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URO Ward Jose Reyes Memorial Medical Center
In Partial Fulfillment of the Requirements In Medical Surgical Nursing III (Related Learning Experience)
Submitted to: Mrs. Jennifer P. Reyes, RN, MAN Clinical Instructor Submitted by: Dungog, Bryan Martin Dizon, Kathleen Zyrelle Ensalada, Dan Ataniel Fernandez, Dianne May Guiao, Nicole Gianne Guimbarda, Roxette Hernandez, Jannefer BSN IV-3 Group J
An adrenal mass is an abnormal growth that develops in the adrenal gland. Adrenal mass known as pheochromocytomas, is a rare condition that involves the formation of an abnormal mass within the adrenal gland. Located just above the kidneys, the adrenal glands work to produce hormones. In the presence of a tumor, hormone production becomes disrupted. Pheochromocytomas most commonly occur in adults aged 20-40 years old. It occurs in about 0.5% to 0.1% of patients with sustained hypertension. It must also be considered that the prevalence of sustained hypertension in the adult population of Western countries is between 15 to 20%. Thus, in Western countries the prevalence of pheochromocytoma can be estimated at 1:2500 to 1:6500 patients, with an annual incidence in the United States of 500 to 1,100 cases per year. It is more frequent in women than in men (1:5). Adrenal masses are common and they increase in frequency with age. It may be benign, malignant or functional. 1 out of 4000 adrenal masses is malignant. Most patients with pheochromocytomas present with signs and symptoms syndrome of is adrenal the steroid excess. Rapidly progressing Cushing’s most frequent presentation. Androgen-secreting
pheochromocytomas in women present with hirsutism and virilization, with male-pattern baldness and oligo/amenorrhea. Rare aldosterone-producing pheochromocytomas present with severe hypertension and profound hypokalemia. Hypertensive crises can present as hypertensive emergency or as hypertensive urgency. Hypertensive emergency exists when blood pressure reaches levels that are damaging organs. On the other hand, hypertensive urgency is a situation where the blood is severely elevated
(180 or higher for the systolic pressure or 110 or higher for diastolic pressure), but there is no associated organ damage. This study will provide a thorough analysis of client BGV, 27 years old, Female, who was admitted to the Urology Ward of Jose Reyes Memorial Medical Center last December 8, 2012, with a chief complaint of vaginal spotting. This goes on to describe the abnormal and normal physiology, in general then description of the physiology involved in Hypertensive Urgency secondary to Adrenal mass, as well as the corresponding ways to treat and manage the condition. With the knowledge acquired from Medical-Surgical Nursing, this case study aims to formulate an individualized Nursing Care Plan which will be used as an instrument on improving client’s health condition through nursing assessment, diagnosis, planning, and intervention. and the management needed for the client’s condition. It will serve as a prioritization guide for the holistic care that must be rendered to the client
II. OBJECTIVES This paper aims to provide a study regarding Hypertensive Urgency secondary to Adrenal Mass which focuses on assessment, different treatment modalities, nursing care and responsibilities on various areas that include pharmacologic treatments and diagnostic procedures. It is also intended to provide a better understanding of the complication process based on the present health history of the patient as well as the underlying condition. Specifically, at the end of the study the student nurses aim to: 1. Understand the prognosis of the disease and its effects to the patient. 2. Be able to make accurate and thorough assessment of the patient to determine her nursing needs
3. Fully grasp the complication process of the patient and to have a better understanding on the patient’s condition. 4. Draw out appropriate and prioritized nursing care plans which will render effective care 5. Be able to render care complying to the doctor’s order and maintaining exact compliance to the treatment regimen of the patient 6. Remain competent and responsible student nurses in providing the best care to the patient III. NURSING HEALTH HISTORY Date of Interview: December 11, 2012 Source of Information: Patient and Patient’s chart Percentage of Reliability: The data obtained are 100 % accurate. A. DEMOGRAPHIC DATA Patient Name: Patient BGV Age: 27 years old Gender: Female Date of Birth: December 5, 1985 Birthplace: Dipolog City Address: Galas, Dipolog City Nationality: Filipino Religion: Protestant Civil Status: Single Educational Attainment: College Graduate Occupation: Teacher B. INITIAL DATA Date of Admission: December 8, 2012 Time of Admission: 2:58pm
She consulted an OB/GYN and was told that she has inflammation of the uterus. . The patient was then transferred to the Urology Ward of Jose Reyes Memorial Medical Center on December 8. 2012 at 2:58pm. the patient experienced irregular menstruation. the patient reported hair fall and vaginal spotting.counter medicines whenever she feels sick. she had her immunizations completed during childhood. She was admitted to Cebu Doctors’ Hospital due to abnormal ECG results and hypertension and was diagnosed with Hypertensive Urgency secondary to Adrenal mass after certain tests. CHIEF COMPLAINT The patient was admitted to the Cebu Doctors’ Hospital due to vaginal spotting and was then transferred to Urology Ward of Jose Reyes Memorial Medical Center. The patient also stated that she has no history of any kind of injury. 1 month prior to confinement. The patient has no known allergies to medications or environmental elements but has reported allergies with sea foods. 9 months prior to confinement. The patient took NSAIDs and reported regular menstruation for the next months.IV. Most of the time. the patient do self-medication and take over-the. Admitting Diagnosis: Hypertensive Urgency secondary to Adrenal mass V. The patient was compliant with her medications. VI. the patient experienced increase in blood pressure and was prescribed to take Neobloc. HISTORY OF PRESENT ILLNESS 1 year prior to confinement. PAST MEDICAL HISTORY According to the patient.
