Download the adrenal cortex

Endocrine Problems
Gail L. Lupica PhD, RN, CNE
Nurs 211
The Endocrine System


Although the nervous system is the dominant
controlling influence over the activities, and
responses of the body;
There is a secondary mechanism in place where one
cell can influence the function of other
cells, or target organs.
 This occurs through the secretion or
inhibition of hormones into the
bloodstream= The Endocrine System

The cells and glands of the endocrine system
each have very specific functions
and coordinate with other cells to create an
environment conducive to the
survival of the total organism.
The Diseases We’re Going to Look At
Anterior Pituitary:
• Hypersecretion of ACTH= Cushing’s Disease
(neoplasm of gland)
• Hypersecretion of Growth Hormone = Giantism
• Hypersecretion of Growth Hormone = Acromegaly
 Posterior Pituitary:
• Hypersecretion of ADH=SIADH
 Posterior Pituitary:
• Hyposecretion of ADH= DI

The Diseases We’re Going to Look At
Adrenal Cortex:
• Insufficient secretion= Addison’s Disease
 Adrenal Cortex:
• Acute adrenal insufficiency=Adrenal Crisis
 Adrenal Cortex:
• Hyperfunction= Cushing’s Syndrome
 Adrenal Medulla
• Hyperfunction=Pheochromocytoma

Pituitary Disorders

The pituitary gland plays a vital role in the
body’s ability to maintain homeostasis. Pituitary
disorders involve an excess or deficiency in one
or more of the pituitary hormones.
The Hypothalamus controls many
Pituitary functions. It signals to the
pituitary to release or inhibit hormone secretion.

The Pituitary gland (hypophysis)

Anterior (6 hormones are secreted by the
anterior pituitary)

1. ACTH: regulates secretion of
adrenal hormones (increases in
response to stress)

2. Growth hormone: has no specific
target organ.(promotes growth
 of bone/cartilage etc…)
 3. Thyroid stimulating Hormone


OB…

4. Follicle Stimulating Hormone: testes/ovaries

5. Luteinizing Hormone: testes/ovaries
6. Lactogenic Hormone (Prolactin):
breast dev/lactation


The Pituitary gland (hypophysis)
 Posterior

(these hormones are synthesized
 in the hypothalamus
 And stored in the posterior pituitary)




1. Anti-diuretic hormone (ADH): renal distal tubules
become more permeable to water, causing a reabsorbtion (also has
a vasopressor effect in high doses)
(alcohol inhibits ADH secretion)
2. Oxytocin: uterine/lactation/fertilization
3. Melanocyte stimulating Hormone
THE ADRENAL CORTEX:
• Regulation of Adrenal hormones is
accomplished through Adrenocorticotropic
hormone (ACTH, which is produced by the
anterior pituitary gland)
– (Aldosterone secretion is primarily accomplished
through the R-A-A system
THE ADRENAL CORTEX…:
• Is responsible for secretion of three major
groups of steroid hormones:
Mineralocorticoids (aldosterone): maintains
sodium, and fluid balance
Glucocorticoids (cortisol): provide the body
with the materials needed for energy; proteins,
fats, glucose, water
Androgens (testosterone): hyper secretion
can cause masculinizing changes



Adrenals

Adrenal glands are located just above each kidney.
 1. Adrenal cortex


2. Adrenal medulla
Although housed together, they are separate organs in
physiologic function. The adrenal medulla is
surrounded by the adrenal cortex.
Adrenal medulla
Produces
and Secretes catecholamines
1. Epinephrine
 2. Norepinephrine

Cushing’s disease
Cushing’s syndrome

Hypersecretion of ACTH.
(disease)
Hypersecretion of ACTH by the anterior
pituitary-causes increased release of both
cortisol and androgenic hormones

Hypersecretion of Cortisol.
(syndrome)
… too much cortisol secreted by the
adrenal cortex organ itself
Cushing’s- clinical manifestations
serum glucose levels increased ….(gluconeogenesis)
eventually the islet cells of the pancreas cannot produce
enough insulin and DM results.
 Loss of protein stores occurs, muscle wasting
 Humoral immunity is reduced, decreasing the
threshold to infection
 Skin tissues lose collagen, and become very thin: tearing
and bruising easily

Cushing’s disease
Cushing’s syndrome

Excess body and facial hair growth in women (from
excess androgen secretion)

Mood swings and psychosis may occur as the effect of
excess cortisol on cognitive function.

