Principles of Management Multi Organ Failure Essay Example

Principles of Management : Multi Organ Failure Essay * Day 6 – 7 /ABC * ABC Principles of Management : Multi Organ Failure /MODS * PRINCIPLES OF MANAGEMENT : ABC / Multi Organ Failure (MODS) * Multiorgan dysfunction syndrome (MODS) is the progressive dysfunction of more than one organ in patients that are critically ill or injured. * It is the leading cause of death in intensive care units (ICUs). * The initial insult that stimulates MODS may result from a variety of causes including, but not limited to, extensive burns, trauma, cardiorespiratory failure, multiple blood transfusions, and most commonly, systemic infection. Schumaker, 2006) * The term MODS has been referred to interchangeably as systemic inflammatory response syndrome (SIRS) and multisystem organ failure (MSOF). (Schumaker, 2006) * A. Determination and Management Multi Organ Failure: Etiology and Risk Factors * Causes of MODS include: * dead tissue * injured tissue * infection * perfusion deficits * persistent sources of inflammation such as pancreatitis or pneumo nitis * High Risk for developing MODS : * Impaired immune responses such as older adults clients with chronic illnesses * clients with malnutrition * and clients with cancer * Clients with prolonged or exaggerated inflammatory responses are at risk, including victims of severe trauma and clients with sepsis * Multi Organ Failure: Classification * 1. Primary MODS – * results directly from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. â€Å" * The direct insult initially causes a localized inflammatory response that may or may not progress to SIRS. An example of primary MODS is a primary pulmonary injury, such as aspiration. * Only a small percentage of clients develop primary MODS. * Multi Organ Failure: Classification * 2. Secondary MODS * is a consequence of widespread systemic inflammation, which develops after a variety of insults, and results in dysfunction of organs not involved in the initial insult. * Th e client enters a hypermetabolic, state that lasts for 14 to 21 days.. * During this body engages in autocatabolism : which causes changes in the bodys metabolic processes. rocess can be stopped,. the outcome for the death. * Secondary MODS occurs with condition septic shock and ARDS. (Black,2005 , p2474) * Multi Organ Failure: Clinical Manifestations * There is usually a precipitating event to MOD: * aspiration, * ruptured aneurysm * Septic shock which is associated with resultant hypotension. * The client is resuscitated; the cause is treated; and appears to do well for a few days. * The following possible sequence of events often develops. * Multi Organ Failure: Clinical Manifestations The client experiences SIRS before MODS Within a few days * there is an insidious onset grade fever, tachycardia, increased numbers and segmented neutrophils on the different count (called a left shift), * dyspnea with the diffuse patchy infiltrates on the chest x-ray client * often has some deteri oration in mental reasonably normal renal and hepatic laboratory results * Multi Organ Failure: Clinical Manifestations * Dyspnea progresses, and intubation and mechanical ventilation are required. * Some evidence of agulopathy (DIC) is usually present. * The client is usually stable hemodynamically and has relative polyuria, n increased in cardiac index (greater than 4. 5 l/min), * Systemic vascular resistance of less 600 dynes cm-5 Clients often have increased blood glucose level in the absence of diabetes * Multi Organ Failure: Clinical Manifestations * Between 7 and 10 days: * Bilirubin level increases and continues to increase, followed serum creatinine. * Blood glucose and lactate level continue to increase because of the hypermetabolic state. * Other progressive changes include nitrogen and protein combined with decrease level of serum albumin, pre-albumin, and retinol binding protein * Multi Organ Failure: Clinical Manifestations Between 7 and 10 days * Bacteremia with enter ic organism is common and infection from candida viruses such as herpes and cytomegalovirus are common. * Surgical wound fail to heal, and pressure ulcer may develop. * During this time, the client needs increasing amounts of fluids and inotropic medications to keep blood volume and cardiac preload near normal and to replace fluid lost through polyuria * Multi Organ Failure: Clinical Manifestations * Between day 14 and day 21: * The client is unstable appears close to death. * The client may lose consciousness Renal failure worsens to the point needs dialysis. * Edema may he present because of low serum protein levels. * Mixed venous oxygen level may increase because of problems with tissue uptake of oxygen caused by mitochondrial dysfunction. * Lactic acidosis worsens, liver enzymes continue to increase, and coagulation disorders become impossible to correct. * Multi Organ Failure: Prognosis * If the process of MODS is not reversed by day 21, it is usually evident that the client w ill die. * Death usually occurs between days 21 and 28 after the injury or precipitating event. Not all clients with MODS die; however, MODS remains the leading cause of death in the intensive care unit with mortality rates from 50% to 90% despite the development of better antibiotics, better resuscitation, and more sophisticated means of organ support. * Multi Organ Failure: Prognosis * For those clients who survive, the average duration of intensive care unit stay is about 21 days. * The rehabilitation, which is directed at recovery of muscle mass and neuromuscular function, lasts about 10 months. * Multi Organ Failure: Medical Management * Restrain the Activators: Manifestations of potential infection must be quickly treated to restrain the activators of MODS. * If the agent is known, antibiotics to which the organism is sensitive should be administered. * If the organism is not -known, broad-spectrum antibiotics are given * If the severity of the sepsis is identified early and d rotrecogin alfa (Xigris) is ad ministered, progression to MODS may be prevented * Multi Organ Failure: Medical Management * If there is progression, the lungs are often the first organs to fail and so require special attention. Aggressive pulmonary care is needed in all clients who are at risk of MODS. * Interventions may be as simple as coughing and deep breathing or ambulation. * The clients oxygen saturation should be monitored as well. * Malnutrition develops from the hypermetabolism and the GI tract often seeds other areas with bacteria, some clinicians require the client to be fed enterally. * They believe that feeding enhances perfusion and decreases the bacterial load and the effects of endotoxins * Multi Organ Failure: Nursing Management Care of the client with MODS is multifaceted, balancing the needs of one system against the needs of another while trying to maintain optimal functioning of each system * Nursing diagnoses appropriate for the client with MODS * The number of independent nursing interventions for the client with MODS is limited. * Multi Organ Failure: Nursing Management * The overall goal for nursing is effective client and family coping: * Nurses must remain sensitive to the needs of the family. Caring for the family of critically ill clients is a challenge in that understanding, predicting, and intervening with families in crisis is less exact, than the calculation of oxygen needs. * There are no easy formulas to use to provide hope, courage, coping, and caring. * Nurses must remain alert to the needs of the family as well as the client during this stressful time. * B. Life saving and Intervention * Detailed discussion and return demo will be discussed on EDN and Vines laboratory. * 1. First Aid Measure * 2. Basic Life Support * 3. Advance Cardiac Life support * First aid measures Is an immediate care given to a person who have been injured or suddenly taken ill. * It includes self help and home care when medical assistance is delayed or not available. * Roles of First Aid: * Bridge that fills the gap between the victim and the physician. * It is not intended to compete with nor take the place of the services of the Physician. * It ends when medical assistan ce begins. * Basic Life Support ( BLS) * An emergency procedure that consists of recognizing respiratory arrest and cardiac arrest or both and the proper application of CPR to maintain life or until a victim recovers or advanced life support is available. C-A-B steps : * Circulation restored * Airway opened * Breathing restored * ADVANCE CARDIAC LIFE SUPPORT (ACLS) * Refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. [1] * ADVANCE CARDIAC LIFE SUPPORT (ACLS) * Extensive medical knowledge and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers * (e. g. hysicians, paramedics, nurses, respiratory therapists, clinical pharmacists, physician assistants, nurse practitioners * and other specially trained health care providers) can provide ACLS, as it requires the ability to manage the patie nts airway, initiate IV access, read and interpret electrocardiograms, and understand emergency pharmacology. * Fluid Resuscitation (Study) * The infusion of isotonic IV fluids to a hypotensive Pt with trauma; aggressive FR may disrupt thrombi, ^ bleeding, and v  survival * Intravenous literature: Boyd, J. H. , Forbes, J. , Nakada, T. A. , Walley, K. We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you FOR ONLY $16.38 $13.9/page Hire Writer R. and Russell, J. A. (2010) * Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical Care Medicine. 2010 Oct 21 * FLUID RESCUCITATION * Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or pathologic processes. * Fluids can be replaced via oral administration (drinking), intravenous administration, rectally, or hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously. * FLUID RESCUCITATION * Procedure * It is important to achieve a fluid status that is good enough to avoid oliguria (low urine production). * Oliguria has various limits, a urine output of 0. 5mL/kg/hr In adults is adequate and suggests adequate organ perfusion. * The parkland formula is not perfect and fluid t herapy will need to be titrated to hemodynamic values and urine output. * The speed of Fluid Replacement may differ between procedures. * The planning of fluid eplacement for burn victims is based on the Parkland formula (4mL Lactated Ringers/kg/% TBSA burned). * The parkland formula gives the minimum amount to be given in 24 hours. * Half of the value is given over the first eight hours after the time of the burn (not from time of admission to ED) and the other half over the next 16 hours. * In dehydration, 2/3 of the deficit may be given in 4 hours, and the rest during approx. 20 hours * FLUID RESCUCITATION The initial volume expansion period is called the fluid challenge, and may be distinguished from succeeding maintenance administration of fluids. During the fluid challenge, large amounts of fluids may be administered over a short period of time under close monitoring to evaluate the patient’s response. * Fluid challenge, as the procedure of giving large amounts of fluid in a short time, may be reserved for hemodynamically unstable patients, distinguished from conventional fluid administration for patients who are not acutely ill, who receive fluids as part of a diagnostic study, or for less acutely ill patients in whom fluid administration can be guided by fluid intake and output recordings. VARIOUS FLUIDS USED IN FLUID RESCUSITATION * Crystalloids are solutions of mineral salts or other water-soluble molecules. * we are talking about salt (saline) ; Since isotonic fluids have the same concentration as the normal cells of the body and blood, when infused intravenously, they will remain in the intravascular space. * Normal saline (0. 