Pamantasan ng Lungsod ng Maynila (University of the City of Manila) Intramuros,Manila COLLEGE OF NURSING

URO Ward Jose Reyes Memorial Medical Center

In Partial Fulfillment of the Requirements In Medical Surgical Nursing III (Related Learning Experience)
Submitted to: Mrs. Jennifer P. Reyes, RN, MAN Clinical Instructor Submitted by: Dungog, Bryan Martin Dizon, Kathleen Zyrelle Ensalada, Dan Ataniel Fernandez, Dianne May Guiao, Nicole Gianne Guimbarda, Roxette Hernandez, Jannefer BSN IV-3 Group J

I. INTRODUCTION

An adrenal mass is an abnormal growth that develops in the adrenal gland. Adrenal mass known as pheochromocytomas, is a rare condition that involves the formation of an abnormal mass within the adrenal gland. Located just above the kidneys, the adrenal glands work to produce hormones. In the presence of a tumor, hormone production becomes disrupted. Pheochromocytomas most commonly occur in adults aged 20-40 years old. It occurs in about 0.5% to 0.1% of patients with sustained hypertension. It must also be considered that the prevalence of sustained hypertension in the adult population of Western countries is between 15 to 20%. Thus, in Western countries the prevalence of pheochromocytoma can be estimated at 1:2500 to 1:6500 patients, with an annual incidence in the United States of 500 to 1,100 cases per year. It is more frequent in women than in men (1:5). Adrenal masses are common and they increase in frequency with age. It may be benign, malignant or functional. 1 out of 4000 adrenal masses is malignant. Most patients with pheochromocytomas present with signs and symptoms syndrome of is adrenal the steroid excess. Rapidly progressing Cushings most frequent presentation. Androgen-secreting

pheochromocytomas in women present with hirsutism and virilization, with male-pattern baldness and oligo/amenorrhea. Rare aldosterone-producing pheochromocytomas present with severe hypertension and profound hypokalemia. Hypertensive crises can present as hypertensive emergency or as hypertensive urgency. Hypertensive emergency exists when blood pressure reaches levels that are damaging organs. On the other hand, hypertensive urgency is a situation where the blood is severely elevated

(180 or higher for the systolic pressure or 110 or higher for diastolic pressure), but there is no associated organ damage. This study will provide a thorough analysis of client BGV, 27 years old, Female, who was admitted to the Urology Ward of Jose Reyes Memorial Medical Center last December 8, 2012, with a chief complaint of vaginal spotting. This goes on to describe the abnormal and normal physiology, in general then description of the physiology involved in Hypertensive Urgency secondary to Adrenal mass, as well as the corresponding ways to treat and manage the condition. With the knowledge acquired from Medical-Surgical Nursing, this case study aims to formulate an individualized Nursing Care Plan which will be used as an instrument on improving clients health condition through nursing assessment, diagnosis, planning, and intervention. and the management needed for the clients condition. It will serve as a prioritization guide for the holistic care that must be rendered to the client

II. OBJECTIVES This paper aims to provide a study regarding Hypertensive Urgency secondary to Adrenal Mass which focuses on assessment, different treatment modalities, nursing care and responsibilities on various areas that include pharmacologic treatments and diagnostic procedures. It is also intended to provide a better understanding of the complication process based on the present health history of the patient as well as the underlying condition. Specifically, at the end of the study the student nurses aim to: 1. Understand the prognosis of the disease and its effects to the patient. 2. Be able to make accurate and thorough assessment of the patient to determine her nursing needs

3. Fully grasp the complication process of the patient and to have a better understanding on the patients condition. 4. Draw out appropriate and prioritized nursing care plans which will render effective care 5. Be able to render care complying to the doctors order and maintaining exact compliance to the treatment regimen of the patient 6. Remain competent and responsible student nurses in providing the best care to the patient III. NURSING HEALTH HISTORY Date of Interview: December 11, 2012 Source of Information: Patient and Patients chart Percentage of Reliability: The data obtained are 100 % accurate. A. DEMOGRAPHIC DATA Patient Name: Patient BGV Age: 27 years old Gender: Female Date of Birth: December 5, 1985 Birthplace: Dipolog City Address: Galas, Dipolog City Nationality: Filipino Religion: Protestant Civil Status: Single Educational Attainment: College Graduate Occupation: Teacher B. INITIAL DATA Date of Admission: December 8, 2012 Time of Admission: 2:58pm

IV. CHIEF COMPLAINT The patient was admitted to the Cebu Doctors Hospital due to vaginal spotting and was then transferred to Urology Ward of Jose Reyes Memorial Medical Center. Admitting Diagnosis: Hypertensive Urgency secondary to Adrenal mass V. HISTORY OF PRESENT ILLNESS 1 year prior to confinement, the patient experienced irregular menstruation. She consulted an OB/GYN and was told that she has inflammation of the uterus. The patient took NSAIDs and reported regular menstruation for the next months. 9 months prior to confinement, the patient experienced increase in blood pressure and was prescribed to take Neobloc. The patient was compliant with her medications. 1 month prior to confinement, the patient reported hair fall and vaginal spotting. She was admitted to Cebu Doctors Hospital due to abnormal ECG results and hypertension and was diagnosed with Hypertensive Urgency secondary to Adrenal mass after certain tests. The patient was then transferred to the Urology Ward of Jose Reyes Memorial Medical Center on December 8, 2012 at 2:58pm.

