Question

Case Study in Endocrine in preparation for Discussion A 51-year old unemployed salesman is brought to the emergency department by EMS at 0800, accompanied by his wife. His wife tells the emergency department nurse that her husband has not been feeling well for the last week, but that when he got up this morning, he was so weak he couldn’t dress himself and didn’t know where he was. She also tells the nurse her husband has been taking a cortisone drug for treatment of his rheumatoid arthritis for the past 2 years, but notes, “We didn’t have the money to buy it this month.” Assessment data includes: The patient is dehydrated with dry oral mucous membranes and tongue, poor skin turgor, and sunken eyeballs. His blood pressure is 94/44, and his pulse is rapid and thread. He is weak, dizzy, and disoriented about time and place. Diagnostic tests done at 0830 reveal the following abnormal findings: o EKG: widening QRS complex and increased PR interval (had peaked T-waves in the ambulance) o Sodium: 129 mEg/L (normal range: 135-145 mEq/L) o Glucose: 54 mg/ dL (normal range: 70-110 mg/dL) o Potassium: 6.2 mEq/L (normal range: 3.5-5 mEq/L) o Cortisol: 2 mg/dL (normal for morning draw: 5-23 mg/dL) The physician determines that the patient is probably suffering from adrenal insufficiency. The physician orders 5% Dextrose in 0.9 % sodium chloride in water (D5NS) to run at 250 mL/hr intravenously and Hydrocortisone 200 mg IV. After initiation of the IV fluids and medication, the patient is admitted to an inpatient bed with continuous heart monitoring.

5. Identify at least 2 methods that could be used to lower the potassium level if the patient has symptomatic hyperkalemia. (2 points)

6. Name 1 priority nursing diagnosis and 1 educational nursing diagnosis. This condition is potentially deadly for the patient, so the priority diagnosis must reflect a serious response to adrenal insufficiency that the nurse can address (4 points)

7. Name a goal statement for each nursing diagnosis. (2 points)

8. List 3 nursing interventions for each nursing diagnosis and please be specific about what is essential to teach this patient and his wife (6 points)

Answer 1

5.The methods which can be used to lower potassium level are

• Medication:Administration of calcium
• IV therapy:Infusion of glucose and insulin to lower potassium
• Decrease the potassium intake through diey
• Avoid foods high in potassium
• If there is acute renal failure ,dialysis is a best way to treat hyperkalemia

6.Priority nursing diagnosis

Decreased cardiac output related to hypovolemia as evidenced by dry oral mucus membrane and tongue, sunken eyeballs, poor skin turgor and decreased blood pressure

Educational nursing diagnosis

Altered metabolism, electrolyte levels related to adrenal insufficiency as evidenced by hypocortisolemia, hyponatremia,

7.Goal

• To maintain normal blood pressure within few minutes to hpur
• To correct electrolyte and metabolic alterations from few hours to less than 5 days

8.Nursing interventions

•Monitor vitals as it is the baseline information to plan for care

•Administer IV fluids to raise blood pressure

• Monitor patient for cardiac complications as it is expected

•• Administer IVF with electrolyte to replace lost electrolyte

••Treat hyperkalemia immediately to reduce cardiac complications

••Hormone replace therapy or steroid threat to be initiated as per order to treat low levels of cortisol