What medication should the nurse be prepared to administer for the client with acute adrenal insufficiency Addisons crisis )?

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Nursing Care Plans
Risk for Deficient Fluid Volume
Risk for Imbalanced Nutrition: Less Than Body Requirements
Risk for Decreased Cardiac Output
Recommended Resources

Addison’s disease or adrenal hypofunction is a rare disorder characterized by inadequate production of the steroid hormones cortisol and aldosterone by the outer layer of cells of the adrenal glands (adrenal cortex).

Also called adrenal insufficiency, Addison’s disease occurs in all age groups and affects both sexes. Addison’s disease can be life-threatening.

Nursing Care Plans

Management for Addison’s disease involves taking hormones to replace the insufficient amounts being made by your adrenal glands, in order to mimic the beneficial effects produced by your naturally made hormones.

Here are three (3) Addison’s disease nursing care plans (NCP) and nursing diagnosis:

Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk for Deficient Fluid Volume

Common Risk Factors

Increase in sodium and water excretion with potassium retention
GI disturbances (e.g., nausea, vomiting, diarrhea, which can be manifestations of Addison’s disease).

Common Expected Outcomes

Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 mL/hr, normotensive blood pressure (BP), heart rate (HR) less than 100 beats/min, consistent weight, and normal skin turgor.

Nursing Interventions	Rationale
Assess skin turgor and mucous membranes for signs of dehydration.	The patient will have dry skin and mucous membranes. Tenting of the skin will occur. The tongue may have longitudinal furrows.
Assess vital signs, especially noting BP and HR for orthostatic changes.	A BP drop of more than 15 mm Hg when changing from supine to sitting position, with a concurrent elevation of 15 beats per min in HR, indicates reduced circulating fluids.
Assess color, concentration, and amount of urine.	Urine volume will decrease, urine specific gravity will increase, and color will be darker.
Assess trends in weight.	Rapid weight loss will occur with fluid volume deficit.
Assess for fatigue, sensory deficits, or muscle weakness, which may progress to paralysis.	These are signs of hyperkalemia. Aldosterone deficiency leads to potassium retention by the kidneys.
Assess electrocardiogram rhythm, as available, for signs of hyperkalemia.	Signs of hyperkalemia are sharp peaked T wave and widened QRS complex.
Assess additional indicated laboratory tests.	Abnormal laboratory findings include hyperkalemia (related to aldosterone deficiency and decreased renal perfusion), hyponatremia (related to decreased aldosterone and impaired free water clearance), and increase in blood urea nitrogen (related to decreased glomerular filtration from hypotension).
Observe for petechiae.	Patient bruises easily.
Encourage oral fluids as the patient tolerates.	As sodium loss increases, extracellular fluid volume decreases. These interventions are necessary to prevent fluid volume deficit because the kidneys are unable to conserve sodium
Instruct the patient to ingest salt additives in conditions of excess heat or humidity.	Sweating increases sodium loss.
If Addisonian crisis occurs:
Refer or admit the patient to an acute care setting.	Immediate hospital admission and treatment are needed because of the high mortality with Addisonian crisis.
Administer parenteral fluids as prescribed. Anticipate the need for an intravenous (IV) fluid challenge with immediate infusion of fluids for patients with abnormal vital signs.	Normal saline is infused initially to restore fluid volume.
Administer Kayexalate.	This ion exchange resin can be given orally or by enema to reduce potassium levels.
Instruct the patient to wear a medical alert bracelet and carry a wallet card.	In the event of trauma or injury, it is important to initiate appropriate therapy immediately.
Administer replacement medications as prescribed or indicated: oral cortisone (Cortone), hydrocortisone (Cortef), prednisone, or fludrocortisone (Florinef).	Cortisone and prednisone replace cortisol deficits, which will promote sodium resorption. Fludrocortisone is a mineralocorticoid for patients who require aldosterone replacement to promote sodium and water replacement. Acute adrenal insufficiency is a medical emergency requiring immediate fluid and corticosteroid administration. If treated for adrenal crisis, the patient requires IV hydrocortisone initially; usually by the second day, administration can be converted to an oral form of replacement.
Assess ECG rhythm, as available, for signs of hyperkalemia.
Remember, steroids administered in the late afternoon or evening may cause stimulation of the central nervous system.	May cause insomnia in some patients
Explain lifelong steroid therapy is necessary	Patient will need to take daily medication to replace the lost hormones. This should ensure patient continue to lead a normal life.

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

Risk for Imbalanced Nutrition: Less Than Body Requirements

Common Risk Factors

Decreased gastrointestinal (GI) enzymes, causing loss of appetite and decreased oral intake tolerance
Decreased gastric acid production
Nausea, vomiting, diarrhea

Common Expected Outcomes

Patient’s nutritional status is optimized as evidenced by maintenance of weight and adequate dietary intake.

