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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buy custom Applications in Corporate Finance essay The point of this analysis is to come up with how best DanAir Airlines can continue to be a thriving industry in the 21st century. This is accomplished by providing a background region analysis of the global industry of airlines. Current and future evolvement of the industry also has to be considered as do the reasons why airlines fail and how to achieve success. Regulation While route scheduling, as well as, the air ticket price has been de-regulated for some time and many of the sections are still under tight control. Governments own and regulate the airports in their regions and control key bottlenecks to airline services such as access to boarding gates and runways. Most airport commissions allocate gates without a formal market mechanism such as a bidding process. In addition, international routes have been de-regulated only gradually, through negotiated bilateral open-sky agreements, which generally allow airline companies from two countries to fly planes within and to each other without restrictions. In many airports, airlines must obtain a slot for their aircraft to land or take off. The regulations that were designed to avoid congestion in extremely busy airports have lagged behind market realities (Vasigh, Fleming, and Mackay, 2010). Service to some small and isolated markets is also subsidized and regulated by said the government. Airline competition has not benefited all consumers. Business travelers paying full fare usually enjoy a superior product in terms of service and flexibility. There is an increased demand for air travel, thus, there are new passengers who air travel. This means that even though competition among airlines may not necessarily profit all categories of passengers, there is an increase of the passengers, which lowers average prices (Shaw, 2007). While profits are volatile, industries without volatile profits operate without substantial government regulation. Free are an advantage for the big industries because they give provisions for firms when it comes to innovation to demand and cost systems. Free markets provide incentives for innovations to spread, thereby increasing efficiency. Impact of Policy on Competition Airlines are a complex mix of competition and standardization, the policy choices made could affect its competition. Policies are the mechanism for allocating airport gates and facilities. The airport commissions usually rely on the mechanisms not from market formations to allocate these resources (Renga and Mentges, 2010). Changes in these policies force the authorities to increase supply as the bid values go higher than the costs. Evidence suggests that the airfares increase as concentration in the market increases and this harms consumers. The concentrated markets benefit from the consumers by creating bigger networks with better flights. A third significant policy dimension involves restrictions on substantial foreign ownerships of airlines and on domestic flights by foreign owned airlines. While profits have fluctuated a great deal in the airline industry, DanAir has been characterized in the past by steady growth, and falling prices. Liberalization Since the horrendous attacks of September 11 2001, global airlines have registered abysmal performances especially when compared with their recorded profits in the years before 2001. The airline industry is structurally challenged by its very nature, facing high fixed costs, and cyclical demands. As such, the number of bankruptcies continues to pile up as airlines seek protection from creditors and look for ways to restructure costs. Facing increase competition and fighting to retain customers and thrive, most airlines have introduced cost cutting measures such as frequent flier programmes that reward customer loyalty with tickets, cabin upgrades, priority check ins, priority boarding, lounge access among other privileges. Passengers can also accumulate mileage point based on distances travelled and in what travel class and then redeem those miles for rewards such as free or discounted tickets. Loyalty programs such as these are often more profitable than other forms of marketing like comparison of routes, services and price. Both airlines and consumers benefit from the advent of loyalty programs. Airlines benefit from a faithful consumer base that remains even with increased fares and passengers earn free tickets and other rewards. Alliances Hardly any airline, no matter its largesse or scope is able to efficiently provide service to all the destinations of the world. To counteract this fault, airlines, even gigantic airlines, form alliances with other airlines to overcome their limited abilities and reap a profit. By amalgamating, they also increase their market presence and expand their network. While larger airlines opt for agreements with regional carriers, the trend of alliances is now beginning to go international. The benefits of this to the consumer are clear: more reachable destinations, lower prices, and more departure times, access to more lounges, faster mileage rewards and around the world tickets. This is the result of the airlines sharing facilities, cooperating in sales and making investments in different regions of the world (Morrel, 2007). Profitability in the Air Industry The ultimate challenge for airlines is selling the most ticets for at the highest prices and targeting the right customers so that price discrimination will occur where customers pay different rates for the very same destination and service. Airlines face additional pressure to fill seats because empty seats are considered perishable goods with the airline having to fly even with empty seats. Striking an ideal balance between price and demand is undoubtedly difficult and airlines resort to a lot of market research to categorize their customers. There are business travelers, and those travelling for urgent personal reasons, and there are leisure travelers who