Nursing Care Plan (NCP) for Cushing’s Disease
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Outline
Lesson Objectives for Cushing’s Disease
- Understanding Cushing’s Disease:
- Define Cushing’s Disease, explaining its pathophysiology, which involves excessive cortisol production, typically due to a pituitary tumor.
- Identification of Signs and Symptoms:
- Recognize and identify the signs and symptoms associated with Cushing’s Disease, such as weight gain, moon face, buffalo hump, and psychological changes.
- Diagnostic Measures:
- Discuss the diagnostic measures for Cushing’s Disease, including laboratory tests (e.g., cortisol levels), imaging studies (e.g., MRI), and dexamethasone suppression tests.
- Medical and Surgical Interventions:
- Explore medical and surgical interventions commonly used to manage Cushing’s Disease, such as medication (e.g., cortisol-lowering drugs) and surgical removal of pituitary tumors.
- Nursing Care and Patient Education:
- Outline nursing care strategies, focusing on patient education about medication management, potential side effects, and the importance of regular follow-ups. Emphasize the role of emotional support.
Pathophysiology of Cushing’s Disease
- Excessive Cortisol Production:
- Cushing’s Disease is characterized by the overproduction of cortisol, a steroid hormone, usually triggered by a benign tumor in the pituitary gland called an adenoma.
- Pituitary Adenoma Presence:
- The pituitary adenoma stimulates the secretion of adrenocorticotropic hormone (ACTH), leading to increased cortisol release from the adrenal glands.
- Hyperstimulation of Adrenal Cortex:
- Elevated ACTH levels cause hyperstimulation of the adrenal cortex, resulting in excessive production and release of cortisol into the bloodstream.
- Effects on Body Systems:
- Excess cortisol affects various body systems, leading to metabolic disturbances, immunosuppression, fluid retention, increased gluconeogenesis, and altered fat metabolism.
- Clinical Manifestations:
- The imbalanced cortisol levels contribute to the clinical manifestations of Cushing’s Disease, including weight gain, central obesity, thinning of the skin, easy bruising, hypertension, and psychological symptoms such as mood swings and cognitive changes.
Etiology of Cushing’s Disease
- Pituitary Adenoma:
- The primary cause of Cushing’s Disease is the presence of a benign tumor (adenoma) in the pituitary gland. This adenoma produces excessive amounts of adrenocorticotropic hormone (ACTH).
- ACTH Overproduction:
- The pituitary adenoma stimulates the overproduction of ACTH, which, in turn, leads to the hyperstimulation of the adrenal glands.
- Adrenal Cortex Hyperactivity:
- Hyperstimulation of the adrenal cortex results in increased synthesis and release of cortisol, the main glucocorticoid hormone.
- Non-Pituitary Sources (Rare):
- In rare cases, Cushing’s syndrome may be caused by ectopic ACTH-producing tumors outside the pituitary gland, such as in the lungs or pancreas.
- Iatrogenic Causes:
- Some cases of Cushing’s syndrome may be iatrogenic, resulting from prolonged and excessive use of corticosteroid medications for various medical conditions.
Desired Outcome for Cushing’s Disease
- Normalization of Cortisol Levels:
- The primary goal is to reduce and normalize cortisol levels to restore the body’s natural hormonal balance.
- Resolution of Symptoms:
- Achieve relief from the clinical manifestations of Cushing’s syndrome, such as weight gain, hypertension, muscle weakness, and mood disturbances.
- Tumor Size Reduction (if applicable):
- In cases where Cushing’s Disease is caused by a pituitary adenoma, the desired outcome includes reducing the size of the tumor through surgery or other interventions.
- Prevention of Complications:
- Minimize or prevent complications associated with prolonged exposure to high cortisol levels, including osteoporosis, cardiovascular issues, and diabetes.
- Improvement in Quality of Life:
- Enhance the patient’s overall well-being by addressing and alleviating the physical and psychological effects of Cushing’s syndrome, allowing for a better quality of life.
Cushing’s Disease Nursing Care Plan
Subjective Data:
- Back pain
- Weakness
- Irregular menstrual cycles
- Shortness of breath
- Poor concentration
Objective Data:
- Red, ruddy face
- Upper body obesity with thinning arms and legs
- Acne or skin infections
- Hypertension
- Uncontrolled diabetes
- Tachycardia
- Tachypnea
Nursing Assessment for Cushing’s Disease
- Clinical History:
- Obtain a comprehensive medical history, with a focus on the onset and progression of symptoms related to Cushing’s syndrome.
- Physical Examination:
- Perform a thorough physical assessment, paying attention to signs such as central obesity, moon face, buffalo hump, purple striae, and proximal muscle weakness.
- Neurological Assessment:
- Evaluate neurological symptoms, especially if Cushing’s Disease is caused by a pituitary adenoma, including changes in vision, headaches, or other indications of increased intracranial pressure.
- Monitoring Vital Signs:
- Regularly monitor blood pressure, heart rate, and respiratory rate, as hypertension and tachycardia are common manifestations of Cushing’s syndrome.
