Adrenal Gland Disorders

Transcription

1 1 Adrenal Gland Disorders Adrenal cortex steroid hormones (corticosteroids) 1. Glucocorticoids Regulate metabolism and blood glucose Critical to physiologic stress response 2. Mineralocorticoids Regulate sodium balance Regulate potassium balance 3. Androgen Contributes to growth and development in both genders Contributes to sexual activity in adult women Cushing Syndrome Cushing syndrome is a spectrum of clinical abnormalities caused by excessive corticosteroids, particularly glucocorticoids. The most common cause is iatrogenic administration of exogenous corticosteroids (e.g., prednisone). Most (85%) cases of endogenous Cushing syndrome are due to adrenocorticotrophic hormone (ACTH) secreting pituitary tumor (Cushing s disease). Other causes include o Adrenal tumors o Ectopic ACTH production in tumors outside hypothalamic pituitary adrenal axis Usually lung and pancreas tumors Key signs include weight gain o Trunk (centripetal obesity) o Face ( moon face, fullness of face ) o Cervical area o Transient weight gain from sodium and water retention

2 2 Other key features include purplish red striae below the skin surface. Other key features include hirsutism in women, hypertension, and unexplained hypokalemia. Hyperglycemia is common. o Glucose intolerance associated with cortisol-induced insulin resistance o Increased gluconeogenesis by liver Protein wasting is key feature o Catabolic effects of cortisol o Leads to weakness especially in extremities o Protein loss in bones leads to osteoporosis, bone and back pain Diagnostic Studies 24-Hour urine for free cortisol o Levels of 50 to 100 mcg/day in adults indicates Cushing syndrome o The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increase cortisol levels. High-dose dexamethasone suppression test used for borderline results of 24-hour urine cortisol CT and MRI of pituitary and adrenal glands Plasma ACTH may be low, normal, or elevated depending on problem o High or normal ACTH levels indicate ACTH-dependent Cushing s disease o Low or undetectable ACTH levels indicate an adrenal or exogenous etiology

3 3 Collaborative Care Treatment is dependent on the underlying cause, and includes surgery and drug therapy to normalize hormone levels. Pituitary adenoma o Surgical removal of tumor and/or radiation Adrenal tumors or hyperplasia o Adrenalectomy Ectopic ACTH-secreting tumors o Managed by treating primary neoplasm Drug therapy indicated when surgery is contraindicated or as adjunct to surgery o Goal of drug therapy is inhibition of adrenal function o Mitotane Suppresses cortisol production Alters peripheral metabolism of cortisol Plasma and urine corticosteroid levels o Metyrapone, ketoconazole, and aminoglutethimide inhibit cortisol synthesis o Common side effects of drug therapy Anorexia Nausea and vomiting GI bleeding Depression Vertigo Skin rashes Diplopia (double vision) Nursing Diagnoses Risk for infection related to lowered resistance to stress and suppression of immune system Imbalanced nutrition: more than body requirements related to increased appetite, high caloric content of foods, and inactivity as evidenced by statement of increased appetite; weight 10% or more than optimum for height Situational low self-esteem related to altered body image, emotional lability, and diminished physical capabilities as evidenced by verbalization of negative feelings regarding personal appearance and inability to perform usual activities Impaired skin integrity related to excess corticosteroids, immobility, and altered skin fragility as evidenced by edema; thin, fragile skin; impaired healing Nursing Planning Patient goals include o Experience relief of symptoms o Have no serious complications (cardiovascular disease, DM, infection) o Maintain positive self-image o Actively participate in therapeutic plan

4 4 Nursing Implementation Emotional support Patient may feel unattractive or unwanted Nursing staff should remain sensitive to patient s feeling and be respectful Reassure patient physical symptoms will resolve when hormone levels return to normal Preoperative care Patient should be in optimal physical condition Control hypertension and hyperglycemia Hypokalemia must be corrected with diet and potassium supplements High-protein diet helps correct protein depletion Teaching depends on surgical approach Include information on postoperative care o Nasogastric tube o Urinary catheter o IV therapy o Central venous pressure monitoring o Leg compression devices Postoperative care Risk of hemorrhage is increased because of high vascularity of adrenal glands Manipulation of glandular tissue may release hormones into circulation BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations High doses of corticosteroids administered by IV during and several days after surgery Report any significant changes in o BP o Respiration o Heart rate Monitor fluid intake and output to assess for imbalances Critical period for circulatory instability ranges from 24 to 48 hours Morning urine levels of cortisol are measured to evaluate the effectiveness of surgery Adrenal insufficiency develops if corticosteroid dosage tapered rapidly Indications of hypocortisolism o Vomiting o Increased weakness o Dehydration o Hypotension Discharge instructions are based on patient s lack of endogenous corticosteroids and resulting inability to react to stressors physiologically. Lifetime replacement therapy is required by many patients. Avoid exposure to stress, extremes of temperature, and infections

