NCMB 316

CUSHING
SYNDROME
OUR LADY OF FATIMA UNIVERSITY - ANTIPOLO
BSN 3-B-7
Members
Members
LOPEZ, BABY ELIZABETH L.
MACASASA, JOHN PATRICK
MANALO, YOHJ GODFFREY
MANLAPAS, RAINIER
MARCOS, JESSA MAE
MARTINEZ, KYLE ANDREI
MENDOZA, JC ANNE
OBLIPIAS, JANZEN
PICAZO, DROL SUSEJ
RAMOS, LEEANNE CYRILLE

CASE
cASE SCENARIO
SCENARIO
 CUSHING SYNDROME

PATIENT PROFILE
T.H. is a 26-year-old elementary school teacher. He seeks the advice of his health care
provider because of changes in his appearance over the past year.

SUBJECTIVE DATA:
Reports weight gain (particularly through his midsection),easy bruising, and edema of
his feet, lower legs, and hands
Has been having increasing weakness and insomnia

OBJECTIVE DATA:
Physical examination: BP 150/110; 2+ edema of lower extremities; purplish striae on
abdomen; thin extremities with thin; friable skin; severe acne of the fae and neck
Blood analysis: Glucose 167 mg/dL (9.3 mmol/L); white blood cell (WBC) count
13,000/uL; lymphocytes 12%; red blood cell (RBC) count 6.6 x 10^6/uL; K+ 3.2 mEq/L (3.2
mmol/L)
 DISCUSSION QUESTIONS

1. Discuss the probable causes of the alterations in T.H.'s laboratory results.

2. Explain the pathophysiology of Cushing Syndrome
3. What diagnostics testing would identify the cause of T.H.'s Cushing syndrome?
4. What is the usual treatment of Cushing Syndrome?
5. What is meant by a "medical adrenalectomy"?
6. Priority Decision: What are the priority nursing responsibilities in the care of this
patient?
7. Priority Decision: Based on the assessment data presented, what are the priority nursing
diagnosis? Are there any collaborative problems?
 Discuss the probable
causes of the alterations
in T.H.'s laboratory
results.
The abnormal lab results in T.H.'s case are:
Glucose: The glucose level of 167 mg/dL (9.3 mmol/L) is higher than the normal
range of 70-99 mg/dL (3.9-5.5 mmol/L). This may be due to excess cortisol in the
bloodstream, which increases blood sugar levels.
The abnormal lab results in T.H.'s case are:

White blood cell count: The WBC count of 13,000/uL is higher than the
normal range of 4,500-11,000/uL. This may indicate an infection or
inflammation caused by excess cortisol suppressing the immune system.
Lymphocytes: The percentage of lymphocytes at 12% is lower than the
normal range of 20-40%. This may also be due to cortisol suppression of
the immune system.
Red blood cell count: The RBC count of 6.6 x 10^6/uL is higher than the
normal range of 4.5-5.5 x 10^6/uL. This may be due to excess cortisol
stimulating the production of red blood cells.
Potassium: The low potassium level of 3.2 mEq/L (3.2 mmol/L) is below the
normal range of 3.5-5.0 mEq/L (3.5-5.0 mmol/L). This may be due to excess
cortisol causing potassium loss in the urine.
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
Pathophysiology CUSHING'S SYNDROME

Non modifiable factors:

Male

Etiology:

Hypersecretion of ACTH
from pituitary adenoma

Normal feedback mechanisms that control

adreno cortical function are ineffective.

S/Sx:

Purple striae on abd

Resulting in excess secretion of adrenal Glucose 167 mg/dL (9.3
cortical hormones Elevated blood glucose level mmol/L)
Severe acne of the face and
neck

Inadequate amount of adrenal cortical Resulting in excess secretion of adrenal

hormones in secretion cortical hormones

S/Sx:
Lab test: White blood cell (WBC High insulin levels
Cortisol Test count 13,600/L;
24 hour urine cortisol and low lymphocytes 12%;
dose (1 mg) o/n Hypercorticolism red blood cell (RBC count
dexamethasone suppresion 6.6 x 10% L;
test K* 3.2 mEq/L (3.2 mmol/L) Targets adipocytes in center of the body
weakness and insomnia

High urine cortisol and not

suppressed (cortisol Weight gain (Truncal
unchanged) Cortisol cross reacts w/ mineralcorticoid Activates lipoprotein lipase obesity)
receptor