are price sensitive and an influence demands. At the extreme end, of the economy spectrum is the least expensive seat, which may be four times less the most expensive seat. Understandably, airlines will focus on filling their first and second class sections which more than over the cost of their lowest economy class seats. Managing Cost Structure In stark contrasts with the management of other service businesses, airlines today need an extensive range of expensive equipment in order to operate efficiently. Companies have traditionally financed their costs by loans or public stock offerings, but recently, airlines are leasing equipment such as aircraft, baggage vehicles, and hangars, having realized that those leases provide greater flexibility in updating equipment while keeping upfront costs down. If the lease is a capital lease, an airline records the asset and a lease liability that is generally equal to the sum of the present value of the lease payment during the lease term. Another benefit of the capital lease is the depreciating expense relating to the asset over the economical life of the asset. Aiming to limit their long-term liabilities, most airlines prefer operational leases (Crans, 1996). In these, neither the asset nor the lease liability is included in the balance sheet. Leases also provide airlines with flexibility. In times of increase of demand, airlines can quickly utilize larger planes to accommodate all their customers. In the post September 11, 2001 era, most airlines have espoused cost-cutting measures as a goal to pursue. The airline industry is labor intensive, and so pilots, flight attendants, baggage handlers, dispatchers, and customer service comprise the biggest portion of the airlines operating expenses. This is due to a highly tenured workforce, higher pension costs, and work rules because of hiring unionized labor. The maintenance department is also under operations focusing on aircraft condition to preserve the airlines most valuable capital asset, the airplanes. This group is essential to the airlines because it can affect the airlines bottom line. Aircrafts cost the airline a lot, whether just sitting idle or in full flight. As a result, maintenance personnel are often charged to keep the planes in tiptop shape to minimize downtime. Reducing Costs of Fuel In consistently seeking to lower fuel costs, management and operations will fill aircraft with more fuel than is necessary for the trip to its destination, as the cost of fuel in the place where it is going may be more than what it is in other areas. To save fuel, pilots use single engine emergency procedures when they doing normal drills as well as selective engine shutdown when the ground procedures are under delay. Cargo personnel can reduce and weigh more effectively the onboard weight while redistributing belly cargo to save on fuel. Pilots can also cruise longer at high altitudes while employing shorter and steeper approaches. DanAir can also optimize flight planning for a minimum fuel burn routes and altitudes. Hubs and schedules should be redesigned to alleviate congestion and DanAir can acquire fuel-efficient airplanes to save on fuel. High priced localities as far as fuel is concerned are also to be avoided. There is another risky option for decreasing fuelling costs, fuel hedging. The basic premise is to purchase a contract that locks in a fuel price in the future at which point the airline will pay that strike price should the price of fuel increase above the current price. Through forward contracts, future contracts and optional swaps, an airline can manage its fuel price risks. The primary difference between forward contracts, future contracts, and optional swaps is that options grant the airline the power to buy or sell at a specific time without obligation whereas future and forward contracts will result in direct losses if fuel prices drop below the contract price, as there is an obligation to pat the contract price. Landing Fees Airport and en route charges are a significant expense in flight operation costs. Both private and public airports charge airlines for the use of their runway and terminal facilities. These fees are quite considerable taking into account the number of aircraft landing and departing each day. Due to the considerable cost of airport charges, DanAir should attempt to fly fewer planes into the priciest airports and try to maximize their load factors during times of high fuel prices. Ancillary Fees In response to the most recent economic downturn, airlines have begun to charge extra fees for services that were once considered complimentary. These include checked baggage, food and beverage, seat selection, priority boarding, ticket changes, reservations via telephone or internet, and carryon baggage fees (Salerno, 2010). Performance Metrics Data revealed in specific metrics can underscore why some airlines are profitable and others slump into bankruptcy. It will underline efficiency measures undertaken in both cutting costs and in generating maximum revenue from each passenger (Banfe, 1992). In revenue metrics, rather than looking at system total operating revenue when comparing airlines, one can glean more information from system passenger revenue per available seat mile. Revenue per available seat mile, which includes both passenger revenue, as well as revenue earned from freight, is also used to compare airlines. It represents how much revenue an airline generates per seat per mile flown. In theory, higher revenue per seat mile translates into higher profit. Expense Metrics Analyzing airline expenses exposes a significant difference between the airlines that dedicate themselves to serious cost minimizing and those that place less value on it. The lower an airlines cost per available seat mile; the more efficient for the airline operations then the airline probably post a profit avoiding bankruptcy. Laborers Laborers in the airline industry have constantly sought to re-negotiate contracts and fight when their demands are not met. It is a constant battle between the