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T3: Cushings

T3: Cushings & Hyperaldosteronism

What are the 3 main classifications of adrenal cortex steroid hormones? glucocorticoids, mineralocorticoids, and androgens
What is the function of glucocorticoids? regulate metabolism; increase blood glucose levels; critical in the physiologic stress response
What is the primary glucocorticoid? cortisol
What is the function of mineralocorticoids? regulate sodium and potassium balance
What is the primary mineralocorticoid? aldosterone
What is the function of androgens? Contribute to growth and development in both genders and to sexual activity in adult women.
This term refers to any one of these 3 types of hormones produced by the adrenal cortex. corticosteroid
Where are glucocorticoids, mineralocorticoids, and androgens produced? adrenal cortex
This is a clinical condition that results from chronic exposure to excess corticosteroid, particularly glucocorticoids. Cushing Syndrome
Several conditions can cause Cushing syndrome. What is the most common cause? Iatrogenic administration of exogenous corticosteroids (prednisone)
Approximately 85% of the cases of endogenous Cushing syndrome are due to what? an adrenocorticotropic hormone (ACTH) - secreting pituitary adenoma (Cushing disease)
What are some other causes of Cushing syndrome? adrenal tumors and ectopic ACTH production by tumors (usually of the lung or pancreas) outside of the hypothalamic-pituitary-adrenal axis
CM of Cushing syndrome centripetal (truncal)/generalized obesity; moon facies with plethora; purplish red striae on abd, breast, or buttocks; easy bruising; hirsutism in women; menstrual disorders; HTN; hypokalemia
The facies in Cushings include? a rounded face (moon facies) with thin, reddened skin
Excess glucocorticoids causes this from accumulation of adipose tissue. weight gain
Excess glucocorticoids causes this due to glucose intolerance and increased gluconeogenesis by the liver. hyperglycemia
Excess glucocorticoids causes muscle wasting which can lead to? weakness
Excess glucocorticoids causes loss of bone matrix which can lead to? osteoporosis and back pain
Excess glucocorticoids causes loss of collagen which can lead to? thin, weaker skin that can bruise easily
Excess glucocorticoids causes catabolic processes that can lead to? delay in wound healing
Excess glucocorticoids can cause the patient to be? irritable, anxious, euphoria, and occasionally psychosis may occur
Excess mineralocorticoid may cause? HTN (secondary to fluid retention)
Adrenal androgen excess may cause? severe acne, virilization in women, and feminization in men
Menstrual disorders and hirsutism in women and gynecomastia and impotence in men occur more commonly with? adrenal carcinomas
What diagnostics are done for Cushings? plasma cortisol measurement (primary glucocorticoid); 24 hr urine collection for free cortisol; low-dose dexamethasone suppression test; urine 17 ketosteroid measurement; CT & MRI of pituitary & adrenal glands
In Cushings what happens to the plasma cortisol levels? May be elevated, with loss of diurnal variation.
What would the urine cortisol levels have to be in order to indicate Cushing syndrome? Would be higher than the normal range of 80-120 mcg in 24 hrs
If the urine cortisol levels are borderline what test is done? a low-dose dexamethasone suppression test
What would plasma ACTH levels be in Cushing disease (pituitary etiology)? high or normal ACTH levels
What would plasma ACTH levels be in Cushing syndrome (adrenal or medication etiology)? low or undetectable ACTH levels
____ and ____ are seen in ectopic ACTH syndrome and adrenal carcinoma. hypokalemia; alkalosis
What is the primary goal of treatment for Cushing syndrome? To normalize hormone secretion
How is treatment determined in Cushings? Is dependent on the underlying cause
If the underlying cause of Cushings is a pituitary adenoma, what is the standard treatment? Surgical removal of the pituitary tumor via the transsphenoidal approach. Radiation therapy may be used for pts who aren't good surgical candidates.
If the underlying cause of Cushings is caused by adrenal tumors or hyperplasia, how is it treated? Adrenalectomy; laparscopic adrenalectomy used unless a malignant adrenal tumor is suspected; an open surgical adrenalectomy is usu performed for adrenal cancer.
Cushings patients with ectopic ACTH-secreting tumors are best managed how? By locating and removing the tumor (usually lung or pancreas). This is usu possible when the tumor is benign. When a tumor is malignant & metastasized, surgical removal may not be possible or successful.
If Cushing syndrome has developed (iatrogenically) during the course of prolonged administration of corticosteroids such as prednisone, how would it be treated? Gradual discontinuation of corticosteroid therapy; reduction of the corticosteroid dose; conversion to an alternate-day regimen.
Why is gradual tapering of corticosteroids necessary? To avoid potentially life-threatening adrenal insufficiency.
An alternate day regimen is one in which twice the daily dosage of a shorter acting corticosteroid is given every other morning to minimize what? hypothalamic-pituitary-adrenal suppression, growth suppression, and altered appearance
The alternate-day regimen is not used when the corticosteroids are given as? hormone therapy
Upon assessment what information is important to obtain from the patient? Past health hx: pituitary tumor (Cushing disease); adrenal, pancreatic, or pulmonary neoplasms; GI bleeding; frequent infections; Medications: use of corticosteroids
Patients with Cushings syndrome are seriously ill b/c the therapy has so many side effects. The focus of assessment is on what? S/S of hormone toxicity, drug toxicity, and complicating conditions (e.g. cardiovascular disease, DM, infection).
What are some nursing interventions for Cushings patients? Assess & monitor vitals, daily weight, glucose level, & possible infection (s/s of inflammation may be minimal or absent); monitor for abnormal thromboembolic events such as PE (sudden chest pain, dyspnea, tachypnea); emotional support
If a Cushings patient must undergo surgery, what interventions should be done preop? HTN & hyperglycemia must be controlled, and hypokalemia must be corrected w/diet & K supplements. A high protein diet helps correct the protein depletion.
