Question:

Cushing’s Syndrome

Ms Maureen Smith was a 24-year old female who presented at her GP complaining about persistent gastrointestinal bleeding and severe abdominal pain.

Maureen was 15 when she was diagnosed with rheumatoid (RA). She has since had numerous exacerbations that required the use high-dose corticosteroids.

She is currently taking 50mg daily of prednisolone and has been since her most recent exacerbation, 2 months ago.

Maureen also has type-2 diabetes that is managed with metformin.

She is currently a nurse student and part-time cook at the local pizza joint.

Maureen’s vital signs were assessed and found to be: PR88 bpm. RR18 bpm. BP154/106. mmHg. Temp. 36.9oC. Spo2 99% in the air.

She has a 28kg/m2 body mass index. The majority of her fat is located around her abdomen, with a slight hump between the shoulders.

Maureen’s husband noted that her face has become more round in recent weeks.

Her fasting BGL level is 14.0mmol/L.

The results of blood tests show that she has low cortisol levels and ACTH levels and high levels low density lipoprotein cholesterol.

She is currently awaiting a test for bone mineral density and is currently collecting urine in preparation for a 24-hour measurement of cortisol.

Case Discussion1.

Define the risks, causes, and consequences of the disease and the effects it may have on the patient and his family.2.

Give five common symptoms and a link to the underlying cause.a.

This can be accomplished in the form a.3.

Name two drugs commonly prescribed for patients with the condition. Also, describe the physiological effects of each drug on the body.a.

This does not apply to certain drugs but rather to the classes that these drugs are part of.4.

Identify and describe, in order, the nursing care strategies that you, as a registered nurse, should use within the first 24-hours after the patient’s admission.

Answer to Question: NRSG353 Acute Care Nursing 2

Cushing’s Syndrome is a disorder or syndrome caused by excess cortisol, or excessive use of corticosteroids.

Cortisol can be described as a hormone found in the kidney’s outer adrenal glands.

A hormone known as adrenocorticotrophic, (ACTH), regulates cortisol production.

It assists the body in times of stress, such as high blood sugar and swelling.

In this case study, Ms Maureen smith used high doses of corticosteroids in her treatment of RheumatoidArthritis. This leads to her Cushing’s syndrome.

This is called iatrogenic.

Harvey Cushing, the first woman to diagnose this disease in 1912, was the one who gave this name to the disease.

This type of disease can be found in nature because corticosteroids have been used to treat diseases like RA.

Adults are more likely to get it than their male counterparts.

Normally, the limit of incidence is between 25 to 45 years.

There are about 5 to 25 cases per 1,000,000 people.

This rare disease is most common in Australia, where it affects 300 to 1200 Australians every year.

Ectopic ACTH is more common in this Cushing’s condition than the normal (approximately 666 per million).

These risk factors include type 2 diabetes and obesity.

All of these symptoms can be seen in the case study 2.

Cushion’s Syndrome can be diagnosed by assessing the cortisol levels, disease duration and general health.

A proper treatment can cure the disease in as little as two to eight months.

Because the treatment takes so much time and results are slow, patients and their families become frustrated.

The patient may feel fatigued and weak which makes it difficult for them and their families to visit their doctor.

Cushing’s syndrome if not treated will cause more problems such as muscle weakness, weight gain in the face, abdomen depression, and mood swings.

Because the patient’s family has to take him to the doctor many times to get blood tests and treatment for his symptoms and complications, it is a serious burden.2.

Cushing Syndrome symptoms

It has a pathophysiology.

Type 2 diabetes

Cushing’s Syndrome patients have diabetes mellitus.

These patients suffer from dysfunctional glucose metabolism. This is due to excessive use of the glucocorticoids.

These drugs stimulate gluconeogenesis. This increases glucose levels and reduces insulin production.

Therefore, the glucose produced is not reduced and diabetic condition can occur (Mazziotti 2017).Obesity

Cortisol can be used to reduce stress and inflammation in the body.

It also regulates carbohydrate, fats and proteins.

The excess use corticosteroid drugs can increase cortisol levels.

