Beruflich Dokumente
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Corticosteroids
23
OB JECTI V ES AP P LY I N G YO UR K N OW LE DGE
After studying this chapter, you will be able to: Sue Hubble is a 70-year-old African-American
female. She is 5 feet 9 inches tall and weighs
1. Review physiologic effects of endogenous corticosteroids. 275 pounds. She has type 2 diabetes mellitus,
2. Discuss clinical indications for use of exogenous and, as a result of lifelong smoking, has been
corticosteroids. diagnosed with chronic obstructive pulmonary
3. Differentiate between physiologic and pharmacologic doses of disease (COPD). In her home, she uses oxygen.
In addition to her respiratory drugs and her
corticosteroids.
drugs for diabetes, she has been taking
4. Differentiate between short-term and long-term corticosteroid prednisone 20 mg PO daily for the past month.
therapy. You are Ms. Hubble’s home care nurse.
5. List at least 10 adverse effects of long-term corticosteroid
therapy.
6. Explain the pathophysiologic basis of adverse effects.
7. State the rationale for giving corticosteroids topically when
possible rather than systemically.
8. Use other drugs and interventions to decrease the need for
corticosteroids.
9. Discuss the use of corticosteroids in selected populations and
conditions.
10. Apply the nursing process with a client receiving long-term
systemic corticosteroid therapy, including teaching needs.
SNS activity continues to stimulate cortisol production and effect of hormones produced by the testes and ovaries, the
overrules the negative feedback mechanism. Excessive and pro- adrenal sex hormones have an insignificant effect on normal
longed corticosteroid secretion damages body tissues. body function. Adrenal androgens, secreted continuously in
Corticosteroids are secreted directly into the bloodstream. small quantities by both sexes, are responsible for most of the
Cortisol is approximately 90% bound to plasma proteins (80% physiologic effects exerted by the adrenal sex hormones. They
to an alpha globulin called transcortin or cortisol-binding increase protein synthesis (anabolism), which increases the
globulin and 10% to albumin). This high degree of protein mass and strength of muscle and bone tissue; they affect devel-
binding slows cortisol movement out of the plasma, so that it opment of male secondary sex characteristics; and they increase
has a relatively long plasma half-life of 60 to 90 minutes. The hair growth and libido in women. Excessive secretion of
remaining 10% is unbound and biologically active. In con- adrenal androgens in women causes masculinizing effects
trast, aldosterone is only 60% bound to plasma proteins and (eg, hirsutism, acne, breast atrophy, deepening of the voice,
has a short half-life of 20 minutes. In general, protein bind- amenorrhea). Female sex hormones are secreted in small
ing functions as a storage area from which the hormones are amounts and normally exert few physiologic effects. Excessive
released as needed. This promotes more consistent blood lev- secretion may produce feminizing effects in men (eg, breast
els and more uniform distribution to the tissues. enlargement, decreased hair growth, voice changes).
↑, increase/increased; ↓, decrease/decreased;
Chapter 23 ● Corticosteroids 355
WBCs
Blood vessel
and 64, respectively. The corticosteroids discussed in this in cases of insufficiency and to suppress corticotropin
chapter are used to treat potentially serious or disabling dis- when excess secretion causes adrenal hyperplasia. These
orders. These disorders include the following: conditions are rare and account for a small percentage of
corticosteroid usage.
● Allergic or hypersensitivity disorders, such as allergic ● Gastrointestinal disorders, such as ulcerative colitis
reactions to drugs, serum and blood transfusions, and and regional enteritis (Crohn’s disease)
dermatoses with an allergic component ● Hematologic disorders, such as idiopathic thrombocy-
● Collagen disorders, such as systemic lupus erythe- topenic purpura or acquired hemolytic anemia
matosus, scleroderma, and periarteritis nodosa. Colla- ● Hepatic disorders characterized by edema, such as cir-
gen is the basic structural protein of connective tissue, rhosis and ascites
tendons, cartilage, and bone, and it is therefore present ● Neoplastic disease, such as acute and chronic leuke-
in almost all body tissues and organ systems. The col- mias, Hodgkin’s disease, other lymphomas, and multi-
lagen disorders are characterized by inflammation of ple myeloma. The effectiveness of corticosteroids in
various body tissues. Signs and symptoms depend on these conditions probably stems from their ability to
which body tissues or organs are affected and the sever- suppress lymphocytes and other lymphoid tissue.