VI. PAST MEDICAL HISTORY According to the patient, she had her immunizations completed during childhood. The patient has no known allergies to medications or environmental elements but has reported allergies with sea foods. The patient also stated that she has no history of any kind of injury. Most of the time, the patient do self-medication and take over-the- counter medicines whenever she feels sick.

VII. PSYCHOSOCIAL HISTORY Patient BGV stated that she doesnt consume alcohol nor engage self to smoking. She is single and still lives with her parents and sibling. She works as pre-school teacher and performs her daily routine unassisted before she became sick.

VIII. FAMILY HEALTH HISTORY Patient BGV lives with her parents and has 2 siblings. The only known case of disease in her family is from her Grandfather who died of Tuberculosis.

IX.

GORDONS FUNCTIONAL HEALTH PATTERNS

TYPOLOGY PATTERN

BEFORE ADMISSION

DURING ADMISSION

CHANGES

Health Perception and Health Manageme nt

The patient is aware of her health. She managed her health problems like fever, colds and cough on her own. She does not practice a regular check-up or seeking medical advice for her

The patient is still aware of his health. She gathers information about her present condition. She seeks medical advice and follows doctors order about her prescriptions and medications.

The patient seeks medical advice and after she was diagnosed. She makes sure that she gathers information about it.

health.

Nutritional Metabolic Pattern

The patient has a good appetite. She eats three times a day, with snacks. She likes to eat anything particularly meat, pork, chicken, vegetables and fruits. She drinks less than 8 glasses of water a day.

When she knew about her condition, she sticks with a diet of vegetables and fruits. She still eats three times a day and drinks water more.

She became a fruit and vegetable eater and drinks more water than before.

Elimination Pattern

The patient The patient defecates every elimination pattern other day. She has not changed. urinates frequently and described with yellowish color. She does not experience any discomfort in urinating and defecating.

No changes.

ActivityExercise Pattern

The patient exercise daily but when she knew about her condition, she limits down her activities. She always watches

The patient does walking as form of exercise. She does her hygiene by herself.

She limits her exercises because of her condition.

television and help with the household chores.

Sleep and Rest

The patient sleeps 5 to 6 hours a day. She does not experience any difficulty in sleeping. She does not take afternoon naps.

The patient sleeprest pattern is the same even she is hospitalized. She was awakened by rounds

Awakened by rounds.

Cognitive Perceptual

The patient is oriented to time, place and person. She responds properly to physical and verbal stimuli. She is a college graduate.

The patient is still oriented to time, place and person. She responds properly to physical and verbal stimuli.

No changes.

Selfperception/ selfconcept

The patient sometimes thinks negative about herself. She thinks that her body image is not good because she thinks shes fat and the

The patient thinks of her condition in a positive way. She is hoping that her condition will be treated and the changes in her body because of her condition will return

She is more optimistic about her condition and herself.

hyperpigmentation to normal. in other parts of her body. But she is positive that these will be solved.

RoleRelationshi p Pattern

The patient stated that she lives with his parents and siblings. She said that he has a good relationship with his brothers and parents. She is the youngest in the family.

The patient stated that she maintains having a good relationship with her family. Her brother and brother-in-law take turns in taking care of her in the hospital.

No changes in their relationship. They care for each other.

Sexuality/R eproductiv e Pattern

She has a regular menstruation and does not experience any difficulty. The patient stated that she had a boyfriend and she broke up with him after she was diagnosed with her condition.

The patient sexuality/reproductiv e pattern is the same.

No changes.

The patient is not

CopingStress Tolerance

open with her problems to her family. She said that when she had a problem, she does openly share it and just pray to God to overcome her circumstances.

The patient sometimes expresses what she feels.

She was able to express some of her concerns.

Value/Belie f Pattern

The patient is a Protestant. She always attends their worships and prays to God.

She maintained her faith and prays to God always. Although she cant attend the worships, she makes sure that she is connects with Him and that her condition will be better.

She cant attend worships but still makes sure to pray to God.

X. REVIEW OF SYSTEMS

General: The patient verbalizes that she gained weight. She maintains her hygiene and grooming as well. Head/Eyes/Ears/Nose/Throat: Head- the patient does not experience any headache Eyes- she denies blurred vision, double vision and pain but she said she feels like she has a acetate like vision.

