disease/ syndrome

• Etiology– Iatrogenic

• Caused by treatment or diagnostic procedure

– Females > Male

Cushing disease/ syndrome

• Signs & Symptoms– Adiposity

• Deposits of adipose tissue in the face, neck & trunk

• Moon shaped face• Buffalo hump

Cushing disease/ syndrome

• S&S– Weight gain– Na & H20 retention– K+ is lost

• Hypokalemia– Purple striae on the

abdomen– Hirsutism–

Cushing disease/ syndrome

• S&S– This extremities d/t

muscle wasting– Boys = early onset of

puberty– Girls = masculine

characteristics– C/O fatigue, muscle

weakness, sleep disturbance, amenorrhea, libido, irritability, emotional labiality

Cushing disease/ syndrome

• S&S– Could be:

• Petechiae• Eccymoses• wound healing• Swollen ankles

Cushing disease/ syndrome

Complications• calcium reabsorption from the bone leading to

osteoporosis & pathologic fractures• Cortisol causes insulin resistance and• ↑hepatic gluconeogenesis and insulin resistance• Leads to glucose intolerance and diabetes mellitus

Cushing disease/ syndrome

Complications• Frequent infections & slow wound healing

– Suppressed inflammatory response can mask severe infections

– Cortisol is an immunosuppressive• Deceased ability to handle stress

– Psych problems i.e. mood swings

Cushing disease/ syndrome

• Diagnosis– Plasma Corticol level– ACTH level– Adrenalangiography

Cushing disease/ syndrome

Medical management• Early dectection key• #1 goal = restore

hormonal balance• Usually meds.

Cushing disease/ syndrome

Med. Management• Tx based on causative

factor• If adrenal cancer

– Surgery• If caused by steroid

meds – Change regiment– Risk to benefit

analysis

Cushing disease/ syndrome

• Surgical management• If pituitary gland

– Hypophysectomy• If adrenal tumor

– Adrenalectomy

Cushing disease/ syndrome

• Aminoglutethimide (cytadren)– Action

• Inhibits synthesis of adrenal steroids

– S/E• Dizziness or drowsiness

– Nrs.• Instruct to avoid

activities that need mental alertness

Cushing disease/ syndrome

• Ketoconazole (Nizoral)– Action

• Antifungal• Inhibits adrenal

steroidogenesis

Cushing disease/ syndrome

Diet• High in protein• High K+• Low sodium• Reduces carbs &

calories

Cushing disease/ syndrome

Nursing Management• Rx history• VS• Lung auscultation

– Crackles• Edema• Skin integrity• Glucose levels• S&S of infection

Adrenalectomy

• Pre-op– Electrolyte imbalance– Hyperglycemia– Prevent adrenal crisis

• Administer glucocorticoids!

• Sudden drop in hormones crisis

Adrenalectomy

• Post-op– Fluid & electrolyte

changes– Replace

glucocorticoids, mineralocorticoids for life

– Bilateral???

Addison’s Disease

• Description– corticol– Adrenal hypofunction– Adrenal insufficiency– Adrenalcortical

insufficiency

Addison’s Disease

• Pathophysiology– 90% of adrenal gland

destroyed– Autoimmune disease– Primary

• ACTH may be high

– Secondary• ACTH will be low

Addison’s Disease

Etiology• Primary

– Bilateral adrenalectomy

• Secondary– ACTH from pituitary– hypothalamus

stimulation

Addison’s Disease

Etiology• Prolonged use of

coticosteroid Rx • ACTH • hormonal release

from adrenal gland• *** esp. at risk if drugs

abruptly DC’ed– Taper dose

Addison’s Disease:Signs & Symptoms

• Hypotension– Lack of aldosterone

– Na+ & H2O loss– K+ reabsorption

• Tachycardia• Orthostatic

hypotension

Addison’s Disease:Signs & Symptoms

• Bronze coloration of skin

• Hypoglycemia• Vitiglio• Fatigue, muscle

weakness• Weight loss• Crave salty foods

Addison’s Disease:Signs & Symptoms

• tolerance for stress– Anxious– Irritable– Confused

• Pulse– Weak

• GI upset– N/V– Anorexia

Addison’s disease: Complications

• Adrenal crisis– Acute Addison’s dis– May occur

• Trauma• Surgery• Stress• Abrupt withdrawl of

cortisone meds

Addison’s disease: Complications

• Adrenal Crisis– S&S

• Na+ & H20 loss• Hypotension• Dehydration• Tachycardia

– IV & administer hydrocortisone

Addison’s disease: Medical Management

• Restore fluid and electrolyte balance

• Replacement of deficient adrenal hormones– Glucocorticoids

(hydrocortisone)– Mineralocorticoids

(fludrocortisone)

Addison’s disease: Pharmacological

• Lifetime steroids• Glucocorticoids

– Hydrocortisone (hydrocortone)

• Mineralocorticoids – Fludrocortisone

acetate (Florinef)• Diurnal rhythm

– 2/3 AM– 1/3 PM

Addison’s disease: Diet

• High in Na+• Low in K+

Addison’s disease: Nursing Management

• Diagnosis???• Fluid volume deficit

– r/t • Na+ level• Vomiting• renal losses

– A.M.B.• Poor skin turgor• Weight loss• Orthostatic

hypotension

Addison’s disease: Nursing Management

• qDay wts• I&O• Glucose• K+ & Na+• Skin turgor• Orthostatic

hypotension

Hypofunction Hyperfunction

Disorder Addison’s disease

Cushing syndrome

S&S Na+ & H20 lossHypotensionHypoglycemiaFatigueHyperkalemia

Na+ & H20 retention Wt. gainHyperglycemiaBuffalo humpMoon faceHypokalemia

Hypofunction Hyperfunction

Usual tx GlucocorticoidsMeneralocorticoidRestore fluid

Alter steroid RxSurgery

Nrs Dx Fluid volume deficit Fluid volume excessGlucose intolerance

Diet Na+ K+

Na+ K+

Pheochromocytoma:Description

• AKA chromaffin cell tumor

• Rare disease• Characterized by

paroxysmal or sustained hypertension– d/t excess secretion

of epi and norepi

Pheochromocytoma:Pathophysiology

• Caused by a tumor– Usually Rt. adrenal

• Etiology– Idiopathic

• Stress can bring on an attack

Pheochromocytoma:Signs & Symptoms

• HTN– > 115 mmHG diastolic– Intermittent– Unstable

• Tachycardia• Unrelenting H/A• Profuse diaphoresis• Palpitations

Pheochromocytoma:Signs & Symptoms

• Visual disturbances• N/V• Feeling of

apprehension• Elevated blood glucose

levels

Pheochromocytoma:Complications

• Stroke• Retinopathy• Heart disease• Kidney damage

Pheochromocytoma:Medical Management / Surgical

• Treatment of choice is…– Surgery

• Stable a surgery• Adrenal gland

removed• BP

Pheochromocytoma:Pharmacological

• Phentolamine mesylate (Regitine)

• Nitroprusside sodium (Nipride)– HTN

Pheochromocytoma:Diet

• protein• Avoid caffeine

Pheochromocytoma:Nursing Management

• Monitor BP• VS• Na+ levels