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Flashcards in Adrenal Dysfunction Deck (21)
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1
Q

Addison’s Disease aka Adrenal Insufficiency: Definition and Causes

A

hypo-function of adrenal cortex
all 3 corticosteroid classes are reduced

Primary cause: autoimmune, antibodies destroy the adrenal cortex, more common in women

Secondary cause: Cushing’s syndrome

  • suppression of hypothalamus-pituitary communication d/t taking steroids
  • abruptly stopping steroids (after taking for long period of time or on a higher dose)

Other causes: TB, amyloidosis, fungal infections, AIDS, metastatic cancer

2
Q

Corticosteroids

A

Glucocorticoids:

  • regulates metabolism, increases BG, critical for stress response
  • inhibit inflammation
  • ex) cortisol

Mineralocorticoid

  • target tissue is kidneys
  • regulates sodium and potassium balance, indirectly regulating water balance
  • ex) aldosterone

Adrenal Androgen Hormones

  • target tissues is ovaries, gonads
  • converted to sex hormones
  • also stimulates: regeneration of RBCs, skin pigmentation, increase protein in bone tissue
3
Q

Iatrogenic Addison’s Disease: Causes

A
  • adrenal hemorrhage from anticoagulant therapy
  • chemotherapy
  • ketoconazole therapy for AIDS (anti-fungal, PO therapy given to AIDS pt, interferes with pathways that produce cortisol and is anti-inflammatory)
  • bilateral adrenalectomy (not producing corticosteroids)
4
Q

Addison’s Disease: S/O data

A
  • gradual onset (insidious onset) - no symptoms until 90% of adrenal cortex is destroyed
  • characterized by fatigue, progressive weakness, weight loss, anorexia
  • N, V, D
  • orthostatic hypotension (loss of aldosterone)
  • skin hyperpigmentation
  • decrease serum cortisol levels
  • decrease NA and increase K (salt cravings)
  • HA
  • joint pain
  • irregular or no menstrual periods (d/t androgen hormones)
  • CT or MRI (looking for tumors)
5
Q

Addisonian Crisis aka Acute Adrenal Insufficiency: Definition

A

Medical Emergency, life threatening
-insufficient or sudden, sharp decrease in hormones
-various triggers:
stress w/o corticosteroid replacements
-abruptly. stopping steroid therapy ->adrenal insufficiency -> hypotension
-adrenal surgery
-sudden pituitary gland destruction (d/t loss of blood flow to brain, trauma to brain, stroke in that space, removal of part or all of pituitary or hypothalamus, radiation to pituitary)

6
Q

Addisonian Crisis: Manifestations of Glucocorticoid and Mineralocorticoid Deficiencies

A
  • HTN is #1 problem -> tachycardia to compensate
  • Dehydration
  • Decreased sodium, increased potassium, decreased glucose
  • Fever, weakness
  • Confusion, altered mental status (d/t decreased Na)
  • severe vomiting, diarrhea, pain in the abdomen (d/t increased K)
  • shock -> circulatory collapse
7
Q

Addisonian Crisis: Interventions

A
  • shock management (perfusion issues d/t low BP -> O2 needs)
  • high-dose hydrocortisone replacement into IV quickly (#1 fix)
  • 0.9% NaCl IV solution w/ 5% dextrose (for BG)
  • IV vasopressors (norepinephrine) to support BP
  • sodium polystyrene PO (kayexalate for high potassium)
  • NG tube for n/v (prevent aspiration)
  • treat underlying cause
  • prevent complications of immobility
8
Q

Addison’s Disease: Dx

A

ACTH stimulation test:

  • baseline levels of cortisol and ACTH from saliva or blood test
  • IV injection of synthetic ACTH given
  • levels rechecked after 30-60 min
  • little or no increase in cortisol levels = addison’s disease
  • high ACTH = primary adrenal insufficiency

Blood work will show:

  • high potassium
  • low chloride, sodium, glucose
  • anemia (d/t low androgen hormone)
  • increased BUN

ECG changes
CT scan, MRI (to look at structures of adrenal/pituitary gland and look for tumors)

9
Q

Addison’s Disease: Interprofessional Care

A

manage underlying cause
lifelong hormone therapy
-hydrocortisone or prednisone to replace cortisol
-increase during periods of stress (double dose for minor stress, triple dose for major stress)
-fludrocortisone (Florinef) PO to replace aldosterone
-women need androgen replacement

increase dietary salt intake

10
Q

Addison’s Disease: Nursing Interventions

A

Education:

  • Dosing: take hydrocortisone in divided doses (2/3 in AM, 1/3 in late afternoon), mineralcorticoids (fludrocortisone) once in the morning.
  • reflects normal circadian rhythm and decreases SE of corticosteroids
  • normal life if adherent and consistent with meds
  • diet: increase protein, carbs, and sodium (metabolism is low)
  • salt additives for excessive heat/humidity (b/c they will sweat more)
  • report s/sx of corticosteroid deficiency and excess to HCP (too much -> symptoms of Cushing)
  • n/v also should be reported to HCP as this will require electrolyte replacement
  • med ID bracelet
  • carry emergency kit (IM hydrocortisone)
11
Q

