Addison’s Disease

IntroductionAddison’s disease, or adrenocortical insufficiency,

occurs when adrenal cortex function is inadequate to meet the patient’s need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is responsible for the vast majority of cases. Other causes include surgical removal of both adrenal glands and infection of the adrenal glands. Tuberculosis and histoplasmosis are the most common infections that destroy adrenal gland tissue. Although autoimmune destruction has replaced tuberculosis as the principal cause of Addison’s disease, tuberculosis should be considered in the diagnostic workup because of its increasing incidence. Inadequate secretion of ACTH from the pituitary gland also results in adrenal insufficiency because of decreased stimulation of the adrenal cortex.

Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency (Porth & Matfin, 2009). Symptoms of adrenocortical insufficiency may also result from the sudden cessation of exogenous adrenocortical hormonal therapy, which suppresses the body’s normal response to stress and interferes with normal feedback mechanisms. Treatment with daily administration of corticosteroids for 2 to 4 weeks may suppress function of theadrenal cortex; therefore, adrenal insufficiency should be considered in any patient who has been treated with corticosteroids.

Patient Profile• Name: A.M.P.• Age: 20 years old• Birthdate: July 31, 1993• Birth place: Tampus, Boac, Marinduque

• Religion: Catholic• Sex: Female• Address: Tampus, Boac, Marinduque

Anatomy

• You have two small adrenal glands that lie just above each kidney. Each adrenal gland has an outer part (adrenal cortex) and an inner part (adrenal medulla). Cells in the adrenal glands make various hormones. A hormone is a chemical which is made in one part of the body but passes into the bloodstream and has effects on other parts of the body.

• Cells in the adrenal cortex (the outer part of the adrenals) make the hormones cortisol and aldosterone. The amount of cortisol that is made is controlled by another hormone called adrenocorticotrophic hormone (ACTH). ACTH is made in the pituitary gland (a small gland that lies just under the brain). ACTH passes into the bloodstream, is carried to the adrenal glands, and stimulates the adrenal glands to make cortisol.

• Cortisol is a hormone that is vital for health. It has many functions which include:– Helping to regulate blood pressure.– Helping to regulate the immune system.– Helping to balance the effect of insulin in regulating the blood sugar level.

– Helping the body to respond to stress.

PathophysiologyRisk Factors: autoimmune, TB, metastatic tumor, hemorrhage

Adrenal gland cannot produce adequate cortisol and

glucocorticoids

Muscle weakness and fatigueWeight loss and decreased appetiteDarkening of your skin (hyperpigmentation)Low blood pressure, even faintingSalt cravingLow blood sugar (hypoglycemia)Nausea, diarrhea or vomitingMuscle or joint painsIrritabilityDepressionBody hair loss or sexual dysfunction in women

Review of SystemNeurologic System: Depression, Emotional lability, Apathy, Confusion, Apprehension, Headache, ShockIntegumentary System: Dark Pigmentation, Cyanosis, PallorCardiovascular System: Hypotension, Rapid and weak pulseRespiratory System: Rapid respirationsGastrointestinal System: Anorexia, Nausea, Vomiting, Abdominal pain, DiarrheaMuscular System: Muscle weaknessRenal System: Low blood glucose, Low serum sodium, High serum potassium, Chronic dehydration

Drug StudyDrug Name

Mechanism of Action

Doses Indication

Contraindication

Side Effects

Nursing Responsibilities

Prednisone

Binds to intracellular glucocorticoid receptors and suppresses inflammatory and immune responses by:• inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivity• stabilizing lysosomal membranes

Adults and adolescents. 5 to 10 mg daily.Children. 5 mg/m2 daily in divided dosesb.i.d.

-To treat adrenal insufficiency and acuteand chronic inflammatory andimmunosuppressive disorders-To treat adrenogenital syndrome

Hypersensitivity to prednisone or its components,systemic fungal infection

CNS: Euphoria, headache, insomnia, nervousness,psychosis, restlessness, seizures,vertigoCV: Edema, heart failure, hypertensionEENT: Cataracts, exophthalmos, glaucoma,increased ocular pressureENDO: Adrenal insufficiency, Cushing’ssyndrome, growth suppression in children,hyperglycemiaGI: Anorexia, GI bleeding and ulceration,increased appetite, indigestion, intestinalperforation, nausea, pancreatitis, vomiting

• Administer once-daily doses of prednisonein the morning to match body’s normalcortisol secretion schedule.• Because prednisone can produce manyadverse reactions, assess regularly for signsand symptoms of such reactions as heartfailure and hypertension. Also monitorfluid intake and output and daily weight.•Monitor growth pattern in children.Prednisone may retard bone growth.• Be aware that prolonged use of prednisonemay cause hypothalamic-pituitary-adrenalsuppression.

GI: Abdominal distention;increased appetite; nausea;peptic ulcer;vomitingGU: Amenorrhea, glycosuria, menstrualirregularitiesHEME: Easy bruising, leukocytosisMS: Arthralgia; aseptic necrosis of femoraland humeral heads;SKIN: Acne; altered skin pigmentation;diaphoresis; Other: Anaphylaxis, hypocalcemia, hypokalemia,hypokalemic alkalosis, impairedwound healing

•When possible, give oral dose with food ormilk to avoid GI distress.• Don’t give acetate injectable suspension byI.V. route.• Give hydrocortisone sodium succinate as adirect I.V. injection over 30 seconds to severalminutes, or as an intermittent or acontinuous infusion. For infusion, diluteto 1 mg/ml or less with D5W, normalsaline solution, or dextrose 5% in normalsaline solution.• Inject I.M. form deep into gluteal muscle,and rotate injection sites to prevent muscleatrophy. Subcutaneous injection maycause atrophy and sterile abscess.

Nursing Care Plan

Discharge PlanningM - The physician prescribed Prednisone 10mg/daily orally.E - Encourage the patient to assist in performing active and passive range of motion exercise and isometric exercises (muscle atrophy) for good blood circulationT - For the treatment, the physician order for continuous prescription of Hydrocortisone 240mg a day.

Health TeachingConduct a health teaching to the client that includes encouraging on good hygiene and performing activities that the patient can do, encourage taking a bath every day to provide comfort, wellness and good skin integrity, advising the patient to increase fluid intake and high protein diet for good recovery of energy. Also fruits like banana, apple, and vegetables.

• Out-patientRemind the patient to come for the follow-up check up

assigned by the physician.

• DietAdvice the patient to have low salt diet, high-protein

diet, increased calcium intake or low fat diet, high fiber and high protein intake.

• SpiritualEncourage patient to have frequent praying to help his

spiritual needs