2. Thick, coarse skin
3. deposits of adipose tissue in the trunk and dorsocervical area
4. weight gain in arms and legs
Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.
2. Decreased cardiac output
3. Impaired physical mobility
4. Imbalanced nutrition: less than body requirement
RATIONALES: (2) An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison’s disease is at risk for infection; however, reducing infection isn’t a priority during an addisonian crisis. Impaired physical mobility is also an appropriate nursing diagnosis for the client with Addison’s disease, but it isn’t a priority in a crisis. Imbalanced nutrition: Less than body requirements is also an important nursing diagnosis for the client with Addison’s disease but not a priority during a crisis.
2. Test urine for ketones
3. Assess vital signs
4. Administer oral hydrocortisone
RATIONALES (3): Because the client in Addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he’s stable. Daily weights are sufficient when assessing the client’s condition. The client shouldn’t have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn’t administered during the first 24 hours in severe adrenal insufficiency.
2. Blood glucose level of 90 mg/dl
3. Serum sodium level of 134 mEq/L
4. Serum potassium level of 5.8 mEq/L
RATIONALES: (4) Addison’s disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison’s disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison’s disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.
2. “I need to weigh myself daily to be sure I don’t eat too many calories.”
3. “I need to call my doctor to discuss my steroid needs before I have dental work.”
4. “I will call the doctor if I suddenly feel profoundly weak or dizzy.”
5. “If I feel like I have the flu, I’ll carry on as usual because this is an expected response.”
6. “I need to obtain and wear a Medic Alert bracelet.”
RATIONALES:(3, 4, 6) Dental work can be a cause of physical stress; therefore, the client’s physician needs to be informed about the dental work and an adjusted dosage of steroids may be necessary. Fatigue, weakness, and dizziness are symptoms of inadequate dosing of steroid therapy; the physician should be notified if these symptoms occur. A Medic Alert bracelet allows health care providers to access the client’s history of Addison’s disease if the client is unable to communicate this information. A client with Addison’s disease doesn’t produce enough steroids, so routine administration of steroids is a lifetime treatment. Daily weights should be monitored to monitor changes in fluid balance, not calorie intake. Influenza is an added physical stressor and the client may require an increased dosage of steroids. The client shouldn’t “carry on as usual.”
2. dairy products
3. processed meats
4. cereals and grains
RATIONALES: (1) Cushing’s syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.
2. hair loss
3. bone mineralization
4. menstrual flow
RATIONALES: (1) Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing’s syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing’s syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing’s syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing’s syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.
2. reduced BUN
RATIONALES (1): In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.
2. chloride and magnesium abnormalities
3. sodium and chloride abnormalities
4. sodium and potassium abnormalities
RATIONALES:(4) In Addison’s disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn’t regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn’t affect levels of these electrolytes directly.
RATIONALES (1): Agitation, irritability, poor memory, loss of appetite, and neglect of one’s appearance may signal depression, which is common in clients with Cushing’s syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing’s syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.
2. Excessive fluid volume
3. Urinary retention
RATIONALES:(1) Addison’s disease decreases the production of all adrenal hormones, compromising the body’s normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison’s disease include Deficient fluid volume and Hyperthermia. Urinary retention isn’t appropriate because Addison’s disease causes polyuria.
4. Hypotonic saline
RATIONALES (2) : Emergency treatment for acute adrenal insufficiency (Addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until the client’s blood pressure returns to normal. Insulin isn’t indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn’t indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.
2. Allowing ambulation as tolerated
3. Offering extra blankets and raising the heat in the room to keep the client warm
4. Placing the client in a private room
RATIONALES(4): The client in addisonian crisis has a reduced ability to cope with stress due to an inability to produce corticosteroids. Compared to a multibed room, a private room is easier to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.
2. Drink 8 oz of fluids.
3. Perform capillary blood glucose monitoring four times daily
4. Continue to take his usual dose of hydrocortisone.
RATIONALES: (1) Clients with Addison’s disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. It’s important to keep well hydrated during stress, but the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn’t indicated in this situation because the client doesn’t have diabetes mellitus. Hydrocortisone replacement doesn’t cause insulin resistance.
2. normal saline solution
RATIONALES: (1) Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.
2. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
3. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
4. “I’ll take the entire dose at bedtime.”
RATIONALES (3): Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
2. an irregular apical pulse
3. dry mucous membranes
4. frequent urination
RATIONALES (2): Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s syndrome.
2. adrenal carcinoma
3. a corticotropin-secreting pituitary adenoma
4. an inborn error of metabolism.
RATIONALES: (3) A corticotropin-secreting pituitary adenoma is the most common cause of Cushing’s syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are often associated with weight loss. Adrenal carcinoma isn’t usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn’t be menstruating.