ADDISON’S DISEASE (ADRENAL INSUFFICIENCY)

ADDISON’S DISEASE (ADRENAL INSUFFICIENCY) – Etiology, Pathophysiology, Signs and Symptoms, Diagnostic Evaluation and Nursing Management

Addison’s disease is a disorder that occurs when the body produces insufficient amounts of certain hormones produced by adrenal glands. In Addison’s disease, adrenal glands produce too little cortisol and often insufficient levels of aldosterone as well.

Glucocorticoids: These hormones, which include cortisol, influence our body’s ability to convert food fuels into energy, play a role in immune system’s inflammatory response and help our body respond to stress.

Mineralocorticoids: These hormones, which include aldosterone, maintain body’s balance of sodium and potassium to keep blood pressure normal.

Androgens: These male sex hormones are produced in small amounts by the adrenal glands in both men and women. They cause sexual development in men and influence muscle mass, libido and a sense of well-being in both men and women.

ETIOLOGY

• Primary Adrenal Insufficiency: Addison’s disease occurs when the cortex is damaged and does not produce its hormones in adequate quantities. The failure of adrenal glands to produce adrenocortical hormones is most commonly the result of the body attacking itself (autoimmune disease). For unknown reasons, immune system views the adrenal cortex as foreign, something to attack and destroy.

Others causes of adrenal gland failure may include:

1. Tuberculosis
2. Other infections of the adrenal glands
3. Spread of cancer to the adrenal glands
4. Bleeding into the adrenal glands

• Secondary Adrenal Insufficiency: Adrenal Insufficiency can also occur if pituitary gland is diseased. The pituitary gland makes a hormone called adrenocorticotropic hormones (ACTH), which stimulates the adrenal cortex to produce its hormones. Inadequate production of ACTH can lead to insufficient production of hormones.
• Another more common cause of secondary adrenal insufficiency occurs when people who take corticosteroids for treatment of chronic conditions, such as asthma or arthritis, abruptly stop taking the corticosteroids.

PATHOPHYSIOLOGY

• Addison’s disease is a chronic condition that results from partial or complete adrenal destruction
• ACTH acts primarily to regulate the adrenal release of glucocorticoids, primarily cortisol, mineralocorticoids including aldosterone; and sex steroids that supplement those produced by the gonads.
• ACTH secretion is controlled by corticotrophin releasing hormone from the hypothalamus and by negative feedback control by the glucocorticoids.
• Cortisol deficiency causes decreased liver gluconeogenesis. Glucose levels of patients on insulin maybe dangerously low.
• Aldosterone deficiency causes increased renal sodium loss and enhances potassium reabsorption. Sodium excretion causes a reduction in water volume that leads to hypotension.
• Androgen deficiency may result in decreased hair growth in axillary and pubic areas, loss of erectile function, or decreased libido.

Autoimmunity is the most common cause of adrenal insufficiency —- this leads to gradual destruction and loss of cortical tissues — cortisol deficiency causes decreased liver glucogenesis (glucose level of patients on insulin may be dangerously low) — this further leads to deficiency of glucocorticoids as well as mineralocorticoids — this results adrenocortical hypofunction

SIGNS AND SYMPTOMS

Addison’s disease symptoms usually develop slowly, often over several months, and may include:

• Muscle weakness and fatigue
• Weight loss and decreased appetite
• Darkening of your skin (hyperpigmentation)
• Low blood pressure, even fainting
• Salt craving
• Low blood sugar (hypoglycemia)
• Nausea, diarrhea or vomiting
• Muscle or joint pains
• Irritability
• Depression
• Body hair loss or sexual dysfunction in women

In acute adrenal failure (Addisonian crisis), the signs and symptoms may also include:

• Pain in lower back, abdomen or legs
• Severe vomiting and diarrhea, leading to dehydration
• Low blood pressure
• Loss of consciousness
• High potassium (hyperkalemia)

