Adrenal Gland

Adrenal Glands

Also known as suprarenal glands Two small glands that are located superior to each kidney Pyramidal in structure and weighs 4g

 The inner part of the adrenal gland is called the medulla.

The outer part of the gland is called the cortex. Zona glomerolusa Zona fasciculata Zona reticularis

Hormones of the Adrenal Medulla

Approximately 80% of the hormones released from the adrenal gland medulla are epinephrine or adrenaline (and adrenaline-like chemicals called catecholamines). The remaining 20% is nonepinephrine

Hormones of the Adrenal Cortex

Mineralocorticosteroids (Aldosterone) Glucocorticosteroids (Cortisol) Androgens (Sex hormones)

Disorders in the Adrenal Gland

1. Pheochromocytoma 2. Addison's Disease

PHEOCHROMOCYTOMA

PHEOCHROMOCYTOMA
A tumor that is usually benign and originates from the adrenal medulla (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that secretes excessive amounts of catecholomines (epinephrine and norepinephrine)

PHEOCHROMOCYTOMA
The cause of high blood pressure in 0.1% of patients with hypertension. May occur as a single tumor or as more than one growth It usually develops in the center (medulla) of one or both adrenal glands. Sometimes this kind of tumor occurs outside the adrenal gland.

Extra-Adrenal Sites
Within the sympathetic nerve chain along the spinal cord (orange spots) Overlying the distal aorta (the main artery from the heart) (green spots) Within the ureter (collecting system from the kidney (yellow spot) Within the urinary bladder (blue spot) Remember, 90% are in the adrenal glands (red spots on the kidneys)

Stages of Malignant Pheochromocytoma

1. Localized: present in only one area of body and has not spread
2. Regional: spread beyond original area and into lymph nodes or tissue surrounding original tumor 3. Metastasis: spread beyond lymph nodes and tissues 4. Recurrent: disease returned after being successfully treated

Signs & Symptoms

headache (usually severe)

excessive sweating
palpitations Tachycardia tremors anxiety w/ panic attacks

nausea & vomiting

 weight loss
nervous shaking pain in the lower chest and upper abdomen weakness fever, heat intolerance, sugar intolerance low blood pressure when standing up

Assessment Findings
hypertension (may be persistent, fluctuating, intermittent, or paroxysmal)
pounding headaches

hyperglycemia and glucosuria

tachycardia, apprehension, palpitations profuse sweating, cold extremities nausea, vomiting dilated pupils

Nursing Assessment
The Five Hs Hypertension Headache Hyperhidrosis Hypermetabolism Hyperglycemia

Note: Presence of these signs has a 93.8% specificity & 90.9% sensitivity for Pheochromocytoma.

Exams & Tests

Reliable levels of adrenal hormones (adrenaline and noradrenaline) and their breakdown products (metanephrines) through blood or urine can usually help your doctor make a diagnosis.
There are three ways your doctor can do this: blood tests, urine tests, and x-ray tests

 Blood tests
Glucagon stimulation test Clonidine

24-hour urine collection suppression test

CT scan MRI MIBG scan Selective vena cava sampling

Medical Management
Pharmacologic Therapy
Decrease BP

Alpha-adrenergic blocking agents. (eg. Phentolamine [Regitine]) Smooth muscle relaxants.(eg. Na nitroprusside [Nipride])

Before and Long-acting alphablocker. During Surgery (Phenoxybenzamine [Dibenzyline])

Ca Channel Blockers.(Nifedipine [Procardia]) Beta-adrenergic blocking agents.(Propranolol [Inderal]) Cathecholamine synthesis inhibitors. (Methyrosine [Demser])

 Surgical Management Adrenalectomy Nipride IV Corticosteroid replacement: Solu-Medrol Oral Corticosteroids: Prednisone

Nursing Management
Stabilize patient: 1) Prescribed Bed rest 2) Pharmacologic Treatment
Patient teaching: Treatment Prognosis Prepare patient for treatment

Monitor: ECG changes, arterial pressures, fluid and electrolyte balance, and blood glucose levels.
Patient teaching: Self-Care, Follow-up visits.

Addisons Disease

Addisons Disease
An Endocrine or hormonal disorder that occurs when the adrenal glands do not produce enough of certain hormones
Symptoms include bronzing of the skin, worsening fatigue, loss of appetite, severe dehydration, and weight loss Can be fatal if left untreated It includes the underproduction of hormones that the adrenal cortex produces

Gland Affected
The Adrenal gland, specifically the adrenal cortex, is the gland affected.
Addisons disease develops when the level of adrenal cortex hormone is low due to hyposecretion (lack of secretion).

Causes
Failure to produce adequate levels of cortisols, or adrenal insufficiency, can occur for different reasons. The problem may be due to a disorder of the adrenal glands themselves ( primary adrenal insufficiency) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency)

Signs & Symptoms

chronic, worsening fatigue muscle weakness loss of appetite emaciation ( extreme weight loss)

hyperpigmentation of the mucuos membranes and the skin

nausea

vomiting
diarrhea

 low blood pressure that falls further when standing, causing dizziness or fainting
irritability and depression hyperkalemia a craving for salty foods due to salt loss hypoglycemia, or low blood glucose

headache
sweating in women, irregular or absent menstrual periods

Diagnostic Tests
ACTH stimulation test to differentiate primary to secondary adrenal insufficiency and from normal adrenal function
Primary insufficiency more than 22.0pmol/L plasma ACTH level

- serum concentration lower than 165nmol/L

Other laboratory findings..

Hypoglycemia
Hyponatremia Hyperkalcemia

Leukocytosis ( increased WBC count)

Medical Management
1. Administering fluids and corticosteroids
2. Monitoring vital signs 3. Placing patient into Recumbent position with the legs elevated 4. Administer vasopressor amines may be required if hypotension persists 5. Antibiotics administration if infection has precipitated adrenal crisis

Nursing Management
1. Assessed the patient: health history and examination focus on the fluid imbalance 2. Monitor blood pressure: when lying, sitting and standing position 3. Watched out for signs & symptoms indicative of addisonian crisis, includes shock; hypotension; pallor, rapid RR; weak pulse 4. Encourage increased fluid intake 5. Instructs the patients family to administer hormone replacement as prescribed 6. If patients condition stabilized, instruct patient to avoid unnecessary activity and stress

Future Trends in Congenital Adrenal Hyperplasia (CAH) Research Expanding the Phenotype of CAH New Endocrine Abnormalities Adrenomedullary Dysfunction: Cortisol is necessary for the normal development and functioning of the adrenal medulla. Cortisol turns on the enzyme necessary for the production of epinephrine (adrenaline), which is a major regulator of blood glucose and suppresses insulin, by the medulla. Classic CAH not only affects cortisol, aldosterone and androgen production in the adrenal cortex, but also severely compromises the adrenal medulla. The implications of this dysfunction are impaired epinephrine response during shortterm high-intensity exercise with no increase in blood glucose. More studies are needed on the risk of low blood glucose in CAH as well as the function of the adrenal medulla in patients with NCAH.

Thank you!