Cushing’s Syndrome Nursing Care Plan & Management

  • Cushing’s Syndrome 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.
Types of Cushing’s Syndrome:
  1. Pituitary Cushing’s syndrome (Cushing’s disease) is the 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.
  2. Adrenal Cushing’s syndrome is associated with adenoma or carcinoma of the adrenal cortex. The disease may recur after surgery.
  3. Ectopic Cushing’s syndrome results from autonomous ACTH secretion by extrapituitary tumors (such as the lungs) producing excess ACTH.
  4. Iatrogenic Cushing’s syndrome is caused by exogenous glucocorticoid administration.

The most common cause of Cushing syndrome is side effects from taking anti-inflammatory steroid medications for conditions such as asthma and rheumatoid arthritis.

The second most common cause is Cushing’s disease, which occurs when the pituitary gland makes too much of the hormone ACTH. ACTH stimulates the adrenal glands to produce cortisol.

Cushing’s disease affects women more often than men.

Cushing syndrome can also be caused by the following:

  • Tumor of the pituitary gland or adrenal gland
  • Tumor elsewhere in the body (ectopic Cushing syndrome)

1. Signs and symptoms of excess glucocorticoid (cortisol) secretion:

  • Weight gain or obesity.
  • Heavy trunk; thin extremities.
  • Fat pad (Buffalo Hump) in neck and supraclavicular area.
  • Rounded face (moon face); plethoric, oily complexion.
  • Skin – fragile and thin; striae and ecchymosis, acne.
  • Musculoskeletal – muscle wasting causes by excessive catabolism, osteoporosis, characteristic kyphosis, back ache.
  • Mental disturbances – mood changes, psychosis.
  • Increased susceptibility to infections.

2. Manifestation of excess mineralocorticoid (aldosterone) secretion:

  • Hypertension
  • Hypernatremia, hypokalemia
  • Weight gain
  • Expanded blood volume
  • Edema

3. Manifestation of excess androgens:

  • Females experience virilism (masculinization) with hirsutism (excessive growth of hair on the face and midline of trunk); atrophied breast, enlarged clitoris, masculinized voice, loss of libido, hermaphroditism (if exposed in utero).
  • Males – loss of libido.
Diagnostic Evaluation
  • Excessive plasma cortisol levels and loss of diurnal variation.
  • Increased blood glucose levels, decreased serum potassium level.
  • Plasma ACTH elevated in patients with pituitary tumors, very low in patients with adrenal tumor.
  • Eosinophils decreased on complete blood count.
  • Elevated urinary 17-hydroxycorticoids and 17-ketogenic steroids.
  • Overnight dexamethasone suppression test, possibly with cortisol urinary excretion measurement, to check for:
    • Unsuppressed cortisol level in Cushing’s syndrome cause by adrenal tumors.
    • Suppressed cortisol level in Cushing’s disease caused by pituitary tumor.
  • Skull X-ray detects erosion of the sella turcica by a pituitary tumor; CT scan and ultrasonography locate tumor.
Primary Nursing Diagnosis
  • Fluid volume excess related to abnormal retention of sodium and water
Medical Management

Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex

  • Surgical removal of the tumor ( transphenoidal hypophysectomy) is the treatment of choce (90% success rate)
  • Radiation of the pituitary gland is successful but takes several months for symptom control
  • Adrenalectomy is performed in patients with primary adrenal hypertrophy
  • Post operatively, temporary replacement therapy with hydrocortisone maybe necessary until the adrenal glands begin to respond normally ( maybe several moths)
  • If bilateral adrenalectomy was performed lifetime replacement of adrenal cortex hormones is necessary
  • Adrenal enzyme inhibitors ( E.g. metyrapone or mitotine) maybe used with ectopic ACTH- secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects
  • If Cushing’s syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate-day therapy to treat the underlying disease