Ms Maureen Smith (24 years old) presented to her GP complaining of persistent gastrointestinal bleeding, severe fatigue, and abdominal pain.
Maureen was first diagnosed with rheumatoid arthritis (RA) in her 15th year. She has been through multiple flare-ups of RA that have required the use high-dose corticosteroids.
She currently takes 50mg of prednisolone every day and has been doing so since her last flare-up 2 months ago.
Maureen also has type 2, which can be managed with metformin.
She is currently a nurse student and works part time at a local pizzeria.
Maureen has the following vital signs: PR 88 bpm and RR 18 at bpm. BP is 154/106 mg. Temp 36.9oC. SpO2 99 on room air.
Her body mass (BMI) is 28kg/m2 with the majority of fat around her abdominal region and a hump between both her shoulders.
Maureen’s husband says that her face has become rounder in the last few weeks.
Her fasting BGL is 14.0mmol/L.
Blood tests revealed low cortisol levels and ACTH levels and high levels low density lipoprotein cholesterol.
She is currently collecting urine for a cortisol level assessment.
Discussion on the case
The causes, incidence, and risk factors of the identified condition should be described and the consequences for the patient and their family.
The following are five signs and symptoms common to each condition. Each link will take you to the underlying pathophysiology.
This can be done by way of a table. Every point should be correctly referenced
Please describe two classes of drugs commonly used in patients with the identified condition, including the physiological effects of each on the body.
This does NOT refer to particular drugs, but to the drug class.
Explain, in order of priority, the nursing care strategies that registered nurses should use within 24 hours after patient admission.
Cushing’s syndrome can be described as a disease or syndrome that results from excessive cortisol levels or excessive use of corticosteroids.
Cortisol is a hormone that is produced in the outer portion of the adrenal glands.
Adrenocorticotrophic hormone (ACTH) regulates the production cortisol.
It is helpful for the body to cope with stress and changes like high blood sugar or swelling.
Ms. Maureen Smith was prescribed high amounts of corticosteroids for her treatment of Rheumatoid arthritis. This causes her Cushing’s Syndrome.
This condition is called iatrogenic.
Harvey Cushing was the first to identify the disease in women and named it after him.
This kind of disease is very common in nature. Corticosteroids are widely used for diseases like RA.
This is more common among adults than in men.
Normally, it is between 25-45 years.
About 5 to 25 cases are reported per million people each year.
It is rare in Australia. The disease affects approximately 300 to 1200 Australians annually.
Ectopic ACTH, which is what causes Cushing’s Syndrome (approximately 660 per Million per year), is more common than the regular form.
This disease is characterized by type 2 diabetes, obesity, high blood sugar, and low control.
All of these symptoms are present in the case study 2.
Cushion’s syndrome is defined by the levels of cortisol and disease time.
When the proper treatment is given, the disease can usually be cured in 2 to 18 month.
Patient and family are frustrated that the treatment is slow and takes so long.
The patient experiences fatigue and weakness which leads to increased visits to the doctor, which can be a problem for both them and their families.
Cushing’s syndrome will make it more difficult for the patient to recover from. The symptoms include weakness in muscle, depression in the abdomen and stomach, and mood swings.
Family members of patients feel a great burden when they have to visit the doctor multiple times to check for the condition and to treat any complications.
Cushing’s Syndrome Symptoms
It has a pathophysiology.
Type 2 Diabetes
Cushing’s syndrome is a form of diabetes mellitus.
The condition is caused by excessive use of glucocorticoids.
These drugs increase gluconeogenesis and degrade insulin production.
This means that the glucose produced does not get degraded, and diabetes occurs (Mazziotti and al., 2017).
Cortisol works as a stress reliever and reduces stress-related conditions such as swelling.
It helps regulate carbohydrates, fats, protein.
This disease can lead to an increase in cortisol due to excessive use of corticosteroid medications.
The body may experience false alarms when it has too much cortisol. This can lead to food metabolization and absorption, even though the body doesn’t need it.
The patient continues to eat and this causes the body to build up excess fats in other areas.
The abdomen and the face are particularly susceptible to fat accumulation (Lee et. al., 2014).
Cushing’s syndrome can lead to hypertension.
Around 80 % suffer from hypertension.
Glucocorticoids are responsible for hypertension due to their inborn mineralocorticoid effect; by activating the renin–angiotensin frame; by upgrading vasoactive chemicals and concealment of vasodilatory mechanisms.
CNS-mediated cardiovascular regulation is also possible with glucocorticoids (Isidori, 2015).
About 60% of Cushing syndrome patients suffer from muscle weakness.
Patients with Cushing’s syndrome feel fatigued and muscle pains.
High doses of corticosteroids alter the protein metabolism.
These drugs slow down the rate of protein synthesis, leading to a higher level of protein breakdown which ultimately leads to the destruction of muscles.
These drugs can cause catabolism of muscle proteins (Fry et. al., (2016).
Cushing’s syndrome manifests itself in the appearance of thin skin and other mucous-mucous membranes.
The patient’s skin becomes very dry and can be easily injured.
The cortisol causes the skin to become dry and irritated.
The skin becomes weaker and forms shiny, thin paper (Raff Sharma & Nieman (2014)).
The treatment of Cushing’s Syndrome is done with two types of drugs: Adrenal corticosteroid-synthesis inhibitor (Metyrapone), (Eckstein and al., 2014).
