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T3: Addison's

Chapter 50: Addison's disease

Hypofunction of the adrenal cortex adrenocortical insufficiency
What causes adrenocortical insufficiency? Prinary: Addison's disease, lack of glucocorticoids, mineralocorticoids, & androgens; Secondary: lack of pituitary ACTH secretion, lack of glucocorticoids & androgens
What are the 3 classes of adrenal corticosteroids? glucocorticoids, mineralocorticoids, & androgens
In this disease, amounts of all 3 classes of adrenal corticosteroids are reduced. Addison's disease
What occurs in secondary adrenocortical insufficiency? The corticosteroid and androgen levels are deficient.
What can cause ACTH deficiency? Pituitary disease or suppression of the hypothalamic-pituitary axis because of the administration of exogenous corticosteroids.
What is the most common cause of Addison's in the U.S.? an autoimmune response against adrenal cortex: adrenal tissue is destroyed by antibodies against the patient's own adrenal cortex
Addison's disease is considered a component of? autoimmune polyglandular syndrome
What is autoimmune polyglandular syndrome? A rare syndrome caused by a mutation in a gene that helps to regulate the immune system. It is inherited as an autosomal recessive trait.
What are some other causes of Addison's disease? TB (uncommon), infarction, fungal infections (histoplasmosis), AIDS, and metastatic cancer.
Iatrogenic Addison's disease may be due to what? Adrenal hemorrhage, often in relation to anticoagulant therapy, chemotherapy, ketoconazole (Nizoral) therapy for AIDS, or bilateral adrenalectomy.
Manifestations of Addison's do not tend to become evident until what? Until 90% of the adrenal cortex is destroyed, the disease is often advanced before it is diagnosed.
CM of Addison's disease Have a very slow (insidious) onset and include progressive weakness, fatigue, weight loss, and anorexia as primary features.
In Addison's increased ACTH causes this striking feature. bronze-colored skin hyperpigmentation
In Addison's, where is the bronze-colored hyperpigmentation primarily seen? Sun-exposed areas of the body, at pressure points, over joints, and in the creases, especially palmar creases.
What causes the changes in the skin in Addison's? Due to increased secretion of B-lipotropin (which contains melanocyte stimulating hormone). This tropic hormone is increased b/c of decreased negative feedback & subsequent low corticosteroid levels.
Patients with secondary adrenocortical hypofunction usually do not have hyperpigmented skin because why? ACTH levels are low
CM of adrenal insufficiency orthostatic hypotension, hyponatremia, salt craving, hyperkalemia, N/V/D, irritability, depression
Patients with adrenocortical insufficiency are at risk for what? acute adrenal insufficiency (Addisonian crisis)
What is Addisonian crisis? A life-threatening emergency caused by insufficient adrenocortical hormones or a sudden sharp decrease in these hormones.
What can trigger an Addisonian crisis? stress (from infection, surgery, psychologic distress); sudden withdrawal of corticosteroid hormone therapy (often done by pt lacking knowledge of importance of therapy); adrenal surgery; sudden pituitary gland destruction
CM of glucocorticosteroid and mineralocorticoid deficiencies (Addisonian crisis) hypotension, tachycardia, dehydration, dec. Na, inc. K, dec. glucose, fever, weakness, confusion, severe vomiting, diarrhea, pain in lower back or legs, hypotension may lead to shock which can lead to circulatory collapse
Circulatory collapse associated with adrenal insufficiency is often unresponsive to the usual treatment which is? vasopressors and fluid replacement
Adrenal insufficiency is characterized by what? depressed serum and urinary cortisol levels
ACTH levels will be _____ in primary adrenal insufficiency and ____ in secondary disease. increased; decreased
How is primary adrenal insufficiency confirmed? When cortisol levels fail to rise over basal levels with an ACTH stimulation test.
What are some abnormal lab findings with Addison's? dec. urinary cortisol and aldosterone; hyperkalemia; hypochloremia; hyponatremia; hypoglycemia; anemia; and inc. BUN levels
What diagnostics would be done for Addison's? ECG may show low voltage and peaked T waves caused by hyperkalemia. CT scans and MRI may be used to identify causes other than autoimmune including tumors, fungal infections, tuberculosis, or adrenal calcification.
What is the treatment of adrenocortical insufficiency? Focuses on management of the underlying cause when possible. Main tx is hormone therapy.
What is the most commonly used form of hormone therapy for Addison;s? hydrocortisone b/c it has both glucocorticoid and mineralocorticoid properties
During situations associated with stress, the glucocorticoid dosage must be increased to prevent what? addisonian crisis
Mineralocorticoid replacement with this is administered daily. fludrocortisone (Florinef)
Should salt in the diet be increased or decreased in Addison's? increased
This is a life threatening emergency necessitating aggressive management. Addisonian crisis
How is Addisonian crisis treated? Tx is directed toward shock mgmt & high dose hydrocortisone replacement. Lge volumes of 0.9% NS & 5% dextrose are administered to reverse hypotension & electrolyte imbalances until BP returns to normal.
When a pt with Addison's disease is hospitalized, nursing management is focused on what? Monitoring the patient while correcting fluid & electrolyte imbalance.
What are basic nursing interventions for a patient with Addison's disease? Vitals & s/s of FVD & electrolyte imbalance. Monitor trends of glucose, Na, & K. Baseline data of mental status, vitals, & weight. Complete med hx for interactions w/corticosteroids. Note changes in BP, wt gain, weakness, or s/s of Cushings syndrome.
What drugs interact with corticosteroids? oral hypoglycemics, cardiac glycosides, oral contraceptives, anticoagulants, and NSAIDS
What are some other important interventions when caring for a patient with Addison's? Protect against exposure to infection, & assist w/daily hygiene. Protect pt from noise, light, & environmental temp. extremes. The pt can't cope w/these stresses b/c of the inability to produce corticosteroids.
