Nursing Management

Adrenal Steroid Hormones: Corticosteroids

•     Glucocorticoids (cortisol)

–   Regulate metabolism

–   Increase blood glucose levels

–   Critical in stress response

•     Mineralocorticoids (aldosterone)

–   Regulate sodium and potassium

•     Androgens

–   Growth and development in both genders

–   Sexual activity in women

Cushing’s Syndrome/Disease

•    Iatrogenic administration of exogenous cortisol

•    ACTH secreting pituitary tumor

•    Cortisol secreting neoplasm within the adrenal cortex

•    Ectopic ACTH secreting tumors outside of the hypothalamic-pituitary-adrenal axis

Clinical Manifestations

•    Seen in most body systems

•    Glucocorticoid excess usually predominate

•    Symptoms of mineralocorticoid and androgen excess also seen


•    What is the difference between Cushing’s syndrome and Cushing’s disease?


•    What are the collaborative treatment options for Cushing’s disease?

Case Study

•    You have just admitted JS a 60 year old man suffering from COPD.  He has been on home oxygen for several years. Two months ago he was started on steroid therapy.  His medications include Alupent inhaler, Theo-Dur, terbutaline, dexamethasone, digoxin, and Lasix.  He has been progressively exhibiting signs and symptoms of Cushing’s syndrome.


•    What findings would you expect to note in your assessment that characterize Cushing’s syndrome?


Clinical Presentation

•     Centripedal (truncal) obesity or generalized obesity

•     Thin arms and legs

•     Bruising

•     Weakness and fatigue

•     Moon-facies with facial plethora

•     Purplish-red striae on abdomen, breasts, and buttocks

•     Hypertension

•     Impaired glucose metabolism


Clinical presentation

•    Unexplained hypokalemia

•    Acne

•    Hirsutism

•    Menstrual irregularities



•    Why would you expect hypokalemia?

•    Why is this finding of importance in this patient?


•    What diagnostic test will confirm the presence of Cushing’s syndrome?

Diagnostic Tests

•    Urine free cortisol

•    Dexamethasone suppression test


•    What teaching would you do for the patient undergoing a test for urine cortisol?

•    What would you want to evaluate prior to the dexamethasone suppression test?

Other diagnostic findings

–   Granulocytosis

–   Hyperglycemia

–   Glycosuria

–   Hypercalciuria

–   Osteoporosis

–   Hypokalemia

–   Alkalosis

–   ACTH levels low, normal or high

–   Plasma cortisol


•    What are 3-4 general topics which must be included in a teaching plan for JS?

General Teaching

•     Promote self-care through good nutrition and maintaining fluid balance

•     Increase awareness of home safety issues

•     Prevent infection particularly related to skin integrity and handwashing

•     Check blood pressure regularly and take blood pressure medications

•     Take medications as scheduled


•    What are the consequences of suddenly stopping the dexamethasone therapy?

Drug Therapy

•    Iatrogenic

–   Gradual discontinuation of therapy

–   Reduction in dose

–   Conversion to alternate-day regimen


•    The physician decides to change JS’s prescription to prednisone given on alternate days

•    What is the rationale for this change?


•    What are some methods to help JS remember to take his pills?


•    What is the difference between the glucocorticoid and mineralcorticoid effects of prednisone?

Medication compliance

•    Checklists

•    Pill boxes

•    Plan to take pills in relation to other activities



•    How would your assessment differ if JS were taking a glucocorticoid that also has significant mineralocorticoid activity?


•    S/S of fluid excess

–   Neck vein distention

–   Decreased UOP

–   Peripheral edema

–   Increased respiratory difficulty, crackles

–   Weight gain

•    S/S of potassium deficit



•    You advise JS to take his prednisone with food and then ask a series of questions related to his vision.

•    What is the rationale for these nursing actions?

Other side effects

•    Predisposition for peptic ulcer disease

•    Impaired tissue healing

•    Hypocalcemia

•    Susceptibility for infection


•    What are some other side effects of steroid therapy?


•    You review JS’s list of medications.  Based on what you know about the side effects of loop diuretics and steroids, what is the potential problem administering these in combination with digoxin?


•    Realizing JS is susceptible to all types of infections, what major points do you need to include in your instructions to him ?

