Topic: Cushing’s Syndrome
These conditions
Members:
Biazon, Samira
Bugahod, Jorge David
Casanova, Jerome
Dataya, Sittie Maiameen
Definition
Cushing syndrome was named after a famous
neurosurgeon, Harvey Cushing.
He was the first exclusive neurosurgeon and the first
person to describe Cushing's disease. In 1912 he
discovered an endocrinological syndrome caused by
a malfunction of the pituitary gland.
According to him, Cushing’s syndrome is an
endocrine disorder with elevated cortisol levels in the
blood.
Cushing's syndrome occurs when your body
makes too much of the hormone cortisol over a long
period of time
Causes
Exogenous
• Exogenous Cushing syndrome is due to
people taking cortisol-like medications such
as prednisone. These drugs are used to treat
inflammatory disorders such as asthma and
rheumatoid arthritis. They also suppress the
immune system after an organ transplant.
Endogenous
• Endogenous Cushing syndrome usually
comes on slowly and can be difficult to
diagnose. This type of Cushing syndrome is
most often caused by hormone-secreting
tumors of the adrenal glands or the pituitary.
In the adrenal glands, the tumor (usually non-
cancerous) produces too much cortisol. Most
tumors that produce ACTH originate in the
pituitary gland but sometimes non-pituitary
tumors, usually in the lungs, can also produce
too much ACTH and cause ectopic Cushing
syndrome.
Risk Factors
• Taking high-dose corticosteroids over a long
period of time
o Some people develop Cushing’s
syndrome symptoms when they take
high levels of oral corticosteroid
medication to treat inflammatory
conditions such as asthma, lupus or
rheumatoid arthritis.
• Genetics
o People with family histories of
certain genetic disorders may face a
higher risk
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pituitary tumors.
are caused by genetic changes passed
down from parents.
• Type-2 diabetes that is not properly
managed
o GC excess is associated with an
increased glucose production, due to
the stimulation of gluconeogenesis
and development of insulin
resistance mainly in the liver and in
the skeletal muscle, which reduces
glycogen synthesis and glucose
uptake.
• High blood pressure (Hypertension)
o Elevated blood pressure seen in
Cushing's syndrome is a
consequence of adrenocorticotrophic
hormone (ACTH) stimulated
increases in cortisol secretion.
• Obesity
o Patients with abdominal obesity have
elevated cortisol levels. Furthermore,
stress and glucocorticoids act to
control both food intake and energy
expenditure. In particular,
glucocorticoids are known to
increase the consumption of foods
enriched in fat and sugar.
Assessment
When Cushing Syndrome is suspected, initial
laboratory testing is usually directed at confirming
excessive glucocorticoid production. What are the
signs and symptoms of excess glucocorticoid
(cortisol) secretion?\
• Weight gain or obesity. - Sometimes
obesity, chronic illness/alcoholism and
depression can cause false-positive results
which they named it as Pseudo Cushing
Syndrome.
• Heavy trunk; thin extremities.
• Fat pad (Buffalo Hump) in neck and
supraclavicular area. High levels of the
hormone cortisol can lead to increased fat
synthesis. With Cushing syndrome, the fat
produced often deposits in the neck, known
as lipodystrophy which now produces
Buffalo Hump.
• Rounded face (moon face); plethoric, oily
complexion. This can result from taking oral
corticosteroid medication. Or your body
might produce too much cortisol. Too much
cortisol can cause some of the hallmark
signs of Cushing syndrome. That's why
people sometimes refer to it as a Cushingoid
appearance.
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 • Skin – fragile and thin; striae and
ecchymosis, acne.
• Musculoskeletal – muscle wasting caused
by excessive catabolism, osteoporosis,
characteristic kyphosis, back ache.
• Mental disturbances – mood changes,
psychosis.
• Increased susceptibility to infections.
Manifestations of excess mineralocorticoid
(aldosterone) secretion:
• Hypertension
• Hypernatremia, hypokalemia
• Weight gain
• Expanded blood volume
• Edema
Manifestations of excess androgens
• Females experience virilism
(masculinization) with hirsutism (excessive
growth of hair on the face and midline of
trunk); atrophied breast, enlarged clitoris,
masculinized voice, loss of libido,
hermaphroditism (if exposed in utero).
• Males – loss of libido.
Pathophysiology
When stimulated by ACTH, the adrenal
gland secretes cortisol and other steroid hormones.
ACTH is produced by the pituitary gland and
released into the petrosal venous sinuses in response
to stimulation by corticotropin-releasing hormone
(CRH) from the hypothalamus. ACTH is released in
a diurnal pattern that is independent of circulating
cortisol levels: peak release occurs just before
awakening, and ACTH levels then decline
throughout the day. Control of CRH and ACTH
release is maintained through negative feedback by
cortisol
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Neuronal input at the hypothalamic level can also
stimulate CRH release.
Although the adenomas of Cushing's disease
secrete excessive amounts of ACTH, they generally
retain some negative feedback responsiveness to
high doses of glucocorticoids. Ectopic sources of
ACTH, usually in the form of extracranial
neoplasms, are generally not responsive to negative
feedback with high doses of glucocorticoids.
However, some overlap exists in the response to
negative feedback between pituitary and ectopic
sources of excessive ACTH.
Signs and Symptoms
• Signs and symptoms of Cushing’s syndrome
vary but most people with the disorder have
upper body obesity, a rounded face,
increased fat around the neck, and relatively
slender arms and legs.
• Children tend to be obese with slowed
growth rates.
• Other signs appear in the skin, which
becomes fragile and thin, bruises easily, and
heals poorly. Purple or pink stretch marks
may appear on the abdomen, thighs,
buttocks, arms, and breasts.
• The bones are weakened, and routine
activities such as bending, lifting, or rising
from a chair may lead to backaches and rib
or spinal column fractures.
• Women with Cushing’s syndrome usually
