Question

Chapter 49 Endocrine Problems

Adrenal Insufficiency or Adrenocortical Insufficiency

Patient Profile

J.S. is a 58-year-old woman brought to the emergency department (ED) at 7:00 am by her husband because when she got up this morning, she was light-headed, confused, and so weak that she could not dress herself. J.S.’s husband immediately drove her to the ED in her pajamas. She has a history of rheumatoid arthritis and had been taking prednisone 10 mg daily.

Subjective Data

• Husband states that J.S. has not been feeling good, has been tired, and has had very little appetite
• Husband states he lost his job a couple of months ago, and J.S. stopped taking her medication a couple of weeks ago because they could not afford it because they no longer had health insurance
• J.S. denies a headache or blurred vision

Objective Data

Physical Examination

• Temperature 98.7°F, pulse 94, respirations 20, blood pressure 100/60
• No difficulty speaking
• Oriented to name only
• Poor skin turgor
• Dry mucous membranes
• Weakness in bilateral upper and lower extremities

Diagnostic Studies

• Lab values

*	Calcium	9.2 mg/dL
*	Sodium	130.0 mEq/L
*	Potassium	5.5 mEq/L
*	HCO3	25.4 mEq/L
*	Chloride	93.5 mEq/L
*	Cortisol	4 mcg/dL (normal 8:00 am level is 5-23 mcg/dL)

Case Study Questions

                                Name: __________________________                 Date: ________________

1. What are four characteristics associated with Adrenal Insufficiency?

a.

b.

c.

d.

2. What other symptoms is J.S experiencing that is not included in the list above, but yet linked to the disease process? Student must list four:

3. What is one major complication associated with adrenal insufficiency or adrenocortical insufficiency and describe it? Additionally, what might trigger this complication in a patient?

a.

4. What diagnostics will be used in diagnosing J.S.?

• 5. What is your critical thinking significance of J.S.’s labs; relate all her labs to the disease process of adrenal insufficiency?
•   
•   
•   

6. What major factor do you believe triggered J.S.’s symptoms?

a.

7. What would you do as the nurse in providing prioritized care to J.S.? Student must list four:

Reference(s):

Harding, M. M., Kwong, J., Roberts, D., Hagler, D., and Reinisch, C. (2020). Lewis’s

     Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11^th Edition),

     St. Louis Missouri: Elsevier.

Answer 1

Answer : Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones, primarily cortisol but may also include impaired production of aldosterone ( a mineralocorticoid ),which regulates sodium conservation, potassium secretion ,and water retention. Major characteristics : 1) Hypoglycemia 2) dehydration 3) weight loss and 4) disorientation .Additional signs and symptoms include : 1) weakness 2) Tiredness 3) dizziness 4) low blood pressure orthostatic hypotension ) 5) cardiovascular collapse 6) muscle aches 7) nausea 8) vomiting and diarrhea. Adrenal insufficiency can present with tanning of the skin that may be patchy or even all over the body .Buccal mucosa goitre and vitiligo may also be present .Eosinophilia may also occur . Complications : Addisonian crisis : if you have untreated Addison's disease, you may develop an addisonian crisis as a result of physical stress such as injuries ,infection or illness. Normally, the adrenal glands produce two to three times the usual amount of cortisol in response to physical stress .With adrenal insufficiency ,the inability to increase cortisol production with stress can lead to an addisonian crisis .An addisonian crisis is a life -threatening situation that result in low blood pressure ,low sugar levels and high levels of potassium .People with this condition have associated autoimmune diseases . Diagnosis : 1) ACTH stimulation test : This is the most specific test for diagnosing adrenal insufficiency. Blood cortisol levels are measured before and after a synthetic form of adrenocorticotrophic hormone, a hormone secreted from the anterior pituitary, is given by injection. 2) Insulin -induced hypoglycemia test : It is used to determine how the hypothalamus ,pituitary and adrenal glands respond to stress .During this test ,blood is dawn to measure the blood glucose and cortisol levels, followed by an injection of fast -acting insulin .Blood glucose and cortisol levels are measured again 30,45 and 90 minutes after the insulin injection .The normal response is for blood glucose levels to fall and cortisol levels to rise . 3 ) CT scan of abdomen : This test used to see if the adrenal glands are diminished in size ,reflecting destruction or enlarged, reflecting infiltration by some independent disease process .This also show signs of calcium deposits ,which may indicate previous exposure to tuberculosis . 1) Emotional stress related to loss of husband job may increased the severity of the disease . 2) she has dry mucous membranes so that there have chances of dehydration. 3) adrenal insufficiency is seen in more than one -third of patients during ongoing low -dose prednisolone treatment for rheumatoid arthritis . 4) stopped the medications is also one of the contributing factor. Nursing care : 1) Check for hupotension and administer iv fluids rapidly according to doctors advise. 2)monitor weight : Lack of appetite due to decreased level of cortisol may cause significant decrease in weight. 3)Encorage oral fluids : deficiency of cortisol may lead to anorexia and GI function .Fluids help to maintain adequate sodium levels and avoid dehydration. 4) monitor intake and output : inform the doctor if urine output below 30 ml and any colour changes.