Cushing's Syndrome

med surg, medical surgical, endocrine

Video Transcript 

Hey friends in today's video, we're going to talk about Cushing syndrome. And if you like this video, make sure to give it a thumbs up and subscribe to my channel. I come out with new videos every week for nurses, nursing students, and pre-nursing students to support you on your nursing journey. Also make sure to check out all the free resources I have down below as well as the NCLEX study guide and pharmacology study guide.

Let's get into it. So Cushing syndrome is a cluster of clinical abnormalities caused by excessive levels of adrenocortical hormones or related corticosteroids, and sometimes androgens or aldosterone. The prognosis depends on the underlying cause, but is typically poor in untreated people or in those with untreatable, ectopic, corticotropin, producing carcinomas.

So the causes include in 70% of patients in excess production of corticotropin and consequence hyperplasia of the adrenal cortex. And then in 30% of patients that usually comes from a tumor that is a quarter goes. That is a cortisol secreted, adrenal tumor, which is usually benign. So if you know me and you've seen my videos, you know, that I love these charts.

So this goes over the pathophysiology of Cushing syndrome. Another name from it is also hyper quarter go Selenia. I like Cushing syndrome. It's easier to say. So this nice little chart gives us the pathophysiology in blue. The mechanisms in purple are signs, symptoms, lab findings in green, and our complications in.

So as we can see, cortisol is a net catabolic hormone, affecting many body systems serving to release energy into the blood in response to stress, excessive cortisol can impact circulation and impair immune function. So cortisol in our body can affect the kidneys and vasculature the liver and peripheral tissues, reproductive systems, adipose tissues, skin, and connective tissue, muscle immune system, and bone and calcium metabolism. And the purple. I'm not going to read through all of these, cause there's just a lot or all the mechanisms of how it affects those different systems. You really don't need to memorize all of this, but it would be important to memorize the green and red. So we're going to just talk about those. So you're going to see some hyperglycemia super ventricular and dorsal fat pads, central obesity around moon face.

Easy bruising. Hypertension, hypokalemia, arrhythmias, paralysis, cramps, proximal, muscle weakness, and, see acne hirsutism. It's pretty much excessive hair on your face and body. In different complications, you're going to see with these patients in fertility, decreased libido, irregular menses, cardiomyopathy, heart failures, poor wound healing, susceptible to infection and osteoporosis.

So clinical manifestations that we're going to see in these patients include muscle weakness due to hyperkalemia or loss of muscle mass from increased catabolism you may also see a Buffalo hump. It's one of these symptoms in the Cushing's triad, and these are fat pads on the upper back. You'll also see a moon face, which is also included in Cushing's triad and recognized as fat over the face.

And you'll see truncal obesity. So these are fat pads throughout the trunk and this is the third part of Cushing's triad. You can also see peptic ulcers resulting from increased gastric production and pepsin, secretion, and decreased gastric mucus. You can see irritability and emotionally labile to euphoric behaviors, you can see depression and even psychosis.

You can see some hypertension due to sodium and water retention, and you'll see a compromised immune system which will increase their susceptibility to infection. And this is due to decrease lymphocyte production and suppressed antibody formation. All right. Continuing on with the clinical manifestation, there is a certain look to Cushing's to be aware of.

So this middle one kind of shows the body shape. They typically, and even on the right, they typically have thinner legs, but there's a lot of fat around the center of the body the moon and the back of the upper back, which is where you'll see that Buffalo hump. So yes, that is sort of what they look like.

And you can see on the left the woman's side profile, you can sort of see the Buffalo hump on the back there as well as the moon face. So complications that can occur. So one is addisonian crisis. So patients with Cushing syndrome whose symptoms are treated by withdrawal of corticosteroids by adrenalectomy, or by removal of a pituitary tumor are at risk for adrenal hypofunction and Addisonian crisis So Addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium. And these situations need immediate medical care. There's also adverse effects of adrenalcortico activities. So the nurse can assess fluid and electrolyte status by monitoring laboratory values and daily weights.

