Endocrine 3

Question 1

Adrenal cortex steroid hormones

Answer 1

Glucocorticoids

Regulate metabolism and ↑ blood glucose
Critical to physiological stress response

Mineralocorticoids regulate

Sodium balance
Potassium balance

Androgen contributes to

Growth and development in both genders
Sexual activity in adult women

Question 2

Cushing’s Syndrome

Answer 2

• Caused by excess of corticosteroids, particularly glucocorticoids

Most common cause

• Administration of exogenous corticosteroids
• Adrenal tumours
• Usually lung and pancreas tumours
• Ectopic ACTH production is more common in men

Question 3

Cushing’s Syndrome Clinical Manifestations

Answer 3

B: Increase Blood Pressure

B: Decrease Bone formation

I: Inflammatory response

I: Decrease Immune response

G: Increase Gluconeogensis

Feminization in men, Masculization in women

• Related to excess corticosteroids
• Weight gain most common feature
• Trunk (centripetal obesity)
• Face (“moon face”)
• Cervical area
• Transient weight gain from sodium and water retention
• Hyperglycemia
• Glucose intolerance associated with cortisol-induced insulin resistance
• Increased gluconeogenesis by liver
• Protein wasting
• Catabolic effects of cortisol
• Leads to weakness, especially in extremities
• Protein loss in bones leads to osteoporosis, bone and back pain
• Loss of collagen
• Wound healing delayed
• Mood disturbances
• Insomnia
• Irrationality
• Psychosis
• Mineralocorticoid excess may cause hypertension secondary to fluid retention
• Adrenal androgen excess may cause
• Pronounced acne
• Virilization (growing hair) in women
• Feminization in men
• Seen more commonly in adrenal carcinomas
• Women: menstrual disorders and hirsutism
• Men: gynecomastia and impotence
• Purplish red striae on abdomen, breast, or buttocks (it looks like stretch marks)

Question 4

Cushing’s Syndrome Assessment

Answer 4

Patient medical history

• Pituitary tumour
• Adrenal, pancreatic, or pulmonary neoplasms
• GI bleeding
• Frequent infections
• Use of corticosteroids
• Weight gain
• Anorexia
• Polyuria
• Prolonged wound healing
• Weakness, fatigue
• Easy bruising
• Insomnia
• Headache, back, joint, bone, and rib pain
• Amenorrhea
• Impotence
• Mood disturbances, anxiety, psychosis, poor concentration
• Truncal obesity
• Buffalo hump
• Moon face
• Hirsutism of body and face
• Thinning of head hair
• Thin, friable skin
• Acne
• Petechiae
• Purpura
• Hyperpigmentation
• Purplish red striae on breasts, buttocks, and abdomen
• Edema of lower extremities
• Hypertension
• Muscle wasting
• Thin extremities
• Awkward gait

Question 5

Nursing Diagnosis and Goals

Answer 5

• Risk for infection
• Imbalanced nutrition
• Disturbed body image
• Impaired skin integrity

Goals

• Experience relief of symptoms
• Have no serious complications
• Maintain positive self-image
• Actively participate in therapeutic plan

Question 6

Nursing Implentation

Answer 6

• Health promotion****** test about priority teaching
• Identify patients at risk for Cushing’s syndrome.
• Long-term exogenous cortisol therapy is major risk factor.

-Teach patients about medication use and to monitor for side effects. **

Acute intervention

Assessment of

• Signs and symptoms of hormone and drug toxicity
• *-Complicating conditions**

>Cardiovascular disease
>Diabetes mellitus
>Infection

Monitor

• Vital signs
• Daily weight
• Glucose
• Infection
• Signs and symptoms of abnormal thromboembolic phenomena

Emotional support

• Patient may feel unattractive or unwanted.
• Nursing staff should remain sensitive to patient’s feeling and be respectful.
• Reassure patient that physical symptoms will resolve when hormone levels return to normal.

