Disorders of Adrenal Cortex • Cushing Syndrome (Adrenocortical Hyperfunction) • Addison’s Disease (Adrenocortical Insufficiency) Fall 2019 Spring 2020 Fluid & Electrolytes Mobility Perfusion Stress & Coping How will you know if your paBent has an adrenal gland disorder? What nursing assessments are involved? 1
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How will you know if your paBent has an adrenal gland disorder?
What nursing assessments are involved? 1
Changes in CorBsol RegulaBon Altera1on Descrip1on/Defini1on Manifesta1ons Interven1ons and
Therapies
Changes in corBsol regulaBon
Symptoms result from excess or deficient secreBon of corBsol from the adrenal glands. • Cushing Syndrome • Addison’s Disease
Excess corBsol results in Cushing syndrome, which is accompanied by a moon face and central obesity along with other symptoms. CorBsol deficiency results in Addison’s disease, which is accompanied by muscle weakness, faBgue, weight loss, and other symptoms.
Cushing syndrome is treated with either decreasing corBcosteroid dosage or surgery to remove a tumor, depending on the cause. Addison’s disease is treated with oral or injected corBcosteroids.
• Assess for S&S of inflammation/infection (which may be minimal or absent), pain, loss of function, thromboembolism, pulmonary emboli
• Provide emotional support – Patient may feel unattractive or unwanted
– Remain sensitive to patient’s feelings and be respectful
– Reassure patient that physical changes and emotional lability will resolve when hormone levels return to normal
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Audience Response QuesBon An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? a. “The medication prevents sodium and water retention after surgery.” b. “The drug prevent clots from forming in the legs during your recovery from surgery.” c. “This medicine is given to help your body respond to stress after removal of the adrenal glands.” d. “This drug stimulates your immune system and promotes wound healing.”
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Interprofessional Care –Surgical Therapy Cushing Syndrome
• Surgical removal of pituitary tumor using the transsphenoidal approach (see pg. 1158)
• Adrenalectomy –if caused by adrenal tumors or hyperplasia
INDICATIONS:
• Surgical removal or irradiation of pituitary adenoma
• Adrenalectomy for adrenal tumors or hyperplasia
• Removal of ACTH-‐secreting tumors
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Interprofessional Care Surgical Therapy Cushing Syndrome
• Meticulous care to prevent infection • Increased risk for:
– Problems with glycemic control – Susceptibility to infection – Delayed wound healing
SURGICAL THERAPY: Postoperative Care Ø Surgical site Ø IVF,I&O,F&E balance Ø NGT, FC, JP drains Ø Diet Ø Activity Ø VTE prophylaxis Ø Pain management Ø High doses of
corticosteroids are given IV during and several days after surgery
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Interprofessional Care Surgical Therapy Cushing Syndrome
15
Nursing Implementation
TEACHING NEEDS: (lack of endogenous corBcosteroids) • Home health nurse • Wear MedicAlert bracelet at all times • Avoid exposure to extremes of temperature,
infection, and stress • Teach patients about medication use and to monitor
for side effects • Teach how to adjust medication and when to call
health care provider • Lifetime corBcosteroid replacement therapy
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Interprofessional Care Surgical Therapy Cushing Syndrome
Patient Goals/Outcomes: • Experience relief of
symptoms • Experience no S&S infection • Avoid serious complications • Maintain positive self-‐image • Verbalize acceptance of
appearance and actively participate in therapeutic plan
• Maintain weight appropriate for height
• Heal skin wounds and maintain intact skin
Nursing Diagnoses: • Risk for
infection • Risk for
overweight • Disturbed body
image • Impaired skin
integrity Fall 2019 -‐ Spring 2020 17
GLAND: ADRENAL; HORMONE: CORTISOL
ETIOLOGY & PATHOPHYSIOLOGY: • Primary: caused by lack of
glucocorticoids, mineralocorticoids, and androgens
• Secondary: lack of pituitary ACTH, lack of glucocorticoids and androgens, mineralcorticoids rarely deficient
Addison’s Disease – HypofuncBon of the adrenal cortex from a primary cause. All 3 classes of adrenal corBcosteroids are reduced
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Addison’s Disease êGLUCOCORTICOIDS • Common causes:
– Autoimmune, antibodies destroy adrenal cortex
– Amyloidosis – Fungal infections – AIDS Metastatic cancer
• Iatrogenic Addison’s disease – Adrenal hemorrhage – Chemotherapy – Ketoconazole therapy for AIDS – Bilateral adrenalectomy
DIAGNOSTIC STUDIES: • ACTH SBmulaBon Test
• Baseline levels of cortisol and ACTH, IV injection of synthetic ACTH
• Levels rechecked after 30 and 60 minutes = ↑ Blood cortisol levels is normal
• Little or no ↑ in cortisol levels in Addison’s disease
• CRH SBmulaBon Test • Abnormal ACTH test
response • IV injection of synthetic CRH • Blood drawn after 30 and 60
minutes = High ACTH levels with no cortisol indicates Addison’s disease
• ↑ Potassium, ↑ BUN, ↓ Chloride, sodium, glucose
• Anemia • ECG changes • CT scan, MRI
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CLINICAL MANIFESTATIONS: General appearance: weight loss, emaciaBon Integumentary: bronzed/smokey hyperpigmentaBon of face, neck, hands (creases), buccal membranes, nipples, genitalia, and scars (if pituitary funcBon normal), viBligo, alopecia Cardiovascular: hypotension, vasodilaBon Gastrointes1nal: anorexia, n/v, cramping, abd pain, diarrhea Musculoskeletal: faBgue Immune: tendency for coexisBng autoimmune diseases Metabolic: hyponatremia, insulin sensiBvity, fever Emo1onal: depression, exhausBon or irritability, confusions, delusion
• Daily weight • Accurate I&O (FC) • Calm environment • Watch for signs of
Cushing syndrome
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Audience Response QuesBon
The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? a. The patient is alert and oriented b. The patient’s lung sounds are clear c. The patient’s urinary output increases d. The patient’s potassium level is 5.0 mEq/L
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Addison’s Disease Interprofessional Care
Patient teaching of dosing medications: • Glucocorticoids in divided doses • Mineralocorticoids once in the morning
– Reflects normal circadian rhythm – Decreases side effects of
corticosteroids • Need to increase corticosteroids during
times of stress Pa1ent Teaching: • Report signs and symptoms of
corticosteroid deficiency and excess to HCP
• Carry identification and wear medical ID bracelet
• Emergency kit • How to administer IM hydrocortisone • Written instructions