OUR LADY OF FATIMA UNIVERSITY-QUEZON CITY

Cushing's
Disease
A Case Presentation of BSN 3YB-7
Core Concepts
CONCEPT MAP
ANATOMY & PHYSIOLOGY
PATHOPHYSIOLOGY
DIAGNOSTIC AND LABORATORY
TREATMENT & MANAGEMENT
DRUG STUDY
NURSING CARE PLAN
DISCHARGE PLANNING

Cushing's Disease
 Patient Profile

Name: Cushen Moh Age: 35 years old Sex: Female

Civil Status: Married Nationality: Filipino
Date of Admission: 8:45 AM Attending Physician: Dr. Cushine Koh

Chief Complaint: Skin is thin, fragile, and easily bruise/ traumatized. Her menstrual
cycle is irregular with muscle weakness, and with a moon-faced appearance upon
looking to a mirror. With acne, and excess hair growth.

History of Present Illness:

One week before admission to Emergency Room, the client complained of the
following: her skin in the extremities becomes thin, fragile, and easily bruised, her
menstrual period is irregular with muscle weakness, facial hair is seen associated with

CASE acne. About 6 months later, she mentioned that her face change into a moon-faced
appearance with a buffalo hump, and back pain is felt sometimes with muscle
weakness.

SCENARIO
 Physical Examination
(+) Polycystic ovarian syndrome by a gynecologist after 6 multiple pregnancies
(+) Diabetes Mellitus, obese
(+) Short-term memory and mood changes (+) Excess hair growth
(+) Sleep disturbances (+) Amenorrhea
(+) Thin skin & stretch marks; easily bruised (+) Violaceous striae

Admission Order:
V/S q 4 hours
IVF: D5 0.9 NSS 1L x 8 hours
Repeat imaging - (+) 7x5 mm microadenoma on the left side of the patient that

reached the medial wall

Scheduled for surgery: Transsphenoidal Resection Hypophysectomy or Bilateral

Adrenalectomy /o EENT Surgeon

Radiation of the pituitary gland

Diagnostic Tests:

CASE CBC, Serum Na, Cl, HCO3 decreased, Serum K increased

Salivary Cortisol Test - 75 mcg/dl elevated
Dexamethasone Suppression Test

SCENARIO CT Scan of the adrenals

 Therapeutics
1. Mefepristone 300 mg BID for 2 months
2. D5 0.9 NSS Fast Drip until Hypotension is controlled
3. Monitor and measure cortisol levels q6 hrs with checking of urine sp. gravity levels
(diabetes insipidus) & Na level (DI & syndrome)
4. Monitor CSF leak level after surgery
5. Monitor lab results on Day 1 to Day 3 = 1.8
6. Replaced with Hydrocortisone
7. Adrenal Enzymes Inhibitors
8. Metyrapone (Metopirone)
9. Aminoglutathiazide (Cytodren)
10. Mitotane (Lysodren)
11. Ketoconazole (Nizoral)
12. Hydrocortisone - may be given after surgery

Diet
Low carbo and Na diet

CASE Lifetime hormone replacement

SCENARIO
This case study aims to broaden the students’ knowledge regarding
Cushing’s Disease, and it is designed to develop and enhance the
skills and attitude in the application of different nursing processes
and management of the patient with Cushing’s Disease
To be able to acquire knowledge regarding Cushing’s Disease, its
background and epidemiology through research.
To trace the pathophysiology of Cushing’s Disease.
To render the necessary nursing care and responsibilities to a
client with Cushing’s Disease OBJECTIVE
To correlate the results of the diagnostic procedures to its
normal values.
/PURPOSE
To formulate and present drug studies of medications given to OF THE
the client as a part of treatment regimen.
To develop an effective nursing care plan and provide health STUDY
teaching about Cushing’s Disease in which the client may benefit
Cushing's disease is a type of Cushing's
syndrome. Cushing's disease is caused by a
benign tumor located in the pituitary gland that
secretes too much ACTH (adrenocorticotropic
hormone), which in turn increases cortisol.
BACKGRO
UND OF
Cushing's disease results from excessive, rather
than deficient, adrenocorticortical activity.
THE
STUDY
Prevalence of Cushing’s Syndrome worldwide
An estimated 10-15 per million people are
affected every year.
Pituitary adenomas (Cushing’s disease)
account for more than 70 percent of cases
in adults and about 60-70 percent of cases BACKGRO
in children and adolescents.
Cushing’s syndrome most commonly affects UND OF
adults ages 20-50 and is more prevalent in THE
females, accounting for about 70 percent of
all cases.
STUDY
Prevalence of Cushing’s Syndrome in the
Philippines
The Philippines. Background and
significance: Endogenous Cushing's
syndrome is a rare disease entity BACKGRO
approximately 13 cases per million UND OF
population.
THE
STUDY
Prognosis of Cushing Disease/Syndrome
Mild (subclinical) Cushing’s syndrome may
be detected in patients with incidentally
discovered adrenal adenomas on abdominal
CT scan performed for other reasons.
Untreated Cushing’s disease (CD) is BACKGRO
associated with a very poor prognosis, UND OF
estimated 5 years’ survival of 50%, though
this is dramatically improved to 86% after THE
bilateral adrenalectomy. STUDY
Pituitary adenoma (Cushing's disease)

