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54 Cards in this Set

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Adrenal Cortex: 3 kinds of steroid hormones
*Glucocorticoids (cortisol)
*Mineralcorticoids (aldosterone)
*Androgens (testosterone & estrogen)
Adrenal glands secrete hormones which help regulate
*chemical balance
*metabolism
*and supplement other glands
Etiology & pathophysiology of excess glucocorticoids
*Primarily women 20-40 years old
*Called Cushing's Syndrome
*Clincal picture caused by excess corticosteroids, particularly gluccocorticoids
Cushing syndrome = increased adrenocortical activity
? Etiology
*Excessive administration of cortisone or ACTH (primary cause = Iatrogenic)
*Tumor of pituitary (ACTH secreting - Cushings)
*Adrenal adenocarcinoma
Other causes
*Primary hyperplasia of adrenals in absence of tumor
*Hypothalamic-pituitary dysfunction
*Excessive ACTH secretion from lung or other malignant carcinoma
Clinical Manifestations
*See handout
*May develop gradually or rapidly
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Promotes gluconeogenesis
Increased Effect:
*increased blood glucose level
Decreased Effect:
*hypoglycemia
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Increases protein metabolism
-inhibits protein synthesis
-enhances protein catabolism
Increased Effect:
*muscle atrophy
*fatigue, weakness
*gout
Decreased Effect:
*weight loss
*fatigue
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Anti-inflammatory action and increased capillary fragility
Increased Effect:
*slow wound healing
*enhanced susceptibility to infection
*ecchymosis, bruising
Decreased Effect:
*vasodilation
*decreased blood pressure
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Influences your emotional being. Serves as stress buffer.
Increased Effect:
*euphoria
*can easily tolerate stress
Decreased Effect:
*depressed
*irritable
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Thins gastric mucosa
Increased Effect:
*gastritis, ulcers
Decreased Effect:
*anorexia
*nausea, vomiting
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Increases blood viscosity; increases platelets
Increased Effect:
*increased incidence of thrombosis
Decreased Effect:
*anemia
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Increases Ca+ release from bones
Increased Effect:
*osteoporosis, fractures, kidney stones
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Increase cholesterol
Increased Effect:
*hypercholesteremia
*premature atherosclerosis
*can lead to possible MI or stroke
Adrenal Cortical Functions: Effects of Glucocorticoids (Cortisol): Increases periperal fat mobilization
Increased Effect:
*moon face
*buffalo hump
*truncal obesity with slender limbs
Adrenal Cortical Functions: Effects of Mineralcorticoids (Aldosterone): Reabsorption of Na+ and Cl-
Increased Effect:
*increased Na+
Decreased Effect:
*decreased Na+ and Cl-
Adrenal Cortical Functions: Effects of Mineralcorticoids (Aldosterone): K+ excretion
Increased Effect:
*edema with increased blood pressure
Decreased Effect:
*increased K+
Adrenal Cortical Functions: Effects of Mineralcorticoids (Aldosterone): H2O reabsorbed (with Na+)
Increased Effect:
*hypokalemia (weakness)
Decreased Effect:
*H2O loss in urine (hypovolemia)
Adrenal Cortical Functions: Effects of Sex Hormones: Androgen (testosterone)
In Males:
*masculinity
In Females:
*influences sexuality and libido
Adrenal Cortical Functions: Effects of Sex Hormones: Estrogen
In Males:
*contributes little
In Females:
*post-menopausal--adrenal cortex is major source of estrogen
Sophie Cushing
*Thinning hair
*Moon face, Flushed face
*Hirsutism - excessive growth of hair or the presence of hair in unusual places
*Mood swings
*Supraclavicular fullness
*Thinning extremities
*Spontaneous ecchymosis - a bruise, that is, superficial bleeding under the skin or a mucous membrane
*Truncal obesity
-Pink striae (stretch marks0
*Generalized edema
*Cervicodorsal fat pad (buffalo hump)
*Produces androgens - sex hormones
*Protrubend abdomen
*Psychosis
Cushing's Syndrome: Diagnosis
*Lab findings
-hyperglycemia, glycosuria, hypernatremia
-hypokalemia, granulocytosis (abnormal increase in the number of granulocytes in the blood), lymphocytopenia (a deficiency of lymphocytes in the blood), eosinopenia (an abnormally small number of eosinophilic cells in the peripheral blood) & alkalosis (an actual or relative increase in blood alkalinity) w/ adrenal carcinoma
-Low ACTH w/ exogenous etiology
-High or normal ACTH w/ Cushing's Syndrome
-24 hour urine for free cortisol & dexamethasone suppression test - see test handout
-Plasma cortisol may be elevated
Adrenal Studies: Cortisol
Description and Purpose
-Measures amount of cortisol in serum and evaluates status of adrenocortical function
Nursing Responsibility
-Inform client that blood sample will be taken. Observe venipuncture site for blooding and hematoma formation. Ensure collection of properly timed blood sample. Draw specimen early in morning when cortisol levels are highest. Mark time on laboratory slip. Minimize stress to avoid raising level.
