Unit 2- Adrenal Insufficiency (primary and secondary)

What are the hormones of the adrenal gland?

(salt) mineralocorticoids ( aldosterone) (sugar) gluccocorticoids (cortisol) (sex) Androgens

The nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which signs and symptoms are related to adrenal insufficiency? Select all that apply. 1.Fever 2.Weakness 3.Hypotension 4. Double vision 5.Mental status changes

1,2,3,5

The nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing interventions are appropriate components of the plan of care? Select all that apply. 1. Monitoring intake and output 2.Maintaining a low-sodium diet 3.Monitoring for changes in mental status 4.Encouraging an intake of low-protein foods 5.Encouraging fluid intake of at least 3000 mL/day

1,3,5

What does medical care look like for a patient w/ Acute Adrenal Crisis?

1. blood sample is collected to determine cortisol level 2. IV infusion of normal saline w/ 5% dextrose 3. INITIAL DOSE OF HYDRO-CORTISONE (solu-Cortef) IV PUSH, followed by infusion of saline and dextrose over 8 hours. 4. Additional doses of hydrocortisone per infusion are a rate of 100 mg every 8 hours to ENSURE CONTINUOUS SOURCE OF GLUCOCORTICOIDS.

What are the functions of glucocorticoids?

1. control of carbohydrate, lipid, fat metabolism, 2. regulation of anti-inflammatory and immune responses 3. control of emotional states.

Adrenal insufficiency may be classified as primary or secondary. What is primary adrenal insufficiency also known as?

Addison's disease

Patients with primary or secondary adrenal insufficiency are at risk for episodes of acute adrenal crisis, also known as?

Addisonian crisis, which is a life-threatening emergency.

A patient comes in with Assessment Weight loss, salt craving, nausea and vomiting, abdominal cramping and diarrhea, muscle weakness and aches, poor stress response, decreased libido, and amenorrhea. Pale skin with bronzed areas, emaciation, sparse body hair, poor skin turgor, hypotension, and muscle wasting

Adrenal Hypofunction

A patient with primary Addison's disease who just ran a marathon has a heart rate of 130 beats/minute and blood pressure of 82/60 mm Hg. Besides intravenous (IV) isotonic fluids, what do you anticipate will be administered? A. Whole blood B. Solu-Cortef C. Vancomycin D. Calcium gluconate

B. Solu-Cortef (hydrocortisone) Acute adrenal insufficiency is caused by excessive stress. In addition to the usual treatment, corticosteroids must be administered so the adrenal glands can respond.

You teach the patient that the best time to take corticosteroids for replacement purposes is A. once each day at bedtime. B. every other day on awakening. C. on arising and in the late afternoon. D. at consistent intervals every 6 to 8 hours.

C. on arising and in the late afternoon. Glucocorticoids are usually given in divided doses: two thirds in the morning and one third in the afternoon. This dosage schedule reflects normal circadian rhythm in endogenous hormone secretion and decreases the side effects associated with corticosteroid replacement therapy.

Signs of a general adrenal disorder are: Decreased energy, mental changes (depression, anxiety, nervousness, confusion), sexual dysfunction, gastrointestinal disturbances, and abnormal skin pigmentation

Decreased energy, mental changes (depression, anxiety, nervousness, confusion), sexual dysfunction, gastrointestinal disturbances, and abnormal skin pigmentation

Which signs/symptoms should the nurse expect to note when collecting data on a client with Addison's disease? 1. Edema and weight gain 2. Hypotension and vomiting 3. Obesity and muscle hypertrophy 4. Hirsutism and excessive hunge

Hypotension and vomiting

Addison's Disease laboratory findings should be what?

Low serum and urinary cortisol level, decreased fasting glucose hyponatremia -sodium(Na+) lower than 135, hyperkalemia- Potassium(K) greater than 5.0 BUN- increased.

Nurse Troy is aware that the most appropriate complication to watch for a client with Addison's disease? a. Risk for infection b. Excessive fluid volume c. Urinary retention d. Hypothermia

a. Risk for infection Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.

The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when a. the patient appears alert and oriented b. the patient's urinary output has increased c. pulmonary edema is reduced as evidenced by clear lung sounds d. laboratory tests reveal serum elevations of K and glucose and a decrease in sodium

a. the patient appears alert and oriented (rationale- confusion, irritability, disorientation, or depressioni s often present in the patient with Addison's dz, and a positive response to therapy would be indicated by a return to alertness and orientation. Other indication of response to therapy would be a decreased urinary output, decreased serum potassium, and increased serum sodium and glucose. The patient with Addison's would be very dehydrated and volume-depleted and would not have pulmonary edema.)

