Adrenal Gland• Cortex

– Glucocorticoids• Cortisol

– Affects carbohydrate metabolism (raises blood sugar in times of stress)

– Mineralocorticoids• Aldosterone

– Maintains normal salt and water balance by action on the kidneys

– Androgens• Sex hormones

2

Disorders of the Adrenal Gland

• adrenal medulla• epinephrine and norepinephrine

• adrenal cortex• mineralocorticoids, glucocorticoids,

adrogens• stimulated by ACTH by the anterior

pituitary gland

stress importance of ACTH

Notes

4

adrenal cortex

• mineralocorticoids• aldosterone

• secreted when blood pressure is low it moves sodium and water from renal tubules to the blood

• this increases blood pressure and blood volume

potassium is excretedregulates water and sodium balance

Notes

6

adrenal cortex

• glucocorticoids• cortisol-most prevalent

• breaks down stored glycogen and increases the amount of glucose in the blood.

• strong anti-inflammatory affect

cortisol is given and known as steroids. these can mimic the effects of glucocorticoids.

Notes

8

adrenal cortex

• androgens• male sex hormones

Adrenal Gland

• Cushing’s syndrome–Disorder of adrenal cortex

• Produces excessive amounts of cortisol• Affects women more than men• Ages 20-50

overstimulation of ACTH or by prolonged administrations of corticoids,

Notes

Cushing’s

• Causes– Adrenal tumors

• Increase production of cortisol– Tumor of pituitary gland

• Increases ACTH release which stimulates adrenal cortex to produce cortisol

– Chronic glucocorticoid therapy– Increased ACTH release from lung or

pancreatic tumors

ACTH comes from anterior pituitary. Glucocorticoids are drugs such as prednisone, it is frequently prescribed for resp. pats. To decrease inflammation, also for transplant pts. Or rheumatoid arthritis.hypersecretion

Notes

Cushing’s

•With increased (hyper) secretion of cortisol– Fat deposits in abdomen, under clavicle,

“buffalo hump” over the upper back, round moon face

– Altered protein metabolism• Muscle weakness, wasting in extremities

– Stress hormone

Pts. Gain weight. Weight gain is seen in trunk and face. Limbs are generally spared excess sweating, thinning of the skin. Which causes bruising and dryness and mucous membranes. Purple stiae (weight gain stretches the skin and is becomes thin and weakened it then has small capillaries hemorrhage. Can develop hypercalcemia which can lead to skin necrosis. Hypercalcemia leads to osteoporosis and compression fractures. Cortisol can affect other endocrine systems such as mineralocorticoid and adrogen. This result in sodium and water retention, which can lead to hypertension. Increase in adrogens can reslut in amenorrhoea and infertility. High blood sugar from insulin resistance. Which can result in diabetes mellitus. Untreated it can lead to heart disease. Think of cortisol as a stress hormone. So it impairs wound healing and depresses inflammatory response. See page 349 Burke.

Excess cortisol secretions result in sodium and water retention. This causes fluid volume excess and wt gain. Sodium and water retention causes htn, bounding rapid pulse. Dependent edema, wheezes crackles.

arms and legs become thin as a result of muscle wastehyperglycemia due to glucose intolerance susceptible to infections but the symptoms may be masked .

Notes

Cushings

• If left untreated can result in hypertension hypernatremia, hypokalemia, elevated blood sugar, heart failure

Hypertension from increased cortisol and stress. Heart failure again from stress affects. Hypernatremia from affects on mineralocorticoid, hypokalemia from affect of mineralocorticoid. Htnfrom increased water and sodium retention.

Notes

Cushing’s

• Diagnosis– Increased plasma cortisol level and elevated

24 hour urine test for 17-ketosteroids, and 17-hydroxycortiocosteroids.

– Plasma ACTH levels are elevated when Cushing’s is caused by pituitary tumor

– Serum glucose and sodium levels are elevated.

