CHARLES Z. ARIOLA JR., MSN., LPT, RN.

INSTRUCTOR I
 ADRENAL GLAND HYPOFUNCTION
CAUSES:
1. Inadequate secretion of Adrenocorticotropic
Hormone
2. Dysfunction of hypothalamic-pituitary
control mechanism
3. direct dysfunction of adrenal gland tissue
 ADRENAL GLAND HYPOFUNCTION
- adrenal insufficiency of steroids causes loss of cortisol
and aldosterone
IMPAIRED SECRETION OF CORTISOL
- causes glucose build up from proteins along with
depletion of liver and muscle glycogen
- it also causes decreased GFR and gastric acid
production which leads to reduced Urea Nitrogen
causing anorexia and weight loss
 ADRENAL GLAND HYPOFUNCTION
IMPAIRED SECRETION OF ALDOSTERONE
- causes water, sodium and potassium imbalances
- HYPERKALEMIA from a decreased potassium
excretion
- HYPONATREMIA increased sodium excretion
- HYPOVOLEMIA from increased water excretion
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HORMONE REPLACEMENT
- start rapid infusion of normal saline or dextrose 5% in normal
saline
- initial dose of hydrocortisone sodium succinate (solu-cortef) is
100 to 300 mg or dexamethasone 4 to 12 mg as an IV Bolus
- infuse additional 100 mg of hydrocortisone sodium succinate
by continuous IV drip over the next 8 hours
- initiate H2 Histamine blocker (ranitidine) IV for ulcer
prevention
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HYPERKALEMIA MANAGEMENT
- administer insulin (20 to 50 units)with dextrose (20 to 50 mg) in normal
saline to shift potassium into cells
- administer potassium binding and excreting resin ( Kayexalate)
- give loop or thiazide diuretics)
- initiate potassium restriction
- avoid potassium-sparing diuretics
- monitor intake and output
- monitor heart rate, rhythm, and ECG for manifestations of hyperkalemia
(slow heart rate, peak T waves,fibrillation and asystole)
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HYPOGLYCEMIA MANAGEMENT
- administer IV glucose
- administer glucagon as needed
- maintain iV access
- monitor blood glucose level hourly
 ADDISON'S DISEASE
- acute adrenal insufficiency
- life threatening event caused by impaired secretion of cortisol
and aldosterone
- often occurs in response to stressful event such as
SURGERY,TRAUMA or SEVERE INFECTION
- classified as PRIMARY and SECONDARY
 CAUSES OF ADDISON'S DISEASE
PRIMARY CAUSES
1. Autoimmune disease
2. TB
3. Metastatic cancer
4. Fungal Lesions
5. AIDS
6. Hemorrhage
7. Gram negative sepsis (Waterhouse-Friderichsen Syndrome)
8. Adrenalectomy
9. Drugs (Mitotane) and Toxins
 CAUSES OF ADDISON'S DISEASE
SECONDARY
1. Pituitary Tumors
2. Postpartum pituitary necrosis (Sheehan's Syndrome)
3. Hypophysectomy
4. High-dose pituitary radiation
5. High-dose whole -brain radiation
 HISTORY ASSESSMENT
1. Lethargy
2. Fatigue
3. Muscle Weakness
4. Salt Craving
5. Anorexia
6. Nausea
7. Vomiting
8. Diarrhea
9. Abdominal Pain
10. Menstrual Changes for women
 CLINICAL MANIFESTATIONS
NEUROMUSCULAR MANIFESTATIONS
- muscle weakness
- fatigue
- joint/muscle pain

GASTROINTESTINAL MANIFESTATIONS
- anorexia - bowel changes
- nausea & vomiting - weight loss
- abdominal pain - salt craving
 CLINICAL MANIFESTATIONS
INTEGUMENTARY MANIFESTATIONS
- vitiligo
- hyperpigmentation

