DISORDERS OF ADRENAL GLANDS

• Adrenal glands sit atop the kidneys
• Adrenal glands consist of the adrenal gland, capsule, cortex, medulla and blood vessels

Adrenal Medulla

• It reacts to the Autonomic Nervous System (SNS)
• It releases epinephrine and norepinephrine

Adrenal Cortex

• Produces Glucocorticoids
• Produces Mineralocorticoids
• Produces Androgens

Glucocorticoids

• Maintains blood glucose level and gluconeogenesis; decreases use of glucose
• Glucocorticoids are anti-inflammatory and immunosuppressive
• Causes CHON catabolism
• Encourages lipolysis (fat breakdown)
• Encourages Na & H20 retention and K+ excretion
• Increases gastric acid and pepsin production
• Decreases scar tissue formation, and increases platelet
• Stimulates appetite and emotional stability
• Increases serum levels & neutrophils

Mineralocorticoids

• Maintains normovolemic state to increase Na & H20 retention in exchange of potassium excretion
• Secreted in the presence of Angiotensin II

Androgens

• Gonadal sex hormones regulate reproductive and sexual functions

Hypersecretion and Cortisol Excess

• Can lead to Cushing's Syndrome

Cushing's Syndrome

• With primary cause it is Cushing's Syndrome
• With secondary cause it is Cushing's Disease
• With ectopic cause it is Cushing's Syndrome coming from a non pituitary site
• Due to latrogenic causes it is latrogenic cushing's

Cushing's Syndrome Symptoms

• Moon face & buffalo hump are caused by adipose deposition to trunks and face
• Muscle wasting, fatigue, and apathy is due to hypo K and Na & H20 favoring
• Pale, purplish striae is shown as thinning of skin & weakening of collagenous fibers
• Bruises easily due to ecchymosis formation (easily traumatized)
• Causes insomnia, nightmares, mood swings and emotional stability
• Can lead to decreased libido, breast atrophy, clitoromegaly, amenorrhea and voice deepening in women
• Causes osteoporosis due to bone matrix wasting
• Leads to low resistance to infection/poor wound healing
• Affects Blood glucose
• Affects WBC, Na, K and Ca

Cushing's Syndrome Complications

• Can involve neuropsychiatric disorders
• Leads to arterial atherosclerosis and vascular disease
• Leads to liver steatosis
• Can weaken bones and cause osteoporosis especially of the femoral neck
• Leads to cardiac disease, may result spinal and vertebral fractures
• Leads to infertility and sexual dysfunction
• May lead to visceral obesity
• Infections may occur
• Can lead to myopathy

Cushing's Syndrome Management

• Involves Adrenalectomy; excision of adrenal (primary) or pituitary tumor (secondary)
• Can involve Irradiation of the PG if due to pituitary adenoma
• Can involve drug therapy with adrenal enzyme inhibitors, with Mitotane, Metyrapone, and Aminoglutethimide

Nursing Management

• DIET: decreased CALORIE, decreased Na, increased K, increased fluids
• Administer diuretics
• Insulin replacement may be needed
• Encourage ROM
• Assist with ambulation

Nursing Diagnosis

• Risk for injury/falls
• Risk for infection
• Risk for impaired tissue integrity
• Monitor Daily weights, and I & O
• Promote Adequate rest
• Avoid stress & infection

Aldosterone Excess

• Also known as Hyperaldosteronism can lead to Conn's Syndrome
• 3 Major Signs may occur: Hypertension, Hypernatremia, and Hypokalemia

Hypokalemia

• Affects muscular contraction causing weakness, paresthesia, hypoactive bowel movements and hypoactive DTR
• Can cause Cardiac arrhythmias
• Can lead to loss of kidney's ability to concentrate & acidify the urine
• Can cause Metabolic alkalosis

Management of Hyperaldosteronism

• Adrenalectomy/ excision of tumor
• Na+ & fluid restriction, Potassium replacement
• After surgery there is typically a temporary suppression of Renin-induced Aldosterone and fluid volume deficit
• If there is an ALDOSTERONE DEFICIT:
  • Treat MILD cases of acidosis, Hyperkalemia with Na bicarbonate, sodium polystyrene sulfonate (Kayexalate) after surgery
  • Treat severe cases with Fludrocortisone

