Cushing Syndrome: Adrenal Hyperfunction

• Cushing syndrome, also called adrenal hyperfunction, involves increased adrenocortical hormones; understanding the mechanisms is key.

Key Points of Cushing Syndrome

• Adrenal hyperfunction refers to the overactivity of the adrenal glands.
• Cushing Syndrome is a hormonal disorder from prolonged exposure to high cortisol levels.
• "Cushy Carl" can be used as a visual aid for remembering the syndrome.

Hormonal Imbalance in Cushing Syndrome

• Results in excess secretion of adrenal hormones, including glucocorticoids, mineralocorticoids, and sex hormones (androgens).

Corticoid Types

• Glucocorticoids are primarily cortisol, which is a steroid hormone.
• Mineralocorticoids are primarily aldosterone, and they regulate sodium and potassium balance.
• Sex hormones like androgens affect libido and can cause hirsutism in women.

Causes of Cushing Syndrome

• Can arise from adrenal tissue hyperplasia, adrenal cortex tumors, ACTH-secreting neoplasms, or prolonged steroid use.

Additional Key Terms

• Hyperplasia refers to the enlargement of an organ or tissue caused by an increased cell reproduction rate.
• ACTH is adrenocorticotropic hormone, which stimulates the adrenal glands.
• Steroid abuse is the overuse of steroids and can mimic Cushing syndrome.

HPA Axis Review

• The hypothalamus releases corticotropin-releasing hormone (CRH).
• CRH stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH).
• ACTH then stimulates the adrenal gland to release cortisol.

Where the Hormones are Released

• Hypothalamus releases CRH.
• Pituitary gland releases ACTH.
• Adrenal gland releases cortisol, which is a glucocorticoid.

Aldosterone and Electrolyte Balance

• Aldosterone, a mineralocorticoid, increases sodium reabsorption and decreases potassium levels leading to water retention and edema.

Electrolyte Regulation

• Aldosterone increases sodium retention and potassium excretion.
• Sodium retention leads to water retention and edema.
• Potassium excretion results in hypokalemia.

Edema

• Edema is swelling caused by excess fluid trapped in the body's tissues.

Effects of Cortisol

• Cortisol increases the use of fats and amino acids for energy and decreases glucose use, leading to hyperglycemia.

Use of Fat and Glucose

• Increased fat and amino acid use provide energy.
• Decreased glucose use conserves glucose for the brain.
• Hyperglycemia is elevated blood glucose levels.

Impact on Immune Response and Wound Healing

• Excess cortisol decreases the immune response, increasing the risk of infection and slows wound healing.
• Impaired tissue repair results in slow wound healing.

Body Changes of Cushing Syndrome

• Promotes fat deposits in the trunk, thin and fragile skin, and fragile bones due to osteoporosis.

Key Features

• Trunk fat deposits result in central obesity.
• Thin and fragile skin leads to easy bruising.
• Osteoporosis leads to an increased risk of fractures.

Sex Hormone Imbalance

• An increase in sex hormones (androgens) leads to decreased libido and hirsutism in women.

Definition of Terms

• Decreased libido is reduced sexual desire.
• Hirsutism is excessive hair growth in women in a masculine pattern.

Common Characteristics of Cushing's Disease

• Visual characteristics include a moon face, buffalo hump, and thin arms and legs due to muscle wasting.

Clinical Signs

• Moon face is a rounded face due to fat deposits.
• Buffalo hump is fat accumulation at the top of the back between the shoulders.
• Muscle wasting leads to thin arms and legs.

Electrolyte Imbalance and Kidney Issues

• High sodium and low potassium levels, hyperglycemia, and potential protein and calcium in the urine can lead to kidney stones.

Potential Electrolyte Observations

• Hypokalemia is low potassium levels.
• Hyperglycemia is high blood sugar levels.
• Kidney stones have potential formation due to calcium in the urine.

