Adrenal Cortex Disorders: Hormones Out

Adrenal cortex disorders: Hormones out

By Ann Crawford, PhD, RN, MRS. S, 46, IS HOSPITALIZED for Each portion has independent glan- and Helene Harris, MSN, RN treatment of an adrenal gland disor- dular functions. Their hormonal der. On admission, she complained secretions affect organs and tissues of weakness, fatigue, and difficulty throughout the body.1,2 falling and staying asleep. For the The adrenal cortex produces and past 6 weeks, she’s noticed weight secretes hormones known as adrenal 2.3 gain and menstrual irregularities. The steroids or corticosteroids. These are ANCC nurse observes that she has a moon- classified as mineralocorticoids, which CONTACT HOURS face appearance, with an obese trunk help control body fluid and electro- and thin arms and legs. Her skin lyte levels, and glucocorticoids, which appears fragile and parchment-like, are involved in many essential life with scattered ecchymoses and striae processes. The adrenal medulla on her abdomen. She’s slightly tachy- secretes small amounts of catechol- cardic with an elevated BP. Her hus- amines as needed to help with stress band states that Mrs. S has been response requirements.1,2 increasingly irritable and moody Aldosterone, the principal mineral- lately. Is Mrs. S suffering from adre- ocorticoid, maintains extracellular nal cortical insufficiency or adrenal fluid volume as part of the renin- cortical hypersecretion? angiotensin-aldosterone system. This article will describe adrenal Secreted in response to decreased cortical insufficiency (also called extracellular volume, aldosterone Addison disease) and adrenal cortical stimulates the kidneys to reabsorb hypersecretion (also called hypercor- sodium and water and excrete potas- tisolism and Cushing syndrome), and sium in an effort to increase plasma explain how to recognize and man- fluid volume and restore normal age these conditions. For more on osmolality. Other factors that stimu- signs and symptoms, see Recognizing late aldosterone secretion include two adrenal disorders and Lab findings elevated serum potassium levels and for patients with adrenal disorders. adrenocorticotropic hormone (ACTH) stimulation.1 About the adrenal glands Cortisol, the main glucocorticoid, The adrenal glands are highly vascu- influences metabolism of protein, fat, lar, tent-shaped organs located on and carbohydrates, and also affects the top of the kidneys. The outer por- body’s stress response, emotional sta- tion is known as the cortex while bility, and immune function. Cortisol the inner portion is the medulla. release is regulated directly by ACTH

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(released from the anterior pituitary gland) and indirectly by corticotropin- releasing hormone (CRH), released from the hypothalamus. Low circulating cortisol levels stimulate the hypothalamus to secrete CRH. The increased levels of CRH stimulate ACTH secretion, which in turn stimulates cortisol secretion. Conversely, high cortisol levels in- hibit CRH release, comprising a nega- tive feedback system. The pattern of hormonal secretion is affected by diurnal cycles as well as physiologic or psychological stress.1–3 Adrenal sex hormones for both genders (primarily androgens) are also secreted by the adrenal cortex, though not in amounts as large as secreted by the gonads.

Adrenal cortical insufficiency Primary adrenal cortical insufficiency is a relatively rare disorder also known as Addison disease. It occurs when the adrenal cortex layers are destroyed by autoimmune disorder, tuberculosis, metastatic carcinomas, MAGES

I hemorrhage, infections, toxins, or

ETTY certain medications (for example,

/ G ketoconazole or mitotane). Second- COM ary adrenal insufficiency may be RF. caused by hypopituitarism, surgical EDICAL

M removal of the pituitary gland, or, BY more commonly, sudden cessation of long-term, high-dose glucocorti- 1,3,4 LLUSTRATION

I coid therapy. Tertiary adrenal

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. insufficiency is caused by problems glucocorticoid and mineralocorticoid patients with adrenal insufficiency). with the hypothalamus. deficiency, and may develop in a Decreased glucocorticoid secretion Manifestations of adrenal insuffi- slow progression or more quickly impairs the body’s ability to regulate ciency are related primarily to with stress (see Assessment findings in blood glucose levels and to control

