ADRENAL EXCESS DISORDER

Overview of Adrenal Gland Adrenal cortex – outer shell Mineralocorticoids – Aldosterone Glucocorticoids – Cortisol Secondary sex hormones – Androgens

and estrogens

Adrenal medulla – inner core works as part of the sympathetic nervous system

•Produces epinephrine and norepinephrine

Cushing’s disease & Cushing’s syndrome

Risk Factors: Endogenous (Cushing’s disease) Adrenal hyperplasia Adrenocortical carcinoma Carcinoma of the lungs, GI tract, or

pancreas, pituitary carcinoma

Exogenous (Cushing’s syndrome) Organ transplant Chemotherapy Autoimmune diseases Asthma Allergies Chronic inflammation diseases

Cushing’s Disease (endogenous) increased secretion of cortisol

caused by increased amounts of ACTH secreted by pituitary gland.

Cushing’s syndrome (exogenous) resulting from chronic and excessive

production of cortisol by adrenal cortex or administration of large doses

Signs and Symptoms:Moon faceBuffalo humpTruncal obesityWeakness FatigueBack and joint pain Irritability or depressionThin, fragile skinBruising and petechiaeHypertensionTachycardiaWeight gainDependent edema

Diagnostics: H&P examMental status examPlasma cortisol levels,Plasma ACTH levelCBC, WBC, Blood chemistries for sodium, potassium, glucoseDexamethasone suppression test 24-hr urine for free cortisol CT scan, MRI.

Collaborative care:Decrease sodium intake, increase intake of potassium, protein, calciumMonitor intake output, daily weightAssess signs of hypervolemiaSkin care, protect against skin breakdown and infectionMedications: Aminoglutethimide (Cytadren), ketoconazole (Nizoral)ChemotherapyHypophysectomy – removal of pituitary glandAdrenalectomy – removal of the adrenal gland

Addison’s DiseaseAdrenocortical insufficiency caused by damage of the adrenal cortexDecreased aldosterone and cortisol

Adrenal crisis (medical emergency) – acute adrenal insufficiency, caused by sepsis, trauma, stress, adrenal hemorrhage, steroid withdrawal

Risk Factors: Primary - autoimmune dysfunction, TB,

hystoplasmosis, adrenalectomy, cancer Secondary – steroid withdrawal,

hypophysectomy, pituitary neoplasm

Signs and Symptoms:HyperpigmentionWeakness and fatigueNausea and vomitingDizziness with orthostatic

hypothension Severe hypotensionDehydrationHyperkalemiaHypglycemiahypercalcemia

(ATI Nursing Education)

Diagnostics:H&P examPlasma cortisol levelUrine cortisol and aldosterone levels Serum electrolytesACTH-stimulate testCT scan, MRIECG, XRAY, CT

http://www.youtube.com/watch?v=qfC2te9Unbw

Collaborative Care: Monitor fluid deficits Administer prescribed

hydrocortisone, continuous infusion of boluses

Treat hypercalemiaTreat Hypoglycemia

Medications : hydrocortisone (Cortef),

Prednisode, cortisone Fludrocortisone (Florinef)

Hyperaldosteronism Characterized by excessive aldosterone secretion. Hallmark disease – hypertension with hypokalemic alkalosis. Primary hyperaldosteronism (PA) – caused by small solitary adrenocortical adenoma. Secondary hyperaldosteronism– occurs in response to a nonaderenal cause and elevated aldosterone levels such as renal artery.

Risk factors : Age 30 -50 y.o. renal artery stenosis renin-secreting tumorsChronic kidney disease

Signs and symptoms: HypernatremiaHypertensionHeadacheMuscle weakness, FatigueCardiac dysrhythmiasGlucose intoleranceMetabolic alkalosisTetany

Diagnostic: CT , MRI18 hydroxycorticosterone- (50ng/dL)

Treatment: Adrenalectomy – 80% control HTNPotassiumCalcium channel blockerPotassium sparing diuretic

(cytaren)dexamethasone

PheochromocytomaA tumor of the center of the adrenal gland and medulla Excessive catecholamines (epinephrine, norepinephrine10% - malignantSevere hypertension

Risk factors: NeurofibromatosisMultiple endocrine neoplasia syndromeAge 40 – 60 y,o

Signs and symptoms: Pain in chest/abdominalHypertensionHeadachesDiaphoresisPalpitationsHeat intoleranceTremorsApprehension

Laboratory test: Vanillymandelic acid (VMA) testing – 24 hr.

urine collectionVMA normal level 2 to 7 mg/24hr.

