A CASE STUDY ON CUSHINGS SYNDROME

In Partial Fulfillment of The course Requirement in Medical Nursing

Presented to The Faculty of Cebu Doctors University College of Nursing

Submitted by: xxxxxxxxxxxxxxxxxxx BSN IV-F

FEBUARY 2008

Table of Contents

Page I. Introduction II. Objectives Student Patient & Significant others III. Nursing Assessment 3.1 Personal History 3.1.1 Patients Profile 3.1.2 Family and Individual Information 3.1.3 Level of Growth and Development 3.1.3.1 Normal Development at particular Stage 3.1.3.2 The Ill person at particular Stage of Patient 3.2 Diagnostic Results 3.3 Present Profile of Functional Health Patterns 3.4 Physiology and Rationale 3.4.1 Normal Anatomy and Physiology of Organ Affected 3.4.2 Schematic diagram of the pathophysiology of the disease and its effect on tissue/organ 3.4.3 Disease process and its effects on different organ/system 3.4.4 Comparative chart of classical signs and symptoms of the disease and actual manifestations of the patient IV. Nursing Intervention 4.1 Care Guide of Patient with Disease Condition 4.2 Actual Patient Care 4.2.1 Assessment 4.2.2 Nursing Care Plan 4.2.3 Drug Therapeutic Record 4.2.4 Brunswick Lens Model 4.2.5 Health Teaching Plan 4.2.6 SOAPIE Charting V. Evaluation and Recommendation VI. Evaluation and Implication of this Case Study to: 6.1 Nursing practice 6.2 Nursing Education 6.3 Nursing Research VII. Bibliography

I. Introduction
Cushings syndrome is a metabolic disorder that results in excessive amounts of corticosteroids in the body because of an inability to regulate cortisol or Adrenocorticotropic hormone (ACTH). It results from excessive rather than deficient, adrenocortical activity. This syndrome may result from excessive administration of corticosteroid or ACTH or from hyperplasia of the adrenal cortex. It is commonly found in females in the second or fourth decades of life, although ectopic ACTH hypersecretion is found most frequently in males, probably because of the higher incidence of oat call carcinoma. The researcher chose this case to gain more knowledge, related on this learning experience in the management of patients with Cushings syndrome. This will initiate the student nurse on what precautionary methods or practices related to Cushings syndrome that should be done and avoided. Awareness on the disease condition will give the idea on how to be an effective nurse, equipped with knowledge, attitude and skills in dealing with patients with this condition. Students on the other hand will be able to gain knowledge regarding this case, impart health teachings to other people and be aware of the things the student may encounter in going through the process. The responsibilities of a nurse therefore, are to give immediate care to the client, to monitor their response to the therapy, to prevent complications and to promote rehabilitation. And also achieve promotion of health and quality of life.

II. Objectives
General Objectives: After 2 days of holistic nursing care, the student nurse will be able to acquire adequate knowledge, manifest positive attitude and exhibit adaptive coping skills in the care of a patient with Cushings syndrome. Specific Objectives: Student After 8 hours of student nurse-patient interaction, the student will be able to: 1) discuss the normal and abnormal anatomy and physiology of the adrenal gland. 2) perform appropriate nursing assessment of patients with Cushings syndrome 3) explain the clinical manifestations of the disease process through a comparative chart. 4) identify the precipitating and predisposing factors leading to the development of the disease. 5) utilize the nursing process as the framework of care for patients with Cushings syndrome.

Patient and Significant others After 8 hours of student nurse- patient and significant others interaction, the patient as well as the significant others will be able to: 1. establish rapport and trusting relationship with the student nurse. 2. identify the factors that predispose and precipitate the occurrence of Cushings syndrome. 3. demonstrate proper way of monitoring blood pressure and weight taking. 4. verbalize understanding regarding the continuation of treatment. 5. show positive attitudes towards new roles and changes brought about after hospitalization.

III.

Nursing Assessment

3.1 Personal history 3.1.1 Patients Profile Name Age Sex Civil Status Religion Date of Admission Room No. : Mr. Noel Sarmago : 44 years old : Male : Single : Roman Catholic : June 12, 2007 : Cebu Doctors University Hospital, 2nd floor, Male Medical ward, MM9 Complaints Diagnosis Physician : Body malaise and anorexia : Cushings syndrome; gouty arthritis : Dr. Garry Tan and Dr. J. Antigua

3.1.2 Family and Individual Information, Social and Health History Mr. Noel Sarmago, male, single from Argao Cebu has been living with his parents and three siblings. He usually spends much time with his friends and is very jolly as mentioned by his brother. He was always on the go when he was still in college. Lately he seldom laughs, opts to stay quiet and only talks when it is needed. This is his second time to be admitted in CDUH. First admission was caused by a motor vehicular accident. Current admission is caused by symptoms of body malaise and anorexia. He has hypertension that started three months ago, negative diabetes mellitus, and no history of asthma. He has maintenance drugs, versant XR 5mg OD; allopurinol; diclofenal bid;

meloxicam 7.5mg PRN for pain. Two weeks prior to admission patient experienced onset of body malaise and anorexia after a few days, he sought consult in a local district hospital. He was advised to see anendocrinologist but did not do so. Blood pressure was taken when taken and so he was prescribed versant XR 5mg OD p.o. but he did not comply. Symptoms persisted that he can no longer take it and sought consult in CDUH and thus he was admitted on June 12, 2007 at 9:22 am. 3.1.3 Level of Growth and Development 3.1.3.1 Normal Development at Particular Stage of Patient MIDDLE ADULT (40- 60 years) The middle- age from 40- 65 years have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or moving away from home. Thus, couples have more time for and with each other and time to pursue interests they may have deferred for years. Physical Changes: At 40, adults can function as effectively as they did in their 20s. However, during ages 40 to 65 many changes take place. In the appearance, hair begins begins to thin and grey hair appears or skin turgor and moisture decreases and wrinkling occurs. Musculoskeletal changes such as skeletal muscle bulk decreases at about age 60 and calcium loss is common among postmenopausal women also occur. The different system and organs also have changes. The eyesight of most adults at 40 to 60 declines the auditory acuity for high frequency sounds also

decreases especially in me. Taste sensations also diminish. Cardiovascular changes also take place, blood vessels loss elasticity and become thicker. Both men and women experience decreasing hormonal production during the middle years. In women menopause occurs. It is the time when menstruation ceases. This usually occurs anytime between ages 40 to 65. At this time ovarian activity declines until ovulation ceases. Climacteric (adropause) happens to men in the other hand. This refers to the change of life in men, when sexual activity decreases. Though androgen decreases slowly men can further have children even in late life. Psychological Development According to Havighurst there are seven tasks for the middle adult. Achieving adult civic and social responsibility. Establishing and maintaining an economic standard of living. Assisting teenage children to become responsible and happy adults. Developing adult leisure-time activities. Relating oneself to ones spouse as a person. Accepting and adjusting to the physiologic changes of middle age. Adjusting to aging parents.

Erik Erikson views the developmental choice of the middle aged adult as generativity vs. stagnation. Generativity is defined as the concern for establishing and guiding the next generation.

Erikson believes that people who expand their interests at this time and do not assume the responsibility of middle age suffer a sense of boredom and impoverishment, that is, stagnation. These people have difficulty accepting their aging bodies and become withdrawn and isolated. They are preoccupied with self and unable to give to others. Some may regress to younger patterns of behavior. Robert Peck Believes that although physical capabilities and function decrease with age, mental and social capabilities tend to increase in the latter part of life. Gail Sheehy suggests that the transition into middle life is as critical as adolescence. She outlines characteristics of midlife crisis ad calls the decade between the ages 35 to 45 deadline decade. According to Sheehy, most women pass through the midlife crisis between 35 and 40; most men between 40 and 45. The crisis occurs when individuals recognize that they have reached the halfway mark of life. Cognitive Development The middle- aged adults cognitive and intellectual abilities change very little. Cognitive process includes reaction time, memory, perception, learning, problem solving and creativity. Reaction time during the middle years stays much the same or diminishes during the later part of the middle years. Memory and problem solving are maintained through the middle adulthood. Learning continues and can be enhanced by increased motivation at this time in life.

