CHAPTER 1
INTRODUCTION
1.1 Background
The
adrenal gland consists of the medulla and the cortex. The
cortex consists of zona glomerulosa, fasikulata, and reticular. Zona
glomerulosa secrete controlled by aldosterone and renin-angiotensin mechanism
and does not rely on the pituitary. Zona
reticularis fasikulata and secrete cortisol and androgenic hormones and
controlled by the pituitary via ACTH. Secretion
of ACTH by the pituitary is controlled by (1) hypothalamic corticotropin
releasing factor, and (2) the feedback effects of cortisol. When
there is a disruption in the formation of these hormones either excess or lack
of, will affect the body and cause an abnormality. Cushing's
syndrome is caused by excess cortisol.
CHAPTER 2
THEORY REVIEW
2.1 Definition of Cushing's
Syndrome
Harvey
Cushing in 1932 describes a condition caused by adenoma pituitary cells
basophils. This is
called "Cushing's disease".
Cushing's
syndrome is a condition caused by the combined metabolic effects of elevated
glucocorticoid levels in the blood is settled. These
high levels may occur spontaneously or as pharmacologic dose glucocorticoid
compounds. (Sylvia
A. Price; Patofisiolgi, p. 1088)
Cushing's
Syndrome clinical picture resulting from an increase in plasma glucocorticoids
long-term pharmacologic dose (latrogen). (William F. Ganang,
Medical Physiology, p 364).
Cushing's
Syndrome is caused by excessive secretion of steroid adrenokortial especially
cortisol. (IDI). Volume III Issue I, p 826).
Cuhsing
Syndrome due to maintenance of blood cortisol levels are abnormally high
because hiperfungsi adrenal cortex. (Pediatrics, Volume 15 It
1979).
2.2 Etiology
Cushing's
syndrome can be caused by:
1. Elevated
levels of ACTH (not always due to pituitary adenoma basophil cell).
2. ATCH
elevated levels due to the tumor outside the pituitary, such as lung tumors,
pancreas that secrete "ACTH-like substance".
3. Adrenal neoplasms are
adenomas and carcinomas.
4. Iatrogenic.
Providing
long-term glucocorticoids in pharmacologic doses. Found
in patients with rheumatoid artitis, asthma, lymphoma and skin disorders who
receive synthetic glucocorticoids as anti-inflammatory agents.
2.3 Clinical Manifestations
Can
be classified according to the function of the adrenal cortex hormones:
cortisol, 17 ketosteroid, aldosterone and estrogen.
1. Symptoms
hypersecretion of cortisol (hiperkortisisme), namely:
a. Sentrifetal obesity and
"moon face".
b. Thin
skin so that the face looks red, raised Strie and ecchymosis.
c. The muscles shrink
due to the effects of protein catabolism.
d. Osteoporosis
can lead to compression fractures and kyphosis.
e. Atherosclerosis is the
cause of hypertension.
f. Diabetes
mellitus.
g. Alkalosis, and hypokalemia
hipokloremia.
2. Symptoms hypersecretion 17
ketosteroid:
a. Hirsutism (male resembles
female).
b. Voice in.
c. Incurred acne.
d. Amenorrhea
or impotence.
e. Enlargement
of the clitoris.
f. Muscles grow (masculinization)
3. Symptoms
of aldosterone hypersecretion.
a. Hypertension.
b. Hypokalemia.
c. Hypernatremia.
d. Nephrogenic
diabetes insipidus.
e. Edema (rare)
f. Plasma
volume increases
When
these symptoms are striking, especially the first two symptoms, a disease
called Conn or primary hyperaldosteronism.
4. Symptoms of estrogen
hypersecretion (rare)
In
Cushing's syndrome is the most characteristic symptoms of hypersecretion of
cortisol, sometimes mixed with other symptoms. Generally
onset disease is not clearly known, the first symptom is weight gain. Often accompanied by
psychological symptoms to psychosis. The
disease is intermittent, then weakness, easy infections, peptic ulcers arise
and possibly vertebral fractures. Deaths
caused by general weakness, cerebrovascular disease (CVD) and rarely by a
diabetic coma.
2.4 Classification
Cushing's
syndrome can be divided into 2 types:
1. Depending ACTH
Hiperfungsi
adrenal cortex may be caused by the pituitary ACTH secretion are abnormal
excessive. This
type first described by the Hervey Cushing in 1932, it is also a condition
called Cushing's disease.
