1. Adrenalectomy: surgical removal of adrenal glands because of tumors or uncontrolled overactivity; also bilateral adrenalectomy may be performed to control metastatic breast or prostate cancer.
    1. Risk factors:
      1. Pheochromocytoma.
      2. Adrenal hyperplasia.
      3. Cushing’s syndrome.
      4. Metastasis of prostate or breast cancer.
      5. Adrenal cortex or medulla tumors.
    2. Assessment:
      1. Objective data: validated evidence of:
        1. Benign lesion (unilateral adrenalectomy) or malignant tumor (bilateral adrenalectomy).
        2. Adrenal hyperfunction that cannot be managed medically.
        3. Bilateral excision for metastasis of breast and sometimes metastasis of prostate cancer.
    3. Analysis/nursing diagnosis:
      1. Knowledge deficit related to planned surgery.
      2. Risk for physical injury related to hormone imbalance.
      3. Risk for decreased cardiac output related to possible hypotensive state resulting from surgery.
      4. Risk for infection related to decreased normal resistance.
      5. Altered health maintenance related to need for self-administration of steroid medications, orally or by injection.
    4. Nursing care plan/implementation:
      1. Goal: preoperative: reduce risk of postoperative complications.
        1. Prescribed steroid therapy, given 1 wk before surgery, is gradually decreased; will be given again postoperatively.
        2. Antihypertensive drugs are discontinued because surgery may result in severe hypotension.
        3. Sedation as ordered.
        4. General preoperative measures.
      2. Goal: postoperative: promote hormonal balance.
        1. Administer hydrocortisone parenteral therapy as ordered; rate indicated by fluid and electrolyte balance, blood sugar, and blood pressure.
        2. Monitor for signs of Addisonian (adrenal) Crisis.
      3. Goal: prevent postoperative complications.
        1. Monitor vital signs until stability is regained; if on vasopressor drugs such as metaraminol (Aramine):
          1. Maintain flow rate as ordered.
          2. Monitor BP q5-15 min, notify physician of significant elevations in BP (dose needs to be decreased) or drop in BP (dose needs to be increased). Note: readings that are normotensive for some may be hypotensive for patients who have been hypertensive.
        2. NPO - attach nasogastric tube to intermittent suction; abdominal distention is common side effect of this surgery.
        3. Respiratory care:
          1. Turn, cough, and deep breathe.
          2. Splint flank incision when coughing.
          3. Administer narcotics to reduce pain and allow patient to cough; flank incision is close to diaphragm, making coughing very painful.
          4. Auscultate breath sounds q2h; decreased or absent sounds could indicate pneumothorax.
          5. Sudden chest pain and dyspnea should be reported immediately (spontaneous pneumothorax).
        4. Position: flat or semi-Fowler’s.
        5. Mouth care
        6. Monitor dressings for bleeding; reinforce prn.
        7. Ambulation, as ordered.
          1. Check BP ql5min when ambulation is first attempte
          2. Place elastic stockings on lower extremities to enhance stability of vascular system.
        8. Diet - once NG tube removed, diet as tolerated.
      4. Goal: health teaching.
        1. Signs and symptoms of adrenal crisis:
          1. Pulse: rapid, weak, or thready.
          2. Temperature: elevated.
          3. Severe weakness and hypotension.
          4. Headache.
          5. Convulsions, coma.
        2. Importance of maintaining steroid therapy schedule to ensure therapeutic serum level.
        3. Weigh daily.
        4. Monitor blood-glucose levels daily.
        5. Report undesirable side effects of steroid therapy or adrenal crisis to physician.
        6. Avoid persons with infections, due to decreased resistance.
        7. Daily schedule: include adequate rest, moderate exercise, good nutrition.
    5. Evaluation/outcome criteria:
      1. Adrenal crisis avoided.
        1. Vitals within normal limits.
        2. No neurological deficits noted.
      2. Healing progresses: no signs of infection or wound complications.
      3. Adjusts to alterations in physical status.
        1. Complies with medication regimen.
        2. Avoids infections.
        3. Incorporates good nutrition, periods of rest and activity into daily schedule.

