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A 51-year-old unemployed salesman, Mr. Don Sardoff, is brought to the emergency room by his wife, Ellen, at 8 A.M. Mrs. Sardoff tells the emergency room nurse that her husband has not been feeling well for the last week, but that when he got up this morning, he was so weak he couldn’t dress himself and didn’t know where he was. Mrs. Sardoff also tells the nurse that her husband has been taking a cortisone drug for treatment of his rheumatoid arthritis for the past 2 years, but notes,“We didn’t have the money to buy it this month.” • Regain normal peripheral perfusion with blood pressure within normal range. • Verbalize knowledge of the causes and effects of adrenal insufficiency.
PLANNING AND IMPLEMENTATION
• Monitor intake and output closely. • Take and record weight at the same time daily. • Monitor blood pressure, pulses, and skin turgor every 2 hours until stable, then 4 times a day. • Monitor electrolytes, and report abnormal results. • Discuss a diet that is high in sodium, low in potassium, and has an increased fluid intake (3000 mL per day).Discuss the types of fluids desired and the best times for intake of increased fluids. • Assist during activity to prevent falls. • Provide verbal and written instructions, and encourage verbal feedback about the causes and effects of the disease, the effects of medications, the effects of not taking long-term cortisone drugs, the diet, and self-care at home.
On admission to the emergency room, Mr. Sardoff is dehydrated, with dry oral mucous membranes and tongue, poor skin turgor, and sunken eyeballs. His blood pressure is 94/44, and his pulse is rapid and thready. He is weak, dizzy, and disoriented about time and place. Diagnostic tests reveal the following abnormal findings at 8:30 A.M.: • • • • • EKG: widening QRS complex and increased PR interval Sodium: 129 mEq/L (normal range: 135 to 145 mEq/L) Glucose: 54 mg/dL (normal range: 70 to 110 mg/dL) Potassium: 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) Cortisol: 2 mg/dL (normal for A.M.: 5 to 23 mg/dL)
Following treatment for acute adrenal insufficiency, Mr. Sardoff is no longer dehydrated, and his blood pressure has returned to his normal reading of 132/88. He is alert and oriented, and anxious to learn to care for himself at home. After dietary instructions and teaching for self-care that included his wife, Mr. Sardoff verbalizes an understanding of his illness and the need to take his medication carefully and accurately. A referral is made to a social worker for assistance with costs of medications.
The medical orders for Mr. Sardoff include intravenous administration of 5% dextrose in normal saline (D5NS) at 250 mL/h and hydrocortisone (Solu-Cortef ) 200 mg. After the fluids and medication are initiated, Mr. Sardoff is moved to an in-hospital medical bed.
• Deficient fluid volume, related to hypovolemia secondary to adrenal insufficiency • Ineffective tissue perfusion: Peripheral, related to fluid volume deficit • Anxiety, related to lack of knowledge about the effects and treatment of adrenal insufficiency
Critical Thinking in the Nursing Process
1. Adrenal insufficiency is often diagnosed only when the client becomes seriously ill in response to a stressor. Explain why this statement is or is not true. 2. Describe the physical assessments that are found in the severely dehydrated client. 3. Outline a teaching plan for Mr. Sardoff with foods for a highsodium, low-potassium diet. See Evaluating Your Response in Appendix C.
• Regain normal fluid balance.