5 5 Addison s Disease In the patient with Addison s disease, all three classes of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens) are reduced. The etiology is mostly autoimmune where adrenal cortex is destroyed by autoantibodies. o Susceptibility genes have been identified Other causes include lack of pituitary ACTH Iatrogenic Addison s disease may be due to adrenal hemorrhage Clinical Manifestations Does not become evident until 90% of adrenal cortex is destroyed Disease usually advanced before diagnosis Manifestations have a slow onset and include weakness, weight loss, and anorexia. Skin hyperpigmentation is seen in sun-exposed areas of body, at pressure points, over joints, and in palmar creases. Orthostatic hypotension Hyponatremia Hyperkalemia Nausea and vomiting Diarrhea

6 6 Complications/ Addisonian Crisis Patients with Addison s disease are at risk for an acute adrenal insufficiency (addisonian crisis), a life-threatening emergency caused by insufficient or sudden decrease in adrenocortical hormones. Addisonian crisis is triggered by stress (e.g., surgery, trauma, hemorrhage, or psychologic distress); sudden withdrawal of corticosteroid hormone replacement therapy; and postadrenal surgery. Manifestations include postural hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative Care The treatment is replacement therapy. Hydrocortisone, the most commonly used form of replacement therapy, has both glucocorticoid and mineralocorticoid properties. During times of stress, glucocorticoid dosage is increased to prevent addisonian crisis. o Situations requiring corticosteroid dose adjustment include Fever Tooth extraction Influenza Physical exertion o Doses are doubled for minor stressors and tripled for major stressors o It is better to err on the side of overreplacement Mineralocorticoid replacement with fludrocortisone acetate (Florinef) is given daily with increased dietary salt. Patient teaching covers medications, techniques for stress management, and that patient must always wear an identification bracelet (Medic Alert). Treatment is shock management and high-dose hydrocortisone replacement. Large volumes of 0.9% saline solution and 5% dextrose are given to reverse hypotension and electrolyte imbalances until blood pressure normalizes. Effects of Corticosteroid Therapy Should be taken in the morning with food to reduce gastric irritation Must not be stopped abruptly Assess for corticosteroid-induced osteoporosis Assess for hyperglycemia. The nurse could prudently question if such a patient is not receiving an IV infusion that is free of dextrose, such as normal saline or one half normal saline. Systemic corticosteroids drugs such as prednisone should not be given concurrently with nonsteroidal antiinflammatory drugs such as ibuprofen because this can increase the risk of GI bleeding.

7 7 Acute intervention Frequent assessment necessary Assess vital signs and signs of fluid and electrolyte imbalances every 30 minutes to 4 hours for first 24 hours Take daily weights Administer corticosteroid therapy diligently Protect against infection Assist with daily hygiene Protect from extremes o Light o Noise o Temperature NCLEX-RN Simulated Questions (Hydrocortisone Therapy) 1. The nurse would monitor for which of the following adverse changes in the patient s laboratory values as a result of being treated with dexamethasone (Decadron)? a. Blood glucose 162 mg/dl b. Potassium 4.9 meq/l c. Sodium 130 meq/l d. Calcium 8.2 mg/dl 2. To maintain patient safety, the nurse would question the physician about an order for prednisone if the patient also had which of the following conditions? a. Systemic fungal infection b. Diabetes insipidus c. Heart failure d. Renal insufficiency 3. The nurse questions an order for a medication when she realizes it should not be given concurrently with prednisone because of increased risk of GI bleeding. Which drug is the order for? a. Morphine sulfate b. Ibuprofen (Motrin) c. Zolpidem (Ambien) d. Ondansetron (Zofran) 4. The nurse would cautiously monitor a patient receiving an IV of 5% dextrose in water, knowing that which of the following medications prescribed for the patient increases the risk of hyperglycemia? a. Calcitriol (Rocaltrol) b. Potassium iodide (SSKI) c. Levothyroxine (Synthroid) d. Methylprednisolone (Solu-Medrol)