Disclaimer: This toolkit is intended to provide resources for school nursing practice as it relates to the care of students with adrenal insufficiency (AI) in Oregon schools. This is not medical nor nurse practice advice and is not prescriptive as it relates to individual students or individual nursing practice. These resources do not override individual assessment, nor clinical judgement. Nurses are responsible for their own assessment and practice.
Adrenal Insufficiency (AI) is a disorder that occurs when the adrenal glands produce inadequate hormones. The adrenal glands, located at the top of the kidneys, make two primary hormones; cortisol and aldosterone. Cortisol is often referred to as “the stress hormone” because it helps the body respond to stress. It is also involved with control of blood pressure, blood glucose, metabolism, and inflammation. Because of this, AI can impair the body’s ability to respond to stress, such as during times of illness, injury, prolonged physical activity, or emotional distress. Individuals with AI are at risk of a life-threatening complication known as Adrenal Crisis (AC), which is an acute condition in which the body does not produce enough cortisol to meet its needs (National Institutes of Health [NIH], 2022).
AI can be classified as primary, secondary, or tertiary. Primary AI, also known as Addison’s disease, is a condition that results in destruction of the adrenal glands. This is most often due to an autoimmune disorder, but can also result from certain infections, surgical procedures, or other damage to the adrenal glands (NIH, 2022). Secondary AI results from reduced production of Adrenocorticotropic Hormone (ACTH), a hormone that controls the release of cortisol from the adrenal glands, by the pituitary gland (NIH, 2022). Tertiary AI results when the hypothalamus decreases production of Corticotropin-releasing Hormone (CRH). CRH stimulates the pituitary gland to produce ACTH. Tertiary AI is most commonly caused by abruptly stopping corticosteroids, but can include other etiologies, such as Cushing’s Syndrome (NIH, 2022).
AI management in the school setting includes both health maintenance and anticipatory guidance:
- Education to staff regarding adrenal insufficiency and adrenal crisis
- Monitoring student health status and communicating with families and providers
- Maintaining emergency policies and procedures
- Maintaining updated Individual Health Protocols, Action Plans, or Emergency Care Plans to address crises at school
(Nisticò et al, 2022).
Basic Disease Information
For review of Adrenal Insufficiency pathophysiology:
At the forefront of nurse case management for school nurses is the understanding of scope of practice as it relates to case management and delegation of nursing tasks in a community setting, as well as knowledge of applicable laws and regulations for health services in the school setting:
Evidence Based Practice
Literature Review
Public Access Practice Resources
The professional nurse in the school setting should understand and access the existing resources and framework for care of students who have been diagnosed with adrenal insufficiency.
Note: the following are national or regional resources that serve as a reference; they may or may not be consistent with Oregon law and do not supersede the Oregon Nurse Practice Act or clinical judgment.
National Institutes of Health - National Library of Medicine
School Nursing 101
Cares Foundation
Professional Development
Nurses need to evaluate their level of knowledge and skill in the area of Adrenal Insufficiency and Adrenal Crisis. Due to the low frequency and complexity of this condition, seeking out educational resources is critical. Evaluation of individual competency is important in determining the level of education the nurse is able to provide to the student and family. Adrenal Insufficiency is a very specialized area of endocrinology, and literature/research demonstrates that endocrinologists with specialized training demonstrated better knowledge of aspects of management; collaboration with such AI providers is important. Seeking out those with expertise in adrenal insufficiency will potentially benefit the care of students and the understanding of management for students and their families (Kampmeyer et al., 2017).
National Library of Medicine
- Munir S, Quintanilla Rodriguez BS, Waseem M, et al. Addison Disease (Nursing) [Updated 2022 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568775/
- Huecker MR, Bhutta BS, Dominique E, et al. Adrenal Insufficiency (Nursing) [Updated 2022 Oct 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568707/
- Elshimy G, Chippa V, Jeong JM. Adrenal Crisis. [Updated 2023 Feb 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499968/
Unlicensed Assistive Personnel (UAP) Training
In the school setting, individuals who administer medications must meet the statutory requirements for training. The Oregon Health Authority training “Treatment of Students with Adrenal Crisis” meets the requirement for emergency medication administration training for school/district staff, to administer Solu Cortef injections to a student.
Oregon Health Authority (OHA)
Oregon Department of Education (ODE)
When choosing school staff to be trained to care for a student with Adrenal Insufficiency, it is important to recognize that PE and Sports are activities with high risk for broken bones and significant injury which could trigger an adrenal crisis (Dineen et al., 2019).
