Metabolic and Endocrine 1.

) Diabetes Mellitus Diabetes mellitus is a kind of metabolic disease that is brought about by either the insufficient production of insulin or the inability of the body to respond to the insulin formed within the system. Causes: Diabetes mellitus occurs when the pancreas doesn't make enough or any of the hormone insulin, or when the insulin produced doesn't work effectively. In diabetes, this causes the level of glucose in the blood to be too high. Signs and symptoms:

Frequent urination Excessive thirst Unexplained weight loss Extreme hunger Sudden vision changes Tingling or numbness in the hands or feet Feeling very tired much of the time Very dry skin Sores that are slow to heal More infections than usual

Management: The goal of diabetes management is to keep blood glucose levels as close to normal as safely possible. monitoring blood glucose levels dietary management

maintaining physical activity keeping weight and stress under control monitoring oral medications and, if required, insulin use via injections or pump

Nursing responsibilities: Nurses play an important role in this process by identifying patients at risk for prolonged hyperglycemia. They must evaluate admission serum glucose levels and closely monitor elevated bedside glycemic levels when caring for critically ill patients, especially neurological patients. Prompt reporting of worrisome observations to the medical team can significantly improve outcomes. Nursing responsibilities for patients receiving insulin include proper administration, assessment of patient response to insulin therapy, and education of patients and their families about insulin's administration, adjustment, and side effects Nurses must educate themselves and their peers about hyperglycemia and its profound negative influence on outcomes. Resistance to improved therapies and new protocols or techniques usually stems from a fear of change or a lack of understanding.

2.) Hypothyroidism Hypothyroidism is when your body doesn't produce enough thyroid hormone. Since the main purpose of thyroid hormone is to run the body's metabolism, people with hypothyroidism will have symptoms associated with a slow metabolism. Causes: Many permanent or temporary conditions can reduce thyroid hormone secretion and cause hypothyroidism. About 95% of hypothyroidism cases occur from problems that start in the thyroid gland. In such cases, the disorder is called primary hypothyroidism. (Secondary hypothyroidism is caused by disorders of the pituitary gland. Tertiary hypothyroidism is caused by disorders of the hypothalamus.)

The two most common causes of primary hypothyroidism are:

Hashimoto's thyroiditis. This is an autoimmune condition in which the body's immune system attacks its own cells. Overtreatment of hyperthyroidism (an overactive thyroid).

Signs and symptoms: Fatigue Weakness Weight gain or increased difficulty losing weight Coarse, dry hair Dry, rough pale skin Hair loss Cold intolerance (you can't tolerate cold temperatures like those around you) Muscle cramps and frequent muscle aches Constipation Depression Irritability Memory loss Abnormal menstrual cycles Decreased libido

Management: Thyroid Hormone Replacement Monitoring thyroid function Intravenous replacement

Suppressive thyroid therapy involves taking levothyroxine in doses that are high enough to block the production of natural TSH but too low to cause hyperthyroid symptoms. It may be used for patients with large goiters or thyroid cancer. Suppressive thyroid therapy places patients, particularly postmenopausal women, at risk for accelerated osteoporosis, a disease that reduces bone mass and increases risk of fractures. Some researchers suggest, however, that such bone loss is too slight to pose any significant risk for fracture. Furthermore, the cholesterol-lowering benefits of suppressive therapy outweigh this small risk. Bone density loss can be reduced or avoided by taking no higher a dose of thyroxine than necessary to restore normal thyroid function. In any case, doses of T4 must be continuously and carefully tailored in all patients to avoid adverse effects on the heart. Nursing responsibilities: Assess the patient for the response to therapy (mental status, quality of skin and hair, subnormal temperature, bracycardia, respiratory rate, BP, worsening heart failure, wt. gain or loss). Provide instructions for adhering to a low calorie diet until the patient's wt. stabilizes within an ideal range. Weight gain deelops when the patient's appetite improves with the start of therapy, but energy levels have not yet improved. Encourage activity as tolerated to reduce constipation Advise the pt. to drink 6-8 glasses of water daily and eat high fiber foods. A stool softner may be needed if diet and exercise are ineffective. Reassure the pt. that energy levels will return to normal after hormone therapy is begun. Maintain patent airway, administering o2, and intravenous fluids for the patient with myxedema coma. Monitor intake, output, and daily weights. Graves' disease is an autoimmune disease in which the patient's own immune system attacks the thyroid gland, causing it to produce too much thyroxine. Thyroxine (T4) is a hormone produced by the thyroid gland that has four iodine molecules attached to its Graves' Disease Center

molecular structure. T4, as well as other thyroid hormones help regulate growth and control metabolism in the body. Causes: Graves' disease is caused by a dysfunction in the body's disease-fighting immune system. Signs and symptoms:

