Let’s move to the Adrenal Glands

1. Let’s move to the Adrenal Glands In this space, please draw an adrenal gland…. Where does it live, what is its shape? Does it communicate with the kidney? Did you include the inner and outer part of the adrenal gland?

2. Lots of Group Activities so let’s get into our groups • Group 1: • Group 2: • Group 3: • Group 4: • Group 5: • Group 6:

3. Now come up with a Name of your Group • Group 1: • Group 2: • Group 3: • Group 4: • Group 5: • Group 6:

4. What are the 2 parts of the Adrenal Gland??? • Inner part is the _________ ________ • What does the inner part secrete or release?  _____________________  ______________________

5. What are the 2 parts of the Adrenal Gland??? • Outer part is the _________ ________ • What does the outer part secrete or release?  _____________________  _____________________  ______________________

6. Sugar….Salt….and Sex

7. Let’s go with the Adrenal Cortex first….. • 3 Hormone types: • Glucocorticoids (Cortisol) • Mineralocorticoids (Aldosterone) • Androgens (Testosterone) Or………..Sugar, Salt and Sex Activity: Giving you 10 minutes, get in your group and create a jingle, song or rap about these 3 types of hormones…..

8. Disorder #1 Cushing’s Disease We are nurses taking care of a patient with Cushing’s Syndrome • What is Cushing’s syndrome? • Too much _______________ • What is a synthetic form of cortisol that you have probably administered in clinical to your patients? • Syndrome vs Disease………..

9. Too much Cortisol…. • What do you remember about cortisol or side effects of glucocorticoids? Write down here what you remember…..

10. Do you need to look up cortisol? • Consult with your team and combine what you all know about cortisol? • Record data here: • _______________________ • _______________________

11. Cushing’s Syndrome vs Cushing’s Disease • Syndrome is iatrogenically induced, how? • ________________________ • Cushing’s disease could be caused by a tumor causing too much cortisol release. • Where could the tumor be located? • ________________ 2._____________ 3. ___________________

12. Textbook Pic of Cushing’s Syndrome/Disease

13. Can we live without glucocorticoids or cortisol? • What does cortisol do in our body? • CHO (carbohydrate) metabolism • Fatty acid mobilization • Protein catabolism • Ding ding

14. Function of Cortisol or Glucocorticoids:***CHO Metabolism • What happens when we break down carbohydrates? • Increase in amount of glucose formed • Increase in amount of glucose released • Therefore a major complication is _______________________

15. Function of Cortisol:*****Fat metabolism • What happens when we mobilize fatty acids somewhere unusual? • Therefore we see some classic body image changes in our patient-name these here: • ________________ • ________________ • ________________

16. Re Group for a POC Activity • Develop a plan of care for a patient with Cushing’s Disease • What are the priorities? • What can the nurse expect to see in this patient?

17. Function of Cortisol:****Protein breakdown or catabolism • What happens in Cushing’s syndrome with protein breakdown, how does this look in our patients? • ____________________________ • ____________________________

18. Re Group for a POC Activity • Develop a plan of care for a patient with Cushing’s Disease • What kind of things can the nurse call the physician about in preventing complications in this patient? SBAR ideas?

19. Clinical reasoning…. • If glucocorticoids have a mineralocorticoid like effect, what would we see in our patients?

20. Too much Aldosterone or Hyperaldosteronism • Excessive retention of Na and H2O • Excessive excreting of K+ • So what would we see in clinical in our patients? • _______________________ • _______________________

21. Still in the Adrenal Cortex…now 2nd major group of hormones • Mineralocorticoids or Aldosterone • You know this…what does aldosterone do? • What stimulates its’ release?

22. Still in the Adrenal Cortex…now 3rd major group of hormones • Androgens or Testosterone • What happens if females have too much testosterone? • _____________ • _____________ • _____________

23. What diagnostic tests could help diagnose Cushing’s Disease? • Serum cortisol levels • Serum ACTH levels • CT scan of abdomen or adrenals • MRI of brain to detect if pituitary adenoma • 24 hour urine for cortisol

24. Normal Cortisol Levels

25. What would we expect to see in Cushing’s, what would the graph look like? • Try to draw here • So in summary, what effects the release of cortisol? • ________________________ • What would the serum levels of cortisol be at 8am vs 8pm? • ________________________