ETIOLOGY
Cushing's syndrome is caused by:
Use of corticosteroid medication
Tumor in of the pituitary gland
Primary hyperplasia of the adrenal glands in
the absence of a pituitary tumor.
Ectopic production of ACTH by
malignancies

ETIOLOGY
Risk factor:
Modifiable
Obesity
Prolonged use of corticosteroid
Non-modifiable
Female
35 years old

ETIOLOGY
 RISK FACTORS:
- Female Gender
- Administration of exogenous
steroids
- Pulmonary problem
- Neurological diseases
- Nephrotic Diseases

ETIOLOGY
 SIGNS AND SYMPTOMS:
- ruddy complexion
- increased facial or body hair in women
- obesity
- rounded face
- fatigue, muscle weakness, backache
- headache
- polyuria
- depression, emotional lability, cognitive
impairment, anxiety
- easy bruising, menstrual irregularities, and
skeletal growth retardation in children. ETIOLOGY
Cushing's Disease Complications
Metabolic syndrome (like visceral obesity, impairment of
glucose metabolism, and dyslipidemia)
Cardiovascular disorders (like systemic arterial
hypertension, cardiac and vascular damage, thrombosis
diathesis)
Immunological disorders
Musculoskeletal disorders (like myopathy, osteoporosis,
and skeletal fractures)
Neuropsychiatric disorders
Impairment of reproductive and sexual function
Dermatological manifestations (acne, hirsutism, and
alopecia)
ETIOLOGY
 Cushing's Disease

ANATOMY &
PHYSIOLOGY
 Pituitary Gland
The Pituitary Gland is referred to as the "Master

Gland" because it monitors and regulates many

bodily functions.
- Anterior Lobe
- Posterior Lobe

Medial wall
Is roughly rectangular and extends from the anterior
lacrimal crest to the orbital apex. At its anterior aspect, it
contains the lacrimal fossa which is bounded by the
anterior and posterior lacrimal crests.
 Adrenal Cortex layers

The Adrenal Cortex comprises three zones, or layers:

Zona glomerulosa (outer), Zona fasciculata and Zona
reticularis. The outermost layer, the zona
glomerulosa, is the main site for the production of
mineralocorticoids, mainly aldosterone. Zona
fasciculata is the layer situated between the
glomerulosa and reticularis.
PATHOPHYSIOLOGY
 GROUP 3
MASTRILI, BEA BIANCA
OLBIS, SOPHIA NICOLE
OTERO, KRISTINE MAE
PIDLAOAN, JAM NICOLE
CLIENT-BASED PATHOPHYSIOLOGY: CUSHING'S DISEASE
GROUP 3
 GROUP 3
MASTRILI, BEA BIANCA
OLBIS, SOPHIA NICOLE
OTERO, KRISTINE MAE
PIDLAOAN, JAM NICOLE
LAO, ONRUBIA, & PINEDA

Skin in the extremities are thin, fragile,

and easily bruised.
Menstrual period is irregular with muscle
weakness.
Decreased libido (theoretical)
Infertility (theoretical)
Facial hair (hirsutism)
Acne
Moon-faced appearance
Buffalo hump
Back pain with muscle weakness.
Short-term memory, and mood changes.
Sleep disturbances
Unable to lift her 4 years old child
(verbalized)
Violaceous striae
 Significant Findings
- Orbista, Pegarum, Laude

Thin, fragile, and easily bruised skin

Violaceous Striae
Muscle Weakness
Inability to lift her 4 year-old child
Moon-faced appearance with a "buffalo hump" upon looking in the mirror
Mental Instability
Short-term memory loss
Mood changes
Sleep disturbances
Excess hair growth
 COMPLETE BLOOD COUNT

SALIVARY CORTISOL TEST

DEXAMETHASONE SUPPRESSION
TEST

CT SCAN

LABORATORY
URINE FREE CORTISOL

ACTH LEVELS

& MRI

DIAGNOSTIC INFERIOR PETROSAL SINUS SAMPLING

 DIAGNOSTIC TEST ABNORMAL NORMAL INDICATIONS

Increased urine unbound cortisol represents the

URINE FREE CORTISOL 200 ug/24 h. 10 to 100 ug/24 h.
high level of cortisol in blood

Increased late night salivary cortisol level

SALIVARY CORTISOL TEST 75 ug/dL <7.5 ug/dL
indicating CS

LOW DEXAMETHASONE Despite the administration of dexamethasone,

15 ug/dL <1.8 ug/dL
SUPPRESSION TEST there is still an increase in cortisol levels.

