UNIVERSITY OF THE ASSUMPTION City of San Fernando, Pampanga Co ege of N!

r"ing

Submitted by: Group C-7 Calma, Jeanne Margot Canlas, Mylene Daag, Claire Dionisio, Sarah Kay Mallari, Emmy Manlapat, Jim Bryan Santos, Junben Submitted to: Mrs. Gloria Vergara, .!., M.".!.

#$ %&tober '##( INTRO#UCTION

)he en*o&rine system is a ma+or &ontrolling system o, the bo*y.

-t is o,ten

&onsi*ere* one o, the most &omple. systems in the human bo*y. )hrough hormones, it stimulates su&h long term pro&esses as gro/th an* *e0elopment, metabolism, repro*u&tion an* bo*y *e,ense. En*o&rine *isor*ers &an alter a patient1s health an* sel,-image. )hese *isor*ers may a,,e&t the patient1s gro/th an* *e0elopment, repro*u&ti0e system, energy le0el, metaboli& rate or ability to a*apt to stress. !urses ha0e a ma+or role in the &are o, &lients /ith en*o&rine *isor*er. )here,ore ha0ing su,,i&ient 2no/le*ge an* ,amiliarity /ith "**ison1s *isease an* other en*o&rine *isor*ers, one &an ha0e a lasting positi0e e,,e&t on patients /ith these *isor*ers by un*erstan*ing the pathophysiology o, the &on*ition, assessing patients a&&urately an* sele&ting an* implementing appropriate nursing *ianoses. ",ter *oing a &omprehensi0e stu*y o, the *isor*er the group aims to3

be ,amiliar /ith the pathophysiology o, "**ison1s *isease be able to assess the &lients /ith "*renal 4ypo,un&tion &orre&tly be &ompetent in i*enti,ying appropriate nursing *iagnoses be able to per,orm planning an* implementation o, appropriate nursing be able to &omprehen* proper me*i&al management an* treatment o, the

management

*iso*er

ANATOMY AN# PHYSIO$O%Y

Adrena % and" )he a*renal glan*s are small 0ital en*o&rine stru&tures that rest upon the upper en* o, ea&h 2i*ney. Ea&h a*renal glan* is &ompose* o, an inner &ore, the me*ulla an* an outer shell, the &orte..

)he inner portion, the me*ulla pro*u&es the &ate&holamines epinephrine an* norepinephrine. )he mu&h larger outer a*renal portion, the &orte. has three 5ones. )he outermost 5one, the 5ona glomerulosa, pro*u&es mineralo&orti&oi*s, primarily al*osterone. )he 5ona ,as&i&ulata, the mi**le an* largest 5one, pro*u&es the glu&o&orti&oi*s &ortisol 6hy*ro&ortisone7, &ortisone, an* &orti&osterone as /ell as small amounts o, se. hormones an*rogen an* estrogen. )he inner 5one, the 5ona reti&ularis, pro*u&es mainly glu&o&orti&oi*s an* some se. hormones.

)he three 687 &lasses o, steroi* hormones pro*u&e* by the a*renal &orte. are all synthesi5e* ,rom &holesterol. )hese &oul* be easily remembere* by representing the 8 ,un&tions o, the hormones o, the a*renal &orte. by the letter 9S:, as salt, sugar, an* se.. Mineralo&orti&oi*s 6primarily al*osterone7 regulate ele&trolyte balan&e by promoting so*ium retention an* potassium e.&retion. )hese physiologi& a&ti0ities, in turn, help sustain normal B; an* &ar*ia& output. Cortisol is the ma+or glu&o&orti&oi* that has e,,e&ts on glu&ose 6in&reases bloo* glu&ose le0el7 an* protein 6tissue /asting7 metabolism, on ,lui* an* ele&trolyte balan&e 6in&reases so*ium retention an* potassium e.&retion7, in in,lammation an* immunity 6suppresses the in,lammatory response to tissue in+ury an* the prote&ti0e immune response to in0asion by in,e&tious agents7, an* on stress 6*e&reases resistan&e to stress7.

