Question

J.S. is a 58-year-old female brought to the emergency department (ED) at 7:00 AM by her husband because when she got up this morning she was light-headed, confused, and so weak that she could not dress herself. J.S.’s husband immediately drove her to the ED in her pajamas. She has a history of rheumatoid arthritis and had been taking prednisone (Deltasone) 10 mg daily. Subjective Data Husband states that J.S. hasn’t been feeling good, has been tired, and has had very little appetite Husband states he lost his job a couple of months ago and J.S. stopped taking her medication a couple of weeks ago because they could not afford it because they no longer had health insurance J.S. denies a headache or blurred vision Objective Data Physical Examination Temperature 98.7° F, pulse 94, respirations 20, blood pressure 100/60 No difficulty speaking Oriented to name only Poor skin turgor Dry mucous membranes Weakness in bilateral upper and lower extremities Diagnostic Studies Lab values Glucose 68 mg/dL Calcium 9.2 mg/dL Sodium 130.0 mEq/L Potassium 5.5 mEq/L HCO3 25.4 mEq/L Chloride 93.5 mEq/L Cortisol 4 mcg/dL (normal 8:00 am level is 5-23 mcg/dL) 1) What is the treatment and nursing care for J.S.’s adrenal insufficiency? 2) What teaching should J.S. receive regarding taking her prednisone? What else can you do to assist J.S. in being compliant with taking her medication?

Answer 1

Rheumatoid arthritis is an autoimmine and inflammatory disease.The pathogenesis of rheumatoid arthritis is hypothalamic pituitary adreno cortical dysfunction.So there will be decreased production of androgens and corisol in rheumatoid arthritis.

In J.S adrenal insufficiency occured due to the rheumatoid arthritis.

1.Adrenal insufficiency is also called Addison's disease. It is a medical emergency characterised by decreased production of aldosterone and cortisol by adrenal gland.More common in females than males. ACTH test is used to diagnose the condition

TREATMENT OF ADRENAL INSUFFICIENCY

As it is a medical emergency it requires immediate fuid replacement and corticosteroid administration

1. Fluid replacement

- IV Fluid administration(normal saline)

-Encourage the patient to take oral fluid as much she can tolerate

2.Hormone Replacement Therapy

Immediately IV Glucocorticosteroid administration

Second day onwards oral form

-Hydrocortisone, Prednisone, Methyl predinsolone to replace the cortisol

-Fludrocortisone to replace the aldosterone

3. Diet

-High protein, low carbohydrate, high sodium diet

4. Symptomatic treatment in case of adverse effects

Nausea, vomiting-Antiemetics

Diarrhoea- antidiarrhoeal

NURSING CARE

Assess the skin turgor, mucous membrane for dehydration

Assess vital signs-BP, HR for assessing orthostatic changes

Assess colour, amount and concentration of urine for identifying dehydration

Assess the weight -weight loss may occur with fluid loss

Assess fatigue, muscle weakness

Check ECG for hyperkalemia (sharp T wave, widened QRS complex)

Assess level of consciousness( in hyponatremia there is LOC)

Assess appetite and presence of nausea , vomiting

Monitor serum glucose level(for hypoglycemia)

Assess the oxygen saturation

Encourage the patient to take oral fuids as tolerated by the patient

Instruct to take salt additives in case of excess sweating

Administer Kayexalate as oral form or enema to reduce pottassium

Encourage to take high protein , low CHO, high sodium diet

Minimize the stress

Provide quite environment

Encourage to monitor urine output

Advice the patient to wear medical alert bracelet

Advice the patient to carry ID card.

Administer IVF (NS)

Administer medication like steroids

TEACHING REGARDING PREDNISONE

1.Prednisone should be taken with food, preferably before 9 AM every day

2.Do not take double dose in case of missed dose

3. Take the advice from the physician while taking certain drugs like estrogen, diuretcs, warfain, diabetic drugs

4. Always consult a doctor before taking any suppliments

5. Inform about the side effects of prednisone like moon face, weight gain,facial hair growth, muscle weakness

6. Inform her about the action of prednisone as immunosuppresant

7.Advice the patient to wear medical alert bracelet

8.Advice the patient to carry ID card.

9. Do not stop the drug with out consulting the doctor

OTHERS

1. Avoid exposure to infections

2. Report the adverse effects to the physician

3. Do not take the drug late in the evening as it may affect the sleep

4. Do not stop the drug abruptly.

5. Advice J.S donot negelect any unusal feelings