7.7 Adrenal Disorders

The adrenal glands are a pair of small, triangular-shaped glands located on top of each kidney. See Figure 7.18^[1] for an illustration of the location of the adrenal glands.

The adrenal glands are responsible for producing several hormones that are essential for maintaining overall health and regulating various body functions. The two primary parts of the adrenal glands are the adrenal cortex and the adrenal medulla, each of which produces different hormones. See Figure 7.19^[2] for an illustration of adrenal cortex and adrenal medulla.

The adrenal cortex produces corticosteroids, including cortisol and aldosterone, which help to regulate metabolism, immune response, and salt and water balance. Cortisol is a glucocorticoid hormone produced by the adrenal glands that regulates physiological processes in the body. It is referred to as the “stress hormone” due to its involvement in the body’s stress response. Aldosterone is a mineralocorticoid hormone produced by the adrenal gland that regulates the salt and water balance of the body in the kidneys by increasing the retention of sodium and water and excreting potassium.

The adrenal medulla produces catecholamines, including epinephrine and norepinephrine. These hormones help induce the fight-or-flight response and play a critical role in elevating heart rate and blood pressure to prepare the body in times of stress or danger.^[3]

Adrenal Insufficiency: Addison’s Disease

Addison’s disease refers to a specific type of adrenal gland insufficiency, resulting in inadequate production of cortisol and aldosterone. Addison’s disease is often the result of an autoimmune response and destruction of the adrenal glands. It can also occur as the result of tuberculosis; infection; or the sudden cessation of long-term, high-dose glucocorticoid treatment.^[4]

Addisonian crisis is a life-threatening medical emergency that occurs when the body’s need for the hormones cortisol and aldosterone exceeds the available supply. This crisis is a severe complication of Addison’s disease, a condition in which the adrenal glands do not produce enough of these critical hormones. The crisis often occurs in response to a stressful event, such as an infection, surgery, trauma, or a significant physical or emotional stressor.^[5],[6] Read additional information about Addisonian crisis in the following box.

Assessment

Common assessment findings for adrenal insufficiency can be seen in Table 7.7a.

Table 7.7a. Common Manifestations of Adrenal Insufficiency^[8]

See Figure 7.20 ^[9]for an illustration of the clinical manifestations of adrenal insufficiency.

Diagnostic Testing

Diagnosing Addison’s disease involves a combination of clinical assessment, laboratory tests, and specialized tests to confirm adrenal insufficiency. Addison’s disease is characterized by the insufficient production of cortisol and often aldosterone by the adrenal glands, so serum cortisol and aldosterone levels are abnormally low. Additionally, as a result of abnormally low aldosterone levels, electrolyte imbalances can also be found, including hyponatremia (low sodium) and hyperkalemia (elevated potassium).^[10] Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

Nursing Diagnoses

Nursing diagnoses for clients with adrenal gland hypofunction can help guide nursing care and address the specific needs of these individuals.

Common nursing diagnoses include the following:

• Risk for Imbalanced Fluid Volume
• Impaired Skin Integrity
• Fatigue
• Imbalanced Nutrition: Less Than Body Requirements

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. 

• The client will maintain adequate fluid balance as evidenced by stable vital signs and absence of signs and symptoms of dehydration or fluid overload.
• The client will exhibit intact skin without any signs of breakdown, ulceration, or infection.
• The client will demonstrate improved ability to perform activities of daily living without excessive fatigue.
• The client will achieve and maintain a stable and appropriate body weight.

Interventions

Medical Interventions

Medical interventions for adrenal insufficiency focus on medication therapy to replace the deficient hormones and effectively manage the condition to prevent adrenal crisis.

Medication Therapy

Clients with Addison’s disease are typically prescribed oral glucocorticoid medications, such as hydrocortisone, prednisone, or dexamethasone, to replace deficient cortisol levels. The dose is often divided into multiple daily doses to mimic the body’s natural cortisol release pattern.

Clients may also require mineralocorticoid replacement with medications like fludrocortisone to replace aldosterone and regulate salt and water balances in the body.

Clients with adrenal insufficiency often have abnormal electrolyte levels. Those presenting with hyperkalemia require urgent treatment to lower their potassium levels, along with close cardiac monitoring.

Hormone Monitoring

Periodic blood tests are conducted to assess hormone levels and adjust medication doses as needed. Clients are educated about the need to increase their glucocorticoid medication during times of illness, injury, or stress to prevent an adrenal crisis.

Lifestyle Changes

Clients are advised to maintain a well-balanced diet and avoid excessive stress, which can exacerbate symptoms.^[11]

Nursing Interventions

Nursing interventions for adrenal insufficiency focus on medication management, health teaching, and nutritional support.

Medication Management

Nurses administer prescribed glucocorticoid and mineralocorticoid replacement medications during inpatient care according to the health care provider’s orders. Health teaching is provided about proper medication administration techniques and adherence to the medication schedule.

Health Teaching

Nurses provide health teaching about several topics to clients with adrenal insufficiency:

• The disease process and the importance of medication adherence.
• Signs and symptoms of adrenal crises and when to immediately notify the health care provider. Additional doses of medications may be required during illness and stressful situations.
• Wearing a medical alert bracelet or necklace to inform health care professionals of their diagnosis if an emergency should occur.

