SALT n Mineralocorticoids (F & E balance) Aldosterone (renin from kidneys controls adrenal cortex production of aldosterone) n Na retention n Water retention n K excretion
Question: If your Na level is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion or
SUGAR n GLUCOCORTICOIDS (regulate metabolism & are critical in stress response) CORTISOL responsible for control and & metabolism of: a. CHO (carbohydrates) amt. glucose formed amt. glucose released
CORTISOL b. FATS-control of fat metabolism n stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism stimulates protein synthesis in liver protein breakdown in tissues
SUGAR n Other fxs of Cortisol inflammatory and allergic response immune system therefore prone to infection
SEX n ANDROGENS hormones which male characteristics n release of testosterone n Seen more in women than men
RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ______
LETS LOOK AT ACTH (adrenocorticotropic Hormone) n Produced in anterior pituitary gland
ACTH n Circulating levels of cortisol levels cause stimulation of ACTH levels cause dec. release of ACTH think tank: What type of feedback mechanism is this??
AFFECTED BY: n Individual biorhythms ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. usually 5AM - 7AM these gradually decrease rest of day n Stress- cortisol production and secretion
ADRENAL MEDULLA n Fight or flight n What is released by the adrenal medulla?
CATECHOLAMINE RELEASE n Epinephrine n Norepinephrine
HYPER AND HYPOFUNCTION ADRENAL CORTEX HORMONES n Too much n Too little
I. CUSHINGS DISEASE (TOO MUCH CORTISOL!) n secretion of cortisol from adrenal cortex n 4X more frequent in females n Usually occurs at 35-50 years of age
ETIOLOGY Cushings n Primary-tumor on the adrenal cortex n Secondary-tumor on the anterior pituitary gland n Ectopic ACTH secreting tumor (lung, pancreas) n Iatrogenic-Steroid administration
SIGNS & SYMPTOMS Cushings n protein catabolism muscle wasting loss of collagen support n thin, fragile skin, bruises easily poor wound healing
SIGNS & SYMPTOMS Cushings n s in CHO metabolism hyperglycemia Can get diabetes-insulin cant keep up Polyuria
SIGNS & SYMPTOMS Cushings n s in fat metabolism truncal obesity buffalo hump moon face weight but strength
SIGNS & SYMPTOMS n immune response More prone to infection resistance to stress Death usually occurs from infection
What sign would the nurse identify in each patient?
SIGNS AND SYMPTOMS Cushings n androgen secretion excessive hair growth acne change in voice receding hairline
SIGNS & SYMPTOMS n mineralocorticoid activity ________ retention _______ retention b.p. from ________
SIGNS & SYMPTOMS MENTAL CHANGES n Mood swings n Euphoria n Depression n Anxiety n Mild to severe depression n Psychosis n Poor concentraion and memory n Sleep disorders
SIGNS & SYMPTOMS n s in hematology n WBCs n lymphocytes n eosinophils
DIAGNOSIS of Cushings n Serum cortisol levels n What will serum cortisol levels be? Draw AT 8AM AND 8PM n What would you expect? n URINARY LEVELS OF STEROID METABOLITES. n 17-OHCS (hydroxycorticoid steroid) n 17-KS (ketosteroid)
TREATMENT of Cushings n Surgery transsphenoidal removal of pituitary tumor adrenalectomy-can be unilateral or bilateral n if bilateral, need hormone replacement for life ectopic -try to remove source of ACTH secretion
Cushings TREATMENT n Radiation to tumors n Palliative drugs MITOTANE destroys tissue in adrenal cortex
REVIEW: WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHINGS?
n Too much aldosterone secretion n Question: What does aldosterone do???? _____________________________ n usually caused by adrenal tumor II. HYPERALDOSTERONISM Conns Syndrome
SIGNS & SYMPTOMS Hyperaldosteronism n Na and water retention H/A, HTN n K+ (hypokalemia) n What is the normal serum K+ level??? n Usually no edema
DIAGNOSIS- Hyperaldosteronism n urinary K n plasma aldosterone levels with low plasma renin levels n CT scan n EKG changes
INTERVENTIONS Hyperaldosteronism n BP -aldactone=Aldosterone antagonist so what will it do to Na, H2O, and K??? n Correct hypokalemia/hypernatremia K+ supplements; low Na diet n Partial or total adrenalectomy
ADRENALECTOMY PRE-OP n Stabilize hormonally n Correct fluid and electrolytes n Cortisol PM before surgery, AM of surgery and during OR.