- Laboratory Tests:
- Conduct relevant laboratory tests, including cortisol levels, adrenocorticotropic hormone (ACTH) levels, and other hormonal assays to confirm the diagnosis and monitor treatment efficacy.
- Bone Density Assessment:
- Assess bone density through dual-energy X-ray absorptiometry (DEXA) scans to evaluate the risk of osteoporosis and fractures associated with Cushing’s syndrome.
- Psychosocial Assessment:
- Evaluate the patient’s mental health and emotional well-being, as Cushing’s syndrome can contribute to mood disorders. Collaborate with mental health professionals as needed.
- Assessment of Skin Integrity:
- Inspect the skin for bruising, thinning, or other changes associated with cortisol excess. Pay attention to wound healing and susceptibility to infections.
Implementation for Cushing’s Disease
- Collaborative Care:
- Work collaboratively with an interdisciplinary team, including endocrinologists, neurosurgeons, and mental health professionals, to ensure comprehensive care.
- Pharmacological Management:
- Administer medications as prescribed, such as adrenal enzyme inhibitors (e.g., ketoconazole, metyrapone) or surgery (transsphenoidal resection of pituitary adenoma), to reduce cortisol levels.
- Monitoring and Adjustment of Medications:
- Regularly monitor hormone levels and adjust medication dosages as needed to achieve optimal control while minimizing side effects.
- Patient Education:
- Educate the patient on the importance of medication adherence, potential side effects, and the need for regular follow-up appointments for monitoring and adjustments.
- Supportive Care:
- Provide emotional and psychological support to the patient, as Cushing’s Disease can impact mental health. Collaborate with mental health professionals to address mood disorders or anxiety.
Nursing Interventions and Rationales
- Assess and monitor cardiac and respiratory status; perform 12-lead EKG to rule out cardiac involvement
Shifts in fluid balance and electrolytes may cause arrhythmias and difficulty breathing.
- Monitor fluid and electrolyte balance; I & O, fluid restrictions as necessary
Overproduction of cortisol causes the body to retain sodium and water which can cause cardiac stress and hypokalemia.
- Administer medications as appropriate to manage symptoms
- Antihypertensives- monitor blood pressure closely as changes in cortisol levels may cause rapid changes in blood pressure
- Diuretics- to treat fluid retention and prevent excess strain on the heart
- Monitor vital signs for hypertension
Excess stress hormone (cortisol) causes an increase in blood pressure. Monitor closely and administer medications as necessary
- Manage blood glucose level
Excess cortisol can cause blood sugar to fluctuate. Monitor blood glucose levels regularly and notify MD if outside patient’s target area. Treat hypoglycemia with juice and crackers but watch for rapid spikes afterwards.
Treat hyperglycemia by having the patient drink water and notify MD if necessary.
- Promote rest
Long term stress and elevated cortisol levels can weaken the immune system and increase the risk of developing bacterial infections.
- Monitor for signs of infection
- Fever
- Wounds that are not healing
- Changes in appetite or bowel habits
- Nausea / vomiting
Cortisol suppresses the immune system and increases the risk of infection. Obvious signs of infection may be masked, so take note of subtle signs.
- Prepare patient for surgery to treat disease
Medication can help manage the symptoms, but there is currently no medication that can fully treat the disease. Surgery to remove the pituitary tumor(s) or adrenal glands is the most common treatment for the disease.
- Reduce risk of infections
Avoid unnecessary exposure to people with infections; stress the importance of good hand hygiene to patient and family members / caregivers
- Educate and encourage positive body image
Changes in the appearance can give the patient a negative self-image and lead to anxiety and depression. Reassure patient and educate them about the changes in fat distribution associated with the disease. Promote an atmosphere of acceptance and encourage the patient to verbalize feelings.
- Nutrition and lifestyle education
- Quit smoking
- Limit or avoid alcohol
- Low sodium diet
Incorporate and educate patient about good dietary and lifestyle choices. Low sodium diet may be supplemented with high potassium foods and low protein to promote a stronger immune system. Encourage exercise as tolerable.
Evaluation for Cushing’s Disease
- Hormone Level Monitoring:
- Regularly assess cortisol levels through laboratory tests to evaluate the effectiveness of treatment and ensure hormone levels are within the target range.
- Clinical Symptom Assessment:
- Evaluate the patient for changes in clinical symptoms such as weight gain, hypertension, mood disturbances, and glucose intolerance. Improvement in these symptoms indicates positive treatment outcomes.
- Medication Adherence:
- Assess the patient’s adherence to prescribed medications and address any barriers to adherence. Non-adherence can negatively impact treatment efficacy.
- Complication Monitoring:
- Monitor for potential complications associated with Cushing’s Disease or its treatment, such as infections, electrolyte imbalances, or surgical complications, and intervene promptly if needed.
- Quality of Life Assessment:
- Use validated tools to assess the patient’s quality of life, including physical and psychological well-being, to determine the overall impact of the disease and its treatment on the patient’s daily life.