26. Collaborative Management of Cushing’s Disease • Need to know what first????? • _____________________________ • Open adrenalectomy or laparoscopic adrenalectomy if tumor or cancer of adrenal gland • What if it is an ectopic tumor releasing too much ACTH? How would this be managed or treated? __________________________ • What other surgery could be necessary? • ______________________________________

27. Medications-Cushing’s Disease • Mitotane (Lysodren) which suppresses cortisol production if surgery not an option • Ketoconazole (Nizoral) inhibits cortisol synthesis • Activity: Look up doses and routes of these medications and list as would be on the MAR

28. Medications-Cushing’s Disease • Mitotane (Lysodren) • Ketoconazole (Nizoral) • Why would these be called a “medical adrenalectomy”

29. Write a detail nurse’s note on the appearance of the client’s skin or “Prednisone skin”

30. Prednisone skin documentation • Skin is fragile, thin and has decreased elasticity. Multiple areas on all 4 extremities of dark purple bruises.

31. What assessment findings would you document?

32. What does Cortisol do to the immune system? • What would you have in your POC? • ______________________ • ______________________ • ______________________ • ______________________

33. Cushing’s Disease-During

34. Cushing’s Disease-After Treatment

35. Now the innermost part of Adrenal Gland • What is it called? • _________________________ • What does it release? • 1.___________________ • 2.___________________ • What “response” does it trigger? • ____________________________

36. Ok let’s summarize, how to collaboratively intervene in patient with Cushing’s disease/syndrome?

37. Disorder #2 Hyperaldosteronism • Too much aldosterone secretion • What does aldosterone do? • _________________ • _________________ • _________________ • Usually caused by a tumor on Adrenal cortex

38. Clinical Manifestations: Hyperaldosteronism • Headache due to Na and H2O retention • HTN due to Na and H2O retention • K+ excretion which leads to ________ • muscle weakness, fatigue • cardiac dysrhythmias • usually no edema

39. Diagnostic Tests: Hyperaldosteronism • urinary K+ • plasma aldosterone levels with low plasma renin levels---WHY? • CT scan will reveal adenoma of adrenal gland • EKG changes

40. Collaborative Management of Hyperaldosteronism • Low sodium diet • K+ sparing diuretic such as aldactone… • How will this help perfectly??? • ___________________________ • Calcium channel blockers to treat the elevated blood pressure • Adrenalectomy

41. Disorder #3 Addison’s Disease • Which famous President had Addison’s Disease?

42. What is Addison’s Disease • Too little of Sugar, Salt, and Sex glucocorticoids mineralocorticoids androgens

43. Not enough Cortisol? POC priorities • ________________________ • ________________________ • ________________________ • ________________________

44. Not enough Aldosterone…..POC priorities • ______________________ • ______________________ • ______________________ • Salt craving—why? • Not enough Androgens…what could be a priority? • ______________________

45. Diagnostic Studies-Addison’s Disease • Serum cortisol levels or • Urine cortisol high or low • Hypo or hyper kalemic? • Serum glucose levels or • Serum aldosterone levels high or low? • EKG peaked T waves due to hyperkalemia

46. In summary… • Low bp • F & E imbalances • Hypoglycemic • Hyponatremia • Hyperkalemia • Nausea and Vomiting • Dehydration • Anxiety, irritable

47. Addisonian Crisis or Acute Adrenal Crisis • Severe hypotension • Tachycardia • Severe nausea and vomiting • Hypovolemic shock • Hypoglycemia • Hyponatremia • Hyperkalemia

48. Emergency Treatment-Addisonian Crisis or Adrenal Crisis • Rapid infusion of IV fluids (D5NS) • Frequent VS and I & O • May need to administer vasopressors to bring up blood pressure • Solucortef IVP until enough glucocorticoid on board

49. Collaborative ManagementAddison’s Disease • Oral glucocorticoids • 2/3 dose in am • 1/3 dose in pm • DOC is Cortatepo • Oral mineralocorticoid • Florinef 0.1mg po • Lifelong hormone replacement • Stress management

50. Patient Teaching-Addison’s –ding ding • Salt additives for excess heat or humidity • Daily glucocorticoid replacement • Daily mineralocorticoid replacement • List of all meds • Medical identification device in wallet, or in the form of a bracelet or necklace • Conditions requiring larger dose of hormones (surgery, trauma, happy stress) • IM glucocorticoid administration by patient (100mg hydrocortisone kit)