Cushing's Disease Flashcards
Etiology and pathophysiology of Cushing Syndrome
Caused by EXCESS of corticosteroids Latrogenic administration of exogenous corticosteroids ACTH-secreting pituitary adenoma Adrenal tumors Ectopic ACTH production by tumors
Clinical manifestations
Cenripetal (truncal)/generalized obestiy Moon face Purplish red striae Hirsutism Menstrual disorders Hypertension Hypokalemia
Clinical manifestations of excess glucocorticoids
Weight gain from accumulation of adipose tissue
Hyperglycemia related to glucose intolerance and increased gluconeogenesis
Muscle wasting leads to weakness
Loss of bone matrix leads to osteoporosis and back pain
Loss of collagen that leads to thin skin, easily bruises
Delay in wound healing
Irritability
Anxiety
Euphoria
Psychosis
What does excess mineralocorticoid excess lead to?
Hypertension
What does excess adrenal androgen lead to?
Severe acne
Virilization in women
Feminization in men
Diagnostic studies
Plasma cortisol measurement 24-hour urine collection for free cortisol Low-dose dexamethasone suppression test Urine 17-ketosteroid measurement CT scan MRI
24-hour urine collection for free cortisol
Urine cortisol levels higher than normal range of 80-120 mcg in 24 hours indicates Cushing Syndrome
Low-dose dexamethasone suppression test
If results are borderline, this test is done
0.5 mg taken orally q 6 hours for a total of 8 doses starting at 0600
A 24 hour urine for free cortisol is done the next day
17-ketosteroids
24 hour urine collection
Meds that could affect outcome stopped temporarily
If high ACTH: Cushing Syndrome
If low ACTH: Addison’s Disease
Plasma ACTH levels, diagnostic studies
High or normal with Cushing disease (pituitary etiology)
Can be low or undetectable with Cushing syndrome (adrenal or medication etiology)
What is seen in ectopic ACTH syndrome and adrenal carcinoma?
Hypokalemia and alkalosis
Ectopic ACTH Syndrome
Occurs when ACTH is produced somewhere else other than the pituitary gland
If the cause is iatrogenic…
Gradually discontinue therapy
Decrease dose
Convert to an alternate-day regimen
Dose must be tapered gradually
Surgical interventions
Adrenal tumors: adrenelectomy
Pituitary causes: hypophysectomy
Subjective data to get
Medical history -pituitary tumor -adrenal, pancreatic, or pulmonary neoplasms -GI bleeding -frequent infections Medications -corticosteroids
Subjective data continued
Malaise Weight gain Anorexia Polyuria Prolonged wound healing Easy bruising Weakness, fatigue Insomnia, poor sleep quality Headache Back, joint, bone, or rib pain Poor concentration and memory Negative feelings Amenorrhea Impotence, decreased libido Anxiety Mood disturbances Emotional liability Psychosis
Objective data
Truncal obesity Supraclavicular fat pads Buffalo hump Moon faces Hirsutism of body and face Thinning of hair Friable skin Acne Petechia, purpura Hyperpigmentation Striae Edema Hypertension Muscle wasting Thin extremities Awkward gait Gynecomastia, testicular atrophy Enlarged clitoris
Objective data from labs
Decreased potassium level Increased glucose level Dyslipidemia Polycythemia Granlucytosis -lymphocytopenia -eosinopenia Increase serum cortisol level Abnormal ACTH levels Abnormal result of dexamethasone suppression Increased urine free cortisol and 17-ketosteroids Glycosuria Hypercalciuria Osteoporosis
Assess and monitor…
VS Daily weight Glucose Signs and symptoms of inflammation/infection Signs and symptoms of thromboembolism
Preoperative care
Optimize physical condition
Control hypertension and hyperglycemia
Correct hypokalemia
High-protein diet to correct protein depletion
Preoperative teaching
Dependent on surgery
What to expect after adrenalectomy
NG tube Urinary catheter IV therapy Central venous pressure monitoring Leg sequential compression devices
Postoperative Care
Increased risk of hemorrhage
Large release of hormones into circulation leads to instabilities in BP, fluid balance, and electrolyte levels
High doses of corticosteroids administered IV during and several days after surgery
Risk for hypertension and subsequent hemorrhage increased
Susceptibility to infection and delayed wound healing also increased
Monitoring postoperatively
Report any significant changes in VS
Monitor fluid intake and output
Administer corticosteroids as ordered
Obtain morning urine samples for cortisol measurement
Monitor for acute adrenal insufficiency postoperative with…
Vomiting, increased weakness Dehydration, hypotension Painful joints Pruritus Peeling skin Severe emotional disturbances
Ambulatory and home care
Home health nurse
Wear MedicAlert bracelet at all times
Avoid exposure to extremes of temperature, infection, and stress
Teach how to adjust medication and when to call HCP
Lifetime replacement therapy
