Addison’s Disease aka Adrenal Insufficiency: Definition and Causes
hypo-function of adrenal cortex
all 3 corticosteroid classes are reduced
Primary cause: autoimmune, antibodies destroy the adrenal cortex, more common in women
Secondary cause: Cushing’s syndrome
- suppression of hypothalamus-pituitary communication d/t taking steroids
- abruptly stopping steroids (after taking for long period of time or on a higher dose)
Other causes: TB, amyloidosis, fungal infections, AIDS, metastatic cancer
Corticosteroids
Glucocorticoids:
- regulates metabolism, increases BG, critical for stress response
- inhibit inflammation
- ex) cortisol
Mineralocorticoid
- target tissue is kidneys
- regulates sodium and potassium balance, indirectly regulating water balance
- ex) aldosterone
Adrenal Androgen Hormones
- target tissues is ovaries, gonads
- converted to sex hormones
- also stimulates: regeneration of RBCs, skin pigmentation, increase protein in bone tissue
Iatrogenic Addison’s Disease: Causes
- adrenal hemorrhage from anticoagulant therapy
- chemotherapy
- ketoconazole therapy for AIDS (anti-fungal, PO therapy given to AIDS pt, interferes with pathways that produce cortisol and is anti-inflammatory)
- bilateral adrenalectomy (not producing corticosteroids)
Addison’s Disease: S/O data
- gradual onset (insidious onset) - no symptoms until 90% of adrenal cortex is destroyed
- characterized by fatigue, progressive weakness, weight loss, anorexia
- N, V, D
- orthostatic hypotension (loss of aldosterone)
- skin hyperpigmentation
- decrease serum cortisol levels
- decrease NA and increase K (salt cravings)
- HA
- joint pain
- irregular or no menstrual periods (d/t androgen hormones)
- CT or MRI (looking for tumors)
Addisonian Crisis aka Acute Adrenal Insufficiency: Definition
Medical Emergency, life threatening
-insufficient or sudden, sharp decrease in hormones
-various triggers:
stress w/o corticosteroid replacements
-abruptly. stopping steroid therapy ->adrenal insufficiency -> hypotension
-adrenal surgery
-sudden pituitary gland destruction (d/t loss of blood flow to brain, trauma to brain, stroke in that space, removal of part or all of pituitary or hypothalamus, radiation to pituitary)
Addisonian Crisis: Manifestations of Glucocorticoid and Mineralocorticoid Deficiencies
- HTN is #1 problem -> tachycardia to compensate
- Dehydration
- Decreased sodium, increased potassium, decreased glucose
- Fever, weakness
- Confusion, altered mental status (d/t decreased Na)
- severe vomiting, diarrhea, pain in the abdomen (d/t increased K)
- shock -> circulatory collapse
Addisonian Crisis: Interventions
- shock management (perfusion issues d/t low BP -> O2 needs)
- high-dose hydrocortisone replacement into IV quickly (#1 fix)
- 0.9% NaCl IV solution w/ 5% dextrose (for BG)
- IV vasopressors (norepinephrine) to support BP
- sodium polystyrene PO (kayexalate for high potassium)
- NG tube for n/v (prevent aspiration)
- treat underlying cause
- prevent complications of immobility
Addison’s Disease: Dx
ACTH stimulation test:
- baseline levels of cortisol and ACTH from saliva or blood test
- IV injection of synthetic ACTH given
- levels rechecked after 30-60 min
- little or no increase in cortisol levels = addison’s disease
- high ACTH = primary adrenal insufficiency
Blood work will show:
- high potassium
- low chloride, sodium, glucose
- anemia (d/t low androgen hormone)
- increased BUN
ECG changes
CT scan, MRI (to look at structures of adrenal/pituitary gland and look for tumors)
Addison’s Disease: Interprofessional Care
manage underlying cause
lifelong hormone therapy
-hydrocortisone or prednisone to replace cortisol
-increase during periods of stress (double dose for minor stress, triple dose for major stress)
-fludrocortisone (Florinef) PO to replace aldosterone
-women need androgen replacement
increase dietary salt intake
Addison’s Disease: Nursing Interventions
Education:
- Dosing: take hydrocortisone in divided doses (2/3 in AM, 1/3 in late afternoon), mineralcorticoids (fludrocortisone) once in the morning.