Anxiety Moodiness and irritability Insomnia Tiredness Arrhythmia (irregular heart beat) Tachycardia (accelerated heart beat) Tremor in the hands and fingers Sensitivity to heat Weight loss, even though the patient eats properly Brittle hair Goiter (thyroid gland is enlarged) Menstrual cycle changes Bowel movements are more frequent

Management: The most common graves disease treatment options usually involve drugs that are used to control hormone production, radioactive iodine therapy whereby radioactive iodine is used to kill of parts of the thyroid, or radical surgery by which part or all of the gland is removed. Naturally as with all synthetic drugs there are often side effects and complications associated with drugs used to treat hyperthyroidism. Side effects can range from fatigue to weight gain, depression and mental lethargy. Nursing responsibilities:

Nursing interventions center on ongoing monitoring, protecting the patient from injury, reducing stress, and initiating teaching. Encourage the patient to follow the medication regimen and reassure him or her while waiting for it to take effect. To determine the response to treatment and to prevent thyroid storm, assess the cardiovascular status, fluid and diet intake and output, daily weights, bowel elimination, and the ability of the patient to perform activities of daily living without excessive fatigue. Reassure the patient's family that the patient's mood swings, nervousness, or anxiety will diminish as treatment continues. If the patient or family requires additional support, ask a clinical nurse specialist or mental health counselor to see the patient or family. Note that extreme anxiety of the undiagnosed or uncontrolled patient makes patient education difficult for all concerned. If you recognize the patient's inability to maintain long cognitive or physical attention spans, you will have better success at patient education. One useful strategy is to ensure that significant others are present during all teaching sessions. 3.) Addisons disease Addisons disease is a rare disorder that affects men and women of all ages. Addisons disease is also referred to as primary adrenal insufficiency. Adrenal insufficiency develops when your adrenal glands do not produce enough of the hormone cortisol. In our Addison's Disease Center, learn about the symptoms and treatments for this adrenal gland disorder. Causes: Addisons disease is caused by damage, destruction or malfunction of the adrenal glands. Your adrenal glands are located just above your kidneys and are responsible for producing various hormones. These hormones are responsible for regulating your bodys stress response, energy needs, immune function, salt and water balance, and sexual development. When your adrenal glands are damaged or destroyed, your body no longer has enough of these hormones and adverse symptoms occur. Signs and symptoms:

Symptoms of Addisons disease usually begin gradually and may be overlooked because they progress slowly. Often, a stressful event, such as an accident or illness, will cause symptoms to worsen and progress more rapidly. The most common symptoms of Addisons disease include fatigue, weakness, loss of appetite, and unintentional weight loss. Other symptoms may affect the digestive tract, respiratory system, nervous system, reproductive system, cardiovascular system, or integumentary system (skin and associated tissues) Management: There is no cure once your adrenal glands are damaged to the point that Addisons disease develops. However, the symptoms of Addisons disease can be controlled by replacing the hormones that your adrenal glands can no longer make. This medication therapy will likely be needed throughout your life. Nursing responsibilities: Frequent assessment

VS and signs of F&E imbalances every 30 minutes to 4 hours for first 24 hours Daily weights Diligent corticosteroid administration Protection against infection Hygiene Protect from light, noise, and temperature extremes As discharge usually occurs before maintenance dose reached, instruct on importance of follow-up appointments Glucocorticoids usually given in divided doses Mineralocorticoids usually given once in the morning Long-term care revolves around recognizing the need for extra medication and techniques for stress management