Corticosteroid Therapy: Expected Effects

A

anti-inflammatory action
immunosuppression
maintenance of normal BP

12
Q

Corticosteroid Therapy: SE

A
  • decreased potassium and calcium (ok side effect to have for addison’s disease)
  • increased glucose and BP (also ok side effect for addison’s disease)
  • delayed healing
  • susceptibility to infection
  • suppressed immune response
  • predisposed to cataracts
  • peptic ulcer disease
  • muscle atrophy/weakness
  • mood and behavior changes
  • moon face, truncal obesity
  • protein depletion (low protein for addison’s but need protein when on corticosteroid therapy)
  • risk for acute adrenal crisis if therapy is stopped abruptly (steroid tapering for short term steroid treatment)
13
Q

Corticosteroid Therapy: Pt Teaching

A
  • dietary, rest and exercise needs
  • sodium restriction if edema occurs
  • need to monitor for hyperglycemia
  • notify HCP if epigastric pain develops (high risk for stress ulcers from this therapy)
  • need to prevent injury/infection/stress
  • inform all HCP (including Dentist)
  • therapies to reduce osteoporosis (prevent falls)
  • check BP at home, don’t want it to get too low, can also get too high on steroids
14
Q

Cushing Syndrome and Cushing Disease: Cause

A

-excess of all 3 corticosteroid classes

other common causes:

  • iatrogenic administration of exogenous corticosteroids for another condition
  • ACTH-secreting pituitary adenoma (this is Cushing disease)
  • adrenal tumors (tumor causes increase in excretion )
  • ectopic ACTH production by tumors (Small Cell Lung Cancer)
15
Q

Cushing Syndrome: Clinical Manifestations

A

Excessive glucocorticoids:

  • hyperglycemia r/t glucose intolerance and increased gluconeogenesis
  • muscle wasting -> weakness (muscle loss d/t protein wasting - arms are skinny even though trunk is large)
  • loss of bone matrix -> osteoporosis (-> pathological fx) and back pain
  • loss of collagen -> thin skin, easily bruises, petechiae
  • delay in wound healing
  • kidney stones b/c of hypercalciuria

Excess mineralocorticoid:

  • hypokalemia (d/t more K wasting)
  • HTN (d/t more sodium retention)

Excess Adrenal Androgen:

  • severe acne
  • male characteristics in women (hirsutism)
  • feminization in men (gynecomastia)

weight gain d/t accumulation of adipose tissue in the trunk, face, cervical area (retention of water and sodium)

skin changes:

  • striae: purple red streaks
  • plethora: redness in face
  • weak, thin skin, ecchymosis
  • delayed wound healing

mental changes

16
Q

Cushing Syndrome: Dx

A

ACTH levels:

  • high or normal = d/t anterior pituitary problem
  • low or undetectable = adrenal cortex problems or prednisone use

CBC: may indicate immune suppression (low WBC)

Chemistries: hyperglycemia, hypokalemia

CT Scans or MRI if suspect tumor

17
Q

Cushing Syndrome: Plans/Interventions (Non-surgical)

A

if d/t prolonged steroid use:

  • gradually d/c use of corticosteroid (taper)
  • alternating day regime (try shorter acting instead of longer acting, etc.)
  • prevent adrenal insufficiency and adrenal insufficiency crisis
  • medications: adrenal corticosteroid inhibitor to decrease adrenal hormone synthesis
  • Nizoral (ketoconazole): antifungal given in high doses (monitor LFTs, med is hard on liver) and GI side effects
18
Q

Cushing Syndrome: Surgical Interventions

A

adrenalectomy as indicated for cushing syndrome caused by tumors or hyperplasia

or:
pituitary adenoma - surgery to remove tumor via transphenoidal approach

hypophysectomy - removal of pituitary gland

19
Q

Cushing Syndrome: Nursing Interventions (Preoperative Care)

A

optimize physical condition
control HTN and hyperglycemia
correct hypokalemia
high-protein diet to correct protein depletion (will be helpful with healing process)

20
Q

Cushing Syndrome: Nursing Interventions (Post-op Care)

A

critical time period for circulatory instability is 24-48 hours after surgery

  • hemorrhage risk for adrenal removal and pituitary removal
  • imbalance of BP, fluid & electrolytes d/t hormone fluctuations
  • monitor nasal drainage/dressing for CSF leak (will be +glucose if there is CSF leak), yellow halo

high dose corticosteroids (intra- and post-operatively) provide adequate response to stress of surgery (help control risk of having adrenal insufficiency crisis after surgery):

  • administer IV then PO, adjusted according to pt response
  • if taper too rapid, may cause adrenal insufficiency
  • may need to have life-long glucocorticoid, mineralocorticoid and hormone replacement therapy (depending on what and how much was removed)
  • if pituitary was removed (messed with brain), ABC’s, bed rest until BP is stable
  • AM urine to monitor effectiveness of surgery (cortisol levels should drop)
  • avoid ICP
  • monitor nasal drainage
  • notify surgeon if increased bleeding, HA, change in mental status
21
Q

Cushing Syndrome: Post Op Surgery Discharge Instructions

A
  • life-long replacement therapy (takes months for hormonal adjustment)
  • avoid temp extremes, infections, emotional upset
  • stress may cause acute adrenal insufficiency
  • self-adjustment of corticosteroid replacement therapy if possible according to own stress level
  • adise s/sx of adrenal insufficiency (adrenal crisis)
  • wear medic alert bracelet
  • carry emergency injection kit