16/03/2015

Gangguan Kelenjar Adrenal

(Cushing Syndrom, Aldosteronism, Addison Diseases)

Titis Kurniawan, MNS

Scope

Physiology of Cortex Adrenal

Cushing Syndrome

Aldosteronism

Addison Diseases

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Anatomy Fisiology Adrenal Gland

Medulla

Catecholamines; epi &

norepinephrin Cortex

Sympathetic Nervous System 

increases in heart rate, blood
pressure, blood glucose levels,
Zona glomerulosa Zona fasciculata Zona reticularis
and a general reaction of the

Aldosterone Cortisol
(mineralocorticoid) Androgen
(glucocorticoid)

Organ target  ginjal (tubule
distal & ductus colectivus)
Katabolik thd protein Fungsi Sistem Reproduksi

Bagian dari renin-angiotensin
Glukoneogenesis & inhibit insulin (pria), ciri sex pria

>> retensi Na dan sekresi K
Immunosupressive

>> retensi cairan
Suppress parasympatis syst 

>> tekanan darah Increase Hcl

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 16/03/2015

Anatomy Fisiology Adrenal Gland

Medulla

Catecholamines; epi &

norepinephrin Cortex

Sympathetic Nervous System 

increases in heart rate, blood
pressure, blood glucose levels,
Zona glomerulosa Zona fasciculata Zona reticularis
and a general reaction of the

Aldosterone Cortisol
(mineralocorticoid) Androgen
(glucocorticoid)

Organ target  ginjal (tubule
distal & ductus colectivus)
Katabolik thd protein Fungsi Sistem Reproduksi

Bagian dari renin-angiotensin
Glukoneogenesis & inhibit insulin (pria), ciri sex pria

>> retensi Na dan sekresi K
Immunosupressive

>> retensi cairan
Suppress parasympatis syst 

>> tekanan darah Increase Hcl

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Cushing Syndrome

Adalah: kumpulan gejala akibat peningkatan
kadar glukokortikoid dalam darah (Maitra, A &
Kumar, V., 2007; Schteingart, 2006)

Dapat muncul secara spontan akibat
pemberian glukokortikoid dosis tinggi

Insidence: 5 – 25 cases/1 million
people/year

Risk: 25 – 45 years old, women,
uncontrolled diabetes, & obesity

Type;

Iatrogenic; long-term glucocorticoid prescription

Spontan; Dependen & Independen ACTH

Etiology

Iatrogenic ; Pemberian glukokortikoid jk panjang
(astma, artritis rheumatoid, limfoma & integument
problem) sebagai anti inflamasi

Spontan; hypersecretion cortisol resulted from
impairment of hipotalamus-hippofisis-adrenal axis
(spontan)

Dependen ACTH

ACTH secretion from hipofisis gland

Adenoma  sintesis & release ACTH ectopic

Independen ACTH

Adenoma sintesis & release peptida = ACTH

Carsinoma sel paru/karsinoid bronkus, & sel pankreas release
CRH ectopic

Hiperplasia cortex adrenal nodular bilateral  >> cortisol

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Pathophysiology
Iatrogenic Spontan
Ggn Sist
>> Glucocorticoid/Cortisol << GnRH Reproduksi
>> Katabolisme Protein

>>
Integumen Katabolisme
Vaskuler Tulang Otot Imun Jaringan karbohidrat
Kerusakan Adiposa
jaringan Rapuh Tipis & Atropi & lemah
<< matrik >> glukosa
elastis rapuh tulang Distribusi di
darah
Mudah Intoleransi sentral tubuh
luka aktivitas
Ptechiae Osteoporosis
Striae Cushingoid
Luka Ggn pembentukan Buffalo hump,
Mudah cidera/
sukar antibodi & moonface
Perub. Postur/
sembuh Vertebra proliferasi limfoid Obesity

<< Respon imunitas

Risiko Ggn Integritas
Ggn. kulit >> aktivasi
Body Risiko Infeksi jantung
Image

Risk Ulkus peptikum >> HCL >> sekresi lambung

Risk. Koping tidak eektif/perilaku Ggn Mood, euforia, depresi Respon psikologis
destruktif

Signs & Symptoms

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Diagnostic Test

Riwayat kesehatan

Pemeriksaan fisik (sign & symptoms)

Urinary free cortisol (UFC) test (220 –
330nmol/24h)

Plasma cortisol test

Low doses dexamethasone test

Cortisol circadian rhythm assessment

MRI

Dll

Normal Range of Cortisol

Reference ranges for blood plasma content of free cortisol
Time Lower limit Upper limit Unit
140 700 nmol/L
09:00 am
5 25 µg/dL
80 350 nmol/L
Midnight
2.9 13 µg/dL

Reference ranges for urinalysis of free cortisol

Lower limit Upper limit Unit
28 or 30 280 or 490 nmol/24h
10 or 11 100 or 176 µg/24 h

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Suspected CS Screening
– Ukur free cortisol urine 24 jam  Reflects
cortisol production.
– Overnight dexamethasone suppression test
– Both tests detect uncontrolled cortisol
production but do not distinguish etiology
– Be careful with Pseudo cushing;
– Related to depression & alcoholism
– Periodic hormonogenesis
– Jika ragu, tunggu 6-12 minggu & re-evaluate!

