 Hi, welcome to nursing school explained in this video about Cushing's disease. Before we dive into the details about Cushing's disease, let's review how the hormones are regulated by the hypothalamic pituitary and adrenal axis. So as I review, the hypothalamus secretes corticotropin-releasing hormone which stimulates the anterior pituitary to secrete ACTH or adrenal corticotropin hormone which then stimulates the adrenal cortex to release these three hormones. First we have glucocorticoids, second mineralocorticoids and third androgens. And the easiest way to remember these are the three S's. So glucocorticoids, steroid, glucose, mineralocorticoids, salt as in sodium or minerals and then androgens which are the sex hormones. And this is given that everything functions normally. So if everything functions normally, the regulation of sugar, salt and sex hormones goes back in a negative feedback loop to the hypothalamus basically it's a report back and if those hormones are now in balance the hypothalamus stops the production and therefore in the bloodstream the production will go down. Now looking at what these hormones do in the body and again this is under normal function of this axis. So glucocorticoids or sugar also mean cortisol which is a stress hormone. We are well aware of this as nursing students. Cortisol has a lot to do with carbohydrate, protein and fat metabolism which means that under stressful situations the body is in need of increased sugar which then it stimulates the liver to release more blood glucose through the process of gluconeogenesis. And again if there is increased stress the cells will decrease their glucose use and increase protein breakdown and fat synthesis in order to meet the metabolic demands. Now for salt or mineralocorticoids think about aldosterone here. Aldosterone is a major player in the RAS system which is the renin angiotensin and aldosterone system. And aldosterone on the normal circumstances is released when blood pressure is low. So it causes the increased reabsorption of sodium and water at the adrenocortex so that blood pressure can then be restored by increasing the blood volume. And in exchange at the renal tubules for increased sodium reabsorption potassium is being excreted. And then we have our androgen sex hormones that we'll get into here. So now let's look at Cushing's disease which is an increase in adrenocorticotropin hormone. So now everything here will be increased which means that sugar, salt and sex hormones are all going to go up. Causes for Cushing's disease most commonly are exogenous in nature meaning coming from outside the body which the most likely culprit is the chronic administration of glucocorticoids also known as steroids. And then can be endogenous reasons for Cushing's disease which would be either pituitary or adrenal tumors. So now if the pituitary or adrenal cortex here are malfunctioning because of a tumor that increases ACTH production again with that production it's going to cause Cushing's disease. So let's look at signs and symptoms. So looking at glucocorticoids knowing that this is cortisol that we're dealing with and increased levels of blood sugar glucocorticoids. The patient will have some weight gain they'll have truncal obesity and then these two terms that we lots of times hear with Cushing's disease which is moon phase and buffalo hump. It's not the most endearing words that we can use and I would definitely avoid using those with your patients but it's basically describing the changes the physical changes that happen when there are increased cortisol levels. So it's basically a lot of adipose tissue that's been deposited around the trunk so around the midsection in the face as well as in the upper back areas. With increased levels of glucocorticoids we're going to have increased levels of blood sugars. I am sure you are aware that a very common side effect of steroid administration is hyperglycemia. Now then this leads to increased protein breakdown which can lead to muscle wasting and weakness in the patient and steroids also make the bones weaker which leads to decreased bone matrix osteoporosis back pain and even fractures that are not even due to any kind of injury. The patient will just experience a fracture because the bones are so weakened because of this chronic steroid use. And then the patient will also have decreased collagen production which will make their skin really weak and bruise easily and they'll have striations on their abdomen which are kind of purplish discolorations that you can see. Now looking at mineralocorticoids so the aldosterone level if all that is increased the body is going to increase the absorption of sodium, water follows and potassium is excreted in exchange. This increased sodium and water reabsorption will lead to hypertension and puts the patient at risk for fluid volume excess as well as hypokalemia. And then for the increased production of androgens signs and symptoms can be acne, menstrual disorders in females and then gynecomastia or enlargement of the breasts in male patients as well as impotence. And many times steroid induced Cushing's disease or really any elevation in ACTH will lead to a more female appearance of male patients and a more masculine appearance of female patients. And to diagnose Cushing's disease we basically need to measure that stress hormone cortisol that we have determined over here is the glucocorticoid that we mostly worry about. And this can be done by obtaining a salivary cortisol level by administering a low dose dexamethasone suppression test or measuring the urine cortisol in a 24 hour urine test as well as obtaining a CT or MRI to evaluate for tumors of the pituitary gland and adrenal glands that we have determined can be reasons for the increased production of ACTH. Treatment, if it's due to a pituitary tumor, the pituitary gland will have to be removed. If it's not possible, if the patient is not a surgical candidate, a lot of times radiation will be performed to try and shrink the tumor. If the reason is an adrenal tumor, an adrenalectomy has to be done which basically means surgical removal of the adrenal gland and we'll look a little bit more into nursing care related to that down here. Now if Cushing's disease is caused by the most common reason which is steroids, we need to gradually reduce the steroid therapy and that means to decrease the dose or go to alternate day regimens which means that the patient will take a dose every other day. And this cannot be done quickly because if we now reduce or abruptly withdraw the steroids from the patient, they will go into the opposite direction. It will drop all their ACTH levels and they'll go into an adisonian crisis because the opposite of Cushing's disease is Addison's disease. So very gradual this continuation of steroids is very, very important. Patients with Cushing's disease can be seriously ill because we know that the mineralocorticoids can affect their blood pressure. We have to be very diligent about monitoring their vital signs as well as their daily weight to monitor for fluid volume access. And eyes and nose are important as well for that reason. We also have to check their blood sugars very frequently because we know with the glucocorticoids the blood sugar can be elevated. And we also have to check their electrolytes because we know it can lead to increased levels of sodium and then hypokalemia which is always worrisome regarding cardiac activity. Patients with Cushing's disease are also prone to infections so we have to monitor the patient very diligently for that as well as DVT and PE and then provide emotional support because of all these physical changes that they're going through also with their sex hormones they might have disturbed body image and a lot of psychosocial issues that we need to help them deal with. Now when there is an adrenalectomy in the pre-op care we have to make sure that we control blood pressure, blood sugar and correct any hypokalemia. The adrenal glands are very vascular glands that sit on top of the kidneys so the patient is at high risk for bleeding after the removal of the adrenal gland. So in addition because now if that adrenal gland is removed meaning that now the cause of the increase in ACTH is gone it would put the patient at a risk for decreased glucocorticoids mineralocorticoids and androgens which means that now we have removed the cause which would basically be as if you would abruptly stop the steroids that you that the patient has been receiving over prolonged periods of time. So postoperatively for adrenalectomies a lot of times the patient will need high dose steroids temporarily because otherwise they can again go into anisonic crisis and high dose steroids put the patient at risk for hypertension which then increases their risk for bleeding. So it's kind of this kind of like vicious circle that you're dealing with here. So we have to monitor the patient very carefully for bleeding and then give them these high dose steroids postoperatively until they can gradually be weaned off just as if the cause was steroid induced Cushing's disease. Thank you for watching this video on Cushing's disease. Please also watch the other video about the opposite of Cushing's which is Adison's disease. Thank you very much for watching Nursing School Explained. See you soon.