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66 Cards in this Set

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  • Back
There are three adrenal issues that we are focusing on. List them.
Cushing Syndrome
Addison's disease
Define if the cortisol levels are UP (hyper) or DOWN (hypo) in each of the following problems:

Cushing Syndrome
Addison's disease
Cushing Syndrome - hyper secretion
Addison's disease - hypo secretion
What is cortisol's role in pheochromocytoma?
Cortisol is not a focus in this disease. Catecholamines are the issue. They are produced by benign tumors. The catecholamines cause vasoconstriction resulting in HTN 200-300/150-175 that comes and goes
How do you diagnose pheochromocytoma?
urine and blood have increased catecholamines
What is treatment for pheochromocytoma?
surgical removal of tumors
Name some catecholamines that are over produced in pheochromocytoma.
Epinephrine and norepinephrine

(so now you understand the vasoconstriction)
Other manifestations (other than the severe high BP) of pheochromocytoma include....
pounding headache
tachycardia with palpations
profuse swweating
unexplained abd and chest pain

There is a triad of symptoms for pheochromocytoma. They include:
1. pounding headache
2. tachycardia
3. profuse sweating
What test would you expect to have to do for a patient that is admitted to r/o pheochromocytoma?
24 hour urine collection
Any surgery on adrenals, what are the post op priority assessments/interventions to be performed?
monitor vitals, especially BP

fluid balance (edema, congestion, i/o)

electrolyte imbalances
Why is there a fluid balance problem post op of adrenalectomy?
manipulation of the adrenals during surgery causes a great amount of cortisol to be released into the system. Because of this, BP, fluid balance and electrolyte levels seem to be unstable.
We tend to think that cushing's syndrome is a problem with only cortisol. In fact, there is another player in this game.....name him.
ACTH - adrenocorticotropic hormone

If this is the problem, then it is called CUSHING's DISEASE. Cushing's disease is a pituitary tumor causing increased secretion of ACTH
What are the manifestations of Cushing's Syndrome?
buffalo hump

round moon face

apple bottom jeans...just kidding (apple body with stick legs)

osteoporosis **remember this

purple striae


HTN (think overweight people usually have HTN)

slow wound healing


thin skin and subcu tissue
What type of wound dressing would you use on a Cushing Syndrome patient, and why?
abdominal binder or montgomery straps (corset)

b/c of their poor skin condition, their skin could tear with tape
What is a diagnostic test that is used to dx Cushing syndrome? (name multiple)
plasma cortisol - loss of circadian rhythm

plasma ACTH - increased in primary, decreased in secondary

24 hour urine ***

serum Na & glucose elevated

serum K decreased

CT and MRI for tumor

ACTH Suppresion Test ***
Why would you use a 24 hour urine collection to diagnose Cushing syndrome?
the elevated level of free cortisol in the urine can indicate cushing syndrome
Describe the ACTH suppresion test.
Dexamethasone (strong steroid) given to patient to suppress ACTH production. Then they measure the cortisol levels

If cortisol level is extremely high, then they think it is a "cortex" problem

If ACTH is not suppressed, adrenal tumor is suspected.

So, this is to determine the cause of the cushing syndrome.
What is the name of the drug that suppresses cortisol function?

(get me SOME!!!! decreased cortisol=tan and skinny remember!!!! haha)
What is the name of the drug that suppresses ACTH secretion?

What is the "problem" in Cushings disease?

(repeated info)
Too much cortisol

Maybe too much ACTH

Too much steroid intake
In addition to mitotane (decreases cortisol) and Somatostatin (suppresses ACTH), what is another drug used to treat Cushing syndrome?
aminogluthemide or ketoconzale
Patient teaching to include for a patient with Cushing syndrome that has been given an RX for ketoconazole or aminoglutethimide....
GI upset take WITH FOOD
GI bleed, depression, vertigo, skin rashes and diplopia...take WITH FOOD
Your patient is going to have a bilateral adrenalectomy tomorrow. What type of pre op instructions do you give her in regard to post op meds she will receive?
she will be on life long hormone replacements
PACU calls and says that you are getting a patient that just had unilateral adrenalectomy. What are your top assessment priorities when she gets up to the room?
Monitor vitals, especially BP. (you are looking for hypertension from mass amounts of hormone released)

Hemorrhage (which is increased with HTN and b/c the adrenals are very vascular)

Hemorrhage will cause drop in BP, but increase in HR. Report any changes in BP, HR and R.

