Cushing's Disease

Question 1

Adrenal Cortex Hormones:
Glucocorticoids regulate metabolism, increase blood glucose levels, and are critical in the physiologic stress response. The primary glucocorticoid is _______.
Mineralocorticoids regulate sodium and potassium balance. The primary mineralocorticoid is ________.
Androgens contribute to growth and development in both genders and to sexual activity in adult women.

Answer 1

cortisol

aldosterone

Question 2

Etiology and Pathophysiology of Cushing’s Syndrome:
Cushing syndrome is a clinical condition that results from chronic exposure to excess corticosteroids, particularly glucocorticoids.
Several conditions can cause Cushing syndrome. The most common cause is iatrogenic administration of exogenous corticosteroids (e.g., ________).

Answer 2

prednisone

Question 3

Etiology and Pathophysiology of Cushing’s Syndrome:
Approximately 85% of the cases of endogenous Cushing syndrome are due to an adrenocorticotropic hormone (ACTH)–secreting pituitary ______ which is CUSHING’S disease.
Other causes of Cushing syndrome include adrenal tumors and ______ ACTH production by tumors (usually of the lung or pancreas) outside of the hypothalamic-pituitary-adrenal axis.

Answer 3

adenoma

ectopic

Question 4

Clinical Manifestations of Cushing’s Syndrome:
The clinical presentation may be the first indication of Cushing syndrome: (1) centripetal (truncal) obesity or generalized obesity including supraclavicular and dorsocervical fat pads (buffalo hump) (2) “moon face” (3) purplish red striae (usually depressed below the skin surface) on the abdomen, breast, or buttocks; (4) ______ in women and menstrual disorders in women; (5) ________; and (6) ________.

Answer 4

hirsutism
hypertension
Hypokalemia

Question 5

Clinical Manifestations of Cushing’s Syndrome:
Loss of libido is seen in both men and women.
________: this include a rounded face (“moon facies”) with thin, reddened skin.
________: broad, purple striae; and easy bruising (image: left antecubital fossa)

Answer 5

Moon Face

Truncal obesity

Question 6

Clinical Manifestations of Cushing’s Syndrome:
Manifestations of Cushing syndrome can be seen in most body systems and are related to excess levels of corticosteroids.
Although signs of _______ excess usually predominate, symptoms of mineralocorticoid and androgen excess may also be seen.
Corticosteroid _____ causes pronounced changes in physical appearance.

Answer 6

glucocorticoid

excess

Question 7

Clinical Manifestations of Cushing’s Syndrome:
Excess Glucocorticoids:
_______, the most common feature, results from the accumulation of adipose tissue in the trunk, face, and cervical spine area.
_______ occurs because of glucose intolerance (associated with cortisol-induced insulin resistance) and increased gluconeogenesis by the liver.

Answer 7

Weight gain

Hyperglycemia

Question 8

Clinical Manifestations of Cushing’s Syndrome:
Excess Glucocorticoids:
Muscle wasting causes weakness, especially in the extremities. A loss of bone matrix leads to osteoporosis and back pain.The loss of _____ makes the skin weaker and thinner, and it bruises easily. ______ processes lead to a delay in wound healing. Irritability, anxiety, euphoria, and occasionally psychosis may also occur.

Answer 8

collagen

Catabolic

Question 9

Clinical Manifestations of Cushing’s Syndrome:
Excess Mineralcorticoids:
_________ EXCESS may cause hypertension (secondary to fluid retention)
Excess Androgens:
Adrenal androgen EXCESS may cause severe acne, _____ in women, and feminization in men. Menstrual disorders and hirsutism in women and gynecomastia and impotence in men occur more commonly with adrenal carcinomas.

