Addison’s Disease and Nursing Care Plan

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Addison’s Disease Etiology and Pathophysiology

• Adrenocortical insufficiency from a primary cause

– All three classes of adrenal corticosteroids reduced

• Most commonly from autoimmune response destroying adrenal tissue

• TB (rare cases)

• Infarction

• Fungal infections

• AIDS

• Metastatic cancer

• Iatrogenic Addison’s

– May be due to adrenal hemorrhage

• Most often occurs in adults ages 30-60

• Affects both genders equally

– Autoimmune Addison’s more common in white females

Addison’s Disease Clinical Manifestations

• Does not become evident until 90% of adrenal cortex is destroyed

• Insidious onset

• Progressive weakness, fatigue, weight loss, anorexia are primary features

• Skin hyperpigmentation

– Areas exposed to sun

– Pressure joints

– Over joints

– In creases

• Hypotension

• Hyponatremia

• Hyperkalemia

• N/V

• Diarrhea

• Secondary adrenocortical hypofunction

– S/S in common with Addison’s

– Characteristically lack hyperpigmentation

 

Addison’s Disease Complications

• Risk for life-threatening crisis caused by insufficient adrenocortical hormones or sudden, sharp decrease in these hormones

– Triggered by stress following withdrawal of corticosteroid replacement therapy

• Severe manifestations of glucocorticoid and mineralocorticoid deficiencies

– Hypotension

– Tachycardia

– Dehydration

– Hyponatremia

– Hyperkalemia

– Hypoglycemia

– Fever

– Weakness

– Confusion

– Can lead to shock

– Circulatory collapse

• Often unresponsive to usual treatment

 

Addison’s Disease Diagnostic Studies

• Subnormal levels of cortisol or levels fail to rise over basal levels with ACTH stimulation test

– Latter indicate primary adrenal disease

– Positive response to ACTH stimulation indicates functioning adrenal gland

• Abnormal lab findings:

– Hyperkalemia

– Hypochloremia

– Hyponatremia

– Hypoglycemia

– Anemia

–­  BUN

• Urine levels of cortisol are low

• ECG

– Low voltage

– Vertical QRS axis

– Peaked T waves from hyperkalemia

• CT and MRI to localize tumors or identify calcifications or enlargement

 

Addison’s Disease Collaborative Care

• Hydrocortisone most commonly used as replacement therapy

• Glucocorticoid dosage must be increased during times of stress to prevent Addisonian crisis

 

Addison’s Disease Diagnostic Studies

• Treatment directed at shock management and high-dose hydrocortisone replacement

• Large volumes of NS and D5 are administered to reverse hypotension and electrolyte imbalances

 

Addison’s Disease Nursing Implementation

• Frequent assessment

• VS and signs of F&E imbalances every 30 minutes to 4 hours for first 24 hours

• Daily weights

• Diligent corticosteroid administration

• Protection against infection

• Hygiene

• Protect from light, noise, and temperature extremes

• As discharge usually occurs before maintenance dose reached, instruct on importance of follow-up appointments

• Glucocorticoids usually given in divided doses

• Mineralocorticoids usually given once in the morning

– Reflects normal circadian rhythm

• Long-term care revolves around recognizing the need for extra medication and techniques for stress management

• For vomiting and diarrhea, notify the health care provider because electrolyte replacement may be necessary and may indicate crisis

• Teach S/S of corticosteroid deficiency and excess and to report findings

• Instruct to wear Medic Alert bracelet at all times

• Provide handouts on medications causing increased need for glucocorticoids

• Instruct on how to take BP and report findings

• Instruct to carry emergency kit with IM hydrocortisone, syringes, and instructions for use

– Teach how to give IM injection

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