Question

You are working on a medical/surgical floor with a client with adrenal dysfunction. The client is a 61-year-old male who presented to the ED in a markedly unwell state. He complains of progressive development of symptoms that include feeling generally not well, weakness, and fatigue. He is dizzy most of the time, and it gets worse upon standing. During your admission assessment he comments on unintentional weight loss and a darkening of his skin, "like a suntan.” His vital signs on admission are: P = 110, RR = 20, BP = 95/55, & T = 97.6 (F). He is diagnosed with primary adrenal insufficiency or Addison’s disease.

Answer the following questions:

1. Explain the pathophysiology of your clients' disease processes.

2. Explain the fluid volume, electrolyte, hemodynamic, and metabolic imbalances your clients are experiencing.

3. What other lab value abnormalities would you anticipate?

4. What symptoms, other than the ones listed, might your clients manifest?

5. What tests would confirm the diagnoses?

6. What medical interventions do you anticipate?

7. What medications do you expect to be ordered, and what are the nursing implications of those meds?

8. What are your priorities in planning care for these clients?

9. What nursing interventions will you implement?

10. What discharge teaching will you provide?

Answer 1

Question 1

Addison's disease is primary chronic adrenocortical insufficiency.There is progressive chronic destruction of 90% of adrenal cortex on both sides.Any condition that causes marked destruction of adrenal cortex can cause this disease. The causes include tuberculosis, autoimmune adrenalitis, histoplasmosis,sarcoidosis,metastatic cancers etc.Most common causes are tuberculosis and autoimmune. Bilaterally adrenal glands will be small and shrunken.Histopathology examination will reveal features of tuberculosis, sarcoidosis etc or a lymphocytic infiltrate in autoimmune adrenalitis. The clinical manifestations are due to decreased secretion of adrenocortical hormones

Question 2

Mineralocorticoid ( aldosterone ) deficiency causes failure of reabsorption of sodium ions,chloride ions and water through the renal tubules,and is lost in urine.This causes hyponatremia, reduced extracellular fluid volume. As a result there is decreased cardiac output and hypotension.Because of the impaired sodium reabsorption, potassium and hydrogen secretion is also affected. This cause hyperkalemia and acidosis.

Glucocorticoid (cortisol) deficiency makes the patient unable to maintain normal blood glucose levels in between meals producing hypoglycemia.This is because cortisol is needed for the process of gluconeogenesis.Also mobilisation of proteins and fat from tissues is affected. Sluggish mobilisation of energy makes the person lethargic.Even if nutrients are available, there will be muscle weakness. Also the person will be susceptible to deteriorating effects of stress.

When there is decreased cortisol secretion, negative feedback to the hypothalamus and anterior pituitary will not occur. As a result, there is excessive secretion of ACTH and MSH(melanocyte stimulating hormone). This causes hyperpigmentation

Question 3

Serum metabolic parameters

-Sodium:- reduced

-Potassium :- increased

-Creatinine:- increased

-Glucose:- decreased

Arterial blood gas analysis

-Shows metabolic acidosis

Other blood investigations

-Normochromic anemia

-TSH increased, other signs of hypothyroidism will be seen

Question 4

The clinical features include

-Asthenia(weakness, lethargy and weight loss)

-Hyper pigmentation of skin and mucous membranes

- Arterial hypotension

-Episodes of hypoglycemia

-Lack of androgens causing loss of hair in women

-Vague gastrointestinal symptoms such as nausea, vomiting, abdominal pain,anorexia

-Reduced GFR, acidosis,hyperkalemia, low serum sodium, chloride and bicarbonate

-Tremor ,restlessness ,confusion etc

Question 5

A short cosyntropin test would confirm the diagnosis.Cut off value is cortisol levels less than 16-18microgram/dl 30-60 minutes of ACTH stimulation.

Question 6

Medical interventions include fluid and electrolyte replacement in the form of intravenous saline with added electrolytes. Intravenous hydrocortisone is the treatment of choice.Vasopressors such as dopamine hydrochloride can be given

Question 7

Replacement of hormones(fludrocortisone acetate,dihydroepiandrosterone, hydrocortisone) is the treatment