...........Diagnostic Test
Dexamethason suppression test

Dexamethason exogenous steroid memberi feedback negatif
pada pituitary utk menurunkan sekresi ACTH

Dexamethasone diberikan pada dosis rendah (1–2 mg)
ataupun tinggi (8 mg)  kemudian kadar cortisol diukur utk
menentukan hasil

Bila pemberian dosis rendah – tinggi  Tidak ada
perubahan kortisol  bukan krn mekanisme HPA axis 
Cushing syndrom mungkin disebabkan oleh sebab lain
(ectopic ACTH syndrome)

Bila dengan dosis rendah tidak berubah tetapi berubah dg
dosis tinggi  HPA axis yg terganggu  Cushing diseases
 pertimbangkan untuk MRI Pituitary utk memastikan
penyebab.

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Nursing Process
Assessment

History; asthma, rheumatoid artritis, konsumsi obat steroid

Psikologis; insomnia, euforia, depresi singkat, mood alteration

General; Obesitas, moon face, buffalo hump

Opthamic; Cataract, glaukoma, keluhan pandangan kabur

Cardiovascular: HT, CHF, ptechie, echymosis

Integumen: luka memar, luka tidak sembuh, striae, acne

Muskuloskeletal: muscle weakness, atropi, myopathy
osteoporosis

Gastrontestinal; peptic ulcer

Pemeriksaan lab; hiperglikemia, hypernatremia, hypokalemia

......Nursing Process
Nursing Diagnoses

Resiko injury b.d weakness, osteoporosis, kulit yg rapuh

Resiko infeksi b.d immunosupresi

Self care deficit b.d muscle weakness, fatigue, altered sleep
patern

Ggn integritas kulit b.d edema, gangguan penyembuhan
luka, kulit yg tipis dan mudah pecah

Ggn Body image b.d perubahan penampilan fisik

Perub proses fikir b.d. perubahan mood, irritabilitas, depresi

Risiko koping tdk efektif b.d. mood, irritabilitas, depresi

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......Nursing Process
Nursing Intervention

Pengendalian resiko injury

Pengendalian resiko infeksi

Anjurk istirahat dan aktivitas yg tepat

Promote integritas kulit→mobilisasi u/ mcegah
breakdown skin

Improve body image

Relationship with other

BB dpt dikendalikan dg Diet low KH, Low sodium

Improve proses berfikir

Improve mekanisme koping

Anatomy Fisiology Adrenal Gland

Medulla

Catecholamines; epi &

norepinephrin Cortex

Sympathetic Nervous System 

increases in heart rate, blood
pressure, blood glucose levels,
Zona glomerulosa Zona fasciculata Zona reticularis
and a general reaction of the

Aldosterone Cortisol
(mineralocorticoid) Androgen
(glucocorticoid)

Organ target  ginjal (tubule
distal & ductus colectivus)
Katabolik thd protein Fungsi Sistem Reproduksi

Bagian dari renin-angiotensin
Glukoneogenesis & inhibit insulin (pria), ciri sex pria

>> retensi Na dan sekresi K
Immunosupressive

>> retensi cairan
Suppress parasympatis syst 

>> tekanan darah Increase Hcl

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ALDOSTERONISM

Adalah; kumpulan gejala akibat kelebihan hormon
aldosteron.

Dampak & gejala;

Peningkatan reabsorbsi Na dan sekresi K & H  peningkatan
retensi Na & air, alkalosis, volume cairan ekstrasel & hipertensi

Hypokalemia interferes with insulin secretion  glucose
intolerance

Type;

Pimer (akibat tumor/hiperplasia korteks adrenal)

Sekunder (ipenurunan tek. arteriola aferen ginjal  renin-

angiotensin  pasien Gagal jantung, sindroma nefrotik  gejala
utama = edema)

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………..Assessment & Diagnostic Findings

High sodium

Low potassium level

High serum aldosterone level

Low serum of renin

24 hours Aldosterone excretion rate after salt
loading is diagnostic for primary aldosteronism  5
days consume high salt  urine test  high urine
aldosterone

Captopril suppression test  single dose captopril
 blood test  high aldosterone & low renin