Na: 95 mEq/L Na: 135 - 145 mEq/L Na: Hyponatremia.

Cl: 60 mEq/L Cl: 98 - 107 mEq/L Cl: Hypochloremia
CBC
HCO3: 17 mEq/L HCO3: 22 - 28 mEq/L HCO3: Metabolic acidosis
K: 7.5 mEq/L K: 3.5 - 5.2 mEq/L K: Hyperkalemia

Right adrenal:
0.61cm
CT SCAN OF ADRENALS
There were no abnormalities found.
Left adrenal:
0.79cm
 DIAGNOSTIC TEST ABNORMAL NORMAL INDICATIONS

Too much ACTH causes the adrenal glands to

ACTH LEVELS INCREASED ACTH 10-60 pg/mL

make too much cortisol.

When pituitary glands' corticoid cells develop a

MRI PITUITARY PITUITARY ADENOMA
tumor, ACTH will be secreted. ACTH will induce
the production of cortisol.

If the ACTH level is higher in the sinus sample,

Elevated ACTH the problem stems from the pituitary. If the
INFERIOR PETROSAL SINUS

produced ny pituitary
ACTH levels are similar between the sinuses and
SAMPLING
tumor forearm, the root of the problem lies outside of
the pituitary gland.
Medical
Surgical
Management
TRANSSPHENOIDAL The pituitary gland is taken out through your nose
via the sphenoid sinus, a cavity near the back of
RESECTION your nose. This is often done with the assistance
of either a surgical microscope or an endoscopic

HYPOPHYSECTOMY camera.

Nursing Consideration
Monitor blood glucose levels, and assess stools for
blood because diabetes mellitus and peptic ulcer are
common problems
In the early postoperative phase, assessing anterior
and posterior pituitary dysfunction is a high priority

Monitor:
Pituitary-adrenal axis
DI
SIADH
Cerebral salt waste syndrome (CSW)
BILATERAL
Bilateral adrenalectomy is an important second-line option for patients with
persistent or recurrent hypercortisolism following transsphenoidal surgery
for Cushing’s disease. The surgeon gives an incision in the waist area to

ADRENALECTOMY
insert the laparoscope. Make 2-3 small skin incisions through which the
surgeon insert the surgical instruments to remove adrenal gland

Nursing Consideration
Before, during, and after surgery, blood glucose
monitoring and assessment of stools for blood are
carried out to monitor for these complications. If
the patient has other symptoms of Cushing
syndrome, these are considered in the
preoperative preparation.
Use meticulous skincare to avoid traumatizing
fragile skin.
Avoid adhesive tape, which can tear and irritate
the skin.
Assess skin and bony prominences frequently.
Encourage and assist patients to change positions
frequently.
RADIATION OF THE PITUITARY GLAND
The usual first treatment for Cushing's disease is
the surgical removal of the pituitary adenoma. In
patients in whom surgery is unsuccessful or who
decline an operation, radiation to the pituitary
offers the possibility of remission. No form of
radiation delivery results in immediate control of
cortisol production.
Until radiation treatment becomes effective,
medical therapy to lower cortisol production is
indicated. The time to remission with radiation
therapy cannot be predicted, medical therapy
should be discontinued every 6 months to assess
response to radiation treatment; a normal 24 h
urine free cortisol being the optimal outcome
Nursing Consideration
All types of radiation delivery cause loss of normal
pituitary function and patients should be
monitored regularly (every 6 months) for the
development of new hypopituitarism and
appropriate hormone replacement(s).
The nurse assesses the patient’s mental function
including mood, responses to questions, awareness
of the environment, and level of depression.
COMPLETE BLOOD COUNT
a blood test used to evaluate your overall health and
detect a wide range of disorders, including anemia,
infection and leukemia.
Blood cell counts showed that Cushing's syndrome
patients had significantly lower lymphocytes, but a
higher total white blood cell count. They also had
increased numbers of neutrophil cells.

SERUM NA
A sodium blood test (also called a serum sodium test)
is a way for your health care provider to measure the
amount of sodium in your blood.
CHLORIDE TEST
measures the amount of chloride in your blood.
Chloride is a type of electrolyte. Electrolytes are
electrically charged minerals that help control the
amount of fluids and the balance of acids and bases in
your body.

BICARBONATE TEST
This test measures the amount of bicarbonate, a form
of carbon dioxide, in your blood.
SERUM K TEST
A potassium blood test measures the potassium levels
in your blood. Too much or too little potassium may
indicate a serious medical problem.

