Question

Patient Profile

T.H. is a 26-year-old elementary school teacher. He seeks the advice of his health care provider because of changes in his appearance over the past year.

Subjective Data

• Reports weight gain (particularly through his midsection), easy bruising, and edema of his feet, lower legs, and hands

• Has been having increasing weakness and insomnia

Objective Data

• Physical examination: BP 150/110; 2+ edema of lower extremities; purplish striae on abdomen; thin extremities with thin, friable skin; severe acne of the face and neck

• Blood analysis: Glucose 167 mg/dL (9.3 mmol/L); white blood cell (WBC) count 13,600/uL; lymphocytes 12%; red blood cell (RBC) count 6.6 x 10^6/uL; k+ 3.2 mEq/L (3.2 mmol/L)

1. Discuss the probable causes of the alterations in T.H.’s laboratory results.

2. Explain the pathophysiology of Cushing Syndrome.

3. What diagnostic testing would identify the cause of T.H.’s Cushing Syndrome?

4. What is the usual treatment of Cushing Syndrome?

5. What is meant by a “medical adrenalectomy”?

6. Priority Decision: What are the priority nursing responsibilities in the care of this patient?

7. Priority Decision: Based on the assessment data presented, what is the priority nursing diagnosis? Are there any collaborative problems?

Answer 1

1.

T . H is the affected by the disease of cushing syndrome. Thats why the all changes came in his body.

Too much of the hormone cortisol in your body causes Cushing syndrome. Cortisol, which is produced in the adrenal glands, plays a variety of roles in your body.

For example, cortisol helps regulate your blood pressure, reduces inflammation, and keeps your heart and blood vessels functioning normally. Cortisol helps your body respond to stress. It also regulates the way your body converts proteins, carbohydrates and fats in your diet into energy.

The role of corticosteroid medications (exogenous Cushing syndrome)

Cushing syndrome can develop from taking oral corticosteroid medications, such as prednisone, in high doses over time.

Oral corticosteroids may be necessary to treat inflammatory diseases, such as rheumatoid arthritis, lupus and asthma. They may also be used to prevent your body from rejecting a transplanted organ.

It's also possible to develop Cushing syndrome from injectable corticosteroids — for example, repeated injections for joint pain, bursitis and back pain. Inhaled steroid medicines for asthma and steroid skin creams used for skin disorders such as eczema are generally less likely to cause Cushing syndrome than are oral corticosteroids. But, in some individuals, these medications may cause Cushing syndrome, especially if taken in high doses.

2.

Pathophysiology :-

When stimulated by ACTH, the adrenal gland secretes cortisol and other steroid hormones. ACTH is produced by the pituitary gland and released into the petrosal venous sinuses in response to stimulation by corticotropin-releasing hormone (CRH) from the hypothalamus (Figure 2). ACTH is released in a diurnal pattern that is independent of circulating cortisol levels: peak release occurs just before awakening, and ACTH levels then decline throughout the day. Control of CRH and ACTH release is maintained through negative feedback by cortisol at the hypothalamic and pituitary levels. Neuronal input at the hypothalamic level can also stimulate CRH release.

Although the adenomas of Cushing's disease secrete excessive amounts of ACTH, they generally retain some negative feedback responsiveness to high doses of glucocorticoids. Ectopic 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.

3.

these diagnostic tests may help pinpoint the cause:

• Urine and blood tests. These tests measure hormone levels and show whether T. H's body is producing excessive cortisol. For the urine test, T. H may be asked to collect your urine over a 24-hour period. Urine and blood samples will be sent to a laboratory to be analyzed

• T. H's doctor might also recommend other specialized tests that involve measuring cortisol levels before and after using hormone medications to stimulate or suppress cortisol.

• Saliva test. Cortisol levels normally rise and fall throughout the day. In people without Cushing syndrome, levels of cortisol drop significantly in the evening. By analyzing cortisol levels from a small sample of saliva collected late at night, doctors can see if cortisol levels are too high.

