Final Project- Google Research Paper Example | Topics and Well Written Essays - 2250 words

Last Project-Google - Research Paper Example This organization is additionally extraordinary in its showcasing systems contrasted with others and the administration formulae also. In any case, much the same as each other organization, it doesn't abandon confronting significant difficulties from both inside and without which require to be fixed so the organization can advance. The organization has a one of a kind administration structure in every territory. They have extended in various pieces of the world and in this way can't bear to chance creation loses because of wrong IT the executives structure. Thus, every area has its own head chief, group of executives and chain of representatives going down. This empowers the tending to of the requirements of every district in a way that best suits those living there. There is additionally a one of a kind factor about the manner by which the Google Company promotes itself. This is done in every district interestingly depending n the social qualities and strict convictions of the area. Partitioning this types of ad empowers the organization initially play out an exploration on what is viewed as moral inside eh network so as to guarantee that he promoting ads they don't hostile to people in general. Every area has various requirements and it is significant that the organization present their item in a way that app ears to address these necessities. Subsequently, there are various types of ad in every district planned for catching the consideration of numerous and winning quantities of clients of the Google web crawler. Despite the fact that the Human Resource division of the Google Company sees the workers as a significant resource and offers pay and advantages, for example, essential pay, clinical office, a reward, tip finance, government disability and pick and drop, the organization despite everything faces difficulties. One of the significant difficulties confronting this association is that both the workers just as the administration may have lost an unmistakable course and a typical reason for the organization. There was low confidence inside the organization because of a few endeavored

Leadership and Culture Essay Example | Topics and Well Written Essays - 4250 words

Initiative and Culture - Essay Example This altering paper generally centers around administration, cooperation and joint effort of these. The specialist portrays that they are not just imperative parts to the accomplishment of an association, yet in addition to the production of the way of life of the association. Culture alludes to the character of an association, and permits a gathering of individuals to address concerns and difficulties that emerge inside the association. This hierarchical culture shapes because of individuals meeting up with the shared objective of effectively maintaining their business and is essentially produced through correspondence. Language, stories, and customs are utilized to frame recognizing bunch societies and achieve a common vision that all workers can get a handle on. Cooperation and coordinated effort and their disparities were broke down in this altering. A group comprises of at least two people with specific jobs that are actualized to meet an esteemed objective. The joint effort ter m is the point at which the gatherings included offer the obligations of consolidating the obligations of the groups. Nonetheless, the essential trademark that they share is that groups should progressively meet up to make a completed item, which is done under such coordinated effort. Taking everything into account, the analyst alludes to a few guides to portray how an association develops and culture is shaped and why cooperation moves flawlessly to coordinated effort. The two can't exist autonomously, the scientist states, however depend on one another if the association wants to be fruitful.

AIDS Essay Example | Topics and Well Written Essays - 1000 words - 2

Helps - Essay Example In acknowledgment of his commitment, in late 1990, the US Congress passed the Ryan White Care Act which gives financing to mind, training and avoidance of Human Immunodeficiency Virus (HIV). HIV is a lentivirus which assaults the insusceptible framework. There are two fundamental strains of the infection: HIV-1 which is especially destructive, and HIV-2. The name lentivirus implies moderate infection †because of the way that they take a long time to destabilize the insusceptible framework. Lentivirii have been found in various warm blooded animals, yet specifically noteworthy is the Simian Immunodeficiency Virus (SIV) which is found in monkeys. HIV-2 is fundamentally the same as at sub-atomic level to SIVsm which harasses the dirty mangabey (otherwise called the green monkey), normally found in West Africa. In 1999 Paul Sharp of Nottingham University and Beatrice Hahn of the University of Alabama finished a multi year concentrate into the starting point of the infection in people. They fulfilled mainstream researchers that the HIV-1 infection had crossed from chimpanzees