01.03 Cushings Syndrome

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Overview

  1. Hypersecretion of glucocorticoids leading to elevated cortisol levels
  2. Greater incidence in women
  3. Life threatening if untreated

Nursing Points

General

  1. Causes
    1. Adrenal or Pituitary Tumor
      1. Pituitary gland controls adrenal hormones
    2. Overuse or Chronic use of Corticosteroids
  2. Adrenal Cortex
    1. Glucocorticoids
      1. Cortisol
      2. Glucose & Fat Metabolism
      3. Anti-inflammatory
    2. Mineralocorticoids
      1. Aldosterone
      2. Regulate fluid and electrolytes
    3. Sex hormones (Androgens)
      1. Testosterone, Estrogen
      2. Control physical features
      3. Control hair distribution
  3. Adrenal Medulla
    1. Epinephrine (Adrenaline)
    2. Norepinephrine (Noradrenaline)
    3. Fight or Flight Response
  4. Cushing’s Syndrome
    1. Excess Cortisol
    2. Excess Aldosterone
    3. Excess Androgens

Assessment

  1. Cardiovascular
    1. Hypertension
    2. Signs of Heart Failure
  2. Metabolic
    1. Redistribution of Fats
    2. Moon Face
    3. Buffalo Hump
  3. Integumentary
    1. Excess hair
    2. Striae on abdomen
    3. Fragile skin
    4. Peripheral edema
  4. Electrolytes
    1. Hypokalemia
    2. Hypocalcemia
    3. Hypernatremia
    4. Hyperglycemia
  5. Decreased Immune Response

Therapeutic Management

  1. Remove Adrenal or Pituitary Tumor
  2. Adrenalectomy
  3. Decrease dose or stop corticosteroid use
  4. Monitor Electrolytes and Cardiovascular Status
    1. Replace electrolytes as needed
  5. Safety → Protect from Injury
    1. Risk for Osteoporosis (hypocalcemia)
    2. Risk for Infection
    3. Risk for Skin breakdown

Nursing Concepts

  1. Fluid & Electrolytes
    1. Monitor and replace electrolytes as needed
    2. Monitor EKG and Cardiac status
    3. Administer medications as ordered
  2. Infection Control
    1. Monitor VS for s/s infection
    2. Meticulous wound care
    3. Infection precautions
  3. Safety
    1. Risk for osteoporosis → protect from injury
    2. Risk for skin breakdown → skin care and meticulous wound care
  4. Comfort and Coping
    1. Changes to appearance
    2. Edema & weight gain

Patient Education

  1. Proper dosing of steroids
  2. Coping strategies as needed
  3. s/s infection to report to provider
  4. Blood sugar monitoring

Reference Links

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Video Transcript

In this lesson we’re going to talk about Cushing’s Syndrome. Now, Cushing’s Syndrome, you’ll see, is the opposite of Addison’s Disease.

First, let’s quickly review the A&P of the adrenal glands. If you can understand what they do, it’s easier to understand what happens when something goes wrong. The adrenal glands sit on top of the kidneys. They have two parts – the outer portion is called the adrenal cortex, the inner portion is the adrenal medulla. The adrenal cortex is responsible for secreting hormones such as glucocorticoids, mineralocorticoids, and androgens. Glucocorticoids help manage glucose and fat metabolism and have anti-inflammatory properties – they suppress immune response. Mineralocorticoids like aldosterone help with fluid & electrolyte balance. And androgens are sex hormones like testosterone and estrogen. The adrenal medulla secretes epinephrine or adrenaline and norepinephrine, or noradrenaline. These hormones are responsible for the fight or flight response in the sympathetic nervous system.

In Cushing’s Syndrome, we see a hypersecretion of hormones, specifically the ones from the adrenal cortex, the outside of the adrenal glands. So that’s increased glucocorticoids like cortisol, increased mineralocorticoids like aldosterone, and increased androgen hormones. It can actually be caused by Cushing’s Disease, but also by excess use of corticosteroids, OR by an adrenal or pituitary tumor – so that’s why we’re talking about Cushing’s Syndrome instead of just Cushing’s Disease. So, start thinking about what this will look like in your patient. Cortisol is responsible for storing fat and it increases glucose levels, so what happens if we have too much that? Aldosterone is responsible for retaining sodium and water, what happens if we have too much of that?

Those effects are going to be seen throughout the body. In the cardiovascular system, we’re going to see hypertension and signs of CHF – why? Because there’s too much aldosterone and it’s holding onto sodium and water – so our intravascular volume is going to go way up. Remember from the hemodynamics lesson that increased volume puts strain on the heart because of the increased preload.
Remember that cortisol is responsible for storing fats, so with excess cortisol, we see this abnormal distribution of fats. Specifically we see what’s referred to as moon face, like you see here – they get the big puffy cheeks and fat build up around their face. We’ll also see what’s called a Buffalo Hump, which is a collection of fat on the back of the neck and top of the back. It’s very prominent and you’ll recognize it when you see it. Because of the excess glucocorticoids, their skin becomes very fragile and almost soggy. They start to have striae on their abdomen and thighs. We’ll see a picture of this on the next slide, but they look like extreme stretch marks on the sides of the abdomen. Because of the excess androgens, we may also see excessive hair growth on the face, arms, and back.

