Prednisolone

TABLE OF CONTENTS
Chapter 1
Introduction ………………………………………………………………. 1 1.1 Case study overview ..………………………………………….. 1 1.2 Prednisolone overview …………………………………………. 1
Chapter 2
Case Analysis [clinical complexities] ………………………………… 2 2.1 Complex Issues [COPD and hypertension] ………………… 2 2.2 Complex Issues [Prednisolone use] ………………………….. 2
Chapter 3
Prednisolone Pharmacokinetics …….………………………………… 3
Chapter 4
Prednisolone Pharmacodynamics …….……………………………… 4
Chapter 5
Nursing Considerations 5.1 Nursing considerations [COPD] ..…………………………….. 5 5.1.1 Clinical Manifestations of COPD .…………………….... 6 5.2 Nursing considerations [prednisolone use] ..…………….. 7 5.2.1 Clinical Manifestations [prednisolone use] …………… 7
Chapter 6
Communication and planning ………………………..……..…….…. 9
Appendix A ……………………………………………………………….. 11
References ……………………………………………………………… 12
Glossary ………………………………………………………………… 13

Chapter 1
Introduction __________________________________________________
1.1 Case Study Overview Jim, a 57 year old male, currently on the post surgery ward 8 days following a total right hip replacement began to deteriorate displaying signs of respiratory distress. Upon a review by the medical team Jim was diagnosed as having exacerbated COPD and prescribed prednisolone
[refer to appendix A for details of Jim’s situation and presentation].

1.2 Prednisolone Overview

Prednisolone is a synthetic form of the naturally occurring corticosteroid known as prednisone produced by the adrenal glands (Craft et al, 2009;
Porth & Matfin, 2009). Prednisolone is classed as an anti inflammatory medication and is used to treat a variety of inflammatory conditions including COPD (Porth & Matfin, 2009; Ynze et al, 2007).

The following report will present a discussion on the use of prednisolone for
COPD, the complexities of Jim’s condition and nursing considerations that would be addressed in the management of Jim’s condition.

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Chapter 2
Case Analysis – Complex Issues ________________________________________________________________
2.1 Complex Issues [COPD and Hypertension]

Jim is in hospital recovering from a total right hip replacement. However this is not a straightforward case as Jim’s medical history indicates a history of hypertension, heavy smoking and emphysema. These comorb - idities complicate Jim’s health status and recovery (Porth & Matfin, Dirksen et al 2011).

Hypertension and emphysema both have negative effects on ventilatory capacity, blood pressure and cardiac function which can lead to a variety of other risks such as respiratory acidosis, altered level of consciousness, respiratory and cardiac failure, coma and death (Marieb, 2011; Craft et al,
2009).

2.2 Complex Issues [Prolonged Prednisolone Use]

Jim’s case has the added complexity of prolonged prednisolone use as this increases arterial blood pressure, causes depression, disrupts intestinal function, disturbs sleep patterns and inhibits bone repair (Ynze et al, 2007;
Bullock & Manias, 2009).

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Chapter 3
Pharmacokinetics of Prednisolone__________________________________________________
Pharmacokinetics

Prednisolone is rapidly absorbed orally through the jejunum with peak plasma levels at 1 – 2 hours and a half life of 2 – 4 hours (Bullock & Manias,
2009; Ynze et al, 2007). Upon absorption into the body prednisolone is then distributed throughout the body via general circulation bound to plasma protein albumin. Upon exerting it’s effect is then metabolised by the liver to an inactive form and excreted by the kidneys within the urine (Bullock &
Manias, 2009; Ynze et al, 2007).

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Chapter 4
Pharmacodynamics of Prednisolone
________________________________________________________________
Pharmacodynamics

Prednisolone inhibits the inflammation process initiated by the immune system and is prescribed to counter the effects of inflammation in cases where this process places a patient at risk Dirksen et al, 2011; Brown &
Edwards, 2008).

Prednisolone works by inhibiting chemical mediators of inflammation such as histamine, prostaglandins and kinins as well as lymphocyte migration to damaged or infected tissue (Bullock & Manias, 2009).

In Jim’s case the inflammation process has exacerbated his COPD placing him at immediate risk of respiratory acidosis and possible respiratory failure
(Marieb et al, 2011; Craft et al, 2009). As such prednisolone has been pre - scribed to counter the inflammation process and help restore normal ventilatory function (Mareib et al, 2011; Craft et al, 2009).

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Chapter 5
Nursing Considerations

5.1 Nursing Considerations [COPD]

Exacerbation of COPD causes changes to acid/base balance, LOC, heart rate and respiratory rate. In Jim’s case the inflammation process has exacerbated his COPD placing him at greater risk of these changes (Mareib,
2011; Ynze et al, 2007; Craft et al, 2009). Upon entering Jim’s room after morning tea it was evident that some of these changes had occurred as Jim displayed shortness of breath, altered LOC as he did not recognise me and lethargy. As Jim’s nurse I would need to consider these changes and any other clinical manifestations of exacerbated COPD in planning for his immediate care (Dirksen et al, 2011).