ity of the inflammatory process. ● Neurologic conditions, such as cerebral edema, brain
● Dermatologic disorders that may be treated with sys- tumor, acute spinal cord injury, and myasthenia gravis
temic corticosteroids include acute contact dermatitis, ● Ophthalmic disorders, such as optic neuritis, sympa-
erythema multiforme, herpes zoster (prophylaxis of thetic ophthalmia, and chorioretinitis
postherpetic neuralgia), lichen planus, pemphigus, skin ● Organ or tissue transplants and grafts (eg, kidney,
rashes caused by drugs, and toxic epidermal necrolysis. heart, bone marrow). Corticosteroids suppress cellular
● Endocrine disorders, such as adrenocortical insuffi- and humoral immune responses (see Chap. 41) and
ciency and congenital adrenal hyperplasia. Cortico- help prevent rejection of transplanted tissue. Drug ther-
steroids are given to replace or substitute for the natural apy is usually continued as long as the transplanted tis-
hormones (both glucocorticoids and mineralocorticoids) sue is in place.
Chapter 23 ● Corticosteroids 357
● Renal disorders characterized by edema, such as the deficiency state and restore normal function (physiologic
nephrotic syndrome effects). Therapeutic purposes require relatively large doses
● Respiratory disorders, such as asthma, status asthmati- to exert pharmacologic effects. Drug effects involve exten-
cus, chronic obstructive pulmonary disease (COPD), sion of the physiologic effects of endogenous corticosteroids
and inflammatory disorders of nasal mucosa (rhinitis). In and new effects that do not occur with small, physiologic
asthma, corticosteroids increase the number of beta- doses. The most frequently desired pharmacologic effects
adrenergic receptors and increase or restore responsive- are anti-inflammatory, immunosuppressive, antiallergic, and
ness of beta receptors to beta-adrenergic bronchodilating antistress. These are glucocorticoid effects. Mineralocorti-
drugs. In asthma, COPD, and rhinitis, the drugs decrease coid and androgenic effects are usually considered adverse
mucus secretion and inflammation. reactions.
● Rheumatic disorders, such as ankylosing spondylitis,
● The drugs are palliative; they control many symptoms
acute and chronic bursitis, acute gouty arthritis, rheuma-
but do not cure underlying disease processes. In chronic
toid arthritis, and osteoarthritis
disorders, they may enable clients to continue the usual
● Shock. Corticosteroids are clearly indicated only for
activities of daily living and delay disability. However,
shock resulting from adrenocortical insufficiency (Addi-
the disease may continue to progress, and long-term
sonian or adrenal crisis), which may mimic hypovolemic
use of systemic corticosteroids inevitably produces
or septic shock. The use of corticosteroids in septic shock
serious adverse effects.
has been highly controversial, and randomized studies
and meta-analyses have indicated that corticosteroids are ● Drug effects vary, so a specific effect may be considered
not beneficial in treating septic shock. However, more therapeutic in one client but adverse in another. For
recent small studies indicate possible clinical usefulness example, an increased blood sugar level is therapeutic
in septic shock, because this form of shock may be for the client with adrenocortical insufficiency or an
associated with relative adrenal insufficiency. In ana- islet-cell adenoma of the pancreas, but is an adverse
phylactic shock resulting from an allergic reaction, cor- reaction for most clients, especially those with diabetes
ticosteroids may increase or restore cardiovascular mellitus. In addition, some clients respond more favor-
responsiveness to adrenergic drugs. ably or experience adverse reactions more readily than
others taking equivalent doses. This is partly caused by
Indications for use, routes and dosage ranges are given in individual differences in the rate at which cortico-
Table 23-1. steroids are metabolized.
● Administration of exogenous corticosteroids suppresses
Contraindications to Use the HPA axis. This decreases secretion of corticotropin,
which, in turn, causes atrophy of the adrenal cortex and
Corticosteroids are contraindicated in systemic fungal
decreased production of endogenous adrenal cortico-
infections and in people who are hypersensitive to drug for-
steroids.
