Chapter 60: Drugs for Disorders of the Adrenal Cortex
When assessing a patient who has Cushing's syndrome, a nurse associates which clinical manifestations with this disorder? (Select all that apply.) A. Osteoporosis B. Moon face C. Glycosuria D. Ketonuria E. Mood swings
A, B, C, and E Rationale: Cushing's syndrome results from excess secretion of adrenocorticotropic hormone (ACTH), and these effects result in manifestations such as redistribution of fat to the face and belly, excess blood sugar, mood changes, and calcium loss from bone. Ketoacidosis does not occur.
Which statements about hydrocortisone are correct? (Select all that apply.) A. It is a synthetic steroid identical to cortisol. B. It is a preferred drug for adrenocortical insufficiency. C. It has glucocorticoid and mineralocorticoid actions. D. It is given IV for chronic replacement therapy. E. It should not be given during times of stress.
A, B, and C Rationale: Hydrocortisone is a synthetic steroid with a structure identical to that of cortisol. Hydrocortisone is a preferred drug for all forms of adrenocortical insufficiency. Oral hydrocortisone is ideal for chronic replacement therapy. Parenteral administration is used for acute adrenal insufficiency and to supplement oral doses at times of stress. Despite being classified as a glucocorticoid, hydrocortisone also has mineralocorticoid actions.
A pt with which condition would most likely be prescribed a glucocorticoid in low doses for replacement therapy? A. Addison's disease B. Rheumatoid arthritis C. systemic lupus erythematosus D. Cushing's syndrome
A. Rationale: Addison's disease is a disease of primary adrenocortical insufficiency that requires physiologic dose for replacement therapy. Conditions such as RA and systemic lupus require a high dose therapy with glucocorticoids. Cushing's syndrome is a disease of excess levels of circulating glucocorticoids.
A nurse is developing a plan of care for a patient who has Addison's disease and is taking hydrocortisone [Cortef]. Which of these outcomes should receive priority in the plan? A. At times of stress, the patient increases the glucocorticoid dose. B. The patient wears a Medic Alert bracelet at all times. C. The patient carries an injectable form and an oral form of glucocorticoid. D. The patient divides the daily dose, taking two-thirds of it in the morning and one-third in the afternoon.
A. Rationale: Patients with adrenal insufficiency require lifelong replacement doses of glucocorticoids. Failure to increase the dosage at times of stress and illness can be life-threatening. Wearing a Medic Alert bracelet, carrying injectable and oral forms of glucocorticoid, and dividing the daily glucocorticoid dose are important for a patient taking hydrocortisone, but they are not priorities over understanding the need to increase the dose during stress.
Therapeutic uses of fludrocortisone (Florinef)
Addison's disease, primary hypoaldosteronism, and congenital adrenal hyperplasia
ketoconazole (Nizoral)
Antifungal. Inhibits ergosterol synthesis; not primary treatment but used as an adjunct therapy for excess adrenal hormones
A pt with Cushing's syndrome is prescribed ketoconazole (Nizoral) 600mg/day before an adrenalectomy. The pt asks the nurse why an antibiotic is needed. Which response by the nurse is best? A. This medication will prevent an abdominal infection after surgery B. The medication will block the adrenal gland from producing steroids. C. You have a UTI that must be treated before surgery. D. It is essential to prevent skin infection in pts undergoing surgery.
B. Rationale; ketoconazole is an anti fungal that also inhibits glucocorticoid synthesis. This dose is much higher than a dose for anti fungal therapy.
A patient who has Cushing's syndrome is taking ketoconazole [Nizoral] as an adjunct treatment to brain radiation. A nurse should expect the patient to have which of these therapeutic responses? A. Increased resistance to infection B. Enhanced radiation effect to the brain C. Suppressed cortisol synthesis D. Increased ACTH production
B. Rationale: Ketoconazole is an antifungal drug that inhibits glucocorticoid synthesis very effectively. It is used as an adjunct to radiation or surgery in patients with Cushing's syndrome. Increased ACTH production and resistance to infection and suppressed cortisol synthesis are not actions of ketoconazole.