Preventing Infection

•    Avoid individuals with infection

•    Wash hands frequently

•    Maintain a nutritious diet

•    Meticulous care of any open wound, report any s/s infection

Collaborative Care

•    Transsphenoidal hypophysectomy for pituitary adenoma

•    Adrenalectomy for adrenal tumors or hyperplasia

•    Treatment of ectopic ACTH-secreting neoplasm

•    Drug therapy

Nursing Management

•    Health promotion

–   Identification of patients at risk

–   Careful patient teaching related to exogenous cortisol use

–   Monitoring of side effects

Nursing Management: Acute

•      Vital signs Q 4 hours

•      Daily weight

•      Signs and symptoms of infection

•      Location, time and duration of abdominal pain

•      Signs and symptoms of abnormal thromboembolic phenomena (chest pain, dyspnea, tachypnea

•      Capillary blood glucose monitoring

•      Bone pain or limited ROM

•      Mental status changes-depression


Preoperative Care

•    Optimum physical conditioning

•    Teaching

–   SCD’s

–   IV’s

–   NGT and suction

–   Exercise, cough, deep breathing


Post-operative Nursing Care

•     Hormone fluctuations

–   Blood pressure

–   Hypertension from release of hormone
–   Increased chance of hemorrhage

–   Fluid and electrolyte balance

•     High doses of corticosteroids-IV

–   Ensure adequate response to stress

–   Withdrawn according to patient’s clinical status and fluid/electrolyte balance

–   Switch to p.o. route as tolerated

–   Maintain line in case of collapse


Post-op cont.

•     Monitor for adrenal insufficiency

–   Vomiting

–   Increased weakness

–   Dehydration

–   Hypotension

–   Painful joints

–   Pruritis or peeling skin

•     Maintain on bed rest until BP stable

•     Meticulous care with dressing change or invasive procedures

Home Care

•    Depends on lack of endogenous corticosteroids

–   Medic alert bracelets

–   Avoid temperature extremes, infections and emotional disturbances

–   Lifetime replacement

–   Adjusted corticosteroid replacement

Adrenal Insufficiency

•     Primary-Addison’s disease

–   All three classes of corticosteroids are deficient

–   Autoimmune

–   TB, fungal infections, AIDS, cancer

–   Iatrogenic due to adrenal hemorrhage from anticoagulants, antineoplastics, ketoconozole or adrenalectomy

•     Secondary-lack of pituitary ACTH

–   Mineralocorticoids rarely deficient

–   Pituitary/hypothalamic suppression or disease

–   Exogenous glucocorticoids


Clinical manifestations

•    Progressive weakness,fatigue,weight loss and anorexia

•    Skin hyperpigmentation

•    Hypotension/circulatory collapse: refractory to fluids and vasopressors

•    Hyponatremia

•    Hyperkalemia

•    Nausea, vomiting, and diarrhea

Diagnostic Studies

•     Cortisol levels are subnormal or fail to rise over basal levels with ACTH stimulation test

•     Hyperkalemia

•     Hypochloremia

•     Hyponatremia

•     Hypoglycemia

•     Anemia

•     Elevated BUN

•     Low urine free cortisol

Collaborative Care

•     Management of underlying cause

•     Hormone replacement with glucocorticoids and Mineralocorticoids

–   Hydrocortisone has both

•     Addisonian crisis

–   Shock management

•   Hydrocortisone 100 mg Q 6 hours

•   Sodium

•   Fluids

•   dextrose


Addisonian Crisis

•     Life threatening emergency

•     Occurs during stress

•     Following sudden withdrawal of corticosteroid hormone replacement therapy

•     Following adrenal surgery

•     Pituitary gland destruction

•     Severe manifestations of glucocorticoid and mineralocorticoid deficiency

Nursing Management: Acute

•    Vital signs Q 30 min-Q4hours

•    Fluid volume/electrolyte imbalance

•    Daily weight

•    Diligent corticosteroid administration

•    Prevent infection-reverse isolation

•    Protect from stress

•    Teaching: need for follow-up


•     Names and dosages of drugs

•     Actions of drugs

•     Symptoms of overdosage/underdosage

•     Conditions requiring increased medication

–   Increase in dose

–   Administration of IM corticosteroid

•     Prevention of infection

•     Lifelong replacement therapy

•     Lifelong medical supervision

•     Medical identification device

Home Care

•    Glucocorticoids

–   2/3 daily dose in a.m.

–   1/3 daily dose in p.m.