mulations. They should be used with caution in clients at P Hydrocortisone, the exogenous equivalent of en-
●
risk for infections (they may decrease resistance), clients
dogenous cortisol, is the prototype of corticosteroid
with infections (they may mask signs and symptoms so that
drugs. When a new corticosteroid is developed, it
infections become more severe before they are recognized
is compared with hydrocortisone to determine its
and treated), diabetes mellitus (they cause or increase
potency in producing anti-inflammatory and antialler-
hyperglycemia), peptic ulcer disease, inflammatory bowel
gic responses, increasing deposition of liver glycogen,
disorders, hypertension, congestive heart failure, and renal
and suppressing secretion of corticotropin. Daily
insufficiency.
administration of physiologic doses (15–20 mg of
hydrocortisone or its equivalent) or administration of
APPLYING YOUR KNOWLEDGE 23-1 pharmacologic doses (more than 15–20 mg of hydro-
You arrive at Ms. Hubble’s home and begin your assessment of cortisone or its equivalent) for approximately 2 weeks
the client. You notice the appearance of white patches on suppresses the HPA axis. HPA recovery usually
Ms. Hubble’s mouth. What action do you take? occurs within a few weeks or months after corticos-
teroids are discontinued, but may take 9 to 12 months.
All adrenal corticosteroids are available as drug prepara- During that time, supplemental corticosteroids are
tions, as are many synthetic derivatives developed by alter- usually needed during stressful situations (eg, fever,
ing the basic steroid molecule in efforts to increase illness, surgical procedures) to improve the client’s
therapeutic effects while minimizing adverse effects. When ability to respond to stress and prevent acute adreno-
corticosteroids are administered from sources outside the cortical insufficiency.
body, they are given mainly for replacement or therapeutic ● Anti-inflammatory activity of glucocorticoids is approx-
purposes. Replacement involves small doses to correct a imately equal when the drugs are given in equivalent
358 Section 4 ● Drugs Affecting the Endocrine System
Glucocorticoids
Beclamethasone oral 1–2 inhalations (40–80 mcg) 2 times
inhalation (QVAR) daily (maximum daily dose
320 mcg)
Nasal inhalation 1–2 inhalations (42–84 mcg in each nos- >6 y: 1–2 inhalations (42–84 mcg)
(Beconase AQ) tril) 2 times daily; as maintenance, each nostril daily
1 inhalation each nostril
Betamethasone PO 0.6–7.2 mg daily initially, gradually
(Celestone) reduced to lowest effective dose
Betamethasone acetate IM 0.5–9 mg daily
and sodium phosphate Intra-articular injection 0.25–2 mL
(Celestone Soluspan)
Budesonide oral inhalation Turbuhaler, 200–400 mcg twice daily Turbuhaler, >6 y: 200 mcg twice daily
(Pulmicort Terbuhaler, Respules, 12 mo–8 y: 0.5 mg daily in
Pulmicort Respules) 1 single or 2 divided doses
Nasal inhalation (Rhinocort) 256 mcg daily initially (2 sprays each nos- > 6 y: Same as adults
tril morning and evening or 4 sprays
each nostril every morning). When
symptoms are controlled, reduce
dosage to lowest effective mainte-
nance dose.
Oral capsule (Entocort EC) Crohn’s disease, PO 9 mg once daily in
the morning, for up to 8 wk
Cortisone (Cortone) PO 25–300 mg daily, individualized for
condition and response
Dexamethasone (Decadron) PO 0.75–9 mg daily in 2–4 doses; higher
ranges for serious diseases
Dexamethasone acetate IM 8–16 mg (1–2 mL) in single dose,
repeated every 1–3 wk if necessary
Dexamethasone sodium IM, IV 0.5–9 mg, depending on severity of
phosphate disease
Flunisolide oral inhalation 2 inhalations (500 mcg) twice daily 6–15 y: Same as adults
(AeroBid)
Nasal inhalation (Nasarel) 2 sprays in each nostril twice daily; maxi- 6–14 y: 1 spray in each nostril 3 times
mal daily dose 8 sprays in each nostril daily or 2 sprays in each nostril 2 times
daily; maximal daily dose 4 sprays in
each nostril
Fluticasone (Flovent) 2 inhalations (88 mcg) 2 times daily (maxi- <12 y: not recommended
oral inhalation mum daily dose 440 mcg inhaled
2 times daily)
(Flonase) nasal inhalation 200 mcg daily initially (2 sprays each nos- ≥12 y: 100 mcg daily (1 spray per nostril
tril once daily or 1 spray each nostril once daily)
twice daily). After a few days, reduce
dosage to 100 mcg daily (1 spray each
nostril once daily) for maintenance
therapy.
