Transcript ADRENAL GLANDS Adrenal Cortex Adrenal Medulla
ADRENAL GLANDS
Adrenal Cortex
Adrenal Medulla
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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
SUGAR con’t
Other functions of Cortisol
What happens to cortisol levels during stressful times?
What does it do to the inflammatory response?
What does it do the immune response?
Can you name some exogenous corticosteroids?
Exogenous Corticosteroids
Common **______________ **______________ **______________ **______________ Betamethasone (Celestone) Budesonide (Entocort EC) Cortisone (Cortone) Prednisolone (Prelone) Triamcinolone (Kenacort, Kenalog)
SALT
Mineralocorticoids (F & E balance)
Aldosterone
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 male characteristics
release of testosterone
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 the rest of day
Stress
- ____ cortisol production & secretion
HYPER & HYPO FUNCTION ADRENAL CORTEX HORMONES
Too much
Too little
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 is the normal serum K+ level?
Usually no edema
DIAGNOSIS Hyperaldosteronism urinary K
CT scan
EKG changes
Labs
plasma aldosterone & Na levels with low plasma renin levels
BP
Presence of hypokalemia with HTN – suspect CONNS
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
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 if not related to exogenous factors
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 carbohydrate 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
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
Clinical presentation is the first indication: truncal obesity “moon facies” – with plethora purplish red striae hirsutism menstrual disorders hypertension unexplained hypokalemia
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 or overly stressed 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
Low/undectable Normal Very High
Cortisol
Not suppressed Lack of suppression Adrenal Cushing syndrome is likely.
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
Urinary 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 - Lymphopenia Eosinopenia Glycosuria Osteoporosis Alkalosis
CT & MRI
Of what?
Looking for what?
- 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 directly suppresses adrenal cortex fx Others: Metyrapone blocks cortisol synthesis
&
Ketocenozole blocks cortisol sysnthesis
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
SIGNS & SYMPTOMS Addison’s Disease
Fatigue, weight loss, anorexia
Changes in skin pigment
small black freckles
Muscular weakness
SIGNS & SYMPTOMS Addison’s
Fluid & electrolyte imbalances
b.p.
Hyponatremia
Hyperkalemia
Hypoglycemia
SIGNS & SYMPTOMS Addison’s
androgens
hair loss, sexual fx
mental disturbances
anxiety, irritability, etc.
salt craving
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
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
Do you need to 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: __________________ __________________ __________________
Addison’sCAUSES
Name 4 causes
1. __________________________
2. __________________________
3. __________________________
4. __________________________
SIGNS & SYMPTOMS Addisonian Crisis
Dehydration Na, K, BP N/V,diarrhea, wt. loss
Weakness & fatigue
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
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ADRENAL MEDULLA
Fight or flight
What is released by the adrenal medulla?
CATECHOLAMINE RELEASE
Epinephrine Norepinephrine Be sure to know what each does.
Epinephrine
Regulates HR & BP inc. blood glucose stimulate ACTH stimulate glucorticoids inc. rate & force of cardiac contractions constricts blood vessels in skin, mucous membranes, & kidneys dilates blood vessels in skeletal muscles, coronary & pulmonary arteries
Norepinephrine
Increases HR & force of contractions Constricts blood vessels throughout the body
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/Treatment Pheochromocytoma
Primary goal?
Primary treatment?
Pre - op
Calcium channel blockers
Cardene
Sympathetic blocking agents
Minipress (
watch for orthostatic hypotension
)
Beta blocking agents
Inderal
INTERVENTIONS
Monitor b.p.
Eliminate attacks
If attack- complete bedrest and HOB 45 degrees
Interventions/Treatment Pheochromocytoma
Diet
high in vitamins, minerals, calories, no caffeine
Sedatives
Laparoscopic Adrenalectomy/ Open abdominal incision
DURING SURGERY
give
REGITINE
&
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?