9% NaCl) and lactated Ringers solution are typical isotonic fluids with sugar in (dextr ose) * Hypertonic fluids –( 3% NaCl) have a higher particle concentration than in normal cells of the body and the blood. These agents draw fluid into the intravascular space from cells. * Hypertonic saline (3% NaCl) is a common hypertonic fluid. * Hypotonic fluids * (0. 45 normal saline, 0. 33 NaCl) are composed mostly of free water and will enter the cells rather than remain in the intravascular space. * Normal saline and lactated Ringers are the two balanced salt solutions most commonly used in current fluid resuscitation * Other products * Albumin, * one of the original plasma expanders, is a protein that maintains osmotic pressure in a cell and helps the cell maintain its internal fluid. When we read about protein in urine, especially in diabetics and those with kidney disease, we are talking about albumin. * Blood transfusion is the only approved fluid replacement capable of carrying oxygen * C. Life Maintaining Intervention * C. 1 AIRWAY MANAGEMENT By: Angkana Lurngnat eetape, MD. * Indication for tracheal intubation * ? Airway protection * ? Maintenance of patent airway * ? Pulmonary toilet * ? Application of positive pressure * ? Maintenance of adequate oxygenation * Oral endotracheal tube size guideline During Laryngoscopy ; Intubation * ? Malposition * – Esophageal Intubation * – Bronchial Intubation * ? Trauma * – Tooth damage * – Lip, tongue, mucosal laceration * – Dislocated mandible * – Retropharyngeal dissection * – Cervical spine * ? Aspiration * C. 2 Managing Patients on Ventilators Clinical Nursing Skills * By Sandra F. Smith * Managing Patients on Ventilators * Preparation: * Double check the ventilator settings against those ordered by the physician. * Plug the machine and turn it on. * Familiarize yourself with location of alarm system Connect the ventilator tubing to patient’s endotracheal tube or traheostomy tube * Procedure: * Monitor pt VS every 5 minutes until stable * Obt ain ABG 15 minutes after ventilation is established. * Monitor ventilation setting. * Check humidifier fluid level. * Records I and O and daily weight Positive pressure may cause positive water balance due to humidification of inspired air. * C. 3 Managing Patients on Ventilators * Suspend ventilator tubing from an IV hook or support it on a pillow to reduce traction on the endotrachael tube. Change ventilator tubing every 24 hours. * Check VS and auscultate lungs every hour. Rationale: Positive pressure ventilation may decrease venous return and cardiac output. * Observe and listen for possible cuff leaks around TT or ET. * Empty accumulated water on ventilator tubing. Disconnect tubing and stretch it to release water trapped into corrugated areas and drained to water basin DO NOT drain water back to humidifier. * Provide patient a method of communication. , such as magic slate. * Test nasogastric drainage pH every hour and administer antacid to maintain pH above 5. Test nasogastri c drainage and fecal matter daily for occult blood. * Assess lungs compliance * Implement methods of stress reduction. * Keep ventilators alarms on * C7 Fluid and electrolyte problems By Canthera Cancer Therapy Center * Fluid and electrolyte problems 1. Water retention * Water retention is simply the buildup of excess fluid in tissues. * Swelling of the feet, ankles and hands are generally the first sign of water retention. * But it can also affect other parts of the body such as the abdomen, chest cavity, face and neck. Possible causes include: * Certain medications (some chemotherapy drugs can cause water retention) * Heart, liver or kidney disease * Blockage of veins or lymph system * Fluid and electrolyte problems * Some symptoms to look for and report to your physician include: * Feelings of tightness in the arms or legs. * Difficulty fitting into clothing. * Rings, wristwatch or shoes fit tighter than usual. * Pitting of the lower legs and arms – when you press on your skin with your finger is there an indentation that remains for a few seconds. * A sense of heaviness or weakness in the arms or legs. Skin that feels stiff or taut. * Any redness, changes in skin temperature or pain in swollen areas can be a sign of infection and should be reported immediately. * Fluid and electrolyte problems * Things that you can do to help manage swelling are: * Do not stand for long periods of time. * When sitting or lying keep feet/legs elevated as much as possible. * Avoid tight clothing (including s ocks) * Do not cross your legs when sitting or lying. * Try to reduce your salt intake. Avoid foods that are high in salt content such as chips, tomato juice, cured meats, and canned soups. Weight yourself daily – a weight gain of 5 pounds or more in one week should be reported to the physician immediately. * If your physician has prescribed medications for your swelling take them exactly as prescribed. Do not reduce or increase the dose. * Treatment of fluid retention depends upon the underlying cause. Since some of the causes of water retention can be related to organ disease/damage and are potentially severe, it is important that you speak with your physician or nurse promptly if you are experiencing this problem. * Fluid and electrolyte problems 2 Electrolyte imbalance * Electrolyte imbalance could also be caused by * vomiting, * diarrhea, * sweating, * high fevers, * kidney disease, * medications unrelated to cancer therapy, * certain chemotherapy drugs such as Cisplatin and targeted therapies such as Erbitux. * Fluid and electrolyte problems * Because electrolytes regulate activity of nerves and muscles, their imbalance could lead to malfunctions in multiple organ systems. * It could cause : * muscle spasms, * weakness and twitching; * irregular heartbeat and blood pressure changes; * lethargy, * confusion, and neurological problems. * Severe electrolyte imbalance can result in death. Monitoring for electrolyte imbalance is a simple process and is accomplished through routine lab work. * Fluid and electrolyte problems * Treatment of electrolyte imbalance is based on identifying and treating the underlying problem causing the imbalance, * and actively correcting the imbalance itself. * Treatment may include intravenous replacement of fluids or electrolytes, dietary changes and/or oral replacement of a particular electrolyte. * Fluid and electrolyte problems * 3. Tumor lysis syndrome Tumor Lysis Syndrome is a serious and sometimes life-threatening c omplication of chemotherapy. * . It is caused by release of breakdown products from dying cancer cells and most frequently occurs in patients with leukemia or lymphoma that have a high tumor burden (large tumor). * Patients with pre-existing kidney disease are also at increased risk for this complication * Fluid and electrolyte problems * Symptoms of tumor lysis syndrome include: * Muscle weakness * Paralysis * Heart arrthymias * Seizures * Tetany * Changes in emotional stability * Decreased urine output Changes in electrolyte and uric acid levels. * Fluid and electrolyte problems * Treated prophylatically with hydration and medications which decrease uric acid levels like Allopurinol. * Treatment for tumor lysis is directed toward stabilizing electrolyte and uric acid levels. * Aggressive hydration with IV fluids and use of diuretics may be instituted. In some cases persons have undergone renal dialysis. * C8 NUTRITION BY Schumaker and Chernecky critical Care and Emergency Nursing * Energy expenditure during respiratory failure is high and is caused by the increased work of breathing. The goal of nutritional support is to provide the needed nutrients to maintain the patients current level of : * metabolism * energize the immune system * and maintain end-organ function. * NUTRITION BY Schumaker and Chernecky critical Care and Emergency Nursing * Enteral Gi feeding is the route of choice to provide the calories and nutrients needed and to assist in maintaining normal GI: function. * if the patient is unable to tolerate enteral feedings, then a parenteral (intravenous) route is necessary until the patient can tolerate enteral feedings. * Medical Management of the Client Receiving Parenteral nutrition by Joyce Black * Parenteral Nutrition (PN). PN is indicated to maintain nutritional status and prevent malnutrition when the client has inadequate intestinal function or cannot be fed orally or by . tube feeding. * The PN prescription is guided by the nutritional assessment and the definition of nutrient goals for calories. and protein. The PN solution contains carbohydrates' as glucose, fats, triglyceride, and protein as amino acid levels designed to meet the caloric and protein need of the client. * C 9 Perioperative Problems by Carl Balita, Nursing Review * D. Psychological and Behavioral Intervention * 1. Measure to relieve anxiety * 2. Fear * 3. Depression * 4. Critical concerns life: * a. Immobility * b. Sleep deprivation * c. Sensory overload * d. body image alteration * e. Grieving * f. sexuality * g. spirituality * Psychosocial and Behavioral Intervention http://www. uspharmd. com * Anxiety * Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. * Anxiety * Defining Characteristics Nursing Diagnosis Anxiety * Expressed concerns due to change in life events; * insomnia * Fear of unspecific consequences * Shakiness * Anxiety * Nursing outcome Nursing Care Plans For Anxiety: * †¢ Appear relaxed and report anxiety is reduced to a manageable level. †¢ Verbalize awareness of feelings of anxiety. †¢ Identify healthy ways to deal with and express anxiety. †¢ Demonstrate problem-solving skills. Use resources/support systems effectively. * Nursing Priority Nursing Care Plans   For Anxiety †¢ Assess level of anxiety †¢ Assist client to identify feelings and begin to deal with problems †¢ Provide measures to comfort and aid client to handle problematic †¢ To promote wellness; teaching/discharge considerations * Fear * Fear is a feeling of anxiety and agitation caused by the pr esence or nearness of danger, evil, pain, etc. ; timidity; dread; terror; fright; apprehension respectful dread; awe; reverence a feeling of uneasiness or apprehension; concern: * Interventions. The client needs an explanation of the disease and all treatment options. * Reinforce information to the client as needed. * The client also needs information concerning operative procedures and postoperative interventions (NPO status, NG tubes, other drains, intravenous infusions). * This information helps decrease the clients fear. * Understanding Depression by Health Guide . org * Feeling down from time to time is a normal part of life. But when emptiness and despair take hold and wont go away, it may be depression. * Common signs and symptoms of depression : * Feelings of helplessness and hopelessness. A bleak outlook—nothing will ever get better and there’s nothing you can do to improve your situation. * Loss of interest in daily activities. No interest in former hobbies, pastimes, social activities, or sex. You’ve lost your ability to feel joy and pleasure. * Appetite or weight changes. Significant weight loss or weight gain—a change of more than 5% of body weight in a month. * Sleep changes. Either insomnia, especially waking in the early hours of the morning, or oversleeping (also known as hypersomnia). * Common signs and symptoms of depression : * Irritability or restlessness. Feeling agitated, restless, or on edge. Your tolerance level is low; everything and everyone gets on your nerves. * Loss of energy. Feeling fatigued, sluggish, and physically drained. Your whole body may feel heavy, and even small tasks are exhausting or take longer to complete. * Self-loathing. Strong feelings of worthlessness or guilt. You harshly