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Adrenal gland Surgery(2)
The adrenal glands produce important hormones that regulate salt, sugar, and sex functions in the body. The adrenal cortex produces mineralocorticoids like aldosterone which regulate sodium and potassium levels, and glucocorticoids like cortisol which regulate carbohydrate, fat, and protein metabolism. The adrenal medulla produces catecholamines like epinephrine and norepinephrine which trigger the fight or flight response. Diseases can result from too much or too little production of these hormones. Cushing's disease occurs when there is too much cortisol and causes weight gain, high blood pressure, and easy bruising. Conn's syndrome features too much aldosterone and causes high blood pressure and low potassium
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Adrenal gland Surgery(2)
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- 3. SALT Mineralocorticoids (F &E balance) – Aldosterone (renin from kidneys controls adrenal cortex production of aldosterone) Na retention Water retention K excretion
- 4. Question: If your Nalevel is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion or
- 5. SUGAR GLUCOCORTICOIDS (regulate metabolism &are critical in stress response) – CORTISOL responsible for control and & metabolism of: a. CHO (carbohydrates) – amt. glucose formed – amt. glucose released
- 6. CORTISOL b. FATS-control offat metabolism stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism – stimulates protein synthesis in liver – protein breakdown in tissues
- 7. SUGAR Other fxs ofCortisol – inflammatory and allergic response – immune system therefore prone to infection
- 8. SEX ANDROGENS – hormones whichmale characteristics release of testosterone Seen more in women than men
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- 10. LET’S LOOK ATACTH (adrenocorticotropic Hormone) Produced in anterior pituitary gland
- 11. ACTH Circulating levels of cortisol –levels cause stimulation of ACTH – levels cause dec. release of ACTH think tank: What type of feedback mechanism is this??
- 12. AFFECTED BY: Individual biorhythms –ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. – usually 5AM - 7AM – these gradually decrease rest of day Stress- cortisol production and secretion
- 13. ADRENAL MEDULLA Fight orflight What is released by the adrenal medulla?
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- 15. HYPER AND HYPOFUNCTION ADRENAL CORTEX HORMONES Toomuch Too little
- 16. I. CUSHING’S DISEASE (TOO MUCH CORTISOL!) secretionof cortisol from adrenal cortex 4X more frequent in females Usually occurs at 35-50 years of age
- 17. ETIOLOGY Cushing’s Primary-tumor on theadrenal cortex Secondary-tumor on the anterior pituitary gland Ectopic ACTH secreting tumor (lung, pancreas) Iatrogenic-Steroid administration
- 18. SIGNS & SYMPTOMS Cushing’s protein catabolism –muscle wasting – loss of collagen support thin, fragile skin, bruises easily – poor wound healing
- 19. SIGNS & SYMPTOMS Cushing’s sin CHO metabolism –hyperglycemia –Can get diabetes-insulin can’t keep up –Polyuria
- 21. SIGNS & SYMPTOMS Cushing’s sin fat metabolism –truncal obesity –buffalo hump –“moon face” – weight but strength
- 22. SIGNS & SYMPTOMS immuneresponse –More prone to infection – resistance to stress –Death usually occurs from infection
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- 25. What sign wouldthe nurse identify in each patient?
- 26. SIGNS & SYMPTOMS mineralocorticoidactivity – ________ retention _______ retention – b.p. from ________
- 27. SIGNS & SYMPTOMS MENTALCHANGES Mood swings Euphoria Depression Anxiety Mild to severe depression Psychosis Poor concentraion and memory Sleep disorders
- 28. SIGNS & SYMPTOMS sin hematology WBCs lymphocytes eosinophils
- 29. DIAGNOSIS of Cushing’s Serum cortisollevels What will serum cortisol levels be? Draw AT 8AM AND 8PM What would you expect? URINARY LEVELS OF STEROID METABOLITES. 17-OHCS (hydroxycorticoid steroid) 17-KS (ketosteroid)
- 30. TREATMENT of Cushing’s Surgery transsphenoidal removalof pituitary tumor adrenalectomy-can be unilateral or bilateral if bilateral, need hormone replacement for life ectopic-try to remove source of ACTH secretion
- 31. Cushing’s TREATMENT Radiation to tumors Palliativedrugs – MITOTANE destroys tissue in adrenal cortex
- 32. REVIEW: WHAT NURSING PRIORITY PROBLEMSWILL YOU EXPECT IN CUSHING’S?
- 33. Too much aldosteronesecretion Question: What does aldosterone do???? _____________________________ usually caused by adrenal tumor II. HYPERALDOSTERONISM “Conn’s Syndrome”
- 34. SIGNS & SYMPTOMS Hyperaldosteronism Naand water retention –H/A, HTN K+ (hypokalemia) What is the normal serum K+ level??? Usually no edema
- 35. DIAGNOSIS- Hyperaldosteronism urinary K plasma aldosterone levels withlow plasma renin levels CT scan EKG changes
- 36. INTERVENTIONS Hyperaldosteronism BP -aldactone=Aldosterone antagonist sowhat will it do to Na, H2O, and K??? Correct hypokalemia/hypernatremia – K+ supplements; low Na diet Partial or total adrenalectomy
- 37. ADRENALECTOMY PRE-OP Stabilize hormonally Correct fluidand electrolytes Cortisol PM before surgery, AM of surgery and during OR.
