Nursing care
Adrenalectomy Care: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated September 2026
Short answer
Adrenalectomy removes one or both adrenal glands, most often for a hormone-secreting tumour or adrenal cancer. Steroid replacement starts before surgery, not after, and may continue for life if both glands are removed. Any drop in blood pressure in the recovery period must be treated as adrenal insufficiency until proven otherwise.
When it is done and why
Adrenalectomy is indicated for pheochromocytoma, aldosterone-secreting adenomas causing Conn's syndrome, cortisol-secreting tumours causing Cushing's syndrome, and adrenal carcinoma. A unilateral procedure removes one gland and leaves the other to take over; a bilateral procedure removes both and leaves the patient with no endogenous cortisol production at all.
Most cases now go laparoscopic, which shortens recovery compared with open adrenalectomy, but pheochromocytoma and larger malignant tumours may still require an open approach for safer control of catecholamine release during dissection. The surgical approach chosen shapes the entire nursing plan, from the type of monitoring needed intraoperatively to expected length of stay.
Preparing the patient
Steroid replacement begins before the patient ever reaches the operating table, not after. Hydrocortisone is typically started the evening before or the morning of surgery to cover the physiological stress response, because the remaining or removed gland cannot yet compensate on its own. Skipping this step is a preventable cause of intraoperative and post-operative crisis.
For pheochromocytoma specifically, alpha-blockade with an agent such as phenoxybenzamine is started days to weeks in advance to prevent a catecholamine surge during tumour manipulation, with beta-blockade added afterward if needed to control reflex tachycardia. Confirm this sequence — alpha before beta — since reversing it can precipitate an unopposed hypertensive crisis.
The steps that matter for safety
Baseline vital signs, an accurate weight, and a full review of the steroid and alpha-blockade regimen must be documented before transfer to theatre. For pheochromocytoma patients, blood pressure trends over the preceding days matter more than a single reading — the surgical team needs evidence the alpha-blockade has been effective.
Confirm IV access appropriate for rapid fluid and vasopressor administration, since catecholamine surges during tumour handling can cause dramatic swings in blood pressure within seconds. Arterial line placement is common for these cases and should be anticipated in the nursing plan, not treated as an afterthought once the patient is already in theatre.
During the procedure — the nurse's role
Intraoperative nursing focuses on continuous hemodynamic monitoring, since manipulation of a pheochromocytoma can trigger sudden catecholamine release and a hypertensive spike, followed by a steep drop once the tumour's venous drainage is ligated. The surgical and anaesthesia teams need immediate access to short-acting vasodilators and vasopressors to manage both extremes.
Circulating and scrub nurses also track steroid administration timing intraoperatively for cases where additional stress-dose hydrocortisone is given, and maintain accurate blood loss and fluid balance records, since large fluid shifts are common with adrenal tumour resection.
After: monitoring and complications
Any drop in blood pressure after adrenalectomy must be treated as adrenal insufficiency until proven otherwise, particularly after bilateral resection or when the contralateral gland has been suppressed by long-standing cortisol excess. This is not a diagnosis of exclusion to work through slowly — it needs immediate stress-dose hydrocortisone while other causes are ruled out in parallel.
Watch for signs of an Addisonian crisis: hypotension unresponsive to fluids, hyponatremia, hyperkalemia, nausea and profound weakness. After removal of a pheochromocytoma, also monitor closely for rebound hypoglycemia, since catecholamines had been suppressing insulin release and that effect disappears once the tumour is gone.
Documentation and teaching
Document steroid doses given, timing, and the patient's response at every step, since this record guides the tapering schedule after discharge. Teach the patient that steroid replacement after bilateral adrenalectomy is lifelong, not a short course, and that missing doses — especially during illness — can precipitate a crisis within hours.
Give the patient a steroid emergency card or medical alert bracelet and teach the sick-day rule: double or triple the usual hydrocortisone dose during fever, vomiting, or significant illness, and seek emergency care immediately if oral doses cannot be kept down. Confirm before discharge that the patient and a family member both understand how to give an emergency injectable hydrocortisone dose if one has been prescribed.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our endocrine practice questions are the closest set to what this page covers.
Common questions
Why is steroid replacement started before surgery instead of after?
The adrenal glands normally increase cortisol output in response to surgical stress, and a patient undergoing adrenalectomy cannot mount that response reliably. Starting hydrocortisone before the incision covers this gap and prevents an intraoperative adrenal crisis.
Is steroid replacement always lifelong after adrenalectomy?
Only after bilateral adrenalectomy, or when the remaining gland has been suppressed and needs time to recover its own function, is replacement lifelong. After a straightforward unilateral removal for a non-functioning issue, the remaining gland often compensates and steroids can eventually be weaned under endocrinology guidance.
What does post-op hypotension after adrenalectomy usually mean?
Treat it as adrenal insufficiency until proven otherwise, especially in the first 24 to 48 hours. Give stress-dose hydrocortisone promptly and investigate other causes such as bleeding in parallel, rather than waiting for confirmation before treating.
Why is alpha-blockade started before beta-blockade in pheochromocytoma patients?
Beta-blockade given first removes the compensatory vasodilation that unopposed alpha-adrenergic stimulation would otherwise cause, which can trigger a severe hypertensive crisis. Alpha-blockade must be established and effective first, with beta-blockade added afterward only if reflex tachycardia needs control.