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Nursing Field Notes / Endocrine · Adrenal · Med-Surg
⚗️ ENDOCRINE SET NG-284 Hyperthyroid NG-285 Hypothyroid NG-286 Parathyroid NG-287 Addison vs Cushing NG-289 Conn's & Pheo

Addison’s vs Cushing’s ⚖️

Too little steroid vs too much — one gland, two opposite patients

NG-287 ENDOCRINE · ADRENAL ADHD-friendly visual edition

Addison’s = steroids ABSENT. Small, weak, tanned — low BP, low sodium, low sugar, HIGH potassium, and an addisonian crisis when stress arrives. Cushing’s = a CUSHION of steroids. Big, round, hairy — high BP, high sugar, LOW potassium, moon face, buffalo hump, thin skin and osteoporosis. Learn them as one see-saw and neither can be reversed on you.

🥉 ADDISON = ABSENTAdds potassium · Decreased BP, sugar, sodium, weight · Darkened skin · Don’t stop steroids.
🎈 CUSHING = CUSHIONCushion of fat (moon face, hump, trunk) · Unusual hair · Skin striae · High sugar & BP.
🚨 ADDISONIAN CRISISProfound hypotension → shock. First action: IV steroid + IV fluids. Stress is the trigger.
⚖️ The K⁺ tellAddison = potassium HIGH. Cushing = potassium LOW. If you remember one lab, remember this one.
🫘

ONE GLAND, FOUR LAYERS

STEP 1 · FOUNDATION

Learn this drawing once and it explains Addison’s, Cushing’s, Conn’s and phaeochromocytoma.

🫘 The adrenal cutaway — salt, sugar, sex, and the core

THE ADRENAL GLAND · cutawayOne picture that explains Conn’s, Cushing’s, Addison’s and phaeochromocytomaADRENAL sits ON the kidneykidney (context)a. artery · v. vein · ureteradrenal vein drains to IVC / renal v.cut open and magnified →capsulefibrous coatZona GLOMERULOSAALDOSTERONE · salt &waterZona FASCICULATACORTISOL · sugar &stressZona RETICULARISANDROGENS · sexhormonesMEDULLAEPINEPHRINE /NOREPINEPHRINE🧠 “Salt · Sugar · Sex — the deeper you go, the sweeter it gets”GFR outside-in = Glomerulosa (salt) · Fasciculata (sugar) · Reticularis (sex)then the MEDULLA in the middle = the fight-or-flight core.
🧠 GFR · Salt · Sugar · Sex — Glomerulosa (aldosterone/salt), Fasciculata (cortisol/sugar), Reticularis (androgens/sex), then the medulla in the middle.
SAME DRAWINGReused on NG-289 · Conn’s & Phaeochromocytoma, where the outer and innermost layers are the ones in trouble.

⚙️ What cortisol actually does

  • Raises blood glucose — gluconeogenesis, insulin resistance
  • Suppresses inflammation and immunity
  • Breaks down protein and redistributes fat centrally
  • Supports vascular tone — without it, vessels do not respond to catecholamines
  • Helps maintain blood pressure and sodium
  • Follows a daily rhythm — highest early morning, lowest late evening

That list read forwards is Cushing’s. Read backwards, it is Addison’s.

🧠 Cortisol = the stress hormone. No stress hormone, no surviving stress.

⚙️ What aldosterone does

From the outermost layer (zona glomerulosa):

AADDS sodium and water back into the blood
LLETS potassium out into the urine

So losing aldosterone (Addison’s) means sodium and water leak out and potassium builds up — low sodium, low BP, HIGH potassium.

🧠 A·L: Adds sodium, Lets potassium go.
SEE ALSOThe opposite problem — too much aldosterone — is NG-289 · Conn’s syndrome.