This type of drug can be used for treatment.
Aminoglutethimide is an example of an anti-steroid drug. It’s marketed under Cytadren.
This drug blocks the formation of steroids that are cholesterol-derived and used in Cushing’s Syndrome.
These drugs are combined with other drugs and used to inhibit the function the adrenal gland of patients with this disease.
In this case, Aminoglutethimide works in two ways.
First, it blocks the activity of the aromatase that produces estrogens from androstenedione/testosterone.
It blocks the enzyme P450scc which prevents cholesterol from being converted to pregnenolone.
These types of drugs cause skin rash, cortisol induction in humans and hepatoxicity.
Adrenal Corticosteroid Sythesis Inhibitor
Metyrapone is used in the treatment of Case disease and to diagnose adrenal insufficiency.
These drugs prevent the synthesis cortisol from being produced by blocking the reversible steroid 11b-hydroxylase.
This causes the stimulation of ACTH to be inhibited and the plasma levels of 11-deoxycortisol to increase.
This type of drug is used in Cushing’s Syndrome hypercortisolism control (Daniel, et al. (2015).
It is used in the control of hypercortisolism.
It also stops adrenal steroidogenesis.
This medication is short term and not meant to be used for long-term management of the disease.
Metyrapone is also used to test the patient for Cushing syndrome.
Metyrapone can cause increased ACTH levels in patients with a dysfunctional pituitary. (Gadelha, Vieira (2014).
These medications can cause additional side effects.
These medications can cause dizziness, headache, nausea, and other side effects.
However, if the medication is used in a high dose, then severe reactions can occur such as vomiting and sudden weakness.
It can cause skin rash, sore throat, fever.
As a registered nursing assistant, I would follow the following strategy when caring for a Cushing’s patient.
To prevent complications, I will be closely monitoring the patient.
My assessment will take into account the patient’s history and the activities that he can engage in each day. It will also consider his self-care activities.
After that, I will perform a physical exam of the skin to determine if there has been any trauma or infection. Then I will assess mental stability. This refers to the patient’s response, moods, and awareness.
The assessment will include 1) the risk of injury- checking weakness, 2) the infection risk- swelling reaction, and 3) deficit in self care- weakness, fatigue, disrupted sleeping patterns, and 4) checking skin injury. 5) Checking for any problems in the body such as decreased activity or a different appearance.
6) Depression and mood swings that are not controlled.
After confirming that the disease has been diagnosed, I will provide treatment (Gulanick & Myers (2013)).
I will make sure that there is a safe environment for the patient so they don’t fall or injure their bones and soft tissue.
I will ensure that they have a good diet high in calcium and protein to prevent muscle loss.
I will reduce contact between patient and other people to decrease the chance of infection.
I will test the patient’s glucose level and provide medication to lower it.
I will encourage the patient to do moderate activity and get plenty of rest.
I will work with the patient to develop a schedule of activity and rest (Llahana & Thomas (2016)).
I will make every effort to reduce the risk of infection by using medications and equipments, including sterilized glassware.
Will ensure the skin is protected from any injury.
Low carbohydrate, high protein and low sodium diets are necessary to reduce the patient’s body weight.
I will attempt to improve the patient’s mood swings, behavior and health by explaining the disease to their family and discussing the possible treatments.
I will discuss the case with the doctor, and then prescribe the appropriate first-line medication to relieve the symptoms.
It is also my responsibility to keep an eye on some important factors, such as hypotension or weak nerve impulse respir rate. Also, I will check for any factors that can cause crisis in patients, such as surgery and trauma.
I will give fluids and electrolytes as required, and check the laboratory for daily weight and laboratory values.
For diabetes testing to be performed, the blood must be drawn.
Incentive spirometry and deep breathing will be encouraged every 2 to 4 hours.
Information to the family and patient about self-care is key.
Families of patients must be told that the use of corticosteroid should be reduced as it will lead to Cushing’s syndrome.
Metyrapone’s effectiveness in cushing’s syndrome: A retrospective multicenter study with 195 patients.
The Journal of Clinical Endocrinology & Metabolism (100(11), 416-4154.
Cushing’s syndrome systemic therapy.
Orphanet journal for rare diseases, 9(1). 122.
Glucocorticoids increase skeletal muscles NF?kB-inducing Kinase (NIK). Link to muscle atrophy
Physiological Reports, 4, 21 e13014
Systematic review on the efficacy of medical treatment for Cushing’s disease.
Clinical endocrinology. 80(1), 1-12.
Nursing care plans: nursing diagnosis & intervention.
Hypertension in Cushing’s Syndrome: Controversies in the pathophysiology, and a focus on cardiovascular complications.
Journal of Hypertension, 33(1). 44-60.
The Lancet 386(9996), 913-927.
Understanding the role of glucocorticoids, and how they influence adipose tissues biology and central obesity.
Cushing’s patients can benefit from structured nursing educational programs to improve their quality-of-life outcomes.
Diabetes in Cushing Disease.
Current Diabetes Reports 17(5), 32.
Cushing’s Syndrome: A guideline for clinical practice by the Endocrine Society.
The Journal of Clinical Endocrinology & Metabolism (100(8), 2807-2831.
The physiological basis for the diagnosis, treatment, and etiology adrenal disorders: Cushing’s Syndrome, adrenal Insufficiency, and Congenital Adrenal Hyperplasia.
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