to people. The traverse of infections starting with one animal categories then onto the next is called zoonosis. It is accepted that the infection changed once it found another host in people to become HIV-1. Since the infection is most handily moved by blood, the vast majority of the hypotheses recommend that the course of transmission probably been either the utilization of a tainted chimpanzee or through a polluted antibody or syringe. The most punctual known demise from HIV-1 occurred in 1959. Notwithstanding, Dr Bette Korber of the Los Alamos National Laboratory introduced brings about January 2000 at the seventh Conference on Retroviruses and Opportunistic Infections which showed that the HIV-1 strain has been around since the 1930s. Belgian analysts drove by Dr Anne-Mieke Vandamme, distributed discoveries in ‘Proceedings of the National Academy of Science’ in 2003. Their decision was that HIV-2 began in dirty mangabeys around 1940 - 1945. They guaranteed that the most probable spot of source was the previous

PA Personal Statement Editing Workshop Essay Seven

In this seventh (and final) installment of our special week-long personal statement workshop, we continue to pull essays submitted from the comments section through our free essay submission processand provide you, and our users, with a more detailed analysis of their essays. This seventh submission is by Jordan and is a real cliffhanger. Jordan, a rock climber, finds himself on the edge of a cliff both in the Canadian Rockies and while facing the diagnosis of a pulmonary embolism in his wife who is 6 months pregnant. At the edge of his rope, he finds solace in the medical team that saves her life. In a matter of time, his purpose becomes clear: "I want to treat and care for patients. I want to change lives. I want to take people from dying to living. I want to get them down from the cliff." We will present you with his original essay and our suggestions. As always, use this as a guide to see where you can improve your own writing, and respect the work of others.It should go without saying this is not your essay, so dont plagiarize. Essay 7:I Want to Take People From Dying to Living, I Want to Get Them Down From the Cliff By:Jordan So here is my first draft. I know it lacks some cohesion and can certainly be tidied up but I mostly want to know if I am first, headed in the right direction and second, where I should go from here. Thanks When I looked down all I could see were dark clouds sweeping up the valley like a tsunami of cold and rain; bad news for two rock climbers a thousand feet off the ground in the Canadian Rockies. Decision time. Do we risk the weather and try to finish the last 500 feet to the summit or do we pack it in and rappel down 5 hours work climbing up Ha Ling Peak with little chance of attempting the climb again. We argued for too long and soon realized we were now subject to the whims of the fickle spring weather in the Rockies. We headed down in the cold and the wet, wishing we had left sooner. While in the uncomfortable embrace of disappointment and a climbing harness, I had no idea that this moment would set the foundation on which I would decide to become a Physician Assistant (PA). I thought to myself, If I can change a life, even just one, how many others will benefit as a result? Each decision we make has a ripple effect that changes not only our lives but also the lives of people arou nd us. Several years later I found myself stuck on the side of a very different cliff. My wife, who was 6 months pregnant, had developed bilateral pulmonary emboli (PE). It was uncommon for me to find her with tears in her eyes but one Sunday night she woke me up and while struggling to breath, told me that she couldnt lie down because her back hurt too much. Frightened and unsure what to do, I did my best to diagnose the problem. I had been trained as an EMT but that provided only a little help under such circumstances. I was suspicious that she had developed a PE but her legs showed no signs of deep vein thrombosis. We made the decision to visit the emergency department and after many hours and many tests, the diagnosis was confirmed and treatment began. It was exactly one week later that my wife called me from work with identical symptoms. At this point I had learned much more about PEs and according to the statistics, I became fairly certain I would soon have to say goodbye to my dear w ife. I distinctly remember this terrible, wrenching feeling in my gut, the kind you get when your big brother punches you for being his little brother. Never in my life had I a wished that I could do more for a person than at that moment. I didnt have to say goodbye. The doctors and PAs changed her life. They took her from dying to living. They got her down from the cliff. It certainly wasnt a light bulb moment. In fact, I had decided I wanted to be a PA almost a year prior. At the time I was the director of clinical research for a small industry research company. I worked with patients in nearly all-therapeutic areas and together with our doctors and PAs we did our best to provide comfortable quality care to our