ADDISON’S disease/ CUSHING’S disease/

Adrenocortical Insufficiency HYPERCORTICOLISM

Main
⮚ Hyposecretion of glucocorticoids, ⮚ Hypersecretion of glucocorticoids
Problem
mineralocorticoids, and sex (cortisol) and mineralo corticoids
hormones) and sex hormones due to
hyperactivity by the adrenal
⮚ The adrenal glands are damage and
cortex due to Increase secretion
cannot produce sufficient amount of of ACTH
cortical hormones
⮚ Due to hypersecretion of adrenal
⮚ Everything is LOW and SLOW except
cortex: Everything is high and
K, Ca, PR fast except K, Ca, PR
⮚ High K, Ca, PR ⮚ When aldosterone ins high, K is
low. Aldosterone promotes
excretion of Potassium
⮚ In CS, there is increased protein
catabolism causes decrease
calcium absorption (low calcium)
⮚ When blood pressure is high, the
PR goes slow
⮚ Women age 20-40 are commonly
affected

Causes of CD
⮚ Autoimmune or atrophy of adrenal ⮚ Prolonged steroid therapy / Use
glands is responsible for 80% to 90% of CORTICOSTEROIDS
of all cases medication
⮚ Surgical removal of adrenal glands ⮚ Over production of
and corticosteroids
⮚ Infection( TB, fungal disease, ⮚ Hyperplasia of Adrenal glands-
Histoplasmosis) are the most results to excessive production of
common infections that destroy the hormones by the adrenal cortex
adrenal gland tissue
⮚ Pituitary adenoma/tumor
⮚ Drugs- use of anticoagulants produces ACTH and stimulates
(resulting to adrenal hemorrhage), the adrenal cortex to increase its
anti convulsant (Phenytoin hormone secretion
(Dilantin), phenorbarbital and
antibiotics (Rifamficin) can be
 associated in the manifestations of
⮚ Increase secretion of ACTH due
Primary Adrenal Insufficiency
to malignancies like bronchogenic
⮚ Inadequate secretion of ACTH from carcinoma
the PG is a secondary cause of
Adrenocortical insufficiency as a
result of decreased stimulation of
the adrenal cortex
⮚ Stress- SUPRESS the function of the
adrenal cortex resulting to Adrenal
insufficiency

Clinical Concept: EVERYTHING IS LOW and SLOW Concept: Everything is HIGH, Except K,
Manifestations. except K, CA, PR. Ca, and PR
The signs and sx of Initial manifestations
CD are primamrily Classic Manifestation:
⮚ Bronze skin/ dark skin pigmentation
results of - Central type or truncal obesity
oversecretions of in the knuckles, knees and elbows - with buffalo hump (in the neck,
glucocorticoids, when adrenal cortex is unable to and supraclavicular areas) due to
mineralocorticoids secrete adequate amount of altered fat distribution
and androgen hormones, the APG is triggered to - Moon’s face appearance and
secrete hormones the ACTH and may experience oiliness and acne
Melanocyte Stimulating Hormone - with thin extremities-due to
production. Resulting to excessive protein catabolism
hyperpigmentation of the skin producing muscle wasting
⮚ Fatigue and Weakness- due to - masculinization/ virilization traits
Hirsuitism among women-
hyperkalemia and hypoglycemia
excessive growth of hair
Other Manifestations - Thin Skin fragile easily
⮚ Hypotension- due to weak pulse and traumatize (Easy bruising
DHN petechiae, ecchymosis), Purple
⮚ Anorexia, NV striae in the abdomen
⮚ Hyponatremia- due to decrease - Fatigue and lassitude
Aldosterone (exhaustion)
⮚ Hypoglycemia- due to low cortisol - Weight gain- truncal obesity
or glucocorticoid secretions - Retention of sodium and water
⮚ Weight loss due to loss of Na and occurs as a result of increased
Water mineralocorticoid activity
⮚ Hyperkalemia- it can’t the excretion producing hypertension and
K due to Low aldosterone. heart failure
⮚ Menstrual changes in women and - Sleep disturbance due to diurnal
impotence in men- due to secretion of cortisol
hyposecretion of sex hormones - Amenorrhea, decrease libido
(men and women)
 ⮚ Depression, emotional lability, - Gynecomastia Impotence among
apathy, and confusion are present men
(20&-40%) - Poor wound healing, recurrent
infections- Low resistance to
infection
- Edema

Diagnostic Serum Cortisol

⮚ Decrease serum cortisol levels-
⮚ high early in the morning
fasting is required, bed rest for 2 (6-8am) and lower in the
hours before the test-activity evening (4-6PM)
increases cortisol level. ⮚ this variation is lost with CS
⮚ Serum Electrolytes-Hyponatremia, ⮚ High- Cushing
⮚ Low- Addison’s Disease
Hyperkalemia
⮚ FBS- hypoglycemia due to decrease Urinal cortisol
⮚ requires 24urine collection
glucocorticoid secretion ⮚ Results are urinary cortisol test
⮚ Increase WBC- indicates are three times higher than
leukocytosis normal range, CS is assumed.
⮚ Stress, obesity, anticonvulsant,
estrogen and rifampin can falsely
elevate cortisol levels