Suspect Cushing's
Measure Plasma ACTH levels
Syndrome S/Sx:
Blood pressure 150/100
Increase blood pressure by retaining fluid (hypertension)
edema of his feet, lower
legs, and hands

ACTH LOW ACTH nl/high

Breakdown of some dermal proteins along with S/Sx:
the weakening of small blood vessels. Easy bruising

Suspect extra adrenal tumor

(ACTH-dependent Cushing's
Sundrome)

High dose (8mg)

dexamethasone suppression
test

Not suppressed (cortisol nl/

↑
)
Suppressed (cortisol ↓)
CT/MRI abdomen
(pancreatic cancer), chest Ectopic ACTH.
(lung ca)
What
What diagnostics
diagnostics testing
testing
would
would identify
identify the
the cause
cause
of
of T.H.'s
T.H.'s Cushing
Cushing
syndrome?
syndrome?
What diagnostics testing would identify the
cause of T.H.'s Cushing syndrome?
Understanding the appropriate application and restrictions of the tests typically used in the
diagnostic work-up is necessary for the diagnosis of individuals with suspected Cushing's
syndrome.

- A 24-hour urine collection with analysis for urinary free cortisol excretion is the
appropriate screening procedure for Cushing's syndrome; elevated values are indicative of
the condition. An ectopic or adrenal cause would be indicated by low or undetectable
plasma ACTH levels, while high or normal levels would indicate Cushing disease from an
ACTH-secreting pituitary adenoma.

- For a definitive diagnosis, it may be necessary to do inferior petrosal sinus catheterization,

low-dose and high-dose dexamethasone suppression tests, a corticotropin-releasing hormone
stimulation test, and corticotropin assays.

 What is the usual

treatment of Cushing
Syndrome?
THE UNDERLYING CAUSE OF EXCESSIVE CORTISOL PRODUCTION AFFECTS HOW CUSHING'S
SYNDROME IS TYPICALLY TREATED. THE COMMON AND POTENTIAL TREATMENTS THAT A
PATIENT WITH CUSHING’S SYNDROME WILL BE HAVING ARE THE FOLLOWING:

REDUCED USE OF CORTICOSTEROIDS

If a patient has a corticosteroid medication, it must be addressed to your physician for an
adjustment of the dosage of the drug over a period of time to manage the underlying
symptoms of Cushing's syndrome. It is important to be guided by a healthcare provider
through the dosage adjustment of corticosteroids, as they must be tapered to avoid
sudden low cortisol levels.

SURGERY
Surgery may be an option for treatment if a tumor is the cause of Cushing syndrome. The
pituitary gland, which is typically removed by a neurosurgeon through the patient's nose,
is the most frequent tumor site that can affect the production of cortisol. To correct the
patient's body's level of cortisol after surgery, a cortisol replacement drug will be
suggested.
THE UNDERLYING CAUSE OF EXCESSIVE CORTISOL PRODUCTION AFFECTS HOW CUSHING'S
SYNDROME IS TYPICALLY TREATED. THE COMMON AND POTENTIAL TREATMENTS THAT A
PATIENT WITH CUSHING’S SYNDROME WILL BE HAVING ARE THE FOLLOWING:

RADIATION THERAPY
Radiation therapy may be recommended for patients who aren't candidates for surgery or
in cases where the neurosurgeon is unable to completely remove the pituitary tumor
through surgery.

MEDICATIONS
Medication is one of the treatment options that can help control the production of cortisol
in a patient when surgery and radiation therapy are not effective for the patient's
condition. It can also be used before and after surgery to maintain normal cortisol levels.
Medications that can control excessive cortisol production at the adrenal gland include
ketoconazole, mitotane, and metyrapone. Additionally, there is a medication for patients
with type 2 diabetes, which is mifepristone, and a new generation of medication for
Cushing's syndrome, which includes pasireotide and osilodrostat. It's important to note
that the specific medication plan should be determined by a qualified healthcare
professional.
What is meant by a
"medical
adrenalectomy"?
Some medical diseases, such as Cushing's syndrome or
pheochromocytoma, that entail excessive hormone production
by the adrenal gland can be treated by a medical
adrenalectomy. The surgical removal of one or both of the
small, triangular-shaped adrenal glands, which are situated
on top of each kidney, is known as an adrenalectomy.