Preoperative care

• Patient should be in optimal physical condition.
• Control hypertension and hyperglycemia.
• Hypokalemia must be corrected with diet and potassium supplements.
• High-protein diet helps correct protein depletion.
• Teaching depends on surgical approach.
• Include information on postoperative care.
• Nasogastric tube
• Urinary catheter
• IV therapy
• Central venous pressure monitoring
• Leg compression devices
• Risk of hemorrhage is increased because of high vascularity of adrenal glands.
• Manipulation of glandular tissue may release hormones into circulation.
• BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations.
• High doses of corticosteroids administered by IV during and several days after surgery
• Report any significant changes in
• BP
• Respiration

-Heart rate

Question 7

Post Op Care

Answer 7

• Monitor fluid intake and output to assess for imbalances.
• Critical period for circulatory instability ranges from 24 to 48 hours.
• Morning urine levels of cortisol are measured to evaluate the effectiveness of surgery. *** urine specific gravity
• Adrenal insufficiency develops if corticosteroid dosage is tapered rapidly
• Indications of hypocortisolism
• Vomiting
• Increased weakness
• Dehydration
• Hypotension
• Patient may complain of
• Painful joints
• Pruritus
• Peeling skin
• Severe emotional disturbances
• Bed rest until BP is stabilized after surgery – may collapse if pt gets up
• Meticulous care should be taken when accessing skin, circulation, or body cavities to avoid infection - because of issues with wound healing
• Normal inflammatory responses are suppressed.
• Ambulatory and home care
• Discharge instructions based on lack of endogenous corticosteroids
• Wear MedicAlert bracelet at all times
• Avoid exposure to stress, extremes of temperature, and infection

-Lifetime replacement therapy is required for many patients

Question 8

Expected Outcomes

Answer 8

Expected outcomes

• Experience no signs or symptoms of infection
• Attain weight appropriate for height
• Increase acceptance of appearance
• Maintain intact skin

Question 9

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to:

Answer 9

1. Prevent sodium and water retention after surgery
2. Prevent clots from forming in the legs during recovery from surgery
3. Provide substances to respond to stress after removal of the adrenal glands
4. Stimulate the inflammatory response to promote wound healing

Question 10

Addison’s Disease

Answer 10

Hypofunction:

Primary insufficiency: Addison’s disease (the gland itself)

• Atrophy, destruction of adrenal gland by autoimmune response, gland destroyed by antibodies against pt’s own adrenal cortex, most common in white females
• Other causes: infarction, fungal infection (i.e. histoplasmosis) , AIDS, metastatic Ca, TB
• From metastasis from other sites: lungs, breast, GI
• Risk factor: taking glucocorticoids for prolonged time (>3 weeks with sudden stop)
• need to taper dose of steroids to stop if suddenly stop its very dangerous

Question 11

Addison’s Disease Clinical Manifestations

Answer 11

• Onset of Addison’s is insidious
• Progressive weakness, fatigue
• Hyperpigmentation of skin
• Weight loss, Listlessness
• Irritability
• Anorexia, N & V, diarrhea
• Postural Hypotension
• Vitiligo

Question 12

Addison’s Disease Diagnosis

Answer 12

Blood hormone levels:

• Low cortisol levels** made from adrenal cortex
• High plasma ACTH (adrenocorticotropic hormone, from anterior pituitary)
• ACTH stimulation test: cortisol levels fail to rise over basal levels
• They give ACTH and if the cortisol levels don’t rise therefore then its coming from your adrenals
• However if it is positive then its coming from your anterior pituitary
• **Serum electrolytes: ** low Na and high K * know difference
• Hypoglycemia when cortisol is low its not activating your metabolism

Question 13

Addisonian Crisis and Clinical Manifestions

Answer 13

• Pt with adrenal insufficiency are at risk for developing Addisonian Crisis:
• if client under stress: surgery, trauma, infection, dehydration, anorexia, fever
• sudden withdrawal of corticosteroid hormone (often when pt lacks knowledge of importance of replacement therapy)