In the postoperative period (for both laparscopic & open adrenalectomy) patients may have what? a NG tube, urinary catheter, IV therapy, central venous pressure monitoring, and leg SCDs to prevent emboli
Why is surgery on the adrenal glands riskier than other types of operations? Because the adrenal glands are vascular so the risk of hemorrhage is increased.
Manipulation of glandular tissue during surgery may release large amount of this which causes what? Hormones into the circulation, producing marked fluctuations in the metabolic processes affected by these hormones.
Postoperatively, BP, fluid balance, and electrolye levels to to be ____ because of these hormone fluctuations. unstable
What is administered IV during surgery and for several days afterward to ensure adequate responses to the stress of the procedure? high doses of corticosteroids (e.g. hydrocortisone-Solu Cortef)
If large amounts of endogenous hormone have been released into the systemic circulation, the pt is likely to develop this, which can also increase this? HTN which increases the risk of hemorrhage
High levels of corticosteroids increase susceptibility to _____ and delay _____. infection; wound healing
The critical period for circulatory instability ranges from 24-48 hrs after surgery. During this time, you must constantly be alert for what? s/s of corticosteroid imbalance
What interventions should be done postoperatively? Report significant changes in vitals; monitor fluid I&O, assess for potential imbalances; administer corticosteroids as ordered; obtain morning urine samples for cortisol measurement.
Why is it important to obtain morning urine samples for cortisol measurement at the same time each morning? to evaluate the effectiveness of the surgery
CM of acute adrenal insufficiency (due to rapid tapering of corticosteroid dosage) vomiting, increased weakness, dehydration, hypotension, painful joints, pruritus, peeling skin, severe emotional disturbances
After surgery, patients are usually maintained on bed rest until? the BP stabilizes
Why should the nurse be alert for subtle signs of postoperative infections? B/c the usual inflammatory responses (fever, redness) are suppressed; assess for pain, loss of function, and purulent drainage
What interventions should be done to prevent infection after surgery? Provide meticulous care when changing the dressing and during any other procedures that necessitate access to body cavities, circulation, or areas under the skin.
You should teach the patient to avoid what? Exposure to extremes of temp, infections, & emotional disturbances.
How can stress produce or precipitate acute adrenal insufficiency? B/c the remaining adrenal tissue cannot meet an increased hormonal demand.
This is characterized by excessive aldosterone secretion. hyperaldosteronism (Conn's syndrome)
What are the main effects of aldosterone? sodium retention and potassium and hydrogen ion excretion
What is the hallmark of hyperaldosteronism? HTN with hypokalemic alkalosis
Primary hyperaldosteronism (PA is most commonly caused by what? a small solitary adrenocortical adenoma
Bilateral adrenal hyperplasia involves what? multiple lesions
Who does PA affect more? women b/t 30 and 60 years
This occurs in response to a nonadrenal cause of elevated aldosterone levels, such as renal artery stenosis, renin-secreting tumors, and chronic kidney disease. secondary hyperaldosteronism
Elevated levels of aldosterone are associated with what? sodium retention and excretion of potassium
Sodium retention leads to what? hypernatremia, hypertension, and headache
Why does edema not usually occur with hyperaldosteronism? B/c the rate of sodium excretion increases which prevents more severe sodium retention.
The potassium wasting in hyperaldosteronism leads to what? hypokalemia
CM of hypokalemia generalized muscle weakness, fatigue, cardiac dysrhythmias, glucose intolerance, & metabolic alkalosis that may lead to tetany.
Hyperaldosteronism should be suspected in all hypertensive patients with hypokalemia who are not being treated with what? diuretics
PA is associated with what? Elevated plasma aldosterone levels, elevated Na levels, decreased serum K levels, & decreased plasma renin activity.
Adenomas are localized by what means? CT scan or MRI
If a tumor is not found, this is measured after overnight bed rest. plasma 18-hydroxycortocosterone
A plasma 18-hydroxycortocosterone level greater than 50 ng/dL indicates what? an adenoma
What is the preferred treatment for PA? surgical removal of the adenoma (adrenalectomy) laparoscopically
Before an adrenalectomy patients should be treated with what? potassium sparing diuretics (spironolactone-Aldactone, eplerenone-Inspra), and antihypertensive agents to normalize serum K levels and BP.
What do spironolactone and eplerenone do? Blocks the binding of aldosterone to the mineralocorticoid receptor in the terminal distal tubules and collecting ducts of the kidney, thus increasing the excretion of Na & water & the retention of K.
Oral K supplements and Na restriction may also be necessary but K supplementation and K sparing diuretics should not be started simultaneously because of the danger of what? hyperkalemia
Patients with bilateral adrenal hyperplasia are treated with what? a K sparing diuretic (spironolactone, amiloride-MIdamor) or with aminoglutethimide (Cytadren), which blocks aldosterone synthesis.
This may also be used to decrease adrenal hyperplasia. dexamethasone
Nursing care for hyperaldosteronism includes? Careful assessment for s/s of fluid & electrolyte balance (esp. K) & cardiovascular status. Monitor BP freq before & after surgery b/ unilateral adrenalectomy is successful in controlling HTN in only 80% of pts w/adenoma.
What are some important things to teach patients with hyperaldosteronism? Pts on maintenance therapy w/K sparing diuretics should know possible SE of gynecomasia, impotence, & menstrual disorders, & s/s of hypokalemia & hyperkalemia. Monitoring their BP frequently.
Created by: eblanc1