criticize yourself for perceived faults and mistakes. * Concentration problems. Trouble focusing, making decisions, or remembering things. * Unexplained aches and pains. An increase in physical complaints such as headaches, back pain, aching muscles, and stomach pain. Depression * Depression is a major risk factor for suicide. The deep despair and hopelessness that goes along with depression can make suicide feel like the only way to escape the pain. * Thoughts of death or suicide are a serious symptom of depression, so take any suicidal talk or behavior seriously * Depression * Intervention: * Lifestyle changes are not always easy to mak e, but they can have a big impact on depression. * Lifestyle changes that can be very effective include: * Cultivating supportive relationships * Getting regular exercise and sleep * Eating healthfully to naturally boost mood Managing stress * Practicing relaxation techniques * Challenging negative thought patterns * Critical Concerns life: * Immobility * Sleep Deprivation * Sensory overload * Body image deprivation * Grieving * Sexuality * Spirituality * Immobility * Immobility is complications that are associated with a limited or absolute lack of movement by the patient; various members of the health care team may collaborate to assist the patient in avoiding these problems. * Nurses must -Prevent the complications of immobility, such as :pneumonia , pressure ulcers, with frequent turning or the use of an oscillating bed. Intervention: * Continue to reposition the patient to relieve skin pressure unless the bed provides more, than 40 degrees of rotation. * The eyes may need to be taped closed to avoid corneal abrasion. * Suctioning may be needed to keep the airway clear and prevent pneumonia. * Passive range-of-motion exercises keep joints mobile and minimize muscle wasting. * Position the extremities in correct alignment to prevent contractures. * Use sequential compression stockings to prevent deep venous thrombosis (DVT); low-dose heparin may also be ordered. All these complications are continually assessed for and are treated promptly if they occur. * Sleep Deprivation Sensory overload * Sleep Deprivation is a sufficient lack of restorative sleep over a cumulative period so as to cause physical or psychiatric symptoms and affect routine performances of tasks. * Sensory overload is a condition in which an individual receives an excessive or intolerable amount of sensory stimuli, as in a busy hospital or clinic or an intensive care unit. * Sleep Deprivation Sensory overload * Sleep deprivation is of particular concern for clients in critical care units. Causes of the following: * The noise level * 24-hour lighting * and frequency of caregiver interruptions create sensory overload and sleep deprivation, which is thought to be a major factor contributing to postoperative psychosis (Joyce Black) * Sleep Deprivation * Causes: * Clients who have had surgery are also at risk for sleep pattern disturbance because of disruptions in circadian rhythms. * The cause is unclear, but the disruptions may be related to the length and type of anesthesia, postoperative analgesia, or mechanisms associated with the procedure itself. * Sleep Deprivation Techniques used to promote sleep include : * massage * relaxing music * progressive relaxation techniques * Medications to promote sleep * Body image deprivation * Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. * This attitude is dynamic and is altered through interaction with other persons and situations and influenced by a ge and developmental level. * As an important part of one’s self-concept, body image disturbance can have profound impact on how individuals view their overall selves. * Body image deprivation In cultures where one’s appearance is important, variations from the norm can result in body image disturbance. * The importance that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. * Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. * Body image deprivation * The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting from bowel or bladder surgery, and head and neck resections are other examples that can le ad to body image disturbance. * Body image deprivation * Defining Characteristics: Verbalization about altered structure or function of a body part * Verbal preoccupation with changed body part or function * Naming changed body part or function * Refusal to discuss or acknowledge change * Focusing behavior on changed body part and/or function * Actual change in structure or function * Refusal to look at, touch, or care for altered body part * Change in social behavior (e. . , withdrawal, isolation, flamboyance) * Compensatory use of concealing clothing or other devices * Body image deprivation * Therapeutic Interventions * Acknowledge normalcy of emotional response to actual or perceived change in body structure or function. Stages of grief over loss of a body part or function is normal, and typically involves a period of denial, the length of which varies from individual to individual. * Help patient identify actual changes. Patients may perceive changes that are not present or rea l, or they may be placing unrealistic value on a body structure or function. Encourage verbalization of positive or negative feelings about actual or perceived change. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth. * Body image deprivation * Therapeutic Interventions * * Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation. * Demonstrate positive caring in routine activities. Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities. * Body image deprivation * Education/Continuity of Care * Teach patient about the normalcy of body image disturbance and the grief process. * Teach patient adaptive behavior (e. g. , use of adaptive equipment, wigs, cosmetics, clothing that conceals altered body part or enhances remaining part or function, use of deodorants). This compensates for actual changed body structure and function. Help patient identify ways of coping that have been useful in the past. Asking patients to remember other body image issues (e. g. , getting glasses, wearing orthodontics, being pregnant, having a leg cast) and how they were managed may help patient adjust to the current issue. * Body image deprivation * Education/Continuity of Care * * Refer patient and caregivers to support groups composed of individuals with similar al terations. Lay persons in similar situations offer a different type of support, which is perceived as helpful (e. g. , United Ostomy Association, Y Me? , I Can Cope, Mended Hearts). http://nursingcareplan. blogspot. com * Grieving by Carl Balita * Sexuality * Sexuality. Sexuality is the behavioral expression of ones sexual identity. * It involves sexual relationships between people as well as the perception of ones maleness or femaleness (gender identification). * Sexuality * Many aspects of sexuality affect health status and are significant to nursing care and client outcomes. * * Aspects include: * (1) physical health problems that affect sexual behavior * (mastectomy, colostomy, skin lesions, venereal diseases, paralysis, physical deformities) * (2) concerns with sexual performance (impotence, premature ejaculation, inability to achieve orgasm, infertility), * (3) issues of sex role function * (homosexuality, bisexuality, sexual ambiguity, transsexual surgery), and * (4) effects of environmental restrictions on sexual performance * (residency in a longterm care facility). * Sexuality * Sexuality and sexual behavior are sensitive topics. * Clients may want to discuss sexuality issues and may look for permission to do so. * Become comfortable with sexuality issues and do not allow personal beliefs and values to interfere with professional care. Accept and interact with clients without judging them or their behavior. * Spirituality * Spiritual beliefs have implications for well-being, such as sustaining hope or assisting with coping during periods of stress. * Include spirituality assessment as part of the, health history and explain the purpose for asking about it * Spirituality * . This portion of the history is usually addressed at the end of the interview after a trusting nurse-client relationship is established. * Because spirituality is personal, respect a clients wishes not to discuss this topic. Ask whether the client prefers to consult someone else wh en spiritual support is needed. * Spirituality * Nurses may be aware that patients have spiritual needs, but in many cases are unable to respond to these needs. * This may result from an inadequacy in nurse education that does not prepare nurses to provide spiritual care. (Michelle Wensley, 2011) * Supportive Management * Supportive Management * (Discussed already on MODS = Medical and Nursing Management on the previous slides) * Preventing Complications * Preventing ICU Complications * Lee-lynn Chen, MD * Assistant Clinical Professor Catheter Related Blood Stream Infection * CRBSI Prevention Bundle : * Hand hygiene * Maximal barrier precautions (mask, gown, gloves and full barrier drapes) and full barrier drapes) * Chlorhexidine skin antisepsis * Optimal catheter site selection, with subclavian vein as the preferred site for non non-tunneled tunneled catheters in adults * Ultrasound guidance * Daily review of line necessity with prompt removal of unnecessary lines * Ventilator Asso ciated Pneumonia * A leading cause of death among hospital acquired infections * Increased length of time on ventilator, in both the ICU and hospital. Estimated cost is $40,000 (2004) * Continuous Aspiration of Subglottic Secretions * Requires intubation with special tube * Separate dorsal lumen that opens in to subglottic area * Aspiration may be continuous or intermittent * Requires frequent monitoring * Pressure Ulcers * Incidence and Cost * Incidence ranging from 0. 4% to 38% * 2. 5 million patients treated annually in US acute care facilities for pressure ulcers related complications * Once pressure ulcer develops, mortality is increased by 2-6 fold with 60,000 deaths * Total annual cost $11 billion * Pressure Ulcers Definition: Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear or friction. * Identifying patients at risk and identifying early skin changes can allow early intervention to pr event a pressure ulcer from developing * Pressure Ulcers: Sites * Sacrum -most common site (30%)Slouching in bed or chair * Higher risk in incontinent pts * Heels-2ndmost common (20%)Immobile or numb legs * Higher risk with PVD diabetes neuropathy * Trochanter * Device related * Minimize pressure * Frequent small position changes (every 1. to 4 hrs) * Keep reclining chair and bed below 30 degree angle to decrease pressure load * Sitting: may need hourly position changes * Increase mobility/Consult PT/OT * Order air mattress if turning protocols are ineffective * Reposition off of any know ulcers * Use pillows to pad bony prominences * Float heels with pillow lengthwise under calves * Minimize friction and shear * Use draw sheet under patient to assist with moving * Do not drag over mattress when lifting up in bed * Avoid mechanical injury-use slide boards, turn sheet, trapeze, corn starch * Manage Moisture Cleanse skin at time of soiling and use absorbent * Provide a non-irritating surface * Barrier ointments and pads * Utilize appropriate fecal/urinary collection devices * Nutrition/hydration * Skin condition reflects overall body function * Skin breakdown may be evidence of general catabolic state * Increase hydration caloric needs * Nutritional goals: ^protein intake1. 2-1. 5 gm/kg body weight daily—unless contraindicated * Consider vitamin supplementation * Rehabilitation * Rehabilitation will be properly coordinated with the Physical Therapy Department

