CHAPTER 38 CORTICOSTEROIDS Mosby items and derived items

FUNCTIONS OF ADRENAL GLANDS (WHERE ARE THEY LOCATED? ) • The adrenal cortex secretes two types of corticosteroids (hormones) • Mineralocorticoids (Addison’s disease & F&L balance) • Fludrocortisone (Addison’s) • Aldosterone (increases Na reabsorption, thus inc B/P) • Glucocorticoids (antiinflammatory, metabolism of CHO, Pro, &Fat) • Cortisone • Hydrocortisone • Prednisone • BTW…. Adrenal Medulla secretes Epinephrine (F/F) Mosby, Inc. , an affiliate of Elsevier Inc. 38 -2

PREMEDICATION ASSESSMENT • Check for electrolyte imbalance: • KNOW NORMAL VALUES • Record intake and output, vital signs • Check for signs of infection (may be masked, low temp) • Perform baseline assessment of patient’s degree of alertness WHY? Steroids can cause Psychosis, esp pt with mental disorder (quickie: AOX 4, ABC’s) • Previous treatment for ulcer, heartburn, stomach pain • Taking NSAIDS, ASA…. . Why? • Taking herbs? (ginko, ginsing, garlic) • Test stools for occult blood Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -3

NURSING PROCESS: IMPLEMENTATION • Monitor glucose levels for elevation; insulin may be required • Follow body’s normal circadian rhythm • Corticosteroids: 2/3 of dose before 9 AM, 1/3 of dose late afternoon • Mineralocorticoids: once daily in evening • Monitor daily weight, I&O • Additional doses may be needed if patient experiences stress, accidental injury; wear ID bracelet Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -4

DRUG CLASS: MINERALOCORTICOIDS • Drug: fludrocortisone (Florinef) The only true mineralocorticoid drug • Actions • Affect fluid and electrolyte balance causing sodium and water retention • Uses • Treat adrenal insufficiency, Addison’s disease (you need to ADD mineralocorticoids to this pt) • Therapeutic outcomes • Control of blood pressure, restore fluid and electrolyte balance • Adverse effects: sodium accumulation, potassium depletion • Remember …. . H 20 follows Na Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -5

AUDIENCE RESPONSE QUESTION 1 • Which laboratory test result is the nurse especially aware of for a patient who is taking fludrocortisone (Florinef) for the treatment of Addison’s disease? A. B. C. D. Potassium depletion Sodium loss Calcium loss Hydrogen increase A- Causes sodium retention and potassium loss Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -6

AUDIENCE RESPONSE QUESTION 2 • The nurse instructs a patient taking fludrocortisone (Florinef) that he should notify the health care provider of the occurrence of which adverse effect? A. B. C. D. Fatigue Weight loss Edema of feet and ankles Nausea • C Na & H 2 O retention, K loss also check daily wt Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -7

DRUG CLASS: GLUCOCORTICOIDS • Actions • Antiinflammatory, antiallergenic (2 nd choice after antihistamines) immunosuppression (autoimmune disorders/ transplants/ cancer) • Uses • Certain cancers, organ transplantation, autoimmune diseases, allergies, shock • Common and serious adverse effects • Electrolyte imbalance, fluid accumulation; susceptibility to infection; behavioral changes; hyperglycemia; peptic ulcer formation; delayed wound healing; visual disturbances; osteoporosis • Long term may use every other day dosing always use the smallest dose for the shortest length of time to avoid neg SE Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -8

CORTICOSTEROID THERAPY: DRUG INTERACTIONS • Diuretics • Corticosteroids may enhance the loss of potassium • Warfarin • Corticosteroids may enhance or decrease the anticoagulant effects of warfarin • Oral hypoglycemic agents or insulin • Diabetic/prediabetic patients must be monitored for hyperglycemia Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -9

STEROID TAPER • Abrupt discontinuation of therapy may result in adrenal insufficiency. Adrenals shut down BC there are steroids in bloodstream • Symptoms • Fever, malaise, fatigue, weakness, dizziness, fainting, anorexia, nausea, hypotension, dyspnea, hypoglycemia, muscle and joint pain • Gradual withdrawal of steroid use prevents symptoms of adrenal insufficiency and allows adrenal glands to start functioning again • That is why QOD dosing works well Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -10

CORTICOSTEROID THERAPY: USE WITH CAUTION • Carefully monitor patients with • • • Diabetes mellitus (hyperglycemia) Heart failure Hypertension Peptic ulcer disease (check stool for OB) Mental disturbance (neuro base line, psych Hx) Suspected infections (may mask S&S) Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -11

PATIENT EDUCATION FOR CORTICOSTEROID THERAPY • Know when to contact health care provider (increased physical or mental stress, signs of infection, edema) • Perform appropriate skin care • Cope with stress • Avoid infections • Ensure proper nutrition • Ensure regular exercise • Foster health maintenance • Maintain a written record Pt self assessment record vs, wt, mood changes, response to Tx) Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -12

AUDIENCE RESPONSE QUESTION 3 • What is a common adverse effect of glucocorticoids? A. B. C. D. Weight loss Hypoglycemia Appetite suppression Delayed wound healing E. D especially significant if pt is diabetic Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -13

AUDIENCE RESPONSE QUESTION 4 The nurse is teaching a patient about a glucocorticoid medication to treat an adrenal disorder. Which statement made by the patient indicates a need for further teaching? A. “I take my medications with breakfast. ” B. “I’ll be careful not to be in crowds of people. ” C. “My prescription ran out, but I’ll refill it next week. ” D. “I’ll follow up with my physician in 1 week. ” Ø c Titrate off to allow adrenal glands to return to normal, do not stop suddenly Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -14

AUDIENCE RESPONSE QUESTION 5 • A patient has been taking an oral corticosteroid to treat inflammation of the respiratory tract. The patient questions the nurse who is administering a dose of insulin. The nurse should respond: A. “Your physician wants you to take this to prevent diabetes. ” B. “Your pancreas is no longer functioning and you need insulin. ” C. “Your respiratory tract inflammation has caused you to be diabetic. ” D. “Corticosteroids frequently cause your blood sugar to increase. ” E. D/ hyperglycemia Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 38 -15