Hydrocortisone PO 20–240 mg daily, depending on con-
(Hydrocortone, Cortef) dition and response
Hydrocortisone sodium IV, IM, Sub-Q 15–240 mg daily in 2
phosphate divided doses
Hydrocortisone sodium IV, IM 100–400 mg initially, repeated at 2,
succinate 4, or 6 hour intervals if necessary
Chapter 23 ● Corticosteroids 359
Mineralocorticoid
Fludrocortisone (Florinef) Chronic adrenocortical insufficiency, PO PO 0.05–0.1 mg daily
0.1 mg daily
Salt-losing adrenogenital syndromes, PO
0.1–0.2 mg daily
*Ophthalmic and dermatologic preparations are discussed in Chapters 63 and 64, respectively.
IM, intramuscular; IV, intravenous; PO, oral; Sub-Q, subcutaneous.
360 Section 4 ● Drugs Affecting the Endocrine System
● Assess for signs and symptoms of adrenocortical ● Help clients identify stressors and find ways to modify
excess and adverse drug effects. or avoid stressful situations when possible. For exam-
● Assess for signs and symptoms of the disease for ple, most clients probably do not think of extreme heat
which long-term corticosteroid therapy is being given. or cold or minor infections as significant stressors.
However, they can be for people taking corticosteroids.
Nursing Diagnoses This assessment of potential stressors must be individ-
● Disturbed Body Image related to cushingoid changes in ualized because a situation viewed as stressful by one
appearance client may not be stressful to another.
● Encourage activity, if not contraindicated, to slow de-
● Imbalanced Nutrition: Less Than Body Requirements
related to protein and potassium losses mineralization of bone (osteoporosis). This is especially
● Imbalanced Nutrition: More Than Body Requirements important in postmenopausal women who are not tak-
related to sodium and water retention and hyperglycemia ing replacement estrogens, because they are very sus-
● Excess Fluid Volume related to sodium and water ceptible to osteoporosis. Walking is preferred if the
retention client is able. Range-of-motion exercises are indicated
● Risk for Injury related to adverse drug effects of impaired in immobilized or bedridden people. Also, bedridden
wound healing, increased susceptibility to infection, clients taking corticosteroids should have their posi-
weakening of skin and muscles, osteoporosis, gastroin- tions changed frequently because these drugs thin the
testinal ulceration, diabetes mellitus, hypertension, and skin and increase the risk of pressure ulcers. This risk
acute adrenocortical insufficiency is further increased if edema also is present.
● Ineffective Coping related to chronic illness; long-term ● Dietary changes may be beneficial in some clients. Salt
drug therapy and drug-induced mood changes, irri- restriction may help prevent hypernatremia, fluid reten-
tability and insomnia tion, and edema. Foods high in potassium may help pre-
● Deficient Knowledge related to disease process and vent hypokalemia. A diet high in protein, calcium, and
corticosteroid drug therapy vitamin D may help prevent osteoporosis. Increased
intake of vitamin C may help decrease bleeding in the
Planning/Goals skin and soft tissues.
● Avoid exposing the client to potential sources of infec-
The client will
● Take the drug correctly
tion by washing hands frequently; using aseptic tech-
● Practice measures to decrease the need for cortico-
nique when changing dressings; keeping health care
personnel and visitors with colds or other infections
steroids and minimize adverse effects
● Be monitored regularly for adverse drug effects
away from the client; and following other appropriate
● Keep appointments for follow-up care
measures. Reverse or protective isolation is sometimes
● Be assisted to cope with body image changes indicated, commonly for those clients who have had
● Verbalize or demonstrate essential drug information organ transplantation and are receiving corticosteroids
to help prevent rejection of the transplanted organ.
● Handle tissues very gently during any procedures
Interventions
(eg, bathing, assisting out of bed, venipunctures). Be-
For clients on long-term, systemic corticosteroid therapy, cause long-term corticosteroid therapy weakens the
use supplementary drugs as ordered and nondrug mea- skin and bones, there are risks of skin damage and frac-
sures to decrease dosage and adverse effects of cortico- tures with even minor trauma.
steroid drugs. Specific measures include the following:
Client Teaching Guidelines for Long-Term Corticosteroid
● Help clients set reasonable goals of drug therapy. For Therapy are presented in the accompanying display.
example, partial relief of symptoms may be better than
complete relief if the latter requires larger doses or Evaluation
longer periods of treatment with systemic drugs.
