Cushing’s syndrome

 Cushing’s Syndrome

Cushing’s syndrome results from secretion of excessive cortisol either in response to excess ACTH production by the pituitary tumors and adrenal adenoma or nodular hyperplasia.

OR

Cushing’s syndrome is simply defined as a hormonal disorder associated with excessive production of corticosteroids by the adrenal gland or the pituitary gland and/or prolonged use of corticosteroids.

 

Causes of Cushing’s Syndrome
  • Prolonged use of corticosteroid medication.
  • Hyperplasia of the adrenal gland.
  • Tumor in the pituitary gland enhancing over production of ACTH.
  • Tumour in one of the adrenal glands above the kidneys.

Clinical Presentation of Cushing’s syndrome.

  • Hirsutism
  •  Amenorrhea
  •  Easy bruising and acne
  •  Osteoporosis may cause bone weakening and fracture
  • Cataracts, glaucoma
  • Hypertension, heart failure
  • Truncal obesity, moon face, buffalo hump, sodium retention, hypokalemia, hyperglycemia, negative nitrogen balance, altered calcium metabolism
  • Decreased inflammatory responses, impaired wound healing, increased susceptibility to
    infections
  • Peptic ulcers, pancreatitis
  • Thinning of skin, striae, acne
  • Mood alterations
  • Depression
Diagnosis
  • Overnight dexamethasone suppression test frequently used for diagnosis administered at 11pm and cortisol level checked at 8am
  • Suppression of cortisol to less than 5mg/dL indicates normal functioning
  • Measurement of plasma ACTH (radioimmunoassay) in conjunction with dexamethasone suppression test helps distinguish pituitary vs. ectopic sites of ACTH.
  • MRI, CT and CT also help detect tumors of adrenal or pituitary.

Management

Treatment is dependent on the site of the disease.

  1.  If pituitary source, may warrant transphenoidal hypophysectomy(surgery done to remove the pituitary gland)
  2.  Radiation of pituitary also appropriate
  3.  Adrenalectomy may be needed in case of adrenal hypertrophy
  4.  Temporary replacement therapy with hydrocortisone or Florinef
  5.  Adrenal enzyme reducers may be indicated if source if ectopic and inoperable. Examples include: ketoconazole, mitotane and metyrapone.
  6.  If cause is related to excessive steroid therapy, tapering slowly to a minimum dosage maybe appropriate.
hypophysectomy

Hypophysectomy

Nursing Care
  • Assess the level of activity and ability to carry out routine and self care activities.
  • Observe skin for trauma, infection, breakdown, bruising, and edema.
  • Note changes in appearance and patients response to these changes, family is good source if information about patients emotional status and changes in appearance.
  • Assess mental function.
  • Nursing Diagnosis
  • Acute pain related to compression fracture of lumber spine as evidenced by back pain.
  • Self care deficit related to weakness, fatigue as evidenced by starry eyes and inability to answer questions.
  • Risk For Excess Fluid Volume related to retention of water and sodium caused by an excess of cortisol and mineralocorticoid levels.
  • Risk For Injury related to decreased bone density or generalized fatigue and weakness or increased capillary fragility or poor wound healing
  • Risk For Infection related to altered protein metabolism or high serum cortisol level or impaired immune response
  • Deficient Knowledge related to lack of experience with Cushing’s syndrome evidenced by repeated hospital admissions for complications or repeated questioning or verbalized misconceptions.
  • Disturbed Body Image related to abnormal fat distribution along with edema resulting in moon face, cervicodorsal fat (buffalo hump), trunk obesity evidenced by compensatory use of concealing clothing.
  • Disturbed Thought Processes related to chemical changes in the brain from high cortisol evidenced by anxiety or irritability or depression .
  • Evaluations
  • Has decreased risk of injury
  • Has decreased risk of infection
  • Increases participation in self care activities
  • Attains or maintains skin integrity
  • Achieves improved body image
  • Exhibits improved mental functioning
  • Experiences no complications
  • Nursing Interventions
  • Assess for signs of circulatory overload i.e Cyanosis, Dyspnea. Edema, Distended neck veins, Shortness of breath, Tachypnea. Rationale; Detection of signs of circulatory overload will help in the immediate intervention. Due to excessive glucocorticoid and mineralocorticoid secretion, the client is predisposed to water and sodium retention.
  • Monitor vital signs, especially Blood pressure and Heart rate.  Rationale: Cushing’s disease may result in increased blood pressure resulted from the expanded fluid volume with sodium and water retention. Tachycardia happens as a compensatory response to circulatory overload.
  • Monitor the client’s sodium and potassium levels Rationale:  excessive cortisol causes sodium and water retention, edema, and increased potassium excretion. Mineralocorticoids regulate sodium and potassium secretion, and excess levels cause marked sodium and water retention as well as marked hypokalemia.
  • Instruct the client to elevate feet when sitting down. Rationale: This position decreases fluid accumulation in the lower extremities.
  • Encourage the client to have low sodium and high potassium diet. Rationale: Too much sodium in the diet promotes fluid retention and weight gain
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