airlines who struggle to cut costs to avoid bankruptcy and the labor unions that seek higher wages or better benefits. To cut costs, some airlines ascribe to employees extra duties that do not fall under their original portfolios but that they can perform easily and efficiently such as asking maintenance personnel to wash parts of the plane (Morrison and Winston, 1995). That can actually increase the bottom line of the said airline by lowering the overhead costs, as well. Stage length is an important strategy to consider, as well. It refers to the average flight times of a particular airline. As stage lengths increase, costs tend to go down which bodes well for the long haul airlines that have fewer take offs and landings. Traffic and Capacity Metrics The most fundamental metrics related to the airline industry are traffic and capacity, which are used as the basis for unit revenue and unit costs. They also provide the essential metric of load factor, which measures the percentage of seats sold out of the available seating places available. Total available seat miles determine which airline has the largest seating capacity as total available seat miles is equal to increasing seats proportionally to the number of miles flown (Doganis, 2002). Airlines strive for the highest load factor as they face high fixed costs for each plane flying. As the plane will typically fly regardless of its load factor, the airline will lose revenue for each seat that goes unsold as it absorbs operating costs, such as fuel, labor and landing costs. It is, therefore, critical for airlines to attempt to sell each seat, as the airline with the largest load factor is likely generating the most revenue for from each flight. Since reaching the low point of 2001, most airlines have steadily increased their load factors. This is primarily due to more efficient and sophisticated yield management systems which allow the airlines to more accurately estimate demand at different price levels resulting in more sold seats. In addition, some airlines have also reduced the number of flights, which increases load factor due to offering less capacity yet facing rising demand. However, while load factor provides insight into how much revenue an airline generates from each flight, it disregards expenses. Moving into the next decade, the airline industry is still at crossroads, and while demand for air travel has increased exponentially, many of the carriers continue to struggle in their quest to turn a healthy profit. A few steps can be taken to avoid bankruptcy and start the journey towards earning ever-increasing profits. (a)Cross utilization of employees. The major airlines must negotiate with their labor unions to seek changes to their agreements as concerns their duties. Management should highlight the advantages of cross utilization to the leaders of the unions, which can translate to a superior working environment, as employees are not limited to one function only. From a corporate perspective, this of course leads to productivity increases thereby decreasing costs (Haines, 2004). (b)Maintaining cost discipline. Airlines need to adopt efficiencies that include eliminating in-flight services such as food and snack distribution, flying more point-to-point routes, and decreasing turnaround times, which contribute to aircraft utilization. (c)Breakeven load factor. This is acquired by decreasing costs. It is the average percentage of seats that must be filled on an average flight at average fares for the airlines passenger revenue to break even with the airlines operating expenses. It is imperative for major airlines to reduce their breakeven load factors by focusing on reducing their unit costs thereby increasing their margins. (d)Intangible. Airlines should provide a fun atmosphere in their aircrafts that promote a fun outlook. They should also source for new aircraft if their present machines are dilapidated and not adopt a policy of providing frugal amenities, which can taint an airline for a long time with a reputation of stinginess. Buy custom Applications in Corporate Finance essay

Special Relationship between Britain & the United States of America Essay

Special Relationship between Britain & the United States of America since World War II - Essay Example (Sherwood Pg 442) Although Sir Winston Churchill denied every saying that but it captures the essence of the "Anglo American special relationship". The term itself was first used by Winston Churchill during his Iron Curtain speed in March 1946 to describe the warm historical, political, diplomatic, and cultural relations between Britain and the United States. However behind this simple term, the relationship between the two countries is considered to be much more complex going through what some may refer to as a rollercoaster ride; from Churchill and Roosevelt to Blair and Bush, from the Cold War alliance to the war on terror, and from the Beatles and Elvis to James Bond and Ronald McDonald. Therefore it is no surprise that the United States and Britain share the world's largest foreign direct investment partnership. American investment in Britain reached $255.4 billion in 2002, while British direct investment in the U.S. added up to a whopping $283.3 billion. This paper explores how and why the two countries worked so closely together in the early 1940s with emphasis on the two iconic personalities of Churchill and Roosevelt, the ups and downs of their political alliance, the seventies during which the relationship apparently swayed apart. The paper also discusses the relationship between Ronald Reagan and Margaret Thatcher in which they championed a new conservative revolution both at home and abroad, and finally the special relationship in the last fifteen years, especially the relationship between Blair and Bush after the September 11 attack and the Iraq war. Since Churchill coined the term "special relationship" it has been used as shorthand for the complex network of links between the United States and Britain. This relationship can be split into three levels which include