Patient Care and Monitoring Adrenal Insufficiency

1. Evaluate patients presenting with the typical clinical manifestations for chronic or acute adrenal insufficiency.

2. Perform initial screening tests to confirm the presence of adrenal insufficiency.

3. Once diagnosis is confirmed, perform further testing to differentiate between primary, secondary, and tertiary adrenal insufficiency.

4. In patients presenting with acute adrenal crisis who have not been previously diagnosed with adrenal insufficiency, immediate treatment with injectable hydrocortisone and IV saline and dextrose solutions should be initiated prior to confirmation of the diagnosis because of the life-threatening nature of this condition. Determine and correct the underlying cause of the acute adrenal crisis (e.g., infection).

5. Glucocorticoid replacement therapy is necessary for patients with adrenal insufficiency, and mineralocorticoid replacement therapy is required for those with Ad-dison's disease.

6. In patients with chronic adrenal insufficiency, when excessive physiologic stress is anticipated (e.g., pending surgery), devise a strategy to give supplemental doses of glucocorticoid during this period. Monitor the patient for signs of an acute adrenal crisis and develop a plan to treat this emergency condition.

7. Monitor the patient for adequacy of treatment as well as adverse reactions from glucocorticoid and/or mineralocorticoid therapy.

8. Determine the duration of treatment for patients with secondary and tertiary adrenal insufficiency.

9. Provide patient education regarding disease state and its treatment:

• Causes of adrenal insufficiency, including drug-induced etiologies.

• How to recognize the clinical manifestations.

• How to prevent an acute adrenal crisis (adhere to therapy and do not abruptly stop glucocorticoid treatment). There may be a need to increase the dose of glucocorticoid during excessive physiologic stress.

• Administration of parenteral glucocorticoid during an acute adrenal crisis.

• Need to notify all health care providers of condition.

• Encourage wearing or carrying a medical alert (e.g., bracelet, card).

• Counsel on dietary and pharmacologic therapy, including duration of treatment and potential adverse consequences of glucocorticoid and mineralocorticoid replacement.

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