References
- https://www.pituitarysociety.org/patient-education/pituitary-disorders/cushings/management-of-cushings-disease-and-cushings-syndrome
- http://pituitary.ucla.edu/cushings-disease
- https://medlineplus.gov/ency/article/000348.htm
- https://ghr.nlm.nih.gov/condition/cushing-disease#diagnosis
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Transcript
Today we are going to be talking about Cushing’s disease. Cushing’s disease is a condition in which your pituitary gland produces too much hormone that causes an overproduction of the stress hormone Cortisol. Cortisol is responsible for so many things, but amongst them, it causes weight gain around your trunk and also weight loss and fat loss in the legs and arms. Some of the considerations we want to think about when we are taking care of these patients, we want to monitor the vital signs. These patients tend to have higher blood pressure because of the stress hormone. We want to assess for increased glucose levels, and we want to monitor for signs of infection. Our desired outcome with Cushing’s patients is to manage the symptoms, to maintain normal blood pressure and to maintain a normal blood glucose level. We want to keep it to an inappropriate age.
So subjective. These patients are always complaining about a few things. One of them being weakness and pain, but specifically back pain. They also have irregular menstrual cycles, and they complain of shortness of breath. Some things that we are going to see are classic when it comes to Cushings. And these are the following: a red, they like to describe it as a red, ruddy face and upper body obesity. They have thin arms, thin legs, but obesity in their trunk area. And then, there’s something called a moon face. So, their face just rounds up. So, that is a moon face. And then the other thing is called Buffalo hump. A Buffalo hump is where there is fat storage that goes right behind the neck. They also have tachycardia and hypertension and osteoporosis. Some things that we want to consider and do and intervene when we are taking care of these patients is that we want to do a really good assessment.
We want to assess these patients really well, focusing on their cardiac and respiratory status. Sometimes we may need to perform a 12 lead and that’s really to rule out any cardiac involvement. Oftentimes these patients will have shifts in their electrolytes and, you know, electrolytes are very responsible for cardiac workups. So we want to make sure that those are good. And we also want to look out for their difficulty breathing. They do have certain medications that they’re going to get. One of the medications is going to be an antihypertensive. We want to make sure that we are controlling their blood pressure because they have way high BP. Their BP is way through the roof because the changing cortisol level is telling them that it’s time to fight and you need that extra blood pressure. We also want to give them some diuretics because patients with Cushing’s disease tend to hold on to water and that just puts on extra strain on the heart. Because these patients have a compromised immune system because of the cortisol levels, we are going to monitor for those infection signs. And those infection signs include fever and wounds that might not be healing. They may complain of nausea and vomiting. Cortisol is telling the body, the immune system to step to the side. That’s good in a fight or flight situation, but with just everyday living, you need your immune system. So we want to monitor for that. We also want to prepare these patients for surgery because some of these patients can not be managed with medications, the surgery to remove the pituitary gland or adrenal glands is the most common treatment for this disease. So we want to do that. Some of the things we want to do with that is we want to keep the patient’s NPO for nothing by mouth, and we want to manage them post-operatively again, because of the electrolyte and the fluid shifts.
We want to manage their electrolyte balance by drawing labs, the cortisol levels, when it’s overproduced, it causes the body to retain sodium and water. So again, that puts more stress on the heart, but it also leads to low potassium or high hypokalemia, low calcium. We want to promote rest, which is very important. I love rest. So we want to promote rest. These patients are in a constant state of fight or flight. And so it weakens the body, weakens the immune system, and it actually increases their risk of developing a bacterial infection. So we want to make sure that these people can rest. We want to do whatever we can to decrease stimulation, to keep them asleep and let them actually have a chance to fight off. And finally, we want to manage the blood glucose level. These patients with Cushing’s disease tend to have a high glucose level, even if they’re not diabetic, the excess cortisol causes their blood sugar to fluctuate.
So, we want to monitor their levels. And if it’s outside of the target range, whatever the doctor has a set, we want to make sure we notify them of that; we could possibly get some insulin orders for that. This is just a quick look at the top things of what a Cushing’s patient will look like. So we discussed this a little bit, but we have the moon face and there is a bit of a Buffalo hump on the back of the neck. They have what we call truncal obesity. So a larger stomach, and it is a little extended. There’s a complaint of osteoporosis; so they have very weak and brittle bones, so easy, easy breaks. Okay. And then they have thin extremities. So you have these patients with these large trunks, but very thin arms and legs. That is a classic classic picture of someone who is dealing with Cushing’s disease.
And the key points, just to remember, is that the pituitary gland causes the overproduction of cortisol, which leads to Cushing’s disease. Some of the things that the patient’s going to tell us is that they’re going to have some back pain and weakness. They’re going to be short of breath. Well, we’re going to see, as nurses, an increase in their heart rate and their blood pressure. They’re also going to have, like I said, that classic Buffalo hump Moon face, high sugars, high blood glucose levels, the glucose management is all about counteracting those increased cortisol levels. So we’re going to do glucose checks and we’re going to treat them as ordered. Also, we’re going to do infection prevention. So part of that is hand hygiene, but we’re also going to encourage the patients to stay away from others who are sick from infections that we just want to encourage and educate the patient about. It’s going to be a fever and wounds that won’t heal. We love you guys; go out and be your best self today. And that’s always happy nursing.
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