Assingnment 1 NRSG 258 ACUTE CARE NURSING ACU PDF

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

Nurses are primarily responsible for the acute care of the patient. The major role of the nurse is to recognize the patient’s health improvement or deterioration while present on the ward through constant inspection. In regards to the case study of Susan suffering from Cushing Syndrome due to a benign tumour in right adrenal gland, firstly, this essay will be discussing the aetiology and pathophysiology of the Cushing’s syndrome(CS). Secondly, nursing management for the post-operative care for the laparoscopic adrenalectomy and lastly, the three major team members from the Multi-Disciplinary team(MDT) for long-term care. “Cushing syndrome is due to chronic, excessive, and inappropriate exposure to glucocorticoid in the body” (Griffing, 2014). Cortisol is one of the glucocorticoid secreted by zona fasciculata of the adrenal cortex in the adrenal gland which helps to cope with stress, increase the glucose metabolism, controls the blood pressure, reduces inflammation, and decreases bone formation (Griffing, 2014). The whole process of cortisol secretion revolves around one set of organs which is hypothalamic–pituitary–adrenal axis (HPA axis). For example, when the body is in stress, the message is sent to the hypothalamus, then hypothalamus releases corticotrophin-releasing hormone (CRH) which acts on the pituitary gland and releases Adrenocorticotropic hormone (ACHT) which acts on adrenal gland and secrets cortisol (Griffing, 2014). The cause for hypercortiolism in Susan is because of a benign tumour in her right adrenal gland also known as “adenoma”. Unlike a malignant tumour, the benign tumour does not multiply. However, adrenal adenomas produce cortisol in excessively high amount. High secretion of cortisol suppresses the CRH and ACTH secretion. Althogh there is no secretion of ACTH hormone acting on adrenal cortex, the presence of a benign tumour on the adrenal gland produces a large amount of cortisol. Thus, the patient (Susan) experiences hypercortisolism (Griffing, 2014). Other factors of Susan contributing to Cushing syndrome

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

are stress and alcohol intake. There are multiple reasons for her to be stressed, for instance, mother of three children under the age of 10, working at night, and diagnosed with type 2 diabetes. High level of stress results in high level of cortisol production. Likewise, there is a strong positive relationship between the alcohol intake and cortisol production. The more the alcohol intake is, the more secretion of cortisol takes place (Griffing, 2014), The signs and symptoms of the Cushing syndrome can be central weight gain, fragile thin skin, slender arms and legs, high blood pressure, high blood glucose, anxiety, a fat pad hum between the shoulders, weak bone and muscles, dexamethasone suppression, and slow wound healing. (Nieman, 2015). Susan went through a laparoscopic right adrenalectomy which is the removal of right adrenal gland through the laparoscopic process. A set of vital signs shows patient’s present condition whether she is deteriorating or improving. According to Royal Prince Alfred Hospital Patient Observation (Vital Signs) Policy - Adult, (2018) the normal ranges for vital signs are blood pressure:110-130mmhg (systolic) & per 60-90mmhg(diastolic), pulse rate is 60-100 beats per minute(bpm), respiratory rate 16-20 bpm, and temperature is 36.5°C to 37.5°C. However, as per the case study, Susan has got abnormal vital signs like temperature 35°C, high systolic blood pressure which is 160mmhg, elevated pulse rate - 128 bpm, a high respiratory rate which is 30 bpm. If these symptoms are taken together then the underlying cause for these abnormal vital signs can be hypothermia. In hypothermia, the body temperature significantly goes below the normal range of core temperature. This can be because of the intraoperative low-temperature environment where the body is exposed for a long period of time (Campbell, Alderson, Smith & Warttig, 2015). The internal body temperature tries to balance the external temperature. A laparoscopic adrenalectomy surgery takes approximately 116 minutes to 289 minutes which is long period of time for the body temperature to drop down if exposed to low temperature

