Bangsamoro Autonomous Region in Muslim Mindanao

Mindanao Institute of Healthcare Professionals Incorporated

College of Nursing
9700, Marawi City, Philippines
RESOURCE UNIT

Clinical Instructor: Sir Jamal Tango P. Alawiya, RN, LPT, MAN (c) Topic: PHEOCHROMOCYTOMA
GENERAL OBJECTIVE: After 20 minutes of discussion about the Pheochromocytoma, the class will able to understand and learn the pathophysiology, clinical
manifestations, Diagnostic tests, medical management, Nursing management of Pheochromocytoma.
SPECIFIC TEACHING TIME
RESPONSIBLE
OBJECTIVES TOPIC/CONTENT STRATEGI REFERENCE ALLOT- EVALUATION
PERSON
ES MENT
To be able to Assalamu Alaikom.
introduce what I am Nadjirah S. Macunte, and we are the group 2. Discussion MACUNTE, 1 min.
topic will be In our discussion you will be able to learn the NADJIRAH S.
discussed by the pathophysiology of pheochromocytoma, its signs and
group symptoms/clinical manifestation, how it is diagnosed
and its Medical and Nursing Interventions.

Q/A
PHEOCHROMOCYTOMA Brunner, L. S.,
- a tumor that is usually benign and originates from the Discussion Suddarth, D. S., & MACUNTE, 3-5 min. Q1: what is
chromaffin cells of the adrenal medulla. Smeltzer, S. C. O. NADJIRAH S. pheochromocytoma?
(2008). Brunner &
- a tumor found on adrenal medulla that secretes Suddarth’s textbook Q2: where does it
to be able to discuss excessive - amounts of catecholamines. of medical-surgical originates?
briefly the nursing (12th ed.).
pheochromocytoma. For us to understand this well, let’s take a look back at Philadephia: Q3: what does this
the anatomy and physiology of our adrenal gland. Lippincott Williams tumor secretes
& Wilkins. excessively?
(Shows picture in the ppt)

As you can see in this picture, we have two adrenal

gland that is sitting at the top of both kidneys.

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Tignan nating yung structure.
We have here the adrenal cortex (pointing at the outer
layer)
And this is our adrenal medulla (pointing at the center
layer)

So ano ang main function ni Adrenal Medulla?

Si adrenal medulla ang nasesecrete ng hormones na
epinephrine and norepinephrine (adrenaline and
noradrenaline) or mas known as “fight or flight”
hormones via chromaffin cells.

Si chromaffin cells is located in the adrenal medulla it Discussion

secretes catecholamines.

Ano ba ang silbi ni catecholamines?

Cathecolamines have a huge influence on how organs
and tissues work. They cause the body to do the
following:

Increase HR and BP
Increase glucose by stimulating the liver to release it
stores of glucose in the blood and blocks the role of
insulin)
Increases fat metabolism for energy
Increases basal metabolic rate
Increases thermogenesis
And how you respond to stress.

PHEO means dark

CHROMO means color
CYT means cell
OMA means Tumor
Therefore, and pheochromocytoma ay dark colored cell
tumor.

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 Ang peak incidence nito ay during 40-50 years old,
affecting both male and female equally.

maari itong tumobo as a single tumor o di kaya ay

bilateral.
Pag naman ito ay tumubo sa ibang glands, these kind of
tumor ang tawag naman dito is parangagliomas.
10% ng pheochromocytoma ay malignant

