21.5 Adrenal Disorders

Clinical Manifestations

Patients with adrenal insufficiency may initially have symptoms such as fatigue, weight loss, generalized weakness, abdominal pain, nausea, vomiting, and dizziness. These symptoms tend to get progressively worse over time. As the disease progresses, hyperpigmentation of the skin (Figure 21.10) occurs in almost all patients (Munir et al., 2023). Female patients may also have decreased axillary and pubic hair.

Figure 21.10 This woman has hyper-pigmentation due to adrenal insufficiency. (credit: “F1: Facial and scar pigmentation” by Department of Diabetes and Endocrinology, Clinical Sciences Centre, University Hospital Aintree, Liverpool, CC BY 2.0)

Adrenal Crisis

An adrenal crisis is an acute, rapid onset of severe cortisol and aldosterone insufficiency, causing the patient to become critically ill and go into shock. It can be caused by abrupt discontinuation of steroid therapy or inadequate dosing of current steroid therapy in patients with adrenal insufficiency or by recent infection or trauma. Signs and symptoms include rapid, progressive onset of adrenal insufficiency symptoms such as nausea, vomiting, abdominal pain, hypotension, altered mental status, or obtundation. The crisis is initially treated by administering intravenous fluids, dextrose, and hydrocortisone, followed by diagnostic testing to discover and treat the underlying cause. Adrenal crisis is an emergency and should be reported to the provider immediately. Mortality is approximately 25 percent (Cleveland Clinic, 2022a).

Diagnostics and Laboratory Values

Diagnosis of adrenal insufficiency is confirmed by low serum cortisol and aldosterone levels, a blunt cortisol response with ACTH stimulation, and an elevated renin activity test. A morning serum cortisol level less than 3 mcg/dL will be present. Serum chemistry results may reveal hyponatremia, hypoglycemia, hypercalcemia, and hyperkalemia. Thyroid stimulating hormone (TSH) may also be elevated, secondary to low cortisol levels.

Other diagnostic testing may be completed to rule out alternative causes of the low hormone levels: for example, a chest X-ray to confirm tuberculosis, or abdominal CT scan to confirm adrenal tumor, mass, or calcification. A biopsy of the adrenal gland may be completed to confirm malignancy.

Nursing Care of the Patient with Adrenal Insufficiency

Nursing care of the patient with adrenal insufficiency involves maintaining nutrition and fluid balance, improving symptoms, and preventing complications, such as adrenal crisis. Careful monitoring, robust patient education, and timely intervention are key interventions to optimize outcomes.

Recognizing and Analyzing Cues

When completing a subjective assessment, ask the patient targeted questions, especially if the patient is experiencing a host of nonspecific symptoms (Munir et al., 2023). Specific questions related to adrenal insufficiency may include:

• Have you experienced fatigue and unexplained weight loss? Has it gotten worse over a period of time?
• Have you been experiencing a loss of appetite, nausea, or chronic abdominal pain?

An objective assessment may reveal generalized hyperpigmentation, especially at the elbows, palmar creases, lips, knuckles, posterior neck, nail beds, nipples, breast areola, and gingival mucosa (Munir et al., 2023). The patient may also have poor coordination, vitiligo (patches of skin without pigment), hypotension, and a weak, irregular pulse.

A slow progression of symptoms indicates a chronic adrenal disease, while a rapid progressive onset indicates an acute, emergent condition. Nurses can analyze the degree of symptom burden incorporating all cues related to cardiovascular stability. Insufficient adrenal activity also predisposes patients to hypoglycemia; therefore, it is important for nurses to recognize symptomatic hypoglycemia such as weakness, tremors, confusion, diaphoresis, and in severe cases, seizures. Rapid identification of abnormal cues will guide clinical intervention if they become of an emergent nature.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

Priorities of patient care include ensuring the patient follows treatment orders and monitoring the patient for adrenal crisis. Care of the patient with adrenal insufficiency includes prioritization of cardiovascular needs, monitoring of electrolyte imbalance, and close monitoring of glucose levels. Nurses should monitor hemodynamic stability with trending blood pressures, heart rate, and laboratory data. Serum sodium levels should be monitored since low levels of aldosterone can cause hyponatremia. Often, patients are placed on telemetry to identify any triggered dysrhythmias from electrolyte disturbance or hypovolemia. Any deviations of these physiological parameters can be catastrophic if this leads to adrenal crisis. An interdisciplinary, collaborative approach is mainstream when delivering care to the patient with adrenal complications. The care team may include a nutritionist to ensure the patient’s diet includes sufficient sodium and potassium to maintain balance. If the patient has a decreased appetite, encourage frequent, small meals throughout the day to maintain a healthy caloric intake. For a patient experiencing fatigue, try to cluster care or activities so the patient has adequate periods of rest. Providing antiembolism stockings or a sequential compression device can prevent VTE in patients who are bedridden.