Training Tools: Primary Adrenal Insufficiency
Solu Cortef is dispensed in a unique vial. To provide adequate staff training, consider obtaining expired Solu Cortef vials for use in physical skills practice. If this is not possible, then a general vial and syringe may be used to provide hands-on practice in drawing up fluids for injections.
Addison’s Disease Self-Help Group Training Videos
Templates
The following templates are modifiable for use by school nurses as it relates to their practice, and should be used in conjunction with Oregon State Board of Nursing delegation laws, and local school district policy.
Individualized Health Plans
An individualized health plan is the totality of the plan that includes all applicable procedures for students with chronic disease. Because these are intended to be individualized, the attached is an example of a compiled IHP for designated caregivers, that can be modified for individual use:
Assessment of student and parent knowledge of Adrenal Insufficiency and Adrenal Crisis is a critical step in care planning. The literature identifies that those who lack an appropriate understanding of their disease process and management are at increased risk for Adrenal Crisis (Kampmeyer et al., 2017). Collaboration with the student’s health care provider to review levels of understanding and knowledge with plans for further patient education may be warranted.
Teacher Notification
Teacher notifications, sometimes referred to as health status notifications or health information pages, can be used or combined with emergency action plans to ensure that all staff working with a student with adrenal insufficiency are informed of the diagnosis and immediate actions when necessary. These are abbreviated documents to provide critical information, but less comprehensive information than a complete IHP. This is a modifiable form for teacher notification:
Procedures
Procedures also greatly vary by student health status, needs, level of care, and type of medication regimen. The following are sample templates for specific procedures. A complete student assessment should be made to determine appropriate procedures:
Authorizations
Administering medications requires parental written consent. A disease-specific form could be used, or the district's general medication authorization form.
Self-Management
Ability to self-manage Adrenal Insufficiency will vary with each student, and should be assessed as part of the IHP development process in collaboration with the student, caregiver(s), and healthcare provider. It should be noted that all students with AI, regardless of self-management abilities, may require emergency assistance from trained staff members.
Prescriber Orders
For students with AI, activities where injury such as broken bones is a greater possibility are of important consideration (Dineen et al., 2019). Evaluate the orders provided by the student’s health care provider to ensure that potential injuries are discussed, such as injuries during sports or recess that might include sprains, potential broken bones, and head injuries.
504 Plans
About
Lead Authors: Denise Cardinali & Alana Russel
Co-Author, Lead SME & Peer Reviewers: Jan Olson
Editorial Reviewer: Heather Godsey
References
Albuquerque Public Schools. (2017). Adrenal crisis action plan - Albuquerque Public Schools. Albuquerque Public Schools.
Retrieved August 5, 2022, from https://www.aps.edu/nursing/nursing-forms/medication-forms/adrenal-crisis-action-plan
Chrisp, G., Maguire, A. M., Quartararo, M., Falhammar, H., King, B. R., Munns, C. F., Torpy, D. J., Hameed, S., & Rushworth,
R. L. (2018). Variations in the management of acute illness in children with congenital adrenal hyperplasia: An audit of three
paediatric hospitals. Clinical Endocrinology (Oxford), 89(5), 577–585. https://doi.org/10.1111/cen.13826
Dineen, R., Thompson, C. J., & Sherlock, M. (2019). Adrenal crisis: prevention and management in adult patients. Therapeutic
Advances in Endocrinology and Metabolism, 10, 2042018819848218–2042018819848218.
https://doi.org/10.1177/2042018819848218
Eyal, Levin, Y., Oren, A., Zung, A., Rachmiel, M., Landau, Z., Schachter-Davidov, A., Segev-Becker, A., & Weintrob, N. (2019).
Adrenal crises in children with adrenal insufficiency: epidemiology and risk factors. European Journal of Pediatrics, 178(5),
731–738. https://doi.org/10.1007/s00431-019-03348-1
Kampmeyer, D., Haas, C. S., Moenig, H., & Harbeck, B. (2017). Self-management in adrenal insufficiency — towards a better
understanding. Endocrine Journal, 64(4), 379–385. https://doi.org/10.1507/endocrj.EJ16-0429
Kumar, R. & Wassif, WS. J. (2022) Adrenal Insufficiency. Clinical Pathology;75:435–442. http://dx.doi.org/10.1136/jclinpath
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Loudon County Public Schools. (2019). Loudoun County Public Schools Adrenal insufficiency action plan. Loudon County
Public Schools. Retrieved August 5, 2022, from. https://www.lcps.org/cms/lib/VA01000195/Centricity/Domain/28226/
Adrenal_Insufficiency_Physicians_Order_Action_Plan.209.pdf
National Institutes of Health ( 2022) Definition & Facts of Adrenal Insufficiency & Addison's Disease.
https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease/definition-facts