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5.1.1 Clinical Manifestations of Exacerbated COPD

* Respiratory acidosis due to decreased gas exchange at the alveolar

capillary interface [V/Q mismatch] leading to increased pulmonary

CO2 levels (Craft et al, 2009; Porth & Matfin, 2009).

* Altered LOC due to increased CSF CO2 levels and decreased cerebral

O2 perfusion (Craft et al, 2009; Porth & Matfin, 2009).

* Tachycardia due to increased sympathetic nervous system activation

of cardiac muscle in response to decreased cardiac and skeletal

muscle O2 perfusion (Dirksen et al, 2011; Marieb, 2011).

It should be noted here that tachycardia in Jim’s case may be masked

by diltiazem as this drug is a cardiac calcium channel blocker

(Bullock & and Manias, 2009).

* Tachypnea due to cerebral respiratory control center increasing

respiratory rate to compensate for and expel increased pulmonary

and CSF CO2 levels (Brown & Edwards, 2008; Mareib, 2011).

* Increased falls risk and limited mobility due to loss of balance related

to decreased cerebral O2 perfusion (Brown & Edwards, 2008; Mareib,

2011).

-6- * Lethargy resulting from decreased skeletal muscle O2 perfusion

required for energy production (Marieb, 2011; Brown & Edwards,

2009).

* Increased risk of respiratory infection [pneumonia] secondary to

presence of fluid and phlegm in the lungs associated with inflam –

mation related to exacerbation of COPD (Dirksenet al, 2011; Ynze et

al, 2007).

5.2 Nursing Considerations [prednisolone use]

Long term prednisolone use also a number of side effects that would need to be considered as Jim has been on this medication for 8 days and has now been prescribed a higher dose (Bullock & Manias, 2009; Brown & Edwards,
2008). Prednisolone is known to cause hypertension, mood changes, constipation and decrease intestinal absorption of calcium and other nutrients (Bullock & Manias, 2009; Brown & Edwards, 2008).

5.2.1 Clinical Manifestations of Long Term Prednisolone Use * Decreased bone healing and tissue repair due to decreased protein

and calcium absorption from the GI tract (Bullock & Manias, 2009; Brown & Edwards, 2008).

-7- * Decreased bone and wound healing due to inflammatory suppression.

Inflammation is a natural response to tissue damage and is needed for

tissue repair and growth and the removal of dead and damaged cells (Bullock & Manias, 2009; Brown & Edwards, 2008). * Hypertension due to fluid retention and subsequent increased

vascular fluid volume as a result of increased aldosterone secretion

and sodium retention (Ynze et al, 2007, Craft et al, 2009).

* Increased risk of a UTI secondary to decreased GFR and urine

output as a result of increased blood pressure causing a decrease

in renal tissue perfusion (Porth & Matfin, 2009; Ynze et al, 2007).

* Electrolyte imbalance caused by excess sodium retention secondary to

prednisolone over stimulating aldosterone secretion (Craft et al, 2009).

* Acid/base imbalance caused by decreased urine output resulting in

subsequent decreased excretion of hydrogen ions (Brown & Edwards, 2008).

* Drug toxicity related to decreased GFR with subsequent decrease in

drug clearance via kidneys (Brown & Edwards, 2008).

* Depression as a consequence of prednisolone’s effects on hippo -

campus remodeling and mood regulation. However, this is not well

understood (Kajiyama et al, 2010).

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Chapter 6
Communication and Planning
_______________________________________________________________
Communication and Planning

According to Chang & Daly (2012) and Ellis et al, (2003) effective planning and communication are vital components of nursing practice. Ellis et al
(2003) clarify this point adding that it allows project participants to manage time frames, negotiate differing points of view, identify strengths and share work loads based on those strengths.

Time management and distribution of work load was established using negotiation and open ended questions to clarify our availability and strengths. This process resulted in the agreement to meet at Belconnen
Mac Donalds when jean finished her shift as it is located right next to
Jeans place of employment. This was appropriate for both us as I am always there and it was convenient for Jean.

Additionally, it was discovered from this process that Jean is very knowledge
- able in the use of power point and me in the area of clinical knowledge.
As such we capitalised on these strengths which allowed each of us to have equal input into the project.

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Finally, differing points of view were resolved using active listening, para - phrasing and referral to the unit outline and text material for clarification.
This allowed both of us to listen to and clarify misunderstandings in each others perspective and make a decision.

