Etiology and Pathophysiology of Cushing’s Syndrome
Discuss about the Longitudinal Cohort Study On Physical Activity.
The essay gives an insight into the nursing management of post-operative complications in patients by the analysis of the case scenario of Susan Summers, a 40 year old female who has undergone laparascopic right adrenalectomy. She had to undergo the surgery due to the presence of benign tumour on her right adrenal gland and diagnosis of Cushing’s syndrome. The essay gives an understanding about the cause of Cushing’s syndrome by discussion on the etiology and pathophysiology of the condition. In response to the vital signs observation of Susan 2 hours post surgery, a discussion on the pathophysiology behind different clinical deteriorations is provided. The essay also provides detail about care priorities for patient 2 hours post op and the role of other health care team for the recovery of Susan in the hospital.
The case study is about Susan Summers, who is a patient with type 2 diabetes patient and recently been admitted to the hospital due to Cushing’s syndrome. It is a disease caused by the excess secretion of cortisol hormone from the adrenal gland, leading to symptoms of stretch marks, abdominal obesity, fatty tissue deposits between the shoulder and thin fragile skin (Lacroix et al., 2015). Susan also experienced such kind of changes in her appearance and the Cushing’s syndrome was caused by a benign tumour of her right adrenal gland. Hence, it can be said that tumor in the pituitary gland was the main cause of the disease. These tumors release adrenocorticotropic hormone (ACTH), which causes the adrenal gland to produce excess amount of cortisol. ACTH is released in diurnal patterns and its level decreases throughout the day. The release of ACTH is controlled by means of negative feedback at the pituitary levels (Raff & Carroll, 2015). Apart from pituitary tumor, Cushing’s syndrome is also caused by primary adrenal neuplasm’s and ectopic ACTH secreting tumors (Lacroix et al., 2015). From this explanation, the etiology and pathophysiology behind Susan’s presenting condition is understood.
Following changes in Susan’s appearance due to Cushing’s syndrome, she was admitted to the hospital for a laparscopic right adrenalectomy under general anaesthesia. However, post-operatively, observation of his vital signs gave indication about deterioration in his clinical condition. For example, Susan respiratory rate was 30 breaths per minute, however the normal breathing rate is 12-20 breaths per minute. Her pulse rate was 128 beats/ minute although pulse rate is 100 beats/ minute (my.clevelandclinic.org, 2018). Such kind of respiratory complications post surgery occurs because of the effect of anesthesia and surgery. Karcz & Papadakos, (2013) has explained that in case of normal patient, general anesthesia and mechanical ventilation impairs pulmonary function and leads to respiratory complication post surgery. This kind of issues increases morbidity of the disease. However, such kind of complication also depends on patient variables too.
In case of Susan, this kind of complication was also seen because of obesity and this contributed to the etiology of post-operative respiratory complications. Susan was obese at 90 kg with a BMI of 36. According to World Health Organization recommendation, a person with BMI above 30kg/m2 is regarded as obese (Kioko, Williams & Newhouse, 2016). Obesity has great impact on physiology of breathing because of the impact of heavy weight on thoracic cage and abdomen. It changes respiratory compliance and alters respiratory muscle function (Brazzale, Pretto & Schachter, 2015). For this reason, airway resistance and increased work of breathing is seen in obese patients. Hodgson, Murphy & Hart, (2015) suggest that respiratory system compliance decreases by 35% in obese patients and fat distribution create high pleural pressure, thus leading to low overall compliance. Hence, in case of Susan, respiratory complication of high breathing is seen due to obesity.
Clinical Deteriorations Post-Surgery
Susan’s vital signs assessment showed BP of 160/90 mmHg. This indicates that the patient is hypertensive post surgery as normal BP is 120/80 (my.clevelandclinic.org, 2018). As Susan is a type 2 diabetes patient, high blood pressure is seen in her mainly because of her diabetes. Obesity also acts as the common pathway behind the etiology of hypertension. In case of obese people, imbalance in energy intake and expenditure acts as a risk factor for hypertension as well as diabetes. Insulin resistance and increase in inflammatory markers in patients with diabetes lead to hypertension (Cheung & Li, 2012). Susan is a hypertension patient, however patients without hypertension also develop high blood pressure during surgery because of the induction of anesthesia. Review of study on persistent hypertension after adrenalectomy suggest that cardiac, renal and vascular system of patient requiring adrenalectomy is affected due to increased exposure to aldosterone. It increases sodium absorption in kidneys resulting in high blood pressure (Carter et al., 2012). Persistent hypertension can have a long-lasting effect on cardiac and vascular system of Susan particularly because she is obese. Hence, managing her blood pressure should be a major care priority post surgery.
In the early anesthesia period, patients experience symptoms of hypertension along with any one events like hypothermia and hypoxia (Lonjaret et al., 2014). Susan’s vital signs observation also showed that she was hypothermic as her body temperature was 35 degree C. This could be the reason for impact on other vital signs like high blood pressure and breathing rate. On the whole, it can be said that abnormal signs of high breathing rate, high blood pressure and pulse rate has been found in Susan mainly because of the effect of surgery and obesity. The condition of Cushing syndrome also predisposed Susan to risk of hypertension because of overexposure to aldosterine. Susan’s urinary output in the last hour was 5 mls, although normal urine output level should be 50-60ml. The reason for low urinary output could be decreased renal perfusion due to blood loss and response of the adrenal cortex to stress. In the first few hours after surgery, release of adrenalcortex affects water and salt retention and lead to oliguria (Kunst & Ostermann, 2017).
