NURSING PROCESS/ PHYSICAL ASSESSMENT- 02 [ WARD: Endocrinology]

Date-29-07-2021 to 31-07-2021

INTRODUCTION: As part of my specialty clinical posting in the endocrinology/W5A of SKIMS Soura Srinagar, the client
assigned to me for case presentation was Dar Khursheed Ahmad, who was admitted in this Hospital on 29/07/ 2018 at 1 am with
the diagnosis of EXOGENOUS ADRENAL INSUFFICIENCY .

Biographic information:

Name: Dar Khursheed Ahmad

Age: 27 years

Sex: Male

Ward: 5A/ENDOCRINOLGY

Address: Ganderbal

Religion: Muslim

Marital Status: Married

MRD NO: 1236208

Income: 25000/month

Occupation: Peon

Languages: Kashmiri, Urdu, Hindi.

Educational Qualification: 12th

Name of the Attendant /Family Member: Shamshada

Relationship with the Client: Wife

D.O.A: 29/07/2021

Diagnosis: EXOGENOUS ADRENAL INSUFFICIENCY

Reason for Hospitalization: SEPSIS WITH SHOCK WITH HYPO ADRENAL STATE

Present Medical /Surgical History:

Patient was in his usual state of health till 2 pm when he complained of recurrent vomiting, fever, and severe abdominal pain, Patient was
initially taken to District hospital Ganderbal, where he was given Injection Ondem and some pain killer I/V, But patients B.P was Dropped
and then the patient was referred to SKIMS. Then the patient was brought to A/E, SKIMS.

Past illness and Hospitalization

No history of past illness except patient got admitted in October 2015 for epigastric pain, nausea, vomiting and shock

Drug history: Patient has taken some AURYEDIC preparation from a BUMS Practitioner for weight gain,
No history of any surgery, Patient is non –diabetic, Normotensive, Euthyroid
Patient has no history of ATT intake

Family History of any Illness: Not significant

FAMILY TREE

PATIENT
FATHER MOTHER

SON DAUGHTER

Socio Economic Status: Middle class.

Dietary Details: Both vegetarian &Non-Vegetarian.

Current Medication being taken:

Life Style Habits and Beliefs: Smoker and believe in ALLAH.

History of any Allergy: Not Significant

Activity: Able to do his daily routine activity, fatigue on exertion

Cognitive: No cognitive impairment.

Rest and Sleep: Normal pattern

Self Perception: He is aware about his disease condition.

Role/Relationship: Maintains his role relationship.

Sexuality: Maintaining

Coping Stress: Good coping strategy

Values and Beliefs: He is having firm belief and values in his personal life.

ENVIRONMENTAL HISTORY:

Drinking water Supply: Tap water

Environmental Sanitation: Adequate

Waste/Excreta disposal: Closed, use of dustbins, dumping

Presence of flies/mosquitoes/rodents: Sometimes

Psychosocial History: Smoker

Language: Kashmiri & Urdu, Hindi

Details of milestones development: Normal mental and physical growth

Social Support available or not: Yes, family & friends

Physical Examination:

Mental Status Conscious, oriented to time, place and person.

Body Development: Lean,

Nutritional Status: Adequate

Dress: Good

Speech: Coherent, Clear and audible

Hygienic Condition: Good

SYSTEMIC PHYSICAL EXAMINATION:

Head:

Skull: Skull is round in shape, symmetrical. No masses noted. Facial movement is symmetrical.

Scalp: Scalp is clear from dandruff. No scars & wounds noted.

Face: Face is normal

EYES:

Eye brows symmetrical

Eyelashes Normal

Eyelids Normal

Eyeballs Symmetrical protruded

Conjunctiva Pink

Pupil Equally reacting to light

Lens Transparent

Vision Normal

EARS:

External ears No discharge

Hearing acuity Normal

NOSE:

External nares No discharge

Nostrils No nasal flaring

MOUTH:

LIPS Black in color and dry.

Tongue Pinkish in colour, moist

Gums Black in colour

Teeth No dental caries

NECK:

Range of motion Normal movement.

Thyroid Normal no Thyromegaly

Lymph nodes No enlargement

RESPIRATORY SYSTEM:

Inspection: Respiratory rate 20/minute, no congenital chest problems.

Palpation: Chest expansion is bilaterally symmetrical.

Percussion: Resonant.