patients as we investigated new medications. While my career was going well, I soon recognized that the part of my job I enjoyed most was the time I spent with my patients, conducting interviews, drawing blood, answering questions and providing education. I wanted more of that and while dodging traffic on the way to the ER, I realized that my desire to help my wife was a magnified version of what I had felt with all of my patients. Each interaction we have provides an opportunity for us to react and our reactions can change the lives of countless people even if we just start with one. Getting stuck on a cliff taught me that. I wanted desperate ly to finish Ha Ling Peak, but even more I wanted to be safe. I wanted a good professional career, but even more I want to treat and care for patients. I want to change lives. I want to take people from dying to living. I want to get them down from the cliff. I never finished climbing Ha Ling Peak and finishing was probably never the point. Everyday there are limitless factors that are out of our control that will get us stuck on the cliff. Our job is to react and adapt to those changes in our circumstance. We are all shaped by moments, tiny portions of our everyday lives that form the majority of who we will become. I guess if you put these moments together you might call it experience. Whatever its called, my moments have fixed in my mind a determined resolution to become PA. Suggestions and Revisions By: Sue Edmondson (personal statement collaborative) Hi Jordan, Youre a good writer, a huge plus, and have an excellent, easy to read yet sophisticated style. All those are sure to grab the attention of admissions folks. Youve improved the essay, but it still needs work. You open with a literal cliffhanger, and I see that youre tied to the mountain climbing experience. The problem is that it doesnt work with the essay it just doesnt fit in with the points youre making about wanting to be a PA. I think its most apparent at the beginning and ends of the essay which are general philosophical statements. Youre straining to tie the climbing experience with your work/life experiences because you like it so much. (I understand what a dramatic, scary, thrilling adventure). But if you are determined to open with the climbing experience, you need to rethink how youll make it work thematically. Right now, its like reading about an apple in one sentence, about broccoli in the next. Its that disconnected. Have a couple of friends or relatives read this part: While in the uncomfortable embrace of disappointment and a climbing harness, I had no idea that this moment would set the foundation on which I would decide to become a Physician Assistant (PA). I thought to myself, If I can change a life, even just one, how many others will benefit as a result? Each decision we make has a ripple effect that changes not only our lives but also the lives of people around us, and ask if they see how you get from the disappointment of leaving the mountain to wanting to change lives by becoming a PA. The other issue is that you talk in depth about your wifes experience but then say it wasnt a light bulb moment, that youd already decided to be a PA. That undermines the whole episode (which by the way, is too long, although I was relieved to learn she survived). Skip generalities. They dont help admissions folks know you, and thats what theyre looking for. Its tempting to philosophize, but this essay is not the place. You are on track when you start to talk about your work experiences, and when you talk about how the PAs and doctors impacted your wifes treatment. In those places you touch on why you want to be a PA. If youre going to use your wifes experience, focus more on the PA interactions and delete the beginning of the next paragraph. Otherwise, pick a patient that you treated and worked on with a PA. Keep going. Writing is rewriting! Sue Edmondson Is your mom or dad really giving you honest feedback on your personal statement? Parents are full of great advice, but when it comes to your personal statement family and friendsdon't make the best editorial team. We offer a bit of free guidance to anyone who takes the time to submit their essay in the comments sectionof the blog.But your essay needs more than the sympathetic feedback provided by a friendly relative. For as little as $59 you can have: Personal guidance from our team of professional (unbiased) writers, with inside knowledge of the PA school personal statement. (We have personally interviewed 12 of the top PA school admissions directors from across the country.) Telephone consultations are included with all purchases above the single edit level.It's often hard to communicateexactly what you want hundreds of miles away;for this reason, we offer the option toedit right alongside us over the telephone while sharing in real-time over Google Docs. We provide feedback, advice and help with brainstorming and topic creation. We will help witha"final touch up" before the big day just in case your essay needs a bit of polish. Click here to learn more. Here is what one of our recent clients had to say: I wanted to give