ADRENAL GLANDS Adrenal Cortex Adrenal Medulla. http://services.epnet.com/GetImage.aspx/getImage.aspx?ImageIID=7262.

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<ul><li> Slide 1 </li> <li> ADRENAL GLANDS Adrenal Cortex Adrenal Medulla </li> <li> Slide 2 </li> <li> http://services.epnet.com/GetImage.aspx/getImage.aspx?ImageIID=7262 </li> <li> Slide 3 </li> <li> http://images.google.com/imgres?imgurl=http://media.medicalcentral.com/picAddisonD iseaseMouthuiowaedu.jpg&amp;imgrefurl=http://www.diseasedisorder.com/diseasedisor derdefinitions/addisonsdisease.asp&amp;usg=__V112XzFmfSG3kLrUzpEOx6SCgAI= &amp;h=201&amp;w=300&amp;sz=12&amp;hl=en&amp;start=20&amp;sig2=ncZQmF9qjo3yu4tCagesMg&amp;tbnid =zWDvim- GYUotJM:&amp;tbnh=78&amp;tbnw=116&amp;prev=/images%3Fq%3Dchanges%2Bin%2Bskin %2Bpigmentation%2Bin%2Baddisons%2Bdisease%26gbv%3D2%26ndsp%3D18 %26hl%3Den%26sa%3DN%26start%3D18&amp;ei=3vLlSczAA5auMcblqe0J </li> <li> Slide 4 </li> <li> ADRENAL CORTEX Sugar Salt Sex </li> <li> Slide 5 </li> <li> SUGAR GLUCOCORTICOIDS (regulate metabolism &amp; are critical in stress response) CORTISOL responsible for control and &amp; metabolism of: a. CHO (carbohydrates) --- Regulation of blood glucose concentration - inc thru gluconeogenesis - dec use during fasting </li> <li> Slide 6 </li> <li> SUGAR cont - Cortisol b. FATS-control of fat metabolism - stimulates fatty acid mobilization from adipose tissue c. PROTEINS-control of protein metabolism stimulates protein synthesis in liver protein breakdown in tissues </li> <li> Slide 7 </li> <li> SUGAR cont Other functions of Cortisol What happens to cortisol levels during stressful times? What does it do to the inflammatory response? What does it do the immune response? Can you name some exogenous corticosteroids? </li> <li> Slide 8 </li> <li> Exogenous Corticosteroids Common **______________ Betamethasone (Celestone) Betamethasone Budesonide (Entocort EC) Budesonide Cortisone (Cortone) Cortisone Prednisolone (Prelone) Prednisolone Triamcinolone (Kenacort, Kenalog) Triamcinolone </li> <li> Slide 9 </li> <li> SALT Mineralocorticoids (F &amp; E balance) Aldosterone What stimulates aldosterone secretion? What inhibits adlosterone secretion? Na retention Water retention K excretion Hydrogen ion excretion </li> <li> Slide 10 </li> <li> Question: If your Na level is low, will aldosterone secretion or If your serum K+ level is high, will aldosterone secretion or </li> <li> Slide 11 </li> <li> SEX ANDROGENS hormones which male characteristics release of testosterone </li> <li> Slide 12 </li> <li> RELEASE OF GLUCOCORTICOIDS IS CONTROLLED BY ___?___ </li> <li> Slide 13 </li> <li> LETS LOOK AT ACTH ( adrenocorticotropic hormone ) Produced where? </li> <li> Slide 14 </li> <li> ACTH Circulating levels of cortisol levels cause __________ of ACTH think tank: What type of feedback mechanism is this?? </li> <li> Slide 15 </li> <li> AFFECTED BY: Individual biorhythms ACTH LEVELS ARE HIGHEST 2 HOURS BEFORE AND JUST AFTER AWAKENING. usually 5AM - 7AM these gradually decrease the rest of day Stress- ____ cortisol production &amp; secretion </li> <li> Slide 16 </li> <li> HYPER &amp; HYPO FUNCTION ADRENAL CORTEX HORMONES Too much Too little </li> <li> Slide 17 </li> <li> Too much aldosterone secretion Question: What does aldosterone do???? _____________________________ usually caused by adrenal tumor HYPERALDOSTERONISM Conns Syndrome </li> <li> Slide 18 </li> <li> SIGNS &amp; SYMPTOMS Hyperaldosteronism Na and water retention What is the normal serum K+ level? Usually no edema </li> <li> Slide 19 </li> <li> DIAGNOSIS Hyperaldosteronism urinary K plasma aldosterone &amp; Na levels with low plasma renin