Truncal obesity: results from the mobilization of fat in
the lower parts of the body, to the trunk causing the
abdomen to become protuberant as the extremities become
thin and wasted.
Cushing’s disease
Cushing’s syndrome
 Purple
striae: appear on the abdomen as a
result of the stretching of the abdominal skin.
They’re purple due to the collagen deficit in
the tissues.
 Round
facial features: fat accumulation
around the neck and cervical area is termed
the buffalo hump.
3/4/10
Cushing’s management
Return cortisol levels to normal!
 So must determine the underlying cause of the
hypersecretion. Surgery to remove neoplasms.
 Physical therapy to improve muscle strength.

Cushing’s

Nursing Diagnoses
Risk for Infection R/T impaired immune response
and tissue repair
Risk of Altered Health Maintenance R/T insufficient
knowledge of disease process
Body Image Disturbance
Risk for Fluid and Electrolyte imbalance
Critical Thinking
1.
2.
3.
Explain to your patient why they can get
Cushingoid features from too much steroids,
from a tumor on their anterior pituitary OR from
hypersecretion from the adrenal cortex.
What causes all the excess hair growth and
acne on the patient with Cushingoid features?
What mechanism/feedback loop activates
aldosterone secretion from the adrenal cortex?
Under what circumstance(s)?
Hyper secretion of Somatotropin (Growth
Hormone) ACROMEGALY
rare condition.
• Excess secretion of somatotropin affects all actively growing
cells.
• It is characterized by an increase in connective tissue,
cartilage, and soft tissue, and by growth and thickening of the
bones in the hands feet and face.
• Glucose metabolism is altered and patients develop secondary
DM.
• Urinary excretion of Na+, K+, and phosphorous decreases so
fluid retention is a problem.
Hyper secretion of Somatotropin (Growth
Hormone) ACROMEGALY
o Neurologic changes
o Headaches
o Slow changes in appearance.
o Enlargement of ears, nose, and circumference
of chest.
o Arthritic changes in the joints of the long
bones and spine.
o Muscle weakness, osteoporosis.
•
ACROMEGALY
o Mandibular growth produces projection of
lower jaw.
o Hands and feet become wide
o Soft tissue changes.
o Cardiomegaly.
• Diagnosis:
o H&P, elevated serum growth hormone levels
• Treatment:
o Surgery
o Somatostat
Hyper secretion of Somatotropin (Growth
Hormone) GIGANTISM
• Hypersecretion of Growth Hormone (GH)
occurs before puberty…before closure of
growth plates.
• Growth proportional growth in the length of
all bones occurs.
Diabetes Insipidus






ADH is synthesized in the hypothalamus
and stored in the posterior pituitary
1. ADH: renal distal tubules become more
permeable to water, causing a reabsorbtion
(also has a vasopressor effect in high doses)
(alcohol inhibits ADH secretion)
Diabetes Insipidus (DI)
Anti diuretic hormone is suppressed
from the post pituitary. The patient
therefore diureses.
What will you see?
1. Copious urine output!
2. High serum sodium > 145 Why?
3. Low urine specific gravity 1.001-1.005 Why?
What kind of problems do you think would prompt
this?
DI- treat, Nsg Dx
Treat underlying cause
 May give exogenous ADH (nasally, IV, po)
 Give IV fluid resusitation/replacement
I&O

What is your PRIMARY Nursing Diagnosis?
Syndrome of Inappropriate Antidiuretic hormone (SIADH)
 Occurs
when there is over
secretion of ADH from the
posterior pituitary
ADH ADH ADH ADH ADH ADH ADH ADH ADH
ADH ADH ADH ADH ADH ADH ADH
ADH ADH ADH ADH ADH ADH ADH ADH ADH
ADH ADH ADH ADH ADH ADH ADH
ADH ADH ADH ADH ADH ADH ADH ADH ADH
ADH ADH ADH ADH ADH ADH ADH
SIADH

