Chapter 38 Corticosteroids Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Functions of Adrenal Glands (where are they located?) The adrenal cortex secretes two types of corticosteroids (hormones) Mineralocorticoids (Addison’s disease & F&L balance) Fludrocortisone (Addison’s) Aldosterone (increases Na reabsorption, thus inc B/P) Glucocorticoids (antiinflammatory, metabolism of CHO, Pro, &Fat) Cortisone Hydrocortisone Prednisone BTW….Adrenal Medulla secretes Epinephrine (F/F) Adrenal glands are located on the top of each kidney; they also regulate sex hormones. Mineralocorticoids and glucocorticoids have different functions and adverse effects. Diseases associated with adrenal glands are Addison’s disease, pheochromocytoma, and hyperpituitarism. Mosby, Inc., an affiliate of Elsevier Inc.

Premedication Assessment Check for electrolyte imbalance: KNOW NORMAL VALUES Record intake and output, vital signs Check for signs of infection (may be masked, low temp) Perform baseline assessment of patient’s degree of alertness WHY? Steroids can cause Psychosis, esp pt with mental disorder (quickie: AOX4, ABC’s) Previous treatment for ulcer, heartburn, stomach pain Taking NSAIDS, ASA…..Why? Taking herbs? (ginko, ginsing, garlic) Test stools for occult blood Lab values to check for electrolyte imbalance: K+, Ca+, Na+, Cl–. Signs of infection to look for in a patient taking steroids: general malaise, sore throat, low-grade fever. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Process: Implementation Monitor glucose levels for elevation; insulin may be required Follow body’s normal circadian rhythm Corticosteroids: 2/3 of dose before 9 am, 1/3 of dose late afternoon Mineralocorticoids: once daily in evening Monitor daily weight, I&O Additional doses may be needed if patient experiences stress, accidental injury; wear ID bracelet Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Mineralocorticoids Drug: fludrocortisone (Florinef) The only true mineralocorticoid drug Actions Affect fluid and electrolyte balance causing sodium and water retention Uses Treat adrenal insufficiency, Addison’s disease (you need to ADD mineralocorticoids to this pt) Therapeutic outcomes Control of blood pressure, restore fluid and electrolyte balance Adverse effects: sodium accumulation, potassium depletion Remember ….. H20 follows Na Used in combination with glucocorticoids. Fludrocortisone is the only drug that has true mineralocorticoid effects. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 1 Which laboratory test result is the nurse especially aware of for a patient who is taking fludrocortisone (Florinef) for the treatment of Addison’s disease? Potassium depletion Sodium loss Calcium loss Hydrogen increase A- Causes sodium retention and potassium loss Answer: A Rationale: The nurse should be especially aware of decreased potassium levels, which can cause muscle weakness and increase the risk of cardiac rhythm abnormalities. Fludrocortisone’s mineralocorticoid and glucocorticoid effects can disrupt fluid and electrolyte balance by acting on the distal renal tubules, causing sodium and water retention and potassium and hydrogen excretion. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Audience Response Question 2 The nurse instructs a patient taking fludrocortisone (Florinef) that he should notify the health care provider of the occurrence of which adverse effect? Fatigue Weight loss Edema of feet and ankles Nausea C Na & H2O retention, K loss also check daily wt Answer: C Rationale: Edema of the feet and ankles can result from taking a prolonged dosing of fludrocortisone, and adverse effects associated with this medication must be reported. Fludrocortisone causes sodium and water retention and potassium excretion, which can then result in fluid leaking out of capillary beds and accumulating in feet and ankles. Weight will also increase due to fluid retention. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Drug Class: Glucocorticoids Actions Antiinflammatory, antiallergenic (2nd choice after antihistamines) immunosuppression (autoimmune disorders/ transplants/ cancer) Uses Certain cancers, organ transplantation, autoimmune diseases, allergies, shock Common and serious adverse effects Electrolyte imbalance, fluid accumulation; susceptibility to infection; behavioral changes; hyperglycemia; peptic ulcer formation; delayed wound healing; visual disturbances; osteoporosis Long term may use every other day dosing always use the smallest dose for the shortest length of time to avoid neg SE For specific drugs, see Table 38-1. All corticosteroids (glucocorticoids and mineralocorticoids) share varying degrees of mineralocorticoid and glucocorticoid effects. Alternate-day therapy may be used to treat chronic conditions. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Corticosteroid Therapy: Drug Interactions Diuretics Corticosteroids may enhance the loss of potassium Warfarin Corticosteroids may enhance or decrease the anticoagulant effects of warfarin Oral hypoglycemic agents or insulin Diabetic/prediabetic patients must be monitored for hyperglycemia Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Steroid Taper Abrupt discontinuation of therapy may result in adrenal insufficiency. Adrenals shut down BC there are steroids in bloodstream Symptoms Fever, malaise, fatigue, weakness, dizziness, fainting, anorexia, nausea, hypotension, dyspnea, hypoglycemia, muscle and joint pain Gradual withdrawal of steroid use prevents symptoms of adrenal insufficiency and allows adrenal glands to start functioning again That is why QOD dosing works well Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Corticosteroid Therapy: Use with Caution Carefully monitor patients with Diabetes mellitus (hyperglycemia) Heart failure Hypertension Peptic ulcer disease (check stool for OB) Mental disturbance (neuro base line, psych Hx) Suspected infections (may mask S&S) Corticosteroids may: cause hyperglycemia in diabetic patients. mask symptoms of infection. induce hypertension. induce psychotic behavioral changes in a patient with a history of mental instability. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education for Corticosteroid Therapy Know when to contact health care provider (increased physical or mental stress, signs of infection, edema) Perform appropriate skin care Cope with stress Avoid infections Ensure proper nutrition Ensure regular exercise Foster health maintenance Maintain a written record Pt self assessment record vs, wt, mood changes, response to Tx) Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 3 What is a common adverse effect of glucocorticoids? Weight loss Hypoglycemia Appetite suppression Delayed wound healing D especially significant if pt is diabetic Answer: D Rationale: Glucocorticoids produce many adverse effects, including delayed wound healing, hyperglycemia, weight gain, fluid retention, increased fat deposition, increased appetite, mood swings, and gastric ulcer formation. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 4 The nurse is teaching a patient about a glucocorticoid medication to treat an adrenal disorder. Which statement made by the patient indicates a need for further teaching? “I take my medications with breakfast.” “I’ll be careful not to be in crowds of people.” “My prescription ran out, but I’ll refill it next week.” “I’ll follow up with my physician in 1 week.” c Titrate off to allow adrenal glands to return to normal, do not stop suddenly Answer: C Rationale: It is very important to not abruptly stop corticosteroid medications, which may result in adrenal insufficiency. The medication must be slowly decreased in increments to allow the body to adjust to the levels. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 5 A patient has been taking an oral corticosteroid to treat inflammation of the respiratory tract. The patient questions the nurse who is administering a dose of insulin. The nurse should respond: “Your physician wants you to take this to prevent diabetes.” “Your pancreas is no longer functioning and you need insulin.” “Your respiratory tract inflammation has caused you to be diabetic.” “Corticosteroids frequently cause your blood sugar to increase.” D/ hyperglycemia Answer: D Rationale:  Corticosteroids do cause an increase in blood sugar, requiring insulin to lower the blood sugar level.  Giving an injection of insulin will not prevent diabetes.  There is no indication that the patient's pancreas is not functioning and corticosteroids do not cause pancreatic failure.  Respiratory tract inflammation does not cause diabetes. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

STEROID MEN Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

STEROID FEMALE Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Moon face before & after Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Moon face baby Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.