Cushing’s Syndrome Nursing Care Plan & Management

Notes

Description
  • Cushing’s Syndrome results from excessive secretion of one or all of the adrenocortical hormones which includes glucocorticoid cortisol (predominant type), the mineralocorticoid aldosterone, and the adrogenital corticoids.
Types of Cushing’s Syndrome:
  1. Pituitary Cushing’s syndrome (Cushing’s disease) is the most common cause of Cushing’s syndrome, and stems from hyperplasia of both adrenal glands caused by over stimulation by adrenocorticotropic hormone (ACTH), usually from pituitary adenoma. The syndrome mostly affects women between ages 20 and 40.
  2. Adrenal Cushing’s syndrome is associated with adenoma or carcinoma of the adrenal cortex. The disease may recur after surgery.
  3. Ectopic Cushing’s syndrome results from autonomous ACTH secretion by extrapituitary tumors (such as the lungs) producing excess ACTH.
  4. Iatrogenic Cushing’s syndrome is caused by exogenous glucocorticoid administration.

Cushing's Syndrome

Causes

The most common cause of Cushing syndrome is side effects from taking anti-inflammatory steroid medications for conditions such as asthma and rheumatoid arthritis.

The second most common cause is Cushing’s disease, which occurs when the pituitary gland makes too much of the hormone ACTH. ACTH stimulates the adrenal glands to produce cortisol.

Cushing’s disease affects women more often than men.

Cushing syndrome can also be caused by the following:

  • Tumor of the pituitary gland or adrenal gland
  • Tumor elsewhere in the body (ectopic Cushing syndrome)
Assessment

1. Signs and symptoms of excess glucocorticoid (cortisol) secretion:

  • Weight gain or obesity.
  • Heavy trunk; thin extremities.
  • Fat pad (Buffalo Hump) in neck and supraclavicular area.
  • Rounded face (moon face); plethoric, oily complexion.
  • Skin – fragile and thin; striae and ecchymosis, acne.
  • Musculoskeletal – muscle wasting causes by excessive catabolism, osteoporosis, characteristic kyphosis, back ache.
  • Mental disturbances – mood changes, psychosis.
  • Increased susceptibility to infections.

2. Manifestation of excess mineralocorticoid (aldosterone) secretion:

  • Hypertension
  • Hypernatremia, hypokalemia
  • Weight gain
  • Expanded blood volume
  • Edema

3. Manifestation 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.
Diagnostic Evaluation
  • Excessive plasma cortisol levels and loss of diurnal variation.
  • Increased blood glucose levels, decreased serum potassium level.
  • Plasma ACTH elevated in patients with pituitary tumors, very low in patients with adrenal tumor.
  • Eosinophils decreased on complete blood count.
  • Elevated urinary 17-hydroxycorticoids and 17-ketogenic steroids.
  • Overnight dexamethasone suppression test, possibly with cortisol urinary excretion measurement, to check for:
    • Unsuppressed cortisol level in Cushing’s syndrome cause by adrenal tumors.
    • Suppressed cortisol level in Cushing’s disease caused by pituitary tumor.
  • Skull X-ray detects erosion of the sella turcica by a pituitary tumor; CT scan and ultrasonography locate tumor.
Primary Nursing Diagnosis
  • Fluid volume excess related to abnormal retention of sodium and water
Medical Management

Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex

  • Surgical removal of the tumor ( transphenoidal hypophysectomy) is the treatment of choce (90% success rate)
  • Radiation of the pituitary gland is successful but takes several months for symptom control
  • Adrenalectomy is performed in patients with primary adrenal hypertrophy
  • Post operatively, temporary replacement therapy with hydrocortisone maybe necessary until the adrenal glands begin to respond normally ( maybe several moths)
  • If bilateral adrenalectomy was performed lifetime replacement of adrenal cortex hormones is necessary
  • Adrenal enzyme inhibitors ( E.g. metyrapone or mitotine) maybe used with ectopic ACTH- secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects
  • If Cushing’s syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate-day therapy to treat the underlying disease
Pharmacologic Intervention
  • Mitotane 2–16 g per day in divided doses PO an antineoplastic, inhibits activity of adrenal cortex; used to treat inoperable adrenocortical carcinomas and Cushing’s syndrome
  • Cyproheptadine 4 mg 2–3 times a day PO an antihistamine agent ; serotonin antagonist, inhibits the release of ACTH from pituitary gland; drug is considered last resort and often causes no improvement
  • Other Drugs: Aminoglutethimide inhibits cholesterol synthesis, and metyrapone partially inhibits adrenal cortex steroid synthesis. These drugs may be used in conjunction with surgery or radiation if the tumor is not completely resectable or if complete remission is not expected.
Nursing Intervention
  • Monitor intake and output, daily weights, and serum glucose and electrolytes.
  • Monitor for signs of infection because risk is high with excess glucocorticoids.
  • After hypophysectomy, monitor for diabetes insipidus, hypothyroidism, and other endocrine changes.
  • Assess the skin frequently to detect reddened areas, skin breakdown or tearing, excoriation, infection or edema.
  • Handle skin and extremity gently to prevent trauma; prevent falls by using siderails.
  • Avoid using adhesive tape on the skin to reduce trauma on its removal.
  • Encourage the patient to turn in bed frequently or ambulate to reduce pressure on bony prominences and areas of edema.
  • Assist the patient with ambulation and hygiene when weak and fatigued. Use assistive devices during ambulation to prevent falls and fractures.
  • Help the patient to schedule exercise and rest. Advise the patient how to recognize signs and symptoms of excessive exertion.
  • Instruct the patient to correct body mechanics to avoid pain or injury during activities.
  • Provides foods low in sodium to minimize edema and provide foods high in potassium (bananas, orange juice, tomatoes) and administer potassium supplements as prescribed to counteract weakness re;ated to hypokalemia.
  • Report edema and signs of fluid retention.
  • Encourage the patient to verbalize concerns about the illness, changes in appearance, and alters role function.
  • Explain to female patient who has benign adenoma or hyperplasia that, with proper treatment, evidence of masculinization can be reversed.
Documentation Guidelines
  • Physical response: Vital signs, neurological assessment, cardiopulmonary assessment, wound healing, signs of infection (fever, wound drainage, productive cough), important laboratory deviations (serious electrolyte imbalances, alterations in glucose levels)
  • Nutrition: Daily weights, appetite, food tolerance, food preference, response to diet teaching, calorie count if indicated
  • Emotional response: Concerns over body image, self-concept, mood, affect
Discharge and Home Healthcare Guidelines

Describe the pathophysiology of the disease. Identify factors that aggravate the disease (stress, changes in diet, injury), as well as the signs and symptoms. Explore complications of the disease, and ask whom to notify if they occur. Describe the treatment plan and expected effects, as well as possible complications. Describe all medications, including the name, dosage, action, side effects, route, and importance of lifelong dosing if indicated.

 

 


Sources:
ADAM for images
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Nursing crib.com
Handbook for Brunner & Suddarth’s, Textbook of Medical-SurgicalNursing, 11th ed

 

Exam

Welcome to your MSN Exam for Cushing’s Syndrome! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 20 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider which condition is typically not linked to a decrease in bone density or an increased risk of osteoporosis.

1 / 20

1. Nurse Arthur is discussing osteoporosis with an elderly woman and considering various factors that could contribute to the condition. He understands that most of the following are known to be associated with the development of osteoporosis, except for one. Which factor does Nurse Arthur recognize as NOT contributing to osteoporosis?

💡 Hint

Think about the common internal factor that leads to the overproduction of ACTH, indirectly causing the symptoms of this disease.

2 / 20

2. Nurse Evans is discussing the etiology of various hormonal disorders with her nursing team. When focusing on Cushing's Disease, she highlights the most frequent cause of this condition. What is the primary factor responsible for the onset of Cushing's Disease?

💡 Hint

Consider which symptom could indicate a potentially serious cardiovascular complication that requires urgent evaluation.

3 / 20

3. In her assessment of a client with Cushing's syndrome, Nurse Taylor is particularly vigilant for signs that require immediate medical attention. Which of the following observations should she promptly report to the physician?

💡 Hint

Focus on the symptoms that are indicative of a sharp decrease in calcium levels, often a complication following this type of surgery.

4 / 20

4. Nurse Rihanna is meticulously evaluating a client who has recently undergone a thyroidectomy. During her assessment, she notes the presence of muscle twitching, tingling sensations, and numbness in the fingers, toes, and perioral area. Based on these clinical findings, Nurse Rihanna should consider the possibility of which postoperative complication?

💡 Hint

Consider the metabolic effects of Cushing's syndrome and which parameter is likely to normalize with successful treatment.

5 / 20

5. Nurse Liza is monitoring the progress of a 29-year-old female client undergoing treatment for Cushing's syndrome. She anticipates seeing improvements in certain conditions associated with the syndrome. Which of the following would Nurse Liza expect to observe a decrease in as the treatment proves effective?

💡 Hint

Consider the condition that is specifically associated with an abnormally large urine output, which may be particularly relevant in the context of a patient who has recently undergone brain surgery.

6 / 20

6. Upon assessing a postcraniotomy client, Nurse Patel notices that the urine output from the catheter is 1500 ml for the first hour and the same for the second hour. Given this significant urine output, Nurse Patel begins to consider potential underlying causes. Which condition should she suspect?

💡 Hint

Prioritize the assessment of the patient whose vital signs indicate a condition that can be immediately life-threatening if not addressed promptly.

7 / 20

7. At the start of the shift, Nurse Jordan has been assigned several patients, each with their own set of medical conditions. She needs to prioritize which patient to assess first based on the urgency of their condition. The patients are:

💡 Hint

Focus on the hormone that is known to be in excess in this condition, impacting various bodily functions and presenting with characteristic symptoms.

