NU654 Unit 5 Seminar Reflection, Adrenal Crisis Example

Not a Busy Night but a Missing Order: A Seminar Reflection on Adrenal Crisis After a Home Prednisone Was Left Off

[Student Name]

Purdue University Global

NU654: AGACNP Acute Care Diagnosis and Management III

Unit 5 Seminar Reflection

[Instructor Name]

[Date]

The case and the seminar are composite; times and values are bracketed, and classmates are described by role.

The Case as the Facilitator Gave It

For [two] years, Mr. [G.], now [64], has taken prednisone [10 mg] daily for polymyalgia rheumatica. He was admitted at [14:00] with [two] days of vomiting and diarrhea. His admission medication orders did not include prednisone. Overnight his blood pressure drifted from [118/70] to [84/50]. He received [one] liter of saline at [21:00], another at [00:30] and a third at [03:00]; each raised his pressure for about an hour. His sodium fell from [133] to [127] mEq/L, and at [04:00] his glucose was [61] mg/dL. The rapid response team was called at [05:10]. He received hydrocortisone [100 mg] intravenously at [05:40], the emergency dose endocrine guidance recommends for adrenal crisis (Bornstein et al., 2016), and his pressure recovered within [two] hours.

Where I Started

When the facilitator asked what went wrong, I said: "It was a busy night, and the cross-cover clinician treated each low pressure as it came. With fewer patients, someone would have seen the pattern sooner." I believed that. Hypotension after two days of vomiting and diarrhea looked like volume loss, and fluid was the right first answer.

The Challenges

A classmate who works in an endocrinology clinic asked one question: where was his prednisone? I had read the case without noticing that it was missing from the admission orders. She explained that two years of daily prednisone at [10 mg] suppresses the adrenal glands, so the body cannot make its own cortisol under stress, and that stopping it suddenly during an acute illness is a classic trigger for adrenal crisis. Adrenal crisis is a life-threatening emergency in which hypotension responds poorly to fluid alone and responds quickly to hydrocortisone (Rushworth et al., 2019).

The facilitator then asked us to read the overnight numbers again as a set rather than one at a time. A pressure that rose with each liter and then drifted back, a falling sodium and a low glucose are each explainable alone. Together they form the pattern of cortisol deficiency. I had been reading the night as a list of separate problems, and the seminar made me read it as one problem with four signs.

I resisted at first. The patient had lost fluid, and the pattern could still have been dehydration. The classmate agreed that dehydration was part of it, but pointed out that three liters should have fixed a volume problem, and did not.

What Changed

Two things changed my view. The first was the evidence on glucocorticoid-induced adrenal insufficiency. A recent guideline from the European Society of Endocrinology and the Endocrine Society advises that patients taking long-term glucocorticoids should not have them stopped abruptly, and should receive stress doses during significant illness, surgery or other physical stress (Beuschlein et al., 2024). Mr. [G.] had both an abrupt stop and a significant illness.

The second was the timeline. The earliest moment the crisis could have been prevented was not [03:00] or [05:10]. It was [14:00], when the admission orders were written without his prednisone. By the time the cross-cover clinician saw the first low pressure, the cause was already nine hours old.

I also thought about why I had missed the prednisone when I read the case. The medication list in the facilitator's summary was long, and prednisone at [10 mg] looked like a small, stable dose for a condition that was not the reason for admission. I had filed it as background. That is the same filing the admitting clinician made, and it shows how easily a drug that seems minor can be the one that matters most when the body is under stress.

So the busy night was real, but it was not the cause. It made a late recognition later. The cause was a missing order, and the fix belongs in the admission process, not in staffing.

What I Will Do

I will read the home medication list for three drugs that must not be stopped without a plan: steroids, anticoagulants and antiepileptic drugs. For any patient on long-term glucocorticoids who is admitted with an acute illness, I will ask whether they need a stress dose rather than simply continuing the home dose. And when I read a night of vital signs, I will look for the pattern across them before treating each number. The classmate who asked about the prednisone taught me more with one question than the rest of the case had.

References

Beuschlein, F., Else, T., Bancos, I., Hahner, S., Hamidi, O., van Hulsteijn, L., Husebye, E. S., Karavitaki, N., Prete, A., Vaidya, A., Yedinak, C., & Dekkers, O. M. (2024). European Society of Endocrinology and Endocrine Society joint clinical guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. The Journal of Clinical Endocrinology & Metabolism, 109(7), 1657-1683. https://doi.org/10.1210/clinem/dgae250

Bornstein, S. R., Allolio, B., Arlt, W., Barthel, A., Don-Wauchope, A., Hammer, G. D., Husebye, E. S., Merke, D. P., Murad, M. H., Stratakis, C. A., & Torpy, D. J. (2016). Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 101(2), 364-389. https://doi.org/10.1210/jc.2015-1710

Rushworth, R. L., Torpy, D. J., & Falhammar, H. (2019). Adrenal crisis. New England Journal of Medicine, 381(9), 852-861. https://doi.org/10.1056/NEJMra1807486