Nursing Intervention	Rationale
Assess appetite and for the presence of nausea, vomiting, or diarrhea.	Cortisol deficiency can impair GI function, causing anorexia, nausea, and vomiting
Monitor trends in weight.	This provides documentation of weight loss trends. Weight loss is a common manifestation of adrenal insufficiency.
Assess foods that patient can tolerate.	Appetite may increase with preferred and tolerable foods.
Monitor serum glucose levels.	Patients with adrenal insufficiency are likely to experience hypoglycemia. It may require adjustment of insulin dosage.
Assess for salt cravings.	Aldosterone deficiency causes increased renal excretion of sodium.
Ask the dietician to provide high-protein, low-carbohydrate, high-sodium diet.	The patient tires because of inadequate production of hepatic glucagon; the recommended diet prevents fatigue, hypoglycemia, and hyponatremia. The patient with primary Addison’s disease needs to increase salt intake 5 g if any activity causes an increase in diaphoresis (activities in warm weather).
Keep a late-morning snack available.	In case the patient becomes hypoglycemic
Suggest need for frequent small meals.	Inadequate caloric intake in meals may precipitate hypoglycemia. Promotion of oral intake maintains adequate blood glucose levels and nutrition.
Encourage rest periods after eating.	This is important to facilitate digestion.

Risk for Decreased Cardiac Output

Nursing Diagnosis

Risk for Decreased Cardiac Output

Risk Factors

Any situations requiring increased corticosteroids (e.g., stress, infection, GI upsets) may lead to shock or vascular collapse

Expected Outcomes

Patient achieves adequate cardiac output (CO) as evidenced by strong peripheral pulses, normal vital signs, urine output greater than 30 mL/hr, warm and dry skin, and alert responsive mentation.

Nursing Interventions	Rationale
Assess skin warmth and peripheral pulses.	Peripheral vasoconstriction causes cool, pale, diaphoretic skin.
Assess level of consciousness.	Early signs of cerebral hypoxia are restlessness and anxiety, leading to agitation and confusion.
Monitor vital signs with frequent monitoring of BP. Include assessment for orthostatic hypotension. Anticipate direct intra-arterial monitoring of pressure for a continuing shock state.	Sudden development of profound hypotension may indicate Addisonian crisis. Auscultatory BP may be unreliable secondary to vasoconstriction.
Monitor for dysrhythmias.	Cardiac dysrhythmias may result from the low perfusion state, acidosis, hypoxia, or electrolyte imbalance. Hyperkalemia is present in Addison’s disease.
Monitor urine output.	Oliguria is a classic sign of inadequate renal perfusion.
Monitor oxygen saturation through pulse oximetry or arterial blood gas results, as appropriate.	The patient will have decreased oxygen saturation.
Monitor temperature.	Hyperpyrexia can result from the hormonal and fluid imbalance and may be an early sign of crisis if accompanied by a sudden drop in BP.
If hemodynamic monitoring is in place, assess central venous pressure (CVP), pulmonary artery diastolic pressure (PAD), pulmonary capillary wedge pressure (PCWP), and CO.	CVP provides information on filling pressures of right side of the heart; PAD and PCWP reflect left-sided fluid volumes.
Minimize stressful situations and promote a quiet environment.	The patient’s normal response to stress is not functioning because he or she cannot produce corticosteroids. Stress can result in a life-threatening situation with Addisonian crisis.
Provide rest periods.	This prevents overexertion.
Assist the patient with activities, as needed.	The patient in crisis should be helped with all activities (turning, feeding, cleansing) to prevent overexertion.
If hypotension develops with signs of decreased CO, administer IV fluids rapidly. Administer glucocorticoid (IV hydrocortisone [Solu-Cortef]).	Fluids restore the patient’s circulating blood volume. Circulatory collapse does not respond to usual treatment (inotropes and vasopressors), and ultimately these patients require glucocorticoids to correct the shock state. Glucocorticoid therapy improves BP by potentiating the vasoconstrictor effect of norepinephrine. Glucocorticoids also cause the renal tubules to increase reabsorption of sodium and water, thus increasing blood volume. In acute situations, it is better to err on the side of overtreatment with glucocorticoids than to inadequately dose the patient with adrenal hypofunction, which could result in adrenal crisis.It is important to be aware of the patient’s risk for adrenal crisis and for adrenal insufficiency, including patients with Addison’s disease or patients with a history of ongoing glucocorticoid treatment, in which an illness or stressful experience could trigger a crisis if replacement therapy is not increased.
Administer antipyretics as needed for fever.	This helps reduce the continuing sodium and water losses from the fever.

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Recommended Resources

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What medication should the nurse be prepared to administer for the client with acute adrenal insufficiency Addisons crisis )?

Nursing Care Plans

Risk for Deficient Fluid Volume

Risk for Imbalanced Nutrition: Less Than Body Requirements

Risk for Decreased Cardiac Output

Recommended Resources

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