a presentation on cushing syndrome

1. MEDICAL SURGICAL NURSING-1
TOPIC: CUSHING SYNDROME
PRESENTED BY
SEIF SAIDKHALFAN (BSc. N, student)

2. 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.

3. 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.

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

5. Etiology of Cushing's syndrome
 Excessive activity of the adrenal cortex
 Corticosteroids / ACTH excess
 Adrenal cortex hyperplasia.

6. 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).

7. 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”.

8. Cont…
• ACTH and cortisol become elevated in
response to stress, such as surgery, trauma,
infection or other medical illnesses. i.e. Stress
response.

10. 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.

11. Signs and Symptoms of
Cushing'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)

12. 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

13. 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

14. 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

15. 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

18. 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 :-

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. Treatment/Management
The 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).

27. 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.

28. 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.

29. 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.

30. 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

31. 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

32. 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.

33. NUSING CARE PLAN

34. DATE NURSING
DIAGNOSIS
NURSING
GOAL/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.

35. 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

36. 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

37. 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.

38. 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