ADDISON’S DISEASE

1. Pathophysiology
- Etiology
Autoimmune
Drugs
Infection
Trauma
Surgery

- Precipitating factors
Immunologic Factor
Viral Factor

- Predisposing factors
With genetic susceptibility

- Signs and symptoms

- Extreme fatigue
- Weight loss and loss of appetite
- Areas of darkened skin
- Low blood pressure, even fainting
- Salt craving
- Low blood sugar, also called hypoglycaemia
- Nausea, diarrhea or vomiting
- Abdominal pain

- Complications
- Medical management
- labs – diagnostic and confirmatory
Purpose:
-This test is helpful in determining if the adrenal and pituitary glands are normal. It is
most often used when adrenal glands disorders, such as Addison’s disease or pituitary
insufficiency, are suspected.

Results:
Clinical significance: This test can help determine whether your adrenal and pituitary
glands are normal. . It is most often used when your health care provider thinks you have
an adrenal gland problem, such as Addison’s disease or pituitary insufficiency.

Nursing responsibilities:
Normal result:
 Cortisol level after ACTH stimulation should be higher than 18 to 20 mcg/dL or 497 to
552 nmol/L, depending on the dose of ACTH used. Normal value ranges may vary
slightly among different laboratories, Some labs use different measurements or may test
different specimens.

Nursing responsibilities:
Monitor fluid and electrolytes for imbalance (K+, Na+).
Monitor heart rate, blood pressure, daily weight.
Low-sodium diet. Administer prescribes medications (antihypertensive, diuretics)

1. You may asked the patient to fast for 6 hours before the test.
2. Monitor fluid and electrolytes for (imbalance (K+, Na+). Monitor heart rate, blood
pressure, daily weight. Low sodium.
3. Administer prescribed medications order (antihypertensive, diuretics)

- drugs
Hydrocortisone (cortenema)
Fludrocortisone acetate (Florinef)

- procedures
- diet
- Prognosis
 Predisposing factors Precipitating factors
 Family history  Autoimmune
 Age  Infection
 Gender  Trauma
 Surgery

Destruction of own tissue

Damage in the adrenal cortex

Decreased production of hormone

Mineral corticoids glucocorticoid ↑ ACTH Androgen

↓K excretion ↓release of Skin pigmentation Lack of secondary

glucose sex characteristics
↑NA Excretion

S/S ↓Libido
Low cardiac output and
hypotension Fatigue
Muscle weakness
S/S
Hypoglycemia
Low blood pressure
Poor response to stress
Dizziness

Confusion

Abdominal pain
 2. 2 drugs studies

Generic Name Classification Dosage and Pharmacologic Indication and Side Effects Nursing

(Brand Name) Route of Effects/ Mechanism Contraindication Responsibilities

Administration of Action

Hydrocortisone Therapeutic Dosage: Decreases Indicated to patient CNS: 1. Observe 14 rights of

giving medication.
Class: 100 mg a day inflammation, mainly with endocrine Euphoria, insomnia,
(Cortenema) Corticosteroids 10 mg/h; 7.5 by stabilizing disorders (adrenal psychotic behavior, 2. Check the doctor’s
order.
mg/h; 2.5 mg/hr; leukocyte lysosomal insufficiency, vertigo, mood swings,

1 mg/hr membranes; congenital adrenal headache, paresthesia, 3. Determine whether

Pharmacologic the patient is sensitive
25 mg daily surpresses immune hyperplasia) seizures
Class: to corticosteroids
Route: response; stimulates
Glucocorticoids Contraindicated in Hematologic:
P.O bone marrow; and 4. Monitor patient’s

patients with Easy bruising weight, blood pressure,

influences protein, fat,
and electrolyte levels.
and carbohydrate hypersensitivity to CV:

metabolism. drug or its Hypertension, edema, 5. Inspect patients skin

ingredients. arrythmias, for petechiae

thrombophlebitis,

thromboembolism

Metabolic:

Hypokalemia,

hyperglycemia,

carbohydrate

intolerance,

hypercholesterolemia,

carbohydrate

intolerance,

hypocalcemia

Musculoskeletal:

Muscle weakness,
osteoporosis, tendon

rupture

Skin:

Hirsutism, delayed

wound healing, acne,

skin eruptions,

injection-site atrophy
Generic Name Classification Dosage and Pharmacologic Indication and Side Effects Nursing

(Brand Name) Route of Effects/ Mechanism Contraindication Responsibilities

Administration of Action

Fludrocortisone Therapeutic Dosage: The main endogenous Indicated to patient Cardiovascular system: 1. Observe 14

acetate Class: Adult: 0.1 mg mineralocorticoid, with partial Hypertension, Fluid rights of

