ADRENAL

GLANDS

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 Review of the Anatomy and
Physiology of the Adrenal Glands

• Located at the apex of each kidney.

• Parts
• Adrenal medulla- secretes the following
hormone under the influence of SNS:
– Catecholamines
– Epinephrine
– Norepinephrine
• Adrenal cortex- secretes:
– MIneralocorticoid
– Glucocorticoid
– Sex hormones
•  
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Functions of glucocorticoids
• 1. Stimulate gluconeogenesis (the formation
of carbohydrates from proteins and other
substances by the liver).
• 2. Provide amino acids and glucose during
times of stress.
• 3. Suppress the immune system due to
powerful immunosuppressive and
antiinflammatory properties.
• 4. Stimulate fat breakdown. Fatty acids are
released and used for energy production.
Glucocorticoids are considered to be
catabolic steroids as they break down the
body’s stored resources during times of
need. Page 6
What causes an increase in
corticosteroid secretion?
• Physical trauma.
• Cold.
• Burns.
• Heavy exercise.
• Infection.
• Shock.
• Decreased oxygen.
• Sleep deprivation.
• Pain.
• Fear.
• Emotional upset and anxiety.
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What causes an increase in
aldosterone secretion?
• Low blood levels of sodium
trigger the renin–angiotensin
system.
• If the sodium level is low, the
kidneys retain it in order to build
the blood level back up.
• The renin–angiotensin system
kicks in, resulting in retention of
sodium and water in the vascular
space
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 An increase in aldosterone secretion is also
caused by:

• Low fluid volume levels in the vascular

space as in shock or hypovolemia
• High blood levels of potassium: when
potassium levels are high in the blood, this
means the sodium levels are low, as
sodium and potassium have an inverse
relationship. Therefore, aldosterone is
secreted, which causes sodium and water
retention in the vascular space and causes
potassium excretion out of the body. This
helps bring the serum potassium back into
the normal range.

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 Sex hormones

• Sex hormones are actually

made by the adrenal cortex and
the gonads, which include the
ovaries and testes.
• Gonadocorticoids is one name
for sex hormones. Another
name is androgens—think
masculine characteristics.

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 Sex hormones
• are usually broken down into three
categories:
1. Androgens, testosterone being the main
one.
2. Estrogens, estradiol being the main one.
3. Progestagens, progesterone being the
main one.

The majority of testosterone in males is

produced during puberty; therefore, this is
when we see secondary sexual
characteristics begin to form.

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 Adrenal medulla
• The adrenal medulla is a sympathetic
nerve ganglion that has secretory cells.
The hormones secreted by the adrenal
medulla are called the “fight or flight”
hormones.
• These hormones are under the control of
the sympathetic nervous system. The
adrenal medulla hormones are:
• 1. Epinephrine (also known as adrenaline).
• 2. Norepinephrine (also known as
noradrenaline).
• Epinephrine and norepinephrine together
are referred to as catecholamines.
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 Catecholamines
• a crucial part of the body’s response to stress. The
different actions of catecholamines are to:
– Increase heart rate.
– Cause peripheral blood vessels to constrict so blood
pressure goes up.
– Increase sweating.
– Cause glycogen to convert to glucose (increases
energy).
– Cause bronchial tubes to dilate (to breathe more air
in).
– Decrease digestion (blood is sent to more important
places like your heart).
– Lower urine output (to conserve fluid).
– Increase alertness.

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 Plasma Cortisol
• This is direct measure of the primary
secretory product of the adrenal
cortex by radioimmunoassay
technique.
• Serum concentration varies with
circadian cycle so normal values
vary with time of day and stress level
of patient (8 a.m. levels typically
double that of 8 p.m. levels).
• Useful as an initial step to assess
adrenal dysfunction, but further
workup is usually necessary.

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 Nursing and Patient Care
Considerations
• A fasting sample is preferred.
• Blood specimens should coincide with
circadian rhythm with draw time indicated on
laboratory slip.
• Interpretation of test results:
– Decreased values seen in: adrenal hyperplasia,
Addison's disease, anterior pituitary hyposecretion,
secondary hypothyroidism, hepatitis, and cirrhosis.
– Increased values seen in: hyperthyroidism, stress
(eg, trauma, surgery), carcinoma, Cushing's
syndrome, hypersecretion of corticotropin by
tumors (oat cell cancer), adrenal adenoma, and
obesity.

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 24-Hour Urinary Free
Cortisol Test
• Test measures cortisol
production during a 24-hour
period.
• Useful to establish diagnosis
of hypercortisolism.
• Less influenced by diurnal
variations in cortisol.

