Med-Surg: Chapter 42: Adrenal Cortical Insufficiency

Question 1

How can Adrenal Insufficiency happen?

Answer 1

may result from

• destruction of the adrenal glands (primary deficiency or Addison’s Disease)
• decreased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland (secondary insufficiency)
• dysfunction of the hypothalamus (tertiary insufficiency)

Question 2

Primary Deficiency/ Addison’s Disease

Answer 2

destruction of the adrenal glands

Question 3

Secondary Insufficiency

Answer 3

decreased secretion of the adrenocorticotrophic hormone (ACTH) from the anterior pituitary gland

Question 4

Tertiary Insifficiency

Answer 4

dysfunction of the hypothalamus

Question 5

Causes of Primary Deficiency

Answer 5

• nonspecific autoimmune destruction of the adrenal gland is the most common cause
• other: infectious, cancerous, and traumatic processes that lead to direct insults to the adrenal cortex

Question 6

Causes of Secondary and Tertiary Deficiencies

Answer 6

related to disorders of the anterior pituitary gland and the hypothalamus

Question 7

Pathophysiology of Adrenal Insufficiency

Answer 7

may be associated with

• decreased secretion of corticotropin-releasing hormone (CRH) from the hypothalamus
• decreased secretion of ACTH from the anterior pituitary gland
• decreased secretion of glucocorticoids and mineralocorticoids from the adrenal cortex

Question 8

Patients who are prescribed exogenous corticosteroids for longer than 2 weeks are at risk for what if the medications are abruptly d/c?

Answer 8

acute adrenal insufficiency (acute adrenal crisis)

Question 9

Clinical Manifestations

Answer 9

• present after 90% of the adrenal cortex is destroyed or nonfunctional
• while the circulating levels of cortisol and aldosterone fall, the hypothalamus and anterior pituitary gland increase secretion of CRH and ACTH, respectively
• b/c melanocyte-stimulating hormone (MSH) and ACTH share a ancestor hormone, there is an increase in secretion of MSH, leading to a darkened, bronze hyperpigmentation that accompanies the increased secretion of ACTH
• secondary to the decreased secretion of cortisol and aldosterone, the patient presents with weakness, weight loss, fatigue, nausea, abdominal pain, gastroenteritis, and emotional lability
• changes in mood: irritability, depression, and inability to concentrate
• hyperpigmentation of the skin and mucous membranes, and decreased pubic and axillary hair (secondary to decreased secretion of sex hormones)
• dehydration and hypotension as a result of the loss of sodium and water

Question 10

Diagnosis

Answer 10

> tests of the hypothalamic-pituitary axis and adrenal cortex
serum electrolytes
-hyponatremia and hyperkalemia develop secondary to decreased aldosterone secretion
-serum cortisol measured; highest in the morning (between 6 and 8 am), levels up to 25 mcg/dL are normal; levels less than 3 mcg/dL are diagnostic for adrenal insufficiency
-serum corticotropin (ACTH) levels; greater than 100 mg/dL are diagnostic of primary adrenal insufficiency
-evaluations of hypothalamic-pituitary axis to evaluate secondary and tertiary adrenal insufficiency
-CT and MRI used to assess for changes in the size and morphology of the adrenal gland; shrinking of the adrenal glad is associated with autoimmune destruction; gland enlargement often observed with infectious processes

Question 11

Laboratory Tests for Adrenal Disorders

Answer 11

> Cortisol

• Normal Range: 5-25 mcg/dL (morning); 3-16 mcg/dL (afternoon)
• Significance: decreased in hypocortisolism (Addison’s); elevated in hypercortisolism (Cushing’s)

> Glucose

• Normal Range: 65-99 mg/dL
• Significance: decreased in hypocortisolism (Addison’s); increased in hypercortisolism (Cushing’s)

> Potassium

• Normal Range: 3.5-5.0 mEq/L
• Significance: Increased in hypofunction of the adrenal cortex; decreased in hyperfunction of the adrenal cortex

> Sodium

• Normal Range: 135-145 mEq/L
• Significance: Decreased in hypocortisolism; Increased in hypercortisolism; Decreased in hypoaldosteronism; Increased in hyperaldosteronism

Question 12

Hypothalamic-Pituitary Axis Tests

Answer 12

• Corticotropic (Cortrosyn) Stimulation Test

- Insulin Tolerance Test

Question 13

Hypothalamic-Pituitary Axis Test: Corticotropic (Cortrosyn) Stimulation Test

Answer 13

Cortrosyn, a synthetic corticotropin (form of adrenocorticotropic hormone), 350 mg, is administered IV followed by measurement of serum cortisol levels 30 and 60 minutes later

> Results:

• cortisol levels of 13-17 mcg/dL = indeterminate
• less than 13 mcg/dL = adrenal insufficiency b/c Cortrosyn should lead to an increase in cortisol levels
• greater than 18 mcg/dL = exclude the diagnosis of adrenal insufficiency