● In clients with bronchial asthma and COPD, other treat- ● Interview and observe for relief of symptoms for which
ment measures should be continued during cortico- corticosteroids were prescribed.
steroid therapy. With asthma, the corticosteroid needs ● Interview and observe for accurate drug administration.
to be given on a regular schedule; inhaled broncho- ● Interview and observe for use of nondrug measures
dilators can usually be taken as needed. indicated for the condition being treated.
● In clients with rheumatoid arthritis, rest, physical therapy, ● Interview and observe for adverse drug effects on a reg-
and salicylates or other nonsteroid anti-inflammatory ular basis.
drugs are continued. Systemic corticosteroid therapy is ● Interview regarding drug knowledge and effects to be
reserved for severe, acute exacerbations when possible. reported to health care providers.
362 Section 4 ● Drugs Affecting the Endocrine System
C L I E N T T E A C H I N G G U I D E L I N E S
Long-Term Corticosteroid Therapy
General Considerations ✔ Ask the prescriber about the amount and kind of activity or exer-
●
cise needed. As a general rule, being as active as possible helps
✔ In most instances, corticosteroids are used to relieve symptoms;
● to prevent or delay osteoporosis, a common adverse effect. How-
they do not cure the underlying disease process. However, they ever, increased activity may not be desirable for everyone. A client
can improve comfort and quality of life. with rheumatoid arthritis, for example, may become too active
✔ When taking an oral corticosteroid (eg, prednisone) for longer
● when drug therapy relieves joint pain and increases mobility.
than 2 weeks, it is extremely important to take the drug as ✔
● Follow instructions for other measures used in treatment of the
directed. Missing a dose or two, stopping the drug, changing the particular condition (eg, other drugs and physical therapy for
amount or time of administration, taking extra drug (except as rheumatoid arthritis). Such measures may allow smaller doses of
specifically directed during stress situations), or any other alter- corticosteroids and decrease adverse effects.
ations may result in complications. Some complications are rela- ✔
● Because the corticosteroid impairs the ability to respond to stress,
tively minor; several are serious, even life threatening. When these dosage may need to be temporarily increased with illness,
drugs are being discontinued, the dosage is gradually reduced surgery, or other stressful situations. Clarify with the prescriber
over several weeks. They must not be stopped abruptly. predictable sources of stress and the amount of drug to be taken if
✔ Wear a special medical alert bracelet or tag or carry an identifica-
● the stress cannot be avoided.
tion card stating the drug being taken; the dosage; the pre- ✔
● In addition to stressful situations, report sore throat, fever, or
scriber’s name, address, and telephone number; and instructions other signs of infection; weight gain of 5 pounds or more in a
for emergency treatment. If an accident or emergency situation week; or swelling in the ankles or elsewhere. These symptoms may
occurs, health care providers must know about corticosteroid drug indicate adverse drug effects and changes in corticosteroid ther-
therapy to give additional amounts during the stress of the apy may be indicated.
emergency. ✔
● Muscle weakness and fatigue or disease symptoms may occur
✔ Report to all health care providers consulted that corticosteroid
● when drug dosage is reduced, withdrawn, or omitted (eg, the non-
drugs are being taken or have been taken within the past year. drug day of alternate-day therapy). Although these symptoms may
Current or previous corticosteroid therapy can influence treatment cause some discomfort, they should be tolerated if possible rather
measures, and such knowledge increases the ability to provide than increasing the corticosteroid dose. If severe, of course,
appropriate treatment. dosage or time of administration may have to be changed.
✔ Maintain regular medical supervision. This is extremely impor-
● ✔
● Dietary changes may be helpful in reducing some adverse effects
tant so that the prescriber can detect adverse reactions, evalu- of corticosteroid therapy. Decreasing salt intake (eg, by not
ate disease status, and evaluate drug response and indications adding table salt to foods and avoiding obviously salty foods, such
for dosage change, as well as other responsibilities that can be as many snack foods and prepared sandwich meats) may help
carried out only with personal contact between the prescriber decrease swelling. Eating high-potassium foods, such as citrus
and the client. Periodic blood tests, x-ray studies, and other fruits and juices or bananas, may help prevent potassium loss. An
tests may be performed during long-term corticosteroid adequate intake of calcium, protein, and vitamin D (meat and dairy
therapy. products are good sources) may help to prevent or delay osteo-
✔ Take no other drugs, prescription or nonprescription, without noti-
● porosis. Vitamin C (eg, from citrus fruits) may help to prevent
fying the prescriber who is supervising corticosteroid therapy. Cor- excessive bruising.
