Cushings Syndrome

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Cushing’s Syndrome

Courtney Hammons

Pathophysiology:
Also known as hypercortisolism a metabolic disorder.
Characterized by hyperactivity of the adrenal cortex.
Excess of corticosteroids, particularly glucocorticosteroids.

Causes:
Most common cause is the administering too much corticosteroids. (Prednisone)
It can also be caused by adrenal tumors and ectopic ACTH production by tumors outside the hypothalamic-pituitary-adrenal axis.

Diagnostic Tests
Plasma cortical levels may be elevated.
ACTH levels may be low, normal, or elevated depending on the underlying problem.
A CBC will indicated granulocytes, lymphopenia, and eosinopenia.
CT scan and MIR are done for tumor localization.
Other tests that are associated, but not diagnostic are hyperglycemia, hypokalemia, glycosuria, hypercalciuria, and osteoporosis.

24 hour-urine free cortisol - There should be a 24 hour urine collection done resulting in 50-100 mcg of free cortisol

Dexamethasone suppression test During this test, you will receive dexamethasone, and the health care provider will measure
your cortisol levels.There are two different types of dexamethasone suppression tests: the low-dose test and the high-dose test. Each
type can either be done in an overnight or standard (3-day) way. Then blood is drawn…

Low-dose overnight method -- you will get 1 mg of dexamethasone at 11 p.m., and a health care provider will draw your blood at 8
a.m. for a cortisol measurement. Standard low-dose method -- urine is collected over 3 days (stored in 24-hour collection
containers) to measure cortisol. On day 2, you will get a low dose (0.5 mg) of dexamethasone by mouth every 6 hours for 48 hours.
High-dose overnight method -- the health care provider will measure your cortisol on the morning of the test. Then you will receive
8 mg of dexamethasone at 11 p.m. Your blood is drawn at 8 a.m. for a cortisol measurement. Standard high-dose test -- urine is
collected over 3 days (stored in 24-hour collection containers) for measurement of cortisol. On day 2, you will receive a high dose (2
mg) of dexamethasone by mouth every 6 hours for 48 hours.

Surgical Intervention Adrenalectomy (see Endocrin procedure outline)

Hypophysectomy- the surgical removal of the hypophysis. It is most commonly performed to treat tumors, especially
craniopharyngioma tumors. Sometimes it is used to treat Cushing's syndrome due to pituitary adenoma.

Clinical Manifestations
Physical appearance changes are dominant… weight gain especially. It is a result from adipose tissue in the trunk, face, and cervical
neck area.
Glucose intolerance occurs because of cortisol-induced insulin resistance.
Protein wasting is caused by the catabolic effects of the cortisol on peripheral tissue. Muscle wasting leads to muscle weakness on
the extremities. Loss of collagen makes the skin weaker and thinner and more susceptible to bruising.
The extra mineralocorticoid may cause hypertension. The extra adrenal androgen causes acne, more manly features in women, and
more feminine features in males.
Other common signs/symptoms:
“Moon face”/buffalo hump
Purple striae on abdomen/breasts/buttocks
Menstrual disorders in females
Unexplained hypokalemia
Hypocalemia/Hypernatremia

Dietary
Foods high in potassium and potassium supplements if hypokalemic
Diet high in protein to correct protein depletion

Nursing Responsibilities/Interventions
Focus should be on hormone and drug toxicity.
Monitor vital signs, glucose, and daily weights.
Watch for signs and symptoms of infection. Especially pain, loss of function, and purulent drainage. Fever and redness will probably
be minimal or absent.
Signs of abnormal thromboembolic phenomena (chest pain, dyspnea, and tachypnea)
*** Emotional Support: the changes in appearances are hard to adjust to ***
Provide skin care.

Collaborative Care/Surgery- What kind/what a nurse needs to do.


Patient could have radiation if it results from pituitary adenoma.
Removal of pituitary adenoma (transsphenoidal hypophysectomy)
Removal of the the adrenal tumor. (adrenalectomy).
Patients with ectopic ACTH- secreting tumors are managed by treating the neoplasm.
If it’s caused by prolonged drug administration then try to gradually discontinue corticosteroid therapy or reduce the dose.
Preop: hypertension & hyperglycemia need to be controlled.
Postop: B/P, fluid imbalance, and F&E imbalance are common b/c of hormone imbalance. Monitor I&O.
Be alert to signs and symptoms of corticosteroid imbalances, if dosage is tapered with too quickly acute adrenal insufficiency may
occur. Vomiting, weakness, dehydration, and hypotension indicate HYPOcorticolism.

Nursing Diagnosis
Risk for infection
Imbalanced nutrition: more than body requires
Situational low self esteem
Impaired skin integrity

Patient Goals
Primary goal is to normalize hormone secretions.
Patient will experience relief of symptoms with no serious complications
Patient will maintain a positive self-image
Patient will participate in therapeutic plans

Patient & Family Education


Discharge: based on the patients lack of endogenous cortisol and results on inability to react to stressors.
Patient should wear Medic-Alert bracelet
Avoid exposure to extreme temperatures, infections, and emotional disturbances.
Corticosteroid replacement therapy should be adjusted to stress levels
If weakness, fainting, nausea, vomiting, or inability to adjust owns medication to stress occur the patient should contact the
physician and dosage should be changed.
LIFETIME REPLACEMENT THERAPY IS REQUIRED by many patients. But it can take several months to achieve satisfactory
results.

Medications
If surgery is contraindicated treatment with mitrotane (Lysodren) may be used. – Supresses cortisol production.
Mytrapone, ketoconazole (Nizoral), and aminogluctethimide (Cytadren) used to inhibit cortisol synthesis.

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