CARE OF THE CLIENTS

WITH ADRENAL
GLAND DISORDERS

CHARLES Z. ARIOLA JR., MSN., LPT, RN.

INSTRUCTOR I
 ADRENAL GLAND
HYPOFUNCTION
CAUSES:
1. Inadequate secretion of
Adrenocorticotropic Hormone
2. Dysfunction of hypothalamic-pituitary
control mechanism
3. direct dysfunction of adrenal gland
tissue
 ADRENAL GLAND
HYPOFUNCTION
- adrenal insufficiency of steroids causes loss of
cortisol and aldosterone
IMPAIRED SECRETION OF CORTISOL
- causes glucose build up from proteins along
with depletion of liver and muscle glycogen
- it also causes decreased GFR and gastric acid
production which leads to reduced Urea Nitrogen
causing anorexia and weight loss
 ADRENAL GLAND
HYPOFUNCTION
IMPAIRED SECRETION OF ALDOSTERONE
- causes water, sodium and potassium
imbalances
- HYPERKALEMIA from a decreased potassium
excretion
- HYPONATREMIA increased sodium excretion
- HYPOVOLEMIA from increased water
excretion
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HORMONE REPLACEMENT
- start rapid infusion of normal saline or dextrose 5% in
normal saline
- initial dose of hydrocortisone sodium succinate (solu-
cortef) is 100 to 300 mg or dexamethasone 4 to 12 mg as
an IV Bolus
- infuse additional 100 mg of hydrocortisone sodium
succinate by continuous IV drip over the next 8 hours
- initiate H2 Histamine blocker (ranitidine) IV for ulcer
prevention
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HYPERKALEMIA MANAGEMENT
- administer insulin (20 to 50 units)with dextrose (20 to 50 mg) in
normal saline to shift potassium into cells
- administer potassium binding and excreting resin ( Kayexalate)
- give loop or thiazide diuretics)
- initiate potassium restriction
- avoid potassium-sparing diuretics
- monitor intake and output
- monitor heart rate, rhythm, and ECG for manifestations of
hyperkalemia (slow heart rate, peak T waves,fibrillation and
asystole)
 EMERGENCY CARE FOR PATIENT WITH ACUTE ADRENAL
INSUFFICIENCY

HYPOGLYCEMIA MANAGEMENT
- administer IV glucose
- administer glucagon as needed
- maintain iV access
- monitor blood glucose level hourly
 ADDISON'S DISEASE
- acute adrenal insufficiency
- life threatening event caused by impaired secretion of
cortisol and aldosterone
- often occurs in response to stressful event such as
SURGERY,TRAUMA or SEVERE INFECTION
- classified as PRIMARY and SECONDARY
 CAUSES OF ADDISON'S DISEASE
PRIMARY CAUSES
1. Autoimmune disease
2. TB
3. Metastatic cancer
4. Fungal Lesions
5. AIDS
6. Hemorrhage
7. Gram negative sepsis (Waterhouse-Friderichsen Syndrome)
8. Adrenalectomy
9. Drugs (Mitotane) and Toxins
 CAUSES OF ADDISON'S DISEASE
SECONDARY
1. Pituitary Tumors
2. Postpartum pituitary necrosis (Sheehan's Syndrome)
3. Hypophysectomy
4. High-dose pituitary radiation
5. High-dose whole -brain radiation
 HISTORY
ASSESSMENT
1. Lethargy
2. Fatigue
3. Muscle Weakness
4. Salt Craving
5. Anorexia
6. Nausea
7. Vomiting
8. Diarrhea
9. Abdominal Pain
10. Menstrual Changes for women
 CLINICAL
MANIFESTATIONS
NEUROMUSCULAR MANIFESTATIONS
- muscle weakness
- fatigue
- joint/muscle pain

GASTROINTESTINAL MANIFESTATIONS
- anorexia - bowel changes
- nausea & vomiting - weight loss
- abdominal pain - salt craving
 CLINICAL
MANIFESTATIONS
INTEGUMENTARY MANIFESTATIONS
- vitiligo
- hyperpigmentation

