Management of Patients With Adrenal Disorders

1. Management of PatientsWith Adrenal Disorders Dr. Belal M. Hijji, RN, PhD

2. Learning Outcomes At the end of this lecture, students will be able to: • Identify the composition and functions of the adrenal glands • Discuss important aspects of common disorders of the adrenal glands 21 & 25/12/2011

3. Introduction • Two adrenal glands; each is two endocrine glands with independent functions. • The medulla secretes catecholamines; the cortex secretes steroid hormones. • The hypothalamus secretes corticotropin releasing hormone (CRH). This stimulates the pituitary gland to secrete ACTH, which stimulates the adrenal cortex to secrete glucocorticoid hormone (cortisol). 21 & 25/12/2011

4. 21 & 25/12/2011

5. 21 & 25/12/2011

6. Catechol Group: C6H4(OH)2 21 & 25/12/2011

7. Common Disorders of Adrenal Glands • Pheochromocytoma • Adrenocortical Insufficiency (Addison’s Disease) 21 & 25/12/2011

8. Pheochromocytoma • Pheochromocytoma is a tumor that is usually benign and originates from the adrenal medulla. • Pheochromocytoma peak incidence is between ages 40 and 50 years. • It affects men and women equally. • Ten percent of the tumors are bilateral, and 10% are malignant. • Pheochromocytoma is the cause of high blood pressure in 0.2% of patients with new onset of hypertension 21 & 25/12/2011

9. Clinical Manifestations • The typical triad of symptoms comprises headache, diaphoresis, and palpitations. • Hypertension, tachycardia, tremor, flushing, and anxiety. Hyperglycemia may result from conversion of liver and muscle glycogen to glucose by epinephrine secretion. • The patient may experience, vertigo, blurring of vision, tinnitus, air hunger, and dyspnea, polyuria, nausea, vomiting, diarrhea, abdominal pain, and a feeling of impending doom. 21 & 25/12/2011

10. Assessment and Diagnostic Findings • Remember the “five Hs”: • hypertension, headache, hyperhidrosis (excessive sweating), hypermetabolism, and hyperglycemia. • Absence of hypertension excludes diagnosis. • Measurements of urine and plasma levels of catecholamines is conclusive of pheochromocytoma. A number of medications and foods (eg, coffee, tea, bananas, chocolate, vanilla, aspirin) may alter the results. • Instruct the patient to avoid restricted items. • Total plasma catecholamine (epinephrine and norepinephrine). • Minimise the stress resulting from venipuncture. 21 & 25/12/2011

11. Medical Management • PHARMACOLOGIC THERAPY • Alpha-adrenergic blocking agents (eg, phentolamine [Regitine]) to lower the blood pressure quickly. • An alpha-blocker ,Phenoxybenzamine (Dibenzyline), which is an antagonist of alpha adrenergic receptors, may be used when the blood pressure is stable to prepare the patient for surgery. • SURGICAL MANAGEMENT • Adrenalectomy. Bilateral adrenalectomy may be necessary. 21 & 25/12/2011

12. Nursing Management • Teaching Patients Self-Care • Informs the patient about follow-up monitoring to ensure that pheochromocytoma does not recur undetected. • Instruct the patient about the purpose, the medication schedule, and the risks of skipping doses or stopping the administration of corticosteroids. • Teach the patient and family how to measure the patient’s blood pressure. • Provide verbal and written instructions about collecting 24-hour urine specimens for urine catecholamine. Continued….. 21 & 25/12/2011

13. Continuing Care • A follow-up visit from a home care nurse may be useful. The home care nurse also obtains blood pressure measurements and assists the patient in scheduling the patient for periodic follow-up appointments to record BP and assess plasma and urine levels of catecholamines. 21 & 25/12/2011

14. Adrenocortical Insufficiency(Addison’s Disease) Pathophysiology • Results when adrenal cortex function is inadequate to meet the patient’s 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 tuberculosis. • Inadequate secretion of ACTH from the pituitary gland also results in adrenal insufficiency because of decreased stimulation of the adrenal cortex. • Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency 21 & 25/12/2011

15. Clinical Manifestations • Muscle weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin due to melanocyte-stimulating hormone, and hypotension. • Mental status changes such as depression, apathy, and confusion. • The patient develops addisonian crisis, characterized by cyanosis, pallor, apprehension, rapid and weak pulse, rapid respirations, and low blood pressure. • Headache, nausea, abdominal pain, diarrhea, confusion, and restlessness. 21 & 25/12/2011

16. Assessment and Diagnostic Findings • The diagnosis is confirmed by the clinical manifestations and laboratory test results. • Hypoglycemia, hyponatremia, hyperkalemia, and leukocytosis. • Low levels of blood or urine adrenocortical hormones and ↓ cortisol. 21 & 25/12/2011

17. Medical Management • Hydrocortisone (Solu-Cortef) is administered intravenously, followed with 5% dextrose in normal saline. • Antibiotics may be indicated. • Intravenous fluids are administered to prevent hypovolemia. • If the adrenal gland does not regain function, the patient needs lifelong replacement of corticosteroids and mineralocorticoids to prevent recurrence of adrenal insufficiency. • Glucocorticoids during stressful procedures or significant illnesses to prevent addisonian crisis 21 & 25/12/2011

18. Nursing Management Assessing The Patient • Inadequate fluid volume by monitoring BP & P as the patient moves from a lying to a standing position. • Skin color and turgor for changes related to chronic adrenal insufficiency and hypovolemia. • Weight changes, muscle weakness, and fatigue. Monitoring And Managing Addisonian Crisis • Monitor the patient for signs and symptoms of the crisis. • Administer intravenous fluid, glucose, and electrolytes, replacement of missing steroid hormones; and vasopressors as prescribed. • Maintain bed rest and meet patient’s needs. • Monitor symptoms, vital signs, weight, and fluid and electrolyte status. 21 & 25/12/2011

19. Restoring Fluid Balance • Assess the patient’s skin turgor, mucous membranes, and weight. • Instruct the patient to report increased thirst. • Assess lying, sitting, and standing blood pressures. A decrease in systolic pressure (20 mm Hg or more) may indicate depletion of fluid volume. • Encourage the patient to consume foods and fluids that will assist in restoring and maintaining fluid and electrolyte balance. • Instruct the patient and family to administer hormone replacement as prescribed. 21 & 25/12/2011

20. Improving Activity Tolerance • Take precautions, until patient is stable, to avoid unnecessary activity and stress that could precipitate another hypotensive episode. • Detect signs of infection or the presence of other stressors. Patients may not, even, tolerate minor stressors. • Explain all nursing procedures to the patient and family to reduce their anxiety. • Increase activity gradually. 21 & 25/12/2011