- 38. ADRENALECTOMY POST-OP ICU-What type ofproblems to expect?? IV cortisol for 24 hours IM cortisol 2nd day PO cortisol 3rd day Poor wound healing If unilateral- steroids weaned – other adrenal takes over 6-12 months
- 39. ADDISON’S DISEASE hypofunction ofadrenal cortex What hormones will you have too little of??? glucocorticoids or _______ mineralocorticoids or _______ androgens or ____________
- 40. Trivia Question: Which famousPresident had Addison’s Disease???
- 42. ETIOLOGY of Addison’s Idiopathic atrophy –autoimmunecondition Antibodies attack against own adrenal cortex –90% of tissue destroyed
- 43. ETIOLOGY of Addison’s TB/fungal infections (histoplasmosis) Iatrogeniccauses – adrenalectomy, chemo, anticoagulant tx
- 44. SIGNS & SYMPTOMS Addison’sDisease fatigue, weight loss, anorexia – Why? think of cortisol fx Changes in skin pigment – small black freckles – cortisol -- ACTH-- MSH Muscular weakness – cortisol helps muscles maintain contraction and avoid fatigue
- 45. SIGNS & SYMPTOMS Addison’s Fluid& electrolyte imbalances – WHY??? b.p. – WHY??? Hyponatremia-why? Hyperkalemia-why? Hypoglycemia-why?
- 46. SIGNS & SYMPTOMS Addison’s androgens –hair loss, sexual fx mental disturbances – anxiety, irritability, etc. salt craving-why?
- 47. DIAGNOSIS-Addison’s serum cortisol urinary 17-OHCSand 17 KS K, Na serum glucose
- 48. INTERVENTIONS Addison’s Disease Life longhormone replacement –primary-need oral cortisone 20- 25mgs in AM and 10-12mg in PM –change dose PRN for stress –also need mineralocorticoid- (FLORINEF)
- 49. INTERVENTIONS Salt food liberally Donot fast or omit meals Eat between meals and snack Eat diet high in carbs and proteins Wear medic-alert bracelet kit of 100mg hydrocortisone IM
- 50. INTERVENTIONS Addison’s Disease Keep parenteralglucocorticoids at home for injection during illness Avoid infections/stress
- 51. COMPLICATIONS Addison’s Disease Adrenal crisis Electrolyteimbalance Hypoglycemia
- 52. ADDISON’S CRISIS Sudden decreaseor absence of adrenal cortex hormones which are: __________________ __________________ __________________
- 53. CAUSES Pt. with Addison’swho doesn’t respond to tx or has stress without dose Pt. with Addison’s but undiagnosed who is exposed to stress Pt. on steroids that are dc’d without tapering Pt. with Addison’s not controlled
- 54. SIGNS & SYMPTOMS AddisonianCrisis Dehydration- Na, K, BP N/V,diarrhea, wt. loss Weakness Confusion,headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH
- 55. TREATMENT Addisonian Crisis Rapid infusionof IV fluids Check VS and urine output frequently Monitor EKG Give solu-cortef IV Q6 hours until S & S disappear
- 56. TREATMENT Try to anxiety Mayhave to give vasopressors – Dopamine or Epinepherine Avoid additional stress
- 57. PHEOCHROMOCYTOMA rare, benign tumorof the adrenal medulla oh no...what are we going to see a hypersecretion of????
- 58. SIGNS AND SYMPTOMS Hallmarkis hypertension-200/150 or greater “Spells” -paroxymal attacks –bladder distension,emotional distress, exposure to cold. NE and Epinepherine released sporadically
- 59. SIGNS & SYMPTOMS Deepbreathing Pounding heart Headache Moist cool hands & feet Visual disturbances
- 60. DIAGNOSIS 24 hour urine-VMA(metabolite of Epinepherine) Plasma catecholamines CT to locate tumor
- 61. INTERVENTIONS-PRE-OP Adrenergic blocking agents –Minipress to bp Beta blocking agents – Inderal to hr, b.p., & force of contraction Diet – high in vitamin, mineral,calorie, no caffeine Sedatives
- 62. INTERVENTIONS Monitor b.p. Eliminate attacks Ifattack- complete bedrest and HOB 45 degrees
- 63. DURING SURGERY GIVE REGITINEAND NIPRIDE TO PREVENT HYPERTENSIVE CRISIS
- 64. POST-OP b.p. may beinitially, BUT CAN BOTTOM OUT Volume expanders Vasopressors Hourly I and O Observe for hemorrhage
- 65. QUESTION?? What if youare not a candidate for surgery??? Demser (drug which inhibits catecholamine synthesis) Avoid opiates, histamines, reglan, anti-depressants. Why?
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