ETIOLOGY

NCM 116: MEDICAL SURGICAL NURSING 1. Iatrogenic causes

ADRENAL DISORDERS o Excessive cortisol level from chronic therapy with
glucocorticoids
WHAT ARE ADRENAL GLANDS?
2. Primary cause
- Glands located on top of each kidney o Excessive cortisol production from adrenal neoplasm
- Produce hormones that humans cannot live without such as adenomas or carcinomas
o Sex hormones 3. Secondary cause
o Cortisol o Excessive production of adrenocorticotropic hormone
§ Respond to stress (ACTH) from the anterior pituitary gland due to pituitary
WHAT ARE THE ADRENAL GLAND DISORDERS? carcinomas/ ectopic ACTH secretion by neoplasm of
lungs, kidneys, pancreas, thyroid etc.
- Gland make or too much or not enough hormones
1. Cushing’s syndrome
o Too much cortisol MANIFESTATIONS
2. Addison’s disease
o Too little cortisol I. Increased Glucocorticoids
o Some people are born with it
1. Protein catabolism
CUSHING’S SYNDROME - affects muscle of the body
o Muscle wasting
o Osteoporosis
DEFINITION
2. Inc. blood glucose
- Excess secretion of the adrenal cortex hormones
- because glucocorticoids has an influence in glucose metabolism
- Excessive adrenocortical activity
o Overt diabetes
- 3 types of hormones produced by adrenal cortex
3. Decreased immunity
o Glucocorticoids
§ Prototype: hydrocortisone - Decreases immune response thus predisposing the person
o Mineralocorticoids o Slow wound healing
§ Aldosterone o infections
o Sex hormones 4. fat catabolism
§ androgens (male) o Inc. blood cholesterol
Remember…. o Acne, oily skin
Without adrenal cortex = severe stress causes peripheral
circulatory failure, circulatory shock and frustration

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II. Increased Mineralocorticoids III. Increase in androgen level
- Exerts major effects in electrolyte metabolism - Androgens
- Act principally on renal tubular and GI epithelium to case in Na+ o 3 major type of steroid hormones
absorption in exchange for K+ or H+ o Produced by adrenal cortex
- ACTH o Effects similar to male sex hormones
o minimally influences aldosterone secretion and primarily o Secretes small amounts of estrogen ( female sex
secreted in response to the presence of angiotensin II hormones)
- Angiotensin II o ACTH control secretion of adrenal androgens and when
o Elevated BP by constricting arterioles secreted in small amounts= little effect but when
o Inc. conc. When renin released from kidney in response secreted in excess in inborn enzyme deficiencies,
to decreased perfusion pressure masculinization may result (ANDROGENITAL SYNDROME)
- Increased aldosterone= Na+ reabsorption by kidney and Gi tract 1. Hirsutisms
to normalize BP o Excess hair in face
- Release of aldosterone is increased by hyperkalemia 2. Loss of libido
- Aldosterone is the hormone of the long term regulation of sodium 3. Voice deepens
balance
4. Amenorrhea and breast atrophy
4. Hypertension
- Leading to cardiovascular failure
5. Na+ retention
- Lead to H2O reabsorption
o Weight gain
o Obesity
o Lethargy
6. Imbalance to Na+ , K+ pump
- Lead to CNS instability

CLASSIC PICTURE OF CUSHING’S SYNDROME

- Adult
o central type of obesity
o fatty buffalo hump in the neck and supraclavicular areas

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 - Moon face, increased oiliness, and acne
o heavy trunk and thin extremities - Inc. susceptibility to infection
o Skin is fragile, thin, and easily traumatized - Hyperglycemia
o Ecchymosis - Weight gain
o Striae - Slow healing of minor cuts
o Red cheeks - Women 20-40 yrs= 5x more likely than men
o Fat hump - Female of all ages= virilization as a result of androgens
o Moon face o Virilization: Appearance of masculine traits and
o High BP recission of feminine traits
o Poor wound healing o Hirsutism
o Pendulous abdomen o Breast atrophy
o Clitoris enlarges
o Menses seizes
o Voice deepens
o Libido is lost