ticosteroid drugs influence reactions to other drugs, and some ✔
● Do not object when your prescriber reduces your dose of oral cor-
other drugs interact with corticosteroids either to increase or ticosteroid, with the goal of stopping the drug entirely or continu-
decrease their effects. Thus, taking other drugs can decrease the ing with a smaller dose. Long-term therapy should be used only
expected therapeutic benefits or increase the incidence or severity when necessary because of the potential for serious adverse
of adverse effects. effects, and the lowest effective dose should be given.
✔ Avoid exposure to infection when possible. Avoid crowds and peo-
● ✔
● With local applications of corticosteroids, there is usually little sys-
ple known to have an infection. Also, wash hands frequently and temic absorption and few adverse effects, compared with oral or
thoroughly. These drugs increase the likelihood of infection, so injected drugs. When effective in relieving symptoms, it is better to
preventive measures are necessary. Also, if infection does occur, use a local than a systemic corticosteroid. In some instances, com-
healing is likely to be slow. bined systemic and local application allows administration of a
✔ Practice safety measures to avoid accidents (eg, falls and possible
● lesser dose of the systemic drug.
fractures due to osteoporosis, cuts or other injuries because of Commonly used local applications are applied topically for skin
delayed wound healing, soft tissue trauma because of increased disorders; by oral inhalation for asthma; and by nasal inhalation
tendency to bruise easily). for allergic rhinitis. Although long-term use is usually well toler-
✔ Weigh frequently when starting corticosteroid therapy and at least
● ated, systemic toxicity can occur if excess corticosteroid is inhaled
weekly during long-term maintenance. An initial weight gain is or if occlusive dressings are used over skin lesions. Thus, a
likely to occur and is usually attributed to increased appetite. Later corticosteroid for local application must be applied correctly and
weight gains may be caused by fluid retention. not overused.
Chapter 23 ● Corticosteroids 363
C L I E N T T E A C H I N G G U I D E L I N E S
Long-Term Corticosteroid Therapy
drugs, because not all corticosteroids are available in acetate salts are used because they have low solubility in
injectable preparations. water and provide prolonged local action.
intolerance, obesity, cosmetic changes, bone loss, growth retar- Acute Respiratory Failure in Chronic Obstructive
dation in children, cataracts, pancreatitis, peptic ulcerations, Pulmonary Disease
and psychiatric disturbances. Doses should be minimized, and Some studies support the use of IV methylprednisolone.
eventually the drugs can be withdrawn in some clients. Thus, if other medications do not produce adequate bron-
chodilation, it seems reasonable to try an IV corticosteroid
Use in Clients With Hepatic Impairment during the first 72 hours of the illness. However, cortico-
steroid therapy increases the risks of pulmonary infection.
Metabolism of corticosteroids is slowed by severe hepatic
disease, and corticosteroids may accumulate and cause signs Adult Respiratory Distress Syndrome
and symptoms of hypercorticism. In addition, clients with Although corticosteroids have been widely used, several
liver disease should be given prednisolone rather than pred- well-controlled studies demonstrate that the drugs are not
nisone. Liver metabolism of prednisone is required to convert beneficial in early treatment or in prevention of adult respi-
it to its active form, prednisolone. ratory distress syndrome (ARDS). Thus, corticosteroids
should be used in these clients only if there are other specific
indications.
Use in Clients With Critical Illness
Sepsis
Corticosteroids have been extensively used in the treatment Large, well-controlled, multicenter studies have shown that
of serious illness, with much empiric usage. the use of corticosteroids in gram-negative bacteremia, sep-
sis, or septic shock has no beneficial effect. In addition, the
Adrenal Insufficiency
drugs do not prevent development of ARDS or multiple
Adrenal insufficiency is the most clear-cut indication for use
organ dysfunction syndrome or decrease mortality in clients
of a corticosteroid, and even a slight impairment of the with sepsis. In addition, clients receiving corticosteroids for
adrenal response during severe illness can be lethal if corti- other conditions are at risk of sepsis, because the drugs impair
costeroid therapy is not instituted. For example, hypotension the ability of white blood cells to leave the bloodstream and
is a common symptom in critically ill clients, and hypoten- reach a site of infection.