Answer 9

Mineralocorticoid

virilizationin

Question 10

Diagnostic Tests for Cushing's Syndrome:
Plasma cortisol (the primary glucocorticoid) 
Levels may be \_\_\_\_\_\_\_\_, often seen with a loss of diurnal variation. 
When Cushing syndrome is suspected, a 24-hour urine collection for free cortisol is done. 
Urine cortisol levels higher than the normal range of \_\_\_ to \_\_\_\_\_mcg in 24 hours indicates that the patient has Cushing syndrome. 
If results are borderline, a low-dose dexamethasone suppression test is done. In a low dose dexamethasone test 0.5 mg is taken orally every 6 hours, for a total of 8 doses, starting at 6 am. A 24 hour urine for free cortisol is done the \_\_\_\_\_ day.

Answer 10

elevated
80 to 120 mcg
next

Question 11

Diagnostic Tests for Cushing’s Syndrome:
Urine levels of _______ may be elevated.
_____ results can occur with depression and with certain drugs.
CT scan and MRI of the pituitary and adrenal glands may be done.

Answer 11

17-ketosteroids

False-positive

Question 12

Diagnostic Tests for Cushing’s Syndrome:
Plasma _____ levels may be low, normal, or elevated, depending on the underlying cause of Cushing syndrome.
High or normal ACTH levels indicates that the patient has ________ (this is caused by pituitary etiology), whereas low or undetectable levels indicate the patient has ______ (this is cause by an adrenal or medication etiology).
______ and ________ are seen in ectopic ACTH syndrome and adrenal carcinoma.

Answer 12

ACTH
Cushing disease
Cushing syndrome
Hypokalemia and alkalosis

Question 13

Collaborative Care of Cushing’s Syndrome:
If Cushing syndrome has developed during the course of prolonged administration of ____, the following alternatives may be implemented:
1. Gradual discontinuation of corticosteroid therapy.
2. Reduction of the corticosteroid dose.
3. Conversion to an _____-day regimen.

Answer 13

corticosteroids (e.g., prednisone)

alternate

Question 14

Collaborative Care of Cushing’s Syndrome:
Gradual ______ of the corticosteroids is necessary to avoid potentially life-threatening adrenal insufficiency.
An alternate-day regimen is one in which twice the daily dosage of a shorter-acting corticosteroid is given every other morning to minimize hypothalamic-pituitary-adrenal suppression, growth suppression, and altered appearance. This regimen is NOT used when the corticosteroids are given as ______ therapy.

Answer 14

tapering

hormone replacement therapy

Question 15

Collaborative Care of Cushing’s Syndrome:
Surgical interventions are done based on whether it is caused by Adrenal or Pituitary tumors.
_______ – procedure that can be preformed to remove either unilateral or bilateral adrenal glands
________ - procedure that can be preformed to remove Pituitary tumors.

Answer 15

Adrenelectomy

Hypophysectomy

Question 16

Nursing Assessment of Cushing’s Syndrome:
Subjective Data:
Obtain the following important health information from the patient:
Past health history: pituitary tumor (Cushing disease); adrenal, pancreatic, or pulmonary neoplasms; ______; frequent infections
Medications: use of corticosteroids

Answer 16

GI bleeding

Question 17

Nursing Assessment of Cushing’s Syndrome:
Subjective Data:
Obtain the following important health information related to pertinent functional health patterns:
Health perception–health management: malaise
Nutritional-metabolic: _______ gain, anorexia
Elimination: polyuria; ________ wound healing, easy bruising.

Answer 17

weight

prolonged

Question 18

Nursing Assessment of Cushing’s Syndrome:
Subjective Data:
Obtain the following important health information related to pertinent functional health patterns:
Activity-exercise: weakness, fatigue
Sleep: insomnia, poor sleep quality
Cognitive-perceptual: headache; back, joint, bone, and ____ pain; poor _______ and memory

Answer 18

rib

concentration

Question 19

Nursing Assessment of Cushing’s Syndrome:
Subjective Data:
Obtain the following important health information related to pertinent functional health patterns:
Self-perception–self-concept: negative feelings regarding changes in personal appearance
Sexuality-reproductive: amenorrhea, impotence, ______ libido
Coping–stress tolerance: anxiety, mood disturbances, emotional ______, psychosis

