ATI Med-Surg: Chp 82: Addison's Disease and Acute Adrenal Insufficiency (Addisonian Crisis)

Acute adrenal insufficiency

Acute adrenal insufficiency, also known as Addisonian crisis, has a rapid onset. It is a medical emergency. If it is not quickly diagnosed and properly treated, the prognosis is poor. ● Older adult clients are less able to tolerate the complications of Addison's disease and acute adrenal insufficiency and need more frequent monitoring.

Addison's disease

Addison's disease is an adrenocortical insufficiency. It is caused by damage or dysfunction of the adrenal cortex. ● With Addison's disease, the production of mineralocorticoids and glucocorticoids is diminished, resulting in decreased aldosterone and cortisol.

Medications: Fludrocortisone (Florinef)

Fludrocortisone (Florinef) is a mineralocorticoid used as a replacement in adrenal insufficiency. ■ Nursing Considerations ☐ Monitor weight, blood pressure, and electrolytes. ☐ Hypertension is a potential adverse effect. ☐ Dosage may need to be increased during periods of stress or illness. ■ Client Education ☐ Advise the client to take the medication as directed. ☐ Warn the client to expect mild peripheral edema.

Medications: Hydrocortisone (Cortef), prednisone (Deltasone), and cortisone

Hydrocortisone (Cortef), prednisone (Deltasone), and cortisone ■ Glucocorticoid is used as an adrenocorticoid replacement for adrenal insufficiency and as an anti-inflammatory. ■ Nursing Considerations ☐ Monitor weight, blood pressure, and electrolytes. ☐ Increase dosage during periods of stress or illness if necessary. ☐ Taper dose if discontinuing to avoid acute adrenal insufficiency. ☐ Give with food to reduce gastric effects. ■ Client Education ☐ Advise the client to: > Take medication as directed. > Avoid discontinuing the medication abruptly. > Report symptoms of Cushing's syndrome (round face, edema, weight gain). > Advise the client to take the medication with food. > Report symptoms of adrenal insufficiency (fever, fatigue, muscle weakness, anorexia).

Care After Discharge: Client Education

■ Advise the client to: ☐ Take prescribed medications as instructed and monitor for adverse reactions. ☐ Avoid using alcohol and caffeine. ☐ Monitor for signs of gastric bleeding (coffee-ground emesis; tarry, black stool). ☐ Monitor for hypoglycemia (diaphoresis, shaking, tachycardia, headache). ☐ Report symptoms of adrenal insufficiency (fever, fatigue, muscle weakness, dizziness, anorexia). ☐ To prevent acute adrenal insufficiency, instruct clients who have Addison's disease to increase corticosteroid doses as directed by a provider during times of stress. ■ Inform the client that medication therapy may be lifelong.

Physical Assessment Findings

■ Clinical manifestations of chronic Addison's disease develop slowly. ■ Clinical manifestations of acute adrenal insufficiency develop rapidly. ■ Clinical manifestations: ☐ Weight loss ☐ Craving for salt ☐ Hyperpigmentation ☐ Weakness and fatigue ☐ Nausea and vomiting ☐ Dizziness with orthostatic hypotension ☐ Severe hypotension (acute adrenal insufficiency) ☐ Dehydration ☐ Hyponatremia ☐ Hyperkalemia ☐ Hypoglycemia ☐ Hypercalcemia

Diagnostic Procedures

■ ECG is used to assess for ECG changes or dysrhythmias associated with electrolyte imbalance. ☐ Client Education - Explain procedures to the client. ■ X-ray, CT scan, and magnetic resonance imaging (MRI) scan ☐ Radiological imaging to determine source of adrenal insufficiency, such as a tumor or adrenal atrophy ☐ Client Education - Explain to the client that tests are noninvasive and not painful.

Laboratory Tests

■ Serum electrolytes - increased K+, decreased Na+, and increased calcium ■ BUN and creatinine - increased ■ Serum glucose - decreased ■ Serum cortisol - decreased ■ Adrenocorticotropic hormone (ACTH) stimulation test - ACTH is infused, and the cortisol response is measured 30 min and 1 hr after the injection. With primary adrenal insufficiency, plasma cortisol levels do not rise.