Middle-aged adults are able to carry out all the strategies described in Piagets phase of formal operations. Some may use postformal operation strategies to assist them in understanding the contraindications that exist in both personal and physical aspects of reality. The experiences of the professional, social, and personal life of the middle-aged persons will be reflected in their cognitive performance. Thus approaches to problem solving and task completion will vary considerably in a middle-aged group. The middle-aged can reflect on the past and current experience and can imagine, anticipate, plan and hope. Moral Development According to Kohlberg, the adult can move beyond the conventional level to the postconventional level. He believes that extensive experience is of personal before and moral can choice reach and the responsibility required people

postconventional level. Kohlberg found that few of his subjects achieved the highest level of moral reasoning. To move from stage 4, a law and order orientation, to stage 5, a social contract orientation, requires that the individual move to a stage in which rights of others take precedence. People in stage 5 take steps to support one anothers rights. Spiritual Development Not all adults progress through Fowlers stages to the fifth, called the paradoxical consolidative stage. At this stage, the individual can view truth from a number of viewpoints. Fowler believes that only some individuals after the age of 30 years reach this stage.

In the middle-age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death and tragedy. 1.3.2 THE ILL PERSON AT PARTICULAR STAGE OF PATIENT The transition from health to illness is a complex and highly individualized experience. In addition to restoring physiologic balance, the two main tasks are 1 to modify the body image, concept of itself, and relations to other people, work and
2

to

readjust realistically to the limitation imposed by the condition. The two tasks begin in the setting in which the person is being treated for the health problem. First Stage The development of symptoms usually is accompanied by unpleasant sensation, loss of vigor and stamina, and a decrease in the ability to function. Anxiety is often present and is handled with the persons usual coping mechanism. To ward off the prospect of illness, one person may be plunged to activity, keeping late hours with extra work and social activities. Another may become passive and withdrawn, hoping that the vague symptoms will go away. A person may put off seeking medical care for fear of the diagnosis, especially if something serious is expected, such as cancer. Anxiety, guilt, shame and denial are prominent during this initial period.

Second Stage The second stage is a shift to the period of accepting illness. The patient recognizes and admits that he is sick and in need of help from others, especially from the medical and nursing staff. Temporarily, he adapts the patient role. This includes abduction from usual responsibilities and cooperation in the task of getting well. In this stage, patients become preoccupied with themselves, their symptoms, and their treatment; interest with current events and even concern about family and friends maybe quite limited. Increased independency accompanies preoccupation with somatic concerns. This behavior is often described as regressive, because it is a return to earlier forms of acting, feeling, and relating to others. Third Stage The third stage is the convalescent or restitution period. The return of health and physical strength often precedes the patients feeling and acting well. Just as lag usually occurs in the initial stage between the appearance of physical symptoms and the emotional acceptance of illness, a reverse lag occurs in recovery. Getting well implies giving up a dependent, regressive position and resuming adult responsibilities and normal relations with others. All though some people are reluctant to give up the patient role, most are motivated toward health but are afraid and hesitant to try out new skills. This is particularly true if the illness and treatment require major changes in work and family relation.

3, 2 Diagnostic Results Diagnostic Test Hematology: June 15,2007 Hemoglobin Hematocrit Red blood Cell White blood Cell Segmenters Neutrophils Eosinophils Lymphocyte Monocyte MCH MCV MCHC Platelet Uric acid serum Blood sugar 14- 17.5 g/dl 41.5- 50.4 % 4.5-5.1x 10 6/uL 4,400- 11,000 50-70% 45-73% 0-4% 20-40% 2-8% 27.5-33.2pg 80-96fL 33.4-35.5% 150k-450k/cumm 2.5-7.5 mg/L 62-117mg/L 9.30 38.2 3.92 9.14 62 62 2 34 2 23.7 78.5 30.2 557,000 14.8 139 Decreased indicates anemia Decreased signifies severe anemia Decreased in all anemia Decreased in leukemia Normal Normal Normal Normal Normal Normal Decreased, may be due to anemia or stress Decreased in microcytic anemia Increased in rheumatoid arthritis Increased in gouty arthritis; acute leukemia Increased in Diabetes mellitus, nephritis, hyperthyroidism Source: Medical Surgical Nursing 10th ed. By Smeltzer and Bare vol.2 pg.2214-2226 Normal Value Result Significance

3.3 Present Profile of Functional Health Patterns 3.3.1 Health Perception Health Management Pattern The client describes that his health is not really good when compared to that of before but he is now feeling better. Client states that he eats properly to maintain healthy and prevent disorders. He says that he thought he only has arthritis and was advised time by his friends much to take NSAIDS for pain and takes dexamethasone forte, he followed the advice for a long period of even without improvement. Now client medicines prescribed by the physician and follows the drug regimen properly without fail. Client states that he thinks hes capable of taking care of himself. 3.3.2 Nutritional Metabolic Pattern Before admission, the client has a good appetite in which that he eats anything. He has no known allergies to food or any restrictions. He usually eats 3x a day with a full meal of rice, vegetables, meat and such. He drinks a fair amount of water everyday about 6-8 glasses. During admission, he has no appetite for food, seldom eats and eats only when he really is hungry. He has not determined any weight loss during the onset of his illness. 3.3.3 Elimination Pattern Client says that before, he doesnt have any problem in eliminating urine or stool and is not using any assistive devices. But when his illness started he had difficulty to urinate but only lasted for 2 days. Then, after which it returned to its usual pattern even until during his admission. The difference only is now that he experiences anorexia the amount of the stool he passes is much less than the usual amount he defecates when he had good appetite. Client states that she usually passes stool

at least once a day and are brown in color and most of the time soft. 3.3.4 Activity Exercise Pattern Client says that before, he occasionally goes on an exercise, but not necessarily that often. His form of exercise is walking, little stretching and moves a little doing house chores sometimes. But he recently has no interest in exercise; he says he is too tired to do so. He has limitations that prevent him from performing such activities and he experiences dyspnea and fatigue afterwards. 3.3.5 Sleep-Rest Pattern Before admission, his sleeping time usually varies according to him but sees to it that he sleeps at least 7 hours a day. He doesnt use any sleeping aids or have any bedtime rituals that allow him to sleep afterwards. During admission he has difficulty in sleeping continuously. He has problems with the environment, the nursing procedures, and the pain and discomfort he feels. He takes naps during the day to compensate for his lack of sleep. 3.3.6 Cognitive-perceptual Pattern Client has 20/20 vision and doesnt have any assistive or correctional devices used for his senses. He can perceive all 5 senses without problems and she is able to read and write and is even a college graduate. Nothing has changed during his admission basing from his condition before admission. 3.3.7 Self-perception Pattern When asked what his concerns were, patient said he has nothing in mind, but kept silent afterwards. He does not want/ avoids questions on his thoughts and feelings of his illness. He only answers closed ended questions. He only nodded when asked if he wanted to get better. 3.3.8 Role-relationship Pattern

The client can speak bisaya, tagalog and English. He speaks in Cebuano when communicating with others most of the time. His speech contents are clearly spoken and are usually relevant to the topic at hand. Client doesnt talk or ask the student much questions. He lives with his parents at Argao City. Currently he doesnt have any problems regarding his family. He has good relationships with friends, siblings, neighbors and family. 3.3.9 Sexuality-Sexual Functioning Client states that he is fine with his sexuality and that he is heterosexual ever since. In terms of libido, the client is ashamed to disclose much about this certain topic. 3.3.10 Coping-stress management Pattern Client states that he makes decisions for himself but considers the advice of others (family and friends). He avoids further questions and does not answer anymore questions but he said that he will be fine and he is OK. 3.3.11 Value-belief System Before, client states that his doubts, fears and worries do not really disturb him. But he prayed to God about it. Now, his problems/ feelings are kept for himself and he now doubts to trust God. He does not go to church, except when he is invited by his friends. 3.4 Physiology and Rationale