levels BP CT scan EKG changes Labs Presence of hypokalemia with HTN suspect CONNS </li> <li> Slide 20 </li> <li> INTERVENTIONS Hyperaldosteronism BP What drugs would you give? Correct hypokalemia/hypernatremia What you would you do? Partial or total adrenalectomy </li> <li> Slide 21 </li> <li> ADRENALECTOMY PRE-OP Stabilize hormonally Correct fluid and electrolytes Would you need to replace cortisol levels before or after surgery? </li> <li> Slide 22 </li> <li> ADRENALECTOMY POST-OP ICU-What type of problems to expect?? IV cortisol for 24 hours IM cortisol 2nd day PO cortisol 3rd day Possible hypo/hyperkalemia If unilateral- steroids weaned </li> <li> Slide 23 </li> <li> Cushing Syndrome vs Cushings Disease </li> <li> Slide 24 </li> <li> CUSHINGS DISEASE (TOO MUCH CORTISOL!) secretion of cortisol 4X more frequent in females Usually occurs at 20-40 years of age if not related to exogenous factors </li> <li> Slide 25 </li> <li> ETIOLOGY Cushings Cushings Disease _____________________ Cushing Syndrome _____________________ </li> <li> Slide 26 </li> <li> SIGNS &amp; SYMPTOMS Cushings protein catabolism muscle wasting *loss of collagen support poor wound healing </li> <li> Slide 27 </li> <li> SIGNS &amp; SYMPTOMS Cushings Electrolyte imbalances Which ones? s in carbohydrate metabolism Hyperglycemia Why? </li> <li> Slide 28 </li> <li> SIGNS &amp; SYMPTOMS Cushings s in fat metabolism ****abdomen aka: _________ cervical spine aka: _________ ****face aka: _________ </li> <li> Slide 29 </li> <li> SIGNS &amp; SYMPTOMS immune response More prone to infection resistance to stress </li> <li> Slide 30 </li> <li> What sign would the nurse identify in each patient? </li> <li> Slide 31 </li> <li> SIGNS AND SYMPTOMS Cushings androgen secretion What would you expect to see? </li> <li> Slide 32 </li> <li> SIGNS &amp; SYMPTOMS mineralocorticoid activity ________ retention _______ retention What happens to blood pressure? </li> <li> Slide 33 </li> <li> SIGNS &amp; SYMPTOMS MENTAL CHANGES Mood swings Euphoria Depression Anxiety Mild to severe depression Psychosis Poor concentration and memory Sleep disorders </li> <li> Slide 34 </li> <li> SIGNS &amp; SYMPTOMS s in hematology WBCs lymphocytes eosinophils </li> <li> Slide 35 </li> <li> Slide 36 </li> <li> DIAGNOSIS of Cushings Clinical presentation is the first indication: truncal obesity moon facies with plethora purplish red striae hirsutism menstrual disorders hypertension unexplained hypokalemia </li> <li> Slide 37 </li> <li> DIAGNOSIS of Cushings 24 hr urine collection for free cortisol How do you do this? What levels would diagnosis Cushing? (When results are borderline..dexamethasone suppression test) Dexamethasone suppression test false positive can occur in depressed or overly stressed pts Serum cortisol levels What will serum cortisol levels be? Draw AT 8AM AND 8PM What would you expect? </li> <li> Slide 38 </li> <li> High Dose Dexamethasone Suppression Test ACTHCortisol Low/undectableNot suppressed Adrenal Cushing syndrome is likely. Normal- Very High Lack of suppression Ectopic ACTH syndrome is likely. If an adrenal tumor is not apparent, a chest CT and abdominal CT is indicated to rule out a different tumor secreting ACTH Normal - ElevatedIs suppressedCushings disease should be considered. A pituitary MRI would be needed to confirm </li> <li> Slide 39 </li> <li> Markers of Adrenal Cortex function Urinary 17-hydroxycorticosteroids (17-OHCS) 17-ketosteroid sulfates (17-KS-S) </li> <li> Slide 40 </li> <li> DIAGNOSIS of Cushings Plasma ACTH levels Low, normal or elevated? Other labs associated with Cushings Leukocytosis- Lymphopenia Eosinopenia- Hyperglycemia Glycosuria- Hypercalcemia