Med-Surg Endocrine System, part 12: Glucocorticoid Hormone Excess (Cushing's Syndrome)

by Cathy Parkes

In this article, we cover glucocorticoid hormone excess, also known as Cushing’s syndrome. Knowing the pathophysiology, symptoms, diagnosis and treatment for this will be key in your Med-Surg exams as well as your nursing career!

These disorders are covered in our Medical-Surgical Flashcards (Endocrine system).

What is Cushing’s syndrome?

Cushing’s syndrome (glucocorticoid hormone excess) happens when there is an overproduction of cortisol by the adrenal cortex.

If you remember from our review on endocrine hormones, the hypothalamus produces CRH, which causes the anterior pituitary to release ACTH, which prompts the adrenal cortex to release cortisol.

Cushing’s syndrome can be caused by an adenoma (benign tumor) in the adrenal gland or pituitary gland. This syndrome is also often caused by prolonged steroid use. If the problem is with the pituitary gland, this is called hyperpituitarism, which we covered in video 8 of this series.

The elevated cortisol levels caused by this syndrome also cause increased glucose levels, protein catabolism, altered fat metabolism, and a decreased immune response in the body. This decreased immune response makes the patient more susceptible to infection.

Signs and symptoms of Cushing’s syndrome

Many of the signs and symptoms of glucocorticoid hormone excess are the same as the side effects of prednisone, which is a glucocorticoid. This includes:

  • A “buffalo hump,” which is a fat deposit between the shoulders on the back.
  • “Moon face,” which is a puffy rounded face
  • Truncal (torso) obesity
  • Weight gain
  • Fluid retention
  • Peptic ulcer disease
  • Diabetes
  • Bone loss
  • Weakness
  • Emotional instability
  • Increased infection

When Cathy was pregnant, she had severe hyperemesis (extreme, persistent nausea), and was given prednisone. So she had the resultant moon face. She remembers telling her family about her debilitating illness, with constant vomiting and inability to eat. They looked at her moon face and thought, “Looks like she’s eating alright to me!” But really she wasn’t. And she and her husband can both recall the emotional instability side effect as well!

If you also remember that cortisol is responsible for regulating the metabolism and immune response, you can piece together that the side effects are weight gain (poorly regulated metabolism) and a poor immune response.

Cool ChickenWhen you have Cushing’s, it will make you look like a cushion. (Because of all the fluid retention, moon face and weight gain.)

Lab values associated with Cushing’s syndrome

Increased glucose and sodium are expected with Cushing’s syndrome, as well as decreased potassium and calcium. In addition, the patient will have elevated levels of cortisol in their saliva.

These lab value ranges are covered in detail in our Lab Values flashcards, including normal ranges and causes/symptoms/treatment for abnormal values.

Diagnosis of Cushing’s syndrome

Cushing’s syndrome can be diagnosed with a dexamethasone suppression test, and then a CT, MRI, or ultrasound to check the pituitary and adrenal glands for a tumor.

Dexamethasone suppression test

Dexamethasone is a glucocorticoid, basically synthetic cortisol. Remember, these hormones act in a negative feedback loop. If a healthy patient is given dexamethasone, the pituitary gland should sense that there is extra cortisol, so it should scale back production of ACTH, which should cause the adrenal gland to reduce production of cortisol.

If the pituitary gland does not scale back ACTH despite the extra cortisol, the negative feedback loop has failed and there must be interference in the pituitary gland—likely, an adenoma.

However, if the pituitary gland performs the expected response effectively and scales back production of ACTH, but the adrenal gland just keeps secreting cortisol, we know it’s an issue with the adrenal gland.

Treatment for Cushing’s syndrome

If there is a tumor on the pituitary gland, the surgery required for that is a hypophysectomy. If there is a tumor on the adrenal gland, the surgery for that is an adrenalectomy, which is certainly an easier name to remember!

Ketoconazole is an antifungal medication that works for Cushing’s syndrome because it inhibits cortisol synthesis. There are some severe side effects to look out for with ketoconazole, including hepatotoxicity, which means it’s basically toxic to the liver. Another side effect is GI bleeding.

Ketoconazole is one of the many medications covered in our Pharmacology flashcards.

Nursing care for Cushing’s syndrome

Diet

Because a patient with Cushing’s syndrome is retaining fluid and sodium, you will need to make sure to restrict their fluid and sodium. Also, encourage increased intake of potassium, calcium, and protein.

What to monitor

A patient with Cushing’s syndrome needs to be monitored for fluid-volume overload and pulmonary edema. Because this patient is retaining so much fluid, it will start affecting the lungs and the patient’s ability to breathe properly.

Protection/prevention

A patient with Cushing’s syndrome has fragile skin. With so much fluid retention, their skin becomes paper thin, which makes it fragile and easy to break down. So handle this patient with care!

