Ncase Study 1: Susan Summers Is A 40-Year-Old

Ncase Study 1: Susan Summers Susan Summers is a 40 Year Old Female Who

Discuss the aetiology and pathophysiology of the patient’s presenting condition.

Critically discuss the underlying pathophysiology of the patient’s post-operative deterioration. Prioritize, outline and justify the appropriate nursing management of the patient during this time.

Identify three members of the interdisciplinary healthcare team, apart from the primary medical and nursing team, involved in the patient's care before discharge, with justification for their involvement.

Paper For Above instruction

Introduction

The case of Susan Summers exemplifies the complex interplay of endocrine disorders, obesity, and post-operative care in medical nursing. Her presentation, primarily driven by Cushing’s syndrome resulting from a benign adrenal tumor, has significant implications for her health status and post-operative management. This paper explores the etiology and pathophysiology of her presenting condition, examines her post-operative deterioration, and discusses a comprehensive interdisciplinary approach to her care before discharge.

Etiology and Pathophysiology of Susan's Presenting Condition

Susan’s presentation is primarily attributed to Cushing’s syndrome, a disorder caused by chronic exposure to excess cortisol. The benign tumor of her right adrenal gland stimulated excessive cortisol production, resulting in clinical features such as obesity, hypertension, and characteristic physical changes. The etiology stems from adrenal adenomas, which autonomously secrete cortisol independent of the hypothalamic-pituitary-adrenal (HPA) feedback system (Newell-Price et al., 2019).

Increased cortisol levels in Cushing’s syndrome impact multiple body systems. Elevated cortisol causes increased gluconeogenesis, leading to hyperglycemia and insulin resistance, explaining her diagnosis of type 2 diabetes (Lindsay et al., 2018). Obesity, particularly central adiposity, develops as cortisol promotes lipogenesis and redistribution of subcutaneous fat, particularly in the face, abdomen, and upper back. Furthermore, cortisol impairs immune function and wound healing, heightening infection risks and complicating postoperative recovery (Pivonello et al., 2017).

The condition’s pathophysiology involves disruption of the normal HPA axis feedback loop. In adrenal adenomas, autonomous cortisol secretion suppresses endogenous adrenocorticotropic hormone (ACTH) levels, but the adenoma's excess cortisol production persists, causing systemic effects (Mandal et al., 2020). The hypercortisolism explains many of her physical alterations and metabolic disturbances, including her hypertension and obesity.

Post-Operative Deterioration and Underlying Pathophysiology

Following adrenalectomy, Susan is at risk of various complications rooted in her pre-existing endocrine imbalance and the physiological stress response to surgery. Her elevated respiratory rate (30 breaths per minute), tachycardia (128 bpm), hypertension (160/90 mmHg), hypothermia (35.0°C), and low urine output (5 mL in the last hour) are concerning signs indicative of potential post-operative deterioration.

The primary concern is adrenal insufficiency due to sudden cessation of cortisol secretion after tumor removal, leading to a state of relative cortisol deficiency. This condition can precipitate hypotension, hypoglycemia, hyponatremia, and shock if unrecognized (Fleseriu et al., 2020). Her tachypnea and tachycardia could also signal sepsis, pain, or hypovolemia, all requiring prompt assessment.

Her hypothermia suggests impaired thermoregulation, possibly due to peripheral vasodilation or systemic inflammatory response syndrome (SIRS). The elevated respiratory rate may reflect metabolic acidosis or hypoxia secondary to postoperative complications such as pneumonia or pulmonary embolism (Krieger et al., 2019). Elevated blood pressure, in contrast, may be residual from her prior hypertensive state or due to pain or stress response.

Key to her management is recognizing she might be developing adrenal crisis, which entails insufficient cortisol levels compounded by surgical stress. The management focuses on hemodynamic stabilization, oxygenation, and hormone replacement therapy. Blood tests assessing serum cortisol, glucose, electrolytes, and infection markers are critical for diagnosis and guiding treatment (Mandel et al., 2018).

Appropriate Nursing Management

Effective nursing management involves prioritizing airway patency, breathing, circulation, and neurological status. Continuous monitoring of vitals to detect deterioration is essential. Administering corticosteroid replacement (e.g., hydrocortisone) is critical in managing potential adrenal insufficiency, as corticosteroid levels drop precipitously post-surgery (Fleseriu et al., 2020). Ensuring fluid balance through intravenous fluids supports blood pressure and volume status.

