Question

In: Nursing

HISTORY: Susan Summers is a 40 year old female who has 3 children under the age...

HISTORY:
Susan Summers is a 40 year old female who has 3 children under the age of 10yrs. Susan has
casual employment stacking shelves in a supermarket at night. Susan is obese at 90kg (BMI 35kg/m2) and has been diagnosed with type 2 diabetes. Susan admits to drinking a bottle of
wine or more per night after work to help her cope with her life. Susan was admitted to hospital
for surgery following changes in her appearance due to Cushing’s syndrome caused by a
benign tumour of her right adrenal gland. Susan is admitted to hospital for a laparoscopic right
adrenalectomy under general-anaesthesia.
After 2 hours in the post-anaesthetic recovery room (PARU) and an uneventful recovery, Susan
was transferred to the ward, where you have been allocated to her care. PRESENTATION TO THE WARD: On return to the ward Susan’s observations are as follows:
• Respirations 30 breaths per minute • BP 160/90mmHg • Pulse 128bpm • Temperature 35.0oC • Pain score 0/10 • Indwelling urinary catheter (IDC) 5mls in the last hour
It is planned for Susan to be discharged after two days on the ward.
QUESTIONS TO BE ANSWERED
In relation to Susan Summers:
Q1. Discuss the aetiology and pathophysiology of the patient’s presenting condition (LO3)
Q2. Critically discuss the underlying pathophysiology of the patient’s post-operative deterioration. Prioritize, outline and justify the appropriate nursing management of the patient during this time (LO1; LO2; LO3; LO5: LO6)
Q3. Identify three (3) members of the interdisciplinary healthcare team, apart from the primary medical and nursing team, who you would involve in the care of the patient before their discharge and provide justification for their involvement. (LO1; LO4: LO5; LO6)

Solutions

Expert Solution

Introduction:

Cushing's syndrome is a metabolic disorder caused by overproduction of corticosteroid hormones by the adrenal cortex and often involving obesity and high blood pressure. Signs and symptoms may include high blood pressure, abdominal obesity but with thin arms and legs, reddish stretch marks, a round red face, a fat lump between the shoulders, weak muscles, weak bones, acne, and fragile skin that heals poorly. Women may have more hair and irregular menstruation. Occasionally there may be changes in mood, headaches, and a chronic feeling of tiredness.

Causes of Cushing's syndrome

Cushing's syndrome is caused by either excessive cortisol-like medication such as prednisone or a tumor that either produces or results in the production of excessive cortisol by the adrenal glands.

The most common cause of Cushing's syndrome is the taking of glucocorticoids prescribed by a health care practitioner to treat other diseases (called iatrogenic Cushing's syndrome). This can be an effect of corticosteroid treatment of a variety of disorders such as asthma and rheumatoid arthritis, or in immunosuppression after an organ transplant.

Endogenous Cushing's syndrome results from some derangement of the body's own system of secreting cortisol. Normally, ACTH is released from the pituitary gland when necessary to stimulate the release of cortisol from the adrenal glands.

  • In pituitary Cushing's, a benign pituitary adenoma secretes ACTH. This is also known as Cushing's disease
  • In adrenal Cushing's, excess cortisol is produced by adrenal gland tumors, hyperplastic adrenal glands, or adrenal glands with nodular adrenal hyperplasia.
  • Tumors outside the normal pituitary-adrenal system can produce ACTH that affects the adrenal glands. This etiology is called ectopic or paraneoplastic Cushing's disease and is seen in diseases such as small cell lung cancer.

       Elevated levels of total cortisol can also be due to estrogen found in oral contraceptive pills that contain a mixture of estrogen and progesterone, leading to Pseudo-Cushing's syndrome.

Pathophysiology of Cushing's syndrome

The hypothalamus is in the brain and the pituitary gland sits just below it. The paraventricular nucleus (PVN) of the hypothalamus releases corticotropin-releasing hormone (CRH), which stimulates the pituitary gland to release adrenocorticotropin (ACTH).

ACTH travels via the blood to the adrenal gland, where it stimulates the release of cortisol. Cortisol is secreted by the cortex of the adrenal gland from a region called the zona fasciculata in response to ACTH.

Elevated levels of cortisol exert negative feedback on CRH in the hypothalamus, which decreases the amount of ACTH released from the anterior pituitary gland.

Cushing's syndrome refers to excess cortisol of any etiology . One of the causes of Cushing's syndrome is a cortisol-secreting adenoma in the cortex of the adrenal gland (primary hypercortisolism/hypercorticism).

The adenoma causes cortisol levels in the blood to be very high, and negative feedback on the pituitary from the high cortisol levels causes ACTH levels to be very low.

Cushing's disease refers only to hypercortisolism secondary to excess production of ACTH from a corticotroph pituitary adenoma (secondary hypercortisolism/hypercorticism) or due to excess production of hypothalamus CRH (Corticotropin releasing hormone) (tertiary hypercortisolism/hypercorticism).