Assess for fluid balance (i/o). looking for edema, congestion, FVE,

Look for electrolyte imbalances (especially Na, K)

Look for hyperglycemia...so monitor BG
Why are you anticipating a problem with glucose for a patient that just had an adrenalectomy?
b/c increased cortisol causes increased glucose in blood. Cortisol is the enemy of insulin.
Why would there be electrolyte imbalances in your post op adrenalectomy patient?
b/c of fluid shift, IV fluids
PACU calls again and says they have ANOTHER adrenalectomy coming to your unit. What type of equipment do you expect to be inplace on this patient?
ng tube (so get suction set up)

urinary catheter

IV therapy (running both fluids and corticosteroids)

central venous pressure monitoring (book says this...)

SCDs to prevent emboli

abdominal dressing (maybe with a binder b/c of skin condition)
Preparing for your post op adrenalectomy patient, what type of meal do you order from dietary?
High protein
High potassium
low in calories
low in CHO
low in salt

chicken, bananas, no chips, no bread roll....
When you are monitoring vitals for post op adrenalectomy patient, why is temperature important to watch?
b/c of increased risk of infection due to increased level of coritsol/corticosteroid IV
Connect the dots between:

hypercorticolism and increased risk of infection/delayed wound healing
Think diabetic....high glucose in blood. Cortisol is enemy of insulin. High glucose in blood delays wound healing. Bad m/o love glucose...immune system suppressed, so increased risk of infection
List other "duh" things to do post op for adrenalectomy.
TCDB/IS q 2 hr

strict med/surg asepsis

passive ROM if bedridden

activity balanced with rest

safe environment

emotional support
Yea! These post op adrenalectomy patients are being discharged. You are going to send them home with a prescription for ____________ and make sure you tell them....

You will take these FOREVER, take in the AM so you can sleep, take with FOOD to decrease GI upset.

If you get ill, here is another prescription for IM cortisol. You want to use this route when you are ill and can't keep food down.

Instruct family members how to inject IM (after you look it up in pharm packet, uhg!)

Instruct them to increase amount of steroid if stressed or ill (hopefully prescription will tell you how much...)
Along with med education you have just provided to your adrenalectomy patient, you also must remember to instruct them to always carry _____________________ with them.
a medical alert/id bracelet

(fashion advice)
The soon to be discharged adrenalectomy patient asks, "How do I know that I am taking the right amount of this life long steroid replacement?". You respond by explaining the symptoms of steroid UNDERUSE and OVERUSE.
Underuse - fatigue, weakness, dizziness

Overdose - severe edema, wt gain
If a person on steroid therapy abruptly stops, what can happen?
fatal adrenal crisis
There are four main effects of corticosteroid therapy. List them.
1. antiinflammatory action

2. immunosuppression

3. Maintenance of normal BP

4. Carbohydrate and protein metabolism
Long Term corticosteroid use can have complications. List some.
(scroll down to see them all)


immune suppression (reactivating TB, decreases resistance to infection and cancer)

inhibits the antibody response to vaccines

protein depletion


infection develops more rapidly and quicker

diabetes mellitus from glucose intolerance

mood and behavior changes

What hormone is decreased in Addison's disease?