VIII. She gathers information about her present condition. She works as pre-school teacher and performs her daily routine unassisted before she became sick. She makes sure that she gathers information about it.VII. She managed her health problems like fever. PSYCHOSOCIAL HISTORY Patient BGV stated that she doesn’t consume alcohol nor engage self to smoking. FAMILY HEALTH HISTORY Patient BGV lives with her parents and has 2 siblings. She does not practice a regular check-up or seeking medical advice for her The patient is still aware of his health. . colds and cough on her own. The only known case of disease in her family is from her Grandfather who died of Tuberculosis. She is single and still lives with her parents and sibling. GORDON’S FUNCTIONAL HEALTH PATTERNS TYPOLOGY PATTERN BEFORE ADMISSION DURING ADMISSION CHANGES Health Perception and Health Manageme nt The patient is aware of her health. IX. The patient seeks medical advice and after she was diagnosed. She seeks medical advice and follows doctor’s order about her prescriptions and medications.
urinates frequently and described with yellowish color. She became a fruit and vegetable eater and drinks more water than before. She still eats three times a day and drinks water more. She eats three times a day. She has not changed. she sticks with a diet of vegetables and fruits. ActivityExercise Pattern The patient exercise daily but when she knew about her condition. Nutritional Metabolic Pattern The patient has a good appetite. pork. chicken. She likes to eat anything particularly meat. She limits her exercises because of her condition. When she knew about her condition. No changes. vegetables and fruits. she limits down her activities. . She does her hygiene by herself. Elimination Pattern The patient The patient defecates every elimination pattern other day. She always watches The patient does walking as form of exercise.health. She does not experience any discomfort in urinating and defecating. She drinks less than 8 glasses of water a day. with snacks.
Cognitive Perceptual The patient is oriented to time. She does not take afternoon naps. She is a college graduate.television and help with the household chores. She does not experience any difficulty in sleeping. place and person. She thinks that her body image is not good because she thinks she’s fat and the The patient thinks of her condition in a positive way. She responds properly to physical and verbal stimuli. The patient sleeprest pattern is the same even she is hospitalized. Selfperception/ selfconcept The patient sometimes thinks negative about herself. The patient is still oriented to time. place and person. She responds properly to physical and verbal stimuli. . She is hoping that her condition will be treated and the changes in her body because of her condition will return She is more optimistic about her condition and herself. No changes. Sleep and Rest The patient sleeps 5 to 6 hours a day. She was awakened by rounds Awakened by rounds.
But she is positive that these will be solved. She is the youngest in the family. The patient is not . She said that he has a good relationship with his brothers and parents. Her brother and brother-in-law take turns in taking care of her in the hospital.hyperpigmentation to normal. in other parts of her body. The patient stated that she maintains having a good relationship with her family. The patient stated that she had a boyfriend and she broke up with him after she was diagnosed with her condition. Sexuality/R eproductiv e Pattern She has a regular menstruation and does not experience any difficulty. No changes in their relationship. The patient sexuality/reproductiv e pattern is the same. They care for each other. No changes. RoleRelationshi p Pattern The patient stated that she lives with his parents and siblings.
She said that when she had a problem. Value/Belie f Pattern The patient is a Protestant. She can’t attend worships but still makes sure to pray to God. Although she can’t attend the worships. double vision and pain but she said she feels like she has a acetate like vision. Head/Eyes/Ears/Nose/Throat: Head. She maintains her hygiene and grooming as well.the patient does not experience any headache Eyes. She maintained her faith and prays to God always. X. She always attends their worships and prays to God. she does openly share it and just pray to God to overcome her circumstances. REVIEW OF SYSTEMS General: The patient verbalizes that she gained weight.she denies blurred vision. She was able to express some of her concerns. The patient sometimes expresses what she feels. she makes sure that she is connects with Him and that her condition will be better.CopingStress Tolerance open with her problems to her family. .
