Corticosteroids

Objectives

1 Review the functions of the adrenal gland.

2 Discuss the normal actions of mineralocorticoids and glucocorticoids in the body.

3 Cite the disease states caused by hyposecretion of the adrenal gland.

4 Identify the baseline assessments needed for a patient receiving corticosteroids.

5 Discuss the clinical uses and potential adverse effects associated with corticosteroids.

Key Terms

corticosteroids () (p. 604)

mineralocorticoids () (p. 604)

glucocorticoids () (p. 604)

cortisol () (p. 608)

Corticosteroids

http://evolve.elsevier.com/Clayton

Corticosteroids are hormones secreted by the adrenal cortex of the adrenal gland. Corticosteroids are divided into two categories based on structure and biologic activity. The mineralocorticoids (fludrocortisone and aldosterone) maintain fluid and electrolyte balance and are used to treat adrenal insufficiency caused by hypopituitarism or Addison’s disease. The glucocorticoids (e.g., cortisone, hydrocortisone, prednisone) regulate carbohydrate, protein, and fat metabolism. Glucocorticoids have anti-inflammatory, antiallergenic, and immunosuppressant activity. (See p. 608 for clinical uses of glucocorticoids.)

Nursing Implications for Corticosteroid Therapy

Assessment

The minimum assessment data for a patient receiving corticosteroids include baseline weight, blood pressure, and results of electrolyte and glucose studies. Monitoring of all aspects of intake, output, diet, electrolyte balance, and state of hydration is important to the long-term success of corticosteroid therapy. Although many of the parameters used for assessment may initially be normal, it is important that a baseline for these parameters be established so that they may be used to monitor steroid therapy.

History

• Ask the patient to describe the current problems that initiated this visit or admission.

• How long have the symptoms been present?

• Is this a recurrent problem? If so, how has it been treated?

• If an infectious process is suspected, determine when the patient was last tested for tuberculosis.

History of Pain Experience.

See p. 317.

Medication History.

Obtain a detailed history of all prescribed and over-the-counter medications (including herbal medicines). Ask if the patient understands why each is being taken. Ask specifically whether corticosteroids have been taken within the past year, and for what purpose. Tactfully determine if the prescribed medications are being taken regularly and if not, why not.

Neurologic

• Mental status: A patient receiving a higher dosage of corticosteroids is susceptible to psychotic behavioral changes. The most susceptible patient is one with a previous history of mental dysfunction. Perform a baseline assessment of the patient’s ability to respond rationally to the environment and the diagnosis of the underlying disease. Check for orientation to date, time, and place and assess for level of confusion, restlessness, or irritability. Make regularly scheduled mental status evaluations and compare the findings.

• Anxiety: What degree of apprehension is present? Did stressful events precipitate the anxiety?

History of Ulcers.

Patients receiving corticosteroid therapy have higher incidences of peptic ulcer disease. Ask the patient about any previous treatment for an ulcer, heartburn, or stomach pain. Periodic testing of stools for occult blood may be ordered.

Physical Assessment

• Blood pressure: Take a baseline blood pressure reading in the sitting, lying, and standing positions. Because patients receiving corticosteroids accumulate fluid and gain weight, hypertension may develop.

• Temperature: Record temperature daily, and monitor more frequently if elevated. Patients receiving corticosteroids are more susceptible to infection, and fever is often an early indicator of infection. Glucocorticoids, however, sometimes suppress a febrile response to infection.

• Weight and fat distribution: Obtain the patient’s weight on admission and use as a baseline in assessing therapy. Because patients receiving corticosteroids have a tendency to accumulate fluid and gain weight, the daily weight is an important tool in assessing ongoing therapy. Observe any changes in the distribution of fat and any muscle weakness or muscle wasting.

• Pulse: Record rate, quality, and rhythm of pulse.

• Heart and lung sounds: Nurses with advanced skills can perform auscultation and percussion to note changes in heart size and heart and lung sounds. (Consult a medical-surgical nursing textbook for details in performing these assessments.) Lung fields are assessed in a sitting position to detect abnormal lung sounds (e.g., wheezes, crackles, and accumulation of fluid).

• Skin color: Note the color of the skin, mucous membranes, tongue, earlobes, and nail beds. Note in particular the development of a rash or the development of ecchymoses (bruises).

• Neck veins: Record any jugular vein distention. This may be an indication of fluid overload.

Status of Hydration

• Dehydration: Assess and record significant signs of dehydration in the patient. Observe for the following signs: poor skin turgor, sticky oral mucous membranes, a shrunken or deeply furrowed tongue, crusted lips, weight loss, deteriorating vital signs, soft or sunken eyeballs, weak pedal pulses, delayed capillary filling, excessive thirst, high urine specific gravity (or no urine output), and possible mental confusion.

• Skin turgor: Check skin turgor by gently pinching the skin together over the sternum, forehead, or on the forearm. In the well-hydrated patient, elasticity is present and the skin rapidly returns to a flat position. With dehydrated patients, the skin remains pinched or peaked and returns very slowly to the flat, normal position.

