Page 44 nursing.elitecme.com Complete Your CE Test Online - Click Here The adrenal hormone cortisol, a glucocorticoid, affects almost every tissue and organ in the body. Cortisol helps maintain blood pressure, slow the immune system’s inflammatory response, and regulate metabolism11,25 . In the event of adrenal insufficiency, decreased levels of cortisol can have the following effects on specific organs[11,25] : ● ● Liver: Reduced hepatic glucose output leading to hypoglycemia which can progress to dangerous levels. ● ● Stomach: Reduced levels of digestive enzymes leading to nausea, vomiting, cramps, and diarrhea. Decreased levels of aldosterone can have the following effects[11,25] : ● ● Kidneys: Sodium and water loss accompanied by potassium retention. Electrolyte imbalances can lead to hypoglycemia and adverse cardiac effects. ● ● Heart: Arrhythmias, decreased output, hypotension. Untreated the effects of adrenal hypofunction can progress to adrenal crisis causing shock, coma, and death[11] . Signs and symptoms The most common signs and symptoms of adrenal hypofunction include [5,25] : ● ● Abdominal pain. ● ● Anorexia. ● ● Craving salty foods. ● ● Depression. ● ● Decreased libido in women. ● ● Diarrhea. ● ● Diaphoresis. ● ● Fatigue (chronic or long-lasting). ● ● Headache. ● ● Hypoglycemia. ● ● Hypotension (especially orthostatic hypotension). ● ● Irritability. ● ● Menstrual abnormalities. ● ● Nausea. ● ● Vomiting. ● ● Weakness. ● ● Weight loss. Addison’s disease usually causes a characteristic, conspicuous bronze coloration of the skin. Patients appear to be deeply suntanned especially in the creases of the hands, over the metacarpophalangeal joints, elbows, and knees. Scars may darken, areas of vitiligo appear, and increased pigmentation of the mucous membranes, particularly of the gingival mucosa[5] . Adrenal hypofunction alert! Abnormalities in skin and mucous membrane coloration are due to decreased secretion of cortisol, which makes the pituitary gland secrete excessive amounts of corticotropin and melanocyte-stimulating hormone [5] . As the disease progresses, additional cardiovascular effects may become evident such as decreased cardiac output, decrease in heart size, and a weak, irregular pulse[5,11] . Other clinical manifestations include[5,11,25] : ● ● Decreased ability to tolerate even the smallest amount of stress. ● ● Poor coordination. ● ● Hypoglycemia. ● ● Retardation of pubic and axillary hair growth. ● ● Amenorrhea. Secondary adrenal hypofunction produces similar clinical manifestations to those of primary adrenal hypofunction but without hyperpigmentation because corticotropin and melanocyte stimulating hormone levels are low. Aldosterone secretions may continue to be fairly normal in the secondary type so electrolyte levels may also be normal and hypotension may not occur[5,11] . Diagnosis After a thorough history and physical and evaluation of signs and symptoms various lab studies are used to confirm a diagnosis of adrenal hypofunction and to categorize the disease as primary or secondary[5,11] . Analysis of plasma and urine shows decreased levels of corticosteroid concentrations. A high level of corticotropin suggests primary adrenal hypofunction. A low level of corticotropin suggests secondary adrenal hypofunction[5,11] . A rapid corticotropin test (ACTH stimulation test) is used to evaluate plasma cortisol response to corticotropin. First, plasma cortisol samples are obtained. Then an intravenous infusion of cosyntropin is administered. Plasma samples are obtained at 30 and 60 minutes after cosyntropin infusion. If plasma cortisol levels do not increase, adrenal insufficiency is suspected[11] . In patients who have characteristic signs and symptoms of Addison’s disease the following laboratory tests indicate acute or crisis level adrenal hypofunction[5,11] : ● ● Increased potassium serum calcium, and blood urea nitrogen levels (BUN). ● ● Decreased serum sodium levels. ● ● Elevated hematocrit, lymphocyte, and eosinophils counts. ● ● X-rays show decreased heart size and adrenal calcification. ● ● Decreased plasma cortisol levels in plasma. Levels are less than 10 mcg/dL in the morning. Levels are lower at night. Adrenal hypofunction diagnostic alert! Note that testing cortisol levels takes considerable amounts of time. Therefore, adrenal crisis treatment should not be delayed while waiting for the results of this particular test[11] . After a diagnosis of Addison’s disease is made, the following tests may help HCPs determine if the disease is related to tuberculosis or to antibodies associated with autoimmune Addison’s disease[25] : ● ● Abdominal ultrasound: Performed to identify adrenal gland abnormalities such as an increase or decrease in size, nodules, or the presence of calcium deposits that may suggest bleeding. ● ● Tuberculin skin test: A positive test suggests adrenal insufficiency related to tuberculosis. ● ● Antibody blood test: The presence of antibodies associated with autoimmune Addison’s disease helps to confirm diagnosis. After a diagnosis of secondary adrenal insufficiency is made, the following tests may be performed to assess pituitary gland functioning [25] : ● ● CT scan: A CT scan can show the size and shape of the pituitary gland and abnormalities such as nodules or tumors. ● ● MRI: An MRI provides three dimensional images of the hypothalamus and the pituitary gland to detect abnormalities in size and the presence of tumors, nodules, or other abnormalities. ● ● Hormonal blood tests: Hormonal blood tests are used to evaluate pituitary functioning. Treatment and nursing considerations All patients affected by primary or secondary adrenal hypofunction need life-long corticosteroid replacement therapy. Cortisone or hydrocortisone is administered because these agents have a mineralocorticoid effect[5,11] . To minimize or prevent dehydration and hypotension, a synthetic drug that acts as a mineralocorticoid (oral fludrocortisones) may be given. Testosterone injections may be given to women who experience a decrease in libido and muscle weakness. However, testosterone injection may cause masculinizing effects[11] . Special nursing considerations include[5,25] : ● ● Monitor for signs of adrenal crisis. Teach patients and families how to recognize adrenal crisis and to seek immediate emergency medical attention if it occurs. ● ● Explain that corticosteroid therapy must be taken for the rest of the patients’ lives. Teach patients how to take their medication