Answer 19

decreased

lability

Question 20

Nursing Assessment of Cushing’s Syndrome:
Objective Data:
Possible focused assessment findings include the following:
General: truncal obesity, supraclavicular fat pads, buffalo hump, _____ face
Integumentary: _____ of body and face in women

Answer 20

moon

hirsutism

Question 21

Nursing Assessment of Cushing’s Syndrome:
Objective Data:
Possible focused assessment findings include the following:
Integumentary: ______ of head hair; thin, friable skin; acne; petechiae; purpura; hyperpigmentation; purplish red _____ on breasts, buttocks, and abdomen; edema of lower extremities.

Answer 21

thinning

striae

Question 22

Nursing Assessment of Cushing’s Syndrome:
Objective Data:
Possible focused assessment findings include the following:
Cardiovascular: hypertension
Musculoskeletal: muscle wasting, thin extremities, awkward gait
Reproductive: _______, testicular atrophy (in men); enlarged ______ (in women) R/T androgens

Answer 22

gynecomastia

clitoris

Question 23

Nursing Assessment of Cushing’s Syndrome:
Objective Data:
Possible focused assessment findings include the following diagnostic findings: ________, hyperglycemia, dyslipidemia; polycythemia, granulocytosis, lymphocytopenia, and _______.

Answer 23

hypokalemia

eosinopenia

Question 24

Nursing Assessment of Cushing’s Syndrome:
Objective Data:
Possible focused assessment findings include the following possible diagnostic findings:
↑ plasma cortisol level; high, low, or normal _____ levels; abnormal result of dexamethasone suppression test;↑ urine _____ and ______;
glycosuria, hypercalciuria; and osteoporosis seen on _______.

Answer 24

ACTH
free cortisol and 17-ketosteroids
x-ray

Question 25

Nursing Diagnosis of Cushing’s Syndrome:
Nursing diagnoses for the patient with Cushing syndrome may include, but are not limited to, the following:
• Risk for ______ related to lowered resistance to stress and suppression of immune system
• Imbalanced nutrition: ______ than body requirements related to increased appetite, high caloric content of foods, and inactivity
• Disturbed body image related to change in ______ from disease process
• Impaired ______ integrity related to excess corticosteroids, immobility, and altered skin integrity (fragility)

Answer 25

infection
more
appearance
skin

Question 26

Planning for Cushing’s Syndrome:
The overall ______ are that the patient with Cushing syndrome will
• Experience relief of symptoms
• Avoid serious complications
• Maintain a positive self-image
• Actively participate in the therapeutic plan

Answer 26

goals

Question 27

Nursing Implementation for Cushing’s Syndrome:
Health promotion is focused on identifying patients at risk for Cushing syndrome.
Patients receiving long-term, ______ corticosteroids for a variety of diseases are at risk. Patient teaching related to medication use and the monitoring of side effects are important preventive measures.

Answer 27

exogenous

Question 28

Acute Nursing Interventions for Cushing’s Syndrome:
Patients with Cushing syndrome are seriously ill. Because the therapy has many side effects, the focus of assessment is on signs and symptoms of hormone toxicity, drug toxicity, and complicating conditions (e.g., cardiovascular disease, _______, infection). Monitor for signs and symptoms of abnormal thromboembolic events such as pulmonary _____ (e.g., sudden chest pain, dyspnea, tachypnea).

Answer 28

diabetes mellitus

emboli

Question 29

Acute Nursing Interventions for Cushing’s Syndrome:
Assess and monitor vital signs, daily weight, glucose level, and possible infection.
Because NORMAL signs and symptoms of inflammation (e.g., fever, redness) may be ______ so the nurse MUST INSTEAD assess for pain, loss of function, and purulent drainage.