Nutritional Support

Nurses advocate for multidisciplinary treatment with a registered dietician to develop a well-balanced diet plan and to ensure adequate sodium intake for clients on mineralocorticoid replacement therapy. The nurse also monitors the client’s dietary intake and hydration status.

Evaluation

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the client’s expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a client’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with others on the interprofessional team.

Nurses refer to the previously identified outcome statements and perform reassessments to determine if they have been met by the current nursing care plan or if additional interventions are required. For example, the nurse would perform assessments related to the previously established outcome criteria and determine if they were “met” or if additional interventions are required.

Cushing’s Disease & Cushing’s Syndrome

Excessive amounts of adrenal hormones, including glucocorticoids (cortisol), mineralocorticoids (aldosterone), and/or catecholamines (epinephrine and norepinephrine), can be caused by a medical condition or a side effect of other medications. Cushing’s disease is typically caused by a benign tumor in the adrenal gland that causes excess hormone production. Cushing’s syndrome is caused by excess glucocorticoid blood levels caused by medication therapy for another medical problem, such as COPD or immunosuppressive therapy after an organ transplant. In both cases, excessive glucocorticoids can cause widespread issues throughout the body.^[12]

Assessment

Common assessment findings for Cushing’s disease and Cushing’s syndrome are summarized in Table 7.7b.

Table 7.7b. Common Manifestations of Cushing’s Disease and Cushing’s Syndrome^[13]

See Figure 7.21 ^[14] by for an illustration of common clinical manifestations of Cushing’s Disease and Cushing’s Syndrome.

Diagnostic Testing

Diagnostic testing includes blood tests of cortisol and aldosterone levels. Review information about cortisol testing under diagnostic testing in the “Adrenal Insufficiency” subsection. Electrolytes are commonly monitored because excessive aldosterone levels can cause hypernatremia (elevated sodium) and hypokalemia (decreased potassium).^[15]

Nursing Diagnoses

Nursing diagnoses for clients with excessive adrenal hormones guide nursing care and address the specific needs of these individuals. Common nursing diagnoses include the following:

• Fluid Volume Excess
• Imbalanced Nutrition: More Than Body Requirements
• Disturbed Body Image
• Impaired Skin Integrity
• Risk for Infection

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. 

• The client will maintain optimal fluid balance as evidenced by normal blood pressure, no signs of edema, and balanced input and output within normal limits.
• The client will achieve and maintain a healthy body weight, with weight gain within recommended limits, while demonstrating knowledge of appropriate portion sizes and balanced dietary choices.
• The client will exhibit improved body image and self-esteem, as evidenced by positive self-talk, engagement in activities they enjoy, and verbalization of self-acceptance.
• The client will maintain intact skin and prevent skin breakdown, as evidenced by the absence of skin lesions, regular skin assessments, and adherence to recommended skin care routines.

Interventions

Medical Interventions

Medical interventions include surgery or radiation therapy, medication therapy, and lifestyle modifications.

Surgery/Radiation Therapy

Surgery may be used to remove a tumor or the affected area of the adrenal gland in cases of adrenal adenoma or pituitary adenoma. Radiation therapy may also be utilized following surgery.

Medication Therapy

If a client is experiencing Cushing’s disease as a result of glucocorticoid therapy for another condition, the medication may be stopped or reduced, if possible. Medications, such as aminoglutethimide and ketoconazole, may be prescribed to suppress cortisol production. Mineralocorticoid receptor antagonists such as spironolactone may also be prescribed to help control blood pressure and manage electrolytes. Beta-blockers may also be prescribed to help manage blood pressure and heart rate.

Lifestyle Modifications

Dietary modifications may be necessary to address weight gain or changes in appetite. Clients may also be advised to reduce sodium intake in conditions of excess aldosterone. Regular exercise, stress management, and healthy lifestyle choices can help manage symptoms and improve overall well-being.^[16]

Nursing Interventions

Nursing interventions for Cushing’s disease and Cushing’s syndrome focus on promoting fluid and electrolyte balance, providing health teaching on diet and exercise, and psychological support.

Promoting Fluid and Electrolyte Balance

Nurses monitor for signs of electrolyte imbalances (e.g., potassium levels) and provide education on dietary changes and medications to address these imbalances. Health teaching about dietary sodium restrictions is provided, if necessary, to help manage fluid balance.

Health Teaching

Nurses provide health teaching to clients with Cushing’s disease on balanced nutrition and weight management. In collaboration with dieticians, meal plans are developed, and clients are taught about portion control and healthy food choices. Clients are encouraged to participate in regular physical activity to improve muscle strength and overall well-being. Exercise routines are planned that are aligned with their energy level and physical capabilities.

Psychological Support

Nurses provide emotional support and encourage open communication to help clients cope with the chronic nature of their condition and any body image changes. Resources are provided for support groups and counseling, as indicated.

Evaluation

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the client’s expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a client’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with others on the interprofessional team.

Nurses refer to the previously identified outcome statements and perform reassessments to determine if they have been met by the current nursing care plan or if additional interventions are required. For example, the nurse would perform assessments related to the previously established outcome criteria and determine if they were “met” or if additional interventions are required.