Dexamethasone (Decadron) suppression

test
⮚ 1mg/ 8mg is given at bedtime to
suppress diurnal formation of
ACTH
⮚ Plasma cortisol level is obtained
at 8 am
⮚ Supression of cortisol less than
5mg/dl indicates that the
hypothalamic pituitary adrenal
axis is normal
⮚ High cortisol indicates Cushings
or Pituitary tumor
⮚ Low- Addison’s Disease

Hypernatremia,
Hyperglycemia- increase secretion of
glucocorticoid through GTT
Hypokalemia (muscle weakness),
⮚ Hypocalcemia- osteoporosis
 ⮚ MRI, CT scan- pituitary or
adrenal tumors

Assessment ⮚ Bronze skin/ dark skin ⮚ Patient activity and ability to

pigmentation in the knuckles, carry out routine and self care
knees and elbows activities
⮚ Fatigue and Weakness ⮚ Observe for trauma, skin
⮚ Weight loss breakdown, bruising and edema
⮚ Menstrual changes in women and ⮚ Changes in physical appearance
impotence in men like moon’s face, truncal
⮚ Emotional lability, apathy, and obesity, thin extremities,
confusion

Nursing Diagnosis - Fluid volume deficit - Fluid volume excess

- Fluid and electrolytes imbalance - Fluid and electrolytes Imbalance
- Activity Intolerance - Disturbed body image r/t
- Disturbed Body Image impaired physical appearance
- Risk for injury related to
weakness
- Risk for infection related to
altered protein metabolism and
inflammatory response
- Risk for activity intolerance
- Impaired for skin integrity r/t
edema, poor wound healing and
thin and fragile skin
- Ineffective coping related to
mood swings, irritability and
depression.

Planning - To manage shock, restore blood - Decrease the risk of injury,

circulation and maintain hydration infection, inactivity
- To combat infection - Improve skin integrity, body
image, mental functions and
absence of complciations

Medical - Administering fluids NS Transsphenoidal Hypophysectomy-

management - Vasopressors to increase BP if removal of tumor in the pituitary gland,
hypotension persist as the treatment of choice and has 80%
- Corticosteroids (Solu-Cortef), success rates
Mineralocorticoids (fludrocortisone) Radiation of the pituitary gland – may
or glucocorticoids (Bethamethasone, take several months to control the
symptoms
Dexamethasone, Hydrocortisone)
Adrenalectomy- treatment of choice in
patients with unilateral adrenal
hypertrophy
 Insulin/OHA- to decrease blood sugar
Adrenal enzyme inhibitors/ Adrenal
Supressant- (Cytadren, metopirone,
ketoconazole)- to reduce
hyperadrenalism

Interventions - Assess health history and physical Decreased risk for injury
examination and level of stress ⮚ Protect from trauma- to prevent
- Assess skin for changes in color and
bruising and fracture. Pt who is
turgor which indicate adrenal
weak may require assistance in
insufficiency and hypovolemia
ambulation to avoid falling or
- Assess change in weight, muscle
bumping onto sharp corners of
weakness, fatigue or stress as these
the furniture
will precipitate the acute crisis
- Monitor VS particularly BP and PR ⮚ Inform the client that there will
to assess inadequate fluid volume. A be slow wound healing.
decrease in SP may indicate fluid ⮚ Diet: Maintain Low Na, LOW
depletion CHO- there is hypernatremia and
- Place pt in RECUMBENT position hyperglycemia,
with the legs elevated ⮚ Diet: High CHON, K, Ca, and Vit D
- Monitor F and E balance to minimize muscle wasting and
- Administer NS IV fluids to prevent osteoporosis
severe hypotension and dehydration
- Encourage oral fluids and foods rich Decreasing the Risk for Infection
in sodium to restore and maintain ⮚ Avoid exposure to others with
fluid and electrolyte balance infection
- Instruct the patient to avoid Encourage rest and activity- to prevent
unnecessary activity, infection and complication of immobility and have rest
stress to prevent hypotensive periods to reduce weakness and fatigue.
episode and Addisonian crisis
- Diet: High Na ,CHO,CHON and low K
- Administer and instruct the client
that treatment will involve lifelong Promoting skin integrity
administration of glucocorticoids, ⮚ Change position frequently -to
mineralocorticoids (fludrocortisone)
prevent skin breakdown
and corticosteroids.
(Bethamethasone, Dexamethasone, ⮚ Assess the skin and bony
Hydrocortisone.) to prevent prominences as these are prone
recurrence of adrenal insufficiency for skin breakdown
⮚ Avoid use of adhesive tape it can
irritate the skin and tear the
fragile tissue when tape is
removed
Improving body image
⮚ Participate in discussion on the
effect of physical changes they
had to improve self concept and
relationship with others
⮚ Diet: Low CHO, LOW sodium,
High CHON intake it can modify
weight and may reduce some
bothersome signs

Improve coping
⮚ Encourage pt and family
members to verbalize their
feelings and concerns
⮚ Psychotic behavior should be
reported.