a brief update: I have had 4 interviews, 2 acceptances, 1 wait-list, and waiting on one more. Right now I have a deposit down at Univ. of Texas Medical Branch. Thanks for all your help. It really did make a difference, and I was even complimented on my narrative during a few interviews.Andrew S. PA-S We are currently accepting essays in all iterations. We have flexible pricing and can do everything from a single one-time edit to a full-service review that will take you from beginning to a finished product. Hurry, as we can only accept a few essays each month. Click here to post your essay or learn more about our service. Have you enjoyed what you read? I hope you have been enjoying this personal statement workshop. Before you go, make sure to sign up forautomatic updatesfrom the blog orsubscribe with Feedly(my favorite RSS reader). And if you haven't already, sign up for the FREE email newsletter (down below) or connect with me on Facebook or Twitter. Ill definitely respond, and I look forward to meeting you! Cheers, Stephen View all posts in this seriesHow to Write the Perfect Physician Assistant School Application EssayThe Physician Assistant Essay and Personal Statement CollaborativeDo You Recognize These 7 Common Mistakes in Your Personal Statement?7 Essays in 7 Days: PA Personal Statement Workshop: Essay 1, A PA Changed My LifePA Personal Statement Workshop: Essay 2, I Want to Move Towards the Forefront of Patient CarePA Personal Statement Workshop: Essay 3, She Smiled, Said Gracias! and Gave me a Big HugPA Personal Statement Workshop: Essay 4, I Have Gained so Much Experience by Working With PatientsPA Personal Statement Workshop: Essay 5, Then Reach, my Son, and Lift Your People up With YouPA Personal Statement Workshop: Essay 6, That First Day in Surgery was the First Day of the Rest of my LifePA Personal Statement Workshop: Essay 7, I Want to Take People From Dying to Living, I Want to Get Them Down From the Cliff.Physician Assistant Personal Statement Workshop: To say I was an accident-prone ch ild is an understatement9 Simple Steps to Avoid Silly Spelling and Grammar Goofs in Your PA School Personel Statement5 Tips to Get you Started on Your Personal Essay (and why you should do it now)How to Write Your Physician Assistant Personal Statement The Book!How to Write Physician Assistant The PA Grammar Guide101 PA School Admissions Essays: The Book!5 Things Ive Learned Going Into My Fourth Physician Assistant Application Cycle7 Tips for Addressing Shortcomings in Your PA School Personal StatementThe #1 Mistake PRE-PAs Make on Their Personal StatementThe Ultimate PA School Personal Statement Starter KitThe Ultimate Guide to CASPA Character and Space Limits10 Questions Every PA School Personal Statement Must Answer5 PA School Essays That Got These Pre-PAs Accepted Into PA School7 Questions to Ask Yourself While Writing Your PA School Personal Statement101 PA School Applicants Answer: Whats Your Greatest Strength? You may also like -PA Personal Statement Workshop: Essay 5, Then Reach, my Son, and Lift Your People up With You In this fifth installment of our special week-long personal statement workshop, we continue to pull essays submitted from the comments section through our free essay submission processand provide you, and our users, with a more []PA Personal Statement Workshop: Essay 6, That First Day in Surgery was the First Day of the Rest of my Life In this sixth installment of our special week-long personal statement workshop, we continue to pull essays submitted from the comments section through our free essay submission processand provide you, and our users, with a more []7 Essays in 7 Days: PA Personal Statement Workshop: Essay 1, A PA Changed My Life In this special week-long introductory session of thepersonal statement workshop, we are pulling essays submitted from the comments section through our free essay submission process and providing you, and our users, with a more []

The Neolithic Era And The Paleolithic Era - 2121 Words

i. The Paleolithic Era began at the beginning of human life and ended 12 thousand years ago. The era was given the nickname â€Å"The Old Stone Age† because stone was used both in tools and to make tools. One of the most important tools used by humans was the spear. Spears were made for hunting for food and protection from dangerous wildlife. During the Paleolithic Era the climate was much colder than the present. This made food limited so humans had to follow the migration of game. ii. Hunter-gatherers, also known as foragers, thrived from the beginning of human life to about 12 thousand years ago. The time period of the hunter-gathers corresponds with the Paleolithic Era. They started off in East Africa and slowly moved to Eurasia. Foragers did not farm and had no fully established homes. They lived in temporary homes that were easy to be made mobile. They migrated with animals and collected other food sources from the land. This lifestyle can be described as nomad ic. iii. Controlled fire was very important to humans during the Paleolithic Era. The first fires were started with lava or lighting at the source. Eventually humans