What do the adrenal glands consist of
Medulla and Cortex
What is the medulla? (2)
1. center of the gland
2. Secretes Catecholamines (EPI)
What is the cortex
1. outer portion of the gland
2. necessary for life b/c of aldosterone
3. Secretes 3 types of steroid hormones
What 3 types of hormones does the adrenal cortex secrete?
What are the 3 actions of the adrenal cortex hormone glucocorticoids (Cortisol)?
1. promotes gluconeogenesis: which maintains BG levels.
2. inhibits inflammatory response to tissue injury.
3. Suppresses allergic reactions
regulated by ACTH release,
What regulates glucocorticoids
What are the 3 actions of the hormone ACTH & what is its source?
regulates MSH, and skin pigmentation.
- regulates glucocorticoids
Source is Anterior pituitary
What is the primary mineralcorticoid & what does it do?
Aldosterone. which promotes retention sodium and water. Also responsible for blood volume
What regulates the androgen hormones
ACTH from the anterior pituitary
If there is an increase of androgen in males what are the 2 actions?
decrease in libido & impotence
If there is an increase of androgen in females what are the 2 actions?
acne & hirsutism (Abnormal growth of hair on a person's face and body)
If there is an decrease of androgen in females what are the 2 actions?
amenorrhea & loss of body hair
What are 2 causes of adrenal insufficiency?
Results from adrenal gland disorder or
From pituitary hypofunction
What is the name of the disease for Adrenal insufficiency
Primary adrenal insufficiency (addison's disease) is a result of what & what can it lead to?
adrenal destruction via an AUTOIMMUNE process or disease
Gradual destruction leads to chronic adrenal insufficiency & loss of hormones
What are 3 risk factors for addison's disease?
1. a hx of endocrine disorders
2. taking glucocorticoids for >3 weeks with sudden stopping → adrenal insufficiency = hypovolemia
Abrupt stopping of this ____ can lead to Addison's Disease
What are 3 Musculoskeletal changes in addison's.
muscle weakness, fatigue, joint muscle pain.
What are 4 Cardio changes in addison's
Anemia, hypotension, hyponatremia, hyperkalemia
What are 2 Neuro changes in addison's
mental confusion, mild depression.
What are 2 Integumentary changes in addison's
Vitiligo no uniform pigmentation & Hyperpigmentation
What are 4 Gastro changes in addison's
anorexia, N&V, weight loss and hypoglycemia.
What are the diagnostic findings of Addison's Disease (Cortisol, ACTH, Blood Glucose, Sodium, Potassium)
- Decrease Cortisol
- Increase ACTH (trying to stimulate Cortisol)
- ***Decrease Blood glucose
- Decreased sodium
- Increase serum potassium
What diagnostic tests would you run for Addison's disease
- CT & MRI of adrenals & pituitary
What is an Addisonian crisis?
it is an acute life threatening emergency caused by insufficient adrenocortical hormones.
What is the Addisonian Crisis precipitated by
Stressor (Ex. surgery)
What are the 4 manifestation of Addisonian Crisis
Dehydration, Hypotension, Hyponatremia, Hypoglycemia
What are the 4 treatments for Addisonian Crisis?
1. IV NS to restore volume GIVE ISOTONIC **FLUIDS
2. replace steroids with IV HYDROCORTISONE
3. correct lyte/blood sugar imbalances
4. monitor vital signs.
What are the 4 actions of prescribed hormones in adrenal hypofunction?
3. Maintenance of normal blood pressure
4. CHO & protein metabolic effects
What are 9 teaching points for patients taking corticosteroids?
1. 2/3 in morning, 1/3 in afternoon
2. Dietary modification during diaphoresis
3. Adjust doses ↑ for minor illnesses and stress
4. Teach to monitor BP
5. KEEP EMERGENCY STEROID INJECTION KIT AVAILABLE, 6. Wear ID bracelet
7. Monitor for osteoporosis
8. Teach S/S of under & over dosage of steroids
9. Will take for life if you have Addison's
What is the name of the mineralcorticoid and when & why should it be taken
Florinef (take in PM)
- take if patient is having hard time maintaining fluid balance. helps reabsorb Na & H20.