SALIVARY CORTISOL TEST

A saliva cortisol test is done to measure the level of
cortisol, a hormone in saliva. Cortisol is made by the
adrenal gland, located on top of each kidney. Cortisol
has many functions. It helps the body use sugar
(glucose) and fat for energy (metabolism).

Late-night salivary cortisol is one of the most

sensitive diagnostic tests for Cushing's syndrome.
Elevated cortisol between 11:00 p.m. and midnight
appears to be the earliest detectable abnormality in
many patients with this disorder.
DEXAMETHASONE SUPPRESSION TEST
measures the response of the adrenal glands to ACTH. Dexamethasone is
given and levels of cortisol are measured. Cortisol levels should decrease in
response to the administration of dexamethasone.

A dexamethasone suppression test is primarily used to help

diagnose Cushing syndrome. Cushing syndrome indicates that you
have an abnormally high level of cortisol. Cortisol is a steroid
hormone produced by the body during high levels of stress.
CT-SCAN
CT scan can provide images of your pituitary and adrenal glands to
detect abnormalities, such as tumors.

This test can help determine whether the cause of Cushing

syndrome is rooted in the pituitary or somewhere else.
 THERAPEUTIC MANAGEMENT
Mefepristone 300 mg BID For 2 months
D5 0.9 NSS FAST DRIP UNTIL HYPOTENSION IS CONTROLLED
Nursing consideration: Please monitor, measuring cortisol levels q6 hours with checking of urine sp. Gravity
levels ( Diabetes Insipidus) & Na level (DI) & SYNDROME)
Monitor CSF leak level after surgery.
Monitor lab results on Day 1 to Day 3.=1.8.
Replaced with Hydrocortisone
Adrenal Enzymes Inhibitors
Metyrapone (Metopirone)
Aminoglutathiazide (cytodren)
Mitotane (Lysodren)
Ketoconazole (Nizoral)
Hydrocortisone: may be given after surgery.
 DIET
Low carbo and low Na diet.
- focuses on proteins and some nonstarchy vegetables. A low-carb diet generally limits
grains, legumes, fruits, breads, sweets, pastas and starchy vegetables, and sometimes nuts
and seeds.
- Reducing sodium intake, Increasing calcium and vitamin D intake, Reducing cholesterol,
Controlling blood sugar, Reducing or eliminating alcohol and tobacco

Lifetime hormone replacement - often necessary after this surgery.

DRUG Mefepristone

Hydrocortisone

STUDY
Metyrapone (Metopirone)

Aminoglutathiazide (cytodren)

Mitotane (Lysodren)

Ketoconazole (Nizoral)

DE BORJA GUILAS LACUARIN

 NURSING
MEDICATION DOSAGE ACTION USAGE ADVERSE EFFECTS
CONSIDERATION

DRUG STOCK DOSE: Blocks the binding Used to There is no adverse 1. Clinically, watch
CLASSIFICATION:
of cortisol to its treat effect reported but for signs of

receptor. It does these are the most fatigue,
200 mg hypercortiso
Synthetic not decrease hypoglycemia,
(Mifeprex) common adverse
lism in hypotension,
steroid cortisol effects
300 mg patients nausea, or
production but

(Korlym) with Anaphylactic

weakness.
reduces the
2. Hypokalemia
effects of excess pituitary reactions needs to be
GENERIC NAME 300 mg BID for 2

cortisol, such as cushing Toxic epidermal monitored in
months
high blood sugar syndrome Necrolysis these patients as
Mifepristone
Adults—At first, levels. Angioedema well.

300 milligrams 3. Patients receiving

(mg) once a day. Works by being treatment for
BRAND NAME Cushing syndrome
Doctor may an antagonist of

are at higher risk
increase dose as glucocorticoid
Korlym and progesterone
for developing
needed. However,
Mifeprex opportunistic
the dose is usually receptors.
infections such as
not more than Pneumocystis
1200 mg per day. jirovecii
pneumonia.
 NURSING
MEDICATION DOSAGE ACTION USAGE ADVERSE EFFECTS
CONSIDERATION

DRUG STOCK DOSE: Decreases Used to treat METABOLIC: 1. Determine

CLASSIFICATION: inflammation, corticosteroid-
whether patient is
Therapeutic Enema: 100- mainly by responsive Hypokalemia sensitive to
another
class: mg/60ml stabilizing dermatoses,
corticosteroid
Corticosteroids leukocyte endocrine Hyperglycemia
2. Monitor patient’s
Pharmacologic Tablets: 5-mg, lysosomal disorders,
BP, and
class: 10-mg, 20-mg membranes; immune Carbohydrate electrolyte levels
Glucocorticoids suppresses conditions, and intolerance 3. Watch for
NOT GIVEN IN immune allergic depression or
GENERIC NAME THE response; disorders. Hypercholestero psychotic

