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.why we have assess for Cushing syndrome

As patient is taking the dexamethasone tablet (corticosteroids) there is a chance of deveping side effect of Cushing syndrome due to excessive cortisol in the body.

2.difference between Cushing syndrome and disease

Cushing syndrome is a group of signs and symptoms which signals there is an excessive level of cortisol in the body. Cushing disease is condition of pituitary gland tumor which will cause increased secretion of adrenocorticotropic hormone thus inducing overproduction of cortisol from adrenal gland.

3. Signs and symptoms of COPD and Cushing syndrome

L indicate COPD. C indicate Cushing syndrome

Barrel chest L

Moon face C

Bp 180/94 C

Pursed lip breathing L

Striae over the trunk and thighs C

Bruising on both arms C

Acne C

Diminished breath sounds L

Truncal obesity C

Supraclavicular and posterior upper back fat C

4.why doctor changed the drug

Dexamethasone is long acting glucocorticoid and Prednisone is short acting glucocorticoid. Dexamethasone is 6 times more potent than Prednisone. So in order to reduce the Cushing syndrome the doctor changed the drug from decadran to Prednisone.

5.why should not stop steroids suddenly

There will be a side effects of steroid withdrawal like loss of appetite, upset stmoch, vomiting, drowsiness, confusion, head ache, muscle and joint pain, weight loss, peeling skin. This occurs due to dependence of body to long term exogenous corticosteroids like decadran.

6. Why should take Prednisone with breakfast

The function of natural cortisol will be in peak during day time. Prednisone mimic the effect of natural cortisol porduced from our body. So if we take the drug with breakfast the possibility of side effects will be less.

7.Three ways to remember the patient to take medication

Ask the patient to write the date and time of taking medicine in diary

Call the patient and remember to take medicine.

Educate the family members about the date and time of drug to be taken.

8. To improve nutritional pattern

Provide semifowler's position to the patient while feeding

Provide drugs helping to ease breathing at least before two hours of taking food.

Provide food as per patient likes.

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