claudications and palpitations.she denies any pain in the ear. She also denies any changes in his sensations. Gastro-intestinal: The patient denies nausea. She has a good appetite Gastro-urinary: The patient said that she does not experience hematuria. coherent. joint and bone pain. stomach upset. tinnitus. vomiting. Cardiac: The patient denies chest pain. Hematology: The patient denies having any blood disorders. dysuria. Musculoskeletal: The patient denies muscle. anuria and straining while defecating. and hearing loss Nose. She also denies weakness. she has an elevated blood sugar. The client was lying in bed with an ongoing IV contraption infused with I L of PNSS at the left metacarpal vein. XI.the patient verbalizes that she feels that there is a blockage in her nose. Neurology: The patient stated that she does not experience dizziness and loss of memory. and oriented to time and place. The patient was cooperative. Endocrine: The patient verbalizes that on her last blood sugar reading. PHYSICAL ASESSMENT GENERAL APPEARANCE The patient was received conscious. Mouth and Throat. able to follow instructions and responds in an appropriate .Ears.she denies any difficulty in swallowing and speaking Respiratory: The patient denies difficulty of breathing.
and cool to touch. shiny and uniform in color. The patient is exhibiting hirsutism. pallor on the nails was noted and revealed convex curvature after performing Schamroth’s test. In addition. There was no presence of rashes noted. the skin is dry. HEAD . hair on scalp is evenly distributed and slight alopecia was seen. moderate pace and exhibits thought association. 8 C PR: 77 bpm RR: 19 cpm BP: 110/90 mmHg SKIN Upon inspection. waist and inguinal area. the skin was thin and the temperature was uniform. She spoke in an understandable. HAIR Upon inspection. Upon palpation. breast. The initial vital signs are taken as follows: T: 36. hair is thin. capillary refill was tested and the color of the nails returned after 3 seconds. Also.manner. The patient has noticeable striae on her armpits. There were no infections and infestations seen. NAILS Upon inspection.
Upon inspection and palpation. Using the penlight the pupils are observed to be black in color. . NOSE Upon inspection.Patient was asked to raise and lower eyebrows which revealed equal movement. the ear color is symmetrical to the facial skin and both ears are symmetrical. nose is in the midline. Upon palpation. No presence of lesions. tenderness. equally round. Thickening of the eyebrows is noted . symmetric and smooth in contour. There were no lesions observed and no palpable nodules. the patient’s skull was assessed to be normocephalic. EYES Upon inspection. Nasal septum is intact and is in midline. no tenderness and lesions were noted. A moon-face appearance is noted. reactive to light and accommodation and equal in size. Upon pinching each nose for patency. discharge and odor were seen. The patient’s ability to blink is intact and bilateral. EARS Upon inspection. symmetrical. Both eyes moved in unison from side to side and up and down and were able to follow the 6 ocular movements in 1 foot distance. and has no discharge. The patient was asked to show teeth and the face showed symmetrical movements. the client’s eyes and eyebrows are symmetrically aligned and evenly distributed.
MOUTH AND OROPHARYNX Upon inspection. Facial sinuses have no areas of tenderness. Breathing pattern was observed and normal breathing pattern was noted. the client’s neck is normal in appearance. nodules. chest is symmetrical with 1:2 ratio of anteroposterior to transverse diameter. There were no palpable lymph nodes on the neck. the patient’s gums and lips were observed to be ashlike in color and without cracks. No enlargement of thyroid gland was observed.the left nostril was slightly obstructed. No mass or lesion was noted. vesicular sounds are present on the lungs. THORAX AND LUNGS Upon inspection. Truncal obesity is present. no tenderness and masses were noted. There was no bleeding and no inflammation of gums observed. HEART . NECK Upon inspection and palpation. Chest wall is intact. The tongue and uvula are in the midline. or infestations found. There were no lesions. Upon auscultation.
Recent recall of memory is also intact. The abdomen moves with respiration. Immediate recall of memory is intact. extremities were asymmetric in length and size. . MUSCULOSKELETAL Upon assessment. no lifts and heaves were observed. the patient’s heart beat rhythms were normal. The patient is oriented to time and place. There was no jugular vein distention. Presence of bipedal edema was noted. and responds to verbal command. ABDOMEN Upon inspection.Upon inspection and palpation of four areas of precordium. Remote memory is also intact. The patient was able to name objects. muscle strength grading is as follows: Right upper extremity: 5/5 Left upper extremity: 5/5 Right lower extremity: 5/5 Left lower extremity: 5/5 NEUROLOGICAL Upon examination. the patient does not display any difficulty in speaking. abdominal sounds were heard on all sites. no evidence of enlarged liver or spleen is observed. Varicosities on lower extremities were noted. Upon auscultation. EXTREMITIES Upon inspection. Upon auscultation.