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Modern marriage consists of an equal partnership between two individuals. However, in the nineteenth-century setting in which Henrik Ibsen set his play, â€Å"A Doll’s House,† marriage was an institution with strict social standards of the roles for both men and women. Men were the independent providers, and women were the caretakers, dependent on their men. The marriage between Nora and Torvald Helmer is an example of these roles, and demonstrates the consequences of breaking with the traditions, for which neither one is responsible. When Nora borrows the money, she steps outside of her traditional, dependent role, which leads her to the realization that her role in her marriage to Torvald does not fulfill her as an individual, and she decides to leave her home and the situation that she has created, hoping to start her life again and live independently. Women in the nineteenth century were expected to live as dependents, first as daughters, and later in life as wives. Nora makes frequent references to her dependence on both her father and her husband throughout the play. For example, when Doctor Rank visits Nora in Act II, she compares her relationship with Torvald to the relationship with her father, saying to Rank: â€Å"you can see how it’s a bit with Torvald as it is with Daddy,† (760). This quote demonstrates to the audience the transition between dependent roles of nineteenth century women, who were allowed few opportunities to live independently of men, with professional choices limited to the textile arts, such as knitting and embroidery. â€Å"The woman of the well-to-do classes was made to understand early that the only door open to a life at once easy and respectable was that of marriage. Therefore she had to depend upon her good looks, according to the ideals of the men of her day, her charm, her little d rawing-room arts,† (Spartacus). Though the marriage between Nora and Torvald appears to be healthy and ideal, every... Free Essays on Doll's House Free Essays on Doll's House Modern marriage consists of an equal partnership between two individuals. However, in the nineteenth-century setting in which Henrik Ibsen set his play, â€Å"A Doll’s House,† marriage was an institution with strict social standards of the roles for both men and women. Men were the independent providers, and women were the caretakers, dependent on their men. The marriage between Nora and Torvald Helmer is an example of these roles, and demonstrates the consequences of breaking with the traditions, for which neither one is responsible. When Nora borrows the money, she steps outside of her traditional, dependent role, which leads her to the realization that her role in her marriage to Torvald does not fulfill her as an individual, and she decides to leave her home and the situation that she has created, hoping to start her life again and live independently. Women in the nineteenth century were expected to live as dependents, first as daughters, and later in life as wives. Nora makes frequent references to her dependence on both her father and her husband throughout the play. For example, when Doctor Rank visits Nora in Act II, she compares her relationship with Torvald to the relationship with her father, saying to Rank: â€Å"you can see how it’s a bit with Torvald as it is with Daddy,† (760). This quote demonstrates to the audience the transition between dependent roles of nineteenth century women, who were allowed few opportunities to live independently of men, with professional choices limited to the textile arts, such as knitting and embroidery. â€Å"The woman of the well-to-do classes was made to understand early that the only door open to a life at once easy and respectable was that of marriage. Therefore she had to depend upon her good looks, according to the ideals of the men of her day, her charm, her little d rawing-room arts,† (Spartacus). Though the marriage between Nora and Torvald appears to be healthy and ideal, every...

