Using the case study below, answer the associated questions. The assignment is to be presented in a question/answer format NOT as an essay (i.e. no introduction or conclusion).
Each answer has a word limit (1600 in total); each answer must be supported with citations.
A reference list must be provided at the end of the assignment.
The answers must be linked to the case study given.
Ms Maureen Smith is a 24 year old female who presented to her GP for ongoing gastrointestinal bleeding, abdominal pain and fatigue which has been worsening, and was referred to the local hospital for further investigation. Maureen was diagnosed with rheumatoid arthritis (RA) when she was 15 years old, and has experienced multiple exacerbations of RA which have required the use of high dose corticosteroids. She is currently taking 50mg of prednisolone daily, and has been taking this dose since her last exacerbation 2 months ago. Maureen also has type 2 diabetes which is managed with metformin. She is currently studying nursing at university and works part-time at the local pizza restaurant.
On assessment, Maureenâ€™s vital signs are: PR 88 bpm; RR 18 bpm; BP 154/106 mmHg; Temp 36.9ÂºC: SpO2 99% on room air. She has a body mass index (BMI) of 28kg/m2 and the fat is mainly distributed around her abdominal area, as well as a hump between her shoulders. Maureenâ€™s husband notes that her face has become more round over the past few weeks. Her fasting BGL is 14.0mmol/L. Blood test results show low cortisol and ACTH levels, and high levels of low high-density lipoprotein cholesterol. She is awaiting a bone mineral density test this afternoon, and is currently collecting urine for a 24-hour cortisol level measurement.
The following questions relates to the patient within the first 24 hours since admission to the emergency department (ED):
1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family (400 words)
2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology (350 words) (This can be done in the form of a table â€“ each point needs to be appropriately referenced)
3. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body (350 words) (This does not mean specific drugs but rather the class that these drugs belong to)
4. Identify and explain, in order of priority the nursing care strategies that should use within the first 24 hours post admission for this patient (500 words).
- Outline the causes, incidence and risk factors for the identified condition and how it can affect the patient and her family
The condition that Ms. Maureen is suffering from is referred to as the Cushing’s syndrome. This syndrome is very rare and is caused by the existence of excess cortisol in the body (Pivonello et al., 2008). Although cortisol is necessary for the body, it is harmful if it exceeds the normal limits. Cushing’s syndrome is mainly caused by cortisol medication and particularly, the glucocorticoids or by the presence of a tumor (Storr et al., 2007). From the case study, Ms. Maureen was taking the high-dose corticosteroids for the treatment of rheumatoid arthritis; which were the primary causes of the syndrome. Other than the medications, there might exist a large tumor in the adrenal gland making too much cortisol and hence occasioning the Cushing’s syndrome. Apart from the adrenal glands, the Cushing’s syndrome might also be caused by the pituitary gland, which is a small organ existing under the brain and which produces hormones, which in turn regulate the other hormone glands found in the body. These pituitary tumors produce the adrenocorticotrophic hormone (ACTH), which then stimulates the adrenal hence making them produce too much-unwanted cortisol (Storr et a., 2007)
The incidences of the Cushing’s syndrome are very rare as the disease is uncommon. However, in the United States, 10-15 per million people are affected by the cases of Cushing’s syndrome every year (The American Association of Neurological Surgeons, 2016). Additionally, the disease is responsible for the more than 70% cases in adults (especially women like Ms. Maureen), and 60-70% cases in children and adolescents. Notably, the female gender is the one that suffers from the syndrome more than men contributing about 70% of the total incidences (Cushing Syndrome: Maybe Not So Uncommon of a Disease, 2016).
According to Steffensen et al. (2010), the risk factors that are associated with the syndrome include type 2 diabetes that Ms. Maureen was suffering from. Additionally, rheumatoid arthritis is a risk factor since it leads to the intake of corticosteroids. Obesity is another risk factor for the cases of the distribution of the fat around the abdominal area. Ms. Maureen had a body mass index of (BMI) of 28kg/m2, which then was a significant risk factor for the Cushing’s syndrome. Moreover, high blood pressure such as the one that Ms. Maureen had (154/106 mmHg) is also a risk factor. Finally, a poorly controlled blood sugar is a high-risk factor. In the present case, the blood sugar for Ms. Maureen is high reading from the body mass index.
- List five (5) common signs and symptoms of the identified condition; for each provides a link to the underlying pathophysiology
i. Weight gain
Cortisol, the primary cause of the syndrome causes lipolysis; metabolism is slowed and the fatty acids a not properly metabolized but rather redistributed. Cortisol metabolizes the food and refuels the body even when there is no need for the same in the body (Mazziotti, Gazzaruso, & Giustina, 2011). Due to that excessive cortisol content, the body naturally gets excessive fat accumulated in various parts, which mainly results in obesity (Bertagna et al., 2009).
i. Round face
Hyperadrenocorticism or hypercortisolism are the primary causes of the moon face. There are massive deposits on the side of the skull, which result from the symptoms of obesity, as there is excessive production of cortisol. The abnormal levels of cortisol lead to the disposition of fatty acids in the face resulting in the large round shaped face that even prevents the ears from being noticed (Pivonello et al., 2008).
ii. Extra fat around neck
Being overweight is the leading cause of this fat. Increased fatty acids in the body caused by increased cortisol leads the body to find the parts where the fats will be deposited. Additionally, the increased fat around the neck is because of cardiovascular complications, which are displayed in the neck. In any case, the excessive fats, which are not metabolized needs a place where they can be deposited (Barahona et al., 2009).