to be able to discuss PATHOPHYSIOLOGY OF

the pathophysiology PHEOCHROMOCYTOMA Brunner, L. S., MACUNTE,
of Suddarth, D. S., & NADJIRAH S 5-10mins.
pheochromocytoma. Please refer kayo sa factsheets na binigay naming. Smeltzer, S. C. O. Q/A
May makikitra kayong color pink na box meaning yan (2008). Brunner &
yung pathophysiology, tapos color puple na box yan Suddarth’s textbook Q1: what are the
naman yung signs & symptoms tsaka lab findings, yung of medical-surgical predisposing factors of
green naman is yung mechanism and yellow is the nursing (12th ed.). Pheochromocytoma?
possible complications. Philadephia:
Lippincott Williams Q2: What is the
Predisposing factors: & Wilkins. 1275- Precipitating factor of
• Aged 40-50 years 1276 p. Pheochromocytoma
Usually, ang nagkakaroon ng pheochromocytoma is
may edad na 40-50 years old
• Familial Disorder (Multiple Endocrine Neoplasm 2 https://calgaryguide
syndrome type A and B, Neurofibromatosis, Von .ucalgary.ca/pheoch
Hippel Lindau syndrome, familial romocytoma-
Pheochromocytoma) pathogenesis-and-
clinical-finding-2/
Ang Multiple Endocrine Neoplasm ay isang rare,
genetic disorder na nakakaapekto sa adrenal glands at
nag caucause ng tumors sa thyroid gland, parathyroid https://www.cancer.
glands, at adrenal glands. gov/publications/di
ctionaries/cancer-
Ang Neurofibromatosis ay isa ring genetic disorders na terms/def/multiple-
nagsasanhi ng pagtubo ng tumor sa nerve tissue. endocrine-

3
Ang Von Hippel Lindau syndrome is a hereditary neoplasia-type-2-
condition associated with tumors arising in multiple syndrome
organs.
So, as you can see lahat naman nito ang common https://www.mayoc
sakanila is hereditary. linic.org/diseases-
conditions/neurofib
romatosis/symptom
Precipitating factor: s-cause/syc-
• Sporadic Mutation (DNA 20350490
damage arising from
exposure to mutagens) https://www.registe
the Sporadic mutation is sporadic genetic disease not rednursern.com/phe
inherited from parents, but arises via a mutation. ochromocytoma-
• 0.1 % hypertension nclex-review-notes/

These factors result to Dysfunction of various tumor

suppressor and/or oncogene proteins.

And then nagkakaroon ng uncontrolled proliferation of

the chromaffin cells in the medulla of the adrenal
gland(s).

Tapos nagkakaroon ng Adenoma Formation which is

makikita sya thru CT scan na may visible na mass doon
sa adrenal gland natin usually bigger than 3cm

Nagkakaroon tayo ng over production ng epinephrine Discussion

and norepinephrine galling doon s ana form na
Adenoma
Sa laboratory natin visible na sa urinalysis and plasma-
membrane natin ang increased secretion ng nasabing
hormones.

After that nagkakaroon ng Episodic hyper-activity of

the sympathetic nervous system.
Pwdeng magkaroon tayo ng complication like Heart
attack, Stroke or worst death.
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Then, increased secretion from the eccrine sweat glands
that leads to diaphoresis

Increased vasoconstriction of peripheral blood vessels

that leads to Pallor and sustained or paroxysmal
hypertension (increased Blood
Pressure) Discussion

Hyper-stimulation of adrenergic receptors of the cardiac

myocytes that leads to tachycardia (increased Heart
Rate), Palpitations and sustained or paroxysmal
hypertension (increased Blood Pressure)

Increase blood pressure results in the activation of

neural pain receptors that leads to headache

Hyper-stimulation of G protein-coupled receptors

involved in metabolic processes then, increased ability
to mobilize glucose into the bloodstream through
enhanced lipolysis, glycogenolysis and gluconeogenesis
that leads to hyperglycemia and Weight loss and
fatigue.

CLINICAL MANIFESTATIONS
We have this mnemonic “FIGHT & FLIGHT” MACUNTE, Q/A
NADJIRAH S. 3-5 mins.
Facial flushing (from hypotension), fluttering in chest Q1: Can anyone give
(palpitations) Clinical Manifestation of
Increased BP and HR Pheochromocytoma?
Glucose high
Headache (sudden and severe) Q2: What is mnemonics
Tremors for the clinical
manifestation of
Frequent sweating (from hypotension) Pheochromocytoma?
Loss of Weight
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 Increased anxiety and fear
Growing tumor can cause back or abdominal pressure
or pain
Heat intolerance
Tired and weak (from constant stimulation)

