ADDISON'S DISEASE (CHRONIC PRIMARY ADRENOCORTICAL INSUFFICIENCY)
Addison's disease, caused by a deficiency of cortical hormones.
Causes
Bilateral adrenalectomy or destruction of adrenal cortex idiopathic atrophy or infections such as tuberculosis or histoplasmosis.
Pathophysiology
Inadequate secretion of ACT11 from the pituitary glands +
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Decreased section of adrenal cortex.
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Adrenal insufficiency
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Also, sudden cessation of exogenous adrenocortical hormonal therapy, which suppresses the body's normal response to stress and interferes with normal feedback mechanisms.
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Symptoms of adrenocortical insufficiency
Clinical Manifestations
1. Muscular weakness, anorexia, GI symptoms, fatigue, emaciation, dark pigmentation of the skin, hypotension, low blood glucose, low serum sodium and high serum potassium.
2. Severe cases, the disturbance of Na and K metabolism
3. Depletion of Na and H₂O and severe, chronic dehydration.
4. As disease progresses-->Addisonian crisis medical emergency cyanosis, fever, classic signs of shock pallor, apprehension, rapid and weak pulse, rapid respirations and low BP. Patient may complain of headache, nausea, abdominal pain and diarrhoea, signs of confusion and restlessness. 1
5. Slight exertion, exposure to cold, acute infections or a decrease in salt intake circulating collapse. Stress of surgery or dehydration resulting from preparation for diagnostic tests or surgery may precipitate an Addisonian or hypertensive crisis
Diagnostic Evaluation
1. Clinical Manifestations
2. Decrease in [the concentrations off blood glucose and sodium (hypoglycaemia and hyponatremia)
3 Increased serum potassium hyperkalaemia,
4 Increased WBC count (leucocytosis)
5 Low levels of adrenocortical hormones in the blood and urine.
6 Serum cortisol levels decreased.
7. If the adrenal cortex is destroyed, baseline values are low and ACTH injection fails to cause the normal rise in plasma cortisol and urinary 17-hydroxy corticosteroids If adrenal gland is normal but not stimulated properly by the pituitary, a normal response to repeated dosages of exogenous ACTH is seen, but no response follows the administration of metyrapone, which stimulates endogenous ACTH
Medical Management
1. Immediate treatment to combat shock: restoring blood circulation, administering fluids, monitoring vital signs and placing the patient in a recumbent position with legs elevated.
2. Hydrocortisone is given intravenously followed by 5% dextrose in Normal Saline
3. Vasopressor amines required if hypotension persists. Antibiotics if infection had precipitated adrenal crisis Oral intake initiated as tolerated by the patient.
4. [IV fluids are decreased and oral fluid are accepted gradually) If adrenal gland does not regain function, the patient will require life-long replacement of corticosteroids and mineralo corticoids to prevent recurrence of adrenal insufficiency and to prevent Addisonian crisis in times of stress and illness.
5. Supplement the dietary intake with added salt during times of GI losses of fluids through vomiting and diarrhoea.
Nursing Interventions
1. Assess fluid I & O and serial daily weights.
2. Monitor vital signs frequently, [a drop in BP may suggest an impending crisis]
3. Monitor results of serum sodium and potassium
4. Assess skin turgor and mucous membranes for dehydration.
5. Encourage diet high in sodium and fluid content; administer or teach self-administration of potassium supplements, if prescribed.
6. Administer or teach self-administration of prescribed glucocorticoids and mineralocorticoids; document response.
7. Administer IV infusions of sodium, H₂O and glucose as indicated.
8. Minimize stressful situations.
9. Protect the patient from-infection.
a. Control the patient's contacts so that infectious organisms are not transmitted.
b. Protect the patient from drafts, dampness, exposure to cold.
c. Prevent overexertion
d. Use meticulous handwashing and asepsis.
10. Assess comfort and emotional status of the patient.
a. Control the temperature of the room to avoid sharp deviations in the patient's temperature.
b. Maintain a quiet, peaceful environment; avoid loud talking and noisy radios
11. Observe and report early signs of Addisonian crisis (sudden drop in BP, nausea and vomiting, fever).
12. Assist the patient with ADLs.
13. Provide for periods of rest and activity to avoid overexertion.
14 . Provide a high-calorie, high protein diet.
15. Identify actions to take to avoid factors that may precipitate addisonian crisis (infection, extremes of temperature, trauma)
16. Instruct the patient about manifestations of excessive use of medications and reportable symptoms.