An Introduction to Iambic Pentameter

An Introduction to Iambic Pentameter When we speak of the meter of a poem, we are referring to its overall rhythm, or, more specifically, the syllables and words used to create that rhythm. One of the most interesting in literature is iambic pentameter, which  Shakespeare nearly always used when writing in verse. Most of his plays were also written in iambic pentameter, except for lower-class characters, who speak in prose. Iamb What Iamb In order to understand iambic pentameter, we must first understand what an iamb is. Simply, put an iamb (or iambus) is a unit of stressed and unstressed syllables that are used in a line of poetry. Sometimes called an iambic foot, this unit can be a single word of two syllables or two words of one syllable each. For instance, the word airplane is one unit, with air as the stressed syllable and plane as the unstressed. Likewise, the phrase the dog is one unit, with the as the unstressed syllable and dog as the stressed.   Putting the Feet Together Iambic pentameter refers to the number of total syllables in a line of poetry- in this case, 10, composed of five pairs of alternating unstressed and stressed syllables. So the rhythm ends up sounding like this: ba-BUM / ba-BUM / ba-BUM / ba-BUM / ba-BUM Most of Shakespeare’s famous lines fit into this rhythm. For example: If mu- / -sic be / the food / of love, / play on(Twelfth Night) But, soft! / What light / through yon- / -der win- / -dow breaks?(Romeo and Juliet) Rhythmic Variations In his plays, Shakespeare didn’t always stick to ten syllables. He often played around with iambic meter  to give color and feeling to his character’s speeches. This is the key to understanding Shakespeares language. For instance, he sometimes added an extra unstressed beat at the end of a line to emphasize a characters mood. This variation is called a feminine ending, and  this famous question is the perfect example: To be, / or not / to be: / that is / the ques- / -tion(Hamlet) Inversion Shakespeare also reverses the order of the stresses in some iambi to help emphasize certain words or ideas. If you look closely at the fourth iambus in the quote from Hamlet above, you can see how he has placed an emphasis on the word â€Å"that† by inverting the stresses. Occasionally, Shakespeare will completely break the rules and place two stressed syllables in the same iambus, as the following quotation demonstrates: Now is / the win- / -ter of / our dis- / content(Richard III) In this example, the fourth iambus emphasizes that it is â€Å"our discontent,† and the first iambus emphasizes that we are feeling this â€Å"now.† Why Is Iambic Pentameter Important? Shakespeare will always feature prominently in any discussion of iambic pentameter because he used the form with great dexterity, especially in his sonnets, but he did not invent it. Rather, it is a standard literary convention that has been used by many writers before and after Shakespeare. Historians are not sure how the speeches were read aloud- whether delivered naturally or with an emphasis on the stressed words. This is unimportant. What really matters is that the study of iambic pentameter gives us a glimpse into the inner workings of Shakespeare’s writing process, and marks him as a master of rhythm to evoke specific emotions, from dramatic to humorous.

Interventions for the working Stage Essay Example | Topics and Well Written Essays - 500 words

Interventions for the working Stage - Essay Example In another proposal, work satisfaction appeared to be affected by work attributes that can be unfavorable for some workers, such as its â€Å"low decision attitude and high job demands† (Cox, 1993, p. 15). Demands on both sides, individual and organizational, generate stressful tensions when shortcomings are foreseen on both sides. Aside from personal and work expectations, a number of maladaptive cognitive and behavioral problems appeared to further hamper better functions of adults in work areas. Cognitive areas need to be constantly updated to better meet occupations demands, thus, inadequate trainings and seminars, in combination with excess workloads, can hamper cognitive development and account for stress and discontent. Behaviorally, people appear to act up when they are not recognized for excellent performance, do not receive incentives, and are plagued by unsupported colleague interactions (Davis & McKay, 2009). The work culture of negative self-talk can aggravate the stressful atmosphere, as the need for affiliated group approvals are interspersed with events of blame for the shortcomings of others, preventing the acceptance of adult newcomers in organizations (Davis, Robbins Eshelman, & McKay, 2000, pp. 107-119).

Innovative Food and Beverage Marketing Ideas Essay

Innovative Food and Beverage Marketing Ideas - Essay Example Rock music usually has a strong back beat. (Wikipedia) In the late 1960s, rock music was blended with folk music to create folk rock, and with jazz, to create jazz-rock fusion. In the 1970s, rock incorporated influences from soul, funk, and Latin music. In the 1970s, rock developed a number of subgenres, such as soft rock, blues rock, heavy metal-style rock, progressive rock, art rock, techno-rock, syth-rock and punk rock. Rock subgenres from the 1980s included hard rock, indie-rock and alternative rock. In the 1990s, rock subgenres included grunge-style rock, Britpop, and Indie rock. (Wikipedia) The influence of rock and roll is far-reaching, and has had significant impact worldwide on fashion, film styles, and even the hospitality industry.. This impact is broad enough that rock and roll may also be considered a lifestyle in addition to a form of music. Rock music was the inspiration of Tigrett and Morton's Hard Rock Caf (HRC) that originated in London. (Wikipedia) HRC is a unique genre in the hospitality industry, being a chain of restaurants, hotels, and casinos that is known for its music and memorabilia rather than its food. Customers come to HRC mainly for the experience of the live music event, which is a highly strategic marketing innovation of the caf. It was founded in 1971 by music-loving entrepreneurs Isaac Tigrett and Peter Morton. The first HRC opened near Hyde Park Corner in London, in a former Rolls Royce car dealership show room. In 1979 Tigrett and Morton began to cover the walls with rock and roll ephemera. Hard Rock was most popular in the 1980s when some people engaged in the hobby of visiting as many locations as possible and collecting a Hard Rock t-shirt bearing the Cafe logo and the location name. The Hard Rock Cafe's motto "Love All, Serve All" was adopted from Tigrett's guru Sathya Sai Baba. (Wikipedia) The HRC Marketing Mix There are about eight million restaurants in the world and some 300,000 restaurant companies. The restaurant industry is a classic mature market. Companies face stiff competition and low profit margins. (Yahoo Finance) Thus, innovative marketing ideas are necessary for any restaurant business to remain competitive and sustainable. Like many other restaurants and cafes, Hard Rock adapts the descriptive labeling for its menu and more. It has reinvented the menu to become an art cum history book. But more than the artistic menu, what makes HRC sustainable is its marketing mix that combines music, food, museum and merchandising. According to Proctor (2000), positioning products in people's minds and making them attractive to market segments requires careful formulation of the marketing mix. Getting the right blend of the product, promotion price and distribution is essential to put the carefully carried out analysis into operation. The aim is to portray an image for the product or service that will match with how one wants the product to be visualised in people's minds, i.e. its positioning. Image is not only reflected in the promotional messages which are directed towards the target market but also in the pricing strategy, the mode of distribution and in the appearance of the product or service itself. Live Rock MusicHRC has position itself for dominance in a market that caters to customers who love not only

