Cushing disease

Cushing’s Disease Nursing Diagnosis Interventions and Care Plans

Cushing’s Disease NCLEX Review Care Plans

Nursing Study Guide on Cushing Disease

Cushing disease is a rare but serious condition that involves too much cortisol in the blood caused by pituitary tumor’s secretion of adrenocorticotropic hormone (ACTH).

ACTH is a hormone responsible for stimulating the adrenal glands, the two glands located above the kidneys, to release cortisol.

In the case of Cushing disease cortisol is released in excessive amounts. Cortisol, also called as stress hormone, is responsible for regulating blood pressure, insulin effects, immune system and the body’s stress response.  

Cushing disease affects 10 to 15 people per million each year, with women accounting for more than 70% of the cases.

It is most commonly seen in adults between 20 to 50 years of age. In some case, symptoms depend on the amount of cortisol in the body, which may cause a delay and difficulty in diagnosis.

Most of the people with Cushing disease have small tumors in the pituitary gland, so removal of the said growth may resolve the problem.

Cushing Disease versus Cushing Syndrome

Cushing disease is a specific type of Cushing syndrome, a condition used to describe excessive cortisol produced solely by pituitary gland, the gland that is responsible for the secretion of the adrenocorticotropic hormone or ACTH.

On the other hand, Cushing syndrome is a general state of having excessive cortisol due to all reasons other than the pituitary gland.

It can be caused by tumor in the adrenal gland, certain types of cancer, depression, anorexia nervosa, or other conditions that increase cortisol levels.

Signs and Symptoms of Cushing Disease

  • Fullness and rounding of the face (moon face, a classic symptom)
    • Added fat on back of neck (buffalo hump)
    • Easy bruising of the skin and poor wound healing
    • Purplish stretch marks on the abdomen (abdominal striae)
    • Excessive weight gain, most prominent in the abdominal region, while the legs and arms remain thin
    • Red cheeks (plethora)
    • Excess hair growth on the face, neck, chest, abdomen and thighs (hirsutism)
    • Generalized weakness and fatigue
    • Noticeable muscle wasting in the upper thighs
    • Menstrual disorders
    • Decreased fertility and/or sex drive
    • Diabetes mellitus, often severe
    • Mood and behavioral changes

Causes and Risk Factors of Cushing Disease

If a small tumor develops in the pituitary gland, ACTH is produced.

This hormone will enter the bloodstream, thereby stimulating the adrenal glands to secrete excessive amounts of cortisol and other steroid hormones that affect different areas of the body.

These hormone peak in the morning, decline throughout the day, and become significantly low at night.

The most common cause of Cushing disease are pituitary microadenomas, which are non-cancerous but are difficult to diagnose due to their size. These benign tumors are less than 10mm in diameter, caused by genetic mutations at birth or those that develop over time.

Pituitary hyperplasia, a condition resulting in an excess growth of pituitary gland can also produce elevated levels of ACTH in the body, leading to high amounts of cortisol.

Cushing disease is more common in women than men, which makes females of reproductive age at high risk for having the disease.

Complications of Cushing’s Disease

  1. Bone loss or Osteoporosis. Cushing disease increases the risk for bone loss and unusual bone fractures such as rib fractures.
  2. Immunosuppression. Prolonged elevation in cortisol level suppresses the body’s immune system which causes susceptibility to frequent and unusual infections such as bacterial and fungal infection
  3. High blood pressure
  4. Type 2 Diabetes
  5. Loss of muscle mass and strength     
  6. Rare conditions. In some rare cases, patients have large pituitary tumors which may cause loss of vision and other visual problems.
  7. Hormone insufficiency or Hypopituitarism. It may reduce sex hormones such as the luteinizing hormone and follicle stimulating hormone.

Diagnosis of Cushing Disease

  1. Hormone testing – if results are below the normal range, indicative of adrenal tumor producing cortisol
    1. 24-hour urine free cortisol measurement
    1. Cortisol saliva testing
    1. Blood ACTH
  2. Magnetic Resonance Imaging
  3. Inferior petrosal sinus sampling
  4. Dexamethasone suppression test

Treatment of Cushing Disease

The treatment for Cushing disease can be extensive that a multidisciplinary approach is required. There are a wide range of options for treating Cushing disease. This includes surgery, medication, and radiation therapy.

  1. Surgery. Surgical removal of the pituitary adenoma provides a long-term cure for this disease accounting to 80-85% of cure rate.  Transsphenoidal tumor resection is performed by an experienced neurosurgeon to dissect and remove the tumor as one piece through the sphenoid sinus using an endoscopic or microscopic approach. An endoscopic technique is considered safer and may lessen hospitalization days. Recovery days vary per patient.
  2. Medications. Although there is no specific drug to decrease ACTH production, there are available medications that can inhibit the adrenal glands’ cortisol production. It can assist in reducing symptoms prior to a surgery, or when the surgery fails to remove the tumor completely, in some patients.
  3. Radiotherapy. Radiation therapy is also another option to consider for patients whose tumors are unable to be completely removed. Stereotactic radiosurgery, a technique that uses radiation beam to target the tumor. It is carefully sculpted to prevent damage in the surrounding brain structures. If the tumor remains unresponsive to surgery, medications and radiation, a bilateral adrenalectomy and hormone replacement therapy may be considered.

Prevention of Cushing Disease

Unfortunately, there is no way of preventing the occurrence of pituitary gland tumors. However, it is best to visit the endocrinologist if there is a familial history of adenomas or if an individual will undergo treatment using steroids. It is still best to have a healthy lifestyle to prevent complications in the future.

Nursing Care Plans for Cushing Disease

Nursing Care Plan 1

Nursing Diagnosis: Disturbed Body Image abnormal fat distribution and increased production of androgens related to Cushing disease, 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 disease.
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 disease 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 disease.
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 disease 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: Fatigue related to increased production of cortisol, as evidenced by overwhelming lack of energy, verbalization of tiredness, muscle wasting, generalized weakness, and shortness of breath upon exertion

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionRationale
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.

Other nursing diagnoses:

  • Risk for Infection Post-Surgery
  • Risk for Excess Fluid Volume
  • 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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