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Course # 30830 • Pituitary and Adrenal Disorders

ACUTE ADRENAL INSUFFICIENCY (ADDISON DISEASE)

Present Illness

Patient A, a man 50 years of age, is admitted for diagnosis and initial management of suspected adrenal hypofunction with acute adrenal insufficiency. For the past five years, Patient A has been under considerable stress managing his failing contracting business. Initially, he dismissed his complaints of fatigue and weakness as job-related. Lately, the symptoms have been difficult to ignore and associated with anorexia, nausea, and vomiting. He has lost 30 pounds over the past three months without dieting. He complains of frequently feeling cold and has had two syncopal attacks in the month prior to admission. He reports that although he has spent essentially all this time indoors at the office, his skin has become as dark as his employees who work outdoors.

On the morning of admission, he did not wake at his usual early hour and told his wife that he felt gravely ill. His wife called the family physician, who instructed her to take Patient A to the emergency department. After evaluation in the emergency department, Patient A is admitted to the critical care unit (CCU).

Medical History

A medical history is obtained from Patient A's wife. She states that the patient has no allergies to medications but was very allergic to ragweed when they were first married. During the first 10 years of their marriage, Patient A had frequent asthma attacks requiring treatment with epinephrine injections. The asthma attacks diminished in frequency during his middle years, and his wife cannot remember when he last had an attack.

Patient A also has a history of coccidioidomycosis, which was active for several years late in adolescence and in early adulthood. Mrs. A has no recollection of being told of changes in the patient's routine chest x-rays for some time. Ten years previously, Patient A was diagnosed with hypertension, but his blood pressure has been well-controlled with daily exercise and dietary changes.

Patient A has been married to his wife for 35 years and has three grown children who live out of state. His contracting business had been successful until five years ago, when a decrease in housing starts resulted in a decline in business and increased financial stress.

Assessment and Diagnosis

Upon admittance to the CCU, a full physical exam is conducted (Table 2). A chest x-ray is done and shows normal lung fields and a smaller than expected heart. Several laboratory tests are ordered, with the following results:

  • Serum chemistry results:

    • Sodium: 125 mEq/L

    • Potassium: 6.2 mEq/L

    • Chloride: 89 mEq/L

    • Carbon dioxide (CO2): 19 mmol/L

    • Blood glucose: 45 mg/dL

    • BUN: 37 mg/dL

  • Hematocrit: 50%

  • White blood count: 3.5 x 109/L

PATIENT A'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
A thin, well-tanned man who seemed mildly confused
Height: 6 feet 2 inches (188 cm)
Weight: 190 pounds (86 kg)
Head and eyes
Normocephalic
Numerous gray-brown freckles on forehead
Pupils equal (4 mm), round, reactive to light and accommodation
Normal fundoscopic exam
Extraocular muscles full
Nasal turbinates slightly reddened, with clear exudate
Brown freckles on oral mucosa
Pharynx clear
Ears
External ear canals clear
Tympanic membranes clear and retracted
Neck
Supple, without masses or thyromegaly
Nonpalpable cervical lymph nodes
Chest
Symmetrical excursion
Areolas darkly pigmented
Lungs clear to percussion and auscultation
Abdomen
Flat with active bowel sounds in all quadrants
Normally unexposed skin appears tanned
Soft, nontender, and without organomegaly or masses
ExtremitiesPulses present, equal, and faint. Normal hair distribution
Genitourinary systemWithin normal limits
Neurologic status
Oriented to person, place, and time but very slow to answer questions
Cranial nerves II–XII grossly intact
Deep tendon reflexes 1+ and symmetrical
Bilateral plantar flexor responses
Cardiovascular system
Cardiac rhythm sinus bradycardia without ectopy
Point of maximal impulse at sixth intercostal space 1 inch left of midclavicular line
Heart sounds quiet with normal S1 and S2, without gallops, rubs, or murmurs
Vital Signs
Blood pressure100/60 mm Hg
Temperature96.5° F
Heart rate58 bpm
Respiratory rate12 breaths per minute

Based on the results of the assessment, Patient A is diagnosed with possible acute adrenal insufficiency and possible Addison disease.

Management

Shortly after arriving in the CCU, Patient A vomits a large amount of bile-colored gastric contents and then develops coma and shock. His blood pressure is 60/10 mm Hg, his heart rate is 50 beats per minute, and his respiratory rate is 8 breaths per minute and gasping. He is quickly resuscitated with rapid IV infusion of normal saline, hydrocortisone sodium succinate (100 mg IV), tracheal intubation, and artificial ventilation. A double lumen nasogastric tube is inserted and connected to low constant suction. An indwelling urinary catheter is inserted and connected to a urine meter. Patient A's condition stabilizes as he becomes alert and orientated, has adequate spontaneous ventilation, and maintains adequate cardiac output and blood pressure. Efforts are made to confirm the diagnosis of Addison disease.