sion caused by adrenal insufficiency may mimic either hypo-
volemic or septic shock. If adrenal insufficiency is the cause Acquired Immunodeficiency Syndrome
of the hypotension, administration of corticosteroids can Adrenal insufficiency is being increasingly recognized in
eliminate the need for vasopressor drugs to maintain ade- clients with AIDS, who should be assessed and treated for it,
quate tissue perfusion. if indicated. In addition, corticosteroids improve survival and
However, adrenal insufficiency may not be recognized decrease risks of respiratory failure with pneumocystosis, a
because hypotension and other symptoms also occur with common cause of death in clients with AIDS. The recom-
many illnesses. The normal response to critical illness (eg, mended regimen is prednisone 40 milligrams twice daily for
pain, hypovolemia) is an increased and prolonged secretion 5 days, then 40 milligrams once daily for 5 days, then 20 mil-
of cortisol. If this does not occur, or if too little cortisol is ligrams daily until completion of treatment for pneumocysto-
produced, a state of adrenal insufficiency exists. One way to sis. The effect of corticosteroids on risks of other opportunistic
evaluate a client for adrenal insufficiency is a test in which a infections or neoplasms is unknown.
baseline serum cortisol level is measured, after which corti-
cotropin is given IV to stimulate cortisol production, and the Use in Home Care
serum cortisol level is measured again in approximately 30
Corticosteroids are extensively used in the home setting, by
to 60 minutes. Test results are hard to interpret in seriously
all age groups, for a wide variety of disorders, and by most
ill clients, though, because serum cortisol concentrations
routes of administration. Because of potentially serious
that would be normal in normal subjects may be low in this
adverse effects, especially with oral drugs, it is extremely
population. In addition, a lower-than-expected rise in serum
important that these drugs be used as prescribed. A major
cortisol levels may indicate a normal HPA axis that is
responsibility of home care nurses is to teach, demonstrate,
already maximally stimulated, or interference with the abil-
supervise, monitor, or do whatever is needed to facilitate cor-
ity of the adrenal cortex to synthesize cortisol. Thus, a criti-
rect use. In addition, home care nurses must teach clients and
cally ill client may have a limited ability to increase cortisol caregivers interventions to minimize adverse effects of these
production in response to stress. drugs.
In any client suspected of having adrenal insufficiency, a
single IV dose of corticosteroid seems justified. If the client
APPLYING YOUR KNOWLEDGE 23-4
does have adrenal insufficiency, the corticosteroid may pre-
Long-term therapy with corticosteroids involves multiple teaching
vent immediate death and allow time for other diagnostic and
opportunities for the nurse. What should you include as priorities
therapeutic measures. If the client does not have adrenal
when providing a teaching plan for Ms. Hubble?
insufficiency, the single dose is not harmful.
Chapter 23 ● Corticosteroids 369
N U R S I N G A C T I O N S
Corticosteroids
NURSING ACTIONS RATIONALE/EXPLANATION
1. Administer accurately
a. Read the drug label carefully to be certain of having the correct Many corticosteroid drugs are available in several different prepara-
preparation for the intended route of administration. tions. For example, hydrocortisone is available in formulations for
intravenous (IV) or intramuscular (IM) administration, for intra-
articular injection, and for topical application in creams and oint-
ments of several different strengths. These preparations cannot be
used interchangeably without causing potentially serious adverse
reactions and decreasing therapeutic effects. Some drugs are avail-
able for only one use. For example, several preparations are for top-
ical use only; beclomethasone is prepared only for oral and nasal
inhalation.
b. With oral corticosteroids:
(1) Give single daily doses or alternate day doses between Early-morning administration causes less suppression of
6 and 9 A.M. hypothalamic–pituitary–adrenal (HPA) function.
(2) Give multiple doses at evenly spaced intervals.
(3) If dosage is being tapered, follow the exact schedule. To avoid adverse effects
(4) Give with meals or snacks. To decrease gastrointestinal (GI) upset
(5) With oral budesonide (Entocort EC), ask the client to This drug is formulated to dissolve in the intestine and have local anti-
swallow the drug whole, without biting or chewing. inflammatory effects. Biting or chewing allows it to dissolve in the
stomach.