Ears- she denies any pain in the ear, tinnitus, and hearing loss Nose- the patient verbalizes that she feels that there is a blockage in her nose. Mouth and Throat- she denies any difficulty in swallowing and speaking Respiratory: The patient denies difficulty of breathing. Cardiac: The patient denies chest pain, claudications and palpitations. Gastro-intestinal: The patient denies nausea, vomiting, stomach upset. She has a good appetite Gastro-urinary: The patient said that she does not experience hematuria, dysuria, anuria and straining while defecating. Hematology: The patient denies having any blood disorders. Endocrine: The patient verbalizes that on her last blood sugar reading, she has an elevated blood sugar. Musculoskeletal: The patient denies muscle, joint and bone pain. She also denies weakness. Neurology: The patient stated that she does not experience dizziness and loss of memory. She also denies any changes in his sensations.

XI.

PHYSICAL ASESSMENT

GENERAL APPEARANCE The patient was received conscious, coherent, and oriented to time and place. The client was lying in bed with an ongoing IV contraption infused with I L of PNSS at the left metacarpal vein. The patient was cooperative, able to follow instructions and responds in an appropriate

manner. She spoke in an understandable, moderate pace and exhibits thought association. The initial vital signs are taken as follows: T: 36. 8 C PR: 77 bpm RR: 19 cpm BP: 110/90 mmHg SKIN Upon inspection, the skin is dry, shiny and uniform in color. The patient has noticeable striae on her armpits, breast, waist and inguinal area. Upon palpation, the skin was thin and the temperature was uniform, and cool to touch. There was no presence of rashes noted. HAIR Upon inspection, hair on scalp is evenly distributed and slight alopecia was seen. In addition, hair is thin. The patient is exhibiting hirsutism. There were no infections and infestations seen.

NAILS Upon inspection, pallor on the nails was noted and revealed convex curvature after performing Schamroths test. Also, capillary refill was tested and the color of the nails returned after 3 seconds. HEAD

Upon inspection and palpation, the patients skull was assessed to be normocephalic, symmetric and smooth in contour. A moon-face appearance is noted. There were no lesions observed and no palpable nodules, tenderness. The patient was asked to show teeth and the face showed symmetrical movements. EYES Upon inspection, the clients eyes and eyebrows are symmetrically aligned and evenly distributed. Thickening of the eyebrows is noted .Patient was asked to raise and lower eyebrows which revealed equal movement. The patients ability to blink is intact and bilateral. Using the penlight the pupils are observed to be black in color, equally round, reactive to light and accommodation and equal in size. Both eyes moved in unison from side to side and up and down and were able to follow the 6 ocular movements in 1 foot distance. EARS Upon inspection, the ear color is symmetrical to the facial skin and both ears are symmetrical. No presence of lesions, discharge and odor were seen.

NOSE Upon inspection, nose is in the midline, symmetrical, and has no discharge. Nasal septum is intact and is in midline. Upon palpation, no tenderness and lesions were noted. Upon pinching each nose for patency,

the left nostril was slightly obstructed. Facial sinuses have no areas of tenderness. MOUTH AND OROPHARYNX Upon inspection, the patients gums and lips were observed to be ashlike in color and without cracks. There was no bleeding and no inflammation of gums observed. The tongue and uvula are in the midline. There were no lesions, nodules, or infestations found. NECK Upon inspection and palpation, the clients neck is normal in appearance. No mass or lesion was noted. No enlargement of thyroid gland was observed. There were no palpable lymph nodes on the neck. THORAX AND LUNGS Upon inspection, chest is symmetrical with 1:2 ratio of anteroposterior to transverse diameter. Breathing pattern was observed and normal breathing pattern was noted. Upon auscultation, vesicular sounds are present on the lungs. Chest wall is intact, no tenderness and masses were noted. Truncal obesity is present.

HEART

Upon inspection and palpation of four areas of precordium, no lifts and heaves were observed. There was no jugular vein distention. Upon auscultation, the patients heart beat rhythms were normal. ABDOMEN Upon inspection, no evidence of enlarged liver or spleen is observed. The abdomen moves with respiration. Upon auscultation, abdominal sounds were heard on all sites. EXTREMITIES Upon inspection, extremities were asymmetric in length and size. Varicosities on lower extremities were noted. Presence of bipedal edema was noted. MUSCULOSKELETAL Upon assessment, muscle strength grading is as follows: Right upper extremity: 5/5 Left upper extremity: 5/5 Right lower extremity: 5/5 Left lower extremity: 5/5

NEUROLOGICAL Upon examination, the patient does not display any difficulty in speaking. The patient was able to name objects, and responds to verbal command. The patient is oriented to time and place. Immediate recall of memory is intact. Recent recall of memory is also intact. Remote memory is also intact.

Glasgow coma scale was utilized and recorded as follows. Eye opening is present upon verbal command, 4. Motor response is present upon verbal command, 6 and verbal response is present as the patient is oriented and converses, 5. Total score is 15.

XII.

