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On successful completion of this unit, you should be able to:
1. Apply clinical decision-making skills to identify and prioritise health problems for individuals experiencing acute medical health alterations
2. Explain the impact of acute medical health alterations for the individual and their family/carers
3. Minimise the psychosocial effects of acute alterations in health for individuals and their families/carers
4. Identify the links between the pathophysiology and manifestations of acute medical health alterations (GA 4)
5. Plan evidence-based, holistic, person-centred care for individuals experiencing acute medical health alterations, including education and discharge planning (GA 5)
6. Determine appropriate nursing therapies and describe medical and allied health interventions for selected acute medical health alterations
7. Evaluate the effectiveness of nursing therapies and interventions
8. Apply evidence, standards and guidelines to analyse selected acute critical incidents and their management
9. Debate legal, ethical and risk issues specific to caring for an individual experiencing an acute medical health alteration.

Introduction to Exogenous Cushing's Syndrome

Q1. Outline the Disease, Causes, Incidence and Risk Factors. Discuss the Impact of the

Exogenous Cushing’s Syndrome on the Patient and Their Family

Ms Maurine Smith is suffering from Exogenous Cushing's Syndrome. According to Jarvis et al. (2016). The disease is caused by prolonged exposure to cortisol hormone that is overproduced from the adrenal glands. Besides, the cortisol may be produced by use of cortisol-like medications such as prednisolone or tumour that activate the adrenal glands to overproduce cortisol hormone. On the other hand, Exogenous Cushing’s Syndrome may be as a result of after medication of diseases such as pituitary adenoma. Other various tumours also cause Cushing’s syndrome whereby some are associated with inherited disorders such as Carney complex.

Moreover, Cushing’s syndrome risk of infection may be increased by other factors such as long term taking of corticosteroid medications and type 2 diabetes and poor regulation of blood glucose levels that may lead to hypertension and blood sugar. Also, Nursing and Midwifery Board of Australia (2016) illustrates that pituitary gland tumour, ectopic ACTH-secreting tumour which is an organ that causes abnormality in the production of ACTH hormone that is responsible for cortisol regulation and primary adrenal gland disease consist of other significant factors responsible for Exogenous Cushing's Syndrome infections.

A research conducted by the Nursing and Midwifery Board of Australia (2018) illustrates that Cushing's syndrome is sporadic with an incidence of less than one case per year over a million people. However, pituitary gland infections are in 1 out of the six individuals. Although researches show a low incidence of exogenous Cushing's syndrome, there are more patients with uncontrolled diabetes mellitus, obesity, and hypertension.

According to Berman (2014), avoidance in the treatment of exogenous Cushing's syndrome may lead to other effects such as bone loss.  Loss of bones reduces the Body Mass Index (BMI) of an individual to abnormal. Besides, exogenous Cushing’s syndrome may lead to bone fractures as a result of the general body weakness and muscle loss. Consequently, exogenous Cushing’s syndrome disease leads to high blood pressure and type 2 diabetes infections that put the patient at high risk of other associated infections (Farrell and Dempsey, 2016). Lastly, the disease results in effects such as the enlargement of the pituitary tumour of the patient and kidney stone a condition that causes instability in glucose balance within the patient's body. By interfering with the pituitary glands due to exogenous Cushing's syndrome, other hormone production within the body also interferes.

Causes and Risk factors

Extensive research conducted by Berman (2017) indicates that the patients suffering from exogenous Cushing’s syndrome suffered from emotional, mental and physical effects. Besides, the analysis illustrates that the results were extended to family members as well as their performance at work and school. For instance, Maureen' s work at the restaurant can be significantly affected by the disease she is suffering from since she cannot perform the tasks assigned correctly while having fatigue or depression. On the other hand, while seeking for medication, it means that Maureen will stop attending the nursing classes regularly. The family members such as the husband should also incur the costs of treatment of his spouse and as well pay attention to the patient while abandoning other tasks he might be having.

