A 45-year-old female patient with Cushing disease presents with significant lower extremity edema, worsening hypertension, fasting blood glucose of 210 mg/dL, hypokalemia, and decreased bone mineral density. Which nursing intervention is most appropriate to address both the edema and hypokalemia?

C) Administer a potassium-sparing diuretic to manage edema and correct hypokalemia.

A) Administer a loop diuretic to reduce fluid retention.

B) Initiate a low-sodium diet to help manage blood pressure.

C) Administer a potassium-sparing diuretic to manage edema and correct hypokalemia.

D) Encourage increased fluid intake to dilute serum glucose levels.

A 45-year-old female patient with Cushing disease is experiencing significant lower extremity edema, worsening hypertension, and hypokalemia. Given these findings, which nursing intervention is the most appropriate to address the patient's electrolyte imbalance?

B) Administer a potassium-sparing diuretic as prescribed.

A) Encourage the patient to consume foods high in sodium.

B) Administer a potassium-sparing diuretic as prescribed.

C) Restrict the patient's fluid intake to 1,000 mL per day.

D) Increase the patient's physical activity to reduce edema.

A patient with chronic hypertension and type 2 diabetes mellitus has been prescribed spironolactone to manage edema and improve potassium levels. The healthcare team also plans to introduce an SGLT2 inhibitor for better glycemic control. Which of the following nursing actions is most important to implement as part of the patient's care plan?

A) Monitor the patient for signs of hyperkalemia.

B) Educate the patient about the importance of a low-sodium diet.

C) Advise the patient to increase fluid intake to prevent dehydration.

D) Schedule regular blood glucose monitoring to assess the effectiveness of the SGLT2 inhibitor.

A patient with hypertension and type 2 diabetes is prescribed spironolactone to manage edema and hypokalemia. Which of the following assessments should the nurse prioritize to prevent potential complications from the new medication?

A) Monitoring serum creatinine levels

B) Measuring blood glucose levels

C) Checking blood pressure readings

D) Assessing for signs of dehydration

A patient with hypertension and edema has been prescribed an increased dose of spironolactone. Which of the following assessments is most important for the nurse to perform to monitor for potential adverse effects of this medication?

A) Monitor the patient's serum potassium levels

B) Assess the patient's blood glucose levels

C) Check the patient's heart rate and rhythm

D) Evaluate the patient's daily weight

A patient with hypertension and diabetes mellitus presents with increased fatigue, muscle weakness, pitting edema, and suboptimal glycemic control. After increasing the dose of spironolactone, what nursing action is most important to prioritize in the care plan to address these clinical changes?

D) Evaluate the patient's serum potassium levels regularly to prevent potential hypokalemia.

A) Monitor the patient's blood glucose levels closely and report any significant elevations.

B) Educate the patient on the importance of adhering to a low-sodium diet to manage edema.

C) Schedule regular follow-up appointments to assess the patient's blood pressure and heart rate.

D) Evaluate the patient's serum potassium levels regularly to prevent potential hypokalemia.

A patient with Cushing's disease presents with increased abdominal discomfort, elevated blood pressure, and worsening glycemic control despite current treatment. Which nursing intervention is the priority to address the patient's current condition?

B) Monitor blood glucose levels closely and report any significant elevations to the healthcare provider.

A) Educate the patient on the importance of adhering to a low-sodium diet to manage hypertension.

B) Monitor blood glucose levels closely and report any significant elevations to the healthcare provider.

C) Assess the patient's understanding of medication changes, including the addition of ketoconazole.

D) Evaluate the patient's fluid status and adjust diuretic therapy as needed.

A patient with Cushing's disease presents with increased abdominal discomfort, persistent hypertension, and worsening glycemic control. Recent tests indicate hypercortisolism and electrolyte imbalances. Which nursing action is most appropriate to prioritize in the care plan to address the patient's current condition?

A) Administer prescribed ketoconazole to decrease cortisol levels

B) Educate the patient on dietary changes to manage elevated blood glucose levels

C) Monitor the patient's blood pressure closely and administer the new antihypertensive as ordered

D) Encourage increased fluid intake to manage slight hypernatremia

A patient with Cushing's disease on ketoconazole therapy presents with persistent fatigue and muscle weakness, low serum potassium, and elevated blood glucose levels. Which nursing intervention should be prioritized to address the electrolyte imbalance?

C) Assess the patient's current medication regimen for potential drug interactions affecting potassium levels.

A) Increase dietary intake of high-potassium foods such as bananas and oranges.

B) Encourage the patient to reduce fluid intake to prevent further potassium loss.

C) Assess the patient's current medication regimen for potential drug interactions affecting potassium levels.

D) Suggest the patient increase physical activity to reduce muscle weakness.

A patient with Cushing's disease is experiencing persistent fatigue and muscle weakness, despite treatment showing some positive changes in cortisol levels and blood pressure. Her potassium level remains low at 3.1 mEq/L. Which nursing intervention is most appropriate to address her electrolyte imbalance and associated symptoms?