3.4.1 Normal Anatomy and Physiology of the Adrenal Gland 1. Anatomy and physiology of the adrenal gland Adrenal glands are two bean shaped glands curved over the top of the kidneys. Although the adrenal gland looks like a single organ, it is structurally and functionally two endocrine organs in one. Much like the pituitary gland, it has a glandular (cortex) and neural tissue (medulla) parts. The central medulla region is

enclosed by the adrenal cortex which contains three separate layers of cells. The adrenal cortex produces three major groups of steroid hormones collectively called corticosteroids- mineralocorticoids, glucocorticoids and sex hormones. The mireraocorticoids, mainly the aldosterone are produced by the outer adrenal cortex cell layer. As their name suggests, the mineralocorticoids are important in regulating the mineral (or salt) content of the blood particularly the concentrations of sodium and potassium ions. Their target is the kidney tubules that selectively reabsorb the minerals or allow them to be flushed out of the body in urine. When blood levels of aldosterone rise, the kidney tubule cells reclaim the increasing amount of sodium ions and allow potassium ions to go out in urine. When sodium is reabsorbed, water follows. Thus the mineralocorticoids regulate both the water and electrolyte balance in body fluids. The middle cortical layer produces glucocorticoids, which include cortisone and cortisol. Glucocorticoids promote normal cell metabolism and help the body to resist long term stressors, primarily by increasing blood glucose levels of glucocorticoids are high, fats and even proteins are broken down by body cells and converted to glucose, which is released to the blood. For this reason, glucocorticoids are said to be hyperglycemic hormones. Glucocorticoids also seem to control the more unpleasant effects of inflammation by decreasing edema, and they reduce pain by inhibiting some pain-causing molecules called prostaglandins. Because of their anti-inflammatory properties, glucocorticoids are often prescribed as drug patients with rheumatoid arthritis, to suppress inflammation. Glucocorticoids are released from the adrenal cortex in response to rising blood levels of ACTH. Regardless of ones gender, both male and female sex hormones are produced by the adrenal cortex throughout life in relatively small amounts. Although the bulk of the sex hormones produced by the inner most cortex layer are androgens, some estrogens are also formed. 3.4.2 Schematic diagram of the pathophysiology of the disease and its effect on tissue/organ

2. Disease Process

CUSHINGS SYNDROME

The major end result of Cushings syndrome is excessive production of cortisol. Early in the noniatrogenic disorders, the most prominent alteration is loss of the diurnal secretory pattern. The morning level of cortisol production may not be abnormally elevated, but the levels during the day do not show the normal decrease below the morning peak. At later stages, cortisol is elevated at all time. result from exaggeration in all alterations in the following:
Predisposing factors TheFemales pathophysiologic factors In their 2nd-4th decades of life Precipitating factors Adrenal adenomas/ carcinoma associated with cortisol excess primarily Adrenal hyperplasia Chronic glucocorticoid therapy known factors of glucocorticoids and include

1. Protein, fat, and carbohydrate metabolism. 2. Inflammatory and immune response PATHOPHYSIOLOGY
Increase in cortisol circulation in 3. Water and mineral metabolism the body causing the normal feedback mechanisms that 4. Emotional stability control the function of the adrenal cortex become ineffective and the 5. Hematology usual diurnal pattern of cortisol is lost.

Excessive cortisol may also disturb secretion of other anterior pituitary hormones (prolactin, thyrotropin, LH, GH) and alterations in sleep patterns. Some of these alterations may contribute to the clinical picture. In many instances cortisol excess is also associated with excessive Signs and Symptoms production of androgen; this results in virilization. Adrenal tumors may secrete cortisol, androgens, and mineralocorticoids in various proportions. Depending on which hormone is produced in excess, the patient will have: (1) the clinical picture associated with Cushings syndrome; (2) only the effects of androgen excess; (3) a clinical picture similar to that for hyperaldosteronism; or (4) any combination of these three. Cushings syndrome occurs when the bodys tissues are exposed to excessive levels of cortisol for long periods of time. Many people suffer the symptoms of Cushings syndrome because they take glucocorticoid hormones such as prednisone for asthma, rheumatoid arthritis, lupus, and other inflammatory diseases or for immunosuppression after transplantation. Others develop Cushings syndrome because of overproduction of cortisol by the body. Normally, the production of cortisol follows a precise chain of events. First, the hypothalamus, a part of the brain which is about the size of a small sugar cube, sends corticotrophin releasing hormone (CRH) to the pituitary gland. CRH causes the pituitary to secrete ACTH (adrenocorticotropin), a

hormone that stimulates the adrenal glands. When the adrenals, which are located just above the kidneys, receive the ACTH, they respond by releasing cortisol into the bloodstream. Cortisol performs vital tasks in the body. It helps maintain blood pressure and cardiovascular function, reduces the immune systems inflammatory response, balances the effect of insulin in breaking down sugar for energy, and regulates the metabolism of proteins, carbohydrates, and fats. One of cortisols most important jobs is to help the body respond to stress. For this reason, women in their last 3 months of pregnancy and highly trained athletes normally have high levels of the hormone. People suffering from depression, alcoholism, malnutrition, and panic disorders also have increased cortisol levels. When the amount of cortisol in the blood is adequate, the hypothalamus and pituitary release less CRH and ACTH. This ensures that the amount of cortisol released by the adrenal glands is precisely balanced to meet the bodys daily needs. However, if something goes wrong with the adrenals or their regulating switches in the pituitary gland or the hypothalamus, cortisol production can go awry. Pituitary Adenomas Pituitary adenomas cause most cases of Cushings syndrome. They are benign or non cancerous, tumors of the pituitary gland which secrete increased amounts of ACTH. Most patients have a single adenoma. This form of the syndrome, known as Cushings disease affects women five times more frequently than men. Ectopic ACTH Syndrome Some benign or malignant (cancerous) tumors that arise outside the pituitary can produce ACTH. This condition is known as ectopic ACTH syndrome. Lung tumors cause over 50 percent of these cases. Men are affected 3 times more frequently than women. The most common forms of ACTH producing tumors are oat cell, or small cell lung cancer, which accounts for about 25 percent of all lung cancer cases, and carcinoid tumors. Other less common types of tumors that can produce ACTH are thymomas, pancreatic islet islet cell tumors, and medullary carcinomas of the thyroid. Adrenal Tumors Sometimes, an abnormality of the adrenal glands, most often an adrenal tumor, causes Cushings syndrome. The average age of onset is about 40 years. Most of these cases involve non-cancerous tumors of adrenal tissue, called adrenal adenomas, which release excess cortisol into the blood.

Adrenocortical carcinomas, or adrenal cancers, are the least common cause of Cushings syndrome. Cancer cells secrete excess levels of several adrenal cortical hormones, including cortisol and adrenal androgens. Adrenocortical carcinomas usually cause very high hormone levels and rapid development of symptoms. Familial Cushings syndrome Most cases of Cushings syndrome are not inherited. Rarely, however, some individuals have special causes of Cushings syndrome due to an inherited tendency to develop tumors of one or more endocrine glands. In Primary Pigmented Micronodular Adrenal Disease, children or young adults develop small cortisol-producing tumors of the adrenal glands. In multiple Endocrine Neoplasia Type I (men I), hormone secreting tumors of the parathyroid glands, pancreas and pituitary occur. Cushings syndrome in MEN I may be due to pituitary, ectopic or adrenal tumors. 4. COMPARATIVE CHART OF THE CLASSICAL SIGNS AND SYMPTOMS OF Pottss DISEASE Classical Symptoms Clinical Symptoms Rationale Related to alterations in fat deposition. The exact mechanism responsible is not known. Moderate central obesity manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1426

Atypical fat distribution usually involves the trunk especially the cervicodorsal region, supraclavicular areas and abdomen. Buffalo hump manifested Source: Medical Surgical Nursing Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1426 Fat also distributes about the face, in the cheeks and under the skin imparting a round and plethoric appearance. Moon face manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427 Muscular weakness, predominantly in the muscles of the pelvic girdle and extremities, secondary to loss of muscle mass maybe experienced and is a result of increased protein catabolism. Muscular weakness manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427

Pink and purplish striae (on abdomen, breast, buttocks and axillae)

Caused by weakening of the collagenous fibers in and under the skin. Protein wasting also takes a toll on blood vessels. Capillary fragility leads to an increased tendency toward bruising and hematoma formation. manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427 Protein wasting also takes a toll on blood vessels. Capillary fragility leads to an increased tendency toward bruising and hematoma formation.

Echymosis, small bruises

manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427 The mineralocorticoid activity of cortisol excess promotes renal retention of sodium and water. This expansion of extracellular volume is one of the causes of observed high blood pressure.