CARDIOVASCULAR MANIFESTATIONS
- anemia
- hypotension
- hyperkalemia
- hypercalcemia
 LABORATORY
ASSESSMENT
- low serum cortisol
- low fasting blood sugar
- low sodium
- elevated potassium
- elevated BUN

ACTH STIMULATION TEST- most definitive test for adrenal insufficiency

- ACTH 0.25 to 1mg is given IV
- plasma cortisol level is otained in 30 mins to 1 hour interval
LABORATORY PROFILE
SIGNIFICANCE OF ABNORMAL
TEST FINDINGS
HYPOFUNCTION OF HYPERFUNCTION OF
ADRENAL GLAND ADRENAL GLAND

SODIUM DECREASED INCREASED

GLUCOSE DECREASED INCREASED
CORTISOL DECREASED INCREASED
POTASSIUM INCREASED DECREASED
CALCIUM INCREASED DECREASED
BICARBONATE INCREASED DECREASED
BUN INCREASED DECREASED
 INTERVENTIONS
GOALS:
- promote fluid balance
- monitor for fluid deficit
- prevent hypoglycemia

NURSING RESPONSIBILITIES
- weigh patient daily
- record intake and output
- assess V/S 1 to 4 hours
- monitor lab values
 DRUG THERAPY
1. CORTISONE
- 25-50 mg orally either once daily in AM or daily in divided doses
NR: instruct patient to take meds with meals

2. HYDROCORTISONE (Cortef, Hycort)

- 25-50 mg orally either once daily in AM or daily in divided doses
NR: Instruct patient to report signs of excessive drug therapy
- Rapid Weight Gain
- Round face
- Fluid Retention
 DRUG THERAPY
3. PREDISONE (Winpred)
- 5-10 mg orally either once daily in AM or daily in divided doses
NR: Instruct patient to report illness such as:
- Severe diarrhea
- vomiting
- fever
NOTE: Do not confuse with prednisolone- another durg that is 4 to 5
times more potent than prednisone
 DRUG THERAPY
4. FLUDROCORTISONE (Florinef)
- 0.05-0.2 mg orally daily
NR: Monitor patient's blood pressure
Instruct patient to report weight gain or edema
 ADRENAL GLAND
HYPERFUNCTION
- Hypresecretion by adrenal cortex results to the following conditions:

1. Hypercortisolism (Cushing's Disease or Cushing's Syndrome)

2. Hyperaldosteronism (excessive mineralocorticoids production)

3. Excessive Androgen production

4. Pheochromocytoma -results from hyperstimulation of adrenal medulla

 CUSHING'S DISEASE
- exaggerated actions of glucocorticoids, causing widespread
problems.
- excessive secretion of cortisol from adrenal cortex
- can be caused by a problem in adrenal cortex itself, problem
in the pituitary gland or in the hypothalamus
-can also be caused by Glucocorticoid Therapy
- excess glucocorticoids affect Nitrogen, carbohydrate and
mineral metabolism which then results to slow-turn over of
plasma fatty acids and redistribute fats causing pattern of
truncal obesity
 ETIOLOGY
1. PITUITARY CUSHING'S DISEASE
- the tissue causing problem is the pituitary itself

2. ADRENAL CUSHING'S DISEASE

- when the problem arises from adrenal cortex and usually
affects one adrenal gland only