have excess hair growth on their face, neck,
chest, abdomen, and thighs. Their menstrual
periods may become irregular or stop.
• Men may have decreased fertility with
diminished or absent desire for sex and,
sometimes, erectile dysfunction.
• Other common signs and symptoms include:
o severe fatigue;
o weak muscles;
o high blood pressure;
o high blood glucose;
o increased thirst and urination;
o irritability, anxiety, or depression;
and
o fatty hump between the shoulders
Diagnostic Tests
- First, diagnosis should be based on a review
of the patient’s medical history, 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.
- 3 most common tests:
o 24-hour urinary free cortisol test
o Measurement of midnight plasma
cortisol or late-night salivary
cortisol; and
o Low-dose dexamethasone
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suppression test
 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.
Midnight plasma cortisol or late-night salivary
cortisol measurements
- 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. The test generally requires a 48-
hour hospital stay to avoid falsely elevated
cortisol levels due to stress.
Low-dose dexamethasone suppression test
(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 one-
time overnight dose. 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.
Radiologic imaging: direct visualization of the
endocrine glands
- Imaging tests reveal the size and shape of
the pituitary and adrenal glands and help
determine if a tumor is present. The most
common imaging tests are the computerized
tomography (CT) scan and magnetic
resonance imaging (MRI).
Petrosal sinus sampling
- This test is not always required, 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 sinuses—veins that drain the
pituitary––by inserting 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 during this test to improve
diagnostic accuracy.
Medical/Surgical Management
• Radiation of the pituitary gland is
successful but takes several months for
symptom
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• Adrenal enzyme inhibitors ( E.g.
metyrapone or mitotane) maybe used with
ectopic ACTH- secreting tumors that cannot
be totally removed; monitor closely for
inadequate adrenal function and side effects
• Temporary replacement therapy with
hydrocortisone may be necessary until the
adrenal glands begin to respond normally (
maybe several months).
• Transsphenoidal hypophysectomy.
Surgical removal of the tumor by
transsphenoidal hypophysectomy is the
treatment of choice if Cushing’s syndrome is
caused by pituitary tumors and has an 80%
success rate.
• Adrenalectomy. is the treatment of choice
in patients with primary adrenal
hypertrophy.
Nursing Diagnosis
Primary Nursing Diagnosis
• Excess fluid volume- may be related to
retention of water and sodium caused by an
excess of cortisol and mineralocorticoid
levels.
Other Nursing Diagnosis
• Risk for infection- possible evidenced by
associated conditions of suppressed
inflammatory response (skin and capillary
fragility, and negative nitrogen balance)
• Self-Care Deficit- may be related to muscle
wasting, generalized weakness, fatigue, and
demineralization of bones, possibly
evidenced by statements of or observed
inability to complete or perform ADLs
• Disturbed Body Image- may be related to
alteration in self-perception (e.g., change in
structure or appearance [effects of disease
process, drug therapy]) possibly evidenced
by negative feelings about body, feelings, or
helplessness, and changes in social
involvement
• Risk for physical trauma- possibly
evidenced by risk factors of impaired
balance and associated conditions of
decrease in muscle coordination and
[increased protein breakdown and
demineralization of bones]
• Sexual Dysfunction- may be related to
associated condition or altered body function
(loss of libido, impotence, and cessation of
menses), possibly evidenced by
verbalization underside change in sexual
function or desire
Nursing Interventions
• Assess vitals
• Assess heart and lung status- hypertension
and fluid overload are common
• Perform
12 lead ECG
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 • Assess neuro vitals- there might be tumor in ment%20data,wasting%2C%20and%20altered%20s
the brain leep%20patterns.
• Check electrolytes- low potassium and high
sodium are common https://www.aafp.org/afp/2000/0901/p1119.html
• Weight patient- weight gain is common
• Check-ins and outs- fluid retention is https://www.betterhealth.vic.gov.au/health/conditio
common nsandtreatments/Hormones-cortisol-and-
• Manage blood glucose levels, which are corticosteroids
usually high
• Encourage bed rest
• Monitor for signs of infection
• Check skin integrity
• Administer antihypertensive drugs as
ordered
• Administer diuretics as prescribed- fluid
retention is common
• If the patient is to undergo surgery, keep the
patient NPO
• Educate patient about the disease
• Encourage hand washing
• Encourage follow up with a clinician

Patient Education
Prevention
- You always need cortisol in your body. You
need it to function. It manages your
respiration, turns your food into energy,
regulates your blood sugar, helps you cope
with stress and more. Cortisol is not your
body’s enemy, but too much of it can be.
Have your healthcare provider monitor your
cortisol levels closely if you’re on
glucocorticoids or steroids. Unfortunately,
there’s no way to prevent a tumor that
causes Cushing’s syndrome.
- Healthy diet (high protein and calcium to
prevent muscle and bone loss caused by high
cortisol levels)
- Proper time and taking of medications
- Avoid foods that can lead to high blood
glucose and high blood glucose (too much
sodium)

References
https://www.netmeds.com/health-
library/post/cushing-syndrome-causes-symptoms-
and-treatment

https://www.ncbi.nlm.nih.gov/books/NBK568708/

https://www.rnpedia.com/nursing-notes/medical-
surgical-nursing-notes/cushings-syndrome/

Cushings_Syndrome_508.pdf

https://my.clevelandclinic.org/health/diseases/5497-
cushings-syndrome

https://nurseslabs.com/cushings-
syndrome/#:~:text=Based%20on%20the%20assess
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