LABORATORY AND DIAGNOSTIC PROCEDURES

HEMATOLOGY RESULTS NORMAL VALUES WBC 6.3 x 103/ mm3 Neutrophils Lymphocyte s Monocytes Eosinophil Basophils RBC 7.6 0.2 0.0 5.24 x 106cells/mm3 0-7 0-3 0-1 Higher compared to normal At normal values Low compared to normal 75.6 16.6 4.8- 10.8 x At normal values 103/ mm3 55-75 20-30 Higher compared to normal Lower compared to normal SIGNIFICANCE

4.00 6.20 x At normal values 106 cells/mm3

Hemoglobin Hematocrit Platelets

14.0 g/dl 43 %

14 18 g/dl At normal values 42-52% At normal values

240 x 109/L 150 400 x At normal values 109/L

INTERPRETATION & ANALYSIS

Based on the result of hematology, it is evident that there is an increase in neutrophils and monocytes which may indicate presence of infection. The hematology result also shows that there is a low count of lymphocyte that indicates that the bodys resistance to fight infection is reduced and may become more susceptible to certain types of infection or tumor.

CLINICAL CHEMISTRY RESULTS NORMAL VALUES CREATININE 36.46 umol/L 45-104 umol/L SODIUM 141.50 135.145 umol/L POTASSIUM 3.36 umol/L 1.4-4.82 umol/L At normal values At normal values Lower than normal SIGNIFICANCE

INTERPRETATION AND ANALYSIS Based on the results of clinical chemistry, it is evident that there is a decrease level of creatinine. Creatinine level shows how well the kidneys are working. Which may indicate that the kidneys are affected by the disease process.

X-RAY

FINDINGS reticular and non-reticular opacities are seen in both upper lobe homogenous band densities are seen in the right lower hemithorax obliterating the costrophrenic sulcus heart normal in size and configuration diaphragm and left costrophrenic sulcus are intact the bony thorax and the soft tissues unremarkable

XIII. ANATOMY AND PHYSIOLOGY

Adrenal Glands Curved over the top of the kidneys, adrenal glands are structurally and functionally two endocrine glands in one. Like the pituitary gland, the adrenals have glandular (cortex) and neural tissue (medulla) parts. The central medulla region is enclosed by the adrenal cortex which contains three separate layers of cells.

Hormones of the Adrenal cortex

Major groups of steroid hormones such as mineralocorticoids, glucocorticoids and sex hormones are produced by the adrenal cortex. These hormones are collectively termed as corticosteroids.

Mineralocorticoids

1. Produced by the outermost layer of the adrenal cortex, the mineralocorticoids, are mainly aldosterone. These hormones play an essential part in regulating the mineral or salt content of the blood particularly the concentrations of sodium and potassium ions. The target organ of the hormone is the kidneys that selectively reabsorbs the minerals or allow them to be flushed out in the body in the form of urine. 2. Increased aldosterone levels in the body would result to rising amounts of reclaimed sodium ions by the kidney tubules and secreting more potassium ions into the urine. When sodium is reabsorbed water follows. Hence, the mineralocorticoids aids in water and electrolyte regulation. 3. Aldosterone is also released when the kidneys produce the enzyme, renin, when blood pressure drops. Production of renin triggers a series of reactions that form angiotensin II, which is a potent stimulator of aldosterone release. 4. To prevent aldosterone release, atrial natriuretic peptide or ANP is released by the heart. The main goal of releasing ANP is to reduce blood volume and blood pressure.

Glucocorticoids

Glucocorticoids are produced by the middle layer of adrenal cortex which includes contisone and cortisol. The functions of this hormone are: 1. Promotion of normal cell metabolism 2. Helping the body resist long-term stressors, by increasing blood glucose levels. Important information about glucocorticoids:
1. Fats and even proteins are broken down by body cells and converted

to glucose when blood levels of glucocorticoids are elevated in the blood. Hence, these hormones are said to be hyperglycemic hormones.

2. Unpleasant effects of inflammation are also controlled by glucocorticoids as they reduce the effects of edema and they reduce the pain by inhibiting some pain-causing molecules called prostaglandins. Thus, because of their anti-inflammatory properties, glucocorticoids are often prescribed as drugs to suppress inflammation for patients with arthritis. 3. Glucocorticoids are released from the adrenal cortex in response to the rising blood levels of ACTH.