CARDIOVASCULAR MANIFESTATIONS
- anemia
- hypotension
- hyperkalemia
- hypercalcemia
 LABORATORY ASSESSMENT
- low serum cortisol
- low fasting blood sugar
- low sodium
- elevated potassium
- elevated BUN

ACTH STIMULATION TEST- most definitive test for adrenal insufficiency

- ACTH 0.25 to 1mg is given IV
- plasma cortisol level is otained in 30 mins to 1 hour interval
LABORATORY PROFILE
SIGNIFICANCE OF ABNORMAL FINDINGS
TEST HYPOFUNCTION OF ADRENAL
GLAND
HYPERFUNCTION OF ADRENAL
GLAND
SODIUM DECREASED INCREASED

GLUCOSE DECREASED INCREASED

CORTISOL DECREASED INCREASED

POTASSIUM INCREASED DECREASED

CALCIUM INCREASED DECREASED

BICARBONATE INCREASED DECREASED

BUN INCREASED DECREASED

 INTERVENTIONS
GOALS:
- promote fluid balance
- monitor for fluid deficit
- prevent hypoglycemia

NURSING RESPONSIBILITIES
- weigh patient daily
- record intake and output
- assess V/S 1 to 4 hours
- monitor lab values
 DRUG THERAPY
1. CORTISONE
- 25-50 mg orally either once daily in AM or daily in divided doses
NR: instruct patient to take meds with meals

2. HYDROCORTISONE (Cortef, Hycort)

- 25-50 mg orally either once daily in AM or daily in divided doses
NR: Instruct patient to report signs of excessive drug therapy
- Rapid Weight Gain
- Round face
- Fluid Retention
 DRUG THERAPY
3. PREDISONE (Winpred)
- 5-10 mg orally either once daily in AM or daily in divided doses
NR: Instruct patient to report illness such as:
- Severe diarrhea
- vomiting
- fever
NOTE: Do not confuse with prednisolone- another durg that is 4 to 5 times more
potent than prednisone
 DRUG THERAPY
4. FLUDROCORTISONE (Florinef)
- 0.05-0.2 mg orally daily
NR: Monitor patient's blood pressure
Instruct patient to report weight gain or edema
 ADRENAL GLAND HYPERFUNCTION
- Hypresecretion by adrenal cortex results to the following conditions:

1. Hypercortisolism (Cushing's Disease or Cushing's Syndrome)

2. Hyperaldosteronism (excessive mineralocorticoids production)

3. Excessive Androgen production

4. Pheochromocytoma -results from hyperstimulation of adrenal medulla

 CUSHING'S DISEASE
- exaggerated actions of glucocorticoids, causing widespread problems.
- excessive secretion of cortisol from adrenal cortex
- can be caused by a problem in adrenal cortex itself, problem in the
pituitary gland or in the hypothalamus
-can also be caused by Glucocorticoid Therapy
- excess glucocorticoids affect Nitrogen, carbohydrate and mineral
metabolism which then results to slow-turn over of plasma fatty acids
and redistribute fats causing pattern of truncal obesity
 ETIOLOGY
1. PITUITARY CUSHING'S DISEASE
- the tissue causing problem is the pituitary itself

2. ADRENAL CUSHING'S DISEASE

- when the problem arises from adrenal cortex and usually affects
one adrenal gland only