Question 14

Hypothalamic-Pituitary Axis Test: Insulin Tolerance Test

Answer 14

uses hypoglycemic stress to induce cortisol production

• the peak serum cortisol response is measured after insulin challenge of 0.1-0.15 units/kg
• test requires close monitoring of the patient and is contraindicated in patients with a history of seizures or cardiovascular disease

> Results:
-cortisol level of less than 18 mcg/dL and a serum glucose level of less than 40 mg/dL = adrenal insufficiency

Question 15

Treatment

Answer 15

-replacement of cortisol is definitive treatment for adrenal insufficiency
-acute adrenal insufficiency require emergency stabilization with IV fluids and glucose, along with IV administration of glucocorticoids (cortisol) such as hydrocortisone sodium succinate (Solu-Cortef) or dexamethasone (Decadron)
>requires close monitoring, frequent vital signs, level of consciousness, and serum sodium, glucose, and potassium to ensure an adequate dosage of cortisol
-with hyperkalemia, treatment with potassium binding or excreting agents (Kayexalate)
-patients with primary adrenal insufficiency require additional doses of glucocorticoids during periods of stress such as surgery, trauma, or infection

Question 16

Hydrocortisone Sodium Succinate (Solu-Cortef)

Answer 16

advantages: has both glucocorticoid and mineralocorticoid actions

Question 17

Complications associated with Adrenal Insufficiency

Answer 17

• acute adrenal insufficiency (adrenal crisis); leads to severe hypovolemia and hypotension
• b/c of decrease in aldosterone and cortisol, patient loses sodium accompanied by fluid loss
• risk for hyperkalemia and hypoglycemia due to a lack of mineralocorticoids and glucocorticoids

Question 18

Adrenal Crisis/ Acute Adrenal Insufficiency

Answer 18

leads to hypovolemia and hypotension
-Risk factors: seen in patients who have underlying adrenal hypofunction and who undergo stressful events such as trauma, surgery, and infections

Question 19

Nursing Management: Assessment and Analysis

Answer 19

clinical manifestations of adrenal insufficiency, whether acute or chronic, are r/t the actions of the adrenal cortex hormones

• hypotension associated with loss of sodium (hyponatremia) and water
• hypoglycemia associated with decreased cortisol
• hyperkalemia associated with decreased aldosterone
• muscular weakness associated with decreased glucocorticoid (cortisol) and hyperkalemia
• abdominal pain, nausea, weight loss
• emotional liability

Question 20

Nursing Diagnoses

Answer 20

• fluid volume deficit associated with sodium and water losses secondary to lack of aldosterone and cortisol
• risk for unstable blood glucose level associated with decreased cortisol secretion from the adrenal cortex
• risk for decreased cardiac output associated with acute adrenal crisis (loss of sodium and water)
• body image disturbance associated with hyperpigmentation secondary to increased secretion of MSH from the anterior pituitary gland

Question 21

Nursing Interventions: Assessments

Answer 21

> Vital Signs

• decreased blood pressure occurs secondary to lack of aldosterone, leading to loss of sodium and water
• while blood pressure decreases, there is a compensatory increase in pulse rate
• irregular heart rate may be associated with hyperkalemia

> Monitor intake and output
-fluid loss occurs secondary to lack of mineralocorticoid and glucocorticoid, leading to loss of sodium followed by loss of water through the kidneys

> Serum Sodium, Glucose, and Potassium

• decreased gluconeogenesis occurs b/c of lack of glucocorticoid
• lack of glucocorticoid and mineralocorticoid leads to loss of sodium and water and retention of potassium

> Serum Cortisol Levels

• random serum levels less than 3 mcg/dL = insufficiency
• levels less than 13 on corticotropic stimulation test = adrenal insufficiency

Question 22

Nursing Actions

Answer 22

> Ensure vascular access for administration of IV fluids containing sodium and glucose
-loss of water occurs secondary to increased excretion of sodium (direct action of aldosterone)

> Administer corticosteroid
-definitive treatment of acute adrenal insufficiency (adrenal crisis) is administration IV cortisone

> Maintain safety precautions such as placing the patient’s bed in the lowest position and always providing assistance when the patient is getting out of bed
-postural hypotension may develop secondary to fluid losses, placing a greater risk for falls

Question 23

Teachings

Answer 23

> Take oral hormone replacement daily
-adrenal cortex replacement is required to maintain fluid balance and normal glucose levels

> Wear medical alert bracelet
-reduces time to definitive tx in emergency situation

> Clinical Manifestations of adrenal insufficiency
-know the early signs b/c it can progress to adrenal crisis

> Signs of corticosteroid excess
-over-replacement of glucocorticoids results in adverse effects including weight gain and osteoporosis

Question 24

Evaluating Care Outcomes

Answer 24

• treatment with exogenous corticosteroids
• vital signs within normal limits
• increased energy
• stable weight
• emotional stability
• during periods of stress, such as invasive procedures, an increase in exogenous corticosteroids is often necessary
• be aware of adrenal insufficiency, especially when prescribing sedatives, narcotics, or anesthetic agents