Skeletal Changes

• Osteoporosis and kyphosis (excessive curve of the thoracic vertebrae) can occur.

Definitions of Skeletal Terms

• Osteoporosis means weak and brittle bones.
• Kyphosis is a hunchback or excessive curvature of the spine.

Susceptibility to Infections

• Patients are highly susceptible to infections, but the usual signs may be subtle due to the suppressed immune response.

Clinical Presentations of Infections

• Subtle infection signs are evidenced by slight temperature increases or redness.
• Impaired immune response makes detection challenging.

Mental and Emotional Changes

• Mental changes, mood swings, and psychosis may occur.

Mental Health Terms

• Mood swings are unstable emotional states.
• Psychosis is a severe mental disorder characterized by a disconnect from reality.

Other Symptoms Associated with Cushing Syndrome

• Loss of libido, severe backache (possibly due to compression fractures), ecchymosis, weight gain, abdominal enlargement, peripheral edema, and elevated blood pressure.

Key Terms for Symptoms

• Compression fracture is a fracture of the vertebrae.
• Ecchymosis is bruising.
• Peripheral edema is swelling in the extremities.

Depression and Suicide Risk

• Depression is common, and patients are at risk of suicide.
• Depression is a common mental health issue; suicide risk requires careful monitoring and support.

Weight Gain and Metabolic Issues

• Weight gain is due to adipose tissue in the trunk, face, and cervical spine area, along with increased appetite and impaired carbohydrate metabolism leading to hyperglycemia.

Terminology

• Adipose tissue is fat tissue.
• Impaired carbohydrate metabolism leads to hyperglycemia.

Skin Changes

• Hirsutism is possible, and striae (stretch marks) may appear on the skin.
• Striae are stretch marks.

Medical Management of Cushing Syndrome

• Treatment options include adrenalectomy for adrenal tumors, radiation or removal for pituitary tumors, and Lysodren for inoperable cases.

Treatments

• Adrenalectomy is the surgical removal of the adrenal gland.
• Lysodren is toxic to adrenal glands.

Dietary Considerations

• Diet should be low in sodium, calories, and carbohydrates, and high in potassium.
• Low sodium manages fluid retention.
• Low calorie addresses weight gain.
• Low carbohydrate controls hyperglycemia.
• High potassium counters hypokalemia.

Nursing Interventions

• Gentle handling prevents bruising; infection prevention due to compromised immune system.
• Skin protection prevents breakdown.
• Utilized stress avoidance, frequent turning, ambulate as tolerated, and rest.
• A medical alert bracelet is important in case of emergencies.
• Meticulous handwashing reduces infection risk.

Psychosocial Support

• Meeting the psychosocial needs of the patient is crucial due to mood swings and depression.
• Psychosocial support addresses emotional and mental health.

Addison's Disease: Adrenal Hypofunction

• Addison's disease is the opposite of Cushing syndrome, involving inadequate secretion of glucocorticoids, mineralocorticoids, and androgens.

Description

• Adrenal hypofunction means underactivity of the adrenal glands; it is the opposite of Cushing syndrome with reduced hormone levels.

Causes of Addison's Disease

• Causes include adrenalectomy, pituitary hypofunction, long-term steroid therapy, idiopathic adrenal atrophy, and cancer of the adrenal glands.

Etiology

• Adrenalectomy is the surgical removal of the adrenal glands.
• Pituitary hypofunction is reduced pituitary gland activity.
• Idiopathic adrenal atrophy is adrenal gland shrinkage with unknown cause.

Addison's Disease Specifics

• Results from deficiencies in aldosterone and cortisol, often due to adrenal cortex damage or tuberculosis (TB).
• Leads to significant electrolyte imbalances and hormonal deficits, impacting various bodily functions.

Hormone Issues

• Low aldosterone leads to low sodium (hyponatremia) and high potassium (hyperkalemia).
• Low cortisol leads to hypoglycemia.