realized rubbing two sticks together or other materials could start a fire also. Fire now allowed for cooked meat which was the number one source of protein. Also fire was used to harden wooden weapons and tools and treating animal hides. Last, fire was used for warmth and light. iv. The Neolithic Revolution began 10,000 years ago. ThisShow MoreRelatedThe Stone Age1403 Words   |  6 PagesPrehistory that Shaped Today The Stone Age was the millennium of the modern world. The Neolithic and the Paleolithic eras consists of many comparisons within entities regarding the usage of stone tools, the development of art paintings, and the differences in physical geography that has shaped the world today. The usage of stone tools began two million years ago with stone chipping. With stone chipping the early humans, or also known as Homo sapiens wanted to find a way to persist. TheRead MoreThe Neolithic Settlement Of Catal Huyuk971 Words   |  4 PagesThe Anatolian Neolithic settlement of Catal Huyuk, which means forked mound, dates between 7000 and 5000 B.C.E. was one of the world’s first towns and the oldest civilizations on earth. Located in the Konya Plain in central Turkey, Catal Huyuk was considered the wheat-growing region. The main mound covered 32 acres and stood 57 feet above the plain with a distance of 3,000 feet above sea level. The population was estimated at upwards of 5,000 people, which was based on the site and the clusterRead MoreThe Greatest Known Prehistoric Individual916 Words   |  4 Pagesrecording is called prehistory. In order to understand this period, one would obtain knowledge from research done by evolutionary biologists archaeologists. Th ere was an evolutions for our ancestors called Homo sapiens. 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These two different styles of obtainingRead MoreThe Influence Of The Paleolithic Period And The Neolithic Period923 Words   |  4 Pageschanges or contributions to the humanities that occurred between the Paleolithic period and the and the Neolithic period are the different techniques develo ped to hunt, the importance of the human figures, and the architecture. Different techniques to hunt were shown by looking at wall paintings, in the Paleolithic era paintings were found in deep caves and showed a realism of the animals they depended on for food, where as the Neolithic era paintings were located on smooth limestone, beneath cliff hangsRead MoreHistory Has Always Revolved Around Technological Advances.1249 Words   |  5 Pagestechnological advances were constantly being discovered. During the Paleolithic, Neolithic, and Bronze Age, new technologies followed under the old proverb â€Å"Necessity is the mother of invention† because each development was created for a purpose. 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Length Of Treatment Analysis - 875 Words

Length of Treatment Evans et al. (2011) focused on two separate treatment groups (high-risk offenders low-risk offenders) who were followed-up on at the 12 and 30 month mark after they were assessed for treatment. The length of treatment, not the classification risk of the offender, was found to be a significant variable of recidivism as those who received a longer length of treatment were less likely to be re-arrested Evans et al. (2011). Because not all offenders are guaranteed treatment, in some circumstances there is no length of prison-based treatment. In order to continue to reduce the prison population and provide treatment to offenders, early parole programs have been developed. Treatment through Early Parole Research by†¦show more content†¦Lurigio and Olson (2014) noted prison-based treatment starts the recovery process, but a continuum of care is a necessity to maximize the effectiveness of treatment. Their research found offenders who participated in prison-based treatment and community aftercare were less likely to re-offend compared to those who only participated in prison-based treatment. Hall et al. (2012) found higher success rates among offenders who participated in prison-based treatment and continued to engage in treatment once released from custody. A lack of education is another factor that plays in the role of recidivism. Dirks-Linhorst et al. (2012) highlighted the importance of community aftercare and the role of education because those who lacked a high-school diploma or GED were more likely to re-offend. Many offenders have poor work histories and Dickson, Leukefeld, Stanton-Tindall, Webster, and Wilson (2014) noted employment is a critical key to the cont inued success of an offender and their treatment. Dickson (2014) suggest offenders who obtain employment once released from custody will be more successful in the reentry process. Policy Alternatives A popular but controversial method of treatment is the use of drug courts or the stipulation of an offender to treatment. Mackenzie, Mitchell and Wilson (2006) addressed this concern by asking, how effective can treatment be if it is forced upon someone? Drug courts are similar to the research by Alterman etShow MoreRelatedThe Efficacy And Effectiveness Of Social Anxiety790 Words   |  4 Pageseffects of modifying conventional CBT approaches by either reducing the number of sessions or shortening the time period across which the sessions are delivered. Early studies sought to establish whether brief, intensive CBT is effective for the treatment of youth anxiety by comparing brief, intensive CBT to a waitlist control. A 2013 study evaluated whether CBT interventions for social anxiety in girls can be administered as effectively in a one week camp-like setting. 