The nurse cares for a pt with primary hypoaldosteronism who took excessive doses of fludrocortisone (Florinef). It is most important for the nurse to assess the pt for what? A. increased urine output and bradycardia B. muscle weakness and irregular heartbeat C. hypotension and poor skin turgor D. weight loss and hyperactive reflexes
B. Rationale: This drug is a potent mineralocorticoid to treat primary hypoaldosteronism; excessive doses can cause retention of sodium and water and excess secretion of potassium, resulting in the expansion of blood volume, hypertension, cardiac enlargement, edema, and hypokalemia. The nurse should assess the pt for signs of salt and water retention like unusual weight gain, swelling of the feet or lower legs and hypokalemia (muscle weakness, and irregular heartbeat)
The nurse is planning care for a patient with signs of acute adrenal insufficiency. What is the priority nursing diagnosis? A. Altered comfort B. Altered nutrition C. Fluid volume deficit D. Activity intolerance
C. Rationale: Acute adrenal insufficiency (adrenal crisis) is characterized by hypotension, dehydration, weakness, lethargy, and gastrointestinal (GI) symptoms of nausea and vomiting. Rapid replacement of fluid, salt, and glucocorticoids is essential to prevent shock and death. Comfort, nutrition, and activity are important to address once fluid balance has been restored.
A patient is taking fludrocortisone [Florinef]. A nurse should recognize that the patient is at risk for developing an electrolyte imbalance if the patient reports which symptom? A. Syncope B. Weight loss C. Muscle weakness D. Numbness and tingling
C. Rationale: Muscle weakness is a sign of hypokalemia, which can occur because fludrocortisone has mineralocorticoid properties, resulting in sodium and fluid retention and potassium excretion. Syncope and weight loss do not occur because of salt and water retention. Numbness and tingling may be associated with another problem but are not related to fludrocortisone.
The patient states that when he takes hydrocortisone 24 mg in the morning, he is very tired by mid-afternoon. Which statement by the nurse is correct? A. "You can take 12 mg in the morning and 12 mg at night." B. "You can take 24 mg at night instead." C. "You can take 16 mg in the morning and 8 mg in the afternoon." D. "This is an adverse effect and you should stop taking the medication."
C. Rationale: To mimic normal cortisol secretion, patients can take the entire daily dose in the morning, immediately after waking. If this schedule results in afternoon or evening fatigue, patients may split the dosage, taking two-thirds in the morning and one-third around 4:00 PM. Patients should not stop taking their medication unless advised by their healthcare provider.
2 most familiar forms of adrenocortical dysfunction
Cushing's syndrome and Addison's syndrome
The nurse teaches a pt with Addison's disease about hydrocortisone replacement therapy. Which statement made by the pt indicates the teaching was effective? A. I can expect my blood sugar levels to be high. B. If I become ill, the dose needs to be reduced. C. It is important to take this medication at bedtime. D. I should keep an emergency supply of this drug available at all times.
D. Rationale: To ensure availability of hydrocortisone in emergencies, the pt with Addison's disease should carry an adequate supple at all times. When given at low doses required for replacement therapy hydrocortisone is devoid of side effects like hyperglycemia. During illness, the pt must increase the dosage. Because the levels usually peak in the morning, the usual practice is to take the entire daily dose immediately after waking. An alternative is to divide the daily doses and take 2/3 in the morning and 1/3 in the afternoon.
The nurse is teaching the patient about oral steroid therapy. Which statement by the patient indicates a need for further teaching? A. "I can take my full dose in the morning." B. "I can break up my dose and take some in the afternoon if I get tired." C. "I understand that I shouldn't experience many adverse effects." D. "When I am traveling for work I will take lower doses."
D. Rationale: To mimic normal cortisol secretion, patients can take the entire daily dose in the morning, immediately after waking. If this schedule results in afternoon or evening fatigue, patients may split the dosage, taking two-thirds in the morning and one-third around 4:00 PM. Stress, such as travel for work, may require an increase in medication.
Pharmacologic effects of glucocorticoids occur at...
HIGH LEVELS when administered in high doses to treat disorders
Acute Adrenal Insufficiency/Adrenal Crisis is caused by
adrenal failure, pituitary failure, or failure to provide pt with replacement therapy of adequate doses of glucocorticoids
Therapeutic uses of hydrocortisone
adrenal insufficiency, allergic reactions to inflammation, and cancer
Adverse reactions of high-dose hydrocortisone therapy
adrenal suppression and Cushing's syndrome
Glucocorticoids' effect on the CNS
affects mood and excitability (increased levels cause euphoria and excitation and decreased levels cause depression)
Most important mineralocorticoid
aldosterone
Treatment of primary hyperaldosteronism
based on underlying cause; can be surgery or aldosterone antagonist like spironolactone
hydrocortisone
both a glucocorticoid and mineralocorticoid that can be used in treatment of Addison's disease
In extreme stress, glucocorticoid deficiency can result in...,
cardiovascular collapse
Which is the most important glucocorticoid?