1.
2.
3.
4.
What will you see? The body is NOT
diuresing. Therefore fluid is reabsorbed into
the vascular space
Pt will be oliguric.
Serum sodium will be very low (< 135). Why?
Specific gravity of urine will be high. Why?
(Pt suffers from symptoms of a dilutional
hyponatremia)
Anterior Pituitary Disorders/ TUMORS
• TUMORS are the most common cause of
primary (anterior) pituitary disorders.
• The most common manifestation is headache.
…visual disturbances due to the expansion of the
mass on the optic nerve.
• The pituitary hormones may hyper secrete or
hypo secrete hormones.
Anterior Pituitary Disorders/ TUMORS
TREATMENT
• Transphenoidal microsurgery is an approach
through the mouth, and along the floor of the
nasal passage.
• The dura mater is incised and the abnormal
tissue is identified and removed. To prevent
CSF leakage, the dura mater may be patched
with a piece of fascia, or muscle taken from the
leg.
Transphenoidal microsurgery
• Pre-op
• Teach- Can’t sneeze, blow nose, cough,
bend over.
TREATMENT Transphenoidal microsurgery
• Post-op
ASSESS neoro staus q1h x 24h , then q4
• The nose is packed and a gauze dressing or
sling is worn under the
• Prophylactic antibiotics
o Diabetes Insipidus
o The patient may need lifelong hormone
replacement therapy.
o Monitor nasal drainage for HALO sign
TREATMENT Transphenoidal microsurgery
o Post-op nursing care is aimed at measures that
reduce ICP.
o Patient’s suture line is at the junction of the
gums and upper lip. Patients must avoid
trauma to the suture line- (Use a foam
toothette, instead of a bristled brush.)
Adrenocortical Insufficiency=Addison’s
disease
• Clinical Manifestations:
Skin color changes occur: hyperpigmentation
due to uninhibited ACTH release from the
anterior pituitary.
Muscle weakness& fatigue
Hypotension
Nausea, vomiting, weight loss, diarrhea
Loss of hair
Hypoglycemia
•
3/4/10
Adrenal crisis (Addisonian crisis, acute
adrenal insufficiency)
• A sudden decrease or absence of
adrenocortical hormones.
• Often occurs when a person is exposed to
major stresses, such as trauma, infection,
surgery, or major illness. (May be due to
hemorrhage, infection, or infarction within the
adrenal gland itself)
Adrenal crisis (Addisonian crisis, acute
adrenal insufficiency)
• Clinical Manifestations:
Severe dehydration Weakness
Confusion
Decreased sodium reabsorption, and increased
potassium retention
Circulatory deterioration
Hypovolemic shock: sodium, water, and
chloride are excreted in great amounts
Cardiac dysrhythmias
•
Adrenal crisis (Addisonian crisis, acute
adrenal insufficiency)
• Management:





Fluid replacement: Isotonic dextrose and saline
Parenteral Dextrose
IV Hydrocortisone
Monitor serum glucose, electrolytes
Hemodynamic and cardiac monitoring
• Eventual hormone replacement
Adrenal Medulla -
Pheochromocytoma
The function of the adrenal medulla is to
produce and secrete catecholamines.
 Epinephrine-80% (heart, BMR)
 Norepinephrine-20% (also secreted by
the sympathetic nerve terminals; arteriole
vasoconstriction)
Pheochromocytoma

They are rare adrenal medullary tumors whose
primary clinical manifestations is that of
hypertension.

They produce and secrete excessive
quantities of epinephrine and
norepinephrine into the bloodstream. The
individual remains in a fight or flight state.
Pheochromocytomaclinical manifestations







Arterial Hypertension
Excessive perspiration
Palpitations
Headaches
Hyperventilation
Flushing
Later: Cardiomegaly, LV failure, CHF
Pheochromocytoma
o
 o
 o
 o

H&P
Urinary catecholamines
Elevated blood glucose levels
CT, MRI of tumor


o
Diagnosis
Management
Surgical excision of tumors
Pheochromocytoma
Pre-op
Stimulant free diet
 Bedrest
 Regitine (alpha adrenergic blocker) and/or
Minipress
 Inderal


Post op
Monitor for Hypovolemic shock caused by rapid
relaxation of constricted blood vessels!
 Monitor for transient hypertensive episodes!

PheochromocytomaNursing Diagnoses
Risk for altered systemic tissue
perfusion R/T fluctuations in CV status

Anxiety R/T increased circulating
catecholamines

Altered Nutrition R/T increased metabolic
rate
 Risk for Altered health Maintenance
R/T insufficient knowledge of follow up care.