S & S of addisonian crisis

Life threatening emergency

• Hypotension: may lead to shock
• Tachycardia
• Dehydration
• Hyponatremia
• Hyperkalemia
• Hypoglycemia
• Fever, weakness, confusion

Question 14

Addisonian Crisis Goals of treatment and Treatment

Answer 14

Goals of Treatment

• Need to correct fluid and electrolyte imbalance
• Close monitoring of serum electrolyte levels
• Correction of hypoglycemia with IV glucose solution
• Steroid replacement: Hydrocortisone 100mg IV bolus followed by 100mg Q8H for 24 hrs.
• Need to take corticosteroid replacement for life with caution

Treatment

• Shock management, VS
• High-dose hydrocortisone replacement
• Large volumes of 0.9 % saline solution
• IV 5% dextrose
• Assess for fluid volume deficit & elect imbalance q 30 min to 4 hrs X first 24 hrs
• Daily weights
• Protect from noise, light, & environmental extreme temperatures because pt cannot cope with stress

Question 15

Addison’s Disease: Ambulatory and home care teaching

Answer 15

• Establish baseline: vital signs, bp lying and standing
• Glucocorticoids usually in divided doses: 2/3 in morning & 1/3 in afternoon
• Mineralocorticoids: once a day, preferably in a.m.
• Dosage schedule reflects normal circadian rhythm
• Decreases side effects

Question 16

Addison’s Disease: Side effects of corticosteroid therapy

Answer 16

_Glucocorticoid: hydrocortisone
Mineralocorticoid: Florinef (fludrocortisone)_

• Wear medic-alert bracelet in case of emergency
• Carry emergency kit: hydrocortisone 100mg syringe
• Depresses immune system: at risk for infections, protect from exposure to infection
• Delays wound healing, at risk for wound dehiscence, capillary permeability is reduced
• (cannot cope with stress, cannot produce own corticosteroid)
• Induced osteoporosis (loss of Ca in bones)
• Increase Ca intake: 1500 mg qd, vit D, biphosphonates (e.g. Fosamax (alendronate), low impact exercise

_Sa&S of hypocalcemia _

• Depression, psychosis
• Hyperreflexia, diarrhea, cardiac arrhythmias
• Hypotension, muscle spasms, paresthesias of feet, fingers, tongue; positive Chvostek’s sign
• Severe deficiency (tetany) may result in carpopedal spasms, spasms of face muscle, laryngospasm, and generalized convulsion

Question 17

Complications of Corticosteroid Therapy

Answer 17

• GI upset (big one so on pantaloc), heartburn: take meds with milk, food
• Teach pt to watch for signs of heartburn or epigastric pain not relieved by antacids, report to physician
• Do not take use aspirin or other OTC drugs unless prescribed by MD
• Moonface, buffalo hump & central obesity
• Hirsutism, acne
• If you have edema - Restrict sodium, less than 2000 mg if edema
• Cortisone causes gluconeogenesis; monitor and control for hyperglycemia, can develop diabetes
• Increased hunger, weight gain
• Edema, insomnia (take steroids in the morning)
• Hypokalemia can lead to muscle weakness and arrhythmias

Question 18

Addison’s Disease Management

Answer 18

• Yearly eye exam, cataracts or glaucoma may develop.
• Unable to tolerate physical or emotional stress without extra corticosteroid
• Long-term care: recognizing need for extra medication & techniques for stress management
• Examples: fever, influenza, extraction of teeth, rigorous physical activity (playing tennis on a hot day, running a marathon)
• If using IUD, use extra contraception, will reduce inflammation, IUD less effective
• Do not breastfeed while taking this drug without consulting a physician, could suppress growth
• Contraindicated in pregnancy: cause fetal abnormalities