Addisons Disease Definition: Adrenocortical insufficiency occurs with inadequate secretion of the hormones of the adrenal cortex, primarily

the glucocorticoids, mineralocorticoids, androgens. Incidence: between ages 30-60 years -Greater in females than males

Etiology: Primary adrenocortical insufficiency (Addison's dis-ease)destruction and subsequent hypofunction of the adrenal cortex, usually caused by autoimmune process. Secondary adrenocortical insufficiencyACTH deficiency from pituitary disease or suppression of hypothalamic-pituitary axis by corticosteroid treatment for nonendocrine disorders causes atrophy of adrenal cortex.

Important Information The medulla is responsible for the secretion of the catecholamines epinephrine and norepinephrine; the cortex is responsible for the secretion of glucocorticoids, mineralocorticoids, and androgen. The principal glucocorticoid, cortisol, helps regulate blood pressure, metabolism, anti-inflammatory response, and emotional behavior. The principal mineralocorticoid, aldosterone, is important for regulating sodium levels. Adrenal insufficiency is characterized by the decreased production of cortisol, aldosterone, and androgen. Cortisol deficiency causes altered metabolism, decreased stress tolerance, and emotional lability. Aldosterone deficiency causes urinary loss of sodium, chloride, and water, resulting in dehydration and electrolyte imbalances. Androgen deficiency leads to the loss of secondary sex characteristics. Pathophysiology: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

_____________________________________________________________________________________ _____________________________________________________________________________________ Clinical Manifestations :manifestations have a very insidious (slow) onset Hyponatremia, hyperkalemia. Water loss, dehydration, and hypovolemia. Muscular weakness, fatigue, weight loss.GI problemsanorexia, nausea, vomiting, diarrhea, constipation, abdominal pain. Hypotension, hypoglycemia, low basal metabolic rate, increased insulin sensitivity. Mental changes depression, irritability, anxiety, apprehension caused by hypoglycemia and hypovolemia. Normal responses to stress lacking. Hyperpigmentation.

Diagnostic Evaluation Blood chemistrydecreased glucose, decreased sodium, increased potassium. 2-Increased lymphocytes on complete blood count. 3-Low fasting plasma cortisol levels; low aldosterone levels. 4:-24-hour urine studies decreased 17-ketosteroids, 17-hydroxycorticoids, and 17-ketogenic steroids; may be decreased. 5-ACTH stimulation testno rise in plasma cortisol and urinary 17-ketosteroids. Medical Management
1-Immediate treatment is directed toward combating circulatory shock: restoring blood circulation, administering fluids and corticosteroids, monitoring vital signs, and placing the patient in a recumbent position with the legs elevated. 2- Hydrocortisone (Solu-Cortef) is administered by IV, followed by 5% dextrose in normal saline. 3-Vasopressor amines may be required if hypotension persists. 4- Antibiotics may be administered if infection has precipitated adrenal crisis in a patient with chronic adrenal insufficiency. 5-In addition, the patient is assessed closely to identify other factors, stressors, or illnesses that led to the acute episode. 6-Oral intake may be initiated as soon as tolerated. IV fluids are gradually decreased after oral fluid intake is adequate to prevent hypovolemia. If the adrenal gland does not regain function, the patient needs lifelong replacement of corticosteroids and mineralocorticoids to prevent recurrence of adrenal insufficiency. During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. In addition, the patient may need to supplement dietary intake with added salt during gastrointestinal losses of fluids through vomiting and diarrhea.

Complications Adrenal crisishypotension, nausea, vomiting, weakness, lethargy, and possi bly coma. May be precipitated by physiologic stress, such as surgery, infection, trauma, dehydration.

HISTORY. Determine if the patient has a history of recent infection, steroid use, or adrenal or pituitary surgery. Establish a history of poor tolerance for stress, weakness, fatigue, and activity intolerance. Ask if the patient has experienced anorexia, nausea, vomiting, or diarrhea as a result of altered metabolism. Elicit a history of craving for salt or intolerance to cold. Determine presence of altered menses in females and impotence in males

. PHYSICAL EXAMINATION. Assess the patient for signs of dehydration such as tachycardia, altered level of consciousness, dry skin with poor turgor, dry mucous membranes, weight loss, and weak peripheral pulses. Check for postural hypotensionthat is, a drop in systolic blood pressure greater than 15 mm Hg when the patient is moved from a lying to a sitting or standing position. Inspect the skin for pigmentation changes caused by an altered regulation of melanin, noting if surgical scars, skin folds, and genitalia show a characteristic bronze color. Inspect the patients gums and oral mucous membranes to see if they are bluish-black. Take the patients temperature to see if it is subnormal. Note any loss of axillary and pubic hair that could be caused by decreased androgen levels. PSYCHOSOCIAL. Because an acute adrenal crisis may be precipitated by emotional stress, periodic psychosocial assessments are necessary for patients with adrenal insufficiency. Patients with an adrenal insufficiency frequently complain of weakness and fatigue, which are also characteristic of an emotional problem. However, weakness and fatigue of an emotional origin seem to have a pattern of being worse in the morning and lessening throughout the day, while the weakness and fatigue of adrenal insufficiency seem to be precipitated by activity and lessen with rest. Patients with adrenal insufficiency may show signs of depression and irritability from decreased cortisol levels. Nursing diagnosis: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Nursing Interventions Achieving Normal Fluid and Electrolyte Balance Assess fluid intake and output and serial daily weights. Monitor vital signs frequently; a drop in BP may suggest an impending crisis. Monitor results of serum sodium and potassium. Assess skin turgor and mucous membranes for dehydration. Encourage diet high in sodium and fluid content; administer or teach self-administration of potassium supplements, if prescribed. Administer or teach self-administration of prescribed glucocorticoids and mineralocorticoids; document response. Administer I.V. infusions of sodium, water, and glucose as indicated. Protecting Well-Being Minimize stressful situations. Protect patient from infection. Control patient's contacts so that infectious organisms are not transmitted. Protect patient from drafts, dampness, exposure to cold. Prevent overexertion. Use meticulous hand washing and asepsis. Assess comfort and emotional status of patient. Control the temperature of the room to avoid sharp deviations in patient's temperature. Maintain a quiet, peaceful environment; avoid loud talking and noisy radios. Observe and report early signs of addisonian crisis (sudden drop in BP, nausea and vomiting, fever). Increasing Activity Tolerance Assist the patient with ADLs. Provide for periods of rest and activity to avoid overexertion. Provide for high-calorie, high-protein diet.

Patient Education and Health Maintenance Instruct the patient about the necessity for long-term therapy for adrenocortical insufficiency and medical followup visits. Inform the patient that therapy must be continued throughout his life span. Emphasize the importance of taking more hormones when under stress. Suggest that the patient carry an identification card that indicates the type of medication being taken and health care provider's telephone number. Instruct the patient about manifestations of excessive use of medications and reportable symptoms. Identify actions to take to avoid factors that may precipitate addisonian crisis (infection, extremes of temperature, trauma). Evaluation: Expected Outcomes Normal skin turgor, moist mucous membranes, stable vital signs No signs of infection or stress Completes daily activities with minimal assistance