Cushing’s syndrome is a hormonal disorder caused by prolonged exposure to high levels of cortisol. This condition can result from various factors, including long-term use of glucocorticoid medications, pituitary tumors, or adrenal gland abnormalities.
As a complex endocrine disorder, Cushing’s syndrome presents unique challenges for nursing care, requiring a comprehensive understanding of its pathophysiology, symptoms, and management strategies.
Causes (Related to)
Cushing’s syndrome can result from several factors that lead to excessive cortisol levels in the body:
- Exogenous causes:
- Long-term use of glucocorticoid medications (e.g., prednisone) for conditions such as asthma, rheumatoid arthritis, or lupus
- Endogenous causes:
- Pituitary adenoma (Cushing’s disease) producing excess ACTH
- Ectopic ACTH-producing tumors (small cell lung cancer)
- Adrenal tumors or hyperplasia leading to autonomous cortisol production
- Genetic factors:
- Rare inherited disorders affecting the endocrine system
Signs and Symptoms (As evidenced by)
Cushing’s syndrome manifests with a wide range of signs and symptoms due to the systemic effects of excess cortisol:
Subjective: (Patient reports)
- Fatigue and muscle weakness
- Mood changes (depression, anxiety, irritability)
- Difficulty concentrating
- Increased thirst and frequent urination
- Decreased libido
- Menstrual irregularities in women
Objective: (Nurse assesses)
- Weight gain, especially in the face (moon face), trunk, and upper back (buffalo hump)
- Thin, fragile skin that bruises easily
- Purple or pink stretch marks (striae) on the skin
- Slow wound healing
- Acne
- Hirsutism (excessive hair growth) in women
- Hypertension
- Osteoporosis
- Glucose intolerance or diabetes mellitus
- Muscle wasting in the extremities
- Edema in the lower extremities
- Facial plethora (redness)
- Proximal muscle weakness
- Laboratory findings:
- Elevated serum cortisol levels
- Abnormal results on dexamethasone suppression test
- Elevated 24-hour urinary free cortisol
- Elevated ACTH levels (in Cushing’s disease)
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for patients with Cushing’s syndrome:
- The patient will demonstrate improved glucose control within the normal range
- The patient will maintain stable blood pressure within the target range
- The patient will report increased energy levels and decreased fatigue
- The patient will show signs of improved skin integrity and wound healing
- The patient will verbalize understanding of the condition and its management
- The patient will demonstrate proper medication administration and adherence to the treatment plan
- The patient will report improved mood and cognitive function
- The patient will maintain or achieve appropriate body weight
- The patient will show no signs of infection or complications related to immunosuppression
Nursing Assessment
Comprehensive nursing assessment is crucial for patients with Cushing’s syndrome. The following steps should be taken:
- Obtain a thorough medical history
Review the patient’s medical history, including the onset and progression of symptoms, medication use (particularly glucocorticoids), and any underlying conditions. - Perform a physical examination.
Assess for characteristic physical signs of Cushing’s syndrome, such as central obesity, moon face, buffalo hump, and striae. - Measure vital signs
Monitor blood pressure, heart rate, respiratory rate, and temperature. Hypertension is common in Cushing’s syndrome. - Assess skin integrity
Examine the skin for thinning, bruising, striae, and delayed wound healing. - Evaluate muscle strength
Assess for proximal muscle weakness, particularly in the upper arms and thighs. - Monitor blood glucose levels.
Check blood glucose regularly, as hyperglycemia is common in Cushing’s syndrome. - Assess mental status and mood
Evaluate for signs of depression, anxiety, or cognitive changes. - Measure weight and assess for fluid retention.
Monitor weight changes and check for edema, particularly in the lower extremities. - Review laboratory results
Analyze cortisol levels, ACTH levels, and results of diagnostic tests such as the dexamethasone suppression test. - Assess for complications
Screen for signs of osteoporosis, cardiovascular disease, and opportunistic infections. - Evaluate nutritional status
Assess dietary intake and any changes in appetite or eating habits. - Review medication regimen
Carefully review all medications, including over-the-counter drugs and supplements, as some may interact with treatments for Cushing’s syndrome.
Nursing Interventions
Effective nursing interventions are essential for managing Cushing’s syndrome and improving patient outcomes. The following interventions should be implemented:
- Administer medications as prescribed
Ensure proper administration of medications used to treat Cushing’s syndrome, such as steroidogenesis inhibitors or glucocorticoid receptor antagonists. - Monitor and manage blood glucose levels.
Implement a blood glucose monitoring schedule and administer insulin or oral hypoglycemic agents as ordered. - Implement fall prevention strategies.
