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Unit 8

The Endocrine System

PROTOTYPE DRUG

Hydrocortisone (Cortef, Hydrocortone, others)

Glucocorticoid

ADVERSE EFFECTS
When used at low doses for replacement therapy, or by the topical or intranasal routes, adverse effects of hydrocortisone are rare. However, signs of
Cushings syndrome can develop with high doses or with prolonged use. If
taken for longer than 2 weeks, hydrocortisone should be discontinued gradually. Hydrocortisone possesses some mineralocorticoid activity, so sodium
and fluid retention may be noted. A wide range of CNS effects have been reported, including insomnia, anxiety, headache, vertigo, confusion, and depression. Cardiovascular effects may include hypertension and tachycardia.
Long-term therapy may result in peptic ulcer disease.
Contraindications: Hydrocortisone is contraindicated in clients with known infections or who are hypersensitive to the drug. Clients with diabetes, osteoporosis, psychoses, liver disease, or hypothyroidism should be treated with caution.

ACTIONS AND USES


Structurally identical with the natural hormone cortisol, hydrocortisone is a
synthetic corticosteroid that is the drug of choice for treating adrenocortical
insufficiency. When used for replacement therapy, it is given at physiological doses. Once proper dosing is achieved, its therapeutic effects should
mimic those of endogenous corticosteroids. Hydrocortisone is also available
for the treatment of inflammation, allergic disorders, and many other conditions. Intra-articular injections may be given to decrease severe inflammation in affected joints.
Hydrocortisone is available in six different formulations. Hydrocortisone base
(Aeroseb-HC, Alphaderm, Cetacort, others) and hydrocortisone acetate (Anusol
HC, Cortaid, Cortef Acetate) are available as oral preparations, creams, and
ointments. Hydrocortisone cypionate (Cortef Fluid) is an oral suspension. Hydrocortisone sodium phosphate (Hydrocortone Phosphate) and hydrocortisone
sodium succinate (A-Hydrocort, Solu-Cortef) are for parenteral use only. Hydrocortisone valerate (Westcort) is only for topical applications.

INTERACTIONS
DrugDrug: Barbiturates, phenytoin, and rifampin may increase hepatic
metabolism, thus decreasing hydrocortisone levels. Estrogens potentiate
the effects of hydrocortisone. Use with nonsteroidal anti-inflammatory
drugs (NSAIDS) increases the risk of peptic ulcers. Cholestyramine and
colestipol decrease hydrocortisone absorption. Diuretics and amphotericin B
increase the risk of hypokalemia. Anticholinesterase agents may produce severe weakness. Hydrocortisone may cause a decrease in immune response
to vaccines and toxoids.
Lab Tests: May increase serum values for glucose, cholesterol, sodium, uric
acid, or calcium. May decrease serum values of potassium and T3/T4.
Herbal/Food: Use of hydrocortisone with senna, cascara, or buckthorn may
cause potassium deficiency with chronic use.
Treatment of Overdose: There is no specific treatment for overdose.

ADMINISTRATION ALERTS
Administer exactly as prescribed and at the same time every day.
Administer oral formulations with food.
Pregnancy category C.
PHARMACOKINETICS
Onset: 12 h PO; 20 min IM
Peak: 1 h PO; 48 h IM
Half-life: 1.52 h
Duration: 11.5 days PO or IM

See the Companion Website for a Nursing Process Focus


specific to this drug.

NURSING PROCESS FOCUS Client Receiving Systemic Glucocorticoid Therapy


Assessment

Potential Nursing Diagnoses

Prior to administration:
Obtain a complete health history including allergies, drug history, and possible drug interactions.
Obtain a complete physical examination, focusing on presenting symptoms.
Determine the reason the medication is being administered.
Obtain serum sodium and potassium levels, hematocrit and hemoglobin levels,
and blood glucose level, and blood urea nitrogen (BUN) and creatinine levels.

