Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)

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Outline

Pathophysiology

The adrenal glands, located above the kidneys, fail to produce an adequate amount cortisol, aldosterone or androgens. Cortisol is a glucocorticoid that influences the body’s ability to respond to stress and produce energy. Aldosterone is a mineralocorticoid that maintains the sodium-potassium balance that regulates blood pressure. Androgens are responsible for sexual development of men and the influence of muscle mass and sense of well-being in men and women.

Etiology

A decrease in adrenal gland function may be caused by an autoimmune disease that damages the adrenal glands in which the body attacks the adrenal glands as if they were a foreign body. Damage to these glands may also be a result of severe infection of the adrenal glands, tuberculosis, or the spread of cancer.

Desired Outcome

Maintain adequate hormone levels for optimized ability to create energy and respond to stress and electrolyte balance to regulate blood pressure

Addison’s Disease (Primary Adrenal Insufficiency) Nursing Care Plan

Subjective Data:

  • Fatigue
  • Lower back / leg pain
  • Abdominal pain
  • Irritability / depression
  • Reports significant weight loss

Objective Data:

  • Decreased blood pressure
  • Electrolyte imbalance
    • Decreased sodium
    • Increased potassium
  • Severe vomiting, diarrhea
    • Dehydration
  • Loss of consciousness

Nursing Interventions and Rationales

  • Monitor weight
  Lack of appetite due to decreased levels of cortisol may cause significant decrease in body weight
  • Encourage oral fluids
  Deficiency of cortisol may lead to anorexia and impaired GI function. Encourage oral fluids to help maintain adequate sodium levels and avoid dehydration.
  • Minimize stress and assist with activities / provide rest periods
  Simple stress and overexertion can cause a life-threatening Addisonian crisis due to lack of corticosteroids that help the body react to and manage stress.
  • Monitor nutrition
  Aldosterone deficiency causes the kidneys to excrete sodium which may result in salt cravings. Encourage patients to increase salt intake and supplements as necessary to prevent hyponatremia. Encourage patients to eat high protein / low carb snacks and meals as tolerated followed by rest periods to prevent fatigue due to hypoglycemia and to facilitate digestion.
  • I & O – monitor intake and output
  Monitor urine for decreased output (desired >30ml/hr), concentration and color which may be darker
  • Assess vitals; temperature, blood pressure and heart rate – watching for orthostatic changes and hyperpyrexia
  • A decrease of 15 mm Hg or more and increase in heart rate (normal <100bpm) may indicate reduced circulation of fluids such as with dehydration
  • Increased temperature may be a sign of Addisonian crisis due to hormonal and fluid imbalance
  • Monitor EKG for signs of hyperkalemia
  • Lack of Aldosterone means increased sodium excretion and increased potassium retention.
  • Signs of hyperkalemia will include peaked T waves and prolonged QRS complex.
  • Monitor for signs of dehydration by noting mucus membranes and skin turgor
  Tenting of the skin and dry mucous membranes indicate dehydration., which is common due to vomiting and anorexia.
  • Administer Medications
    • Kayexalate
    • Cortef or Cortone
    • Prednisone
    • Florinef
  • Kayexalate – Can be given orally or by enema to reduce potassium levels
  • Cortef or Cortone and prednisone may be given orally or IV to increase cortisol levels
  • Florinef – Given orally to promote replacement and retention of sodium and water

Writing a Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)

A Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

We are going to make a care plan for Addison’s disease. Addison’s disease is when the adrenal glands, which are located above the kidneys, fail to produce an adequate amount of cortisol, aldosterone, or androgens. Some things that we want to be mindful of with taking care of these patients are EKG monitoring. We want to get frequent vital signs. We want to assess these patients for what’s called an Addisonian crisis. We would like to monitor I’s and O’s and we want to assess for dehydration. The desired outcome with Addison’s patients is to make sure we maintain adequate hormone levels for optimized ability to create energy and respond to stress. And, we want to keep those electrolytes balanced and help regulate their blood pressure. When these patients come in to see you, they are going to have a list of complaints. One of the things that they are going to tell you, some of the objective things that they’re going to say is they are going to complain about being fatigued or tired. 

Okay. They’re also going to complain of pain. So they’re going to have lower back pain, leg pain, abdominal pain, or they are going to be in pain. They’re also going to be, you’re going to notice they’re going to be irritable. They are going to, uh, complain of being depressed and they are going to, uh, report significant weight loss. These patients are going to be thin. Um, these patients, when you see them and you’re going to observe them. Some of the objective things that you’re going to notice is you’re going to notice that on their vital signs, they are going to have low BP. They’re going to have decreased blood pressure. Their electrolytes are going to be way out. So you may see them with hyponatremia or low sodium, or hyperkalemia. Uh, they’re going to have high potassium. They’re also going to have severe vomiting and diarrhea. 

They’re going to be losing those electrolytes that way. They’re also going to have some dehydration as well as it’s possible that they’ll have some, uh, loss of consciousness. So when, uh, caring for these patients, some things that we want to focus on, the first thing that we want to do is we want to get them hooked up to an EKG, and we want to monitor for signs of high potassium or hyperkalemia. And the reason why is because they have low aldosterone levels. And aldosterone is just a hormone that regulates sodium and potassium. It retains potassium and it loses sodium. So if aldosterone is low because of Addison’s, that means potassium is high. So low aldosterone equals high K. The next thing we want to do is we want to monitor for signs of dehydration. We want to take a look at their mucus membranes, their skin turgor. 

Remember, if a patient is tense, when you assess the skin turgor, that means that they are dehydrated. And this is very common when the patient has severe diarrhea and vomiting.  Following that, we want to encourage oral fluids when necessary. And we want to make sure that we monitor their ins and outs, and we want to make sure we let them know that we will need to institute some IV fluids if they are not able to take PO because of the vomiting. The low cortisol levels, uh, create a space where they’re not able to drink. Uh, they are not able to maintain their adequate sodium level and, uh, they have decreased urine output. So, their urine output is decreased. Okay. The urine will be concentrated and much darker as well. We want to make sure we administer appropriate medication. So, there’s three medications off the top that we want to think of if we want to think about Kayexalate, which is something that’s given to reduce potassium levels. 

Okay, excellent. And just in K exit K exit. So the K is going out. Cortef or any type of steroid prednisone, that’s going to increase cortisol levels. And then, also Florinef. That’s also going to, uh, promote replacement and retention of sodium. So we want to make sure we keep that sodium in water. Finally, we want to keep their vitals in the front and an increased temperature can indicate an Addisonian crisis, uh, in the decreased BP can indicate dehydration. Some key points that we want to focus on when taking care of these patients. Uh, first thing, the adrenal glands, when they fail to produce an adequate amount of, uh, hormones, cortisol, aldosterone, and androgens, that’s when a patient can develop Addison’s disease. Some things that they’re going to tell you, pain, think pain, abdominal pain, leg pain, back pain. They’re going to be irritable, uh, weight loss. We’re going to notice some, uh, low BP, some hypotension, low sodium increased, uh, potassium levels. Also, they’re going to have some vomiting and diarrhea. They’re going to be dehydrated, Medications that we’re going to administer, Kayexalate to lower that K uh, Cortef have to increase that cortisol level and Florinef, enough to increase their sodium levels. We want to do EKG and frequent vitals because the EKG is going to show any arrhythmias because of the hyperkalemia, the increased potassium and a fever may indicate Addisonian crisis. 

We love you guys, and we want you to go out and be your best self today. And as always, happy nursing.

 

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