GLAND

HORMONE

FUNCTION Regulate metabolic pathways to promote catabolism of stored fuels to meet caloric needs from endogenous sources

DYSFUNCTION Pheochromocytoma

ETIOLOGY is a tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. Its peak incidence is between ages 40 and 50 years

S/SX The typical triad of symptoms comprises headache, diaphoresis, and palpitations Hypertension and other cardiovascular disturbances are common Other symptoms may include tremor, headache, flushing, hyperglycemia and anxiety.

ADRENAL Catecholamine GLAND hormones: epinephrine and norepinephrine

DIAGNOSTIC TEST Measurements of urine and plasma levels of catecholamines are the most direct and conclusive tests for overactivity of the adrenal medulla. Measurements of urinary catecholamine metabolites (metanephrines [MN] and vanillylmandelic acid [VMA]) or free catecholamines are the standard diagnostic tests used in the diagnosis of pheochromocytoma. A 24-hour specimen of urine is collected for determining free catecholamines, MN, and VMA. Clonidine suppression test may be performed if the results of plasma and urine tests of catecholamines are inconclusive. Imaging studies, such as CT scans, MRI, and ultrasound, may also be carried out to localize the pheochromocytoma and to determine whether more than one tumor is present. Use of 131I-metaiodobenzylguanidine (MIBG) scintigraphy may be required to determine the location of the pheochromocytoma and to detect metastatic sites outside the adrenal gland.

MANAGEMENT Medical Management During an episode or attack of hypertension, tachycardia, anxiety, and the other symptoms of pheochromocytoma, the patient is placed on bed rest with the head of the bed elevated to promote an orthostatic decrease in blood pressure. The patient may be moved to the intensive care unit for close monitoring of ECG changes and careful administration of alphaadrenergic blocking agents or smooth muscle relaxants to lower the blood pressure quickly. Phenoxybenzamine (Dibenzyline), a longacting alpha-blocker, may be used when the blood pressure is stable to prepare the patient for surgery. Beta-adrenergic blocking agents, such as propranolol (Inderal), may be used in patients with cardiac dysrhythmias or those not responsive to alpha-blockers The definitive treatment of pheochromocytoma is surgical removal of the tumor, usually with adrenalectomy. . Phentolamine or phenoxybenzamine (Dibenzyline) may be used safely without causing undue hypotension. Other medications (metyrosine [Demser] and prazosin [Minipress]) have been used to treat pheochromocytoma. The patient needs to be well hydrated before, during, and after surgery to prevent

hypotension. Intravenous administration of corticosteroids (methylprednisolone sodium succinate [Solu-Medrol]) may begin the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency. Nursing Management Monitor patient for several days in the intensive care unit with special attention given to ECG changes, arterial pressures, fluid and electrolyte balance, and blood glucose levels. inform the patient about the importance of follow-up monitoring to ensure that pheochromocytoma does not recur undetected Instruct the patient about corticosteroids its purpose, the medication schedule, and the risks of skipping doses or stopping their administration abruptly Teach the patient and family how to measure the patients blood pressure and when to notify the physician about changes in blood pressure. Provides verbal and written instructions about the procedure for collecting 24-hour urine specimens to monitor urine catecholamine levels Medical Management Immediate treatment is directed toward combating circulatory shock: restoring blood circulation, administering fluids and

Adrenal Gland

Steroid Hormones

help control metabolism, inflammation, immune functions, salt

ADRENOCORTICAL INSUFFICIENCY (ADDISONS DISEASE)

results when adrenal cortex function is inadequate to meet the

muscle weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark

The diagnosis is confirmed by laboratory test results. It is confirmed by low levels of adrenocortical hormones in the blood or urine and decreased

and water balance, development of sexual characteristics, and the ability to withstand illness and injury

patients need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is responsible for 80% of cases. ). Other causes include surgical removal of both adrenal glands or infection of the adrenal glands. Tuberculosis and histoplasmosis are the most common infections that destroy adrenal gland tissue Inadequate secretion of ACTH from the pituitary gland also results in adrenal insufficiency because of decreased stimulation of the adrenal

pigmentation of the skin, knuckles, knees, elbows, and mucous membranes, hypotension, and low blood glucose levels, low serum sodium levels, and high serum potassium levels. Mental status changes such as depression, emotional lability, apathy, and confusion are present in 60% to 80% of patients. With disease progression and acute hypotension, the patient develops addisonian crisis, which is characterized by cyanosis and the classic signs of circulatory shock: pallor, apprehension, rapid and weak pulse, rapid respirations, and low blood pressure

serum cortisol levels.

corticosteroids, monitoring vital signs, and placing the patient in a recumbent position with the legs elevated. Hydrocortisone (Solu-Cortef) is administered intravenously, followed with 5% dextrose in normal saline. The patient may need to supplement dietary intake with added salt during times of gastrointestinal losses of fluids through vomiting and diarrhea Nursing Management monitor the blood pressure and pulse rate as the patient moves from a lying to a standing position. assesses the skin color and turgor for changes related to chronic adrenal insufficiency and hypovolemia. Check for weight changes, muscle weakness, and fatigue and investigating any illness or stress that may have precipitated the acute crisis. anticipate the patients needs and takes measures to meet them Encourage the patient to consume foods and fluids that will assist in restoring and maintaining fluid and electrolyte balance Assists the patient to select foods high in sodium during gastrointestinal disturbances and very hot weather. Instruct the patient and family to administer hormone replacement as prescribed and to modify the dosage during

cortex.

