Cushing's Disease

Question 1

Etiology and pathophysiology of Cushing Syndrome

Answer 1

Caused by EXCESS of corticosteroids
Latrogenic administration of exogenous corticosteroids
ACTH-secreting pituitary adenoma
Adrenal tumors
Ectopic ACTH production by tumors

Question 2

Clinical manifestations

Answer 2

Cenripetal (truncal)/generalized obestiy
Moon face
Purplish red striae
Hirsutism
Menstrual disorders
Hypertension
Hypokalemia

Question 3

Clinical manifestations of excess glucocorticoids

Answer 3

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

Question 4

What does excess mineralocorticoid excess lead to?

Answer 4

Hypertension

Question 5

What does excess adrenal androgen lead to?

Answer 5

Severe acne
Virilization in women
Feminization in men

Question 6

Diagnostic studies

Answer 6

Plasma cortisol measurement
24-hour urine collection for free cortisol
Low-dose dexamethasone suppression test
Urine 17-ketosteroid measurement
CT scan
MRI

Question 7

24-hour urine collection for free cortisol

Answer 7

Urine cortisol levels higher than normal range of 80-120 mcg in 24 hours indicates Cushing Syndrome

Question 8

Low-dose dexamethasone suppression test

Answer 8

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

Question 9

17-ketosteroids

Answer 9

24 hour urine collection
Meds that could affect outcome stopped temporarily
If high ACTH: Cushing Syndrome
If low ACTH: Addison’s Disease

Question 10

Plasma ACTH levels, diagnostic studies

Answer 10

High or normal with Cushing disease (pituitary etiology)

Can be low or undetectable with Cushing syndrome (adrenal or medication etiology)

Question 11

What is seen in ectopic ACTH syndrome and adrenal carcinoma?

Answer 11

Hypokalemia and alkalosis

Question 12

Ectopic ACTH Syndrome

Answer 12

Occurs when ACTH is produced somewhere else other than the pituitary gland

Question 13

If the cause is iatrogenic…

Answer 13

Gradually discontinue therapy
Decrease dose
Convert to an alternate-day regimen
Dose must be tapered gradually

Question 14

Surgical interventions

Answer 14

Adrenal tumors: adrenelectomy

Pituitary causes: hypophysectomy

Question 15

Subjective data to get

Answer 15

Medical history
-pituitary tumor
-adrenal, pancreatic, or pulmonary neoplasms
-GI bleeding
-frequent infections
Medications
-corticosteroids

Question 16

Subjective data continued

Answer 16

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

Question 17

Objective data

Answer 17

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

Question 18

Objective data from labs

Answer 18

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

Question 19

Assess and monitor…

Answer 19

VS
Daily weight
Glucose
Signs and symptoms of inflammation/infection
Signs and symptoms of thromboembolism

Question 20

Preoperative care

Answer 20

Optimize physical condition
Control hypertension and hyperglycemia
Correct hypokalemia
High-protein diet to correct protein depletion

Question 21

Preoperative teaching

Answer 21

Dependent on surgery

Question 22

What to expect after adrenalectomy

Answer 22

NG tube
Urinary catheter
IV therapy
Central venous pressure monitoring
Leg sequential compression devices

Question 23

Postoperative Care

Answer 23

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

Question 24

Monitoring postoperatively

Answer 24

Report any significant changes in VS
Monitor fluid intake and output
Administer corticosteroids as ordered
Obtain morning urine samples for cortisol measurement

Question 25

Monitor for acute adrenal insufficiency postoperative with…

Answer 25

Vomiting, increased weakness
Dehydration, hypotension
Painful joints
Pruritus
Peeling skin
Severe emotional disturbances

Question 26

Ambulatory and home care

Answer 26

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