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is a hormonal disorder caused by prolonged exposure of the
body¶s tissues to high levels of the hormone cortisol. Sometimes called þ
Cushing¶s syndrome is relatively rare and most commonly affects adults aged 20 to 50. People
who are obese and have type 2 diabetes along with poorly controlled blood glucose²also called
blood sugar²and high blood pressure have an increased risk of developing the disorder.
results from excessive secretion of one or all of the
adrenocortical hormones which includes glucocorticoid cortisol (predominant type) the
mineralocorticoid aldosterone and the adrogenital corticoids.
"
or
# is an endocrine disorder
caused by excessive levels of the endogenous corticosteroid hormone cortisol. It may also be
induced iatrogenically by treatment with exogenous corticosteroids for other medical conditions.
It was discovered by American physician surgeon and endocrinologist Harvey Cushing (1869-
1939) and reported by him in 1932.
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occurs when the body¶s tissues are exposed to high levels of
cortisol for too long. Many people develop Cushing¶s syndrome because they take
glucocorticoids²steroid hormones that are chemically similar to naturally produced cortisol²
such as prednisone for asthma rheumatoid arthritis lupus and other inflammatory diseases.
Glucocorticoids are also used to suppress the immune system after transplantation to keep the
body from rejecting the new organ or tissue.
Other people develop Cushing¶s syndrome because their bodies produce too much
cortisol. Normally the production of cortisol follows a precise chain of events. First the
hypothalamus a part of the brain about the size of a small sugar cube sends corticotropin-
releasing hormone (CRH) to the pituitary gland. CRH causes the pituitary to secrete
adrenocorticotropin hormone (ACTH) which stimulates the adrenal glands. When the adrenals
which are located just above the kidneys receive the ACTH they respond by releasing cortisol
into the bloodstream.
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1. c
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most common cause of Cushing¶s syndrome and stems from hyperplasia of both
adrenal glands caused by over stimulation by adrenocorticotropic hormone
(ACTH) usually from pituitary adenoma. The syndrome mostly affects women
between ages 20 and 40.
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is associated with adenoma or
carcinoma of the adrenal cortex. The disease may recur after surgery.
3.
results from autonomous ACTH
secretion by extrapituitary tumors (such as the lungs) producing excess ACTH.
4. c
is caused by exogenous
glucocorticoid administration.
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The list of signs and symptoms mentioned in various sources for Cushing's syndrome
includes the 77 symptoms listed below:
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When the amount of cortisol in the blood is adequate the hypothalamus and pituitary
release less CRH and ACTH. This process ensures the amount of cortisol released by the adrenal
glands is precisely balanced to meet the body¶s daily needs. However if something goes wrong
with the adrenals or the regulating switches in the pituitary gland or hypothalamus cortisol
production can go awry.
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Although the adenomas of Cushing's disease secrete excessive amounts of ACTH they
generally retain some negative feedback responsiveness to high doses of glucocorticoids. |ctopic
sources of ACTH usually in the form of extracranial neoplasms are generally not responsive to
negative feedback with high doses of glucocorticoids. However some overlap exists in the
response to negative feedback between pituitary and ectopic sources of excessive ACTH.
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is categorized as ACTH dependent or ACTH independent (Y ).
This division is convenient for organizing the work-up of patients with suspected
hypercortisolism.
epression alcoholism medications eating disorders and other conditions can cause
mild clinical and laboratory findings similar to those in Cushing's syndrome termed "pseudo-
Cushing's syndrome." The laboratory and clinical findings of hypercortisolism disappear if the
primary process is successfully treated.17-19
examethasone an exogenous glucocorticoid is used to test for Cushing's syndrome.
This gluococorticoid does not interfere with cortisol assays but induces similar physiologic
responses.
have equal detection rates (Raff & Findling 2003). A novel approach
is sampling cortisol in saliva over 24 hours which may be equally sensitive. Other pituitary
hormones may need to be determined and performing physical examination directed for any
visual field defect may be necessary if a pituitary lesion is suspected (which may compress the
optic chiasm causing typical bitemporal hemianopia).
