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T3: Cushings
T3: Cushings & Hyperaldosteronism
| Question | Answer |
|---|---|
| What are the 3 main classifications of adrenal cortex steroid hormones? | glucocorticoids, mineralocorticoids, and androgens |
| What is the function of glucocorticoids? | regulate metabolism; increase blood glucose levels; critical in the physiologic stress response |
| What is the primary glucocorticoid? | cortisol |
| What is the function of mineralocorticoids? | regulate sodium and potassium balance |
| What is the primary mineralocorticoid? | aldosterone |
| What is the function of androgens? | Contribute to growth and development in both genders and to sexual activity in adult women. |
| This term refers to any one of these 3 types of hormones produced by the adrenal cortex. | corticosteroid |
| Where are glucocorticoids, mineralocorticoids, and androgens produced? | adrenal cortex |
| This is a clinical condition that results from chronic exposure to excess corticosteroid, particularly glucocorticoids. | Cushing Syndrome |
| Several conditions can cause Cushing syndrome. What is the most common cause? | Iatrogenic administration of exogenous corticosteroids (prednisone) |
| Approximately 85% of the cases of endogenous Cushing syndrome are due to what? | an adrenocorticotropic hormone (ACTH) - secreting pituitary adenoma (Cushing disease) |
| What are some other causes of Cushing syndrome? | adrenal tumors and ectopic ACTH production by tumors (usually of the lung or pancreas) outside of the hypothalamic-pituitary-adrenal axis |
| CM of Cushing syndrome | centripetal (truncal)/generalized obesity; moon facies with plethora; purplish red striae on abd, breast, or buttocks; easy bruising; hirsutism in women; menstrual disorders; HTN; hypokalemia |
| The facies in Cushings include? | a rounded face (moon facies) with thin, reddened skin |
| Excess glucocorticoids causes this from accumulation of adipose tissue. | weight gain |
| Excess glucocorticoids causes this due to glucose intolerance and increased gluconeogenesis by the liver. | hyperglycemia |
| Excess glucocorticoids causes muscle wasting which can lead to? | weakness |
| Excess glucocorticoids causes loss of bone matrix which can lead to? | osteoporosis and back pain |
| Excess glucocorticoids causes loss of collagen which can lead to? | thin, weaker skin that can bruise easily |
| Excess glucocorticoids causes catabolic processes that can lead to? | delay in wound healing |
| Excess glucocorticoids can cause the patient to be? | irritable, anxious, euphoria, and occasionally psychosis may occur |
| Excess mineralocorticoid may cause? | HTN (secondary to fluid retention) |
| Adrenal androgen excess may cause? | severe acne, virilization in women, and feminization in men |
| Menstrual disorders and hirsutism in women and gynecomastia and impotence in men occur more commonly with? | adrenal carcinomas |
| What diagnostics are done for Cushings? | plasma cortisol measurement (primary glucocorticoid); 24 hr urine collection for free cortisol; low-dose dexamethasone suppression test; urine 17 ketosteroid measurement; CT & MRI of pituitary & adrenal glands |
| In Cushings what happens to the plasma cortisol levels? | May be elevated, with loss of diurnal variation. |
| What would the urine cortisol levels have to be in order to indicate Cushing syndrome? | Would be higher than the normal range of 80-120 mcg in 24 hrs |
| If the urine cortisol levels are borderline what test is done? | a low-dose dexamethasone suppression test |
| What would plasma ACTH levels be in Cushing disease (pituitary etiology)? | high or normal ACTH levels |
| What would plasma ACTH levels be in Cushing syndrome (adrenal or medication etiology)? | low or undetectable ACTH levels |
| ____ and ____ are seen in ectopic ACTH syndrome and adrenal carcinoma. | hypokalemia; alkalosis |
| What is the primary goal of treatment for Cushing syndrome? | To normalize hormone secretion |
| How is treatment determined in Cushings? | Is dependent on the underlying cause |
| If the underlying cause of Cushings is a pituitary adenoma, what is the standard treatment? | Surgical removal of the pituitary tumor via the transsphenoidal approach. Radiation therapy may be used for pts who aren't good surgical candidates. |