Be&ause &ortisol is so 0ital to health, the amount o, &ortisol pro*u&e* by the a*renals is pre&isely balan&e*. <i2e many other hormones, &ortisol is regulate* by the brain=s hypothalamus an* the pituitary glan*. >irst, the hypothalamus sen*s ?releasing hormones? to the pituitary glan*. )he pituitary respon*s by se&reting other hormones that regulate gro/th, thyroi* an* a*renal ,un&tion, an* se. hormones su&h as estrogen an* testosterone. %ne o, the pituitary=s main ,un&tions is to se&rete "C)4 6a*reno&orti&otropin7, a hormone that stimulates the a*renal glan*s. @hen the a*renals re&ei0e the pituitary=s signal in the ,orm o, "C)4, they respon* by pro*u&ing &ortisol. Completing the &y&le, &ortisol then signals the pituitary to lo/er se&retion o, "C)4.

A##ISON&S #ISEASE

A ternati'e name" "*renal -nsu,,i&ien&y "*reno&orti&al 4ypo,un&tion 4ypo&ortisolism ;rimary "*reno&orti&al -nsu,,i&ien&y Chroni& "*renal -nsu,,i&ien&y Chroni& ;rimary "*renal -nsu,,i&ien&y O'er'ie( "*reno&orti&al insu,,i&ien&y o&&urs /hen the a*renal &orte. se&retes ina*eAuate amounts o, a*reno&orti&al hormones, primarily glu&orti&oi*s an* mineralo&orti&oi*s. )he *isor*er o&&urs in t/o 6'7 ,orms. ;rimary a*reno&orti&al insu,,i&ien&y 6"**ison1s *isease7 results ,rom *estru&tion an* subseAuent hypo,un&tion o, the a*renal &orte., usually &ause* by an autoimmune pro&ess. Se&on*ary a*reno&orti&al insu,,i&ien&y o&&urs be&ause o, a*reno&orti&otropi& hormone 6"C)47 *e,i&ien&y ,rom pituitary *isease atrophy. or suppression o, the hypothalami&-pituitary a.is by &orti&osteroi*s a*ministere* to treat non en*o&rine *isor*ers, /hi&h &auses the a*renal &orte. to Either primary or se&on*ary "**ison1s *isease &an progress into a*renal &alle* a**isonian &risis, /herein there is &riti&al *e,i&ien&y o, &risis, also

mineralo&orti&oi*s an* glu&o&orti&oi*s. "**ison=s *isease is a rare en*o&rine, or hormonal *isor*er that a,,e&ts about B in B##,### people. -t o&&urs in all age groups an* a,,li&ts men an* /omen eAually. )he *isease is &hara&teri5e* by /eight loss, mus&le /ea2ness, ,atigue, lo/ bloo* pressure, an* sometimes *ar2ening o, the s2in in both e.pose* an* none.pose* parts o, the bo*y. "lso &alle* a*renal insu,,i&ien&y or hypo&ortisolism, "**ison=s *isease &an o&&ur at any age, but is most &ommon in people ages 8# to C#.

"**ison=s *isease o&&urs /hen the a*renal glan*s *o not pro*u&e enough o, the hormone &ortisol an* in some &ases, the hormone al*osterone. >or this reason, the *isease is sometimes &alle* &hroni& a*renal insu,,i&ien&y, or hypo&ortisolism. #efinition "**ison=s *isease is a se0ere or total *e,i&ien&y o, the hormones ma*e in the a*renal &orte., &ause* by a *estru&tion o, the a*renal &orte..