Osteoporosis- ****Hypokalemia Alkalosis CT &amp; MRI Of what? Looking for what? </li> <li> Slide 41 </li> <li> TREATMENT of Cushings Primary goal: What do you think? Treatment related to underlying cause!!!!! </li> <li> Slide 42 </li> <li> TREATMENT of Cushings Surgery transsphenoidal -removal of pituitary tumor ectopic ACTH secreting tumor -try to remove source of ACTH secretion adrenalectomy -can be unilateral or bilateral -if bilateral, need hormone replacement for life -Laproscopic vs Open Surgical </li> <li> Slide 43 </li> <li> TREATMENT of Cushings Radiation to tumors Why would one choose radiation? Palliative drugs Goal of drug therapy? MITOTANE directly suppresses adrenal cortex fx Others: Metyrapone blocks cortisol synthesis &amp; Ketocenozole blocks cortisol sysnthesis </li> <li> Slide 44 </li> <li> TREATMENT of Cushings What if Cushing Syndrome is result of exogenous corticosteroids? </li> <li> Slide 45 </li> <li> REVIEW: WHAT NURSING PRIORITY PROBLEMS WILL YOU EXPECT IN CUSHINGS? </li> <li> Slide 46 </li> <li> Nursing Diagnosis Risk for infection Imbalanced nutrition more than requirements Risk for injuryinc muscle wasting Disturbed body image Impaired skin integrity Fluid volume excess </li> <li> Slide 47 </li> <li> ADDISONS DISEASE hypofunction of adrenal cortex What hormones will you have too little of??? glucocorticoids or _______ mineralocorticoids or _______ androgens or ____________ </li> <li> Slide 48 </li> <li> Trivia Question: Which famous President had Addisons Disease??? </li> <li> Slide 49 </li> <li> ETIOLOGY of Addisons Idiopathic atrophy autoimmune condition antibodies attack against own adrenal cortex 90% of tissue destroyed </li> <li> Slide 50 </li> <li> ETIOLOGY of Addisons Malignancy TB Fungal infections (histoplasmosis) AIDS Iatrogenic causes </li> <li> Slide 51 </li> <li> SIGNS &amp; SYMPTOMS Addisons Disease Fatigue, weight loss, anorexia Changes in skin pigment small black freckles Muscular weakness </li> <li> Slide 52 </li> <li> SIGNS &amp; SYMPTOMS Addisons Fluid &amp; electrolyte imbalances b.p. Hyponatremia Hyperkalemia Hypoglycemia </li> <li> Slide 53 </li> <li> SIGNS &amp; SYMPTOMS Addisons androgens hair loss, sexual fx mental disturbances anxiety, irritability, etc. salt craving </li> <li> Slide 54 </li> <li> DIAGNOSIS-Addisons ____serum cortisol ____urinary 17-OHCS and 17 KS ____K ____Na ____serum glucose ____plasma ACTH ____urine free cortisol </li> <li> Slide 55 </li> <li> INTERVENTIONS Addisons Disease Life long hormone replacement primary-need_______________ 20-25mgs in AM &amp; 10-12mg in PM When might one need to increase the dose? also need mineralocorticoid- (FLORINEF) </li> <li> Slide 56 </li> <li> INTERVENTIONS Salt food liberally Do not 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 </li> <li> Slide 57 </li> <li> INTERVENTIONS Addisons Disease Keep parenteral glucocorticoids at home for injection during illness Do you need to avoid infections/stress? </li> <li> Slide 58 </li> <li> COMPLICATIONS Addisons Disease Adrenal crisis Electrolyte imbalance Hypoglycemia </li> <li> Slide 59 </li> <li> ADDISONS CRISIS Sudden decrease or absence of adrenal cortex hormones which are: __________________ </li> <li> Slide 60 </li> <li> AddisonsCAUSES Name 4 causes 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________ </li> <li> Slide 61 </li> <li> SIGNS &amp; SYMPTOMS Addisonian Crisis Dehydration- Na, K, BP N/V,diarrhea, wt. loss Weakness &amp; fatigue Confusion, headache Hypovolemic shock, coma Pallor, Inc. HR,RR, hypoglycemia Renal shut-down-DEATH </li> <li> Slide 62 </li> <li> Question If an EKG were performed on a client in Addisonian Crisis, what