SURGICAL INTERVENTION

- Pituitary surgery
- Transsphenoidal adenomectomy or hypophysectomy.
- Transfrontal craniotomy may be necessary when a pituitary tumor has enlarged beyond the
sella turcica.
- Bilateral adrenalectomy
- Radiation therapy

NCP

Risk for Infection related to a decrease in immune response, inflammatory response.

Goal: Infection does not occur after the intervention.

Nursing Intervention :
1. Assess frequently for subtle signs of infections.
- Note that, Corticosteroids usually mask signs of inflammation and infection.
2. Measure vital signs every 8 hours.
- Temperature increased is an indicator of infection.
3. Use strict medical and surgical asepsis when providing care - As this would prevent cross
infection.
4. Restrict visitors as indicated.
- Cortisol suppresses the immune system. Therefore, restricting visitors reduces exposure to
other infectious pathogens.
5. Place the client in isolation as indicated.
- In some cases, isolation techniques is needed to prevent the spread / protect other patients
from infection process.
6. Emphasized the importance of good nutrition.
- Adequate nutrition enhances immune system natural defense mechanism.
7. Lastly, Administer antibiotics as prescribed.
- Antibiotic therapy reduces the risk of nosocomial infection.

Activity Intolerance related to muscle weakness and changes in protein metabolism.

Nursing Intervention :
1. Assess client's ability to perform activities.
2. Increase bed rest / sit.
- Periods of rest are energy saving techniques.
3. Note the response to activities such as tachycardia, dyspnea, fatigue.
4. Increase active involvement of the patient in accordance with his ability.
- Adding a level of confidence and self-esteem of patients both in abundance according to the
level of activity is tolerated.
5. Provide assistance activities as needed.
- This would help meet the needs of client activity.
6. Provide appropriate entertainment activities.
- This would increase relaxation and energy savings, refocus and improve coping.
Risk for Injury related to generalized fatigue and weakness
Goal: Client will be free of fractures or soft tissue injuries.
Client will implement measures to prevent injury.

Nursing Interventions:
1. Assess the skin frequently to check for reddened areas, skin breakdown, tearing, or
excoriation.
- Cushing’s disease causes thinning of the skin because cortisol causes the breakdown of some
dermal proteins along with the weakening of small blood vessels. Therefore, the skin may
become so weak which allows it to be damaged easily.
2. Discuss with client safety measures for ambulation and daily activities.
- Precaution with activities is done to reduce the occurrence of trauma that can result in injury.
So it is important to assist the patient or use assistive devices during ambulation also to prevent
falls fractures, and other injuries to bones and soft tissues.
3. Provide a protective environment.
4. Encourage the client to increase dietary intake high-protein foods, calcium, and vitamin D;
refer to dietitian for assistance.
- Eating a high-protein diet can help prevent the muscle loss associated with Cushing
syndrome; also, client with Cushing’s disease develop osteoporosis (fragile bones). Calcium
and vitamin D are important in strengthening bones.

Disturbed Body Image related to abnormal fat distribution along with edema as evidenced by
change in social behavior

Desired Outcomes
● Client will verbalize feelings about the changes in appearance, sexual function and activity
level.
● Client will demonstrate enhanced body image and self-esteem as evidenced by ability to look
at, touch, talk about, and care for actual and perceived altered body parts and functions.

Nursing Interventions:
1.Assess the client’s coping mechanism.
- Previously successful coping skills may be inadequate in the present situation.
2. Assess client’s feelings about their changed appearance and coping mechanism.
- Negative statements about changes in appearance indicate a disturbed body image. The client
may withdraw from social interaction. And depression may occur.
3. Reassure the client that the physical changes are a result of the elevated hormone levels and
most will resolve when those levels return to normal
- Information helps the client develop realistic expectations about the changes in the physical
appearance. These information may enhance the client’s willingness to participate in
recommended treatments.
4. Encourage the client to verbalize feelings about the body image changes.
- It is worthwhile to encourage the client to separate feelings about changes in body structure or
function from feelings about self-worth. The expression of feelings can enhance the client’s
coping strategies.
5. Promote an atmosphere of acceptance and positive caring.
- Client asks other people for feedback about their appearance. When the nurse responds to the
client in an accepting manner, it supports the client’s adjustment to his or her appearance.
6. Promote coping methods to deal with the client’s change in appearance (e.g., adequate
grooming, flattering clothes).
- Learning methods to compensate for changes in appearance enhances the client’s self-
esteem. Helping clients remember how they managed body image issues in the past may
facilitate an adjustment to the current issues.
7. Refer to local support groups.
- Being exposed to people with same experiences provide social support. Members of a support
group may offer coping strategies that have proven successful.