Cushing’s

• Medications– Used when cushing’s syndrome is caused by

inoperable pituitary or adrenal tumor• Mitotane (Lysodren) suppresses activity of the

adrenal cortex• Metyrapone and aminoglutethimide (Cytadren)

inhibit cortiosol synthesis by the adrenal cortex

diet low in sodium for hypernatremia, reduced calories and carbohydrates for hyperglycemia,

Notes

Cushing’s syndrome

• Nursing considerations– Body image, infection, injury, fluid and

electrolyte imbalance.

Cushing’s

Monitor for side effects of medicationscaused by decreased adrenal function

such as anorexia, nausea, vomiting, and diarrheaSevere side effects include hypotension and tachycardiaClient is at risk for severe infections related to suppressed immunity.

Also patient is at risk for severe infections can be life threatening.

Notes

Cushing’s

• Treatment– If caused by tumor and adenalectomy is done

• Usually only one adrenal gland is involved• if both are removed the client is required to take

lifelong corticosteroid and mineralocorticoid replacement therapy.

• ICU– Monitor for Addison’s

Cushing’s

• Surgical removal of pituitary gland is indicated when the disease is caused by pituitary tumor.– Hypophysectomy

• Radiation therapy– If inoperable brain tumor causing Cushing’s

• Radioactive isotopes implanted

do not abruptly discontinue corticoids as this can lead to addison’s

Notes

Addison’s disease

• Primary– Adrenal Cortex undersecretion (hypofunction)

• Secondary– Undersecretion of pituitary ACTH

Addison’s disease

• Occurs more frequently in women under the age of 60– Primary addison’s is an automimmune

response destroys client’s own adrenal cortex• Leads to reduced glucocorticoids, mineralcorticoids,

and androgens• Slow onset and manifestations occur when more

than 90% of your gland is destroyed.

Addisonian Crisis

• Aka adrenal crisis– Serious life threatening response to acute

adrenal insufficiency. • Major stressors precipitate this condition

– Surgery, trauma, severe infections • Abrupt withdrawal of corticosteroid medications

Addisonian Crisis

• Monitor client for hypotension, rapid weak pulse, extreme weakness, confusion resulting from circulatory collapse and shock.

• Client is managed in ICU for IV fluids, glucose, NA and glucocorticoids. – Keep warm and quiet.

K levels can reach dangerously high levels. This can lead to cardiac dysrhytmias. Client has fluid volume deficit, resulting from water and NA loss from bvomiting and diarrhea. This can lead to hypovolemic shock. Increase oral fluids. Pt is hyponatremic.

Notes

Addison’s disease

• Treatment– Cortisol replacement

• Can induce Cushing’s syndrome– Mineralocorticoid replacement

• Fludrocortisone (Florinef)– Hydrocortisone is given PO to replace cortisol– During crisis (surgery, serious illness, or

trauma) may need increased corticosteroids or mineralocorticoids.

Adrenal Medulla

• Pheochromocytoma– Benign tumor of the adrenal medulla

• Adults 40-50 years of age• Erratically produces excessive amounts of

catecholomines– Stimulate SNS

Pheochromocytoma

• Increased SNS– B/P 200-300 systolic and a diastolic greater

than 150. – Pounding headache– Tachycardia– Profuse sweating– Flushing– Palpitations

Pheochromocytoma

• If left untreated can lead to MI and stroke– Pt. in ICU– Life threatening

Bring down the b/p. Hemodynamic monitoring, iv antihypertensive

Notes

Pheochromocytoma• Diagnosis

– Increased catecholamine levels in blood or urine

– CT scan– MRI

Pheochromocytoma

• Treatment to remove tumor– May need adrenal hormone replacement

therapy– May require antihypertensives

Review

• What clinical manifestation can the nurse expect with Addison’s disease?– Multiple bruises– Postural hypotension– Peripheral edema– SOB

Notes

With lack of mineralocorticoid aldosterone, blood volume and blood pressure are lower which results in postural hypotension. Multiple bruises are noted in Cushing’s peripheral edema and SOB are not found in addisons.