Cortisol levels in excess can sometimes cause false alarms, and food metabolization or absorption may be affected even if the body does not need it.

Because of this, patients continue to eat and their bodies begin to accumulate excess fats.

Particularly, fat accumulation occurs in the abdomen region and the face (Lee and al. (2014)).Hypertension

Cushing syndrome patients often experience hypertension.

Hypertension is a common symptom in Cushing’s syndrome. It affects around 80 %.

Glucocorticoids may cause hypertension via their inborn mineralocorticoid actions; by activating the renin–angiotensin frame; by upgrading vasoactive substance levels and concealment of vasodilatory methods.

CNS control of cardiovascular health may also be affected by glucocorticoids, according to Isidori et. al. (2015).

Muscle weakness

Cushing’s syndrome affects around 60% of people.

Muscle weakness can cause muscle fatigue and muscle pain.

Corticosteroids increase protein metabolism.

These drugs lower the rate protein synthesis and cause more protein to be broken down, leading to the destruction of muscles.

These drugs incite catabolism and muscle protein (Fry, et al. (2016).

Thinning of the skin

Cushing syndrome symptoms include thinning of skin or other mucous membranes.

The patient’s skin becomes extremely dry and easily gets damaged.

The cortisol causes some of the dermal proteins to be degraded and some blood vessels to thin.

This results in skin becoming very thin and shiny quality paper thin, which can be torn easily (Raff Sharma & Nieman 2014.3.

The two main classes of drugs that are used for Cushing’s syndrome treatment are Adrenal corticosteroid synthetic inhibitor (Metyrapone), or Anti-steroid Drugs (Aminoglutethimide).Anti Steroid Drugs:-

This drug is used in the treatment of this disease.

Aminoglutethimide (also known as Cytadren) is one type of anti-steroid drug.

This drug blocks the production cholesterol-derived steroids. They are also used in Cushing’s syndrome.

These drugs are combined with other drugs and are used to inhibit patients with the disease’s adrenal gland function.

Aminoglutethimide is responsible for two types of disease.

It blocks aromatase, which is responsible for the production of estrogens out of androstenedione (and testosterone) and helps to prevent it from happening.

It is also effective in blocking the enzyme called P450scc that prevents cholesterol being converted into pregnenolone.

These drugs can lead to rash in the skin, human cortisol inhibition and hepatoxicity. (Niema et al., 2015).

Inhibitor of Adrenal Corticosteroid Steroid Synthesis:-

Metyrapone, a type of drug similar to Metyrapone, is generally used to diagnose and treat insufficiency.

These drugs inhibit the release of cortisol through inhibition of reversibly steroid11 b-hydroxylase.

This reduces ACTH secretion and increases plasma 11 deoxycortisol.

This drug is used to treat hypercortisolism (Cushing’s syndrome) (Daniel (2015).

It is used to stop hypercortisolism.

It also stops adrenal steroids.

This drug is used to temporarily relieve symptoms but not for long term treatment.

Metyrapone may also be used for Cushing’s Syndrome testing.

Metyrapone may cause an increase of ACTH in patients with no functioning pituitary.

You may also experience other side effects.

Dizziness, headaches and nausea are some of the side effects of this medication.

It can cause severe side effects such as nausea and vomiting.

It can also cause skin reactions such as a sore throat or fever.4.

As a registered nurses, I would adopt the following strategy for patients with Cushing’s syndrome.

First, I will keep an eye on the patient to prevent any complications.

My assessment will include the patient’s medical history, as well as the ability to perform daily activities and self-care activities.

First, I will conduct a skin examination to assess for injury or infection. Next, I’ll check for mental stability. That is the patient’s response and moods.

The assessment will include the 1) risk of injury- checking and checking for weakness, 2) injury risk- swelling response, and 3) deficits in self care- weakness, fatigue, disruption of sleeping pattern, and 4) checking and checking for skin injuries, and 5) checking and checking for problems in the body, such as lower activity levels and altered physical appearance.

6) Changes in mood swings or depression.

I will assess the patient and provide care (Gulanick & Myers 2013).

