Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Endocrine Module:Endocrine Module:Adrenal Cortex Hyposecretion: Adrenal Cortex Hyposecretion:

Addison’s DiseaseAddison’s Disease

Addison’s Disease: AetiologyAddison’s Disease: Aetiology

Idiopathic auto-immune condition Idiopathic auto-immune condition (gradual onset and development)(gradual onset and development)

Post-adrenal surgeryPost-adrenal surgery Post-pituitary surgeryPost-pituitary surgery Abrupt or premature discontinuation Abrupt or premature discontinuation

of steroid therapy: (steroid therapy of steroid therapy: (steroid therapy atrophies gland and suppresses atrophies gland and suppresses normal adrenal cortical secretion)normal adrenal cortical secretion)

TBTB

Addison’s Disease: Addison’s Disease: PathophysiologyPathophysiology

Hyposecretion of Corticosteroids:Hyposecretion of Corticosteroids: HypotensionHypotension HypoglycaemiaHypoglycaemia Reduced cellular metabolism (↓energy)Reduced cellular metabolism (↓energy) Hyposecretion of Aldosterone:Hyposecretion of Aldosterone: HyponatraemiaHyponatraemia DehydrationDehydration HyperkalaemiaHyperkalaemia

Addison’s Disease:Addison’s Disease:Clinical ManifestationsClinical Manifestations

Depression, apathy, confusionDepression, apathy, confusion Muscular weakness, fatigue Muscular weakness, fatigue Hypoglycaemia, emaciation, anorexiaHypoglycaemia, emaciation, anorexia Dehydration (hyponatraemia)Dehydration (hyponatraemia) Hypotension (↓ sympathetic stimulation)Hypotension (↓ sympathetic stimulation) GI symptoms: nausea, cramps, diarrhoea, GI symptoms: nausea, cramps, diarrhoea,

headache (↑K) headache (↑K) Dark skin pigment over jointsDark skin pigment over joints

Addison’s Disease: DiagnosisAddison’s Disease: Diagnosis

Patient history and clinical picturePatient history and clinical picture HypoglycaemiaHypoglycaemia HyponatraemiaHyponatraemia HyperkalaemiaHyperkalaemia Leukocytosis (neutrophils)Leukocytosis (neutrophils) Blood and urine cortisol (low)Blood and urine cortisol (low) ACTH present in blood/ urine to ACTH present in blood/ urine to

differentiate from pituitary insufficiency; differentiate from pituitary insufficiency; trial of response to ACTH trial of response to ACTH

Addison’s Disease:Addison’s Disease:Addisonian CrisisAddisonian Crisis

Occurrence:Occurrence:

A patient with Addison’s disease A patient with Addison’s disease when subject to stress, fatigue, when subject to stress, fatigue, infection, exposure to cold, fastinginfection, exposure to cold, fasting

A patient on steroid therapy if rapid A patient on steroid therapy if rapid withdrawalwithdrawal

Addisonian Crisis: Addisonian Crisis: Clinical ManifestationsClinical Manifestations

Circulatory collapse and hypotensionCirculatory collapse and hypotension Hypovolaemic shock, severe Hypovolaemic shock, severe

dehydration dehydration Hyperkalaemia → dysrhythmias, Hyperkalaemia → dysrhythmias,

rapid, thready pulserapid, thready pulse Tachypnoea, cyanosis, pallor, feverTachypnoea, cyanosis, pallor, fever Hypoglycaemia → apprehension, Hypoglycaemia → apprehension,

mental apathy, restlessness → coma mental apathy, restlessness → coma → death → death

Addisonian Crisis: ManagementAddisonian Crisis: Management

ICU: emergency treatment of shockICU: emergency treatment of shock Raise foot of bedRaise foot of bed IV fluids (Dextrose 5%/ Saline 0.45%)IV fluids (Dextrose 5%/ Saline 0.45%) *IV Hydrocortisone**IV Hydrocortisone* IV vasopressor amines (Dopamine IV vasopressor amines (Dopamine

infusion)infusion) IV antibiotics if infection triggered IV antibiotics if infection triggered

crisiscrisis

Addisonian Crisis: Addisonian Crisis: Nursing ConsiderationsNursing Considerations

Strict monitoring of vital signsStrict monitoring of vital signs BP supine and erect (as able) to BP supine and erect (as able) to

assess sympathetic activityassess sympathetic activity Hourly intake/ output (watch for Hourly intake/ output (watch for

acute renal failure)acute renal failure) Observe skin turgorObserve skin turgor Monitor IV fluidsMonitor IV fluids Care and support to patient and Care and support to patient and

familyfamily

Addison’s Disease: Addison’s Disease: Longterm TreatmentLongterm Treatment

Lifelong corticosteroid therapy/ Lifelong corticosteroid therapy/ AldosteroneAldosterone

Monitor clinical response/ blood cortisolMonitor clinical response/ blood cortisol ↑ ↑ steroids in illness, stress, surgery or steroids in illness, stress, surgery or

dizziness (postural hypotension)dizziness (postural hypotension) Early antibiotics if infectionEarly antibiotics if infection Extra salt if vomiting, diarrhoeaExtra salt if vomiting, diarrhoea Quiet lifestyle, avoid ↑ exercise, stressQuiet lifestyle, avoid ↑ exercise, stress Regular screen: DM, osteoporosis, Regular screen: DM, osteoporosis,

cataract, glaucoma cataract, glaucoma

Addison’s Disease: Addison’s Disease: Long-term Nursing ConsiderationsLong-term Nursing Considerations

Patient awareness about steroid therapy:Patient awareness about steroid therapy: Do not miss dose; never stop abruptlyDo not miss dose; never stop abruptly Consult doctor at once if ill or vomiting Consult doctor at once if ill or vomiting Advise carefully about extra requirements Advise carefully about extra requirements

in stress (and early antibiotics)in stress (and early antibiotics) Diet:Diet:↓ ↓ fat, simple CHO;fat, simple CHO;↑ ↑ protein, calciumprotein, calcium Attend for regular screening (BP, cortisol, Attend for regular screening (BP, cortisol,

blood glucose, eye exam, bone density)blood glucose, eye exam, bone density) Low-impact exercise; adequate rest/ sleepLow-impact exercise; adequate rest/ sleep