INTRODUCTION

Addison’s disease is an endocrine, or

hormonal, disorder that occurs when the
adrenal glands do not produce enough of
certain hormones.
The adrenal glands are located just above
the kidneys.
 DEFINITION

 Also known as primary adrenal insufficiency and hypocortisolism,

is a long-term endocrine disorder in which the adrenal glands  do not
produce enough steroid hormones.
 or
• Disorder resulting from destruction or dysfunction of the
adrenal cortex resulting in chronic deficiency of cortisol,
aldosterone & adrenal androgens characterized by weight
loss, muscle weakness, fatigue, low blood pressure, and
sometimes darkening of the skin in both exposed and non-
exposed parts of the body.
 T YPES

1. Primary adrenal insufficiency

2. Secondary adrenal insufficiency

 PRIMARY ADRENAL INSUFFICIENCY
• Occurs when the adrenal glands damaged and can’t
produce enough adrenal hormone cortisol and
aldosterone.
• Failure of adrenal glands is most commonly the
result of the body attacking itself (autoimmune
disease),or unknown reasons, immune system
views the adrenal cortex as something foreign
particles, so immune system attack on adrenal
cortex and try destroy it.

• Addison’s disease affects 110 to 144 of every 1

million people in developed countries.
 SECONDARY ADRENAL INSUFFICIENCY
• It occurs when the pituitary gland (pea-sized gland at the base of the
brain) fails to produce enough adrenocorticotropic (ACTH) hormone
that stimulates the adrenal glands to produce the cortisol hormone.

• If ACTH output is too low, cortisol production drops.

• Eventually, the adrenal glands can shrink due to lack of
ACTH stimulation.

• Secondary adrenal insufficiency is much more common than

Addison’s disease.
 CAUSES

Primary Secondary
• Infection like adrenalitis • Pituitary abnormality
• tuberculosis

• Autoimmune adrenalitis
• Congenital ACTH deficiency
• Adrenal infiltration
• Metastasis sarcoidosis

• Bilateral adrenalectomy
• Hypothalamic abnormality
Pathophysiology
Sign and symptoms
 INTEGUMENTARY SYSTEM

• Delayed wound healing.

• Dry and itchy skin (in women)
• Skin hyperpigmentation (primary adrenal insufficiency)
• Alabaster-coloured pale skin (secondary adrenal insufficiency)
• Loss of axillary or pubic hair (in women),
• Absence of adrenarche or pubarche in children
 CARDIO VASCULAR SYSTEM
• Low blood pressure (systolic RR < 100 mm Hg),
• postural hypotension (pronounced in primary adrenal insufficiency)
• Tachycardia.
• Arrhythmias
 MUSCULOSKELETAL SYSTEM

• Myalgia,
• Weakness.
• Joint Pain.
• Muscle wasting.
• reduced muscle strength
 GASTRO INTESTINAL SYSTEM

• Anorexia.
• Diarrhea.
• Nausea & Vomiting.
• Gastric pain
 REPRODUCTIVE SYSTEM

• Menstrual changes.
• Loss or impairment of libido (in women)
 METABOLIC CHANGES

• Hyperkalemia.
• Hypoglycemia.
• Hyponatremia.
• Hypercalcemia
• Raised serum creatinine
 OTHER SIGN AND SYMPTOMS

• Fever
• lack of energy or stamina,
• weight loss (in children failure to thrive)
• Salt craving
• Anaemia,
• lymphocytosis,
• Eosinophilia
• Increased thyroid stimulating hormone
 ADRENAL CRISIS
• Sudden, severe worsening of adrenal insufficiency symptoms
is called adrenal crisis.
• If the person has Addison’s disease, this worsening can also
be called an Addisonian crisis.
 SIGN AND SYMPTOMS
• Sudden, severe pain in the lower back, abdomen, or legs
• Severe vomiting and diarrhoea
• Dehydration
• Low blood pressure
• Loss of consciousness
If not treated, an adrenal crisis can cause death
DIAGNOSTIC
EVALUATION
• History collection
• Physical examination
Hormonal Blood and Urine Tests
ACTH (Adrenocorticotropic hormone) stimulation test
• ACTH stimulation test is the most commonly used test for diagnosing
adrenal insufficiency.
• In this test, the patient is given intravenous (IV) injection of synthetic
ACTH, and samples of blood, urine, both are taken before and after
the injection.
• The cortisol levels in the blood and urine samples are measured.
The normal
response after an ACTH injection is a rise in blood and urine cortisol
levels.
CRH(Corticotropin-releasing hormone) stimulation test

