Addison's & Cushing’s Disease
Addison's disease is an adrenocortical insufficiency. It is caused by
damage or dysfunction of the adrenal cortex. (Pg. 541)
● With Addison's disease, the production of mineralocorticoids and
glucocorticoids is diminished, resulting in decreased aldosterone and
cortisol.
The adrenal cortex produces:
 Mineralocorticoids - aldosterone (increases sodium absorption,
causes potassium excretion
 Glucocorticoids - cortisol (affects glucose, protein, and fat
metabolism; the body's response to stress; and the body's immune
function)
 Sex hormones - androgens and estrogens
Acute adrenal insufficiency
Acute adrenal insufficiency, also known as the Addisonian crisis, has
a rapid onset. It is a medical emergency. If it is not quickly diagnosed
and properly treated, the prognosis is poor.
● Older adult clients are less able to tolerate the complications of
Addison's disease and acute adrenal insufficiency and need more
frequent monitoring.
Risk Factors:
Causes of primary Addison's disease
■ Idiopathic autoimmune dysfunction (majority of cases)
■ Tuberculosis
■ Histoplasmosis
■ Adrenalectomy
■ Cancer
Causes of secondary Addison's disease
■ Steroid withdrawal
■ Hypophysectomy
■ Pituitary neoplasm
◯Acute adrenal insufficiency is a life-treating event that left untreated can lead to death.
Factors that precipitate acute adrenal insufficiency are as follows:
■ Sepsis
■ Trauma
■ Stress (myocardial infarction, surgery, anesthesia, hypothermia, volume loss,
hypoglycemia)
■ Adrenal hemorrhage
■ Steroid withdrawal
Physical Assessment Findings: (pg. 541)
■ Clinical manifestations of chronic Addison's disease develop slowly.
■ Clinical manifestations of acute adrenal insufficiency develop
rapidly.
■ Clinical manifestations:
☐ Weight loss
☐ Craving for salt
☐ Hyperpigmentation
☐ Weakness and fatigue
☐ Nausea and vomiting
☐ Dizziness with orthostatic hypotension
☐ Severe hypotension (acute adrenal insufficiency)
☐ Dehydration
☐ Hyponatremia
☐ Hyperkalemia
☐ Hypoglycemia
☐ Hypercalcemia
Laboratory Tests:
■ Serum electrolytes - increased K+, decreased Na+, and increased
calcium
■ BUN and creatinine - increased
■ Serum glucose - decreased
■ Serum cortisol - decreased
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■ Adrenocorticotropic hormone (ACTH) stimulation test - ACTH is infused,
and the cortisol response is measured 30 min and 1 hr after the injection.
With primary adrenal insufficiency, plasma cortisol levels do not rise.
Diagnostic Procedures:
■ ECG is used to assess for ECG changes or dysrhythmias associated with
electrolyte imbalance.
☐ Client Education - Explain procedures to the client.
■ X-ray, CT scan, and magnetic resonance imaging (MRI) scan
☐ Radiological imaging to determine source of adrenal insufficiency, such
as a tumor or adrenal atrophy
☐ Client Education - Explain to the client that tests are noninvasive and not
painful.
Nursing Care:
◯Monitor the client for fluid deficits and electrolyte imbalances. Administer
saline infusions to restore fluid volume. Observe for dehydration. Obtain
orthostatic vital signs.
◯Administer hydrocortisone IV bolus and a continuous infusion or
intermittent IV bolus.
◯Monitor for and treat hyperkalemia:
■ Obtain a serum potassium and ECG.
■ Administer sodium polystyrene sulfonate (Kayexalate), insulin, calcium,
glucose, and sodium bicarbonate.
◯Monitor for and treat hypoglycemia:
■ Perform frequent checks of the client's neurologic status, monitor for
hypoglycemia, and check serum glucose.
■ Administer food and/or supplemental glucose.
◯Maintain a safe environment:
■ Provide assistance when ambulating.
■ Raise side rails.
■ Prevent falls by keeping floors clear.
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Medications: Hydrocortisone (Cortef), prednisone (Deltasone), and
cortisone
Hydrocortisone (Cortef), prednisone (Deltasone), and cortisone
■ Glucocorticoid is used as an adrenocortical replacement for adrenal
insufficiency and as an anti-inflammatory.