Acute Adrenal Crisis(Addisonian Crisis) usual results from a sudden marked decrease in available ____________ hormones.

adrenal

In post-menopausal women, the __________ ___________ is the primary source of endogenous estrogen.

adrenal cortex

Renin acts on plasma proteins to release angiotensin I, which is catalyzed in the lung to angiotensin II. Angiotensin II stimulates the secretion of ______________, which results in the retention of sodium and water,

aldosterone

The zona glomerulosa produces mineralocorticoids. What is the most abundant?

aldosterone

What is idiopathic atrophy?

an autoimmune disease in which adrenal tissue is destroyed by antibodies formed by the patiens own immune system. -most common cause of Addison's

Secondary adrenal insufficiency leads to decreased what?

androgen and cortisol production

A patient with Addison's disease comes to the emergency department with complaints of N/V/D, and fever. The nurse would expect collaborative care to include a. parenteral injections of ACTH b. IV administration of vasopressors c. IV administration of hydrocortisone d. IV administration of D5W with 20mEq of KCl

c. IV administration of hydrocortisone (rationale- vomiting and diarrhea are early indicators of addisonian crisis and fever indicates an infection, which s causing additional stress for the patient. treatment of a crisis requires immediate glucocorticoid replacement, and IV hydrocortisone, fluids, sodium and glucose are necessary for 24hours. Addison's disease is a primary insufficiency of the adrenal gland, and ACTH is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's. Potassium levels are increased in Addison's dz, and KCl would be contraindicated.)

Which of the following nursing implications is most important in a client being medicated for Addison's disease? a. Administer oral forms of the drug with food to minimize its ulcerogenic effect. b. Monitor capillary blood glucose for hypoglycemia in the diabetic client. c. Instruct the client to never abruptly discontinue the medication. d. Teach the client to consume a diet that is high in potassium, low in sodium, and high in protein.

c. Instruct the client to never abruptly discontinue the medication. The primary medical treatment of Addison's disease is replacement of corticosteroids and mineralcorticoids, accompanied by increased sodium in the diet. The client needs to know the importance of maintaining a diet high is sodium and low in potassium. Medications should never be discontinued abruptly because crisis can ensue. Oral forms of the drug are given with food in Cushing's disease.

A patient is scheduled for bilateral adrenalectomy. During the postoperative period, the nurse would expect administration of corticosteroids to be a. reduced to promote wound healing b. withheld until symptoms of hypocortisolism appear c. increased to promote an adequate response to the stress of surgery d. reduced because excessive hormones are released during surgical manipulation of the glands

c. increased to promote an adequate response to the stress of surgery (rationale- although the patient with Cushing syndrome has excess corticosteroids, removal of the glands and the stress of surgery require that high doses of cortisone be administered postoperatively for several days. The nurse should monitor the patient postoperatively to detect whether large amounts of hormones were released during surgical manipulation and to ensure the healing is satisfactory.)

The glucocorticoid must be present for other processes to occur.. such as?

catecholamine activity excitability of the myocardium

If adrenal crisis is untreated, fluid and electrolyte imbalances can lead to...

circulatory collapse, cardiac arrhythmias, cardiac arrest, coma, and death

What is the most abundant glucocorticoid?

cortisol

Renin release is stimulated by?

decrease in ECF.

What is the mainstay of treatment for patients with secondary adrenal insufficiency?

glucocorticoids, mineralocorticoids are not needed.

What do mineralocorticoids do?

help maintain an adequate ECF

Acute Adrenal Crisis is treated with IV fluids, ______________, electrolytes, and dextrose to restore the blood level to normal.

hydrocortisone

What are the signs/symptoms of Acute Adrenal Crisis?

hypotension, tachycardia, dehydration, confusion, hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia. symptoms of mineralocorticoid and glucocorticoid deficiency

What is the most common cause of Addison's Disease?

idiopathic atrophy.

Any factor that causes stress in a person can initiate Acute Adrenal Crisis. Some include:

infection, illness, trauma, emotional or psychiatric disturbances,

What is the primary function of adrenal androgens?

male masculinity

In women, estrogen is supplied by the _________ and the ___________ ________.

ovaries, adrenal glands

What is the cause of secondary adrenal insufficiency?

pituitary tumors. postpartum necrosis of the pituitary (Sheehan syndrome) hypophysectomy radiation therapy pituitary or intracranial lesions high-dose, long-term glucocorticoid treatment(which suppresses the adrenal glands' intrinsic activity)

What is the mainstay of treatment of patients with Addison's Disease(primary insufficiency)?

replacement therapy w/ glucocorticoids and mineralocorticoids.

The secretion of aldosterone is regulated by many factors. Give examples.

serum levels of potassium renin-angiotensin mechanism ACTH

Aldosterone functions at the renal collecting tubule to promote the reabsorption of __________, and the excretion of ___________.

sodium, potassium

Hydrocortisone has a short halflife, so patients get another dose to ensure what?

the patient has a continuous level of glucocorticoids

What is Addison's disease?

the result of a destructive disease process affecting the adrenal glands; results in deficiencies of cortisol and aldosterone

What is secondary adrenal insufficiency?

the result of dysfunction of the hypothalamus or pituitary that leads to decreased androgen and cortisol productio. Aldosterone may be affected

What are the other causes of Addison's Disease?

tuberculosis, hemorrhage related to anticoaguland therapy, fungal infections, AIDS, mestatic cancer, gram negative sepsis, etc.