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 Nursing and Patient Care
Considerations
• Instruct patient in appropriate
collection technique.
• Collection jug should be kept on ice
and sent to laboratory promptly
when collection completed.
• Interfering factors:
– Elevated values:pregnancy, oral
contraceptives, spironolactone, stress.
– Recent radioisotope scans can
interfere with test results.

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Dexamethasone Suppression
Test
• The dexamethasone suppression test (DST) is a
valuable method to evaluate adrenal
hyperfunction.
• Adrenal production and secretion of cortisol is
stimulated by adrenocorticotropic hormone
(ACTH, corticotropin) from the pituitary gland.
• Dexamethasone is a synthetic steroid effective
in suppressing corticotropin secretion.
• In a healthy patient, the administration of
dexamethasone will inhibit corticotropin
secretion and will cause cortisol levels to fall
below normal.

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 Nursing and Patient Care
Considerations
• Explain the procedure to the
patient.
– Overnight 1 mg DST (used primarily to
identify those without Cushing's
syndrome).
– High-dose overnight DST (helpful to
distinguish Cushing's disease from
other forms of Cushing's syndrome).
• Encourage patient to take
dexamethasone with milk because
it may cause gastric irritation.
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 Adrenocorticotropic
Stimulation Test
• ACTH stimulates the production
and secretion of cortisol by the
adrenal cortex.
• Demonstrates the ability of the
adrenal cortex to respond
appropriately to ACTH.
• This is an important test to evaluate
adrenal insufficiency, but may not
distinguish primary insufficiency
from secondary insufficiency.

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 Nursing and Patient Care
Considerations
• Obtain baseline cortisol level.
• Administer 0.25 mg ACTH (cosyntropin
[Cortrosyn] I.V. or I.M.).
• Collect cortisol levels at times ordered (usually
at 30 and 60 minutes).
• Interpretation of test results:
– Range of normal responses may vary; however,
typically a rise in cortisol of double baseline value is
considered normal.
– Diminished response—adrenal insufficiency with
low cortisol values, adrenal tumor with high cortisol
values, prolonged glucocorticoid therapy.
– Exaggerated response—adrenal hyperplasia with
high cortisol values.

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 Corticotropin Releasing
Hormone Stimulation Test
• Test measures responsiveness of pituitary
gland to corticotropin-releasing hormone
(CRH), a hypothalamic hormone that
regulates pituitary secretion of ACTH.
• Useful to differentiate the cause of excess
cortisol secretion when ectopic source of
ACTH is suspected.
• In general, CRH will stimulate ACTH
secretion in the pituitary, but not in
nonpituitary corticotropin-secreting
tissues.

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 Nursing and Patient Care
Considerations
• Describe procedure to patient.
– Patient is given CRH (1 mcg/kg or 100 mcg) I.V.
– Catheters are advanced through the femoral veins to areas
near the adrenal glands, so sampling can take place near
ACTH secretion.
– Blood samples for ACTH test are collected at 2, 5, 10, and
15 minutes.
• Normal response is a rise in ACTH to at least double
the baseline value.
• Interpretation of test results:
– Brisk rise in ACTH double baseline value: Cushing's disease.
– No response in ACTH: corticotropin-independent Cushing's
syndrome (adrenal tumor) or ectopic source of corticotropin
secretion (ectopic tumor).
– Test can produce false-negative response.

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 Plasma Catecholamines

• Direct measure of circulating catecholamines

using radioimmunoassay technique; more
sensitive test than urine test, but more prone
to false-positive results.
• Nursing and Patient Care Considerations
• Collect sample from I.V. catheter 20 to 30
minutes after venipuncture, if possible, to
reduce the rise in catecholamine levels from
pain and anxiety.
• Collect the sample in a heparinized tube.
• Interpretation: levels greater than 2,000 ng/L
diagnostic for pheochromocytoma.

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Clonidine Suppression Test

• Based on the principle that catecholamine

production by pheochromocytomas is
autonomous, as opposed to other causes
of excess catecholamines, which are
regulated by the sympathetic nervous
system.
• Clonidine (Catapres), as a central alpha-
adrenergic agonist, suppresses
production of catecholamines.
• Useful to differentiate pheochromocytoma
from essential hypertension when test
results are inconclusive.

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 Nursing and Patient Care
Considerations
• Collect baseline catecholamine sample from I.V.
catheter 20 to 30 minutes after venipuncture, if
possible, to reduce the rise in catecholamine levels
from pain and anxiety.
• Give clonidine 0.3 mg orally.
• After 3 hours, collect second catecholamine
sample.
• Interpretation: in patients without
pheochromocytoma, a significant drop in
catecholamines should be seen at 3 hours (less
than 500 pg/mL or reduction of total
catecholamines by 50%), whereas in patients with
pheochromocytoma, no drop in catecholamines
will be evident.

