Addison's Disease

Question 1

Etiology and Pathophysiology of Addison’s Disease:
In secondary adrenocortical insufficiency, corticosteroid and androgen levels are deficient, but ________ are usually normal.
ACTH deficiency may be caused by pituitary disease or suppression of the _________ axis because of the administration of exogenous corticosteroids.

Answer 1

mineralocorticoids

hypothalamic-pituitary

Question 2

Etiology and Pathophysiology of Addison’s Disease:
The most common cause of Addison’s disease in the United States is an _______ response.
Adrenal tissue is destroyed by antibodies against the patient’s own adrenal cortex.
Although tuberculosis causes Addison’s disease worldwide, it is now an uncommon cause in the United States. Other causes include infarction, fungal infections (e.g., ________), acquired immunodeficiency syndrome (AIDS), and metastatic cancer.

Answer 2

autoimmune

histoplasmosis

Question 3

Etiology and Pathophysiology of Addison’s Disease:
Iatrogenic Addison’s disease may be due to adrenal hemorrhage, often in relation to _______ therapy, chemotherapy, _______ (Nizoral) therapy for AIDS, or bilateral adrenalectomy for adrenal tumors.

Answer 3

anticoagulant

ketoconazole

Question 4

Clinical Manifestations of Addison’s Disease:
Because manifestations do not tend to become evident until 90% of the ______ is destroyed, the disease is often advanced before it is diagnosed.
The manifestations have a very slow (insidious) onset and include progressive weakness, fatigue, weight loss, and anorexia as primary features.

Answer 4

adrenal cortex

Question 5

Clinical Manifestations of Addison’s Disease:
_________: This is caused by ncreased secretion of ACTH causes the striking feature of bronze-colored skin. It is seen primarily in sun-exposed areas of the body, at pressure points, over joints, and in the creases, especially palmar creases.

Answer 5

Hyperpigmentation

Question 6

Clinical Manifestations of Addison’s Disease:
Other manifestations of adrenal insufficiency are orthostatic hypotension, _________, salt craving, _________, nausea and vomiting, and diarrhea. Irritability and depression may also occur.

Answer 6

hyponatremia

hyperkalemia

Question 7

Complications of Addison’s Disease:
Patients with adrenocortical insufficiency are at risk for acute adrenal insufficiency which is also called _______ which is a life-threatening emergency caused by insufficient adrenocortical hormones or a sudden sharp decrease in these hormones.

Answer 7

ADDISONIAN CRISIS

Question 8

Complications of Addison’s Disease:
______ is triggered by (1) stress (e.g., from infection, surgery, psychologic distress), (2) the sudden withdrawal of corticosteroid hormone therapy (which is often done by a patient who lacks knowledge of the importance of this therapy), (3) adrenal surgery, or (4) sudden pituitary gland destruction.

Answer 8

Addisonian crisis

Question 9

Complications of Addison’s Disease:
During __________, severe manifestations of glucocorticoid and mineralocorticoid deficiencies are exhibited, including hypotension (particularly postural), tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

Answer 9

Addisonian crisis

Question 10

Complications of Addison’s Disease:
GI manifestations include severe vomiting, diarrhea, and pain in the abdomen.
_____ may occur in the lower back or legs.
Hypotension may lead to shock.
________ associated with adrenal insufficiency is often unresponsive to the usual treatment Ex. vasopressors and fluid replacement.

Answer 10

Pain

Circulatory collapse

Question 11

Diagnostic Studies for Addison’s Disease:
Adrenal insufficiency is characterized by decreased serum and urinary cortisol levels.
______ levels will be increased in primary adrenal insufficiency and decreased in secondary disease.
________

Answer 11

ACTH

Question 12

Diagnostic Studies for Addison’s Disease:
Primary adrenal insufficiency is confirmed when cortisol levels fail to rise over basal levels with an ACTH stimulation test:
#1: 0.25 – 1mg of synthetic ACTH given IV
#2: Plasma cortisol levels obtained at 30 min & 1 hour
#3: Normally, the cortisol level ______ within 1 hour

In Primary insufficiency – cortisol response is ______
In secondary insufficiency – response is ______

Answer 12

doubles
absent/decreased
increased

Question 13

Diagnostic Studies for Addison’s Disease:
Urine levels of _______ and ________ are low.
Other abnormal laboratory findings in some cases include hyperkalemia, hypochloremia, hyponatremia, hypoglycemia, anemia, and increased BUN levels.

