Cushing’s Syndrome

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Cushing’s syndrome results from excessive adrenocortical activity. It may result from excessive administration of corticosteroids or adrenocorticotropic hormone (ACTH) or from hyperplasia of the adrenal cortex. It may be caused by several mechanism, including a tumor in the pituitary gland or less commonly an ectopic malignancy that produces ACTH. Regardless of the  cause, the negative feedback mechanisms that control the functions of the adrenal cortex  become ineffective, resulting in oversecretion of glucocorticoids, androgens, and possibly mineralocorticoid. Cushing syndrome occurs five times more often in women ages 40 to 60 years than in men.

Clinical Manifestations

  • Arrested growth, weight gain and obesity, musculoskeletal changes, and glucose intolerance
  • Classic features: central-type obesity, with a fatty “buffalo hump” in the neck and supraclavicular area, a heavy trunk, and relatively thin extremities; skin is thin, fragile, easily traumatized, with ecchymoses and striae
  • Weakness and lassitude; sleep is disturbed because of altered diurnal secretion of cortisol.
  • Excessive protein catabolism with muscle wasting and osteoporosis; kyphosis, backache, and compression fractures of the vertebrae are possible
  • Retention of sodium and water, producing hypertension and heart failure
  • “Moon-faced” appearance, oiliness of skin and acne
  • Increased susceptibility to infection; slow healing of minor cuts and bruises
  • Hyperglycemia or overt diabetes
  • Virilization in females (due to excess androgens) with appearance of masculine traits and recession of feminine traits (eg; excessive hair on face, breasts atrophy, menses cease, clitoris enlarges, and voice deepens); libido is lost in males and females
  • Changes occur in mood and mental activity; psychosis may develop and distress and depression are common
  • If Cushing’s syndrome is the result of a pituitary tumor, visual disturbances are possible cause of pressure on the optic chiasm

Assessment and Diagnostic Findings

  • Overnight dexamethasone  suppression test to measure plasma corticol level (stress, obesity, depression, and medications may falsely elevate results)
  • Computed tomography (CT) or magnetic resonance imaging (MRI) scan or ultrasound may localize adrenal tissue and detect adrenal tumors

Medical Management

Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex.

  • Surgical removal of the tumor (transsphenoidal hypophysectomy) is the treatment of choice (90% success rate.
  • Radiation of the pituitary gland is successful but takes several months for symptom control.
  • Adrenalectomy is performed in  patients with primary adrenal hypertrophy
  • Postoperatively, 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
  • Adrenal enzyme inhibitors (eg, metyrapone or mitotane) may be used with ectopic ACTH-secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects
  • If Cushing’s syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate day therapy to treat the underlying disease.

NURSING PROCESS: The Patient with Cushing’s Syndrome

Assessment

  • Focus on the effects on the body of high concentrations of adrenal cortex hormones
  • Assess patient’s level of activity and ability to carry out routine and self-care activities
  • Observe skin trauma, infection, breakdown, bruising and edema
  • Note changes in appearance and patient’s response to these changes, family is good source of information about patient’s emotional status and changes in appearance
  • Assess patient’s mental function. including mood, response to questions, depression, and awareness of environment

Diagnosis

Nursing Diagnoses

  • Risk for injury related to weakness
  • Risk for infection related to altered protein metabolism and inflammatory response
  • Self-care deficits related to weakness, fatigue, muscle wasting, and altered sleep patterns
  • Impaired skin integrity related to edema, impaired healing, and thin and fragile skin
  • Disturbed body image related to altered appearance, impaired sexual functioning, and decreased activity level
  • Disturbed thought processes related to mood swings, irritability, and depression

Collaborative Problems/Potential Complications

  • Addisonian crisis
  • Adverse effects of adrenocortical activity

Planning and Goals

Major goals include decreased risk for injury, decreased risk for infection, increased ability to carry out self-care activities, impaired skin integrity, improved body image, improved mental function, and absence of complications.

Nursing Interventions

Decreasing Risk for Injury

  • Provide a protective environment to prevent falls, fractures, and other injuries to bones and soft tissues
  • Assist the patient who is weak in ambulating to prevent falls or colliding into furniture
  • Recommend foods high in protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis; refer to dietitian for assistance

Decreasing Risk for Infection

  • Avoid unnecessary exposure to people with infections
  • Assess frequently for subtle signs of infections (corticosteroids mask signs of inflammation and infection)

Promoting Skin Care

  • Use meticulous skin care to avoid traumatizing fragile skin
  • Avoid adhesive tapes, which can tear and irritate the skin
  • Assess skin and bony prominences frequently
  • Encourage and assist patient to change positions ffrequently

Improving Body Image

  • 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’s syndrome can be treated.
  • Weight gain and edema may be modified by a low-carbohydrate, low-sodium diet; a high in protein intake can reduce some bothersome symptoms

Improving Thought Processes

  • Explain to patient and family the cause of emotional instability and help them cope with mood swings, irritability, and depression
  • Report any psychotic behavior
  • Encourage patient and family members to verbalize feelings

Encouraging Rest and Activity

  • Encourage moderate activity to prevent complications of immobility and promote self-esteem
  • Plan rest periods throughout the day and promote a relaxing, quiet environment for rest and sleep

Preparing Patient for Surgery

  • Adrenal hypofunction ans addisonians crisis: monitor for hypotension; rapid, weak pulse, rapid respiratory rate; pallor; and extreme weakness. Note factors that may have led to crisis (eg, stress, trauma, surgery).
  • Administer intravenous fluids and electrolytes  and corticosteroids before, during and after surgery or treatment as indicated.
  • Monitor for circulatory collapse and shock present in addisonian crisis; treat promptly.
  • Assess fluid and electrolyte status by monitoring laboratory values and daily weight.
  • Monitor blood glucose level, and report elevations to physician.

 

Reference:

Joyce Young Johnson et.al Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Wiliams &Wilkins pp; 286-291

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One Response to “Cushing’s Syndrome”

  1. Thank you so very much for making this information available to me! I have been ill for almost 20 years and no diagnosis – Doctors only treated the symptoms! I have lots of family support or I would have been dead by now – so I’m not looking for attention – just needed to know what was wrong so it could be treated properly! I have all the signs and symptoms but I’ve been diagnosed with so much else by so many doctors that the ones I currently see are being very thorough now for determining the underlying cause of the Cushing’s. I’m cautiously optimistic about a recovery! Thanks again!

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