Risk for Deficient Fluid Volume — Addison’s Disease Nursing Care Plans

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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.

NOC Outcomes

• Fluid Balance;
• Electrolyte and Acid-Base Balance

NIC Interventions

• Fluid Monitoring;
• Fluid Management; Electrolyte Management

Assessment

• 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/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).

Nursing Interventions

• 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.