-
LABORATORY RESULTS
- Hypernatremia
- Hypokalemia
- Hyperglycemia
- Hypercholesterolemia
- Midnight serum cortisol level
o >7.5 mg/dl
Remember… - Inc. 24-hr urinary free cortisol
o >100 mg/24h
- Due to overproduction of adrenocortical hormones leading to - Corticotropin-releasing hormone (CRH) simulation test
arrest of growth, obesity, and musculoskeletal changes along o Useful to distinguish pituitary (ACTH-dependent) from
with glucose intolerance ACTH independent (adrenal tumors, adrenal hyperplasia,
- Prolonged exposure to elevated levels of indigenous exogenous glucocorticoid administration) causes of
glucocorticoids or exogenous glucocorticoids Cushing’s syndrome
- Excessive protein catabolism occurs = muscle wasting and - Low ACTH are consistent with adrenal adenoma
osteoporosis - CT scan, UTZ, MRI
- Kyphosis , back ache ,and compression factures of vertebrae o to localize adrenal tissue and detect lung tumors of
results adrenal glands
- Retention of H20 and Na+ because of inc. mineralocorticoid - Reduced eosinophils
activity= HTN and HF - Disappearance of lymphoid tissue
- Measurement of urinary and plasma cortisol are obtained

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 - Blood samples are collected= determine whether normal diurnal o first used for pituitary adenomas because of high
variation in plasma level is present; absent in adrenal dysfunction mortality and morbidity assoc. with surgical procedure
- If several blood samples are required= must be collected on time on hypophysis
specified and time collection must be noted on request slip o radiotherapy is used as part of overall tx
- Measurement of plasma ACTH by radioimmune assay is used in o also with pituitary tumors
conjunction with high dose suppression test to distinguish o aim with tumor is to control growth of tumor and
pituitary tumors from ectopic sites of ACTH prod as cause of remaining tumors from surgery and prevent it from
Cushing’s syndrome enlarging
- Elevation of ACTH and cortisol= pituitary/ hypothalamic disease
- Low ACTH high cortisol= adrenal disease

SCREENING TEST - stereotactic radiotherapy

o photon knife or gamma knife
Dexamethasone suppression test o specialist type of external beam radiation therapy
- Overnight supp test is mostly used for dx of pituitary and adrenal (stereotactic radiation
causes of Cushing’s syndrome o focused radiation therapy targeting a well defined tumor
- Dexamethasone of 1mg is administered orally at 11 pm and o relies on detailed imaging, computerized 3D treatment
plasma cortisol level is obtained at 8 am planning, and precise treatment setup to deliver the
- Suppression of less than 5 mg/dl= hypothalamic pituitary adrenal radiation dose with accuracy
access is functioning properly o 2 types:
§ Stereotactic radiosurgery
TREATMENT • Delivers 1-5 stereotactic radiation
treatment to brain/spine
- Varies with its cause • Does not involve surgery
1. Pituitary adenoma • No incision
- Transsphenoidal hypophysectomy • No tissue surgically removed
o Pituitary is taken out through the nose via sphenoid • Delivered by team
sinus, a cavity near the back of nose o Radiation oncologist
o Done with the assistance of either a surgical microscope o neurosurgeon
or endoscopic camera § stereotactic body radiation therapy
• stereotactic ablative radiotherapy
• delivers 1-5 stereotactic radiation tx to
tumors within the body excluding brain
or spine
- Pituitary irradiation - total bilateral adrenalectomy
o for patients not cured by transsphenoidal surgery o for patients not cured by transsphenoidal surgery or
pituitary irradiation

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 2. adrenal neoplasm o Establish a protective environment
- surgical resection of the affected adrenal gland § Prevent falls, fracture, injuries to bones and soft
- glucocorticoid replacement tissues
o for approximately 9-12 mos after surgery to allow time o Assistance from the nurse in ambulating
for the contralateral adrenal gland to recover from its § Very weak pt to prevent further injury
prolonged suppression o Food high in protein, calcium, and vit. D, are
recommended to minimize muscle wasting and
3. Ectopic ACTH osteoporosis
- Surgical resection of the ACTH-secreting neoplasm o Assist the pt in selecting appropriate food that are also
low in Na+ and calories
§ Referral to dietician
NURSING MANAGEMENT 2. Risk for infection related to altered protein metabolism and
ASSESSMENT inflammatory response
- Health history o Pt should avoid unnecessary exposure to others with
o Ability to carry out routine and self- care activities infections
o Skin is observes and assessed for trauma, infection, o Frequently assess the pt for subtle signs of infection
breakdown, bruising and edema because the anti-inflammatory effects of corticosteroids
o Appearance are noted and response are elicited may masks the common signs of inflammation and
o Mood, response to questions Awareness of environment, infection
level of depression 3. Activity intolerance related to weakness, fatigue, muscle
§ Family is a good source of info of gradual wasting, and altered sleep patterns
changes in physical appearance and emotional o Encourage moderate activity to prevent complications of
status immobility
o Changes in memory, attention span, behavior o Help the patient plan and space rest periods throughout
o Sleep- wake pattern the day
o Patient’s changed affect, short term memory, emotional o Promote a relaxing, quiet environment for rest and sleep
instability, ability to concentrate 4. Impaired skin integrity related to edema, impaired healing and
o Weight gain and changes in body proportions thin and fragile skin
o Hirsutism, oily skin, acne, purple striae, poor wound
o Meticulous skin care
healing
§ To avoid trauma to skin
o Changes in menstruation
o Use of adhesive tape is avoided
o Changes in libido
§ Irritate skin and tear tissue
o Changes in appetite and thirst
o Assess the skin and bony prominences
o Change positions frequently to prevent skin breakdown
NURSING DIAGNOSES AND INTERVENTIONS 5. Disturbed body image related to altered physical appearance,
1. Risk for injury related to muscle weakness and fatigue impaired sexual functioning, and decreased activity level