Diagnostic procedures:Clonidine suppression test Administration of phenotolamine (Regitine)

Treatments: Alpha adrenergic blockers –

prazosin, phenoxybenzmineBeta blockers – metoprolol

(Lopressor)Glucocorticoids – Prednisone

(Deltasone)Adrenalectomy surgery –

complications of hypertensive crisis

NCLEX QUESTION #1 A client is diagnosed with pheochromocytoma. A nurse prepares a plan of care for the client; while planning, the nurse understand that pheochromocytoma is a condition that:

1. causes profound hypotension

2. is manifested by severe hypoglycemia

3. is not curable and is treated symptomatically

4. causes the release of excessive amounts of catecholamines

Answer: 4 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver.

NCLEX QUESTION #2 A nurse is providing discharge instructions to a client who has Cushing’s syndrome. Which client statement indicates that instructions related to the dietary management are understood?

1. “I can eat food that have a lot of potassium in them.”

2. “I will need to limit the amount of protein in my diet.”

3. “I am fortunate that I can eat all the salty foods I enjoy.”

4. “I am fortunate that I do not need to follow any special diet.”

Answer: 1Rationale: A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing’s syndrome. Such diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.

NCLEX QUESTION #3 A nursing instructor asks a student to be describe the pathophysiology that occurs in Cushing’s disease. Which statement by the student indicates and accurate understanding of this disorder?

1. “Cushing’s disease results from an oversecretion of corticotropic hormones.:

2. “Cushing’s disease results from an undersecretion of mineralocorticoid hormones.”

3. “Cushing’s disease results from an undersecretion of mineralocorticoid hormones.”

4. “Cushing disease results from an increased pituitary secretion of adrenocorticotropic hormone.”

Answer: 4 Rationale: Cushing’s disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison’s disease is hypo secretion of adrenal cortex hormones from the adrenal gland.

NCLEX QUESTION #4 A nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. IN the preoperative period, the priority nursing action would be to monitor:

1. Vital signs

2. Intake and output

3. Blood urea nitrogen results

4. Urine for glucose and ketones

Answer: 4 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches.

NCLEX QUESTION #5 A nurse is performing an assessment on a client with pheochromocytoma. Which of the following assessment data would indicate a potential complication associated with this disorder?

1. A coagulation time of 5 minutes

2. A urinary output of 50 mil per hour

3. A blood urea nitrogen level of 20 mg/dL

4. A heart rate that is 90 beats/min and irregular

Answer: 4 Rationale: the complications associated with pheochromocytoma include hypertensive retinopathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias or dissection aortic aneurysm.

References Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing, assessment and management of clinical problems. (8th ed., Vol. 2, pp1430-1433 &1276-1284). St. Louis, MO: Mosby Inc.

RN Adult Medical Surgical Nursing Review Module Edition 8.0 pages 1066-1091

Silvestri, L. A., (2012). Saunders Q&A review for the NCLEX-RN examination. (5th ed.)St. Louis, MO: Elsevier Inc.

Vicennati, V., Repaci, A., di Dalmazi, G., Rinaldi, E., Golfieri, R., Giampalma, E., & ... Pasquali, R. (2012). Combined Aldosterone and Cortisol Secretion by Adrenal Incidentaloma. International Journal Of Surgical Pathology, 20(3), 316-319. doi:10.1177/1066896911427036

Terzolo, M. M., Pia, A. A., & Reimondo, G. G. (2012). Subclinical Cushing's syndrome: definition and management. Clinical Endocrinology, 76(1), 12-18. doi:10.1111/j.1365-2265.2011.04253.x

http://www.youtube.com/watch?v=qfC2te9Unbw