What drug is taken for hypotension with Addisonian Crisis
Midodrine hydrochloride is a vasopressor/antihypotensive agent
What is the result of adrenal hyper function?
results in excess production of corticosteroids, particularly cortisol
What are 2 types of adrenal hypersecretion.
Cushings disease and cushings syndrome.
What is Cushing's disease & what are 3 results from having this disease
- It is rare, results from adrenal overactivity
1. Pituitary tumors
2. non-endocrine tumors
3. Adrenal cancer
What is Cushings syndrome & what are 4 etiologies
- Iatrogenic due to long-term administration of steroids for treatment of illness such as:
2. Autoimmune disorders (Ex. lupus)
3. Organ transplantation
4. allergic responses.
What are 2 Cardio changes in adrenal hyperfunction.
HTN, Edema (b/c Na & H20 are reabsorbed → FVE)
What are 5 Integumentary changes in adrenal hyperfunction.
thin fragile skin, purplish-red striae, bruises, poor wound healing, decreased s/s of inflammation.
What are 5 General changes in adrenal hyperfunction.
Truncal obesity, buffalo hump, moon faces, acne, hirsutism (abnormal growth of hair on a person's face and body)
What are 2 Musculoskeletal changes in adrenal hyperfunction.
Muscle wasting, osteoporosis.
What are the diagnostic findings of Cushing's (Sodium, Potassium, Blood glucose, Urinary and blood cortisol, WBC)
- Na increased
- K decreased
- Blood glucose increased
- urinary and blood cortisol increased
- WBC increased (Leukocytosis maybe)
In treating adrenal hyperfunction what are 3 drugs used to inhibit corticosteroid synthesis?
In treating adrenal hyperfunction what are 2 drugs interfere with ACTH production & what results would you see if successful?
Weight loss & increased urine output
In treating adrenal hyperfunction when would you use Radiation therapy & what is the procedure?
- For pituitary tumors or ACTH-secreting adenomas
- Applied internally or externally
- used concurrently with drug therapy & surgery
What are the 2 surgical options of adrenal hyperfunction when there is an increase in pituitary secretion of ACTH.
Transphenoidal hypophysectomy or hypophysectomy.
What are the 2 surgical options of adrenal hyperfunction when there are adrenal adenomas or cancer?
partial or complete adrenalectomy or laparoscopic adrenalectomy.
What are 6 Pre-op care tasks for adrenalectomy or hypophysetomy?
1. correction of lyte imbalances
2. monitor BG levels & treat hyperglycemia
3. minimize risks for falls
4. increase calorie and protein diet
5. administration of glucocorticoids pre-op & intra-op.
6. Teach post-op care management
Where is the incision for the transphenoidal hypophysectomy approach & how is it done?
- Above upper lip through sphenoid sinus
- done microscopically under general anesthesia in sitting position
- once gland is removed, skin graft taken to support area & prevent CSF leakage
- nasal packing inserted; mustache dressing applied
What are 5 post-op management for transphenoidal hypophysectomy
1. monitor neuro
2. monitor for diabetes insipidus
3. assess nasal drainage
4. teach patients to avoid coughing, straining upon defecation
5. Teach self-care re: taking of replacement steroid for 1-2 years
What should you monitor the nasal drainage for in post-op management for transphenoidal hypophysectomy (3)
1. Presence of glucose = CSF
2. Light yellow color at edge of clear drainage = halo sign = CSF
3. Complaint of headache may indicate leakage of CSF
What 4 things need to be monitored after an adrenalectomy in critical care?
1. Prevent shock and infection
2. monitor VS
3. close I&O
4. LABS, Electrolytes
what 4 complications should be prevented after an adrenalectomy?