This causes the blood ACTH levels to be elevated along with cortisol from the adrenal gland. The ACTH levels remain high because the tumor is unresponsive to negative feedback from high cortisol levels.

UNDERLYING PATHOPHYSIOLOGY FOR PATIENT’S POST OPERATIVE DETERIORATION:

After adrenalectomy procedure, patient develops hypertension due to primary aldosteronism which has developed as a result of removal of the adrenal gland. The rennin angiotensin, aldosterone mechanism in maintaining the normal blood pressure gets affected resulting in increased blood pressure.

Some renal actions related to aldosterone determine the clinical characteristics. Aldosterone increases the number of open sodium channels in the luminal membrane of the principal cells in the collecting tubule and thus, leads to sodium reabsorption increase . The subsequent loss of cationic sodium makes the lumen electronegative, producing an electrical gradient that favors the secretion of cellular potassium into the lumen through potassium channels in the luminal membrane . The typical signs include hypertension and hypokalemia.

Adrenelectomy also leads to some renal structural damage Resulting in decline in estimated glomerular filtration rate (eGFR) which further leads to decreased urinary output.

NURSING MANAGEMENT:

Postoperative nursing care

Nursing diagnosis:

Ineffective protection related to inability to produce adrenal hormones

Risk for infection related to suppressed inflammatory response caused by high adrenocorticoid levels preoperatively and use of adrenocorticoid replacement postoperatively.

Risk for injury related to dramatic fluctuations in blood pressure caused by sudden changes in adrenocorticoid or catecholamine levels or both.

Nursing interventions:

  • The patient is usually extubated in the OR before transport to the postanesthesia care unit (PACU).
  • The orogastric tube is removed at the completion of the procedure. A chemistry screen and complete blood cell count are obtained in the PACU. Because the adrenal glands play an integral part in stress responses and BP regulation, close monitoring of BP is necessary via an arterial line or BP cuff.
  • patients require close monitoring of electrolytes, especially potassium. The PACU RN must also monitor the patient closely for signs of acute hemorrhage.
  • The PACU nurse assesses the patient's level of pain and medicates the patient for pain as ordered. Typically, the patient won't require patient-controlled analgesia (PCA) as would be needed with an open adrenalectomy. Due to the small laparoscopic incisions, patients are prescribed pain medications at regular intervals on an as needed basis. Patients are encouraged to ambulate shortly following surgery.
  • The urinary drainage catheter is removed on the first postoperative day.
  • A clear-liquid diet is started on the first postoperative day, and the diet is advanced as tolerated.
  • Serum cortisol levels are evaluated to assure that no element of adrenal insufficiency requires supplementation.
  • A patient undergoing a unilateral adrenalectomy may require temporary replacement of glucocorticoids.
  • Follow-up with the surgeon is usually a few days to a week after surgery.
  • Patients can generally return to unrestricted activity approximately 4 weeks after surgery
  • Take and record vital signs, measure intake and output, and monitor electrolytes on a frequent schedule, especially during the first 48 hours after surgery.
  • Intravenous fluids are also administered.
  • Assess body temperature, WBC levels, and wound drainage. Change dressings using sterile technique.
  • Impaired wound healing increases the risk of infection in clients with adrenal disorders. Use aseptic technique to decrease this Provide routine post-op care.
  • Observe for hemorrhage and shock.
  • Administer IV therapy and vasopressors as ordered.
  • Encourage coughing and deep breathing to prevent respiratory infection
  • Administer cortisone or hydrocortisone as ordered to maintain cortisol levels.
  • Provide general care for the client with abdominal surgery.
  • Provide client teaching and discharge planning concerning
  • Self-administration of replacement hormones
  • Unilateral adrenalectomy: replacement therapy for 6-12 months until the remaining adrenal gland begins to function normally.

THREE (3) MEMBERS OF THE INTERDISCIPLINARY HEALTHCARE TEAM

SOCIAL WORKERS

Social workers can assist the patient and family in coping with the impact of illness, injury and hospitalization.

They provide emotional support and counselling that may focus on adjustment, self-esteem, dealing with loss, and managing relationships.

They facilitate discharge planning, and can address practical needs such as finances and connecting to the resources the patient need in the community.

Social workers may work together with discharge planners to make sure the patient has somewhere to live when they are discharged.

PSYCHOLOGISTS

Psychologists assess, diagnose, and councels the patient to cope up with the bodily changes that patient undergoes after surgery.

.

They help in managing the disorders , adjusting difficulties, overcome anxiety for both patient and family.

PHARMACISTS

Pharmacists and pharmacy technicians review and monitor all medications ordered for patients in hospital and post operative hormone replacement.

They will check for allergies, drug interactions and other potential safety concerns.

They are also available to teach about your medications, importance of hormone replacement and answer any questions the patient have about them.


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