personal ties between leaders, elite cooperation and mass sentiment. The first one of these is the most common which according to most historians paralleled the personal one that existed between Roosevelt and Churchill. Similarly it was the closeness between Reagan and Thatcher that helped maintain the special relationship between the US and Britain. Even Bush and Blair are said to have close personal ties. The importance of the relationship for the two countries and for international relations is visible when one glances at the world economic order, European security, cold war diplomacy and global containment that this special relationship helped contribute to from the Second World War till the early sixties. Throughout the sixties this special relationship ranged across trade, migration, investment, communication flows, and military linkage just to name a few. Although the relationship was not without its frictions but it was nevertheless important not just to both governments but to the shaping of the post war world. A decade later William Wallace in a study of British foreign policy gave examples of the relationship as "wartime joint American/British boards, informal meetings between political leaders of the two countries, close consultation by diplomatic personnel, military and intelligence service cooperation and other instances of intergovernmental cooperation" (Wallace 1975) The one

At the Benihana Restaurant Essay Example | Topics and Well Written Essays - 750 words

At the Benihana Restaurant - Essay Example We got so curious that we set out on a task to see the different types of kinemes. The analysis we did was in a restaurant called Benihana restaurant. Being a social space we had an excellent chance of making appropriate observations on the various forms, emblems, illustrators, regulators, adaptors, and affect displays of kinesics. Emblems defined as a substitute for words and phrases. Illustrators are gestures that accompany verbal communication. Affect displays defined as gestures that show emotion. Regulators are gestures that control the pace of the conversation. Adopters are the gestures that reduce the tension between two people conversing. On entering the Benihana restaurant, the waiter ushered us in and we noticed that he had put on a broad smile when he was greeting us, and when directing us to the table the waiter used his hand to show as the location of the table reserved for us. We saw nods directed at us by some friends that were present in the restaurant, and this we as sumed was a form of greeting. As we had made an observation of illustrators, the waiter pointing into the direction of the table, the smile he directed to us on the entrance of the restaurant was an affect display and the nods directed to us by our colleagues’ we took them for emblems. ... The welcoming, smile by the waitress is an affect display, and the nod is an emblem. The restaurant was playing jazz music in the background; I could tell that a lot of people in this place loved this genre of music since most people were swaying their head to the flow of the music. A look at the people carrying on with their conversation we could see a lady who from time to time, kept rolling a strand of hair that kept falling on her face, this we assumed was her way of making herself comfortable. Looking around for other gestures, we came up with people tapping on the table, others continuously rubbed their hands together, while others took in deep breaths from time to time. These expressions are what we call adaptors. The affect displays we observed in the room made us know that most of the meetings in that room were romantic dates. We could tell this from the smiles exchanged for couples they were not just ordinary smiles but affectionate smiles. We also observed a couple holding hands from time to time, exchange of different kisses, peck on the cheeks, forehead and the back of the hands all served as affection displays. We also; had a look at the regulators which included people shaking hands before they departed while others exchanged kisses and departed. Some people glanced at their watches signalling the end of the meeting. Among the emblems that we observed in the restaurant included, nods that most of the time we interpreted as ok, a swaying of the head from side to side in a continuous motion meant a no, a lift of the shoulders with the hand spread meant a maybe, waving of hands continuously to say bye. In addition, the thumbs up sign to show agreement could be spotted. We came to a

Othello by Lawrence Fishburne Essay Example | Topics and Well Written Essays - 500 words

Othello by Lawrence Fishburne - Essay Example Through Iago, Shakespeare reveals his remarkable understanding of the human psyche. The villain's cold manipulation of the key players in the script like so many puppets on strings chills one to the bone. Iago uses the technique of psychological suggestion to bring about the downfall of Othello. All the characters are merely pawns in Iago's deadly mental game. Everyone calls him "Honest Iago" and no one is wise to the rot in his character. Outwardly Iago shuns violence and plays the peacemaker while in reality he is usually the catalyst responsible for setting off cataclysmic bouts of violence. He passionately refutes dark suspicions which nobody would have entertained if he had not suggested it in the first place. He exploits individual weaknesses, and appeals to the dark side in human nature skillfully undoing the restraining bonds of conscience and decency and finally unleashing the beast that is an integral part of every individual. In this manner Iago goes about bringing his mon strous plot to fruition and plays a direct role in the death of the lovers. Shakespeare's genius lies in his ability to use his understanding of human psychology in the creation of his perfect villain, Iago. It is this feat which raises the text to the lofty realms of brilliance. The work evoked myriad emotions in this writer, pity, anger and a grudging admiration for the machinations of the villainous Iago.