Sex Hormones

The adrenal cortex produces the sex hormones regardless of ones gender. Production of sex hormones takes place throughout a persons life but the amount formed is relatively small. It is the innermost layer of the cortex that produces a large amount of androgens, male sex hormones and some estrogen, female sex hormone. Hormones of the Adrenal Medulla Like the knot of nervous tissue where posterior pituitary gland develops, the adrenal medulla has the same development. When this structure is stimulated by the sympathetic nervous system neurons, epinephrine, also called adrenaline, and norepinephrine, otherwise known as noradrenaline, are released into the bloodstream. Collectively, these hormones are called catecholamines. 1. Physical or emotional stress and threat would bring about the fight-orflight response. The response is necessary to help a person cope up with the stressful situation. One of the organs stimulated in these situations is the adrenal medulla which is responsible for pumping catecholamines or hormones into the bloodstream to enhance and prolong the effects of neurotransmitters of the sympathetic nervous system. 2. Presence of catecholamines has the following effects: increased heart rate, elevated blood pressure and rising blood glucose levels. Also, small passageways of the lungs are dilated with presence of these hormones to cater more oxygen in the blood and a faster circulation to the organs most importantly to the brain, heart and muscles. Increase glucose and oxygen would make the body fit to fight or deal with shortterm stressors.

Medical Management Biopsies: Biopsies may be incisional or excisional. In incisional biopsy, a scalpel, cutting or aspiration needle, or punch is used to remove a portion of tissue from large, multiple, hidden lesions. Fine needle aspiration differs slightly from traditional needle biopsy. Although the procedure is the same, it provides a smaller specimen, requires cytologic (not histologic) studies, and is usually performed on outpatients for breast biopsies. Incision of a hidden lesion is called a closed, or blind, biopsy. In excisional biopsy, a scalpel is used to remove abnormal tissue from the skin or subcutaneous tissue. When such tissue can be easily and completely removed, excisional biopsy is preferred, because it combines diagnosis and treatment. Biopsies commonly take place in the hospital, but they may also take place in clinics and physicians' offices. Open biopsy, performed in the operating room, usually requires general anesthesia. Open biopsy is required when the results of a closed biopsy or other diagnostic tests (i.e., CT scan) suggest the need for complete excision of a tissue mass. Tissue preparation and Tissue Classification: Tissue preparation involves several time-consuming steps in the fixation of specimens on slides for examination by pathologist. Even a stat tissue preparation can take 24 hours. The exception to this normal method of fixation of slides is a frozen section. Frozen sections may provide results in 10-15 minutes in emergency situations. However, frozen section results are not reliable and will usually be confirmed by the standard process. After standard analysis, tissue classification takes place. The pathologist's report provides both gross and microscopic descriptions, which result in histopathological classification of the tumor. Typically, results of this analysis are expressed on a scale of four grades: G1--well differentiated; G2-moderately well differentiated; G3--poorly differentiated; G4--anaplastic. A staging system is then used to direct the treatment and predict the prognosis when biopsy results confirm malignancy.

There are many different types of biopsy: Scrape - cells are removed from the surface of tissue, as may occur when a sample of the inside of the mouth is required, or from the neck of the womb(cervix). Punch biopsy - a punch (a round shaped knife) is used for cutting and removing a disk of tissue; commonly used for collecting a sample of skin tissue to check for malignancy (cancer). Needle biopsy - a needle is used to remove a sample of (usually) liquid. A wide needle is used for a core biopsy while a thin one is used for fine-needle aspiration biopsy. Endoscopic biopsy - an endoscope is used to collect the sample. An endoscope is a long-thin, lighted optical instrument used to get deep inside the body and examine or operate on organs. Specially adapted endoscopes include a cystoscope for the bladder, nephroscope for the kidneys, bronchoscope for the bronchi (in the lungs), laryngoscope for the voice box (larynx), and otoscope for the ear. Capsule biopsy - to take a sample from the intestines. Sterotactic biopsy - samples are taken from the brain, using stereotactic surgery to find the biopsy site. Sterotactic is a three-dimensional coordinates system to locate small targets inside the body. Colposcopic biopsy - used to evaluate a (female) patient who has had an abnormal Pap smear. The colposcope is a close-focusing telescope that allows the doctor to see areas of the cervix in detail. FNA biopsy, adrenal vein sampling, and biochemical testing FNA biopsy is another useful tool in distinguishing adrenal masses. However, it is difficult to distinguish among normal adrenal tissue, adenoma, and welldifferentiated carcinoma. Before performing an FNA biopsy, it is important to exclude pheochromocytoma to prevent a hypertensive crisis or worse. FNA biopsy is usually reserved for patients with known extraadrenal malignancy when tissue diagnosis of the adrenal metastasis is necessary to guide therapy. In this setting, it is almost 100% accurate. Adrenal vein sampling is not done very often. It has a high complication rate of pneumothorax, pancreatitis, and hemorrhage and is indicated only when the physician is trying to rule out idiopathic hyperaldosteronism, which is treated by removing both glands. In these cases, adrenal vein sampling can distinguish separate bilateral from unilateral secretion of aldosterone. A variety of biochemical tests can be performed after an adrenal mass is found, whether the mass is biochemically active or not. Tests can determine levels of dexamethasone suppression; 24-hour urinary free cortisol; urinary 17-hydroxycortisol and 17-ketosteroid; plasma androgens, testosterone,