Patient teaching should include information about adrenal insufficiency, especially the importance of medication and treatment compliance. Avoidance of stress and healthy coping mechanisms to reduce stress and increase relaxation should also be discussed with the patient and family. Other teaching should include:

• Signs and symptoms to report to the provider, such as adrenal crisis
• Infection prevention measures, such as staying away from people who are sick
• Utilization of an alert bracelet stating the patient has adrenal insufficiency
• Technique for self-administering an emergency hydrocortisone injection in times of stress

Evaluating Nursing Care of the Patient with Adrenal Insufficiency

To evaluate the effectiveness of nursing actions, the nurse should review any goals created and see if they were achieved and by the set deadline. For example, if the patient was experiencing a decrease in appetite, were they still able to maintain a healthy caloric intake throughout the day? Re-assessment should compare current status to initial status. If the patient was not able to maintain a healthy caloric intake, inquire as to reasons for inability or barriers. Were the patient’s food preferences taken into consideration? Were frequent, small meals offered to the patient throughout the day? If the goal is not met, the nursing care will need to be modified.

Evaluating Outcomes

Evaluating outcomes looks at the patient from a larger view. Questions the nurse can ask may include:

• Did the patient experience a decrease in the symptoms of adrenal insufficiency?
• Are the patient’s cortisol levels, electrolytes, and vital signs within normal limits?
• Is the patient able to state the importance of following the treatment plan?

If these outcomes were not achieved, the plan will need to be re-evaluated and modified.

Medical Therapies and Related Care

Treatment of adrenal insufficiency involves repletion of low cortisone and aldosterone with synthetic versions of the hormones. Hormonal replacement is a lifelong therapy. A glucocorticoid, such as hydrocortisone or prednisone, will be prescribed to replace low levels of cortisone. For low aldosterone levels, fludrocortisone acetate, a mineralocorticoid, will be prescribed to help control sodium and potassium levels in the body. Medication dosages are determined by clinical response and return of electrolyte balance.

In situations of high stress, such as fever, infection, and pregnancy, an increase of glucocorticoid therapy will be required to compensate for a stress response. It is important for the patient to maintain all appointments with the endocrinologist and receive adequate patient education about the disease, treatment, and symptoms to report to the practitioner.

Clinical Manifestations

Clinical manifestations of Cushing’s syndrome include weight gain, water retention, weakness, fatigue, headache, delayed wound healing, easy bruising, bone pain, loss of height, hirsutism (excess hair growth), impotence, decreased libido, menstrual irregularities, and frequent infections (Figure 21.11). Patients may also have depression, cognitive dysfunction, or peptic ulcer disease.

Figure 21.11 Cushing’s syndrome affects many body systems. (credit: “ Cushing's syndrome (vector image)” by Mikael Häggström/Wikimedia Commons, CC0 1.0)

Diagnostics and Laboratory Values

Signs and symptoms of Cushing’s syndrome may vary depending on the level of extra cortisol in the body (Belleza, 2023). An accurate assessment during initial diagnosis can prevent complications. Diagnostic testing can provide information about the underlying cause and severity of the disease.

A dexamethasone suppression test is done by giving the patient a low dose of dexamethasone at night, then collecting a serum cortisol level the next morning. A patient with Cushing’s syndrome will not have the ability to suppress cortisol production, resulting in a high serum cortisol level. A 24-hour urine collection for free cortisol can detect overproduction of cortisol in the body. Serum electrolytes may show hypokalemia and hypocalcemia, and fasting blood glucose levels may be elevated.

A CT scan or ultrasound of the kidneys may reveal an adrenal tumor. MRI of the brain may be done to evaluate for a pituitary tumor. X-rays may also be completed to evaluate for osteoporosis.

Nursing Care of the Patient with Cushing’s Syndrome

Nursing care should be based on assessment data with the goal to reduce symptoms. For example, patients with Cushing’s syndrome are more prone to pressure injuries and falls secondary to weakness, fatigue, and poor healing (Belleza, 2023). To decrease risk for pressure injury, the nurse should ensure the patient changes positions frequently while in bed. To protect skin integrity, the nurse can also frequently inspect the patient’s skin and teach the patient how to care for their skin and avoid anything that can irritate or tear it. To prevent falls, institute fall precautions, provide assistance to the patient when ambulating, and ensure frequently used items are within the patient’s reach.

