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Signs and Symptoms

Discuss about the Cushings Syndrome for Production of ACTH Hormone.

Cushing’s syndrome is a disease that results from a high production of a hormone called cortisol or excessive production of other steroid hormones. This hormone is often produced in the adrenal glands. Cushing’s disease often causes Cushing’s syndrome due to excessive production of ACTH hormone. This hormone is produced by the pituitary gland. ACTH is responsible for stimulating the adrenal glands to release the cortisol hormone (De Miguel et al., 2010). Another cause of the Cushing’s syndrome is the tumor in the pituitary gland, adrenal gland or even tumor in any other part of the body. It can also be caused by constant use of corticosteroids drug which is used in the treatment of asthma and arthritis. The total incidence is approximated as 2 new cases per 1 million per year. Females are 8 times susceptible to form hypercortisolism and three times more likely to develop an adrenal tumor. Cushing’s syndrome mostly occurs during adulthood. Cushing’s syndrome incidences in children are estimated at 0.2 cases per million per persons in a year. In persons with years from 25-40, there is peak incidence of the occurrence of the Cushing’s syndrome. This is mostly due to adrenal and pituitary gland tumor (Nieman, 2015). The main risk factors for Cushing’s syndrome are the growth of tumor in the pituitary and the adrenal glands and the constant use of corticosteroids. Cushing’s syndrome does not only affect the person inflicted with it but also the people around them, for example, the family and friends. Different symptoms and signs force family and friends to make some adjustments in their daily routine chores. For example, the loss in weight and mood swings may change the way friends are planning their leisure activities. Family and friends are able to notice the stress in a Cushing’s syndrome patient.

The physical appearance of a patient with Cushing’s syndrome may even change. Change in physical appearance may include loss of hair, gain in weight and probably the formation of acne and skin infections on the skin (Nieman, 2015). This might make the patient feel like sidelining themselves from family and friends. They will totally isolate themselves from them. Patients also tend to be weak and are not always able to do some things, for example, walking through the stairs. This limits them from having fun because they do not have enough energy to walk around or even go shopping and go outdoors (Nieman, 2014). This, therefore, affects the family life of the patient and how the patient relates to their partners.

Signs and Symptoms

Pathophysiology

Weight

There is a gain in weight and an increase in fat deposition. Fatty tissue deposition mostly occurs in the midsection, face, shoulder and upper back. This is often considered as central obesity. An individual can, therefore, have a condition normally termed as buffalo hump and moon face. Uneven distribution of fat is due to changes in the levels of the cortisol. This may cause the legs and arms to be thin when compared to the face and chest of the patient.

Changes in the skin

There is often the formation of stretch marks around the buttocks, thighs, arms and breasts. There are purple and pinkish lines in the areas where the skin has stretched. There may be spots on the shoulders, chest and the face. It also characterized by the darkening of the neck. The ability of the skin to be healed is reduced. When the insect bites an individual with the syndrome, it takes longer to heal. This is also caused by increased levels of cortisol in the body. Skin proteins are often broken down causing the blood vessels weakening.

Bones and Muscles

Bones and muscles of the patient often weaken due to increasing levels of cortisol hormone. This might cause bone fractures because the density of bone is reduced. This may also lead to osteoporosis.

Psychological Symptoms

Patients with Cushing’s syndrome often feel tired so easily. This is due to depression and symptoms of psychology which includes anxiety and sadness, anger and irritability and finally the control over emotion is reduced. Individuals always experience mood swings and experience difficulty in controlling their emotions. Due to this, individuals are prone to crying and laughing at odd moments.

High blood pressure

There are high chances of blood pressure for individuals with ectopic Cushing’s syndrome. This is often referred to as hypertension. When there is high blood pressure then the more severe are the symptodiagnosisms felt. This arises due to increased secretion of glucocorticoids. The reduction in blood pressure is often due to a reduction in the cortisol hormone. When the levels of cortisol are increased then blood pressure increases. Effects of cortisol always increase on both type 1 and type 2.