• Oral mucous membranes: When adequately hydrated, the membranes of the mouth feel smooth and glisten. When dehydrated, they are sticky and appear dull.

• Laboratory changes: The values of the hematocrit, hemoglobin, blood urea nitrogen (BUN), and electrolytes will appear to fluctuate, based on the state of hydration. A dehydrated patient will show higher values as a result of hemoconcentration. When a patient is overhydrated, the values appear to drop because of hemodilution.

• Overhydration: Increased abdominal girth and circumference of medial malleolus, weight gain, and neck vein engorgement indicate overhydration. Measure the patient’s abdominal girth daily at the umbilical level. Measure the extremities bilaterally every day, approximately 5 cm above the medial malleolus.

• Edema: Is edema present? Where is it located? Is it pitting or nonpitting? It may be an indicator of fluid and electrolyte imbalance.

Laboratory Tests

• Patients taking corticosteroids are particularly susceptible to the development of electrolyte imbalance. Physiologically, corticosteroids cause sodium retention (hypernatremia) and potassium excretion (hypokalemia); hyperglycemia may be observed with high-dose glucocorticoids.

• Patients most likely to develop electrolyte disturbances are those who, in addition to receiving corticosteroids, have histories of renal or cardiac disease, hormonal disorders, massive trauma or burns, or are on diuretic therapy.

• Review laboratory tests and report abnormal results to the health care provider promptly. Tests may include serum electrolytes, especially sodium, potassium, calcium, and magnesium, arterial blood gases, glucose, electrocardiography, chest x-ray, urinalysis and kidney function, and hemodynamic assessment.

• Because the symptoms of most electrolyte imbalances are similar, the nurse should assess changes in the patient’s mental status (alertness, orientation, and confusion), muscle strength, muscle cramps, tremors, nausea, and general appearance.

Nutrition.

Obtain a history of the patient’s diet. Ask questions regarding appetite and the presence of nausea and vomiting. Anorexia, nausea, and vomiting are early indications of corticosteroid insufficiency.

Hyperglycemia.

Corticosteroid therapy may induce hyperglycemia, particularly in prediabetic or diabetic patients. All patients must be monitored for the development of hyperglycemia, especially during the early weeks of therapy. Assess regularly for hyperglycemia and report abnormalities.

Activity and Exercise.

Ask questions to obtain information about the effect of exercise on the patient’s functioning:

• Is the person normally sedentary, moderately active, or very active?

• Has there been a reduction in activity level to cope with associated fatigue or dyspnea?

• Is the person performing the activities of daily living?

Implementation

History of Illness.

If an infectious disease process is suspected and tuberculosis testing is planned, it should be performed before initiating corticosteroid therapy.

Medication History.

Review prescription medications as well as over-the-counter medications (including herbal medicines) being taken, and establish whether they are being taken correctly. Analyze nonadherence issues and plan interventions with the patient. Plan to review drug administration as needed.

Medication Administration

• Glucocorticoids may cause hyperglycemia, necessitating the monitoring of blood glucose levels at appropriate intervals. If elevated, insulin therapy may be required. Initiate a diabetic flow sheet, and mark the medication profile or computer to clearly identify the insulin orders.

• During steroid replacement therapy, the administration schedule for the replacement drugs should mimic the body’s normal circadian rhythm. Therefore, glucocorticoids ordered twice daily are usually scheduled with two thirds of the dose administered before 9 A.M. (usually with breakfast) and one third of the dose in the late afternoon (usually with dinner). Alternate-day therapy is also used in some cases to maintain a more normal body rhythm. Mineralocorticoids are usually given once daily in the evening.

• Steroid replacement therapy is gradually discontinued in small increments (tapered) to ensure that the patient’s adrenal glands are able to start secreting steroids appropriately as the drug dosage is reduced.

Neurologic.

Plan for stress reduction education and discussion of effective means of coping with stressful events. Note on the Kardex or computer file to monitor the patient’s mental status every shift.

• Perform neurologic assessment to determine changes in mental status.

• Deal calmly with an anxious patient, offer explanations of procedures being performed, and listen to concerns and intervene appropriately.

Fluid Volume Status.

Plan to monitor intake and output at intervals appropriate to the patient’s condition. Report intake that exceeds output.

Nutritional History.

Examine the dietary history to determine if referral to a nutritionist would help the patient understand the diet regimen. Plan interventions needed to deal with dietary nonadherence.

Medications.

Order medications prescribed, and schedule these on the medication profile. Corticosteroids should be scheduled to be taken with food. Perform focused assessments to determine effectiveness and adverse effects of pharmacologic interventions. Monitor for hyperglycemia.

Pain Management.

When pain is present, comfort measures must be implemented to allow the patient to decrease the pain. Fatigue may increase pain perception; spacing activities so that fatigue does not occur is recommended. Maintain a flow sheet of pain ratings and evaluate for the effectiveness of medications in the management of pain.

Vital Signs and Status of Hydration