Q2. Discuss Three (3) Common Signs and Symptoms of Exogenous Cushing’s Syndrome and Explain the Underlying Pathophysiology of Each  

Symptom

Underlying Pathophysiology

1. The patient experiences weight gain around the trunk and waist. Besides, there is also the loss of fats in the legs and arms. The lost fats are deposited in the mid-section of the patient’s body (McCance and Huether, 2014).

1. Fats accumulated in the mid-section of the patient's face leads to a rounded face or a moon-shaped face. Furthermore, fat deposits also experienced in the shoulders and the back causing a buffalo hump. Similarly, fat accumulation may lead to narrowing of veins and arteries, a condition that limits efficient blood flow leading to increased blood pressure together with sodium concentrations and low water retention.

2. The patient’s pituitary gland secretes too much ACTH hormone. ACTH hormone in excess corresponds to overproduction of excess cortisol hormone from the adrenal gland that is responsible for stress.

2. The patient may experience headache and anxiety. Besides the patient may experience increased depression and similarly dysfunction in cognitive (McCance and Huether, 2014). Stress also puts the patient at high risk of other disease infection such as hypertension. Thus, low water concentrations, sodium and potassium accumulations that increase the blood pressure of the patient. Increase in the patient's blood pressure makes even movements difficult therefore easy fat accumulation within the patient's body which leads to the development of other related abnormalities.

3. There is a weakened immune system of the patient infected with Exogenous Cushing’s Syndrome. The weak immune system is further extended to mood disorders such as anxiety and depressions.

3. Other diseases such as diabetes and RA easily attack the patient infected with the disease. Among the other illnesses that the patient is at high risk to suffer from including the thinning of the skin that bruises easily, injuries that occur on the skin that are not easy to heal, bone loss and muscle weakness (Martini, Nath, and Bartholomew, 2017). As a result of muscle weaknesses, it becomes difficult for the patient to make movements easily and therefore demanding patient support when conducting the nursing care plans. On the other hand, the bruised skins may lead to overbreeding that leads to loss of body fluids and causing open wounds that are at risk of other associated infections.

Q3. Discuss the Pharmacodynamics & Pharmacokinetics of One (1) Common Class of Drug Relevant to Ms Maureen Smith

Exogenous Cushing’s syndrome can be treated using various options that include surgery, reducing corticosteroid use, medications, and radiation therapy. However, according to Tiziani (2017), medicines as a means of treating exogenous Cushing's syndrome is associated with different pharmacodynamics and pharmacokinetics. Medications control cortisol production especially when surgery and radiation therapy fail to work.

Furthermore, medications improve signs and symptoms before surgery, thus minimising surgical risks. Besides Tiziani (2017) illustrates that medications help control excessive production of cortisol from the adrenal glands such as the Nizoral, mitotane, and metyrapone. Also, other drugs such as Mifepristone help in the treatment of patients with two diabetes and blocking of cortisol effects on the patient’s tissues.

However, the above-stated medications are associated with side effects such as fatigue, muscle aches, vomiting, nausea, swelling, low potassium, and high blood pressure. Other current medications include the use of pasireotide that helps in decreasing ACTH production from a pituitary tumour more especially when surgery is impossible (Tiziani, 2017). Like other medications, they are associated with side effects such as diarrhoea, abdominal pain, and nausea.

Q4. In Order of Priority, Develop A Nursing Care Plan for Your Chosen Patient Who Has Just Arrived on The Ward from Ed. Nursing Care Plan Goals, Interventions, and Rationales Must Relate to the First 8 Hours Post Ward Admission

 

 

Assessment

 

Nursing Diagnosis

Patient

Outcomes

 

Interventions

Rationale

Evaluation

of Outcomes

Objective Data:

-Abdominal pain and fatigue which has been worsening.

-Gastrointestinal bleeding

-PR 88 bpm

-RR 18 bpm

- BP 154/106 mmHg

-Temp 36.9? C.

-SpO2 99% on room air.

-Body Mass Index (BMI) of 28kg/m?

-Fat distributed around her abdominal area.

-Hump between her shoulders.

#1: Excess fluid volume associated with a hump between her shoulders.

#2: Body image disturbance, associated with physical changes secondary to Cushing’s syndrome

#3: Risk for injury, associated with generalised weakness and fatigue.

