Critical Care Nursing-Cushing’s Syndrome-Susan Summers Case Study

Question: Discuss about the Critical Care Nursing-Cushings Syndrome-Susan Summers Case Study. Answer: This essay focuses on Susan Summers, a female client aged 40 years with three children all aged below ten years. She works in a supermarket as a casual at night. She takes wine in order to adapt to her. She had been diagnosed with type 2 diabetes and obesity with 90kg which corresponds to a Body Mass Index of 35kg/m. She was admitted for laparoscopic right adrenalectomy following noticeable changes in her general appearance because of Cushings syndrome which resulted from a benign tumor on the right adrenal gland. Cushings syndrome is a medical condition associated with excessive levels of cortisol hormone. Susan had to undergo right adrenalectomy under general anesthesia. Adrenalectomy refers to the surgical removal of the adrenal grand. Susan stayed in the Post-anesthetic recovery room (PARU) for two hours and then taken to the ward. She had an indwelling Urinary Catheter and a record of observations. The essay will focus on causes and pathophysiology of Cushings syndrome. It will also discuss the pathophysiology behind the deterioration of Susans condition post operation and the appropriatenursing interventions. Lastly, the essay will touch on some of the members of the interdisciplinary health care team. Cushings syndrome is associated with prolonged or excessive exposure of body tissues to excessive levels of cortisol hormone which is produced by the adrenal glands. Adrenal gland also produce other hormones such as epinephrine, dehydroepiandrosterone and norepinephrine. Cortisol hormone is responsible for regulation of blood pressure, counteraction of allergies and inflammation, maintaining stress resistance and normal functioning of the cardiovascular system. A tumor on the adrenal gland may lead to excessive production of cortisol hormone. It can also result from excessive use of corticosteroids such as prednisone (Nieman et al, 2015 High levels of cortisol hormone are associated with factors such as stress, alcoholism, malnutrition, depression and emotional stress. A tumor on the pituitary gland may lead to excessive release of adrenocorticotropic hormone (ACTH) which consequently leads to increased release of cortisol from the adrenal gland cortex. A primary disease of the adrenal gland can also lead to excessive production of cortisol leading to Cushings syndrome. Heredity is also a contributing factor to Cushings syndrome but rarely. High levels of cortisol leads to hypertension, hyperglycemia, insulin resistance, obesity, weight gain, type 2 diabetes and fat deposition on the neck, face and belly (Craft et al, 2015). After making a diagnosing Cushings syndrome, Susan had to go for laparoscopic adrenalectomy of the right adrenal gland based on her clinical presentation, location and size of the tumor (Maestre-Maderuelo et al, 2013). After operation, Susan was taken to post-anesthetic recovery unit (PARU) for recovery from the general anesthesia. At post anesthetic recovery unit (PARU) she was put under close monitoring for any signs of deterioration and complications. She was later taken to the ward for management as she awaited discharge after two days. Her observations in the ward include: Blood pressure-160/90mmHg, Temperature-35.0c, respirations-30breaths per minute, pain score-0/10, pulse-128beats per minute and an Indwelling Urinary Catheter indicating 5mls of urine for 1hour (Maestre-Maderuelo et al, 2013). Operation under general anesthesia could have led to hypothermia temperature of 35.0c compared to normal of (36.5-37.0c). During general anesthesia, the normal mechanisms of thermoregulation in the body are inhibited leading to low body temperature (Aksu et al, 2014). Postoperative hypothermia is also associated with female gender, old age, emergency surgery and amount of blood loss during the surgical procedure. Prolonged anesthetic period or surgery, technique used in anesthesia and room temperature can also lead to hypothermia. Postoperative hypothermia can lead to infection of the surgical site, blood transfusions, discomfort, pressure sores and mortality (Aksu et al, 2014). A pulse rate of more than 100 beats per minute is termed as tachycardia. Excessive alcohol consumption, obesity, Cushings syndrome and hypertension are associated with tachycardia. Alcohol leads to increased fats in the blood stream which can clog the blood vessels. This leads to increased peripheral resistance and increased pressure exerted on the walls of the blood vessels .Increased peripheral resistance leads to a consequential increase in blood pressure. Alcohol also causes thickening and narrowing of blood vessels, which makes the heart to strain as it tries to compensate for the disorientation in its normal functioning. This results to increased heart rate of 128 beats per minutes and high blood pressure (160/90mmHg). Obesity is a risk factor for hypertension. Obesity is associated with increased intravascular volume which leads to increased cardiac output (Lacroix et al, 2015) Based on a normal respiration rate of 12-20 breaths/minute, Susan had tachypnea with a respiration rate of 30 breaths per minute. Some of the factors which could have led to tachypnea are hypertension, fluid loss and damage of the heart as a result of alcohol. Bleeding during operation or post-operation could be another possible cause of increased rate of respiration and tachycardia to Susan. The normal urine output is more than about 20 mls/hr/kg in an adult which indicates sufficient renal perfusion and functioning (Harding, 2017) Susans incidence of 5mls of urine in hour can be termed as oliguria. Oliguria refers to a urine output less than 20ml/kh/hour in an adult. Postoperatively, decreased urinary output results from blood or fluid loss due