An Overview Of Varanasi Tourism Essay

An Overview Of Varanasi Tourism Essay Varanasi Varanasi, also commonly known as Banaras or Kashi is one of the holiest cities in India and is situated in the northern Indian state of Uttar Pradesh. The city is situated on the west bank of the river Ganga and is one of the oldest, continually inhabited city in the world. Significance Varanasi is believed to have been established by Lord Shiva about 5000 years ago and, in addition to being one of the twelve Jyotirlingas, the city has long been a centre of religion and spiritualism. The city of Varanasi finds a mention in ancient Hindu religious texts and scriptures like the Ramayana, the Mahabharata, Rigveda amongst others. It is holy shrine of Lord Kashi Vishwanath, a manifestation of Lord Shiva and was here that Gautam Buddha was born and Varanasi is perhaps one of the few holy cities that enjoys a revered position among devouts of Hindus, Buddhists and Jains. Attractions Over the years, the city of Varanasi has earned several sobriquets, the city of temples, the city of lights and the city of learning. No wonder then, Varanasi is home to several temples, however, most of these places of worship were destroyed by pillaging Muslim armies of Mahmud of Ghazni and Mohammad Ghori. Varanasi is also home to over one hundred ghats scattered along the banks of river Ganga. The Kashi Vishwanath Temple: This temple was built in 1780 by Maharani Ahilyabai Holkar and encloses the holy Jyotirlinga of Lord Shiva and is said that a view of this Jyotirlinga is makes for a very profound spiritual awakening. The temple is a magnificent piece of architecture and is adorned by ornate carvings. Intricate carvings can also be seen on the dome that is the roof of this temple. Durga Temple: Is another temple of worship and is presided over by Goddess Durga. The temple is home to a large number of monkeys who can be found wandering around in the courtyard and the Durga kund, a small tank near the temple and is therefore, sometimes referred to as Monkey Temple. The temple built in the 18th century is a classic example of the Nagara style of architecture. The Sankat Mochan Temple: The Sankat Mochan temple is dedicated to Lord Hanuman and is one of the popular temples in Varanasi. This temple, unfortunately, was also the site of a vicious terrorist attack but that failed to diminish the faith of the devotees who still throng to this temple in large numbers to pay obeisance to Hanuman. Other Attractions Varanasi is also home to over hundred ghats located along the banks of the Ganga. By day, these ghats witness frantic activity of devotees wanting to take a dip in the holy waters and by evening, these ghats turn into a magnificent spectacle of lights it is here that the Ganga aarti is performed in the evening. How to Reach Varanasi has its own airport, the Babatpur airport, that is about 25 km from the city centre. The city is well connected by rail and road with other cities in India.

Hiding Places :: essays research papers

We go to places of comfort to get away from the burden of harsh realities. People use hiding places of physical means like a closet or library, to maybe think of things they care for and things that make them happy and . Whether it be your bedroom, your closet, you know you can always count on the satisfaction of you hidden place to be there for you and blanket you. No matter what, your hiding place is always going to be easily accessible and very accommodating . People enjoy this because it is a place they can go to for a guaranteed refreshing experience. Someone might resort to their room with the door shut and locked after a break up with a partner and write about the past experiences that they have endured together. The hiding place gives off an aura of familiarity and comfort. Something we can all use in a desperate time. Essentially, a hiding place has to provide a familiar physical stimuli. Hiding places often reside in the pages of literature. Within literature lies the tales of people lives, experiences, and knowledge. People love to play the part in Shakespeare, or be one of the knights from King Arthur’s Round table. It sets them closer to freedom. In books, inhibitions are set free, and people can ultimately be what they want. This is important when someone is feeling insignificant. Everyone needs to feel wanted, loved, and noticed, and if someone can not obtain these needs from someone, they will resort to someWHERE they can. Potential problems for hiding places is the disregard for the realities of the modern world. Someone who spends all there time in books is living there life falsely and will face tasks that they will not be able to conquer due to insecurities. Examples of the insecurities they endure are lack of confidence and lack of trust in others.