High blood pressure

manifested Source: Medical Surgical Nursing,

Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427-1428 Peptic ulcers may form because cortisol excesses promote acidic gastric secrations and pepsin production. Because cortisol also inhibits gastric mucus production, susceptibility to ulcer formation is increased. Peptic ulcers manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1427 Cortisol is thought to increase calcium resorption from the bone and inhibit collagen synthesis, thus interfering with bone formation and replenishment. Osteoporosis Not manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1428 Virilization (hirsutism, thinning scalp hair, acne, decreased libido, an enlarged clitoris, and menstrual changes) May be seen in women as a result of increased androgen secretion. Not manifested Source: Medical Surgical Nursing, Pathophysiological Concepts

2nd ed. By Maxine L. Patrick pg. 1428 Sometimes patients are admitted first to psychiatric unit during exacerbations of their disease. The cause of the exacerbations is unknown but appears to relate to increased circulating levels of cortisol and ACTH. Some emotional instability may be the patients response to altered body image and decreased self-esteem. Frank psychosis Not manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1428 RBC and granulocyte counts may be elevated. Lymphopenia and a decrease in eosinophils may also be observed. Hypokalemia occurs in 20% of cases, because cortisol promotes potassium excretion in the renal tubules. Increased plasma cortisol levels, with loss of normal diurnal variations, along with elevated urinary levels of steroids metabolites are always seen. Hematological changes Not manifested Source: Medical Surgical Nursing,

Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1428 Increased hepatic glucogenesis and impaired insulin use results in postprandial hyperglycemia and occasionally frank diabetes mellitus with all of its signs and symptoms. Altered carbohydrate metabolism manifested Source: Medical Surgical Nursing, Pathophysiological Concepts 2nd ed. By Maxine L. Patrick pg. 1428

IV. NURSING INTERVENTIONS 1. Care guide of patient with Cushings syndrome Treatments for Cushings syndrome are designed to lower the high level of cortisol in the body. The best treatment depends on the cause of the syndrome. Treatment options include: Reducing corticosteroid use. If the cause of Cushings syndrome is long-term use of corticosteroid medications, the doctor may be able to keep Cushings signs and symptoms under control by reducing the dosage of the drug over a period of time, while still adequately managing asthma, arthritis or other condition. For many of these medical problems, the doctor can prescribe noncorticosteroid drugs, which will allow him or her to reduce the dosage or eliminate the use of corticosteroids altogether. Surgery. If the cause of Cushings syndrome is a tumor, the doctor may recommend complete surgical removal. Pituitary tumors are typically removed by a neurosurgeon, which may perform the procedure through the nose. If a tumor is present in the adrenal glands, lung or pancreas, the surgeon can remove it through a standard operation or in some cases using minimally invasive surgical techniques, with smaller incisions.

After the operation, patient will need to take cortisol replacement medications to provide the body with the correct amount of cortisol. In most cases, patient will experience a return of normal adrenal hormone production, and the doctor can taper off the replacement drugs. However, this process can take up to a year or longer. In some instances, people with Cushings syndrome never experienced a resumption of normal adrenal function; they then need lifelong replacement therapy. Radiation therapy. If the surgeon cant totally remove the pituitary tumor, he or she will usually prescribe radiation therapy to be used un conjunction with the operation. Additionally, radiation may be used for people who arent suitable candidates for surgery. Radiation can be given in small doses over a six-week period, or by a technique called stereotactic radiosurgery or gamma-knife radiation. In the latter procedure, administered as a single treatment, a large dose of radiation is delivered to the tumor, and the radiation exposure to surrounding tissues is minimized. Medical therapy. In some situations, when surgery and radiation dont produce a normalization of cortisol production, the doctor may advise medical therapy. Medications to control excessive production of cortisol include ketoconazole (Nizoral), mitotane (Lysodrin) and metyrapone (Metopirone). Medical therapy is also sometimes used before surgery for people who are very sick. Doing so may improve their signs and symptoms and minimize their surgical risk. In some cases, the tumor or its treatment will cause other hormones produced by the pituitary or adrenal gland to become deficient and the doctor will recommend hormone replacement medications.

Home treatment for Cushings syndrome consists of lifestyle changes to prevent weight gain, strengthen muscles and bones, and prevent complications. Patients should do the following:

Eat a low-calorie, nutritious diet high in protein and calcium. This can help prevent muscle and bone loss caused by the high cortisol levels in the body. Take calcium vitamin D supplements to decrease bone loss. Ask a health professional whether he/she needs medication to help slow bone loss. Limit salt (sodium) in the diet. This is especially important if patient has high blood pressure, a complication of Cushings syndrome. Get regular exercise to help maintain muscles and bones mass and prevent weight gain. To maintain muscle and bone mass, try weight bearing exercises such as push-ups, sit-ups, or lifting weights. To prevent weight gain, try aerobic exercises to increase your heart rate. Examples of aerobic exercise include fast walking, jogging, cycling, and swimming. Consult a health professional before beginning any exercise program. Avoid possible falls by removing loose rugs and other hazards from your home. Falling may lead to broken bones and other injuries. Pay close attention to all wounds. Too much cortisol slows wound healing. Clean all wounds immediately with antibacterial soap and use antibiotic ointment and dressings to prevent infection. Seek counseling if patient needs help dealing with changes in your body image. Get regular eye exams to check for glaucoma and cataracts. See a health professional regularly to help diagnose and treat diabetes, high blood pressure, and other potential complications.

PHYSIOLOGIC ASSESSMENT BODY PART I P P A

HEAD

Normocephalic; Round; Proportionate Thick, black short hair; normally distributed. No visible dandruff flakes. Oily areas on face; Few pimples Notable moon face Same color with the face; no lesions Sinuses are not inflamed and clear Evenly distributed Symmetrical Meets the iris, no lesions Evenly distributed Slightly curved Pinkish in color Not clear in color Black in color Equally round reactive to light and accommodation Nasal septum Midline; patent,moist Symmetrical, pinna in line with outer canthus of the eye No sensation felt upon touching. No mass, slightly dry No masses noted No masses, non tender Intact, no masses, non tender No mass Positive nodules

-Hair

-Scalp FACE -shape -forehead -sinuses -eyebrows EYES -eyelids(upper) -eyelids(lower) -conjunctiva -screla -iris -pupil

NOSE EARS

MOUTH -lips Dry, pinkish pale in color, cracked. -tongue Pinkish in color, no sores, midline -gums Reddish pink, no lesions -uvula At the mid line -neck -chest Buffalo hump present, mobile rise and fall is regular. R/R is 17. Presence of bruise/skin discolorations Presence of purple striae; protuberant central/truncal obesity noted EXTREMITIES -upper Complete; thin for his leg trunk IVF on left arm, presence of small bruises; weak muscles; fingers deformed Thin for his size; positive Echymosis; weak movement deformed toes Symmetrical, warm, dry, fair, turgor. Non tender

-abdomen

-lower

SKIN

Name of Patient: Mr. Noel Sarmago Room Number: MM9 Chief Complaint: Body weakness/malaise and anorexia

Needs/

Nursing

Scientific

Objectives

Nursing

Rationale

Problems/ Cues I. Physiologic deficit 1. Lack of appetite Cues: -Not able to consume food served in his plate -poor muscle tone -abnormal laboratory findings -nausea Depressive behaviors Subjective Cue: -arang-arang naman akong pamati, dili lang gyud ko ganahan mu kaon, wa koy gana.

Diagnosis

Basis/ Significance Simple anorexia or lack of appetite is a common symptom of many diseases. Prolonged anorexia may lead to serious consequences , such as malnutrition. The appetite center stimulates or suppresses the appetite. Pleasant or noxious food odors, effect of drugs, emotional stress, fear, psychological problems or illness may affect appetite. Brief periods of anorexia are not life threatening, but can cause temporary malnutrition. -Introductory Medical Surgical Nursing, 8th edition by Barbara K. Timby;

of Care

Actions

Measures to: 1. Increase patients appetite After 8 hours of varied student nursepatient interaction, The patient will be able to: 1. Verbalize understandi ng of causative factors known and the necessary intervention s. a. Identify clients risk for malnutrition (restricted intake; effects of drugs, etc.) b. Ascertain understandin g of individual nutritional needs c. Discuss eating habits including food preferences, intolerance and aversions d. Assess drug interactions/di sease effects e. Assist in developing individualized regimen f. Promote pleasant and relaxing environment including socialization when possible g. Prevent/mini

-To assess contributing factors

Imbalanced nutrition; less than body requirement : lack of appetite (anorexia) Related to physiologica l problems (depressive behavior).

