Addison’s disease occurs when the adrenal cortex function is inadequate to meet the patient’s need for cortical hormones.
- Most cases result from autoimmune or idiopathic atrophy of the adrenal glands.
- Surgical removal or infections of the adrenal glands
- Inadequate secretion of adrenocorticotropic hormone (ACTH)
- Adrenocortical insufficiency most commonly results from therapeutic use of corticosteroids. Symptoms may result from sudden cessation of exogenous adrenocortical hormonal therapy, which interferes with normal feedback mechanisms.
Assessment Findings
- Muscle weakness, fatigue, emaciation, dark pigmentation of the skin and mucous membranes, hypotension, low blood glucose, low serum sodium, and high serum potassium.
- Onset often begins with non-specific symptoms.
- Mental changes (depression, emotional liability, apathy, and confusion) are present in 60% to 80% of patients.
- Disturbance of sodium and potassium may be marked by depletion of sodium and water as well as severe, chronic dehydration.
Diagnostic Examination
- Greatly increased plasma ACTH (more than 22.0 pmol/L) as the pituitary attempts to increase adrenal cortex hormone levels.
- Serum cortisol levels are lower than normal (less than 165 nmol/L).
- Hypoglycemia, hyponatremia, and hyperkalemia from decreased aldosterone levels.
- Leukocytosis
Medical Management
Combat circulatory shock. Restore blood circulation, administer fluids and corticosteroids, monitor vital signs, and place the patient in a recumbent position with legs elevated.
- Administer IV hydrocortisone, followed by D5NSS.
- Vasopressor amines may be required if hypotension persists.
- Antibiotics may be administered if infections precipitate adrenal crisis.
- Oral intake should be initiated as soon as tolerable, and salt is supplemented to address GI losses, including through vomiting and diarrhea.
- If adrenal gland function is lost, lifeline replacement of corticosteroids and mineralocorticoids.
Nursing Management
Assessment
- Focus on assessment of ==fluid balance and stress==.
- Monitor blood pressure and pulse rate as the patient shifts between positions. Findings may be indicative of deficient fluid volume.
- Assess skin color and turgor.
- Assess history of weight change, muscle weakness, and fatigue.
- Ask the patient and family about the onset of illness or increased stress that may have precipitated the crisis.
- Watch out for an Addisonian Crisis:
- Monitor for S/S indicative of crisis, which can include shock, hypotension, rapid and weak pulse, rapid respiratory rate, pallor, and extreme weakness.
- Advise the client to avoid any physical and psychological stressors such as cold exposure, overexertion, infection, and emotional distress.
- Immediately treat with IV fluids, glucose, electrolytes (especially sodium), replacement hormones, and vasopressors.
Intervention
- Restoring Fluid Balance:
- Dietary adjustments (esp. supplementation with salt) for fluid and electrolyte balance. Collaborate with a dietitian.
- Instruct the patient and family for the prescription and administration of hormone replacement therapy, and to adjust its dosage during illness and stress.
- Provide written and verbal instructions about the administration of mineralocorticoids (Florinef) or corticosteroids (Prednisone) as prescribed.
- Improving Activity Tolerance:
- Avoid unnecessary activities and stress that might precipitate a hypotensive episode.
- Detect signs of infection or presence of stressors that might have triggered the crisis.
- Explain the rationale for minimizing stress during periods of acute crisis.
- Promote Home-based and Community-based Care:
- Explicitly verbal and written instructions about the rationale for replacement therapy and proper dosage.
- Teach the patient and family on how to modify drug dosage and increase in salt intake during period of illness, hot weather, and stressful situations.
- Educate clients on signs of excessive or insufficient hormone replacement.
- Provide pre-loaded single-injection syringes of corticosteroids for emergency use. Provide instructions for use.
- Instruct patient to modify diet and fluid intake to maintain fluid and electrolyte balance.
- Have the patient inform any other health care provider about the use of steroids.
- Urge the patient to wear a medical alert bracelet and information about their needs.