McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 3 6 Adrenocortical agents

■■ The glucocorticoids increase glucose production, stimulate fat deposition and protein breakdown and inhibit protein formation. They are used clinically to block inflammation and the immune response and in conjunction with mineralocorticoids to treat adrenal insufficiency. ■■ Individuals receiving glucocorticoids need to be protected from exposure to infection, have their blood glucose monitored regularly and dietary changes made as needed. They will also not heal well because of the inhibition of protein formation. protect from exposure to infections to prevent serious adverse effects. Evaluation ■ ■ Monitor response to the drug (relief of signs and symptoms of inflammation, return of adrenal function to within normal limits). ■ ■ Monitor for adverse effects (increased susceptibility to infections, skin changes, endocrine dysfunctions, fatigue, fluid retention, peptic ulcer, psychological changes). ■ ■ Evaluate the effectiveness of the teaching plan (person can name drug, dosage, adverse effects to watch for and specific measures to avoid them).

and thereby minimise suppression of the hypothalamic–pituitary axis.

■ ■ Space multiple doses evenly throughout the day to try to achieve homeostasis. ■ ■ Use the minimal dose for the minimal amount of time to minimise adverse effects. ■ ■ Taper doses when discontinuing from high doses or from long-term therapy to give the adrenal glands a chance to recover and produce adrenocorticoids. ■ ■ Arrange for increased dose when the person is under stress to supply the increased demand for corticosteroids associated with the stress reaction. ■ ■ Use alternate-day maintenance therapy with short- acting drugs whenever possible to decrease the risk of adrenal suppression. ■ ■ Do not give live virus vaccines when the person is immunosuppressed because there is an increased risk of infection. ■ ■ Protect the person from unnecessary exposure to infection and invasive procedures because the steroids suppress the immune system and the person is at increased risk for infection. ■ ■ Assess the person carefully for any potential drug– drug interactions to avoid adverse effects. ■ ■ Provide thorough teaching, including measures to avoid adverse effects, warning signs of problems and the need for regular evaluation, including blood tests, to enhance knowledge of drug therapy and promote compliance. Explain the need to THE SITUATION M.W., a 48-year-old woman, was diagnosed with severe rheumatoid arthritis 7 years ago. She has been retired, on disability, from her job as an art teacher in the local high school. Her pain is no longer controlled by aspirin, and her doctor ordered 5 mg prednisone three times a day. Over the next 4 weeks, M.W.’s symptoms were markedly relieved; she was able to start painting again, and she became much more mobile. She also noted that for the first time in years she felt “really good”. Her appetite increased, she was no longer fatigued and her outlook on life was markedly improved. At her follow-up visit, M.W. had gained 4 kilograms; she had slight oedema in both ankles, and her blood pressure was 150/92 mmHg. An inflamed, oozing lesion was found on her right hand, which she stated became infected a few weeks ago after she cut her hand while peeling potatoes. Her range of motion and joints were markedly improved. The doctor decided that M.W.

KEY POINTS

CRITICAL THINKING SCENARIO Adrenocortical agents

was past her crisis and that the prednisone should be tapered to 5 mg/day over a 4-week period.

CRITICAL THINKING Think about the pathophysiology of rheumatoid arthritis. What effects did the prednisone have on the process at work in M.W.’s joints? What effects does the adrenocorticoid steroid have on the rest of M.W.’s body? What can be expected to occur when a person is on prednisone for a month? What precautions should be taken? What care interventions are appropriate for M.W. at this visit? DISCUSSION The most urgent problem for M.W. at this time is the infected lesion on her hand.