2. ACTH-independent
The
existence of ACTH-secreting pituitary adenoma, in addition there is
histological evidence of pituitary hyperplasia kortikotrop, it remains unclear
whether kikroadenoma maupum reciprocal hyperplasia due to impaired release of
CRH (Cortikotropin Realising hormone) by neurohipotalamus. (Sylvia A. Price;
Pathophysiology. Matter 1091).
2.5 Complications
• Crisis Addisonia
• The
adverse effects on the activity of adrenal correction
• Fractures due to
osteoporosis
2.6 Diagnosis comparison
Clinical
diagnosis can be made when there are three or more of the following signs:
1. Fatigue great and small
muscles
2. Centripetal obesity
and cessation of growth.
3. Strie
reddish.
4. Ekhimosis without platelet
disorders.
5. Hypertension.
6. Osteoporosis.
7. Diabetes
mellitus.
2.7 Examination Support
1. In
simple laboratory tests, it was found limfositofeni, neutrophil number between
10,000 - 25.000/mm3. eosinophils
50 / mm3 hiperglekemi (Dm occurred in 10% of cases) and hypokalemia.
2. Examination of diagnostic
laboratory.
Examination
cortisol levels and "overnight dexamethasone suppression test" is to
give 1 mg dexametason at 11 pm, the next day plasma cortisol levels checked
again. In normal
circumstances these levels decreased. Pemerikaan
17 hydroxy corticosteroids in the urine 24 hours (the metabolism of cortisol),
17 ketosteroid in the urine 24 hours.
3. Specific
tests to distinguish hyperplasia-adenoma or carcinoma:
- Urinary deksametasone suppression test. Measure 17 hidroxi kostikosteroid levels in the urine of 24 hours, then given dexametasone 4 X 0.5 mg for 2 days, check again 17 hidroxi corticosteroid levels in the absence of or only slightly decreased, there may be abnormalities. Give dexametasone 4 x 2 mg for 2 days, when levels of corticosteroids decreased 17 hidroxi means there is suppression of adrenal abnormalities in the form of hyperplasia, when there is no possibility of suppression of adenoma or carcinoma.
- Short oral metyrapone test. Metirapone cortisol inhibits the formation of up to 17 hidroxikortikosteroid. In hyperplasia, 17 hidroxi corticosteroid levels will go up to 2 times, in adenoma and carcinoma is not an increase in urinary levels of 17 hidroxikortikosteroid.
- Measurement of plasma ACTH levels.
- ACTH stimulation test, the adenoma was found increased levels up to 2-3 times, at kasinoma no increase.
2.8 Management
Treatment
of ACTH dependent Cushing's syndrome is not uniform, depending on whether the
source is pituitary ACTH / ectopic.
a. If
you found a pituitary tumor. Should attempted
tranfenoida tumor resection.
b. If
there is evidence of hiperfungsi pituitary tumor but could not be found to do
so instead kobait radiation on the pituitary gland.
c. Excess
cortisol can also be overcome by adrenolektomi total and followed by
administration of physiological doses of cortisol.
d. When
excess cortisol is caused by neoplasm followed by chemotherapy in patients with
carcinoma / surgical therapy.
e. Used
with kind metyropone drugs, amino gluthemide o, p-ooo could secrete cortisol
(Silvia A. Price; Pathophysiology Issue 4 case 1093)
2.9 Web of causation
Cushing Syndrome
Attached.
CHAPTER 3
NURSING CARE
3.1 Assessment
A. Identity Client
The
identity of clients includes name, gender, place / date of birth, age,
education, religion, address, date of admission. Often
more prevalent in women than in men and have peak incidence between the ages of
20 and 30 years old.
B. Main complaint
There
is bruising of the skin, the patient complained of weakness, weight gain
occurs.
C. History
of the disease before
Assess
whether the patient ever used any drugs kartekosteroid in a long time.
D. Family
history of disease
Assess
whether the family had suffered from the disease Cushing's syndrome.
E. Physical
examination
1. B1 (Breath)
Inspection:
nostril breathing is sometimes seen, symmetrical chest movement
Palpation:
Vocal premitus palpable rate, there is no tenderness
Percussion: resonant voice
Auscultation:
Sounds normal breath sounds, no sound extra breath.
2. B2 (Blood)
Percussion
deaf, S1 S2 single sounds, hypertension, increased TD.