Recognizing two adrenal disorders1-3

System Addison disease Cushing syndrome

Musculoskeletal • Muscle weakness • Muscle weakness and atrophy • Fatigue • Fatigue • Joint or muscle pain • Thin extremities • Osteoporosis • Pathologic fractures • Poor fracture healing Gastrointestinal • Weight loss • Weight gain • Anorexia • Gastric ulcers or bleeding • Nausea and vomiting • Abdominal pain • Constipation or diarrhea Integumentary • Vitiligo • Thinning skin (translucent or parchment-like) • Altered pigmentation (hyperpigmentation and • Striae on the abdomen, thighs, or upper arms “bronzed” appearance with primary Addison • Hyperpigmentation of skin disease, or patchy hypopigmentation) • Ecchymoses • Bluish-black color to gums and oral mucous • Petechiae membranes • Acne • Decreased body, pubic, and axillary • Hirsutism hair (more often in women) • Fine hair on face and body • Male pattern balding (in women) Genitourinary • Menstrual irregularities • Enlarged clitoris Cardiovascular • Orthostatic hypotension • Hypertension • Fluid volume deficit (dehydration) • Tachycardia • Potential for dysrhythmias • Fluid volume overload • Dependent edema • Fragile capillaries Hematologic • Anemia • Increased risk of thrombus formation Neurologic • Headache • Mood swings • Lethargy • Emotional lability • Depression • Irritability • Confusion • Confusion • Mood swings • Difficulty concentrating • Tremors • Depression • Psychotic behaviors • Difficulty sleeping Immune system • Increased risk for infection • Decreased immunity (decreased lymphocytes and immunoglobulin production) • Decreased inflammatory response • Potential masking of infection or inflammation • Decreased neutrophil activity • Decreased production of cytokines, histamines, and prostaglandins Other • Decreased stress tolerance • General appearance: moon face, buffalo hump, • Fever protruding abdomen (truncal obesity) with thin • Salt craving extremities.

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. the effects of the immune and in- therapy includes hydrocortisone flammatory responses. Reduced cor- for maintenance, with the addition tisol release leads to hypoglycemia of fludrocortisone (a mineralocorti- as glycogen stores are depleted; a coid) for patients who don’t attain decrease in urea nitrogen excretion an adequate salt-retaining effect by the kidneys and a decrease in with hydrocortisone (see Treating gastric acid production may lead to patients with adrenal insufficiency).3 anorexia and weight loss.1–3 Pain in adrenal insufficiency, re- Diminished aldosterone secretion lated to fluid and electrolyte imbal- triggers fluid and electrolyte imbal- ances, can occur in the abdomen, ances. Sodium and water excretion lower back, and legs. Over-the- is increased, with resultant hypona- counter (OTC) medications such as tremia and hypovolemia. Potassium acetaminophen help manage pain; excretion is reduced, causing hyper- patients also may need adjustments kalemia. Potassium retention also to the dosages of glucocorticoid facilitates reabsorption of hydrogen replacement drugs. ions within the renal tubules, which Adrenal crisis requires immediate may cause acidosis. The adrenal glands treatment to maintain essential met- Acute adrenal crisis (also called are highly vascular, abolic functions. Follow the “5 S’s” Addisonian crisis) is a life-threatening tent-shaped organs for management: complication in which adrenal insuf- located on top 1. salt replacement ficiency manifests without warning, of the kidneys. 2. sugar (dextrose) replacement often due to a stressful event such as 3. steroid replacement surgery, trauma, or infection. The 4. support of physiologic functions. patient’s need for cortisol and aldos- 5. search for and treat any identified terone is greater than the body’s sup- sodium. Potassium and blood urea cause.3 ply, so hyponatremia, hypovolemia, nitrogen (BUN) levels are elevated. Replace extracellular fluid volume and hyperkalemia progress rapidly, Patients with primary adrenal insuf- with 5% dextrose and 0.9% sodium putting the patient at risk for car- ficiency also have an elevated ACTH chloride solution as prescribed. diovascular collapse (more on level and an elevated eosinophil Monitor for electrolyte abnormali- this later).1,3 count secondary to decreased levels ties; hyperkalemia is often present of circulating cortisol. and may be treated with I.V. insulin Recognizing adrenal The most conclusive diagnostic and glucose to shift potassium into insufficiency test for adrenal insufficiency is an the cells. Administer I.V. hydrocorti- Lab results show decreased serum ACTH stimulation test, performed sone or dexamethasone, followed levels of cortisol, fasting glucose, and by administering I.V. ACTH and by continued use of hydrocortisone assessing plasma cortisol levels at for long-term treatment, as pre- Lab findings for patients 30 minutes and 1 hour. Patients scribed. with adrenal disorders with primary insufficiency will Mineralocorticoid treatment show little or no cortisol response; usually isn’t required during the Addison disease • patients with secondary insufficiency acute phase of treatment due to the Hyponatremia will have elevated cortisol levels.1 larger amounts of hydrocortisone • Hyperkalemia Computed tomography, magnetic being administered, but as the • Hypoglycemia • Hypercalcemia resonance imaging, arteriography, corticosteroid dosage is decreased, • Leukocytosis and X-rays may all help determine fludrocortisone will be added for 1–3 • Elevated BUN pituitary or adrenal causes for maintenance. • Eosinophilia insufficiency. • Possible acidosis Adrenal cortical Cushing syndrome Treating adrenal insufficiency hypersecretion • Hypernatremia Hormone replacement therapy, Hyperfunction of the adrenal cortex • Hypokalemia usually a combination of glucocorti- can result in oversecretion of one or • Hyperglycemia • coids and mineralocorticoids, is more hormones. Hypersecretion of Lymphocytopenia prescribed to treat adrenal insuffi- the adrenal cortex may produce • Eosinopenia ciency. Glucocorticoid replacement hypercortisolism, hyperaldosteronism www.Nursing2012.com October l Nursing2012 l 35