With a medical adrenalectomy, hormone production is

decreased and the adrenal gland's function is suppressed
using medication. When surgery is not a possibility or is
deemed to be too hazardous for the patient, this strategy
may be utilized.
Medications that prevent the effect of adrenal hormones,
such spironolactone or metyrapone, or that limit the
development of adrenal hormones, like ketoconazole, may
be used during a medical adrenalectomy. Therapy with
these drugs can help to manage the underlying condition's
symptoms and avoid consequences.

It is important to note that medical adrenalectomy is not a

long-term fix and may be necessary. Also, it's critical to
carefully check over individuals undergoing this treatment
to make sure hormone levels are correctly managed and to
look out for any possible pharmaceutical adverse effects.
 Priority Decision:
What are the priority
nursing responsibilities
in the care of this
patient?
According to patient T.H’s data, he currently has an elevated blood pressure (150/110
mmhg), elevated blood glucose count (167 mg/dL), elevated white blood cell count,
decreased lympocytes, decreased K+, and he’s been experiencing insomia and weakness.
As a nurse, we should prioritize the following interventions to address patient T.H’s
problem;

Provide a calm and relaxing environment, relaxing techniques, guided imagery, etc., to
minimize the environmental stressors that affects the symphatetic stimulation.

Assist the patient to rest in bed or chair. Advice them to restrict activities that may cause
physical stress and tension that affects their blood pressure.

Administer antihypertensive medications which can help decrease their blood pressure, as per
doctor’s order.

Continuous monitoring of blood pressure to see whether there are any changes in it.
Watch out for signs of hyperglycemia. (Dry mouth, increased thirst, weakness,
headache, blurred vision, frequent urination)
Administer metformin or medications that helps lower glucose levels, as per
doctor’s order.
Monitoring and managing complications, input/output, blood glucose levels,
electrolyte imbalances, daily weight, hormone toxicity, manifestations of
inflammation, manifestations of nephrolithiasis and changes in mental status
Assess neurovitals, vital signs and lung status (hypertension, fluid overload and
abnormalities in vital signs may be present)
Promote skin integrity
WOF signs of skin infection due to high glucocoticoids
Assess and detect sisgns of reddened areas, skin breakdown or tearing,
excoriation and edema
Assess bony prominences frequently
Avoid adhesive tape and use appropriate skin care to avoid damaging the
skin
Ecourage the patient to:
Ambulate to prevent complications of immobility, while asssisting
patient to prevent falls, fractures and other injuries
Turn body frequently in the bed to reduce pressure on bony
prominences and promote circulation
Verbalize and discuss changes in appearance, concerns about the
illness
Perform hygiene to promote cleanliness and prevent risk of infection
Bed rest
Provide patient low sodium and high potassium diet to minimize edema
and counter weakness and fatigue, recommend a diet high in protein,
calcium and vitamin D as well to minimize muscle wasting and
osteoporosis.
Provide emotional support and teach self-care
 Priority Decision:
Based on the assessment
data presented, what are
the priority nursing
diagnosis? Are there any
collaborative problems?
 NURSING DIAGNOSIS

Risk for infection related to lowered resistance to stress and suppression of immune
system

Imbalanced nutrition: more than body requirements related to increased appetite, high
caloric intake, and inactivity

Situational low self-esteem related to altered body image and diminished physical
capabilities

 COLLABORATIVE PROBLEMS
OBESITY
Elevated cortisol levels, for instance, can stimulate hunger and contribute to a desire for
"comfort food," as well as shift white adipose tissue to the abdomen, which might also
eventually result in central obesity.

HYPERTENSION
Your adrenal glands produce and release the stress hormone cortisol into your
bloodstream as soon as your body senses stress. Cortisol, also known as the "stress
hormone," raises your blood pressure and heart rate. Humans have survived for tens of
thousands of years thanks to their instinctive "flight or fight" response

WEAKNESS
It was found that Cushing's disease significantly increases fat deposits, notably in the
thigh muscles, which reduces endurance and muscular power.
 COLLABORATIVE PROBLEMS

INSOMNIA
According to reports, Cushing Syndrome patients frequently have insomnia and poor
sleep quality, which is thought to be caused by a high cortisol level. Contrary to the
majority of people, those with Cushing's syndrome have consistently elevated cortisol
levels throughout the night.

POTENTIALCOMPICATIONS: thromboembolism, cardiac dysrhythmias,

pathologic fractures, nephrolithiasis, diabetes mellitus, hypertensive crisis,
impaired skin integrity

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THANK
THANK YOU!!!
YOU!!!