to decreased rate of glomerular filtration secondary to hypotension and hypovolemia. Reduced tissue and organ perfusion can also lead to reduced kidney functioning resulting to reduced urine production. It can also be due to adrenal cortex response to stress due to increased release of aldosterone and antidiuretic hormone. The general anesthesia used during the surgery and stress associated with surgery could also be other causes of reduced urinary output post operation. Anesthesia influences the sympathetic activities, hemodynamics and humoral regulation. Opioids, benzodiazepines and barbiturates cause a reduction in the rate of glomerular filtration leading to reduced urinary output. Medications and medical conditions can disorient kidney perfusion and functioning lea ding to abnormalities in the amount of urine output (Harding, 2017) For better postoperative outcome and good prognosis of Susans condition, appropriatenursing interventions were required. Appropriate and qualitynursing management is important to promote patient recovery and prevent deterioration of the patients health condition due to complications associated with poor nursing management. ISBAR (Identify, Situation, Background, Assessment and Recommendation) tool can be used to promote improvement of safety when transferring critical patient information from one department to another in health care system, for instance from theatre to PARU then to the ward (Morton et al, 2017 The key priorities of Susan are stabilization of vitals, fluid and electrolyte balance and prevention of deterioration and complications. On arriving in the ward, the ABCDE approach is important in a clinical emergency for fast assessment of the patients condition and immediate initiation of treatment (Estes et al, 2016). This approach aims at providing life-saving management, breaking down complex medical situations to manageable portions and establishing common awareness of the situation among all health care providers. To implement on this approach, it is recommended to check for patency of the airway. Airway can be partially or completely blocked by foreign objects, secretions or inflammation which can lead to breathing difficulties to the patient. On breathing, one should ensure that the patient is breathing sufficiently. Insufficient breathing is manifested through cyanosis, tracheal lateralization and distension of neck veins (Morton et al, 2017 Sufficient circulation should be assessed to ascertain any abnormalities such as variations in pulse rate, sweating, color changes and decreased consciousness level. Assessment of disabilities gives more information on the level of consciousness of the patient. Consciousness can be assessed using tools such as AVPU (Alert, Voice responsive, Pain Responsive and Unresponsive) and Glasgow Coma Scale. Exposure aspect of the ABCDE approach gives the general condition of the patient which includes signs of bleeding, trauma and skin reactions such as rashes (Brown et al, 2017). The elevated blood pressure of 160/90mmHg and tachycardia (128beats per minute) can be managed through close cardiovascular observation. This can be implemented by accurately and continuously measuring and monitoring pulse and blood pressure in order to detect any signs of improvement or deterioration. Postoperatively, most patients are at high risk of fluid and electrolyte imbalance because of fluid or blood loss, starvation and exposure during surgical operation (Brown et al, 2017). Low amount of urine output (5mls of urine in hour) is an indication of fluid volume deficit. In this instance, administering intravenous fluids following prescriptions is an important nursing intervention. Secondly, it is important to closely monitor the input/output using charts to ascertain any kidney dysfunctions. It is important to encourage the patient to avoid movements which are precipitating factors of hypertension and tachycardia. For the postoperative hypothermia characterized by a temperature of 35.5 centigrade, it is important to monitor temperature variations and keep the patient warm using synthetic blankets. Since Susan has an indwelling catheter, catheter care is very important to prevent infections (Brown et al, 2017). A multidisciplinary health care team is important during the care of Susan and her life after she has been discharged from the hospital. Susan is a single parent with three children whom she raises alone from her job as a casual worker. Recommending her to a social worker would be important. It is recommendable if she is given a leave of two months from work for her recovery. A counselor would be important to guide her on how to handle her family and work without having to take alcohol in order to cope with her life (Momsen et al, 2012 A diabetes health educator could also be recommended for her since she has type 2 diabetes. The educator can provide more information about diabetes, its risk factors, causes and lifestyle modifications important for prevention of diabetes. An IDEAL discharge plan should be applied since it incorporates the patient and her family to prevent complications and deterioration after discharge hence promoting patient satisfaction. Objectives of the discharge include prevention of complexities and promote healing (Momsen et al, (2012 In conclusion, the underlying etiology and pathophysiology of Cushings syndrome were highlighted and explained. Base on the case study of Susan, the essay has captured the presenting medical condition, its causes, pathophysiology, manifestations and nursing management interventions. Nursing interventions have been based on the patients health care priorities. The essay has also addressed the importance of the multidisciplinary health care team counsellor, social worker and a health educator in care of the patient. 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