 For vomiting and diarrhea, notify the health care provider because electrolyte replacement may be necessary and may indicate crisis Teach S/S of corticosteroid deficiency and excess and to report findings Instruct to wear Medic Alert bracelet at all times Provide handouts on medications causing increased need for glucocorticoids Instruct on how to take BP and report findings Instruct to carry emergency kit with IM hydrocortisone, syringes, and instructions for use

4.) Cushing's Syndrome Cushing's syndrome is a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol. Sometimes called "hypercortisolism," it is relatively rare and most commonly affects adults aged 20 to 50. Causes: Cushing's syndrome occurs when the body's tissues are exposed to excessive levels of cortisol for long periods of time. Signs and symptoms: Obesity Rounded face Increased fat around the neck thinning arms and legs Other symptoms appear in the skin, which becomes fragile and thin Purplish pink stretch marks may appear on the abdomen, thighs, buttocks, arms and breasts. The bones are weakened, and routine activities such as bending, lifting or rising from a chair may lead to backaches, rib and spinal column fractures. Management:

Treatment depends on the specific reason for cortisol excess and may include surgery, radiation, chemotherapy or the use of cortisol-inhibiting drugs. If the cause is long-term use of glucocorticoid hormones to treat another disorder, the doctor will gradually reduce the dosage to the lowest dose adequate for control of that disorder. Once control is established, the daily dose of glucocorticoid hormones may be doubled and given on alternate days to lessen side effects. Nursing responsibilities: Consult a dietician to plan a high in protein and potassium but low in calories, carbohydrates, and sodium. Use protective measures to reduce the risk of infection. Schedule activites around the patients rest periods to avoid fatigue. Institute safety precaustions to minimize the risk of injury from the falls. Help the client to walk, to avoid bumps and bruises. Help the bedridden patient to turn and reposition herself every 2 hours. Use extreme caution when moving the patient to minimize trauma and bone stress. Provide frequent skin care, especially over bony prominences. Provide support with pillows and a convoluted foam mattress. Encourage the patient to verbalize her feelings about the body image changes and sexual dysfunction. Prepare the patient for surgery if indicated.

Inflammatory and Immunologic 1.) Myasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction,[1] inhibiting the excitatory effects of

the neurotransmitter acetylcholine on nicotinic receptors throughout neuromuscular junctions Causes: Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles. It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction - the place where nerve cells connect with the muscles they control.

Signs and symptoms: Myasthenia gravis may affect any voluntary muscle, muscles that control eye and eyelid movement, facial expression, and swallowing are most frequently affected. Management: Thymectomy, the surgical removal of the thymus gland There are several therapies available to help reduce and improve muscle weakness. Medications used to treat the disorder include anticholinesterase agents such asneostigmine and pyridostigmine, which help improve neuromuscular transmission and increase muscle strength. Immunosuppressive drugs such asprednisone, cyclosporine, and azathioprinemay also be used. These medications improve muscle strength by suppressing the production of abnormal antibodies. Nursing responsibilities: Listen to the patients concerns and answer the questions honestly. Administer medications on time and at evenly spaced intervals, as ordered, to prevent relapses. Plan exercise, meals, patient care, and activities to make the most of energy peaks. When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk of

choking. After severe exacerbations, try to increase social activity as soon as possible. Establish accurate neurologic and respiratory baseline. Stay alert for signs of impending myesthenic crisis such as increased muscle weakness and difficulty talking or chewing. Help the patient plan daily activities to coincide with energy peaks. Stress the need for frequent rest periods. If surgery is scheduled, provide perioperative teaching.

2.) Agammaglobulinemia is an inherited disorder in which there are very low levels of protective immune system proteins called immunoglobulins. People with this disorder repeatedly develop infections. Causes: Agammaglobulinemia is a rare disorder that mainly affects males. It is the result of a genetic abnormality that blocks the development of normal, mature immune system cells called B lymphocytes. As a result, the body produces very little (if any) immunoglobulins in the bloodstream. Immunoglobulins play a major role in the immune response, which protects against illness and infection. Signs and symptoms:

Bronchitis Chronic diarrhea Conjunctivitis (eye infection) Otitis media (middle ear infection) Pneumonia Sinusitis Skin infections Upper respiratory tract infections

Infections typically appear in the first 4 years of life.

