by Cathy Parkes August 17, 2020
In this article, we cover two disorders, pheochromocytoma and hyperaldosteronism. These are disorders that result from improper activity by the adrenal gland caused by tumors. Knowing the pathophysiology, symptoms, diagnosis and treatment for these two disorders will be key in your Med-Surg exams as well as your nursing practice.
These disorders are covered in our Medical-Surgical Flashcards (Endocrine system).
Pheochromocytoma is a rare tumor on the adrenal gland, which causes excess secretion of norepinephrine and epinephrine. If you remember from our overview of norepinephrine and epinephrine, these hormones are catecholamines from the adrenal medulla.
Another way to think about pheochromocytoma is to break down the word. Pheo- comes from the Greek phios, which means dark or dusky, -chromo- means color, -cyt- which means cell, and -oma, which means tumor. When cells from the adrenal medulla are treated with chromium salts (preserved), they turn a signature dark brown color. So, “pheochromocyt-” means “dark brown cells” but it’s really referring to cells of the adrenal medulla. Unfortunately, this root is a bit weird, but at least with -oma, you can remember that it’s a tumor.
To learn more root words that will help you translate medical words you might not recognize (for instance, in crunch time on an exam!) check out our Medical Terminology flashcards.
Signs and symptoms of pheochromocytoma include tachycardia (heartbeat above 100 BPM), hypertension, headache, diaphoresis (excessive sweating), and shortness of breath.
If you want to think critically to remember the synonyms for pheochromocytoma, remember that this disorder is caused by an excess secretion of norepinephrine and epinephrine (adrenaline), which are the fight or flight hormones released in response to acute stress. If you are acutely stressed, your heart is beating faster, blood pressure is going up, and you’re sweating.
There are multiple methods to diagnose pheochromocytoma: a 24-hour urine test, a clonidine suppression test, or a CT/MRI to locate an adrenal tumor.
To diagnose a patient with pheochromocytoma, we can perform a 24-hour urine test. A 24-hour urine test tests for vanillylmandelic acid and metanephrine, which are byproducts from the breakdown of epinephrine and norepinephrine.
Elevated levels of vanillylmandelic acid and metanephrine in the urine over a 24-hour period can indicate pheochromocytoma.
Another way to diagnose pheochromocytoma is with a clonidine suppression test. Clonidine is a medication for high blood pressure that acts on the central nervous system to decrease sympathetic outflow. With decreased sympathetic nervous system outflow, you should see decreased secretion of epinephrine and norepinephrine.
However, if this patient shows continued high levels of epinephrine and norepinephrine regardless of central nervous system function, this strongly indicates there is a problem with the adrenal medulla and the pheochromocytoma tumor may be present.
The patient with pheochromocytoma will need surgery to remove the tumor. This surgery is known as an adrenalectomy, which is a removal of one or both of the adrenal glands. This one is easy to remember since adrenal is obviously adrenal, and the suffix -ectomy means removal.
Ectomy is one of the suffixes you will encounter very often. Thyroidectomy, hypophysectomy, and adrenalectomy are all surgery options you will need to be familiar with for your Med-Surg exams. We created our Medical Terminology flashcards to help you know which suffixes, prefixes, roots and abbreviations are the most important ones for nursing school and healthcare practice in general.
Before a patient with pheochromocytoma undergoes adrenalectomy surgery, they will still have symptoms that include potentially dangerous hypertension, and will require specific antihypertensive medications. Some of the commonly prescribed antihypertensives before an adrenalectomy are the beta blockers metoprolol, atenolol and propranolol.
If you’re studying for a pharmacology exam, there are a lot of different antihypertensive medications to know. In our Pharmacology series, we cover the antihypertensives you will most need to know for ATI, NCLEX, HESI, or a Pharm exam. This video series corresponds with our Pharmacology flashcards, which makes memorizing these medications easy.
Here’s something important to remember about the nursing care for a patient with pheochromocytoma: do not palpate the abdomen. Although abdomen palpation is a step in physical assessment, it should not be done on this patient because it can cause a sudden release of catecholamines, which can trigger severe hypertension which is very dangerous for this patient.
Hyperaldosteronism is an excess amount of aldosterone secreted by the adrenal gland, caused by an adenoma or tissue overgrowth in that adrenal gland.
If you have been following along in our Endocrine series, you might have noticed that glandular tumors often result in excess secretion of the hormone that gland is supposed to secrete, which can lead to a disease or disorder.
Signs and symptoms of hyperaldosteronism include hypertension, headache, weakness, paresthesias (pins and needles), and tetany (muscle spasms or cramps).
In order to think critically about the symptoms of hyperaldosteronism, remember what aldosterone does. If you recall from our overview of aldosterone, aldosterone causes reabsorption of sodium and water and excretion of potassium. So if we have too much aldosterone, this causes too much sodium and water to be reabsorbed and too much potassium to be excreted. When excess water is reabsorbed, this increases the blood volume, which increases blood pressure.
The lab values that are often associated with hyperaldosteronism are high sodium and low potassium, and...drumroll please...increased aldosterone!
The expected range of sodium is 136 - 145 mEq/L, and sodium amounts greater than 145 mEq/L can indicate hypernatremia. Hypernatremia is seen in patients with hyperaldosteronism because their excess aldosterone causes that excess reabsorption of sodium and water.