Diagnostic test:
Brunner, L. S.,
24-HR Urine Sample: Suddarth, D. S., &
It's used to detect and manage a wide range of Smeltzer, S. C. O. MACAPADO,
disorders, such as urinary tract infections, kidney (2008). Brunner & HANIN A. 5-10mins Q/A
disease, diabetes and so on. A urinalysis involves Suddarth’s textbook
checking the appearance, concentration, and content of of medical-surgical Q1: Enumerate the test
urine nursing (12th ed.). to be done with a patient
Philadephia: who has
Plasma levels of Catecholamines: Lippincott Williams pheochromocytoma.
This test measures the levels of catecholamines in the & Wilkins.
blood. Catecholamines are hormones made by the
adrenal glands. The three catecholamines are
epinephrine (adrenalin), norepinephrine, and dopamine.

This test is used to diagnose or rule out certain rare

tumors, such as pheochromocytoma or neuroblastoma.
to be able to discuss It may also be done in patients with those conditions to
the Clinical determine if treatment is working.
manifestations GLUCOSE TEST:
pheochromocytoma. Brunner, L. S.,
test measures the glucose levels in your blood. Glucose Suddarth, D. S., &
is a type of sugar. It is your body's main source of Smeltzer, S. C. O.
energy. A hormone called insulin helps move glucose (2008). Brunner &
from your bloodstream into your cells. Too much or too Suddarth’s textbook
little glucose in the blood can be a sign of a serious of medical-surgical
medical condition nursing (12th ed.).
Philadephia:
Lippincott Williams
& Wilkins.
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 Adrenal Biopsy:

needle biopsy of the adrenal gland is a procedure to https://www.ucsfhe

take a tiny sample of your adrenal gland tissue. The alth.org/medical-
procedure is also called a core biopsy. The tissue tests/catecholamine
sample will be checked under a microscope for cancer -
To be able to or other problems. It may take a few days to get the bloodtest#:~:text=N
discuss the different results. ormal%20Results,(
diagnostic test to a 195.8%20pmol%2F
patient with a MRI OF ABDOMEN: L)
PHEOCHROMOC
YTOMA MRI provides detailed pictures of the belly area from
many views. It is often used to clarify findings from
earlier ultrasound or CT scan exams. This test may be
used to look at: Blood flow in the abdomen. https://www.medlin
eplus.gov/lab-
CT SCAN: ABDOMINAL tests/blood-glucose-
test
A CT (computed tomography) scan, also called a CAT Discussion
scan, is a type of specialized X-ray. The scan can show https://www.healthl
cross-sectional images of a specific area of the body. ine.com/health/abd
With a CT scan, the machine circles the body and sends ominal-ct-scan
the images to a computer, where they’re viewed by a
technician. An abdominal CT scan helps your doctor https://www.cancer.
see the organs, blood vessels, and bones in your gov/publications/di
abdominal cavity. The multiple images provided give ctionaries/cancerter
your doctor many different views of your body. ms/def/ultrasonogra
phy
ULTRASONOGRAPHY: procedure that uses high-
energy sound waves to look at tissues and organs inside
the body. The sound waves make echoes that form
pictures of the tissues and organs on a computer screen
(sonogram). Ultrasonography may be used to help
diagnose diseases, such as cancer. It may also be used
during pregnancy to check the fetus (unborn baby) and

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during medical procedures, such as biopsies. Also
called ultrasound.

CLONIDINE SUPPRESSION TEST: test has been

used to diagnose pheochromocytoma and those
paragangliomas that may secrete epinephrine,
norepinephrine, or both. Such tumors may cause
paroxysmal or persistent hypertension.

Expected Lab test of patient with

Pheochromocytoma:

24-HR Urine Sample:

• Normal range urinary catecholamines (upto

14mg/100ml urine
• Normal amount VMA (vanillylmandelic) is less
than 7mg in 24 hrs.

