1. Discuss the probable causes of the alterations in T.H.'s laboratory results.

Manifestations of hyperglycemia, hypokalemia related to hypersecretion of glucocorticoids.

Decreased inflammatory and immune response results in high levels of cortisol which destroys
lymphocytes.
Laboratory findings:
increased blood glucose level
decreased lymphocyte count
decreased RBC count
decreased K+
increased sodium level

2. Explain the pathophysiology of Cushing syndrome.

Cushing syndrome occurs when there is too much of cortisol present in the body. Cortisol is also
known as stress hormones which when gets accumulated in the body causes swelling, edema and
weight gain specially near the mid portion of the body.
The adrenal gland secretes cortisol and other steroid hormones when stimulated by ACTH.
The pituitary gland produxes ACTH and released into the petrosal venous sinuses in response to
stimulation by corticotropin-releasing hormone (CRH) from the hypothalamus.
Hence increases the cortisol levels in the body.

3. What diagnostic testing would identify the cause of T.H.'s Cushing syndrome?
It can be diagnosed by the urine test i.e 24 hours urine test as in this test level of cortisol is
checked. Late night salivary test to check the cortisol levels in the body.
4. What is the usual treatment of Cushing syndrome?

Treatment for Cushing syndrome is dependent on the specific cause of the disease. Many of the
clinical manifestations of drug-induced Cushing syndrome resolve when medication is
discontinued. However, to prevent an acute episode of adrenal insufficiency, the corticosteroid
medication must be tapered.
Cushing disease is best treated with surgical removal of the pituitary tumor and longterm
hydrocortisone replacement therapy (6–36 months) until ACTH-secretory function recovers. The
cure rate approaches 90%.
Another treatment option is gamma knife radiosurgery, which normalizes cortisol levels in two
thirds of patients within 1 year. Conventional radiation therapy is only curative in approximately
one in four patients, but provides an option for patients who are not good surgical candidates.
Adrenal neoplasms secreting cortisol are resected laparoscopically. Adrenal carcinomas that have
spread outside the adrenal gland are treated systemically with the anticancer drug mitotane.
Ectopic ACTH-secreting tumors should also be surgically removed. If tumors cannot be resected,
laparoscopic removal of both adrenal glands is recommended.

When patients are not good candidates for surgery, a pharmacologic approach may be tried.
Ketoconazole may be used to suppress cortisol synthesis, but liver enzymes must be monitored for
hepatotoxicity. Metyrapone also inhibits cortisol synthesis but may promote masculinizing effects
in females. When given parenterally, the somatostatin analog octreotide suppresses ACTH
secretion in approximately one third of cases.

5. What is meant by a "medical adrenalectomy"?

An adrenalectomy is surgery to remove one or both adrenal glands. One adrenal gland sits above
each of your kidneys. Your two adrenal glands produce various hormones that help regulate your
metabolism, immune system, blood pressure, blood sugar and other essential functions

6. Priority Decision: What are the priority nursing responsibilities in the care of this
patient?
The basis of medical management for hypercortisolism and fluid overload include:
Patient safety
Drug therapy
Nutrition therapy
Monitoring

Management
Focuses on preventing complications associated with:
Fluid overload
Immune status
Skin integrity
Body structure

Prevent fluid overload- monitor for indicators:

bounding pulse
increasing neck vein distention
lung crackles
increasing peripheral edema
reduced urine output
7. Priority Decision: Based on the assessment data presented, what are the priority
nursing diagnoses?

Disturbed body imagine related to acne on face and neck.

Risk for infection related to abnormal lab values.
Risk for injury related to potential diminished bone density.

Are there any

collaborative problems?
Complications of Hypercortisolism
Osteoporosis:
may develop relative to the effects of cortisol on bone density
Increase the risk of pathological fractures

Acute adrenal crisis

may occur in patients with hypercortisolism secondary to exogenous corticosteroid therapy if the
medication is abruptly withdrawn

Elevated serum glucose

may complicate the management of diabetes mellitus in patients with this disorder

Gastrointestinal bleeding:
May develop as a result of:
decreased mucus production in the GI tract
decreased blood flow
release of hydrochloric acid secondary to the effects of cortisol.

Infection:
Increased risk
Glucocorticoids reduce both the inflammation and the immune responses.

Risk for impaired skin integrity

Risk for thromboembolism
Cardiac dysrhythmias
HTN
Kidney stones