Answer 13

free cortisol

aldosterone

Question 14

Diagnostic Studies for Addison’s Disease:
An ECG may show low voltage and peaked T waves caused by ________.
______ or ______ may be used to identify causes other than autoimmune including tumors, fungal infections, tuberculosis, or adrenal calcification.

Answer 14

Hyperkalemia

CT scans and MRI

Question 15

Collaborative Care for Addison’s disease:
Treatment of adrenocortical insufficiency is focused on management of the underlying cause when possible.
The mainstay of treatment for the adrenocortical insufficiency is hormone therapy.
________, the most commonly used form of hormone therapy, has both glucocorticoid and mineralocorticoid properties.
During situations associated with stress, the glucocorticoid dosage must be increased to prevent addisonian crisis.
Mineralocorticoid replacement with _______ is administered daily.
_____ in the diet needs to be increased.

Answer 15

Hydrocortisone
fludrocortisone (Florinef)
Salt

Question 16

Collaborative Care of Addisonian Crisis:
Addisonian crisis is a life-threatening emergency necessitating aggressive management.
Treatment must be directed toward shock management and high-dose hydrocortisone replacement.
With high doses of steroids, initiate intravenous ________.
Large volumes of _____ and _____ are administered to reverse hypotension and electrolyte imbalances until BP returns to normal.
Treatment should also include to treat hyperkalemia give _______and hypoglycemia.

Answer 16

H2 histamine blockers
NS solution and D5W
kayaxalate

Question 17

Nursing Interventions for Addison’s Disease:
When the patient with Addison’s disease is hospitalized, nursing management is focused on ________ the patient while correcting fluid and electrolyte imbalance.
Frequently assess vital signs and signs of fluid volume deficit and electrolyte imbalance.
Monitor trends in serum ______, _____, and ______ levels.
Establish baseline data regarding mental status, vital signs, and weight.

Answer 17

monitoring

glucose, sodium, and potassium

Question 18

Obtain a complete medication history to determine potential drugs that can interact with corticosteroids. These drugs include _____, _____, ______, ______, and ______.
Note changes in blood pressure, weight gain, weakness, or other manifestations of Cushing syndrome.

Answer 18

Oral hypoglycemics, cardiac glycosides, oral contraceptives, anticoagulants, and NSAIDs

Question 19

Acute Nursing Interventions for Addison’s Disease:
In addition, protect against exposure to infection, and assist with daily hygiene.
Protect the patient from _____, _____, and environmental temperature extremes.
The patient cannot cope with these stresses because of the inability to produce corticosteroids.

Answer 19

noise

light

Question 20

Patient Education Nursing Interventions for Addison’s Disease:
Dosing: Glucocorticoids are usually given in _____ divided doses: two thirds in the morning and one third in the afternoon. Mineralocorticoids are given ____ daily, preferably in the morning. _______ contains both glucocorticoids and mineralocorticoids. _________ has only mineralocorticoids.
This dosage schedule reflects normal circadian rhythm in endogenous hormone secretion and decreases the side effects associated with corticosteroid therapy.

Answer 20

three
once
Hydrocortisone
Fludrocortisone

Question 21

Patient Education Nursing Interventions for Addison’s Disease:
Patients with Addison’s disease are unable to tolerate physical or emotional stress without _______ their dose of exogenous corticosteroids. Long-term care revolves around recognizing the need for extra medication and techniques for stress management. Examples of situations necessitating an increase in the dose of corticosteroid are fever, influenza, extraction of teeth, and _______, such as playing tennis on a hot day or running a marathon.

Answer 21

increasing

rigorous physical activity

Question 22

Patient Education Nursing Interventions for Addison’s Disease:
If vomiting or diarrhea occurs, as may happen with ________, notify the health care provider immediately because electrolyte replacement and parenteral administration of cortisol may be necessary. Overall, patients who take their medications consistently can anticipate a normal life expectancy.

