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CUSHING’S SYDROME
• Cushing’s syndrome (hypercortisolism) is a hormonal disorder caused by prolonged exposure high levels of steroid hormones called glucocorticoids.
• It is commonly caused by use of corticosteroid medications and is infrequently the result of excessive corticosteroid production secondary to hyperplasia of the adrenal cortex.
Cont…
• It may also be caused by several mechanisms, including a tumor of the pituitary gland or less commonly an ectopic malignancy that produces adrenocorticotropic hormone (ACTH).
• Regardless of the cause, the normal feedback mechanisms that control the function of the adrenal cortex become ineffective, resulting in over secretion of glucocorticoids, androgens, and possibly mineralocorticoid.
Etiology of Cushing's syndrome
Excessive activity of the adrenal cortex
Corticosteroids / ACTH excess
Adrenal cortex hyperplasia.
Pathophysiology
• Normally, the production and release of cortisol
follows a precise chain of events. Corticotropin-
releasing hormone (CRH) released from the
hypothalamus causes the pituitary gland to
secrete ACTH, which in turn results in the
production of cortisol from the adrenal glands
(located just above the kidneys).
Cont…
• In healthy people, cortisol begins to rise between 3 and 4 am, reaches a peak between 7 and 9 am, and then falls for the rest of the day to the lowest levels when the person is unstressed and asleep at midnight.
• Cortisol controls its own production and release by switching off the hormones CRH and ACTH, a form of hormonal regulation known as “negative feedback”.
Cont…
• ACTH and cortisol become elevated in response to stress, such as surgery, trauma, infection or other medical illnesses. i.e. Stress response.
Types of Cushing's syndrome• Exogenous Cushing’s syndrome: caused by
taking excessive amounts of medications e.g. prednisone, dexamethasone for chronic asthma, rheumatoid arthritis, lupus, to suppress immune system after transplant to prevent rejection, other inflammatory diseases.
• Endogenous Cushing’s syndrome: excess cortisol produced by the adrenal glands. This is far rarer, but if left undiagnosed & untreated it can result in a shorter lifespan.
Signs and Symptoms ofCushing's syndrome
Most people with Cushing syndrome will have:
• Upper body obesity (above the waist) and thin arms and legs
• Round, red, full face (moon face)
Cont..
• Skin changes that are often seen:
a) Acne or skin infections
b) Purple/red marks (1/2 inch or more wide) called striae on the skin of the abdomen, thighs, and breasts
c) Thin skin with easy bruising
Cont…
• Muscle and bone changes include:
a) Backache, which occurs with routine activities
b) Bone pain or tenderness
c) Collection of fat between the shoulders (buffalo hump)
d) Rib and spine fractures (caused by thinning of the bones)
e) Weak muscles
Cont…
Women with Cushing syndrome often have:
• Excess hair growth on the face, neck, chest, abdomen, and thighs
• Menstrual cycle that becomes irregular or stops
Men may have:
• Decreased or no desire for sex
• Impotence
Cont…
Other symptoms that may occur with this disease:
• Mental changes, such as depression, anxiety, or changes in behavior
• Fatigue
• Headache
• Increased thirst and urination
Diagnostic measure
• Diagnosis is based on a review of a person's medical history, a physical examination, and laboratory tests. X rays of the adrenal or pituitary glands can be useful in locating tumors.
• No single lab. test is perfect and usually several are needed. The most common tests used to diagnose Cushing's syndrome are :-
1. 24-hour urinary free cortisol level.
• In this test, a person's urine is collected several
times over a 24-hour period and tested for
cortisol. Levels higher than 50 to 100 micrograms
a day for an adult suggest Cushing's syndrome.
The normal upper limit varies in different
laboratories, depending on which measurement
technique is used.
2.Midnight plasma cortisol and late-night salivary cortisol measurements.
• The midnight plasma cortisol test measures cortisol concentrations in the blood.
• Cortisol production is normally suppressed at night, but in Cushing's syndrome, this suppression doesn't occur. If the cortisol level is more than 50 nanomoles per liter (nmol/L), Cushing's syndrome is suspected.
Cont…
• The test generally requires a 48-hour hospital stay to avoid falsely elevated cortisol levels due to stress.
• However, a late-night or bedtime saliva sample can be obtained at home, then tested to determine the cortisol level. Diagnostic ranges vary, depending on the measurement technique used.
3.Low-dose dexamethasone suppression test (LDDST).
• In the LDDST, a person is given a low dose of dexamethasone, a synthetic glucocorticoid, by mouth every 6 hours for 2 days
• Urine is collected before dexamethasone is administered and several times on each day of the test. A modified LDDST uses a onetime overnight dose.
Cont…
• Cortisol and other glucocorticoids signal the
pituitary to release less ACTH, so the normal
response after taking dexamethasone is a
drop in blood and urine cortisol levels. If
cortisol levels do not drop, Cushing's
syndrome is suspected.
4.Dexamethasone-corticotropin-releasing
hormone (CRH) test.
• Some people have high cortisol levels but do not develop the progressive effects of Cushing's syndrome, such as muscle weakness, fractures, and thinning of the skin.