Americans for Safe Access vs Dea Essay Example for Free

Americans for Safe Access vs Dea Essay Abstract This paper examined The American’s for Safe Access’s petition before a federal court to have the Drug Enforcement Administration reduce its current classification of marijuana as a Schedule I drug. As this case goes before the court, there could be three possible outcomes: a judgment in favor of the plaintiff, the defendant, or a decision for the DEA to reexamine marijuana’s current classification. Of these three outcomes, I believed there would be sufficient evidence in my findings to support a decision by the justices to reexamine marijuana’s classification. One key component to this decision will be whether or not enough evidence exists to support marijuana’s medical use, as a drug that is used for medical treatment is typically not classified as Schedule I. Evidence for arguments from both sides was gathered from various sources, including medical publishings, the University of Washington’s School of Medicine archives, and online articles. After reviewing this information, the conclusion that enough evidence exists to reexamine marijuana’s current classification was reached. Introduction As more and more states petition to and effectively pass legislation to legalize medical marijuana, its current classification as a highly banned substance by the Federal Drug Administration continues to serve as a harsh stance against the desires of the public for the option of marijuana as a medical treatment. The escalation of this debate in the political and federal arena appears to be overtaking the medical industries ability to determine marijuana’s harms and benefits. Perhaps the heart of this debate lies in marijuana’s current classification by the Drug Enforcement Administration as a Schedule 1 drug. Of all of the drugs on the current DEA Schedule I, list marijuana is the only one that has doctors supporting its medical uses. In light of this, does marijuana still deserve the same classification as heroin and LSD? As more states are passing this legislation and more states desire it, is it now time to reexamine marijuana’s current classification? Section 1: Case/Issue Summary Last year, the Drug Enforcement Administration rejected a petition by medical marijuana advocates to reduce its classification as a Schedule I drug, which kept marijuana in the same category as drugs such as heroin. The DEA concluded that there wasnt a consensus opinion among experts on using marijuana for medical purposes (Press, 2012). However, medical marijuana advocates have not given up in their pursuit to reduce the Justice Department and Drug Enforcement Administration’s classification of marijuana. In my chosen case, the plaintiff is Americans for Safe Access and the defendant is the Justice Department. Once again, the key issue at hand is the Drug Enforcement Administrations continued classification of marijuana as a Schedule I drug. In order to be classified as a Schedule I drug, the drug must be officially determined to have no medical use and a high potential for abuse (McClathy, 2012). Justice Department attorneys site an absence of available evidence of acceptable and controlled studies, and a lack of agreement among experts as to marijuanas effectiveness as a medicine, as their basis for its current Schedule I classification. Those standing against the Justice Department claim that regulators are disregarding hundreds of peer-reviewed studies on the effectiveness of medical marijuana and the subsequent medical marijuana laws passed by 16 other states. The concerns for both the plaintiff and the defendant lie in the same key issue – is there enough acceptable medical evidence that marijuana does in fact have medicinal benefits? Studies and opinions as to which side has the most support to back its claim are widely varied, but both sides claim they have sufficient evidence to support their assertions. Take, for example, to very different statements, one from the medical book â€Å"Marijuana as Medicine?: The Science Beyond the Controversy† (Mack Joy, 2001), and the other from the medical book â€Å"Marijuana and Medicine, Assessing the Science Base† (Joy Stanley, 1999): â€Å"The cannabis plant (marijuana) . . . [has] therapeutic benefits and could ease the suffering of millions of persons with various illnesses such as AIDS, cancer, glaucoma, multiple sclerosis, spinal cord injuries, seizure disorders, chronic pain, and other maladies.† – from the editor’s introduction to Cannabis in Medi cal Practice, by Mary Lynn Mathre, R.N. (Mack Joy, 2001). â€Å"Consequently, the rapid growth in basic research on cannabinoids contrasts with the paucity of substantial clinical studies on medical uses.† (Joy Stanley, 1999). These two statements help highlight just how much inconsistency on exists on this issue, inconsistency that could be a concern for both the plaintiff and the defendant. Section 2: Identification and Evaluation of all Main Possible Solutions Though the challenge filed by the plaintiff is directly asking for one solution, there are several solutions that could be reached. The first solution would be that the judges would dismiss the challenge without review. The result of this would be that the appeals court considers marijuana’s current classification to be proper and this would represent solid validation of the DEA’s authority to determine a drug’s status and classification. There would be evidence to back this decision. According to the doctors that authored â€Å"Marijuana and Medicine†, more extensive data exists on the harmful effects of marijuana than data on its medical benefits (Joy Stanley, 1999). It is the opinion of these doctors that clinical studies on marijuana’s positive and negative effects are difficult to conduct, due to both difficulty in procuring funding and the encumbrances of the many federal regulations involved with such testing (Joy Stanley, 1999). The court could also reach this decision due to the bioethical principle of Nonmaleficence. Under the standards of care, this is the principle that a healthcare provider should not bring harm to a patient (McCormick, 1998). Should the court determine that not enough evidence exists to support marijuana’s medical benefits, it would have to conclude that prescribing marijuana to a patient could lead to their harm. This decision by the court would serve as a strong deterrent to future challenges of the DEA’s classifications of drugs. The consequences would be a major setback for advocates of widespread legalization of prescription marijuana. Dismissing the challenge would, for the time being, lay to rest all claims made by American’s for Safe Access. Another solution would be for the district court to decide a reduction in marijuana’s drug classification to be justified. For the plaintiffs, reducing marijuana’s classification from a Schedule I drug to a lesser controlled substance would be a major step in their ultimate quest to see marijuana legalized for medical use in the remaining 34 states that don’t already allow for such use (Press, 2012). Should its classification be reduced to a Schedule II drug, it would then be legal for marijuana to be prescribed to patients in need. Along with the physical medical benefits, reducing marijuana’s classificati on would also lessen the penalties faced by those found in possession of it. Currently, possession of a Schedule I drug can carry a maximum sentence of up to 7 years in prison. Ruling in favor of the plaintiff could indicate that the judges felt the principle of beneficence – that a healthcare professional must act to provide medical benefit to a patient – is involved (McCormick, 1998). In this case, the benefit to the patient would be relief from pain and protection from harm. A recent petition by Governor and former senator Lincoln Chafee of Rhode Island, and Governor Christine Gregoire of Washington filed made the assertion that â€Å"patients with serious medical conditions who could benefit from medical use of cannabis do not have a safe and consistent source of the drug as a result of its current classification† (Madison, 2011). This ruling could also be a result of the justices deciding that enough trusted medical evidence does in fact exists to support the use of marijuana for medical purposes. According to the book â€Å"Marijuana Medical Handbook: Practical Guide to Therapeutic Uses of Marijuana†, some medical marijuana specialists have reported a significantly large amount of uses for medical marijuana, ranging from treatment for nausea and convulsions to an appetite stimulant for cancer patients (Gieringer, Rosenthal Carter, 2010) For the Justice Department and Drug Enforcement Administration, seeing marijuana’s classification reduced would be a major setback in its efforts to eradicate a drug that Justice Department lawyer Lena Watkins says is â€Å"the most widely abused drug in the United States, (Press, 2012). A decision against them by the federal court would essentially erase all of their efforts, along with damaging their ability to make similar determinations in the future. A third solution could be that the court could order the Drug Enforcement Administration to take a more in-depth look at the available evidence (McClathy, 2012). This would be a blow to the DEA, who claims they have spent a substantial amount of time and energy in executing due diligence to determine marijuana’s Schedule I classification. It would counter their stance that not enough acceptable evidence and proper studies can be found to support marijuana’s medical benefits. In turn, a decision by the court for the DEA to reexamine its evidence could ultimately lead to another challenge for its legalization. Consequently, this same decision would be very positive for American’s for Safe Access. They claim that the DEA has failed to consider notable support for medical marijuana from many respected institutions, all of whom support the reclassification of marijuana (McClathy, 2012). A request by the Court of Appeals for the DEA to reexamine its findings could be due to the principle of respect for autonomy. This principle protects the patient’s right to make their own informed decisions with regards to treatment (McCormick, 1998). Not having access to the best evidence as to marijuana’s medical benefits could act against this principle. The principle of justice could also play a part in this ruling. A patient in Missouri suffering the same amount of pain as a patient in California, but not having the opportunity to benefit from the same medicinal advancements as a patient in California, might be a constitute a breach of the principle of judgment in the eyes of the court. Section 3: Decision Statement and Defense Against Weaknesses After examining the facts of the case and all possible solutions, the solution to allow for the reduction of marijuana’s classification to a Schedule II drug seems the most prudent. This conclusion was reached for several reasons. Despite the DEA’s claims, there appears to be enough acceptable evidence on the ASA’s side to support its assertion that marijuana has applicable medical benefits. Cocaine is certainly proven to be a harmful substance when taken irresponsibly, yet its remote medical benefits have landed it on the Drug Enforcement Administration’s Schedule II. For marijuana to remain on the Schedule I list while cocaine is on Schedule II hardly seems just considering there is even one state that has passed legal medical marijuana legislation. That there is even a small amount of substantial evidence from credible institutions supporting marijuana’s medical benefits makes the penalties involved with its possession seem severe. The recent petition sighted earlier by the two governors offers that they have support from many respected institutions, including The American Medical Association, The American College of Physicians, the Rhode Island Medical Society, the Washington State Medical Association the Washington State Pharmacy (Madison, 2011). All of these institutions are respected, making a decision to dismiss the challenge without even a reexamination seem imprudent. One also can’t help but wonder if the DEA’s current stance comes from a fear of its potential legalization for recreational use. This solution would also address another important issue in terms of marijuana use, and that would be to provide â€Å"safe, reliable, regulated use of marijuana for patients who are suffering,, as the governors have suggested (Press, 2012). In conclusion, certainly it seems that the current Schedule 1 classification of marijuana obstructs the medical principles of autonomy, beneficence, and justice . References Gieringer, D., Rosenthal, E., Carter, G. T. (2010). Marijuana medical handbook, practical guide to therapeutic uses of marijuana. Oakland: Quick American Archives. Joy, J. E., Stanley, J. W. (1999). Marijuana and medicine, assessing the science base. National Academies Press. (Joy Stanley, 1999) Mack, A., Joy, J. E. (2001). Marijuana as medicine?, the science beyond the controversy. Washington, D.C.: National Academies Press. (Mack Joy, 2001) Madison, L. (2011, November 30). Govs. chafee, gregoire lobby for reclassification of marijuana. Retrieved from http://www.cbsnews.com/8301-503544_162-57334326-503544/govs-chafee-gregoire-lobby-for-reclassification-of-marijuana/?tag=contentMain;contentBody McClathy, N. (2012, October 12). Medical marijuana case going before court. Maine Sunday Telegram. Retrieved from http://www.pressherald.com/news/medical-marijuana-case-going-before-court_2012-10-13.html McCormick, T. R. (1998). Principles of bioethics. Ethics in edicine: University of Wa shinton School of Medicine, Retrieved from http://depts.washington.edu/bioethx/tools/princpl.html Press, A. (2012, October 16). Federal court considers marijuana classification. Retrieved from http://www.cbsnews.com/8301-201_162-57533647/federal-court-considers-marijuana-classification/

