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ADRENAL GLANDS Adrenal Cortex Adrenal Medulla http://services.epnet.com/GetImage.aspx/getImage.aspx?ImageIID=7262 http://images.google.com/imgres?imgurl=http://media.medicalcentral.com/picAddisonD iseaseMouthuiowaedu.jpg&imgrefurl=http://www.diseasedisorder.com/diseasedisor derdefinitions/addisonsdisease.asp&usg=__V112XzFmfSG3kLrUzpEOx6SCgAI= &h=201&w=300&sz=12&hl=en&start=20&sig2=ncZQmF9qjo3yu4tCagesMg&tbnid =zWDvimGYUotJM:&tbnh=78&tbnw=116&prev=/images%3Fq%3Dchanges%2Bin%2Bskin %2Bpigmentation%2Bin%2Baddisons%2Bdisease%26gbv%3D2%26ndsp%3D18 %26hl%3Den%26sa%3DN%26start%3D18&ei=3vLlSczAA5auMcblqe0J ADRENAL CORTEX Sugar Salt Sex SUGAR GLUCOCORTICOIDS (regulate metabolism & are critical in stress response) – CORTISOL responsible for control and & metabolism of: a. CHO (carbohydrates) --- Regulation of blood glucose concentration - inc thru gluconeogenesis - dec use during fasting SUGAR con’t - Cortisol b. FATS-control of fat metabolism - stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism – stimulates protein synthesis in liver – protein breakdown in tissues How much per day? SUGAR con’t Other functions of Cortisol – What does it do to the inflammatory response? – What does it do the immune response? Exogenous Corticosteroids **______________ **______________ **______________ **______________ ______________ ______________ ______________ ______________ ______________ SALT Mineralocorticoids (F & E balance) What stimulates aldosterone secretion? What inhibits adlosterone secretion? Na retention Water retention K excretion Hydrogen ion excretion Question: If your Na level is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion or SEX ESTROGENS ANDROGENS – hormones which characteristics release male of testosterone Do women produce androgens? RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ______ LET’S LOOK AT ACTH (adrenocorticotropic hormone) Produced where? ACTH Circulating levels of cortisol – levels cause __________ of ACTH – levels cause __________ of ACTH think tank: What type of feedback mechanism is this?? AFFECTED BY: Individual biorhythms – ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. – usually 5AM - 7AM – these gradually decrease rest of day Stress- ____cortisol production & secretion HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES Too much Too little II. HYPERALDOSTERONISM “Conn’s Syndrome” Too much aldosterone secretion Question: – What does aldosterone do???? _____________________________ usually caused by adrenal tumor SIGNS & SYMPTOMS Hyperaldosteronism Na and water retention – What s/s would you expect? What is the normal serum K+ level? – What s/s would you expect? Usually no edema – Why? DIAGNOSISHyperaldosteronism urinary K CT scan EKG changes plasma aldosterone & Na levels with low plasma renin levels INTERVENTIONS Hyperaldosteronism BP – What drugs would you give? Correct hypokalemia/hypernatremia – What you would you do? Partial or total adrenalectomy ADRENALECTOMY PRE-OP Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol levels before or after surgery? ADRENALECTOMY POST-OP ICU-What type of problems to expect?? – IV cortisol for 24 hours – IM cortisol 2nd day – PO cortisol 3rd day Possible hypo/hyperkalemia – What are some s/s of this? – What would an ekg look like for hypokalemia? If unilateral- steroids weaned Cushing Syndrome vs Cushing’s Disease CUSHING’S DISEASE (TOO MUCH CORTISOL!) secretion of cortisol 4X more frequent in females Usually occurs at 20-40 years of age ETIOLOGY Cushing’s Cushing’s Disease – _____________________ Cushing Syndrome – _____________________ – _____________________ – _____________________ SIGNS & SYMPTOMS Cushing’s protein catabolism – muscle wasting – ****loss of