Electrolyte Imbalances

• Hyponatremia is sodium excretion leading to water loss, causing dehydration and hypovolemia.
• Hyperkalemia is elevated potassium levels.

Common Signs and Symptoms

• Weight loss, often accompanied by nausea, vomiting, and anorexia.
• Salt cravings due to sodium loss.
• Hypoglycemia, orthostatic hypotension, progressive weakness, and fatigue.
• Hyperpigmentation of the skin in sun-exposed areas, pressure points, joints, and creases.

Nursing Interventions for Addison's Disease

• Strict intake and output, monitoring daily weights, and checking skin turgor for dehydration.
• Frequent monitoring of vital signs, including temperature and blood pressure.
• Screening visitors for infectious diseases.

Possible Symptoms

• Blood pressure drops when moving from lying to sitting or standing, causing vertigo, weakness, and syncope.

Psychological Impact

• Includes poor stress handling, anxiety, and apprehension.

Adrenal Crisis

• A severe, life-threatening exacerbation of Addison's disease requires immediate intervention.

Symptoms for Adrenal Crisis

• Severe headache, disorientation, abdominal pain, generalized joint and muscle pain.
• Changes in body temperature, orthostatic hypotension, hyponatremia, and hyperkalemia.
• Profound fatigue and dehydration.
• Sudden, severe drop in blood pressure.
• Nausea, vomiting, and extremely high temperature; cyanosis.

Pathophysiology

• Vasomotor collapse: collapse of arteries and veins, potentially leading to death.

Treatment for Adrenal Crisis

• Restore fluid and electrolytes.
• Replace hydrocortisone, a glucocorticoid and mineralocorticoid.
• Administer fludrocortisone, a mineralocorticoid.
• Offer a high-sodium, low-potassium diet.
• Administer IV corticosteroids and large volumes of normal saline and dextrose.

Emergency Prepardness

• Patients must carry an emergency pack with IM cortisone and know how to self-inject.
• Damaged adrenal gland, injured pituitary gland, or improperly treated adrenal insufficiency can cause adrenal crisis.

Risk Factors for Adrenal Crisis

• Dehydration, infection, physical stress, injury to the adrenal or pituitary gland.
• Sudden cessation of steroid treatment (e.g., prednisone, hydrocortisone).
• Surgery to the adrenal gland (potential for hemorrhage), and psychological stress.
• Shock should be managed through high-dose hydrocortisone.

Pheochromocytoma

• A benign adrenal tumor, usually in the adrenal medulla, resulting in excessive epinephrine and norepinephrine (catecholamines) production.
• Typically occurs between 20 and 60 years of age.

Catecholamines

• Epinephrine and norepinephrine are "fight or flight" hormones.

Symptoms

• Severe hypertension (intermittent or persistent), potentially leading to hypertensive crisis (e.g., 300/180 mmHg).
• Stroke, kidney damage, retinopathy (potentially causing blindness), cardiac damage leading to heart failure.
• Severe headaches, palpitations, nervousness, nausea, heat intolerance.
• Unexplained abdominal pain, trouble sleeping, diaphoresis, dilated pupils.
• Glycosuria, hyperglycemia, and shortness of breath.

Diagnostic Tests

• 24-hour urine test to measure catecholamine levels.
• CT and MRI scans to locate the tumor.

Pre-operative Management

• Restrict oral intake for eight hours before IVP.
• Administer Oral Laxatives.
• Administer medications like regitine or dibenzyline to control blood pressure.
• Deseril may be given if the tumor is inoperable.

Post-operative Management

• Carefully assess blood pressure due to potential fluctuations.
• Avoid stress, get plenty of rest, and consider sedatives.
• Avoid stimulants and caffeine.
• Vasopressins and corticosteroids may be administered.

Diabetes Mellitus

• Diabetes mellitus is a condition where the body's insulin supply is absent, deficient, or the target cells resist insulin's action.
• Results in impaired glucose metabolism and hyperglycemia.
• Decreased/lack of insulin production by the beta cells of the islets of Langerhans (located in the pancreas).
• There is insulin resistance at the cellular level.

