Scenario You graduated 3 months ago and are working with a home care agency. One

Question

Scenario
You graduated 3 months ago and are working with a home care agency. One patient in your caseload is
J.S., a 60-year-old man with chronic obstructive pulmonary disease (COPD) related to cigarette smoking.
He has been on home oxygen, 2L oxygen by nasal cannula, for several years. Approximately 10 months
ago, he started on chronic oral steroid therapy. His current medications include an ipratropium/albuterol
(Combivent) inhaler, beclomethasone (Beclovent) inhaler, dexamethasone (Decadron), digoxin (Lanoxin),
and furosemide (Lasix).

1. On the way to J.S.'s home, you make a mental note to check him for signs and symptoms of
Cushing syndrome. Why?
2. Differentiate between Cushing syndrome and Cushing disease.

3. Your assessment includes the following findings. Determine whether the findings are
attributable to J.S.'s COPD or possible Cushing syndrome. Place an L beside the symptoms
consistent with COPD and a C next to those consistent with Cushing syndrome.
_____ 1. Barrel chest
_____ 2. Full-looking face (moon face)
_____ 3. BP 180/94mm Hg
_____ 4. Pursed-lip breathing, especially when patient is stressed
_____ 5. Striae over trunk and thighs
_____ 6. Bruising on both arms
_____ 7. Acne
_____ 8. Diminished breath sounds throughout lungs
_____ 9. Truncal obesity with thin extremities
_____10. Supraclavicular and posterior upper back fat
4. You inform the physician of J.S.'s assessment. The physician believes J.S. has developed
Cushing syndrome and decides to change his prescription from dexamethasone (Decadron)
daily to prednisone (Deltasone) given on alternate days. Explain the rationale for this change.

5. Identify possible consequences of suddenly stopping dexamethasone (Decadron) therapy.
6. You advise J.S. to take the prednisone (Deltasone) at breakfast. Why?

7. Cushing syndrome can affect memory. Patients can easily forget what medications have been
taken, especially when there are several different medications and some are taken on
alternating days. List at least three ways you can help J.S. remember to take his medications
as prescribed.
8. J.S. states that his appetite has increased but he is losing weight. He reports trying to eat, but
he gets short of breath and cannot eat any more. How would you address this problem?
9. You ask him questions related to the presence gastric discomfort, vision, and joint pain. Why?

10. Differentiate between the glucocorticoid and mineralocorticoid effects of prednisone
(Deltasone).

11. How would your assessment change if J.S. were taking a glucocorticoid that had significant
mineralocorticoid activity?
12. Review J.S.'s list of medications. Based on what you know about the side effects of loop
diuretics and steroids, discuss the potential problem of administering these in combination
with digoxin.
13. You need to assess J.S. for signs and symptoms of an infection. Why?

14. What signs and symptoms of infection do you assess for in J.S.? Select all that apply.
a. Pain
b. Fever
c. Loss of function
d. Palpitations
e. Unusual drainage
f. Localized edema

15. Realizing J.S. is susceptible to infection, you review with him ways to reduce the risk of
infection. Identify four major points to include.
16. In addition to measures to reduce the risk of infection, what other information would you
want to stress to J.S. at your visit? Select all that apply.
a. Drink at least 4000mL of fluids daily.
b. Increase intake of foods high in sodium.
c. Weigh yourself first thing in the morning.
d. Take vitamin and electrolyte supplements as prescribed.
e. Notify the physician if your pulse is lower than 60 beats/min.
f. Call the doctor if your weight increases more than 2-3 pounds in 1 day.
g. Take the furosemide (Lasix) first thing in the morning and again at bedtime.

Glucocortocoids Medications

Fludrocortisone

Dexamethasone

Aminpglutethimide

Metyrapone

Mitotane

Etomidate

The Nursing Process

What nursing assessment will you perform regarding each medication? 

What planning and implementation do you need to do for each medication?

How would you evalute the effectiveness of each medication?