• These people may have pseudo-Cushing's syndrome, a condition sometimes found in people who have depression or anxiety disorders, drink excess alcohol, have poorly controlled diabetes, or are severely obese.
Cont…
• Pseudo-Cushing’s does not have the same long-term effects on health as Cushing's syndrome and does not require treatment directed at the endocrine glands.
Treatment/ManagementThe management/treatment of Cushing's syndrome can be
surgical, medical or radiation.
Treatment is usually directed at the pituitary gland
because most cases are due to pituitary tumors rather than
tumors of the adrenal cortex.
The following are the treatment/management of Cushing's
syndrome.
• Surgical removal of the tumor by transsphenoidal
hypophysectomy is the treatment of choice (80% success
rate).
Cont…• Radiation of the pituitary gland is successful but takes several
months for symptom control.
• Adrenalectomy is performed in patients with primary adrenal hypertrophy.
• Post-operatively, temporary replacement therapy with hydrocortisone may be necessary until the adrenal glands begin to respond normally (may be several months).
• If bilateral adrenalectomy was performed, lifetime replacement of adrenal cortex hormones is necessary.
Cont…
• Adrenal enzyme inhibitors (eg, metyrapone, aminoglutethimide, mitotane, ketoconazole) may be used with ectopic ACTH secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects.
• If Cushing syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate day therapy to treat the underlying disease.
GENERAL NURSING MANAGEMENT
• Weigh each morning, using the same scale.
• Maintain an accurate record of intake and output.
• Ensure adequate lighting in the room, and wear glasses and shoes when getting out of bed.
• Develop a written schedule of rest and activity periods.
• If agreeable, provide a private room, and restrict visitors at this time.
Cont…• Use strict medical and surgical asepsis when
providing care.
• Provide time for discussion of the disease and
treatment; encourage verbalization of feelings and
identify successful coping mechanisms used in the
past.
•Encourage turning, coughing, and deep breathing
and/or incentive spirometry every 2–4 hours
Complications
• If you don't receive prompt treatment for Cushing syndrome, complications may occur, such as:
• Bone loss (osteoporosis), which can result in unusual bone fractures, such as rib fractures and fractures of the bones in the feet
• High blood pressure (hypertension)
• Diabetes
Cont…• Frequent or unusual infections
• Loss of muscle mass and strength
• When the cause of Cushing syndrome is a
pituitary tumor (Cushing disease), it can
sometimes lead to other problems, such as
interfearing with the production of other
hormones controlled by the pituitary.
DATE NURSING DIAGNOSIS
NURSINGGOAL/OUTCOME
INTERVENTION EVALUATION
Risk for injury
related to
weakness
Decreased risk of
injury to the
patient.
1) Provide a protective environment to prevent falls, fractures, and other injuries to patient.
2) Assist the patient who is
weak in ambulating to
prevent falls or colliding
into furniture.
3) Recommend foods high
in protein, calcium, and
vitamin D to minimize
muscle wasting and
osteoporosis; refer
to dietitian for assistance.
Patient has
decreased risk of
injury.
DATE NURSING DIAGNOSIS
NURSING GOAL
NURSING INTERVENTION
EVALUATION
Risk for infection
related to
altered protein
metabolism and
inflammatory
response.
Decreased
risk of
infection.
1) Avoid unnecessary
exposure to people
with infections.
2) Assess frequently for
subtle signs of
infections (corticosteroid
s mask signs of
inflammation and
infection).
Has decreased risk of
infection
DATE NURSING DIAGNOSIS
NURSING GOAL
NURSING INTERVENTION EVALUATION
Impaired skin
integrity related
to edema,
impaired
healing, and thin
and fragile skin
Improved
skin integrity
1) Use meticulous skin care
to avoid traumatizing
fragile skin.
2) Avoid adhesive tape,
which can tear and irritate
the skin.
3) Assess skin and bony
prominences frequently.
4) Encourage and assist
patient to change
positions frequently.
Attains or maintains
skin integrity
DATE N.DIAGNOSIS NURSING GAOL
NURSING INTERVENTION EVALUATION
Disturbed body
image related to
altered
appearance, imp
aired sexual
functioning, and
decreased
activity level
Improved
body image
1) Discuss the impact that
changes have had on
patient’s self-concept and
relationships with others.
Major physical changes will
disappear in time if the
cause of Cushing syndrome
can be treated.
2) Weight gain and edema
may be modified by a low-
carbohydrate, low-sodium
diet; a high-protein intake
can reduce some bother
some symptoms.
Achieves
improved body
image of the
patient.
DATE N.DIAGNOSIS NURSING GOAL
NURSING INTERVENTION EVALUATION
Disturbed patient’s
mental function
related to mood
swing, response to
questions,
depression, and
awareness of
environment.
Improving
Thought
Processes
1) Explain to patient and
family the cause of
emotional instability,
and help them cope
with mood
swings, irritability, and
depression.
2) Report any psychotic
behavior.
3) Encourage patient and
family members to
verbalize feelings and
concerns.
Exhibits
improved mental
functioning
Experiences no
complications
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