(Mazziotti et al, 2011). (Nieman, 2015)

Classes of drugs used for patients with Cushing’s syndrome

This is the types of drugs that used in controlling the cortisol production. This is done by decreasing the production of steroid hormone by the adrenal glands. It achieves this by inhibiting one or more enzyme that aid in steroid synthesis. Inhibitors of steroidogenesis can be used mostly for blocking the production of cortisol either completely or partially (Fleseriu et al., 2012). The doses of steroidogenesis inhibitors are often adjusted so that the normal cortisol level of urine diagnosis. This is done when the partial blockade is required. Whenever complete blockade is needed, doses of steroidogenesis is given such that complete inhibition of the synthesis of cortisol and glucocorticoids is achieved. After this, the physiologic needs are replaced. Examples of steroidogenesis inhibitors include fluconazole aminoglutethimide, mitotane, ketoconazole, metyrapone and etomidate. KTZ and metyrapone are mostly used because they have good properties of inhibiting the various pathways of steroids, therefore, reducing the synthesis of cortisol (Feelders et al., 2010). Mitotane action, on the other hand, is prolonged upon use. KTZ acts as an antifungal agent blocking multiple steps of the synthesis.

Pathophysiology

This works differently from other medications as it helps in blocking the action of cortisol on the body instead of decreasing the amount of cortisol produced (Fleseriu et al, 2012). The physical appearance of the patients is often achieved when these drugs are used. There is also a blood sugar improvement when used. Side effects of mifepristone are significantly high. Mifepristone antagonizes the negative feedback of pituitary glucocorticoids (Fleseriu & Petersenn, 2012). The drugs are mostly absorbed immediately into the body and are administered only once on a daily basis because it has a long life span in the body. It always blocks the progesterone hormone in the female, therefore, altering the menstrual cycle. Individuals using the drug often have a high level of cortisol because it does not lower its levels. It helps in the improvement of blood levels and blood sugar in the body and aids in the loss of weight. It is therefore not advisable for patients planning to have children. This drug has many adverse effects on the patient, for example, nausea, muscle discomfort and loss of appetite (Fleseriu et al, 2012).

A nurse should try as much as possible to be close to a patient with Cushing’s syndrome. The first thing I will do is to assess the patient. This helps in focusing on the effects of the body with the high concentration of cortex upon exposure to aldosterone and cortisol levels. In this step, the nurse should focus on the health history of the patient (Tritos et al., 2011). This involves the level of activity of the patient and patient’s capability to do their own activities. The other things to be assessed is the physical appearance of the patient. The observation of the skin is considered, for example, bruising, infection or even edema. Thereafter, the nurse should assess the mental functionality of the patient for example mood swings, depression level and environmental awareness.

The second thing is the diagnosis according to the patient assessment data. The major diagnosis includes a risk of injury which is related to weakness (Juszczak & Grossman, 2012). This may result from the environment compromising with the individual’s health. In this, the skin of the individual is frequently checked especially for bruises. The feces also are also assessed for occult blood to check whether gastrointestinal bleeding has begun. The client is also prepared for evaluation of the bone density. Another diagnosis is the risk to infection (Juszczak & Grossman, 2012). It this, the patient is diagnosed if he is at an increased risk of being infected with pathogenic infections. The patient is then advised by the nurse on how to maintain hygiene for example hand washing. Another thing a nurse diagnosis is body image disturbance. This involves the physical appearance of the patient and patient’s activity level. Another diagnosis is the disturbed thought processes which include the mood swings of the patient (Juszczak & Grossman, 2012).