androstenedione, renin, and aldosterone; urinary vanillylmandelic acid; plasma catecholamines; and plasma metanephrine and normetanephrine. 24 hour urine collection A 24-hour urine collection is a simple diagnostic procedure that measures the components of urine. The test is noninvasive (the skin is not pierced), and is used to assess kidney (renal) function. Twenty-four hour urine collection is performed by collecting a person's urine in a special container over a 24-hour period. The container must be kept cool during this time until it is returned to the lab for analysis. Urine consists of water and dissolved chemicals such as sodium, potassium, urea (formed from protein breakdown), and creatinine (formed from muscle breakdown), along with other chemical compounds. Normally, urine contains specific amounts of these waste products. If these amounts are not within a normal range, or if other substances are present, it may be an indication of a particular disease or condition. The results of a 24-hour urine collection may provide information to help your doctor make or confirm a diagnosis. Related procedures that may be used to diagnose kidney disease include kidney ultrasound, kidney scan, kidney biopsy, and renal arteriogram.

Nursing Management Hypertension: Blood pressure taking every 1 hour Increase fluid intake Checking of intake and output specially urine Note for urine characteristics Health teaching about her condition Health education about lifestyle modification Intravenous Fluid monitoring Ensure compliance to medications

Stretch marks Around the waist (trunchal obesity) Back of the head (Buffalo Hump) Face (moonfac e) Weight gain

Thining of the hair

Thining of the skin

Vasoconstricti on of blood vessel

Protein wasting

Fat deposition Appetite

Irregular, fluctuating , and small in amount but constant menstruati on/ Blockage of (1) LH & FSH action on gonads and (2) secretion of GnRH in Hypothalamus

enhancement of vasoconstrictive effect of circulatory catecholamine

Sensitivation of A- adrenergic receptors on surface of smooth muscle

Protein catabolism Protein Breakdown

Stimulation of satiety center (hypothalamus)

PATHOPHYSIOLOGY

Predisposing Factors: Sporadic incidence of disease hereditary (multiple endocrine neoplasia type 2,Von Hippel Lindau syndrome, neurofibromatosis type 1, and germline mutations in the succinate dehydrogenase B;C;or D genes) Age (27) Sex- female (1:4)

Precipitating Factor: Stress

Abnormal transformation of chromaffin cells of adrenal gland (tumor) Release of catecholamines (norepenephrine and epinephrine) in the blood Release of ACTH precursor

Proopiomelanocortin (POMC) molecule Stimulation of Melanin synthesis on melanocytes Hyperpigmentati on of skin

Pro-ACTH molecule Stimulation of androgen synthesis Virilization Stimulation of Aldosterone synthesis Hyperaldosteroni sm Hirsutis m Na & H20 retention Hypersecretion of cortisol

Stimulation of alpha adrenergic receptors

High blood pressure

Darkened striae

Darkene d skin

Acne

Hypercortisoli sm/ CUSHINGS SYNDROME

Nursing Care Plan

Name: GAB Age: 27 yo Sex: Female Date: Dec. 10, 2012 Chief complaint: Vaginal spotting Diagnosis: Hypertensive urgency secondary to adrenal mass Assessment Nursing Inference Goal/Plan Interventions Rationale Evaluation Cues Diagnosis Subjective Cue: Disturbed body image related to Hindi naman change in dati ganito appearance ang hitsura ko. as verbalized by the patient Within 8 hours of nursing intervention, the patient Changes in will verbalize appearance understandin g of body changes related to Altered selfdisease esteem and condition as confidence evidenced by: Verbalizatio n of (-) feelings about body (-) apprehe nsion (-) aloofne ss (+) eye contact (+) interacti Appearance of clinical symptoms 1. Establish therapeutic nursepatient relationship, conveying an attitude of acceptance and care. 2. Encourage verbalization of feelings, thoughts and concerns. 3. Visit patient frequently and acknowledg e her as someone worthwhile. 4. Be alert and cautious with own 1. To gain the trust and confidence of the patient by showing genuine care and concern. 2. To reduce anxiety and fear and to build a trusting relationship with the patient. 3. A caring presence of the nurse promotes self-esteem of the patient. 4. Facial expression and nonGoal met. Within 8 hours of nursing intervention, the patient verbalized understanding of body changes related to disease condition as evidenced by: (-) apprehe nsion (-) aloofnes s (+) eye contact

Objective Cues: (+) apprehe nsion (+) aloofnes s (+) infreque

Changes in

nt eye contact (+) change in social involve ment (+) poor interacti on

social involvement

on

Aloofness, apprehensio n, infrequent eye contact

facial expression and nonverbal behavior. 5. Offer positive reinforceme nt for efforts made by the patient. 6. Provide counseling. 7. Provide activities that will promote interaction.

verbal cues should match verbal expression to eliminate doubt and build trust. 5. Praises and acknowledg ment help gain confidence and selfesteem. 6. Listening and counseling encourages verbalization of concerns. 7. To promote socialization.