Adrenal Studies: Aldosterone
Description and Purpose
-Normal values are 5-20 ng/dl (upright position) and 8.5 ng/dl (supine position)
Nursing Responsibility
-Increases with low-salt diet (less than 2g/day), stress, an upright posture, and diuretics; decreases with a high-salt diet, ACE inhibitors such as captopril, and lying in supine position. Determine which maneuvers will be done and advise client.
Adrenal Studies: ACTH (adrenocorticotropic hormone) stimulation
Description and Purpose
-Used to evaluate adrenal function. After baseline samples are drawn, 250µg synthetic ACTH is given as IV or IM bolus; samples are drawn 30 and 50 minutes after bolus. Baseline ACTH sample is often drawn in case results are abnormal. Plasma cortisol at 60 minutes should be (1) greater than baseline and (2) greater than 20µg/dl
Nursing Responsibility
-Inject ACTH with a plastic syringe and collect samples for ACTH in plastic, heparinized tubes. Administer test with continuous-infusion method. Monitor site and rate of IV infusion. Ensure sample collection at appropriate times.
Adrenal Studies: Dexamethasone suppression (overnight)
Description and Purpose
-Assesses adrenal function and is especially helpful if hyperactivity is suspected. Useful in evaluation of Cushing's Syndrome. Dexamethasone (Decadron) 2mg is given at 11 p.m. to suppress secretion of corticotropin-releasing hormone. Plasma cortisol sample is drawn at 8 a.m. Cortisol level less than 5µg/dl indicates normal adrenal response (50% decrease in cortisol production).
Nursing Responsibility
-Ensure that client has fasted. Inform client that blood sample will be taken. Observe venipuncture site for bleeding and hematoma (a swelling comprising a mass of extravasated blood (usually clotted)) formation. Do not test acutely ill clients; those under stress are not tested. ACTH may override suppression. Screen client for drugs such as estrogen and glucocorticoids, which may give false-positive results. Ensure accurate timing of medication and sample collection.
Goals
*NORMALIZE HORMONE SECRETION
*RX DEPENDS ON CAUSE
-Taper steroids
-Surgery of pituitary or adrenal
-Medication
-Radiation
Treatment
*If r/t prolonged adm of steroids may:
-Gradual d/c steroids
-Reduce dose
-Alternate days
Sometimes can't taper, treat symptoms
Treatment
*Surgery=rx of choice for tumors or hyperplasia (excessive proliferation of normal cells in the normal tissue arrangement of an organ).
-Pre-op bring to optimal level of health
-May be pituitary surgery or adrenal surgery
Treatment for pituitary adenoma (a benign (not malignant) tumor made of epithelial cells, usually arranged like a gland).
*Transsphenoidal surgical removal of pituitary ademoma
-Post-op-HOB 30 degrees
-Assess for s&s cerebral edema, increased intracranial pressure
-Incision in upper lip and gingiva
Hypophysectomy
Excision of the hypophysis cerebri (pituitary gland).
Post-op Nursing Care
-Avoid coughing, straining
-Assess for CSF leak, meningitis (inflammation of the membranes of the spinal cord or brain, usually but not always caused by an infectious illness).
-No tooth brush for 2 weeks, oral care
-Assess for decreased ADH, adrenal & thyroid def.
Adrenal Surgery
*Adrenalectomy if tumor or hyperplasia
-Open surgical
-Laparoscopic
-See care plan (page 9 in lecture packet)
Drug Therapy
*Inoperable adrenocortical carcinoma = mitotane (Lysodren)
-suppresses cortisol production, alters metabolism of cortisol & decreases plasma & urine corticosteroid levels
-(medical adrenalectomy)
Other treatment
*Ketoconazole (Nizoral) is an antifungal used to inhibit cortisol production,
-used as an adjunct only to surgery or radiation in Cushing's Syndrome.