Etio ogy and Ri") Fa*tor" Eighty to ninety per&ent o, &ases o, "**ison=s *isease are sai* to be *ue to autoantibo*ies *ire&te* against a*renal &ells 6autoimmune7 &ontaining 'B-hy*ro.ylase, an en5yme in0ol0e* in the pro*u&tion o, &ortisol an* al*osterone. -*iopathi& atrophy o, the a*renal glan*s is also sai* to be responsible ,or the &ases o, a*reno&orti&al insu,,i&ien&y. )he remain*er o, &ases are *ue to tuber&ulosis, 4-V, sar&oi*osis, amyloi*osis, hemo&hromatosis, metastati& &an&er to the a*renal glan*s, a*renal hemorrhage, @aterhouse->ri*eri&hsen syn*rome 6massi0e, usually bilateral, hemorrhage into the a*renal glan*s &ause* by ,ulminant meningo&o&&emia,7, &ongenital a*renal hyperplasia an* use o, bloo*-thinning *rugs 6anti&oagulants7. )herapeuti& use o, &orti&osteroi*s is the most &ommon &ause o, a*reno&orti&al insu,,i&ien&y. Symptoms may also result ,rom the su**en &essation o, e.ogenous a*reno&orti&al hormonal therapy, /hi&h suppresses the bo*y1s normal response to stress an* inter,eres /ith normal ,ee*ba&2 me&hanisms. is2 ,a&tors ,or the autoimmune type o, "**ison=s *isease in&lu*e other autoimmune *iseases3 )ype *iabetes, 4ypoparathyroi*ism, 4ypopituitarism, ;erni&ious anemia, )esti&ular *ys,un&tion, Gra0es= *isease, Chroni& thyroi*itis, Can*i*iasis, Dermatis herpeti,ormis, Vitiligo an* Myasthenia gra0is.

C ini*a Manife"tation"

)he onset o, "**ison=s *isease is usually insi*ious. )he &lient e.perien&es mil* ,atigue, languor, irritability, /eight loss, nauseaD0omiting, an* postural hypotension /ee2s or months be,ore *iagnosis o, the *isease. "s the *isor*er progresses, mani,estations intensi,y. )he *e0elopment o, &lini&al mani,estations o, a*reno&orti&al insu,,i&ien&y reAuires the loss o, o0er $#E o, both a*renal &orti&es. HORMONE "l*osterone FUNCTION ;romotes retention so*ium 6an* /ater7 2i*ney A##ISON&S #ISEASE More than $#E o, a*renal glan* is *estroye* be,ore the &lini&al pi&ture o, a*renal insu,,i&ien&y emerges. -n&rease* se&retion o, so*ium an* /ater in,luen&es *ehy*ration, hyponatremia, orthostati& hypotension, *e&rease* urine output, *e&rease* &ar*ia& output, /eight loss, salt &ra0ing, a&i*osis, &ir&ulatory &ollapse an* sho&2 De&rease* glu&oneogenesis &auses *eplete* li0er gly&ogen stores mani,este* by hypogly&emia, /ea2ness, ,atigue anore.ia, /eight loss, 0omiting, mental &on,usion, emotional *isturban&es 6mil* neurosis to *epression7 -na*eAuate release o, epinephrine pro*u&es hypogly&emia an* hypotension <o/ers resistan&e to stress an* pro*u&es a 9hyperresponse 9 to

o, in

Cortisol

;romotes glu&oneogenesis Maintains plasma glu&ose le0el ;romotes appetite

Causes release o, epinephrine ,rom a*renal me*ulla "ssists in a*aptation to stress by in&rease* glu&oneogenesis releasing

"C)4

an anti in,lammatory responseF augmenting release o, &ate&holamines to in&rease B; regulates melano&yte stimulating hormone

stressors3 hypogly&emia, hypotension, hyperthermia Stimulates an in&rease MS43 in&reases s2in an* mu&ous membrane pigmentation, espe&ially ,ingers, toes an* sun e.pose* bo*y parts 6s2in appears bron5e*7 oligomenorrhea or amenorrhea, *e&rease in bo*y hair !o mani,estations in males be&ause testes pro*u&e a*eAuate Auantities o, se. hormones

