Chapter 49-Addison's and Cushing's

•↑ Plasma aldosterone levels •↑ Sodium levels •↓ Potassium levels •↓ Renin activity

In primary aldosteronism, how will plasma aldosterone, sodium, potassium, and renin be?

In times of stress

When is it necessary to increase corticosteroids in Addison's disease?

In the morning with food to reduce gastric irritation

When should corticosteroids be taken?****

When hormone levels return to normal

When will physical changes and emotional lability return for the patient with Cushing?

•With ectopic ACTH syndrome and adrenal carcinoma

When would hypokalemia and alkalosis occur?

White females

Who does Addison's occur most commonly in?

decrease BP

Why are CCBs given to the pt with hyperaldosteronism?

to block aldosterone synthesis

Why are potassium-sparing drugs given to the pt with hyperaldosteronism?

decrease hyperplasia

Why is dexamethasone given to the pt with hyperaldosteronism?

Decreases the side effects of corticosteroids

Why is dosing timing important for Addison's patients?

Decrease

How is cortisol affected in an Addisonian crisis?

c. "This medicine is given to help your body respond to stress after removal of the adrenal glands."

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? a. "The medication prevents sodium and water retention after surgery." b. "The drug prevent clots from forming in the legs during your recovery from surgery." c. "This medicine is given to help your body respond to stress after removal of the adrenal glands." d. "This drug stimulates your immune system and promotes wound healing."

Divided doses

How are glucocorticosteroids given (dose wise)?

•Gradually discontinue therapy •Decrease dose •Convert to an alternate-day regimen Dose must be tapered gradually

How is Cushing syndrome treated if the cause is iatrogenic?

•Surgical removal or irradiation of pituitary adenoma •Adrenalectomy for adrenal tumors or hyperplasia •Removal of ACTH-secreting tumors

How is Cushing syndrome treated if the cause is tumors?

a. The patient is alert and oriented.

The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? a. The patient is alert and oriented. b. The patient's lung sounds are clear. c. The patient's urinary output decreases. d. The patient's potassium level is 5.7 mEq/L.

•Problems with glycemic control •Susceptibility to infection •Delayed wound healing

What are Cushing syndrome patients at an increased risk for postop?

Manifestations of glucocorticoid and mineralocorticoid deficiencies: •Hypotension, tachycardia •Dehydration •↓ Sodium, ↑ potassium, ↓ glucose •Fever, weakness, confusion •Severe vomiting, diarrhea, pain •Shock → circulatory collapse

What are complications of Addison's?

An autoimmune response where antibodies destroy adrenal cortex

What are most cases of Addison's caused by?

•High or normal with Cushing disease (pituitary etiology)

What are plasma ACTH levels like in Cushing disease?

•Low or undetectable with Cushing syndrome

What are plasma ACTH levels like in Cushing syndrome?

Increased infection Increased glucose levels Weight gain

What are side effects of long-term use of corticosteroids?

•Vomiting, increased weakness •Dehydration, hypotension •Painful joints •Pruritus •Peeling skin •Severe emotional disturbances

What are signs and symptoms of acute adrenal insufficiency?

Thinning of hair Red cheeks Supraclavicular fat pad Thin extremities w/ muscle atrophy Think skin and subQ tissue Acne Moon face Increased body and facial hair Weight gain Purple striae Pendulous abdomen Ecchymosis from easy bruising** Slow wound healing

What are some clinical manifestations of Cushing syndrome (the picture)?

Baseline levels of cortisol and ACTH

What are the ACTH and CRH diagnostic test for Addison's looking at?

Insidious onset •Anorexia •Nausea •Progressive weakness •Fatigue •Weight loss •Abdominal pain •Diarrhea •Headache •Orthostatic hypotension •Salt craving •Joint pain

What are the clinical manifestations of Addison's disease?

•Severe acne •Virilization in women •Feminization in men

What are the clinical manifestations of cushing syndrome due to excess adrenal androgen?

•Hyperglycemia related to glucose intolerance and ↑ gluconeogenesis •Muscle wasting → weakness •Loss of bone matrix → osteoporosis and back pain •Loss of collagen → thin skin, easily bruises •Delay in wound healing

What are the clinical manifestations of cushing syndrome due to excess glucocorticoids?