🔁 The cortisol loop — and why the lab pattern names the cause

THE CORTISOL LOOP · hypothalamus → pituitary → adrenalCortisol switches its own loop off. Break the loop anywhere and the pattern tells you where.HYPOTHALAMUSCRHPITUITARYACTHADRENALCORTISOLnegative feedbackCortisol tells the pituitary:“enough — stop sending ACTH.”PRIMARY ADRENAL FAILUREAddison’s diseaseACTHHIGH ↑↑CORTISOLLOW ↓↓ALDOSTERONELOW ↓↓The adrenal is destroyed.The pituitary keepsshouting ACTH — and theextra ACTH is what BRONZESthe skin.ACTH-DRIVEN CUSHING’Spituitary adenoma / ectopic ACTHACTHHIGH ↑↑CORTISOLHIGH ↑↑ALDOSTERONEnormal-ishToo much ACTH drives toomuch cortisol.Pigmentation can appearhere too, because ACTH ishigh.STEROID-INDUCED CUSHING’Slong-term prednisone — the commonest causeACTHLOW ↓↓CORTISOL (own)LOW ↓↓drug steroidHIGH ↑↑The outside steroidswitches the loop off andthe adrenals shrink. Stopit suddenly and there isNOTHING left — adrenalcrisis.
🧠 Cortisol low + ACTH high = the gland is broken (Addison’s). Cortisol high + ACTH low = the steroid is coming from outside (a prescription).

🟤 Why Addison’s patients go BRONZE

When the adrenal cortex fails, cortisol cannot switch the pituitary off, so ACTH goes very high.

ACTH is made from the same precursor molecule as melanocyte-stimulating hormone, so a flood of ACTH also stimulates melanocytes in the skin.

Look where it shows first: skin creases, knuckles, elbows, scars, the gum line and buccal mucosa, nipples, and the palmar creases — including in patients who tan easily anyway.

Key exam point: hyperpigmentation appears in primary adrenal insufficiency (Addison’s), not in secondary insufficiency from pituitary failure or from steroid therapy, because in those the ACTH is low.

🧠 Bronze = ACTH shouting. No shouting, no tan.
🥉

ADDISON’S — STEROIDS ABSENT

SIDE A · TOO LITTLE

Small, weak, tanned. Everything that cortisol and aldosterone hold up falls down.

⭐ Patho & causes

Primary adrenal insufficiency — the adrenal cortex itself is destroyed, so both cortisol and aldosterone fall.

  • Autoimmune destruction — the most common cause in high-income countries
  • Infection — tuberculosis (the leading cause worldwide), HIV, fungal infection
  • Adrenal hemorrhage or infarction — trauma, sepsis, anticoagulation
  • Metastatic cancer in the adrenal glands

Secondary insufficiency comes from a pituitary problem or — far more often — abruptly stopping long-term steroid therapy. Here aldosterone is usually preserved and there is no hyperpigmentation.

🧠 Primary kills the gland. Secondary silences the order.

📉 Signs — nearly everything goes DOWN

Blood pressureHypotension, orthostatic dizziness, syncope
SodiumHyponatremia (under 135) + salt craving
GlucoseHypoglycemia — worse with fasting or illness
WeightLoss, anorexia, nausea, vomiting, diarrhea, abdominal pain
Energy & moodProfound fatigue, weakness, depression, confusion
Potassium ↑Hyperkalemia — over 5.0 mEq/L
Pigment ↑Bronze skin, dark gums, dark scars and creases

Also expect body-hair loss (especially axillary and pubic hair in women), muscle and joint aches, and cold intolerance.

Only TWO things go UP in Addison’s: potassium and pigment.

🧠 A·D·D — Adds potassium · Decreases everything else · Darkens the skin.

✅ Treatment & the teaching that saves lives

  • Lifelong glucocorticoid replacement — a “-sone/-solone” drug such as hydrocortisone or prednisone
  • Mineralocorticoid replacement (fludrocortisone) when aldosterone is also lost
  • Diet: high protein, high carbohydrate, and generous sodium — especially in hot weather or with heavy sweating
  • Increase the dose during stress — the “sick day rules”: fever, infection, surgery, dental work, trauma, vomiting
  • Medical alert bracelet + an emergency injection kit and card
  • Daily weight and blood pressure; report a fall in either

Never stop steroids abruptly, and never skip doses because the patient feels well.

