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Scenario You graduated 3 months ago and are working with a home care agency

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Scenario

You graduated 3 months ago and are working with a home care agency. One patient in your caseload is

J.S., a 60-year-old man with chronic obstructive pulmonary disease (COPD) related to cigarette smoking.

He has been on home oxygen, 2 L oxygen by nasal cannula, for several years. Approximately 10 months

ago, he started on chronic oral steroid therapy. His current medications include an ipratropium/albuterol

(Combivent) inhaler, beclomethasone (Beclovent) inhaler, dexamethasone (Decadron), digoxin (Lanoxin),

and furosemide (Lasix).

 

1. On the way to J.S.'s home, you make a mental note to check him for signs and symptoms of

Cushing syndrome. Why?

2. Differentiate between Cushing syndrome and Cushing disease.

3. Your assessment includes the following findings. Determine whether the findings are

attributable to J.S.'s COPD or possible Cushing syndrome. Place an L beside the symptoms

consistent with COPD and a C next to those consistent with Cushing syndrome.

_____ 1. Barrel chest

_____ 2. Full-looking face (moon face)

_____ 3. BP 180/94 mm Hg

_____ 4. Pursed-lip breathing, especially when patient is stressed

_____ 5. Striae over trunk and thighs

_____ 6. Bruising on both arms

_____ 7. Acne

_____ 8. Diminished breath sounds throughout lungs

_____ 9. Truncal obesity with thin extremities

_____10. Supraclavicular and posterior upper back fat

4. You inform the physician of J.S.'s assessment. The physician believes J.S. has developed

Cushing syndrome and decides to change his prescription from dexamethasone (Decadron)

daily to prednisone (Deltasone) given on alternate days. Explain the rationale for this change.

5. Identify possible consequences of suddenly stopping dexamethasone (Decadron) therapy.

6. You advise J.S. to take the prednisone (Deltasone) at breakfast. Why?

7. Cushing syndrome can affect memory. Patients can easily forget what medications have been

taken, especially when there are several different medications and some are taken on

alternating days. List at least three ways you can help J.S. remember to take his medications

as prescribed.

8. J.S. states that his appetite has increased but he is losing weight. He reports trying to eat, but

he gets short of breath and cannot eat any more. How would you address this problem?

9. You ask him questions related to the presence gastric discomfort, vision, and joint pain. Why?

10. Differentiate between the glucocorticoid and mineralocorticoid effects of prednisone

(Deltasone).

11. How would your assessment change if J.S. were taking a glucocorticoid that had significant

mineralocorticoid activity?

12. Review J.S.'s list of medications. Based on what you know about the side effects of loop

diuretics and steroids, discuss the potential problem of administering these in combination

with digoxin.

13. You need to assess J.S. for signs and symptoms of an infection. Why?

14. What signs and symptoms of infection do you assess for in J.S.? Select all that apply.

a. Pain

b. Fever

c. Loss of function

d. Palpitations

e. Unusual drainage

f. Localized edema

15. Realizing J.S. is susceptible to infection, you review with him ways to reduce the risk of

infection. Identify four major points to include.

16. In addition to measures to reduce the risk of infection, what other information would you

want to stress to J.S. at your visit? Select all that apply.

a. Drink at least 4000 mL of fluids daily.

b. Increase intake of foods high in sodium.

c. Weigh yourself first thing in the morning.

d. Take vitamin and electrolyte supplements as prescribed.

e. Notify the physician if your pulse is lower than 60 beats/min.

f. Call the doctor if your weight increases more than 2-3 pounds in 1 day.

g. Take the furosemide (Lasix) first thing in the morning and again at bedtime.