1. prevent shock and infection
2. prevent skin breakdown (b/c thin, fragile skin)
3. pathologic fractures (due to osteoporosis)
4. GI bleeding
What is the primary cause of hyperaldosteronism
Conn's Syndrome from adrenal lesion
What is the secondary cause of hyperaldosteronism
- condition causing overproduction of aldosterone
Diuretic, Laxative abuse, Renal disease (high levels of angiotensin II)
What 2 imbalances does hyperaldosteronism lead to?
What are 4 medical treatments/management of hyperaldosteronism?
1. Decreased Na diet
2. Spironolactone (Potassium sparing diuretic)
3. Increase Potassium in diet, or potassium supplements
4. Check K+ levels
This is a catecholamine producing benign tumor that arises mainly in the adrenal medulla
What is the peak incidence of pheochromocytoma, is it genetic & what can it cause?
- 20-50 years old
- appears to have a familial basis
- can produce death b/c of excessive catecholamines
What cells of the SNS in the adrenal medulla form the benign tumor in pheochromocytoma?
What are 8 mechanisms of action of epinephrine
1. Constricts superficial blood vessels
2. Dilates brain, coronary vessels, muscles, fight/flight
3. Raises BP and Pulse dramatically
4. Increases CO
5. Increases RR
6. Stimulates CNS
7. Dilates pupils
8. Increases alertness
What are 7 clinical manifestations of pheochromocytoma
1. Headache (worst ever had)
4. Hypertension (persistent, fluctuating, paroxysmal)
5. Symptoms of DM (Glucosuria, increased BS),
6. Anxiety, emotional instability
5 H's of sympathetic nervous system overactivity.
Hypertension, Headache, Hyperhydrosis (excessive sweating), Hypermetabolism, Hyperglycemia.
What are 4 labs done to test for pheo?
1. a urinary VMA in 24 hour study
2. Plasma catecholamines
3. clonidine (Catapres) suppression test
4. Xray imaging
What is the prep for a urinary VMA (24hr urine) for pheochromocytoma?
1. No meds 2-3 days prior to test
2. No chocolate, tea, vanilla, fruits 2 days prior to test
What are 3 pre-op management tasks (7-10 days prior) for pheochromocytoma?
1. rest, relief from stress, dark room
2. increase calories, vitamins, no caffeine (b/c of s/s they are experiencing = ↑ epi)
3. monitor VS
What are the 2 pharmacologic therapies pre-op for pheochromocytoma
1. Administer prescribed sedatives
2. Administer Alpha blocking agents to keep BP under control (Nipride, Regitine, Dibenzyline (long lasting), Inderal (if not responsive to alpha blockers)
What are 4 alpha blocking agents used pre-op for pheochromocytoma
1. Nipride = potent antihypertensive
3. Dibenzyline (long lasting)
4. Inderal (if not responsive to alpha blockers)
What are 4 Post-op tasks/management of a pheo via adrenalectomy.
- usually adrenalectomy b/c tumor on adrenal gland
1. monitor vitals
2. Administer anti-hypertensives = nipride
3. corticosteroid replacement therapy for both bilateral or unilateral (temporary)
4. also assess for hypoglycemia and fluid and lyte balance.
What is hyperpituitarism?
condition of hormone over secretion which occurs with tumors
In Hyperpituitarism tumors arise from what 3 types of cells?
1. Somatotropic cells (GH)
2. Lactotropic cells (PRL)
3. corticotropic cells (ACTH)
What is the most common hormone secretion tumor with hyperpituitarism
What does prolactin inhibit and what are 3 results?
Inhibits secretion of gonadal steroids,
results in galactorrhea, amenorrhea, infertility
What drug reduces serum prolactin
What is Gigantism?
- GH hyper-secretion PRIOR to puberty resulting in accelerated linear growth
- result is excessive growth but proportionate height.