•Hypokalemia •Hypertension

What are the clinical manifestations of cushing syndrome due to excess mineralocorticoid?

ACTH stimulation CRH stimulation

What are the diagnostic tests done for Addison's?

Confirmation of ↑ plasma cortisol levels •Midnight or late night salivary cortisol •Low-dose dexamethasone suppression test •24-hour urine cortisol

What are the diagnostic tests for Cushing syndrome?

•Anti-inflammatory action •Immunosuppression •Maintenance of normal BP

What are the expected effects of corticosteroids therapy?

•Potassium-sparing diuretics •Antihypertensives •Oral potassium supplements •Sodium restrictions

What are the medications given preop to the patient with hyperaldosteronism?

•↓ Potassium and calcium •↑ Glucose and BP •Delayed healing •Susceptibility to infection •Suppressed immune response •Peptic ulcer disease •Muscle atrophy/weakness •Mood and behavior changes •Moon facies, truncal obesity •Protein depletion •Risk for acute adrenal crisis if therapy is stopped abruptly

What are the side effects of corticosteroid therapy?****

Circulatory collapse

What can shock in Addison's lead to?

Little or no cortisol

What cortisol levels indicate Addison's disease when the ACTH or CRH test is done?

•CT scan or MRI •Plasma 18-hydroxycorticosterone level

What diagnostic studies are done for hyperaldosteronism?

•↑ Potassium •↓ Chloride, sodium, glucose •Anemia •↑ BUN •ECG changes •CT scan, MRI

What diagnostic study changes will you see in a patient with Addison's?

makes cortisol

What does ACTH do?

•Sodium retention •Potassium and hydrogen ion excretion •Hypertension with hypokalemic alkalosis

What does hyperaldosteronism lead to?

•Lack of glucocorticoids, mineralocorticoids, and androgens

What does primary Addison's disease result from?

•Lack of pituitary ACTH •Lack of glucocorticoids and androgens

What does secondary addison's result from?

•Light •Noise •Temperature

What extremes should you protect the Addison client from?

excess of corticosteroids

What is Cushing syndrome caused by?

Hyperpigmentation

What is a hallmark of Addison's disease?

other autoimmune d/os.

What is common with Addison's disease

•Identify patients at risk for Cushing syndrome •Long-term exogenous cortisol therapy is major risk factor •Teach patients about medication use and to monitor for side effects

What is included in the health promotion for the patient with Cushing?

Hydrocortisone •Increase during periods of stress Fludrocortisone (Florinef)

What is included in the hormone therapy for Addison's?

•Medications and side effects •Signs and symptoms of hypokalemia and hyperkalemia •Frequent monitoring

What is included in the patient teaching for the patient with hyperaldosteronism?

•↑ Risk of hemorrhage •Large release of hormones into circulation → instabilities in BP, fluid balance, and electrolyte levels •High doses of corticosteroids are given IV during and several days after surgery •Report any significant changes in vital signs •Monitor fluid intake and output •Administer corticosteroids as ordered •Obtain morning urine samples for cortisol measurement •Monitor for acute adrenal insufficiency

What is included in the postop care of Cushing?

Once in the morning

When are mineralocorticosteroids given to the patient with Addison's?

•Optimize physical condition •Control hypertension and hyperglycemia*** •Correct hypokalemia*** •High-protein diet to correct protein depletion*** •Depends on planned surgical approach

What is included in the preop care for the patient with Cushing?

Primary adrenal insufficiency

What is indicated if the ACTH is done and there are high levels of ACTH?

Secondary adrenal insufficiency

What is indicated if the CRH is done and there is no ACTH?

•Malaise •Weight gain •Anorexia •Polyuria •Prolonged wound healing •Easy bruising •Weakness, fatigue •Insomnia, poor sleep quality •Headache •Back, joint, bone, and rib pain •Poor concentration and memory •Negative feelings •Amenorrhea •Impotence, decreased libido •Anxiety •Mood disturbances •Emotional lability •Psychosis

What is some subjective data you might expect from the patient with Cushing?