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. (Conn syndrome), or elevated andro- medications such as prednisone or gen production. by adrenal tumors. Excessive secretion of cortisol can Diagnosis of glucocorticoid be due to problems with the hypo- hormone excess is contingent on the thalamus or the anterior pituitary finding of cortisol hypersecretion. One gland (Cushing disease), the adrenal of the earliest signs of hypercortisolism gland, or long-term administration of is the loss of diurnal pattern of cortisol potent glucocorticoid medications secretion.3 Late night (between 2300 (iatrogenic Cushing syndrome). All and 2400 hours) serum or salivary body systems will be affected by this cortisol levels can be inappropriately excessive secretion. Without treat- elevated, and 24-hour urine tests ment, hypercortisolism can be fatal. will show elevated cortisol.3 Serum A dexamethasone suppression sodium and glucose levels will be test is the most widely used screen- increased, while serum potassium and ing tool for Cushing disease with eosinophil levels will be decreased.1,2 pituitary and adrenal causes. Dexa- Imaging studies may identify methasone is administered at 2300 abnormalities such as adrenal gland to 2400 hours, and a plasma cortisol or anterior pituitary gland tumors Adrenal cortical hormone 1,2 level is drawn at 0800 hours the levels that are out of causing hypercortisolism. next morning. Suppression of corti- kilter cause various health Treating adrenal cortical sol indicates normal functioning of problems, some life hypersecretion the pituitary and adrenal glands. If threatening. plasma cortisol levels are elevated Depending on the cause, treatment (greater than 5 mg/dL), further test- can include surgery, irradiation, or ing is needed to determine the Altered plasma ACTH levels pharmacologic interventions to cause. Because stress, obesity, de- will differ depending on the cause. reduce plasma cortisol levels without pression, and certain medications ACTH is elevated in Addison disease causing permanent damage to the may cause false elevation in cortisol and pituitary tumor-related Cushing anterior pituitary or adrenal glands.3 levels, clinical suspicion and addi- disease. Levels are usually normal or Surgery to remove a pituitary or ad- tional lab findings will also help to decreased in Cushing syndrome renal tumor is performed with the point toward the diagnosis.2,5 caused by glucocorticoid-containing goal of leaving the remaining endocrine tissue for continued function. Assessment findings in patients with adrenal Following surgery, the patient is insufficiency3 placed on cortisol replacement therapy for 6 months to a year, or until Secondary/ adrenal function returns. If the entire Finding Primary tertiary pituitary gland or both adrenal Anorexia and weight loss Yes Yes glands are removed, the patient requires lifelong hormonal replace- Fatigue and weakness Yes Yes ment. Irradiation may be used for pitu- Nausea, diarrhea, abdominal pain Yes Yes itary tumors, often as an adjunctive Myalgia, arthralgia Yes Yes therapy if pituitary surgery is unsuc- cessful. With radiation, the effects Orthostatic hypotension Yes Yes may not be immediately evident and Hyponatremia Yes Yes normal tissue may be damaged, which can cause other adverse reac- Hyperkalemia Yes No tions such as headaches, hyperten- Hyperpigmentation Yes No sion, dry skin, and alopecia. Also, patients must continue medication Secondary deficiencies of testosterone, growth No Yes therapy for several months while hormone, thyroxine, antidiuretic hormone awaiting the final results of the Associated autoimmune conditions Yes No radiation therapy. Regular monitor- ing is necessary to determine the