Other symptoms include:

Bronchiectasis (a disease in which the small air sacs in the lungs become damaged and enlarged) Unexplained asthma

Management: The goal of treatment is to reduce the number and severity of infections, and to provide genetic counseling to affected families. Receiving immunoglobulins (IVIG) through a vein (intravenously) helps boost the immune system by providing the body with the antibodies that are decreased or missing. Routine treatment with IVIG is central to the treatment of this disorder. Antibiotics are often needed to treat bacterial infections. Nursing interventions: Monitor for infections Teach family infection control in their house to prevent Follow-up check-ups and continuous taking of medicines

CHONIC GRANULOMATOUS DISEASE is a diverse group of hereditary diseases in which certain cells of the immune system have difficulty forming the reactive oxygen compounds (most importantly, the superoxide radical) used to kill certain ingested pathogens.[2] This leads to the formation of granulomata in many organs. Causes: This situation arises due to a defect in nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity. NADPH oxidase is a membrane bound enzyme complex that takes part in the generation of superoxides or anti-oxidants. Signs and symptoms: Skin infections

Pneumonia (Respiratory disease characterized by inflammation of the lung tissue) Lung abscesses (collection of pus) Inflammation of lymph nodes (Suppurative lymphadenitis) Diarrhoea (due to Inflammation of the intestine, i.e. enteritis) Perianal or perirectal abscesses (collection of pus in the adjacent areas of anus or rectum) Abscesses in liver or spleen Inflammation of bones (osteomyelitis) and septicemia (Invasion of the bloodstream by infective microbes) can also be presenting features of the ailment.

Management: Antibiotics- Antibiotics like trimethoprim-sulfamethoxazole are often prescribed to prevent bacterial infections. This drug has the advantage of not tampering the normal bacterial flora of the digestive tract. Fungal infections are usually prevented using itraconazole. The utility of voriconazole for this purpose is under study. Immunomodulation - has been in vogue as a standard treatment for CGD for a considerable time. Immune system is manipulated using drugs like interferons (in the form of interferon gamma-1b). They prevent infections in CGD patients by 70% and to reduce their severity. Hematopoietic stem cell transplantation - is a curative technique though associated with risks. Surgical techniques may be required to relieve obstructions. Gene therapy - is being studied as a treatment for chronic granulomatous disease. Experimental trials on 2 patients had yielded promising results (clearance of pre-existing infections and increased oxidase activity in neutrophils) in 2006. Long term complications and efficacy are unknown.

Perception and coordination

1.) Hallucinogen persisting perception disorder (HPPD)

is a disorder characterized by a continual presence of visual disturbances that are reminiscent of those generated by theingestion of hallucinogenic substances. Causes:

The cause(s) of HPPD are not yet known. The most current neurological research indicates that HPPD symptoms may manifest from abnormalities in CNS function, following hallucinogen use. One theory derived from this research is that inhibitory mechanisms involved with sensory gating are disrupted.
Signs and symptoms: halos or auras surrounding objects, trails following objects in motion difficulty distinguishing between colors, apparent shifts in the hue of a given item the illusion of movement in a static setting, air assuming a grainy or textured quality (visual snow or static by popular description, not to be confused with the normal "blue field entoptic phenomenon") distortions in the dimensions of a perceived object, and a heightened awareness of floaters.

Management: As of yet, there is no cure available for HPPD. The principal treatments seek to reduce symptoms and distress without treating underlying causes. Benzodiazepines including clonazepam (Klonopin), diazepam (Valium) and alprazolam (Xanax) are prescribed with a fair amount of success. The anticonvulsant drug Levetiracetam has been reported to diminish some of the visual symptoms, as well as reducedepersonalization and derealization symptoms , that can occur along with HPPD. Some medications have been contraindicated on the basis of their effects on HPPD or the concurrent mental issues. The atypical [antipsychotic] Risperidone is reported to worsen symptoms of HPPD during the drug's duration in some people. Those with HPPD are often advised to discontinue all drug use, many of which are thought to increase visuals in the short-term. There are also less concrete factors that may be generally detrimental to those with HPPD. For example, sleep deprivation and stress are thought to increase HPPD symptoms. However, no published studies have investigated whether any of these recommendations are helpful. Nursing responsibilities: Seek an official diagnosis. HPPD can mimic other medical problems or disorders, including lesions and infections of the brain, visual epilepsies, stroke and schizophrenia. Recognize that no current cure exists for HPPD. People with this disorder must find ways to manage symptoms in order to minimize the impact of HPPD on daily life.