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

(Burpee, Jossart, & Gagner, 2011). Secondly, during surgery, there is more likely to be fluid loss. Fluid loss causes more heat loss than in the air (Campbell, Alderson, Smith & Warttig, 2015). Thirdly, the anaesthetics used during surgery inhibits movement of the muscle which inhibits production of heat resulting in heat loss. The Intra Venous(IV) fluids administered has also contributed to hypothermia (Campbell, Alderson, Smith & Warttig, 2015). Lastly, the anaesthesia used during the surgery also causes the decrease in body temperature (Belayneh, 2014). Thus, Susan is experiencing hypothermia. During hypothermia, there is vasoconstriction. Therefore, the pressure increases on the heart while pumping the blood and results in hypertension (Spranger et al., 2017). In addition, the cause of hypertension can be obesity, diabetes and Cushing syndrome. The cortisol facilitates in water and sodium retention which increases the plasma volume and then increases the blood pressure (Isidori et al., 2015). Due to vasoconstriction, there is less flow of blood through the vessels. Consequently, the heart has to work faster in order to supply blood all over the body which results in tachycardia. Furthermore, Susan is more likely to have hypoxia because she has got elevated breathing. Due to less oxygen in the blood, the organs and tissues aren’t getting enough oxygen and the workload of heart increases. Moreover, Susan usually drinks alcohol every night but at present, she has withdrawn alcohol drinking. Withdrawal of alcohol drinking causes elevated heart rate. Thus, Susan is experiencing tachycardia. The normal urine output for an adult is 0.5-1.0cc/kg/hr. Calculating Susan urine output, it is only 0.05cc/kg/hr which means she is having oliguria. The reason for post-operative oliguria could be dehydration, and hypovolemia (Prasad, 2017). In addition, there could be sepsis causing blood clots where the catheter is placed causing less flow of urine in the catheter. Furthermore, Susan is in no pain after the surgery. Pain is subjective so the capacity

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

of bearing pain varies in every individual. In addition, the small incisions during the surgery might not be painful in case of Susan. The post-operative elevated respiratory rate can be the cause of inadequate ventilation. Due to insufficient oxygen in the body through a ventilator, the workload on the lungs increases which results in high respiratory rate. She is suffering from hypercapnia having low oxygen level and high carbon dioxide level in the bloodstream (Karcz, & Papadakos, 2013). In terms of priority care need for laparoscopic adrenalectomy of Susan, following the Airway, Breathing, Circulation, Disability, and Exposure(ABCDE) approach of resuscitation and based on the given set of vital signs, she seems to have problem in the breathing and circulation. Her hypercapnia can be treated by providing enough oxygenated air with the help of a ventilator (Karcz, & Papadakos, 2013). When Susan receives adequate oxygen then the workload on lung reduces and the respiratory rate decreases which is more likely to come in normal range. Susan is having problem in the circulation in which she has got elevated pulse rate and elevated blood pressure. The underlying causes for these abnormalities is hypothermia. In addition, hypothermia causes reduced tissue perfusion to wound tissue, slows the motility of immune cells, and reduces scar formation and all these inhibits wound healing and in relation to the laparoscopic adrenalectomy. The nursing care for Susan would be the improvement of hypothermia. Gradually and passively warming of the body is important because Susan is suffering from mild hypothermia. The warm blankets, electric blankets, and administering heated IV fluids at 45°C techniques can be used to bring the temperature up (Sessler, 2018). The level of fluid output also needs to be increased. The oral fluid intake should be increased if possible. Another option can be administering of fluid intravenously if prescribed. The adrenal gland is responsible for the release of many hormones. So, there might be inadequate hormone secretion by left adrenal gland after the surgery. Therefore, blood cultures need to be

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

taken for the level of hormones produced before administering any replacement hormones of the adrenal gland (Nwariaku, 2017). According to Nwariaku (2017), the safe care needs for the laparoscopic adrenalectomy postoperatively 2 hours could be an inspection in the surgical site for any redness, swelling, heat or any other sign of sepsis. The vital signs have to be checked hourly for 4 hours and 4 hourly for 24 hours after 2 hours of post-operative care (Royal Prince Alfred Hospital Patient Observation (Vital Signs) Policy – Adult, 2018). The surgical site has to be inspected frequently as she is diabetic so there can be slow wound healing process. Moreover, taking pain assessment because pain may be suppressed due to intraoperative anaesthesia and may develop later. After nursing care and Susan’s improvement in health, she is planned to get discharged on the second day of post operation. The multidisciplinary team members such as a medical counsellor, dietician and podiatrist can be referred for the long-term recovery. A medical counsellor is important because they deal with the mental and physical issues of the patient. They help with the lifestyle, family problem and gives advice and can educate Susan about her drinking alcohol, obesity and diabetes mellitus problem. These problems are the underlying cause of the chronic diseases in a long run. They also help to cope with ongoing family issues as Susan has got 3 kids and it is more likely to have family problems (Lim, 2018). The second team member from MDT team is dietician. Dietician will help to plan the diet for Susan considering her surgery, obesity, diabetes, Cushing syndrome and hypertension. A regular check-up with dietician gives Susan a good understanding of the healthy eating and reducing the complications of her present condition. The proper food intake can help in the faster wound healing (Lim, 2018). And lastly, the third team member can be an osteopath. An Osteopath deals with the patient musculoskeletal system. Susan is