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Surgical treatment is currently the mainstay for treating patients with acute uncomplicatedRead MoreOpioid Dependence Treatment, Buprenorphine Or Methadone, Has The Smallest Potential For Causing Neonatal Abstinence Syndrome?1271 Words   |  6 PagesResearch Question The researchers conducting this study wanted to know which opioid dependence treatment, buprenorphine or methadone, has the smallest potential for causing neonatal abstinence syndrome (NAS) in newborns. Rationale for Treatment Methadone is typically given to treat opioid dependence. This drug, which is a mu-opioid agonist, works by limiting withdrawal symptoms and the desire to use opiates. However, methadone has been shown to have a high incidence of causing neonatal abstinenceRead MoreThe Protective Effects Of Statins On Clinical Outcomes Among Bacteremic Patients1144 Words   |  5 Pagesevaluated by quantifying the effects of their use on clinical outcomes among bacteremic patients in a large, nationally representative cohort. A retrospective cohort study design will be used to assess multiple outcomes, such as inpatient mortality and length of hospital stay, among statin exposed v/s non-exposed patients. A retrospective cohort study is an analytical study in which individuals with differing exposures to a suspected factor are identified and then observed for the occurrence of certainRead MoreEffects of Gum Chewing on Post Operative Ileus1274 Words   |  6 Pagesthat occurs after many abdominal sur geries and operations. An ileus is where the bowels â€Å"fall asleep† after trauma and fail to â€Å"awaken† for quite some time following surgery. Postoperative ileus can affect patient nutrition, comfort and especially length of stay, which results in a major cost to insurance companies and hospitals. According to Chan and Law (2007), the economic burden resulting from postoperative ileus is $7.5 billion per year in the United States alone not including the expense ofRead MoreLab Report On The 20 Wheat Seedlings925 Words   |  4 Pagesused in each of the five treatments, see Table 1. Among those 10 unpaired t-tests two out of the 10, Test 5 (Shoot length 1XCM vs 4XCM) and Test 6 (Seedling biomass Water vs 1XCM) had actual p-values greater than 0.05 (see Table 1). The calculated t-values for the previously mentioned two t-tests were lower than the critical t-value, 2.024 (see Table 1). For shoot length (cm), the trend shows mean shoot length to increase with increa sing concentration of nutrient treatment until 3XCM, where the meanRead MoreUse Of Statistical Evidence From The Rye Seeds1312 Words   |  6 Pagesand shoot length for each of the five treatments (1) control: full nutrient complement; (2) Nitrogen deficient (full complement minus N); (3) Phosphorus deficient (full complement minus P); (4) Potassium deficient (full complement minus K) and (5) water. The factors, shoot biomass and length that are determined will be significant for finding the cause of length. Based on the background information, one can hypothesize that there would be a significant difference between the shoot lengths and biomassRead MoreDifferent Tylage Methods for Treflan Herhicide Controlling Weed1082 Words   |  4 PagesRandomized complete Block design in 4 frequencies and 9 treatments in DEZFUL Agriculture and industry Martyr Beheshti in farming year 2007-2008. Results of the test showed that ratings of herbicide treflan on sevevel weed of Berseem- clover has been meaningful at a level of 5 percent and hasnt been meaningful on several Bullwort weed, wild carrot, total weeds, dried weight of weeds, canola height, overall numbers of canola branches, harvest index, length of sheath, sheath seed number, weight of thousandRead MoreFactors, Stages And Phases Of Hen Diets1281 Words   |  6 Pages period 2 and 3 treatments included 50:50 granulated limestone:Ca chips, where Phase 1, period 1 and 2 only included granulated limestone. All phases and periods of diet also included mono-dicalcium phosphate as another dietary calcium and phosphorus source. Proximate analysis for phase 1 diets, fed during period 1 and 2 (Appendix B.1) revealed the 900  µm corn PS treatment starter (period 1 and 2) had increased crude protein (CP) compared to the 600, 1200, and 1500  µm treatments (17.52 vs. 16.10Read MoreImportance Of Study Selection Methods In Rese arch847 Words   |  4 Pageswas valued at 90mW/cm2 (Chung et al., 2012).Among the eleven studies, only one provided the energy value of the laser device used, and its value was at 3.0J per session. Six of the eleven studies utilized a length of time of either twenty-two or twenty-five weeks however the treatment length varied between two months and two years (Lanzafame et al., 2013). Considering the frequencies per week and the time duration per session, we can say that the differences were negligible. Considering the changes