0 5.6 16.6 0.00 – 6.0 g/dl 43 % 14 – 18 g/dl At normal values 42-52% At normal values 240 x 109/L 150 – 400 x At normal values 109/L INTERPRETATION & ANALYSIS . XII.8 x At normal values 103/ mm3 55-75 20-30 Higher compared to normal Lower compared to normal SIGNIFICANCE 4.8.3 x 103/ mm3 Neutrophils Lymphocyte s Monocytes Eosinophil Basophils RBC 7. LABORATORY AND DIAGNOSTIC PROCEDURES HEMATOLOGY RESULTS NORMAL VALUES WBC 6. Motor response is present upon verbal command. 6 and verbal response is present as the patient is oriented and converses.Glasgow coma scale was utilized and recorded as follows.10. 4. Total score is 15.24 x 106cells/mm3 0-7 0-3 0-1 Higher compared to normal At normal values Low compared to normal 75. Eye opening is present upon verbal command.20 x At normal values 106 cells/mm3 Hemoglobin Hematocrit Platelets 14.6 4. 5.2 0.
46 umol/L 45-104 umol/L SODIUM 141. Which may indicate that the kidneys are affected by the disease process.82 umol/L At normal values At normal values Lower than normal SIGNIFICANCE INTERPRETATION AND ANALYSIS Based on the results of clinical chemistry.Based on the result of hematology. Creatinine level shows how well the kidneys are working. X-RAY .36 umol/L 1.145 umol/L POTASSIUM 3. it is evident that there is a decrease level of creatinine.50 135. it is evident that there is an increase in neutrophils and monocytes which may indicate presence of infection. CLINICAL CHEMISTRY RESULTS NORMAL VALUES CREATININE 36. The hematology result also shows that there is a low count of lymphocyte that indicates that the body’s resistance to fight infection is reduced and may become more susceptible to certain types of infection or tumor.4-4.
The central medulla region is enclosed by the adrenal cortex which contains three separate layers of cells. ANATOMY AND PHYSIOLOGY Adrenal Glands Curved over the top of the kidneys. Like the pituitary gland. the adrenals have glandular (cortex) and neural tissue (medulla) parts. adrenal glands are structurally and functionally two endocrine glands in one. Hormones of the Adrenal cortex .FINDINGS • • • • reticular and non-reticular opacities are seen in both upper lobe homogenous band densities are seen in the right lower hemithorax obliterating the costrophrenic sulcus heart normal in size and configuration diaphragm and left costrophrenic sulcus are intact the bony thorax and the soft tissues unremarkable XIII.
Important information about glucocorticoids: 1. the mineralocorticoids. these hormones are said to be hyperglycemic hormones. • Mineralocorticoids 1. 2. glucocorticoids and sex hormones are produced by the adrenal cortex. The functions of this hormone are: 1. The main goal of releasing ANP is to reduce blood volume and blood pressure. • Glucocorticoids Glucocorticoids are produced by the middle layer of adrenal cortex which includes contisone and cortisol. To prevent aldosterone release. Produced by the outermost layer of the adrenal cortex. the mineralocorticoids aids in water and electrolyte regulation. The target organ of the hormone is the kidneys that selectively reabsorbs the minerals or allow them to be flushed out in the body in the form of urine. when blood pressure drops. . renin. are mainly aldosterone. Increased aldosterone levels in the body would result to rising amounts of reclaimed sodium ions by the kidney tubules and secreting more potassium ions into the urine. Hence. Promotion of normal cell metabolism 2. Fats and even proteins are broken down by body cells and converted to glucose when blood levels of glucocorticoids are elevated in the blood. which is a potent stimulator of aldosterone release. Production of renin triggers a series of reactions that form angiotensin II.Major groups of steroid hormones such as mineralocorticoids. atrial natriuretic peptide or ANP is released by the heart. 4. 3. Aldosterone is also released when the kidneys produce the enzyme. by increasing blood glucose levels. When sodium is reabsorbed water follows. These hormones play an essential part in regulating the mineral or salt content of the blood particularly the concentrations of sodium and potassium ions. Helping the body resist long-term stressors. Hence. These hormones are collectively termed as corticosteroids.
Glucocorticoids are released from the adrenal cortex in response to the rising blood levels of ACTH. epinephrine. elevated blood pressure and rising blood glucose levels. also called adrenaline. Thus. The response is necessary to help a person cope up with the stressful situation. Also. small passageways of the lungs are dilated with presence of these hormones to cater more oxygen in the blood and a faster circulation to the organs most importantly to the brain. otherwise known as noradrenaline. the adrenal medulla has the same development. glucocorticoids are often prescribed as drugs to suppress inflammation for patients with arthritis. female sex hormone. Production of sex hormones takes place throughout a person’s life but the amount formed is relatively small. • Sex Hormones The adrenal cortex produces the sex hormones regardless of one’s gender. heart and muscles. Collectively. Increase glucose and oxygen would make the body fit to fight or deal with shortterm stressors. are released into the bloodstream. One of the organs stimulated in these situations is the adrenal medulla which is responsible for pumping catecholamines or hormones into the bloodstream to enhance and prolong the effects of neurotransmitters of the sympathetic nervous system. male sex hormones and some estrogen. Presence of catecholamines has the following effects: increased heart rate. It is the innermost layer of the cortex that produces a large amount of androgens. and norepinephrine. . Physical or emotional stress and threat would bring about the fight-orflight response. Hormones of the Adrenal Medulla Like the knot of nervous tissue where posterior pituitary gland develops. 1. 2. Unpleasant effects of inflammation are also controlled by glucocorticoids as they reduce the effects of edema and they reduce the pain by inhibiting some pain-causing molecules called prostaglandins.2. because of their anti-inflammatory properties. 3. When this structure is stimulated by the sympathetic nervous system neurons. these hormones are called catecholamines.
