The adrenal glands control a lot of what goes on in our bodies, from responding to stress, to regulating our blood pressure and controlling our metabolism.
And when the adrenal glands start malfunctioning, they affect everything. That can happen either because of Cushing’s syndrome or Addison’s disease.
This is exactly what I discuss in this week’s episode of NCLEX Ready, so if you need a deep dive into these two disorders, this is the episode for you!
Are you ready to learn more?
Tune in now!
What Are the Adrenal Glands?
Before understanding the disorders of the adrenal glands, you must know the role of the adrenal glands.
The adrenal glands are located above each kidney and their role is to respond to stress and regulate blood pressure, immune system, and metabolism. The cortex and the medulla make up the adrenal glands and are responsible for different hormones.
The adrenal cortex is the outer shell of the adrenal gland. It’s responsible for glucocorticoids, which are cortisol, cortisone, and corticosterone. It’s also responsible for mineralocorticoids, which is aldosterone. This regulates the electrolyte balance by promoting sodium retention and potassium excretion.
The adrenal medulla is the inner core of the adrenal gland, and produces epinephrine and norepinephrine. The medulla works as part of the sympathetic nervous system.
Cushing’s Syndrome and Cushing’s Disease
Cushing’s Syndrome
With Cushing’s syndrome, the adrenal cortex produces too much cortisol. It can also result from a large amount of glucocorticoids administration over several weeks. ACTH-secreting tumors can also be the cause of Cushing’s syndrome.
Cushing’s Disease
In Cushing’s disease, the pituitary gland produces excess cortisol as a result of increased ACTH.
To differentiate between Cushing’s syndrome and Cushing’s disease, think of the adrenal cortex with Cushing’s SYNDROME, and of the pituitary gland with Cushing’s DISEASE.
The excess production of ACTH stimulates the adrenal glands to increase the production of cortisol. The overproduction of ACTH is a result of a pituitary adenoma, which is a benign tumor in the pituitary gland. Cushing’s disease is what leads to Cushing’s syndrome.
In most patients with Cushing’s, you will observe osteoporosis. This is due to increased steroids which can potentially reduce bone density. Calcium and vitamin D supplements are encouraged for those with osteoporosis.
Lab monitoring is required to note changes in lab values, such as serum sodium, potassium, and calcium. Keep in mind that due to salt retention, weight gain can occur, so daily weight monitoring is also encouraged.
Diagnosing Cushing’s Syndrome/Disease
To determine if the patient has Cushing’s syndrome or Cushing’s disease, an overnight dexamethasone suppression test is done.
Dexamethasone is given at bedtime. If the patient does not have Cushing’s disease, then the morning cortisol should be suppressed. Dexamethasone will suppress ACTH, which is the adrenocorticotropic hormone. However, if the patient does have Cushing’s disease, the suppression does not occur.
Addison’s Disease
What Is Addison’s Disease?
Due to hyposecretion of adrenal cortex hormones, lifelong glucocorticoid replacement as well as a potential lifelong mineralocorticoid replacement is required for a patient with Addison’s disease.
Stress can exacerbate Addison’s disease, so during stressful events, corticosteroid replacement may be increased.
Addisonian Crisis
Addisonian crisis is a life-threatening disorder. It’s the result of acute adrenal insufficiency, aka when there isn’t enough cortisol.
Addisonian crisis can be a complication of Addison’s disease. It can also be caused by sudden withdrawal of corticosteroid medication. This can lead to complications, such as hyponatremia, hyperkalemia, hypoglycemia, and hypovolemic shock.
Those experiencing Addisonian crisis may have severe headache, generalized weakness, irritability, confusion, severe hypotension, and shock. Reports of severe pain may be located in the abdomen, leg, and lower back. We expect to see hypotension with Addison’s disease, so if there is Addisonian crisis, then there will be severe hypotension.
Knowing these signs will help you understand the nursing interventions. If there is a possibility of severe hypotension, then expect to monitor the blood pressure. If irritability and confusion can occur, then expect to monitor neurological status of the patient. Monitor lab values, such as sodium, potassium, and glucose. We want to prevent low sodium, high potassium, and low glucose levels from occurring.
As for treatment, hypovolemic shock is treated with oxygen and IV fluids. High-dose IV hydrocortisone replacement, IV fluids, glucocorticoid, and mineralocorticoid may also be prescribed.
The Signs and Symptoms of Addison’s and Cushing’s
Addison’s disease and Cushing’s syndrome/disease are like yin and yang. Addison’s disease will cause hypotension, so Cushing’s syndrome or disease will cause hypertension. If you can remember one, you can expect the opposite for the other.
