by Cathy Parkes August 13, 2020
In this article, we cover one disorder, adrenocortical insufficiency, and related critical care topic: an Addisonian Crisis. Knowing the pathophysiology, symptoms, diagnosis and treatment for these will be key in your Med-Surg exams as well as your nursing career.
These disorders are covered in our Medical-Surgical Flashcards (Endocrine system).
Adrenocortical insufficiency is inadequate secretion of hormones by the adrenal cortex. These hormones include aldosterone, cortisol, and androgens (sex hormones — the precursors for testosterone and estrogen).
If you recall from our lesson on cortisol, the hypothalamus produces corticotropin-releasing hormone (CRH), which causes the pituitary gland to produce adrenocorticotropic hormone (ACTH), and this allows the adrenal gland to secrete cortisol.
With primary adrenocortical insufficiency, there is some kind of trauma or infection to the adrenal gland that causes partial or total destruction of the gland and prevents it from producing cortisol.
One of the key causes of primary adrenocortical insufficiency is Addison's disease, which is an autoimmune disorder. In patients with Addison’s disease, the immune system is attacking, and therefore damaging, its own adrenal cortex.
When there is a problem outside the adrenal gland, this is known as a secondary cause of adrenocortical insufficiency.
If there is an insufficient amount of CRH from the hypothalamus or ACTH from the pituitary gland, this hypopituitarism can suppress the whole HPA system (hypothalamus-pituitary gland-adrenal cortex) and result in secondary adrenocortical insufficiency.
Another cause of secondary adrenocortical insufficiency can be abrupt cessation of corticosteroids. Chronic use of corticosteroids can lead to inadequate function of the HPA system and thus, when the corticosteroids are stopped, the patient may find themselves with adrenocortical insufficiency.
Signs and symptoms of adrenocortical insufficiency include weakness, fatigue, weight loss, hypotension (low blood pressure), dehydration, hypoglycemia, and a bronzed skin appearance.
It has been reported that President John F. Kennedy had Addison’s disease, and if you look at pictures of him, you can see that he looks very tan. Apparently, this was not from sunbathing on the white house lawn. It’s because he had adrenocortical insufficiency due to Addison’s disease, and bronzed skin was definitely one of the side effects.
The labs that you would see on a patient with adrenocortical insufficiency include elevated potassium, calcium, and blood urea nitrogen (BUN); and decreased cortisol, sodium and glucose.
That’s a lot of lab values to remember for one disease. Cathy recommends you take the time to think critically about the hormones involved, which hormones are missing, you can deduce what the lab values and symptoms are.
With adrenocortical insufficiency, the patient does not have enough cortisol. Cortisol is the stress hormone and over time can cause elevated levels of glucose. So low cortisol, low glucose (which is why hypoglycemia is a symptom).
With adrenocortical insufficiency, the patient does not have enough aldosterone. If you recall from our lesson, aldosterone allows for reabsorption of water and sodium, and excretion of potassium. Low aldosterone, low sodium and water (which is why hyponatremia, hypotension, and dehydration are symptoms). And low aldosterone, potassium is not being excreted, so high potassium (which is why hyperkalemia is a symptom).
|Hormone||Causes||Without this, then…(lab)||Without this, then… (symptom)|
|Cortisol||Increasing glucose||Low glucose||Hypoglycemia|
|Aldosterone||Reabsorption of water||High BUN, high calcium||Dehydration|
|Reabsorption of sodium||Low sodium||Hyponatremia|
|Excretion of potassium||High potassium||Hyperkalemia|
These lab values and many more are covered in our Lab Values flashcards for your convenience! This includes their normal ranges, and causes and symptoms of above/below range.
We use the ACTH stimulation test to determine whether the patient has primary or secondary adrenocortical insufficiency.
Remember, the hypothalamus produces CRH, which triggers the pituitary gland to product ACTH, so the adrenal gland can produce cortisol.
In primary adrenocortical insufficiency, the adrenal gland itself has the problem. It’s actually getting sufficient ACTH, but it’s not doing its job in response to that. So if you give a patient the ACTH and nothing happens, you know it’s a problem with the adrenal gland and that patient has primary adrenocortical insufficiency.
In secondary adrenocortical insufficiency, the problem is further back along the chain. The body is not getting the ACTH it needs from its pituitary gland in order to stimulate the adrenal cortex to release cortisol. So if you give a patient ACTH and their adrenal gland suddenly starts producing cortisol like it’s supposed to, then you know it was not an issue with the adrenal gland, and was actually an issue with the pituitary gland or hypothalamus. Therefore, you know it’s secondary adrenocortical insufficiency.
