Cushing's Syndrome Chapter 42
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| adrenal glands? | small paired highly vascular glands that act independently of one another
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| how many parts does the adrenal gland have? | two
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| what are teh two parts of the adrenal gland? | adrenal medulla(center) and the adrenal cortex(outer)
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| which gland makes up 90% of the the adrenal gland? | adrenal cortex(outer)
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| what is the purpose of the adrenal gland? | maintain salt levels in the blood, maintain BP, help control kidney function, control overall fluid concentrations in the body
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| adrenal medulla? | produces 2 hormones(catecholamines)
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| what two hormones does the adrenal medulla produce? | epinephrine and norepinephrine
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| epinephrine(adrenaline) function? | increases blood glucose by stimulating the release of ACTH from pituitary-stimulated the adrenal cortex to release glucocorticoides; increases rate and force of cardiac contractions
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| epinephrine function on blood vessels? | constricts in skin, mucous membranes & kidneys; dilates in skeletal muscles, coronarry & pulmonary arteries
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| norepinephrine(noradrenaline) function? | increases heart rate and force of contractions, constricts blood vessels throughout body
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| levofed | synthetic norephinephrine
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| what hormones are produced by the adreanl cortex? | mineralcorticoids and glucocorticoids
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| mineralcorticoids | aldosterone
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| aldosterone? | retains sodium and water to increase blood volume and pressure; decreases potassium b/c promotes urinary excretion of dietary potassium;holds on to water and sodium and gets rid of potassium
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| glucocorticoids? | cortisol
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| function of cortisol? | stress hormone; carb metabolism by regulating glucose use in body tissue, mobilizing fat, shifting energy sourcefor muscle cells from glucose to fat; responds to stress
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| chronic adrenocortical insufficiency? | Addison's disease
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| Addison's disease? | dysfunction of adrenal cortex, chronic deficiency of cortison, aldosterone adrenal androgens; more common in women and those adults under 60
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| causes of addison's disease? | autoimmune destruction of adrenal tissue, accounts for 80% of spontaneous cases; occurs alone or with polyendocrine deficiency syndrome
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| causes of addison's disease? | trauma in clients on an anticoagulant resulting in b/l adrenal hemorrhage
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| causes of addison's disease? | pituitary dysfunction from tumors, surgery, radiation
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| causes of addison's disease? | abrupt withdrawal of from long-term, high dose corticosteroids(mineralcorticoids & gloucocorticoids)
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| clincial manifestations of addison's disease? | slow onset, r/t decreased levles of cortisol and aldosterone, lack of functions of adrenal cortex or decrease in "sugar, salt and sex", hyponatremia, hyperkalemia, low circulating bv, postural hypotension, syncope & possibly hypovolemic shock
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| clinical manifestations of addison's disease? | dizziness, confusion, cardiac dysrhthmias, hypoglycemia, n/v, weakness, lethargy, diarrhea, irritability, depression, hyperpigmentatino due to increased ACTH levels(bronzed appearance in caucasions)
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| clinical manifestations of addison's disease? | salt craving, body hair may decrease, chronic, worsening fatigue, loss of appetite, wt loss
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| potassium functions | maintains ICF, promotes neuromuscular functions and regulates cardiac impulses
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| sodium functions | maintains serum osmolality, regulates water balance(ECF volume), transmits nerve impulses, contracts muscles
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| diagnostic tests for addison's disease | serum cortisol decreased, urine 17-ketosteroids and 17 hydroxycorticosteroids are decreased, electrolytes show hyponatremia,hyperkalemia, serum glucose is decreased, hematocrit and BUN are elevated
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| diagnostic tests for addison's disease | ct scan head may be done to determine if intracranial lesion affecting pituitary gland
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| normal BUN levels | 7-18
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| normal Hct levels | 36-47%
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| ACTH stimulation test is the... | most specific test for diagnosing addison's disease
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| how is ACTH stimulation test done? | blood cortisol is measured vefore and after a synthetic form of ACTH is given by injection, measurement is repeated 30-60 mins after an IV ACTH injection
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| what is the normal response after an injection of ACTH? | a rise in blood and urine cortisol
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| what kind of response does a pt have with adrenal insufficiency? | poorly or not at all
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| addisonian crises is... | a life threatening response to acute adrenal insufficiency
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| addisonian crises occurs in clients with... | addison's disease in response to major stressors
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| major symptoms of addisonian crises include? | high fever, weakness, abd pain, severe hypotension, circulatory collapse, shock, and coma
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| treatment for addisonian crises is... | rapid IV replacement of fluids and glucocorticoids(cortisol
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| nursing care for acute addisonia crises? | rapid IVF infusion(0.9%), replacement therapy, get labs first, hydrocortisone IV(Solu-cortef) bolus then infusion over 8 hrs, hydrocortisone IM q 12 hrs, after crises-adjust dosages
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| caution: salt restriction or diuretics may cause... | adrenal crises
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| medication management of addison's crises | hydrocortisone(glucocorticoid replacement), fludrocorticsone(Florinef)-mineral corticoid replacement
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| what s/s shoudl be reported indicating excessive drug therapy? | rapid wt gain, round face, fluid retention
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| what illness' should be reported during medication management? | severe vomitting, diarrhea or fever
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| Diet during addison's crises? | increased salt, at least 1 1/2 liters of water daily