No single lab test is perfect and usually several are needed. The three most common tests
used to diagnose Cushing¶s syndrome are the 24-hour urinary free cortisol test measurement of
midnight plasma cortisol or late-night salivary cortisol and the low-dose dexamethasone
suppression test. Another test the dexamethasone-corticotropin-releasing hormone test may be
needed to distinguish Cushing¶s syndrome from other causes of excess cortisol.
R u '( ) (( * In this test a person¶s urine is collected several
times over a 24-hour period and tested for cortisol. Devels higher than 50 to 100
micrograms a day for an adult suggest Cushing¶s syndrome. The normal upper limit
varies in different laboratories depending on which measurement technique is used.
R +,' -. (( + ,' * (( .. The
midnight plasma cortisol test measures cortisol concentrations in the blood. Cortisol
production is normally suppressed at night but in Cushing¶s syndrome this suppression
doesn¶t occur. If the cortisol level is more than 50 nanomoles per liter (nmol/D)
Cushing¶s syndrome is suspected. The test generally requires a 48-hour hospital stay to
avoid falsely elevated cortisol levels due to stress.
The DST may not show a drop in cortisol levels in people with depression
alcoholism high estrogen levels acute illness or stress falsely indicating Cushing¶s
syndrome. On the other hand drugs such as phenytoin and phenobarbital may cause
cortisol levels to drop falsely indicating that Cushing¶s is not present in people who
actually have the syndrome. For this reason physicians usually advise their patients to
stop taking these drugs at least 1 week before the test.
R Monitor intake and output daily weights and serum glucose and electrolytes.
R Monitor for signs of infection because risk is high with excess glucocorticoids.
R After hypophysectomy monitor for diabetes insipidus hypothyroidism and other
endocrine changes.
R Assess the skin frequently to detect reddened areas skin breakdown or tearing
excoriation infection or edema.
R Handle skin and extremity gently to prevent trauma; prevent falls by using siderails.
R Avoid using adhesive tape on the skin to reduce trauma on its removal.
R |ncourage the patient to turn in bed frequently or ambulate to reduce pressure on bony
prominences and areas of edema.
R Assist the patient with ambulation and hygiene when weak and fatigued. pse assistive
devices during ambulation to prevent falls and fractures.
R Help the patient to schedule exercise and rest. Advise the patient how to recognize signs
and symptoms of excessive exertion.
R Instruct the patient to correct body mechanics to avoid pain or injury during activities.
R Provides foods low in sodium to minimize edema and provide foods high in potassium
(bananas orange juice tomatoes) and administer potassium supplements as prescribed to
counteract weakness re;ated to hypokalemia.
R Report edema and signs of fluid retention.
R |ncourage the patient to verbalize concerns about the illness changes in appearance and
alters role function.
R |xplain to female patient who has benign adenoma or hyperplasia that with proper
treatment evidence of masculinization can be reversed.
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X After 2 hours of nursing intervention the patient will be able to achieve timely
wound healing.
*( 2 (1
*(1
X After 2 hours of nursing intervention the patient was able to achieve timely
wound healing.
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X 1 |valuate client with impaired cognition developmental delay eed for/ use of
restraints long term immobility.
X
1 To identify risk for injury/ safety requirements.
*(1
,(1
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X 1 Ascertain ability to stand and move about and degree of assistance necessary/
used of equipment.
X
1 To determine current status and needs associated with participation in
needed/desires activities.
X 1 Adjust activities.
X
1 To prevent overexertion.
X 1 assist with activities and provide/ monitor clients use of assistive devices.
X
1 To protect client from injury.
*(1
X After 2 hours of nursing intervention the patient was able to participate willingly
in necessary/desired activities.
R Cushing's disease: 10
R Primary adrenal: 3
R |ctopic ACTH: 1.4
rm
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Many cases can be cured. Results depend on the underlying
cause and severity of the problem.
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The prognosis for individuals with Cushing's syndrome
varies depending on the cause of overproduction of cortisol. With treatment most individuals
with Cushing's syndrome show significant improvement while improvement for others may be
complicated by various aspects of the causative illness. Some kinds of tumors may recur. Most
cases of Cushing's can be cured.
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