What should you teach the patient when it comes to glucocorticoid dosing? Should be given in divided doses: 2/3 in the morning & 1/3 in the afternoon
What should you teach the patient about mineralocorticoid dosing? Should be given once daily preferably in the morning.
What is the importance of this dosage schedule with the glucocorticoids & the mineralocorticoids? It reflects normal circadian rhythm in endogenous hormone secretion & decreases the side effects associated with corticosteroid therapy.
Patients w/Addison's disease are unable to tolerate physical or emotional stress w/o additional what? exogenous corticosteroids
Long term care for Addison's revolves around what? Recognizing the need for extra medication & techniques for stress management.
What are some examples of situations necessitating corticosteroid adjustment? fever, flu, teeth extraction, & rigorous physical activity (playing tennis on a hot day or running a marathon). If V/D occur (w/flu), notify doc immediately b/c electrolyte replacement & parenteral admix of cortisol may be necessary.
It is critical that the patient with Addison's wears what or carries this? Wear an identification bracelet (MedicAlert) & carry a wallet card stating the pt has Addison's so that appropriate therapy can be initiated in case of an emergency.
Patient teaching for Addison's Teach pt s/s of corticosteroid deficiency & excess (Cushings), how to take their BP, to increase salt intake, & report any significant changes to their HCP.
An Addison's patient should carry an emergency kit at all times. What should this kit consist of? 100 mg of IM hydrocortisone, syrines, & instructions for use. Teach pt & SO how to give an IM injection in case hormone therapy can't be taken orally.
Corticosteroid therapy is used to relieve s/s associated with many diseases and disorders but what can occur with long-term administration of corticosteroids in therapeutic doses? Serious comps & side effects occur. This therapy isnt rec. for minor chronic cond. Therapy reserved for diseases that carry a risk of death or permanent loss of function & for conditions which short term therapy is likely to produce remission or recovery.
What are the expected effects of corticosteroid therapy? antiinflammatory action, immunosuppression, and maintenance of normal BP
Examples of how a beneficial effect of corticosteroids in one situation may be a harmful one in another. Decreasing inflammation in arthritis can increase the risk for infection. Suppression of inflammation & the immune response can save a person w/anaphylaxis or an organ transplant but cause reactivation of latent TB & reduce resistance to other infections.
The vasopressive effect of corticosteroids is critical in enabling a person to function in stressful situation, but this effect can produce what when used for drug therapy? HTN
What are some side effects of corticosteroid therapy? Dec. K; dec. Ca r/t anti-vitamin D; BP inc b/c of excess blood vol, HTN lead to HF; Inc glucose lead to DM; delayed healing leads to inc risk for wound dehiscence; risk for infection inc.; s/s of inflammation (red, tender, heat, swell, edema) suppressed
What can happen to the skeletal muscles due to corticosteroid therapy? atrophy and weakness occur
What can happen to the fat from extremities due to corticosteroid therapy? redistributed to trunk and face
Protein depletion is a side effect of corticosteroid therapy which can cause what to happen? Decreases bone formation, density, & strength, leading to predisposition to pathologic fractures, especially compression fractures of the vertebrae (osteoporosis).
If corticosteroid therapy is stopped abruptly what is the patient at risk for? acute adrenal crisis
Side effects of corticosteroid therapy. PUD, muscle atrophy/weakness, mood & behavior changes, moon facies, truncal obesity, protein depletion, risk for acute adrenal crisis, dec. K & Ca, inc. glucose & BP, delayed healing, risk for infection, suppressed immune response
When corticosteroids are used as nonreplacement therapies, when should they be taken? Once daily or once every other day. Taken early in the morning w/food to decrease gastric irritation.
Exogenous corticosteroid administration may suppress what? endogenous ACTH and therefore endogenous cortisol (suppression is time and dose dependent)
Because exogenous corticosteroid administration may suppress endogenous ACTH (therefore endogenous cortisol) what should you emphasize to the patient? The danger of abrupt cessation of corticosteroid therapy.
Corticosteroids taken for longer than 1 week will suppress what? adrenal production
Ensure that increased doses of corticosteroids are prescribed in acute care or home care settings in situations of what kind? physical or emotional stress
Corticosteroids-induced osteoporosis is an important concern for patients who receive corticosteroid treatment for prolonged periods of time, longer than what? 3 months
What therapies are used to reduce the resorption of bone? Increased Ca intake, vitamin D supplementation; bisphosphonates (alendronate-Fosamax), and institution of a low impact exercise program.
What kind of diet would you plan for a patient undergoing corticosteroid therapy? Plan a diet high in protein, Ca (at least 1500mg/day), and K but low in fat and concentrated simple carbs such as sugar, honey, syrups, and candy.
What are some measures to ensure adequate rest and sleep for patients undergoing corticosteroid therapy? Daily naps and avoidance of caffeine late in the day.
What should you teach the patient to do to maintain bone integrity while on corticosteroid therapy? develop and maintain an exercise program
Patients on corticosteroid therapy should be taught to recognize edema and restrict Na to how much a day? <2000 mg/day
Patients on corticosteroid therapy should be taught to monitor glucose levels and recognize symptoms of hyperglycemia such as? polydipsia, polyura, blurred vision; report symptoms or glucose levels exceeding 120 mg/dL
Patients on corticosteroid therapy should see an eye specialist yearly to assess for what? development of cataracts
What are some safety measures for patients on corticosteroid therapy? Get up slowly from bed or chair, use good lighting to avoid accidental injury.
Patients on corticosteroid therapy should do what to prevent infections? Maintain good hygiene practices and avoid contact with persons with colds or other contagious illnesses.
Created by: eblanc1
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