Addison’s disease will cause hypoglycemia and hyponatremia, which means Cushing’s will cause hyperglycemia and hypernatremia.
If hypokalemia and hypocalcemia are seen in Cushing’s syndrome or disease, then what is expected with Addison’s disease? If you’ve guessed hyperkalemia and hypercalcemia, you’re getting the hang of it!
With Addison’s disease, dehydration, hypotension, low sodium, and high potassium levels are due to the loss of mineralocorticoid aldosterone.
Weight loss is also seen with Addison’s disease and truncal obesity with thin extremities is noted with Cushing’s syndrome or disease. “Moon face” and “buffalo hump” are also classic signs of Cushing’s.
Let’s Answer Some NCLEX Questions!
Question #1: Nurse Rose is providing care for a patient with suspected Cushing’s syndrome. Which of the following signs and symptoms would the nurse expect to find? Select all that apply:
- Moon face
- Truncal obesity
- Hypotension
- Hyponatremia
Answer: Moon face and truncal obesity.
Rationale: Moon face and truncal obesity are normal classic findings in Cushing’s syndrome. Hypotension and hyponatremia are findings that are normally noted with Addison’s disease.
Question #2: Nurse Camille is providing care for a patient diagnosed with Addison’s disease who came to the Emergency Department with a fractured right arm. Which of the following findings should be reported to the healthcare provider?
- Blood pressure of 90/66 mm Hg
- Blood pressure of 160/88 mm Hg
- Serum potassium 2.5 mEq/L
- Serum sodium 150 mEq/L
Answer: Blood pressure of 90/66 mm Hg.
Rationale: Stress events can exacerbate Addison’s disease and a fractured right arm can be categorized as a stress event. Hypotension can occur with Addison’s disease and should be reported to the healthcare provider. Hypertension, hypernatremia, and hypokalemia usually occurs with Cushing’s syndrome or disease.
Question #3: Nursing student Rosebelle is learning about adrenal disorders. Which of the following statements demonstrates an understanding of secondary adrenal insufficiency?
- Secondary adrenal insufficiency is due to the result of hypersecretion of ACTH from the posterior pituitary gland.
- Secondary adrenal insufficiency is due to the result of hyposecretion of ACTH from the posterior pituitary gland.
- Secondary adrenal insufficiency is due to the result of hypersecretion of ACTH from the anterior pituitary gland.
- Secondary adrenal insufficiency is due to the result of hypersecretion of ACTH from the anterior pituitary gland.
Answer: Secondary adrenal insufficiency is due to the result of HYPOSECRETION of ACTH from the ANTERIOR pituitary gland.
Rationale: This one is tough because only a couple of words have been adjusted. You can eliminate 1 and 3 because hyposecretion of ACTH occurs with secondary adrenal insufficiency. You just need to jog your memory if this is due to the anterior or the posterior pituitary gland. In this case, you can associate secondary adrenal insufficiency with the ANTERIOR pituitary gland.
Question #4: Nurse Diane is providing care for a patient suspected with Cushing’s syndrome. Which of the following diagnostic testing is expected to be performed to confirm if the patient has Cushing’s syndrome or disease?
- T3 and T4 resin uptake test
- Radioactive iodine uptake
- Overnight dexamethasone suppression test
- Needle aspiration of the thyroid tissue
Answer: Overnight dexamethasone suppression test.
Rationale: To determine if the patient has Cushing’s syndrome or Cushing’s disease, an overnight dexamethasone suppression test is done. Dexamethasone is given at bedtime. If the patient does not have Cushing’s disease, then the morning cortisol should be suppressed. Dexamethasone will suppress ACTH, which is the adrenocorticotropic hormone. If the patient does have Cushing’s disease, the suppression does not occur.
T3 and T4 resin uptake test, needle aspiration of the thyroid tissue, and radioactive iodine uptake are diagnostic testings for the thyroid.
Question #5: Nurse Justine is providing care for a patient with Addison’s disease who reported that he stopped taking his corticosteroid medication. The nurse is monitoring the patient for Addisonian crisis. Which of the following electrolyte imbalance should the nurse expect to monitor?
- Hyperkalemia and hypernatremia
- Hyperkalemia and hyponatremia
- Hypokalemia and hyponatremia
- Hyperkalemia and hypocalcemia
Answer: Hyperkalemia and hyponatremia.
Rationale: Hyperkalemia and hyponatremia are potential complications that occur with Addisonian crisis, which can happen with sudden withdrawal of corticosteroid medication.