One of the key medications for a patient with adrenocortical insufficiency is hydrocortisone. This corticosteroid (glucocorticoid) is a hormone replacement drug for cortisol.
This patient’s hyperkalemia also needs to be treated — hyperkalemia is dangerous and can cause cardiac dysrhythmias. Kayexalate (sodium polystyrene sulfonate) is one hypokalemic agent that can be used for this.
You can also give the patient insulin to lower potassium levels. Insulin helps move potassium into the cells and out of the bloodstream. The problem is, insulin does the same with glucose, and this patient already has hypoglycemia. They shouldn’t be losing more glucose. So this patient would need insulin with glucose.
The patient may also need calcium gluconate, like Kalcinate, to help protect their heart from the detrimental effects of hyperkalemia.
When it comes to giving nursing care to a patient with adrenocortical insufficiency, administer fluids and electrolytes as ordered. Provide food and supplemental glucose to help treat the hypoglycemia.
Ensure continuous cardiac telemetry is in place due to the changes in potassium levels. Monitor for fluid volume deficit if kayexalate is administered, as this can lead to diarrhea.
A patient with adrenocortical insufficiency might need additional corticosteroid doses during times of illness or stress in the future, so they don’t get too low on their cortisol levels.
An Addisonian crisis is a life-threatening disorder caused by adrenal insufficiency. It’s a critical care topic important for Med-Surg exams like the NCLEX.
Causes of an Addisonian crisis can include stress and trauma. Normally, the body greatly increases cortisol production to handle stress, but in a patient with adrenal insufficiency, those cortisol stores can become quickly depleted, leading to acute onset of all the symptoms of adrenal insufficiency. Other causes can include infection or abrupt discontinuation of corticosteroids.
Signs and symptoms of an addisonian crisis are very similar to the signs and symptoms of general adrenal insufficiency. This means weakness, fatigue, dehydration, etc. But in an Addisonian crisis, the patient will have severe hypotension, and this can cause the patient to go into shock. You may also see dysrhythmias because of the very elevated levels of potassium (hyperkalemia).
To treat an addisonian crisis, the patient will need IV glucocorticoids as well as fluids with dextrose (glucose). It’s also important to find and treat the underlying cause of the Addisonian crisis. For example, if the patient has an infection or some kind of trauma, that needs to be addressed and treated.
When providing care to a patient undergoing an Addisonian crisis, make sure to closely monitor their vital signs, their I&Os, and their weight.
You should also monitor the patient for signs of shock. Some of the key signs of shock include decreased levels of consciousness and decreased urine output, below 30 ml/hour.
Monitor the patient for dysrhythmias because of the hyperkalemia, and provide them with bed rest and a quiet environment to reduce stress. Reducing stress reduces the cortisol their body needs to use.
Cathy’s teaching on this disorder and its complication is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.
Okay. In this video, we are going to talk about adrenocortical insufficiency, and we're also going to get into our first critical care topic of the endocrine system and talk about an Addisonian crisis.
So what is adrenocortical insufficiency? This is where we have insufficient secretion of hormones from the adrenal cortex. These hormones include aldosterone, cortisol, and androgens.
So in terms of the pathophysiology behind this disease, we have either primary causes or secondary causes of this disease.
With primary causes, we have some kind of injury or infection to the adrenal gland that causes partial or total destruction of the gland. One of the key causes of primary adrenocortical insufficiency is Addison's disease, which is an autoimmune disorder. In terms of secondary causes of adrenocortical insufficiency, this is where we have problem outside of the adrenal gland.
One secondary cause is abrupt discontinuation of corticosteroid therapy.
Another secondary cause could be an issue with the pituitary gland or the hypothalamus. So if you recall, the hypothalamus produces CRH which causes the pituitary gland to produce ACTH and this prompts the adrenal gland to secrete cortisol. So if we have issues with either the hypothalamus or the pituitary gland, then the adrenal gland isn't getting the right message to produce cortisol. So those are secondary causes of adrenocortical insufficiency.
In terms of signs and symptoms, signs and symptoms include weakness, fatigue, weight loss, hypotension, dehydration, hypoglycemia, and a bronzed skin appearance. So it's been reported that JFK, President Kennedy, had Addison's disease, and if you look at pictures of him, he always has this very tan or bronzed appearance, which, apparently, was not from laying out in the sun. It's because he had Addison's disease and this is definitely one of the side effects.
In terms of labs that you will see when someone has adrenocortical insufficiency, you would expect elevated potassium, calcium, and BUN, but you would expect decreased cortisol, sodium, and glucose.
Instead of just remembering all these up or down labs, if you think about the hormones involved and which hormones we don't have enough of, you can kind of better understand or think critically about what values will be up and which values will be down.
