7.3 Adrenal gland disorders

Adrenal gland disorders can wreak havoc on the body's hormone balance. Cushing's syndrome and Addison's disease are two key conditions that mess with cortisol levels, causing a range of symptoms from weight changes to mood swings.

Diagnosing these disorders involves hormone tests and imaging. Treatment focuses on managing cortisol levels through meds or surgery. Nurses play a crucial role in patient care, from giving meds to teaching about stress management and recognizing adrenal crisis signs.

Adrenal Gland Disorders

Pathophysiology of adrenal disorders

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• Cushing's syndrome
  • Excessive cortisol production by the adrenal glands due to long-term glucocorticoid therapy, pituitary tumor (Cushing's disease), or adrenal tumor
  • Leads to characteristic physical changes (moon face, buffalo hump, truncal obesity) and systemic effects (skin thinning, muscle weakness, hypertension, glucose intolerance, mood changes)
• Addison's disease
  • Primary adrenal insufficiency caused by autoimmune destruction of the adrenal cortex
  • Results in deficiency of cortisol and aldosterone leading to fatigue, weight loss, hyperpigmentation, hypotension, electrolyte imbalances (hyponatremia, hyperkalemia), hypoglycemia, and gastrointestinal symptoms (nausea, vomiting, abdominal pain)

Diagnostic tests for adrenal dysfunction

• Cushing's syndrome
  • 24-hour urinary free cortisol and late-night salivary cortisol assess cortisol levels
  • Low-dose dexamethasone suppression test evaluates feedback suppression of cortisol production
  • Imaging studies (MRI or CT) identify pituitary or adrenal tumors causing excessive cortisol production
• Addison's disease
  • Low serum cortisol and aldosterone levels indicate adrenal insufficiency
  • ACTH stimulation test assesses adrenal responsiveness to stimulation
  • Serum electrolyte abnormalities (hyponatremia, hyperkalemia) reflect mineralocorticoid deficiency
  • Autoantibodies against 21-hydroxylase support autoimmune etiology

Nursing care for adrenal disorders

• Cushing's syndrome
  • Administer adrenal enzyme inhibitors (ketoconazole, metyrapone) or glucocorticoid receptor antagonists (mifepristone) to reduce cortisol effects
  • Prepare patients for surgical intervention to remove pituitary or adrenal tumors
  • Encourage a balanced diet, regular exercise, and stress management techniques to improve overall health
  • Educate patients on the importance of regular follow-up and monitoring to assess treatment effectiveness and detect complications
• Addison's disease
  • Administer lifelong glucocorticoid (hydrocortisone, prednisone) and mineralocorticoid (fludrocortisone) replacement therapy
  • Adjust stress doses of glucocorticoids during illness or surgery to prevent adrenal crisis
  • Teach patients to recognize signs and symptoms of adrenal crisis and provide instructions on stress dose adjustments
  • Encourage wearing a medical alert bracelet to inform healthcare providers of adrenal insufficiency

Management of adrenal crisis

• Recognize adrenal crisis by its hallmark features
  1. Severe hypotension and hypovolemic shock
  2. Altered mental status and fever
  3. Abdominal pain, nausea, and vomiting
• Manage adrenal crisis promptly
  1. Administer high-dose intravenous hydrocortisone immediately
  2. Provide fluid resuscitation with normal saline to restore blood volume
  3. Continuously monitor vital signs and electrolytes to assess response to treatment
  4. Identify and treat underlying causes (infections) to prevent recurrence
  5. Continue stress dose glucocorticoid coverage until the crisis resolves and the patient stabilizes