Panama Canal’s Legacy in American History

Assuredly the Panama Canal, If you didn’t know already, was one of the most economic and socialized marvels of its time. It was, at first, attempted by the French in the late 1800s, but they were unable to carry out the canal because of financial problems. Not only that, but yellow fever and malaria flooded the campgrounds with the aid of mosquitoes, which made the workforce unbalanced (Avery). Then in 1904, the Americans were to take over under the leadership and guidance of President Theodore Roosevelt. Even then Americans had a difficult time with construction. Moreover, with the canal built, it’s more sufficient then sailing around the tip of South America. Even today, the canal is used several times a day to bring benefits to the U. S. The French Admittedly, the French owned the Panama Canal before the U. S. Therefore, they were entitled to its construction under the leadership of Ferdinand de Lesseps, who worked on the Suez Canal in earlier years (Avery). Either Nicaragua or Panama would be the location for this engineered creation. Nicaragua was intentionally the first location for the canal (Jones) until one of the French leaders, one day, received a letter in the mail. As usual, the letter had a postage stamp on it (Avery). From there, Panama was then chosen to become the passageway, for the stamp showed Nicaragua’s terrain with erupting volcanoes, in which they didn’t want that to destroy their plans (Avery). From there, Engineers were sent to survey the area (Avery). Since the area was owned to the Columbian court, they had to persuade them to grant permission to build the canal (Jones). Finally, they were given permission to precede with their construction plans (Avery). Ferdinand De Lesseps. The man in control, Ferdinand de Lesseps, was an older man who was completely vain from his earlier success in the Suez Canal (Avery). To him, the Panama Canal would be no different. Clearly, he believed that the Panama Canal would be done quicker than the Suez, but was mistaken for in Panama consisted of nothing but mountains and rocky soil (Avery). In Egypt, it was only sand. His idea of the canal was that it would become a sea leveled canal, like the Suez and be parallel to the Panama Railroad that was built by the Americans earlier in the 1800s (Avery). With Him, a man named General Stephen Turr, who was a close Hungarian companion of de Lesseps, decided to help him in the canal (Avery). With Turr, the canal would be two thirds of the way done from the Rio Grande to the city of Colon, but it would be a take time and many lives, for Panama was infested with monstrous diseases that could kill men within forty eight hours. Disease Yellow Fever and Malaria roamed the French and, of course, American construction sites. Stegomya faciata was the species of mosquito that carried these diseases from one person to the next (Easmon). Thousands of men died from these diseases that, at first, seemed like a case of influenza because your body would be using a vast amount of substance to rid the infection (Easmon). Pursuing this further, it would worsen to a more serious case of the disease. Yellow fever is intellectually known as virus that has been transmitted from primates to humans through mosquitoes (Easmon). When the mosquito bit into the primate, it would then become permanently infected with the disease and ends up developing in the mosquitoes salivary glands to be spread to other organisms, which in this case, humans (Easmon). When bitten, the virus would travel into the bloodstream to make its way into the liver, kidneys, or blood vessels to incubate through time period of three to sixteen days before symptoms would occur (Easmon). Symptoms included headache, diarrhea, vomiting and anorexia. Soon after the body would recover for a time period of twenty four hours before it became more serious (Easmon). During this time the body would experience anemia (yellowing of the skin), liver inflammation, and jaundice, in other words, yellowing of the eyes (Easmon). Hence the reason it was given that name yellow fever (Easmon). The kidneys would become infected as well and cause the person to bleed from the nose, mouth and stomach (Easmon). What was interesting, though, was that the West Indian Negroes, which worked on the canal, were somehow immune to yellow fever, but they severely suffered from malaria (Avery). Malaria, on the other hand, was far off more deadly then Yellow fever for it consisted of parasites (Malaria). An engineer once quoted â€Å"If we could control malaria, I would be less anxious about other diseases. If we cannot control malaria, our mortality is going to very heavy† (American Canal Construction). Consequently, these infections developed in mosquito salivary glands as well and reproduce in the liver (Malaria). Above all, this incubation period could last for months to a year at a time (Malaria). When the parasites leave the liver they reenter the bloodstream where they are able to infect red blood cells to reproduce once again until