Recall Exercise: Cushing Syndrome

 Directions:  For mental exercises, try to recall as much information as you can in response to each question.  You may write it down, if you like.  Use your mouse to highlight the white space underneath the question to reveal the secret answer key.  This exercise is designed to help nursing students recall information they know, and discover what information is still missing from memory.

1. Recall:  What is Cushing Syndrome?

↱ Cushing Syndrome is caused by excessive production of Cortisol and Androgens by the adrenal glands over the kidneys.  In some cases, Aldosterone secretion by the adrenals may be increased as well. ↲

2. Recall: What might cause an excess in adrenal hormone production?

→ Overuse of Corticosteroid Medications

→ Excessive ACTH production by pituitary

→ Hyperplasia of the adrenal cortex

→ Ectopic Production of ACTH by cancers

3. Recall: What condition is the opposite of Cushing Syndrome?

↱ Addison Disease.  Addison Disease is characterized by LOW adrenal activity. ↲

4. Recall: How does Cushing Syndrome affect body weight?

↱  Obesity of trunk with twiggy limbs. "Buffalo Hump." "Moon Face."

Problems with elevated blood glucose develops, often leading to diabetes. ↲

5. Recall: How does Cushing Syndrome affect the skin?

↱ Skin becomes fragile, thin and easily injured.  It's common to see bruises and stretch marks.  The skin may be extra greasy and develop acne.  Even small wounds heal slowly. ↲

6. Recall: How does Cushing Syndrome affect muscles and bones?

↱ Cushing Syndrome causes excessive protein catabolism which leads to osteoporosis and muscle wasting / weakness.  This can lead to kyphosis, backache, or compression fractures of the spine. ↲

7. Recall: How might someone with Cushing Syndrome feel?

↱  Weak, weary, tired, fatigued, lethargic, debilitated. ↲

8. Recall: How does Cushing Syndrome affect the cardiovascular system?

↱ High levels of Aldosterone cause the body to retain sodium, which leads to water retention.  Water follows sodium.  Water retention leads to hypertension and heart failure. ↲

9. Recall: Who is more likely to get Cushing Syndrome: Man or Woman?

↱ Woman.  Women are 5 x more likely to develop this disease.  Most cases develop from age 20-40.  ↲

10. Recall: How might Cushing Syndrome affect a woman's body image?

↱ Cushing Syndrome can cause women to experience virilization.  This is when a woman takes on the physical characteristics of a man. Including: muscle bulk, unwanted body hair or a deeper voice.  At the same time, the person may lose feminine characteristics.  Breasts atrophy, menses ceases and clitoris enlarges. Virilization is caused by the production of excess androgens by the adrenal cortex.  ↲

11. Recall: What is hirsutism?

↱ Excessive, unwanted hair growth on the face. ↲

12. Recall: How does Cushing Syndrome affect intimate relationships?

↱ This disorder can cause a loss of libido in both men and women.  This can lead to depression and emotional distress, often depending on how severe the physical and functional changes are.  ↲

13. Recall: How does Cushing Syndrome affect vision?

↱  Cataracts or Glaucoma may be present.  Problems with vision may point to the possibility of a pituitary tumor (as it presses against the optic chiasm).   ↲ 

14. Recall: What are the three tests that are used to conclusively DIAGNOSE Cushing Syndrome?

→ Serum (blood) Cortisol: Loss of level fluctuation throughout day is positive for Cushing Syndrome

→ Urinary Cortisol:  3 x the high end of the normal range is a positive indicator for Cushing Syndrome

→ Dexamethasone Suppression Test (Decadron): Used to pinpoint dysfunction in the hypothalamic-pituitary-adrenal axis. Normal to High level is a positive indicator for Cushing Syndrome 

15. Recall: When are cortisol levels highest and lowest during the day?

↱ Highest in the morning between 6-8 AM.  Lowest in the evening between 4-6 PM.  If the person has Cushing Syndrome, this fluctuation in cortisol level over the course of the day disappears.  ↲