  2. Addison’s disease: chronic primary adrenal corticotropic insufficiency. A hormonal (endocrine) disorder involving destruction of the adrenal glands, which then are unable to produce sufficient adrenal hormones (cortisol) necessary for the normal body functions.
    1. Pathophysiology:
      1. Atrophy of adrenal gland is most common cause of adrenal insufficiency; manifested by decreased adrenal cortical secretions.
        1. Deficiency in mineralocorticoid secretion (aldosterone) - increased sodium excretion —> dehydration —> hypotension —> decreased cardiac output and resulting decrease in heart size.
        2. Deficiency in glucocorticoid secretion (cortisol) —> decrease in gluconeogenesis —> hypoglycemia and liver glycogen deficiency, emotional disturbances, diminished resistance to stress. Cortisol deficiency —> failure to inhibit anterior pituitary secretion of ACTH and melanocyte-stimulating hormone —> increased levels of ACTH and hyperpigmentation.
        3. Deficiency in androgen hormone —> less axillary and pubic hair in women (testes supply adequate sex hormone in men, so no symptoms are produced).
    2. Risk factors:
      1. Autoimmune processes.
      2. Infection.
      3. Malignancy.
      4. Vascular obstruction.
      5. Bleeding.
      6. Environmental hazards.
      7. Congenital defects.
      8. Bilateral adrenalectomy.
      9. Tuberculosis.
    3. Assessment:
      1. Subjective data:
        1. Muscle weakness, fatigue, lethargy.
        2. Dizziness, fainting.
        3. Nausea, food idiosyncrasies, anorexia.
        4. Abdominal pain/cramps.
      2. Objective data:
        1. Vital signs: decreased BP, orthostatic hypotension, widened pulse pressure.
        2. Pulse - increased, collapsing, irregular.
        3. Temperature - subnormal.
        4. Vomiting, diarrhea, and weight loss.
        5. Tremors.
        6. Skin: poor turgor, excessive pigmentation (bronze tone).
        7. Lab data:
          1. Blood:
            1. Decreased: sodium (<135 mEq/L); glucose (<60 mg/dL), chloride (<98 mEq/L), bicarbonate (<23 mEq/L).
            2. Increased: hematocrit, potassium (>5 mEq/L).
          2. Urine: decreased (or absent) 17-ketosteroids, 17-hydroxycorticosteroids (<5 mg/24 hr).
        8. Diagnostic tests:
          1. CT scan, MRI
          2. ACTH stimulation test (cortisol levels are measured before and after administration of synthetic ACTH).

    4. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to decreased sodium.
      2. Altered renal tissue perfusion related to hypotension.
      3. Decreased cardiac output related to aldosterone deficiency.
      4. Risk for infection related to cortisol deficiency.
      5. Activity intolerance related to muscle weakness and fatigu
      6. Altered nutrition, less than body requirements, related to nausea, anorexia, and vomiting.
    5. Nursing care pian/implementation:
      1. Goal: decrease stress.
        1. Environment: quiet, nondemanding schedule.
        2. Anticipate events for which extra resources will be necessary.
      2. Goal: promote adequate nutrition.
        1. Diet: acute phase - high sodium, low potassium; nonacute phase - increase carbohydrates and protein.

        2. Fluids: force, to balance fluid losses; monitor I&O, daily weights.
        3. Administer lifelong exogenous replacement therapy as ordered:
          1. Glucocorticoids - prednisone, hydrocortison
          2. Mineralocorticoids - fludrocortisone (Florinef).
      3. Goal: health teaching.

        1. Take medications with food or milk.
        2. May need antacid therapy to prevent GI disturbances.
        3. Side effects of steroid therapy.
        4. Avoid stress; may need adjustment in medication dosage when stress is increased.
        5. Signs and symptoms of addisonian (adrenal) crisis: very serious condition characterized by severe hypotension, shock, coma, and vasomotor collapse related to strenuous activity, infection, stress, omission of prescribed medications. If untreated, could quickly lead to death.
      4. Goal: prevent serious complications if Addisonian Crisis evident.
        1. Complete bed rest; avoid stimuli.

        2. High dose of hydrocortisone IV or cortisone IM.
        3. Treat shock - IV saline.
        4. I&O, vital signs ql5min to 1 hr or prn until crisis passes.

    6. Evaluation/outcome criteria:
      1. No complications occur.
      2. Medication regimen followed, is adequate for patient’s needs.
      3. Adequate nutrition and fluid balance obtained.