After standard analysis. a scalpel. cutting or aspiration needle. frozen section results are not reliable and will usually be confirmed by the standard process. multiple. results of this analysis are expressed on a scale of four grades: G1--well differentiated. biopsy. . Typically. Open biopsy. hidden lesions. a scalpel is used to remove abnormal tissue from the skin or subcutaneous tissue. excisional biopsy is preferred. Frozen sections may provide results in 10-15 minutes in emergency situations. In excisional biopsy.Medical Management Biopsies: Biopsies may be incisional or excisional. However. G4--anaplastic. The exception to this normal method of fixation of slides is a frozen section. or blind. tissue classification takes place. or punch is used to remove a portion of tissue from large. Although the procedure is the same. In incisional biopsy. A staging system is then used to direct the treatment and predict the prognosis when biopsy results confirm malignancy. because it combines diagnosis and treatment. Incision of a hidden lesion is called a closed. The pathologist's report provides both gross and microscopic descriptions. When such tissue can be easily and completely removed. G3--poorly differentiated. and is usually performed on outpatients for breast biopsies. performed in the operating room. Biopsies commonly take place in the hospital. Open biopsy is required when the results of a closed biopsy or other diagnostic tests (i. Tissue preparation and Tissue Classification: Tissue preparation involves several time-consuming steps in the fixation of specimens on slides for examination by pathologist. Fine needle aspiration differs slightly from traditional needle biopsy. usually requires general anesthesia. G2-moderately well differentiated.e. Even a stat tissue preparation can take 24 hours. requires cytologic (not histologic) studies. which result in histopathological classification of the tumor. it provides a smaller specimen.. but they may also take place in clinics and physicians' offices. CT scan) suggest the need for complete excision of a tissue mass.
or from the neck of the womb(cervix). . using stereotactic surgery to find the biopsy site. A variety of biochemical tests can be performed after an adrenal mass is found. and hemorrhage and is indicated only when the physician is trying to rule out idiopathic hyperaldosteronism.There are many different types of biopsy: Scrape . Before performing an FNA biopsy.a needle is used to remove a sample of (usually) liquid. An endoscope is a long-thin. bronchoscope for the bronchi (in the lungs). Adrenal vein sampling is not done very often. pancreatitis. as may occur when a sample of the inside of the mouth is required. In this setting. The colposcope is a close-focusing telescope that allows the doctor to see areas of the cervix in detail. commonly used for collecting a sample of skin tissue to check for malignancy (cancer). nephroscope for the kidneys. and welldifferentiated carcinoma.cells are removed from the surface of tissue. it is almost 100% accurate. it is important to exclude pheochromocytoma to prevent a hypertensive crisis or worse. it is difficult to distinguish among normal adrenal tissue. testosterone. adrenal vein sampling can distinguish separate bilateral from unilateral secretion of aldosterone. Capsule biopsy . Endoscopic biopsy .an endoscope is used to collect the sample. 24-hour urinary free cortisol. Sterotactic biopsy . Sterotactic is a three-dimensional coordinates system to locate small targets inside the body. which is treated by removing both glands. Needle biopsy .to take a sample from the intestines. adenoma.a punch (a round shaped knife) is used for cutting and removing a disk of tissue. and biochemical testing FNA biopsy is another useful tool in distinguishing adrenal masses. lighted optical instrument used to get deep inside the body and examine or operate on organs. FNA biopsy is usually reserved for patients with known extraadrenal malignancy when tissue diagnosis of the adrenal metastasis is necessary to guide therapy.samples are taken from the brain. However. In these cases. Specially adapted endoscopes include a cystoscope for the bladder. It has a high complication rate of pneumothorax. urinary 17-hydroxycortisol and 17-ketosteroid. FNA biopsy. A wide needle is used for a core biopsy while a thin one is used for fine-needle aspiration biopsy. Tests can determine levels of dexamethasone suppression. Colposcopic biopsy . plasma androgens. whether the mass is biochemically active or not. and otoscope for the ear. Punch biopsy . laryngoscope for the voice box (larynx).used to evaluate a (female) patient who has had an abnormal Pap smear. adrenal vein sampling.
