NRSG353 Acute Care Nursing 2

Question:

Cushing’s Syndrome

Ms Maureen Smith, a 24-year-old female, presented to her GP with ongoing gastrointestinal bleeding, stomach pain, and fatigue. She was referred to the hospital for further examination.

Maureen was diagnosed as having rheumatoid arthritis (RA) at the age of 15. She has had multiple exacerbations and required high-dose corticosteroids.

Since her last exacerbation two months ago, she is currently taking 50mg prednisolone daily.

Maureen has type 2 diabetes, which she manages with metformin.

She is currently a student in nursing and part-time works at a local pizza place.

Maureen’s vital sign results were: PR 88/RR 18 bpm, BP 154/106mmHg, BP 154/106mmHg; and Temp 36.9oC. SpO2 99% in room air.

Her body mass index (BMI), is 28kg/m2. The fat is concentrated around her abdomen and between her shoulders.

Maureen’s husband noticed that her face has been rounder over the last few weeks.

Her fasting BGL was 14.0mmol/L.

The blood tests showed low levels of cortisol, ACTH and low levels of low-density lipoprotein cholesterol.

She is currently waiting for a bone mineral density test and is collecting urine to measure her cortisol levels over the next 24 hours.

Case Discussion

Describe the risk factors, causes and incidence of the condition. Also discuss the impact it has on the patient’s family.

You can list five symptoms that are common to the condition and provide links to the underlying pathophysiology.

You can do this by creating a table. Each point must be properly referenced

Two common drugs that are used to treat patients suffering from the condition you have identified, along with their physiological effects on the body, will be described.

This does not refer to specific drugs, but the class they belong to.

Name and explain in priority, the nursing strategies that you as a registered nurse should use for this patient within the first 24 hour after admission.

Answer:

Cushing’s syndrome refers to a condition or disease that is caused either by excessive cortisol production or high-dose corticosteroids.

Cortisol, a hormone produced in the outer part of the adrenal glands of the kidney, is known as cortisol.

A hormone called adrenocorticotrophic is responsible for controlling the production of cortisol.

It aids the body when there are changes or stress such as swelling or high blood sugar.

Ms. Maureen Smith was prescribed high levels of corticosteroids to treat her Rheumatoid arthritis. This causes her Cushing’s Syndrome.

This is known as iatrogenic. It is a side effect of high doses of steroid hormones that is used to treat life-threatening diseases like Rheumatoid arthritis (RA). (Lacroix et. al., (2015).

Harvey Cushing, who first identified the disease in women in 1912, gave this disease its name.

This disease is quite common in nature, as corticosteroids are used worldwide to treat diseases such as RA.

It is more common in adults than it is in children.

Normally, the age limit is between 25 and 45 years.

It is estimated that there are approximately 5 to 25 cases per million people.

This disease is extremely rare in Australia and affects between 300- 1200 Australians each year.

This Cushing’s syndrome is caused by Ectopic ACTH (almost 660 per Million per year).

Type 2 diabetes, obesity and low blood sugar control are all risk factors for this disease.

These symptoms can all be found in case studies 2.

Cushion’s Syndrome symptoms and deficiency are determined by the level of cortisol, the time of disease and the normal health of the patient.

The disease can be treated with proper care within two to 18 months.

Patients and their families are frustrated by the slow pace of treatment and frustration.

Patients feel tired and weak, which causes them to visit the doctor more frequently. This is a problem for both the patient and their family.

Cushing’s syndrome can lead to more symptoms such as weakness, depression, mood swings, and weight gain.

Patients’ families feel a heavy burden as they must take their loved one to the doctor for treatment and blood tests.

Cushing’s syndrome symptoms

It is also linked to pathophysiology

Type 2 diabetes

Cushing’s syndrome patients suffer from diabetes mellitus.

Excessive use of glucocorticoids can cause disfunctioning glucose metabolism.

These drugs cause gluconeogenesis, which increases the glucose level and decreases insulin production.

The glucose is not affected by these drugs and diabetic conditions are possible (Mazziotti, et al. 2017, 2017).

Cortisol is a stress reliever that helps reduce stress levels in the body, such as swelling.

It regulates carbohydrates, fats, and protein.

Corticosteroid drug abuse can cause an increase in cortisol levels.

Sometimes, excess cortisol in the body can cause false alarms. It may also affect food metabolism and absorption even though it is not required by the body.

This is why the patient continues to eat and causes the body to accumulate excess fats in different parts of the body.

Fat accumulation is most common in the abdomen and on the face (Lee, et al. 2014).

Cushing’s syndrome is known for hypertension.

Hypertension affects approximately 80 percent of patients.

Glucocorticoids can cause hypertension through their inborn mineralocorticoid activity; through the activation of the renin–angiotensin framework, by upgrading vasoactive substances and by concealing the vasodilatory system.

CNS regulation of cardiovascular function is also affected by glucocorticoids (Isidori and al., 2015).

Muscle weakness

Muscle weakness is a common symptom of Cushing’s syndrome.

They feel tiredness, muscle pains and weakness.

Corticosteroids can cause a change in protein metabolism.

The drugs reduce the rate at which protein is synthesized, which causes a greater protein breakdown and leads to muscle degradation.

These drugs cause muscle protein catabolism (Fry and al., (2016).

Thickening of the skin

Cushing’s syndrome is characterized by the thinning skin and other mucous membranes.

Cushing’s syndrome causes the skin to become dry and prone to injury.

Cortisol can cause the degradation of certain dermal proteins as well as the thinning or thinning of blood vessels.