Explanation / Answer

1. Cushing's syndrome is caused due to excessive cortisol production in the body. It is also caused due to excessive use of corticosteroid. Hence, it is also known as hypercotisolism. It is common in males above 60 years of age with chronic obstructive pulmonary disease (COPD). J.S. has been suffering from COPD and is taking beclomethasone (Beclovent), and dexamethasone (Decadron), both of which are corticosteroid. Hence, he was checked for Cushing’s syndrome.

2.

Cushing’s disease

Cushing’s Syndrome

1) It is caused by a pituitary tumor that produces excessive adrenocorticotropic hormome (ACTH). ACTH causes the adrenal gland to increase cortisol production.

1) It is caused by excessive production of cortisol

2) Pituitary tumors causes this disease

2) Steroid hormones (Corticosteroids), adrenal gland tumors and non-Pituitary ACTH tumors can causes this syndrome.

3) Cushing’s disease causes Cushing’s syndrome

3) Cushing’s syndrome doesn’t cause Cushing’s disease

4) Both pituitary and adrenal glands are affected.

4) Only adrenal glands are affected.

3. 1) Barrel Chest- L

COPD develop a barrel chest due to lungs being chronically overinflated with air. Hence the rib cage remains partially expanded all the time. Breathing is affected leading to aggravation of shortness of breath.

2) Full-looking face (moon face): C

Moon face is due to swelling of face in a rounded shape. It is caused by excessive deposition of fat. Corticosteroids cause swelling of the face. It activates aromatase enzyme to convert testosterone to estrogen, which cause fat deposition.

3) BP 180/94mm Hg: C

180/94 mm of Hg is high blood pressure (normal 120/80 mm of Hg) resulting in hypertension. Cushings syndrome causes hypertension as it increases heart issues. Corticosteroids increase blood pressure due to stimulation of mineralocorticosteroid receptors, insulin resistance, sleep apnea and overexpression of renin-angiotensin system.   

4) Pursed-lip breathing, especially when patient is stressed: L

Exhaling through tightly pressed (pursed lips) and inhaling through the nose with the mouth closed helps to improve shortness of breath in COPD patients.

5) Striae over trunk and thigh: C

Striae are stetch marks over the thighs abdomen. This is an effect of excessive cortisol in blood due to excessive fat deposition that can cause skin changes.

6) Bruising on both arms: C

Bruising on arms is caused due to skin changes as a result of corticosteroid use. The skin becomes fragile and is prone to bruising.

7) Acne: C

Acne is developed on the skin due to imbalances in the skin as a result of corticosteroid use. Skin changes will cause bacteria to infect the skin and cause acne.

8) Diminished breath sounds throughout lungs: L

There is reduced gas exchange due to obstruction in the lungs in COPD. This results in shortness of breath causing less breath sounds in lungs, causing difficulty in hearing the movement of air in lungs.

9) Truncal obesity with thin extremites: C

Increased appetite, weight gain is an effect of corticosteroid use. As a result, there is increased deposition of fat in the back.

10) Supraclavicular and posterior upper back fat: C

There is increased fat deposition in Cushing’s syndrome due to effect of cortisol. This fat is present in Supraclavicular and posterior upper back regions.

As per Chegg’s rules, only one question needs to be answered.

Cushing’s disease

Cushing’s Syndrome

1) It is caused by a pituitary tumor that produces excessive adrenocorticotropic hormome (ACTH). ACTH causes the adrenal gland to increase cortisol production.

1) It is caused by excessive production of cortisol

2) Pituitary tumors causes this disease

2) Steroid hormones (Corticosteroids), adrenal gland tumors and non-Pituitary ACTH tumors can causes this syndrome.

3) Cushing’s disease causes Cushing’s syndrome

3) Cushing’s syndrome doesn’t cause Cushing’s disease

4) Both pituitary and adrenal glands are affected.

4) Only adrenal glands are affected.

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