cortisol
Adrenal cortex response in neonates
during delivery the fetus releases a burst of glucocorticoids to act on the lungs and accelerate maturation (DOESN'T OCCUR IN PRETERM LABOR)
Mineralocorticoid of choice for adrenal hormone insufficiency
fludrocortisone
Regulation of glucocorticoids
generally regulated by negative feedback inhibition
3 classes of steroid hormones produced by the adrenal cortex
glucocorticoids, mineralocorticoids, and androgens
Physiologic effects of carbohydrate metabolism on the body
help sully the brain by stimulating gluconeogenesis; reduces peripheral glucose utilization, inhibits glucose uptake by muscle and adipose tissue, and promotion of glucose storage in the form of glycogen (OPPOSITE OF INSULIN)
Glucocorticoid of choice for adrenal hormone insufficiency
hydrocortisone, prednisone, and dexamethasone
Causes of Cushing's syndrome
hyper secretion of adrenocorticotropic hormone (ACTH), hypersecretion of glucocorticoids, and administration of glucocorticoids in large doses
Adverse effects of fludrocortisone (Florinef)
hypertension, edema, cardiac enlargement, and hypokalemia
What will occur if glucocorticoid levels are deficient in times of stress?
hypoglycemia and hypotension
Causes of primary hyperaldosteronism
hypokalemia, metabolic alkalosis, and hypertension (can increase risk for heart failure)
Aldosterone deficiency can cause
hyponaturemia, hyperkalemia, acidosis, cellular dehydration, renal failure, circulatory collapse, then death
Clinical presentation of acute adrenal insufficiency (adrenal crisis)
hypotension, dehydration, weakness, lethargy, and GI symptoms like vomiting and diarrhea
Adrenal androgens
in normal situations physiological effects of adrenal androgens are minimal
Glucocorticoids and stress
in response to stress the adrenal cortex secretes increased amounts of glucocorticoids to maintain BP and serum glucose levels
Cardiovascular actions of mineralocorticoids
increase aldosterone levels can cause CV issues like heart failure and increased BP
Mineralocorticoids
influence renal processing of sodium, potassium, and hydrogen
Glucocorticoids' effect on the CV system
maintains the integrity; when levels decrease capillary membranes are more permeable, vasoconstriction ability decreases, and there will be a decrease in blood pressure
Hormones of the adrenal cortex affect
maintenance of glucose, regulation of H2O and electrolyte imbalance , development of sex characteristics, and live preserving responses to stress
Mineralocorticoids
modulate H2O and salt balance
Clinical presentation of Cushing's syndrome
obesity, hyperglycemia, glycosuria, hypertension, muscle weakness/myopathy, hirsutism, and fluid and electrolyte disturbances
Administration of mineralocorticoids for adrenal hormone insufficiency
only taken once a day
Prednisone and dexamethasone are the preferred drugs for
oral therapy of chronic adrenal insufficiency
In adult males, the effects of adrenal androgens are...
overshadowed by the effects of testosterone produced by the testes
Glucocorticoids effect on protein metabolism
promote the breakdown of proteins
Glucocorticoids' effect on fat metabolism
promotes lipolysis (fat breakdown) and at high levels for an extended period of time can cause redistribution of fat (Cushing's syndrome)
Specific CV effects of aldosterone (mineralocorticoid)
promotes myocardial remodeling, increases risk of dysrhythmias, activates sympathetic NS and suppresses norepinephrine uptake, promotes vascular fibrosis, and disrupts baroreceptor reflex
Treatment of acute adrenal insufficiency (adrenal crisis)
rapid replacement of fluid and administration of glucocorticoid (hydrocortisone 100mg IV bolus then additional 50mg every 8 hours)
Androgens
regulation of expression of sexual characteristics
Treatment for Addison's disease
replacement therapy with adrenocorticoids (hydrocortisone is the drug of choice)
Method of replacement therapy for adrenal hormone insufficiency
should be taken when normal glucocorticoids are secreted so in the morning or 2/3 doses in the morning and 1/3 in the afternoon
Glucocorticoids' effect on the skeletal system
support function of muscles and maintain circulatory competence; with decrease steroid levels there will be decrease muscle perfusion and decrease work capacity
Physiologic effects of glucocorticoids occur from
the levels produced by release of glucocorticoids from healthy adrenal glands or administering in LOW DOSES
Control of aldosterone is regulated by...
the renin angiotensin aldosterone system
Glucocorticoids
used for carbohydrate metabolism (increase the availability of glucose
Addison's disease (primary adrenocortical insufficiency) clinical presentations
weakness and hypotension, emaciation, hypoglycemia, Hyperkalemia, hyponaturemia, increased skin pigmentation, and mucous membranes
Treatment of adrenal hormone excess (Cushing's syndrome)
with carcinoma/adenoma- removal of the adrenal gland; replacement therapy with glucocorticoids and mineralocorticoids, drugs used as an adjunct to surgical treatment (Ketoconanzole)