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. effectiveness of radiation therapy and development of new pituitary Treating patients with adrenal insufficiency3,7-9 hormone deficiency.2,6 Hydrocortisone is a synthetic adrenocortical steroid with glucocorticoid and miner- If the cause of Cushing syndrome alocorticoid properties. This drug mimics the effects of the body’s own cortico- is long-term use of corticosteroids, steroids and achieves similar effects. Hydrocortisone also has immunosuppressive treatment involves a slow weaning properties and alters the body’s metabolism of fats, carbohydrates, and proteins. of the medication to let the body Fludrocortisone, another synthetic adrenocortical steroid, is used for its mineralocor- resume normal cortisol production. ticoid properties (it also has glucocorticoid properties). Fludrocortisone binds the Abruptly discontinuing these mineralocorticoid receptor (aldosterone receptor) and causes an increase in ion and water transport, raising extracellular fluid volume and BP and lowering serum medications could lead to deficient potassium levels. cortisol levels (mimicking adrenal Nursing considerations: Perform a thorough history and physical assessment as a 2 insufficiency). baseline for further assessment findings and continue to monitor the patient as Drug therapy also can help con- follows. trol manifestations of hypercorti- • Assess for infections before beginning these drugs and continue to monitor for solism. Medications are specifically signs and symptoms of infection. used for controlling cortisol pro- • Monitor vital signs regularly, assessing for orthostatic hypotension and other signs duction and include ketoconazole, and symptoms of decreased cardiac output. metyrapone, mifepristone, and • Monitor intake and output, and watch for signs and symptoms of dehydration. • mitotane, which have antiglucocor- Monitor serum electrolytes regularly, and assess for abnormalities, especially ticoid properties. hyponatremia and hyperkalemia. Also monitor serum glucose levels and weight. • Administer potassium supplements and place the patient on a low-sodium, high-potassium diet as prescribed. Nursing responsibilities • Assess for bowel sounds and monitor for nausea, vomiting, and diarrhea, which When caring for a patient with an may predispose the patient to fluid volume deficit. adrenal hypersecretion disorder, • Auscultate lung and heart sounds, and assess peripheral pulses and capillary refill. obtain a thorough health history and • Assess the patient’s skin for hyperpigmentation, especially around the nipples and perform a comprehensive physical in skin folds. assessment. Assess for muscle weak- • Assess the patient’s mental status, being cognizant of the potential for mood ness, fatigue, and pain; assist with swings and depression. ambulation and activities of daily • Monitor for cushingoid effects such as moon face, and for petechiae. • living as needed. Assess the patient’s Assess for signs of peptic ulcer disease or ulcerative colitis. • skin for discoloration and an in- Institute fall prevention strategies and assist with ambulation and daily activities as needed. crease in fat deposits. Assess for the • Regularly assess the patient’s pain. Use a pain intensity rating scale and intervene development of hirsutism in women, appropriately. as well as irregularities in the men- Patient education: Tell patients to notify their healthcare provider if they gain three strual cycle. or more pounds in 1 week and to notify their healthcare provider immediately if Regularly assess the patient’s car- they develop heartburn or indigestion. Tell patients not to take OTC medications for diovascular and pulmonary status, heartburn, or any OTC or herbal medications without talking to their healthcare renal function, and neurologic status. provider. Instruct patients to report insomnia or mood changes to their healthcare Monitor vital signs and assess for provider. Explain the importance of avoiding alcohol and aspirin, which may con- signs and symptoms of fluid volume tribute to the development of peptic ulcer disease. Teach patients which foods are overload, including hypertension, high in vitamin D, protein, and calcium to help reduce the risk of osteoporosis. Tell pulmonary crackles, peripheral the patient or family to report any wounds that are slow to heal or aren’t healing. Explain the importance of adhering to the medication regimen and follow-up edema, and jugular vein distension, appointments with their healthcare provider. Tell patients not to discontinue taking secondary to sodium and water re- medication without consulting with their healthcare provider. tention. Monitor intake and output, Because many patients with adrenal insufficiency have episodes of hyponatremia serum glucose and electrolyte levels and hypoglycemia, they should maintain a regular schedule for food intake and for abnormalities, especially hypoka- activity. Advise patients to wear a medical-alert bracelet or medal identifying their lemia and hypernatremia. condition in case of emergency. Because of the decreased inflammatory and immune responses, depression. Allow the patient to cortisolism. She’s treated surgically monitor the patient for signs and express concerns, and make appro- with a unilateral adrenalectomy symptoms of infection. Monitor priate referrals as necessary.1,2 and placed on cortisol replacement the patient’s mental status and be Mrs. S, whom we met at the medications. Postoperatively, she’ll alert for mood swings, anger, and beginning of this article, has hyper- need to be monitored for several www.Nursing2012.com October l Nursing2012 l 37