A Bruised Way of Life :: essays research papers

A Bruised Way of Life   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"BONG!† is the one and only word that anyone in my family has to say to bring back the memories of an incident that happened at the age of eight. Oh, but this horrifying happening couldn’t have happened in my home, it had to have happened in the middle of my favorite place in the world. None other than the original Downtown Disney, on the most beautiful day there has ever been at the beginning of December. The day was sunny, cloudless, and warm. Or at least warm to me after my accident.   Ã‚  Ã‚  Ã‚  Ã‚  First, let me take you back in time. To the day that changed the way my family would make fun of me for the rest of my natural life. On the second day of our vacation to Walt Disney World, my parents, brother, and I decided that we all wanted to get some early shopping into our schedule before actually â€Å"hitting† all of the major parks that Disney World is known for. The usual routine for this area of vacationing was usually left up to the women in our family since it is the shopping area. Everything was going fine, going through the shops and looking at all of the merchandise we wished we were able to afford, when my brother, Brandon, spotted the water fountains that came up from the ground to play in. Before long, Brandon was begging and pleading my parents to go play in the water with the other kids. Even though they were strangers. My parents, of course, said yes.   Ã‚  Ã‚  Ã‚  Ã‚  After the first few minutes of Brandon’s fun in the water, I just had to join in. There was no way that I was going to let my brother have all of the fun, then decide to shove it in my face. No way was I going to let that happen to me. By the time a couple of minutes had passed, both my brother and I, were completely soaked from head to toe. That didn’t stop the fun though! The two of us were having such a great time that it had become a chore for our parents to get us to stop. Although, it seemed like a game for Brandon and me! Brandon was the first to finally give in to my parents and stop playing so we could do some more shopping. But getting me out was a totally different story.

A Study of Ethiopian Immigrants in Toronto by Ilene Hyman

A research on the Ethiopian immigrants in Toronto was done by; Ilene Hyman, Sepali Guruge and Robin Manson. Their main concern was the impact of migration on marital relationships among the newcomer Ethiopians in Toronto. The purpose of this essay is to review the research and the methodology used.The Ethiopian population in Toronto is growing hastily. There were 35,000 Ethiopians in Toronto by 2001, according to the Ethiopian association in Toronto. Ethiopia is a war torn country and many of its citizens have sort refugee status in other countries. However, only a small percentage of Ethiopians have migrated to Europe. Most of the immigrants surveyed could not speak French or English when they entered Canada.The survey on the female immigrants revealed that face challenges like unemployment, discrimination, housing, loss of social status, culture shock, language barriers and lack of credibility for employment. However, experiences for the women have not been the same. For some reloc ation gave them cost-effective sovereignty and administrative power within their households.On the other side, there are those whose position within their family has not changed.   Researchers believe that change in gender role that comes about due to migration is responsible for most of the marital conflict. This is especially so if the change in gender roles is not matched by a change in perception and attitude in the spouse (Jewkes, 2002).The report is concerned with the impact of migration on marital relationships among newcomer communities, with an emphasis on Ethiopians in Toronto. The authors investigate what effects migration has on marriages and how the couples adopt to the new circumstances. The research data was derived from married, divorced and separated couples that had recently migrated from Ethiopia to Toronto. The aim of the study was to find out the changes in the lives of new Ethiopian immigrant couples and the impact the migration had on the change in their mar ital relationship.Importance of the researchThe location of marriage in the civilization today needs to be carefully assessed. Cases of break up, separation, marital aggression and physical attack are on the rise.Past sociology, research has not given attention to the effects of migration on society and the impact on the family structure. Therefore, it is very significant to study the results that migration has on marriages.The methodology usedThe research had two phases; to evaluate the risk of marital conflict among Ethiopian couples who had migrated to Canada. (Phase 1); to examine conflict among Ethiopian men and women who were divorced or separated after migration to Canada (phase 2). The objectives for the research were set, participants recruited, data collected and then analyzed (Ottawa, 2001).For the first phase participants had to be Ethiopian immigrants who were married or living together pre-migration. Both partners had to give their consent for the process.The second ph ase targeted couples that separated or divorced post-migration. Various methods were used to attract participants such as newspaper ads, flyers at Ethiopians social events, word of mouth and so on. Participants for the first phase were easier to recruit compared to those of the second phase. Honorarium was given for participation; $50 (phase 1) and $75 (phase 2).Data was collected through interviews and demographic questionnaires. The survey also included the past of the pair preceding migration. Two Amharic-speaking Ethiopians, trained in research (male and female) assisted in data collection.This was commendable in order to overcome any language barrier. The participants were given a choice as to who should interview them whether, male or female. However, according to the report a pre-test indicated that the participants did not give preference to any particular sex.The participants were interviewed separately so that the presence of the other spouse could not influence their resp onse. After analyzing, the data collected from the interviews focus groups were formed according to sex. The aim of the focus groups was to verify or refute the findings of the data collected.Focus groups were however, not conducted for separated or divorced couples. The Ethiopian community associated some kind of stigma due to divorce. This was evident due to the low turn up of divorced couples.All the interviews and focus group debates were put on audio tape, written down and interpreted into English. The findings of the research focus on several themes such as; change, adaptation, conflict and resolving differences among the couples (Attaca & Berry, 2002).