| If the underlying cause of Cushings is caused by adrenal tumors or hyperplasia, how is it treated? | Adrenalectomy; laparscopic adrenalectomy used unless a malignant adrenal tumor is suspected; an open surgical adrenalectomy is usu performed for adrenal cancer. |
| Cushings patients with ectopic ACTH-secreting tumors are best managed how? | By locating and removing the tumor (usually lung or pancreas). This is usu possible when the tumor is benign. When a tumor is malignant & metastasized, surgical removal may not be possible or successful. |
| If Cushing syndrome has developed (iatrogenically) during the course of prolonged administration of corticosteroids such as prednisone, how would it be treated? | Gradual discontinuation of corticosteroid therapy; reduction of the corticosteroid dose; conversion to an alternate-day regimen. |
| Why is gradual tapering of corticosteroids necessary? | To avoid potentially life-threatening adrenal insufficiency. |
| An alternate day regimen is one in which twice the daily dosage of a shorter acting corticosteroid is given every other morning to minimize what? | hypothalamic-pituitary-adrenal suppression, growth suppression, and altered appearance |
| The alternate-day regimen is not used when the corticosteroids are given as? | hormone therapy |
| Upon assessment what information is important to obtain from the patient? | Past health hx: pituitary tumor (Cushing disease); adrenal, pancreatic, or pulmonary neoplasms; GI bleeding; frequent infections; Medications: use of corticosteroids |
| Patients with Cushings syndrome are seriously ill b/c the therapy has so many side effects. The focus of assessment is on what? | S/S of hormone toxicity, drug toxicity, and complicating conditions (e.g. cardiovascular disease, DM, infection). |
| What are some nursing interventions for Cushings patients? | Assess & monitor vitals, daily weight, glucose level, & possible infection (s/s of inflammation may be minimal or absent); monitor for abnormal thromboembolic events such as PE (sudden chest pain, dyspnea, tachypnea); emotional support |
| If a Cushings patient must undergo surgery, what interventions should be done preop? | HTN & hyperglycemia must be controlled, and hypokalemia must be corrected w/diet & K supplements. A high protein diet helps correct the protein depletion. |
| In the postoperative period (for both laparscopic & open adrenalectomy) patients may have what? | a NG tube, urinary catheter, IV therapy, central venous pressure monitoring, and leg SCDs to prevent emboli |
| Why is surgery on the adrenal glands riskier than other types of operations? | Because the adrenal glands are vascular so the risk of hemorrhage is increased. |
| Manipulation of glandular tissue during surgery may release large amount of this which causes what? | Hormones into the circulation, producing marked fluctuations in the metabolic processes affected by these hormones. |
| Postoperatively, BP, fluid balance, and electrolye levels to to be ____ because of these hormone fluctuations. | unstable |
| What is administered IV during surgery and for several days afterward to ensure adequate responses to the stress of the procedure? | high doses of corticosteroids (e.g. hydrocortisone-Solu Cortef) |
| If large amounts of endogenous hormone have been released into the systemic circulation, the pt is likely to develop this, which can also increase this? | HTN which increases the risk of hemorrhage |
| High levels of corticosteroids increase susceptibility to _____ and delay _____. | infection; wound healing |
| The critical period for circulatory instability ranges from 24-48 hrs after surgery. During this time, you must constantly be alert for what? | s/s of corticosteroid imbalance |
| What interventions should be done postoperatively? | Report significant changes in vitals; monitor fluid I&O, assess for potential imbalances; administer corticosteroids as ordered; obtain morning urine samples for cortisol measurement. |
| Why is it important to obtain morning urine samples for cortisol measurement at the same time each morning? | to evaluate the effectiveness of the surgery |
| CM of acute adrenal insufficiency (due to rapid tapering of corticosteroid dosage) | vomiting, increased weakness, dehydration, hypotension, painful joints, pruritus, peeling skin, severe emotional disturbances |