Pain management remains pivotal, even with a reported pain score of 0/10, as physiological stress can elevate cortisol, impacting recovery. Vigilance for signs of infection is necessary since her immunocompromised state and obesity predispose her to wound infections. Maintaining a warm environment and monitoring temperature help prevent hypothermia.

Addressing her metabolic alterations involves monitoring blood glucose levels closely due to her diabetes history. Elevated respiratory rate necessitates oxygen therapy as needed and assessment for pulmonary complications. Adequate pain control, proper positioning, and early mobilization reduce risks of venous thromboembolism, which she is predisposed to because of obesity and postoperative immobilization.

Nursing interventions should also include psychological support to address anxiety related to her health status and impending discharge, ensuring she understands medication regimens and signs of complication that require urgent attention.

Interdisciplinary Healthcare Team

Effective postoperative care requires collaboration with various healthcare professionals. Three key team members include:

1. Endocrinologist: Specializes in hormonal disorders, particularly adrenal tumors and cortisol management. Their involvement ensures proper hormone replacement therapy, monitors for adrenal insufficiency, and manages her underlying endocrine disorder. An endocrinologist’s guidance is vital to prevent adrenal crisis and ensure appropriate surgical follow-up (Newell-Price et al., 2019).

2. Dietitian: Given her obesity, diabetes, and surgical recovery, a dietitian plays a crucial role in providing tailored nutritional advice. Proper dietary management aids in weight control, glycemic regulation, and wound healing support. Addressing her alcohol consumption and its impacts on health further underscores the importance of dietary intervention.

3. Physiotherapist: Early mobilization post-surgery reduces complications such as deep vein thrombosis and pneumonia. A physiotherapist assesses her physical capacity, develops tailored mobilization plans, and promotes respiratory exercises to enhance lung function and overall recovery (Krieger et al., 2019).

Other key professionals include psychologists or social workers to support mental health and social needs, and pharmacy staff to optimize medication management, especially regarding corticosteroid therapy.

Conclusion

Susan’s case highlights the importance of understanding endocrine pathophysiology and comprehensive post-operative nursing care. Her presentation with Cushing’s syndrome due to an adrenal tumor, compounded by obesity and diabetes, presents unique challenges that require coordinated interdisciplinary efforts. Recognizing her post-surgical risks, particularly adrenal insufficiency and infection, and implementing appropriate nursing interventions, are vital to optimize her recovery. Facilitating a multidisciplinary approach ensures holistic care and seamless transition from hospital to home, promoting her long-term health and well-being.

References

  • Fleseriu, M., Biller, B. M. K., & Salpea, P. (2020). Advances in the diagnosis and management of adrenal insufficiency. Endocrine Reviews, 41(3), 388–425.
  • Krieger, J., Kourbeti, I., & Alexopoulos, D. (2019). Postoperative care in endocrine surgery: Focus on adrenalectomy. Surgical Endoscopy, 33, 1820–1828.
  • Lindsay, J. R., Newell-Price, J., & Sharples, G. J. (2018). Glucose metabolism in Cushing's syndrome. Endocrinology and Metabolic Clinics of North America, 47(4), 713–725.
  • Mandel, M., Dain, S., & De La Timmer, M. (2018). Postoperative management of adrenal surgery patients. Current Opinion in Endocrinology, Diabetes & Obesity, 25(4), 231–238.
  • Mandal, K., Haldar, S., & Bhattacharyya, S. (2020). Pathophysiology of adrenal tumors: Focus on cortisol-secreting adenomas. International Journal of Endocrinology, 2020, 1–12.
  • Newell-Price, J., Bertagna, X., & Chrousos, G. P. (2019). Clinical aspects of Cushing's syndrome. The Lancet Diabetes & Endocrinology, 7(4), 298–306.
  • Pivonello, R., De Martino, M. C., & Salernos, M. (2017). Wound healing in Cushing’s syndrome: Pathophysiology and management. Endocrine Practice, 23(9), 1078–1084.
  • Provan, J., & Smith, L. (2018). Obesity and surgical outcomes: Implications for perioperative nursing. Journal of Perioperative Practice, 28(9), 255–260.
  • Krieger, J., Kourbeti, I., & Alexopoulos, D. (2019). Postoperative care in endocrine surgery: Focus on adrenalectomy. Surgical Endoscopy, 33, 1820–1828.
  • Rossi, G., & Papavasiliou, C. (2022). Multidisciplinary approach to adrenal tumors: A case-based review. Endocrine Connections, 11(2), R45–R56.

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