4 Addison’s Disease Nursing Care Plans

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 and Management

The nursing care planning goals for patients with Addison’s disease include maintaining optimal adrenal hormone balance, managing symptoms and complications, promoting fluid and electrolyte balance, preventing an adrenal crisis, providing patient education on medication management, and supporting psychological well-being and coping strategies.

Nursing Problem Priorities

The following are the nursing priorities for patients with Addison’s disease:

• Administer hormone replacement therapy (glucocorticoids and mineralocorticoids).
• Monitor electrolyte levels and manage any imbalances.
• Educate patients on the importance of medication adherence and stress management.
• Monitor adrenal function and adjust hormone replacement therapy as needed.
• Provide support and guidance for managing physical and emotional stressors.
• Educate patients on the signs and symptoms of adrenal crisis and the appropriate actions to take.

Nursing Assessment

Assess for the following subjective and objective data:

• Fatigue and weakness
• Chronic or recurrent muscle aches and pains
• Decreased appetite or weight loss
• Nausea or vomiting
• Abdominal pain or discomfort
• Dizziness or lightheadedness
• Salt cravings
• Mood changes or depression
• Darkening of the skin (hyperpigmentation)
• Hypotension, tachycardia
• Dehydration signs, such as dry mucous membranes or decreased skin turgor
• Weight loss or low body mass index (BMI)
• Low levels of cortisol and aldosterone

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with Addison’s disease based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

• The 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.
• The patient’s nutritional status is optimized as evidenced by maintenance of weight and adequate dietary intake.
• The 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 and Actions

Therapeutic interventions and nursing actions for patients with Addison’s disease may include:

1. Managing Fluid Volume

Addison’s disease is a condition where the adrenal glands do not produce enough hormones, including aldosterone, which regulates the body’s fluid and electrolyte balance. Without adequate aldosterone, patients may experience decreased sodium levels and increased potassium levels, leading to dehydration and electrolyte imbalances, and consequently an increased risk for deficient fluid volume. Therefore, careful monitoring of fluid and electrolyte balance is important in nursing care plans for patients with Addison’s disease.

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 a supine to a 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 an 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 an 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 the Addisonian crisis.

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 parenteral fluids as prescribed. Anticipate the need for an intravenous (IV) fluid challenge with an immediate infusion of fluids for patients with abnormal vital signs.
Normal saline is infused initially to restore fluid volume.

Administer Kayexalate.
See Pharmacologic Management
This ion exchange resin can be given orally or by enema to reduce potassium levels.

Administer replacement medications as prescribed or indicated: oral cortisone (Cortone), hydrocortisone (Cortef), prednisone, or fludrocortisone (Florinef).
See Pharmacologic Management
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
The patient will need to take daily medication to replace the lost hormones. This should ensure patient continues to lead a normal life.

2. Promoting Nutritional Balance

Patients with Addison’s disease may experience decreased appetite, nausea, and vomiting, which can lead to inadequate intake of nutrients. Additionally, the disease can cause increased metabolism, leading to a higher need for nutrients. Therefore, it is important to monitor and provide adequate nutrition in nursing care plans for patients with Addison’s disease.

Assess appetite 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 the 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 an adjustment of insulin dosage.

Assess for salt cravings.
Aldosterone deficiency causes increased renal excretion of sodium.

Ask the dietician to provide a 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 by 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 the 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.

3. Managing Decreased Cardiac Output

Addison’s disease can cause low blood volume and decreased peripheral vascular resistance, which can result in decreased cardiac output. This is because the heart has to work harder to maintain blood pressure and circulation, leading to an increased risk of cardiac complications. Therefore, careful monitoring of cardiac function and hemodynamics is important in nursing care plans for patients with Addison’s disease

Assess skin warmth and peripheral pulses.
Peripheral vasoconstriction causes cool, pale, diaphoretic skin.

Assess the 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 an Addisonian crisis. Auscultatory BP may be unreliable secondary to vasoconstriction.

Monitor for dysrhythmias.
Cardiac dysrhythmias may result from a 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 the 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 an 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.
See Pharmacologic Management

4. Administer Medications and Provide Pharmacologic Support

The primary medications used in the treatment of Addison’s disease are glucocorticoids, such as hydrocortisone or prednisone, which replace the deficient cortisol hormone and help regulate various physiological functions. While mineralocorticoid replacement therapy with fludrocortisone may be prescribed to replace the deficient aldosterone hormone and maintain proper sodium and potassium balance. These medications are essential for managing symptoms and preventing adrenal crisis.

Kayexalate
This ion exchange resin can be given orally or by enema to reduce potassium levels.

Corticosteroids such as 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.

Antipyretics
This helps reduce the continuing sodium and water losses from the fever.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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