C) Collaborate with the healthcare provider to adjust medications that may be affecting potassium levels.

A) Increase dietary intake of potassium-rich foods and continue current potassium supplementation.

B) Discontinue potassium supplementation and focus on fluid restriction to manage edema.

C) Collaborate with the healthcare provider to adjust medications that may be affecting potassium levels.

D) Encourage increased physical activity to enhance muscle strength and alleviate fatigue.

CUSHING DISEASE - Nursing Case Study

Pathophysiology

• Primary mechanism: Cushing disease is primarily caused by a pituitary adenoma that secretes excess adrenocorticotropic hormone (ACTH), leading to overstimulation of the adrenal cortex. This results in elevated cortisol levels, disrupting normal feedback mechanisms.

• Secondary mechanism: The persistent high levels of cortisol cause metabolic disturbances, including protein catabolism, gluconeogenesis, and fat redistribution. This leads to clinical features like muscle wasting, hyperglycemia, and characteristic fat deposition (e.g., moon face, buffalo hump).

• Key complication: Chronic cortisol elevation suppresses the immune response and increases risk for infections, hypertension, and osteoporosis, significantly impacting patient health and requiring careful management.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Diagnosed with Cushing disease 2 years ago, hypertension, type 2 diabetes

• Current medications: Hydrocortisone, Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and muscle weakness

• Key symptoms: Rapid weight gain, particularly in the face and abdomen, easy bruising, high blood sugar levels, and high blood pressure

• Vital signs: Blood pressure 155/98 mmHg, heart rate 92 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, blood glucose 190 mg/dL

Section 1

As the healthcare team continues to monitor the 45-year-old female patient with Cushing disease, a recent change in her status raises concerns. Over the past week, she has developed new symptoms of significant lower extremity edema and worsening hypertension, with blood pressure readings consistently in the range of 165/102 mmHg. Additionally, her fasting blood glucose has spiked to 210 mg/dL, despite adherence to her current diabetic management regimen. The patient reports increased difficulty with mobility due to both the edema and generalized muscle weakness, and she expresses frustration over her inability to perform daily activities at work and home.

In light of these developments, a comprehensive workup is initiated to identify potential complications. Laboratory tests reveal further electrolyte imbalances, including hypokalemia with a serum potassium level of 3.2 mEq/L, which may be contributing to her muscle weakness and cardiac strain. A recent bone density scan indicates a marked decrease in bone mineral density, suggesting early osteoporosis, which is a known complication of prolonged cortisol exposure. An echocardiogram is ordered to assess the impact of sustained hypertension on cardiac function, given the patient's elevated blood pressure and increased cardiovascular risk profile.

These findings necessitate a multidisciplinary approach to adjust the patient's treatment plan. The healthcare team considers optimizing her antihypertensive therapy, potentially adding a potassium-sparing diuretic to address both the edema and hypokalemia. Additionally, there is a discussion regarding the potential need for surgical intervention to address the underlying pituitary adenoma, as medication adjustments alone may not sufficiently control her cortisol levels and associated complications. The team also emphasizes the importance of regular follow-up and monitoring for early signs of infection, given her immunosuppressive state, as well as implementing strategies to prevent further bone loss. The patient's journey continues as the team works collaboratively to manage her evolving condition and improve her quality of life.

Section 2

As the healthcare team reviews the recent assessment findings, attention is drawn to the patient's cardiovascular status, given the persistent hypertension and the new symptom of significant lower extremity edema. The echocardiogram reveals mild left ventricular hypertrophy, a common consequence of chronic high blood pressure, which further underscores the urgency of optimizing her hypertensive management. The decision is made to add spironolactone, a potassium-sparing diuretic, to her treatment regimen to not only address the edema but also correct her hypokalemia, with the hope of alleviating some of her muscle weakness.

In parallel, the patient's elevated fasting blood glucose level warrants a re-evaluation of her diabetic management. The endocrinologist suggests intensifying her current regimen by introducing an SGLT2 inhibitor, which may offer the dual benefit of improving glycemic control and providing some cardiovascular protection. The patient's ongoing difficulty with mobility is also addressed through a referral to physical therapy to develop a personalized exercise plan that accommodates her limitations while aiming to strengthen her muscles and improve her functional capacity.

Over the next few weeks, the patient reports moderate improvement in her symptoms. Her blood pressure readings begin to stabilize, averaging around 140/90 mmHg, and her serum potassium level rises to 3.8 mEq/L, indicating a positive response to the spironolactone. However, her blood glucose levels remain erratic, prompting further discussion about her diet and lifestyle modifications. Throughout these adjustments, the healthcare team continues to monitor for any new complications, particularly given the increased risk of infections and fractures due to her immunosuppressive state and osteoporosis. The collaborative approach and patient engagement lay the groundwork for the next phase of her journey, focusing on long-term management strategies that aim to enhance her quality of life.