Patient’s Impression On Assessments Exhibits Cushing’s Syndrome

Question: Discuss about the Patients Impression On Assessments Exhibits Cushings Syndrome. Answer: Introduction The case study review entails a female Patient, Smith Moureen aged 24 years. She is experiencing gastrointestinal bleeding, abdominal pain and fatigue which are worsening. The patient has a history of rheumatoid arthritis and is currently under corticosteroids medication. Further, she has type II diabetes and she is on metformin medication for the same. On admission various vital information have been undertaken and the patients impression on assessments exhibits Cushings syndrome. Causes of Cushings syndrome Cushing syndrome is a collection of various signs and symptoms caused by prolonged exposure of cortisol drug. Accompanying symptoms include high blood pressure, abdominal obesity characterised by slender arms and legs, fat lumps observed on the shoulders and skin which is fragile which is occasioned by poor healing process. Women have been observed to have more hair growth and abnormal menstruation periods. There can also be occasioned headaches and feeling of tiredness, (Bertagna et al, 2009). Cushing syndrome is caused by excessive cortisol related drugs like prednisone or tissue growth which leads to excessive production of cortisol in the adrenal glands. The functions of cortisol in the body include regulation of blood pressure, reducing the immune system response on inflammatory system, conversion of carbohydrates, proteins and fats into energy form, regulation of insulin effects and stress response, (Melmed et al, 2011). The body can be induced to produce elevated levels of cortisol based on factors such as stress levels, alcoholism, malnutrition and depression. Thus the most common causes of Cushing disease is the excessive use of corticosteroid and maintenance of high doses for longer durations, (Jeffcoate et al, 1979). Incidences of Cushing syndrome The incidences of Cushing syndrome have been imprecise and are likely to be under estimated. Pituitary ACTH Cushing syndrome is approximately 5-6 times common than other forms caused by benign or malignant tumours, (Govindan et al, 2006). The epidemiologic reports indicate that there are approximately 5-25 per million cases per year, however with this statistics, the reported cases are much lower at 1.2-2.4 per million in any given year, (James et al, 2016). The associative prevalence of hypercortisolinism has been estimated to be around 2%-5% among patients with poor control and management of diabetes and hypertension. The female gender has high prevalence to the male gender in the ratio of 3:1, (Melmed et al, 2011). Cushing syndrome is a rare disease among children. the disease is fatal as it can cause death and increased morbidity and mortality rate which is characterised by cardiovascular complications,(Steffensen et al, 2010). In US, studies have estimated that the incidence was higher than those reported form European based studies. The results indicated that it affected an estimate of 6.2 to 7.6 per million persons- years, (Broder et al, 2015). Risks factors Cushing syndrome risks factors are well established; however epidemiological studies have diagnosed more females than males. Further it is common among the age group of 25 years to 40 years. The common risks factors for the disease are; Type diabetes, obesity and fluctuating blood glucose levels Long term usage of corticosteroid drugs Pituitary gland tumours Adrenal gland disease and Ectopic ACTH forms of secreting tumours Impacts on the patient and family Cushing disease has tremendous effects on the patients and the family. Weight management of the patients is affected and further it deteriorates the health status of the patients through increased mortality and morbidity. The patients often experience sudden increase in weight, poor wound management, prolong fatigue, anxiety disorders, emotional disturbances, sleep disorders, experiencing menstrual irregularities. These impacts have enormous effects on psychological and emotional disturbance on the patients and their families. The patients often feel increasing signs of sickness but symptoms seem like depression or hypochondriac lacking diet and exercise fitness. Further often the family; dont understand the situation the patient is undergoing and support your getting is just to advise you to change the lifestyle, further deteriorating the impact on the patient. Signs and symptoms Sign and symptom Path physiology linkage Rapid weight gain - The patients often experience weight gain on the trunk locations and face areas. It is often characterised by growth of fat pads on the back and the neck side of the body, (Assie et al., 2007). Memory and attention dysfunction - This commonly characterised by depression which is often linked to elevated usage of cortisol medication in the body. Further it is compounded