Case Study 1: Susan Summers
The following is an evaluation of a case study of Susan Summers, a patient who has undergone right laparoscopic adrenelectomy, following a benign tumour on the adrenal gland that caused her to get Cushing Syndrome. In this paper, the writer will discuss the aetiology, and pathophysiology of the presenting condition, the underlying pathophysiology of the patient’s post-operative deterioration, and lastly identify members of the interdisciplinary healthcare team who would be involved of the care of the Susan Summers before her discharge.
Cushing syndrome, also referred to as hypercortiaolism occurs when the body is subjected to the long-term exposure of high levels of cortisol hormone (Raffaelli, De Crea, D’amato, Gallucci, Lombardi, & Bellantone, 2017). The condition also occurs when the body is producing too much cortisol on its own. Cortisol is produced by the adrenal glands and its plays a crucial role in the effective functioning of the body. Nieman (2015) explains that some of the body functions that cortisol helps with include balancing the effects of insulin, lowering the inflammatory response of the immune system, regulating the blood pressure, regulating the cardiovascular system, converting fats, proteins, and carbohydrates into energy and responding to stress.
The adrenal glands are integral components of the endocrine system found retroperitoneal above the kidneys (Melmed, 2016). The adrenal glands have two major sections; the adrenal medulla that secretes catecholamines and the adrenal cortex that secretes mineral corticoids, glucocorticoids and adrenal androgen hormones. The adrenal glands are responsible for regulation of electrolytes, maintaining of normal blood pressure and electrolytes and alsoplay a part in sexual development. Some of the reasons as to why the adrenal glands may produce high levels of cortisol include malnutrition, high levels of stress, athletic training, alcoholism, panic disorders, and depression. The most common cause of Cushing syndrome is the use of corticosteroid medications, such as prednisone, in high levels for an extended period (Sharma, Nieman, & Feelders, 2015). These are medications that can be prescribed by physicians after an organ transplant. They are also used to treat inflammatory illnesses, such as arthritis and lupus. Cushing syndrome can also be cause by the continuous administration of injectable steroids for the treatment of back pain in high doses (Sharma, Nieman, & Feelders, 2015). However, lower dose steroids that take the form of inhalants, such as asthma inhalants and eczema creams normally aren’t enough to cause the syndrome.
Other causes of Cushing syndrome include pituitary gland tumor whereby the pituitary gland releases too much adrenocorticotropic hormone, chronic obstructive pulmonary disease, ectopic ACTH syndrome which causes tumors that befall the pancreas, lung, thymus or thyloid gland, iatrogenic causes such as treatment and diagnostic procedures of an adrenal gland tumor or abnormality (Lacroix, Feelders, Stratakis, & Nieman, 2015). Lastly, the syndrome can be caused by familial. Normally, Cushing syndrome is not inheritable but it is possible to have an inherited tendency to develop tumors situated in the endocrine glands.
Some of the risk factors of Cushing’s syndrome include patients with neurologic conditions and those with nephrologic conditions, people between the ages 25 and 40 years of age, females are more at risk than men (Lacroix et a.l, 2015). Common symptoms of the syndrome include severe fatigue, upper body obesity, high blood pressure, amnesia, increased growth of body and facial hair, increased blood sugar, muscle weakness, reddened stretch marks on the skin, backache, and easy bruising (Nieman, 2015).
The adrenocorticotropin hormone (ACTH) stimulates the adrenal glands to secrete cortisol and other steroid hormones. The pituitary glands produce ACTH and release it into the petrosal venous sinuses as a response to stimulation by corticotropin-releasing hormone (CRH) from the hypothalamus. The release of ACTH follows a diurnal pattern that is independent of circulating levels of cortisol. The highest amount is released just before waking up, and ACTH levels decline as the day progresses. The regulation of ACTH and release of CRH is maintained through negative feedback by cortisol at the pituitary and hypothalamic levels. The release of CRH can also be triggered by the neuronal input at the hypothalamic level (Schneeberger, Gomis, & Claret, 2014). The adenomas in Cushing’s disease secrete excess amounts of ACTH; they generally retain some negative response to the high doses of glucocorticoids. Ectopic sources of ACTH do not respond to excessive glucocorticoids.
The diagnosis of Cushing syndrome can be made on a basis of abnormal levels of cortisol in the body. It usually involves a review of a patient’s medical history and symptoms and a physical examination. The doctor can also order for laboratory tests, such as a low-dose dexamethasone suppression test, a one day urinary free cortisol test, a midnight plasma cortisol and late-night measurement of salivary cortisol levels (Raff, Auchus, Findling, & Nieman, 2015). Following the diagnosis of this condition, a physician must determine the cause of the production of excess cortisol in the body. Some of the tests that assist in determining the cause of Cushing syndrome include a high-dose dexamethasone suppression test and a corticotropin-releasing hormone stimulation test. The doctor might also order imaging studies including MRI scans and CT scans.