Plasma level Catecholamine:

• Epinephrine: 0.02-0.2mg/dl
• Norepinephrine: 0.1-0.5 mg/dl

Glucose test:
Discussion
• Normal range lower than 140mg/dl (7.8mmdl/L)
– higher than expected impaired glucose
tolerance

Clonidine suppression:

• It lowers the norepinephrine in normal persons

but not in patients with Pheochromocytoma

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 • 300mcg orally->failure of suppression to normal
range with in 120-180min

PHARMACOLOGIC THERAPY:

• Phentolamine (Regitine) - alpha-adrenergic blocking

agent
Q2: Enumerate the
• Nitroprusside (Nitropress) - smooth muscle relaxants different drugs to be
given
• Phenoxybenzamine (Dibenzyline) - long-acting alpha-
blocker

• Nifedipine (Procardia) - Calcium channel blockers

• Propranolol (Inderal) - Beta-adrenergic blocking agent

• Metyrosine (Demser) - catecholamine synthesis

inhibitor

SURGICAL MANAGEMENT:
Brunner, L. S., H.ALI,
Adrenalectomy is to prevent sudden rise or fall in the Suddarth, D. S., & NAHARA 5-10mins.
blood pressure in order to prevent cardiac dysfunction Smeltzer, S. C. O.
and arrhythmia caused by the circulating (2008). Brunner &
catecholamines. Suddarth’s textbook Q/A
of medical-surgical
The adrenalectomy is surgery to remove one or both nursing (12th ed.). Q1. Wat are the nursing
adrenal glands. Your two adrenal glands produce Philadephia: intervention will you
various hormones that help regulate your metabolism, Lippincott Williams applied for a patient with
immune system, blood pressure, blood sugar and other & Wilkins. pheochromocytoma?
essential functions.

What happens after an adrenalectomy?

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 You will be sore for a week or two after surgery.

Good morning, I am Noryah D. Somirado and today I SOMIRADO,

To be able to will discuss in front of you about the nursing NORYAH D.
discuss the nursing intervention of patient with pheochromocytoma.
interventions of
pheochromocytoma Nursing diagnosis:
• Risk for altered systemic tissues perfusion related to
fluctuation in CV status.
• Anxiety related to increased circulating
catecholamines.
• Altered nutrition related to increased metabolic rate.
• Risk for altered health maintenance related to
insufficient knowledge of follow up care. Q2. What will you
instruct to a patient
during pre and post
WHAT NURSING INTERVENTIONS SHOULD I DO operation?
FOR A PATIENT WITH PHEOCHROMOCYTOMA?

• PRIORITY NURSING INTERVENTIONS

-AVOID OVER STIMULATION

• STABILIZE PATIENT
- Provide bedrest
- Provide a calm and cool environment
- Administer pharmacologic treatment as 5-10 mins.
prescribed/ordered Q/A
Brunner, L. S.,
• PATIENT TEACHING Suddarth, D. S., & Q1: What are the
- Treatment Smeltzer, S. C. O. possible surgical
- Eat high calorie diet (2008). Brunner & management for patient
- Self-care Suddarth’s textbook having
- avoid stimulant substances of medical-surgical Pheochromocytoma?
- Follow-up visits nursing (12th ed.).
Philadephia:
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 Lippincott Williams
• MONITOR FOR & Wilkins.
-ECG changes
- hypertensive crisis
-Fluid and electrolyte balance https://www.ncbi.nl
-Glucose levels m.niih.gov/boooks/
NBK70002/

At the end of Pre-op https://www.Nanda

discussion, the • Stimulant free diet -nursing-care-
learners will be able • Bedrest plan.blogsspot.com
to Identify what is • Administer Alpha adrenergic blocker as prescribed
possible surgical
management of
patient having Post op
pheochromocytoma • Monitor for hypovolemic shock caused by rapid
relaxation of
constricted blood vessels
• Monitor for transient hypertensive episodes

Monitor vital signs, especially blood pressure changes.

Administer antihypertensive medications as order.
To determine the Promote rest and decrease stressful stimuli. Provide
importance of high calories, well balanced diet. Q2: 2. What is nursing
knowing the Instruct the patient to avoid smoking and stimulants like diagnosis for patient
problem and signs coffee and tea it may influence catecholamine release. having
and symptoms. For client with an adrenalectomy, observe for BP Pheochromacytoma
changes- clients are risk for shock due to drastic drop in
catecholamine levels.

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