the cell bursts (Malaria). As a result, it caused anemia and jaundice from the lack of blood cells (Malaria). Other symptoms include seizures, confusion, coma and death (Malaria). Thus, the French were not able to keep up with the rapid growth of infected patients. They had only a few nurses in the infirmary that where nuns and it didn’t benefit them at all since they were untrained, which lost even more lives (Avery). For example, the nurses would leave in the evening without giving any other care to the patients, which could have prevented the deaths of several lives if was brought up (Avery). Victims of disease were actually contained in screened cases with buckets of water to prevent insects from crawling up the beds (Avery). This created a breeding ground for mosquitoes (Avery). Later on, when the Americans took over they prevented this by oiling cesspools and canisters, fumigating Panama City, and ridding stagnant waters (American Canal Construction). Financial Problems Eight years after the French started the canal; they experienced financial problems with getting the canal finished. Ferdinand De Lesseps proceeded to travel back to France to attempt to find loans (Jones). He soon found out that France could not afford the vast amount he was asking for, which was around three million francs. The country could only pay eight percent of that amount (Jones). Engineers gathered together to calculate and survey the canal to discuss the completion of it and decided that it could not be done (Avery). Finally, in 1889, the French abandoned the Canal project pay back loans (Avery). In the final analysis, they were only able to finish two fifths of the canal (Avery). Most of the money that they used went to camp rent and maintenance, supplies, property and medical necessities, but non advised buying and those who stole money for possession greatly affected the outcome(Avery). One anonymous member of the French once quoted that â€Å"one part expended on the canal work, one third wasted, and one third stolen†. They left the canal up to America to finish the job and in 1894 the Americans had taken full control over the canal with Theodore Roosevelt’s leadership and power (Avery) President Theodore’s Impact President Roosevelt was first elected into office in 1901 (This Great Enterprise). For him, the canal could be easily used for military and economic power(This Great Enterprise). To peruse this even farther, he started negotiating Columbia for the possession for the canal. He offered forty million dollars to gain their permission to finish the canal, but Columbia refused (Buschini). Roosevelt became enraged with their decision, but Roosevelt knew that Panama was preparing to revolt against Columbia and decided to join them (Buschini). He then quoted â€Å"I was prepared to at once to occupy the Isthmus anyhow and proceed to dig the canal, but I deemed it likely that there would be a revolution in Panama soon† (Buschini). He then sent marines and gunboats to gain control over the canal and successfully forced Columbia to accept his request and grant Panama’s Independence (This Great Enterprise). In conclusion, the Panamanians and Roosevelt negotiated the Hay Bureau Varilly Treaty (Jones) that would trade U. S. military power for the independence of Panama and entitle the U. S. construction for the Panama Canal (This Great Enterprise). Many Americans didn’t approve of Roosevelt’s act against Columbia for the reason that they believed it was deemed unconstitutional, but Theodore Roosevelt Resumed his work and announced that â€Å"I took the Isthmus, started the canal, and then left congress—not to debate the canal, but to debate me†¦ While the debate goes on, the canal does to; and they are welcome to debate me as long as they wish, provided that we can go on with the canal†(Buschini). As Americans Built the Canal, they found several warehouses containing Machinery and supplies (Avery). Several Machines were found under water as well and allowed Americans to use them for spare parts (Avery). Also locomotives, cranes and other machinery were used to get the Panama Canal under way (Avery). Steam shovels were used instead of ladder dredges and Dump cars were loaded with soil to be shipped out of the area on the Panama Railroad (Avery). The Plan for America was to make the sea level canal into a lock canal with the depth of twenty nine and a half feet and ninety eight feet wide(Avery). Finally in 1914, the Panama Canal was able to open under the presidency of Woodrow Wilson (This Great Enterprise). To make sure there was no tension between the Columbian court and America, he negotiated a treaty paying Columbia twenty five million dollars to dissolve any potential conflicts (This Great Enterprise). Later on in 1978, President Jimmy Carter created a treaty to be ratified by the Senate that the Panama Canal would be given back to the people of panama to own and manage by the year 2000(This great Enterprise). The Canal’s Effect on the U. S. Indeed, the Panama Canal’s legacy brought several economic and social