When the response to the ACTH test is abnormal, a CRH stimulation test
can help determine the cause of adrenal insufficiency.
In this test, the patient is given an IV injection of synthetic CRH, and
blood is taken before and 30, 60, 90, and 120 minutes after the injection.
The cortisol levels in the blood samples are measured.
If Addison’s disease responds by producing high levels of
ACTH, yet no cortisol.
If secondary adrenal
insufficiency does not produce ACTH or have a delayed
response.
CRH will not stimulate ACTH secretion
if the pituitary is damaged, so no ACTH response points to the
pituitary as the cause.
A delayed ACTH response points to the hypothalamus as the
cause.
• Blood glucose levels.
• BUN level.
• Urinary 17 hydroxy corticoids & 17 Ketosteroids levels.
• CT scan of head.
• Abdominal CT & X-Ray
• Ultrasound of the abdomen
• Tuberculin skin test
• Antibody blood tests
 e n t
a na g em
M
 MEDICAL MANAGEMENT

• Adrenal insufficiency treated by replacing, or substituting, the

hormones that the adrenal glands are not making.
• The dose of each medication is adjusted to meet the needs of the
patient.
• Cortisol is replaced with a corticosteroid, such as hydrocortisone,
prednisone, or dexamethasone, taken orally one to three times each day,
depending on which medication is chosen.
• If aldosterone is also deficient, it is replaced with oral doses
of a mineralocorticoid hormone, called fludrocortisone
acetate (Florinef), taken once or twice daily.
• People with secondary adrenal insufficiency normally
maintain aldosterone production, so they do not require
aldosterone replacement therapy.
 THE TREATMENT

• Glucocorticoids: prednisone, or dexamethasone 150-200mg or

hydrocortisone 150-200 mg intravenously (I/V) by the stream (jet)
introduction, then to 1.000 mg within 24 hours by drop form.
• Mineralocorticoids: fludrocortisone acetate 5-10 mg (1-2 ml)
intramuscularly (i/m) in 6 hours.
• Ascorbic acid 5% solution to 50 ml, cocarboxylase –
200-300 mg;
• in collapse: noradrenaline – 1ml (with addition of 500 ml
of isotonic solution of natrium chloride), dophamine – 5 ml
of 4% solution or 1 ml of 1% mezaton solution;
• symptomatic therapy: antibiotics,
 HOW ADRENAL CRISIS TREATED?

• Adrenal crisis is treated with adrenal hormones.

• People with adrenal crisis need immediate treatment.
• Any delay can cause death.
• When people with adrenal crisis are vomiting or unconscious and
cannot take their medication, the hormones can be given as an injection.
• Adrenal insufficiency person should carry corticosteroid injection
at all times and make sure that he and other person know how and
when to administer the injection, in case the person becomes
unconscious

• The dose of corticosteroid needed may vary with a person’s age or

size.
• For example, a child younger than 2 years of age can receive 25
milligrams (mg),
child between 2 and 8 years of age can receive 50 mg,
and child older than 8 years should receive the adult dose of 100 mg.
Nursing management
 NURSING ASSESSMENT-

• Complete health history

•Baseline weight
•Muscle weakness/ fatigue
•History of illness
•Stress response
•Assess glucose levels
•Baseline vitals
•Skin pigmentation
•Skin turgor
•Assess mood
•Assess knowledge of disease
1- Risk for fluid Volume Deficit related to hypovolemia or nausea
and vomiting.

Goal- to prevent from deficient fluid volume

Intervention-
• Assess skin turgor and mucous membranes for signs of dehydration
• Assess vital signs, especially noting BP and HR for orthostatic changes.
• Assess colour, concentration, and amount of urine.
• Assess trends in weight.
2- Risk for imbalanced nutrition less than body requirements related
to loss of appetite and decreased oral intake.

Goal- Patient’s nutritional status is optimized

Intervention-
• Continue monitor patient’s weight.
• Suggest need for frequent small meals.
• Encourage for bed rest.
• Assess for salt craving.
3- Risk for injury related to extreme weakness.
Goal- reduce the risk of injury.
Intervention-
• Assess the base line data.
• Educate for avoid alone journey
• Educate for proper rest
COMPLICATIONS FROM ADRENAL CRISIS