🧠 Stress · Surgery · Sepsis = more Steroid. Four S’s, one rule.

⭐ Monitoring — what you chart

  • Blood pressure lying and standing — orthostatic drop is an early warning
  • Daily weight at the same time on the same scale
  • Strict intake and output
  • Potassium, sodium and glucose with every set of bloods
  • Cardiac rhythm when potassium is high (peaked T waves)
  • Skin color changes — record where the pigmentation is
🧠 A falling BP plus a rising K⁺ is the crisis warming up.
🎈

CUSHING’S — A CUSHION OF STEROIDS

SIDE B · TOO MUCH

Big, round, hairy. Cortisol excess remodels the whole body from the face down.

⭐ Patho & causes — the commonest cause is a prescription

  • Long-term glucocorticoid therapy — prednisone for asthma, rheumatoid arthritis, IBD, transplant, lupus. By far the most common cause. ACTH is LOW.
  • Pituitary adenoma secreting ACTH (Cushing disease) — ACTH is HIGH
  • Adrenal tumor making cortisol directly — ACTH is LOW
  • Ectopic ACTH from a tumor elsewhere — classically small-cell lung cancer

“Cushing disease” means specifically the pituitary cause; “Cushing syndrome” is the clinical picture whatever the source.

🧠 Ask “what tablets have you been on for months?” before you order a scan.

📈 Signs — nearly everything goes UP

Fat redistributionMoon face · buffalo hump · truncal obesity with THIN arms and legs
Blood pressureHypertension, fluid retention, edema
GlucoseHyperglycemia — “steroid diabetes”
HairHirsutism — facial and body hair in women; acne
Infection riskImmunosuppression with a blunted fever response
Potassium ↓Hypokalemia — under 3.5 mEq/L
Bone & muscle ↓Osteoporosis, fractures, proximal muscle wasting
Skin ↓Thin fragile skin, easy bruising, wide purple striae, poor healing

Also: mood swings, insomnia, psychosis at extremes, cataracts and glaucoma, peptic ulceration, and in women menstrual irregularity.

Purple/violet striae — not the silvery stretch marks of pregnancy or weight change.

🧠 C·U·S·H — Cushion of fat · Unusual hair · Skin striae · High sugar and BP.

✅ Treatment

  • If it is drug-induced: reduce to the lowest effective dose and taper slowly — alternate-day or once-daily morning dosing is often used to mimic the natural rhythm
  • Pituitary adenoma: transsphenoidal surgery
  • Adrenal tumor: adrenalectomy — then lifelong steroid replacement, because the remaining gland is suppressed
  • Ectopic ACTH: treat the underlying cancer
  • Drugs that block cortisol production may be used when surgery is not possible

The paradox to hold onto: treating Cushing’s successfully can create an Addison’s patient. Anyone who has an adrenal gland removed goes home on replacement steroid.

🧠 REmove the organ → REplace the hormone.

⭐ Nursing priorities in Cushing’s

  • Infection is the quiet killer — cortisol blunts fever, so a normal temperature does not rule out sepsis. Watch for new confusion, tachycardia and a falling BP instead.
  • Protect the skin — paper tape or no tape, careful transfers, pressure-injury prevention, gentle washing and emollients
  • Fall and fracture precautions — osteoporosis plus proximal muscle weakness
  • Monitor glucose, blood pressure, daily weight and potassium
  • Diet: high protein, high calcium, high potassium, LOW sodium, LOW simple carbohydrate
  • Support body-image concerns — the changes are visible and distressing
🧠 Skin · Sugar · Sepsis · Skeleton. Four S’s again — the opposite four.
🔍

TELL THEM APART

STEP 4 · COMPARE

If you can only remember one line: Addison’s potassium is HIGH, Cushing’s potassium is LOW.