- reflects normal circadian rhythm and decreases SE of corticosteroids
- normal life if adherent and consistent with meds
- diet: increase protein, carbs, and sodium (metabolism is low)
- salt additives for excessive heat/humidity (b/c they will sweat more)
- report s/sx of corticosteroid deficiency and excess to HCP (too much -> symptoms of Cushing)
- n/v also should be reported to HCP as this will require electrolyte replacement
- med ID bracelet
- carry emergency kit (IM hydrocortisone)
Corticosteroid Therapy: Expected Effects
anti-inflammatory action
immunosuppression
maintenance of normal BP
Corticosteroid Therapy: SE
- decreased potassium and calcium (ok side effect to have for addison’s disease)
- increased glucose and BP (also ok side effect for addison’s disease)
- delayed healing
- susceptibility to infection
- suppressed immune response
- predisposed to cataracts
- peptic ulcer disease
- muscle atrophy/weakness
- mood and behavior changes
- moon face, truncal obesity
- protein depletion (low protein for addison’s but need protein when on corticosteroid therapy)
- risk for acute adrenal crisis if therapy is stopped abruptly (steroid tapering for short term steroid treatment)
Corticosteroid Therapy: Pt Teaching
- dietary, rest and exercise needs
- sodium restriction if edema occurs
- need to monitor for hyperglycemia
- notify HCP if epigastric pain develops (high risk for stress ulcers from this therapy)
- need to prevent injury/infection/stress
- inform all HCP (including Dentist)
- therapies to reduce osteoporosis (prevent falls)
- check BP at home, don’t want it to get too low, can also get too high on steroids
Cushing Syndrome and Cushing Disease: Cause
-excess of all 3 corticosteroid classes
other common causes:
- iatrogenic administration of exogenous corticosteroids for another condition
- ACTH-secreting pituitary adenoma (this is Cushing disease)
- adrenal tumors (tumor causes increase in excretion )
- ectopic ACTH production by tumors (Small Cell Lung Cancer)
Cushing Syndrome: Clinical Manifestations
Excessive glucocorticoids:
- hyperglycemia r/t glucose intolerance and increased gluconeogenesis
- muscle wasting -> weakness (muscle loss d/t protein wasting - arms are skinny even though trunk is large)
- loss of bone matrix -> osteoporosis (-> pathological fx) and back pain
- loss of collagen -> thin skin, easily bruises, petechiae
- delay in wound healing
- kidney stones b/c of hypercalciuria
Excess mineralocorticoid:
- hypokalemia (d/t more K wasting)
- HTN (d/t more sodium retention)
Excess Adrenal Androgen:
- severe acne
- male characteristics in women (hirsutism)
- feminization in men (gynecomastia)
weight gain d/t accumulation of adipose tissue in the trunk, face, cervical area (retention of water and sodium)
skin changes:
- striae: purple red streaks
- plethora: redness in face
- weak, thin skin, ecchymosis
- delayed wound healing
mental changes
Cushing Syndrome: Dx
ACTH levels:
- high or normal = d/t anterior pituitary problem
- low or undetectable = adrenal cortex problems or prednisone use
CBC: may indicate immune suppression (low WBC)
Chemistries: hyperglycemia, hypokalemia
CT Scans or MRI if suspect tumor
Cushing Syndrome: Plans/Interventions (Non-surgical)
if d/t prolonged steroid use:
- gradually d/c use of corticosteroid (taper)
- alternating day regime (try shorter acting instead of longer acting, etc.)
- prevent adrenal insufficiency and adrenal insufficiency crisis
- medications: adrenal corticosteroid inhibitor to decrease adrenal hormone synthesis
- Nizoral (ketoconazole): antifungal given in high doses (monitor LFTs, med is hard on liver) and GI side effects
Cushing Syndrome: Surgical Interventions
adrenalectomy as indicated for cushing syndrome caused by tumors or hyperplasia
or:
pituitary adenoma - surgery to remove tumor via transphenoidal approach
hypophysectomy - removal of pituitary gland
Cushing Syndrome: Nursing Interventions (Preoperative Care)
optimize physical condition
control HTN and hyperglycemia
correct hypokalemia
high-protein diet to correct protein depletion (will be helpful with healing process)
Cushing Syndrome: Nursing Interventions (Post-op Care)
critical time period for circulatory instability is 24-48 hours after surgery
- hemorrhage risk for adrenal removal and pituitary removal
- imbalance of BP, fluid & electrolytes d/t hormone fluctuations
- monitor nasal drainage/dressing for CSF leak (will be +glucose if there is CSF leak), yellow halo
high dose corticosteroids (intra- and post-operatively) provide adequate response to stress of surgery (help control risk of having adrenal insufficiency crisis after surgery):
- administer IV then PO, adjusted according to pt response
- if taper too rapid, may cause adrenal insufficiency
- may need to have life-long glucocorticoid, mineralocorticoid and hormone replacement therapy (depending on what and how much was removed)
- if pituitary was removed (messed with brain), ABC’s, bed rest until BP is stable
- AM urine to monitor effectiveness of surgery (cortisol levels should drop)
- avoid ICP
- monitor nasal drainage
- notify surgeon if increased bleeding, HA, change in mental status
Cushing Syndrome: Post Op Surgery Discharge Instructions
- life-long replacement therapy (takes months for hormonal adjustment)
- avoid temp extremes, infections, emotional upset
- stress may cause acute adrenal insufficiency
- self-adjustment of corticosteroid replacement therapy if possible according to own stress level
- adise s/sx of adrenal insufficiency (adrenal crisis)
- wear medic alert bracelet
- carry emergency injection kit
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KUBP Dysfunction42
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AKI/CKD5
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Acute Respiratory Problems40
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Tracheostomy6
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Upper and Lower Respiratory Tract Cancers12
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COPD and OSA9
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Adrenal Dysfunction21
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Thyroid and Parathyroid Disease43
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Neurological Dysfunctions30
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Peripheral Nerve Problems12
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Chronic Neurological Dysfunctions28
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CVA, TIA - Brain Attack33
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Advanced Nutrition23
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Upper GI Dysfunctions34
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Intestinal Problems Student75
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Dysfunctions of Liver, Biliary Tract, and Pancreas54
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Cancer and Health Promotion24
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Care of a Client with Cancer21