Answer 22

influenza

Question 23

Patient Education Nursing Interventions for Addison’s Disease:
Teach the patient about the signs and symptoms of corticosteroid _____ and ______ (Cushing syndrome) and to report these signs to their health care provider so the dose can be individually adjusted. It is critical that the patient wear an ______ (e.g., MedicAlert) and carry a wallet card stating the patient has Addison’s disease so that appropriate therapy can be initiated in case of an emergency.

Answer 23

deficiency and excess

identification bracelet

Question 24

Patient Education Nursing Interventions for Addison’s Disease:
Instruct patients using mineralocorticoid therapy _______ how to take their BP and to report any significant changes to their health care provider like weight gain, edema, increased blood pressure. Provide written instructions as to when the dose should be changed.

Answer 24

fludrocortisone [Florinef])

Question 25

The patient should carry an emergency kit at all times. The kit should consist of 100 mg of IM _______, syringes, and instructions for use. Instruct the patient and significant others how to give an IM injection in case the hormone therapy cannot be taken orally. Have the patient verbalize instructions and practice IM injections with saline.

Answer 25

hydrocortisone

Question 26

Corticosteroid Therapy for Addison’s Disease:
A beneficial effect of corticosteroids in one situation may be a harmful one in another.
For example, decreasing inflammation in arthritis is an important therapeutic effect, but increasing the risk for ______ is a harmful effect.
Suppression of inflammation and the immune response may help save lives in persons with anaphylaxis and in those receiving an organ transplant, but it causes reactivation of latent ______ and greatly reduces resistance to other infections and cancers.
The ________ effect of corticosteroids is critical in enabling a person to function in stressful situations, but this effect can produce hypertension when used for drug therapy. Monitor blood pressure.

Answer 26

infection
tuberculosis
vasopressive

Question 27

Side Effects of Corticosteroid Therapy for Addison’s Disease:
________ may develop.
Hypocalcemia related to anti–vitamin D effect may occur.
Glucose intolerance predisposes the patient to ______.
Blood pressure increases because of excess blood volume and increased vasoconstrictor effects. Hypertension predisposes to the patient to _______.

Answer 27

Hypokalemia
diabetes mellitus
heart failure

Question 28

Side Effects of Corticosteroid Therapy for Addison’s Disease:
Healing is delayed. There is increased risk for wound _______.
Susceptibility to infection is increased. Infection develops more rapidly and spreads more widely.
Manifestations of inflammation, including redness, tenderness, heat, swelling, and local edema, are ________.
Predisposition to peptic ulcer disease develops.
Skeletal muscle atrophy and weakness occur.
Mood and behavior changes may be observed.
Fat from extremities is redistributed to trunk and face. Ex. ______ and _______
dehiscence
not evident so the patient will appear asymptomatic

Answer 28

Moon Face and Truncal Obesity

Question 29

Side Effects of Corticosteroid Therapy for Addison’s Disease:
Bones are made up of a protein matrix. Protein ______ decreases bone formation, density, and strength, leading to predisposition to pathologic fractures, especially compression fractures of the vertebrae (osteoporosis). ______ excretion by the kidneys in the urine also decreases skeletal mass and bones become weaker. Corticosteroid deficiency is likely if hormones are withdrawn abruptly. Therefore always ______ down corticosteroid doses over time to avoid complications.

Answer 29

depletion
Calcium
TAPER

Question 30

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
When corticosteroids are used as ______ therapies, they are taken once daily or once every other day. They should be taken early in the morning with food to decrease ______ irritation.

Answer 30

non-replacement

gastric

Question 31

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Exogenous (externally introduced) corticosteroid administration may suppress endogenous (internally secreted) ______ (the body becomes lazy and stops producing it on its own because of the pills) and therefore endogenous cortisol suppression becomes ____ and ___ dependent.

Answer 31

ACTH

time and dose

Question 32

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Emphasize the danger of abrupt cessation of corticosteroid therapy to patients and caregivers. Corticosteroids taken for longer than ___ week will suppress adrenal production, and oral cortiosteroids must be tapered.
Ensure that ______ doses of corticosteroids are prescribed in acute care or home care settings in situations of physical or emotional stress.