3. CUSHING'S SYNDROME
- when it results from drug therapy for another health
problem
 CLINICAL MANIFESTATIONS
1. GENERAL APPEARANCE
- moon face
- truncal obesity
- buffalo hump
 CLINICAL MANIFESTATIONS
2. CARDIOVASCULAR MANIFESTATIONS
- Hypertension
- Increased risk for thromboembolic events
- frequent dependent edema
- Capillary Fragility
- Bruising
- Petechiae
 CLINICAL MANIFESTATIONS
3. MUSCULOSKELETAL MANIFESTATIONS
- Muscle atrophy (most apparent in extremities)
- Osteoporosis (loss of bone density)
- pathologic fractures
- decreased height with vertebral collapse
- aseptic necrosis of the femur head
- slow or poor healing of bone fractures
CLINICAL MANIFESTATIONS
4. SKIN MANIFESTATION
- Thinning skin (paper-like appearance especially on the back of the hands
- striae
5. IMMUNE SYSTEM MANIFESTATIONS
- increased risk for infection
- decreased immune function
- decreased circulating lymphocytes
- decreased production of immunoglobins (antibodies)
- decreased inflammatory responses
- decreased eosinophil count
- decreased production of proinflammatory cytokines, histamine, prostaglandins
 PSYCHOSOCIAL
ASSESSMENT
- Emotional lability
- mood swings
- irritability
- confusion
- depression
- neurotic/psychotic behavior
LABORATORY ASSESSMENT
- Lab Tests include:
- Blood
- salivary
- urine
- ACTH is high in Pituitary Cushing Disease
- ACTH is low in Adrenal Cushing's Disease or when
Cushing's Diseaseresults from chronic steroid use
LABORATORY ASSESSMENT
- Increased blood glucose
- decreased lymphocyte
- increased sodium
- decreased potassium
- decreased calcium
COMMON NURSING DIAGNOSES
1. Excess fluid volume related to excess water and
sodium reabsorption
2. Risk for injury related to skin thinning, poor
wound healing and bone density loss
3. Risk for infection related to immunosupression
and inadequate primary defenses
NURSING INTERVENTIONS
EXCESS FLUID VOLUME
1. Patient Safety
- Monitor for indicators of fluid overload every 2 hours
such as:
- increased pulse quality
- increased neck vein distention
- presence of crackles in the lungs
- increased peripheral edema
- reduced urinary output
NURSING INTERVENTIONS
2. DRUG THERAPY
- Aminoglutethimide (Elipten, Cytadren) given to interfere
- Metyrapone (Metopirone) with ACTH
production
- Cyproheptadine (Periactin)
- Mitotane (Lysodren)
- Adrenal Cytotoxic agent used for inoperable adrenal tumors
NR: Monitor electrolytes especially Potassium and Sodium
NURSING INTERVENTIONS
3. NUTRITION THERAPY
- “No added salt” for table foods in mild fluid overload
- For severe fluid overload, sodium is restricted to 2
gm/day to 4 gm/day
- patient is taught to read labels for sodium restriction
4. MONITORING OF INTAKE AND OUTPUT
- check patient's intake and output
- check specific urine gravity
NURSING INTERVENTIONS
5. RADIATION THERAPY
- used to treat hypercortisolism caused by adrean
adenomas
- not always effective and often destroys normal tissue
Nursing Responsibilities:
- observe for neurologic changes such as:
- headache, elevated BP or pulse, disorientation or
changes in pupil size or reaction
- observer for skin dryness, redness, flushing or
alopecia or the radiation site
SURGICAL MANAGEMENT
HYPOPHYSECTOMY
- If the adrenal hyperfunction is due to increased pituitary
secretion of ACTH

ADRENALECTOMY
- if hypercortisolism is caused by adrenal tumors
SURGICAL MANAGEMENT
PREOPERATIVE CARE
- Electrolyte imbalances are corrected before the procedure
- continue to monitor blood potassium, sodium and chloride
levels
- hyperglycemia is monitored before the surgery
- prevent infection by performing handwashing and aseptic
technique
- decrease the risk for falls by raising bed upper siderails
- high calorie and high protein diet is prescribed before
surgery
SURGICAL MANAGEMENT
OPERATIVE PROCEDURES
- Unilateral or Bilateral
- can be abdominal or lateral flank
POSTOPERATIVE CARE
- after surgery, patient is usually sent to critical care unit
- assess patient every 15 minutes for shock
- monitor intake and output
- monitor electrolytes
- weigh patient daily
SURGICAL MANAGEMENT
BILATERAKL ADRENALECTOMY
- Requires lifelong glucocorticoid and mineralocorticoid
replacement starting after surgery