16. Recall: How do nurses prepare for a urinary cortisol test?

↱  We need to do a 24-hour urine collection:  Note the time.  Urinate and discard.  Keep all subsequent urine for 24 hours.  At the end of the time period, urinate and keep the final urine output.  ↲

17. Recall: How do doctors diagnose someone with Cushing Syndrome?

↱  After performing three diagnostic tests (see problem 14), the doctor bases his positive diagnosis on the presence of at least 2 undeniably abnormal lab results.    ↲

18. Recall: How do we do a Dexamethasone Suppression Test?

↱  The patient ingests 1-8 mg of Dexamethasone at around bedtime.  The next morning, around 8 AM, blood is drawn and serum cortisol and ACTH is measured.   The tests are a bit complex.  ↲

 Here is an excellent YouTube video that goes into depth on how it works.

19. Recall: What do results of a Dexamethasone Suppression Test tell us?

↱   If serum cortisol is less than 5 mg/dL, it indicates that the hypothalamic-pituitary-adrenal axis is working right.  This is a negative result, and suggests the patient does NOT have Cushing Syndrome.

If the patient has Normal-High Cortisol levels the morning after taking Dexamethasone, it is a positive indicator for Cushing Syndrome.   ↲

20. Recall: List as many things as you can think of that might cause falsely elevated cortisol level?
→ Stress
→ Obesity
→ Depression
→ Certain medications: Estrogen, Rifampin, anticonvulsants
→ Pregnancy (Excess Estrogen)

21. Recall: What are five additional lab values that can point to Cushing Syndrome?

↱               ↑ BG ↑ Sodium   ↓ Potassium ↓ WBCs ↓ Cortisol Fluctuation

Blood test shows elevated glucose and sodium.  It also shows a decrease in potassium.  It may reveal a decrease in the number of eosinophils and lymphocytes.  Serum cortisol may be measured at specific times of day to determine whether the usual cortisol fluctuations in concentration are taking place.  ↲

22. Recall: How does Cushing Syndrome affect Cortisol levels?

↱ Cortisol levels will be high in Cushing Syndrome.  ↲

23. Recall: How does Cushing Syndrome affect  the Immune System?

↱ Patient may susceptible to infections, due to depression of eosinophils and lymphocytes.  The inflammatory response may not work as well either.  ↲

24. Recall: How can Cushing Syndrome lead to metabolic alkalosis?

↱  Cushing syndrome causes hypokalemia.  Low potassium in the blood triggers a shift of hydrogen ions into cells.  When this happens, potassium shifts out of cells. The massive shift of hydrogen ions, which are acidic, causes metabolic alkalosis.  ↲

25. Recall: What two surgical interventions are used to treat Cushing Syndrome?

→ Transsphenoidal hypophysectomy 

→  Adrenalectomy

26. Recall:  How is Cushing Syndrome caused by long-term Corticosteroid treatment dealt with?

↱  The dose is reduced to the minimum needed to maintain adequate function.  One way is by having the patient take Corticosteroids every OTHER day, rather than daily.   ↲

27. Recall:  An ectopic tumor is making excessive amounts of ACTH, the hormone that stimulates the adrenal glands. What medications are used to treat this condition?

↱ Adrenal enzyme inhibitors.

Examples:  metyrapone (Metopirone),

                   aminoglutethimide (Cytadren)

                   mitotane (Lysodren)

                   ketoconazole (Nizoral).    ↲

28. Recall:  You are caring for a patient who has Cushing Syndrome.  You've identified some applicable nursing diagnoses.   Consider each one and formulate a response.  How would you address each problem?