-To determine what information to provide for client and SO

-To appeal to clients likes/desires

-May affect appetite or food intake

-To correct or control underlying causative factors

-To enhance intake

-To avoid negative effects on appetite Source:

pg.741

mize unpleasant odors or sights

Nurses Pocket Guide by Doenges, 9th edition Page 347-351

II. Psychologic problem 2. charges in physical appearance Cues: -buffalo hump on neck -moon face appearance -deformed fingers and toes -striae on abdomen -secretly looking at hands and toes -no eye

Disturbed body image:

Cushings syndrome is commonly caused by use of corticosteroid medications and is frequently due to excessive corticosteroid production by the adrenal cortex. Hyperadrenali sm affects most body systems that cause many changes in appearance and physiology. Distress and depression

2. Seek information and understandi ng of body changes

a. Discuss pathophysiolo gy present and situation affecting the individual

-To assess causative/con tributing factors

b. Determine whether condition is permanent or no hope for resolution

-To promote optimal healing or adaptation

c. Assist in correcting underlying problems (gouty arthritis)

-Verbalizing feelings with a supportive person increases the clients ability to cope with stress

-Being honest

contact with student nurse -non verbal response to actual change in structure

are common and are increased by the severity of the physical changes that occur with this syndrome. -Medical Surgical Nursing Brunner and Suddarth textbook by Smeltzer and Bare Pg. 1239

d. Provide client opportunities to express feelings over physical changes.

and sharing accurate information promotes the clients trust and confidence

e. Explain that when the cause of the disorder is eliminated, some of the physical changes gradually improves, but others such as striae and kyphosis are permanent

f. Offer suggestions to help disguise physical changes that the client finds difficult to tolerate.

-Although the clients perception of physical change is exaggerated than others, he may feel more confident in social situations with techniques that minimizes changes in appearance Source: Nurses Pocket Guide by Doenges, 9th edition Page 98-101 Introductory Medical Surgical Nursing 8th edition by Barbara Timby pg. 874-875

Needs/ Problems/ Cues III. Physiologic deficit/ overload Body weakness -blood pressure of 140/90 -exertional discomfort -complaint upon admission is body weakness -gouty arthritis -wa koy gana anang exercise kapoy kaayo akong lawas. As verbalized by the patient

Nursing Diagnosis

Scientific Basis/ Significance Muscular weakness, predominantl y in the muscles of the pelvic girdle and extremities, secondary to loss of muscle mass may be experienced and is a result to increased protein catabolism. Medical Surgical nursing pathophysiolo gical concepts 2nd edition by Maxine Patrick pg. 1427

Objectives of Care

Nursing Actions

Rationale

3. Enhanced activity tolerance a. Schedule activities with periods of rest b. Allow patient to have adequate rest c. Discuss methods in conversing energy d. Provide environment conducive for relief of fatigue e. Instruct significant others to monitor responses to activity f. Talk to patient constantly g. Apply therapeutic touch to patient

-To avoid stressing out the patient -To increase participation -To reduce feeling of tiredness -To lessen effect of exhaustion -To indicate activity level -To have sense of encouragem ent -For feeling of importance Source: Nurses Pocket Guide by Doenges, 9th edition Pg. 60-63

Activity into tolerance: body weakness v/t Muscle weakness

3. Enhanced activity tolerance

Name of patient: Mr. Noel Sarmago

Date: June 18, 2007

Hospital number: MM9 72447

Physician: Dr. Jerry Tan Dr. J Antigua

Impression/ Diagnosis: Cushings syndrome

DRUG THERAPEUTIC RECORD

Drug/Dose/ Frequency/ Route

Classification / Mechanism of action

Indications/ contraindicatio ns/ side effects

Principle of care

Treatment s

Evaluatio n

Co-amoxiclav (augmentin) 1 gm. PO BID x 2 more days 8am 6pm

Anti-infective -binds to bacterial cell wall causing cell death.

Indications: Treatment of a variety of infections including skin and skin structure infections Contraindication: Hypersensitivity to penicillin Side-effects: Seizure, diarrhea, rashes, allergic reactions, anaphylaxis, serum sickness, super infection.

1. Instruct the patient to take medication around the clock and to finish the drug completely as directed. 2. Advise patient to report signs of super infection.

1. Administer with meals for gastrointesti nal problems. 2. Monitor bowel function

Sodium bicarbonate 6r x 650mg.tab, 2 tabs. PO TID with meals 8am-1pm6pm

Electrolytes and minerals Anti-ulcer agent - Acts as an alkalinizing agent by releasing bicarbonate which is capable of neutralizing gastric acid.

Indications: management of metabolic acidosis; used to alkalinize urine and promote excretion of certain drugs in over a dosage situation. Antacid. Contraindication: Metabolic respiratory alkalosis, hypocalcemia, excessive chloride loss, renal failure Side-effects: Edema,

1. Tablets must be taken with a full glass of water. 2. For peptic ulceradminister 1 or 3 hours after meal. 3. Advise patient not to take milk products concurrently

1. Assess for epigastric or abdominal pain. 2. Inform patient of symptoms of electrolyte imbalance 3. Monitor I/O including urine PH.

Health Teaching Plan

Objectives Contents Methodology Evaluation

General Objectives: After 1 week of nurse patient and significant others will be able to acquire knowledge, skills and attitude in the management of patient with Cushings syndrome Lecture- discussion Specific Objectives: After 45 minutes of student nursepatient-significant others interaction, the patient and significant others will be able to: 1. Define ROM and ROM exercises ROM- is the maximum movement that is possible for a body part or joint. Joint range of motion varies from individual to individual and is determined by genetic makeup, developmental patterns the presence/absence of a disease and the amount of physical activity in which the person normally engages. ROM exercises- exercise that ill people may need until they have/ can regain their normal/ usual activity levels. Informal Discussion associated with sharing from significant others. Demonstrationreturn demonstration Sharing Patient participated during the informal discussion. He asked some questions regarding the topic. Though he did not really participate in the return demonstration.

2. Cite the different classification on ROM exercises

Active ROM exercise: are isotonic exercises in which the client moves each joint in the body through its complete range of movement, maximally stretching all muscles with in each plane over the joint. - These exercises maintain or increase muscle strength and endurance and help maintain cardiorespiratory function in an immobilized client. They also prevent deterioration of joint muscles, ankylosis and contractures. Passive ROM exercise: another person moves each of the joints through its complete range of movement maximally stretching all muscle groups in each plane over each joint. These has of no value in maintaining muscle strength due to none contraction of muscles, but are useful in maintaining joint flexibility, for this reason passive exercises should be done when the client is unable to accomplish the movement activity. - Passive ROM exercise should be done to the point of

2.1 Active ROM exercises

2.2 Passive ROM exercise

2.3 Active assistive ROM exercise

slight resistance with no discomfort. Should be systematic and same sequence should be followed each session. Each exercise should be done 3x and a series of exercise should be done 2x a day. Active Assistive ROM exercise: client uses a stronger opposite arm or leg to move each of the joints of a limb incapable of active motion. The client learns to support and move the weak arm or leg with the strong arm or leg as far as possible. Then the nurse continues the movement passively to its maximal degree. This activity increases active movement on the strong side of the body and maintains joint flexibility on the weak side.

3. Demonstrate ROM exercise as tolerated by the patient

Simple joint movements (basic movements) Flexion- decreasing angle of a joint (ex. Dorsiflexion, radical

flexion) Extension- increasing angle of a joint (plantar flexion, straighten fingers) Hyperextension- further extension or straightening of a joint. Abduction- movement of the bone away from the midline of the body Adduction- movement of the bone towards the body midline of the body Rotation- movement of the bone/body part around its central axis Circumductionmovement of the distal part of the bone in circle while the proximal end remains. Eversion- turning the sole of foot outward by moving the ankle joint. Inversion- turning the sole of foot inward by the ankle joint. Pronation- moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body

Supination- moving the bones to the forearm so that the palm of the hand faces upward. * If muscle spasticity

occurs during movement, stop the movement temporarily but continue to apply slow gentle pressure on the part until the muscle relaxes, then proceed with the motion. * If contractures are present, apply a slow firm pressure without causing pain to stretch the muscle fibers. * If rigidity occurs apply pressure against it and continue exercise slowly.

VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO: A. Nursing Practice This case study of Cushings syndrome is very important for the nursing students and as a reference for the nursing practice in the clinical setting. This serves as a guide on how to treat or care people with Cushings syndrome by identifying the interventions, complication prevention, and education regarding the treatment plan, rehabilitation and lifestyle modification. The nursing implication of this case study is to help nurses in planning care for clients with Cushings syndrome. Nursing assessment also focuses on the patients psychological and mental status as the patient and the family faces this experience, treatment

modalities and progression of disease. Student will be able to determine ways on how to approach patient diagnosed with Cushings syndrome, this would also serve as a guide in identifying the needs of the patient and in giving proper nursing interventions. The nurse will be able to anticipate needs and possible complications in relation to the disease concern. Interventions appropriate for the care will also be developed. B. Nursing Education Manifestations of Cushings syndrome are varied and must be approached with astuteness, patience, and creativity. With this case study, more information can be presented for a wider range of perception regarding the disease process and the exact pathophysiology of this specific disease. By acquiring the knowledge and skills necessary, many misconceptions would be corrected and the community will be participating in promoting healthy lifestyles. Being much confident in doing the right approach to patient is going through. This case study can provide more depth and understanding of the disease. It shall help in the further analysis of the risks and causes that will give rise to awareness in nursing students. Knowledge of the classical and clinical signs and symptoms shall also assist nursing students in being sensitive to the patients needs. It will broaden the students perception and concept regarding the disease which her patient has been going through. It will also pave a way for further litigation and what might be done of required from the knowledge learned. It can open new doors to new facts about the condition. C. Nursing Research Nursing research should focus on how to prevent occurrence of disease and promoting quality of life in those who have been diagnosed with the disease. This case study adds information in having a wider scope on how to care and interact with this kind of condition. This also showed that further assessment leads to early detection and screening to achieve diagnosis and prompt intervention to halt the disease condition. This will have a basis of information or data for further studies.

SOAPIE # 1

June 18, 2007 S- wa koy gana anang exercise, kapoy kaayo akong lawas. As verbalized by the patient. O- Patient seen on bed with conscious, coherent. With IV number 1 of D5LRiL @ 10gtts/min on left arm, ambulatory with assistance, notable weak extremities, echymisis on skin, with the following vital signs BP 140/100 mmHg, PR 90 beats/min. RR 17 breaths/min. Temperature of 37.4. A- Activity intolerance: exertional discomfort related to muscle weakness P- To enhance activity tolerance I- Monitored vital signs and I/O Scheduled activities with periods of rest: provided environment conductive for relief of fatigue, clustered activities/nursing procedures, applied therapeutic touch, Talked to patient frequently, motivated significant others to take time with patient, provide non-pharmacologic treatments such as relaxation. E- Patient answered the student nurses question if hes comfortable with the activities done. Lovelijune M. Mioza Name of Student SOAPIE # 2 June 19, 2007 S- Kapoy akong lawas, Mura kong malipong usahay as verbalized by the patient. O- Patient seen on bed, conscious, coherent, IVF on left hand of D5LRiL @ 10gtts/min, ambulatory with assistance, notable weak extremities, small bruises on arms and legs, with limited range of motion. A- Risk for injury related to muscle weakness and muscle wasting due to protein catabolism. P- To promote safety. I- Assisted client in repositioning of self.

Observed for signs of injury, scheduled activities with adequate rest periods, increased fluid intake, keep environment free from clutter or water spills. E- Patient was free from harm

Lovelijune M. Mioza Name of Student

V. EVALUATION AND RECOMMENDATION Prognosis For me the patient has good prognosis because the cause of the patients condition is a result of chronic use or high doses of exogenous glucocorticoids where signs and symptoms can easily be reduced by gradually reducing the dosage or continuing steroid therapy and in some cases alternative therapy can be attempted.

Recommendation Corticosteroid medication is causing Cushings syndrome of the patient; I recommend that the patient gives strict compliance in lowering the dose or gradually stopping the medication. It may take a while for the signs and symptoms of Cushings syndrome to go away. Living with Cushings syndrome means making lifestyle changes to prevent weight gain and strengthen muscles and bones. The patient should see his physician regularly to check for other conditions that may develop because of Cushings syndrome, such as diabetes, osteoporosis, and high blood pressure.

As we learned, research is dynamic and never-ending for mans quest for the truth since we nurses should have been equipped with knowledge,

attitude and skills as we interact with our patients. Research is an integral part in the nursing profession since human beings are continuously changing and so is their responses are changing over time. Nurses should learn to adopt and adjust to these changes and research is a contributor in connecting to and through their needs. This case study can indeed serve as a fuel for advancement and development of the profession which we all have to look up and take much consideration to. VII. BIBLIOGRAPHY Kozier, et.al. Fundamentals of Nursing, 5th edition: 1998, Addison Welsy Suzanne Smeltzer and Brenda Bare. Medical-Surgical Nursing. 9th edition 1996, Lippincott Wiliams and Wilkins, Philadelphia. Elaine Marieb. Essentials of Human Anatomy and Physiology, 6th edition: 2000, Addison Wesley Longman, Incorporated, U.S.A. Barbara K. Timby and Nancy E. Smith Introductory Medical-Surgical Nursing, 8th edition: 2005, Lippincott Wiliams and Wilkins, Philadelphia. Maxine L. Patrick Medical-Surgical Nursing, concepts and clinical practice, 2nd edition: 1991, J.B. Lippincott company Wilma J. Phipps, Barbara C. Long and Nancy Fugate. Medical-Surgical Nursing, concepts and clinical practice, 3rd edition: 1987, C.V. Mosby Company http://www.mayoclinic.com/ http://www.wikipedia.org/ http://www.merck.com/ http://www.endocrine.niddk.nih.gov/pubs/cushings/cushings.htm#research http://health.yahoo.com

(Rexs work ends here)

3.4.3 Disease organ/system

process

and

its effects

on different

Through the various precipitating and predisposing factors that happen, abnormalities happen in the genetic material of the

cells. These abnormalities may be due to the effects of carcinogens, such as tobacco smoke, radiation, chemicals, or infectious agents. Other cancer-promoting genetic abnormalities may be randomly acquired through errors in DNA replication, or are inherited, and thus present in all cells from birth. Complex interactions between carcinogens and the host genome may explain why only some develop cancer after exposure to a known carcinogen.

Cancer-promoting oncogenes are often activated in cancer cells, giving those cells new properties, such as hyperactive growth and division, protection against programmed cell death, loss of respect for normal tissue boundaries, and the ability to become established in diverse tissue environments. These atypical cells have collected in the ducts in the breast. These ducts are the tiny tubes that carry milk from the lobules, where its made, to the nipple. At some point, these atypical cells broke through the duct wall, and started moving into the surrounding tissue replacing the normal breast tissue in the area thus forming a lump on the breast that is palpable. This is when your cancer crossed the line from DCIS or ductal carcinoma in situ to invasive (infiltrating) ductal carcinoma or IDC. If left untreated, the ductal carcinoma can metastasize (spread) via lymphatics to nearby lymph nodes, usually those under the arm.

Upon metastasizing, breast cancer can also spread to other parts of the body via blood vessels. So it can spread to the lungs, pleura (the lining of the lungs), liver, brain, and most commonly to the bones. Seventy percent of the time that breast cancer

spreads to other locations, it spreads to bone, especially the vertebrae and the long bones of the arms, legs, and ribs. Breast cancer cells "set up house" in the bones and form tumors. Usually when breast cancer spreads to bone, it eats away healthy bone, causing weak spots, where the bones can break easily. That is why breast cancer patients are often seen wearing braces or using a wheelchair, and why they complain about aching bones.

3.4.4 Comparative chart of classical signs and symptoms of the disease and actual manifestations of the patient

IV.