Risk Factors for Diabetes

• Genetic predisposition, viruses, aging, diet, lifestyle, and obesity.

Normal Insulin Response

• Peak insulin levels occur about 30 minutes after eating and return to normal within two hours.

Role of Glucose and Insulin

• A simple sugar that is the body's primary source of energy and hyperglycemia are elevated blood glucose levels.
• Insulin acts as a "key" that unlocks cell doors, allowing glucose to enter to be used for energy.

Type 1 Diabetes

• An autoimmune disorder is where the body's immune system attacks its own beta cells in the pancreas.
• Beta cells are responsible for producing insulin and this results in an absolute deficiency of insulin.

Characteristics of Type 1 Diabetes

• Progressive destruction of beta cells caused by improper metabolism of carbohydrates, fats, and proteins.
• The body still responds normally to insulin, but cannot produce it.
• Usually diagnosed before age 30, and patients are normal weight or underweight.
• Abrupt onset of signs and symptoms.
• Requires insulin to prevent ketoacidosis and sustain life.

Type 2 Diabetes

• Characterized by insulin resistance, where the body's cells do not respond effectively to insulin.
• This can lead to a relative insulin deficiency over time.

Terminology

• Insulin resistance is a condition in which cells do not respond normally to insulin.

More on Characteristics

• Generally occurs in people older than 35.
• 80% of patients are obese, typically controlled with oral diabetic medications, diet, and exercise.
• May require insulin during illness and stress.
• Gradual onset; may be asymptomatic at onset.

Complications of Diabetes

• Numerous long-term complications are due to damage to blood vessels and nerves including heart disease, hypertension, stroke, and renal failure.
• Other complications are erectile dysfunction, neuropathy (nerve damage), and retinopathy (eye damage) leading to blindness.
• Increased risk of infection and impaired healing can also occur.

Foot Care is Crucial

• Proper foot care is crucial for diabetics to prevent complications such as infections and ulcers.
• Assess feet regularly, especially if the patient cannot see the bottom of their feet.
• Wash feet daily with mild soap and warm water, testing the water temperature first.
• Evaluate for cuts, blisters, edema, and tender areas.
• Use lanolin on feet to prevent skin from drying and cracking, but avoid applying between the toes.

Other Interventions

• Don't use commercial remedies to remove calluses or corns; this is to be done by a physician.
• Cleanse cuts with warm water and mild soap, covering with a dressing.
• Avoid iodine, alcohol, or strong adhesives and report infections and non-healing wounds to the provider.

Pathophysiology

• The liver plays a crucial role in glucose metabolism, and insulin is essential for glucose use by cells.
• In diabetes, either a lack of insulin or insulin resistance leads to Hyperglycemia.

Consequences of Diabetes

• The liver can convert glycerol and fatty acids into glucose and is stored as glycogen.
• Fatty acids can be converted into ketone bodies to serve as fuel for muscles and the brain.
• Free glucose is used by the brain and kidneys.
• Insulin is necessary for muscle cells and other body cells to use glucose.

More Pathophysiology of Diabetes

• Hyperglycemia in diabetes leads to a cascade of physiological responses, including glycosuria, polyuria, polydipsia, and polyphagia.
• Glycosuria refers to the kidneys excreting glucose in urine; polyuria is increased urination to dilute the excess sugar.
• Polydipsia results from excessive thirst due to fluid loss, and polyphagia is increased hunger because cells are malnourished.

Metabolic Derangements in Type 1 Diabetes

• The body cannot use carbohydrates properly, leading to the breakdown of proteins and fats for energy.
• This results in the production of acidic ketone bodies, which can lead to ketoacidosis.

Resulting Conditions

• Ketone bodies are produced as a byproduct of fat breakdown.
• The body's inability to use glucose leads to the breakdown of proteins and fats for energy.