Due to muscle weakness and osteoporosis risk, ensure a safe environment and assist with mobility as needed. - Provide skincare
Implement measures to protect fragile skin, prevent breakdown, and promote wound healing. - Assist with weight management.
Collaborate with a dietitian to develop a balanced, low-sodium diet plan to manage weight and fluid retention. - Encourage regular exercise
Promote physical activity within the patient’s limitations to help maintain muscle strength and bone density. - Provide emotional support
Offer counseling or referrals to mental health professionals to address mood changes and psychological effects of the condition. - Educate about infection prevention.
Teach the patient about the importance of hand hygiene and avoiding potential sources of infection due to immunosuppression. - Monitor for signs of adrenal insufficiency.
Be vigilant for symptoms of adrenal crisis, especially in patients undergoing treatment to lower cortisol levels. - Assist with stress management.
Teach relaxation techniques and stress-reduction strategies to help manage cortisol levels. - Provide patient education
Educate the patient and family about Cushing’s syndrome, its treatment, and the importance of medication adherence and follow-up care. - Coordinate care with the healthcare team.
Collaborate with endocrinologists, surgeons, and other specialists in the patient’s care.
Nursing Care Plans
The following nursing care plans address common problems associated with Cushing’s syndrome:
Care Plan 1: Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired Skin Integrity related to effects of hypercortisolism on skin structure and healing processes.
Related factors/causes:
- Thinning of skin due to cortisol excess
- Impaired collagen synthesis
- Decreased inflammatory response
- Poor wound healing
- Increased susceptibility to bruising and skin tears
Nursing Interventions and Rationales:
- Perform a comprehensive skin assessment daily.
Rationale: Early detection of skin changes allows for prompt intervention. - Implement a gentle skincare routine using pH-balanced, fragrance-free products.
Rationale: Minimizes skin irritation and maintains skin integrity. - Apply moisturizer to dry areas of skin at least twice daily.
Rationale: Helps maintain skin hydration and elasticity. - Teach the patient to avoid prolonged exposure to hot water during bathing.
Rationale: Hot water can further dry and irritate fragile skin. - Encourage the use of sun protection when outdoors.
Rationale: It helps prevent further skin damage and reduces the risk of skin cancers. - Implement strategies to prevent pressure ulcers, such as frequent repositioning and use of pressure-relieving devices.
Rationale: Reduces the risk of skin breakdown in patients with limited mobility. - Educate the patient on proper techniques for skin inspection and care.
Rationale: The patient is to participate in their skin health management.
Desired Outcomes:
- The patient will maintain intact skin without signs of breakdown or injury.
- The patient will demonstrate an understanding of skin care techniques and their importance.
- The patient will report any new skin changes or concerns promptly to healthcare providers.
Care Plan 2: Imbalanced Nutrition: More Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: More Than Body Requirements related to altered metabolism and increased appetite secondary to hypercortisolism.
Related factors/causes:
- Increased appetite due to cortisol excess
- Altered fat distribution (central obesity)
- Impaired glucose metabolism
- Fluid retention
Nursing Interventions and Rationales:
- Assess the patient’s current dietary habits and nutritional status.
Rationale: Provide baseline data for developing an appropriate nutrition plan. - Collaborate with a dietitian to develop a balanced, calorie-controlled meal plan.
Rationale: Ensures nutritional needs are met while managing weight gain. - Educate the patient on the importance of portion control and choosing nutrient-dense foods.
Rationale: Helps manage calorie intake and provides essential nutrients. - Encourage regular physical activity as tolerated.
Rationale: Promotes calorie expenditure and helps maintain muscle mass. - Monitor weight and body measurements regularly.
Rationale: Allows for tracking of progress and adjustment of interventions as needed. - Teach strategies for managing increased appetite, such as eating smaller, more frequent meals.
Rationale: Helps control excessive calorie intake while maintaining stable blood glucose levels. - Provide education on the relationship between Cushing’s syndrome and weight gain.
Rationale: Increases patient understanding and motivation for dietary adherence.
Desired Outcomes:
- The patient will demonstrate a stabilization or reduction in weight over time.
- The patient will verbalize understanding of the relationship between Cushing’s syndrome and nutrition.
- The patient will adhere to the recommended dietary plan.
Care Plan 3: Risk for Infection
Nursing Diagnosis: Risk for Infection related to immunosuppression secondary to hypercortisolism.
Related factors/causes:
- Suppressed immune function due to excess cortisol
- Impaired wound healing
- Potential use of immunosuppressive medications in treatment
Nursing Interventions and Rationales:
- Assess for signs and symptoms of infection regularly.
Rationale: Early detection allows for prompt treatment of infections. - Implement strict hand hygiene protocols for staff, patients, and visitors.