(6) Do not give these drugs with an antacid containing The antacids decrease absorption of corticosteroids, with possible
aluminum or magnesium (eg, Maalox, Mylanta). reduction of therapeutic effects.
c. For IV or IM administration:
(1) Shake the medication vial well before withdrawing Most of the injectable formulations are suspensions, which need to be
medication. mixed well for accurate dosage.
(2) Give a direct IV injection over at least 1 minute. To increase safety of administration
d. For oral or nasal inhalation of a corticosteroid, check the These drugs are given by metered-dose inhalers or nasal sprays, and
instruction leaflet that accompanies the inhaler. correct usage of the devices is essential to drug administration and
therapeutic effects.
2. Observe for therapeutic effects The primary objective of corticosteroid therapy is to relieve signs and
symptoms, because the drugs are not curative. Therefore, therapeutic
effects depend largely on the reason for use.
a. With adrenocortical insufficiency, observe for absence or These signs and symptoms of impaired metabolism do not occur with
decrease of weakness, weight loss, anorexia, nausea, vomiting, adequate replacement of corticosteroids.
hyperpigmentation, hypotension, hypoglycemia, hyponatremia,
and hyperkalemia.
b. With rheumatoid arthritis, observe for decreased pain and
edema in joints, greater capacity for movement, and increased
ability to perform usual activities of daily living.
c. With asthma and chronic obstructive pulmonary disease,
observe for decrease in respiratory distress and increased toler-
ance of activity.
d. With skin lesions, observe for decreasing inflammation.
(continued)
370 Section 4 ● Drugs Affecting the Endocrine System
APPLYING YOUR KNOWLEDGE: ANSWERS 6. What adverse effects are associated with chronic
23-1 Notify Ms. Hubble’s physician. This is a sign of thrush use of systemic corticosteroids?
or oral candidiasis, a fungal infection. The client 7. What are the main differences between adminis-
requires immediate treatment and may not be able to tering corticosteroids in adrenal insufficiency
continue on the prednisone if the infection becomes versus in other disorders?
systemic. Systemic fungal infections are a contraindi-
cation to the administration of corticosteroids. 8. When a corticosteroid is given by inhalation to
clients with asthma, what is the expected effect?
23-2 Prednisone is a drug that will treat the symptoms of
COPD, but it is not designed to cure the underlying
disease process. Because the drug reduces respiratory NCLEX-Style Questions
inflammation, Ms. Hubble will have less difficulty 9. It is important to taper the dose in long-term sys-
with breathing. temic corticosteroid therapy rather than stopping
23-3 Prednisone causes hyperglycemia in many clients and the drug abruptly because tapering results in which
especially in clients with diabetes mellitus. The of the following?
physician should be notified for a change in Ms. Hub- a. less suppression of hypothalamic–pituitary–
ble’s diabetic medication. Also, the nurse should adrenal function
review Ms. Hubble’s diet. b. increased client compliance with drug therapy
c. greater tolerance of adverse effects
23-4 The teaching plan should include taking the drug as d. significantly increased anti-inflammatory effect
ordered, carrying medical alert identification that
includes the drugs taken, taking measures to avoid 10. A nurse is instructing a client regarding the correct
infection, and observing for any signs of infection or way follow the order, “prednisone 10 mg PO once
delayed wound healing. The nurse should encourage daily.” The nurse should tell the client to take
activity as tolerated to prevent osteoporosis, and teach a. the entire dose once a day at bedtime
the client when to seek medical attention. b. the entire dose once a day on arising
c. half of the dose in the morning and half at
bedtime
Review and Application Exercises d. one third of the dose in the morning and two
thirds in the afternoon
Short Answer Exercises
11. A client who has been on long-term cortico-
1. What are the main characteristics and functions of
steroid therapy begins to gain weight and com-
cortisol?
plains that her rings no longer fit on her hands.
2. What is the difference between glucocorticoid and She asks the nurse why she is gaining weight.
mineralocorticoid components of corticosteroids? The nurse tells the client that the most likely
3. How do glucocorticoids affect body metabolism? cause of later weight gain when undergoing corti-
costeroid therapy is
4. What is meant by the HPA axis? a. increased appetite
5. What are the mechanisms by which exogenous b. hyperglycemia
corticosteroids may cause adrenocortical insuffi- c. muscle hypertrophy
ciency and excess? d. fluid retention
372 Section 4 ● Drugs Affecting the Endocrine System