A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Answer:

Potential Condition:

Acute Adrenal Crisis

• The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
• Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

• Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

• Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

• Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

• Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

• Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
• Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
• Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

• Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
• Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
• Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

• Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
• Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
• Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.