Cushing’s Syndrome

IntroductionCushing syndrome occurs when your body is exposed to high

levels of the hormone cortisol for a long time. The most common cause of Cushing syndrome, sometimes called hypercortisolism, is the use of oral corticosteroid medication. The condition can also occur when your body makes too much cortisol.Too much cortisol can produce some of the hallmark signs of

Cushing syndrome — a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, diabetes.Treatments for Cushing syndrome can return your body's

cortisol production to normal and noticeably improve your symptoms. The earlier treatment begins, the better your chances for recovery.

Anatomy

The adrenal axis (hypothalamic-pituitary-adrenal axis) refers to a complex set of interactions and feedback loops between the hypothalamus, pituitary and adrenal glands. This system regulates the bodies response to stress, immune function, energy expenditure, mood, emotions & libido. It is therefore an incredibly important body system which can cause huge problems if it malfunctions.• Cortisol 

Cortisol is a steroid hormone (glucocorticoid)which is released under stress & low steroid levels.

It’s main function is to increase blood glucose levels by promoting gluconeogenesis.

Cortisol also suppresses the immune system & increases fat, protein & carb metabolism.Random Fact!You may recognise cortisol’s pharmaceutical name which is HydrocortisoneHydrocortisone is used to reduce inflammation leveraging Cortisol’s immunosuppresive effect

• AldosteroneAldosterone is also a steroid

hormone (mineralocorticoid). It’s main function is to increase blood volume. It causes reabsorption of sodium and water as well as causing excretion of potassium

Random Fact!Drugs that interfere with the secretion or action of Aldosterone are in used as antihypertensivesAn example is Spironolactone which blocks Aldosterone receptors

How Cortisol Works• Corticotrophic releasing hormone (CRH) is secreted from

the Hypothalamus• This release is influenced by stress levels, time of

day & serum cortisol levels• CRH travels in the blood & binds to specific receptors

on the Pituitary Gland• This binding causes increased production

of ACTH (adrenocorticotrophic hormone)• ACTH is released into the blood stream where it travels

to the Adrenal glands• ACTH binds to specific receptors on the Adrenal Cortex• This stimulates the Adrenal Cortex to

release Cortisol into the blood• Cortisol enables the body to cope with stress in a more

effective manner• Increased levels of Cortisol also have

an immunosuppresive effect• Blood glucose is also increased via breakdown

of glycogen, protein & fat• Increased serum Cortisol inhibits production

of CRH & ACTH via negative feedback.

Pathophysiology

Use of corticosteroid medications

Stimulates anterior pituitary gland

Pituitary produces increased ACTH

ACTH stimulates adrenal cortex to

release glucocorticoidsArrest of growth

ObesityMusculoskeletal ChangesGlucose IntoleranceExcessive Protein

CatabolismHyoerglycemia

Increased AldosteroneSodium and Water

RetentionIncreased Plasma Volume

Increased BP

Patient’s Profile• Name: A.M.P.• Age: 20 years old• Birthdate: July 31, 1993• Birth place: Tampus, Boac, Marinduque

• Religion: Catholic• Sex: Female• Address: Tampus, Boac, Marinduque

Review of SystemsCardiovascular• Hypertension

Endocrine• Truncal Obesity• Moon Face• Buffalo Hump• Menstrual

Irregularities

Metabolic• Sodium Retention

• Hypokalemia• Altered Calcium Metabolism

Immune• Decreased inflammatory responses

• Impaired wound healing

• Increased susceptibility to infection

Skeletal• Osteoporosis• Spontaneous Fractures

Muscular• Myopathy• Muscle WeaknessGastrointestinal• Peptic Ulcer• PancreatitisDermatologic• Thinning of Skin• Striae• Acne

Nursing PrioritizationNursing Diagnosis Prioritization RationaleRisk for injury High Safety of patient

is always of great concern

Risk For Infection Medium Although there is still no

infection, the patient is still at risk, so close

monitoring is important.

Disturbed Body Image

Low Patient’s perception of

herself may also be affected. It is

a must that we also give

attention to this aspect.

Drug StudyDrug Name

Machanism of Action

Dose Side Effects

Indications

Contraindication

Nursing responsibility

hydrocortisone

Binds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by: inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivitystabilizing lysosomal membranes

Adults. 20 to 240 mg daily as a single doseor in divided doses.I.V. INFUSION OR I.V., I.M., OR SUBCUTANEOUSINJECTION (HYDROCORTISONE SODIUM PHOSPHATE);I.M. INJECTION (HYDROCORTISONE)Adults. 15 to 240 mg daily as a single doseor in divided doses. Usual: One-half to onethirdthe oral dose.DOSAGE ADJUSTMENT Dosage increased tomore than 240 mg daily if needed to treatacute disease.I.V. INFUSION; I.V. OR I.M. INJECTION(HYDROCORTISONE SODIUM SUCCINATE)Adults. 100 to 500 mg every 2, 4, or 6 hr.

CNS: Ataxia, behavioral changes, depression,dizziness, euphoria, fatigue, headache,CV: Arrhythmias (from hypokalemia), fatembolism, heart failure,

To treat severe inflammation or acuteadrenal insufficiency

Hypersensitivity to hydrocortisone or itscomponents, idiopathic thrombocytopenicpurpura (I.M.), intestinal conditions prohibitingintrarectal steroids (P.R.), recentlive-virus vaccination, systemic fungalinfection

Advise patient to take daily dose of hydrocortisoneat 9 a.m.• Instruct patient to take tablets or oral suspensionwith milk or food.• Teach patient how to use foam or enemaform, if prescribed.• Caution patient not to stop drug abruptlywithout first consulting prescriber.

Nursing Care Plan

Discharge Planning• MedicationThe physician prescribed Hydrocortisone 240mg/daily

orally. • ExerciseEncourage the patient to assist in performing active

and passive range of motion exercise and isometric exercises (muscle atrophy) for good blood circulation.

• TreatmentFor the treatment, the physician order for continuous

prescription of Hydrocortisone 240mg a day.

• Health teachingConduct a health teaching to the client that includes encouraging on

good hygiene and performing activities that the patient can do, encourage taking a bath every day to provide comfort, wellness and good skin integrity, advising the patient to increase fluid intake and high protein diet for good recovery of energy. Also fruits like banana, apple, and vegetables.

• Out-patientRemind the patient to come for the follow-up check up assigned by the

physician.

• DietAdvice the patient to have low salt diet, high-protein diet, incrased

calcium intake or low fat diet, high fiber and high protein intake.

• SpiritualEncourage patient to have frequent praying to help his spiritual needs