Then, just like in Addison’s Disease, since we know that our mineralocorticoids are affected, we’re going to see electrolyte abnormalities. Remember that aldosterone is responsible for retaining sodium and water….and this time we have excessive secretion – we have too much aldosterone. So the kidneys begin to retain a ton of sodium and water. So we’ll see hypernatremia. And any time the kidneys are retaining sodium, they are going to excrete potassium, so we’re gonna see hypokalemia. Both of these conditions are dangerous for patients because of their effects on the cardiovascular and neurological systems. Then, in Cushing’s Syndrome we see hypocalcemia (just remember it goes the same direction as the potassium in these disorders). And, then because there’s so much glucocorticoid in the system, we’ll see severe hyperglycemia. This even happens when we administer corticosteroids because that’s part of their job is to increase glucose levels in the system. You’ll have a patient without diabetes get put on steroids and then you start to see their sugars running in the 200’s. They are not a diabetic, they are experiencing this effect of the steroids.

When we’re managing a patient with Cushing’s Syndrome, the only treatment besides monitoring and managing electrolytes is to remove the source of the problem. If it was caused by excess use of steroids, we can lower the dose or switch them to a different anti-inflammatory option. We could remove the tumor if that’s what’s causing it. Pituitary tumors cause this because they are the master gland, they control the secretion of these hormones from the adrenal gland. Or, we could remove the adrenal glands altogether. The problem is, that flips them over into Addison’s Disease – so they’ll have to be on hormones and electrolyte monitoring for the rest of their lives. Either way, we’ll monitor their electrolytes and their cardiovascular status closely. We want to protect them from injury because hypocalcemia can lead to brittle bones. We know that excess glucocorticoids can cause a decreased immune response. They’re anti-inflammatory, which is great, but it suppresses the immune system and puts the patient at risk for infection. And then we know they have fragile skin and get those striae like you can see in this image – their skin is at risk for tearing or breaking down. We want to make sure we do really good skin care and good wound care since they will be so prone to infection. We also want to help patients cope – the changes in their physical appearance alone can be very distressing.

So our top priority nursing concepts for a patient with Cushing’s Syndrome are going to be fluid & electrolytes, hormone regulation, and glucose metabolism. Plus of course safety and infection control. Make sure you check out the care plan attached to this lesson for detailed nursing interventions and rationales.

So let’s quickly recap. Cushing’s Syndrome is caused by hypersecretion or excess circulating adrenal cortex hormones like glucocorticoids, mineralocorticoids, and androgens. We want to monitor their fluid and electrolyte status because they can be volume overloaded, hyponatremic, and hyperkalemic, plus their blood sugars can be significantly elevated. If left untreated, patients can progress to heart failure so we need to address the cause and treat the symptoms. We also want to prevent complications. Patients are at risk for infection, brittle bones, and hyperglycemia, so we practice good infection control measures and monitor their sugars closely.

So those are the basics of Cushing’s Syndrome. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!

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  • Question 1 of 7

The nurse is working with a client who has been diagnosed with Cushing’s syndrome. The nurse has provided teaching about the disease process and management. Which of the following statements by the client demonstrates a need for additional teaching?

  • Question 2 of 7

A 79-year-old client with Cushing’s disease has developed some cognitive effects that are impacting his ability to care for himself. Which cognitive effects are most likely to develop in a client with Cushing’s disease?

  • Question 3 of 7

A client with Cushing’s syndrome has become more withdrawn from friends and relatives because of changes in appearance. Upon admission to the healthcare center, the nurse gives the client a nursing diagnosis of Social Isolation related to discomfort with others and feelings of rejection by other people. Which of the following nursing interventions is most appropriate in this situation?

  • Question 4 of 7

A nurse is caring for a client who has been diagnosed with Cushing syndrome. The client is at risk of impaired skin integrity related to skin dryness and edema. Which of the following goals would be most appropriate for this client?

  • Question 5 of 7

A client is suffering from excess cortisol excretion as a result of an adenoma on the pituitary gland. Which of the following skin changes is an expected finding in a client with this condition? Select all that apply.

  • Question 6 of 7

The nurse is performing an admission assessment on a client and notes that the client has a moon-shaped face. The nurse understands that this could indicate which of the following?

  • Question 7 of 7

The nurse is caring for a client with Cushing syndrome. The nurse knows to perform which daily activity?