What part of the adrenal gland is messed up?
cortisol, aldosterone, adrenal androgens

the cortex (which is the outer part)
Addison's disease is more common in what age group?
less than 60
What type of disease can Addison's disease be classified as?

primary cause only

What is the mental picture of a person with Addison's disease that Ms. Utlaut described?
skinny and tan, clothes hanging off of them
What can cause Addison's disease?
autimmune destruction (primary)

bilateral adrenalectomy (would be secondary)

hemorrhage into adrenal gland


tuberculosis, HIV/Aids

Fungal infections

Abrupt withdrawal from high dose, long term steroid therapy **
List the manifestations of Addison's disease.
hyperpigmentation of skin
delayed wound healing
joint pain
muscle pain/wasting
orthostatic hypotension
What is the potassium level in a person with uncontrolled Addison's disease?
Addison's disease has _________ levels of blood glucose.

skinny person not much sugar
Cushing's disease has ________ levels of blood glucose.

fatter person lots of sugar
Addison's disease has _______ levels of sodium.

skinny person not holding onto salt, not holding on to fluid...skinny
Cushing's disease has a ___________ level of sodium in the blood.

Puffy person, holding salt, holding water, edema.
What is the biggest complication that can happen to a person with Addison's disease?
Addisonian crisis
What test do they use to diagnose Addison's disease?
ACTH stimulation test (cortisol is low)

Plasma cortisol (decreased) **

Plasma ACTH

24 hour urine for free cortisol

Glucose, Na decreased, K and BUN up ***
Why is the BUN elevated in Addison's disease?
renal insufficiency
What type of diagnostic lab would include the electrolyte panel?
Chem 7, 9, 15

Why is glucose down in Addison's disease?

(think relation of cortisol to glucose)
in Addison's disease, the low level of cortisol means there is less "messing with" insulin. When insulin can do its job, it will drive glucose into the cells, thus decreasing the BG level.

Cortisol and Insulin are enemies

Addison's disease has low cortisol, so insulin is working. Result is LOW Blood Sugar
What are the treatments of Addison's disease?
hydrocortisone therapy - replaces cortisol

fludrocortisone acetate - replaces mineralocorticoids
Although replacing the cortisol can treat Addison's disease, what should the focus of treatment be on?
the underlying cause

(although if it is autoimmune, drugs are the only treatment)
What is the fluid volume of the body in Addison's disease (and especially Addisonian Crisis)?
Fluid Volume Deficit
What is the PC for fluid volume deficiency?
PC: circulatory collapse (leading to...)

PC: shock (leading to...)

PC: coma (leading to...)

PC: death
The manifestations of Addisonian crisis include the Addison's disease mans:(low cortisol, hyperkalemia, tan skin, anorexia, fatigue) plus....
SEVERE pain in ABD, lower back and legs
SEVERE vomiting/diarrhea
SEVERE hypotension

circulatory collapse, shock, coma and ......PC: death
Name three TOP priority things you would immediately know to do to treat Addisonian Crisis.
Rapid IV fluids (D5NS)

Rapid IV steroids

Watch that BP for drop
Along with fluids, steroids and monitoring BP status of an Addisonian crisis patient, what other interventions would you perform?
monitor BG (for high glucose)

Assess vitals

Assess fluid status

Monitor for electrolyte imbalances
What is an Addisonian crisis person's level of potassium....BEFORE treatment and AFTER treatment?
hyperkalemia BEFORE (look for arrhythmias)

hypokalemia AFTER (look for muscle weakness, paralysis)
IV steroids to treat Addisonian crisis include:

1. dexamethazone (3 times stronger than prednisone)

2. prednisone
Patient education for steroid treatment includes:

increased urine frequency
The Addison's disease patient and especially the Addisonian crisis patient needs to be protected from........because they can not produce cortisol needed to "deal with it".

keep lights down, temperature constant, calm, quiet environment
How often should you assess fluid status during Addisonian crisis and Addison's disease hospitalization?
q 30 minues to 4 hours

you are also checking vital signs this much
What should you include in patient teaching when discussing the "triggers" that can cause Addisonian crisis in an Addison's disease patient?
infection, injury and profuse sweating in hot weather may preciptate crisis

(Utlaut said, don't have them work outside in the hot weather)
Your patient with Addison's disease is being discharged. Her family is present. What type of teaching might you include the family in?

(don't forget Fashion Advice)
1. how to inject IM corticosteroid for a "bad day"

2. wear the medical ID bracelet (fashion advice)

3. instruct patient on signs of overdose, underdose of steroids (just think manifestations of cushings vs addisons)

4. diet changes: high protein, calcium, potassium....low fat and simple carbs