Recognizing Cues and Analyzing Cues

Subjective questions during the initial nursing assessment to target symptoms of Cushing’s syndrome may include:

• Have you had unexplained weight gain or water retention?
• Do you bruise easily?
• Have you been experiencing any bone pain, fatigue, or muscle weakness?
• Have you noticed any increase in hair growth on your face, chest, or abdomen?
• Have you noticed a decrease in libido or sexual dysfunction?
• Are your periods regular? (Female patients)

Be sure to obtain an accurate medication history. In some instances, Cushing’s syndrome may be caused by certain medications, such as prednisone, used to treat other conditions. Physical findings may show fatty deposits around the face (“moon face”) and between the shoulders (“buffalo hump”), hirsutism, thin extremities, muscle wasting, swollen ankles, purplish striae, skin atrophy, acne, and central obesity. Patients who have physical signs, such as moon face or a buffalo hump, may be experiencing body image issues. Listen to the patients’ concerns and discuss how physical signs may fade with treatment (Vera, 2023). Talk to the patient about dietary changes they can make to decrease fluid retention, such as a low sodium diet.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

Based upon the findings, the nurse may hypothesize Cushing’s syndrome. The nurse will discuss the findings with the patient, then collaborate with the practitioner about a plan of care. Since the diagnostic priority is to evaluate cortisol production and discover the underlying cause, the nurse would expect to draw serum bloodwork and possibly prep the patient for imaging, such as X-ray, CT scan, or MRI.

Patients should be educated about the disease, testing, and treatment. Be sure to include:

• importance of monitoring daily weights and proper nutrition
• ways to prevent infection, such as avoiding large crowds, using proper hand hygiene, and keeping away from people who are sick
• injury prevention strategies
• stress reduction and relaxation techniques
• the importance of keeping all follow-up appointments
• wearing a medical alert bracelet stating the patient has Cushing’s syndrome

In addition to improving symptoms, the nurse must monitor for complications. Similar to adrenal insufficiency, adrenal crisis can occur in Cushing’s syndrome if glucocorticoid medications are abruptly stopped. The nurse should also monitor vital signs, electrolytes, daily weights, intake and output, and serum blood glucose for imbalances (Vera, 2023).

Evaluating Nursing Care of the Patient with Cushing’s Syndrome

An improvement in symptoms and prevention of complications would indicate adequate nursing care. For instance, if the patient does not experience any falls or skin breakdown during treatment, nursing interventions were adequate for care. If the nurse notices a patient has an area of redness over a bony prominence, nursing care should be adjusted to prevent any further injury; the nurse may initiate a strict turn/repositioning schedule or request an overlay mattress to further prevent pressure to that area.

Evaluating Outcomes

Any goals created during the nursing care process should be evaluated. Interventions are fluid and should be adjusted as appropriate during the care process. To support this process, the nurse may ask questions such as:

• Did the patient’s skin remain free from injury?
• Did the patient’s blood sugar achieve target norms?
• Did the patient remain free from infection?
• Did the patient’s nutrition meet their ideal body weight?

Constant collaboration with the interdisciplinary team and open communication with the patient and family are also key to supporting nursing care goals.

Medical Therapies and Related Care

Treatment is dependent on the underlying cause. If Cushing’s disease is exogenous, then the patient may be tapered off steroid therapy. The taper is done slowly, sometimes over months, to prevent adrenal crisis and give the adrenal glands a chance to return to normal function (Chaudhry & Singh, 2023). Mifepristone, a cortisol receptor blocker, may be prescribed to control blood glucose levels until adrenal function improves.

In endogenous cases caused by an adrenal tumor, surgery is the first therapy of choice for treatment. Patients are then closely monitored to evaluate if normal cortisol production is present. If the cause is a pituitary tumor, hypophysectomy surgery may be done; radiation therapy may also be performed. In some cases, if a tumor cannot be completely resected, a bilateral adrenalectomy may be performed; the patient will then require lifelong glucocorticoid and mineralocorticoid replacement therapy. Bisphosphonates may also be prescribed to prevent osteoporosis. Additional medications may be prescribed to control signs and symptoms, such as potassium supplements, diuretics, and antihypertensives.