The physician orders diagnostic tests of adrenal, thyroid, and pituitary function. Results of the 24-hour urine collection assessed for 17-ketosteroids and 17-hydroxycorticosteroids indicates that adrenal secretion of cortisol, corticosterone, cortisone, and 11-hydroxycorticosternone is inadequate. The result of the plasma cortisol response to ACTH test confirms the diagnosis of Addison disease. The latest results of tests of thyroid and pituitary function are within normal limits.

Patient A is prescribed fludrocortisone acetate (0.1 mg daily) and hydrocortisone (20 mg daily) as replacement therapy. He responds well and is transferred out of the CCU four days after admission.

Study Questions

Consider the information that has been presented in this course regarding adrenal insufficiency and Addison disease.

  1. What fluid and electrolyte imbalances are usually associated with adrenal insufficiency? How does the pathophysiology of adrenal insufficiently create these imbalances?

  2. What are the expected results of the plasma cortisol response to ACTH test and 24-hour urine collection in adrenal insufficiency? How are the tests conducted?

  3. What risks will subsequent critical illness pose for Patient A?

  4. What nursing observation would be important in a critically ill patient with a history of adrenal insufficiency?

  5. How might chronic adrenal insufficiency be managed during a critical illness?

  6. What are the symptoms and signs of hypoadrenalism?

  7. What is the most common type of hypoadrenalism?

  8. What are the other causes of hypoadrenalism?

  9. How is hypoadrenalism diagnosed?

DIABETES INSIPIDUS

Present Illness

Patient B, a man 26 years of age, is in the hospital recovering from surgical clipping of an aneurysm on the anterior communicating artery. Three days after surgery, he begins voiding large quantiles of very pale urine. His IV intake is 80 mL/hour, and his oral intake is minimal. The specific gravity of the urine is 1.002, and the patient's calculated urine output is more than 200 mL/hour for four consecutive hours. The nurse observes that during the past two hours Patient B's blood pressure has declined from 120/80 mm Hg to 110/70 mm Hg and that his heart rate has increased from 68 beats per minute to 110 beats per minute. The nurse notifies the neurosurgeon of the large unconcentrated urinary output and the changes in vital signs.

Medical History

Patient B has suffered chronic severe headaches, and the diagnosis of cerebral aneurysm led to the cerebrovascular procedure. The surgical procedure went well, and Patient B was recovering as expected.

Assessment and Diagnosis

Upon the onset of diuresis, a full physical exam is conducted (Table 3). Laboratory findings are:

  • Plasma osmolality: 289 mOsm/L

  • Urine osmolality: 108 mOsm/L

  • Serum sodium level: 150 mEq/L

PATIENT B'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
A young African American man who appears his stated age and is alert and oriented
Height: 5 feet 11 inches (180.5 cm)
Weight: 190 pounds (86 kg)
Head and eyes
Normocephalic
Dressing dry and intact
No ecchymosis visible
Pupils equal (4 mm), round, reactive to light and accommodation
Normal fundoscopic exam
Extraocular muscles full
Nasal turbinates and oral mucosa pink and moist
Pharynx clear
Ears
External ear canals clear
Tympanic membranes clear
NeckSupple, without masses or thyromegaly
Chest
Symmetrical excursion
Lungs clear to percussion and auscultation
Abdomen
Flat with active bowel sounds in all quadrants
Soft, nontender, and without organomegaly or masses
ExtremitiesPulses present, equal, and moderate
Genitourinary systemWithin normal limits
Neurologic status
Oriented to person, place, and time
Cranial nerves II–XII grossly intact
Deep tendon reflexes 1+ to 2+ and symmetrical
Bilateral plantar flexor responses present
Cardiovascular system
Cardiac rhythm normal sinus without ectopy
Point of maximal impulse at fifth intercostal space 2 cm left of midclavicular line
Heart sounds normal S1 and S2, without gallops, rubs, or murmurs
Vital Signs
Blood pressure110/70 mm Hg
Temperature98.4° F
Heart rate69 bpm
Respiratory rate11 breaths per minute

Based on the findings of the assessment, Patient B is diagnosed with diabetes insipidus secondary to manipulation of the pituitary.

Management

The neurosurgeon orders 2.5 units of aqueous vasopressin to be administered immediately intramuscularly. Following administration, urine output is reduced to 60 mL/hr in 30 minutes. The urine osmolality level two hours later is 760 mOsm/L. Patient B continues to be monitored to determine if the pituitary damage is permanent and if he requires long-term desmopressin therapy.

Study Questions

Consider the information that has been presented in this course regarding diabetes insipidus.

  1. What are the key signs and symptoms of diabetes insipidus? How did it present in Patient B?

  2. What is the action of vasopressin?

  3. What are the main types of diabetes insipidus? What type does Patient B have?

  4. What causes central diabetes insipidus? What causes nephrogenic diabetes insipidus?

  5. What diagnostic test(s) can reveal whether diabetes insipidus is central or nephrogenic? How are these conditions treated?

