Ineffective Therapeutic Regimen Management — Addison’s Disease Nursing Care Plans

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Common Risk Factors

• Lack of experience with adrenocortical insufficiency
• Complexity of regimen
• Knowledge deficits

Common Expected Outcomes

• Patient verbalizes understanding of adrenal insufficiency and guidelines for replacement therapy.

NOC Outcomes

• Knowledge: Disease Process;
• Knowledge: Medication

NIC Interventions

• Teaching: Disease Process;
• Teaching: Prescribed Medication

Assessment

• Assess knowledge of adrenal insufficiency, including the need for lifelong medication.

  • Regardless of the cause of adrenal insufficiency, treatment focuses on replacement with glucocorticoids. The need for lifelong replacement therapy must be addressed because of the serious nature of the disease in order to plan long-term management.

• Assess available support systems and the ability to comply with treatment.

  • The management of adrenal insufficiency is focused on the patient’s ability to avoid risks for crisis and maintain scheduled medication administration. The patient is more likely to be successful adopting these new health behaviors if a strong social support system is available.

• Assess ability to identify or verbalize signs and symptoms that require physician consultation: fever, nausea and vomiting, weight loss, diaphoresis, progressive weakness, and/or dizziness.

  • These are signs of adrenal insufficiency and the patient may be at risk of developing Addisonian crisis, which is a life-threatening emergency

Therapeutic Interventions

• Instruct patient in self-administration of steroids, including expected effects and dosage. The patient with adrenal insufficiency will also require aldosterone replacement (e.g., fludrocortisone acetate [Florinef], a mineralocorticoid), which is taken daily or three times a week.

  • Knowledge of the disease process and drug regimen will promote compliance. Lifelong glucocorticoid replacement is required in primary Addison’s disease. A patient with secondary adrenocortical insufficiency does not require aldosterone replacement because mineralocorticoid release does not depend on ACTH secretion.

• Offer information about the need to adjust corticosteroid dosage when under stress.

  • The goal of replacement therapy is the return to normal hormone levels. The need for glucocorticoids is proportional to stress levels, because these patients cannot produce endogenous hormone in response to an increase in stress levels. Doses are usually doubled with minor infection or dental work and tripled with major stress such as more extensive surgical procedures or severe infection.

• Inform the patient of the availability of injectable cortisol with a sterile syringe.

  • Patients should carry a readily injectable syringe of cortisol at all times. This syringe may be used by the patient or significant other when the patient is unable to take the oral form and is experiencing symptoms of inadequate replacement therapy.

• Emphasize the need for morning or evening dose.

  • The patient must identify personal stressors and learn to adjust steroidal drugs to compensate for the stress response. Twice-daily dosing is encouraged to prevent crisis. Glucocorticoids are usually given in divided doses with two thirds in the morning and one third in the afternoon. They should not be taken late in the evening because they are stimulating to the central nervous system (CNS) and may cause insomnia. The twice-daily dosing mimics the body’s normal cortisol secretion pattern. However, alternate-day therapy is also common with long-term administration in which the patient is instructed to take twice the usual daily glucocorticoid dose every other morning.

• Instruct the patient to take the glucocorticoid after eating.

  • This reduces gastric irritation.

• Stress importance of follow-up health care visits.

  • Drug levels may be adjusted to the patient’s requirements during visits. With adrenal insufficiency, there is a lifelong need for medical supervision.

• Explain how to obtain a medical identification tag and the importance of wearing it.

  • This tag may be lifesaving for the patient with adrenal insufficiency in the case of unexpected trauma, accident, or crisis.

• Discuss signs or symptoms requiring physician consultation. Patients should be taught signs and symptoms of glucocorticoid deficiency and excess.

  • Recognition of early signs and symptoms may prevent Addisonian crisis.