The treatment of this condition depends on the cause and physicians should prescribe a medication that can help to treat the condition (Nieman, 2015). Some medicines lower the production of cortisol hormone in the adrenal glands or lower the production of ACTH in the pituitary gland. Other medications protect individuals from the effects of cortisol on body tissues. Some tumors can be malignant, or benign and surgical removal might be needed. Radiation therapy and chemotherapy can also be used for to treat Cushing’s syndrome (Syro, Rotondo, Ortiz, & Kovacs, 2018). Failure to treat Cushing’s syndrome can result to bone fractures, muscle weakness, bone loss, type 2 diabetes, infections, kidney stones, enlargement of a pituitary tumor, and high blood pressure. Furthermore, Cushing syndrome that results from pituitary tumors can interfere with hormone production.
In this scenario, the patient treatment procedure involved a surgical procedure. The main goal of the surgical treatment is to cure hypercortisolism by eliminating the tumor while reducing the possibility of endocrine deficiency or long-term dependence on medications. Following the surgery, an assessment reveals that the patient’s blood pressure was elevated; this can be due to the age of the patients or presence of a larger adrenal gland size. The cause of the increase in blood pressure can also be due to compensation of the left adrenal gland following right laparoscopic adrenelectomy. The other plausible explanation for the increase in blood pressure might be due to the residual presence of catecholamine’s or compensation (Edelstein & Metry, 2017). The patient might have also lost a significant amount of blood in this case the nurse should be worried about the decreased cardiac ouput and therefore fluid replacement therapy will be a priority management. The nurse should place IV lines if there are none and start on fluid replacement with either normal saline or ringers lactate since the patient is at a risk for hypokalemia.
The patients pulse is also high, the normal values being between 60 to 100 beats per minute, this might be attributed to the increased blood pressure (Pistrosch, Ganz, Bornstein, Birkenfeld, Henkel, & Hanefeld, 2015). It may be as a mechanism for compensation. In this case the same management will apply, use of fluid replacement therapy. The indwelling catheter produces 5mls per hour the normal being 50 mls to 60 mls per hour. The most plausible cause is the fluid and electrolyte imbalance and a decrease in cardiac output. The body is trying to retain the little fluid that it has and therefore the output amounts to 5mls per litre.
The assessment also reveals signs of hypothermia, the patient might have experienced this secondary to general anaesthesia which is more often than not associated with great decline in temperature (Edelstein & Metry, 2017). The nurse in this case should therefore monitor the temperature frequently; the room conditions should be favourable for the patient at 24 degrees Celsius prewarming and give warm IV fluids. According to Jones (2015), the removal of the adrenal gland in animals showed significance effects the respiratory rate. There was increased metabolism following thyroid gland removal and increased respiration following removal of adrenal gland. This can therefore be related to the patient and managed by giving hormonal supplements as prescribed, positioning the patient, and giving oxygen if need be.
Patients who are diagnosed with this syndrome are exposed to chronically elevated levels of steroid hormones, which suppress the normal adrenal functioning in the contralateral gland (Raffaelli, et al., 2017). In this scenario, following the laparoscopic right adrenalectomy, Susan might have transient adrenal inadequacy which requires monitored steroid therapy. She should be maintained on stress-dose steroids for the next 48 hours and she should be monitored for symptoms of adrenal insufficiency. Further, oral maintenance therapy should be initiated prior to discharge and continued until adrenal functions recovers. Many times, antihypertensive medications can be administered for an extended period after the operation.
An interdisciplinary health care team involves a group of health practitioners who would work together to deliver comprehensive patient care before her discharge (Reeves, Pelone, Harrison, Goldman, & Zwarenstein, 2017). In this case, the interdisciplinary team should consist of the primary medical and nursing team, an endocrinologist, a physicist, a community health nurse and a health educator. The endocrinologist with consider the values and preferences of Susan and enlighten her on the treatment options that were available. The health educator would also be needed to help with addressing some of the risk factors associated with the condition including drinking habits, physical exercise, and management of diabetes. The physicist would help in the effective provision of medication for the patient during the post-operative period. Another member of the interdisciplinary team who would play a crucial role is the community health nurse who would be responsible for the long-term follow up of Susan including screening and treatment of comorbidities that mat persist even after the surgery was successful.
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