🧍 The two bodies

THE TWO BODIES · you can often spot these from the doorwayAddison = SMALL, WEAK, TANNED · Cushing = BIG, ROUND, HAIRY🥉 ADDISON’S — steroids ABSENT (too little)🎈 CUSHING’S — steroids CUSHION (too much)🟤 Bronze / hyper-pigmented skincreases, knuckles, scars, gums, nipples📉 Weight LOSS, muscle wastinganorexia, nausea, vomiting💧 Hypotension, dizzy on standingvolume down — orthostatic drop🧂 Salt cravingaldosterone is low, so sodium leaks out🩸 Hypoglycemiano cortisol to hold the sugar up🥱 Profound fatigue and weaknessplus depression and confusion🚨 ADDISONIAN CRISISProfound hypotension and shock. A stressor — infection,surgery, trauma, or a missed steroid dose — is what tipsthem over the edge. Treat it as a medical emergency.🌕 Moon face + flushed cheeksround, plethoric, may grow facial hair🦬 Buffalo humpfat pad between the shoulder blades🎈 Truncal obesity, thin limbscentral fat, wasted arms and legs💜 Purple striae on the abdomenwide and violet — not silvery stretch marks🩹 Thin fragile skin, easy bruisingtears with tape; wounds heal badly🦴 Osteoporosis + muscle wastingfractures and proximal weakness⚠️ THE QUIET KILLER: INFECTIONCortisol suppresses immunity AND blunts the fever response.A “normal” temperature does not rule out sepsis here. Watch forsubtle change: new confusion, tachycardia, a falling BP.
🧠 Addison = SMALL, WEAK, TANNED. Cushing = BIG, ROUND, HAIRY.

📊 The lab see-saw

THE LAB SEE-SAW · Addison vs CushingNearly every row points in opposite directions — that is the whole comparison🥉 ADDISON’S (too little)🎈 CUSHING’S (too much)BLOOD PRESSURE—▼ LOWhypotension, orthostatic▲ HIGHhypertensionSODIUM Na⁺—▼ LOWhyponatremia — salt craving▲ HIGHretained — fluid overloadPOTASSIUM K⁺—▲ HIGHhyperkalemia — over 5.0▼ LOWhypokalemia — under 3.5GLUCOSE—▼ LOWhypoglycemia▲ HIGHhyperglycemia, steroid diabetesWEIGHT—▼ LOWweight LOSS, wasting▲ HIGHweight GAIN, truncalSKIN PIGMENT—▲ HIGHBRONZED — high ACTHn/athin, striae, bruisingWHITE CELLS / IMMUNITY—n/anormal-ish▼ LOWsuppressed — blunted feverCALCIUM—▲ HIGHcan be high▼ BONEserum normal · bone loss → osteoporosis

Typical adult reference ranges: potassium ≈ 3.5–5.0 mEq/L, sodium ≈ 135–145 mEq/L — ranges vary by laboratory, so confirm the range printed on your patient's result.

🧠 Cover one column and rebuild it by flipping the other. Every row inverts except immunity.

📋 Everything on one table

 ADDISON’S 🥉 (absent)CUSHING’S 🎈 (cushion)
CortisolLOWHIGH
ACTHHIGH in primary diseaseLow if steroid-induced or adrenal; high if pituitary/ectopic
Blood pressureLOW — orthostatic, dizzyHIGH
SodiumLOW (<135) + salt cravingRetained — fluid overload, edema
PotassiumHIGH (>5.0)LOW (<3.5)
GlucoseLOW — hypoglycemiaHIGH — steroid diabetes
Weight & shapeLoss, wasting, thin all overGain — truncal, moon face, buffalo hump, thin limbs
SkinBronze hyperpigmentationThin, fragile, purple striae, easy bruising
HairLoss of body hairHirsutism — extra facial/body hair
ImmunityRoughly normalSuppressed — infection with blunted fever
BoneAches, weaknessOsteoporosis, fractures
MoodDepressed, apathetic, confusedLabile, euphoric or depressed, psychosis at extremes
EmergencyADDISONIAN CRISIS — shockInfection/sepsis; hypertensive and glycemic complications
Core treatmentGive steroids, increase for stressReduce/taper steroids; remove the tumor
DietHigh protein, high carb, HIGH sodiumHigh protein, high calcium/potassium, LOW sodium
The neverNever stop steroids abruptlyNever assume no fever means no infection
🧠 Addison ADDS potassium. Cushing CUTS it.