NURSING INTERVENTION
1. When preparing the client for the surgical procedure, be sure to: a. Listen Attentively b. Use calm, reassuring approach c. Explain the procedure d. Provide factual information concerning diagnosis, treatment, and prognosis e. Encourage verbalization of feelings, perceptions and fears f. Support the use of appropriate defense mechanisms g. Impose NPO

h. Transfer patient to stretcher prior to operation. 2. Interventions for post-operative patients of modified radical masectomy: 2.1 In dealing with post-operative pains a. assess pain levels b. promote verbalization of pain c. use distractional activities d. promote relaxational activities e. encourage deep breathing exercises 10x/hr f. administer opioid medications as prescribed by physician g. reassess pain levels 2.2 Maintaining asepsis a. use proper septic technique b. check for signs of infection on skin c. screen visitors for any infections d. administer anti-biotics as prescribed by wifey 2.3 In dealing with disturbed body image a. use anticipatory guidance b. discuss stressors affecting body image c. monitor if client can look at body part affected d. provide atmosphere of caring and acceptance e. refer client to support group who experienced the same loss

Name of Students: Tankiatsy, James Impression/Diagnosis: IDC Attending Physician: Dr. Patricio NURSING ASSESSMENT Nursing History Body part Mrs. Lynn Datanaga n, 35 years of Head Hair I Normocephalic , round black, P P A

oily

age, female, who lives in Tawog, Argao, Cebu Province, is a native born Filipino. She practices the Roman Catholic religion. She currently hasnt been able to conceive any children during the course of her marriage. She doesnt smoke, drink or have any other vices. She was previously advised 5 years ago to undergo FineNeedle Aspiration Biopsy (FNAB) of

Scalp Forehead Eyes Eyeballs Eyebrows Iris Extraoc ular Movemen ts Schlera Cornea Nose Ears Face Tongue Lips Chest

equally distribut No lesion ed No bruis No dandruff es Prominent Symmetrica l Slightly sunken Black, symmet rical Black or Darkbro wn Movements are well coordin ated. anicteric Transparent No dischar ges noted Nontend ner Nonten dne r

No bruits

Neck

With good auditory Nontend acuity ner Smooth, symmet rical No Centrally located Pink, moist With equal tend erne ss, no lesio

Nonten dne r

Lungs Abdomen

20 breaths per min Resonan ce

Normal

the breast Bladder mass located at her 10 oclock of Extremiti her right es breast. Upper The Lower results turned out benign. Mass continuall y grew to the size 3x3cm on the right breast with no other symptoms manifeste d. 3 days prior to admission, she resought a consult and had undergon e fineneedle aspiration biopsy (FNAB) once more, and this time the results indicated a presence of a malignanc y

chest expansi on. Symmetrical

ns

Nonten dne r

bowel sounds

Nontend ner

Saggy, no abrasio n Not distend ed, no assistiv e device used. With IVF, dry skin and with good reflexes . Dry skin, nail beds are pale, with good reflexes . Radial pulse = 92 bpm

Name of Patient: Mrs. Lynn Datanagan

Room/Ward: CDU-H 3rd Floor room 318

Age: 35 years old

Physician: Dr. Patricio

Moscoso
Complaints: for operative procedure (Breast mass biopsy and MRM)

NURSING CARE PLAN

Needs/ problems/ cues I. Physiologic

Nursing Diagnosis Altered

Scientific Basis

Objective

Nursing Rationale intervention Measures to

Overload: Altered Comfort

Cues: Objective: -Postoperative wound at right breast -occasional teeth clenching -facial grimace -labored movement on right portion of the body

comfort: Pain related to surgical removal of the right breast and axillary lymph nodes

Usually invasive surgical procedures involve inflicting trauma to the skin barrier and layers downward in order to achieve the therapeutic benefits. Trauma stimulates the pain fibers in the general area affected.

After 8 hours of student nursepatient interaction, the patient will be able to: 1. manifest

relieve pain:

a. assess pain levels

-to gather baseline data

signs of pain relief as evidenced by a pain scale of 4 or below.

b. promote verbalizati on of pain

Verbalizati on allows one to release built up tension and feelings about pain

www.en.wi ki pedia.org/ wiki /surgery

Subjective: -Pain rating scale of 8 out of 10

c. use distraction al activities distraction al activities takes the patients mind off the pain d. promote relaxationa l activities

relaxationa l activities allows one

-sakit jud siya uy as verbalized by client e. encourage deep breathing exercises 10x/hr

to use comfort to counter pain -deep breathing exercises allows one to focus on a certain act more thoroughly thus leaving the sensations of pain less prominent

- Opioids give out a strong analgesic effect f. administer opioid medication s as prescribed by physician

-to

reassess if objective are met.

g. reassess pain levels

Name of Patient: Mrs. Lynn Datanagan

Room/Ward: CDU-H 3rd Floor room 318

Age: 35 years old

Physician: Dr. Patricio

Moscoso
Complaints: for operative procedure (Breast mass biopsy and MRM)

NURSING CARE PLAN

Needs/

Nursing

Scientific

Objective

Nursing Rationale

problems/ cues I. Physiologic

Diagnosis

Basis

intervention

Overload: Risk for Infection

Cues: Objective: -Postoperative wound at right breast - WBC count of 16.4x10^9 /UL -neutrophil count of 90% lymphocyt e count of 08% -increased metabolic needs -body fatigue

Risk for infection related to surgical removal of breast tissue and axilliary lymph nodes

Any wound that is subjected to improper treatment has a chance of getting infected especially when factors such as sanitation, health status are poor.

2. maintain a healthy and uninfected body

Measures to

prevent infection:

a. stress proper handwashi ng techinique

-to maintain asepsis

b. maintain sterile technique when performing procedures

www.en.wi ki pedia.org/ wiki/ infection

-to prevent contaminati on and spread of causative agents of infection

c. promote proper nutrition

-a poor

nutritional status predisposes one to infection

d. encourage rest to avoid

-lack of

energy also predisposes one to be

fatigue

more likely to contract infection

e. administer antibiotics as prescribed by physician

-to kill microorganis ms in the body that might cause infection

Name of Patient: Mrs. Lynn Datanagan

Room/Ward: CDU-H 3rd Floor room 318

Age: 35 years old

Physician: Dr. Patricio

Moscoso
Complaints: for operative procedure (Breast mass biopsy and MRM)

NURSING CARE PLAN

Needs/ problems/

Nursing

Scientific

Objective

Nursing Rationale

cues I. Psychologi

Diagnosis

Basis

intervention

c Overload: Disturbed Body Image

Disturbed Body image: spacing out related to surgical removal of right breast

Cues: Objective: -Surgical Removal of the right breast - Not looking at the part affected -change in social involveme nt -patient seems to be aloof or to space out often

Masectomy always proved to be a difficult operation to accept. Patients, usually female, go through a period of distorted sense of body image due to the removal of her breast.

3. verbalize relief and adaptation to altered body state.

Measures to

promote relief and adaptation to altered body state:

a. assess clients level of adaptation

www.en.wi ki pedia.org/ wiki/ masectom y

b. encourage verbalizati on of feelings

-to establish a baseline data for future referral

-to release built up tension within the patient

c. discuss stressors affecting body image

-to identify

areas of actual concern for the client

Subjective: -unsaun naman nalang

-to

incorporate the body change to

ni?? as verbalized by patient to S.O. -feeling of helplessne ss

d. promote looking at the body part affected

the patient -to provide emotional support

e. provide atmospher e of caring and acceptanc e

f. refer client to support group who experience d the same loss

-to make client feel that she isnt the only one suffering from the condition

-to determine any progress with the goals.

g. reassess clients level of adaptation

Hospital No: 246641 James

Physician: Dr. Patricio Moscoso

Student Nurse: Tankiatsy,

Diagnosis: Infiltrating Ductal Carcinoma

DRUG THERAPEUTIC RECORD

Drug/ Dose/ Frequen cy/ Route/ Timing 1.

Classificatio n/ Mechanism of action

Side effects/ Indication/ Contraindicati on

Principles of care

Treatment

Evaluation

Zegen 500 mg 1 tab BID P.O.

Classificatio n

- give drug along with - pharyngitis, food to - anti-biotic tonsillitis, prevent otitis media, gastrointestin lower al upset. Mechanism respiratory infections, of Action: UTI, uncomplicat -when given bactericidal in tablet form, ed ; inhibits do not crush gonorrhea, synthesis dermatologi the tablet. of cell wall c infections, in bacteria prophylactic causing agent in cell death prevention of infection.

Indication:

- prepare vitamin K in case the patient develops hypoprothr ombinemia

- the

discontinue drug if hypersensit ivity reactions occur

patient was able to remain uninfecte d by any microorg anism through out the period of my care for her.

Contraindication: - allergy to

cephalospori ns, and penicillins.

