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.

1. Identify at least 2 methods that could be used to lower the potassium level if the patient has symptomatichyperkalemia. (2 points)
2. 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)
3. Name a goal statement for each nursing diagnosis. (2 points)
4. 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

#. Methods to manage hyperkalemia :-

Administer I.V. calcium and insulin along with inhaled beta-adrenergic blockers as initial treatment to stabilize the patient; give calcium slowly over 20 to 30 minutes. Once stabilized, administer sodium polystyrene sulfonate and diuretics to help reduce total body potassium

#. Priority Nursing diagnosis - Hyperkalemia related to adrenal insufficiency as evidenced by serum potassium levels.

#. Educational Nursing diagnosis - Deficient knowledge about the disease condition as evidence by non compliance to treatment

#. Goal statement for priority nursing diagnosis -

To maintain the serum potassium within normal range

#. Goal outcome for educational nursing diagnosis - To make the couple's aware about the adrenal insufficiency .

#. Nursing interventions for priority nursing diagnosis :-

Check the serum sample. (See Avoiding false results.)

Give prescribed drugs:

Administer I.V. calcium and insulin along with inhaled beta-adrenergic blockers as initial treatment to stabilize the patient; give calcium slowly over 20 to 30 minutes.

Once stabilized, administer sodium polystyrene sulfonate and diuretics to help reduce total body potassium.

Anticipate the need for dialysis if the patient doesn't respond to treatment.

#. Nursing interventions for educational nursing diagnosis :-

- Explaining about the disease condition in a layman terms

- Encouraging them to express their concens

- Explaining about the importance of medications and compliance