Which statement should the nurse make when teaching the client about taking oral corticosteroids

General

Inhaltsverzeichnis Show

• Classification Section
• Introduction
• Genetic Considerations
• Gender, Ancestry, and Life Span Considerations
• Global Health Considerations
• Physical Examination
• Psychosocial
• Diagnostic Highlights
• Primary Nursing Diagnosis
• Planning Implementation
• Collaborative
• Independent
• Evidence Based Practice Health Policy
• Documentation Guidelines
• Discharge and Home Healthcare Guidelines
• What is the rationale for monitoring vital signs of a client receiving corticosteroids?
• Which of the following would be a nursing priority for a client just diagnosed with Addison's disease?
• Which of the following would be observed in a patient with Addisonian crisis?
• Which is the most common cause of adrenal insufficiency?

DRG Category: 644

Mean LOS: 4.5 days

Description MEDICAL: Endocrine Disorders With CC

Introduction

Adrenal insufficiency can be primary or secondary. Addison disease, or primary adrenal insufficiency, occurs rarely, but when it occurs, there is loss of at least 90% of the adrenal cortex. Secondary insufficiency occurs from disorders of the pituitary gland. The adrenal glands consist of the medulla and the cortex. The medulla is responsible for the secretion of the catecholamines epinephrine and norepinephrine; the cortex is responsible for the secretion of glucocorticoids, mineralocorticoids, and androgen. The principal glucocorticoid, cortisol, helps regulate blood pressure, metabolism, anti-inflammatory response, and emotional behavior. The principal mineralocorticoid, aldosterone, is important for regulating sodium levels. Adrenal insufficiency is characterized by the decreased production of cortisol, aldosterone, and androgen. Cortisol deficiency causes altered metabolism, decreased stress tolerance, and emotional lability. Aldosterone deficiency causes urinary loss of sodium, chloride, and water, resulting in dehydration and electrolyte imbalances. Androgen deficiency leads to the loss of secondary sex characteristics. Approximately 8% of people with adrenal insufficiency require hospital treatment each year for adrenal crisis (see acute adrenal crisis). The major cause of illness or death for people with Addison disease is a delay in making the diagnosis, or failure to begin appropriate therapy with glucocorticoids and/or mineralocorticoids. Complications include bone loss and hypothyroidism.

Causes

Primary adrenal insufficiency is caused by the destruction of the adrenal gland. Idiopathic adrenal atrophy is the most common cause of adrenal insufficiency. It is not known exactly why this occurs, but it is believed to be related to an autoimmune response that results in the slow destruction of adrenal tissue. Tuberculosis, histoplasmosis, AIDS, malignancies, and hemorrhage into the adrenal glands have all been associated with destruction of the adrenal glands. All patients with adrenal insufficiency or steroid-dependent disorders are at risk for an acute adrenal crisis. Secondary adrenal insufficiency results from hypopituitarism due to hypothalamic-pituitary disease or suppression of the hypothalamic-pituitary axis by steroid therapy. Secondary adrenal failure can also occur with adrenocorticotropic hormone (ACTH) deficiency caused by disorders of the pituitary or hypothalamus or suppression because of glucocorticoid therapy. Other causes include physiological stress, including surgery, anesthesia, fluid volume loss, trauma, asthma, hypothermia, alcohol abuse, myocardial infarction, fever, hypoglycemia, pain, and depression.

Genetic Considerations

Addison disease has a strong genetic component, with a recent twin study estimating a heritability of 97%. The most well established risk factors include variants in the human leukocyte antigen (HLA) genes, which follow a recessive pattern of inheritance. There is also a form of X-linked congenital adrenal insufficiency that is associated with mutations in the NR0B1 gene that produce the DAX1 protein. DAX1 mutations also appear to contribute to milder disease or delayed onset. Adrenal insufficiency is often seen in families in association with other autoimmune disorders, most commonly with autoimmune polyendocrine syndrome (APS).

Gender, Ancestry, and Life Span Considerations

Addison disease, particularly idiopathic autoimmune Addison disease, affects females more than males and occurs most often in adults from ages 30 to 50. Children may develop the condition if they have genetic susceptibility. Ethnicity and race have no known effects on the risk for Addison disease.

Global Health Considerations

In developed countries, the incidence in Western countries is 50 cases per 1 million persons. No data are available on Eastern countries or many developing nations.

Assessment

Primary Nursing Diagnosis

Diagnosis: Imbalanced nutrition: less than body requirements related to insufficient dietary intake as evidenced by anorexia, nausea, vomiting, and/or diarrhea

Outcomes: Fluid balance; Hydration; Nutritional status: Food and fluid intake; Nutritional status: Energy

Interventions: Fluid/electrolyte management; Hypoglycemia management; Nutritional management; Nutritional counseling

Planning Implementation

Documentation Guidelines

• Physical findings: Cardiovascular status, including blood pressure and heart rate; tissue perfusion status, including level of consciousness, skin temperature, peripheral pulses, and urine output; fluid volume status, including neck vein assessment, daily weights, and fluid input and output
• Laboratory findings: Blood levels of potassium, sodium, hematocrit, and blood urea nitrogen (BUN)

Discharge and Home Healthcare Guidelines

PREVENTION. To prevent acute adrenal crisis, teach patients how to avoid stress. Emphasize the need to take medications as prescribed and to contact the physician if the patient becomes stressed or unable to take medications. Make sure the patient knows to alert the surgeon about adrenal insufficiency prior to all surgical procedures. Parenteral corticosteroids will likely be prescribed during any major procedure or times of major stress or trauma.

MEDICATIONS. Be sure the patient understands the reason for steroids that are prescribed. (See Box 1 for a full explanation.) Some patients will be taught to give themselves an IM injection of steroids to be administered if they are unable to take their medication orally.

RESOURCES. Referrals may be necessary to identify potential physical and emotional problems. Notify the hospital's social service department before patient discharge if you have identified obvious environmental stressors. Initiate home health nursing to ensure compliance with medical therapy and early detection of complications. If you identify emotional problems, refer the patient to therapists or self-help groups.

Patient Teaching for Corticosteroids

• Emphasize the lifetime nature of taking corticosteroids.
• Provide name, dosage, and action of the prescribed medication.
• Explain the common side effects of weight gain, swelling around the face and eyes, insomnia, bruising, gastric distress, gastric bleeding, and petechiae.
• Advise the patient to take the medication with meals to avoid gastric irritation and to take the medication at the time of day prescribed, usually in the morning.
• Suggest the patient weigh self daily, at the same time each day, and call the healthcare provider if weight changes by 5 pounds.
• Emphasize that the patient should always take the medication. Not taking it can cause life-threatening complications. Tell the patient to call the healthcare provider if she or he is unable to take medication for more than 24 hours.
• Explain that periods of stress require more medication. Tell the patient to call the healthcare provider for changes in dose if he or she experiences extra physical or emotional stress. Illness and temperature extremes are considered stressors.
• Explain preventative measures. Tell the patient that to prevent getting ill, she or he should avoid being in groups with people who are ill and environments where temperatures change from very hot to very cold.
• Teach the patient to recognize signs of undermedication: weakness, fatigue, and dizziness. Emphasize the need to report underdosing to the healthcare provider.
• Teach the patient to avoid dizziness by moving from a sitting to a standing position slowly.
• Urge the patient to always wear a medical alert necklace or bracelet to inform healthcare professionals of the diagnosis.