MEDICAL SURGICAL NURSING-1

TOPIC: CUSHING SYNDROME

PRESENTED BY

SEIF SAID KHALFAN (BSc. N, student)

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.

Cont…

• Cushing syndrome occurs five times more often in women ages 20 to 40 years than in men.

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.

NUSING CARE PLAN

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