would you expect to see? </li> <li> Slide 63 </li> <li> TREATMENT Addisonian Crisis Rapid infusion of IV fluids What IV fluids will be used? Check VS &amp; UO frequently Why? Monitor EKG Treat hyperkalemia How? Give Solu-Cortef IV Q6 hours until S &amp; S disappear </li> <li> Slide 64 </li> <li> TREATMENT Try to anxiety May have to give vasopressors Dopamine or Epinepherine Avoid additional stress </li> <li> Slide 65 </li> <li> Adrenal Medulla </li> <li> Slide 66 </li> <li> http://images.google.com/imgres?imgurl=http://media.medicalcentral.com/picAddisonD iseaseMouthuiowaedu.jpg&amp;imgrefurl=http://www.diseasedisorder.com/diseasedisor derdefinitions/addisonsdisease.asp&amp;usg=__V112XzFmfSG3kLrUzpEOx6SCgAI= &amp;h=201&amp;w=300&amp;sz=12&amp;hl=en&amp;start=20&amp;sig2=ncZQmF9qjo3yu4tCagesMg&amp;tbnid =zWDvim- GYUotJM:&amp;tbnh=78&amp;tbnw=116&amp;prev=/images%3Fq%3Dchanges%2Bin%2Bskin %2Bpigmentation%2Bin%2Baddisons%2Bdisease%26gbv%3D2%26ndsp%3D18 %26hl%3Den%26sa%3DN%26start%3D18&amp;ei=3vLlSczAA5auMcblqe0J </li> <li> Slide 67 </li> <li> ADRENAL MEDULLA Fight or flight What is released by the adrenal medulla? </li> <li> Slide 68 </li> <li> CATECHOLAMINE RELEASE Epinephrine Norepinephrine Be sure to know what each does. </li> <li> Slide 69 </li> <li> Epinephrine Regulates HR &amp; BP inc. blood glucose stimulate ACTH stimulate glucorticoids inc. rate &amp; force of cardiac contractions constricts blood vessels in skin, mucous membranes, &amp; kidneys dilates blood vessels in skeletal muscles, coronary &amp; pulmonary arteries </li> <li> Slide 70 </li> <li> Norepinephrine Increases HR &amp; force of contractions Constricts blood vessels throughout the body </li> <li> Slide 71 </li> <li> Hyperfunction of the Adrenal Medulla PHEOCHROMOCYTOMA rare, benign tumor of the adrenal medulla oh no...what are we going to see a hypersecretion of???? </li> <li> Slide 72 </li> <li> SIGNS AND SYMPTOMS Pheochromocytoma What do you think is the hallmark sign? Paroxymal attacks**** NE and Epinepherine released sporadically Attacks may be provoked by meds antihypertensives, opioids, contrast media If untreated DM, cardiomyopathy, death Why? </li> <li> Slide 73 </li> <li> SIGNS &amp; SYMPTOMS Pheochromocytoma Deep breathing Pounding heart Headache Moist cool hands &amp; feet Visual disturbances </li> <li> Slide 74 </li> <li> DIAGNOSIS Pheochromocytoma Often missed 24 hour urine fractionated metanephrines fractionated cathecholamines creatinine Are these increased or decreased? Plasma catecholamines When are these drawn? Are these increased or decreased? CT to locate tumor </li> <li> Slide 75 </li> <li> Interventions/Treatment Pheochromocytoma Primary goal? Primary treatment? Pre - op Calcium channel blockers Cardene Sympathetic blocking agents Minipress (watch for orthostatic hypotension) Beta blocking agents Inderal </li> <li> Slide 76 </li> <li> INTERVENTIONS Monitor b.p. Eliminate attacks If attack- complete bedrest and HOB 45 degrees </li> <li> Slide 77 </li> <li> Interventions/Treatment Pheochromocytoma Diet high in vitamins, minerals, calories, no caffeine Sedatives </li> <li> Slide 78 </li> <li> DURING SURGERY give REGITINE &amp; NIPRIDE to prevent hypertensive crisis Laparoscopic Adrenalectomy/ Open abdominal incision </li> <li> Slide 79 </li> <li> POST-OP b.p. may be initially, BUT CAN BOTTOM OUT Volume expanders Vasopressors Hourly I and O Observe for hemorrhage </li> <li> Slide 80 </li> <li> QUESTION?? What if you are not a candidate for surgery? Demser (drug which inhibits catecholamine synthesis) Avoid opiates, histamines, Reglan, anti-depressants. Why? </li> </ul>

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