NURSING PROCESS: THE PATIENT WITHCUSHING’S SYNDROME
The health history and examination focus on the effects on the body of high concentrations of adrenal cortex hormones and on the inability of the adrenal cortex to respond to changes in cortisol and aldosterone levels. The history includes informa-tion about the patient’s level of activity and ability to carry out routine and self-care activities. The skin is observed and as-sessed for trauma, infection, breakdown, bruising, and edema. Changes in physical appearance are noted, and the patient’s re-sponses to these changes are elicited. The nurse assesses the patient’s mental function, including mood, responses to ques-tions, awareness of environment, and level of depression. The family is often a good source of information about gradual changes in the patient’s physical appearance as well as emo-tional status.
Based on all the assessment data, the major nursing diagnoses of the patient with Cushing’s syndrome include the following:
· 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 wast-ing, and altered sleep patterns
· Impaired skin integrity related to edema, impaired healing, and thin and fragile skin
· Disturbed body image related to altered physical appear-ance, impaired sexual functioning, and decreased activity level
· Disturbed thought processes related to mood swings, irri-tability, and depression
Based on assessment data, potential complications may include the following:
· Addisonian crisis
· Adverse effects of adrenocortical activity
The major goals for the patient include decreased risk for injury, decreased risk for infection, increased ability to carry out self-care activities, improved skin integrity, improved body image, im-proved mental function, and absence of complications.
Establishing a protective environment will help to prevent falls, fractures, and other injuries to bones and soft tissues. The patient who is very weak may require assistance from the nurse in ambu-lating to prevent falls or bumping into sharp corners of furniture. Foods high in protein, calcium, and vitamin D are recommended to minimize muscle wasting and osteoporosis. Referral to a di-etitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.
The patient should avoid unnecessary exposure to others with infections. The nurse frequently assesses the patient for subtle signs of infection because the anti-inflammatory effects of cor-ticosteroids may mask the common signs of inflammation and infection.
The patient is prepared for adrenalectomy, if indicated, and the postoperative course. If Cushing’s syndrome is a result of a pituitary tumor, a transsphe-noidal hypophysectomy may be performed. Dia-betes mellitus and peptic ulcer are common in the patient with Cushing’s syndrome. Therefore, insulin therapy and medication to treat peptic ulcer may be initiated if needed. Before, during, and after surgery, blood glucose monitoring and assessment of stools for blood are carried out to monitor for appropriate inter-vention. If the patient has other symptoms of Cushing’s syn-drome, these are considered in the preoperative preparation. For example, if the patient has experienced weight gain, special in-struction is given about postoperative breathing exercises.
Weakness, fatigue, and muscle wasting make it difficult for the patient with Cushing’s syndrome to carry out normal activities. Yet the nurse should encourage moderate activity to prevent com-plications of immobility and promote increased self-esteem. In-somnia often contributes to the patient’s fatigue. It is important to help the patient plan and space rest periods throughout the day. Efforts are made to promote a relaxing, quiet environment for rest and sleep.
Meticulous skin care is necessary to avoid traumatizing the pa-tient’s fragile skin. Use of adhesive tape is avoided because it can irritate the skin and tear the fragile tissue when the tape is re-moved. The nurse frequently assesses the skin and bony promi-nences and encourages and assists the patient to change positions frequently to prevent skin breakdown.
If the cause of Cushing’s syndrome can be treated successfully, the major physical changes disappear in time. The patient may benefit from discussion of the effect the changes have had on his or her self-concept and relationships with others. Weight gain and edema may be modified by a low-carbohydrate, low-sodium diet, and a high-protein intake may reduce some of the other bothersome symptoms.
Explanations to the patient and family members about the cause of emotional instability are important in helping them cope with the mood swings, irritability, and depression that may occur. Psy-chotic behavior may occur in a few patients and should be re-ported. The nurse encourages the patient and family members to verbalize their feelings and concerns.
The patient with Cushing’s syndrome whose symptoms are treated by withdrawing corticosteroids, by adrenalectomy, or by removing a pituitary tumor is at risk for adrenal hypofunction and addisonian crisis. If high levels of circulating adrenal hor-mones have suppressed the function of the adrenal cortex, atro-phy of the adrenal cortex is likely. If the circulating hormone level is decreased rapidly because of surgery or by abruptly stop-ping corticosteroid agents, manifestations of adrenal hypofunc-tion and addisonian crisis may develop. Therefore, the patient with Cushing’s syndrome is monitored closely for hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Efforts are made to identify factors that may have led to the crisis.