Auscultation: Normal breath sound over right &left side is heard. Bilateral air entry +ve

CARDIOVASCULAR SYSTEM:

Inspection: Capillary refill was less than 3 seconds.

Palpation: Point of maximal impulse can be felt at 5th inter-costal space.

Percussion: Cardiac border is felt at 3rd & 5th inter-costal space.

Auscultation: Presence of S1 & S2 sound. No Murmurs heard.

GASTRO-INTESTINAL SYSTEM:

Inspection:

Mouth and Pharynx: No cleft lip, no gingivitis,

Lips: Smooth, pink, dry, symmetrical. No lesions or discoloration seen.

Buccal Mucosa: Glistening, pink, moist and smooth.

Gums: Normal, pink, no bleeding.

Teeth: No dental caries and cavities. Poor dental hygiene

Tongue: Pink in color, smooth and moist, the floor of the mouth is vascular

Plate: No lesions or ulcers seen.

Pharynx: Pharyngeal tissues pink, smooth and moist, No tonsillitis seen.

Abdomen: Normal contour, no scars or lesions seen. No abnormal movements seen. No distension observed.
No mass, No ascites, seen

Auscultation: Peristalsis present. Bowel movements present. Bowel sounds heard .No signs of Paralytic ileus
found.

Palpation: No tenderness in any region of abdomen. No masses, hernias or organo-megaly felt.

Percussion: No thrill movement present. No dull sounds detected.

GENITO-URINARY SYSTEM:

Inspection: Urine is pale yellow in color.

Palpation: Presence of tenderness over the costo-vertebral angle.

Percussion: Dullness is heard over the bladder.

Auscultation: Bruit sounds are absent.

MUSCULOSKELETAL SYSTEM:

Muscular system:

Inspection: Normal range of motion. Absence of congenital abnormalities

Spinal cord: Body curvature is normal.

Palpation: Muscle strength is normal, no muscle atrophy

Muscle power: Upper limbs Rt. 5/5

Left 5/5

Lower limbs Rt. 3/5

Left 5/5

Muscle tone: Upper limb Rt. Normal

Lt Normal

Lower limb Rt. Normal

Lt Normal
Skeletal System:

Inspection: Gait is normal. Standing posture upright with parallel alignment of hips and posture bilateral
symmetry in length

Palpation: No bony mass or enlargement on palpation

INTEGUMENTARY SYSTEM:

Skin Inspection:

Colour of the skin Fair, Normal, and No cyanosis in lips, No jaundice in sclera on Skin or mucous membranes

Nail: Nail beds and palms seen, No cyanosis or clubbing of the nails seen .

Palpation: Skin is hot. Normal turgor

CENTRAL NERVOUS SYSTEM:

Level of consciousness: Fully conscious, oriented to time, place & person GCS=15/15

Motor function: Motor function is normal, cranial nerve function is normal.

Sensory function: Patient has normal sensation to temperature, pain, touch, vibration& position.

Reflexes:

REFLEX RIGHT LEFT

BICEPS ++ ++

TRICEPS ++ ++
 PATELLAR ++ ++

ANKLE ++ ++

PLANTER Up going/Extensor Down going/Flexor

ENDOCRINE SYSTEM:

Inspection: No enlargement of thyroid gland observed. No features of acromegaly, Cushings syndrome or

No protrusion of eyes or exophthalmus seen. Excessive thirst, dry mouth

Palpation: Thyroid gland not palpable.

EXCRETORY SYSTEM:

Inspection: Skin normal. No odema present depicting normal kidney function.

Palpation: tenderness in flank area.

Percussion: No dull sounds on tenderness

VITAL ASSESSMENT:

S.N TEMPRATURE PULSE RESPIRATION BLOOD

O PRESSURE
DAY 990F 80/min 18/min 80/60mmHg
1ST
DAY 97.60F 86/min 26/min 90/60mmHg
2ND
DAY 98.60F 84/min 28/min 110/70mmHg
3RD

LABORATORY INVESTIGATIONS

[Link] TEST PATIENT VALUE NORMAL VALUE REMARKS

1 CBC:

Hemoglobin 13.3gm/dl 13-18gm/dl Normal

TLC 21.15/cumm 4,500-11000/cumm Increased

MCV 88fl 75-95fl Normal

HCT 40% 40-50% Normal

WBC 12.32 4-10/cumm Increased

LYMPH 18.4% 20-25% Decreased

NEUT 68.9% 40-75% Normal

MONO 6.8% 01-10% Normal

 EISONO 5.7% 1-6% Normal

BASO 0.2% 00-01% Normal

PLT 128/cumm 140-440/cumm Decreased

2. KFT:

Urea 82mg/dl 10-50mg/dl INCREASED

Creatinine 1.37mg/dl 0.5-1.5mg/dl INCREASED

ELECTROLYTES:

3. Na+ 143mmol/L 135-145mmol/L NORMAL

K+ 7.36mm0l/L 3.5-5.0mm0l/L Increased

PH 7.29 7.35-7.45 BASIC

Po2 95 90-100 Normal

4. SERUM CHEMISTRY:

Uric acid 6.0mg/dl 2.5-8mg/dl Normal

Calcium 6.1mg/dl 8.6-10.2mg/dl Normal

Blood glucose;

Fasting 70 mg/dl 60-110mg/dl Normal

 Post prandial 90 mg/dl 65-140mg/dl Normal

5. LFT:

Bil 0.64 0.3-1.0mg/dl Normal

ALT (Alanine aminotransferase) 51 10-40U/ml Increased

ALP(Alkaline phosphate) 112 50-120U/L Normal

Proteins 5.18 6.0-8.0g/dl Decreased

Alb 2.91 3.5-5.5g/dl Decreased.

SPECIFIC INVESTIGATIONS

EGD Normal study

ECG NSR

Radiological examination B/L Lung normal

CT Abdomen Multiple small mesenteric nodes present

Vidal Negative

Brucellosis Negative

Dengue serology Negative

Serum cortisol levels 14.65

Weight 74kgs

Height 165cm

TREATMENT
 1. Injection N/S With injection Dopamine @ 5 mg / hour

2. Injection HYDROCORTISONE 100 mg IV Bid

3. Injection Neurobion 1 ampule in 100ml of N/S OD

4. Sodium polystyrene sulphonate 1 sachet in ½ litre of Water

DISEASE CONDITION:

ADRENAL INSUFFICIENCY

DEFINTION:

The term ADRENAL INSUFFICIENCY is defined as the hypofunction of adrenal cortex, if the disorder originate from the adrenal
gland itself it is called primary adrenal insufficiency or if it originate from the pituitary – hypothalamic unit it is called secondary
adrenal insufficiency

ETIOLOGY

BOOK PICTURE PATIENTS PICTURE

 Primary adrenal insufficiency is commonly known as Present

Addison’s disease results from idiopathic cause which leads
to idiopathic destruction of the adrenal gland,
 Primary adrenal insufficiency is commonly seen in the patients Not Present
with HIV/AIDS, Tuberculosis, and metastasis.

 Risk factors
1. A history of other endocrine disorder Not present
 2. Taking glucocorticoids for more than 3 Weeks with Significantly present
cessation
3. Adrenalectomy Not present

PATHOPHYSIOLOGY:

Auto immunity is the most common cause of adrenal insufficiency. Lymphocytic infiltration of the adrenal cortex is a characteristic
feature, Addison’s disease is frequently accompanied by other immune disorders, gradual destruction leads to chronic adrenal
insufficiency, continued loss of cortical tissue accompanies a deficiency of mineralo -corticoids as well as Glycocorticoids.
Hypofunction results in decreased levels of mineralo corticoids [ALDOSTERONE], Glycocorticoids [CORTISOL] and Androgens.

SIGNS AND SYMPTOMS:

Mild fatigue, languor, irritability Present

Hypotension, Loss of consciousness, and Present

Shock, Hypoglycemia

Weight loss Absent

Nausea and vomiting Present

Penetrating pain in the back, abdomen Present

and legs

Changes in menstruation Absent as patient male

DIAGNOSTIC EVALUATION:
 BOOK PICTURE PATIENTS PICTURE

1. Blood and urine hormone assays  Blood cortisol levels are on higher side
2. Serum electrolytes  Done-serum potassium on higher side
3. x-studies  Done- normal
4. CT  Done –CT abdomen showing mesenteric nodes
5. MRI  Not done

MEDICAL MANAGEMENT:

The Medical management includes correcting fluid and electrolyte imbalance, it includes Vasopressors, or volume expanders, correct
hypoglycemia, replace steroids