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 o Self-help groups - rapid decrease of circulating adrenal hormones bc of surgery /
o Listen to the patient abrupt halt of corticosteroid= adrenal hypofunction and
§ When sharing his/her story Addisonian crisis develop
o Weight gain and edema management with diet and - patients with adrenal insufficiency, inability to increase cortisol
exercise production with stress can lead to Addisonian crisis
§ Major physical changes disappears in time if the - management:
cause of Cushing’s syndrome is treated o IV administration of fluids, electrolytes, corticosteroids
§ Benefit from discussion on effect of changes to o Treat circulatory collapse and shock
his self-concept and relation to others - It may be due to surgical removal of the adrenals or pituitary and
§ Weight gain and edema can be modified by low abrupt stoppage of corticosteroid therapy
carbs low Na and high protein intake reduce - Highly stressful events may lead to such crisis characterized by:
symptoms o Circulatory collapse
6. Disturbed thought process related to mood swings, irritability o Hypotension
and depression o Dehydration
o Explanations to the patient and family members about o Nausea/ vomiting
the cause of emotional instability o Hypoglycemia
§ Helping them cope with mood swings o Hyperkalemia
§ Psychotic behavior may occur and must be 2. Hyperglycemia
reported - Regular blood glucose monitoring
o Encourage the patient and family members to verbalize - Report elevated blood glucose levels to the physician
their feelings and concerns
3. Health teachings: self-care
COMPLICATIONS and MANAGEMENT - Do not stop the corticosteroid use abruptly and without medical
supervision
1. Addisonian crisis o Must be tapered to allow normal adrenal function to
- Life threatening situation that results in low blood pressure, low return and to prevent steroid induced adrenal
sugar, high K+ insufficiency
o Monitor for hypotension, rapid weak pulse, rapid RR, o Ensure adequate supply of corticosteroids, skipping and
pallor extreme weakness running out = precipitate Addisonian crisis
o Identify factors that led to the crisis - Ensure an adequate supply of the corticosteroid, because running
- it is the sever hypofunction of the adrenal cortex out of the medication and skipping doses can precipitate
- withdraw corticosteroid/ adrenalectomy / remove pituitary tumor Addisonian crisis
at risk for adrenal hypofunction and Addisonian crisis - Adequate calcium intake without increasing the risk for
- high levels of circulating adrenal hormones are suppressed= hypertension, hyperglycemia and weight gain
function of adrenal cortex, atrophy of adrenal cortex is likely - Regularly monitor blood pressure, blood glucose levels and weight
- Wear medical alarm bracelet
- Patient compliance with the medicine regimen

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 - Regular medical follow-up 3. GI symptoms
- Health promotion activities 4. Fatigue
o health screening, including bone mineral density testing 5. Emaciation (very thin)
6. Dark pigmentation of skin, knuckles, knee, elbows, mucous
ADDISON’S DISEASE membrane
7. Hypotension
DEFINITION 8. Low blood glucose
- primary adrenocortical insufficiency is characterized by 9. Low serum Na+
inadequate secretion of corticosteroids resulting from partial or 10. High serum K+
complete destruction of the adrenal glands 11. Mental status changes – 60-80% of pts
- adrenal insufficiency o Depression
- uncommon when body doesn’t produce enough hormones
o Emotional ability
- too little cortisol and often too little aldosterone
o apathy
- need hormone replacement therapy for life
o Confusion
- cortisol: stress response (illness, surgery, injury); maintain BP;
12. chronic dehydration
heart fx; immune system; blood glucose
- aldosterone: Na+ and K+ balance in blood; controls the amount of o Disturbance of Na+ and K+= Depletion of Na+ and H2O =
fluid that kidney removes as urine which affect blood volume and severe chronic dehydration
BP 13. Disease progression and acute hypotension = Addisonian crisis
ETIOLOGY o Cyanosis
o Circulatory shock:
- autoimmune destruction of the adrenals
§ Pallor
o idiopathic atrophy of adrenal glands: 80% of cases
§ Apprehension
o replaced TB as the principal cause
§ Rapid and weak pulse
- removal of both or infection
§ Rapid RR
- carcinomatous destruction of the adrenal glands
§ Low BP
- tuberculosis
o most common Remember…
o considered in dx workshop bc of increasing incidence
Some cases such as injury, illness or time of intense stress=
- adrenal infarction
symptoms can come quickly and cause serious event (Addisonian
- advanced stages of AIDS
crisis/ acute adrenal insufficiency
o Medical emergency
MANIFESTATIONS o Can lead to shock and death