androstenedione. and renal arteriogram. and is used to assess kidney (renal) function. it may be an indication of a particular disease or condition. Normally. kidney biopsy. plasma catecholamines. urinary vanillylmandelic acid. along with other chemical compounds. Urine consists of water and dissolved chemicals such as sodium. renin. Related procedures that may be used to diagnose kidney disease include kidney ultrasound. urea (formed from protein breakdown). If these amounts are not within a normal range. or if other substances are present. urine contains specific amounts of these waste products. potassium. The container must be kept cool during this time until it is returned to the lab for analysis. The test is noninvasive (the skin is not pierced). and plasma metanephrine and normetanephrine. The results of a 24-hour urine collection may provide information to help your doctor make or confirm a diagnosis. 24 hour urine collection A 24-hour urine collection is a simple diagnostic procedure that measures the components of urine. . and aldosterone. Twenty-four hour urine collection is performed by collecting a person's urine in a special container over a 24-hour period. and creatinine (formed from muscle breakdown). kidney scan.
Nursing Management Hypertension: • • • • • • • • Blood pressure taking every 1 hour Increase fluid intake Checking of intake and output specially urine Note for urine characteristics Health teaching about her condition Health education about lifestyle modification Intravenous Fluid monitoring Ensure compliance to medications .
and germline mutations in the succinate dehydrogenase B.adrenergic receptors on surface of smooth muscle ↑ Protein catabolism ↑ Protein Breakdown Stimulation of satiety center (hypothalamus) PATHOPHYSIOLOGY • • • • Predisposing Factors: Sporadic incidence of disease hereditary (multiple endocrine neoplasia type 2.female (1:4) Precipitating Factor: • Stress .C.Von Hippel Lindau syndrome. and small in amount but constant menstruati on/ Blockage of (1) LH & FSH action on gonads and (2) secretion of GnRH in Hypothalamus enhancement of vasoconstrictive effect of circulatory catecholamine Sensitivation of A.or D genes) Age (27) Sex. fluctuating . neurofibromatosis type 1.Stretch marks Around the waist (trunchal obesity) Back of the head (Buffalo Hump) Face (moonfac e) Weight gain Thining of the hair Thining of the skin Vasoconstricti on of blood vessel Protein wasting Fat deposition ↑ Appetite Irregular.
Abnormal transformation of chromaffin cells of adrenal gland (tumor) Release of catecholamines (norepenephrine and epinephrine) in the blood Release of ACTH precursor Proopiomelanocortin (POMC) molecule ↑Stimulation of Melanin synthesis on melanocytes Hyperpigmentati on of skin Pro-ACTH molecule ↑Stimulation of androgen synthesis Virilization ↑Stimulation of Aldosterone synthesis Hyperaldosteroni sm Hirsutis m ↑ Na & H20 retention Hypersecretion of cortisol Stimulation of alpha adrenergic receptors High blood pressure Darkened striae Darkene d skin ↑Acne Hypercortisoli sm/ CUSHING’S SYNDROME Nursing Care Plan .
A caring presence of the nurse promotes self-esteem of the patient. thoughts and concerns. 2. 4. Establish therapeutic nursepatient relationship. 3.” as verbalized by the patient Within 8 hours of nursing intervention. 2. Be alert and cautious with own 1. To gain the trust and confidence of the patient by showing genuine care and concern. 3. 2012 Chief complaint: Vaginal spotting Diagnosis: Hypertensive urgency secondary to adrenal mass Assessment Nursing Inference Goal/Plan Interventions Rationale Evaluation Cues Diagnosis Subjective Cue: Disturbed body image related to “Hindi naman change in dati ganito appearance ang hitsura ko. Encourage verbalization of feelings.Name: GAB Age: 27 yo Sex: Female Date: Dec. 10. 4. To reduce anxiety and fear and to build a trusting relationship with the patient. the patient Changes in will verbalize appearance understandin g of body changes related to Altered selfdisease esteem and condition as confidence evidenced by: • Verbalizatio n of (-) feelings about body • • • (-) apprehe nsion (-) aloofne ss (+) eye contact (+) interacti Appearance of clinical symptoms 1. Within 8 hours of nursing intervention. Visit patient frequently and acknowledg e her as someone worthwhile. Facial expression and nonGoal met. the patient verbalized understanding of body changes related to disease condition as evidenced by: • • • (-) apprehe nsion (-) aloofnes s (+) eye contact Objective Cues: • • • (+) apprehe nsion (+) aloofnes s (+) infreque Changes in . conveying an attitude of acceptance and care.