In patients like Susan, who are in post-anaesthetic recovery room (PARU) 2 hours post operation, safe care is one where wound care and pain management is done by means of vital signs assessment and observing for any complication in patient. The focus should be to minimize potential problem in patients like changes in pulse rate, respiratory rate, temperature, capillary refill time, urine output and level of consciousness. After reviewing the vital signs of Susan, the main care priority is to manage abnormal vital signs of patient (like high blood pressure, breathing rate and hypothermia) and provide specific care in relation to wound management post removal of adrenal tumor. Controlling BP of Susan is important because persistence of high blood pressure may increase risk of organ damage ischemic risk for patients (Cheung & Li, 2012). Hence, managing vital signs of Susan should be a major priority. Nurse can manage BP of Susan by means of pharmacological interventions like giving short acting beta-blockers or other medications after consultation with clinician (Glynn et al., 2010). As Susan was found to have reduced urine output, it is a sign of hypovolemia and this should be immediately managed by nurse in consultation with other medical staff. In addition, controlling symptom of hypothermia is also necessary to prevent risk of infection in patient. Apart from management of vital signs, other specific care priority 2 hours post adrenalectomy will to assess wounds, monitor for wound drainage, manage fluid intake of patient and observe for signs of hypovolemic shock. Many patients may develop hypovolemic shock because of adrenal insufficiency caused due to removal of the adrenal gland (Polistina et al., 2016).
Causes of Respiratory Complications Post-Surgery
As Susan is going to remain in the hospital even after initial managements of symptoms, role of other interdisciplinary healthcare team apart from nursing and medical team is also necessary for the care of patient. Firstly, the role of a dietician is important because Susan is an obese patient with diabetes. Hence, it will be essential that Susan gets a diet that keeps her sugar and blood pressure under control and prevent her from any suffering during hospital stay. Intake of proper diet with appropriate fluid intake can minimize hypoglycemic events and high BP in patient (Berkowitz et al., 2018). The role of physiotherapist is also critical in the post-operative care of Susan as they have the skills to promote functional ability and independence in patient. A physiotherapist can work with Susan and other medical team to educate her about restricted movement post-operation and providing special exercise so that Susan can regain loss of movement and muscle weakness (Wainwright, McDonald& Burgess, 2017). Rehabilitation counselor can also support Susan to safely recover from post-operative stress and teach her the ways to engage in self-care post discharge too (Alingh et al., 2015). The collaboration of all these inter-professional team members can help in optimal recovery of Susan.
From the discussion on the post-operative management of Susan post adrenalectomy, it can be concluded that obese patients and patients with diabetes are at additional risk of post-operative complications post surgery. Hence, assessment of vital signs 2 hours post surgery is a critical point to effectively manage patient’s condition and initiate appropriate intervention to minimize post-operative morbidity in patient. From the discussion on nursing management of Susan and role of other interprofessional team, it is understood that collaboration between interpofessional health care staffs is vital for the recovery of patient and supporting them to effectively manage their condition post discharge too.
References:
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Carter, Y., Roy, M., Sippel, R. S., & Chen, H. (2012). Persistent hypertension after adrenalectomy for an aldosterone-producing adenoma: weight as a critical prognostic factor for aldosterone’s lasting effect on the cardiac and vascular systems. journal of surgical research, 177(2), 241-247.
Cheung, B. M., & Li, C. (2012). Diabetes and hypertension: is there a common metabolic pathway?. Current atherosclerosis reports, 14(2), 160-166.
Cleveland Clinic. (2018). Vital Signs | Cleveland Clinic. Retrieved 4 March 2018, from https://my.clevelandclinic.org/health/articles/10881-vital-signs
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Kioko, E., Williams, K., & Newhouse, B. (2016). Improving Metabolic Syndrome Screening on Patients on Second Generation Antipsychotic Medication. Archives of psychiatric nursing, 30(6), 671-677.
Kunst, G., & Ostermann, M. (2017). Intraoperative permissive oliguria–how much is too much?. BJA: British Journal of Anaesthesia, 119(6), 1075-1077.
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Polistina, F. A., Farruggio, A., Gasparin, P., Pasquale, S., & Frego, M. (2016, April). Spontaneously metachronous ruptures of adrenocortical carcinoma and its contralateral adrenal metastasis. In International Cancer Conference Journal (Vol. 5, No. 2, pp. 90-97). Springer Japan.
Raff, H., & Carroll, T. (2015). Cushing’s syndrome: from physiological principles to diagnosis and clinical care. The Journal of physiology, 593(3), 493-506.
Wainwright, T., McDonald, D., & Burgess, L. (2017). The role of physiotherapy in Enhanced Recovery after Surgery in the intensive care unit. ICU Management and Practice, 17(3), 146-147.
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