Detail Clinical Significance/Impact It is Wednesday afternoon (Time…

QuestionAnswered step-by-stepDetail Clinical Significance/Impact It is Wednesday afternoon (Time…Detail Clinical Significance/ImpactIt is Wednesday afternoon (Time 1215), and you are working in a busy Emergency Department.  History of present illness: You are caring for Joy, a 39-year-old female. She arrived at the emergency department with her spouse, John. She complains of shortness of breath and lethargy. She reports her breathing is worse in the evening and resolves when she wears her CPAP for bedtime. She is afebrile and appears well kept. The breathing problem started yesterday, but she has been “tired” for weeks now.       Social History (from Joy and John) Joy is a bus driver who works 9 months out of the year. She enjoys her job and has been a bus driver for 7 years. She has a sedentary lifestyle and eats fast food 6 days a week. Joy and John make a “home cooked” meal on Sundays. Her BMI is 36. Joy states that she has been “heavy” her entire life, even as a child. She reports sleeping 6-8 hours a night on average, but still feels tired in the morning. She does not enjoy doing things she once enjoyed. She denies illicit drug use, alcohol, and tobacco. She schedules an annual checkup once a year but has not gone to the appointment yet. Her spouse reports that she always goes to her appointments and takes her medication as prescribed so he “doesn’t know why she is sick?”. She checks her blood pressure and blood sugar every day and says it is “always high even if I take my medicine”. She admits that she feels short of breath when the weather begins to change, which it did yesterday.   Medical History: Amenorrhea, morbid obesity, OSA, HTN, COPD, Asthma, and Dyslipidemia.     Subjective History (from Joy): Joy was born and raised in Oklahoma. She enjoys her career and plans on retiring with the school district as a bus driver. Joy has always been overweight, even as a child. John reports that her face has gotten more “round” this year, but he thinks that she looks “healthy” otherwise. Joy has noticed that she has progressively felt unwell over the past year. She reports feeling tired and more “depressed” this year. She has noticed that her skin has changed and bruises easily but does not remember how she injured herself. Her last COPD exacerbation was 5 months ago. She has a decreased libido which has caused issues in her marriage. She lives in an apartment with her husband on the second floor and has trouble climbing stairs.  She takes the following RX medications:Medication Dose Last dose takenProventil HFA (Albuterol) inhaler 2 puffs PRN for SOB 1130 todayLipitor (atorvastatin) 40 mg QD 0800 todayHCTZ (hydrochlorothiazide) 25 mg QD 0800 todayInsulin (aspart) Novolog 5 units ACHS 1100 todayCPAP  Ipap 5, Qhs 2100 yesterday      Nursing Assessment: What assessment data is important and why?                                                Detail Clinical Significance/ImpactObjective DataGeneral Appearance: Joy looks unwell. She is   laying in the bed with the HOB elevated to 90 degrees. She is clean and well groomed. She is anxious. Her spouse is at bedside holding her hand. She complains of shortness of breath and is on oxygen therapy.  Temp: 36.8°C (98.24°F)BP:165/80 mmHg MAP 108HR: 115 bpm RR: 27SpO2: 95% on 3L NC NEURO: Alert and oriented to person/place/time/situation. GCS 15. PERRLA. Anxious.CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable x4 at +2. No edema. No murmurRESP: Expiratory wheezes in RML, RLL, LLL and inspiratory wheezes in RUL and LUL. No stridor. Respirations are symmetrical and labored.GI: Abdomen obese. Soft, non-tender. NABS x4. Last BM was today. Negative for nausea and vomiting. GU: Voids painlessly and without hesitation. Clear, yellow urine. UA normal. Drug screen urine negative for illicit drugs.Musculoskeletal: Moves all extremities with generalized weakness. More difficulty raising arms. Ambulates unassisted but is slow paced. Equal grip strength bilaterally. Integumentary: Scalp hair is thin, oily face and acne on the neck and shoulders. Striae noted on abdomen and upper BL thighs measuring 0.6 cmPsychosocial: Decreased libido, depressed, flat affect.          What diagnosis do you suspect and why? Clinical Significance/Impact     You receive the following orders from the provider. Clinical Significance/ImpactCT abdomen    HgA1C    Urine albumin    WBC    POC glucose    Serum Cortisol    Urinary free cortisol level (24 hour)    CRH after dexamethasone test    The RN receives the following orders from the provider. Clinical Significance/ImpactIntravenous access    Continuous cardiac monitoring    1800 CHO diet       ACHS blood glucose test    Diagnostic Test Results Clinical Significance/ImpactCT abdomen Adrenal lesion 8 cm x 6 cm. Increased visceral fat is evident.  