"n*rogens

>emale Male

-n some &ases, "**ison=s symptoms may present rapi*ly. )his ?a&ute a*renal ,ailure? is 2no/n as an "**isonian &risis 6an e.aggerate* state o, a*renal &orti&al insu,,i&ien&y7. "n illness or a&&i*ent &an aggra0ate the a*renal problems &ausing the "**isonian &risis, although the most &ommon &ause is abrupt *is&ontinuation o, &orti&osteroi* therapy /ithout tapering the *ose. -t may be pro0o2e* by physi&al stress, su&h as an in+ury, in,e&tion or illness. "n a**isonian &risis is a li,e-threatening situation that results in lo/ bloo* pressure, lo/ bloo* le0els o, sugar an* high bloo* le0els o, potassium. )his situation reAuires imme*iate me*i&al &are an* &an be ,atal i, not treate* Aui&2ly. #iagno"ti* Te"t" Diagnosis o, "**ison=s *isease *epen*s primarily on bloo* an* urine hormonal assays. ;rimary a*renal insu,,i&ien&y is &hara&teri5e* by a lo/ &ortisol pro*u&tion rate an* a high plasma "C)4 &on&entration. Se&on*ary a*renal insu,,i&ien&y is &hara&teri5e* by a lo/ &ortisol pro*u&tion rate an* a lo/ plasma "C)4 &on&entration.

%ther *iagnosti& tests may be or*ere* to e0aluate the e,,e&ts o, hypo,un&tion o, the a*renals on the bo*y3 serum ele&trolytes 6espe&ially hyponatremia an* hyper2alemia in primary a*renal insu,,i&ien&yF hyponatremia alone in se&on*ary *isease7F bloo* glu&oseF &omplete bloo* &ount 6to assess ,or anemia7F .-rays or &ompute* tomography 6C)7 or magneti& resonan&e imaging 6M -7 o, the a*renals an* pituitary. NURSIN% CONSI#ERATONS Cortisol plasma E0aluates ,un&tion ;lasma le0el o, a*renal &orte. &ortisol le0el ha0e *iurnal e,,e&t3 le0els higher in "M than ;M >asting prephlebotomy ' hours o, supine a&ti0ity are ne&essary be,ore test be&ause a&ti0ity in&reases &ortisol le0el B7-4y*ro.ysteroi*s Measures 'H-hour urine 6;orter Silber metabolites o, &olle&tion to be 2ept rea&tion7 glu&o&orti&oi*s an* on i&e al*osterone C) or M - o, -*enti,ies an* !o preparation a*renals lo&ates a*renal e.&ept &lient glan*s e*u&ation TEST PURPOSE Cosyntropin test Diagnoses a*renal Gi0e "C)4 -V then insu,,i&ien&y /ith HC min later obtain "C)4 stimulation serum &ortisol INTERPRETATION G *isease "**ison1

G *isease

"**ison1

api* stimulation

"C)4

B7-2etosteroi*s

Gi0e &osyntropin -V then obtain plasma &ortisol an* al*osterone le0el at baseline an* a,ter 8# mins Measures steroi* 'H-hour urine G hypo,un&tion o, metabolites ,rom test a*renal, or in &lients

Small, atrophie* glan*s G autoimmune a*renal insu,,i&ien&y G *ys,un&tion o, hypothalami&pituitary a.is, se&on*ary a*renal insu,,i&ien&y &ortisol an* al*osterone G primary a*renal insu,,i&ien&y

"l*osterone

Client to be supine ' hours be,ore phlebotomy enin Client in supine position esults high in "M !ote so*ium inta2e in *iet ;lasma "C)4 or )ests anterior >asting serum &orti&otropin pituitary ,un&tion as sample it may &ause Stress may "**ison1s *isease arti,i&ially in&rease result

a*renal &orte. an* testes 6*oes not in*i&ate testosterone7 Measures mineralo&orti&oi* pro*u&tion Measures renin 6en5yme pro*u&e* in response to *e&rease* bloo* ,lo/ to 2i*neys7

Keep &olle&tion &ol*

/ith remo0al testes or o0aries G *isease

o,

"**ison1

G 4;!, upright position /ith phlebotomy G high so*ium *iet G "**ison1s *isease &ause* by a*renal glan* ,ailure, surgi&al remo0al o, a*renals, a*renal suppression /ith long term e.ogenous steroi* supply G se&on*ary a*renal insu,,i&ien&y &ause* by hypopituitarism G primary a*renal insu,,i&ien&y G se&on*ary asrena insu,,i&ien&yt