(Florinef) Corticosteroids daily aldosterone, is replacement retention, and edema medication

Route: produced in the zona therapy for primary (may cause swelling of 2. Check the

P.O glomerulosa of the and secondary lower limbs), Doctor’s order

Pharmacologic 3. Assess patient

adrenal cortex adrenocortical congestive heart failure.
Class: for
- It acts on insufficiency in
Glucocorticoids Nervous system: hypersensitivity
mineralocortic addison’s disease

oid receptors for the treatment of Headache, increased 4. Educate the

in the kidney salt-losing intracranial pressure, patient to take

to increase adrenogenital vertigo, change in the medication

behavior, convulsion. same time daily

sodium syndrome. to maintain its

reabsorption Gastrointestinal: effects

and potassium Contraindicated in May impair gastric 5. Assess dizziness

excretion, patients with protective barrier and that might affect

which in turn systemic fungal cause stomach ulcer, gait, balance

helps to infections and in perforation. and other

regulate these with a history functional

of possible or Endocrine:
plasma activities
known Menstrual
electrolyte 6. Report signs of
hypersensitivity to abnormalities, growth
composition adrenal
these agents. delay in child, acute
and blood suppression,
adrenal insufficiency in
pressure. including
times of stress.
hypotension,

weight loss,
Musculoskeletal:
weakness,
Can cause muscle
nausea,
weakness, can reduce
vomiting,
muscle mass, increase anorexia,

risk of osteoporosis and lethargy,

pathological fracture, confusion, and

vertebral compression, restlessness.

necrosis of femoral 7. Monitor and

head. report signs of

low potassium

levels

(hyperkalemia),

or hypokalemic

alkalosis. Signs

include

headache,

lethargy, cardiac

arrhythmias and

muscle

dysfunction
 (muscl

weakness,

aches, cramps).

8. Notify physician

immediately if

these signs

occur.
3. Nursing Diagnosis (5)

1. Fluid Volume deficit related to diarrhea as evidenced by poor skin turgor and dry mucous
membranes
2. Decreased cardiac output r/t hypovolemia as evidenced by alterations in vital signs
3. Imbalanced nutrition: less than body requirements related to insufficient dietary intake as
evidenced by vomiting and weight loss
4. Disturbed body image related to increased skin pigmentation as evidenced by dark patches on
skin
5. Fatigue related to decreased metabolic energy production as evidenced by lethargy or inability
to do Activities of daily living.
 4. 2 Priority NCP’s

Nursing Objective of Nursing Actions with Rationale

Date / Cues Needs Evaluation
Diagnosis Care

January 06, P Deficient fluid After 2 hours of Independent: Goal met:

2023 Volume r/t Nursing
H Interventions, the 1.Monitor and document vital signs, After 2 hours of Nursing
diarrhea as
Y patient is able to re- especially BP and HR. Interventions, the patient is able
8:00 am evidenced by
S dry mucous establish and to re-establish and maintain
maintain normal A decrease in circulating blood volume can
Subjective membrane and normal bowel functioning
I bowel functioning cause hypotension and tachycardia.
data: poor skin turgor. Goal Partially Met:
O 2.Assess skin turgor and oral mucous
“Palaging
membranes for signs of dehydration. After 2 hours of Nursing
humihilab ang L Interventions, the patient has
tiyan ko at Signs of dehydration are also detected
O minimal frequent bowel
naging Rationale: through the skin.
movement but does not
madalas po
G 3.Monitor fluid status in relation to dietary maintain normal bowel
yung pag dumi Dehydration is
when there is a intake. functioning
ko” as I
verbalized by loss of too much Most fluid comes into the body through Goal not met:
C fluid from the
the patient drinking, water in food, and water formed
body. This leads After 2 hours of Nursing
A by the oxidation of foods.
to a lack of Interventions, the patient is not
Objective data: L water in the 4.Monitor serum electrolytes and urine able to re-establish and
body’s cells and osmolality, and report abnormal values. maintain normal bowel
-diarrhea Needs
blood vessels. functioning
Elevated blood urea nitrogen suggests fluid
-ACTH (Fluids and
deficit. Urine-specific gravity is likewise
stimulation Electrolytes)
increased.
test-
confirmatory 5.Identify the possible cause of the fluid
test disturbance or imbalance.
Establishing a database of history aids
accurate and individualized care for each
patient.
6.Assess for abdominal discomfort, pain,
cramping, frequency, urgency, loose or
liquid stools, and hyperactive bowel
sensations.
These assessment findings are usually linked
with diarrhea
7. Assess for fecal impaction.
Liquid stool (apparent diarrhea) may seep
past fecal impaction.

