Nurse Troy is aware that the most appropriate nursing diagnosis for a patient with Addison’s disease is which of the following?
A. Excessive fluid volume
B. Risk for infection
C. Urinary retention
D. Hypothermia
Correct Answer: B. Risk for infection
Addison’s disease decreases the production of all adrenal hormones, compromising the body’s normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison’s disease include Deficient fluid volume and Hyperthermia.
Option A: Assess skin turgor and mucous membranes for signs of dehydration. The patient will have dry skin and mucous membranes. Tenting of the skin will occur. The tongue may have longitudinal furrows. A BP drop of more than 15 mm Hg when changing from supine to sitting position, with a concurrent elevation of 15 beats per min in HR, indicates reduced circulating fluids.
Option C: Urinary retention isn’t appropriate because Addison’s disease causes polyuria. Assess color, concentration, and amount of urine. Urine volume will decrease, urine specific gravity will increase, and color will be darker. As sodium loss increases, extracellular fluid volume decreases. These interventions are necessary to prevent fluid volume deficit because the kidneys are unable to conserve sodium
Option D: Hyperpyrexia can result from the hormonal and fluid imbalance and may be an early sign of crisis if accompanied by a sudden drop in BP. Administer antipyretics as needed for fever. This helps reduce the continuing sodium and water losses from the fever.
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