SCENARIO stimulates bone lemia episodes,
Hydrocortisone BUT this may marrow; and especially during

be given after influence Hypocalcemia high dose therapy
4. Diabetic patient
BRAND NAME surgery. protein, fat and
may need to

carbohydrate
increased insulin;
Colocort metabolism. monitor glucose
Cortef level
Cortenema
 NURSING
MEDICATION DOSAGE ACTION USAGE ADVERSE EFFECTS
CONSIDERATION

DRUG STOCK DOSE Used as a Abdominal 1. Monitor for allergies and

CLASSIFICATION Capsule, Metopirone is an diagnostic discomfort hypersensitivity reaction
Steroid 11- gelatin inhibitor of drug for Dizziness with the drug.
beta- coated: 250 endogenous testing Fall in arterial 2. Monitor v/s, alertness,
and other side effects of the
monooxygenas mg (ORAL adrenal hypothalami blood
drug.
e inhibitor ROUTE) corticosteroid c-pituitary pressure
3. Drug may cause CNS
Adrenal Steroid Single dose synthesis. ACTH Headache depression, which may
Synthesis test: 30 (Adrenocorti Nausea impair physical or mental
Inhibitor mg/kg PO at Inhibits formation cotropic Pulse rate abilities.
midnight; of cortisol, Hormone) increase 4. Ensure safety of the
not to corticosterone, function. Sedation patient with the side effects
GENERIC NAME exceed 3 and aldosterone Occasionally of the drug in CNS. Avoid
Metyrapone g/dose used in driving, using machines, or
perform any task that can be
Multiple Cushing's
dangerous when dizzy or not
BRAND NAME dose test:: syndrome.
alert.
Metopirone 750 mg PO
q4hr x6
doses
 ADVERSE
MEDICATION DOSAGE ACTION USAGE NURSING CONSIDERATION
EFFECTS

DRUG STOCK DOSE Reduces the Used for Elevations in 1. Monitor v/s, alertness, and
CLASSIFICATION Tablets: production of D5- suppression (1) total other side effects of the drugs.
Adrenal 250 mg pregnenolone and of adrenal 2. Ensure safety of the patient
cholesterol,
with the side effects of the
corticosteroid orally four blocks several other function in (2) low
drug in CNS. Avoid driving,
inhibitors times steps in steroid selected density
using machines, or perform any
Antineoplastic daily, synthesis, including the patients lipoprotein task that can be dangerous
Aromatase C-11, C-18, and C-21 with cholesterol, when dizzy or not alert.
Inhibitor hydroxylations and the Cushing's (3) apoprotein 3. Monitor hypersensitivity
hydroxylations syndrome B, and (4) reactions of the patient with
required for the apoprotein C- the drug.
GENERIC NAME aromatization of III. 4. Apply non-pharmacological
Aminoglutathiazide androgens to Hyponatremia treatment for fever whenever
body temperature rises. Then
estrogens, mediated Malaise
consider giving analgesics as
BRAND NAME through the binding of Fever
prescribe by the physicians.
Cytadren aminoglutethimide to Chills 5. Provide comfort with the
cytochrome P-450 Facial fullness client whenever the patient
complexes. experience chills.
 MECHANISM OF
CONTRAIND
ADVERSE

MEDICATION INDICATION NURSING CONSIDERATION

ACTION ICATION EFFECTS

DRUG
reduces cortisol use to Hyperse
Anorexia Monitor signs of CNS toxicity,

CLASSIFICATION control nsitivity including irritability, headache,

production by Nausea and

Adrenocortical
hypercortisole dizziness, decreased mental

blocking cholesterol Vomiting

Suppresants acuity, lethargy, tremors,

side-chain cleavage mia in benign Diarrhea vertigo, and functional

and 11 β- causes of Decreased

GENERIC NAME impairments.

hydroxylase. Cushing's memory Monitor any breathing

Mitotane syndrome.
- Absorption: 5-40% Changes in
problems such as wheezing or

- Distribution: widely vision shortness of breath. Report

BRAND NAME
distributed with Unusual
severe or prolonged

Lysodren respiratory impairments.

primary concentra- drwosiness
Instruct patient to report any

DOSAGE,
ion in adipose tissue
hearing loss or vision

FREQUENCY and
- Metabolism: Partly
problems (blurred vision,

ROUTE OF
converted to an double vision).
ADMINISTRATION uncharacterized Advise patient about the

