Cushing Syndrome and Nursing Care Plan

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Cushing Syndrome Etiology and Pathophysiology

• Caused by an excess of corticosteroids, particularly glucocorticoids

• Most common cause:

– Iatrogenic administration of exogenous corticosteroids

• 85% of endogenous is due to ACTH-secreting pituitary tumor

• Other causes include adrenal tumors and ectopic ACTH production by tumors outside hypothalamic-pituitary-adrenal axis

• Cushing’s disease and primary adrenal tumors are more common in women aged 20-40

• Ectopic ACTH production is more common in men

Cushing Syndrome Clinical Manifestations

• Weight gain most common

– Trunk

– Face

– Cervical area

– Sodium/water retention

• Hyperglycemia

– Glucose intolerance

– Increased gluconeogenesis by liver

• Protein wasting

– Catabolic effects of cortisol

– Leads to weakness

– Protein loss in bones leads to osteoporosis, bone and back pain

• Loss of collagen

– Skin thinner and weaker

• Wound healing delayed

• Mood disturbances

• Insomnia

• Irrationality

• Psychosis

• Mineralocorticoid excess may cause hypertension

• Adrenal androgen excess may cause acne, virilization in women, and feminization in men

• Menstrual disorders and hirsutism in women and gynecomastia and impotence in men

• Purple striae on abdomen, breast, or buttocks

 

Common Characteristics of Cushing Syndrome

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Cushing Syndrome Diagnostic Studies

• 24-hour urine for free cortisol

• Low-dose dexamethasone suppression test

– False positives can occur with depression, stress, or alcoholism

• Plasma cortisol levels may be elevated with loss of diurnal variation

• CT and MRI are used for tumor localization

• Other findings but not diagnostic of Cushing syndrome:

– Agranulocytosis

– Lymphopenia

– Eosinopenia

– Hyperglycemia

– Glycosuria

– Hypercalciuria

– Osteoporosis

• Hypokalemia and alkalosis seen in ectopic ACTH syndrome and adrenal carcinoma

• Plasma ACTH may be low, normal, or elevated depending on problem

• High or normal ACTH levels indicate ACTH-dependent Cushing disease

• Low or undetectable ACTH levels indicate adrenal or exogenous etiology

 

Cushing Syndrome Collaborative Care

• Goal of normalizing hormone secretion

• Treatment dependent on cause

• Surgical removal or radiation for pituitary adenoma

• Adrenalectomy for adrenal tumors or hyperplasia

• Ectopic ACTH-secreting tumors managed by treating primary neoplasm

• Drug therapy indicated when surgery is contraindicated

• Goal is inhibition of adrenal function

• Mitotane

– Suppresses cortisol production

– Alters peripheral metabolism of cortisol

– Decreases plasma and urine corticosteroid levels

• Metyrapone, ketoconazole, and aminoglutethimide inhibit cortisol synthesis

• If developed during use of corticosteroids

– Gradual discontinuance

– Reduction of dose

– Conversion to alternate-day regimen

• Avoids potentially life-threatening adrenal insufficiency

 

Cushing Syndrome Nursing Assessment

• PMH

– Pituitary tumor

– Adrenal, pancreatic, or pulmonary neoplasms

– Frequent infections

• Use of corticosteroids

• Weight gain

• Anorexia

• Polyuria

• Prolonged wound healing

• Easy bruising

• Insomnia

• Back, joint, bone, and rib pain

• Amennorrhea

• Impotence

• Mood disturbances, anxiety, psychosis

•Truncal obesity

• Buffalo hump

• Moon facies

• Hirsutism of body and face

• Thinning of hair

• Thin, friable skin

• Acne

• Petechiae

• Purpura

• Hyperpigmentation

• Striae

• Hypertension

• Muscle wasting

•Risk for infection

• Imbalanced nutrition: more than body requirements

• Disturbed self-esteem

• Impaired skin integrity

 

Cushing Syndrome Nursing Planning

• Patient will:

– Experience relief of symptoms

– Have no serious complications

– Maintain positive self-image

– Actively participate in therapeutic plan

 

Cushing Syndrome Nursing Implementation

• Identify risks for Cushing syndrome

– Long-term exogenous cortisol

– Teaching related to medications

• Assessment of S/S of hormone and drug toxicity, complicating conditions

– Cardiovascular disease

– Diabetes

– Infection

– Pathologic fractures

• Monitor:

– VS

– Daily weight

– Glucose

– S/S of infection

• Redness, fever may be minimal or absent

– S/S of thromboembolic phenomena

• Emotional support

– May feel unattractive or unwanted

– Physical symptoms will resolve when hormone levels return to normal

• Pre-op care

– Hypertension and hyperglycemia must be controlled

– Hypokalemia is corrected with supplements

– High-protein meals prevent depletion

• Teaching depends on surgical approach

– Include information on post-op care

• NG tube

• Urinary catheter

• IV therapy

• Central venous pressure monitoring

• Leg compression devices

• Post-op

– Risk of hemorrhage is increased

– Manipulation of glandular tissue may release hormones into circulation

– BP, F&E tend to be unstable due to hormone fluctuations

– High doses of corticosteroids are administered IV during and several days after surgery to ensure adequate response to surgery

– Report any significant changes in BP, F&E, RR, or HR

– Monitor I&O

– Critical period for circulatory instability ranges from 24 to 48 hours post-op

– Morning urine levels of cortisol are measured to evaluate effectiveness of surgery

• Adrenal insufficiency may develop if corticosteroid dosage is tapered too rapidly

• Vomiting, increased weakness, dehydration, and hypotension may indicate hypocortisolism

– S/S of painful joints

– Pruritus

– Peeling skin

– Severe emotional disturbances should be reported so doses can be adjusted

– Maintain bed rest until BP stabilizes

– Meticulous care when accessing skin, circulation, or body cavities to prevent infection

• Inflammatory responses suppressed

• Discharge instructions based on lack of endogenous corticosteroids

• Wear Medic Alert bracelet at all times

• Avoid exposure to stress, extremes of temperature, and infections

• Lifetime replacement therapy for many

 

Cushing Syndrome Nursing Evaluation

• No infection/early detection of infectious process

• Maintenance of body weight or no more than 1-2 lb loss per week

• Verbalization of acceptance of and self-care of appearance

• Intact skin

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