💓 The same see-saw on the monitor

THE POTASSIUM ECG · Addison vs CushingOpposite potassium, opposite strip — and both can stop the heartHYPERKALEMIA · ADDISON’S (K⁺ > 5.0)tall PEAKED T waves, then a widening QRS and a flattening P — cardiac arrest riskpeaked THYPOKALEMIA · CUSHING’S (K⁺ < 3.5)flattened T · ST depression · prominent U wave — then arrhythmiasU

Both extremes of potassium are dangerous. In Addison’s the potassium climbs and the T waves go tall and peaked; in Cushing’s it falls and you get a flattened T, ST depression and a U wave.

🧠 Peaked T = potassium piled up. U wave = potassium used up.

⚠️ NCLEX-style trap check

Which of these belong to Cushing’s? (answers below)

  • Easy bruising
  • Increased blood glucose
  • Increased blood pressure
  • Increased potassium
  • Increased abdominal girth
  • Decreased weight
Show the answer

Cushing’s: easy bruising ✔ · increased glucose ✔ · increased blood pressure ✔ · increased abdominal girth ✔.

Not Cushing’s: increased potassium ✘ (that is Addison’s — Cushing’s potassium is LOW) · decreased weight ✘ (Cushing’s gains weight; Addison’s loses it).

🧠 The two distractors in that question are always potassium and weight.

🔬 How each one is diagnosed

Addison’s: low morning cortisol; an ACTH stimulation test that fails to raise cortisol; high ACTH in primary disease; plus the electrolyte picture (low Na, high K, low glucose).

Cushing’s: 24-hour urinary free cortisol, late-night salivary cortisol, and a dexamethasone suppression test; then ACTH level and imaging to find the source.

A careful medication history answers the Cushing’s question more often than any test does.

🧠 Stimulate to find Addison’s. Suppress to find Cushing’s.
🚨

ADDISONIAN CRISIS & THE TAPER

STEP 5 · EMERGENCY

The single most testable idea on this page: steroids are never stopped suddenly.

📉 Why tapering exists

WHY YOU TAPER STEROIDS · never stop them suddenlyWeeks of outside steroid put the adrenal glands to sleep — they need time to wake updosetime →SAFE: step down over weeksABRUPT STOPno drug · no own cortisol🚨 ADRENAL CRISIShypotension → shock → death⬆️ WHEN THE DOSE GOES UP• Infection or fever• Surgery or a procedure• Trauma or a burn• Severe emotional stress• Vomiting/diarrhea (can’t keep it down → call)✅ ALWAYS TEACH• Medical alert bracelet + emergency card• Never run out — get refills early• Take with food; report black stools• Daily weight and BP log🧠 “The adrenal glands are asleep, not dead — wake them slowly.”The same rule applies to anyone on more than about 2–3 weeks of systemic steroid for any reason — asthma, RA, IBD, transplant.
🧠 The adrenal glands are asleep, not dead — wake them slowly.
SEE ALSOFull corticosteroid pharmacology is on NG-288 · Steroids.

🕕 Why the morning dose, and why late-night cortisol is measured

CORTISOL HAS A DAILY RHYTHMHighest first thing in the morning, lowest near midnight — dosing copies that curvecortisolmidnight6 amnoon6 pmmidnightPEAK 6–8 amtake replacement steroid nowTROUGH near midnighta HIGH value here = Cushing’s⭐ WHY IT MATTERSReplacement steroid is givenin the MORNING to copy thenatural peak — evening dosescause insomnia and suppressthe axis harder.A late-night cortisol thatstays HIGH is a screeningclue for Cushing syndrome.And cortisol should SURGEwith stress — in Addison’s itcannot, which is the crisis.🧠 “Wake up with cortisol.”Morning dose · with food · never a sudden stop · more during illness or surgery.
🧠 Copy the body’s own curve. Morning dose with food, never an abrupt stop.

