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CUSHING·S SYNDROME

Reported by: Group 4

Mariel FortunaDiane Ellisson AguinaldoSharmaine FajardoGlairievy BeltranMarie Joy VillaquidanJennifer Marie ManaloMary Christ LacadenKristine Bautista

Christopher Reglos



CUSHING·S SYNDROME

--(also called hyperadrenocorticism orhypercorticism) is a hormone (endocrine) disorder

caused by high levels of cortisol (hypercortisolism) in

the blood. This can be caused by taking glucocorticoid

drugs, or by tumors that produce cortisol or

adrenocorticotropic hormone (ACTH).--Cushing's disease refers to one specific cause, a tumor

(adenoma

) in the pituitary gland that produces large

amounts of ACTH, which in turn elevates cortisol. It

can usually be cured by surgery. It was described byHarvey Cushing in 1932.



CUSHING·S SYNDROME

--is a hormonal disorder caused by prolonged exposureof the body·s tissues to high levels of the hormone

cortisol. Sometimes called hypercortisolism, Cushing·s

syndrome is relatively rare and most commonly affects

adults aged 20 to 50. People who are obese and have

type 2 diabetes, along with poorly controlled blood

glucose³also called blood sugar³and high blood

pressure, have an increased risk of developing the

disorder



CAUSES

Other people develop Cushing·s syndrome becausetheir bodies produce too much cortisol. Normally, the

production of cortisol follows a precise chain of events.

First, the hypothalamus, a part of the brain about the

size of a small sugar cube, sends corticotropin-

releasing hormone (CRH) to the pituitary gland. CRH

causes the pituitary to secrete adrenocorticotropin

hormone (ACTH), which stimulates the adrenal

glands. When the adrenals, which are located just

above the kidneys, receive the ACTH, they respond byreleasing cortisol into the bloodstream.



CAUSES

�

Cortisol performs vital tasks in the body including>helping maintain blood pressure and cardiovascular function

>reducing the immune system·s inflammatory response

>balancing the effects of insulin, which breaks down glucosefor energy

>regulating the metabolism of proteins, carbohydrates, andfats

The hypothalamus sends CRH to the pituitary, whichresponds by secreting ACTH. ACTH then causes theadrenals to release cortisol into the bloodstream.

� One of cortisol·s most important jobs is to help the bodyrespond to stress. For this reason, women in their last 3months of pregnancy and highly trained athletes normallyhave high levels of the hormone. People suffering fromdepression, alcoholism, malnutrition, or panic disordersalso have increased cortisol levels.



CAUSES

� Pituitary Adenomas

Pituitary adenomas cause 70 percent of Cushing·s

syndrome cases,excluding those caused by

glucocorticoid use. These benign, or noncancerous,

tumors of the pituitary gland secrete extra ACTH.Most people with the disorder have a single adenoma.

This form of the syndrome, known as Cushing·s

disease, affects women five times more often than

men.



CAUSES

� Ectopic ACTH SyndromeSome benign or, more often, cancerous tumors that

arise outside the pituitary can produce ACTH. This

condition is known as ectopic ACTH syndrome. Lung

tumors cause more than half of these cases, and men

are affected three times more often than women. The

most common forms of ACTH-producing tumors are

small cell lung cancer, which accounts for about 13

percent of all lung cancer cases, and carcinoid

tumors³small, slow-growing tumors that arise fromhormone-producing cells in various parts of the body.

Other less common types of tumors that can produce

ACTH are thymomas, pancreatic islet cell tumors, and

medullary carcinomas of the thyroid.



CAUSES

Adrenal TumorsIn rare cases, an abnormality of the adrenal glands, most

often an adrenal tumor, causes Cushing·s syndrome.

Adrenal tumors are four to five times more common in

women than men, and the average age of onset is about 40.

Most of these cases involve noncancerous tumors of adrenaltissue called adrenal adenomas, which release excess

cortisol into the blood.

Adrenocortical carcinomas³adrenal cancers³are the least

common cause of Cushing·s syndrome. With adrenocortical

carcinomas, cancer cells secrete excess levels of severaladrenocortical hormones, including cortisol and adrenal

androgens, a type of male hormone. Adrenocortical

carcinomas usually cause very high hormone levels and

rapid development of symptoms.



CAUSES

F amilial Cushing·s Syndrome

Most cases of Cushing·s syndrome are not inherited.

