Adult Medical-Surgical Nursing Endocrine Module: Disorders of the Adrenal Cortex: Cushing’s Syndrome

Secretions of the Adrenal Cortex (Corticosteroids):  Glucocorticoids (Cortisone)  Mineralocorticoids (Aldosterone)  Androgens

Functions of Glucocorticoids  Glucose metabolism: antagonise insulin  Response to stress:  ↑ secretion raises blood glucose by gluconeogenesis from glycogen and protein breakdown  Mobilises free fatty acids  Potentiates sympathetic activity (peripheral vasoconstriction):maintains BP  Anti-inflammatory action

Functions of Mineralocorticoids  Water and electrolyte balance:  Aldosterone promotes sodium (and water) reabsorption in kidney tubules (and potassium excretion)  Maintenance of normal blood pressure

Functions of Androgens:  Sexual changes and secondary sex characteristics at puberty

Over-production of Adrenal Cortex: (Cushing’s Syndrome): Aetiology  Maybe ↑ ACTH related to pituitary tumour  Maybe ↑ corticosteroids related to tumour of the adrenal cortex  Same clinical manifestations related to steroid therapy

Cushing’s Syndrome: Pathophysiology  ↓ protein synthesis (growth/repair); ↓ mucus  ↑ protein breakdown for gluconeogenesis  ↑ blood glucose (diabetic tendency)  Fat redistribution and obesity  ↑ sympathetic activity  ↑ sodium (& H2O) reabsorption; (K ↓ )  Decalcification of skeleton (osteoporosis)  Hirsutism, amenorrhoea

Cushing’s Syndrome: Clinical Manifestations  Muscle wasting and weakness  Poor healing; fragile skin; prone to infection, peptic ulcer, prone to fracture  Diabetic tendency, cataract, glaucoma  Truncal obesity, thin extremities, moonface, buffalo hump  Weight gain (fat/ fluid), oedema  ↑ BP  Infertility, hirsutism, mood changes

Cushing’s Syndrome: Diagnosis  Patient history and clinical picture (including possible steroid therapy)  Hormonal assays: ACTH and cortisol (if both elevated, problem with pituitary)  Dexamethasone test (should suppress cortisol production overnight: if ACTH normal or lower and cortisol still raised indicates adrenal disorder)

Cushing’s Syndrome: Management  Excision of pituitary tumour if pituitary responsible  Adrenalectomy if overproduction of adrenals (may remove one gland)  Lifetime hormone replacement (HRT) as required following surgery (steroids)

Cushing’s Syndrome: Nursing Considerations  Patient awareness of risks related to condition  Monitor BP, weight, oedema, blood glucose, blood calcium and bone density  Manage wound healing and infection  If steroid therapy required (HRT), patient awareness and management →

Steroid therapy: Precautions  If taking long-term steroids:  Increased dosage required to cover stress, infection, trauma, surgery, pregnancy  If follows adrenalectomy or hypophysectomy, lifetime requirement and must not be stopped  If steroid therapy is for unrelated condition: never stop abruptly as the adrenals are suppressed and need time to recover