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

obese with 90kgs weight with increase upper body weight due to Cushing syndrome. This indicates Susan is at more risk of osteoporosis. Therefore, an osteopath will examine Susan’s history and perform a physical examination and figure out the problem associated with muscles and bones. They also provide the osteopathic care plan which helps to heal the problem (Healthtimes, 2015). In conclusion, this essay has successfully discussed the cause of Cushing’s syndrome which is an excess level of cortisol in the bloodstream. Likewise, the abnormal vital signs reflect the underlying cause of the deterioration of patient health. However, the abnormal vital signs can be improved with the help of proper nursing management and care plan for the patient. The care of the patient depends on the MDT members. Therefore, patient is provided proper referrals which helps in eliminating the long-term complications of the surgery and present health problems.

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

References:

Belayneh, T. (2014). Post-operative Hypothermia in Surgical Patients at University of Gondar Hospital, Ethiopia. Journal Of Anesthesia & Clinical Research, 05(10). http://dx.doi.org/10.4172/2155-6148.1000461 Burpee, S. E., Jossart, G. H., & Gagner M. (2011). Laparoscopic adrenalectomy. Surgical Treatment: Evidence-Based and Problem-Oriented. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK6872/ Campbell, G., Alderson, P., Smith, A., & Warttig, S. (2015). Warming of intravenous and irrigation fluids for preventing inadvertent perioperative hypothermia. Cochrane Database Of Systematic Reviews. pp. 1-2. Retrieved from: http://dx.doi.org/10.1002/14651858.cd009891.pub2 Griffing, T. G. (2014). Serum Cortisol: Reference Range, Interpretation, Collection and Panels. Medscape. Retrieved from https://emedicine.medscape.com/article/2088826-overview#a1. Isidori, A., Graziadio, C., Paragliola, R., Cozzolino, A., Ambrogio, A., & Colao, A. et al. (2015). The hypertension of Cushingʼs syndrome. Journal of Hypertension, 33(1), 44-60. Retrieved from http://dx.doi.org/10.1097/hjh.0000000000000415

Karcz, M., & Papadakos, P. J. (2013). Respiratory complications in the postanesthesia care unit: A review of pathophysiological mechanisms. Canadian Journal of Respiratory Therapy: CJRT = Revue Canadienne de La Thérapie Respiratoire : RCTR, 49(4), 21–29.

Lim, R. B. (2017). Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient. In D. Jones (Ed.) Retrieved March 25, 2018:

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

https://www-uptodate-com.ezproxy2.acu.edu.au/contents/hospital-accreditationaccommodations-and-staffing-for-care-of-the-bariatric-surgical-patient?search=role %20of%20a%20hospital %20counsellor&source=search_result&selectedTitle=3~150&usage_type=default &display_rank=3

Nwariaku. F. (2017). Adrenalectomy techniques. In S. E. Carty (Ed.), Uptodate. Retrieved March 25, 2018 from: https://www-uptodatecom.ezproxy2.acu.edu.au/contents/adrenalectomy-techniques? search=Adrenalectomy %20techniques&source=search_result&selectedTitle=1~150&usage_type=default &display_rank=1#H6113154 Prasad, D. (2017). Oliguria: Background, Etiology, Epidemiology. Emedicine.medscape.com. Retrieved 28 March 2018, from https://emedicine.medscape.com/article/983156overview Royal Prince Alfred Hospital Patient Observation (Vital Signs) Policy - Adult. (2014). New South Wales. pp. 6-9. Retrieved from: https://www.safetyandquality.gov.au/wpcontent/uploads/2012/02/RPAobservations-policy-directive.pdf Sessler. D. (2018). Perioperative temperature management. In G. P. Joshi (Ed.), Uptodate. Retrieved March 25, 2018 from: https://www.uptodate.com/contents/perioperativetemperature-management Spranger, M., Kaur, J., Sala-Mercado, J., Krishnan, A., Abu-Hamdah, R., & Alvarez, A. et al. (2017). Exaggerated coronary vasoconstriction limits muscle metaboreflex-induced increases in ventricular performance in hypertension. American Journal of

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NRSG 258(ASSIGNMENT 1)

SUSAN SUMMERS – CUSHING SYNDROME

KAJOL RAUNIYAR(S00217983)

Physiology-Heart And Circulatory Physiology, 312(1), H68-H79. doi. http://dx.doi.org/10.1152/ajpheart.00417.2016 What is an Osteopath? (2015). Health Times. Retrieved March 25, 2018 from: https://healthtimes.com.au/hub/allied-health/66/guidance/nc1/what-is-anosteopath/571/

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