Rarely, however, Cushing·s syndrome results from an

inherited tendency to develop tumors of one or more

endocrine glands. Endocrine glands release hormones

into the bloodstream. With primary pigmentedmicronodular adrenal disease, children or young adults

develop small cortisol-producing tumors of the adrenal

glands. With multiple endocrine neoplasia type 1

(MEN1), hormone-secreting tumors of the parathyroid

glands, pancreas, and pituitary develop; Cushing·s

syndrome in MEN1 may be due to pituitary, ectopic, or

adrenal tumors.



SIGNS AND SYMPTOMS

1. Rapid weight gain2. Hyperhidrosis (excess sweating)

3. Telangiectasia ( dilation of capillaries)

4. Thinning of the skin

5. Hirsutism

6. Baldness and/or cause hair to become extremely dry

and brittle

7. Bufallo hump

8. Moon face



SIGNS AND SYMPTOMS

9. Reduced libido10. Impotence, amenorrhea/ oligimenorrhea, infertility

OTHER COMMON SIGNS AND SYMPTOMS

INCLUDE

severe fatigue

weak muscles

high blood pressure

high blood glucose

increased thirst and urination

irritability, anxiety, or depression

a fatty hump between the shoulders



K EY FEATURES OF HYPERCOTISOLISM

(CUSHING·S SYNDROME/DISEASE)

GENERAL APPERANCE

1. Fat redistribution

Moon face Buffalo hump

Truncal obesity

2. Weight Gain





CARDIOVASCULAR MANIFESTATIONS

1. Hypertension

2. Increased risk for thromboembolic events

3. Frequent dependent edema

4. Capillary fragility

Bruising

Petechiae

MUSCULOSK ELETAL MANIFESTATIONS

1. Muscle Atrophy ( most apparent in extremities)





2. Osteoporosis ( bone density loss)

Pathologic fractures

Decreased height with vertebral collapse

Aseptic necrosis of the femur head Slow or poor healing of bone fractures

SK IN MANIFESTATIONS

1.

Thinning of skin ( ´paper-likeµ appearance, esp.on the back of the hands)

2. Striae

3. Increase pigmentation ( with ectopic orpituitary production of ACTH)





IMMUNE SYSTEM MANIFESTATIONS

1. Increased risk for infection

2. Decreased immune functions

Decreased circulating lymphocytes

Decreased production of immunoglobulins(antibodies)

3. Decreased inflammatory responses

Decreased eosinophil count

Slight increased in neutrophil count but activity is

reduced4. Decreased production of proinflammatory cytokines,

histamine, & prostaglandines

5. Manifestations of infections/inflammations may bemasked



IF LEFT UNTREATED:

1. Heart Disease2. Pathologic Fractures

3. Skin Breakdown

4. GI Bleeding



RISK FACTORS



NURSING INTERVENTION

Goals of treatment for Cushing·s syndrome are the

reduction of plasma cortisol levels, removal of tumors,

prevention of complications, and restoration of normalacceptable body apperance



NURSING INTERVENTIONS

NON SURGICAL MANAGEMENT

Weigh the ct. daily and monitor intake and output.

Drug Therapy. Drugs that interfere with ACTH

production or adrenal hormone synthesis, however,may be used for temporary relief. ( cyproheptadine

[periactin])

Radiation Therapy. Radiation may be use to treat

hypercorticolism caused by pituitary adenomas.However, radiation is not always effective and




and often destroys normal tissue.

SURGICAL MANAGEMENT

Preoperative Care. Electrolyte imbalances are

corrected before surgery. Continue to monitor blood

potassium, sodium, and chloride levels, dysrhythmias

from potassium imbalance may occur, and cardiac

monitoring is needed. Hyperglycemia is controlled

before surgery and blood glucose levels are monitored.

Prevent infection with hand washing and aseptic technique. Decrease risk for




falls by raising bed siderails and encouraging the client to ask for assistance when getting out

of bed. A high-calorie, high-protein diet is prescribed

before surgery.

The client continues to receive glucocorticoids during

surgery to prevent adrenal crisis because the removal

of the tumor results in a sudden drop of cortisol levels.




Post Operative Care. After an adrenalectomy, aclient is usually sent to critical care unit. Immediately

after surgery, assess the client every 15 min for

shock (e.g., hypotension, a rapid, weak pulse,

and decreasing urine output) due to possible

insufficient glucocorticoid replacement. Monitor

ongoing V/S and other hemodynamic variables

(central venous pressure, pulmonary wedge

pressure), I & O, daily weight and serum

electrolytes levels.