8 / 20

8. In a detailed discussion about the etiology of Cushing's Syndrome, Nurse Harper elaborates on the potential causes. She outlines the following possibilities:

💡 Hint

Consider the distinction between a specific cause related to the pituitary gland and broader causes that could affect cortisol levels.

9 / 20

9. Nurse Thompson is discussing with a student nurse the differences between Cushing's Disease and Cushing's Syndrome during a clinical teaching session. She emphasizes the importance of understanding the underlying causes of each condition. Is it accurate to say that Cushing’s Disease and Cushing’s Syndrome are caused by the same factors?

💡 Hint

Focus on the disorder known for its association with high levels of cortisol, often leading to distinctive physical characteristics and systemic effects.

10 / 20

10. Nurse Thompson is reviewing endocrine disorders with her patient, discussing the specific symptoms and causes of each. She describes a condition that is characterized by a collection of symptoms resulting from an excess of free circulating cortisol from the adrenal cortex. Which disorder is Nurse Thompson explaining?

💡 Hint

Focus on the system that is directly involved in inflammation and defense mechanisms, and is notably affected by corticosteroids.

11 / 20

11. Corticosteroids are known for their strong ability to suppress the body's inflammatory response. Among the options listed, which condition or action do corticosteroids primarily suppress?

💡 Hint

Consider which symptom may indicate a potentially serious complication that can arise in patients with Cushing’s disease and requires prompt medical attention.

12 / 20

12. In monitoring a patient with Cushing's disease, Nurse Green notes several findings during her assessment. She understands that certain symptoms require immediate communication with the physician. Which of these findings should prompt Nurse Green to notify the physician right away?

💡 Hint

Focus on the symptom that is most visually evident and commonly associated with the hormonal imbalances found in Cushing's Syndrome.

13 / 20

13. Nurse Davis is educating her team about the signs and symptoms of Cushing's Syndrome. She wants to highlight the most characteristic and noticeable manifestation of the condition. Which symptom should she emphasize?

💡 Hint

Consider the psychological condition that can manifest with mood disturbances, cognitive changes, and alterations in personal care and appetite.

14 / 20

14. Nurse Terence is meticulously documenting the symptoms of a female client with Cushing's syndrome who has just been admitted to the medical-surgical unit. The client's presentation includes agitation, irritability, memory issues, loss of appetite, and a generally unkempt appearance. Which condition do these symptoms most closely align with?

💡 Hint

Consider the gland often involved in the overproduction of ACTH, which can lead to an excess of cortisol, characteristic of this syndrome.

15 / 20

15. During a lecture on endocrine system disorders, Nurse Carter emphasizes the significance of understanding the source of various conditions. She asks her students about the origin of Cushing's Syndrome. Which gland is primarily associated with the onset of this disorder?

💡 Hint

Consider which option listed is not characteristic of the fat distribution pattern typically seen in Cushing's Disease.

16 / 20

16. In discussing Cushing's Disease, Nurse Parker is highlighting the typical signs and symptoms associated with this condition. However, she points out one option that is not a typical manifestation of Cushing's Disease. Which of the following does NOT commonly present in a patient with Cushing's Disease?

💡 Hint

Consider the term that is synonymous with the pituitary gland and encompasses both its anterior and posterior components.

17 / 20

17. Nurse Mitchell is conducting a session on endocrine system anatomy with a group of nursing students. She refers to the pituitary gland and asks the students to recall its other commonly used name. What is the correct term she is looking for?

💡 Hint

Think about the specific pattern of fat distribution and other physical changes typically seen in individuals with Cushing's syndrome.

18 / 20

18. Nurse Robert is evaluating a client who may have Cushing's syndrome. He knows that certain physical characteristics are commonly associated with this condition. Based on his knowledge, what would Nurse Robert expect to find in a client with Cushing's syndrome?

💡 Hint

Focus on the hormone that is a part of the hypothalamic-pituitary-adrenal axis and is known for its role in stress response and metabolism.

19 / 20

19. Adrenocorticotropic hormone (ACTH) secreted by the pituitary gland specifically targets which glands, and what does it stimulate these glands to release?

💡 Hint

Consider the term that doesn't directly relate to the hormonal or physiological aspects commonly associated with Cushing's Syndrome.

20 / 20

20. Among the terms listed below, which one is NOT recognized as an alternative name for Cushing's Syndrome?

Nursing Care Plan

Nursing Diagnosis
  1. Risk for injury and Risk for infection related to weakness and changes in protein metabolism and inflammatory response.
  2. Self-care Deficit: weakness, feeling of tiredness, muscle atrophy and changes in sleep patterns.
  3. Impaired skin integrity related to edema, impaired healing and the skin is thin and fragile.
  4. Disturbed Body Image related to changes in physical appearance, sexual dysfunction and decreased activity levels.
  5. Disturbed Thought Processes related to fluctuations in emotions, irritability and depression.
Reference Sample