Chapter 18 | Endocrine Disorders 441
Nursing Interventions ● Frequent laboratory assessment
CRITICAL COMPONENT Adrenal Insufficiency, Congenital Adrenal Hyperplasia, and Hormone Replacement It is important to remember that children with adrenal insufficiency and/or CAH require lifelong hormone replacement. Children with adrenal insufficiency tend to grow poorly in height and weight, but puberty will present at a normal age despite the growth delay. These children may require GH replacement therapy along with corticosteroid and mineralocorticoid replacement therapy (Prete et al, 2019).
● Administration of corticosteroids such as Solu-Cortef; this medication is given two to three times per day (Merke & Auchus, 2021) ● Administer IM Solu-Cortef if the child is vomiting, nause- ated, or has diarrhea and is unable to tolerate oral intake (Table 18-2) ● Assessment of hydration status ● Strict intake and output to avoid dehydration ● Teach the parents how to administer IM Solu-Cortef for home emergencies ● Careful assessment for symptoms of hypovolemic shock in the severely dehydrated patient ● Make sure the child has been referred to a pediatric endocri- nologist for diagnosis and treatment Caregiver Education ● Emergency care involves teaching parents signs of adrenal crisis and how to administer IM Solu-Cortef if the child develops crises outside of the hospital (Prete et al, 2019). ● Chronic home care involves teaching the parents the impor- tance of medication compliance and avoidance of skipping doses because this can lead to adrenal crisis. ● The child should wear a medical alert bracelet at all times. ● Teach the parents how to “stress dose” in times when the child has a fever, vomiting, diarrhea, emotional stress, trauma, or surgery. ● Teach the parents to make sure the child is well-hydrated before physical activity or sports. ● Educate schoolteachers and staff regarding the potential for dehydration and hypovolemic shock so that measures can be taken to provide the child with extra fluids before and during physical activity. ● Encourage the child and parents to increase salt intake during the warmer months of the year to maintain adequate miner- alocorticoid levels.
● Low blood pressure ● Serum cortisol level drawn around 8 a.m. because levels are the highest upon rising ● Cortisol levels less than 3 mcg/dL indicate Addison’s disease; levels between 3 and 18 mcg/dL are considered suspicious, and further testing is needed to confirm the diagnosis
SAFE AND EFFECTIVE NURSING CARE: Promoting Safety
Addisonian Crisis Addisonian crisis is a life-threatening event that requires the child to receive immediate medical attention. If ignored, the child may die. The symptoms of an Addisonian crisis are weakness, severe vomiting and diarrhea, severe abdominal pain, dehydration, low blood pressure, hypoglycemia, and loss of consciousness (Ilie, 2020). This type of crisis is very overwhelming for parents, and a detailed plan of care and patient education can help the parents be ready for an emergency if it occurs (Prete et al, 2019).
TABLE 182 Medications Used to Treat Adrenal Disorders
FLUDROCORTISON ACETATE FLORINEF
HYDROCORTISONE SOLUCORTEF, HYDROCORTONE, CORTEF
How Supplied
0.1-mg tablets (100 mcg)
Tablets—5, 10, 20 mg Injection—100, 250, 500, 1,000 mg/vial
Physiological dosing: PO: 0.56 mg/kg/day or 15–20 mg/m 2 in single or divided doses IM: 0.186–0.28 mg/kg/day or 10–12 mg/m 2 /day in divided doses Stress dosing: Two to three times the normal physiological dose, depending on the severity of the illness or stress Hypertension, euphoria, insomnia, acne, hyperglycemia, increased inter- cranial pressure, immunosuppression, and adrenal suppression
Dose/Route
50–100 mcg/daily PO
Potential Side Effects Hypertension, edema, congestive heart failure, hypokalemia alkalosis
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