Addison’s Disease (Primary Adrenocortical Insufficiency)

Wikipedia

Addison’s disease is caused by a deficiency of cortical hormone. It results when the adrenal cortex function is inadequate to meet the patient’s need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is responsible for 80% to 90% of cases. Other causes include surgical removal of both adrenal glands or infection (tuberculosis or histoplasmosis) of the adrenal glands. Inadequate secretion of adrenocorticotrophic¬† hormone (ACTH) from the primary pituitary gland results in adrenal insufficiency. Symptoms may also result from sudden cessation of exogenous adrenocortical hormone therapy, which interferes with normal feedback mechanisms.

Clinical Manifestations:

Clinical manifestations include muscle weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin and mucous membranes, hypotension, low blood glucose, low serum sodium and high serum potassium. The onset usually occurs with nonspecific symptoms. Mental changes (depression, emotional lability, apathy and confusion) are present in 60% to 80% of patients. In severe cases, disturbance of sodium and potassium metabolism may be marked by depletion of sodium and water and severe, chronic dehydration.

Addisonian Crisis

This medical emergency develops as the disease progresses. Signs and symptoms include:

  • Cyanosis, fever, and classic signs of circulatory shock: pallor, apprehension, rapid and weak pulse, rapid respirations, and low blood pressure
  • Headache, nausea, abdominal pain, diarrhea, confusion and restlessness
  • Slight overexertion, exposure to cold, and acute infections, decrease salt intake and may lead to circulatory collapse, shock and death
  • Stress of surgery or dehydration from preparation for diagnostic tests or surgery may precipitate addisonian or hypotensive crisis
  • Decreased blood glucose and sodium levels, increased serum potassium (hyperkalemia), and leukocytosis.

Assessment and Diagnostic Findings

Primary adrenocortical insufficiency:

  • greatly increased plasma ACTH (>22.0 pmol/L)
  • serum cortisol low normal or lower than normal (<165 nmol/L)
  • decreased blood glucose (hypoglycemia)
  • decreased sodium levels (hyponatremia)
  • increased serum potassium (hyperkalemia)
  • increased white cell count (leukocytosis)

Medical Management

Immediate treatment is directed toward combating shock.

  • Restore blood circulation, administer fluids, monitor vital signs, and place patient in a recumbent position with legs elevated
  • Administer intravenous hydrocortisone, followed by 5% dextrose in normal saline
  • Vasopressor amines may be required if hypotension persists
  • Antibiotics may be prescribed for infection
  • Oral intake may be initiated as soon as tolerated
  • If adrenal gland does not regain function, lifelong replacement of corticosteroids and mineralocorticoids is required
  • Dietary intake should be supplemented with salt during times of gastrointestinal losses of fluids through vomiting and diarrhea

NURSING PROCESS: The Patient with Addison’s Disease

Assessment

Assessment focuses on fluid imbalance and stress

  • Check blood pressure from a lying to standing position; check pulse rate
  • Assess skin color and turgor
  • Assess history of weight changes, muscle weakness, and fatigue
  • Ask patient and family about onset of illness or increased stress that may have precipitated crisis

Diagnosis

Nursing Diagnoses

  • Deficient fluid volume related to inadequate fluid intake and fluid loss secondary to inadequate adrenal hormone secretion
  • Deficient knowledge about need for hormone replacement and dietary modification

Collaborative Problems/Potential Complications

Addisonian crisis

Planning and Goals

Goals may include improving fluid balance, improving response to activity, decreasing stress, increasing knowledge about need for hormone replacement and dietary modifications, and ensuring absence of complications.

Nursing Interventions

Restoring Fluid

  • Record weight changes daily
  • Assess skin turgor and mucous membranes
  • Instruct patient to report increased thirst
  • Monitor lying, sitting, and standing blood pressures frequently
  • Assist patient in selecting, and encouraging patient to consume, food and fluids that assist in restoring and maintaining fluid and electrolyte balance (eg, foods high in sodium during gastrointestinal disturbances and very hot weather). Include a dietitian for added guidance.
  • Assist patient and family in learning to administer hormone replacement and to modify dosage during illness and stress
  • Provide written and verbal instructions about mineralocorticoid and glucocorticoid therapy.

Improving Activity Intolerance

  • Avoid unnecessary activities and stress that might precipitate a hypotensive episode
  • Detect signs of infection or presence of stressors that may have triggered the crisis
  • Provide a quiet, nonstressful environment during acute crises; carry out all activities for patient
  • Explain all procedures to reduce fear and anxiety
  • Explain rationale for minimizing stress during acute crisis

Monitoring and Managing Complications (Addisonian Crisis)

  • Assess for signs and symptoms of crisis: circulatory collapse and shock
  • Avoid physical and psychological stress, including exposure to cold, overexertion, infection, and emotional distress
  • Initiate immediate treatment with intravenous fluid, glucose, and electrolytes, especially sodium; corticosteroid supplements; and vasopressors
  • Avoid patient exertion; anticipate and take measures to meet patient’s needs
  • Monitor symptoms, vital signs, weight, and fluid and electrolyte balance to evaluate return to precrisis state
  • Identify factors that led to crisis

 

Reference:

Joyce Young Johnson et.al Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp; 21 – 24

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