*Possible radiation for palliation
REVIEW LEHNE
Nursing Process
*See Care Plan (after page 38 in lecture packet) Patient with Cushing Syndrome
Adrenal insufficiency
*Primary = Addison's Disease
-Iatrogenic (any injury or illness that occurs as a result of medical care) = chemo, Anticoag, Surg. removal of Adrenals
-Idiopathic (pertaining to illnesses whose cause is either uncertain or as yet undetermined) atrophy or destruction by TB, AIDS, or autoimmune (approx. 75%, antibodies destroy cortex)
Adrenal insufficiency
*Secondary=
-Suppression of Adrenal Function, commonly sudden discontinued high dose, long term glucocorticoids
-Disorder due to pituitary or hypothalmic dysfunction
Adrenal insufficiency
*Most common 30-60 year olds
*If Addison's caused by autoimmune=white female
*Otherwise insufficiency = in both sexes
Addison's Disease Pathophysiology
DECREASED ADRENOCORTICAL HORMONES
-Aldosterone deficiency (only primary)
-Androgen deficiency
-Cortisol deficiency
-Refer to handout
Manifestations
*Onset usually insidious
*Often dx when > 90% fx gone
-Progressive weakness
-Fatigue
-Weight loss
-Anorexia
-Skin hyperpigmentation (pressure points, creases, palmer, sun exposed)
Manifestations
*Hypotension
*Hyponatremia
*hyperkalemia
*N/V, diarrhea
ADA ADDISON
*Neurosis to deep depression
DECREASED CORTISOL:
-weight loss
-weakness
-fatigue
-hypoglycemia
-intolerance to stress
-hyperpigmentation
-GI complaints: N/V, ABD pain, diarrhea
DECREASED ALDOSTERONE:
-decreased BP
-hyponatremia
-hyperkalemia
-dehydration
-decreased cardiac output
ANDROGEN LACK (IN FEMALES)
-loss of hair
Addisonian crisis
-Decreased BP
-Vasomotor collaspe
-Anorexia
-N/V/D, HA, COMA, Hyperpyrexia (an elevation of body temperature that is markedly abnormal)
Diagnosis: Addison's Disease
*ACTH Stimulation Test
*Hyperkalemia
*Hypochloremia, Hyponatremia, and hypoglycemia, anemia
*Free cortisol urine levels low
*EKG changes
Treatment: Addison's Disease
*Treat Underlying Cause
*Lifelong Hormone Replacement
-Most common = Hydrocortisone which also has mineralcorticoid qualities
-May be INCREASED to prevent Addisonian Crisis in periods of increased stress
-Must carry injectable in case of emergencies
-Must notify MD if unable to take medication
-Need increased teaching
Corticosteroids
USES = multiple
*Effects =
-Anti-inlammatory
-Immunosuppression
-Maintain normal blood pressure
-CHO and protein metabolism
Side effects of corticosteroids
*Susceptible to infection, delayed healing, bruising
*Protein depletion - muscle atrophy
*Mood and behavior changes
*Cusionoid patterns - face and trunk
*Increased BP may = cardiac problems
*Decrease mucous production = ulcers
*GRADUALLY TAPER DOSE TO PREVENT GLUCOCORTICOID DEFICIENCY
Nursing Process
*Activity Intolerance
*Risk for Fluid Volume Deficit
*Risk for Infection
*Altered Nutrition, less than requirement
*Altered Health Maintenance (Meds, medic alert. Emergency kit w/ med for self inject)
*Decreased Cardiac Output
*Lack of knowledge (need to increase replacement r/t stress)
Acute Care
*Daily Weights, Assess fluid status
*Protect from noise, light and temp. extremes
*Administer corticosteroids
*Protect from infection
*Assess labs, electrolytes
*Cannot cope w/ stress!!!
*Prevent Addisonian Crisis (surgery, infection, pregnancy, sudden withdrawal of hormone) Could be Fatal
Clinical Findings in Adrenal Crisis
*Hypoglycemia
*Hyponatremia
*Hypovolemia
*Hypotension
*Hyperkalemia
*Hyperpigmentation
Nonspecific Symptoms:
*N/V
*Abdominal pain
*Fatigue
*Malaise
*Weakness
Treatment
*High dose hydrocortisone
*May be life threatening = shock
-Vasopressors (An agent that stimulates contraction of smooth muscle of arteries and arterioles. This increases the resistance to the flow of blood and thus elevates blood pressure)
-Fluids & electrolytes
-May not respond
?????
*The nurse identifies that additional instruction is needed when a client with Addison's states:
a. I will call my doctor if I develop N/V
b. If my weight goes down, my steroids are probably too high
c. I should double my steroids with vigorous exercise
d. I need to carry injectable hydrocortisone for emergencies
Answer:
b. If my weight goes down, my steroids are probably too high
Current Trends/Research
*PCB effects on thyroid
*Long term post-op follow-up of Cushing's Syndrome
*Allergies and Adrenal Glands
www.clinicaltrials.gov