 Hi and welcome to nursing school explain this video on adesence disease. But before we look into the details let's review the hypothalamic pituitary and adrenal axis and how it regulates our hormones. So the hypothalamus releases corticotropin releasing hormone that stimulates the anterior pituitary to release ACTH or adrenocorticotropic hormone. That hormone stimulates the adrenocortex to release glucocorticoids, mineralocorticoids and androgens. And the easiest way to remember these three are the three Ss. Salt, mineral, glucose, sugar and sex hormones androgens. And then the normal circumstances the level of these will be reported back to the hypothalamus by this negative feedback loop and if there are enough of these floating around the hypothalamus will then stop or decrease secreting CRH which will lead to decreased production of ACTH and then the production of bloodstream will go down for a nice balanced system. And on the normal circumstances when ACTH is normal the production of glucocorticoids helps us to respond to stress by secreting cortisol. Now glucocorticoids also help with carbohydrate protein and fat metabolism and when we are under stress we're going to need increased sugar which then stimulates the liver to produce more blood glucose by the process of gluconeogenesis. And also the cells use decreased glucose which then leads to increased protein breakdown and increased fat synthesis to kind of keep everything in balance. For mineralocorticoids or salt aldosterone is the main hormone here which is a big part of the renin angiotensin and aldosterone system otherwise known as RAS and that usually responds to a low blood pressure. So when there's low blood pressure the renal tubules will increase sodium and water reabsorption therefore holding on to more fluid or volume and elevating that blood pressure. But in exchange at the renal tubule for the increased sodium reabsorption potassium is excreted and then we have our sex hormones androgens which are also important here. In adesins disease we have decreased ACTH or also called adrenocorticoinsufficiency so now we're dealing with decreased levels of ACTH which will lead to decrease of glucocorticoids, mineralocorticoids and androgens. So the causes of adesins disease primary adesins disease is usually called by autoimmune disorders and cause and is 80% of the causes for a adesins disease. And in that case all three of the glucocorticoids mineralocorticoids and androgens will be decreased. If it's secondary adrenocorticoinsufficiency that basically means it comes from somewhere else besides the adrenocortex and it's usually related to pituitary disorders and what we'll see there is decreased glucocorticoids, mineralocorticoids but no decrease in androgens. Unfortunately signs and symptoms of adesins disease are often not recognized or visible until about 90% of the adrenocortex is destroyed by this autoimmune disease that's causing it. And they can be very vague such as anorexia, nausea, vomiting, diarrhea, abdominal pain, weakness, salt craving, headache, fatigue, weight loss, joint pain and then a very significant finding bronze colored hyperpigmentation at sun exposed areas as well as orthostatic hypotension. And these here salt cravings and orthostatic hypotension can certainly be due to a lot of other disorders but salt cravings here happens because we're now not able to preserve the salt and orthostatic hypotension because with unable to been unable to preserve the salt and water it'll lead to fluid volume deficit therefore the patient can have orthostatic hypotension. Now complications from adesins disease is adisonian crisis and that can be life threatening. Triggers can be stress or sudden withdrawal of steroids the opposite of adesins disease is called Cushing's disease and that is when we have too much ACTH in the system and that is 90% induced by steroids by chronic administration of steroids. So now if suddenly these steroids are withdrawn it can lead to the opposite of adesins disease. Adrenalectomy so if the adrenal cortex is suddenly removed it cannot produce any of these 3s hormones and then will lead to an adisonian crisis or if there is sudden destruction of the pituitary glands such as in radiation and that would be the treatment for Cushing's disease which is the opposite because a tumor would produce increased ACTH but we would want to get rid of that if it was the opposite Cushing's disease. So triggers can be stress, sudden withdrawal of steroids, adrenalectomy or sudden pituitary destruction due to radiation. Signs and symptoms of adisonian crisis would basically be all of these hormones would be decreased so now for our glucose glucocorticoids the patient could suffer from hypoglycemia. For our mineralocorticoids here so if we know that usually we reabsorb sodium and water now this will lead to decrease sodium reabsorption which then will lead to hyperkalemia because these two always balance each other out. If we can't reabsorb the sodium we're also going to excrete more water which will make the patient weak and cause fluid volume deficit or dehydration which is evident by low blood pressure and increased heart rate and can lead to circulatory collapse hence it's called an adisonian crisis. Other signs and symptoms are fever, weakness and confusion and the confusion is mostly due because of the low sodium levels that can always be evident with any kind of alterations in mental status. Now how is adison's disease diagnosed? It's usually with an ACTH stimulation test so now if we're suspecting ACTH is low we're going to give the patient IV ACTH and check the serum levels at 30 and 60 minutes. Normal response that's expected would be if we administer ACTH we would expect the ACTH serum levels to rise but if there's adison's disease the ACTH will go up but we won't produce the cortisol here so that won't we won't be able to measure that. If this is there's an abnormal test right here then we can also test the corticotropic releasing hormone that would basically go up a step here and check if the hypothalamus is working on the pituitary and if we have a pituitary disorder it would mean that the pituitary is now not able to produce ACTH which would basically mean that none of this can be measured and we would basically measure the ACTH in the serum. Lab results to be expected in adison's disease would be low sodium and chloride because again we're not able to do the reabsorption here everything is decreased which then leads to hyperkalemia which can lead to peak T waves on an EKG and can be dangerous. It'll lead to hypoglycemia as we discussed over here and we would want to evaluate a CT or MRI to see if there's any kind of structural defects to the adrenals or the pituitary gland. Now nursing care for a patient with adison's disease if they are in a crisis and need inpatient treatment we would monitor the vital signs and the neurologic status because we know that hyponatremia can lead to mental status changes. Certainly we would have to monitor their electrolytes very diligently as well as their daily weight and INOs because they are at risk for fluid volume deficit. If the patient is treated on an outpatient basis they will need glucocorticoids and mineralocorticoids to be administered they basically would need these hormones to be replaced because their adrenal cortex is not working. So glucocorticoids are recommended to be taken BID twice a day with two-thirds of the dose in the morning and one-third in the evening to mimic the circadian rhythm. If the glucocorticoids are taken at night only or more of a dose it can lead to sleep disturbances because the circadian rhythm gets disturbed. Mineralocorticoids need to be taken once a day and that would be Fluid Recorder Zone is one of those that would be prescribed for the patient and if they are managed on an outpatient basis besides medication teaching we would also teach them how to monitor their blood pressure at home because we know they're at risk for low blood pressure as well as teach them to increase their sodium intake because their kidneys can't really concentrate it to manage their stress to wear a medical alert bracelet. Very important because we know that they can go into Addisonian crisis with increased stress and they might need increased cortical steroids if they are ill with a minor illness such as the flu or with increased activity physical activity. And then they should also have an emergency dose of Fluid Recorder Zone available and that is usually 100 milligrams that they would be able to administer intramuscularly in case that they are detecting that they are at risk for Addisonian crisis. Thank you for watching this video on Addison's disease. Also watch the video on the opposite where the ACTH is increased which is Cushing's disease so that you can really understand the difference that these make in the sugar, salt and sex hormones. Thanks for watching Nursing School Explained.