This is a condition which mostly occurs due to excess exposure to high cortisol level for a long time. Cortisol is a hormone which is made by the adrenal gland and it is responsible for managing stressful situations in the body such as illness. Too much cortisol causes Cushing’s syndrome regardless of the cause. Adrenal tumors are one of the causes of increased production of cortisol in the body but in this case study, MS Mary Smith has been on cortisol treatment for 9 years since she was 15 years due to rheumatoid arthritis and has been experiencing multiple exacerbations that required high doses of oral corticosteroids.
Cushing’s syndrome is not common and it is often found in women than in men and mainly occurs between ages 20 and 40, exogenous Cushing syndrome is drug-induced and is commonly seen in the clinical setting. Its clinical manifestations are more prominent and gradual than of endogenous Cushing syndrome.
This is health problems that result from exogenous Cushing syndrome: a low immune system which predisposes the patient to frequent infections, damage to the nerves of the eyes, kidney due to untreated high blood sugar, high cholesterol level, and Diabetes. Mary has been diagnosed with diabetes and she is currently under medication which is a risk factor of the underlying disease. Risk factors can also be factors that increase the risk of Cushing syndrome and they include type 2 diabetes, poorly controlled blood sugar levels which still cause retinopathy and nephropathy and high blood pressure resulting from the glucocorticoids or adrenocorticotrophic hormone administration.
Majority of patients said about how Cushing syndrome has affected their everyday life and effect on their families at work and both at school. Quality of life is increasingly impaired in patients with this disease regardless of treatment strategies and patients with Cushing syndrome report more negative perception than those other patients with acute and chronic illnesses. Patient experienced mental problems such as depression, anxiety, anger, and hostility mostly due to the disease process and hospitalization, these conditions affect patient’s concentration and even memory. Patients with this disease also experienced low self-esteem due to impaired body shape especially deposits of fat in the abdomen and round face. Patients experience pain. Patients with this condition also experience complications for example kidney failure due to damage to its nerves. This disease imposes a burden to the family caregivers and even others. Families experienced psychological and non-health effects. They include changes in their daily activities, some even didn’t go for work to take care of the patient. Families had to even sell some of their properties or raise money for payment of bills of a loved one who is sick
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Signs and symptoms |
Pathophysiology |
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Weight gain |
Weight gain often occurs at the trunk and not accompanied by weight gain in the arms and the legs. High level of cortisol in the body leads to redistribution of fats to the chest and stomach area. This goes hand in hand with rounding of the face, becomes puffy and red. A “buffalo hump” develops due to the accumulation of fats in the shoulders and the neck. Because cortisol level will be more than normal it will require more carbohydrate. So cortisol metabolizes the food and refuels the body even when there is no requirement within the body thus leading to weight gain. (Wilson, 2017) |
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Skin changes |
The skin thins because cortisol causes breakdown of dermal proteins responsible for hardening and thickening of the skin, it also weakens blood vessels.it weakens the skin such that it becomes shiny, a paper-thin quality which allows it to be torn so easily thus it bruises easily. Reddish-purplish stretch marks called striae appear commonly on the stomach, thighs, arms limbs, breast and buttocks, this is because Cushing syndrome stretches the skin which is already thin due to cortisol causing it to hemorrhage and stretch so permanently, healing by fibrosis(Williams,2015). Spots develop on the chest, shoulders, and face due to acne as hair follicles plug oil and dead skin which clog skin pores leaving dark spots. Darkened skin appears on the neck due to prolonged exposure to cortisol which causes hyperpigmentation. Edema and water retention occurs within the skin due to excess fluid buildup in the lower legs and feet as a result of medication and underlying disease. Minor injuries take long to heal, minor like insect bites, cuts, and scratches because corticosteroids impair wound healing and surgical morbidity. (Guifarro, 2017) |
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Hypertension |
It results from the coordination of several pathophysiologic mechanisms which includes stimulation of mineralocorticoid and glucocorticoid receptors as well as insulin resistance causing elevation of cardiac output and peripheral resistance because e they are the determinants of arterial pressure. Increased cardiac output resulting from sympathetic dysfunction is said to be the major trigger of hypertension. Cortisol increases the concentration of erythropoietin. Erythropoietin is direct. Vasoconstrictor which causes an increase in blood pressure which in turn causes hypertension.it is the common cause of death of patients. (Isidori, 2015) |
It binds to cell receptors specifically cytoplasmic receptors and inhibits DNA synthesis, when hormone-receptor occurs it either inhibit transcription from those genes thus its action is to modulate gene expression in a specific target cell. Side effects include infections, heartburn, and insomnia. Its pharmacokinetics is that it is active drug pharmacologically which is converted to its active form in the liver. This drug is administered orally and it is rapidly absorbed after an oral administration. It has a half-life of 1-3 hours. Its bioavailability is approximately 80%, it can have impaired absorption in some individual with some conditions such as liver disease. Increase in the dose of prednisolone causes a significant increase in plasma concentration thus it does not bind to plasma proteins thus there should be reduced doses in patients with conditions such as hypoalbuminemia. Prednisolone is also dependent on age; its half-life is shorter in children. It has a pharmacokinetic drug interaction with anticonvulsants such as barbiturates.it is excreted in urine as free and conjugated metabolites.