Initial: 1.5 g PO
water-soluble likelihood of GI reactions such

divided q6-8hr;
metabolite as diarrhea, nausea, vomiting,

not to exceed 3
Half-life: 18 - 159 and loss of appetite. Instruct

g PO q8hr patient to report severe or

days
Excretion:Urine prolonged GI problems.
 MECHANISM OF
CONTRAIN
ADVERSE

MEDICATION INDICATION NURSING CONSIDERATION

ACTION DICATION EFFECTS

DRUG
Inhibition of P450 control of Hypers
Nausea and
Receive full medication

CLASSIFICATION hypercortisolism of ensitivi

history and screen

enzymes includes the vomiting

Anti-fungal
either pituitary or forcontraindications
first step in cortisol ty Abdominal pain
agent Monitor daily pattern of

synthesis, cholesterol adrenal origin. Its Diarrhea bowel activity, stool

side-chain cleavage, effect appears to Head ache

GENERIC NAME consistency. Assess for

and conversion of be mediated by Dizziness dizziness, provide assistance

Ketoconazole inhibition of
11-deoxycortisol to as needed.
cortisol adrenal 11 beta-
BRAND NAME
- Absorption: Well hydroxylase and Instruct patient to avoid

Nizoral alcohol
absorbed from GI 17,20-lyase, and it,
tract following PO in some unknown
DOSAGE,
May cause dizziness; avoid

FREQUENCY and
administration way, prevents the
tasks that require alertness,

ROUTE OF
-Protein binding - expected rise in
motor skills until response to

ADMINISTRATION 93%-96% ACTH secretion in

drugs is established
600-800
- Metabolism: liver patients with Monitor and be alert for

mg/day PO Half-life: 8 hours Cushing's disease. hepatotoxicity: dark urine,

Excretion: Urine pale stools, jaundice, fatigue,

(13%) and in feces anorexia, nausea, or vomiting

(57%)
NURSING
CARE
PLAN

 NCP #1 : RISK FOR INJURY

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective SHORT TERM INDEPENDENT SHORT TERM
After 4 hours of nursing Assess the skin Cushing’s disease causes
After 4 hours of
"naghihina ang mga
Risk for Injury interventions the client thinning of the skin because

frequently to check nursing interventions

kasu-kasuhan ko at
related to muscle will: for reddened areas,
cortisol causes the breakdown of

to the client the goal

some dermal proteins along with

konting sagi lang

weakness as skin breakdown, was met as evidenced
the weakening of small blood

sa'kin at madali
evidenced by the Verbalize tearing, or by:
vessels. Therefore the skin may

akong nagkaka-
patients' thin and understanding of excoriation become so weak which allows it

pasa" as verbalized
individual factors to be damaged easily. Verbalized
easily bruised
by the patient that contribute to understanding of
skin. individual factors
possibility of injury

that contributed to
Objective Assess the skin for The accumulation of fat caused
possibility of
Demonstrate and
Thin and fragile
signs of bruising. by Cushing’s syndrome stretches
injury
implement
skin the skin which is already thin

behaviours that
Malaise and weakened due to cortisol
Demonstrated and
reduces risk factors action, causing it to hemorrhage

Bruise spots on
was able to
from injury and and stretch permanently, healing

her legs implement

protect self from by fibrosis, susceptible to rupture
behaviors that
injury with minimal trauma. The client

reduces the risk

may experience easy bruising.
factors from injury
and is able to
protect self from
injury
 NCP #1 : RISK FOR INJURY
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
LONG TERM Ask the client about Increased cortisol levels increase
LONG TERM
problems with poor the catabolism of peripheral

After 2-3 days of nursing wound healing. tissues. Impaired nitrogen

After 2-3 days of
interventions the client metabolism associated with
nursing interventions to
will: Cushing’s disease contributes to
the client the goal was
Be free of fractures impaired protein synthesis and
met as evidenced by:
or soft tissue injuries. delayed wound healing. The client is free
of fractures or soft
tissue injuries.
Instruct the client about Excessive dryness or excessive

keeping the skin clean moisture increases the risk for

and moisturized skin breakdown.

Discuss with client Precaution with activities is done

safety measures for to reduce the occurrence of

ambulation and daily trauma that can result in injury,

activities bruising, or bleeding. Cushing’s

is associated with loss of bone

density. The client is at risk for

pathological fractures as a result

of minor stress on the weaker

bones.
 NCP #1 : RISK FOR INJURY
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Encourage the client to Client with Cushing’s disease
increase dietary intake develop osteoporosis (fragile

of calcium, and vitamin bones). Calcium and vitamin D

D. are important in strengthening

bones.

Instruct the client about Excessive dryness or excessive

keeping the skin clean moisture increases the risk for

and moisturized. skin breakdown.

Instruct the client in Electric razor reduces the risk of

activities to decrease cutting the skin when shaving

the risk for bleeding while soft toothbrush decreases

such as using of electric trauma to the gums.

razor soft toothbrush.

Instruct the patient to To avoid pain or injury during

correct body mechanics activities.