collagen support – poor wound healing SIGNS & SYMPTOMS Cushing’s Electrolyte imbalances – Which ones? s in CHO metabolism – Hyperglycemia Why? SIGNS & SYMPTOMS Cushing’s s in fat metabolism – ****abdomen aka: _________ – cervical spine aka: _________ – ****face aka: _________ SIGNS & SYMPTOMS immune response – More prone to infection – resistance to stress Common cause of death? Before After What sign would the nurse identify in each patient? SIGNS & SYMPTOMS mineralocorticoid activity – ________ retention _______ retention – What happens to blood pressure? SIGNS & SYMPTOMS MENTAL CHANGES Mood swings Euphoria Depression Anxiety Mild to severe depression Psychosis Poor concentration and memory Sleep disorders SIGNS & SYMPTOMS s in hematology WBCs lymphocytes eosinophils DIAGNOSIS of Cushing’s 24 hr urine collection for ‘free cortisol’ – How do you do this? – What levels would diagnosis Cushing? (When results are borderline…..dexamethasone suppression test) Dexamethasone suppression test – false positive can occur in depressed pts Serum cortisol levels – What will serum cortisol levels be? – Draw AT 8AM AND 8PM What would you expect? High Dose Dexamethasone Suppression Test ACTH Cortisol Low/undectable Not suppressed Adrenal Cushing syndrome is likely. NormalVery High Lack of suppression Ectopic ACTH syndrome is likely. If an adrenal tumor is not apparent, a chest CT and abdominal CT is indicated to rule out a different tumor secreting ACTH Normal - Elevated Is suppressed Cushing’s disease should be considered. A pituitary MRI would be needed to confirm Markers of Adrenal Cortex function 17-hydroxycorticosteroids (17-OHCS) 17-ketosteroid sulfates (17-KS-S) DIAGNOSIS of Cushing’s Plasma ACTH levels – Low, normal or elevated? Other labs associated with Cushing’s – – – – – Leukocytosis Eosinopenia Glycosuria Osteoporosis Alkalosis CT & MRI – Of what? – Looking for what? - Lymphopenia - Hyperglycemia - Hypercalcemia - ****Hypokalemia TREATMENT of Cushing’s Primary goal: – What do you think? – Treatment related to underlying cause!!!!! TREATMENT of Cushing’s Surgery transsphenoidal -removal of pituitary tumor ectopic ACTH secreting tumor -try to remove source of ACTH secretion adrenalectomy -can be unilateral or bilateral -if bilateral, need hormone replacement for life -Laproscopic vs Open Surgical TREATMENT of Cushing’s Radiation to tumors – Why would one choose radiation? Palliative drugs – Goal of drug therapy? – MITOTANE destroys tissue in adrenal cortex TREATMENT of Cushing’s What if Cushing Syndrome is result of exogenous corticosteroids? REVIEW: WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHING’S? Nursing Diagnosis Risk for infection Imbalanced nutrition more than requirements Risk for injury…inc muscle wasting Disturbed body image Impaired skin integrity Fluid volume excess ADDISON’S DISEASE hypofunction of adrenal cortex What hormones will you have too little of??? glucocorticoids or _______ mineralocorticoids or _______ androgens or ____________ Trivia Question: Which famous President had Addison’s Disease??? ETIOLOGY of Addison’s Idiopathic atrophy –autoimmune condition Antibodies attack against own adrenal cortex –90% of tissue destroyed ETIOLOGY of Addison’s Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes – adrenalectomy, chemo, anticoagulant tx SIGNS & SYMPTOMS Addison’s Disease fatigue, weight loss, anorexia – Why? think of cortisol fx Changes in skin pigment – small black freckles – Why? Muscular weakness – Why? SIGNS & SYMPTOMS Addison’s Fluid & electrolyte imbalances – WHY? b.p. – WHY? Hyponatremia-why? Hyperkalemia-why? Hypoglycemia-why? SIGNS & SYMPTOMS Addison’s androgens – hair loss, sexual fx mental disturbances – anxiety, irritability, etc. salt craving-why? DIAGNOSIS-Addison’s ____serum cortisol ____urinary 17-OHCS and 17 KS ____K ____Na ____serum glucose ____plasma ACTH ____urine free cortisol INTERVENTIONS Addison’s Disease Life long hormone replacement – primary-need_______________ 20-25mgs in AM & 10-12mg in PM Why different doses? – When might one need to increase the dose? – also need mineralocorticoid(FLORINEF) INTERVENTIONS Salt food liberally Do not fast or omit meals Eat between meals and snack Eat diet high in carbs and proteins Wear medic-alert bracelet kit of 100mg hydrocortisone IM INTERVENTIONS Addison’s Disease Keep parenteral glucocorticoids at home for injection during illness Avoid infections/stress COMPLICATIONS Addison’s Disease Adrenal crisis Electrolyte imbalance Hypoglycemia ADDISON’S CRISIS Sudden decrease or absence of adrenal cortex hormones which are: __________________ __________________ __________________ CAUSES Name 4 causes – 1. __________________________ – 2. __________________________ – 3. __________________________ – 4. __________________________ SIGNS & SYMPTOMS Addisonian Crisis DehydrationNa, K, BP N/V,diarrhea, wt. loss Weakness Confusion,headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH Question If an EKG were performed on a client in Addisonian Crisis, what would you expect to see? TREATMENT Addisonian Crisis Rapid infusion of IV fluids – What IV fluids will be used? Check VS & UO frequently – Why? Monitor EKG Treat hyperkalemia – How? Give Solu-Cortef IV Q6 hours until S & S disappear TREATMENT Try to anxiety May have to give vasopressors – Dopamine or Epinepherine Avoid additional stress Adrenal Medulla http://images.google.com/imgres?imgurl=http://media.medicalcentral.com/picAddisonD iseaseMouthuiowaedu.jpg&imgrefurl=http://www.diseasedisorder.com/diseasedisor derdefinitions/addisonsdisease.asp&usg=__V112XzFmfSG3kLrUzpEOx6SCgAI= &h=201&w=300&sz=12&hl=en&start=20&sig2=ncZQmF9qjo3yu4tCagesMg&tbnid =zWDvimGYUotJM:&tbnh=78&tbnw=116&prev=/images%3Fq%3Dchanges%2Bin%2Bskin %2Bpigmentation%2Bin%2Baddisons%2Bdisease%26gbv%3D2%26ndsp%3D18 %26hl%3Den%26sa%3DN%26start%3D18&ei=3vLlSczAA5auMcblqe0J ADRENAL MEDULLA Fight or flight What is released by the adrenal medulla? CATECHOLAMINE RELEASE Epinephrine Norepinephrine Hyperfunction of the Adrenal Medulla PHEOCHROMOCYTOMA rare, benign tumor of the adrenal medulla oh no...what are we going to see a hypersecretion of???? SIGNS AND SYMPTOMS Pheochromocytoma What do you think is the hallmark sign? Paroxymal attacks**** – NE and Epinepherine released sporadically Attacks may be provoked by meds – antihypertensives, opioids, contrast media If untreated DM, cardiomyopathy, death – Why? SIGNS & SYMPTOMS Pheochromocytoma Deep breathing Pounding heart Headache Moist cool hands & feet Visual disturbances DIAGNOSIS Pheochromocytoma Often missed 24 hour urine – fractionated metanephrines – fractionated cathecholamines – creatinine – Are these increased or decreased? Plasma catecholamines – When are these drawn? – Are these increased or decreased? CT to locate tumor INTERVENTIONS-PRE-OP Adrenergic blocking agents – Minipress to Beta blocking agents – Inderal to bp hr, b.p., & force of contraction Diet – high in vitamin, mineral,calorie, no caffeine Sedatives INTERVENTIONS Monitor b.p. Eliminate attacks If attack- complete bedrest and HOB 45 degrees Laparoscopic Adrenalectomy/ Open abdominal Incision DURING SURGERY GIVE REGITINE AND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS POST-OP b.p. may be initially, – BUT CAN BOTTOM OUT Volume expanders Vasopressors Hourly I and O Observe for hemorrhage QUESTION?? What if you are not a candidate for surgery? – Demser (drug which inhibits catecholamine synthesis) Avoid opiates, histamines, reglan, anti-depressants. Why? Now Let’s Practice Some Questions….