Hypertension results from peripheral vascular sensitivity to adrenergic agonists. It can also be as a result of angiotensinogen, a substrate from the hepatic production. The activation of the renal tubular 1 (mineral corticoid) receptors by the cortisol can also be an underlying pathophysiology (Pivonello et al., 2008).
If the Cushing’s syndrome is not adequately treated or not treated at all, the complex endocrine condition might result in serious health complications. The syndrome is treated with surgery. However, when an operation fails, then some medications can be used to temporarily suppress excessive cortisol production. This helps as the primary causes of the syndrome; cortisol is stopped from being reproduced into high quantities. According to Schteingart (2009), The pharmacological approaches to the treatment of the syndrome include; inhibitors of steroidogenesis (drugs that are taken with an intention of suppressing the excessive production of cortisol) and glucocorticoid receptor antagonists.
Inhibitors of steroidogenesis are made to reduce the level of production of cortisol in the body, which is the primary cause of Cushing’s syndrome (Schteingart, 2009). Examples of such drugs include Ketoconazole, metyrapone, fluconazole aminoglutethimide, etomidate, and mitotane. However, out of all those Ketoconazole is the only one that is currently used alone (Castinetti et al., 2008). The others were employed in the past individually or in combination with others not have since ceased to be used. When applied on the body, these classes of drugs can lead to irritation, burning, and severe itching (Fleseriu et al., 2012). Additionally, they cause mild hair loss and excessive pain on the part applied. Although the drugs are taken for a good reason, they nevertheless can result into unfavorable physiological effects.
The second class of medications is those referred to as glucocorticoid receptor antagonists. The purpose of these drugs is to inhibit the activation of glucocorticoid receptor (Schteingart, 2009). Additionally, they are intended to ameliorate the disease states that are dependent on hormone such as the cortisol. In the view of Feelders et al. (2010), Effective antagonists should inhibit the glucocorticoid-mediated transcription. These include octal hydro phenanthrenes, triphenylmethanes, and diaryl ethers, chromenes, aryl pyrazole azo decalins pyrimidinediones, dibenzyl anilines, dihydro isoquinoline’s, aza decalins, and spirocyclic dihydropyridines (Schteingart, 2009). These drugs, however, cause skin fragility, which in turn results in bruising. Additionally, they cause the breakdown of the muscles making them weak. These physiological effects of the drugs contribute to their side effects (Fleseriu et al., 2008).
Nursing care is essential for Ms. Maureen as she goes through the diagnosis and treatment of the Cushing’s syndrome. According to Biller et al. (2008), it is important for nurses to take immediate measures in the first 24 hours of the admission of Maureen to ensure that the signs and symptoms of the syndrome are evaluated and established. This will enable the medical personnel to take measures aimed at containing the condition. Notably, unless the major signs and symptoms are determined, it will be very hard to design the mode of treatment that is appropriate for the patient. The following are the nursing care strategies that should be used within the first 24 hours after admission of Ms. Maureen into the hospital;
The first of those strategies the evaluation of the effects on the body that the effects that the high concentrations of adrenal cortex hormones. Notably, after the patient is admitted to the hospital for the condition, the first thing that is done is to determine if there is too much cortisol that is being produced spontaneously. The nurses measuring the amount of cortisol that is contained in the saliva or even the urine achieves this. Additionally, according to Boscaro, & Arnaldi (2009), it is important to assess whether there is an overproduction of cortisol by administering the dexamethasone drug that mimics cortisol (dexamethasone suppression test). In this regard, if there is excessive production of cortisol, then the levels will decrease, however, if there is the presence of the Cushing’s syndrome, then this will not be the case.
The next assessment that should be made is the ability of the patient to carry out routine self-care activities. Additionally, the nurses should observe the skin of the patient for any bruising, infection, trauma, or even edema (Diez, & Iglesias, 2007). This should take place within the first 24 hours after admission. The family of the patient will provide valuable information about the emotional status of the patient as well as the appearance changes. Afterward, the nursing process requires that observation is made as to the mental function of the patient including her mood, response to general questions, depression and her ability to recognize the environment that she is in.
After the assessment, the nurses should evaluate the risk for injury that may result from weaknesses of the bones, and osteoporosis (Matt Vera, 2012). Additionally, there should be a diagnosis of any infection related to the altered protein metabolism and inﬂammatory response.
Nieman et al. (2008), opines that there is a need for the nurses to provide a protective environment where the patient will be away from any falls, fractures, and any other probable injuries to her bones and other soft tissues. Additionally, a recommendation of foods, which are high in protein, calcium, and vitamin D, is imperative.
The nurses should ensure that the patient is not exposed to other patients who have already been infected with the syndrome. Additionally, they should observe the patient for any signs of infections including the corticosteroids mask evidence of inﬂammation.
After the patient is admitted, it is important that she rest so that she can prevent the problems of immobility. Therefore, a quiet restful and relaxing environment will offer her rest and sleep.
After the assessment has been done and the patient is diagnosed with the Cushing’s syndrome, there is a need for her to be prepared for the surgery. This will involve her being monitored for the levels of glucose, and assess the stool for any blood (Steffensen et al., 2010).
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