(+) interacti on

Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessment Nursing Inference Cues Diagnosis Subjective cue: Dati wala akong mga marks sa skin ko. as verbalized by the patient. Impaired skin integrity related to overstretchin g and skin pigmentation changes Adrenal mass Sex: Female Diagnosis: Goal/Plan Hypertensive Date: Dec. urgency Rationale 1. Daily inspectio n and monitorin g provides informati on on the rate and extent of changes of skin lesion. 2. To prevent secondary 10, to

Interventions 1. Inspect skin and lesion on a daily basis, describing the lesion characteris tics and changes. 2. Keep the area clean and dry. 3. Maintain appropriat e moisture

Evaluation Goal met. Within 1 hour of nursing intervention, the patient will participate in identifying preventive measures and treatment process.

Within 1 hour of (pheochromocyto nursing ma) interventio n, the patient will Secretion ACTH participate precursor in identifying preventive measures Increased and melanin treatment synthesis, fat

Objective cues: (+) striae on axillary, inguinal and popliteal area (+) poor skin turgor, dryness (+) venous prominen ce on lower extremitie s

deposition and thinning of skin

process.

Changes in skin pigmentation and Appearance of lesion and striae

of skin. 4. Provide safety and comfort measures. 5. Encourage verbalizati on of feelings. 6. Encourage to increase consumpti on of vitaminrich food.

3.

4.

5.

6.

microorg anisms from invading the skin leading to infection. To prevent further deteriorat ion of skin. To prevent injury that will aggravat e the situation. To relieve anxiety and stress. To promote skin rejuvenat ion.

Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessment Nursing Inference Cues Diagnosis Subjective Cue: Deficient knowledge regarding Ano ba ung condition, sakit ko? as prognosis, verbalized by self-care and ADRENAL MASS Sex: Female Diagnosis: Goal/Plan Within 1 hour of nursing intervention, the patient will demonstrate Hypertensive Date: Dec. urgency Rationale 1. To assess learner s need and facilitat e easy secondary 10, to

Interventions 1. Determine patients ability and barriers to learning. 2. State objectives

Evaluation Goal met. Within 1 hour of nursing intervention, the patient demonstrated

Hospitalizatio n

the patient.

Objective Cues: (+) Appreh ension (+) Agitatio n

treatment related to lack of exposure and information misinterpretat ion.

sufficient knowledge Lack of regarding exposure to disease sources of condition, information self-care and and treatment as misinterpreta evidenced by: tion of (-) information Appreh Deficient knowledge ension (-) Agitatio n

clearly in learners terms. 3. Use short, simple sentences and concepts. Repeat and summarize as needed. 4. Provide information relevant only to the situation. 5. Provide written information / guidelines and selflearning modules for client to refer as necessary.

transfer of informat ion once barriers are overco me. 2. Stating clearly the objectiv es meets the level of the learner s need. 3. To facilitat e memory recall of informat ion given. 4. To prevent informat ion overloa d, focus

sufficient knowledge regarding disease condition, selfcare and treatment as evidenced by: (-) Apprehens ion (-) Agitation

only on what is relevant and immedi ately needed. 5. To reinforc e learning .

Nursing Care Plan

Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Assessmen Nursing Inference t Cues Diagnosis

Sex: Female Diagnosis: Goal/Plan Hypertensive

Date: Dec. urgency secondary

10, to

Interventions 1. Perform strict hand hygiene before and after contact with patient. 2. Maintain sterile technique for all invasive procedures such as IV insertion, catheterizat ion etc. 3. Administer prophylactic antibiotics as indicated. 4. Encourage to consume highly nutritious

Rationale 1. To prevent spread of infection from one patient to another. 2. To avoid creating a portal of entry for microorgani sms. 3. To avoid contracting infection from the environmen t. 4. To provide nourishmen t to the body. 5. To promote wellness. 6. To avoid contracting

Evaluation Goal met. Within 1 hour of nursing intervention, the patient will be able to identify intervention s to prevent the risk for infection.

Risk for Adrenal mass Within 1 infection hour of (pheochromocyto related to nursing ma) immunosuppre intervention ssed , the patient inflammatory will be able Secretion of pro- to response identify ACTH secondary to intervention presence of s to prevent hypercotisolism the risk for Hypercotisolism infection. (chronic)

Suppression of inflammatory response

Risk for infection

5.

6.

7.

8.

foods and drinks. Encourage to take multivitami ns. Encourage to keep a germ-free environmen t. Stress the importance of proper hygiene. Teach the patient hand hygiene measures.

infection from the environmen t. 7. Proper hygiene does not only prevent infection but also promote a sense of well-being. 8. To maintain the optimal health status of the patient.