PHARMACOLOGICAL THERAPY:
NAME OF THE MECHANIS- ROUTE INDICATIO SIDE EFFECTS CONTRAINDICTI- NURSES RESPONSIBILITY
DRUG M OF N-S ON
ACTION
1. Sodium Sodium Oral/ Used for The most  Hypokalemia  First of all check the drug chart.
polystyrene polystyrene rectal potassium common side  Obstructive  Get the serum electrolytes
sulfonate sulfonate Is levels in the effects of this bowel disease. done and check their level
[kayexalate] Cation blood drug is  Dysrarrthymias  Check for any history of
exchange gastrointestinal  Pregnancy/ arrhythmias, or
resin used to e.g. gastritis’s, Lactation  any cardiac surgery has been
reduce high constipation,  Kidney disease performed
levels of hypokalemia,  Check for base line KFT levels.
potassium anorexia, nausea,  Document the dosage/timing
[Hyperkalemi . vomiting, heart /and the route
a], it removes rhythm
potassium by abnormalities
exchanging
sodium ions
for potassium
in the
intestines.

[Link]- dopamine Dopamine is a IV Dopamine Allergic reaction Donot give Keep Inj -hydrocortisone and Avil
catecholamine injection is to dopamine, dopamine in heart
neurotransmit used to treat hives, difficult ventricle rhythm, Check vital signs,
ter found in conditions breathing,
neurons both such as swelling of face, fast heart beat , Check pulse rate frequently, report
central and shock, which lips, tongue or for any irregularity in pulse
peripheral may be throat, serious decreased oxygen in
nervous caused by side effect is chest tissues in tissues , Maintain the drop rate and infuse
system, it heart failure, pain fast, slow the fluid as advised.
works by kidney failure heart beats, pheochromocytoma
improving or any other painful urination,
the pumping serious confusion,
Strength of medical cold feeling,
 the heart and condition chills,
improves Goosebumps,
blood flow to Nausea/vomiting
kidneys

Injection It is a IV and Hydrocortiso Dizziness ,nausea, High blood pressure, Establish base line and continuing
Hydrocortisone corticosteroid oral /IM ne is used for insomnia hypokalemia data on BP, weight, fluid &
agonist, it Topical as adrenal blistering, glaucoma electrolyte balance & blood sugar.
stimulates the well. insufficiency, headache, heart brain injury, Be alert to signs of hypokalemia.
body’s inflammation burn, itching, chronic heart failure, Be alert to possibility masked
normal flow Shock, menstrual high blood sugar infection & delayed healing.
of cortisol anaphylaxis , changes, weight Ophthalmic examination are
Asthma gain, puffiness of recommended
Eczema face, hiccups

NURSING MANAGEMENT THROUGH NURSING PROCESSES

NURSING ASSESSMENT
Subjective Assessment
Pain in the back, legs, and abdomen
Fear and anxiety
Objective Assessment
Fever
Hypotension
Shock

NURSING GOAL INTERVENTION RATIONALE EVALVATION

DIAGNOSES
Acute pain related to Relief of pain 1. Monitor and evaluate  The pain scale will
acute adrenal pain using pain scale 0 - help in diagnosing as
insufficiency 10 something is very
wrong and needs a
prompt and intelligent
action. Pain relieved
2. Analgesics given to  Analgesics help by
ensure maximum relief blocking the chemicals
of pain [prostaglandins] which
sensitize the peripheral
pain receptors to send
to the central nervous
system

Hypotension To Maintain a normal Administer isotonic Isotonic solution has the Blood pressure is
blood pressure solution, E.g. same concentration as maintained within the
0.9%NS,RL that of our blood. normal limits.

Electrolyte imbalance To keep the electrolytes Administer sodium Kayexalate reduce the The high potassium
related to adrenal crisis. Within the normal polystyrene sulphonate high levels of potassium levels are decreased to the
limits. [kayexalate] In the blood by normal limits.
exchanging sodium
ions.
Anxiety and fear related To reduce the anxiety Encourage Verbalization Verbalization reduces Reports less anxiety.
to disease condition. Of Concerns And Fears. the stress level.

