Adrenal Gland Disorders
Hyperfunction (Cushing's Syndrome)
Pathophysiology
Drug Therapy
Aminoglutethimide (Cytadren), inhibitor of ACTH synthesis
metyrapone (Metopirone), inhibitor of ACTH synthesis
cyproheptadine (Periactin), interferes with ACTH production
mitotane (lysodren), adrenal cytotoxic agent
cimetidine (Tagamet), H2-histamine antagonist
omeprazole (Prilosec), PPI anti-ulcer
Nursing Interventions
• Encourage client to protect himself from exposure to infection
• Good hand washing technique
• Monitor for signs of infection
• Teach safety measures
• Provide low sodium diet; encourage foods that contain vitamin D and calcium
• Provide good skin and perineal care
• Discuss possibility of weaning form steroids
• Monitor I&O
• Provide Ulcer prophylaxis
Manifestations
Truncal obesity
Thin extremities
Moon face
Buffalo hump
Fragile skin, poor wound healing
Hypervolemia
Edemaof lower extremities
Hypertension
Glycosuria
hypercalciuria
Risk for kidney stones
Muscle wasting in extremities
Fatigue
Osteoporosi
Hyperglcemia
Hirsutism
Menstrural irregularities
Enlarge clitoris
Gynecomastia and testicular atrophy in men
Diagnostics
Plasma cortisol
Urine cortisol levels (80-120mcg/24hr)
Low-dose dexamethasone suppression test
CT & MRI of of pituitary and adrenal gland may be done Plasma ACTH
Incidence:
Cushing disease and primary adrenal tumors are more common in women in the 20- to 40- year old age group
Ectopic ACTH production is more common in men
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Hypofunction (Addison’s Disease)
Medications
⭐ Glucocorticoids given in divided doses, 2/3 in morning 1/3 in the afternoon e.g hydrocortisone
⭐ Daily mineralocorticoid (fludrocortisone [Florinef]) in the morning
⭐ Salt additives for excess heat or humidity
⭐ Increased doses of cortisol for stress situations (e.g., surgery, hospitalization)
Collaborative Care
Main treatment is hormone therapy
✅ Hydrocotisone: glucocorticoid and mineralocorticoid properties
if stressful situation then dose increased, prevention of addisonian crisis.
✅ Mineralocorticoid replacement with fludrocortisone (Florinef) is administered daily.
✅ Increased salt needs to be added in the diet.
Addisonian crisis is a life-threatening emergency requiring aggressive management. Treatment: shock management and high-dose hydrocortisone replacement.
✅ Large volumes of 0.9% saline solution and 5% dextrose are administered to reverse hypotension and electrolyte imbalances until BP returns to normal.
Interventions
a. Monitor vital signs, particularly blood pressure, weight, and
intake and output.
b. Monitor white blood cell (WBC) count; blood glucose; and
potassium, sodium, and calcium levels.
c. Administer glucocorticoid or mineralocorticoid medications as
prescribed.
d. Observe for addisonian crisis caused by stress, infection, trauma,
or surgery.
Client education
a. Avoid individuals with an infection.
b. Diet: High protein and high carbohydrate, normal sodium intake
c. Avoid strenuous exercise and stressful situations.
d. Need for lifelong glucocorticoid therapy
e. Avoid over-the-counter medications.
f. Wear a Medic-Alert bracelet.
g. Signs and symptoms of complications such as underreplacement
and overreplacement of hormones
Etiology:
Cushing Syndrome:
Most common cause is iatrogenic administration of exogenous corticosteroids (prednisone)
Cushing Disease:
ACTH-secreting pituitary adenoma
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Pathophysiology
The body's own immune cells mistakenly attacks the adrenal cortex, the exact cause of why this happens is unknown.
This leads to the adrenal tissue to be destroyed.
Corticosteroids are reduced specifically cortisol and aldosterone.
If not treated a stressor can trigger Addisonian Crisis which can lead to death!
Incidence
Adrenal insufficiency is most common in adults younger than 60, and it affects both genders equally.
If Addison's disease is caused by an autoimmune response it is more common in white females.
Etiology
The most common cause of Addison's diseases in the US is autoimmune.
Other causes are: Tuberculosis mostly in developing country's, infarction, fungal infection, AIDS, and metastatic cancer.
Labs:
depressed serum and urinary cortisol levels.
hyperkalemia
hyponatremia,
hypoglycemia,
anemia
increased BUN levels
Urine levels of free cortisol are low
An ECG may show low voltage and peaked T waves caused by hyperkalemia.
ACTH-stimulation test
CT scans
MRI: used to identify causes other than autoimmune,
including tumors, fungal infections, tuberculosis, or
adrenal calcification
Hypothalamus
Corticotropin-releasing hormone (CRH)
Pituitary gland secretes ACTH
(Adrenocorticotropic hormone)
Adrenal Cortex
Adrenal Gland to produce steroids:
*Glucocorticoids (Cortisol)
Mineralocorticoids (Aldosterone)
Androgens (Sex traits)*
SurgicalManagement
Hypophysectomy
Adrenalectomy
caused by overproduction of corticosteroid hormones by the adrenal cortex