Corti&otropin Measures C 4 releasing hormone ,orm hypothalamus 6C 47 stimulation to pituitary ne&essary to stimulate "C)4 an* &ortisol release $a+oratory finding" <aboratory test results sho/3
De&rease* bloo* glu&ose 6hypogly&emia7

Gi0e C 4 -V then measure "C)4 an* &ortisol at baseline an* a,ter BC, 8#, an* (# min

De&rease* serum so*ium le0els 6hyponatremia7 -n&rease* serum potassium le0els 6hyper2alemia7 -n&rease* @BC 6leu2o&ytosis7 I Ele0ate* hemato&rit on CBC

 -n&rease* bloo* nitrogen 6BJ!7 le0els <o/ al*osterone le0els De&rease* &ortisol le0els in plasma I high plasma "C)4 &on&entration 6;rimary7 <o/ &ortisol pro*u&tion rate an* lo/ plasma "C)4 &on&entration 6Se&on*ary7 'H-hour

urine

stu*ies

sho/s

*e&rease*

le0els

o,

B7-2etosteroi*s,

B7-

hy*o.y&orti&oi*s an* B7-2etogeni& steroi*s Medi*a Management and Treatment -mme*iate treatment is *ire&te* to/ar* &ombating &ir&ulatory sho&23 restoring bloo* &ir&ulation, a*ministering ,lui*s an* &orti&osteroi*s, monitoring 0ital signs an* pla&ing patient in a re&umbent position /ith legs ele0ate*. 4y*ro&ortisone is a*ministere* intra0enously, ,ollo/e* /ith CE *e.trose in normal saline. %ral inta2e may be initiate* as soon as tolerate*. Gra*ually, intra0enous ,lui*s are *e&rease* /hen oral ,lui* inta2e is a*eAuate to pre0ent hypo0olemia. "*renal &risis reAuires prompt a*ministration o, *e.amethasone, hy*ro&ortisone, or both. <ater *oses o, hy*ro&ortisone are gi0en -.V. until the patients &on*ition stabili5es. @ith proper treatment, the &risis usually subsi*es Aui&2ly, bloo* pressure stabili5es, an* ,lui* an* so*ium le0els return to normal. SubseAuent oral maintenan&e *oses o, hy*ro&ortisone preser0e stability. "ntibioti&s may be a*ministere* i, in,e&tion has pre&ipitate* a*renal &risis in a patient /ith &hroni& a*renal insu,,i&ien&y. Corti&osteroi* repla&ement, usually /ith &ortisone or hy*ro&ortisone 6both also ha0e mineralo&orti&oi* e,,e&t7, is the primary li,elong treatment ,or patients /ith primary or se&on*ary a*renal hypo,un&tion. "**itionally, the patient may nee* to supplement *ietary inta2e /ith a**e* salt *uring times o, gastrointesintinal losses o, ,lui*s through 0omiting an* *iarrhea.

N!r"ing Management T,e t,ree ma-or goa " of inter'ention are t,e fo o(ing. e0ersal o, sho&2 estoration o, bloo* &ir&ulation 6the &lient usually su,,ers ,rom a *e,i&it o, at least '#E o, e.tra&ellular ,lui* 0olume7

eplenishment /ith essential steroi*s

N!r"ing Inter'ention"
Monitor 0ital signs &are,ully ,or hypotension, 0olume *epletion, an* other signs o,

sho&2 6*e&rease* <%C an* urine output7.

@at&h ,or hyper2alemia be,ore treatment an* hypo2alemia a,ter treatment ,rom

e.&essi0e mineralo&orti&oi* e,,e&t.

-, the patient also has *iabetes, &he&2 bloo* glu&ose le0els perio*i&ally be&ause

steroi* repla&ement may ne&essitate &hanging the insulin *osage.