Rationale: Reduces the risk of pathogen transmission. - Educate the patient on infection prevention strategies, including proper hand washing and avoiding crowds during peak illness seasons.
Rationale: Empower the patient to take an active role in infection prevention. - Ensure all vaccinations are current, consulting with the healthcare provider for any special considerations.
Rationale: It provides additional protection against preventable infections. - Monitor white blood cell count and other relevant laboratory values.
Rationale: Helps assess the patient’s immune status and risk for infection. - Implement neutropenic precautions if necessary.
Rationale: Provides additional protection for severely immunocompromised patients. - Teach the patient to recognize early signs of infection and when to seek medical attention.
Rationale: Promotes early intervention for potential infections.
Desired Outcomes:
- The patient will remain free from signs and symptoms of infection.
- The patient will demonstrate proper hand hygiene and infection prevention techniques.
- The patient will verbalize understanding of when to seek medical attention for potential infections.
Care Plan 4: Disturbed Body Image
Nursing Diagnosis: Disturbed Body Image related to physical changes associated with Cushing’s syndrome.
Related factors/causes:
- Rapid weight gain and changes in fat distribution
- Development of striae and bruising
- Facial changes (moon face)
- Hirsutism in women
Nursing Interventions and Rationales:
- Assess the patient’s perception of body image and emotional response to physical changes.
Rationale: Provides insight into the patient’s psychological state and areas of concern. - Provide emotional support and active listening.
Rationale: Validates the patient’s feelings and concerns about body image changes. - Educate the patient on the relationship between Cushing’s syndrome and physical changes.
Rationale: Helps the patient understand that these changes are due to the condition and are often reversible with treatment. - Refer to a mental health professional if needed for additional support.
Rationale: Provides specialized care for patients experiencing significant distress related to body image. - Encourage participation in support groups for patients with Cushing’s syndrome.
Rationale: Allows sharing experiences and coping strategies with others facing similar challenges. - Teach strategies for managing visible symptoms, such as proper skin care for striae or cosmetic techniques for facial changes.
Rationale: Provides practical tools for improving self-image and confidence. - Emphasize the importance of adherence to treatment in potentially reversing physical changes.
Rationale: Motivates the patient to continue treatment by focusing on potential improvements.
Desired Outcomes:
- The patient will verbalize improved acceptance of body image.
- The patient will demonstrate the use of positive coping strategies when discussing body image concerns.
- The patient will participate actively in the treatment plan to address physical changes.
Care Plan 5: Risk for Impaired Physical Mobility
Nursing Diagnosis: Risk for Impaired Physical Mobility related to muscle weakness and osteoporosis secondary to hypercortisolism.
Related factors/causes:
- Proximal muscle weakness
- Increased risk of osteoporosis and fractures
- Fatigue
- Potential weight gain affecting mobility
Nursing Interventions and Rationales:
- Assess the patient’s current level of mobility and muscle strength.
Rationale: Provides baseline data for developing an appropriate mobility plan. - Implement a progressive mobility program in collaboration with physical therapy.
Rationale: Helps maintain and improve muscle strength and overall mobility. - Teach proper body mechanics and safe transfer techniques.
Rationale: Reduces the risk of injury during movement and activities. - Encourage regular weight-bearing exercises as tolerated.
Rationale: Helps maintain bone density and muscle strength. - Implement fall prevention strategies, such as ensuring a clutter-free environment and proper lighting.
Rationale: Reduces the risk of falls and potential fractures. - Educate the patient on the importance of calcium and vitamin D intake for bone health.
Rationale: Supports bone density maintenance and may slow osteoporosis progression. - Monitor for signs of fatigue during activities and encourage rest periods as needed.
Rationale: Prevents overexertion and reduces the risk of falls due to fatigue.
Desired Outcomes:
- The patient will maintain or improve the current level of mobility.
- The patient will demonstrate proper use of assistive devices if required.
- The patient will verbalize understanding of fall prevention strategies and implement them consistently.
References
- Nieman, L. K. (2020). Cushing’s syndrome: Update on signs, symptoms and biochemical screening. European Journal of Endocrinology, 183(1), R45-R57.
- Sharma, S. T., Nieman, L. K., & Feelders, R. A. (2015). Cushing’s syndrome: epidemiology and developments in disease management. Clinical Epidemiology, 7, 281-293.
- Pivonello, R., Isidori, A. M., De Martino, M. C., Newell-Price, J., Biller, B. M., & Colao, A. (2016). Complications of Cushing’s syndrome: state of the art. The Lancet Diabetes & Endocrinology, 4(7), 611-629.
- Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International nursing diagnoses: Definitions & classification 2018-2020. Thieme.
- Carpenito-Moyet, L. J. (2013). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins.