→ Risk for injury: weakness

→ Risk for infection: impaired immune response

→ Risk for activity intolerance

→ Risk for impaired skin integrity: edema, impaired healing, thin & fragile skin

→ Risk for disturbed body image: altered physical appearance, impaired sexual function & decreased activity level

→ Risk for ineffective coping: mood swings, irritability, depression

↱   

• Risk For Injury: Assist with ambulation, and clear the environment of tripping hazards.
• Risk for Infection:  Avoid unnecessary exposure to other who are sick, monitor for subtle signs of infection since corticosteroids often masks common signs and symptoms.
• Risk for Activity Intolerance: Encourage moderate level of activity to prevent complications and promote self-esteem.  Plan activity between rest periods.  Establish a relaxing, quiet place to rest and sleep.  Avoid exercising near bedtime. 
• Risk for Impaired Skin Integrity: Don't use adhesive tape as it can irritate and tear fragile tissue.  Assess skin and bony prominences frequently and help the patient change positions often to prevent skin breakdown.  Encourage good hygiene to keep skin dry and reduce bacterial colonization. 
• Risk for Disturbed Body Image: Remind the person that once Cushing Syndrome is under control, the undesirable physical changes disappear gradually.  Educate that a low-carbohydrate, low-sodium diet with high protein intake will help speed the process to recovery.
• Risk for Ineffective Coping: Educate the patient and family that mood lability is a common symptom of Cushing Syndrome.  In a few cases, the patient even experiences psychotic episodes.  Encourage open discussion, and an understanding that this behavior is not the new normal.  It is not "who this person is."  Educate that balance can be recovered with proper care.    ↲

29. Recall:  What is a serious complication of poorly managed Cushing Syndrome?

↱   Addisonian crisis.  The patient who is treated for Cushing syndrome may experience a sharp reduction in adrenocortical hormones when the offending body part is surgically removed.  This can trigger an addisonian crisis.    ↲

30. Recall:  What are some dietary recommendations for anyone with Cushing Syndrome?

↱   Foods high in protein, calcium and vitamin D to combat tendency toward osteoporosis and muscle wasting.  Foods low in sodium and calories to combat obesity and water retention, due to hyperaldosteronism.     ↲

31. Recall:  How does Cushing Syndrome affect the digestive tract?

↱  Patients with Cushing Syndrome commonly experience peptic ulcers.  Some develop pancreatitis.    ↲

32. Recall:  What are some monitoring parameters for someone with uncontrolled Cushing Syndrome?  

↱  Daily Weights / Laboratory Values / Blood Glucose / Stool for Occult Blood    ↲

33. Recall:  What are some signs and symptoms of an addisonian crisis?

→ Hypovolemia and Hypotension.

→ Nausea, vomiting, abdominal pain, and diarrhea.  

→ Headache, confusion, restlessness.

→ Pale with blue mucus membranes.

→  Fever.

34. Recall:  What health screening should you recommend to someone with Cushing Syndrome?

↱  Bone mineral density testing.   ↲

35. Recall:  What is an important piece of patient education for someone being treated with medications for Cushing Syndrome?

↱  Take all medications as prescribed, and do not stop taking them abruptly as this can cause lfe-threatening imbalances.   ↲

36. Recall:  What is the outcome of untreated Addisonian Crisis?

↱  Eventually the person experiences circulatory collapse, shock and death.    ↲

37. Recall:  How do we treat addisonian crisis?

↱  First Thing:  Give corticosteroids IV push.  

Give 5% dextrose in normal saline to restore circulatory volume and blood pressure. 

Check blood glucose and treat, as prescribed.   ↲

38. Recall:  What can trigger an addisonian crisis?

↱  SLIGHT increases in stress can trigger an addisonian crisis.  Examples: slight overexertion, exposure to cold, becoming sick, or not getting enough salt in the diet.  Surgery or restricted fluid intake (as in preparing for diagnostic procedures) can also cause a crisis.    ↲

39. Recall:  A patient has just arrived at the ER in Addisonian Crisis. What do you do FIRST?

↱  Attach a heart monitor.    ↲

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