Care,ully re&or* /eight an* inta2e an* output, be&ause the patient may ha0e

0olume *epletion.
>or&e ,lui*s to repla&e e.&essi0e ,lui* loss until the onset o, mineralo&orti&oi*

e,,e&ts.
"rrange ,or a *iet that maintains so*ium an* potassium balan&e. -, the patient is

anore&ti&, suggest si. small meals per *ay to in&rease &alorie inta2e. "s2 the *ieti&ian to pro0i*e a *iet high in protein an* &arbohy*rates.
%bser0e the patient re&ei0ing steroi*s ,or &ushingoi* signs su&h as ,lui* retention

aroun* the eyes an* ,a&e.

@at&h ,or ,lui* an* ele&trolyte imbalan&e, espe&ially i, the patient re&ei0es

mineralo&orti&oi*.
Monitor ,or mani,estations o, a**isonian &risis3

Sudden profound weakness

 Severe abdominal, back, and leg pain Hyperpyrexia (although this may be suppressed by Steroids) followed by hypothermia Hypotension in association with high cardiac output, normal wedge pressure, and low systemic resistance Coma Renal shutdown and death Emergen*y Sit!ation
Monitor bloo* pressure "*minister -V in,usion an* me*i&ations. Monitor hourly urine output an* report oliguria 6a mani,estation o, sho&27. Minimi5e e.posure to emotional an* physi&al stress. %bser0e ,or mani,estations o, glu&o&orti&oi* o0er*ose an* o0erhy*ration, su&h as

generali5e* e*ema *ue to ,lui* retention, hypertension, ,la&&i* paralysis resulting ,rom hypo2alemia, psy&hosis, an* loss o, &ons&iousness.
E0aluate ele&trolytes ,or hyper2alemia, hyponatremia, an* hypogly&emia an*

&orrelate these ,in*ings /ith &lient mani,estations Tea*,ing Tip"

E.plain the li,elong &ortisone repla&ement therapy is ne&essary. "*0ise the patient o, symptoms o, o0er*ose an* un*er*ose, an* that he1ll nee* to

in&rease the *osage *uring times o, stress. 6 /hen he has a &ol*, ,or e.ample7
@arn that in,e&tion, in+ury, or pro,use s/eating in hot /eather pre&ipitate &risis. -nstru&t the patient to al/ays &arry a me*i&al i*enti,i&ation &ar* an* /ear a bra&elet

stating the name an* *osage o, the steroi*s he ta2es.

)ea&h the patient ho/ to gi0e himsel, a hy*ro&ortisone in+e&tion )ell patient to 2eep an emergen&y 2it &ontaining hy*ro&ortisone in a prepare*

syringe ,or use in times o, stress.

 @arn that he may nee* a**itional &ortisone to pre0ent a &risis a,ter any type o,

stress. Note.
"*renal insu,,i&ien&y is a potentially li,e-threatening &on*ition, but /hen properly

re&ogni5e* an* treate*, it has little or no e,,e&t on li,e span.

)here are no *ietary or a&ti0ity restri&tions.

E'a !ation "s a result o, su&&ess,ul therapy ,or a*renal hypo,un&tion, the patient /ill3
maintain a proper *iet maintain normal serum so*ium, potassium, an* plasma &ortisol le0els un*erstan* the nee* to ta2e his me*i&ations routinely Ma2e ne&essary a*+ustments in times o, stress

REFERENCES 4an*boo2 o, Diseases 'n* e*ition (Springhouse) -llustrate* Manual o, !ursing ;ra&ti&e 8r* e*ition (Springhouse) <ippin&ott1s ;o&2et Manual o, !ursing ;ra&ti&e ( ettina) Me*i&al K Surgi&al !ursing B#th e*ition (Smelt!er " #are) Me*i&al K Surgi&al !ursing3 Con&ept an* Clini&al "ppli&ation Me*i&al K Surgi&al !ursing Ma*e -n&re*ibly Easy ($ippinocott %illiams " %ilkins) Mosby1s Diagnosti& an* <aboratory )est e,eren&e ' n* e*ition (&agana) ;athophysiology Ma*e -n&re*ibly Easy 8r* e*ition ($ippinocott %illiams " %ilkins)