The patient with Cushing’s syndrome who experiences highly stressful events, such as trauma or emergency surgery, is at in-creased risk for addisonian crisis because of long-term suppression of the adrenal cortex. The patient may require intravenous ad-ministration of fluid and electrolytes and corticosteroids before, during, and after treatment or surgery. If addisonian crisis oc-curs, the patient is treated for circulatory collapse and shock.
The nurse assesses fluid and electrolyte status by monitoring laboratory values and daily weights. Because of the increased risk for glucose intolerance and hyperglycemia, blood glucose monitoring is initiated. The nurse reports elevated blood glu-cose levels to the physician so that treatment can be prescribed if indicated.
The patient with Cushing’s syndrome and the patient’s family require teaching and support to enable them to prevent problems associated with the syndrome and to manage those that cannot be prevented. The nurse presents information verbally and in writing. If the disorder is a result of corticosteroid use for treat-ment of a chronic disease, the patient and family need to under-stand that stopping the corticosteroid use abruptly and without medical supervision is likely to result in acute adrenal insuffi-ciency and reappearance of the underlying symptoms of the chronic disease. The nurse emphasizes the need to ensure an ad-equate supply of the corticosteroid, because running out of the medication and skipping doses can precipitate addisonian crisis. Refer to the later discussion, Therapeutic Uses of Corticosteroids, for more information.
The nurse stresses the need for dietary modifications to ensure adequate calcium intake without increasing the risk for hyper-tension, hyperglycemia, and weight gain. The patient and family may be taught to monitor blood pressure, blood glucose levels, and weight. Wearing a medical alert bracelet and notifying other health providers (eg, dentist) are important to alert others that the patient has Cushing’s syndrome (Chart 42-11).
The need for follow-up depends on the origin and duration of the disease and its management. The patient who has been treated by adrenalectomy or removal of a pituitary tumor requires close monitoring to ensure that adrenal function has returned to nor-mal and to ensure adequacy of circulating adrenal hormones. The patient who requires continued corticosteroid therapy is moni-tored to ensure understanding of the medications and the need for a dosage that treats the underlying disorder while minimizing the side effects. Home care referral may be indicated to ensure a safe environment that minimizes stress and risk for falls and other side effects. The home care nurse assesses the patient’s physical and psychological status and reports changes to the physician. The nurse also assesses the patient’s understanding of the med-ication regimen and the patient’s compliance with the regimen, and reinforces previous teaching about the medications and the importance of taking them as prescribed. The nurse emphasizes the importance of regular medical follow-up, the side effects and toxic effects of medications, and the need to wear medical iden-tification with Addison’s and Cushing’s disease. Additionally, the nurse reminds the patient and family about the importance of health promotion activities and recommended health screening, including bone mineral density testing.
Expected patient outcomes may include:
1) Decreases risk for injury
a) Is free of fractures or soft tissue injuries
b) Is free of ecchymotic areas
2) Decreases risk for infection
a) Experiences no temperature elevation, redness, pain, or other signs of infection and inflammation
b) Avoids contact with others who have infections
3) Increases participation in self-care activities
a) Plans activities and exercises to allow alternating peri-ods of rest and activity
b) Reports improved well-being
c) Is free of complications of immobility
4) Attains/maintains skin integrity
a) Has intact skin, without evidence of breakdown or infection
b) Exhibits decreased edema in extremities and trunk
c) Changes position frequently and inspects bony promi-nences daily
5) Achieves improved body image
a) Verbalizes feelings about changes in appearance, sexual function, and activity level
b) States that physical changes are a result of excessive corticosteroids
6) Exhibits improved mental functioning
7) Absence of complications
a) Exhibits normal vital signs and weight and is free of symptoms of addisonian crisis
b) Identifies signs and symptoms of adrenocortical hypo-function that should be reported and measures to take in case of severe illness and stress
c) Identifies strategies to minimize complications of Cushing’s syndrome
d) Complies with recommendations for follow-up appoint-ments and health screening.
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