–   Should not be taken late in the evening due to CNS stimulation-insomnia

•    Mineralocorticoids

–   Once daily

–   Evening dose

Medication adjustment

–    Recognize need for extra medication

•    Fever

•    Influenza

•    Extraction of teeth

•    Rigorous physical activity

–    Triple dose with major stress

–    Double dose with minor stress

–    Fluid and electrolyte replacement with vomiting or diarrhea

–    Drug interactions:dilantin, rifampin, barbiturates, antacids

–    Blood pressure monitoring

–    IM injections

Case Study

•     EH is a 60 year old woman who has rheumatoid arthritis.  For the past 12 years she has been taking prednisone 60 mg daily (40 am and 20 pm) and NSAIDS to control her disease and symptoms.  As a result of her autoimmune disorder and/or long-term steroid use, EH has adrenal insufficiency.  The physician adjusts her steroid dosage for replacement therapy. You are asked to conduct education for EH to teach about her condition and the treatment she needs.


•    EH states she doesn’t understand how her taking steroids has caused her body to lose it’s ability to produce “the real thing”.

•    How do you explain this paradox?


•    What are the S/S of inadequate steroid replacement?


•    What would you teach someone like EH about nutritional implications of adrenal insufficiency?


•    Why is the am dose of prednisone higher?


•    How would teaching differ for this patient on replacement therapy as compared with teaching for the patient taking therapeutic doses of glucocorticoids?


•    EH states she is under a lot of stress because of her son’s recent diagnosis of cancer and her husband’s upcoming retirement.

•    What are the teaching implications of this information?


•    Since EH is taking lifelong steroids, would you expect to see the signs/symptoms associated with Cushing’s syndrome in this individual?


•    You instruct EH on administration of a parenteral form of hydrocortisone.

•    Under what conditions should she take the parenteral form of the drug?


•    What measures should EH take to prevent an acute episode of adrenal insufficiency?

Corticosteroid Therapy

•    Anti-inflammatory action

•    Immunosuppression

•    Maintenance of normal blood pressure

•    Carbohydrate and protein metabolic effects

Side Effects

•      Susceptibility to infection

•      Increased blood pressure

•      Glucose intolerance

•      Protein depletion decreases bone formation, density and strength

•      Hypocalcemia related to anti-vitamin D effect

•      Decreased mucus production

•      Delayed healing: wound dehiscence and evisceration

•      Hypokalemia

•      Skeletal muscle atrophy

•      Suppression of ACTH synthesis

•      Mood and behavior changes

•      Redistribution of fat from extremities to trunk and face

Patient teaching

•      Diet high in protein, calcium and K+ but low in fat, and simple concentrated carbohydrates

•      Adequate rest and sleep

•      Exercise program

•      Sodium restriction if edema noted

•      Monitor glucose levels; signs of hyperglycemia

•      Postprandial heartburn not relieved by antacids

•      Avoid accidental injury

•      Good hygiene practices



Primary Hyperaldosteronism

•    Adenoma of the adrenal zona glomerulosa or bilateral adrenal hyperplasia

•    Affects women between 20-40 years of age

•    Hypertension

•    Hypokalemia alkalosis

Clinical Manifestations

•     Sodium retention

–   Hypernatremia

–   Hypertension

–   Headache

•     Increased loss of potassium

–   Generalized muscle weakness

–   Cardiac arrhythmias

–   Glucose intolerance

–   Metabolic alkalosis

–   Tetany

Diagnostic Studies

•    Increased plasma aldosterone levels

•    Elevated serum sodium levels

•    Decreased serum potassium levels

•    CT localization of tumors



•    Unilateral adrenalectomy

•    Potassium sparing diuretics

•    Low sodium diet

•    Antihypertensives

•    Monitoring for hypokalemia and tetany

Secondary Hyperaldosteronism

•    Extra adrenal stimulus – usually angiotensin, renal artery stenosis or juxtaglomerular cell tumors

•    Treatment – ACE inhibitors


    Tumor of the adrenal medulla producing excessive catecholamines

    95% are encapsulated and benign. May occur in either gender at any age but most commonly is found in 30-50 year old

Clinical Manifestations

•    Severe episodic hypertension

–   Severe pounding headaches

–   Tachycardia

–   Profuse sweating

•    May be provoked by medications

•    Duration of attacks vary from a few minutes to several hours


•    Urinary metanephrines

•    Elevated plasma catecholamines


•    Tumor removal

•    Pre-op

–   Sympathetic blocking agents

•   Orthostatic hypotension

–   Calcium channel blockers