6.• • nt eye contact (+) change in social involve ment (+) poor interacti on social involvement on Aloofness. infrequent eye contact facial expression and nonverbal behavior. 5. Listening and counseling encourages verbalization of concerns. Provide counseling. verbal cues should match verbal expression to eliminate doubt and build trust. Provide activities that will promote interaction. 5. Praises and acknowledg ment help gain confidence and selfesteem. 7. • (+) interacti on . Offer positive reinforceme nt for efforts made by the patient. To promote socialization. 7. 6. apprehensio n.
to Interventions 1. describing the lesion characteris tics and changes. 2. To prevent secondary 10.” as verbalized by the patient. Within 1 hour of nursing intervention. Keep the area clean and dry. 2. 3. Inspect skin and lesion on a daily basis.Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessment Nursing Inference Cues Diagnosis Subjective cue: “Dati wala akong mga marks sa skin ko. Maintain appropriat e moisture Evaluation Goal met. urgency Rationale 1. Daily inspectio n and monitorin g provides informati on on the rate and extent of changes of skin lesion. the patient will Secretion ACTH participate precursor in identifying preventive measures Increased and melanin treatment synthesis. fat . the patient will participate in identifying preventive measures and treatment process. Within 1 hour of (pheochromocyto nursing ma) interventio n. Impaired skin integrity related to overstretchin g and skin pigmentation changes Adrenal mass Sex: Female Diagnosis: Goal/Plan Hypertensive Date: Dec.
• Changes in skin pigmentation and Appearance of lesion and striae • of skin. 4. Encourage verbalizati on of feelings. Encourage to increase consumpti on of vitaminrich food. 3. 6. 4. To promote skin rejuvenat ion.Objective cues: • (+) striae on axillary. To prevent injury that will aggravat e the situation. inguinal and popliteal area (+) poor skin turgor. 5. 5. 6. Provide safety and comfort measures. To prevent further deteriorat ion of skin. microorg anisms from invading the skin leading to infection. . To relieve anxiety and stress. dryness (+) venous prominen ce on lower extremitie s deposition and thinning of skin process.
to Interventions 1.Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessment Nursing Inference Cues Diagnosis Subjective Cue: Deficient knowledge regarding “Ano ba ung condition. the patient will demonstrate Hypertensive Date: Dec. Within 1 hour of nursing intervention. urgency Rationale 1. sakit ko?” as prognosis. State objectives Evaluation Goal met. Determine patient’s ability and barriers to learning. verbalized by self-care and ADRENAL MASS Sex: Female Diagnosis: Goal/Plan Within 1 hour of nursing intervention. To assess learner’ s need and facilitat e easy secondary 10. the patient demonstrated Hospitalizatio n . 2.
Stating clearly the objectiv es meets the level of the learner’ s need. 3. 4. Repeat and summarize as needed. transfer of informat ion once barriers are overco me. 3. selfcare and treatment as evidenced by: • • (-) Apprehens ion (-) Agitation . To facilitat e memory recall of informat ion given. sufficient knowledge Lack of regarding exposure to disease sources of condition. information self-care and and treatment as misinterpreta evidenced by: tion of • (-) information Appreh • Deficient knowledge ension (-) Agitatio n clearly in learner’s terms. focus sufficient knowledge regarding disease condition. 4. 5. simple sentences and concepts. Provide information relevant only to the situation. 2. To prevent informat ion overloa d. Provide written information / guidelines and selflearning modules for client to refer as necessary. Objective Cues: • • (+) Appreh ension (+) Agitatio n treatment related to lack of exposure and information misinterpretat ion. Use short.the patient.
5. To reinforc e learning .only on what is relevant and immedi ately needed. Nursing Care Plan .
To promote wellness. 4. urgency secondary 10. To avoid creating a portal of entry for microorgani sms. Encourage to consume highly nutritious Rationale 1. the patient will be able to identify intervention s to prevent the risk for infection. To provide nourishmen t to the body. 4. 3. Risk for Adrenal mass Within 1 infection hour of (pheochromocyto related to nursing ma) immunosuppre intervention ssed . Perform strict hand hygiene before and after contact with patient. to Interventions 1. Maintain sterile technique for all invasive procedures such as IV insertion.Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessmen Nursing Inference t Cues Diagnosis Sex: Female Diagnosis: Goal/Plan Hypertensive Date: Dec. 2. 5. To avoid contracting Evaluation Goal met. Administer prophylactic antibiotics as indicated. To prevent spread of infection from one patient to another. 2. 3.to response identify ACTH secondary to intervention presence of s to prevent hypercotisolism the risk for Hypercotisolism infection. Within 1 hour of nursing intervention. catheterizat ion etc. To avoid contracting infection from the environmen t. the patient inflammatory will be able Secretion of pro. (chronic) Suppression of inflammatory response Risk for infection . 6.
5. 7. 6. To maintain the optimal health status of the patient. Teach the patient hand hygiene measures. infection from the environmen t. 8. Encourage to keep a germ-free environmen t. Proper hygiene does not only prevent infection but also promote a sense of well-being. Encourage to take multivitami ns. foods and drinks. . 7. 8. Stress the importance of proper hygiene.
Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Sex: Female Diagnosis: Hypertensive Date: Dec. to . urgency secondary 10.