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Aldosterone (Urine or Blood)

• Direct measure, using

radioimmunoassay technique, of
aldosterone, a hormone secreted by the
adrenal cortex, which regulates renal
control of sodium and potassium.
• May be measured in the blood or in 24-
hour urine collection sample.
• Urine test is more reliable because it is
less influenced by short-term fluctuations
in the bloodstream.
• Useful to diagnose primary
aldosteronism.

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 Nursing and Patient Care
Considerations
• Test results can be elevated by
stress, strenuous exercise, upright
posture, and medications, such as
diazoxide (Hyperstat), hydralazine
(Apresoline), and nitroprusside
(Nipride).
• Test results may be decreased by
excessive licorice ingestion and the
medications fludrocortisone
(Florinef) and propranolol (Inderal).

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 ADDISON’S DISEASE
(ADRENOCORTICAL INSUFFICIENCY)

• Decrease in the secretion of adrenal

cortex hormones
Risk factors/etiology:
• Autoimmune
• Bilateral adrenalectomy
• Abrupt withdrawal from long-term
corticosteroid therapy.
• Failure to take medication
• Stress

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 Clinical manifestations:

• Fatigue and weakness

• Weight loss
• GI disturbances
• Bronze pigmentation of the skin
• Postural hypotension
• hypoNa, hyperK
• Hypoglycemia
Adrenal crisis:
– Profound fatigue
– Dehydration
– Vascular collapse

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 Diagnostics:
• Plasma ACTH level
• Decreased serum Na,
increased serum K level

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Test Results That Suggest Addison's Disease
Test Result
Blood chemistry
Serum Na < 135 mEq/L
Serum K > 5 mEq/L
Ratio of serum Na:K < 30:1
Plasma glucose, fasting < 50 mg/dL (< 2.78
mmol/L)
Plasma HCO3 < 15–20 mEq/L
BUN > 20 mg/dL (> 7.1
mmol/L)
Hematology
Hct Elevated
WBC count Low
Lymphocytes Relative lymphocytosis

Eosinophils Increased
Imaging
Evidence of
Calcification in adrenal
areas
Renal TB
Pulmonary TB Page 36
 Nursing and medical
management:
• Initiate and maintain IV infusion of NSS.
• Administer large doses of corticosteroid through
IV bolus initially.
• Monitor V/S.
• Evaluate K level.
• Keep client quiet and immobilized.
• Steroid therapy:
• Give with food
• Check weight daily.
• Increase intake of protein and carbohydrates
• Evaluate for edema and fluid retention
• Risk for infection
• Lifelong steroid therapy especially during
periods of stress.
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CUSHING’S SYNDROME

• Results from excessive

levels of adrenal cortex
hormone.
Risk factors/etiology:
• More common in women.
• Pituitary hypersecretion.
• A benign pituitary tumor
• Long term steroid therapy

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Clinical manifestations:
• Marked changed in personality.
• Moon face
• Deposit of fat on the back.
• Amenorrhea
• Hirsutism
• Thin skin, purple striae.
• Truncal obesity with thin
extremities.
• Bruises and petechiae
• Persistent hyperglycemia
• GI distress
• Osteoporosis
• Increased susceptibility to infection.
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 Diagnostics:
• Increased serum Na and
decreased serum K level.
• Hyperglycemia
• Increased plasma cortisol
level.

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 Complications:
• CHF
• HPN
• Pathological fracture
• Psychosis

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 Nursing and medical
management:
• Restrict water and sodium intake.
• Monitor fluid and electrolyte level.
• Evaluate for hyperglycemia.
• Prevent infection.
• Monitor for cardiac dysrhythmias.
• Weight bearing exercise
• Adrenalectomy
• Hypophysectomy
• Radiation therapy

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PHEOCROMOCYTOMA

•  The adrenal medulla

secretes an excess of
epinephrine and
norepinephrine

Risk factors/Etiology:
• Chromaffinoma
• Pregnancy

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Clinical manifestations:

• SNS overactivity as
manifested by:
• 5 H’s
– Hypertension
– H/A
– Hyperhydrosis
– Hypermetabolism
– Hyperglycemia

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 Diagnostics:
• Serum assay of
catecholamines
• VMA test

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Nursing and medical
management:
• Bedrest HOB elevated.
• Decrease intake of stimulants.
• Sedate as indicated.
• Maintain calm and quiet environment.
• Assess V/S.
• Anti HPN drug- clonidine, vasodilator
• Monitor for hemorrhagic problems.
• Monitor renal perfusion.
• adrenalectomy

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• end

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