-take full course of the therapy even if improveme nt occurs

Side effects:

Headache,

dizziness, nausea, vomiting, neurotoxicity , bone marrow depression, rash, fever,

hypoprothro mbinemia

Indication:

classificatio 2.Arcox ia 120mg 1tab OD P.O.

n: -Non-

steroidal antiinflammato ry drug

-rheumatoid arthritis, osteoarthriti s, acute pain, primary dysmenorrh eal, ankylosing sponylitis

-drug may be given with food, but it is not necessary

-rehydrate patient before starting with therapy

Mechanism of Action: -thought to

Contraindication: - allergy to

-take only prescribed doses

-inform patient it may take days to feel consistent pain relief

-the patient was able to receive adequate pain relief and verbalize d a pain scale of 3.

inhibit prostaglan din synthesis, impeding cyclooxyge

NSAIDs, hepatic impairement , pregnant and lactating women.

nase to produce antiinflammato ry, analgesic and antipyretic effects

Side effects: -dizziness,

headache, diarrhea, nausea, vomiting, flatulence, abdominal pain

Name: Ms. Lynn Datanagan

Student Nurse: Tankiatsy,

James
Age : 35 years old

Diagnosis: Infiltrating Ductal Carcinoma

Physician: Dr. Patricio

Moscoso
HEALTH TEACHING PLAN OBJECTIVES General Objectives: After 5 days of holistic student nurse-patient interaction, the patient and S.O. will be able to acquire knowledge, attitude and skills in the management of the postCONTENTS METHODOLOGY EVALUATION

operative body condition of modified radical masectomy.

Specific Objectives: After 30-45 minutes of student nurse-patient interaction, the patient will be able to: 1. understand the importance of having undergone MRM as evidenced by lesser degree of frustration over body image

1. Modified Radical Masectomy is a vital and critical procedure which was a necessary step to prevent further damage by imminent metastasizing infiltrating ductal carcinomas. Once the carcinoma has successfully metastasized, the complications would soon spread

- Informal discussion

- After the health teaching was imparted, the patient grew to understand the importance of having undergone the procedure and was able to appreciate slightly the procedure.

to the lungs,

pleura (the lining of the lungs), liver, brain, and most commonly to the bones in
which the condition of the patient would be less desirable. Prognosis is very bad when the cancer reaches stage IV (metastasis). -Lecture discussion -The patient was able to gain selfesteem as evidenced by slight traces of smiling

2. conform to a positive selfconcept despite insecurity brought about by adistorted body image

3. comprehend

2. an anxious person can better cope up with his or her new found insecurities if he/she is given time to herself in a quiet environment to reflect on the situation. Ofcourse, comfort measures should always still be given as well as distractional activities. Engaging in positive self talk seems to be fruitful in boosting up the clients self-esteem as it allows the patient to have a positive selfconcept about his

-informal lecture - patient was able to understand how to prevent infection and maintain

how to prevent infectious complications to the post-operative wound

or herself.

asepsis.

4. demonstrate proper ways in the management of the post-operative wound inflicted in MRM

-the hands should always be washed prior to coming into contact with the patient so as to perform care activities. Too many visitors isnt recommended as the patient recently came out from the OR and is immunosuppressed as of the moment. Strict compliance to the anti-biotic regimen should help drastically with preventing any serious microbial infection

-demonstration and Return demonstration - The patient was able to understand and perform what needed doing and was able to avoid performing what are prohibited of her.

The patient should always be assisted when sitting up or lying down, the right arm should be kept at the side always. Abductions and exertions using the right arm should be avoided and turning to the sides is not recommended and always remember to make sure not to place the pressure

cuff of the sphygmanometer on that side of the arm.

Patients name: Datanagan, Lynn James Diagnosis: Invasive Ductal Carcinoma

Student Nurse: Tankiatsy,

SOAPIE # 1 S gikapoy mana siya tungod gahapun as verbalized by S.O. O Seen patient lying on bed with IV #2 D5LR at 10 gtts/min, infusing well on left arm. Patient seems fatigued, weak, and lacked energy to perform daily tasks. A Activity intolerance: Fatigue r/t recent major surgical operation P To promote gradual activity intolerance I provided quiet environment and non stimulating surroundings. Promoted rest. Encouraged the use of distractional methods and relaxational techniques. Promoted the conservation of energy and avoidance of strenuous activities. E Patient listened and decided to sleep and conserve energy. The patient thanked me for the advices.

Patients name: Datanagan, Lynn James Diagnosis: Invasive Ductal Carcinoma

Student Nurse: Tankiatsy,

SOAPIE # 2 S sakit-sakit pasad dira sa right dapita as verbalized by patient O Seen patient lying on bed without IV. Patient seems to clench teeth slightly with a facial mask that shows pain, slight clenching of left fist happened also. Patient states that intermittent pain on her right chest that lasts for a few seconds, sharp in nature and aggravated by movement. Rest seems to alleviate the pain and she is given Arcoxia 1 tab OD PO. A altered comfort: pain r/t surgical removal of the breast tissue and axilliary lymph nodes P to provide relief of pain as evidenced by a pain rating scale of 4 or below. I provided quiet environment and non stimulating surroundings. Promoted rest. Encouraged the use of distractional methods and relaxational techniques. Guided imagery and deep breathing exercises 10 times every hour is encouraged. Verbalization of pain was recommended also and lastly, arcoxia tablet was given. E Patient was able to gradual gain slight relief of pain and was thankful to me for the advice.

V. Evaluation and Recommendation

5.1

Prognosis:

There are several prognostic factors associated with infiltrating ductal carcinoma. Stage is the most important, as it takes into consideration local involvement, lymph node status and whether metastatic disease is present. The higher the stage at diagnosis, the worse the prognosis. Infiltrating ductal carcinoma patients whose lymph nodes are cancer free have a much better prognosis than those whose lymph nodes are positive for cancer.

The presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor which may guide treatment. Hormone receptor positive ductal carcinoma is usually associated with much better prognosis compared to hormone negative breast cancer.

HER2/neu status has also been described as a prognostic factor. Patients whose cancer cells are positive for HER2/neu have more aggressive disease and may be treated with trastuzumab, a monoclonal antibody that targets this protein.

In the case of Lynn Datanagan, her choice to have early masectomy performed now has increased the chances that ductal carcinoma will not be able to metastasize and thus that indicates that chances for improved or total recovery from ductal carcinoma might be an

obtainable dream. So as long as she continues following her drug regimen and promote the prevention of reoccurrence of ductal carcinomas and develop successfully effective coping mechanisms, developing another malignant breast mass might not just happen any time soon.

5.2

Recommendation:

In order to increase the chances of allowing Lynn Datanagan to enjoy a normal life once again, it is recommended that nursing and medical interventions including the prevention interventions of redeveloping cancer are carried out with vigilance and regularity.

VI.

Evaluation and Implication of this Case Study to:

6.1

Nursing practice

With this study on infiltrating ductal carcinoma and modified radical masectomy, nurses and even other health practitioners would be able to have a general understanding of infiltrating ductal carcinoma and modified radical masectomy so as that it would improve the quality and type of nursing care we are able to render to our less fortunate sisters and even brethren. Knowledge and skill of the reader will be enhanced through the use of this case study. With the information gathered from this case study, the maximum potential of the nursing profession would be closer and much more attainable to reach both for us, nurses, and for patients alike.

6.2

Nursing Education

With the help of this case study, the nursing students will be able to read first hand exposures of the disease and treatment, infiltrating ductal carcinoma and modified radical masectomy, experienced by actually people. The students would be able to understand the pathophysiology of the disease and the procedure with even more extent. Students will be able to understand the effects of the interventions done for the patient and their subsequent results. This case study not only serves to benefit nursing students, but all other medical practitioners would benefit from acquiring the data gathered on this case study.

6.3

Nursing Research

Through the efforts of this case study, new information, knowledge, findings, and interventions the data could possibly be gathered With the and new formulated from presented within.

knowledge, one would be able to provide care with improved knowledge regarding the disease and procedure and with greater impact. New interventions would be able to advance further the effectiveness and efficiency of the care rendered by the health practitioners.

VI.

Bibliography
1. Ignativicius, Donna D. and Workman M. Linda. Medical-Surgical Nursing: Critical Thinking for Collaborative Care (5th edition): Elsevier Saunders, pp.1793-1822. 2. http://en.wikipedia.org/wiki/Breast_cancer 3. http://en.wikipedia.org/wiki/ductal_carcinoma 4. http://woman-health.org/virtual/Infiltrating_Ductal_Carcinoma

5. http://en.wikipedia.org/wiki/Masectomy 6. http://en.wikipedia.org/wiki/Breast 7. http://www.healthcentral.com/breast-cancer/types-36003-5.html 8. http://cancer.health.ivillage.com/breastcancer/ductalcarcinoma9.cf m

Actually this is not yet done But at least you will have a guide