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE SECRETION

Present Illness

Patient C is a Hispanic man, 60 years of age. He is brought to the emergency department by his family because of acute mental confusion and combativeness. His wife and son report that he has been complaining of anorexia, a nonproductive cough, and unusual fatigue and weakness for the past seven months. During this time, he lost 40 pounds. In the past two weeks, Patient C has been unusually irritable and occasionally irrational. The day before admission, the patient's confusion and disorientation became so severe that he tried to hit his wife. Because she could not manage him alone, the patient's wife asked their son to come and stay with them.

The morning of the admission, Patient C has a seizure (with signs consistent with a tonic-clonic seizure), and the family transports the patient to the emergency department for evaluation.

Medical History

Patient C's wife reports that her husband drinks six 12-ounce beers daily and has smoked two to three packs of cigarettes per day for the 35 years of their marriage. She has no knowledge of Patient C's family medical history. In addition, Patient C has only rarely seen a physician for illnesses and has never had a routine physical examination.

Assessment and Diagnosis

Upon presentation to the emergency department, a full physical exam is conducted (Table 4). An electrocardiogram (ECG) is normal with nonspecific ST-T wave changes. Skull imaging is normal, but a chest x-ray visualizes a mass in the lower right lobe. Laboratory studies find:

  • Blood chemistry levels:

    • Sodium: 115 mEq/L

    • Potassium: 3.8 mEq/L

    • Chloride: 80 mEq/L

    • Calcium: 7.2 mg/dL

    • Total protein: 5.8 mg/dL

  • CO2: 25 mmol/L

  • BUN: 15 mg/dL

  • Blood glucose: 90 mg/dL

  • Creatinine: 0.9 mg/dL

  • Serum osmolality: 235 mOsm/L

  • Urine osmolality: 260 mOsm/L

PATIENT C'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
A thin, disoriented, and irritable man who appears older than his stated age and coughs frequently
Height: 5 feet 8 inches (173 cm)
Weight: 149 pounds (68 kg)
Head and eyes
Normocephalic
All structures normal
Ears
External ear canals clear
Tympanic membranes clear
Neck
Supple, without thyromegaly
Firm 2 x 3 cm lymph node in right supraclavicular area
Jugular vein distention to the angle of the jaw while sitting up 45 degrees
Chest
Increased anteroposterior diameter and increased curvature to thoracic spine curvature
Dullness to percussion in right base
Lungs have scattered rhonchi and diminished breath sounds in the right base
Abdomen
Flat with active bowel sounds in all quadrants
Soft with mild tenderness in right upper quadrant
Liver palpable 5 cm below right costal margin
Extremities
Peripheral pulses present, equal, and bounding
Normal hair distribution
Genitourinary systemWithin normal limits
Neurologic status
Confused, oriented to self only
Unable to follow instructions for cranial nerve exam
Deep tendon reflexes symmetrically diminished, with bilateral plantar flexion
Cardiovascular system
Heart sounds are normal S1 and S2 with S3 with a soft systolic murmur the base
No pericardial friction rub
Vital Signs
Blood pressure140/80 mm Hg, supine and standing
Temperature98.9° F
Heart rate100 bpm
Respiratory rate18 breaths per minute

Based on the findings of the assessment, Patient C is diagnosed with severe hyponatremia secondary to water intoxication. A lack of history for excessive water intake suggests SIADH.

Management

The physician suspects that Patient C has SIADH, and further diagnostic studies are planned and carried out. The supraclavicular lymph node is biopsied. The pathology report identifies the node as small-cell lung cancer.

Patient C's serum cortisol is 10 mcg/dL in the morning. A 24-hour urine collection is completed, and 17-ketosteroids excretion is 9 mg per day and sodium excretion is 150 mEq per day. Patient C's fluid intake is restricted, furosemide is administered, and hypertonic saline is carefully infused. As the patient undergoes diuresis, his serum sodium gradually returns to normal and his sensorium improves. His wife is relieved at the return of her normally gentle husband.

Extended management includes assessment of the underlying cause of the SIADH, assumed to be metastatic small-cell lung cancer. The patient is referred to an oncologist for further testing and treatment.

Study Questions

Consider the information that has been presented in this course regarding SIADH.

  1. What are the key signs and symptoms of SIADH? What pathophysiology underlies these effects?

  2. How do diabetes insipidus and SIADH present differently? How are they similar?

  3. What studies assist in confirming the diag­nosis of SIADH? What are the nursing responsibilities in conducting these tests?

  4. What safety precautions should be implemented for Patient C because he is confused and oriented to self only?

  5. What nursing observations and actions are required to compensate for patients who are not alert and/or do not have access to food and water and therefore cannot use normal physiologic mechanisms to achieve fluid and electrolyte balance?

  6. What typically causes SIADH?

  7. How is SIADH treated?

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