Cushing syndrome

Cushing Syndrome Nursing Diagnosis Interventions and Care Plans

Cushing Syndrome NCLEX Review Care Plans

Nursing Study Guide on Cushing Syndrome

Cushing syndrome is a disorder that involves the excessive levels of cortisol in the body.

Cortisol plays a variety of roles in the body, an example of which is that it helps in reducing inflammation and in controlling blood pressure.

It also plays a key role when the body responds to stress, also known as the “fight or flight” mechanism.

Cortisol regulates the metabolism of proteins, carbohydrates, and fat in the diet.

Some of the remarkable signs of Cushing syndrome or hypercortisolism include a fatty hump between the shoulders (“buffalo hump”), a rounded face (“moon face”), and pink or purple stretchmarks or striae.

On top of these changes, people diagnosed with Cushing syndrome can also have hypertension, bone loss and on occasion, type 2 diabetes.

Addressing the high levels of cortisol sooner can contribute to better health outcomes and improved quality of life.

Signs and Symptoms of Cushing Syndrome

  • Weight gain; prominently on the face, upper back, and midsection
  • Pink or purple stretch marks
  • Skin abnormalities (acne, poor wound healing)
  • Hirsutism in women
  • Abnormal menses (irregular or absent)
  • Decreased libido and erectile dysfunction (in men)
  • Severe fatigue
  • Impaired growth in children
  • Cognitive dysfunction
  • Depression, anxiety and irritability

Causes and Risk factors of Cushing Syndrome

Cushing syndrome could either be exogenous or endogenous in nature.

Exogenous Cushing Syndrome develops when the body is receiving high doses of corticosteroid medications, may they be in oral or injectable form.

Oftentimes, the body would need high and continuous doses of steroid medications to control inflammation (e.g. post-transplant patients, those with asthma).

Since these medications act the same way as cortisol in the body, they contribute to the development of Hypercortisolism to patients on steroid regimen.

Endogenous Cushing Syndrome occurs when there is excess production in the adrenal glands, or  when there is an overproduction of the adrenocorticotropic hormone (ACTH).

A pituitary adenoma (benign pituitary tumor), an ACTH secreting tumor (benign or malignant and can be found in the lungs, thyroid, etc.), a primary adrenal gland disease (disorders in the adrenal glands) and familial Cushing syndrome (hereditary Cushing syndrome) are the primary contributors to exogenous Cushing syndrome.

Complications of Cushing Syndrome

Complications from Cushing syndrome are common and may lead to more serious and permanent disability.

  1. Musculoskeletal disorders. Bone loss (Osteoporosis) and muscle wasting due to Cushing syndrome can result in unusual bone fractures such as fractures on the bones of the feet, or ribs.
  2. Hypertension and Cardiovascular disorders. Excessive levels of cortisol may lead to hypertension and stiffening of the blood vessels, thus predisposing the patient to cardiovascular diseases.
  3. Type 2 diabetes. Due to imbalances on metabolism brought about by overproduction of cortisol, the patient is prone to developing type 2 diabetes, bringing in new health problems.
  4. Infection. Frequent and unusual infections may also occur due to the imbalances in cortisol levels.

Diagnosis of Cushing Syndrome

Diagnosing Cushing Syndrome can be difficult due, to its signs and symptoms sharing similarities with other conditions, but can be made through:

  • Physical assessment – to look for the classic signs
  • Testing for cortisol levels in the urine, blood, and saliva
  • Imaging tests of the pituitary and adrenal glands
  • Petrosal sinus sampling

Treatment of Cushing Syndrome

Treatment options for Cushing syndrome can be varied due to the cause of the syndrome but all share the same goal: to reduce the cortisol levels in the body.

  1. Tapering down of steroids. For medication-induced Cushing Syndrome, gradual tapering of steroid doses may be done to control the effects of long-term use. Doctors may prescribe non-corticosteroid drugs altogether to eliminate dependence on the use of steroids in managing inflammatory diseases, like asthma.
  • Surgery. If tumors are the cause of Cushing syndrome, the first line of choice would be surgery, or resection of the tumor. However, since patients who had their tumors resected may never get the normal function of their adrenal glands, these patients would likewise be needing long term cortisol replacement therapy. If all else fails, a bilateral adrenalectomy (surgical removal of the adrenal glands) may be done. However, lifelong cortisol replacement therapy would be needed to compensate for the loss of adrenal functions.
  • Radiotherapy. The second of line of choice for unresectable or partially resectable adrenal or pituitary tumors would be radiation therapy. One form of radiotherapy is stereotactic radiosurgery wherein a single, large dose of radiation is targeted to the tumor, thereby reducing radiation exposure to surrounding tissues.
  • Medications. When surgery or radiation therapy fails, the doctor would manage the Cushing syndrome with prescribed medications to control over-production of cortisol in the body. Likewise, for patients with Type 2 diabetes intolerance or glucose intolerance, the doctor may use specific drugs for blocking the effects of cortisol in the body and to decrease ACTH production from a pituitary tumor.