This causes skin to become very fragile and shiny paper thin (Raff Sharma & Nieman 2014).

Two classes of drugs are used to treat Cushing’s syndrome: Adrenal corticosteroid synthesizer inhibitor (Metyrapone), and anti-steroid drugs (Aminoglutethimide). (Eckstein, et al. (2014)

This drug is used to treat the disease.

Aminoglutethimide, a type anti-steroid drug, is one example. It is also known as Cytadren.

This drug blocks the production steroids, which are cholesterol-derived drugs and are used in Cushing’s syndrome.

These drugs can be used in combination with other drugs to inhibit the function of the adrenal glands of patients suffering from this disease.

This disease is caused by two mechanisms of action for Aminoglutethimide.

It works by blocking the aromatase involved in the generation of estrogens from androstenedione or testosterone.

It also helps to block the enzyme P450scc, which is responsible for the conversion of cholesterol into pregnenolone.

These drugs can cause rash, cortisol inhibition in humans and hepatoxicity.

Adrenal Corticosteroid Synthesis inhibitor:-

Metyrapone and other drugs such as it are used to diagnose insufficiency adrenalin or treat Case disease.

These drugs inhibit the production of cortisol and inhibit the reversible steroid 11b hydroxylase.

This results in the inhibition of reversible steroid 11 b hydroxylase, which stimulates the secretion ACTH and increases plasma 11-deoxycortisol levels.

This drug is used to control hypercortisolism associated with Cushing’s syndrome (Daniel and al. (2015).

It is used to control hypercortisolism.

It can also stop adrenal steroidogenesis.

It is not intended for long-term treatment, but it can be used as a short-term relief.

Metyrapone can also be used to test for Cushing’s syndrome.

Metyrapone will cause an increase in ACTH levels in patients who do not have functioning pituitary (Gadelha and Vieira (2014)).

They can also cause other side effects.

This medication can cause nausea and dizziness, as well as headaches.

If the medication is taken in high doses, severe side effects can occur like sudden weakness and vomiting.

It can also cause skin rash, sore throat, and fever.

As a registered nurse, I would use the following strategy to care for a patient with Cushing’s syndrome.

To avoid any complications, I will first closely monitor the patient.

My assessment will base on his history, including how active he is and what self-care activities he engages in daily.

Next, I will examine the skin for signs of infection or trauma. Finally, I will check for mental stability. This is their response to stress and how they feel.

After the assessment, I will perform a disease assessment. This includes 1) checking for injury- checking to see if there is weakness; 2) checking for infection- swelling response; 3) checking for self-care- weakness, fatigue, and disruption of sleeping patterns, 4) checking if there has been a skin injury, and 5) looking for signs of a problem such as decreased activity and alterations in physical appearance.

6) Mood swings or depression.

After confirming the diagnosis, I will attempt to provide the care required (Gulanick & Myers 2013, 2013).

To reduce the chance of injury, I will provide a safe and supportive environment to ensure that the patient doesn’t fall and injures their bones and soft tissues.

To reduce muscle loss, I will provide a healthy diet rich in calcium and protein.

To reduce infection, I will try to minimize contact with patients and check for inflammation.

I will assess the patient’s glucose levels and prescribe medications to reduce it.

I will engage the patient by offering moderate activities and plenty of rest.

I will attempt to create a schedule for rest and activity (Llahana & Thomas 2016, 2016).

To reduce the chance of infection, I will use medication and equipment, including glassware in sterile conditions.

To avoid injury to fragile skin, I will ensure that my skin is well-maintained.

Patients should lose weight by eating low carbohydrate, low sodium, and high protein diets.

I will explain to the family the causes of the disease and the treatment options. This will help improve the patient’s mood swings.

After consulting with the doctor, I will attempt to provide the first-line medications necessary to treat the symptoms immediately.

Also, I need to monitor some critical factors such as hypotension and weak nerve impulse respiratory rates. I also need check for potential factors that could cause crisis in patients such as trauma or surgery.

If necessary, I will administer fluids and electrolytes to the patient and also check laboratory values and daily weight.

To determine if the patient has diabetes, a blood test must be taken.

Incentive spirometry will be used every two to four hours.

It is important to inform the patient and their family about self-care.

Family members of patients should be informed that corticosteroid usage is not recommended as it can lead to an increase in Cushing’s syndrome symptoms.

A retrospective multicenter study of 195 patients to determine the effectiveness of metyrapone for Cushing’s syndrome treatment.

The Journal of Clinical Endocrinology & Metabolism 100(11), 4146-4154.

Cushing’s syndrome: Systemic therapy

Orphanet journal on rare diseases, 9(1): 122.

Glucocorticoids increase the skeletal muscle NF.kB-inducing kinase. (NIK). Links to muscle atrophy.

Physiological Reports 4(21), e13014.

A systematic review of the effectiveness of medical treatment for Cushing’s disease.

Clinical endocrinology 80(1): 1-12.

Nursing care plans: nursing diagnosis, intervention.

(2015).

Journal of hypertension 33(1): 44-60.

The Lancet, 386(9996) 913-927.

The roles of glucocorticoids and adipose tissue biology in central obesity development.

Cushing’s syndrome patients benefit from structured nursing education programs that improve their quality of life.

Diabetes in Cushing Disease.

Current Diabetes Reports, 17(5) 32.

Cushing’s syndrome treatment: An endocrine society clinical guideline.

The Journal of Clinical Endocrinology & Metabolism 100(8), 2807–2831.

The physiological basis for diagnosing, treating, and etiology of adrenal disorders: Cushing syndrome, adrenal insufficiency and congenital adrenal hyperplasia.

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