This patient should also be protected from bone fractures because of the side effect of bone loss that comes with Cushing’s syndrome. So, implement fall procedures according to your facility policy

This patient needs to be protected from GI bleeding since they are at increased risk for this to happen. So, for example, do NOT give this patient a medication like an NSAID or aspirin, as these medications reduce blood clotting and could exacerbate the issue and increase the risk of GI bleeding.

Finally, we want to prevent infection in a patient with Cushing’s syndrome because their immune response is decreased.

Want to teach yourself the key facts for Med-Surg? Check out our Medical-Surgical Nursing Flashcards, which contain just the most important information you need for your exams and clinical practice! Cathy’s teaching on this disorder and its complication is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.


Full transcript

In this video, we are going to talk about glucocorticoid hormone excess or Cushing's syndrome.

With this syndrome, we have overproduction of cortisol by the adrenal cortex. Some common causes of this disorder include an adenoma, which is like a benign tumor, in either the adrenal gland or the pituitary gland, or it's often caused by prolonged steroid administration.

So due to one of these causes, we have elevated cortisol levels, which causes elevated glucose levels as well as increased protein catabolism, altered fat metabolism, and decreased immune response in the body, which predisposes an individual to higher rates of infection.

So in terms of signs and symptoms, many of these signs and symptoms will be the same as you would see with prednisone, which is a glucocorticoid. So if you know some of those side effects, you will see that a lot of those side effects are the same here with Cushing's syndrome. So this includes a buffalo hump, which is basically like a lump of fat between the shoulders on the back, or a moon face so big round face, truncal obesity, weight gain, fluid retention, possible peptic ulcer disease, diabetes, bone loss, weakness, emotional instability and increased infection, like I mentioned before.

So when I was pregnant, I had severe hyperemesis, and they treated it using prednisone, which is a glucocorticoid. So I actually had a few of these symptoms. Not all of them, but I did have a bit of a moon face going on. I used to tell my friends and family about my debilitating illness, and how I was barfing my guts out and couldn't eat anything, and I'm sure they looked at my big face and said, "Oh, she looks like she's eating fine to me." But I really wasn't. It just looked really big. And then emotional instability may have also been a side effect I had. If my husband was here, he'd be like, "You think?" Anyway, so I can relate to some of these side effects just because of that prednisone.

Another hint or clue that I can give you to remember this disorder and at least one of the side effects is that when you have Cushing's, it will make you look like a cushion because you're retaining all of this fluid and you've just-- you've got the weight gain and the fluid retention so you kind of look like a cushion. Hence, Cushing's syndrome.

Alright. In terms of labs that you can expect with this disorder: elevated glucose and sodium are expected, as well as decreased potassium and calcium. In addition, you will find elevated levels of cortisol in the saliva.

To diagnose Cushing's syndrome, we would do a dexamethasone suppression test. Dexamethasone is basically a glucocorticoid. It's like a synthetic form of cortisol.

And if we give the patient dexamethasone, what should happen is that the pituitary gland would sense that we have all of this synthetic cortisol, so it should scale back production of ACTH, which should cause the adrenal gland to scale back production of cortisol.

However, if the pituitary gland does not scale back ACTH despite the fact that we're giving the patient all this dexamethasone, then we know it's a problem with the pituitary gland, and, likely, it's an adenoma in the pituitary gland.

However, if the pituitary gland does its job effectively and it does scale back production of ACTH but the adrenal gland just keeps pumping out cortisol regardless, then we know it's an issue with the adrenal gland.

So in terms of how we can further diagnose the issue, we can do a CT, MRI, or ultrasound to help see if there is a tumor in the pituitary gland or in the adrenal gland.

And then in terms of treatment, we would need to remove the tumor, possibly do a hypophysectomy or an adrenalectomy.

And then there is one medication that can be used, ketoconazole, which helps to inhibit cortisol synthesis.

In terms of nursing care, because this patient is retaining all of this fluid and sodium, we're going to want to restrict fluid and sodium.

We're also going to encourage increased intake of potassium, calcium, and protein for this patient.

And then we definitely want to monitor the patient for fluid-volume overload and pulmonary edema because if they retain so much fluid, then it will start affecting the lungs and the patient's ability to breathe effectively.

Also, we're going to want to protect the patient's skin from breakdown. So when a patient is retaining all of this fluid, their skin becomes paper thin and very fragile and very easy to break down. So we're going to have to handle that patient very carefully.

We also want to protect them from bone fractures because of the side effect of bone loss with this condition.

And we're also going to want to protect them from GI bleeding because of the increased risk for peptic ulcer disease and GI bleeding. So we would never give this patient a medication such as an NSAID or aspirin because that would definitely exacerbate the issue and the risk of having GI bleeding.

And then finally, we want to prevent infection in this patient because their immune response is decreased with this condition.

Alright. So that's it for Cushing's syndrome, and we will pick it up with more endocrine topics in my next video. Thanks so much for watching.


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