Adrenal Cortex and Medulla Disorders

Cushing Syndrome

• caused by excess of corticosteroids

  • iatrogenic administration of exogenous corticosteroids

  • ACTH-secreting pituitary adenoma

  • adrenal tumors

  • extopic ACTH production by tumors

clinical manifestations of Cushing Syndrome

• excess cortisol

• moon face, buffalo hump

• truncal obesity

• hyperglycemia

• thin skin and bruising

Nursing priorities for Cushing Syndrome

• monitor for infection

• manage hyperglycemia

• protect skin integrity

• monitor weight and fluid status

Interprofessional Care and Cushing Syndrome

• gradual corticosteroid taper

  • Never stop steroids abruptly

• surgical removal if present

Primary adrenocortical insufficiency

• Addison’s disease

• reduction of glucocorticoids, mineralocorticoids, and androgens

Secondary adrenocortical insufficiency

• Lack of pituitary ACTH

• lack of glucocorticoids and androgens

Addison’s disease clinical presentation

• insidious onset

• decreased cortisol and aldosterone

• hypotension and dehydration

• weight loss and fatigue

• hyperpigmentation

• hyperkalemia

• hyponatremia

Long-term care of Addison’s disease

• lifelong corticosteroid therapy (hydrocortisone)

  • increase dose during periods of stress

• women need androgen replacement

• increase dietary salt intake

• patient must carry emergency steroid kit

  • IM hydrocortisone

Addisonian Crisis

• life-threatening adrenal insufficiency

• severe hypotension, tachycardia, shock

• vomiting, weakness, confusion

• various triggers

  • stress- infections, surgery

  • sudden withdrawal of corticosteroids

  • adrenal surgery; pituitary gland destruction

• treatment

  • IV fluids

  • IV corticosteroids

ACTH stimulation test

• baseline levels of cortisol and ACTH

• IV injections of synthetic ACTH (cosyntropin) given

• levels rechecked after 30 and 60 minutes

  • elevated blood cortisol level is normal

  • little or no increase in cortisol levels in Addison’s disease

  • High ACTH level in primary adrenal insufficency

Key points of Corticosteroid therapy

• anti-inflammatory and immunosuppressive

• Side effects:

  • Hyperglycemia

  • infection risk

  • osteoporosis

• Never stop abruptly —> risk of adrenal crisis

Examples of Corticosteroid therapies

• Hydrocortisone

• prednisone

• methylprednisolone

• dexamethasone

Pheochromocytoma

• rare, catecholamine-secreting tumor within adrenal medulla

• causes excess production of epinephrine and norepinephrine

• results in life-threatening hypertension and tachycardia

Clinical manifestations of pheochromocytoma

• severe hypertension (episodic or sustained)

• tachycardia, palpitations

• diaphoresis (excessive sweating)

• severe headache

• anxiety, panic attacks, feelings of impending doom

• hyperglycemia

• unexplained weight loss

Interdisciplinary management of pheochromocytoma

• alpha blockers FIRST

• beta blockers SECOND

• alpha administered BEFORE beta-blockers to prevent a hypertensive crisis

• beta-blockers given 2nd (after alpha blockers) to control tachycardia

• surgery with or without chemotherapy for definitive treatment

Nursing management for pheochromocytoma

• monitor BP and HR closely

• Avoid palpating the abdomen

  • can trigger catecholamine

• administer alpha blockers BEFOREEEEE beta blockers!

• prep for adrenalectomy to remove tumor

• patient teaching

  • need to avoid triggers for HTN exacerbation

    • stress, physical exertion, tyramine-rich foods, decongestants