ADRENALECTOMY POST-OP n ICU-What type of problems to expect?? n IV cortisol for 24 hours n IM cortisol 2nd day n PO cortisol 3rd day n Poor wound healing n If unilateral- steroids weaned other adrenal takes over 6-12 months
ADDISONS DISEASE hypofunction of adrenal cortex n What hormones will you have too little of??? n glucocorticoids or _______ n mineralocorticoids or _______ n androgens or ____________
Trivia Question: Which famous President had Addisons Disease???
ETIOLOGY of Addisons n Idiopathic atrophy autoimmune condition Antibodies attack against own adrenal cortex 90% of tissue destroyed
ETIOLOGY of Addisons n TB/fungal infections (histoplasmosis) n Iatrogenic causes adrenalectomy, chemo, anticoagulant tx
SIGNS & SYMPTOMS Addisons Disease n fatigue, weight loss, anorexia Why? think of cortisol fx n Changes in skin pigment small black freckles cortisol -- ACTH-- MSH n Muscular weakness cortisol helps muscles maintain contraction and avoid fatigue
SIGNS & SYMPTOMS Addisons n Fluid & electrolyte imbalances WHY??? n b.p. WHY??? n Hyponatremia-why? n Hyperkalemia-why? n Hypoglycemia-why?
SIGNS & SYMPTOMS Addisons n androgens hair loss, sexual fx n mental disturbances anxiety, irritability, etc. n salt craving-why?
DIAGNOSIS-Addisons n serum cortisol n urinary 17-OHCS and 17 KS n K, n Na n serum glucose
INTERVENTIONS Addisons Disease n Life long hormone replacement primary-need oral cortisone 20- 25mgs in AM and 10-12mg in PM change dose PRN for stress also need mineralocorticoid- (FLORINEF)
INTERVENTIONS n Salt food liberally n Do not fast or omit meals n Eat between meals and snack n Eat diet high in carbs and proteins n Wear medic-alert bracelet n kit of 100mg hydrocortisone IM
INTERVENTIONS Addisons Disease n Keep parenteral glucocorticoids at home for injection during illness n Avoid infections/stress
COMPLICATIONS Addisons Disease n Adrenal crisis n Electrolyte imbalance n Hypoglycemia
ADDISONS CRISIS n Sudden decrease or absence of adrenal cortex hormones which are: __________________
CAUSES n Pt. with Addisons who doesnt respond to tx or has stress without dose n Pt. with Addisons but undiagnosed who is exposed to stress n Pt. on steroids that are dcd without tapering n Pt. with Addisons not controlled
SIGNS & SYMPTOMS Addisonian Crisis n Dehydration- Na, K, BP N/V,diarrhea, wt. loss n Weakness n Confusion,headache n Hypovolemic shock, coma n Pallor, Inc. HR,RR, hypoglycemia n Renal shut-down-DEATH
TREATMENT Addisonian Crisis n Rapid infusion of IV fluids n Check VS and urine output frequently n Monitor EKG n Give solu-cortef IV Q6 hours until S & S disappear
TREATMENT n Try to anxiety n May have to give vasopressors Dopamine or Epinepherine n Avoid additional stress
PHEOCHROMOCYTOMA n rare, benign tumor of the adrenal medulla n oh no...what are we going to see a hypersecretion of????
SIGNS AND SYMPTOMS n Hallmark is hypertension-200/150 or greater n Spells-paroxymal attacks bladder distension,emotional distress, exposure to cold. n NE and Epinepherine released sporadically
SIGNS & SYMPTOMS n Deep breathing n Pounding heart n Headache n Moist cool hands & feet n Visual disturbances
DIAGNOSIS n 24 hour urine-VMA (metabolite of Epinepherine) n Plasma catecholamines n CT to locate tumor
INTERVENTIONS-PRE-OP n Adrenergic blocking agents Minipress to bp n Beta blocking agents Inderal to hr, b.p., & force of contraction n Diet high in vitamin, mineral,calorie, no caffeine n Sedatives
INTERVENTIONS n Monitor b.p. n Eliminate attacks n If attack- complete bedrest and HOB 45 degrees
DURING SURGERY GIVE REGITINE AND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS
POST-OP n b.p. may be initially, BUT CAN BOTTOM OUT n Volume expanders n Vasopressors n Hourly I and O n Observe for hemorrhage
QUESTION?? n What if you are not a candidate for surgery??? n Demser (drug which inhibits catecholamine synthesis) n Avoid opiates, histamines, reglan, anti-depressants. Why?