So assessment and diagnostic findings. So we can look at a low dose dexamethazone suppression test. So this is when. Dexamethazone one milligram is administered orally at 11:00 PM and the plasma cortisol level is obtained at 8:00 AM the next morning. And this usually confirms the diagnosis of Cushing syndrome.

There's also a stimulation test and in a stimulation test, they administer metyrapone which blocks cortisol productions by the adrenal glands test the ability of the pituitary gland and hypothalamus to detect incorrect or low levels of plasma cortisol by increasing corticotropin production. There's also imaging studies such as an ultrasound, CT scan, or an angiogram, which localizes adrenal tumors, and may identify pituitary tumors.

We can look at electrolyte levels before. Patients with Cushing syndrome usually have an increase in serum sodium and a decrease in potassium level. We can look at blood studies, so, Cushings can be indicated if there's an increase in blood glucose level or reduced a number of eosinophils and disappearance of lymphoid tissue.

So medical management of Cushings includes pituitary irradiation. Patients with pituitary dependent Cushing syndrome with adrenal hyperplasia and severe Cushing syndrome symptoms such as psychosis, poorly controlled diabetes, osteoporosis and severe pathological fractures may require pituitary irradiation.

Radiation therapy uses high energy x-rays or particle rays to kill tumor cells. And this type of treatment is given by a doctor called a radiation oncologist, and they pretty much direct the radiation in the direction of the tumor from outside of the body so if we just go back to this real quick, you can see the pituitary gland is very small in like the center of the brain, kind of the front center of the brain to kind of lower, lower front center of the brain.

Pharmacologic therapy includes adrenal enzyme inhibitors. So again, we talked about this earlier, but the metyrapone and aminoglutethimide and ketoconazole may be used to reduced hyperadrenalism. If the syndrome is caused by ectopic act H secretions by a tumor that can not be eradicated or they can use cortisol therapy, which is essential during and after surgery to help the patient tolerate the physiological stress imposed by the removal of the pituitary or adrenals.

So surgical management. So we can have a. transsphenoidal hypophysectomy, this is a surgical remover of the tumor by a transsphenoidal hypophysectomy. And it's the treatment of choice for Cushing syndrome that is caused by pituitary tumors and has an 80% success rate.

There is also. Adrenalectomy which is the treatment of choice for patients with adrenal hypertrophy. So let's look at these a little bit more. So this is the transsphenoidal hypophysectomy this is the pituitary gland is taking out. The brain by going through the nose via the Synthroid sinus, which is a cavity near the back of the nose.

This is often done with assistance of either a surgical microscope or an endoscopic camera. And then an adrenal ectomy is the surgical removal of one or both adrenal glands. And it's usually advised for patients with tumors of adrenal. The procedure can be performed using an open incision or a laparoscopic technique.

So our nursing assessment can include things like a health history, which includes information about the patient's level of activity and ability to carry out routine and self care activities. Also a physical exam, or we're looking at the skin. Assessing it for trauma infection, breakdown, bruising, and edema.

We want to look at mental function, including mood, their responses, to questions, awareness of environment and level of depression. Our nursing diagnoses could include things like risk for injury related to weakness, risk for infection related to altered protein metabolism and inflammatory process. Self care deficiency related to weakness, fatigue, muscle wasting, and altered sleep patterns, impaired skin integrity related to edema impaired healing and thin and fragile skin disturbed body image related to altered physical experience impaired sexual functioning and decreased activity level disturbed thought processes related to mood swings, irritability and depression.

Our nursing care planning goals can include things like a decreased risk of injury. Decreased risk of infection, increased ability to carry out self-care activities, improve skin, integrity, improve body image, improve mental function. Okay. So let's look at the nursing interventions for a patient with Cushing's.

There is quite a few. So first we want to look at decreasing the risk of injuries. So to do this, we want to provide a protective environment to prevent falls, fractures and other injuries to bones and soft tissue. We want to assist patients who are weak and ambulating and prevent falls. We want to recommend foods high in protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis.

We can also use an interdisciplinary approach by having a dietician for assistance. We want to decrease risks of infection. So to do this, we're going to avoid people with infections and we're going to assess frequently for signs of infection.