Answer 29

minimal or absent

Question 30

Nursing Implementation for Cushing’s Syndrome:
Emotional Support:
Another important focus of nursing care is emotional support.
Changes in appearance such as ______ obesity, multiple bruises, hirsutism in women, and gynecomastia in men can be distressing.
The patient may feel unattractive, repulsive, or unwanted. You can help by remaining sensitive to the patient’s feelings and offering respect and unconditional acceptance.

Answer 30

centripetal

Question 31

Nursing Implementation for Cushing’s Syndrome:
Emotional Support:
Reassure the patient that the physical changes and much of the emotional lability will RESOLVE when _____ levels return to NORMAL.
If treatment involves surgical removal of a pituitary adenoma, an adrenal tumor, or one or both adrenal glands, nursing care will additionally focus on preoperative and postoperative measures.

Answer 31

hormone

Question 32

Nursing Implementation for Cushing’s Syndrome:
Preoperative Care:
Before surgery, the patient’s physical condition should optimized.
_____ and _____ must be controlled, and hypokalemia must be corrected with diet and potassium supplements.
A high- ______ diet helps correct the protein depletion.

Answer 32

Hypertension and hyperglycemia

protein

Question 33

Nursing Implementation for Cushing’s Syndrome:
Preoperative Teaching:
Preoperative teaching will depend on the type of surgical approach planned (hypophysectomy or adrenalectomy), and should include information regarding the postoperative care that the patient should anticipate.
In the postoperative period (for both laparoscopic and open adrenalectomy), patients may have a nasogastric tube, a urinary catheter, IV therapy, ________ monitoring, and leg sequential compression devices to prevent emboli.

Answer 33

central venous pressure

Question 34

Nursing Implementation for Cushing’s Syndrome:
Postoperative Teaching:
Surgery on the adrenal glands poses risks beyond those of other types of operations.
Because the adrenal glands are vascular, the risk of ______ is increased. Surgical manipulation of adrenal gland tissue during surgery may release LARGE amounts of hormones into the circulation, producing NOTICEABLE CHANGES in the metabolic processes affected by these hormones. Postoperatively, BP, fluid balance, and electrolyte levels tend to be _____ because of these hormone fluctuations.

Answer 34

hemorrhage

unstable

Question 35

Nursing Implementation for Cushing’s Syndrome:
Postoperative Care:
High doses of corticosteroids (e.g., ________) are administered IV during surgery and for several days afterward to ensure adequate responses to the stress of the procedure.
If large amounts of endogenous hormone have been released into the systemic circulation during surgery, the patient is likely to develop _______, which increases the risk of hemorrhage.

Answer 35

hydrocortisone [Solu-Cortef]

hypertension

Question 36

Nursing Implementation for Cushing’s Syndrome:
Postoperative Care:
High levels of corticosteroids increase susceptibility to infection and delay wound healing.
The critical period for circulatory instability ranges from ____ to ____ hours after surgery. During this time, you must constantly be alert for signs of corticosteroid imbalance.
Report to the DOCTOR any ______ or significant changes in BP, respirations, or heart rate.
Monitor fluid intake and output carefully, and assess for potential imbalances.
IV corticosteroids are given, and the dose and rate of flow are adjusted to the patient’s clinical manifestations and fluid and electrolyte balance. Oral doses are given as tolerated. Keep the IV line in place after IV corticosteroids are withdrawn to enable quick administration of corticosteroids or _______.

Answer 36

24 to 48 hours
SUDDEN
vasopressors

Question 37

Nursing Implementation for Cushing’s Syndrome:
Postoperative Care:
Obtain morning urine samples (collected at the same time each morning) for _______ measurement to evaluate the effectiveness of the surgery.
If corticosteroid dosage is tapered too rapidly after surgery, ________ may develop.
Vomiting, increased weakness, dehydration, and hypotension may indicate _______.
In addition, the patient may complain of painful joints, pruritus, or peeling skin and may experience severe emotional disturbances.
Report these signs and symptoms so that drug doses can be adjusted as necessary.