Complications: Acute adrenal insufficiency (Addisonian crisis)

◯ Acute adrenal insufficiency (Addisonian crisis) occurs when there is an acute drop in adrenocorticoids due to sudden discontinuation of glucocorticoid medications or when induced by severe trauma, infection, or stress. ◯ Nursing Actions ■ Administer insulin to move potassium into cell. Glucose often is given with insulin. ■ Administer calcium to counteract the effects of hyperkalemia and protect the heart, as well as sodium polystyrene sulfonate (Kayexalate), a resin that absorbs potassium. ■ If acidosis occurs, administer sodium bicarbonate to promote alkalinity and increase uptake of and move potassium into cells. ■ Loop or thiazide diuretics are used to manage hyperkalemia. ■ Establish an IV line and initiate a rapid infusion of 0.9% sodium chloride. ■ Monitor vital signs and monitor for clinical manifestations of hyperkalemia such as bradycardia, heart block, high T wave, and prolonged PR interval. ■ Monitor electrolytes. ■ Administer hydrocortisone sodium succinate (Solu-Cortef) as replacement therapy. ◯ Client Education ■ Advise the client to notify the provider of any infection, trauma, or stress that may increase the need for adrenocorticoids. ■ Advise the client to take the medication as directed. ■ Advise the client not to discontinue the medication abruptly.

Risk Factors

◯ Causes of primary Addison's disease ■ Idiopathic autoimmune dysfunction (majority of cases) ■ Tuberculosis ■ Histoplasmosis ■ Adrenalectomy ■ Cancer ◯ Causes of secondary Addison's disease ■ Steroid withdrawal ■ Hypophysectomy ■ Pituitary neoplasm ◯ Acute adrenal insufficiency is a life-treating event that left untreated can lead to death. Factors that precipitate acute adrenal insufficiency are as follows. ■ Sepsis ■ Trauma ■ Stress (myocardial infarction, surgery, anesthesia, hypothermia, volume loss, hypoglycemia) ■ Adrenal hemorrhage ■ Steroid withdrawal

Complications: Hyperkalemia/Hyponatremia

◯ Decrease in aldosterone levels can cause an increased excretion of sodium and a decreased excretion of potassium. ◯ Nursing Actions - Monitor electrolytes and ECG. ◯ Client Education ■ Advise the client to take the medications as directed. ■ Instruct the client to report signs of hyperkalemia (muscle weakness, tingling sensation, irregular heart beat).

Complications: Hypoglycemia

◯ Insufficient glucocorticoid causes increased insulin sensitivity and decreased glycogen, which leads to hypoglycemia. ◯ Nursing Actions - Monitor glucose levels. ◯ Client Education ■ Advise the client and family to monitor for hypoglycemia. ☐ Symptoms may include diaphoresis, shaking, tachycardia, and headache. ■ Instruct the client to have a 15 g carbohydrate snack readily available.

The adrenal cortex produces:

◯ Mineralocorticoids - aldosterone (increases sodium absorption, causes potassium excretion in ◯ Glucocorticoids - cortisol (affects glucose, protein, and fat metabolism; the body's response to stress; and the body's immune function) ◯ Sex hormones - androgens and estrogens

Nursing Care

◯ Monitor the client for fluid deficits and electrolyte imbalances. Administer saline infusions to restore fluid volume. Observe for dehydration. Obtain orthostatic vital signs. ◯ Administer hydrocortisone IV bolus and a continuous infusion or intermittent IV bolus. ◯ Monitor for and treat hyperkalemia: ■ Obtain a serum potassium and ECG. ■ Administer sodium polystyrene sulfonate (Kayexalate), insulin, calcium, glucose, and sodium bicarbonate. ◯ Monitor for and treat hypoglycemia: ■ Perform frequent checks of the client's neurologic status, monitor for hypoglycemia, and check serum glucose. ■ Administer food and/or supplemental glucose. ◯ Maintain a safe environment: ■ Provide assistance ambulating. ■ Raise side rails. ■ Prevent falls by keeping floors clear.