3. CUSHING'S SYNDROME
- when it results from drug therapy for another health problem
 CLINICAL MANIFESTATIONS
1. GENERAL APPEARANCE
- moon face
- truncal obesity
- buffalo hump
 CLINICAL MANIFESTATIONS
2. CARDIOVASCULAR MANIFESTATIONS
- Hypertension
- Increased risk for thromboembolic events
- frequent dependent edema
- Capillary Fragility
- Bruising
- Petechiae
 CLINICAL MANIFESTATIONS
3. MUSCULOSKELETAL MANIFESTATIONS
- Muscle atrophy (most apparent in extremities)
- Osteoporosis (loss of bone density)
- pathologic fractures
- decreased height with vertebral collapse
- aseptic necrosis of the femur head
- slow or poor healing of bone fractures
CLINICAL MANIFESTATIONS
4. SKIN MANIFESTATION
- Thinning skin (paper-like appearance especially on the back of the hands
- striae
5. IMMUNE SYSTEM MANIFESTATIONS
- increased risk for infection
- decreased immune function
- decreased circulating lymphocytes
- decreased production of immunoglobins (antibodies)
- decreased inflammatory responses
- decreased eosinophil count
- decreased production of proinflammatory cytokines, histamine, prostaglandins
PSYCHOSOCIAL ASSESSMENT
- Emotional lability
- mood swings
- irritability
- confusion
- depression
- neurotic/psychotic behavior
LABORATORY ASSESSMENT
- Lab Tests include:
- Blood
- salivary
- urine
- ACTH is high in Pituitary Cushing Disease
- ACTH is low in Adrenal Cushing's Disease or when
Cushing's Diseaseresults from chronic steroid use
LABORATORY ASSESSMENT
- Increased blood glucose
- decreased lymphocyte
- increased sodium
- decreased potassium
- decreased calcium
 COMMON NURSING DIAGNOSES
1. Excess fluid volume related to excess water and sodium
reabsorption
2. Risk for injury related to skin thinning, poor wound
healing and bone density loss
3. Risk for infection related to immunosupression and
inadequate primary defenses
 NURSING INTERVENTIONS
EXCESS FLUID VOLUME
1. Patient Safety
- Monitor for indicators of fluid overload every 2 hours such as:
- increased pulse quality
- increased neck vein distention
- presence of crackles in the lungs
- increased peripheral edema
- reduced urinary output
- assist patient to change position every 2 hours
 NURSING INTERVENTIONS
2. DRUG THERAPY
- Aminoglutethimide (Elipten, Cytadren) given to interfere
- Metyrapone (Metopirone) with ACTH production
- Cyproheptadine (Periactin)
- Mitotane (Lysodren)
- Adrenal Cytotoxic agent used for inoperable adrenal tumors
NR: Monitor electrolytes especially Potassium and Sodium
 NURSING INTERVENTIONS
3. NUTRITION THERAPY
- “No added salt” for table foods in mild fluid overload
- For severe fluid overload, sodium is restricted to 2 gm/day to 4
gm/day
- patient is taught to read labels for sodium restriction
4. MONITORING OF INTAKE AND OUTPUT
- check patient's intake and output
- check specific urine gravity
 NURSING INTERVENTIONS
5. RADIATION THERAPY
- used to treat hypercortisolism caused by adrean adenomas
- not always effective and often destroys normal tissue
Nursing Responsibilities:
- observe for neurologic changes such as:
- headache, elevated BP or pulse, disorientation or changes in
pupil size or reaction
- observer for skin dryness, redness, flushing or alopecia or the
radiation site
 SURGICAL MANAGEMENT
HYPOPHYSECTOMY
- If the adrenal hyperfunction is due to increased pituitary
secretion of ACTH

ADRENALECTOMY
- if hypercortisolism is caused by adrenal tumors
 SURGICAL MANAGEMENT
PREOPERATIVE CARE
- Electrolyte imbalances are corrected before the procedure
- continue to monitor blood potassium, sodium and chloride levels
- hyperglycemia is monitored before the surgery
- prevent infection by performing handwashing and aseptic
technique
- decrease the risk for falls by raising bed upper siderails
- high calorie and high protein diet is prescribed before surgery
- Glucocorticoids are given before surgery
 SURGICAL MANAGEMENT
OPERATIVE PROCEDURES
- Unilateral or Bilateral
- can be abdominal or lateral flank
POSTOPERATIVE CARE
- after surgery, patient is usually sent to critical care unit
- assess patient every 15 minutes for shock
- monitor intake and output
- monitor electrolytes
- weigh patient daily
 SURGICAL MANAGEMENT
BILATERAKL ADRENALECTOMY
- Requires lifelong glucocorticoid and mineralocorticoid
replacement starting after surgery

