5 Adrenal Disorders and Nursing Care

Adrenal hormone disorders

The adrenal cortex produces cortisol and aldosterone. These hormones are relevant to the body’s stress response, blood pressure, fluid and electrolyte balance, and metabolism. Adrenal disorders include inadequate cortisol production and prolonged exposure to excess cortisol.

Recognizing adrenal insufficiency

Adrenal insufficiency may be primary, secondary, or tertiary. In primary adrenal insufficiency, damage to the adrenal glands may reduce both cortisol and aldosterone. In secondary or tertiary insufficiency, reduced pituitary ACTH or suppression of the hypothalamic-pituitary-adrenal axis lowers cortisol; aldosterone is usually preserved. Suppression may follow prolonged glucocorticoid therapy.

Common findings include persistent fatigue, weakness, reduced appetite, weight loss, nausea, abdominal discomfort, and low blood pressure, sometimes with dizziness on standing. Primary disease may also cause salt craving, dehydration, low sodium, high potassium, and darkening of the skin. Symptoms can develop gradually, making sudden deterioration during illness or injury particularly important to recognize.

Assessment includes vital signs, including orthostatic measurements when appropriate; hydration status; weight; mental status; and medication history, especially current or recent glucocorticoid use. Evaluation may include cortisol and ACTH testing and, when the patient is stable enough, a corticotropin stimulation test. Renin, aldosterone, and electrolyte results help assess mineralocorticoid deficiency.

Long-term care for adrenal insufficiency

Long-term treatment replaces deficient hormones. Hydrocortisone is commonly used for cortisol replacement. People with primary disease and aldosterone deficiency may also need fludrocortisone. Doses and monitoring are individualized.

Assess energy level, weight, blood pressure, symptoms that may indicate under-replacement—such as dizziness or salt craving—and symptoms of excess replacement. Review relevant electrolyte results. Teach patients to take medication as prescribed and not to stop long-term glucocorticoids abruptly.

Patients need an individualized plan for increased glucocorticoid coverage during illness or other physical stress, as well as instructions for situations in which vomiting prevents oral medication. Encourage them to follow their prescribed emergency plan, carry medical identification, and know when to seek urgent care.

Recognizing and responding to adrenal crisis

An adrenal crisis is an emergency: acute, severe cortisol deficiency can cause shock and death. It may affect someone with known adrenal insufficiency when stress needs exceed replacement, or be the first sign of previously unrecognized disease. Triggers include infection, fever, surgery, trauma, and persistent vomiting or diarrhea; current or recent glucocorticoid therapy can also be relevant. Warning signs include profound weakness, severe hypotension or shock, dehydration, abdominal symptoms, confusion, and possible hypoglycemia.

Immediate priorities:

1. Activate the emergency response and notify the treating team. Assess airway, breathing, circulation, mental status, and vital signs; establish IV access and prepare for urgent resuscitation.

2. Administer parenteral hydrocortisone promptly as ordered or under the applicable emergency protocol. Adult guidance commonly specifies an immediate dose of $100\,\text{mg}$ IV or IM, followed by $200\,\text{mg}$ over $24$ hours by continuous IV infusion or $50\,\text{mg}$ every $6$ hours. Pediatric dosing is based on weight or body surface area and requires pediatric guidance. Do not wait for test results before treatment.

3. Support circulation and correct fluid deficits. Rapid IV isotonic saline is commonly used; add dextrose when indicated, including for hypoglycemia. Monitor response and reassess frequently.

4. Monitor blood pressure, pulse, mental status, intake and output, glucose, sodium, potassium, and response to treatment. Assist with evaluating and treating the precipitating cause, such as infection.

Do not delay emergency treatment to obtain diagnostic tests when adrenal crisis is suspected. After stabilization, the treating team guides ongoing treatment and transition to oral replacement according to clinical recovery. Reinforce sick-day and emergency medication education before discharge.

Recognizing Cushing syndrome

Cushing syndrome is caused by prolonged exposure to excess cortisol, including cortisol from prescribed glucocorticoid medicines. Cushing disease is the specific form caused by an ACTH-secreting pituitary tumor. Other endogenous causes include adrenal tumors and ectopic ACTH production.

Possible findings include progressive weight gain, central fat accumulation, a rounded face, fat over the upper back, thin skin, easy bruising, wide purple stretch marks, proximal muscle weakness, mood changes, hypertension, and hyperglycemia. Excess cortisol can also increase infection risk and contribute to bone loss. These features have other possible causes, so evaluation relies on appropriate cortisol testing and investigation of the source—not appearance or imaging alone.

Treatment and nursing care for Cushing syndrome

Treatment depends on the cause. For endogenous Cushing syndrome, removal of the causative tumor is generally preferred when feasible. Other options may include medicines that reduce cortisol production or action, radiation, or additional procedures. When prescribed glucocorticoids cause the syndrome, the dose may need gradual reduction under the prescriber’s direction; abrupt discontinuation should not be advised.

Treat and monitor associated problems, including hypertension, diabetes, low potassium, infection, osteoporosis, and psychological symptoms. Nursing care focuses on trends and complications: monitor blood pressure and glucose; assess for infection, skin injury, muscle weakness, mood changes, and fall risk; and support skin protection, mobility, nutrition, and prescribed bone-health measures.

Around adrenal or pituitary surgery, closely monitor hemodynamic status, glucose, electrolytes, and signs of postoperative cortisol deficiency. Patients may need glucocorticoid replacement after successful treatment, along with education about adrenal insufficiency and follow-up.