Encourage to cope with triggers that may set off HPPD. Some of these include caffeine, alcohol, getting too little or too much sleep and stress. Instruct to beware of treatment with medications. Physicians report limited success with benzodiazepines, anticonvulsants, antidepressants and other medications. However, there have also been cases when pharmacology treatment has worsened HPPD symptoms. Encourage to ake an appointment with a psychiatrist. Psychotherapy can help victims with adjustment and coping mechanisms. Encourage family to participate. Surround patient with supportive people. You don't need people in your life who believe that "it serves a person right for taking hallucinogens." Monitor friends or family members suffering from HPPD for suicidal tendencies.

2.) Apraxia

is a poorly understood neurological condition. People who have it find it difficult or impossible to make certain motor movements, even though their muscles are normal.
Causes:
There is something in the child's brain that is not allowing messages to get to the mouth muscles to produce speech correctly. In most cases, the cause is unknown. However, some possible causes include: Genetic disorders or syndromes Stroke or brain injury

Signs and symptoms:

difficulty stringing syllables together in the appropriate order to make words, or inability to do so minimal babbling during infancy difficulty saying long or complex words repeated attempts at pronunciation of words speech inconsistencies, such as being able to say a sound or word properly at certain times but not others incorrect inflections or stresses on certain sounds or words excessive use of nonverbal forms of communication distorting of vowel sounds omitting consonants at the beginnings and ends of words

seeming to grope or struggle to make words

Management:
Patients with apraxia may participate in rehabilitation to alleviate its consequences for communication or for safe performance of activities of daily living. A number of small group or case studies have demonstrated that behavioral treatments provided by rehabilitation professionals can be effective for improving skilled movements of the limbs or speech. Some treatment methods use drills and practice with speech or limb movements to restore skills or to engage other neural regions to mediate skilled movements. In other treatments, clinicians teach patients to compensate for the symptoms of apraxia using alternative communication modalities or methods to complete daily living activities. Patients with apraxia participate in speechlanguage treatment to alleviate its consequences for communication. Nursing responsibilities: Nursing and medical rehabilitation staff providing care for individuals with apraxia may need to implement strategies recommended by rehabilitation professionals. This will help foster communication with patients with apraxia of speech, and ensure patient safety in the hospital environment for individuals with limb apraxia. Individuals with severe limb apraxia may require close supervision when using tools and implements in daily living activities (e.g., grooming or eating).

3.) Developmental coordination disorder Developmental coordination disorder is diagnosed when children do not develop normal motor coordination (coordination of movements involving the voluntary muscles). Causes: There are no known causes of developmental coordination disorder. There are, however, various theories about its possible causes. Some theories attribute the disorder to biological causes. Some of the possible biological causes include such prenatal complications as fetal malnutrition. Low birth weight or prematurity are thought to be possible causes, but there is no hard evidence supporting these claims. Signs and symptoms:

 general unsteadiness and slight shaking an at-rest muscle tone that is below normal muscle tone that is consistently above normal inability to move smoothly because of problems putting together the subunits of the whole movement inability to produce written symbols Children with developmental coordination disorder have difficulty performing tasks that require motor skills or eye-hand coordination, such as catching a ball. visual perception problems related to development of the eye muscles Management: No treatments are known to work for all cases of developmental coordination disorder. Experts recommend that a specialized course of treatment, possibly involving work with an occupational therapist, be drawn up to address the needs of each child. Many children can be effectively helped in special education settings to work more intensively on such academic problems as letter formation. For other children, physical education classes designed to improve general motor coordination, with emphasis on skills the child can use in playing with peers, can be very successful. Any kind of physical training that allows the child to safely practice motor skills and motor control may be helpful.