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. months to determine if adrenal Staying in balance 4. Reddy P. Clinical approach to adrenal insufficiency in hospitalized patients. Int J Clin Pract. function returns, and her medica- Adrenal cortical hormones affect 2011;65(10):1059-1066. tions will be adjusted accordingly. virtually every body system. When 5. Carroll TB, Findling JW. The diagnosis of Cush- these hormone levels are out of kilter, ing’s syndrome. Rev Endocr Metab Disord. 2010; Patient education they can cause many problems and 11(2):147-153. 6. Vance ML. Cushing’s disease: radiation therapy. Teach patients with hypercortisolism even be life threatening. By under- Pituitary. 2009;12(1):11-14. about the disease and its manifesta- standing manifestations of hormonal 7. Adams M, Koch R. Pharmacology: Connections to tions, and their medications and abnormalities, treatments, and appro- Nursing Practice. Upper Saddle River, NJ: Pearson; 2010. adverse reactions. Make sure they priate nursing interventions, you can 8. Skidmore-Roth L. Mosby’s Nursing Drug Refer- know when to call their healthcare help patients with adrenal disorders ence. 23rd ed. St. Louis, MO: Elsevier Mosby; 2010. provider. Explain the effects of hy- keep their balance. ■ 9. Hodgson B, Kizior R. Saunders Nursing Drug percortisolism, treatment plans, and Handbook. St. Louis, MO: Elsevier Saunders; 2012. continued care needs. Emphasize the REFERENCES Ann Crawford is a professor in the College of Nursing at the University of Mary Hardin-Baylor in Belton, Tex. importance of keeping scheduled 1. Ignatavicius D, Workman L. Medical-surgical Helene Harris is a clinical educator at Central Texas appointments with the healthcare Nursing, Critical Thinking for Collaborative Care. 6th Veterans Healthcare System in Temple, Tex. ed. Philadelphia, PA: Elsevier Saunders; 2010. provider and of notifying the health- 2. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. This article originally appeared in Nursing2011 CriticalCare. 2011;7(4):20-35. care provider if symptoms increase. Textbook of Medical-surgical Nursing. 11th ed. Phila- delphia, PA: Lippincott Williams & Wilkins; 2008. Encourage patients to wear a medical- The authors have disclosed that they have no finan- 3. Porth C, Matfin G. Pathophysiology: Concepts of cial relationships related to this article. alert bracelet or medal in case of Altered Health States. 8th ed. Philadelphia, PA: emergency.1,2 Lippincott Williams & Wilkins; 2009. DOI-10.1097/01.NURSE.0000419427.99685.16

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