Infection, Risk for, related to immunosuppression


Injury, Risk for, related to side effects of drug therapy
Knowledge, Deficient, related to drug therapy
Breast-feeding, Interrupted, related to drug therapy

Planning: Client Goals and Expected Outcomes


The client will:
Exhibit a decrease in the symptoms for which the drug is being given.
Exhibit no symptoms of infection.
Demonstrate an understanding of the drugs action by accurately describing drug side effects and precautions.
Adhere to drug and laboratory studies regimen.

Implementation
Interventions and (Rationales)

Monitor vital signs. (Blood pressure may increase because of increased blood
volume and potential vasoconstriction effect.)

Client Education/Discharge Planning

Instruct client to report dizziness, palpitations, or headaches.

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Drugs for Pituitary, Thyroid, and Adrenal Disorders

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NURSING PROCESS FOCUS Client Receiving Systemic Glucocorticoid Therapy (Continued)


Implementation
Interventions and (Rationales)

Client Education/Discharge Planning

Monitor for infection. Protect client from potential infections. (Glucocorticoids


increase susceptibility to infections by suppressing the immune response.)

Instruct client to:


Avoid people with infection.
Report fever, cough, sore throat, joint pain, increased weakness, and malaise.
Consult with the healthcare provider before receiving any immunizations.

Monitor clients compliance with drug regimen. (Sudden discontinuation of


these agents can precipitate an adrenal crisis.)

Instruct client:
Never to suddenly stop taking the medication.
In proper use of self-administering tapering dose pack.
To take oral medications with food.

Monitor for symptoms of Cushings syndrome, such as moon face, buffalo


hump, weight gain, muscle wasting, and increased deposits of fat in the
trunk. (Symptoms may indicate excessive use of glucocorticoids.)

Instruct client:
To weigh self daily.
That initial weight gain is expected; provide the client with weight gain
parameters that warrant reporting.
That there are multiple side effects to therapy and that changes in health status
should be reported.

Monitor blood glucose levels. (Glucocorticoids cause an increase in gluconeogenesis and reduce glucose utilization.)

Instruct client to:


Report symptoms of hyperglycemia such as excessive thirst, copious urination,
and insatiable appetite.
Adjust insulin doses based on blood glucose levels as directed by the healthcare
provider.

Monitor skin and mucous membranes for lacerations, abrasions, or break in


integrity. (Glucocorticoids impair wound healing.)

Instruct client to:


Examine skin daily for cuts and scrapes and to cover any injuries with a sterile
bandage.
Watch for symptoms of skin infection such as redness, swelling, and drainage.
Notify the healthcare provider of any nonhealing wound or symptoms of
infection.

Instruct client to report GI side effects, such as heartburn, abdominal pain, or


tarry stools.

Monitor GI status for peptic ulcer development. (Glucocorticoids decrease gastric mucus production and predispose client to peptic ulcers.)

Monitor serum electrolytes. (Glucocorticoids cause hypernatremia and


hypokalemia.)

Instruct client to:


Consume a diet high in protein, calcium, and potassium, but low in fat and
concentrated simple carbohydrates.
Keep all laboratory appointments.

Monitor changes in musculoskeletal system. (Glucocorticoids decrease bone


density and strength and cause muscle atrophy and weakness.)

Instruct client:
To participate in exercise or physical activity, to help maintain bone and muscle
strength.
That drug may cause weakness in bones and muscles.
To avoid strenuous activity that may cause injury.

Monitor emotional stability. (Glucocorticoids may produce mood and behavior


changes such as depression or feeling of invulnerability.)

Instruct client that mood changes may be expected and to report mental status
changes to the healthcare provider.

Evaluation of Outcome Criteria


Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see Planning).
The client states that symptoms have decreased.
The client is free from signs of infection.
The client demonstrates an understanding of the drugs action by accurately describing drug side effects and precautions.
The client verbalizes the importance of adhering to drug and laboratory studies regimen.

See Table 43.4 for a list of drugs to which these nursing actions apply.