What is Acromegaly?
- GH excess AFTER puberty causing growth of extremities (enlargement of bones of the face, hands, and feet)
- caused by excessive production of the growth hormone by the pituitary gland
What are the clinical findings for acromegaly
THICKENED, OILY SKIN
DEEPENING OF VOICE
ENLARGED HANDS, FEET
↑ HEAD SIZE
PROTRUSION OF LOWER JAW
JOINT ENLARGEMENT & PAIN
KYPHOSIS & BACKACHE
EXCESSIVE SWEATING (HANDS, FEET, FACE)
COARSE FACIAL FEATURES
AIRWAY NARROWING, SLEEP APNEA
ORGANOMEGALY (spleen, liver)
What are diagnostics for hyperpituitarism? (5)
1. EXCESS OF PRL, GH, ACTH
2. SKULL XRAYS
3. CT & MRI
4. GLUCOSE TOLERANCE TEST
5. THYROID FUNCTION TESTS
What are the 2 drug therapies for hyperpituitarism & what is the goal?
1. Octreotide (**Sandostatin) - acts on anterior pituitary to inhibit GH for acromegaly
2. Bromocriptine (Parlodel) - decreases prolactin levels by inhibiting release used in hyperprolactinemia
Goal is to return to normal hormone levels
How does Octreotide (Sandostatin) work with hyperpituitarism acromegaly?
acts on anterior pituitary to inhibit GH for acromegaly
How does Bromocriptine (Parlodel) work with hyperpituitarism?
decreases prolactin levels by inhibiting release used in hyperprolactinemia
What are 4 post-op management for transphenoidal hypophysectomy for hyperpituitarism?
- Avoid activity interfering with healing
- No bending at waist or tying shoes
- minimize constipation
- avoid toothbrushing for 2 weeks
What drug might be needed to maintain fluid balance after a transphenoidal hypophysectomy for hyperpituitarism? Also, what 3 other hormone replacements might be necessary?
Vasopressin (ADH) = maintain fluid balance
What is hypopituitarism?
A deficiency of one or more of the hormones produced by the anterior pituitary
Growth Hormone deficiencies
NINE I's = CAUSES; MOST COMMON IS TUMOR
FAILURE TO SECRETE GH & GONADOTROPINS, OR TSH, ACTH & PROLACTIN
Hypopituitarism: The insufficient secretion of what hormone during childhood causes limited growth and dwarfism
List 5 non-specific symptoms of hypopituitarism from GH
weakness, fatigue, headache, sexual dysfunction, fasting hypoglycemia
What are 3 S/S of hypopituitarism?
1. Failure to grow
What is the permanent hormonal replacement drug for hypopituitarism & what is the major side effect
Somatotropin (Growth hormone)
S/E = fluid retention
- a rare form of diabetes resulting from a deficiency of ADH
- excretion of large quantities of dilute urine
What is the cause of Central or Primary Diabetes insipidus
(Head trauma, MVA, Drugs, Infections)
What is the cause of Nephrogenic Diabetes insipidus
- extremely rare, heredity disorder.
- ADH produced, kidneys do not respond
What are 5 Cardio changes in DI
Weak Peripheral pulses
Increase serum osmo >300.
Hemoconcentration resulting in increase Hgb and Hct
What are 2 Neuro Changes in DI
irritability and decreased cognition.
What are 2 Renal changes in DI
- increases urine output with dilute and low specific gravity (1.005)
- voiding around 2 to 18 liters/day
What are the 2 Gastro Changes in DI
weight loss, polydipsia (thirst)
What are the 2 Integumentary changes in DI
poor skin tugor, dry cool mucous membranes.
Diagnostic findings in DI (Sodium, Spec Gravity, Serum Osmolarity, & Water Deprivation test)
increased sodium (b/c dehydrated)
decreased specific gravity (b/c lots of dilute urine)
increased serum osmolarity (b/c dehydrated)
positive water deprivation test.
