Addison's Disease Nursing Care Plans

The danger with Addison's disease is the crisis. The adrenal cortex is not making enough cortisol and aldosterone, so the patient cannot mount a stress response. An infection, an injury, a missed dose, surgery, or a hot day can tip them into circulatory collapse fast. Your job on the floor is to keep volume and electrolytes balanced, watch for the early signs of Addisonian crisis, and never let a stressor go unanswered with steroid coverage. Adrenal hypofunction is rare, hits both sexes and all ages, and is life-threatening when missed.

Nursing Care Plans and Management

Priorities: replace the missing hormones, keep fluids and electrolytes balanced, prevent adrenal crisis, and teach the patient how to stay out of one.

Nursing Problem Priorities

• Give hormone replacement (glucocorticoids and mineralocorticoids).
• Monitor electrolytes and correct imbalances.
• Drill medication adherence and stress management.
• Track adrenal function and adjust replacement doses.
• Support the patient through physical and emotional stressors.
• Teach the signs of adrenal crisis and exactly what to do.

Nursing Assessment

Assess for the following subjective and objective data:

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

Nursing Goals

• The patient maintains adequate fluid volume and electrolyte balance: urine output greater than 30 mL/hr, normotensive BP, HR less than 100 beats/min, stable weight, and normal skin turgor.
• The patient's nutritional status holds: stable weight and adequate intake.
• The patient maintains adequate cardiac output (CO): strong peripheral pulses, normal vital signs, urine output greater than 30 mL/hr, warm dry skin, and alert mentation.

Nursing Interventions and Actions

1. Managing Fluid Volume

Without aldosterone, sodium drops and potassium climbs. The patient dehydrates and slides toward an electrolyte crisis, so fluid and electrolyte monitoring drives this whole care plan.

Assess skin turgor and mucous membranes for dehydration. Expect dry skin and mucous membranes, tenting, and longitudinal furrows on the tongue.

Assess vital signs for orthostatic changes. A BP drop of more than 15 mm Hg from supine to sitting with a concurrent HR rise of 15 beats/min signals reduced circulating volume.

Assess urine color, concentration, and amount. Volume falls, specific gravity rises, and color darkens.

Track weight. Rapid loss means fluid volume deficit.

Assess for fatigue, sensory deficits, or muscle weakness progressing to paralysis. These are hyperkalemia signs. Aldosterone deficiency makes the kidneys retain potassium.

Assess ECG rhythm for hyperkalemia. Watch for sharp peaked T waves and a widened QRS complex.

Review labs. Expect hyperkalemia (aldosterone deficiency, decreased renal perfusion), hyponatremia (low aldosterone, impaired free water clearance), and rising BUN (decreased glomerular filtration from hypotension).

Watch for petechiae. These patients bruise easily.

Encourage oral fluids as tolerated. As sodium loss rises, extracellular volume falls and the kidneys cannot conserve sodium.

Tell the patient to add salt in heat or humidity. Sweating increases sodium loss.

If Addisonian crisis develops, admit to acute care immediately. Mortality is high without prompt treatment.

Have the patient wear a medical alert bracelet and carry a wallet card. After trauma or injury, this lets responders start therapy right away.

Give parenteral fluids as prescribed; anticipate an IV fluid challenge for abnormal vital signs. Normal saline goes first to restore volume.

Give replacement medications as ordered (see Pharmacologic Support). Acute adrenal insufficiency is a medical emergency needing immediate fluid and corticosteroid. In crisis, start IV hydrocortisone; by about the second day you can usually convert to oral.

Teach that steroid therapy is lifelong. Daily replacement keeps the patient functioning normally. Note that steroids given in late afternoon or evening can stimulate the CNS and cause insomnia.

2. Promoting Nutritional Balance

Cortisol deficiency causes anorexia, nausea, and vomiting, and these patients run hypoglycemic. Keep intake up and blood glucose steady.

Assess for nausea, vomiting, or diarrhea. Cortisol deficiency impairs GI function.

Track weight. Loss is a common sign of adrenal insufficiency.

Identify tolerated foods. Appetite improves with preferred foods.

Monitor serum glucose. These patients tend toward hypoglycemia and may need an insulin dose adjustment.

Assess for salt cravings. Aldosterone deficiency increases renal sodium excretion.

Order a high-protein, low-carbohydrate, high-sodium diet. Inadequate hepatic glucagon production causes fatigue; this diet prevents fatigue, hypoglycemia, and hyponatremia. Increase salt intake by 5 g when activity or warm weather raises diaphoresis.

Keep a late-morning snack available. For hypoglycemia.

Offer frequent small meals. Steady intake holds blood glucose and nutrition.

Encourage rest after eating. Aids digestion.

3. Managing Decreased Cardiac Output

Low volume and dropped vascular resistance cut cardiac output. The heart works harder to hold pressure, so watch hemodynamics closely.

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

Assess level of consciousness. Restlessness and anxiety are early cerebral hypoxia, progressing to agitation and confusion.

Monitor vital signs with frequent BP checks, including orthostatics; anticipate intra-arterial monitoring in continuing shock. Sudden profound hypotension may mean Addisonian crisis. Auscultated BP can be unreliable with vasoconstriction.

Monitor for dysrhythmias. They follow low perfusion, acidosis, hypoxia, or electrolyte imbalance. Hyperkalemia is present in Addison's.

Monitor urine output. Oliguria is a classic sign of inadequate renal perfusion.

Monitor oxygen saturation by pulse oximetry or ABG. Expect decreased saturation.

Monitor temperature. Hyperpyrexia from hormonal and fluid imbalance can be an early crisis sign if it comes with a sudden BP drop.

If hemodynamic monitoring is in place, assess CVP, pulmonary artery diastolic pressure (PAD), pulmonary capillary wedge pressure (PCWP), and CO. CVP reflects right-sided filling; PAD and PCWP reflect left-sided volumes.

Minimize stress and keep the environment quiet. The patient cannot produce corticosteroids, so stress can trigger a life-threatening Addisonian crisis.

Provide rest periods and assist with all activities in crisis. Turning, feeding, and cleansing prevent overexertion.

If hypotension develops with decreased CO, give rapid IV fluids and IV hydrocortisone (Solu-Cortef). Circulatory collapse here does not respond to inotropes and vasopressors alone; glucocorticoids are required. They raise BP by potentiating norepinephrine's vasoconstrictor effect and by driving renal sodium and water reabsorption. In acute situations, err toward overtreatment with glucocorticoids rather than underdosing, which risks crisis. Stay alert to crisis risk in any patient with Addison's or a history of ongoing glucocorticoid use, where illness or stress can trigger collapse if replacement is not increased.

Give antipyretics as needed for fever (see Pharmacologic Support).

4. Pharmacologic Support

Glucocorticoids (hydrocortisone, prednisone) replace cortisol. Mineralocorticoid replacement (fludrocortisone) replaces aldosterone and holds the sodium-potassium balance. These prevent and treat adrenal crisis.

Kayexalate. This ion exchange resin, oral or by enema, lowers potassium.

Corticosteroids: oral cortisone (Cortone), hydrocortisone (Cortef), prednisone, or fludrocortisone (Florinef). Cortisone and prednisone replace cortisol and promote sodium resorption. Fludrocortisone is the mineralocorticoid for patients needing aldosterone replacement to hold sodium and water. Acute adrenal insufficiency needs immediate fluid and corticosteroid; start IV hydrocortisone in crisis and convert to oral by about the second day.

Antipyretics. Reduce the ongoing sodium and water losses driven by fever.