•Shock management •High-dose hydrocortisone replacement •0.9% saline solution and 5% dextrose

What is the management during an Addisonian crisis?

•Frequent assessment necessary •Correct fluid and electrolyte imbalance •Assess vital signs and neurologic status •Daily weight •Accurate I and O •Obtain complete medication history Watch for signs of Cushing syndrome •Guard against infection •Assist with daily hygiene •Protect from extremes

What is the nursing management for the patient with Addison's disease?

Potassium

What is the only increased substance in Addison's disease?

•Rest and exercise needs •Sodium restriction if edema occurs •Need to monitor for hyperglycemia •Notify health care provider if epigastric pain develops •Need to prevent injury/infection •Inform all health care providers •Should be taken in the morning with food to reduce gastric irritation •Must not be stopped abruptly •Needs to increase in times of stress •Measures to reduce the occurrence of osteoporosis

What is the patient teaching for a patient taking corticosteroids?

↓ Sodium, ↑ potassium, ↓ glucose

What is the sodium, potassium, and glucose like in Addison's?

Hormone therapy Increased dietary salt intake

What is the therapy for Addison's disease?

•Adrenalectomy to remove adenoma

What is the treatment for hyperaldosteronism?

•Solitary adrenocortical adenoma

What is the usual cause of primary hyperaldosteronism?

Nonadrenal cause •Renal artery stenosis •Renin-secreting tumors •Chronic kidney disease

What is the usual cause of secondary hyperaldosteronism?

•Glucocorticoid •Mineralocorticoid •Adrenal androgen hormones

What is there a loss of in Addison's?

Glucocorticoids Mineralocorticoid Adrenal androgen

What is there excess of in Cushing syndrome?

Give steroids (High dose hydrocortisone)

What is your PRIORITY when a person is in Addisonian crisis?

•↓ Potassium level •↑ Glucose level •Dyslipidemia •Polycythemia •Granulocytosis •Lymphocytopenia •Eosinopenia •↑ Serum cortisol level •Abnormal ACTH levels •Abnormal dexamethasone suppression test •↑ Urine free cortisol and 17-ketosteroids •Glycosuria •Hypercalciuria

What lab values will you expect for the patient with Cushing?

>80-120 mcg/24 hours

What levels of cortisol indicate Cushing syndrome when doing a 24-hour urine cortisol?

corticosteroids

What medications cause cushing syndrome?

•Pituitary tumor; adrenal, pancreatic, or pulmonary neoplasms; GI bleeding; frequent infections

What might you find in the patient health history that could be the cause of the Cushing syndrome?

•Truncal obesity •Supraclavicular fat pads •Buffalo hump •Moon facies •Plethora •Hirsutism of body and face •Thinning of hair •Friable skin •Acne •Petechiae, purpura •Hyperpigmentation •Striae Edema

What objective data might you see in the patient with Cushing syndrome***

•Wear MedicAlert bracelet at all times •Avoid exposure to extremes of temperature, infection, and stress •Teach how to adjust medication and when to call health care provider Lifetime replacement therapy

What should be taught to the patient postop with CUshing syndrome?

•Fluid and electrolyte balance •Cardiovascular status

What should the nurse assess in the patient with hyperaldosteronism?

•Vital signs •Daily weight •Glucose •Inflammation/infection •Thromboembolism

What should you monitor and assess for in the patient with Cushing?

•Report signs and symptoms of corticosteroid deficiency and excess to HCP •Carry identification and wear medical ID bracelet (bc of increased risk of shock and hypoglycemic episode) •Emergency kit •How to administer IM hydrocortisone •Written instructions

What should you teach the patient with Addison's disease?

•Muscle weakness •Fatigue •Cardiac dysrhythmias •Glucose intolerance •Metabolic alkalosis → tetany

What will the patient with hyperaldosteronism experience as a result of hypokalemia?

•Hypernatremia, hypertension, headache •NO EDEMA

What will the sodium retention cause in hyperaldosteronism?

Addisonian Crisis

•Acute adrenal insufficiency •Insufficient or sudden, sharp decrease in hormones •Life-threatening Various triggers

Hyperaldosteronism

•Excessive aldosterone secretion