The expected range of potassium is 3.5 - 5.0 mEq/L, and potassium amounts less than 3.5 can indicate hypokalemia. Hypokalemia is seen in patients with hyperaldosteronism because their excess aldosterone causes that excess excretion of potassium. Hypokalemia can be dangerous for the patient because it can put them at risk for life-threatening dysrhythmias. (Check out our EKG series to learn more about the different dysrhythmias!)
We created our Lab Values flashcards to help you remember the ranges of sodium, potassium, and 64 other lab values you need to know for most nursing exams.
There is no special test The main way that hyperaldosteronism is diagnosed is through a CT scan of the adrenal gland. This CT scan allows us to see if there is a tumor on the adrenal gland.
An adrenalectomy, which we described above for pheochromocytoma, may be what’s needed for hyperaldosteronism.
We can also give a patient with hyperaldosteronism a potassium-sparing diuretic, which will help them get rid of the excess fluid, but also help them keep their potassium, which is important since they are low. The potassium-sparing diuretic you’ll likely need to know for exams is spironolactone,which is covered in the Renal system section of our Pharmacology flashcards.
In rare cases, glucocorticoid therapy can be used for hyperaldosteronism. When this is the case, the disorder is known as glucocorticoid-remediable aldosteronism.
When you are caring for a patient with hyperaldosteronism, it’s important to monitor their blood pressure, their input & outputs, and their potassium levels (since potassium dropping too low can be very dangerous).
A patient with hyperaldosteronism should make sure their diet is low in sodium (since they have too much sodium already) and high in potassium (since they don’t have enough).
Cathy’s teaching on these disorders is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.
In this video, we are going to talk about pheochromocytoma and hyperaldosteronism.
Let's first talk about pheochromocytoma, which is where we have a tumor on the adrenal gland, which causes excess secretion of norepinephrine and epinephrine, which are catecholamines from the adrenal medulla, which is like the inside part of the adrenal gland. So with this excess secretion of epinephrine and norepinephrine, that activates the body's sympathetic response, and basically, throws the body into fight or flight mode.
So signs and symptoms of this condition include tachycardia, hypertension, headache, diaphoresis, and shortness of breath.
In terms of diagnosis, we can do a 24-hour urine test where we test for byproducts from the breakdown of epinephrine and norepinephrine. So some of these byproducts include vanillylmandelic acid as well as metanephrine. So if we find that we have elevated levels of these substances over a 24-hour period in the urine then that would be indicative of pheochromocytoma.
The other test we can do is a clonidine suppression test. So clonidine is a medication we give for high blood pressure. It acts on the central nervous system and should decrease the sympathetic outflow and with decreased sympathetic nervous system outflow, we should have decreased secretion of epinephrine and norepinephrine. However, if we have continued high levels of epinephrine and norepinephrine being released from the adrenal gland regardless of central nervous system function, then that is also strongly indicative that we may have a tumor and pheochromocytoma present.
And then lastly, we can, of course, do a CT/MRI of the adrenal gland to help identify that tumor.
So in terms of treatment, the patient's going to need surgery.
We need to remove that tumor and they may need an adrenalectomy. And then prior to surgery, we definitely want to be giving the patient antihypertensive medications because of that extreme hypertension that's related to this disorder.
One important thing for you to remember as a nurse is you never want to palpate the abdomen of a patient who is suspected of having pheochromocytoma because that can trigger the sudden release of catecholamines, which, in turn, can trigger severe hypertension in the patient, which can be very dangerous.
Now let's talk about hyperaldosteronism. This is where we have an adenoma or hyperplasia in the adrenal gland such that excess amounts of aldosterone are being secreted. And if you recall, aldosterone is a hormone that causes reabsorption of sodium and water and excretion of potassium. So if we have too much aldosterone, that's going to cause excess reabsorption of sodium and water and excess excretion of potassium.
So in terms of signs and symptoms, hypertension is going to be a key symptom, and it makes sense, right? If we are reabsorbing all this water, that's going to bring our blood volume up, which is going to increase blood pressure. Other signs and symptoms include headache and weakness.
In terms of the labs we'll see with this condition, because we're reabsorbing all of this sodium and water, we're going to have hypernatremia. And because we're getting rid of all this potassium, we're going to have hypokalemia, which can be dangerous to the patient. Anytime we have abnormally high or low levels of potassium, that places the patient at risk for life-threatening dysrhythmias. Aldosterone will be elevated in these patients, which makes sense because we're talking about hyperaldosteronism.
And then in terms of diagnosis, we can do a CT scan of the adrenal gland.
And then treatment may include an adrenalectomy.
Also, we can give the patient a potassium-sparing diuretic, which is spironolactone. So that will help get rid of that excess fluid, but retention of potassium, which is important for this patient.
And then in terms of nursing care, we're definitely going to want to monitor the patient's blood pressure, their I's and O's, and their potassium levels.
And then we want to encourage that patient to consume a low-sodium and high-potassium diet in order to help balance those electrolyte levels.
Okay. So that's it for this video. When I come back, we will start talking about thyroid disorders. Thanks so much for watching!
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by Cathy Parkes Oct 20, 2020 1 Comment
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