3. B3 (Brain)
Composmentis
(456), natural instability to feelings of depression mania
4. B4 (Bladder)
Polyuria,
sometimes forming kidney stones, sodium retention.
5. B5 (Bowel)
There
are weight gain, pain in the stomach area, striae found in the abdomen, mucosal
dry lips, faint voice.
6. B6
(musculoskeletal and integument)
Thin
skin, increased pigmentation, easy bruising, muscle atrophy, ecchymosis, slow
wound healing, muscle weakness, osteoporosis, moon face, punguk bison, obesity
tunkus.
3.2 Nursing Diagnosis
1. Risk
of injury associated with weakness and decreased bone matrix.
2. High
risk of infection associated with immunodeficiency.
3. Intregritas
skin disorders associated with fragile thin skin daan.
4. Self
care deficit related to weakness, fatigue, muscle mass maintenance.
5. Body
image disturbance associated with changes in physical appearance.
6. Pain associated
with injury in the gastric mucosa.
7. Impaired
thought processes associated with fluctuating emotions and depression
3.3 Intervention
1. Risk
of injury associated with weakness and decreased bone matrix.
Objective: To reduce the
risk of injury
Criteria
results: Clients are free from soft tissue injuries or fractures
Intervention:
1. Create
a protective environment
Rationale:
Preventing falls, fractures and other injuries to the bones and soft tissues.
2. Help clients
ambulation
Rationale:
Prevents dropped or bumped on the sharp corners of furniture.
3. Collaboration
with a team of nutrition by administering a diet high in protein, calcium, and
vitamin D
Rationale:
Minimize depletion of muscle mass and osteoporosis.
2. High
risk of infection associated with immunodeficiency.
Objective: To reduce
the risk of infection
Criteria
results: Clients not increase body temperature, redness, pain, or signs of
infection and other inflammatory.
Intervention:
1. Assess
TTV (TD, Nadi, body temperature and other signs of infection symptoms every 4
hours)
Rational:
to know the signs of the infection as early as possible
2. Explaining the
cause of the infection in patients
Rationale:
Patient understanding and cooperative about the cause of the infection
3. Place on a particular
space and limit visitors
Rational
avoid or reduce the contact source of infection, to keep clients from
pathogenic agents that can cause infection
3. Intregritas
skin disorders associated with fragile thin skin daan.
Goal:
Reduce the risk of lesions / decrease in the integrity of the skin
Criteria
results: Clients are able to maintain the integrity of the skin, demonstrating
behaviors / techniques to prevent damage / injury to the skin.
Intervention:
1. Inspection
of the skin to change color, turgor, vascular.
Rational:
indicates poor circulation area / damage that can lead to the formation of
infection.
2. Monitor
fluid intake and hydration of the skin and mucous membranes.
Rational:
detect dehydration / hydration excessively affecting circulation and tissue
integrity at the cellular level.
3. Inspections
are dependent edema.
Rational:
tissue edema were more likely damaged / torn.
4. Give
skin care. Give ointment or
cream.
Rational:
lotions and ointments may be desirable to eliminate dry skin tears.
5. Encourage use loose cotton
clothes.
Rationale:
prevent direct dermal irritation and improve skin moisture evaporation.
6. Collaboration in the provision
foam mattress.
Rational:
reducing pressure on the old network.
4. Body
image disturbance associated with changes in physical appearance.
Destination:
the client can accept her situation.
Expected outcomes:
Clients
express their feelings and coping methods for negative perceptions about
changes in appearance, and activity level. Declare acceptance of the
situation themselves.
Intervention:
1. Assess
the patient's level of knowledge about the condition and treatment.
Rational:
identify broad issues and the need for intervention.
2. Discuss the meaning of the
changes in a patient.
Rational:
some patients view the situation as a challenge, multiple difficulty accepting
the change of life / performance roles and lose the ability to control your own
body.
3. Encourage
people closest to treat patients as normal and not as a disabled person.
Rational:
expressed the hope that the patient is able to manages the situation and helps
to maintain a sense of self and purpose in life.
3.4 Evaluation
The
evaluation was conducted at any time after nursing plan done while evaluating
ways in accordance with the objective criteria of success keparawatan plan. Thus,
the evaluation can be carried out in accordance with the criteria / arrangement
detailed progress notes written on a sheet containing SOAPIER (data subject,
object, Asesment, Implementation, Evaluation, Revision).
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