■ Nursing Considerations
☐ Monitor weight, blood pressure, and electrolytes.
☐ Increase dosage during periods of stress or illness if necessary.
☐ Taper dose if discontinuing to avoid acute adrenal insufficiency.
☐ Give with food to reduce gastric effects.
■ Client Education
☐ Advise the client to:
> Take medication as directed.
> Avoid discontinuing the medication abruptly.
> Report symptoms of Cushing's syndrome (round face, edema, weight
gain).
> Advise the client to take the medication with food.
> Report symptoms of adrenal insufficiency (fever, fatigue, muscle
weakness, anorexia).
Medications: Fludrocortisone (Florinef)
Fludrocortisone (Florinef) is a mineralocorticoid used as a replacement in
adrenal insufficiency.
■ Nursing Considerations
☐ Monitor weight, blood pressure, and electrolytes.
☐ Hypertension is a potential adverse effect.
☐ Dosage may need to be increased during periods of stress or illness.
■ Client Education
☐ Advise the client to take the medication as directed.
☐ Warn the client to expect mild peripheral edema.
Care After Discharge: Client Education
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■ Advise the client to:
☐ Take prescribed medications as instructed and monitor for adverse
reactions.
☐ Avoid using alcohol and caffeine.
☐ Monitor for signs of gastric bleeding (coffee-ground emesis; tarry, black
stool).
☐ Monitor for hypoglycemia (diaphoresis, shaking, tachycardia, headache).
☐ Report symptoms of adrenal insufficiency (fever, fatigue, muscle
weakness, dizziness, anorexia).
☐ To prevent acute adrenal insufficiency, instruct clients who have
Addison's disease to increase corticosteroid doses as directed by a
provider during times of stress.
■ Inform the client that medication therapy may be lifelong.
Complications: Acute adrenal insufficiency (Addisonian crisis)
Acute adrenal insufficiency (Addisonian crisis) occurs when there is an
acute drop in adrenocorticoids due to sudden discontinuation of
glucocorticoid medications or when induced by severe trauma, infection, or
stress.
Nursing Actions:
■ Administer insulin to move potassium into cell. Glucose often is given
with insulin.
■ Administer calcium to counteract the effects of hyperkalemia and protect
the heart, as well as sodium polystyrene sulfonate (Kayexalate), a resin
that absorbs potassium.
■ If acidosis occurs, administer sodium bicarbonate to promote alkalinity
and increase uptake of and move potassium into cells.
■ Loop or thiazide diuretics are used to manage hyperkalemia.
■ Establish an IV line and initiate a rapid infusion of 0.9% sodium chloride.
■ Monitor vital signs and monitor for clinical manifestations of hyperkalemia
such as bradycardia, heart block, high T wave, and prolonged PR interval.
■ Monitor electrolytes.
■ Administer hydrocortisone sodium succinate (Solu-Cortef) & prednisone
as replacement therapy.
Client Education
■ Advise the client to notify the provider of any infection, trauma, or stress
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that may increase the need for adrenocorticoids.
■ Advise the client to take the medication as directed.
■ Advise the client not to discontinue the medication abruptly.
Complications: Hypoglycemia
◯Insufficient glucocorticoid causes increased insulin sensitivity and
decreased glycogen, which leads to hypoglycemia.
Nursing Actions - Monitor glucose levels.
Client Education:
■ Advise the client and family to monitor for hypoglycemia.
☐ Symptoms may include diaphoresis, shaking, tachycardia, and
headache.
■ Instruct the client to have a 15 g carbohydrate snack readily available.
Complications: Hyperkalemia/Hyponatremia
◯Decrease in aldosterone levels can cause an increased excretion of
sodium and a decreased excretion of potassium.
Nursing Actions: - Monitor electrolytes and ECG.
Client Education:
■ Advise the client to take the medications as directed.
■ Instruct the client to report signs of hyperkalemia (muscle weakness,
tingling sensation, irregular heartbeat).