Encourage the client to These measure minimizes the

eat a high-fiber diet risk for developing constipation,

with adequate fluid which can result in lower GI

intake. bleeding.
 NCP #1 : RISK FOR INJURY

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Encourage the client to Eating a high-protein diet can

eat a high-protein diet. help prevent the muscle loss

associated with Cushing

syndrome.

DEPENDENT
Administer medications To control the massive or

such as adrenocortical excessive cortisol production

suppressants and that causes the Cushing's

corticosteroids as disease.
ordered.

COLLABORATIVE
Refer to physical To help the patient in

therapist for specialized maintaining her physical

exercises activities that will help her to

prevent future injury.

 NCP #2 : DISTURBED BODY IMAGE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Disturbed body image SHORT TERM INDEPENDENT: SHORT TERM:
related to abnormal fat
"Ayoko na magsuot ng distribution along with After a day of nursing Assess client's feeling After a day of nursing
Negative statements about
shorts, sando, palda edema as evidenced by interventions, the patient about their changed changes in appearance indicate interventions, the patient
dahil ang taba-taba ko verbal identification of will verbalize feelings appearance and coping a disturbed body image. was able to verbalize his
na, kita stretch marks ko feeling about altered about the changes in her mechanism. Depression may occur. feelings about the
at mga pimples ko" as body structure like appearance and changes in his
verbalized by the patient feeling about moon understand the disease Listen to client's Different situations are appearance.
face structure, buffalo and it's treatment. comments and responses upsetting to different people,
OBJECTIVE DATA: hump, facial hair, acne to the situation. depending on individual
and obesity. LONG TERM coping skills. LONG TERM:
Moon face
Buffalo hump After 1 week of nursing Evaluate the level of the May indicate acceptance or After 1 week of nursing
Obesity interventions, the patient client's knowledge of nonacceptance of the situation. interventions, the patient
Facial hair will demonstrate and anxiety related to was able to demonstrate
Acne enhanced body image and situation. enhanced body image
Stretch marks self-esteem as evidenced and self-esteem as
Hiding of body by ability Have the patient Identifies self-image and evidenced by ability
parts describe self, noting whether there is a discrepancy
HEIGHT: 5'2 ft what is positive and between own view, how client
WEIGHT: 95 kg what is negative. Be believes others see her, this
aware of how the patient may affect on how client
believes others see self. perceives changes.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
to look at, touch, talk
Promote an atmosphere Client asks other people for to look at, touch, talk
about and care for actual
of acceptance and feedback about their about and care for
and perceived altered
positive caring. appearance. To respond to the actual and perceived
body parts and functions.
client in an accepting manner, altered body parts and
it supports the client’s functions.
adjustment to her appearance.

Promote coping methods Learning methods to

to deal with the client's compensate for changes in
change in appearance appearance enhances the
(e.g., adequate grooming, client's self-esteem.
and flattering clothes)

Reassure the client that

the physical changes are Information helps the client
a result of the elevated develop realistic expectations
hormone levels and most about the changes in the
will resolve when those physical appearance.
levels return to normal
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Educate the patient To boost patient's

about the cause of knowledge and
these body changes by expectations and the
discussing what current situation and the
cortisol and Cushing treatment outcome. this
syndrome are. will increase the
likelihood of compliance
and cooperation during
treatment.

Assist patient to To promote continuation

incorporate therapeutic of the program and to
regimen into activities keep from gaining weight
of daily living(ADL). and losing more muscle
strength.

DEPENDENT:
Administer diuretics as Diuretics promote
prescribed. sodium and water
excretion.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Apply lotion or cream This can promote

with retinoids, such as collagen production
Retin-A as prescribed and reduce redness,
by the doctor which may be helpful
with reducing the
overall appearance of
COLLABORATIVE marks
Refer to local support Members of a support
groups group may offer coping
strategies that have
proven successful.

Refer to a For proper diet and

nutritionist/dietitian nutrition and to cure
obesity.

