Medica nursing 2

1. CUSHING SYNDROME
BY
MARIA NAKAWEESI

2. DEFINITION
• Cushing syndrome is a disorder of the adrenal
cortex.
• It is a clinical condition that results from chronic
exposure to excess corticosteroids particularly
glucocorticoids.

3. Recap of the adrenal cortex
• It is part of the adrenal gland.
• It produces three kinds of steroid hormones
namely; androgens, mineralcorticoids and
glucocorticoids.
• Glucocorticoids:- they regulate metabolism,
increase glucose levels and are critical in the
physiological stress response.

4. Cont'd
• The primary glucocorticoid is cortisol.
• Mineralcorticoids:-regulate sodium and potassium
balance. The primary hydrocortisone is
aldosterone.
• Androgens:- these contribute to growth and
development in both genders.

5. Epidemiology of Cushing
syndrome
• The incidence and prevalence is not known.

6. Etiology
• iatrogenic administration of exogenous
corticosteroids e.g prednisone
• Cushing syndrome can be caused by endogenous
corticosteroids due to presence of ACTH- secreting
pituitary adenoma.
• Adrenal tumors

7. Pathophysiology
• The pathophysiology of Cushing's syndrome is
linked to hypercortisolism which can develop by
excess ACTH secretion or excess cortisol secretion
by adrenal glands. The underlying mechanisms are
usually genetic mutations or overexpression of
proteins.

8. Cont'd
• Excess ACTH secretion;-
• The excess ACTH secretion can be due to the pituitary
adenoma or ectopic (non-pituitary) ACTH secretion. ACTH
stimulates the adrenal cortex to release cortisol and is not
regulated by the feedback mechanism.
• Pituitary adenoma: It is the most important cause of
ACTH-dependent cushing's syndrome and is also called
cushing's disease. It is considered that the corticotroph
tumors are resistant to glucocorticoid negative feedback
inhibition which results in the pathological adrenal
cortisol secretion.

9. Continued
• Ectopic ACTH secretion: The molecular defects in
the neuroendocrine tumors leading to ectopic
ACTH secretion from gastroenteropancreatic
tumors are largely unknown.
• Ectopic secretion of ACTH can be seen as a
manifestation of the paraneoplastic syndrome in
small cell lung carcinoma and carcinoid
tumors(bronchial and thymus).

10. Cont'd
• Excess secretion of cortisol by adrenal gland
• Excess secretion of the cortisol by the adrenal gland
is due to the adrenal causes independent of ACTH
secretion.
• Bilateral adrenal hyperplasia

11. Continued
• Benign Adrenocortical adenoma
• Adrenal cortical carcinoma It is associated with
germline TP53 mutations and MEN syndrome.

12. Clinical manifestations

13. Diagnosis
• History taking
• Physical examination
• Plasma cortisol levels for diurnal variation test
• Plasma ACTH Test
• CBC
• Dexamethasone suppression test
• CT scan
• MRI

14. Management
• Goals of treatment
• To normalize hormone secretion
• Treatment depends on cause;
• If it's due to a ;
1. pituitary daemons- then a surgical removal is
done. Radiation therapy is done for candidates
who are poor surgical candidates.

15. Continued
• Adrenocortical adema, carcinoma/ hyperplasia
• adrenalectomy
• Drug therapy
• Ectopic - ACTH- secreting tumor
• Surgical removal

16. Cont'd
• Exogenous corticosteroid therapy
• Gradually discontinue treatment or alter dose
•
• Decrease the corticosteroid dose

17. Drug therapy
• When the patient is a poor candidate for surgery or
prior surgery has failed, drug therapy is attempted
• The goal of drug therapy is to suppress the
synthesis and secretion of cortisol from the adrenal
gland (medical adrenalectomy).

18. Drug therapy
• Drugs used include ketoconazole (Nizoral),
aminoglutethimide (Cytadren), and mitotane
(Lysodren).
• These are used cautiously because they are often
toxic at the dosages needed to reduce cortisol
secretion.

19. Cont'd
• Hydrocortisone or prednisone may beneeded to
avoid adrenal insufficiency.
• Mifepristone (Korlym) may be used to control
hyperglycemia in patients with endogenous
Cushing syndrome who have type 2 diabetes.

20. Complications
• Bone loss
• Hypertension
• Type 2 diabetes
• Frequent infections
• Loss of muscle mass and strength.

21. Nursing diagnosis
• Disturbed body image
• Disturbed thought process
• Anxiety
• Risk for infection
• Excess fluid volume

22. Nursing care plan
• Risk for injury and Risk for infection related to weakness and
changes in protein metabolism and inflammatory response.
• Self-care Deficit: weakness, feeling of tiredness, muscle
atrophy and changes in sleep patterns.
• Impaired skin integrity related to edema, impaired healing
and the skin is thin and fragile.
• Disturbed Body Image related to changes in physical
appearance, sexual dysfunction and decreased activity
levels.
• Disturbed Thought Processes related to fluctuations in
emotions, irritability and depression.

23. Nursing Care Planning & Goals
• The major nursing goals for the patient include:
• Decrease risk of injury.
• Decrease risk of infection.
• Increase ability to carry out self-care activities.
• Improve skin integrity.
• Improve body image.
• Improve mental function.

24. Interventions
• Decreasing Risk of 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.

25. Intervention
• Decreasing Risk of Infection
• Avoid unnecessary exposure to people with
infections.
• Assess frequently for subtle signs of infections
(corticosteroids mask signs of inflammation and
infection).

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

27. Intervention
• 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 and concerns.