The third step is the nurse planning and goals. The nurse tries to reduce what he had diagnosed. For example, decreasing the risk of injury, decreasing the infection risk, increasing self-care activities ability, body image improvement, mental function improvement, and skin integrity improvement (Tiemensma et al., 2011). In order to decrease injury risk, the nurse provides an environment where bones and injuries to the tissues s very minimal. The nurse also assists a weak patient to avoid falls and collision with the furniture (Tiemensma et al., 2010). The nurse should advise the patient to eat food rich in vitamin D and calcium to reduce the risk of wasting muscles. When preparing the patient for surgery, glucose levels and blood stools should be monitored. This is because diabetes mellitus is one of the common problems (Tiemensma et al., 2011). When improving skin integrity, meticulous skin care should be used to avoid a fragile skin. The nurse should also talk with the patient about the cause of emotional stress and help them deal depression and mood swings. The nurse should also encourage the patients to verbalize their emotions and thoughts. Before discharging the patient family and the patient should be taught home care guidelines, for example, modifying the diet. the diet should be rich in calcium and vitamins. The patient is also told to monitor the blood pressure levels, weight and their sugar levels. The nurse should also encourage the patient to follow up appointments.

References

De Miguel, V., Redal, M. A., Viale, M. L., Kahan, M., Glerean, M., Beskow, A., & Fainstein Day, P. (2010). Aberrant expression of glucagon receptors in adrenal glands of a patient with Cushing’s syndrome and ACTH-independent macronodular adrenal hyperplasia. Medicina (B Aires), 70(3), 254-256.

Feelders, R. A., Hofland, L. J., & De Herder, W. W. (2010). Medical treatment of Cushing’s syndrome: adrenal-blocking drugs and ketaconazole. Neuroendocrinology, 92(Suppl. 1), 111-115.

Fleseriu, M., & Petersenn, S. (2012). Medical management of Cushing’s disease: what is the future?. Pituitary, 15(3), 330-341.

Fleseriu, M., Biller, B. M., Findling, J. W., Molitch, M. E., Schteingart, D. E., Gross, C., ... & SEISMIC Study Investigators include. (2012). Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with Cushing's syndrome. The Journal of Clinical Endocrinology & Metabolism, 97(6), 2039-2049.Valassi, E., Crespo, I., Gich, I., Rodríguez, J., & Webb, S. M. (2012). A reappraisal of the medical therapy with steroidogenesis inhibitors in Cushing's syndrome. Clinical endocrinology, 77(5), 735-742.

Juszczak, A., & Grossman, A. (2012). The investigation of Cushing syndrome: essentials in optimizing appropriate diagnosis and management. Annals of Saudi medicine, 32(5), 455.

Mazziotti, G., Gazzaruso, C., & Giustina, A. (2011). Diabetes in Cushing syndrome: basic and clinical aspects. Trends in Endocrinology & Metabolism, 22(12), 499-506.

Nieman, L. (2014). Epidemiology and clinical manifestations of Cushing’s syndrome. UpToDate. Waltham (MA): Available at: https://www. uptodate. com/contents/epidemiology-and-clinical-manifestations-of-cushings-syndrome.

Nieman, L. K. (2015). Cushing's syndrome: update on signs, symptoms and biochemical screening. European journal of endocrinology, 173(4), M33-M38.

Tiemensma, J., Kaptein, A. A., Pereira, A. M., Smit, J. W., Romijn, J. A., & Biermasz, N. R. (2011). Coping strategies in patients after treatment for functioning or nonfunctioning pituitary adenomas. The Journal of Clinical Endocrinology & Metabolism, 96(4), 964-971.

Tiemensma, J., Kokshoorn, N. E., Biermasz, N. R., Keijser, B. J. S., Wassenaar, M. J., Middelkoop, H. A., ... & Romijn, J. A. (2010). Subtle cognitive impairments in patients with long-term cure of Cushing’s disease. The Journal of Clinical Endocrinology & Metabolism, 95(6), 2699-2714.

Tritos, N. A., Biller, B. M., & Swearingen, B. (2011). Management of Cushing disease. Nature Reviews Endocrinology, 7(5), 279.

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