#4: Risk of infection, associated with an impaired immune response due to RA and type 2 diabetes

Patient will:

1. Regain the normal body fluid balance and avoid gastrointestinal bleeding.

2. Remain free from injury.

3. Remain free from other infections.

4. Verbalise understanding of the physical effects of the disease process and realistic expectations of desired changes in appearance.

5. Normal face shape and uniform distribution of fats within the patient’s body

1. Weigh the patient’s Body Mass Index using the same scale.

2. Monitor the vital signs especially BP and RR (Tiziani, 2017)

3. Ask the patient to elevate feet while sited

4. Develop a schedule for the rest of the activity periods

5. Lighting should be adequate in the room and ensure the patients wear shoes and glasses when getting out of bed (Farrell and Dempsey, 2014)

6. If in agreement provide a private room and restrict parents and teachers at the moment.

7. When providing care, use strict and surgical asepsis.

8. Time should be created for the discussion regarding the disease and treatment. Identify the successful coping mechanisms used in the past and encourage verbalization.

9. For every 2-4 hours, coughing, turning and deep breathing incentive spirometry.

1. Due to the expanded fluid. Cushing's syndrome may result in increased pressure with sodium and water retention

2. Elevating feet when sitting down reduces fluid accumulation in the lower extremities

1. Gastrointestinal with no bleedings.

2. Blood pressure decreased (Perrin, 2014).

3. Uniform distribution of fats with no hump between the patient’s shoulders.

4. The wound did not have signs of added infection.

5. Patient’s face regaining the original shape with fewer infections.

Subjective Data:

-Patient’s husband noted the patient’s face becoming round over the past few weeks.

-Patient’s fasting BGL is 14.0mmol/L

-Blood tests results show low cortisol and ACTH levels

-High levels of low-density lipoprotein cholesterol.

3. Excess cortisol will increase blood pressure as a result of sodium and water retention (McKenna and Lim, 2014).

Medical Diagnoses:

-She was diagnosed with rheumatoid arthritis (RA) at 15 years old.

- She has experienced multiple exacerbations of RA and is currently taking 50mg of prednisolone.

-Patient has two types of diabetes that are managed with metformin.

 

References

Berman, A., Snyder, S., Kozier, B., Erb, G., Levett-Jones, T., Dwyer, T., et al. (2014). Kozier and Erb’s fundamentals of nursing. (3rd Australian ed.) French’s Forest, NSW: Pearson Australia.

Berman, A., Snyder, S., Kozier, B., Erb, G., Levett-Jones, T., Dwyer, T., et al. (2017). Kozier and Erb’s fundamentals of nursing. (4th Australian ed.) French’s Forest, NSW: Pearson Australia.

Farrell, M., & Dempsey, J. (2014). Smeltzer and Bare’s textbook of medical-surgical nursing (3rd Australian and New Zealand ed.). Sydney: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Farrell, M., & Dempsey, J. (2016). Smeltzer and Bare’s textbook of medical-surgical nursing (4th Australian and New Zealand ed.). Sydney: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Jarvis, C. Australian Adapting Editors Forbes, H., Watt, E. (2016). Physical Examination & Health Assessment (2nd Australian and New Zealand ed.). Chatswood, NSW: Elsevier/ Saunders

Martini F., Nath J & Bartholomew E. (2017). Fundamentals of anatomy and physiology. 11th ed). San Francisco: Pearson.

McCance, K., & Huether, S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis: Elsevier/Mosby.

McKenna, L. & Lim, A. G. (2014). Pharmacology for nursing and midwifery. (2nd Australian and New Zealand Edition). Broadway: Lippincott Williams & Wilkins

Nursing and Midwifery Board of Australia. (2016). Registered nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Nursing and Midwifery Board of Australia. (2018). Professional Standards. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Perrin, R. (2014) Pocket guide to APA Style (5Massachusetts: Wadsworth/ Cengage Learning. (Highly recommended). the ed.) Boston

Tiziani, A. (2017). Harvard’s nursing guide to drugs. (10th ed.). Sydney: Mosby/Elsevier

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