Endocrine – Adrenal Gland Part 1
Dec 23, 2015
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
• 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
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
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
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: 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 loss
Hypotension
Hypoglycemia
Fatigue
Hyperkalemia
Na+ & H20 retention Wt. gain
Hyperglycemia
Buffalo hump
Moon face
Hypokalemia
Hypofunction Hyperfunction
Usual tx Glucocorticoids
Meneralocorticoid
Restore fluid
Alter steroid Rx
Surgery
Nrs Dx Fluid volume deficit Fluid volume excess
Glucose 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:Medical Management / Surgical
• Treatment of choice is…– Surgery
• Stable a surgery• Adrenal gland
removed• BP
Pheochromocytoma:Pharmacological
• Phentolamine mesylate (Regitine)
• Nitroprusside sodium (Nipride)– HTN