Metformin decreases glucose production by decreasing hepatic glucose production, it does this by decreasing intestinal glucose absorption by improving insulin receptors sensitivity to glucose and also by increasing peripheral uptake of glucose and utilization in the body system.it has some side effect for example diarrhea, flatulence, and lower blood sugar level.Metformin has an oral bioavailability of 40 to 60% and it completely absorbed after 6hours of ingestion, it is absorbed in tubules of the kidney and it is excreted unchanged in the urine, its half-life is approximately 6hours. Metformin is detected in the plasma within 24hours of ingestion of single dose..This drug is contraindicated in patients with renal disease.
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Assessments |
diagnosis |
Goal/outcome |
interventions |
Rationale |
implementation |
Evaluation |
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Edema |
A risk for excess fluid overload related to water retention of water and sodium caused by an excess of cortisol and mineralocorticoid levels |
After the 8hours of nursing intervention, Mary will be stable weight, balanced fluid intake, and output, reduction of edema, .she will be able to show no signs of pulmonary congestion. |
Carry out fluid intake and output. Asses any sign of circulatory overload Monitor vital signs such as blood pressure every 4 hours. Monitor the patient’s sodium and potassium level. Instruct the patient to reduce fluid patient. |
To ensure that there is balanced fluid intake. For early detection of circulatory overload so that it can be treated immediately. Cushing syndrome may result in increased blood pressure thus it should be monitored. Mineralocorticoids regulate sodium and potassium secretion and also excess levels as evidenced by water retention and also hypokalemia. This help reduce fluid overload and especially prevent circulatory overload |
The nurse carried out the fluid intake and output and documented The nurse was able to check for signs of circulatory overload The nurse monitored vital signs every 4hours and documented. Electrolyte level was monitored |
After 8hours of nursing, intervention patient had a stable weight and reduced edema |
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Skin reddens Bruises on the skin |
The risk of injury related to decreased bone density, weak muscles, and poor wound healing |
After 8 hours of nursing intervention, patients will be free of fracture or soft tissue injury. The patient will be able to verbalize on measures to prevent injury |
Asses the skin frequently for reddened areas, skin breakdown or bruises. Asses patient for signs of kyphosis or decreased height |
Cushing syndrome cause thinning of skin due to cortisol as it causes damage of dermal proteins and weakening of blood vessels thus the skin becomes very weak and easy to be damaged. Due to weak bone density, spinal compression can easily occur and it causes fractures which cause decreased height. |
Nurse assessed the skin of the patient for any sign of redness or bruises. Nurse encourage patient on ways of preventing injury. |
After 8hours of nursing intervention patient was free of fracture and was able to verbalize on ways of preventing injury to herself |
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Risk for infection related to altered protein metabolism, high serum cortisol level, and impaired immune response |
The patient will be able to verbalize on interventions to prevent risk for infection. The patient will be able to display the absence of infection that will be evidenced by normal body temperature and also normal white blood cell count. |
Asses for signs of infections and also patient to avoid unnecessary exposure to people with infections Stress proper hand washing techniques |
Cortisol suppresses the immune system thus patient will be prone to frequent infections and also corticosteroids show signs of inflammation and infection. Hand washing serves as the first line of defense against nosocomial infections |
Nurse assessed for a sign of infection such as taking body temperature and white blood cell and it was documented. |
After 8hours of nursing intervention patient was free of infection |
References.
Guifarro, M. R., Chavez, J., Guifarro, D., Martinez, E., Figueroa, A., & Orellana, I. (2017). IATROGENIC CUSHING’S SYNDROME PRESENTING SEVERE ATIPICAL SKIN LESIONS EXTENDED IN THE BODY. Endocrine Practice, 23, 21.
Isidori, A. M., Graziadio, C., Paragliola, R. M., Cozzolino, A., Ambrogio, A. G., Colao, A., … & Pivonello, R. (2015). The hypertension of Cushing’s syndrome: controversies in the pathophysiology and focus on cardiovascular complications. Journal of hypertension, 33(1), 44.
Markowicz-Piasecka, M., M Huttunen, K., Mateusiak, L., Mikiciuk-Olasik, E., & Sikora, J. (2017). Is metformin a perfect drug? Updates in pharmacokinetics and pharmacodynamics. Current pharmaceutical design, 23(17), 2532-2550.
Paul, E. M., Jose, S., Achar, Y., & Raghunath, B. D. (2016). Prednisolone Induced Cushing Syndrome: A Case Report. Indian Journal of Pharmacy Practice, 9(2), 141.
Williams, D. M. (2018). Clinical Pharmacology of Corticosteroids. Respiratory Care, 63(6), 655-67.
Wilson, D. P., Hamilton, L., Prakash, S., Castro-Silva, F. J., & Friedman, J. (2017). Dyslipidemia, weight gain, and decreased growth velocity in a 14-year-old male. Journal of clinical lipidology, 11(2), 562-566.
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