Dependent:
1.Administer parenteral fluids as prescribed.
Consider the need for an IV fluid challenge
with an immediate infusion of fluids for
patients with abnormal vital signs.
Fluids are necessary to maintain hydration
status. Determination of the type and
amount of fluid to be replaced and infusion
rates will vary depending on clinical status.
2. Administer oral cortisone as prescribed
Rationale: Cortisone and prednisone replace
cortisol deficits, which will promote sodium
resorption.
3. Give antidiarrheal drugs as ordered.
Most antidiarrheal drugs suppress
gastrointestinal motility, thus allowing for
more fluid absorption
4. Administer steroids as prescribed in late
afternoons
Rationale: Steroid may cause insomnia in
some patients
5. Administer Kayexalate.
Rationale: This ion exchange resin can be
given orally or by enema to reduce
potassium levels.

Interdependent:
1. Refer patient to a
gastroenterologist
Rationale: For better diagnosis of the
patient’s condition because diseases such as
gastroenteritis and Crohn’s disease can
result in malabsorption and chronic diarrhea.

Health Teaching
1.Educate patient about possible causes and
effects of fluid loss or decreased fluid
intake.
Enough knowledge aids the patient in taking
part in their plan of care.
2.Teach family members how to monitor
output in the home. Instruct them to monitor
both intake and output.
An accurate measure of fluid intake and
output is an important indicator of a
patient’s fluid status.
DATE/CUES NEEDS NURSING OBJECTIVE OF NURSING ACTION WITH EVALUATION
DIAGNOSIS CARE RATIONALE
January 10, P Decreased Within 8 hours of Independent: Goal met:
2023 cardiac output nursing
H
related to intervention, the
8:00am 1. Assess heart rate and blood pressure. - Within 8 hours of nursing
Y hypovolemia patient will
Subjective (blood pressure) demonstrates intervention, the patient is able
S and (increased adequate cardiac Rationale: to demonstrates adequate
Data:
I heart rate) output as evidenced - Compensatory tachycardia is a common cardiac output as evidenced by
“Ako ay by normal blood normal blood pressure
response for patients with significantly low
naghihina at O pressure (120/80mmHg) and normal
blood pressure to reduce cardiac output.
nahihilo kapag Rationale: (120/80mmHg) and pulse (60-100 bpm) and
L Initially, this compensatory response has a
tumatayo” as normal pulse (60- rhythm within normal
- Decreased favorable effect on cardiac output but can be
verbalized by O 100 bpm) and parameters for patient.
cardiac output harmful when it becomes persistent.
the patient. rhythm within
G occurs if the 2. Check for peripheral pulses. Perform
Objective normal parameters
I blood pumped capillary refill test (CRT). Goal partially met:
Data: for patient.
by the heart
 BP: C does not meet
Rationale:
80/70mm the metabolic - Within 8 hours of nursing
Hg demands of the - Weak pulses are present in reduced stroke intervention, the patient is able
 PR: N body. volume and cardiac output. Capillary refill is to partially demonstrates
120bpm sometimes slow or absent. Current studies adequate cardiac output as
E
 Increased indicate that capillary refill test evidenced by normal blood
heart rate E measurement is affected by multiple pressure (120/80mmHg) and
 Dizziness external factors (Pickard et al., 2011). CRT
 Clammy D normal pulse (60-100 bpm)
is an easy and quick test to perform; and rhythm within normal
skin S unfortunately, its results cannot be parameters for patient.
 Weakness
interpreted with any degree of confidence in
the adult population (Lewin & Maconochie,
(Circulation) 2008). Clinical decisions should not be Goal not met:
based on CRT measurement alone.
3. Auscultate heart sounds for gallops (S3, Within 8 hours of nursing
S4); auscultate breath sounds.
intervention, the patient is not
able to demonstrates adequate
Rationale: cardiac output as evidenced by
- The new onset of a gallop rhythm, normal blood pressure
tachycardia, and fine crackles in lung bases (120/80mmHg) and normal
can indicate the onset of heart failure. If the pulse (60-100 bpm) and
patient develops pulmonary edema, there rhythm within normal
will be coarse crackles on inspiration and parameters for patient.
severe dyspnea. S3 indicates reduced left
ventricular ejection and is a class sign of left
ventricular failure. S4 occurs with reduced
compliance of the left ventricle, which
impairs diastolic filling.
4. Note skin color, temperature, and
moisture.

Rationale:
- Cold, clammy, and pale skin is secondary
to a compensatory increase in sympathetic
nervous system stimulation and low cardiac
output and oxygen desaturation (Leier,
2007; Bolger, 2003).

5. Check for any alterations in level of

consciousness.

