464 UNIT IV / Responses to Altered Endocrine Function
Nursing Care Plan
A Client with Cushing’s Syndrome
Sara Domico is a 30-year-old lawyer living in a • Remain free of injury.
major metropolitan area. She has never been • Remain free of infection.
married, and she shares her life with her cat, Beau, and her parents, • Verbalize understanding of the physical effects of the disease
who live nearby. Her physician recently diagnosed Ms. Domico as process and realistic expectations of desired changes in ap-
having Cushing’s syndrome and admits her to the hospital for sur- pearance.
gery for an adrenal cortex tumor (adrenalectomy). She has been
having increased muscle weakness, so much so that she has diffi-
PLANNING AND IMPLEMENTATION
• Weigh each morning, using the same scale.
culty climbing the one flight of stairs to her apartment. She has
• Maintain an accurate record of intake and output.
also had difficulty sleeping, irregular menstrual periods, and hy-
• Ensure adequate lighting in the room, and wear glasses and
pertension. Ms. Domico is especially concerned about her pro-
shoes when getting out of bed.
truding abdomen, round face, development of facial hair, and the
• Develop a written schedule of rest and activity periods.
numerous bruises that have appeared on her skin.
• If agreeable, provide a private room, and restrict visitors to par-
ASSESSMENT ents at this time.
When Ms. Domico arrives at the hospital the morning of surgery, • Use strict medical and surgical asepsis when providing care.
she is admitted by her case manager, Ann Sprengel, RN, CNS. Ann • Provide time for discussion of the disease and treatment; en-
completes a physical assessment that includes abnormal findings courage verbalization of feelings and identify successful coping
of thin lower extremities, an enlarged abdomen, purple striae over mechanisms used in the past.
the abdomen and buttocks, a round face, and obvious facial hair. • Encourage turning, coughing, and deep breathing and/or in-
Her blood pressure is 160/96. Ms. Domico tells Ann that she is al- centive spirometry every 2–4 hours.
ways tired and that sometimes it “just wears me out to walk from
the bedroom to the kitchen.” Diagnostic tests conducted prior to
EVALUATION
Ms. Domico states that she is “ready to have surgery and start feel-
admission reveal the following abnormal findings (all except cor-
ing better.” She has not fallen or injured herself, and she has re-
tisol levels are corrected before surgery).
mained free of infection. Although edema is still present, she has
Glucose: 186 mg/dL (normal range: 70 to 110 mg/dL) lost 8 lb (3.6 kg), and her blood pressure is decreased. Ms. Domico
Sodium: 152 mEq/L (normal range: 135 to 145 mEq/L) has openly discussed her concerns about the way she looks and
Potassium: 3.2 mEq/L (normal range: 3.5 to 5.0 mEq/L) feels; she understands that symptoms will improve following sur-
Calcium: 4.3 mEq/L (normal range: 4.5 to 5.5 mEq/L) gery. She has strong religious beliefs and family support, both of
Cortisol: 35 mg/dL (normal for A.M.: 5 to 23 mg/dL) which provide strength and help her cope with the effects of the
disorder and the need for any further treatment.
DIAGNOSIS
• Fluid volume excess, related to sodium retention causing edema Critical Thinking in the Nursing Process
and hypertension 1. When Ms. Domico was admitted to the hospital, several of her
• Risk for injury, related to generalized fatigue and weakness test results were abnormal. Describe the pathophysiologic
• Risk for infection, related to impaired immune response and reason for those results.
edema 2. List the assessments that nurses can make to determine body
• Body image disturbance, related to physical changes secondary fluid balance.
to Cushing’s syndrome 3. Develop a plan of care for this client for the nursing diagnosis
EXPECTED OUTCOMES Fatigue.
• Regain a normal body fluid balance. See Evaluating Your Response in Appendix C.
PATHOPHYSIOLOGY • Adrenoleukodystrophy, an X-linked disorder characterized
by an accumulation of very long chain fatty acids in the ad-
There are many possible causes of Addison’s disease. The eti-
renal cortex, testes, brain, and spinal cord.
ologies include:
• ACTH deficit, resulting from pituitary tumors, pituitary sur-
• Autoimmune destruction of the adrenals. This is the most gery or irradiation, and the use of exogenous steroids.
common cause, accounting for about 80% of spontaneous • Clients who are abruptly withdrawn from long-term, high-
cases (Tierney et al., 2001). It may occur alone, or as part of dose steroid therapy. Other clients at risk are those with tu-
a polyglandular autoimmune syndrome (PGA). Type 2 PGA berculosis or acquired immune deficiency syndrome (AIDS);
is seen in adults, often associated with autoimmune thyroid the pathogens responsible for either disease can infiltrate and
disease (usually hypothyroidism), type 1 diabetes, primary destroy adrenal tissue.
ovarian or testicular failure, and pernicious anemia. Adrenocortical destruction initially causes a decrease in ad-
• Clients who are taking anticoagulants, have major trauma, or renal glucocorticoid reserve. Basal glucocorticoid secretion is
are having open heart surgery. Such clients may have bilat- normal, but does not increase in response to stress and surgery.
eral adrenal hemorrhage. Trauma or infection can precipitate an adrenal crisis. As the de-