UNILATERAL ADRENALECTOMY
- hormone replacement continuous until the remaining
adrenal gland increases hormone production
NURSING INTERVENTIONS
RISK FOR INJURY
1. SKIN INJURY
- assess for reddened areas, excoriation, breakdown and
edema
- turn patient every 2 hours and pad bony prominences
- instruct to avoid activities that can cause skin trauma
- teach to use soft toothbrush and elctric shaver
- advise patient to keep skin clean and dry
- exert pressure over the puncture site after venipuncture
or arterial puncture
NURSING INTERVENTIONS
2. PATHOLOGIC FRACTURES
- prevent patient from falls or bumps
- use lift sheet instead of grasping the patient
- remind pt to call for help when ambulating
- discuss ambulatory aids (walkers and canes) if necessary
- keep room free of extraneous objects that might cause a
fall
- high calorie is instructed to patient
- include increase amount of calcium and vitamin D in the
diet
NURSING INTERVENTIONS
3. GI BLEEDING
- common and is result of systemic changes
- cortisol inhibits production of thick gel-like mucus that
protects stomach lining, which triggers blood flow to the
area and triggers the release of hydrochloric acid
- H2 Blockers
NURSING INTERVENTIONS
RISK FOR INFECTION
- protect patient from infection
- perform frequent handwashing
- anyone with URTI must wear mask when entering client's room
- assess for fever
- monitor patient's WBC and CBC and ANC
- inspect mouth per shift for lesions and mucosa breakdown
- assess lungs every hours for crackles, wheezes and reduced breath
sounds
- assess urine for odor and cloudiness
- ask patient for urgency, burning or pain present on urination
NURSING INTERVENTIONS
- take vital signs at least every 4 hours to assess for fever
- teach patient about hygiene
- instruct to perform daily bathing
- if patient is immobile, turn patient every hour and apply
skin lubricant
- perform pulmonary hygiene every 2 to 4 hours
- urge patient to cough and deep breathe or perform
sustained maximum inhalations every hour while awake
 PHEOCHROMOCYTOMA
- is a catecholamine -producing tumor that arises in
teh adrenal medulla.
- usualy benign an d and at least 10% malignant
- the tumors produce , store and release
epinephrine and norepinephrine which stimulate
adrenergic receptors
- the cause is unknown but is associated with
Multiple Endocrine Neoplasia (MEN) syndromes.
- it occurs at any age but most commonly in patients
between ages 40 and 60.
 ASSESSMENT
- intermittent episodes of hypertension that vary in length
from few minutes to several hours
S/SX: Headache
Palpitations
Profuse Diaphoresis
Flushing
Apprehension
Pain in chest and abdomen
Nausea and Vomiting
DIAGNOSTIC TEST
1. 24 hour urine collection for VMA or
Vanillylmandelic Acid, Metanephrine and
Catecholamines
- most common diagnostic test
2. Clonidine suppresion and stimulation testing
3. MRI or CT Scan
4. After diagnosis, CT scans for chest and abdomen
may be used to locate other tumors
 INTERVENTIONS
1. Surgery is the main treatment for pheochromocytoma
2. Management is focused on tissue perfusion, nutritional
needs and comfort measures
3. Monitor BP
- Blood Pressure is the hallmark of the disease
4. Teach patient not to smoke and drink caffeine-containing
beverages
5. Instruct not to change position suddenly
6. Do not palpate abdomen
7. Assess patient's hydration status
 INTERVENTIONS
8. Administer Phenoxybenzamine (Dibenzyline) starting
several weeks before surgery
9. Closely monitor patient for hypertension and hypotension
after surgery
10. Assess for hemorrage and shock
11. Monitor Vital signs and fluid intake and output