Drug Therapy with Corticosteroids – Abrams study guide – Flashcards
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______ also called glucocorticoids or steroids are hormones producted by the adrenal cortex, part of the adrenal glands
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Corticosteroids
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_____ are used as drugs in a variety of disorders
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Exogenous corticosteroids
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When plasma corticosteroid levels rise to an adequate level, secretion of corticosteroids _____ or _____.
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Slows (or) stops
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The mechanism by which the hypothalamus and anterior pituitary "learn" that no more corticosteroids are needed is called a ____ ____ ____
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negative feedback mechanism
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____ are secreted directly into the bloodstream
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corticosteroids
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Produced by inadequate secretion of corticotropin, most often caused by prolonged administration of corticosteroids
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Secondary adrenocortical insufficiency
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Associated with destruction of the adrenal cortex by disease processes or hemorrhage and with atrophy of the adrenal cortex
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Primary adrenocortical insufficiency (Addison's disease)
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A rare disorder caused by adenoma or hyperplasia of the adrenal cortex cells that produce aldosterone
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Hyperaldosteronism
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Result from deficiencies in one or more enzymes required for cortisol production
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Congenital adrenogenitcal syndromes and adrenal hyperplasia
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May result from excessive corticotropin or a primary adrenal tumor
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Adrenocortical hyperfunction (Cushing's disease)
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Discuss the process by which corticosteroids secretion is controlled.
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Corticosteroid secretion is controlled by the hypothalamus, the anterior pituitary, and adrenal cortex (the hypothalamic-pituitary-adrenal, or HPA, axis). Various stimuli (e.g., low plasma levels or corticosteroids, pain, anxiety, trauma, illness, anesthesia) activate the system. These stimuli cause the hypothalamus of the brain to secrete corticotropin-releasing hormone or factor (CRH or CRF), which stimulates the anterior pituitary gland to secrete corticotropin, and corticotropin then simulates the adrenal cortex to secrete corticosteroids.
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How does the stress response affect the sympathetic nervous system?
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The stress response activates the sympathetic nervous system (SNS) to produce more epinephrine and norepinephrine and adrenal cortex to produce as much as 10 times the normal amount of cortisol. The synergistic interaction of these hormones incrases the person's ability to respond to stress. However, the increased SNS activity continues to stiumlate cortisol production (the main glucocorticoids secreted as part of the body's response to stress) and overrules the negative feedback mechanism. Excessive and prolonged corticosteroid secretion damages body tissues.
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What are glucocorticoids, and how do they affect the body's processes?
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Glucocorticoids are important in metabolic, inflammatory, and immune processes. Glucocorticoids include cortisol, corticosterone, and cortisone. Cortisol activity accounts for at least 95% of glucocorticoid activity; corticosterone and cortisone account for a small amount of activity. Glucocorticoids are secreted cyclically, with the largest amount being produced in the early morning and the smallest amount during the evening hours ( in people with a normal day-night schedule). At the cellular level, glucocorticoids account for most of the characteristics and physiologic effects of the corticosteroids.
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What are mineralocorticoids, and how do they affect the body's processes?
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Mineralocorticoids are a class of steroids that play a vital role in the maintenance of fluid and electrolyte balance through their influence on salt and water metabolism. Aldosterone is the main mineralocorticoid and is responsible for approximately 90% of mineralocorticoid activity.
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What are the adrenal sex hormones, and how do they affect the body's processes?
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The adrenal cortex secretes male (androgens) and female (estrogens and progesterone) sex hormones. Compared with the effect of hormones produced by the testes and ovaries, the adrenal sex hormones have an insignificant effect on normal body function. Adrenal androgens, secreted continuously in small quantities by both sexes, are responsible for most of the physiologic effects exerted by the adrenal sex hormones. They increase protein synthesis (anabolism), which increases the mass and strength of muscle and bone tissue; they affect development of male secondary sex characteristics; and they increase hair growth and libido in women.
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A patient is diagnosed with systemic lupus erythematosus. Where would you expect to find inflammation in this patient?
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Systemic lupus erythematosus is a collagen disorder, as are scleroderma and periarteritis nodosa. Collagen is the basic structural protein of connective tissue, tendons, cartilage, and bone, and it is therefore present in almost all body tissues and organ systems. The collagen disorders are characterized by inflammation of various body tissues, particularly tendons, cartilage, and connective tissues. Signs and symptoms depend on which body tissues or organs are affected and the severity of the inflammatory process.
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Name some skin disorders that may be treated with corticosteroids.
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Dermatologic disorders that may be treated with systemic corticosteroids include acute contact dermatitis, erythema multiforme, herpes zoster (prophylaxis or postherpetic neuralgia), lichen planus, pemphigus, skin rashes caused by drugs, and toxic epidermal necrolysis.