Nursing Care Plan Name: GAB Age: 27 yo 2012 Chief complaint: Vaginal spotting adrenal mass Sex: Female Diagnosis: Hypertensive Date: Dec. urgency secondary 10, to

CUES Subjective: Nabobored na ako dito wala akong magawa. As verbalized by the patient. Objective: >VS: Temp. 36.3 C PR 115 cpm RR 25 bpm >restlessnes s >inattentive ness

INFERENCE

DIAGNOSIS

PLANNING

INTERVENTIO N

RATIONAL E

EVALUATI ON Goal met. After 30 minutes of nursing intervention s, the patient was able to engage in satisfying activities within personal limitations as manifested by: >participati ng of the patient in activities being encourage her to do >calmness and less irritation from being in the hospital

Adrenal Mass Deficient (Pheochromocyto Diversional ma) Activity related to long-term Hypertensive hospitalizati urgency, on cushings syndrome and hyperaldosteroni sm Need for longterm hospitalization Deficient divertional activity

After 30 Independent: To minutes of Establish establish nursing rapport with trust and intervention the patient cooperatio s, the n on the patient will client Monitor be able to vital signs To engage in obtain the satisfying baseline activities >Acknowledge data within reality of personal situation and >to limitations feelings of the establish as patient therapeutic manifested relationship by: >Determine to with the ability to patient >ability to participate/inte participate rest in >Presence in activities activities that of mobility being are available. or anxiety encourage might her to do interfere >Encourage with the >calmness mix of desired desired and less activities activity irritation from being >to provide in the the patient hospital the activity with her best interest

NEOBLOC DRUG ACTION INDICATION CONTRAINDICATIO SIDE/ADVERS N E EFFECTS It is contraindicated to patients with AV blocks 2 and 3; with relevant sinus bradycardia; CHF; and pregnancy. Fatigue Dizziness Headache GI disturbances Sleep disturbances Nausea Vomiting NURSING CONSIDERATIO NS Observe the 10 rights in giving the medications. Assess blood pressure and apical/radial pulse (rate, rhythm and quality) before therapy. Monitor periodically

Dosage: For hypertensi on and functional heart disorders with palpitation : 100 mg,

Exerts mainly 1adrenergic blocking activity but also blocks beta-2 receptors at high doses. It reversibly and

Hypertension

Titrate up to 400 mg/day.

competitivel y combines with beta1adrenergic receptors to block sympathetic nerve impulses, resulting to decreased myocardial contractility, heart rate, cardiac output and myocardial oxygen consumption .

during treatment. Monitor urine output, IO ratio and weight daily. Advised patient to take medication with food to prevent GI upset Instruct patient to take drug as prescribed, do not double or skip doses. Missed dose may be taken as soon as remembered at least 4 hours from the next dose.

DEXAMETHASONE DRUG Dosage Initial: 0.75 9 mg/day Suppresion test for Cushing ACTION Synthetic glucocorticoid with marked antiinflammatory effect because of its ability to INDICATION Testing of adrenal cortical hyperfunction; management of primary or secondary adrenal cortex CONTRAINDICA SIDE/ADVERS TION E EFFECTS Infections, especially tuberculosis, fungal infections, amebiasis, varicella and Headaches Nausea Vomiting Depression Hyperglycemia Hypokalemia Hypertension NURSING CONSIDERATI ONS Observe the 10 rights in giving the medications. Advise to take drug with food

syndrome:

inhibit prostaglandin 1 mg at 11 am; synthesis, assay plasma inhibit cortisol at 8 am migration of the next day. For macrophages, greater accuracy, leukocytes and give 0.5 mg fibroblasts at every 6 hrs for sites of 48 hours and inflammation, collect 24 hour phagocytosis urine to and lysosomal determine 17enzyme hydroxycorticost release. eroid excretion

insufficiency.

antibiotic resistant infections.

Fluid and Electrolyte disturbances Impaired wound healing Dry mouth Thromboemboli sm Thrombophlebit is

to decrease GI symptoms. Monitor patients weight and glucose level.(notify physician of weekly gain>5 lbs or hyperglycemia Assess potassium depletion: fatigue, nausea, vomiting. Monitor cardiac status: blood pressure, edema, dysrhythmias and chest pain. Monitor plasma cortisol level during long term therapy. (138-635 nmol/L when assessed at 8 am)

Advise patient to avoid exposure to infection Report weight gain, swelling of extremities, muscle weakness, fever.

AMLODIPINE DRUG ACTION INDICATION SIDE/ADVERSE NURSING

Dosage: 5 mg once daily; may be increased to maximum of 10 mg.

Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle, decrease peripheral vascular resistance of smooth muscles.

Hypertension; Chronic Stable Angina; Vasopastic Angina

EFFECTS Palpitations Tachycardia Bradycardia Headache Dizziness Fatigue Nausea Abdominal Discomfort

CONSIDERATION Observe the 10 rights in giving the medications. Advise to take drug with meals to decrease GI disturbances Assess cardiorespiratory status. Assess hydration and fluid volume status. Advice patient to avoid hazardous activities until stabilized on drug and dizziness is no longer a problem. Advise patient to comply in all areas of medical regimen: diet, exercise stress reduction etc.