HgA1C 12 %   Urine albumin Positive    WBC 13,000/ mm3   POC glucose 235 mg/dL   Serum Cortisol 14 mcg/dL   Urinary free cortisol level (24 hour) 150 mcg/24   CRH after dexamethasone test < 1.4 mcg/dL (38 mmol/L)   Family Education Clinical Significance/ImpactThe provider informed Joy that she has an adrenal lesion. What education is essential to communicate to Joy and her spouse right now about the probable cause of her Cushing's syndrome?    Joy asks, "why is it important to keep cortisol levels normal?" How would you respond to her?    Case Study Continued Clinical Significance/ImpactJoy is being transferred to the operating room to undergo an adrenalectomy. She will then go to Surgical ICU after the procedure for observation and monitoring. You prepare to call report to the ICU nurse, Desiree RN. You review Joy's most recent labs and presenting symptoms. Joy's oxygenation is stable, but she is nervous about surgery. A CHG bath has been completed. She received 10 units of fast acting insulin to treat a bsg of 235 mg/dL. She is NPO and on D5 NS at 50 mL/hr. She has an 18g left hand peripheral IV. She is alert and oriented. Her husband has been escorted to the OR waiting room.       Considering Joy's history, what information is important to include in handover? Practice using the SBAR format.Situation:        Background:          Assessment:                Recommendation:          What medication orders will Desiree anticipate?  Clinical Significance/Impact                                                                                               What are the adverse effects of ketoconazole?      What medication if ordered, may interact with ketoconazole?             What nursing interventions will Desiree implement and why?Administer medications  NPO effective now  CHG bath x 1 now  D5 NS at 50 mL/hr  Observe PIV catheter site  Assess BP and HR every 1-2 hours.  Respiratory assessment Q4 hours   Assess pain  Monitor telemetry  Administer oxygen as needed  Monitor vital signs  Assist patient with ADL's (nutrition, elimination, hydration, personal hygiene).     Test your knowledge!True/False: Patients with Cushing's syndrome are at increased risk of death from cardiovascular disease including, MI, stroke, and thromboembolism?  Cushing's syndrome can be categorized into which clinical system manifestations?       What are the causes of Cushing's syndrome?    What are some complications of Cushing's syndrome?        Discharge InstructionsYou are preparing Joy for discharge home. After her adrenalectomy she stayed in ICU for 5 days, PCU for 3 days and Medsurg for 2 days. She is newly diagnosed with Cushing's syndrome. Her vital signs are stable. Her blood glucose levels have normalized. She is prescribed new medications to begin at home. She is able to eat without assistance and is on a low-carb diet. She reports feeling "overwhelmed" with everything but is excited to finally be going home. Her husband is here to listen to discharge instructions and to take Joy home. She has follow-up appointments scheduled.  The following are new or adjusted prescription medications:Medication DoseHCTZ (hydrochlorothiazide) 50 mg QDInsulin (aspart) Novolog 10 units ACHSCPAP  Ipap 5, QhsHydrocortisone  30 mg QD (Taper dose regimen) What instructions will be included for her at discharge?      NCLEX style question:The PACU nurse is caring for a client with a PMH of alcoholism with ascites that has just now underwent a unilateral adrenalectomy with laparoscopic approach. The abdomen laparoscopic sites are constantly oozing clear, yellow drainage. The client complains of severe pain (10 out of 10). The nurse collects vital sign data as follows: 135/80 mmHg, heart rate 102 BMP, respirations 18 breaths/minute, and oral temperature 100.2°F. Which information should the nurse notify the health care provider of immediately?Answer ChoicesA. The nurse reports the wound drainage color and amount.B. The nurse reports the pain score.C. The nurse reports the temperature.D. The nurse reports the heart rate.           References Adler, G. (2010). Cushing syndrome: A review. Medscape CME/CE. Retrieved on October 20, 2020 from Medscape.org/viewarticle/727356_7Hinkle, J.L., & Cheever, K.H. (2018). Assessment and management of patients with endocrine disorders. Brunner & Suddarth's textbook of medical-surgical nursing (1539). Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins. (2012). Cardiac disorders. The Washington Manual of Critical Care. (128). Philadelphia: Wolters Kluwer.Nieman, L., Lacroix, A., & Martin, K. (2020). Epidemiology and clinical manifestations of cushing's syndrome. Uptodate. Philadelphia: Wolters KluwerNieman, L., Lacroix, A., & Martin, K. (2020). Establishing the diagnosis of cushing's syndrome. Uptodate. Philadelphia: Wolters KluwerPagana, K.D (2020). Mosby's diagnostic and laboratory test reference. St. Louis: Elsevier Mosby.     Health ScienceScienceNursingNURS PNP235Share Question