🚨 Recognizing an addisonian crisis

  • Profound hypotension — e.g. 80/40 and falling — progressing to shock
  • Severe weakness, then confusion and reduced consciousness
  • Nausea, vomiting, diarrhea, severe abdominal or flank pain
  • Fever — very often from the infection that triggered it
  • Hyperkalemia with peaked T waves, hyponatremia, hypoglycemia
  • Tachycardia with a weak thready pulse

Any Addison’s patient with vomiting or a fall in blood pressure is a crisis until proven otherwise.

🧠 “Low BP that will kill.” The pressure is the alarm.

✅ First nursing actions

1
Call for help & get IV access
this is a shock state — do not leave the patient
▼
2
Give the IV steroid
an IV glucocorticoid such as hydrocortisone is the priority drug, per order
▼
3
IV fluids
isotonic saline, often with glucose, to restore volume and sugar
▼
4
Correct the chemistry
treat hyperkalemia and hypoglycemia; continuous cardiac monitoring
▼
5
Find and treat the trigger
usually infection, surgery, trauma, vomiting, or a missed dose

Then: frequent vitals, strict I&O, daily weight, and a quiet environment with all stressors minimized.

🧠 Steroid + Saline + Sugar — the three S’s of the crisis.

⭐ Sick day rules — the discharge teaching

  • Increase the steroid dose during fever, infection, injury, surgery or dental procedures, exactly as instructed by the prescriber
  • Carry an emergency injection kit and know how to use it
  • Cannot keep tablets down? That is an emergency call, not a wait-and-see
  • Wear a medical alert bracelet and carry a steroid card
  • Never run out — refill early, and take a spare supply when traveling
  • Weigh daily and check BP; report a drop in either

Never omit or “save up” a dose, and never let a patient taper themselves.

🧠 Sick? Double the guard. The body cannot make its own stress hormone any more.

🧠 Quiz yourself — no peeking

8 questions with answers
Q1: Potassium 5.8, sodium 128, glucose 54, BP 84/48. Addison’s or Cushing’s?
Addison’s. High potassium with low sodium, low glucose and low blood pressure is the classic adrenal insufficiency pattern.
Q2: Which single lab most reliably separates the two?
Potassium. It is HIGH in Addison’s and LOW in Cushing’s.
Q3: Why does Addison’s cause bronze skin but steroid-induced adrenal insufficiency does not?
In primary Addison’s the pituitary pumps out huge amounts of ACTH, which also stimulates melanocytes. With exogenous steroids the ACTH is suppressed, so there is no pigmentation.
Q4: A patient on prednisone for two years stops it because they feel better. What are you worried about?
Adrenal crisis. The adrenal glands are suppressed and cannot make cortisol, so stopping abruptly leaves the patient with none at all. Steroids must be tapered.
Q5: A Cushing’s patient has a temperature of 37.0 °C but is newly confused and tachycardic. What do you think?
Possible sepsis. Cortisol blunts the fever response, so a normal temperature does not rule out infection. Escalate on the other signs.
Q6: What diet does each patient need?
Addison’s: high protein, high carbohydrate, generous sodium. Cushing’s: high protein, high calcium and potassium, LOW sodium and low simple carbohydrate.
Q7: First action in an addisonian crisis?
Get help and IV access, then give the ordered IV glucocorticoid with IV fluids. It is a shock state — steroid and volume come first.
Q8: A patient has one adrenal gland removed for a cortisol-secreting tumor. What goes home with them?
Steroid replacement, sick-day rules, a medical alert bracelet, and instructions never to stop the medication abruptly. Remove the organ, replace the hormone.
🥉 Addison = ABSENTLow BP · low Na · low sugar · HIGH K⁺ · bronze skin · weight loss.
🎈 Cushing = CUSHIONHigh BP · high sugar · LOW K⁺ · moon face · hump · striae · thin skin · osteoporosis.
🚨 Crisis = shockSteroid + Saline + Sugar. Triggered by stress, infection, surgery or a missed dose.
❌ The absolute neverNever stop steroids abruptly. Taper them, and increase during stress.