by anxiety disorders and depression symptoms, (Clayton et al, 2011). High blood pressure and increased urination - With the effect and functionality of cortisol on epinephrine vasoconstriction, (Clayton et al 2011). Insulin resistance - This is associated with production of ACTH outside pituitary gland. This leads to diabetes mellitus and resistance to insulin. Gastrointestinal disturbance - This is characterised by increased cortisol, further it can lead to mergence of opportunistic infections and suppression of immunity, (Cavagnini Pecori 2001). - Linked to patient BMI status which at the level of obesity class three with fat distribution based on the abdominal area and hump shoulders. - The patient is exhibiting increased fatigue which could be linked to attention dysfunction and anxiety leading to fatigueless. - Vital assessments of the patients indicate elevated levels of blood pressure of 154/106 mmHg against a normal Bp of ranges of 120/80-140/90 - The blood sugar level for the patient is 14.0mmol/L, way above the standard ranges, and signifying resistance to metformin medication. - The patient exhibits gastrointestinal bleeding and abdominal pain. Medication for Cushing syndrome management The role of medication is to decrease the secretion of cortisol and blockage of receptors of glucocorticoids and inhibition of ACTH. The various classes of these drugs are; Steroid genesis inhibitors OpDDD drugs are aimed at reducing the cleavage around cholesterol. It inhibits cortisol secretion among patients with Cushing syndrome. It is effective in half of the patients and has been shown to induce adrenal atrophy, (Castinetti et al., 2008). Another drug inhibitor drug is Ketaconazole which inhibits production of cytochrome p450 enzymes. It normalizes the levels of cortisols, (Castinetti et al., 2008). Metyrapone drug blocks the synthesis of cortisol through inhibiting beta hydroxylase. It is effective in more than 50% of the patients, it further induces low production of potassium and hyperandrogenism, (Obinata et al, 2008). Glucocorticoid receptor antagonist drugs Mifepristone drug is a receptor antagonist drug under this class. It is effective clinical signs control in hypercortisolism, (Castinetti et al., 2009). ACTH lowering drugs The drugs under this class are effective anti secretory and anti tumoral in prolactinomas disease. Nursing Care strategies for the patient Monitoring and management of associative complications In the first 24 hours, there is need for management of adrenal hypofunction, which calls for close monitoring for weak pulse, respiratory rates and body weakness. There is need for administration of IV fluids to the patient and management of electrolytes and presence of corticosteroids, before and after treatment. Further close monitoring of lab results to check statuses of electrolytes is key for the patient. Further since the patient is diabetic, there is need for close monitoring of blood glucose levels and taking appropriate actions towards increase in blood sugar levels. Further there is need for close monitoring for acute adrenal condition, which is a life threatening condition characterised by low levels of cortisol hormone from adrenal glands. Monitoring the intake and output of the patient is key in ensuring daily weights and glucose levels and accurate assessment of electrolytes. Urine sample tests will be initiated at 24 hours before medication. Blood samples assessment ensures there is regular management of the hormone levels for the patient. Normal levels cortisol in both urine and blood needs to drop after initiation of medication, since the drug initiates signal on pituitary gland to lower levels of Adrenocorticotropic hormone. Assessment of late night corticosol in saliva is key in ensuring there is sufficient production. The level of cortisols at night normally drops and this might be an indicator for corticosol production management which may require further diagnosis. Decreasing risk of injury As a nurse there is need for providing protective environment for the patient to prevent any fall, fracture and other injuries which are linked to bones and body tissues. Further there is need to assist the patient, as he is weak in ambulation and to ensure that there is prevention of falls. Reduction of risk of infection There is need to ensure that the patient is kept in an unexposed environment which might lead to infections. As a nurse, there is need to assess subtle infections. In case the patient has been scheduled for surgery in the first 24 hours, there is need to monitor frequently the blood sugar levels and managing it and stool assessments for diabetes mellitus and peptic ulcers which are predominant problems associated with. References Assi, G., Bahurel, H., Coste, J., Silvera, S., Kujas, M., Dugu, M. A., ... Bertagna, X. (2007). Corticotroph tumor progression after adrenalectomy in Cushings disease: a reappraisal of Nelsons syndrome. The Journal of Clinical Endocrinology Metabolism, 92(1), 172-179. Bertagna, X., Guignat, L., Groussin, L., Bertherat, J. (2009). Cushing's disease. 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