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Appendix A
Jim is 57 old and has been an inpatient for 8 days post his elective ® total hip replacement. Intraoperative complications of haemorrhage has delayed Jim’s recovery. His past history includes (L) total hip replacement in 2010, ex heavy smoker, moderate emphysema & hypertension.
Current medications are diltiazem 240mg mane, perindopril 2mg daily, glucosamine, prednisolone 2mg daily, calcium carbonate, tiotropium mane and salbutamol inh PRN.
You have been caring for Jim the last two mornings on the Orthopaedic ward and have noticed that he is less chatty and appears lethargic. When you enter his room after morning tea, he appears SOB, diaphoretic and he does not recognise you. Jim continues to deteriorate during the shift.
After a medical review Jim is diagnosed with severe exacerbation of COPD and he is additionally prescribed 1gm amoxycillin intravenously and a higher dose of prednisolone.

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References
Brooker, C. (2008). Churchill Livingston medical dictionary. New York, USA: Mosby Elsevier.
Brown, D & Edwards, H. (2008). Medical surgical nursing. [2ND ed.]. Mosby Elsevier: Sydney, Australia: Mosby Elsevier.
Bullock, S & Manias, E. (2011). Fundamentals of pharmacology. [6th ed.]. Sydney, Australia: Pearson Publishing.
Chang, E & Daly, J. (2012). Transitions in Nursing: Preparing for professional practice. [3rd ed.]. Sydney, Australia: Elsevier.
Craft, J., Gordon C & Tiziani, A. (2011). Understanding pathophysiology. Sydney, Australia: Mosby Elsevier.
Crisp, J & Taylor, T. (2008). Potter and perry’s fundamentals of nursing. [3rd ed.]. Sydney, Australia: Mosby Elsevier.
Dirksen , S., Lewis, S., Heitkemper, M & Bucher, L. (2011). Medical surgical nursing: Assessment and management of clinical problems. [8th ed.]. Missouri: USA: Mosby Elsevier.
Ellis, R., Gates, B & Kenworthy, N. (2003). Interpersonal communication in nursing. Philadelphia: USA: Churchill Livingston.
Kajiyama Y, Iijima Y, Chiba S, Furuta M, Ninomiya M, Izumi A, Shibata S, Kunugi H. (2010). Prednisolone causes anxiety and depression like behaviours and altered expression of apoptotic genes in mice hippocampus. Progress in Neuro – Pshycopharmacology and Biological Psychiatry. 34, (1), 159 – 65.
Marieb, E. (2011). Essential of anatomy and physiology. [10th ed.]. San Francisco: USA: Benjamin Cummings Publishing.
Porth, C & Matfin, G. (2009). Pathophysiology: concepts in altered health states. New York: USA: Linppincott Williams & Wilkins.
Ynze P., Uil, S., Grotjohan, P., Postma, S., Kerstjens, A.M & Van den Berg, J. (2007)
Oral or IV Prednisolone in the Treatment of COPD Exacerbations: A Randomized, Controlled, Double-blind Study. American College of Chest Physicians. 132, (6), 1741 – 1747.

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Glossary of Terms
Aldosterone: Hormone secreted by the endocrine system that stimulates the kidneys to retain sodium and water
Amoxacillin: Antiobiotic
COPD: Chronic obstructive pulmonary disease
CSF: Cerebral spinal fluid
Electrolyte: Salts and minerals that can conduct electricity within the body
GFR: Glomerular filtration rate
Hippocampus: Part of the brain that controls memory and helps regulate mood
Hypertension: High blood pressure
Jejunum: Middle section of the small intestine
Lethargy: Low energy levels
LOC: Level of consciousness
Lymphocytes: White blood cells that locate and destroy foreign substances within the body
Respiratory Acidosis: Excess CO2 within the pulmonary circulation and lungs
Tachycardia: Increased heart rate
Tachypnoea: Increased respiratory rate
UTI – Urinary tract infection
V/Q mismatch: Ventilation perfusion mismatch

References: Brooker, C. (2008). Churchill Livingston medical dictionary. New York, USA: Mosby Elsevier. Brown, D & Edwards, H Bullock, S & Manias, E. (2011). Fundamentals of pharmacology. [6th ed.]. Sydney, Australia: Pearson Publishing. Chang, E & Daly, J Craft, J., Gordon C & Tiziani, A. (2011). Understanding pathophysiology. Sydney, Australia: Mosby Elsevier. Crisp, J & Taylor, T Dirksen , S., Lewis, S., Heitkemper, M & Bucher, L. (2011). Medical surgical nursing: Assessment and management of clinical problems. [8th ed.]. Missouri: USA: Mosby Elsevier. Ellis, R., Gates, B & Kenworthy, N Porth, C & Matfin, G. (2009). Pathophysiology: concepts in altered health states. New York: USA: Linppincott Williams & Wilkins. Ynze P., Uil, S., Grotjohan, P., Postma, S., Kerstjens, A.M & Van den Berg, J Oral or IV Prednisolone in the Treatment of COPD Exacerbations: A Randomized, Controlled, Double-blind Study. American College of Chest Physicians. 132, (6), 1741 – 1747. -12-