UNILATERAL ADRENALECTOMY
- hormone replacement continuous until the remaining adrenal
gland increases hormone production
 NURSING INTERVENTIONS
RISK FOR INJURY
1. SKIN INJURY
- assess for reddened areas, excoriation, breakdown and edema
- turn patient every 2 hours and pad bony prominences
- instruct to avoid activities that can cause skin trauma
- teach to use soft toothbrush and elctric shaver
- advise patient to keep skin clean and dry
- exert pressure over the puncture site after venipuncture or arterial
puncture
 NURSING INTERVENTIONS
2. PATHOLOGIC FRACTURES
- prevent patient from falls or bumps
- use lift sheet instead of grasping the patient
- remind pt to call for help when ambulating
- discuss ambulatory aids (walkers and canes) if necessary
- keep room free of extraneous objects that might cause a fall
- high calorie is instructed to patient
- include increase amount of calcium and vitamin D in the diet
- advise to avoid caffeine and alcohol
 NURSING INTERVENTIONS
3. GI BLEEDING
- common and is result of systemic changes
- cortisol inhibits production of thick gel-like mucus that protects
stomach lining, which triggers blood flow to the area and triggers
the release of hydrochloric acid
- H2 Blockers
 NURSING INTERVENTIONS
RISK FOR INFECTION
- protect patient from infection
- perform frequent handwashing
- anyone with URTI must wear mask when entering client's room
- assess for fever
- monitor patient's WBC and CBC and ANC
- inspect mouth per shift for lesions and mucosa breakdown
- assess lungs every hours for crackles, wheezes and reduced breath sounds
- assess urine for odor and cloudiness
- ask patient for urgency, burning or pain present on urination
 NURSING INTERVENTIONS
- take vital signs at least every 4 hours to assess for fever
- teach patient about hygiene
- instruct to perform daily bathing
- if patient is immobile, turn patient every hour and apply skin
lubricant
- perform pulmonary hygiene every 2 to 4 hours
- urge patient to cough and deep breathe or perform sustained
maximum inhalations every hour while awake
 PHEOCHROMOCYTOMA
- is a catecholamine -producing tumor that arises in teh
adrenal medulla.
- usualy benign an d and at least 10% malignant
- the tumors produce , store and release epinephrine and
norepinephrine which stimulate adrenergic receptors
- the cause is unknown but is associated with Multiple
Endocrine Neoplasia (MEN) syndromes.
- it occurs at any age but most commonly in patients
between ages 40 and 60.
 ASSESSMENT
- intermittent episodes of hypertension that vary in length from few
minutes to several hours
S/SX: Headache
Palpitations
Profuse Diaphoresis
Flushing
Apprehension
Pain in chest and abdomen
Nausea and Vomiting
 DIAGNOSTIC TEST
1. 24 hour urine collection for VMA or Vanillylmandelic Acid,
Metanephrine and Catecholamines
- most common diagnostic test
2. Clonidine suppresion and stimulation testing
3. MRI or CT Scan
4. After diagnosis, CT scans for chest and abdomen may be
used to locate other tumors
 INTERVENTIONS
1. Surgery is the main treatment for pheochromocytoma
2. Management is focused on tissue perfusion, nutritional needs and
comfort measures
3. Monitor BP
- Blood Pressure is the hallmark of the disease
4. Teach patient not to smoke and drink caffeine-containing beverages
5. Instruct not to change position suddenly
6. Do not palpate abdomen
7. Assess patient's hydration status
 INTERVENTIONS
8. Administer Phenoxybenzamine (Dibenzyline) starting several weeks
before surgery
9. Closely monitor patient for hypertension and hypotension after
surgery
10. Assess for hemorrage and shock
11. Monitor Vital signs and fluid intake and output