Nursing care
Adrenal Crisis nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 6 min read · Updated September 2026
Short answer
Adrenal crisis is acute cortisol deficiency causing hypotension, hypoglycaemia and shock that does not correct with fluids alone. The priority action is IV hydrocortisone, given before lab confirmation if the presentation fits. Fluids and glucose support the picture but do not replace the missing hormone, and delay in steroid administration is what turns a reversible event into a fatal one.
What it is and why it happens
Adrenal crisis is the acute decompensation of cortisol deficiency. Cortisol maintains vascular tone, supports glucose production, and blunts the inflammatory response to stress. When it drops below what the body needs, none of that holds, and the patient tips into shock.
Two patient groups account for most cases. Primary adrenal insufficiency, as in Addison's disease, means the adrenal cortex itself has failed and cannot raise output no matter how hard the pituitary drives it. Secondary insufficiency comes from long-term exogenous steroid use that has suppressed the hypothalamic-pituitary-adrenal axis; stop those steroids abruptly, or fail to increase the dose during illness or surgery, and the adrenal glands cannot respond because they have been switched off for weeks or months.
Infection, trauma, surgery, and missed oral steroid doses are the usual triggers. In a patient already living with adrenal insufficiency, any physiological stress raises the cortisol demand well above baseline, and a body that cannot mount that response decompensates fast.
How it presents — what you will actually see
The dominant picture is shock that does not fit the story. Blood pressure is low, often profoundly, in a patient without an obvious source of major fluid loss or sepsis severe enough to explain it. Tachycardia is usually present, but it can be blunted or absent, which is easy to misread as reassuring.
Look for nausea, vomiting, and abdominal pain severe enough to suggest an acute abdomen, alongside profound weakness and confusion. Hypoglycaemia is common because cortisol normally supports gluconeogenesis. Hyponatraemia and hyperkalaemia point to mineralocorticoid loss in primary disease, though these electrolyte shifts are typically absent in secondary insufficiency, where aldosterone production is intact.
Fever may be present from an underlying infection or from the crisis itself. The overall picture is a patient sicker than their vital signs or presenting complaint would predict, and that mismatch is often the first clue.
Nursing assessment priorities
Confirm steroid history first. Ask about long-term corticosteroid use for asthma, COPD, rheumatoid disease, or transplant, and ask about a known diagnosis of Addison's disease or hypopituitarism. A recent tapering schedule, a missed dose, or a course stopped cold are all relevant.
Trend the vital signs rather than reading them once. Repeated blood pressure checks after a fluid bolus tell you whether you are dealing with straightforward hypovolaemia or something that fluid cannot fix. Check point-of-care glucose immediately, since hypoglycaemia is fast to correct and easy to miss if you are focused on the blood pressure.
Send or anticipate cortisol and ACTH levels, but do not let the wait for results delay treatment. Electrolytes matter too: sodium, potassium, and glucose shape both the diagnosis and the immediate fluid plan.
Interventions and what to do first
Hypotension unresponsive to fluids in a steroid-dependent patient is hydrocortisone, not more fluid. This is the detail that separates adrenal crisis from ordinary shock management. If a patient with known steroid dependence is hypotensive and a fluid bolus has not moved the pressure, escalate for IV hydrocortisone rather than repeating the bolus and waiting.
Hydrocortisone 100 mg IV is the standard starting dose, given as soon as the diagnosis is suspected clinically. Do not wait for a cortisol level to come back before advocating for the dose; treatment is empiric and time-sensitive.
Run isotonic IV fluids to support the circulating volume and correct hypovolaemia, and correct hypoglycaemia with IV dextrose if the glucose is low. Continuous cardiac monitoring is warranted given the arrhythmia risk from hyperkalaemia in primary disease. Treat any identified trigger, such as infection, alongside the hormone replacement, since the crisis will not fully resolve until the precipitant is addressed.
Complications to watch for
Refractory shock is the immediate danger if hydrocortisone is delayed or under-dosed. Watch for a blood pressure that keeps sliding despite fluids and pressors, since vasopressors are far less effective without adequate cortisol on board to support vascular tone.
Cardiac arrhythmia from hyperkalaemia is a real risk in primary adrenal insufficiency, so keep the patient on a monitor and recheck potassium after treatment starts. Persistent hypoglycaemia can recur even after an initial dextrose bolus, particularly if oral intake stays poor, so repeat glucose checks rather than assuming one correction is enough.
Watch closely for the underlying trigger declaring itself, whether that is a worsening infection or a surgical complication, since the crisis can mask or be mistaken for the primary problem in the first hours.
Patient teaching before discharge
Every patient with known adrenal insufficiency needs to leave with sick-day rules: double or triple the oral steroid dose during febrile illness, vomiting, or significant physical stress, and know when that self-adjustment is not enough. Vomiting that prevents oral steroids being kept down is itself an indication to seek emergency care for an injectable dose.
Teach the patient and a family member how to give an emergency IM hydrocortisone injection at home, and make sure the prescription and kit are actually in hand before discharge, not just mentioned in the paperwork.
Recommend a medical alert bracelet or similar identification stating adrenal insufficiency and steroid dependence, since a patient who cannot communicate during a future crisis relies on that information reaching the treating team fast. Reinforce that oral steroids should never be stopped abruptly, even when the patient is feeling well, and that any planned surgery or procedure needs the care team told in advance so stress-dose steroids can be arranged.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our endocrine practice questions are the closest set to what this page covers.
Common questions
Why doesn't fluid resuscitation fix the hypotension in adrenal crisis?
Cortisol is needed for blood vessels to respond properly to catecholamines and maintain tone. Without it, vessels stay dilated and pressors and fluids work poorly. Only replacing the missing hormone with IV hydrocortisone restores that vascular responsiveness.
What dose of hydrocortisone is given in adrenal crisis?
The typical starting dose is 100 mg IV, given as soon as the crisis is suspected. Institutional protocols may specify a continuous infusion or repeated dosing afterwards, but the priority is not to delay that first dose while waiting for labs.
Can adrenal crisis happen in a patient who isn't on long-term steroids?
Yes, though it is less common. Undiagnosed primary adrenal insufficiency, pituitary failure, or bilateral adrenal haemorrhage can all precipitate a first-time crisis without any prior steroid history, which is why the diagnosis is easy to miss in a patient with no known endocrine disease.
What labs confirm adrenal crisis, and should I wait for them?
A low random cortisol alongside sodium, potassium, and glucose derangements supports the diagnosis, and ACTH helps distinguish primary from secondary disease. Treatment should never wait for these results; hydrocortisone is given empirically based on the clinical picture.
How is adrenal crisis likely to appear on the NCLEX?
Expect a scenario describing a patient on chronic steroids, or with known Addison's disease, who is hypotensive and not responding to a fluid bolus. The correct next action is almost always to prepare or administer IV hydrocortisone, not to repeat the fluid bolus or simply notify the provider and wait.