T3: Cushings & Hyperaldosteronism
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| What are the 3 main classifications of adrenal cortex steroid hormones? | glucocorticoids, mineralocorticoids, and androgens
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| What is the function of glucocorticoids? | regulate metabolism; increase blood glucose levels; critical in the physiologic stress response
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| What is the primary glucocorticoid? | cortisol
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| What is the function of mineralocorticoids? | regulate sodium and potassium balance
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| What is the primary mineralocorticoid? | aldosterone
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| What is the function of androgens? | Contribute to growth and development in both genders and to sexual activity in adult women.
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| This term refers to any one of these 3 types of hormones produced by the adrenal cortex. | corticosteroid
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| Where are glucocorticoids, mineralocorticoids, and androgens produced? | adrenal cortex
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| This is a clinical condition that results from chronic exposure to excess corticosteroid, particularly glucocorticoids. | Cushing Syndrome
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| Several conditions can cause Cushing syndrome. What is the most common cause? | Iatrogenic administration of exogenous corticosteroids (prednisone)
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| Approximately 85% of the cases of endogenous Cushing syndrome are due to what? | an adrenocorticotropic hormone (ACTH) - secreting pituitary adenoma (Cushing disease)
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| 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
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| 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
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| The facies in Cushings include? | a rounded face (moon facies) with thin, reddened skin
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| Excess glucocorticoids causes this from accumulation of adipose tissue. | weight gain
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| Excess glucocorticoids causes this due to glucose intolerance and increased gluconeogenesis by the liver. | hyperglycemia
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| Excess glucocorticoids causes muscle wasting which can lead to? | weakness
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| Excess glucocorticoids causes loss of bone matrix which can lead to? | osteoporosis and back pain
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| Excess glucocorticoids causes loss of collagen which can lead to? | thin, weaker skin that can bruise easily
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| Excess glucocorticoids causes catabolic processes that can lead to? | delay in wound healing
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| Excess glucocorticoids can cause the patient to be? | irritable, anxious, euphoria, and occasionally psychosis may occur
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| Excess mineralocorticoid may cause? | HTN (secondary to fluid retention)
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| Adrenal androgen excess may cause? | severe acne, virilization in women, and feminization in men
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| Menstrual disorders and hirsutism in women and gynecomastia and impotence in men occur more commonly with? | adrenal carcinomas
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| 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
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| In Cushings what happens to the plasma cortisol levels? | May be elevated, with loss of diurnal variation.
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| 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
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| If the urine cortisol levels are borderline what test is done? | a low-dose dexamethasone suppression test
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| What would plasma ACTH levels be in Cushing disease (pituitary etiology)? | high or normal ACTH levels
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| What would plasma ACTH levels be in Cushing syndrome (adrenal or medication etiology)? | low or undetectable ACTH levels
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| ____ and ____ are seen in ectopic ACTH syndrome and adrenal carcinoma. | hypokalemia; alkalosis
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| What is the primary goal of treatment for Cushing syndrome? | To normalize hormone secretion
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| How is treatment determined in Cushings? | Is dependent on the underlying cause
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| 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.
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| 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.
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| 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.
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| 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.
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| Why is gradual tapering of corticosteroids necessary? | To avoid potentially life-threatening adrenal insufficiency.
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| 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
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| The alternate-day regimen is not used when the corticosteroids are given as? | hormone therapy
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| 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
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| 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).
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| 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
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| 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.
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| 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
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| 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.
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| 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.
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| Postoperatively, BP, fluid balance, and electrolye levels to to be ____ because of these hormone fluctuations. | unstable
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| 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)
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| 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
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| High levels of corticosteroids increase susceptibility to _____ and delay _____. | infection; wound healing
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| 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
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| 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.
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| 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
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| 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
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| After surgery, patients are usually maintained on bed rest until? | the BP stabilizes
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| 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
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| 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.
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| You should teach the patient to avoid what? | Exposure to extremes of temp, infections, & emotional disturbances.
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| How can stress produce or precipitate acute adrenal insufficiency? | B/c the remaining adrenal tissue cannot meet an increased hormonal demand.
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| This is characterized by excessive aldosterone secretion. | hyperaldosteronism (Conn's syndrome)
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| What are the main effects of aldosterone? | sodium retention and potassium and hydrogen ion excretion
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| What is the hallmark of hyperaldosteronism? | HTN with hypokalemic alkalosis
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| Primary hyperaldosteronism (PA is most commonly caused by what? | a small solitary adrenocortical adenoma
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| Bilateral adrenal hyperplasia involves what? | multiple lesions
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| Who does PA affect more? | women b/t 30 and 60 years
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| 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
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| Elevated levels of aldosterone are associated with what? | sodium retention and excretion of potassium
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| Sodium retention leads to what? | hypernatremia, hypertension, and headache
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| Why does edema not usually occur with hyperaldosteronism? | B/c the rate of sodium excretion increases which prevents more severe sodium retention.
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| The potassium wasting in hyperaldosteronism leads to what? | hypokalemia
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| CM of hypokalemia | generalized muscle weakness, fatigue, cardiac dysrhythmias, glucose intolerance, & metabolic alkalosis that may lead to tetany.
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| Hyperaldosteronism should be suspected in all hypertensive patients with hypokalemia who are not being treated with what? | diuretics
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| PA is associated with what? | Elevated plasma aldosterone levels, elevated Na levels, decreased serum K levels, & decreased plasma renin activity.
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| Adenomas are localized by what means? | CT scan or MRI
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| If a tumor is not found, this is measured after overnight bed rest. | plasma 18-hydroxycortocosterone
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| A plasma 18-hydroxycortocosterone level greater than 50 ng/dL indicates what? | an adenoma
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| What is the preferred treatment for PA? | surgical removal of the adenoma (adrenalectomy) laparoscopically
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| 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.
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| 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.
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| 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
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| Patients with bilateral adrenal hyperplasia are treated with what? | a K sparing diuretic (spironolactone, amiloride-MIdamor) or with aminoglutethimide (Cytadren), which blocks aldosterone synthesis.
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| This may also be used to decrease adrenal hyperplasia. | dexamethasone
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| 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.
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| 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.
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