Adrenal Disorders: Diagnosis and Care

• This document will cover coordinating care for patients with adrenal disorders

Adrenal Cortex

• The adrenal cortex produces mineralocorticoids (aldosterone), glucocorticoids (cortisol), and androgens (sex hormones).
• Too little production results in primary adrenal cortical insufficiency.
• Too much production results in adrenal cortex hyperfunction.

Adrenal Cortical Insufficiency

• Adrenal Cortical Insufficiency concerns the pathophysiology, assessment, and diagnostics of adrenal disorders

Pathophysiology

• Primary adrenal cortical insufficiency is also known as Addison's Disease.
• Primary adrenal cortical insufficiency manifests as low cortisol and high ACTH levels.
• Secondary adrenal cortical insufficiency stems from the pituitary gland.
• Other causes are infections of the adrenal glands, or tumors of the kidneys or adrenal glands.
• Trauma to the chest or flank, AIDS, and tuberculosis can also induce adrenal cortical insufficiency.

Assessment

• Darkened, bronzed hyperpigmentation and weakness are common signs.
• Abdominal pain, gastroenteritis (N/V/Diarrhea), and fatigue are further indications.
• Increased ATCH due to low cortisol is another symptom.

Diagnostics

• Lab tests will show high CRNH, high ATCH, low cortisol, and low aldosterone.
• Additional lab findings include abnormal sodium and potassium levels.
• A CBC may identify signs of infection.
• Imaging options include Brain CT/MRI and Kidney imaging.

Medications

• Medications include the replacement of cortisol/aldosterone.
• Dexamethasone (cortisol) and Flucortisone (synthetic aldosterone) are two common medications.

Nursing Care

• Ensure vascular access for medication administration.
• Cortisol IV administration may be necessary for crisis situations.
• Monitor electrolyte balance, particularly sodium and potassium levels.
• Telemetry monitoring may be required.
• Implement safety precautions due to the risk of hypotension and falls, change positions slowly.

Complications

• Adrenal Crisis, where hormone levels are critically low (especially cortisol), is a major complication.

Patient Education

• Take medications at the same time every day to maintain consistent hormone levels.
• Wear a medical alert bracelet to inform healthcare providers of the condition in emergencies.
• Long-term corticosteroid use can cause side effects like weight gain and increased blood sugar.
• Irritability, insomnia, osteoporosis, and osteopenia can also result from long-term corticosteroid use.
• Other side effects can include risk of infection or steroid mania.
• Abruptly stopping steroids is dangerous; tapering is necessary to avoid adrenal crisis.

Adrenal Crisis

• Life-threatening complication of adrenal insufficiency that can be triggered by stress, sudden discontinuation of steroids, or autoimmune processes.
• Symptoms of Adrenal Crisis include Acute hypovolemia, hyperkalemia, and hypoglycemia.
• Acute hypovolemia can lead to hypotension and irreversible shock.
• Hyperkalemia is indicated by potassium levels greater than 5.1
• Signs of hypoglycemia are indicated by glucose levels less than 70 d/t low cortisol.

Adrenal Crisis Management (The 5 S's)

• Steroid: Administer IV hydrocortisone if the patient is unconscious, or give Oral dexamethasone if conscious.
• Sugar: Administer IV dextrose to combat hypoglycemia.
• Salt: Administer IV NS (or D5NS) to address hyponatremia.
• Support: Provide telemonitoring, monitor vital signs, and check serum electrolytes.
• Search: Investigate the underlying cause of the crisis.
• Hyperkalemia: Administer medication to bind potassium and facilitate its excretion (e.g., Kayexalate).

Adrenal Cortical Hyperfunction (Cushing's)

• Occurs more often in females, and characterized by the excessive circulation of glucocorticoid(s).
• This can also be the excessive secretion of ACTH

Assessment

• Includes abnormal fat distribution
• Decreased muscle mass and fragile skin
• Thin arms/legs plus osteoporosis
• Hyperglycemia and hypertension
• Distinguishing features include moon face and buffalo hump
• Irregular periods and or irritability

Diagnostics

• Can include Lab tests and Imaging tests

Lab Tests

• A 24-hour urine cortisol test is required.
• Blood work should be drawn first thing in the morning when cortisol is at its peak.
• Aldosterone measurement may also be taken
• MRI/CT imaging can be used

Medications

• Requires medication that suppresses ACTH and Glucocorticoid production

Surgical Management

• Transsphenoidal Hypophysectomy may be necessary

Nursing Care

• Elevate the head of bed (HOB) due to fluid overload.
• Turn the patient frequently.
• Address fragile skin as a result of skin tears and pressure ulcers.
• Monitor blood sugar levels.
• Check and maintain potassium levels.
• Maintain temperature, as increased cortisol suppresses immune function.

Complications

• Cardiac dysrhythmias (hypokalemia)

Patient Education

• Recognize the symptoms of adrenal crisis.
• Monitor salt intake to prevent hypernatremia.
• Medication adherence is critical for managing this disorder.

Explore adrenal disorders. We will cover the adrenal cortex and adrenal cortical insufficiency. Learn about the pathophysiology, assessment, and diagnostics of adrenal disorders like Addison's Disease and secondary adrenal cortical insufficiency.