| After surgery, patients are usually maintained on bed rest until? | the BP stabilizes |
| Why should the nurse be alert for subtle signs of postoperative infections? | B/c the usual inflammatory responses (fever, redness) are suppressed; assess for pain, loss of function, and purulent drainage |
| What interventions should be done to prevent infection after surgery? | Provide meticulous care when changing the dressing and during any other procedures that necessitate access to body cavities, circulation, or areas under the skin. |
| You should teach the patient to avoid what? | Exposure to extremes of temp, infections, & emotional disturbances. |
| How can stress produce or precipitate acute adrenal insufficiency? | B/c the remaining adrenal tissue cannot meet an increased hormonal demand. |
| This is characterized by excessive aldosterone secretion. | hyperaldosteronism (Conn's syndrome) |
| What are the main effects of aldosterone? | sodium retention and potassium and hydrogen ion excretion |
| What is the hallmark of hyperaldosteronism? | HTN with hypokalemic alkalosis |
| Primary hyperaldosteronism (PA is most commonly caused by what? | a small solitary adrenocortical adenoma |
| Bilateral adrenal hyperplasia involves what? | multiple lesions |
| Who does PA affect more? | women b/t 30 and 60 years |
| This occurs in response to a nonadrenal cause of elevated aldosterone levels, such as renal artery stenosis, renin-secreting tumors, and chronic kidney disease. | secondary hyperaldosteronism |
| Elevated levels of aldosterone are associated with what? | sodium retention and excretion of potassium |
| Sodium retention leads to what? | hypernatremia, hypertension, and headache |
| Why does edema not usually occur with hyperaldosteronism? | B/c the rate of sodium excretion increases which prevents more severe sodium retention. |
| The potassium wasting in hyperaldosteronism leads to what? | hypokalemia |
| CM of hypokalemia | generalized muscle weakness, fatigue, cardiac dysrhythmias, glucose intolerance, & metabolic alkalosis that may lead to tetany. |
| Hyperaldosteronism should be suspected in all hypertensive patients with hypokalemia who are not being treated with what? | diuretics |
| PA is associated with what? | Elevated plasma aldosterone levels, elevated Na levels, decreased serum K levels, & decreased plasma renin activity. |
| Adenomas are localized by what means? | CT scan or MRI |
| If a tumor is not found, this is measured after overnight bed rest. | plasma 18-hydroxycortocosterone |
| A plasma 18-hydroxycortocosterone level greater than 50 ng/dL indicates what? | an adenoma |
| What is the preferred treatment for PA? | surgical removal of the adenoma (adrenalectomy) laparoscopically |
| Before an adrenalectomy patients should be treated with what? | potassium sparing diuretics (spironolactone-Aldactone, eplerenone-Inspra), and antihypertensive agents to normalize serum K levels and BP. |
| What do spironolactone and eplerenone do? | Blocks the binding of aldosterone to the mineralocorticoid receptor in the terminal distal tubules and collecting ducts of the kidney, thus increasing the excretion of Na & water & the retention of K. |
| Oral K supplements and Na restriction may also be necessary but K supplementation and K sparing diuretics should not be started simultaneously because of the danger of what? | hyperkalemia |
| Patients with bilateral adrenal hyperplasia are treated with what? | a K sparing diuretic (spironolactone, amiloride-MIdamor) or with aminoglutethimide (Cytadren), which blocks aldosterone synthesis. |
| This may also be used to decrease adrenal hyperplasia. | dexamethasone |
| Nursing care for hyperaldosteronism includes? | Careful assessment for s/s of fluid & electrolyte balance (esp. K) & cardiovascular status. Monitor BP freq before & after surgery b/ unilateral adrenalectomy is successful in controlling HTN in only 80% of pts w/adenoma. |
| What are some important things to teach patients with hyperaldosteronism? | Pts on maintenance therapy w/K sparing diuretics should know possible SE of gynecomasia, impotence, & menstrual disorders, & s/s of hypokalemia & hyperkalemia. Monitoring their BP frequently. |
Created by:
eblanc1
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