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Cushing’s pg 535. RN Medical Surgical Nursing
Leukopenia:
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Low WBC
Fever 100.4 or greater
Chills, sweating,
Sore throat
Mouth sores stomatitis
White patches in the mouth
Low neutrophils (can get neutropenia so avoid fresh fruits, flowers, no raw
vegetables, avoid crowds, reverse/ neutropenic isolation, surgical mask
outside of their room)
Thrombocytopenia
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Low platelets
Fatigue
Risk for bleeding, bruising
Coffee ground emesis
Tarry or stools
Easy bruising
Petechiae
Hold injection sites for 5 minutes
Bleeding gums
Electric razor
Increased menstrual flow
Hepatotoxicity
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Jaundice
Increased AST, ALT,
Dark urine
Clay- colored stools
Increased PT INR
Abdominal pain with N/V
Fatigue fever
Edema
Ascites
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 Severe itching- pruritus
Diabetic Ketoacidosis Type 1: (
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Elevated blood sugar 250 mg/dl
N/V
Urine ketones
Abdominal pain
Fruity acetone breath
Normal saline
Fluid & electrolyte replace
potassium
IV insulin- priority to correct
HHNKS- Type 2 diabetes:
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Severe hyperglycemia > 600
Severe dehydration
Absence
Elevated serum osmolarity > 320 & elevated glucose 250- 300
LOC
Fluid replacement is the priority – large bore IV, normal saline,
Insulin administration
STROKE: (pg. 87)
 Ischemia- lack of blood flow
 Hemorrhage
 Clot buster TPA- restores blood flow- patient must sign a consent high risk
for bleeding
 F- facial drooping
 A- arms weak
 S- slurred speech
 T- must administer clot buster within
 Confusion
 20 % of blood flow is needed altering within 30 seconds and cell death in
 CO2- can change the cerebral blood flow (ABGs)
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ICP- less than 15 greater than 20 problems- avoid coughing, stool softener,
Neck and head should be aligned
HOB 30 degrees
Positive Babinski – most damage to the brain
Need oral anticoagulant or oral thrombolytic (Eliquis or Xarelto)
Smoking, alcohol, cocaine
TIAs
Ischemic Stroke
Age Blood pressure C Diabetes score (Pg 1333 Lewis Med- Surg Nursing)
Thrombolytic Stroke figure 57.2
Aphasia & Dysphagia:
Visual field pg. 1347- homonymous hemianopsia in one or both eyes affected
Chapter 58:
Migraine
Tension
Triggers: hormones, smells,
Pg 1353 table 58.1
Imitrex/ sumatriptan
Topamax- teach the patient not to stop abruptly due to risk for seizure
Beta blocker- Lopressor,
Tegretol cannot be taken with grapefruit juice
pg 1362
Role of the RN for the seizures patient
Teaching for seizure patient
Multiple sclerosis progressively gets worse
Interferon (pg 1368)
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Parkinson’s disease – levodopa/ carbodopa.
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Characteristics
Monitor for dyskinesia
Short-term N/V
Delayed
Report uncontrolled eye movements
Do not give with food as it prevents proper absorption.
Myasthenia gravis- (pg. 1378)
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(better in the morning than in the afternoon)
Cholinergic drugs
risk for a cholinergic crisis due to toxicity- frequent urination &
donepezil & neostigmine if given excessively can cause
Dementia vs Delirium (pg. vs 1384)
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Test Review: Pg 1388 table 59.4 early warning signs for Alzheimer’s disease
 Mini-mental exam – three words and then clock
1. Interventions for Alzheimer’s patients
2. Keep them safe
3. Diversional activities for confused patients
4. Parkinson’s disease clinical manifestations
5. CVA
6. Dysphagia
7. Actions for seizures and nursing responsibilities
8. Anticipated care for Myasthenia gravis
9. MS nursing actions and teaching
10. Clinical manifestations for delirium
11. S/S hypoglycemia
12. Type I & Type II
13. Treatment for DKA
14. Treatment for HHNS
15. Treatment for hypothyroidism
16. Clinical manifestation hypothyroidism
17. Treatment of thyroidectomy
18. Clinical manifestations of thyroidectomy
19. Clinical manifestations of SIADH & DI
20. Expected findings for SIADH & DI
21. Signs to report to PCP with a new colostomy
22. Signs of bleeding in a colon resection patient
23. Troubleshooting an NG Tube
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22. Clinical manifestation of GI bleed.
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