Risk for Excess Fluid Volume related to Retention of water and sodium caused by an excess
of cortisol and mineralocorticoid levels.

Desired Outcomes
● Client will be normovolemic as evidenced by stable weight (or loss attributed to fluid loss),
urinary output 30ml/hr or greater, balanced intake and output, absence or reduction of edema,
HR less than 100 beats per minute, absence signs of pulmonary congestion.

Nursing Interventions:
1.Assess for signs of circulatory overload: • Crackles. • Cyanosis • Dyspnea. • Edema. •
Distended neck veins. • Shortness of breath. • Tachypnea
- Detection of signs of circulatory overload will help in the immediate intervention. Due to
excessive glucocorticoid and mineralocorticoid secretion, the client is predisposed to water and
sodium retention.
2. Assess for cardiac dysrhythmias.
- As the level of potassium decreases in Cushing’s syndrome, the chances of abnormal heart
rhythms increases.
3. Monitor vital signs, especially BP and HR.
- Cushing’s disease may result in increased blood pressure resulted from the expanded fluid
volume with sodium and water retention. Tachycardia happens as a compensatory response to
circulatory overload.
4. Monitor the client’s sodium and potassium levels.
- Excessive cortisol causes sodium and water retention, edema, and increased potassium
excretion. Mineralocorticoids regulate sodium and potassium secretion, and excess levels
cause marked sodium and water retention as well as marked hypokalemia.
5. Instruct the client to elevate feet when sitting down.
- This position decreases fluid accumulation in the lower extremities. Instruct the client to reduce
fluid intake as indicated. Limiting fluid intake is important in preventing circulatory overload.
6. Encourage the client to have low sodium
- Too much sodium in the diet promotes fluid retention and weight gain. There should be an
adequate potassium in the diet since the elevation of cortisol level causes hypokalemia. and
high potassium diet.
7. Administer antihypertensive medications as prescribed.
8. Administer diuretics as prescribed.
- Diuretics promote sodium and water excretion. Potassium-sparing diuretics such as
Spironolactone (Aldactone) may also be prescribed to prevent additional loss of potassium.
Deficient Knowledge related to lack of experience with Cushing’s disease as evinced by
verbalized misconceptions.

Desired Outcomes
● Client will verbalize an understanding of Cushing’s disease and guidelines for therapy.
● Client will implement appropriate therapy

Nursing Interventions:
1.Assess the client’s level of knowledge of Cushing’s disease and its treatment regimen.
- The client or family must understand the disease process and receive specific instructions
related to treatment, methods to control symptoms, signs of infection, complications, and
indicators of when to notify the physician.
2. Discuss the following diagnostic test to the client: Some of the tests requires cooperation in
collecting urine specimens over an extended period.
• Computed tomography, magnetic resonance imaging, and selected arteriography. These
diagnostic studies are used to localize adrenal tumors and may identify pituitary tumors.
• Urine free cortisol, 17-ketosteroids (17-KS), 17-hydroxycorticosteroids (17-OHCS). Urine free
cortisol involves collecting urine several times over a 24-hour and then testing it for cortisol. An
adult with levels of cortisol higher than 50 to 100 mcg per day would be considered high. In
Cushing’s disease, urine free cortisol, levels of 17-OHCS (metabolites of cortisol) and 17-KS
(metabolites of androgens) are increased.
• Dexamethasone suppression tests. This is used to evaluate adrenal gland function by
measuring how cortisol levels change in response to an injection of dexamethasone. It is
typically used to diagnose Cushing’s syndrome.
3. Anticipate the need to discuss or reinforce the probable treatment in correcting the
hypersecretion of hormone;