” As verbalized by the patient.3 C PR – 115 cpm RR – 25 bpm >restlessnes s >inattentive ness INFERENCE DIAGNOSIS PLANNING INTERVENTIO N RATIONAL E EVALUATI ON Goal met. Objective: >VS: Temp.CUES Subjective: “Nabobored na ako dito wala akong magawa. on cushing’s syndrome and hyperaldosteroni sm Need for longterm hospitalization Deficient divertional activity After 30 Independent: To minutes of Establish establish nursing rapport with trust and intervention the patient cooperatio s. or anxiety encourage might her to do interfere >Encourage with the >calmness mix of desired desired and less activities activity irritation from being >to provide in the the patient hospital the activity with her best interest . After 30 minutes of nursing intervention s. – 36. the n on the patient will client Monitor be able to vital signs To engage in obtain the satisfying baseline activities >Acknowledge data within reality of personal situation and >to limitations feelings of the establish as patient therapeutic manifested relationship by: >Determine to with the ability to patient >ability to participate/inte participate rest in >Presence in activities activities that of mobility being are available. the patient was able to engage in satisfying activities within personal limitations as manifested by: >participati ng of the patient in activities being encourage her to do >calmness and less irritation from being in the hospital Adrenal Mass Deficient (Pheochromocyto Diversional ma) Activity related to long-term Hypertensive hospitalizati urgency.
CHF. rhythm and quality) before therapy. with relevant sinus bradycardia. Exerts mainly 1adrenergic blocking activity but also blocks beta-2 receptors at high doses. Fatigue Dizziness Headache GI disturbances Sleep disturbances Nausea Vomiting NURSING CONSIDERATIO NS Observe the 10 rights in giving the medications. It reversibly and Hypertension . Assess blood pressure and apical/radial pulse (rate.NEOBLOC DRUG ACTION INDICATION CONTRAINDICATIO SIDE/ADVERS N E EFFECTS It is contraindicated to patients with AV blocks 2 and 3. Monitor periodically Dosage: For hypertensi on and functional heart disorders with palpitation : 100 mg. and pregnancy.
do not double or skip doses. resulting to decreased myocardial contractility. Missed dose may be taken as soon as remembered at least 4 hours from the next dose. during treatment. Monitor urine output. competitivel y combines with beta1adrenergic receptors to block sympathetic nerve impulses.Titrate up to 400 mg/day. heart rate. . cardiac output and myocardial oxygen consumption . IO ratio and weight daily. Advised patient to take medication with food to prevent GI upset Instruct patient to take drug as prescribed.
amebiasis. fungal infections. management of primary or secondary adrenal cortex CONTRAINDICA SIDE/ADVERS TION E EFFECTS Infections. especially tuberculosis.DEXAMETHASONE DRUG Dosage Initial: 0.75 – 9 mg/day Suppresion test for Cushing ACTION Synthetic glucocorticoid with marked antiinflammatory effect because of its ability to INDICATION Testing of adrenal cortical hyperfunction. Advise to take drug with food . varicella and Headaches Nausea Vomiting Depression Hyperglycemia Hypokalemia Hypertension NURSING CONSIDERATI ONS Observe the 10 rights in giving the medications.
edema.syndrome: inhibit prostaglandin 1 mg at 11 am. antibiotic resistant infections. Monitor plasma cortisol level during long term therapy. vomiting. (138-635 nmol/L when assessed at 8 am) .5 mg fibroblasts at every 6 hrs for sites of 48 hours and inflammation. nausea.(notify physician of weekly gain>5 lbs or hyperglycemia Assess potassium depletion: fatigue. synthesis. Monitor patient’s weight and glucose level. leukocytes and give 0. greater accuracy. Fluid and Electrolyte disturbances Impaired wound healing Dry mouth Thromboemboli sm Thrombophlebit is to decrease GI symptoms. eroid excretion insufficiency. dysrhythmias and chest pain. Monitor cardiac status: blood pressure. For macrophages. assay plasma inhibit cortisol at 8 am migration of the next day. collect 24 hour phagocytosis urine to and lysosomal determine 17enzyme hydroxycorticost release.
AMLODIPINE DRUG ACTION INDICATION SIDE/ADVERSE NURSING . fever.Advise patient to avoid exposure to infection Report weight gain. muscle weakness. swelling of extremities.
Hypertension.Dosage: 5 mg once daily. Advise patient to comply in all areas of medical regimen: diet. . exercise stress reduction etc. may be increased to maximum of 10 mg. decrease peripheral vascular resistance of smooth muscles. Vasopastic Angina EFFECTS Palpitations Tachycardia Bradycardia Headache Dizziness Fatigue Nausea Abdominal Discomfort CONSIDERATION Observe the 10 rights in giving the medications. Chronic Stable Angina. Advise to take drug with meals to decrease GI disturbances Assess cardiorespiratory status. Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle. Assess hydration and fluid volume status. Advice patient to avoid hazardous activities until stabilized on drug and dizziness is no longer a problem.