So with this disease, we don't have enough cortisol. And if you recall, cortisol is our stress hormone and it causes elevated levels of glucose. Well, if we don't have enough cortisol, then our glucose levels go down and that's why we have hypoglycemia.
Also, with this disorder, we don't have enough aldosterone. And if you recall, aldosterone allows for reabsorption of water and sodium and excretion of potassium. So when we don't have enough aldosterone, we are not reabsorbing all that water and sodium. We're excreting it instead, which is why we end up with hyponatremia as well as hypotension and dehydration, just getting rid of all that water.
But we're also retaining all that potassium instead of excreting it. So that's why we end up with hyperkalemia. So it all comes down to really understanding what those hormones are supposed to do, and then you can really understand what to expect when those hormones are not on board.
Right. Now let's now talk about diagnosis of adrenocortical insufficiency. We would use an ACTH stimulation test to help differentiate whether we have primary adrenocortical insufficiency or secondary causes of this disorder.
So if a patient has a primary cause of this disorder that means there's a problem with the adrenal gland itself and it's getting sufficient ACTH from the pituitary gland and it doesn't care, like, "You can give me all the ACTH you want. I'm just not going to produce cortisol." So if we give them external ACTH, it doesn't care. He's like, "You can give it to me from the pituitary gland or externally. Either way, I'm kind of injured or damaged and I'm not going to produce cortisol." So we give them the ACTH. If that doesn't make any difference, then we know it is a primary cause of adrenocortical insufficiency. There's a problem with the adrenal gland.
However, if we give the patient who has a secondary cause of this disorder ACTH-- so with the secondary cause, remember they're not getting enough ACTH from the pituitary gland. If we give them the ACTH and the adrenal gland's pumped and excited, like, "Finally. I've been waiting for this ACTH and it hasn't been coming. And now I can produce cortisol." So if the adrenal gland suddenly starts producing cortisol like it's supposed to, then we know it was an issue with the pituitary gland or the hypothalamus. It's a secondary cause of this disorder.
That's an explanation of how this ACTH stimulation test works.
In terms of treatment, one of the key medications we'll give somebody who has adrenocortical insufficiency is hydrocortisone.
We also need to treat that hyperkalemia because if you recall, hyperkalemia is really dangerous and can cause cardiac dysrhythmias. So you really want to bring those potassium levels down. And ways we can do this is-- one medication is called Kayexelate. That helps to bring potassium levels down.
You can also give the patient insulin. So insulin helps move potassium into the cells and out of the bloodstream. The only problem is, it also moves glucose into the cells and out of the bloodstream and we have hypogyclemia with this disease. So if we're giving the patient insulin to help bring those potassium levels down in the bloodstream, we also need to give them glucose in order to bring up those glucose levels in the bloodstream. So we're going to give insulin with glucose.
We're also going to need to give the patient calcium gluconate to help protect their heart from the detrimental effects of hyperkalemia.
In terms of nursing care, we're definitely going to administer our fluids and electrolytes as ordered. We're going to provide food and supplemental glucose to help treat that hypoglycemia. And we're going to teach the patient that in the future, additional corticosteroid doses may be needed during times of illness or stress so that they don't get too low on their cortisol levels.
Now let's talk about an Addisonian crisis. So if you're following along with cards, I'm on Card 29 in the endocrine system [in the Medical-Surgical Flashcard deck]. An Addisonian crisis is where we have a life-threatening disorder caused by adrenal insufficiency.
And causes of this crisis can include infection, stress, trauma, or abrupt discontinuation of corticosteroids.
In terms of the signs and symptoms, a lot of them are going to be fairly similar to what we just talked about. So weakness, fatigue, that type of thing. But we're also going to have severe hypotension that can cause shock. And then, we also may have dysrhythmias because we have very elevated levels of potassium.
In terms of treatment, we're definitely going to give this patient IV glucocorticoids as well as fluids with dextrose. And we need to really identify and treat the underlying cause of this crisis. So if the patient has infection or some kind of trauma, we need to try to address that.
In terms of nursing care, we're going to want to closely monitor this patient's vital signs, their I&Os, and their weight. And monitor for signs of shock.
Some of the key signs of shock include decreased level of consciousness and decreased urine output. So urine output that drops below 30 ml per hour.
We're also going to want to closely monitor for dysrhythmias because of that hyperkalemia and provide the patient with bed rest and a quiet environment.
So that is it for this video. When we pick it up in my next video, we will talk about Cushing's Disease. Thanks so much for watching. And if you've enjoyed this content, be sure to like this video and leave us a comment with any suggestions you have for future content!
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