Evidence- Based Practice Article Essay

Reference: Taleporos, G & McCabe M.P (2002). The impact of sexual esteem, body esteem, and sexual satisfaction on psychological well-being in people with physical disability. Sexuality and Disability, 20(3) Fall 2002 Overview: The objective of this study is to investigate the association between sexuality and psychological well-being in people with physical disabilities. 1196 respondents completed the study. Previous studies have suggested that sexual satisfaction and body esteem are important to the overall well-being of people with physical disability. The extent to which sexuality is related to other aspects of psychological well-being, and differs from relationships among the general population, is unknown. Problem: The problem being investigated is the relationship of sexuality (sexual and body esteem and sexual satisfaction) and psychological wellbeing (depression and self-esteem) among people with physical disabilities, and to compare these relationships with those found in able-bodied people. TR: The literature review was comprehensive to investigate the problem for this study. Research question: Can sexuality as a variable be a significant predictor of psychological well-being in both groups of respondents? Can the relationship of sexuality and well-being variables be of similar strength among people with physical disability and able-bodied respondents and in both men and women? Methods and procedures: 1196 subjects were randomly selected from America and Australia ages 18-69 years old and were identified as having physical disabilities. The following instruments were used: Demographic Questions; 21 item Depression, Anxiety and Stress Scale (DASS); 10 items the Rosenberg Self-Esteem Scale; Sexual esteem subscale in Snell and Papini’s; Body Esteem Scale; and Sexual Satisfaction Survey; Multiple Regressions Analysis. Results: Taleporos & McCabe’s (2002) revealed that among people with physical disability, high levels of body esteem and sexual satisfaction predicted high levels of self-esteem (p=

The greatest Essay Example

The greatest Essay Example The greatest Essay The greatest Essay The Greatest I chose Stephen Curry of the Golden State Warriors as the greatest point guard in the NAB because he has shown great characteristics such as leadership, team player and also a very caring person on the court as well as in his local community and different Countries. He shows great quality as far someone who comes from a very strong basketball family, starting with his father who played several seasons in the NAB all the way down to younger brother playing basketball at Duke University. Stephen chose to use summer as a time to go over to Africa and spend time with the coals. While there, he got a chance to see how people lived and what they go through every day. ESP. reports that Stephen curry donates 816 nets for every three- point shoot he makes. While most players spend their time off with their families, he chooses to go to a different country. He is also a member of the NAB Cares Program and he helps the organization by visiting children in the hospital and build homes in the San Francisco area. Leadership is another characteristic that Stephen Curry tends to show at young age in his NAB career. This makes him the greatest to e because without good leader nothing can be accomplished. Curry leads his team in every game by making sure that everyone gets involved the plays on offense and defense. He makes everyone on the floor better because he puts the other players in the right position to score. He also provides advice for whom ever needs it whether it be for a rookie or veteran player. Finally, what makes Stephen Curry the greatest of all time is that he is a great team player which means he is loved all over the Bay area and in the locker room where he is very well respected by the locals and the Warrior basketball team franchise.

Braving the Storm

Heavy raindrops pelted the thin panes of glass and claps of thunder rumbled through the walls; my only refuge from the typhoon raging outside. Occasional bursts of lightning illuminated the bedroom, revealing tear stains on the pillow. Wracked with homesickness, muffled sobs escaped my clenched mouth. Going to Sri Lanka was not an idea I was particularly fond of as a ten year old. I wanted to play with my friends at home, go to the pool or the park and have fun. But there I sat, weeping away the horrors and trying to make sense of a completely different world. Slowly crying myself to sleep that stormy summer night, events of the past week drifted in and out of my head. Children my own age picking at piles of garbage with stray dogs, haggard men toiling away at their menial jobs, and gaunt women cooking over fire pits in little shacks. I could not understand why the lived this way. â€Å"They are poor. They cannot afford the nice things we have,† my mother explained. And when I asked whether I should give them a dollar as I did back home, she shook her head. A mere dollar could not make a difference for them; it could not buy them a stove, send them to school, or find them better jobs. The rain battered down harder now, and I buried myself deeper under the blankets. It sounded like thousands of bullets being fired from guns, and the fear of being shot made me tremble. Soldiers patrolled the streets back then and occasionally still do, with their machine guns slung over their shoulders like a backpack on a schoolboy. I had never seen a real gun before, and I couldn’t comprehend why one would be needed. â€Å"Sri Lanka is in the middle of a civil war,† my father explained, â€Å"the terrorists in the North want to hurt the people here in the South.† War? My ten year old mind could not gr asp it. America was at war, but soldiers did not parade the streets with their shiny toys in hand. I only knew of the war on television with tanks, helicopters, and bombs. With these thoughts still fresh in my mind, my tired body succumbed to sleep to the lullaby of guns and destitution. Sunshine streamed in through the crystal clear windows that next morning. The typhoon had passed, but broken tree branches and monstrous puddles of rainwater littered the dirt roads. But the birds sang, the same impoverished children frolicked about, and the adults amused themselves with cups of tea and a game of carrom. These people enjoyed themselves and were happy, despite their lack of material possession and low standing in society. Smiling, I dressed and went down to join them. Lamenting my lost innocence and ignorance of the world would do no good. The world is far from perfect, but I cannot let adversity break my spirit.

Theme of Hamlet and how it relates to me Essay Example | Topics and Well Written Essays - 750 words

Theme of Hamlet and how it relates to me - Essay Example Taking revenge on one’s enemy entails a lot of complex planning and deft handling. The person taking revenge keeps in close contact with his audience and this is done through soliloquies that are narrated from time to time throughout the play. The crime usually takes place within the family circle and is committed against a family member. The avenger usually isolates himself from the others and this tragic lonely state culminates into madness before executing his demonic deed. All of these salient features spoken of can be found in the tragic story of ‘Hamlet’. The isolation in Hamlet is interrupted by soliloquies prompted by a ghostly apparition that haunts him. Hamlet keeps in very close contact with his audience in the seven soliloquies of the play that included the famous soliloquy ‘To be or not to be’. (Act 3, Scene 1) The period of revenge begins from the time of crisis when the avenger begins to doubt the sanctity or good intentions or actions of the one to be avenged. From that moment he seeks to punish his opponent through tough and complex planning of his crime. In Hamlet, Shakespeare beautifully brings out the darkness of the play by introducing a ghost who speaks to a Hamlet during the dark nights, all the while prodding and forcing him to commit his murderous deed. The meeting of the ghost with Hamlet has a great impact on the audience by making them guess that something hateful and gruesome was about to take place. The seed of revenge is sowed in Hamlet’s heart when Claudius decides to marry Hamlet’s mother Gertrude. The ghost plays an important role by moving the story forward with his insinuations, telling Hamlet that he had been chosen to take revenge on Claudius because he had to get punished for his sexual misdeeds. Hamlet, wants to take his revenge immediately by murdering Claudius, but he drags on this crime right to the end of the play. In order to avenge the death of his father, Hamlet stalks his enemy Claudius by