Management of DI (4)
Maintain F&E balance
1. IV admin of saline & glucose
2. They NEED ADH LIKE NOW! Ex. of 2 ADH drugs
・Vaspressin IV, SQ or IM
・give DDAVP for LT therapy as a nasal preparation
4. Also determine and correct the underlying causes.
What is SIADH
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE
EXCESSIVE ADH SECRETION FROM POSTERIOR PITUITARY
What are 5 symptoms seen in SIADH related to water retention.
weight gain without edema, JVD, crackles, tachycardia and tachypnea.
What are 5 etiologies of SIADH
ETIOLOGY OFTEN NON-ENDOCRINE IN NATURE
1. SMALL CELL LUNG CANCER SYNTHESIZES & RELEASES ADH
2. HEAD INJURY
3. BRAIN SURGERY
What are 6 symptoms seen in SIADH related to hyponatremia.
Hyponatremia b/c of FVE
Neuro & GI symptoms:
confusion, lethargy, seizures, decreased GI motility anorexia and nausea.
Diagnostic findings related to SIADH (Sodium, Spec Gravity, Serum Osmolarity, & Hemodilution)
high specific gravity
Decreased serum osmolarity
Hemodilution - ↓HGB and HCT
SIADH to restore fluid volume & osmolarity: what should you do if symptoms are mild?
1. restrict fluids to 1L/day → will result in gradual rise in serum NA+ and osmolarity
SIADH to restore fluid volume & osmolarity: what 2 actions should you do if fluid restriction is insufficient?
1. Hypertonic (3%) normal saline IV
2. lasix to promote diuresis
SIADH to restore fluid volume & osmolarity: Administer what drug & what are the actions?
・Facilitates free water clearance
・blocks ADH at level of distal & collecting tubules
What 2 hormones are produced by the hypothalmus and stored in the posterior pituitary
A gland responds to a low hormone level by releasing additional hormones, as the hormone level returns to normal the hormone release is inhibited this is considered what type of system
Negative feedback system (Simple)
The interaction of the hypothalamus, the anterior pituitary, and the thyroid, adrenal cortex, and gonads are all part of what type of system
Complex Negative Feedback System
List the 3 types of intrinsic rhythmicity
1. Rhythms originate in the brain structures
2. Circadian Rhythms (Diurnal) hormone levels fluctuate during a 24hr period
3. Ultradian Rhythms : longer than 24hrs
What 6 hormones are produced by the anterior pituitary
GH, TSH, ACTH, Prolactin, FSH and LH
List 6 stimuli that will release the ADH (Anti-diruetic hormone) from the posterior pituitary
1. Increased serum osmolality (high & dry)
2. Decreased blood volume
6. Certain drugs (Lithium=hyponatremia)
What 3 hormones does the adrenal medulla secrete
Epinephrine (80%), Norepinephrine, and Dopamine
What are the functions of epinephrine
1. Fight or Flight = stress response
2. Induce release of free fatty acids
3. Increase BMR (basal metabolic rate)
4. Elevate blood glucose levels
With the pancreas where does endocrine activity occur?
Islets of Langerhans
What 3 type of cells do the Islets of Langerhans have?
Alpha, Beta, Delta
What does the Alpha, Beta, Delta cells produce of the pancreas
Alpha = Glucagon
Beta = Insulin
Delta = Gastrin, Somatostatin
What are 5 major endocrine alterations with aging
1. Decreased ovarian function (40-60yrs) ↓ estrogen & progesterone
2. Decreased ADH secretion (dehydration)
3. Decreased thyroid hormone levels (might need replacement)
4. Impaired glucose tolerance (might need oral hyperglycemic)
5. Altered calcium homeostasis (osteoporosis, arthritis)
___ is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormone
Name 3 unique appearances that an infant will have with cretinism
Dull look, puffy face, thick tongue that sticks out