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Corticosteroids are effective in the treatment of neoplastic disease. What mechanism of action do they have that makes them effective?
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The effectiveness of corticosteroids in neoplastic diseases, such as acute and chronic leukemias, Hodgkin's disease, other lymphomas, and multiple myelomas, probably stems from their ability to suppress lymphocytes and other lymphoid tissue.
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A patient received a kidney transplant 6 months ago. He is not comfortable with the changes in his body related to the corticosteroids he must take. He asks why they are necessary. How would you respond?
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Corticosteroids suppress cellular and humoral immune responses and help prevent rejection of transplanted tissue. Drug therapy is usually continued as long as the transplanted tissue is in place.
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In patients with asthma, what is the effect of corticosteroids? In patients with anaphylactic shock resulting from an allergic reaction, what is the effect of corticosteroids?
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In patients with asthma, corticosteroids increase the number of beta-adrenergic receptors and increase or restore the responsiveness of beta receptors to beta-adrenergic bronchodilating drugs. In cases of asthma, COPD, and rhinitis, the drugs decrease mucus secretion and inflammation. In anaphylactic shock resulting from an allergic reaction, corticosteroids may increase or restore cardiovascular responsiveness to adrenergic drugs.
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A female patient's physician discontinues her systemic corticosteroids using a sliding scale and orders an inhaler. The patient asks if she can being flunisolide; her friend uses it and suggested it as the patient's next option. How should the nurse respond? a. "I will ask the physician to change his original prescription." b. "Flunisolide is a safe option." c. "Flunisolide is not the primary medication to treat her disease process." d. "The physician did not order flunisolide because it may cause death."
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d. A black box warning has been issued by the FDA for the people who are transferred from systemically active corticosterois, to flunisolide systemically active corticosteroids to flunisolide inhaler; deaths from adrenal insufficiency have been reported.
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Systemic corticosteroids may cause which side effects? (Select all that apply) a. Hirsutism b. Hypertension c. Glucose intolerance d. Premature puberty in children e. Fat pad on the buttocks (Buffalo hump)
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b and c. Adverse effects of systemic corticosteroids may include infections, hypertension, glucose intolerance, obesity, cosmetic changes, bone loss, growth retardation in children, cataracts, pancreatitis, peptic ulcerations, and psychiatric disturbances. Patients also develop cervicodorsal fat pad or buffalo hump, which exists between the shoulder blades, not on the buttocks.
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What is a strategy to minimize HPA suppression and risks of acute adrenal insufficiency?
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Administering a systemic corticosteroid during high-stress situations in patients on long-term systemic therapy. Rationale: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include administering a systemic corticosteroid during high-stress situations in patients who are on long-term systemic therapy (i.e., are steroid dependent).
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A male patient experiences an acute exacerbation of his asthma secondary to an allergic reaction. The physician orders what type of therapy to minimize HPA suppression and risks of acute adrenal insufficiency?
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A short course of systemic therapy. Rationale: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include giving short courses of systemic therapy for acute disorders.
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A female patient experiences weight gain secondary to her systemic steroid therapy for temporal arteritis. She calls the physician's office to ask if she can discontinue the medication for 1 week, to fit into her dress for her class reunion. Which response is appropriate?
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"Your prescription must be tapered gradually with the physician's order." Rationale: Strategies to minimize HPA suppression and risks of adrenal insufficiency include gradually tapering the dose of any systemic corticosteroid.
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A male patient develops a mild rash secondary to sensitivity to a new laundry detergent. The physician orders a topical corticosteroid. The patient states that this medication will take too long to work and asks whether he can just take a steroid by mouth. What is the most appropriate response?
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"Using local rather than systemic corticosteroids reduces adrenal insufficiency." Rationale: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include using local rather than systemic therapy when possible, alone or in combination with low doses of systemic drugs.
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The mother of a child who has just been diagnosed with asthma is receiving medication teaching about the prednisone (Deltasone) that the child will be taking for the next 2 weeks. Which statement by the mother indicates the need for further instruction?
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"I am so glad that this medication cure his asthma." Rationale: The mother will need further instruction is she believes that a corticosteroid will cure the asthma. This class of drugs is intended to control symptoms, not cure illness.
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A male patient is diagnosed with Addison's disease. What daily medication would the nurse expect to be administered?
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Prednisone. Rationale: Daily administration of corticosteroids and mineralocorticoids is required in cases of chronic adrenocortical insufficiency (Addison's disease)
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A 65-year-old patient who has been on long-term corticosteroid therapy is admitted to the hospital and will need an IV inserted. What adverse effect of corticosteroid may negatively affect this procedure?