⮚ Instruct the client to report signs

of infection because the anti
inflammatory effects of
corticosteroids may mask the
signs of infection or inflammation
⮚ Instruct the client that treatment
will involve lifelong
administration of glucocorticoids
synthesis inhibitors (ex:
Mitotane)
⮚ Adrenal Supressant- (Cytadren
and metopirone)
⮚ Antidiabetic agent- Insulin/ OHA

⮚ Diuretics-lasix

⮚ K supplement- KCL

⮚ Administer chemo agent and

radiation therapy as prescribe
 ⮚ Prepare the
Hypophysectomy/Bilateral
Adrenalectomy

Pre-operative Care for Adrenalectomy

⮚ Complete history and physical
examination is mandatory in the
evaluation of a patient with an
adrenal mass.
⮚ A complete endocrinologic
evaluation should include
measurement of serum
electrolytes, serum hormone
levels, and urine levels of steroid
hormones and their metabolites
⮚ Monitor VS, blood glucose level,
F and E balance
⮚ Consent must be signed and
witnessed.
⮚ NPO
⮚ large-bore intravenous line
should be inserted and
electrolyte imbalances such as
hypokalemia should be
corrected preoperatively
⮚ the patient should be typed and
screened because of the
potential for blood loss during
surgery
⮚ Bowel preparation isn't
mandatory for the procedure;
however, it can be helpful to
decompress the bowel to
facilitate the laparoscopic
approach

Manage ADDISONIAN CRISIS POST ADRENALECTOMY

ADDISIONIAN - a life threatening cause by acute - Monitor pt for adrenal crisis for
CRISIS adrenal insufficiency, severe lacking of 12 hrs -48 hours after surgery
mineralocorticoids and glucocorticoids due to reduction of high levels of
- Precipitated by stress, Surgery, circulating adrenal hormones
infection, trauma
- Cathecolamine level drops as a
result of the surgery which can
Signs
 - severe headache, severe abdominal result to cardiovascular collapse,
and lower back pain, severe hypotension and shock
hypotension, severe hypoglycemia , - Monitor the patient closely
hyponatremia, Shock, hyperkalemia, particularly BP, signs of acute
- generalized weakness, irritability and
hemorrhage. Hemorrhage can
confusion related to severe
hypoglycemia
occur because of high vascularity
- Cyanosis related to shock, fever, NV, of the adrenal glands.
pallor, diarrhea - Assess the patient's level of
pain and medicates the patient
Management for pain as ordered.
- Patient are encouraged to
ambulate shortly following
- Monitor VS especially BP surgery.
- Monitor neurological status - urinary drainage catheter is
- Monitor I and O removed on the first
- Monitor sodium and K and glucose levels postoperative day.
- Administer - A clear-liquid diet is started on
glucocorticoid(hydrocortisone) IV with
the first postoperative day, and
vasopressors, NSS IV then oral fluids to
the diet is advanced as
reverse shock and hyponatremia
tolerated.
- Serum cortisol levels are
evaluated to assure that no
element of adrenal insufficiency
requires supplementation.
- Instruct the patient that lifelong
glucocorticoid replacement
therapy is necessary with
bilateral adrenalectomy
- Temporary glucocorticoid
replacement up to 2 years is
necessary for unilateral
adrenalectomy
- Follow-up with the surgeon is
usually a few days to a week
after surgery. Patients can
generally return to unrestricted
activity approximately 4 weeks
after surgery.

Nursing ⮚ Monitor BP. Retention of sodium and

Interventions in water may cause elevation of BP
Steroid Therapy ⮚ Monitor weight, I and O. presence of
(Glucocorticoids, edema
Mineralocorticoids)
⮚ Avoid exposure to infection. Steroids
may mask the signs of infection and are
immunosuppressant.
⮚ Monitor Ca and K levels. Steroids may
cause hypokalemia and hypocalcemia
⮚ Give steroids after Meals. This stimulate
gastric acid secretion resulting to gastric
irritation and PUD
⮚ Diet:
- High CHON and High CHO- provides
nutritional supports to prevent muscle
wasting
- High K- prevent hypokalemia
- Low Na- prevent hypernatremia and
retention of water.
⮚ Monitors the Side effects of Steroids
- Hyperglycemia, Hypokalemia,
Hypocalcemia
- Hypertension
- Edema- due to Na and water retention
- Increase susceptibility to infection-
immunosuppressant
- Mood swings
- Gastric irritation
⮚ Dose should be tapered and not stop
abruptly- to prevent Addisonian Crisis.