Addison's Disease

Question 1

What is Addison’s Disease?

Answer 1

1. Adrenal Gland HYPOfunction
2. Insufficient secretion of ACTH from anterior pituitary or hypothalamus dysfunction

Question 2

Causes of Addison’s Disease

Answer 2

1. Autoimmune destruction of adrenal gland (acute or chronic)
2. Cancer, infection, physical trauma to adrenal gland, steroid use/withdrawal
3. Disorders of anterior pituitary gland and hypothalamus

Question 3

Signs and Symptoms of Addison’s Disease

Answer 3

1. Neuromuscular:
   o Muscle Weakness
   o Fatigue
   o Joint and/or Muscle Pain
2. Gastrointestinal:
   o Anorexia
   o Nausea, Vomiting
   o Abdominal Pain
   o Constipation or diarrhea
   o Weight Loss
   o Salt Craving
3. Skin Symptoms
   o Hyperpigmentation
4. Cardiovascular
   o Anemia
   o HYPOtension
   o HYPOnatremia
   o HYPERkalemia
   o HYPERcalemia

Question 4

History

Answer 4

1. Ask about symptoms and factors that cause adrenal hypofunction
2. Ask about any changes in activity level because LETHARGY, FATIGUE and MUSCLE WEAKNESS are usually present
3. Ask about salt intake because SALT CRAVING often occurs with hypofunction
4. Ask about weight loss during past months
    GI problems (anorexia, nausea, vomiting, diarrhea, and abdominal pain) often occur
    Women have menstrual changes related to weight loss
    Men may report impotence

Question 5

Physical Assessment

Answer 5

1. HYPOGLYCEMIA (sweating, headaches, tachycardia, and tremors),
2. FLUID DEPLETION (postural hypotension and dehydration)
3. HYPERKALEMIA (can cause dysrhythmias with irregular heart rate and results in cardiac arrest
4. HYPONATREMIA leading to hypotension and decreased cognition is often the first indicators of adrenal insufficiency
5. Hyperpigmentation
6. Decreased Body Hair

Question 6

Psychosocial

Answer 6

1 Depending on the degree of imbalance, the patient may appear:
 Lethargic
 Depressed
 Confused
 Psychotic
2. Assess the patient’s orientation to person, place, and time
3. Families may report that the patient has wide mood swings and is forgetful

Question 7

Diagnostic and Labs

Answer 7

1. Sodium: LOW
2. Potassium: HIGH
3. Glucose (fasting): LOW
4. Calcium: HIGH
5. ACTH: LOW

Question 8

Intervention

Answer 8

1. Focus on:
   o Promoting Fluid balance
   o Monitoring for Fluid Deficit
   o Preventing Hypoglycemia
2. Because HYPERKALEMIA can cause DYSRHYTHMIAS with an irregular heart rate and results in cardiac arrest
   > ASSESSING CARDIAC FUNCTION IS A PRIORITY
   > Assess vital signs 1 to 4 hours depending on the patient’s condition and the presence of dysrhythmias or postural hypotension
3. WEIGH PATIENT DAILY and record intake and output
4. Monitor labs to identify hemoconcentration (increase hematocrit or BUN; dehydration)

Question 9

Drug Therapy

Answer 9

1. Most common drug given for this purpose is PREDNISONE
    Instruct the patient to report illness because the usual daily dosage may not be adequate during periods of illness or severe stress
2. An additional mineralocorticoid hormone (Fludrocortisone) may be needed to MAINTAIN or RESTORE fluid and electrolytes (sodium and potassium)
    Dosage adjustment may be needed especially in hot weather when more sodium is loss due to excessive perspiration
    Monitor BP to assess for the potential side effect of HYPERTENSION
    Instruct the patient to report weight gain or edema because sodium intake may need to be restricted
    SALT RESTRICTION or DIURETIC THERAPY should NOT be started without considering whether it might lead to an adrenal crisis
3. Cortisone
    Instruct the patient to take the drug with meals or a snack to avoid gastric irritation
4. Hydrocortisone
    Instruct the patient to report signs or symptoms of excessive drug therapy (rapid weight gain, round face, fluid retention) which indicates Cushing Syndrome and a possible need for a dosage adjustment

Question 10

Emergent Interventions for Acute Adrenal Insufficiency

Answer 10

1. Hormone Replacement
   o Start rapid infusion of normal saline or dextrose 5% in NS
   o Initial higher doses of hydrocortisone sodium or dexamethasone is administered as an IV bolus
   o Administer additional hydrocortisone sodium by continuous IV infusion over the next 8 hours
   o Given an additional dose of hydrocortisone IM concomitantly with hydration every 12 hours
   o Initiate an H2 histamine blocker (cimetidine) IV for ulcer prevention
2. Hyperkalemia Management
   o Administer insulin in units equal to the same number of mg of extra dextrose in NS IV to shift potassium into cells
   o Give potassium binding and excreting resin
   o Give loop or thiazide diuretics
   o Avoid potassium-sparing diuretics
   o Initiate potassium restriction
   o Monitor intake and output
   o Monitor heart rate, rhythm and ECG for signs and symptom of hyperkalemia (slow heart rate, heart block, tall, peaked T-waves, fibrillation, asystole)
3. Hypoglycemia Management
   o Administer IV glucose
   o Prepare to administer glucagon as needed and prescribed
   o Maintain IV access
   o Monitor glucose levels hourly