Section 3

As the weeks progress, the healthcare team remains vigilant in monitoring the patient's response to the adjusted treatment plan. During a routine follow-up appointment, the nurse notes a concerning change in the patient's status. The patient reports experiencing increased fatigue and a noticeable decline in her ability to engage in daily activities, which she attributes to persistent muscle weakness. Additionally, she mentions an unintentional weight gain of five pounds over the past two weeks, a symptom that raises a red flag given her existing edema and potential fluid retention issues.

Upon examination, the patient's blood pressure has risen again, now averaging 150/95 mmHg. Her heart rate is slightly elevated at 102 beats per minute, and her respiratory rate is 20 breaths per minute, with oxygen saturation stable at 96% on room air. The physical assessment reveals increased pitting edema in the lower extremities, extending up to the mid-calf. These findings prompt the team to order a repeat set of laboratory tests. The results indicate a serum potassium level of 3.5 mEq/L, which, while improved, remains on the lower end of normal. Her fasting blood glucose level is 180 mg/dL, and her HbA1c has increased to 8.2%, suggesting that her glycemic control is still suboptimal despite recent interventions.

Given these developments, the team reassesses the patient's treatment plan. The decision is made to increase the dose of spironolactone to further address the edema and hypertension. Additionally, a consultation with a dietitian is arranged to provide more tailored dietary recommendations aimed at achieving better blood glucose control. The possibility of adding another antihypertensive medication is also discussed to achieve more optimal blood pressure management. The healthcare team remains committed to a multidisciplinary approach, emphasizing the importance of patient education and engagement in her care to prevent further complications and enhance her overall quality of life. This comprehensive strategy lays the groundwork for the next phase of her treatment, with particular attention to monitoring for any additional complications that may arise.

Section 4

Several weeks later, during a scheduled follow-up, the patient presents with new complaints of increased abdominal discomfort and intermittent headaches. She reports that her edema has only minimally improved despite the adjusted dose of spironolactone. Additionally, she has noticed a purple striae developing on her abdomen, which has become more pronounced. Her blood pressure remains elevated at 155/98 mmHg, and her heart rate is now 108 beats per minute. Her weight has further increased by three pounds, and the edema in her lower extremities has not subsided significantly, raising concerns about the effectiveness of the current diuretic therapy.

The healthcare team orders a more comprehensive set of diagnostic tests, including a 24-hour urinary free cortisol test, which reveals a significantly elevated level, confirming the persistence of hypercortisolism. Her serum sodium is slightly elevated at 146 mEq/L, and her fasting blood glucose has increased to 200 mg/dL, with her HbA1c now at 8.5%, indicating worsening glycemic control. The patient's serum potassium has decreased slightly to 3.3 mEq/L, suggesting continued potassium-wasting effects likely attributable to the underlying disease pathology.

In response to these findings, the team decides to initiate a more aggressive intervention to manage her cortisol levels, considering options such as surgical intervention or the addition of medications like ketoconazole to reduce cortisol production. A new antihypertensive agent is prescribed to better control her blood pressure, while her diabetes management plan is intensified, incorporating both medication adjustments and dietary modifications. This phase of treatment marks a critical juncture in addressing the multi-faceted complications of Cushing's disease, requiring careful monitoring and a coordinated approach to prevent further deterioration and improve the patient's overall health outcomes.

Section 5

Several weeks into the newly implemented treatment regimen, the patient returns for a follow-up visit. She reports that her headaches have decreased in frequency and intensity, and her abdominal discomfort has slightly improved. However, she continues to experience significant fatigue and muscle weakness, which have begun to affect her daily activities. On examination, her blood pressure has improved slightly to 148/92 mmHg, and her heart rate is now 100 beats per minute. Her weight has stabilized, but the edema in her lower extremities remains prominent, and the purple striae on her abdomen are unchanged.

Laboratory results reveal that her serum cortisol levels have started to decrease, indicating a positive response to the added ketoconazole. However, her serum potassium remains low at 3.1 mEq/L, despite potassium supplementation, prompting concerns about the need for further adjustment in her electrolyte management. Additionally, her fasting blood glucose has slightly improved to 180 mg/dL, but her HbA1c remains elevated at 8.2%, necessitating ongoing refinement of her diabetic management plan. Her serum sodium is stable at 145 mEq/L, suggesting that fluid balance is being cautiously maintained.

The healthcare team considers these mixed results as they plan the next steps in her treatment. They decide to adjust her potassium supplementation and review her current medications to address potential interactions that may be contributing to her electrolyte imbalance. They also plan to consult with a dietitian to optimize her nutritional intake, aiming to support both her glycemic control and overall energy levels. The team schedules more frequent follow-ups to closely monitor her progress and swiftly address any emerging complications, recognizing the complexity of managing Cushing's disease and its associated symptoms.