Answer 37

cortisol
acute adrenal insufficiency
hypocortisolism

Question 38

Nursing Implementation for Cushing’s Syndrome:
Postoperative Care:
After surgery, patients are usually maintained on bed rest until the _____stabilizes.
Be alert for ____ signs of postoperative infections because the usual inflammatory responses are suppressed.
To prevent infection, provide meticulous care when changing the dressing and during any other procedures that necessitate access to body cavities, circulation, or areas under the skin.

Answer 38

BP

subtle

Question 39

Nursing Implementation for Cushing’s Syndrome:
Ambulatory and Home Care:
Discharge instructions are based on the patient’s lack of endogenous corticosteroids and resulting INABILITY to physiologically react to stressors.
Consider a _____ nurse referral, especially for older adults, because of the need for ongoing evaluation and educational needs.

Answer 39

home health

Question 40

Nursing Implementation for Cushing’s Syndrome:
Ambulatory and Home Care:
Instruct the patient to wear a MedicAlert bracelet at all times and carry medical identification and instructions in a wallet or purse.
Teach the patient to avoid exposure to extremes of ________, infections, and emotional disturbances. Stress may produce or precipitate _______ because the remaining adrenal tissue CANNOT meet an increased hormonal demand.

Answer 40

temperature

acute adrenal insufficiency

Question 41

Nursing Implementation for Cushing’s Syndrome:
Ambulatory and Home Care:
Teach patients to ADJUST their corticosteroid replacement therapy in accordance with their ______ levels. Consult with the patient’s health care provider to determine the parameters for dosage changes if this plan is feasible.
If the patient cannot adjust his or her own medication according to stress levels appropriately or if weakness, ______, fever, or nausea and vomiting occur, the patient should contact the health care provider for a possible adjustment in corticosteroid dosage.
Many patients require ______ replacement therapy. However, it may take several months to adjust the hormone dose satisfactorily, and patients should be prepared accordingly.

Answer 41

Stress
fainting
lifetime

Question 42

Nursing Evaluation of Cushing’s Syndrome:
Patient Outcomes:
The expected outcomes are that the patient with Cushing syndrome will
• Experience no signs or symptoms of infection
• Attain weight appropriate for height
• ______ acceptance of appearance and treatment regimen
• Demonstrate healing of skin and maintenance of intact skin

Answer 42

Verbalize

Question 43

Quick Review of Cushing’s Syndrome:
Cushing syndrome is a clinical condition that results from chronic exposure to excess corticosteroids, particularly glucocorticoids.
The most common cause is the administration of exogenous corticosteroids (e.g., prednisone). Most cases of endogenous Cushing syndrome are due to an adrenocorticotropic hormone (ACTH) secreting pituitary tumor (pituitary adenoma or adrenal tumor).
Key manifestations include central or generalized obesity, “moon face” (fullness of face), purplish-red striae below the skin surface, hirsutism in women, hypertension, and unexplained ______.
Treatment is dependent on the underlying cause and includes surgery and drug therapy to normalize _______ levels.

Answer 43

hypokalemia

hormone

Question 44

Quick Review of Cushing’s Syndrome:
Nursing care revolves around the risk of infection, imbalanced nutrition, disturbed self-esteem, risk of injury, and impaired skin integrity.
Lifetime hormone therapy is required by patients who undergo _______ or ______. Care instructions are based on patient’s inability to react physiologically to a stressor.

Answer 44

adrenalectomy or hypophysectomy

Question 45

Adrenal Cortex Hormones:
Hyperfunction of the Adrenal glands is also known as ______ or Cushing’s disease. There are three main classifications of adrenal cortex steroid hormones: glucocorticoids, mineralocorticoids, and androgens. The term corticosteroid refers to any one of these three types of hormones produced by the adrenal cortex.

Answer 45

hypercortisolism