Nursing Care of Patient with Cushing

Syndrome and Pheochromocytoma

• https://youtu.be/w_I-8aKaq68

• https://www.youtube.com/watch?v=1NPHpwe_VSA

• https://youtu.be/CjBD0IiRqEE Addison disease

 Objectives

At the end of the teaching session students should be able to:

• Give an overview of the adrenal gland
• Identify the types of adrenal gland disorders
• Define Cushing Syndrome
• Identify the causes of Cushing Syndrome
• State the signs and Symptoms of Cushing Syndrome
 Objectives

• Identify diagnostic Evaluations of Cushing Syndrome.

• Describe the nursing management of Cushing Syndrome
using the nursing process
• Define Pheochromocytoma
• Identify diagnostic Evaluations of Pheochromocytoma
• Describe the nursing management of Pheochromocytoma
Overview
 Overview of the Adrenal Glands
• Paired pyramid-shaped organs, situated close to the upper part of
the kidney.

• Each adrenal gland consists medulla and cortex.

• The adrenal cortex—produces hormones such as cortisol (the main

secreting product, which is needed to maintain life and protect the
body from stress); and aldosterone (which conserves sodium)
(Heuther & McCance, 2013)
Types of Adrenal Gland Disorder

• Cushing syndrome

• Addison disease

• Pheochromacytoma

(Heuther & McCance, 2013).

 Definition

• Cushing Syndrome is a condition resulting from hypersecretion of

cortisol from the adrenal cortex.

Heuther & McCance, 2013).

 Causes of Cushing Syndrome
Most common cause:
• Exogenous administration of cortisone (Prednisone, dexamethasone).

Other Causes:
• Cushing disease (excessive production of cortisol)resulting from
increased secretion of the adrenocorticotrophic hormone by the
pituitary gland.

• Tumor
(Heuther &McCance, 2013)
 Signs and Symptoms of Cushing
Syndrome

• Weight gain: adipose tissue in the trunk (truncal obesity), facial

(moon face) and cervical areas (buffalo hump).
• Muscle wasting
• Osteoporosis
• Brownish hyper pigmentation of the skin, mucous membranes
and hair
• Reddish purple striae on abdomen and upper thighs and
breasts.
(Heuther &McCance, 2013)
 Signs and Symptoms of Cushing
Syndrome Cont’d

• Thin skin with easy bruising and face ruddy.

• Women: Masculine characteristics and periods that become
irregular or stop.
• Men: may have decreased or no desire for sex.
• Mental changes such as depression, anxiety, or changes in
behavior.

(Heuther &McCance, 2013)

Signs and Symptoms of Cushing
Syndrome Cont’d

• Signs and symptoms of diabetes mellitus resulting from

lowered carbohydrate tolerance.

• Increase susceptibility to wound and prolonged healing.

(Heuther &McCance, 2013)

 Diagnostic Evaluation

• History and physical examination

• Mental Status Examination
• Plasma cortisol levels for diurnal variations
• Plasma ACTH levels
• Complete blood count with WBC differentials.
• Blood Chemistry for potassium, sodium and glucose.
(Dirksen & Bucher,2014)
 Diagnostic Evaluation
• Dexamethasone suppression test ( if levels are low

• 24 hour urine for free cortisol (normal levels 80-120mcg/24 hr. Higher
urine cortisol levels are indicative of Cushing syndrome).

• CT Scan, MRI (adrenal and pituitary gland may be done).

• Luecocytosis, hyperglycemia, osteoporosis (associated, but not diagnostic)

(Dirksen & Bucher,2014)
 Scenario

• A 28 year old lawyer was admitted with a history of, weight

gain, easy bruising, and edema to his lower legs, weakness
and insomnia. On examination skin thin/fragile and purplish
straie observed to breasts. Moon face, truncal obesity and 2+
edema observed to feet. Blood pressure 148/100 mmHg.
Laboratory results: elevated blood glucose and white blood
cell count.
 Assessment
• Signs and symptoms

• Laboratory findings

• Note changes in patients response to these changes

• Assess mental function (mood, response to question,

depression and awareness of environment).
 Nursing Diagnoses
• Risk for injury related to weakness.

• Risk for infection related to fragile skin.

• Self-care deficit (bathing/hygiene) related to weakness and altered

sleep patterns.

• Impaired skin integrity related to edema and thin fragile skin.

(Hinkle &Cheever, 2014)
 Nursing Diagnoses Cont’d

• Disturbed body image related to altered appearance and

decreased activity level.

• Ineffective coping related to mood swings, irritability, and

depression.