DX PROCEDURES/ TEST

Midnight plasma cortisol and late-night salivary cortisol measurements. The midnight plasma

cortisol test measures cortisol concentrations in theblood. Cortisol production is normally suppressed atnight, but in Cushing·s syndrome, this suppression

doesn·t occur. If the cortisol level is more than 50nanomoles per liter (nmol/L), Cushing·s syndrome issuspected. The test generally requires a 48-hourhospital stay to avoid falsely elevated cortisol levelsdue to stress.

However, a late-night or bedtime saliva sample can beobtained at home, then tested to determine the

cortisol level. Diagnostic ranges vary, depending on

the measurement technique used.



DX PROCEDURES/ TEST

� 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.

Cortisol and other glucocorticoids signal the pituitary to release

less ACTH, so the normal response after takingdexamethasone is a drop in blood and urine cortisol levels. If

cortisol levels do not drop, Cushing·s syndrome is suspected.

The LDDST may not show a drop in cortisol levels in people with

depression, alcoholism, high estrogen levels, acute illness, or

stress, falsely indicating Cushing·s syndrome. On the otherhand, drugs such as phenytoin and phenobarbital may cause

cortisol levels to drop, falsely indicating that Cushing·s is not

present in people who actually have the syndrome. For this

reason, physicians usually advise their patients to stop taking

these drugs at least 1 week before the test.



DX PROCEDURES/ TEST

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 conditionsometimes found in people who have depression or

anxiety disorders, drink excess alcohol, have poorly

controlled diabetes, or are severely obese. Pseudo-

Cushing·s does not have the same long-term effects onhealth as Cushing·s syndrome and does not require

treatment directed at the endocrine glands.



TEST TO FIND THE CAUSE

CRH stimulation test. The CRH test, withoutpretreatment with dexamethasone, helps separate

people with pituitary adenomas from those with

ectopic ACTH syndrome or adrenal tumors. As a result

of the CRH injection, people with pituitary adenomas

usually experience a rise in blood levels of ACTH andcortisol because CRH acts directly on the pituitary.

This response is rarely seen in people with ectopic

ACTH syndrome and practically never in those with

adrenal tumors.




high-dose dexamethasone suppression test (HDDST). The HDDST is the same as the LDDST,

except it uses higher doses of dexamethasone. This test

helps separate people with excess production of ACTH

due to pituitary adenomas from those with ectopic

ACTH-producing tumors. High doses of dexamethasone usually suppress cortisol levels in

people with pituitary adenomas but not in those with

ectopic ACTH-producing tumors.




Petrosal sinus sampling. This test is not alwaysrequired, but in many cases, it is the best way to

distinguish pituitary from ectopic causes of Cushing·s

syndrome. Samples of blood are drawn from the

petrosal sinuses³veins that drain the pituitary³byinserting tiny tubes through a vein in the upper thigh

or groin region. A local anesthetic and mild sedation

are given, and x rays are taken to confirm the correct

position of the tubes. Often CRH, the hormone that

causes the pituitary to release ACTH, is given duringthis test to improve diagnostic accuracy.



PREVENTING COMPLICATIONS

Skin Breakdowns

1. Assess client·s skin.

2. Instruct client to avoid activities that can result

in skin trauma.3. Reduce tissue injury.




4. Excessive dryness can be prevented by moisturizinglotion.

Pathologic Fractures. Hypercortisolism causes bone

density loss and osteoporosis.

1.

Teach client about safety issues and dietary needs.2. The client is at risk for fractures as a result of minor

falls or bumps.




Gastrointestinal Bleeding. Interventions aim toreduce gastric irritation, usually through drug

therapy. Drug therapy involves agents that protect the

GI mucosa and those that decrease the secretion of

HCL.



COMMON NURSING DIAGNOSES &

COLLABORATIVE PROBLEMS

Disturbed Body Image r/t illness

Fatigue r/t sleep deprivation

Excess fluid volume r/t excess water and sodiumreabsorption

Risk for infection r/t immunosuppresion and inadequateprimary defenses

Risk for Injury r/t poor wound healing and bone densityloss

Deficient K nowledge (Illness and treatment) r/t lack of

interest in learning and unfamiliarity with informationresources

Imbalanced nutrition: More than body requirements r/texcess intake in relation to metabolic need as a result of appetite stimulation by cortisol



MNEMONIC

C - Central obesity, Cervical fat pads, Collagen

fibre weakness, Comedones (acne)

U - Urinary free cortisol and glucose increase

S - Striae, Suppressed immunityH - Hypercortisolism, Hypertension,

Hyperglycaemia, Hirsutism

I - Iatrogenic (Increased administration of

corticosteroids)N - Noniatrogenic (Neoplasms)

G - Glucose intolerance, Growth retardation

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