Answer 32

1

increased

Question 33

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Corticosteroid-induced _____ is an important concern for patients who receive corticosteroid treatment for prolonged periods of time (longer than ___ months).
Therapies to reduce the resorption of bone may include increased calcium intake, vitamin D supplementation, bisphosphonates (e.g., _______, and institution of a low-impact exercise program.

Answer 33

osteoporosis
3 months
Alendronate / Fosamax

Question 34

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Include the following instructions when teaching the patient and/or caregiver to manage corticosteroid therapy.
Plan a diet _____ in protein, calcium (at least _____ mg/day), and potassium but ____ in fat and concentrated simple carbohydrates such as sugar, honey, syrups, and CANDY.
Identify measures to ensure adequate rest and sleep, such as daily naps and avoidance of _____ late in the day.

Answer 34

High
1500 mg/day
Low
caffeine

Question 35

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Develop and maintain an exercise program to help maintain bone integrity.
Recognize edema and ways to restrict sodium intake to less than _______ mg/day if edema occurs.

Answer 35

2000 mg/day

Question 36

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Monitor glucose levels and recognize symptoms of hyperglycemia (e.g., polydipsia, polyuria, blurred vision). Report hyperglycemic symptoms or capillary glucose levels exceeding _____ mg/dL (10 mmol/L).

Answer 36

120 mg/dL

Question 37

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Notify health care provider if experiencing heartburn after meals or epigastric pain that is not relieved by ________.
See an eye specialist yearly to assess for development of cataracts.

Answer 37

antacids

Question 38

Corticosteroid Therapy Patient Teaching for Addison’s Disease:
Use safety measures such as getting up slowly from bed or a chair, and use good lighting to avoid accidental ________.
Maintain good hygiene practices and avoid contact with persons with colds or other ______ illnesses to prevent infection.
Inform all health care providers about long-term corticosteroid use.

Answer 38

injury

contagious

Question 39

Quick Review for Addison’s Disease:
Primary hypofunction of the ________, or Addison’s disease, results in a reduction of all three classes of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). Secondary disease results from ______ dysfunction.

Answer 39

adrenal cortex

pituitary

Question 40

Quick Review for Addison’s Disease:
The most common cause in the United States is _______, where the adrenal cortex is destroyed by autoantibodies.
Manifestations have a slow onset and include weakness, weight loss, and anorexia. Due to increased _______, skin hyperpigmentation is seen in exposed and unexposed areas of the body, at pressure points, over joints, and in palmar creases.

Answer 40

autoimmune

ACTH

Question 41

Quick Review for Addison’s Disease:
Treatment is hormone therapy. Hydrocortisone, the most commonly used form of hormone therapy, has both ______ and ______ properties. During times of stress, glucocorticoid dosage is increased to prevent Addisonian crisis.
Mineralocorticoid replacement with fludrocortisone acetate (Florinef) is given daily with increased dietary salt.

Answer 41

glucocorticoid

mineralocorticoid

Question 42

Quick Review for Addison’s Disease:
Patients with Addison’s disease are at risk for acute adrenal insufficiency, a life-threatening emergency caused by a sudden decrease in adrenocortical hormones. It is triggered by stress (e.g., surgery, trauma, psychologic distress), sudden _______ of corticosteroid hormone therapy, and post-adrenal surgery.

Answer 42

withdrawal

Question 43

Quick Review for Addison’s Disease:
Manifestations include postural hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Treatment is ______ management and high-dose hydrocortisone replacement. Large volumes of 0.9% saline solution and 5% dextrose are given to reverse ________ and electrolyte imbalances until blood pressure (BP) normalizes.

Answer 43

shock

hypotension

Question 44

Etiology and Pathophysiology of Addison’s Disease:
Adrenocortical insufficiency (hypofunction of the adrenal cortex) may be from a primary cause (Addison’s disease) or a secondary cause (lack of pituitary ACTH secretion). 
In Addison’s disease, amounts of all three classes of adrenal corticosteroids Ex. \_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_, and \_\_\_\_\_\_\_\_are reduced.

Answer 44

Glucocorticoids
Mineralocorticoids
Androgens