Nursing Care Plans for Cushing Syndrome

Nursing Care Plan 1

Nursing Diagnosis: Disturbed Body Image abnormal fat distribution and increased production of androgens related to Cushing syndrome, as evidenced by buffalo hump, striae on the skin, hirsutism, low mood, and verbalization of sadness and low self-esteem

Desired Outcome: The patient will demonstrate enhanced body image and self-esteem.

InterventionRationale
Use open-ended questions in exploring feelings and thoughts about present body condition.To encourage the patient to express his/her feelings towards the body changes brought by Cushing syndrome.
Assess the coping mechanism of the patient.To check which coping mechanisms work best to improve the patient’s body image.
Educate the patient about the cause of these body changes by discussing what cortisol and Cushing syndrome are. Re-assure the patient that most of these changes return to normal when treatment has been given successfully.To boost the patient’s knowledge and expectations about the current situation and the treatment outcome. This will increase the likelihood of compliance and cooperation during treatment.
Promote a positive caring atmosphere in the ward and encourage the family and friends to do this as well.To provide psychological support to the patient and encourage participation in treatment.
Encourage positive coping methods that pique client’s interest, such as proper grooming and clothing.To enhance the patient’s self-esteem. 

Nursing Care Plan 2

Nursing Diagnosis: Disturbed Thought Processes related to chemical changes of the brain due to elevated cortisol levels, as evidenced by irritability, insomnia, low mood and mood swings, memory problems, and verbalization of sadness and low self-esteem

Desired Outcome: The patient will have improved mentation and regain normal thought processes.

InterventionRationale
Use open-ended questions in exploring feelings and thoughts about diagnosis and treatment.To encourage the patient to express his/her feelings towards the changes brought by Cushing syndrome.
Assess the coping mechanism of the patient.To check which coping mechanisms work best to improve the patient’s mentation.
Educate the patient about the cause of the changes in body and mental status by discussing what cortisol and Cushing syndrome are. Re-assure the patient that most of these changes return to normal when treatment has been given successfully.To boost the patient’s knowledge and expectations about the current situation and the treatment outcome. This will increase the likelihood of compliance and cooperation during treatment.
Promote a positive caring atmosphere in the ward and encourage the family and friends to do this as well.To provide psychological support to the patient and encourage participation in treatment.
Encourage positive coping methods that pique client’s interest, such as proper grooming and clothing.To enhance the patient’s self-esteem and mood. 
Administer medications to lower cortisol levels.Psychiatric symptoms may be caused by excessive levels of cortisol.
Refer the patient to psychotherapy if he/she provides consent.To help provide expert psychological support that will improve the patient’s mood and reduce symptoms of anxiety, irritability, and depression.

Nursing Care Plan 3

Nursing Diagnosis: Risk for Excess Fluid Volume related to water and sodium retention due to high cortisol levels

Desired Outcome: The patient will maintain normal fluid volume as evidenced by urinary output of at least 30 mL/hr, stable weight, normal respirations, absence of edema, and balanced input and output.

InterventionRationale
Assess the vital signs. Assess for signs of cardiac dysrhythmias and circulatory overload.Water and sodium retention put the patient at risk for cardiac dysrhythmias and circulatory overload.
Place the patient on strict Input and Output monitoring. Follow the fluid restriction as indicated by the physician.To ensure that the patient is having an adequate but not excessive fluid intake as per doctor’s ordered fluid restriction.
To check if the patient has a urinary output of at least 30 mL/hr.
Encourage a low sodium, high potassium diet. Refer to the dietitian as required.To discourage sodium and water retention. Cushing syndrome may cause reduced potassium levels.
Administer diuretics and/or antihypertensive medications as prescribed.Diuretics (preferably potassium-sparking diuretics)– to promote water and sodium excretion. Antihypertensives – water and sodium retention may cause high blood pressure levels
Educate the patient to elevate the legs and feet when sitting or lying down.To reduce the risk of edema formation in the legs and feet.

Other nursing diagnoses:

  • Anxiety
  • Risk for Injury
  • Deficient Knowledge

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures. 

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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