Diabetic Ketoacidosis (DKA)

• A severe metabolic disturbance caused by a critical lack of insulin and subsequent uncontrolled hyperglycemia.
• Leads to the accumulation of ketones and metabolic acidosis that is a life-threatening condition.
• Caused by a severe lack of insulin resulting in uncontrolled hyperglycemia and accumulation of ketones.

Acute Insulin Deficiency and Glucose Utilization

• Acute insulin deficiency or the body's inability to use glucose effectively leads to increased fat mobilization and ketogenesis.
• Specifically seen in Type 2 diabetics, an insulin deficiency or ineffective insulin action.
• Fat utilization is from the breakdown of fat stores for energy, ketogenesis is the production of ketones as a result of fat metabolism.

Acidosis and Respiratory Compensation

• When there's an excess of acid in the body (acidosis), the body tries to compensate by increasing respiration rate to expel carbon dioxide (CO2).

Resulting Symptoms

• In acidosis, the blood is too acidic (pH is subsequently low).
• The lungs' attempt to regulate pH by altering CO2 levels is respiratory compensation.
• Kussmaul respirations are a rapid and deep breathing pattern used to eliminate CO2.

Kussmaul Respirations and Symptoms

• Kussmaul respirations are rapid and deep breaths used to expel excess acid, resulting in fruity breath and an intoxicated apperance.
• Caused by acetone, a ketone body. Altered mental status is a result of the acidosis.

Treatment of Acid-Base Imbalance

• Treatment for severe acid-base imbalance involves administering fluids to correct acidosis and hypotension.
• Insulin is also administered to facilitate glucose intake by cells.

Key Points

• Fluid resuscitation corrects dehydration and hypotension.
• Insulin moves glucose from the blood into cells.
• The entire treatment process aims to restore normal blood pH

Elevated Blood Glucose

• Elevated blood glucose levels manifest in various signs and symptoms.
• Drowsiness (fatigue and lethargy), air hunger (feeling short of breath), and polyuria (frequent urination).
• Acetone breath: fruity-smelling breath and excessive thirst.

Progression to DKA

• Uncorrected elevated blood glucose can lead to DKA, a severe complication characterized by both hyperglycemia, ketosis, and acidosis.

Diabetes Type Manifestations

• Characterized by the "3 Ps": polyuria, polydipsia, and polyphagia.
• Increased urine output, thirst, and appetite.
• Type 2 is often asymptomatic in the early stages, and are identified upon development of complications.

Diagnoses

• Symptoms include cooler extremities, cramping in calves and feet during exercise, decreased sensation, and nerve pain (neuropathy).
• Cooler Extremities indicate reduced blood flow, resulting in damage (neuropathy), numbness, or tingling

Additional Assessments and Considerations

• Include checking for erectile dysfunction, pruritus (itching), assessing knowledge, monitoring wound healing.
• Wound healing also is slow due to impaired circulation and immune function.
• Yeast infections are more common in women due to increased glucose levels.

Patient Educaction

• Patients need to demonstrate the ability to check their glucose and inject insulin with the healthcare provider.
• Regular blood sugar checks are labeled as glucose monitoring.

Gastroparesis

• Delayed stomach emptying is a complication of diabetes.

Diagnostic Criteria

• Diagnosis is based on history, lab findings, random glucose levels, fasting levels, and 2-hour postprandial levels.
• Random glucose is >200 mg/dL; fasting glucose is >126 mg/dL after an 8-hour fast; 2-hour postprandial is >200 mg/dL.

Frequency of Testing

• Determined by the doctor and is more frequent initially or if the patient is "brittle" (poorly controlled).
• Brittle diabetes is unstable and difficult-to-control resulting in requiring finger stick monitoring.