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Thinning of the skin. Rationale: The patient's thinning skin may make IV insertion more difficult because the skin is so much more fragile and it bruises so easily due to capillary fragility.
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What are the most frequently desired pharmacologic effects of exogenous corticosteroids? (Select all that apply.)
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Anti-inflammatory Immunosuppressive Analgesic Rationale: The most frequently desired pharmacologic effects of exogenous corticosteroids are anti-inflammatory, immunosuppressive, antiallergic, and anti-stress effects. Corticosteroids have been shown to decrease pain as they decrease inflammation, but they are not usually prescribed for their analgesic properties.
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The nurse is working in a home care setting. A female patient is prescribed oral corticosteroids by her physician secondary to a diagnosis of Addison's disease. What is the nurse's responsibility in this situation?
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Supervising and monitoring the administration of the drug. Rationale: Because of potentially serious adverse effects, especially with oral drugs, it is extremely important that corticosteroids be used as prescribed. A major responsibility of home care nurses is to teach, demonstrate, supervise, monitor, or do whatever is needed to facilitate correct use.
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A male patient is diagnosed with pneumocystosis, and his physician orders corticosteroids. What is an accurate statement to include in the teaching plan for the patient?
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Corticosteroids decrease risks of respiratory failure. Rationale: Corticosteroids improve survival and decrease the risk of respiratory failure with penumocystosis, a common cause of death in patients with AIDS.
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A female patient is diagnosed with septic shock. What wqould the nurse expect a long course of low-dose corticosteroids to do?
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Improve her survival without causing harm Rationale: Sepsis may be complicated by impaired corticosteroid production. There is sufficient evidence to support the idea that giving a long course of low-dow corticosteroids in patients with septic shock can improve survival without causing harm. However, overall, corticosteroids do not affect mortality.
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A male patient is diagnosed with adult respiratory distress syndrome. His family asks whether corticosteroids may help him to breathe easier. Which statement about corticosteroids is accurate?
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They are not a beneficial treatment for ARDS. Rationale: Although corticosteroids have been widely used, several well-controlled studies demonstrated that the drugs are not beneficial in early treatment or in prevention of adult respiratory distress syndrome (ARDS).
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A male patient receives IV methylprednisolone to treat status asthmaticus. Corticosteroid use may increase the risk of what condition for the patient?
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Pulmonary infection Rationale: Some studies support the use of IV methylprednisolone. So, if other medications do not produce adequate bronchodilation, it seems reasonable to try an IV corticosteroid during the first 72 hours of the illness. However, corticosteroid therapy increases the risks of pulmonary infection.
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A female patient is diagnosed with adrenal insufficiency. She presents to the emergency department with hypotension. What would the nurse expect the physician to prescribe?
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Corticosteroids Rationale: In adrenal insufficiency, hypotension is a common symptom in critically ill patients, and hypotension caused by adrenal insufficiency may mimic either hypovolemic or septic shock. If adrenal insufficiency is the cause of the hypotension, administrations of corticosteroids can eliminate the need for vasopressor drugs to maintain adequate tissue perfusion.
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A patient who receives long-term corticosteroid therapy is at risk for the development of which conditions?
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Diabetes mellitus Peptic ulcer disease COPD Rationale: Long-term corticosteroid therapy may cause a patient to develop diabetes due to the increase in glucose tolerance, peptic ulcer disease due to the gastric erosion, and tuberculosis because of the decreased immunity. It is used as a treatment for rheumatoid arthritis and COPD.
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A 45-year-old women has been taking a corticosteroid and calls the clinic complaining of the development of acne-like lesion on her face as well as facial hair. What is the nurse's best response?
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"Sadly, this is an adverse effect seen in women. It should improve when you finish the medication." Rationale: An adverse effect in women who take corticosteroids is acne and hair on the face. This side effect usually resolves after the medication is discontinued. The drug should never be stopped abruptly, but weaned gradually.
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The use of corticosteroids in older adults may aggravate which conditions?
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Congestive heart failure Diabetes mellitus Arthritis Rationale: Corticosteroids are used for the same conditions in older adults as in younger ones. Older adults are especially likely to have conditions that are aggravated by the drugs (e.g., CHF, hypertensions, diabetes mellitus, arthritis, osteoporosis, increased susceptibility to infection, concomitant drug therapy that increases risks of GI ulceration and bleeding). Consequently, risk-benefit rations of systemic corticosteroid therapy should be carefully considered, especially for long-term therapy, It is used as a treatment for contact dermatitis.
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The nurse is caring for a patient who has just returned to the unit after having a craniotomy. What drug does the nurse anticipate that the physician will order for this patient?
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IV dexamethasone Rationale: After a craniotomy, the drug of choice is either IV or PO dexamethasone.