Adrenal Gland

Steroid Hormones

help control metabolism, inflammation, immune functions, salt and water balance, development of sexual characteristics, and the ability to withstand illness and injury

CUSHINGS SYNDROME

results from excessive, rather than deficient, adrenocortical activity. It may result from excessive administration of corticosteroids or ACTH or from hyperplasia of the adrenal cortex

When overproduction of the adrenal cortical hormone occurs, arrest of growth, obesity, and musculoskeletal changes occur along with glucose intolerance. The classic picture of Cushings syndrome in the adult is that of central-type obesity, with a fatty buffalo hump in the neck and supraclavicular

Measurements of plasma and urinary cortisol levels are obtained. Several blood samples may be collected to determine whether the normal diurnal variation in plasma levels is present An overnight dexamethasone suppression test is the most widely used screening test for diagnosis of pituitary and adrenal causes of Cushings syndrome Other diagnostic studies include a 24-hour urinary free cortisol level and a high-dose or low-dose dexamethasone suppression test. Measurement of plasma ACTH by radioimmunoassay is used in conjunction with the high-dose

illness and other stressful occasions. Provide written and verbal instructions about the administration of mineralocorticoid (Florinef ) or corticosteroid (prednisone) as prescribed take precautions to avoid unnecessary activity and stress that could precipitate another hypotensive episode maintains a quiet, nonstressful environment and performs all activities (eg, bathing, turning) for the patient. Explain all procedures to the patient and family will reduce their anxiety. Explain the rationale for minimizing stress during the acute crisis assists the patient to increase activity gradually. Medical Management Surgical removal of the tumor by transsphenoidal hypophysectomy is the treatment of choice. Radiation of the pituitary gland also has been successful Adrenalectomy is the treatment of choice in patients with primary adrenal hypertrophy Adrenal enzyme inhibitors may be used to reduce hyperadrenalism if the syndrome is caused by ectopic ACTH secretion by a tumor that cannot be eradicated Nursing Management Observe skin and assess for trauma, infection, breakdown, bruising, and edema. Assess the patients mental function, including mood, responses to ques- tions, awareness of environment, and level of depression.

areas, a heavy trunk, and relatively thin extremities. The skin is thin, fragile, and easily traumatized; ecchymoses (bruises) and striae develop. Weakness, lassitude, sleep disturbance Excessive protein catabolism producing muscle wasting and osteoporosis, Kyphosis, backache, and compression fractures of the vertebrae may result. The patient develops a moonfaced appearance and may experience increased oiliness of the skin and acne. There is increased susceptibility to infection. Hyperglycemia or overt diabetes may develop. In females of all ages, virilization may occur as a result of excess androgens Libido is lost in men

suppression test to distinguish pituitary tumors from ectopic sites of ACTH production as the cause of Cushings syndrome A CT scan, ultrasound, or MRI may be performed to localize adrenal tissue and detect tumors of the adrenal gland.

Establish a protective environment to prevent falls, fractures, and other injuries to bones and soft tissues. Instruct patient to eat foods high in protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis Encourage rest and moderate activity Promote increased self esteem Assists the patient to change positions frequently to prevent skin breakdown Monitor closely for hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness Assess fluid and electrolyte status by monitoring laboratory values and daily weights. Teach the patient and the family to monitor blood pressure, blood glucose levels, and weight. Assess the patients understanding of the medication regimen and the patients compliance with the regimen, and reinforces previous teaching about the medications and the importance of taking them as prescribed Emphasize the importance of regular medical follow-up, the side effects and toxic effects of medications, and the need to wear medical identication with Addisons and Cushings disease.

and women. Adrenal Gland Aldosterone promote Na+ and water retention, and lower plasma K+ PRIMARY ALDOSTERONISM condition that occurs when your adrenals produce too much of the hormone aldosterone profound decline in the serum levels of potassium and hydrogen ions (alkalosis), as demonstrated by an increase in pH and serum bicarbon- ate level Hypertension is the most prominent and almost universal sign Hypokalemia is responsible for the variable muscle weakness, cramping, and fatigue Polyuria, polydipsia and glucose intolerance occur measurement of the aldosterone excretion rate after salt loading is a useful diagnostic test for primary aldosteronism reninaldosterone stimula- tion test and bilateral adrenal venous sampling are useful in differentiating the cause of primary aldosteronism Medical Management Treatment of primary aldosteronism usually involves surgical removal of the adrenal tumor through adrenalectomy Spironolactone may be prescribed to control hypertension. Corticosteroids are used extensively for adrenal insufficiency and are also widely used in suppressing inflammation and autoimmune reactions, controlling allergic reactions, and reducing the rejection process in transplantation Nursing Managment Frequent assessment of vital signs Explain all treatments and procedures Instruct patient to limit sodium in your diet and focus on fresh foods Provide comfort measures and rest