I will create a safe and comfortable environment that prevents the patient from falling and injures their bone and soft tissue.

To minimize muscle loss, I’ll make sure that they get a balanced diet with calcium and rich protein.

I will limit contact with patient and check for inflammation.

I will monitor the patient’s blood sugar levels and administer medications to help it.

I will provide moderate activities for the patient and adequate rest.

I will create a schedule that includes rest and activity (Llahana & Thomas 2016).

I will reduce the chances of infection by using medication and equipment, including glassware that is in sterile condition.

Will take care of fragile skin by giving a meticulous skin care.

A diet high in protein, carbohydrate, and low sodium should be used to lower the patient’s weight.

To improve patient’s mood swings or behavior, I will inform the patient’s loved ones about the illness and offer treatment options.

After consulting the doctor, I will give the required first line medications to reduce symptoms.

Monitoring of critical factors like hypotension weaken nerve impulse respiratory rate and checking for signs that may indicate a crisis such as trauma and surgery is essential.

I will administer fluids or electrolytes to the patient as needed and will also check daily weight and laboratory values.

For the diagnosis of diabetes, blood testing must be done.

Incentive spirometry is also encouraged.

Important work is to give information to family members and patients about self-care.

The patient’s family should be made aware that excessive corticosteroid use can increase Cushing syndrome symptoms.References:-Daniel, E., Aylwin, S., Mustafa, O., Ball, S., Munir, A., Boelaert, K., … & Davis, J. (2015).

Retrospective multicenter study on 195 Cushing’s Syndrome patients.

The Journal of Clinical Endocrinology & Metabolism. 100(11), 4146-4154.Eckstein, N., Haas, B., Hass, M. D. S., & Pfeifer, V. (2014).

Cushing’s syndrome.

Orphanet journal about rare diseases, 9(1).122.Fry, C. S., Nayeem, S. Z., Dillon, E. L., Sarkar, P. S., Tumurbaatar, B., Urban, R. J., … & Choudhary, S. (2016).

The link to muscle atrophy: Glucocorticoids increase muscle NF.kB inducing.

Physiological Reports (4(21), e13014.Gadelha, M. R., & Vieira Neto, L. (2014).

A systematic review of Cushing’s disease treatment efficacy.

Clinical endocrinology. 80(1). 1-12.Gulanick, M., & Myers, J. L. (2013).

Nursing care plans: nursing diagnosis. Elsevier Health Sciences.Isidori, A. M., Graziadio, C., Paragliola, R. M., Cozzolino, A., Ambrogio, A. G., Colao, A., … & ABC Study Group. (2015).

The hypertension of Cushing’s syndrome: controversy in the pathophysiology with a focus upon cardiovascular complications.

Journal of hypertension, 33(1).Lacroix, A., Feelders, R. A., Stratakis, C. A., & Nieman, L. K. (2015). Cushing’s syndrome.

The Lancet, 386 (9996), 913-927.Lee, M. J., Pramyothin, P., Karastergiou, K., & Fried, S. K. (2014).

Analyzing the roles of the glucocorticoids within adipose and central obesity biology. Biochimica et Biophysica Acta (BBA)-Molecular Basis of Disease, 1842(3), 473-481.Llahana, S., & Thomas, N. (2016).

Cushing’s Syndrome patients experience better quality of life when they have structured nursing education programs. Endocrine, 53(1), 1-3.Mazziotti, G., Formenti, A. M., Frara, S., Maffezzoni, F., Doga, M., & Giustina, A. (2017).

Diabetes in Cushing Disease.

Current Diabetes Reports (17(5), 32).Nieman, L. K., Biller, B. M., Findling, J. W., Murad, M. H., Newell-Price, J., Savage, M. O., & Tabarin, A. (2015).

Cushing’s syndrome: A clinical practice guideline of the endocrine societies.

The Journal of Clinical Endocrinology & Metabolism. 100(8): 2807-2831.Raff, H., Sharma, S. T., & Nieman, L. K. (2014).

The physiological basis of the etiology and diagnosis of adrenal disorders. Comprehensive Physiology.