(Hinkle &Cheever, 2014)

 Goals

• Decreased risk for injury

• Decreased risk for infection
• Increased ability to carry out self care activities
• Improved skin integrity
• Improved body image
• Improved mental function
Nurs i ng
 Implementation
Intervention Rationale
• Monitor vital signs particularly Hypertension is frequent in cushing
blood pressure syndrome as cortisol stimulates
renal reabsorption of sodium

• Strictly monitor input and output

and weight
(Hinkle & Cheever, 2014). (Singh, Kotwal & Menon,2011).
 Implementation Cont’d
Intervention Rationale
• Monitor lab values (blood • There can be hyperglycemia that can
lead to diabetes
glucose, white blood cell count.

• Allow patient to discuss feelings

related to body appearance.

(Singh, Kotwal & Menon,2011).

(Hinkle & Cheever, 2014).
Decreased risk for
injury

Intervention
• Provide protective
environment
• Assess patient level of
activity and ability.
• Assist patient who is weak
in ambulating
(Hinkle & Cheever, 2014).
Rationale
• To prevent fall, fractures and other
injuries to bones and soft tissue.
• To carry out routine and self care
activities.
• To avoid falling or bumping into
furniture.
(Hinkle & Cheever, 2014).
Decreased risk for
infection
Intervention Rationale
As immune system is compromised
• Avoid unnecessary
exposure to others with
• Corticosteroid masks signs of inflammation and
infection
infection
• Assess frequently for
subtle signs of infection
• Provide good skin care: • To decrease the risk for infection
Observe skin for trauma,
infection, breakdown,
bruising and edema.
• (Hinkle & Cheever, 2014). (Hinkle & Cheever, 2014).
Encourage rest
and activity
Intervention Rationale
• Encourage moderate • To prevent complications of immobility
activity and promote self –esteem.
• Plan rest periods • To facilitate rest and sleep.
throughout the day and
promote relaxing, quiet
environment for rest and
sleep.
(Hinkle & Cheever, 2014) (Hinkle & Cheever, 2014)
 Implementation Cont’d
• Administer chemotherapeutic agents as prescribed for inoperable
adrenal tumors.

• Prepare client for radiotherapy as prescribed if condition results from

pituitary tumor.

• Prepare client for surgery if condition results from increased pituitary

secretion of ACTH.

(Silvestri, 2005).
 Pheochromocytoma
• Rare tumor of adrenal medulla.

• Results in the release of excess epinephrine and norepinephrine

(control heart rate metabolism, and blood pressure).

• Very few of these tumors are cancerous (10%).

(Silvestri, 2005)
 Diagnostic Test

• Urinary vanillylmandelic acid (VMA).

• Normal value :< 6.8 mg in 24 hour

• VMA values increase with pheochromocytoma.

(Silvestri, 2005)
 Brief Nursing Management

• Monitor vital signs especially blood pressure.

• Administer antihypertensive.

(Silvestri, 2005)
 Any
Questions
 References
• Dirksen, L., & Bucher, H. (2014).Medical surgical nursing:Assessment and
management of clinical problems (9th ed.). Canad:.Mosby. Retreved from
https://books.google.com.jm/books?id=owEyAgAAQBAJ&pg=PA1209&dq=n
ursing+management+of+cushing+syndrome&hl=en&sa=X&redir_esc=y#v=o
nepage&q=nursing%20management%20of%20cushing%20syndrome&f=false
• Heuther, S. E., & McCance, K. L. (2013). Understanding Pathophysiology. (5th ed.).United
States. Elsevier
• Hinkle, J. L., & Cheever, K. H. (2014). Brunner & suddarth's textbook of medical-surgical
nursing. (13th ed.). China: Lippincott Williams & Wilkins. Retrieved from
https://books.google.com.jm/books?id=gE-
eAgAAQBAJ&pg=PA254&dq=nursing+management+of+cushing+syndrome&
hl=en&sa=X&redir_esc=y#v=onepage&q=nursing%20management%20of%20cushing
%20syndrome&f=false
 References Cont’d
• National Institute of Health (2013). Adrenal Gland Disorders:
Condition Information. Retrieved from
https://www.nichd.nih.gov/health/topics/adrenalgland/conditio
ninfo/Pages/default.aspx
• Silvestri, L. A. (2005). Saunders: Comprehensive review for the NCLEX-
RN examination. (3rd ed.).St, Louis: Missouri. Elsevier
• Singh, Y., Kotwal, N., & Menon, A. S. (2011). Endocrine hypertension–
Cushing's syndrome. Indian journal of endocrinology and
metabolism,15(Suppl4), S313.