Refer to a For proper skin care

dermatologist and medication in
reducing acne
production & reducing
the appearance of
stretch marks..
DISCHARGE PLANNING
BY: PULMONES & RAMIREZ
 MEDICATIONS
The medications should be accurate and taken at the right time, right dosage, and
right route of medication as prescribed by the physician.
Mefepristone 300 mg BID For 2 months; orally
Metyrapone (Metopirone) - 750 mg orally, every 4 hours for 6 doses
Aminoglutathiazide (cytodren) - 250 mg orally every 6 hours
Mitotane (Lysodren) - 2 g to 6 g orally, in 3 or 4 divided doses per day
Ketoconazole (Nizoral) - apply 1-2 times daily on affected area, topically
Do not stop any of the medications on your own.
Lifetime hormone replacement
20 mg per day, orally preferably 3 times a day.
Instruct the patient not to stop corticosteroids abruptly and without medical
supervision because the syndrome could recur, so the patient should always
have an adequate supply of the corticosteroids medication to avoid running
out.
 ENVIRONMENT
Avoid stressful environments.
Avoiding falls and start removing loose rugs and other hazards at home. Falling
may lead to broken bones and other injuries.
Ask the support group of the patient to establish a trusting and caring relationship
for the comfort of communication about the situation and needs in the future.
Active listening should also be observed by the support group of the patient.
 EXERCISE
Walk as much as possible.
Heavy lifting, straining, and exercise that might cause bleeding should be avoided
during the first two weeks.
Avoid activities that would tense or strain the abdominal muscles for at least 4 weeks
or as directed by the physician. These activities may include lots of twisting or
vacuuming.
Hot baths, massages and low-impact exercises, such as water aerobics and yoga, can
help alleviate some of the muscle and joint pain that accompanies Cushing syndrome
recovery.
The patient can also slowly increase the duration of their aerobic activities for up to
60 to 90 minutes.
Generally, the patient can return to work in 2 to 3 weeks depending on the work she
does.
 TREATMENT
Remind the patient to follow doctor’s order when it comes to her medications.
Test her blood at regular intervals during the first 2 weeks after surgery for possible
high blood sodium levels
Try to keep the incision dry for the first week.
The patient can cover the abdominal incision with plastic when she showers during
the first week after surgery. She can get the incision wet after 7 days.
Avoid wearing tight restrictive clothing.
Do not apply ointments or powders to the incision unless specifically directed to do
so by the physician.
HEALTH TEACHING
Teach patient and family to monitor blood pressure, blood glucose levels, and weight.
Avoid smoking. It prevents proper wound healing.
Weigh yourself at the same time every morning after you urinate, but before you eat.
Learn new ways to relax, such as deep breathing.
Emphasize the need to keep an adequate supply of glucocorticoid and
mineralocorticoid to prevent running out or skipping a dose, because this could result
in other complications.
Stress the importance of wearing a medical alert bracelet and notifying other health
professionals that he or she has Cushing disease.
Use meticulous skin care to avoid traumatizing fragile skin.
 OUT-PATIENT
Instruct patient to visit physician after a week for a following check-up at Outpatient
Department.
Visit physician regularly to help diagnose and treat diabetes, high blood pressure, and
other possible complications.
If during the first 2 weeks after surgery your fever goes above 101 degrees F/ 38.3
degree C, call the physician.
Contact your healthcare provider or specialist if:
You gain more weight than your healthcare provider said you should.
Your pain is worse or does not go away even after you take pain medicine.
Your symptoms get worse.
You have questions or concerns about your condition or care.
Seek care immediately if:
You have trouble staying awake or are confused.
You have a severe headache or feel dizzy.
You have blurred or double vision.
You have chest pain.
You have trouble breathing or shallow breathing.
 DIET
Reducing sodium intake
Focus on fruits, vegetables, and reduced-sodium soups, dressing, and spreads.
Increasing calcium and vitamin D intake
This includes kale, cheese and broccoli, as well as milk and beverages fortified with
vitamin D. Multivitamins are also a valuable source of calcium and vitamin D. Adults
should aim for a daily intake of about 800 mg of calcium and five to 15 micrograms
of vitamin D, with vitamin D intake increasing with age
Reducing cholesterol
Avoiding fatty foods and eating more high-fiber foods such as kidney beans, apples,
pears, barley and prunes may help offset the effects of higher cholesterol associated
with Cushing’s.
Controlling blood sugar
Eat foods low in sugar, such as whole grains, nuts, seeds, and legumes.
Reducing or eliminating alcohol and tobacco intake.
 SPIRITUAL
Ask the patient and family to pray for faster recovery.
Suggest the patient to ask a pastor, priest or spiritual leader for guidance and
spiritual support.

Isaiah 41:29-31 “He gives strength to the weary and increases the power of the weak.
Even youths grow tired and weary, and young men stumble and fall; but those who
hope in the LORD will renew their strength. They will soar on wings like eagles; they
will run and not grow weary, they will walk and not be faint.”
Reference:
lhttps://nurseslabs.com/cushings-disease-nursing-care-plan/5/

Alila Medical Media (2020), Cushing Syndrome Animation.

https://youtu.be/v-jUwEpIzkE

Dr. James Findling, S. (2014, October 19). Diagnostic testing for

Cushing's syndrome - CSRF - cushing's support; Research Foundation.
CSRF. Retrieved March 22, 2022, from https://csrf.net/understanding-
cushings/diagnostic-testing/?
fbclid=IwAR1xKbfQoQ9le__Z5VgeM6TXHPxgzoP3GibPd7DTTOMoNy
O7yI_WIGfQmHA