1. muscle weakness
2. anorexia

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 - Prednisone
o 5 mg in morning and 2.5 mg at bedtime
- Oral fludrocortisone 0.05 mg/day to 0.20 mg/day
- Increase glucocorticoid replacement in times of stress
- Parenteral glucocorticoids if diarrhea or vomiting occurs
- Combating circulatory shock: restoring blood circulation,
administering fluids and corticosteroids, monitoring vital signs,
and placing the patient in a recumbent position with the legs
elevated
- Hydrocortisone and antibiotics may be administered
- Oral intake may be initiated
- Lifelong replacement of corticosteroids and mineralocorticoids

COMPLICATIONS and MANAGEMENT

LABORATORY RESULTS
1. Addisonian crisis
- Blood cortisol level < 3 mg/dl o Monitor s/sx for crisis
- ACTH level >100mg/dl § Shock
- Hyperkalemia, hyponatremia § Hypotension
- Dec. glucose level § Rapid weak pulse
- Mild normocytic normochromic anemia, neutropenia § Rapid RR
- Decreased 24- hour urinary cortisol § pallor
§ extreme weakness
IMAGING STUDIES § risk for Addisonian collapse and shock
• physical and psychological stressors
1. Abdominal x-ray must be avoided
- Adrenal calcifications may be notes if the adrenocortical • exposure to cold
insufficiency is secondary to TB or fungal infection • overexertion
• infection
2. Abdominal CT scan • emotional distress
- Small adrenal glands o IV of fluid, glucose, electrolytes, sodium
- Idiopathic atrophy or long standing tuberculosis o Replacement of missing steroid hormones and
vasopressors
TREATMENT o Measure plasma cortisol level
o Administer hydrocortisone 50 mg IV q8h for 24 hrs
- hydrocortisone § If pt shows good clinical response, gradually
o 15-20 mg PO q morning taper dosage and change to oral maintenance
o 5-10 mg late afternoon dose (usually prednisone 7.5 md/day)

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 o Provide adequate volume replacement with D5NS sol’n o Encourage the pt to consume food an fluids high in Na+
until hypotension, dehydration, and hypoglycemia are during GI disturbance and very hot weather
completely corrected
3. Activity intolerance related to fatigue and muscle weakness as
NURSING MANAGEMENT evidenced by inability to participate in exertional activities
o Avoid unnecessary activity and stress
ASSESSMENT o Detect signs of infection or the presence of other
- Health history stressors
- Physical examination o Maintain a quiet, nonstress full environment
- Monitor BP and pulse rate o Assist in ADLs
- Assess the skin color and turgor § Perform activities such as bathing, turning, and
- Check for weight changes, muscle weakness, and fatigue explaining procedure reduce anxiety
- Investigate any illness or stress that may have precipitated the o Increase activity gradually following a crisis
acute crisis § Explain rationale for minimizing stress during
acute crisis assist pt to increase activity
NURSING DIAGNOSES AND INTERVENTIONS gradually

1. Risk of injury related to Addisonian crisis as evidenced by 4. Knowledge deficit related to self-care after discharge
hypotension and other signs of shock o Instruct about rationale for replacement therapy and
o Monitor for signs and symptoms of shock: proper dosage of medications
§ Hypotension o How to modify the medication dosage and increase salt
§ Rapid weak pulse intake in times of illness, very hot weather, and other
§ Rapid RR stressful situations
§ Pallor o To wear medical alert bracelet and carry info at all times
§ Extreme weakness about the need for corticosteroids
o Avoid physical and psychological stressors exposure to
cold, overexertion, infection, and emotional distress
o Avoid exertion
o Monitor VS, weight , fluid and electrolyte status
o Identify and reduce factors that led to crisis

2. Fluid volume deficit related to disease condition as evidenced by

decreased skin turgor and postural hypotension
o Assess the patient’s skin turgor, mucous membranes, and
weight loss
o Instruct pt to report increased thirst
o Monitor lying, sitting, and standing blood pressure

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