Rationale:
- Alterations in cardiac output, either acutely
or chronically, can lead to changes in
cerebral blood flow (Meng et al., 2015).
Decreased cerebral perfusion and hypoxia
are reflected in irritability, restlessness, and
difficulty concentrating. Older patients are
particularly susceptible to reduced cerebral
perfusion.
6. Note respiratory rate, rhythm, and
breath sounds. Identify any presence of
paroxysmal nocturnal dyspnea (PND), or
orthopnea.

Rationale:
- Shallow, rapid respirations are
characteristics of decreased cardiac output.
Crackles indicate fluid buildup secondary to
impaired left ventricular emptying.
Orthopnea is defined as aggravated
shortness of breath when lying down; it is
common among patients with cardiovascular
disorders (Martins et al., 2010). Paroxysmal
nocturnal dyspnea (PND) is a sensation of
shortness of breath that awakens the patient,
often after 1 or 2 hours of sleep, and is
usually relieved in the upright position
(Mukerji, 2011). PND is closely related to
decreased cardiac output. While sleeping at
night, peripheral edema is reabsorbed,
causing systemic and pulmonary
hypervolemia, with consequent aggravation
of pulmonary congestion ultimately leading
to PND.
7. Assess oxygen saturation with pulse
oximetry both at rest and during and
after ambulation.

Rationale:
- An alteration in oxygen saturation is one of
the earliest signs of reduced cardiac output.
Hypoxemia is common, especially with
activity. Administer supplemental oxygen as
needed.
8. Note chest pain. Identify location,
radiation, severity, quality, duration,
associated manifestations such as nausea,
and precipitating and relieving factors.

Rationale:
- Chest pain or chest discomfort generally
suggests myocardial ischemia or inadequate
blood supply to the heart, which can
compromise cardiac output (Yancy et al.,
2017).
Dependent:
9. Administer supplemental oxygen as
needed.

Rationale:
- Patient’s oxygen saturation may be low
and may require supplemental oxygen in
order to maintain appropriate levels.
Appropriate oxygenation is necessary to
improve overall condition and bodily
functions.
10. Administer intravenous (IV) fluids, as
indicated.

Rationale:
- Rapid fluid replacement may be necessary
to improve circulating volume, but must be
balanced against signs of cardiac failure and
need for inotropic support.

11. Administer medications, as indicated,

such as: Beta blockers, for example,
propranolol (Inderal), atenolol
(Tenormin), nadolol (Corgard), and
pindolol (Visken).
Rationale:
- Beta blockers are the mainstay of
symptomatic therapy for thyrotoxicosis,
such as tachycardia, tremors, and
nervousness.
12. Administer medications as indicated
such as Corticosteroids, for example,
dexamethasone (Decadron).

Rationale:
- Provides glucocorticol support, decreases
hyperthermia, relieves relative adrenal
insufficiency, inhibits calcium absorption,
and reduces peripheral conversion of T4 to
T3.

Collaborative:

13. Refer the patient to specialist if

ordered by the medical provider.

Rationale:
-To enable patient to receive more
information and specialized care
management if needed.
14. Refer patient to nutritionist or
dieticians.

Rationale:
- To determine appropriate diet plan of the
patient.

Health teaching:
15. Educate patient on home self-care.

Rationale:
- Providing education for patients will allow
them to understand the pathophysiology of
what is occurring in regards to their health.
Education will also assist patients in
understanding measures they can take at
home to improve their cardiac health and
prevent further deterioration.

16. Educate patient to avoid Valsalva

maneuvers.
Rationale:
- These maneuvers can put extra strain on
the cardiac muscle.
17. Advise patient to use a commode or
urinal for toileting and avoid using a
bedpan.

Rationale:
- Getting out of bed to use a commode or
urinal does not stress the heart more than
staying in bed to the toilet. In addition,
getting the patient out of bed minimizes
complications of immobility and is often
preferred by the patient.
18. Educate the patient and significant
other about the disease process,
complications of the disease process,
information on medications, the need for
weighing daily, and when appropriate to
call a primary care provider.

Rationale:
- Early recognition of symptoms facilitates
early problem solving and prompt treatment.
Offer ongoing support and encourage the
client to ask questions and express any
concerns they may have.
19. Educate patients on the need for and
how to incorporate lifestyle changes.

Rationale:
- Psycho-educational programs including
information on stress management and
health education have been shown to reduce
long-term mortality and recurrence of
myocardial infarction in heart patients.

20. Encourage client to adopt a healthy

lifestyle. Explain the importance of
smoking cessation and avoidance of
alcohol intake.

Rationale:
- Educating the patient on the effects of
smoking can help them understand the
health risks involved in smoking. Smoking
is associated with an increased risk of heart
failure, but the risk decreases with
increasing duration since smoking cessation.
Any form of heavy drinking of alcohol
should be discouraged. These measures can
help improve cardiac output and overall
health.