Adrenal Cortex Hormones and Cushing's Syndrome

• The adrenal cortex produces steroid hormones, including glucocorticoids, mineralocorticoids, and androgens

Glucocorticoids

• Regulate metabolism, increase blood glucose, and modulate the immune response
• Cortisol is an example
• Critical for physiological stress response

Mineralocorticoids

• Regulate electrolyte and fluid balance
• Aldosterone is an example

Androgens

• Promote growth and development in both genders
• Influence sexual desire and satisfaction in women

Cushing's Syndrome

• Results from excessive corticosteroids, particularly glucocorticoids
• Clinical abnormalities can occur

Causes of Cushing’s Syndrome

• ACTH-secreting pituitary tumour (Cushing’s disease)
• Cortisol-secreting neoplasm (carcinoma or adenoma) in the adrenal cortex
• Excessive ACTH secretion from carcinoma of the lung or other malignant growth outside the pituitary or adrenal glands
• Prolonged high doses of corticosteroids

Diagnostic Studies for Cushing’s Syndrome

• Utilize at least two of the three screening tests:
• 24-hour urine free cortisol test measure cortisol levels in urine
• Late night/bedtime salivary cortisol levels measure cortisol levels in saliva
• 1 mg overnight dexamethasone suppression test screens for excess cortisol production
• False positives can occur due to exercise, depression, acute stress, and alcoholism
• CT and MRI scans are performed on the pituitary and adrenal glands
• Plasma ACTH levels can vary (low, normal, or elevated) Hypokalemia and alkalosis may indicate ectopic ACTH syndrome or adrenal carcinoma

Cushing’s Syndrome: Nursing Assessment

• Assess past medical history:
• Pituitary tumour
• Adrenal, pancreatic, or pulmonary neoplasms
• GI bleeding
• Frequent infections
• Use of corticosteroids
• Subjective symptoms include:
• Amenorrhea, erectile dysfunction
• Anxiety, mood disturbances, psychosis
• Headache, or pain in back, joints, bone, ribs
• Poor concentration and memory
• Insomnia, poor sleep quality
• Weight gain or anorexia
• Polyuria
• Prolonged wound healing, easy bruising
• Weakness, fatigue

Effects of Excess Glucocorticoids (Cortisol)

• Cardiovascular: Hypertension, hypervolemia, edema
• Fluid and electrolytes: Sodium and water retention, edema, hypokalemia
• Physical appearance: Central obesity, thin extremities, moon facies, buffalo hump
• Immune suppression, inhibition of inflammation, delayed wound healing
• Hyperglycemia: Glucose intolerance due to cortisol-induced insulin resistance
• Protein wasting: Catabolic effects lead to muscle weakness (especially in extremities), osteoporosis, bone and back pain
• Loss of collagen: Skin becomes weaker, thinner, and bruises easily
• Mood disturbances (irritability, anxiety, euphoria), insomnia, irrationality, psychosis (occasionally)

Effects of Excess Mineralocorticoids

• Hypertension, secondary to fluid retention
• Sodium and water retention, edema

Effects of Excess Androgens

• Pronounced acne
• Hyperpigmentation
• Lower sex drive
• Fertility issues
• Menstrual disorders
• Hirsutism
• Erectile dysfunction

Cushing’s Syndrome: Goals of Treatment

• The primary goal is to normalize hormone secretion
• Treatment options depend on the cause
• Pituitary adenoma: Surgical removal of a tumour or radiation
• Adrenal tumours or hyperplasia: Adrenalectomy
• Ectopic ACTH-secreting tumours: Managed by treating primary neoplasm
• Prolonged administration of corticosteroids: Reduce dose or convert to alternate-day regimen
• Medications are used when surgery is contraindicated or as an adjunct
• Medication therapy aims to inhibit adrenal function

Cushing’s Syndrome: Objective Data

• Truncal obesity, buffalo hump, moon facies
• Hirsutism of body and face
• Thinning of head hair
• Thin, friable skin
• Acne
• Petechiae, purpura
• Hyperpigmentation
• Edema of lower extremities
• Purplish-red striae on breasts, buttocks, and abdomen
• Hypertension
• Muscle wasting
• Thin extremities
• Awkward gait
• Gynecomastia (in men)
• Testicular atrophy (in men)
• Enlarged clitoris (in women)

Cushing’s Syndrome: Nursing Planning

• Patient goals include:
• Relief of symptoms
• Avoidance of serious complications
• Maintenance of positive self-image
• Active participation in the therapeutic plan

Cushing’s Syndrome: Acute Intervention

• Assessment of signs and symptoms of hormone and medication toxicity
• Assessment of complicating conditions (cardiovascular disease, diabetes mellitus, infection)
• Monitoring of vital signs, daily weight, glucose, and signs of infection
• Monitor for signs and symptoms of abnormal thromboembolic phenomena
• Provide emotional support and health teaching

Cushing’s Syndrome: Nursing Evaluation

• Expected outcomes:
• No signs or symptoms of infection
• Attainment of weight appropriate for height
• Increased acceptance of appearance
• Healing and maintenance of intact skin