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Cushing Syndrome(Hypercortisolism)

Titis Kurniawan, MNS

Scope

� Physiology of Cortex Adrenal

� Overview Cushing’s syndrome (CS)

� Etiology CS

� Diagnostic test

� Sign & Symptom CS

� Patophysiology CS

� CS Management

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Anatomy Fisiology Adrenal Gland

Cortex

Medulla

Aldosterone

(mineralocorticoid)Cortisol

(glucocorticoid)Androgen

Catecholamines; epi &

norepinephrin

Zona glomerulosa Zona fasciculata Zona reticularis

� Katabolik thd protein� Glukoneogenesis & inhibit insulin� Immunosupressive� Suppress parasympatis syst �

Increase Hcl

Fungsi Sistem Reproduksi (pria), ciri sex pria

� Organ target � ginjal (tubule distal & ductus colectivus)

� Bagian dari renin-angiotensin� >> retensi Na dan sekresi K� >> retensi cairan� >> tekanan darah

Sympathetic Nervous System �

increases in heart rate, blood pressure, blood glucose levels, and a general reaction of the

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Normal Range of Cortisol

Reference ranges for blood plasma content of free cortisol

Time Lower limit Upper limit Unit

09:00 am140 700 nmol/L

5 25 µg/dL

Midnight80 350 nmol/L

2.9 13 µg/dL

Reference ranges for urinalysis of free cortisol

Lower limit Upper limit Unit

28 or 30 280 or 490 nmol/24h

10 or 11 100 or 176 µg/24 h

Cushing Syndrome

� Is: group of symptoms resulted from any conditions that increase of blood glukokortikoid level (Maitra, A & Kumar, V., 2007; Schteingart, 2006)

� Can spontaneously occured follow high dose glukokortikoid prescription

� Insidence: 5 – 25 cases/1 million people/year

� Risk: 25 – 45 years old, women,uncontrolled diabetes, & obesity

� Type;� Iatrogenic; long-term glucocorticoid prescription� Spontan; Dependen & Independen ACTH

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Etiology� Iatrogenic ; Long term glukokortikoid prescription

(astma, artritis rheumatoid, limfoma & integument problem who receive glucocorticoid/steroid as anti inflamation agent

� Spontan; hypersecretion cortisol resulted from impairment of hipotalamus-hippofisis-adrenal axis (spontan)�Dependen ACTH

� ACTH secretion from ipofisis gland� Adenoma � sintesis & release ACTH ectopic

� Independen ACTH� Adenoma sintesis & release peptida = ACTH� Carsinoma sel paru/karsinoid bronkus, & sel pankreas release

CRH ectopic� Hiperplasia cortex adrenal nodular bilateral � >> cortisol

PathophysiologyIatrogenic Spontan

>> Glucocorticoid/Cortisol>> Katabolisme Protein

OtotIntegumen

Tulang

<< matrik tulang

Osteoporosis

Mudah cidera/ Perub. Postur/

Vertebra

Rapuh

Mudah luka

Luka sukar

sembuh

Kerusakan jaringan elastis

Striae

Risiko Ggn. Body Image

Ggn Integritas kulit

Vaskuler

Tipis & rapuh

Ptechiae

Atropi & lemah

Intoleransi aktivitas

Imun

Ggn pembentukan antibodi &

proliferasi limfoid

Risiko Infeksi

Jaringan Adiposa

Distribusi di sentral tubuh

CushingoidBuffalo hump,

moonface Obesity

>> Katabolisme karbohidrat

>> glukosa darah

<< Respon imunitas

>> sekresi lambung

Respon psikologis

>> HCLRisk Ulkus peptikum

Ggn Mood, euforia, depresi Risk. Koping tidak eektif/perilaku destruktif

<< GnRHGgn Sist

Reproduksi

>> aktivasi jantung

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Signs & Symptoms

Diagnostic Test

� Riwayat kesehatan

� Pemeriksaan fisik (sign & symptoms)

� Urinary free cortisol (UFC) test (220 –330nmol/24h)

� Plasma cortisol test

� Low doses dexamethasone test

� Cortisol circadian rhythm assessment

� MRI

� Dll

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Suspected CS Screening

– 24 hour urine free cortisol - Reflects cortisolproduction. Always measure urinary creatinineto insure completeness of collection

– Overnight dexamethasone suppression test– Both tests detect uncontrolled cortisol

production but do not distinguish etiology– Be careful with Pseudo cushing;

– Related to depression & alcoholism

– Periodic hormonogenesis

– When in doubt, wait 6-12 weeks and re-evaluate!

Dexamethason suppression test� Dexamethason exogenous steroid that provides negative

feedback to the pituitary to suppress the secretion of ACTH

� The test is given at low (usually 1–2 mg) and high (8 mg) doses of dexamethasone and the levels of cortisol are measured to obtain the results

� Low & high dose � no change cortisol � other causes (ectopic ACTH syndrome)

� Low dose � not change, but change with High dose �Cushing diseases � MRI of Pituitary considered

...........Diagnostic Test

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Nursing Process

Assessment� History; asthma, rheumatoid artritis, konsumsi obat steroid

� Psikologis; insomnia, euforia, depresi singkat, mood alteration

� General; Obesitas, moon face, buffalo hump

� Opthamic; Cataract, glaukoma, keluhan pandangan kabur

� Cardiovascular: HT, CHF, ptechie, echymosis

� Integumen: luka memar, luka tidak sembuh, striae, acne

� Muskuloskeletal: muscle weakness, atropi, myopathy

osteoporosis

� Gastrontestinal; peptic ulcer

� Pemeriksaan lab; hiperglikemia, hypernatremia, hypokalemia

Nursing Diagnoses

� Resiko injury b.d weakness, osteoporosis,

� Resiko infeksi b.d immunosupresi

� Self care deficit b.d muscle weakness, fatigue, altered sleeppatern

� Ggn integritas kulit b.d edema, gangguan penyembuhan luka, kulit yg tipis dan mudah pecah

� Ggn Body image b.d perubahan penampilan fisik

� Perub proses fikir b.d. perubahan mood, irritabilitas, depresi

� Risiko kping tdk efektif b.d. mood, irritabilitas, depresi

......Nursing Process

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Nursing Intervention�Pengendalian resiko injury

�Pengendalian resiko infeksi

�Anjurk istirahat dan aktivitas yg tepat

�Promote integritas kulit→mobilisasi u/ mcegah breakdown skin

� Improve body image

�Relationship with other

�BB dpt dikendalikan dg Diet low KH, Low sodium

� Improve proses berfikir

� Improve mekanisme koping

......Nursing Process