Androgen Excess

• Results from Adrenal adenoma/carcinoma, or Adrenal hyperplasia
• Causes no obvious signs in males
• Causes Hirsutism, and virilism in females

Adrenal Medulla Catecholamine Excess

• Causes Pheochromocytoma which is a tumor producing catecholamine

Pheochromocytoma Manifestations are known as "The 5 H's"

• Hypertension
• Headache
• Hyperhidrosis
• Hypermetabolism
• Hyperglycemia
• Death may occur with shock, CVA, renal failure, dysrhythmia or aneurysm

Pheochromocytoma Diagnostic Tests

• Utilize the Vanillylmandelic Acid (VMA) Test with a 24 hour urine specimen; the norm is up to 9 mg/24h
• Check for a Total Plasma Catecholamine Concentration, using a butterfly needle inserted 30 mins before the blood specimen when drawn
  • Normal EPI=100 pg/ml
  • Normal NorEpi = 100 – 550 pg/ml
• Use a Clonidine Suppression Test with Catapres (Clonidine)
  • NORMAL: If 2 -3 hrs catecholamine decreases @least 40% from the baseline
  • (+) PHEOCHROMOCYTOMA indicates catecholamines remain elevated

Pheochromocytoma Treatment

• CT Scan, MRI, UTZ
• Includes Adrenalectomy
  • UNILATERAL requires corticosteroids for the 1st few days or weeks post op
  • BILATERAL requires lifetime steroid Tx
• Pre-Op Priority – HPN to prevent hypertensive crisis
• Bed rest, non-stimulating environment, elevate head of bed
• Phentolamine (Regitine)
• Sodium nitroprusside (Nipride)
• Diuretics (Lasix)
• Corticosteroid therapy and BP measurement is necessary
• Avoid stimulants, and smoking

Hyposecretion

• Can lead to Addison's Disease
• Occurs when adrenal cortex is inadequate to meet the patient's need for cortical hormones
• Can be caused by:
  • Primary, secondary, and iatrogenic factors
  • Autoimmune, idiopathic and sx - adrenalectomy
  • TB or Histoplasmosis

Mineralocorticoids Deficiency

• Causes Hyponatremia
• Causes Hyperkalemia
• Causes Hypotension
• Causes Hemoconcentration (DHN)
• Causes Mild acidosis
• Causes DHN and decreased cardiac output

Glucocorticoid Deficiency

• Decreased blood glucose
• Causes Hypotension
• Causes Stress intolerance
• Causes Nausea and Vomiting
• Causes Weight loss
• Causes Sodium depletion
• Causes Apathy, lethargy
• Causes Confusion, psychosis
• Causes Hyperpigmentation

Androgen Deficiency

• Causes Loss of body hair, and loss of libido
• May cause impotence
• Disrupts Menstrual/ fertility disorders

Addison's Disease Management

• Glucocorticoids (Cortisone & Hydrocortisone) in Steroid therapy -Give 2/3 dose in AM and 1/3 dose @ night with meals, milk, & antacid
• Encourage small frequent feedings
• Encourage: Increased CHO & CHON
• Avoid stress and trauma
• Avoid strenuous exercise especially during hot weather
• Consume salt tablets or salty foods if excessively sweating

Addisonian Crisis

• Occurs with an Absolute or complete absence of adrenocortical hormones
• Precipitated by stress, infection, trauma or surgery
• Precipitated by abruptly withdrawing glucocorticoid replacement therapy

Addison'S Disease Manifestations

• Hypotension -Shock (vascular collapse)
• Hypovolemia
• Hypoglycemia
• Leads to muscle weakness and Coma

Addisonian Crisis Treatment

• Treat with IVF
• Administer IV glucocorticoids and vasopressor
• Increase dosage of steroids to treat shock
• Treat with antibiotics
• Strictly enforce CBR and eliminate all stressful stimuli
• Protect from infection