Download Nursing Management Assessing The Patient

Management of Patients
With Adrenal Disorders
Dr. Belal M. Hijji, RN, PhD
Learning Outcomes
At the end of this lecture, students will be able to:
• Identify the composition and functions of the adrenal glands
• Discuss important aspects of common disorders of the adrenal
glands
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Introduction
• Two adrenal glands; each is two endocrine glands with
independent functions.
• The medulla secretes catecholamines; the cortex secretes steroid
hormones.
• The hypothalamus secretes corticotropin releasing hormone
(CRH). This stimulates the pituitary gland to secrete ACTH,
which stimulates the adrenal cortex to secrete glucocorticoid
hormone (cortisol).
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Catechol Group:
C6H4(OH)2
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Common Disorders of Adrenal Glands
• Pheochromocytoma
• Adrenocortical Insufficiency (Addison’s Disease)
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Pheochromocytoma
• Pheochromocytoma is a tumor that is usually benign and
originates from the adrenal medulla.
• Pheochromocytoma peak incidence is between ages 40 and 50
years.
• It affects men and women equally.
• Ten percent of the tumors are bilateral, and 10% are malignant.
• Pheochromocytoma is the cause of high blood pressure in
0.2% of patients with new onset of hypertension
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Clinical Manifestations
• The typical triad of symptoms comprises headache,
diaphoresis, and palpitations.
• Hypertension, tachycardia, tremor, flushing, and anxiety.
Hyperglycemia may result from conversion of liver and
muscle glycogen to glucose by epinephrine secretion.
• The patient may experience, vertigo, blurring of vision,
tinnitus, air hunger, and dyspnea, polyuria, nausea, vomiting,
diarrhea, abdominal pain, and a feeling of impending doom.
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Assessment and Diagnostic Findings
• Remember the “five Hs”:
– hypertension, headache, hyperhidrosis (excessive sweating),
hypermetabolism, and hyperglycemia.
– Absence of hypertension excludes diagnosis.
• Measurements of urine and plasma levels of catecholamines is
conclusive of pheochromocytoma. A number of medications
and foods (eg, coffee, tea, bananas, chocolate, vanilla, aspirin)
may alter the results.
• Instruct the patient to avoid restricted items.
• Total plasma catecholamine (epinephrine and norepinephrine).
• Minimise the stress resulting from venipuncture.
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Medical Management
• PHARMACOLOGIC THERAPY
– Alpha-adrenergic blocking agents (eg, phentolamine
[Regitine]) to lower the blood pressure quickly.
– An alpha-blocker ,Phenoxybenzamine (Dibenzyline),
which is an antagonist of alpha adrenergic receptors, may
be used when the blood pressure is stable to prepare the
patient for surgery.
• SURGICAL MANAGEMENT
– Adrenalectomy. Bilateral adrenalectomy may be necessary.
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Nursing Management
• Teaching Patients Self-Care
– Informs the patient about follow-up monitoring to ensure
that pheochromocytoma does not recur undetected.
– Instruct the patient about the purpose, the medication
schedule, and the risks of skipping doses or stopping the
administration of corticosteroids.
– Teach the patient and family how to measure the patient’s
blood pressure.
– Provide verbal and written instructions about collecting 24hour urine specimens for urine catecholamine.
Continued…..
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• Continuing Care
– A follow-up visit from a home care nurse may be useful.
The home care nurse also obtains blood pressure
measurements and assists the patient in scheduling the
patient for periodic follow-up appointments to record BP
and assess plasma and urine levels of catecholamines.
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Adrenocortical Insufficiency
(Addison’s Disease)
Pathophysiology
• Results when adrenal cortex function is inadequate to meet the
patient’s need for cortical hormones. Autoimmune or
idiopathic atrophy of the adrenal glands is responsible for 80%
of cases. Other causes include surgical removal of both adrenal
glands or tuberculosis.
• Inadequate secretion of ACTH from the pituitary gland also
results in adrenal insufficiency because of decreased
stimulation of the adrenal cortex.
• Therapeutic use of corticosteroids is the most common cause
of adrenocortical insufficiency
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Clinical Manifestations
• Muscle weakness, anorexia, gastrointestinal symptoms,
fatigue, emaciation, dark pigmentation of the skin due to
melanocyte-stimulating hormone, and hypotension.
• Mental status changes such as depression, apathy, and
confusion.
• The patient develops addisonian crisis, characterized by
cyanosis, pallor, apprehension, rapid and weak pulse, rapid
respirations, and low blood pressure.
• Headache, nausea, abdominal pain, diarrhea, confusion, and
restlessness.
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Assessment and Diagnostic Findings
• The diagnosis is confirmed by the clinical manifestations and
laboratory test results.
– Hypoglycemia, hyponatremia, hyperkalemia, and
leukocytosis.
– Low levels of blood or urine adrenocortical hormones and
↓ cortisol.
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Medical Management
• Hydrocortisone (Solu-Cortef) is administered intravenously,
followed with 5% dextrose in normal saline.
• Antibiotics may be indicated.
• Intravenous fluids are administered to prevent hypovolemia.
• If the adrenal gland does not regain function, the patient needs
lifelong replacement of corticosteroids and mineralocorticoids
to prevent recurrence of adrenal insufficiency.
• Glucocorticoids during stressful procedures or significant
illnesses to prevent addisonian crisis
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Nursing Management
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Assessing The Patient
Inadequate fluid volume by monitoring BP & P as the patient
moves from a lying to a standing position.
Skin color and turgor for changes related to chronic adrenal
insufficiency and hypovolemia.
Weight changes, muscle weakness, and fatigue.
Monitoring And Managing Addisonian Crisis
Monitor the patient for signs and symptoms of the crisis.
Administer intravenous fluid, glucose, and electrolytes,
replacement of missing steroid hormones; and vasopressors as
prescribed.
Maintain bed rest and meet patient’s needs.
Monitor symptoms, vital signs, weight, and fluid and
electrolyte status.
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Restoring Fluid Balance
Assess the patient’s skin turgor, mucous membranes, and
weight.
Instruct the patient to report increased thirst.
Assess lying, sitting, and standing blood pressures. A decrease
in systolic pressure (20 mm Hg or more) may indicate
depletion of fluid volume.
Encourage the patient to consume foods and fluids that will
assist in restoring and maintaining fluid and electrolyte
balance.
Instruct the patient and family to administer hormone
replacement as prescribed.
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Improving Activity Tolerance
Take precautions, until patient is stable, to avoid unnecessary
activity and stress that could precipitate another hypotensive
episode.
Detect signs of infection or the presence of other stressors.
Patients may not, even, tolerate minor stressors.
Explain all nursing procedures to the patient and family to
reduce their anxiety.
Increase activity gradually.
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