We also want to keep in mind that if a patient is taking corticosteroids, they will mask the signs of inflammation or infection. So we will not see those in these patients. If a patient is going to surgery, we want to prepare them for surgery. We're going to monitor blood glucose levels and assess stools for blood because diabetes and peptic ulcers are common problems.

We want to encourage rest inactivities activities. So we'll encourage moderate activity to prevent complications of immobility and promote self-esteem. But we also want to plan rest periods throughout the day and promote a relaxing, quiet environment for rest and sleep. We want to promote skin integrity.

So we're going to use meticulous skincare to avoid traumatizing, fragile skin. We're going to avoid adhesive tape, which can tear and irritate the skin. We're going to assess skin and bony prominences frequently, and we're going to encourage and assist patients to change positions frequently.

We want to work on improving body image so we can discuss the impact that change has had on the patient's self concept and relationship with others. We can look at weight gain and edema, which may be modified by a low carb, low sodium high protein intake, which can reduce some of their symptoms.

We want to improve that process. So explain the patient and the family, the cause of the emotional instability and help them cope with mood swings, irritability, and depression. We want to report any psychotic behaviors. We want to encourage the patient and family to verbalize feelings and concerns. We also want to monitor and manage complications.

We want to manage adrenal hypofunction and Addison crises. We want to monitor for hypotension rapid weak pulse, rapid respiratory rate, pallor and extreme fatigue and extreme weakness. And we want to note any factors that may lead to a crisis. So stress trauma surgery want to administer IV fluids and electrolytes and corticosteroids before, during and after surgery as indicated we want to monitor for circulatory collapse and shock present in Addisonian crisis. And we want to treat promptly assess fluid and electrolyte status by monitoring lab values and daily weights. We want to monitor blood glucose levels and report elevations to the physician and for acute adrenal crisis, it's a life-threatening condition that occurs when there's not enough cortisol.

Which is a hormone produced by the adrenal glands. So we also want to teach patients self care. So we want to stress the importance of wearing a medical alert, bracelet, and notifying other health professionals that they have Cushing syndrome want to refer home care as indicated to ensure a safe environment with minimal stress and risk for falls and other side effects.

When to emphasize the importance of regular medical, follow-up ensuring that the patient is aware of. The side-effects and toxic effects medications. We want to present information about Cushing syndrome verbally and in writing to the patient and family. If indicated stress to the patient and the family that stopping corticosteroid use abruptly and without medical supervision can result in adrenal insufficiency and reappearance of symptoms.

We want to emphasize the need for an adequate supply of corticosteroids to prevent running out or skipping a dose because this could result in an Addisonian crisis. When a stress, the need for dietary modifications to ensure adequate calcium intake without increased risk for hypertension, hyperglycemia, and weight gain.

We want to teach the patient and family to monitor blood pressure, blood glucose levels, and weights. So depending on our patient outcomes these are just some evaluations that we may have. So. Decrease risk for injury, decrease risk for infection, increase ability to carry out self care activities, improve skin integrity, improve body function, and improve mental function.

So our discharge in home care planning should include. Instructing the patient not to stop the corticosteroid abruptly and without medical supervision, because then the syndrome could reoccur the patient should always have an adequate supply of corticosteroid medications and avoid running out. The nurse should stress the need for diet modifications to include adequate calcium intake without increasing the risk for hypertension hyperglycemia in weight gain.

Adequate monitoring. So the patient and families should be taught to monitor blood pressure, blood glucose, and weight and follow up appointments. And regular medical care should be planned. And they should wear a medical alert bracelet that identified they have Cushing's disease and documentation guidelines should include attainment of progress towards desired outcomes, modifications to the plan of care, client and caregiver, understanding of individual risks and safety concerns, availability, and use of resources.

Recent or current antibiotic therapy, signs and symptoms of infection, functional level and specific limitations. Needed resources and adaptive devices, plan of care. And who's involved teaching plan, individual responses to intervention, teaching and actions performed and specific actions and changes made.

So if you guys liked this video and found it helpful, if you did make sure to give it a thumbs up and subscribe down below, also check out all those free resources and NCLEX and pharmacology study guides, and I'll see you next time. Bye.