Addison’s Disease

1. Addison’s Disease Chapter 50

2. Case Study iStockphoto/Thinkstock • S.C., a 30-year-old woman, comes to the ED with syncope after standing up. • You notice that her skin is hyperpigmented over her joints and on her palms.

3. Case Study iStockphoto/Thinkstock • She tells you that she has just been very tired and weak lately. • She has recently lost 15 lb without trying. • She has no significant medical history.

4. Case Study iStockphoto/Thinkstock • The ED physician suspects S.C. may have primary adrenal insufficiency. • What is Addison’s disease? • How does it differ from secondary adrenal insufficiency?

5. Etiology and Pathophysiology • Primary • Addison’s disease • Lack of glucocorticoids, mineralocorticoids, and androgens • Secondary • Lack of pituitary ACTH • Lack of glucocorticoids and androgens

6. Etiology and Pathophysiology • Autoimmune response against adrenal cortex • TB, infarction, fungal infections, AIDS, metastatic cancer • Iatrogenic (drugs, adrenalectomy)

7. Clinical Manifestations • Not evident until 90% of adrenal cortex is destroyed • Insidious onset • Progressive weakness • Fatigue • Weight loss • Anorexia

8. Hyperpigmentation

9. Case Study iStockphoto/Thinkstock • For what additional clinical manifestations will you assess in S.C.?

10. Clinical Manifestations • Orthostatic hypotension • Hyponatremia and salt craving • Hyperkalemia • Nausea and vomiting • Diarrhea • Irritability, depression

11. Complications • Addisonian crisis • Acute adrenal insufficiency • Insufficient or sudden, sharp decrease in hormones • Life-threatening • Various triggers

12. Case Study iStockphoto/Thinkstock • What clinical manifestations, displayed by S.C., would indicate that she is experiencing an acute adrenal insufficiency?

13. Complications • Manifestations of glucocorticosteroid and mineralocorticoid deficiencies • Hypotension, tachycardia • Dehydration • ↓ Sodium, ↑ potassium, ↓ glucose • Fever, weakness, confusion • Severe vomiting, diarrhea, pain • Shock → circulatory collapse

14. Case Study iStockphoto/Thinkstock • What diagnostic studies would you expect the health care provider to order for S.C.?

15. Diagnostic Studies • ↓ Serum and urinary cortisol • ACTH levels • ↑ In primary adrenal insufficiency • ↓ In secondary adrenal insufficiency • ACTH stimulation test • Distinguishes between primary and secondary disease

16. Diagnostic Studies • ↓ Urinary cortisol and aldosterone • ↑ Potassium • ↓ Chloride, sodium, glucose • Anemia • ↑ BUN • ECG changes • CT scan, MRI

17. Case Study iStockphoto/Thinkstock S.C.’s laboratory values reveal • ↑ ACTH • ↓ Plasma cortisol • ↓ Sodium • ↓ Glucose • ↑ Potassium

18. Case Study iStockphoto/Thinkstock • Do these laboratory values reflect primary or secondary adrenal insufficiency? • What treatment would you expect the health care provider to prescribe?

19. Collaborative Care • Correct underlying cause • Hormone therapy • Hydrocortisone • Increase during periods of stress • Fludrocortisone (Florinef) • Increase dietary salt intake

20. Collaborative Care • Addisonian crisis • Shock management • High-dose hydrocortisone replacement • 0.9% saline solution and 5% dextrose

21. Nursing Implementation • Acute intervention • Frequent assessment necessary • Assess vital signs and signs of fluid and electrolyte imbalance • Monitor trends in laboratory values • Monitor mental status and weight • Obtain complete medication history • Watch for signs of Cushing syndrome

22. Nursing Implementation • Acute intervention • Protect against infection • Assist with daily hygiene • Protect from extremes • Light • Noise • Temperature

23. Case Study iStockphoto/Thinkstock • What critical patient teaching about her medication should you provide S.C.? • What lifestyle modifications should she make?

24. Nursing Implementation • Patient teaching • Dosing • Glucocorticoids in divided doses • Mineralocorticoids once in the morning • Reflects normal circadian rhythm • Decreases side effects of corticosteroids • Need to increase corticosteroids during times of stress

25. Nursing Implementation • Patient teaching • Signs and symptoms of corticosteroid deficiency and excess • Wear medical ID bracelet • If patient takes mineralocorticoid, needs to check BP, increase salt intake, and know what to report to health care provider

26. Nursing Implementation • Patient teaching • Emergency kit • How to administer IM hydrocortisone • Written instructions

27. Corticosteroid Therapy • Effective in treating variety of disorders • Complications and side effects with long-term use • Potential benefits must be weighed against risks

28. Corticosteroid Therapy • Expected effects of corticosteroid therapy • Antiinflammatory action • Immunosuppression • Maintenance of normal BP

29. Corticosteroid Therapy • Side effects • ↓ Potassium and calcium • ↑ Glucose and BP • Delayed healing • Susceptibility to infection • Suppressed immune response

30. Corticosteroid Therapy • Side effects • Peptic ulcer disease • Muscle atrophy/weakness • Mood and behavior changes • Moon facies, truncal obesity • Protein depletion • Risk for acute adrenal crisis if therapy is stopped abruptly

31. Corticosteroid TherapyPatient Teaching • Should be taken in the morning with food to reduce gastric irritation • Must not be stopped abruptly • Needs to increase in times of stress • Measures to reduce occurrence of osteoporosis

32. Corticosteroid TherapyPatient Teaching • Dietary needs • Rest and exercise needs • Sodium restriction if edema occurs • Need to monitor for hyperglycemia • Notify health care provider if epigastric pain develops • Need to prevent injury/infection • Inform all health care providers

33. Audience Response Question The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? • The patient is alert and oriented. • The patient’s lung sounds are clear. • The patient’s urinary output decreases. • The patient’s potassium level is 5.7 mEq/L.

34. Audience Response Question An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? • “The medication prevents sodium and water retention after surgery.” • “The drug prevent clots from forming in the legs during your recovery from surgery.” • “This medicine is given to help your body respond to stress after removal of the adrenal glands.” • “This drug stimulates your immune system and promotes wound healing.”