DIAGNOSTIC EVALUATION

• Blood test: measuring blood levels of sodium, potassium, cortisol and ACTH gives an initial indication of whether adrenal insufficiency may be causing signs and symptoms. A blood test can also measure antibodies associated with autoimmune Addison’s disease.
• ACTH stimulation test: this test involves measuring the level of cortisol in blood before and after a injection of synthetic ACTH. ACTH signals adrenal glands to produce cortisol. If adrenal glands are damaged, the ACTH stimulation test shows that output of cortisol in response to synthetic.
• Insulin-induced hypoglycemia test: occasionally, this test has to be done if pituitary disease is a possible cause of adrenal insufficiency (secondary adrenal insufficiency). The test involves checking blood sugar and cortisol levels at various intervals after an injection of insulin. In healthy people, glucose levels fall and cortisol levels increase.
• Imaging tests: computerized tomography (CT) scan of abdomen to check the size of adrenal glands and look for other abnormalities that may give insight to the cause of the adrenal insufficiency.

MANAGEMENT

• Oral corticosteroids, fludrocortisones to replace aldosterone. Hydrocortisone, prednisone or cortisone acetate maybe used to replace cortisol.
• Corticosteroid injections
• Androgen replacement therapy: to treat androgen deficiency in women, dehydroepiandrosterone can be prescribed.
• An ample amount of sodium is recommended, especially during heavy exercise, when the weather is hot, or gastrointestinal upsets, such as diarrhea.

Management of Addisonian Crisis

Addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium. This situation requires immediate medical care. Treatment typically includes intravenous injections of:

• Hydrocortisone
• Saline solution
• Sugar (dextrose)

Nursing Management

Assessment

Assessing the Patient

• Assess the daily weights or intake and output to monitor fluid volume
• Check the pulse careful, at least every 4 hours
• Assess bone prominences for pressure ulcers in immobilized clients
• Monitor for exposure to cold and infections
• Assess for manifestations of sodium and potassium imbalance
• Skin should be assessed for changes in color and turgor which could indicate chronic adrenal insufficiency

Diagnosis

1. Risk for Injury: Addisonian crisis related to adrenal insufficiency

Interventions

• Monitor for sudden profound weakness, severe abdominal, back and leg pain
• Immediately on admission, 1000 ml of normal saline with water soluble glucocorticoid added is rapidly infused.
• Hypoglycemia is controlled by a glucose infusion
• Monitor BP, administer IV infusion and medication
• Monitor hourly urine output and minimize exposure to emotional and physical stress
• Observe for manifestation of glucocorticoid overdose and overhydration, such as generalized edema, hypertension, psychosis and loss of consciousness.
• When the client can tolerate food and fluids by mouth, steroid replacement can be administered orally
• Keep bed in lowest position, to increase ease with which patient can get into bed and decrease the possibility of failing
• Keep side rails up to all times unless patient refuses
• Instruct patient to call for assistance when getting into or out of bed

• Deficient fluid volume related to inability to conserve fluid secondary to glucocorticoid deficiency.

Interventions

• Monitor intake and output hourly
• Monitor blood pressure and heart rate hourly until normal
• Monitor weigh daily: to determine fluid and nutritional needs. Fluid deficit results in weight loss. Fluid restoration results in weight gain
• Administer intravenous fluids as prescribed
• Monitor hemoglobin, blood urea nitrogen and serum creatinine daily
• Administer cortisol as prescribed

• Ineffective coping related to inability to respond to stressors secondary to adrenal insufficiency

Interventions

• Decrease environmental stressors (noise, lights, and temperature changes) patient has reduced ability to respond to any stressors. External stressors need to be controlled until patient is able to cope in his usual manner
• Explain all procedures and interventions to the patient this will help to reduce the fair and anxiety
• Maintain consistency of care providers for first 24 hours. Consistency of personnel increases the patient trust and reduce stress
• Provide care in calm and unhurried manner. If the nurse is calm the patient is more likely to be calm
• Encouraging family members to remain with patient, if they are comforting to him. The presence of family members often increases comfort and security and reduce stress.