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| nursing care goal during addison's crises | promoting fluid and electrolyte balance & monitoring fluid defecit
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| nursing care during addison's crises | weigh daily and I&O, VS q 1-4 hrs, monitor lab values, glucocorticoid therapy & mineral corticoids for electrolyte balance, education
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| nursing care addison's dx | pt must continue under medical care and should wear medical id bracelet
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| nursing care addison's dx | pt and family must be aware of need to continue meds and s/s of insufficient hormone levels
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| nursing care addison's dx | care must be taken whenever pt will face stressor such as sx, serious illness
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| nursing diagnoses for addison's dx | defecient fluid volume
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| nursing diagnoses for addison's dx | decreased c/o r/t decreased vascular volume
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| nursing diagnoses for addison's dx | risk for ineffective therapeutic regimen management
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| nursing diagnoses for addison's dx | fatigue r/t disease state
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| adrenal hypersecretion | adrenal cortex-cushings syndrome(increased corticosteroids), adrenal medulla-pheochromocytoma-increased catecholamines
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| cushing's syndrome | chronic disorder hyperfunction of adrenal cortex producing excessive amounts of ACTH or cortisol
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| hypercortisolism | cushing's syndrome
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| cushing syndrome is more common in... | females between the ages of 30 and 50
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| cushing syndrome occurs in persons on... | high dose steroids for long periods of time
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| patients who are at high risk for cushing syndrome are... | asthma pt's, auto immune dx pt's, transplant pt's, COPD pt's
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| causes of cushing syndrome | (endogenous)adrenal hyperplasia, pituitary tumor, Ca of lung, GI or pancreas, adrenal tumors; (exogenous)therapeutic use of glucocorticoids
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| cushing syndrome affect functions of... | adrenal cortex "sugar, salt and sex" (glucose metabolism, secondary sex characteristics and mineralcorticoid levels)
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| characteristics of someone with cushing's syndrome? | obesity and redistribution of body fat: central obesity, fat pads under clavicles & upper back (buffalo hump), rounded face
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| Glucose and electrolyte imbalance in cushing's syndrome include... | hyperglycemia, hypernatremia, hypokalemia
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| signs of cushing syndrome | HTN, thinning of skin, bruises easily, abdominal striae, altered immunity, delayed healing, prone to infection, altered calcium absorption increasing osteoporosis and risk for fractures
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| A pt with cushing syndrome has an increased... | gastric acid secretion increasing risk for ulcer
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| what kind of emotional chages does a pt with cushing syndrome have? | from depression to psychosis
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| what kind of changes in secondary sexual characteristics occur in cushing's syndrome? | hirsuitism(hair in irregular places) in females, gynecomastia in males
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| Menstrual irregularities is what occurs in cushing's syndrome? (T or F) | True
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| cushing's assessment will include | truncal obesity, buffalo hump, moon face, thin skin, bone density loss, decreased muscle mass, abnormal sleep patterns, HTN
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| diagnosing cushing syndrome will include... | measurement of plasma cortisol(alterations in normal diurnal alteration: higher in mornings, lower in afternoons and evenings)
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| diagnosing cushing syndrome will include... | 24 hour urine collections for measurements of hormones: 17 ketosteroids and 17 hydroxycorticosteroids which are elevated
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| diagnosing cushing syndrome will include... | electrolytes and glucose levels (elevated Na, glucose; decreased K)
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| Treament for cushing syndrome | tumors may be treated with surgery, radiation, medications, or a combination
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| medications for cushing syndrome with inoperable pituitary or adrenal tumors | mitotane, metyrapone, ketoconazole-which suppress adrenal cortex, decrease cortisol synthesis
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| surgery for cushing syndrome include... | adreanlectomy and hypophysectomy
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| adrenalectomy? | removal of adrenal gland if tumor is in the adrenal gland; if both glands are removed, client will need to be on lifelong hormone replacement
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| hypophysectomy? | removal of pituitary gland through transphenoidal route or craniotomy
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| nursing care post op? | clients being treated for adrenal or pituitary sx need intensive care; pt's who have undergone tx often need to be on life long hormone replacement & wear id bracelet; must not abruptly stop hormone or could develop addisonian crisis
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| nursing diagnoses for cushing's syndrome | excess fluid volume r/t excess water & Na reabsorption; risk for infection r/t immunosuppression & inadequate primary defenses; fattigue r/t sleep deprivation; disturbed body image r/t illness
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| pheochromocytoma definition... | tumor of the adrenal medulla that produces excessive levles of catecholamines(epinephrine and norepinephrine)
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| symptoms of pheochromocytoma | severe h/a, generalized excessive sweating, tachycardia & palpitations, HTN, anxiety/nervousness, tremors, pain in lower chest or upper abd, nausea with or w/out vomitting, wt loss, heat intolerance
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| assessment of pt's with pheochromcytoma | hx may include intermittent hypertensive episodes, 24 hr urine for vanillylmandelic acid(VMA)- a product of epinephrine & norepinephrine(catecholamines)
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| VMA testing | restrict foods for 2-3 days(coffee tea, bananas, chocolate, cocoa, citrus, fruits, and vanilla), meds to hold, collect 24 hr urine, decrease stress, starvation, and physical activity
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| interventions during VMA testing | DO NOT PALPATE ABDOMEN, avoid smoking and caffeine, MONITOR BP, hydration
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| post op adrenalectomy | monitor hypovolemia, monitor VS, I&O, monitor for hemorrhage and shock
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