Fasting Blood Sugar

• Normal fasting blood sugar is 60-110 mg/dL, depending on the lab. High levels are abnormal based on each labs levels.
• If abnormal. greater than 126 mg/dL

Hemoglobin A1C

• Measures the amount of glucose attached to hemoglobin in red blood cells, reflecting average blood sugar levels over the past three months.
• It is the average blood glucose over 3 months. It requires red blood cells and adherence to treatment plan must occur.
• Elevated A1c indicates hyperglycemia over the past 3 months.

Initial Actions

• Initially, finger sticks may be required before each meal and at bedtime, they also require individualized monitoring techniques.
• Once levels are controlled, frequency may be decreased.

Potential Side Effects

• Illness can cause blood sugar to rise, necessitating more frequent monitoring.
• Exercise improves cardiovascular function, and can reduce insulin resistance for 72 hours.
• Hypoglycemia (low blood sugar) can result.

Medical Instructions

• Should be between 100-200 mg/dL and only exercise if glucose > 250 mg/dL.

Illness and Surgery

• Illness and surgery can increase blood glucose levels, requiring adjustments to insulin dosage.
• Temporary insulin dosage adjustments, along with any other anti-diabetic agent dose may need to be reduced during surgery.

Important General Guidelines

• Never omit insulin or oral hypoglycemics, don't skip meals, and replace lost fluids.
• Consistent correct medication usage and adequate hydration are key.

Hypoglycemia

• A dangerous condition that leads to complications and requires prompt recognition.
• Defined as a blood glucose level less than 60 mg/dL and is often fatal if left untreated.
• Is more dangerous when it occurs during the peak action of insulin.

Treatment of Hypoglycemia

• Administer a fast-acting sugar source (e.g., candy, orange juice with sugar) and follow up with a complex carbohydrate (e.g., sandwich).
• Blood sugar should be rechecked frequently after any form of treatment.
• Orange juice or other fruit juice, hard candy, honey, commercial glucose products can be administered.
• If unconscious, Glucagon (SubQ, IM, or IV by RN) or Glucose 10% or 50% IV (by RN) can be administered.
• Do not put anything in the patient's mouth if they are not awake and alert.

Managing Diabetes

• Requires comprehensive nursing to test blood sugar accurately, and have knowledge of appropriate dietary management.
• Provide Skin Care related to proper neuropathy management.
• Inflammation and degeneration of peripheral nerves, teach proper footcare and test for long-term complication of orthostatic hypotension.

Diabetes Diet Management

• Blood sugar should be less than 126 mg/dL to help them maintain a reasonable body weight.
• Help patient Monitor blood glucose levels, hemoglobin A1c, and lipids through dietitian consultation.
• Women: 1,600 to 2,400 calories; Men: 2,000 to 3,000, with low carbohydrates, saturated fats, and alcohol intake.
• Those with insulin-dependence patients usually are often given three meals a day, plus an afternoon and bedtime snack to fight hypoglycemia.
• Total carbohydrate caloric intake should be 45-50%, with sugar subsitutes should be used.

Stressed and Impacted Blood Sugar

• Emotional and physical stress increases blood sugar levels due to release of epinephrine from the liver to break down glycogen into glucose.
• Plan for time zone changes to maintain meal schedules, avoid long gaps between meals to prevent hypoglycemia and make sure to have quick acting carbs.
• Inform travel companions about the signs of hypoglycemia and necessary actions along with packing a Medic Alert bracelet.

Values for Dietary Care

• Women should get 1,600 to 2,400 calories per day, and men should get 2,000 to 3,000, with a goal of intake that is low in carbohydrates, saturated fats, and alcohol.
• 45 to 50% of the diet carbs, in combination with no more than 30% fat should be consumed.

Neuropathy Related to Diabetes

• Neuropathy is the inflammation and degeneration of the peripheral nerves.
• Patients cannot feel the bottom of their feet, with education on orthostatic hypotension and gastroparesis.
• Should be informed that stress prompts the liver to break down glycogen into glucose.
• Insulin need to be in line when stress causes the release of epinephrine in turn to prompts the liver to break down glycogen into glucose.