NURSING CARE PLAN

Patient’s Initial: ___T.H._____ Age: _34 yrs old__ Gender: __Male__ Date Handled: _May 3, 2021___
Medical Diagnosis: _Cushing Syndrome_____ Chief Complaint: __changes in his appearance over the past year ________ Clinical Area: __________________

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Excess Fluid Short Term Goal: Independent: Short Term Evaluation
• The patient reports Volume related to After 8 hours of nursing • Educate patient and family members • Information is key to After 8 hours of nursing
weight gain (particularly compromised intervention the client will be regarding fluid volume excess and its managing problems. intervention the goal to:
through his midsection), regulatory able to: causes. • maintain normal blood pressure
easy bruising, and edema mechanism (fluid • maintain normal blood • maintain normal urine output
of his feet, lower legs, and sodium pressure • Monitor weight regularly using the • Sudden weight gain may • verbalize causative factors,
and hands retention) as • maintain normal urine same scale and preferably at the same mean fluid retention. symptoms and treatment of the
• The patient has been evidenced by output time of day wearing the same amount Different scales and clothing condition was:
having increasing increased blood • verbalize causative factors, of clothing. may show false weight
weakness and insomnia pressure, edema symptoms and treatment of inconsistencies. _√_ met
in lower the condition. ___ partially met
extremities and • Monitor and note BP and HR. • increased BP and HR are the ___ unmet
Objective: increased RBCs As evidenced by: evident signs of fluid
• Physical examination: count. • blood pressure within retention As evidenced by:
: BP 150/110 normal limits • blood pressure within normal
: 2+ edema of lower • urine output greater than or • Monitor fluid intake. • This enhances compliance limits
extremities equal to 30 ml/hr with the regimen. • urine output greater than or
: purplish striae on equal to 30 ml/hr
abdomen • Instruct the client to elevate feet when • This position decreases fluid
: thin extremities with Long Term Goal: sitting down. accumulation in the lower
thin friable skin After 1 day of nursing extremities. Long Term Evaluation:
: severe acne of the intervention the client will be After 1 day of nursing intervention
face and neck able to: • Educate patient and family members • Knowledge heightens the goal to:
• demonstrate absence of the importance of proper nutrition, and compliance with the • demonstrate absence of edema
• Blood analysis: edema diet modification. treatment plan. • demonstrate balanced input
: Glucose -167 mg/dL • demonstrate balanced input and output and stable weight was:
(9.3 mmol/L) and output and stable weight • Monitor the client’s sodium and • To monitor the occurrence of
: White blood cell potassium levels. hypokalemia. _√_ met
(WBC) Count - As evidenced by: ___ partially met
13,600/µL • absence of swelling in lower • Encourage the client to have low • Too much sodium in the diet ___ unmet
: Lymphocytes - 12% extremities sodium and high potassium diet. promotes fluid retention and
: Red blood cell weight gain.
(RBC) count - 6.0 × • the amount of intake is equal As evidenced by:
106/µL to the amount of output. • Monitor and manage complications • absence of swelling in lower
: K+ - 3.2 mEq/L (3.2 such as skin ulcer and infection extremities
mmol/L) • the amount of intake is equal to
Dependent: the amount of output.
• Limit sodium intake as prescribed. • Restriction of sodium aids in
decreasing fluid retention

• Instruct the client to reduce fluid intake • Limiting fluid intake is

as indicated. important in preventing
circulatory overload.
• Administer antihypertensive
medications as prescribed. • To treat high blood pressure.

• Administer diuretics as prescribed. • Diuretics promote sodium

and water excretion.
Potassium-sparing diuretics
may also be prescribed to
prevent additional loss of
Interdependent/ potassium.
Collaborative:
• Cooperate with the pharmacist to • Concentration decreases
maximally concentrate IV fluids and unnecessary fluids.
medications.

• Consult dietitian as needed. • To develop dietary plan and

identify foods to be limited.

• Assist with and result • To assess etiology and

from laboratory tests precipitating factors.
and diagnostic studies.