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………..Management

Surgical removal of tumor; adrenalektomi parsial, reseksi

adenoma penghasil aldosteron, dan pemberian
antagonis aldosteron  spironolakton

Correct hypokalemia

Usual postoperative care with abdominal surgery

Administer steroids

Fluids

Monitoring of blood sugar

Control of hypertension with spironolactone

Anatomy Fisiology Adrenal Gland

Medulla

Catecholamines; epi &

norepinephrin Cortex

Sympathetic Nervous System 

increases in heart rate, blood
pressure, blood glucose levels,
Zona glomerulosa Zona fasciculata Zona reticularis
and a general reaction of the

Aldosterone Cortisol
(mineralocorticoid) Androgen
(glucocorticoid)

Organ target  ginjal (tubule
distal & ductus colectivus)
Katabolik thd protein Fungsi Sistem Reproduksi

Bagian dari renin-angiotensin
Glukoneogenesis & inhibit insulin (pria), ciri sex pria

>> retensi Na dan sekresi K
Immunosupressive

>> retensi cairan
Suppress parasympatis syst 

>> tekanan darah Increase Hcl

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ADDISON’s DISEASES

Adalah; insufficiency adrenocortical
akibat kerusakan/disfungsi keseluruhan
adrenal cortex

Etiology; autoimun, ACTH deficit,
adrenal hemorrhage

Dampak; gangguan fungsi
glukokortikoid & mineralocorticoid
(<<aldosteron, << cortisol, <<
androgen, dll)

Incidence; lebih banyak pada wanita

dan anak-anak, usia 30-50 th

……..Addison’s Diseases
Gejala;

Ggn glukoneogenesis  berkurangnya glikogen hati,
peningkatan kepekaan jar. Perifer thd insuline hipoglikemia

Meningkatnya propiomelanokortin (POMC) 
hiperpigmentasi pada distal ekstremitas, genitalia, mukosa
pipi, sendi-sendi jari, lipatan telapak tangan

Insufisiensi kortisol  Ggn mekanisme kompensasi thd
stress pembedahan, trauma, infeksi  kolapse vaskular

Defisiensi aldosteron; << reabsorbsi Na pd ginjal 
hiponatremia, hipotensi & takikardi ortostatik, >> potasium (K)

Kegagalan renin-angiotensin (renin >> , aldosteron <<)

Defisiensi androgen ; rambut axila & pubis rontok (lebih pd
wanita)

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…….Addison Diseases

Addison Crisis:

Circulatory shock

Pallor, apprehension, weak & rapid
pulse, rapid respirations and low blood
pressure

Headache, nausea, abdominal pain and
diarrhea

Can be brought on by overexertion,
exposure to cold, acute infection,
decrease in salt intake

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…….Addison Diseases
ACTH Stimulating Test

Cara:

Synthetic ACTH 250 mcg (0.25 mg) diberikan secara IM/ IV

30 - 60 menit setelah injeksi lakukan pemeriksaan darah (2
tabung  untuk cortisol & aldosterone)

Interpretasi Hasil:

Bila (1) ada peningkatan nilai kortisol >7 mcg/dL atau
(2) nilai kortisol mencapai > 20 mcg/dL  normal
adrenal glucocorticoid function.

Bila tidak ada perubahan nilai kortisol/hanya sedikit
perubahan/tidak memenuhi kriteria di atas  Addison diseases

Nx diagnosis
• Deficit fluid volume r/t hypovolemia
secondary to adrenal insuficiency
• Ineffective tissue perfussion; peripheral r/t
volume deficit
• Anxiety r/t lack of knowledge about the
diseases & treatment effect

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…….Addison Diseases
Penatalaksanaan

IV access should be established urgently

NaCl 0,9%  untuk mengganti cairan yang hilang dan mengatasi
hipotensi (beberapa pasien perlu glucose supplementasi)

Berikan 100 mg hydrocortisone dalam 100 cc NaCl 0,9% (drip)
dengan kecepatan tetesan 10-12 cc/h.

Bila dalam kondisi krisis  pemberian 100 mg of hydrocortisone
dilakukan melalui IV bolus.

Berikan mineralocorticoid (9-alpha-fludrocortisone) dengan dosis
0.05-0.10 ml

…….Addison Diseases
Penatalakasanaan (Keperawatan):

Monitor & maintain status cairan  cegah dehidrasi

Monitor & maintain TD (waspadai hipotensi ortostatik)

Diet tinggi Natrium (Na) rendah potasium (K)

Bantu aktivitas  cegah /minimalisasi risiko jatuh

Lakukan penimbangan secara rutin

Monitor dampak pemberian steroid, seperti:

Improper replacement; Morning headaches, weakness, and dizziness

Over-replacement = cushingoid features. A periodic bone dual-energy x-
ray absorptiometry (DEXA)  deteksi dini osteoporosis

Pemberian informasi tentang:

Penyakit

Pentingnya kepatuhan pengobatan

Dampak pengobatan

Tanda-tanda kegawatan/perburukan kondisi

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