Respond Honestly , Stress reduction helps to Appears rest full

Correct mis-Conceptions enhance feeling of well
about the Disease, and helps in recovery.
Interventions , Or
Prognosis
DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION

Impaired tissue Normal tissue 1. Administer Ionotropic  Ionotropic drugs • Normal tissue
perfusion related to perfusion is drugs like dopamine, affect the contraction perfusion
shock which is related maintained of the heart muscles,
to the disease hence maintains the
condition. normal tissue
perfusion
2. Give vasodilators  Vasodilators cause • Normal blood flow
decrease in vascular is maintained
resistance and an
increase in the blood
flow.
3. Check the urine out put  Low urine output is an • Normal urine output
indicator for impaired is there.
tissue perfusion.
4. Assess for capillary  CRT is a monitor for • Good blood flow is
refill blood flow to the going to nail bed in
tissues. less than two seconds.

APPLICATION OF NURSING THEORY:

I have selected Orem’s Nursing System theory for application of nursing process on my patient with ADRENAL INSUFFICIENCY the
focus of Orem’s model of nursing is to enhance the patient’s ability for self care and extend their ability to care for their dependents. A
person self care deficit is the result of their environment. Three systems exist within this model: The Wholly Compensatory-in which the
nurse provides the total care; the partially compensatory-in which the patient and nurse share responsibility for care; and supportive
educative- in which the patient has the primary responsibility for personal health, with the nurse acting as a consultant. I have selected all
the three systems for my patient because for some activities he was totally dependent on the nurse.

WHOLLY COMPENSATORY SYSTEM

Patient had severe Hypotension with shock, I administered IV fluids and

Nurse Patient’s action is
Ionotropic drugs
action limited
I maintained intake output chart of my patient, checked his vital signs.

I administered the prescribed medications to my patient and provided

support to the patient.

PARTIALLY COMPENSATORY SYSTEM

I assisted him in performing various self care activities. Patient

Nurse Like taking his meals, in drinking water.
action I assisted him in ambulation. action

I checked his vital signs.

Patient is able to perform self care activities like brushing etc.

Patient is now taking the medications himself( orally)

Patient is able to walk

SUPPORTIVE EDUCATIVE SYSTEM

 Educated the patient to follow the instructions which are given during follow
Khursheed Ahmad
es up
is taking all
n Educated him about avoid taking the preparations which he has taken for the medication and is
elf) weight gain. following all the
said advice.
Advised him to take the medicines as prescribed by the doctor.
Advised him to perform hand washing before and after any procedure.
Advised him to come for regular follow up.

PROGRESS NOTE

Day one Patient conscious, oriented to time, place and person Responding to verbal command, Chest pain,
anxiety, activity intolerance,
29/07/2021
Vital Signs:

BP: 150/90mmHg

Resp: 18/min

Temp:99.4F

Pulse: 86/min

DAY 2 Patient conscious, chest pain improving

30/07/2021 Vital Signs:

BP: 130/80 mmHg

 Resp: 18/min

Temp:98 F

Pulse: 70/min

D ay 3 Patient conscious, oriented. Stable, chest pain decreased

31/07/2021 Vital Signs:

BP: 130/80 mmHg

Resp: 18/min

Temp:98 F

Pulse 78/min

Patient was discharged.

HEALTH EDUCATION/ DISCHARGE TEACHING

As a preparation for discharge the patient was educated on various aspects of care like:

 Patient is advised to carry an ID [medic –alert bracelet] indicating that adrenal insufficiency is there as a diagnosis and in case of
crisis injection hydrocortisone is given.

 Advice is given about that he should always carry 100 mg of injection hydrocortisone along with the syringe. [IM self injection kit
to be available all the time].

 Patient & his significant others are give written instruction on self administration of steroids.

 Instruction given to him about self care activities.

  Monitor vital signs and weight should remain stable

 Advice is given to take medication daily, without fail.

 Follow up: Explained The Importance of Follow Up

- Periodic blood laboratory testing for cortisol.

-Reminded the patient to keep semiannual appointments with the physician, even when his health is good.

CONCLUSION AND SUMMARY:

My patients namely DAR KHURSHEED AHMAD, 26 years old male with the diagnosis of ADRENAL INSUFFICIENCY, commonly
known as: ADDISONS DISEASE

During my case presentation

 I provided health education to my patient,

 Checked his vital signs along with blood pressure

 Maintained the intake output chart

 Did the blood sampling of the patient for serum chemistry

 Administered the necessary medications to my patient

 Advised him about the importance of treatment

 Advised him about the importance of Medi –alert bracelet showing the diagnosis and the need for cortisol replacement

 Advised him to come for regular follow

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 Joyce young Johnson “Handbook of medical surgical Nursing” Eleventh edition.
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