• Collaborate in • To treat the underlying

treatment of underlying cause of excess fluid volume.
condition that might
be causing the excess fluid volume

Discussion Questions

1. Discuss the probable causes of the alterations in T.H.'s laboratory results.

 Hyperglycemia. Cushing's syndrome is a condition that occurs when there are high levels of cortisol in the blood. Cortisol elevates our blood pressure and glucose levels.
 Increased WBCs and Decreased Lymphocytes. Cushing syndrome was caused by excessive endogenous exposure to pathologic Glucocorticoids levels, causes changes
in white blood cell count and function, including granulocytosis, increased monocytes, and a decrease in lymphocytes. And elevated white blood cell (WBC) counts in
Cushing's disease are associated with hypercortisolism; this is because glucocorticoid receptors expressed by WBCs play a part in cell adhesion and WBC recruitment
from the bone marrow.
 Increased RBCs. Corticosteroids have such an erythropoietic effect that can result in polycythemia or increased in red blood cells count.
 Decreased Potassium level. By acting on mineralocorticoid receptors, cortisol reduces glomerular filtration rate and renal plasma flow from the kidneys, increasing
phosphate excretion as well as sodium and water retention and potassium excretion.

2. Explain the pathophysiology of Cushing syndrome.

 CD is caused by a benign monoclonal pituitary corticotroph adenoma that secretes too much ACTH, resulting in supraphysiological glucocorticoid release from the
adrenal glands. Excess circulating cortisol disrupts the natural physiological diurnal variance in cortisol levels and inhibits CRH secretion from the hypothalamus through
negative feedback inhibition. The adenoma, on the other hand, is relatively resistant to inhibition by endogenous circulating cortisol. As a result, CD is associated with
suppressed CRH secretion and elevated ACTH levels in comparison to the degree of cortisol intake.

3. What diagnostic testing would identify the cause of T.H.'s Cushing syndrome?
 Blood and urine tests. These tests assist the doctor in determining the volume of hormones in the body, such as cortisol and adrenocorticotropic hormone (ACTH).
 Dexamethasone-Suppression test. Dexamethasone is a corticosteroid, which is a type of hormone released by the adrenal glands. The body's natural reaction to
dexamethasone is to momentarily avoid producing cortisol when the brain senses the presence of dexamethasone and recognizes that it does not need to transmit the
ACTH signal to produce the body's own cortisol. However, people with Cushing's syndrome, on the other hand, appear to produce cortisol even though dexamethasone is
administered.
 Saliva test. Cortisol levels fluctuate during the day; they are strongest in the morning and very low or undetectable after midnight. People with Cushing's syndrome, on
the other hand, have less fluctuations in their cortisol levels and higher levels at night than usual. A tiny late-night salivary extract will be used by the doctor to assess your
cortisol levels.
 Imaging tests. Imaging examinations, such as computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans, will assist the specialist in detecting
any anomalies in your pituitary and/or adrenal glands.
• Abdominal CT - to examine the abdomen for an adrenal gland tumor or another kind of tumor
• Pituitary MRI - to check for a pituitary tumor
• Dual x-ray absorptiometry (DXA) - to assess bone mineral density; people with Cushing's syndrome also have low bone mass.

4. What is the usual treatment of Cushing syndrome?

 Pharmacologic treatment
• Adrenal enzyme inhibitors - used to reduce hyperadrenalism.
• Potassium-sparing diuretics - promotes sodium excretion while conserving potassium.
 Radiation therapy
 Surgical treatment
• Transsphenoidal hypophysectomy - if caused by the pituitary tumor
• Adrenalectomy - if caused by adrenal tumor/disfunction

5. What is meant by a “medical adrenalectomy”?

 It is often used to describe procedures that aim to inhibit adrenal activity instead of adrenalectomy. This term can only be applied to regimens that create a hormonal
environment that is similar to that produced by surgical adrenalectomy. It is used to describe treatments that aim to inhibit adrenal steroidogenesis.

6. Patient-Centered Care: What are the priority nursing responsibilities in the care of T.H.?
 Monitor vital signs, intake and output.
 Restrict sodium and provide low carbohydrates, high protein and high potassium in the diet.
 Weight the patient daily assessing abdominal girth
 Reverse isolation due to immunosuppression
 Provide or assst in skin care

7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
 Excess Fluid Volume related to compromised regulatory mechanism (fluid and sodium retention) as evidenced by increased blood pressure, edema in lower extremities
and increased RBCs count.
 For collaborative, we can cooperate with the pharmacist to maximally concentrate IV fluids and medications and/or consult dietitian as needed.