• Imaging tests. CT or MRI scans can provide images of your pituitary and adrenal glands to detect abnormalities, such as tumors.

• Petrosal sinus sampling. This test can help determine whether the cause of Cushing syndrome is rooted in the pituitary or somewhere else. For the test, blood samples are taken from the veins that drain the pituitary gland (petrosal sinuses).

  A thin tube is inserted into your upper thigh or groin area while T. H is sedated and is threaded to the petrosal sinuses. Levels of ACTH are measured from the petrosal sinuses and from a blood sample taken from the forearm.

  If the ACTH level is higher in the sinus sample, the problem stems from the pituitary. If the ACTH levels are similar between the sinuses and forearm, the root of the problem lies outside of the pituitary gland.

• 4.

• Cushing’s syndrome treatment

• The overall goal of Cushing’s syndrome treatment is to lower the levels of cortisol in body. This can be accomplished in several ways. The treatment that receive will depend on what’s causing condition.

T. H's healthcare provider may prescribe a medication to help manage cortisol levels. Some medications decrease cortisol production in the adrenal glands or decrease ACTH production in the pituitary gland. Other medications block the effect of cortisol on tissues.

Examples include:

ketoconazole (Nizoral)

mitotane (Lysodren)

metyrapone (Metopirone)

pasireotide (Signifor)

mifepristone (Korlym, Mifeprex) in individuals with type 2 diabetes or glucose intolerance

If T. H use corticosteroids, a change in medication or dosage may be necessary. Don’t attempt to change the dosage u sh. T. H should do this under close medical supervision.

Tumors can be malignant, which means cancerous, or benign, which means noncancerous.

If t. H's condition is caused by a tumor, your healthcare provider may want to remove the tumor surgically. If the tumor cannot be removed, your healthcare provider may also recommend radiation therapy or chemotherapy.

5.

Medical adrenelectomy:-

Agents that inhibit steroidogenesis, such as mitotane, ketoconazole, metyrapone, and etomidate, have been used to cause medical adrenalectomy. These medications are often are toxic at the doses required to reduce cortisol secretion. For instance, ketoconazole's prescribing information was revised to include a black box warning regarding hepatotoxicity, including fatalities and liver transplantation. Thus, medical treatment should be initiated cautiously and, ideally, in consultation with a specialist. Efficacy of these medical interventions can be assessed with serial measurements of 24-hour urinary free cortisol. Patients receiving these medications may require glucocorticoid replacement to avoid adrenal insufficiency. Patients should be counseled on the signs and symptoms of adrenal insufficiency when starting these drugs.

An orally administered steroidogenesis inhibitor, osilodrostat (Isturisa) acts on 11-beta-hydroxylase, an enzyme that catalyzes the last step of cortisol synthesis in the adrenal cortex. It is indicated for adults with Cushing disease who cannot undergo pituitary surgery or in whom the operation has not been curative.

6.

The priority nursing responsibilty in the care of patient is to

To identify nursing diagnoses, two experts analyzed signs and symptoms registered in medical charts at the time of risk classification. For priority level I patients, the most frequent nursing diagnoses were acute pain (65.0%), respiratory insufficiency (45.0%), and impaired gas exchange (40.0%).

Nursing Care Planning & Goals

The major nursing goals for the patient include:

Decrease risk of injury.

Decrease risk of infection.

Increase ability to carry out self-care activities.

Improve skin integrity.

Improve body image.

Improve mental function.

7.

Based on the assessment data, the major nursing diagnoses of the patient with Cushing’s syndrome include:

Risk for injury related to weakness.

Risk for infection related to altered protein metabolism and inflammatory response.

Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns.

Impaired skin integrity related to edema, impaired healing, and thin and fragile skin.

Disturbed body image related to altered physical appearance, impaired sexual functioning, and decreased activity level.

Disturbed thought processes related to mood swings, irritability, and depression.

Yes, it is colloborative problem.

the home health nurse needs the patient's complete medication history but the patient tells the nurse that many changes were made in the hospital