benefits for the U. S. In the U. S. it would create several more jobs to aid the canal’s shipment process and contain inflation for the hassle of transporting goods and by traveling around South America (Panama Canal). Since prices would decrease on imported goods, the American people would gain more money to spend on other necessities. In return, this would boost America’s economy through spending. The only consequences that resulted from this achievement was that it cost America three hundred and fifty two million dollars to complete the canal in addition to several acres of tropical forests were destroyed, people were driven from their homes and several lives were lost through disease and natural causes (Panama Canal). Socially, this canal would allow military alliances stronger between America and other countries and showed its importance through foreign intervention. To pursue these even farther, treaties were also created through the canal’s construction that brought America and other countries together as well (Panama Canal). Conclusion All in all, it has taken the Panama Canal about four decades to be completed. Through the French’s financial problems to America’s success in 1920, several hardships were created and overcome. America’s success would never have been accomplished if it wasn’t the determination of President Theodore Roosevelt and his revolt against Columbia. Even though the French were unsuccessful to complete the canal, they still have the right to know that they aided the Americans by leaving assets for repair, spare parts, and aving the U. S. thousands of dollars in medical centers, cabins, tools and supplies. Several lives were lost as well through Panama’s horrific diseases and other factors such as landslides, but it’s social and economic impact on America greatly affected its economy and alliances through military aid and trades. Through the twentieth century, the legacy of the panama was one of the most social and economic investments of its time and will always and forever be a part of America’s success.

Biography of John W. Young

Biography of John W. Young John Watts Young (September 24, 1930 - January 5, 2018), was one of the best-known of NASAs astronaut corps. In 1972, he served as commander of the Apollo 16  mission to the moon and in 1982, he served as commander of the first-ever flight of the space shuttle Columbia. As the only astronaut to work aboard four different classes of spacecraft, he became known throughout the agency and the world for his technical skill and calm under pressure. Young was married twice, once to Barbara White, with whom he raised two children. After their divorce, Young married Susy Feldman. Personal Life John Watts Young was born in San Francisco to William Hugh Young and Wanda Howland Young. He grew up in Georgia and Florida, where he  explored nature and science as a Boy Scout. As an undergraduate at Georgia Institute of Technology, he studied aeronautical engineering and graduated in 1952 with highest honors. He entered the U.S. Navy straight out of college, eventually ending up in flight training. He became a helicopter pilot, and eventually joined a fighter squadron where he flew missions from the Coral Sea and the USS Forrestal. Young then moved to become a test pilot, as so many astronauts did, at Patuxent River and the Naval Test Pilot School. Not only did he fly a number of experimental aircraft, but he also set several world records while flying the Phantom II jet. Joining NASA In 2013, John Young published an autobiography of his years as a pilot and astronaut, called Forever Young. He told the story of his incredible career simply, humorously, and humbly. His NASA years, in particular, took this man- often referred to as an astronauts astronaut- from the Gemini missions of the early to mid-1960s to the Moon aboard Apollo, and eventually to the ultimate test pilot dream: commanding a shuttle to orbital space. Youngs public demeanor was that of a calm, sometimes wry, but always professional engineer and pilot. During his Apollo 16 flight, he was so laid-back and focused that his heart rate (being tracked from the ground) barely rose above normal. He was well-known for thoroughly examining a spacecraft or instrument and then zeroing in on its mechanical and engineering aspects, often saying, after a blizzard of questions, Im just asking... Gemini and Apollo John Young joined NASA in 1962, as part of Astronaut Group 2. His classmates were Neil Armstrong, Frank Borman, Charles Pete Conrad, James A. Lovell, James A. McDivitt, Elliot M. See, Jr, Thomas P. Stafford, and Edward H. White (who died in the Apollo 1 fire  in 1967). They were referred to as the New Nine and all but one went on to fly several missions over the next decades. The exception was Elliot See, who was killed in a T-38 crash. Youngs first of six flights to space came in March 1965 during the early Gemini era, when he piloted Gemini 3 in the first manned Gemini mission. The next year, in July 1966, he was the command pilot for Gemini 10 where he and teammate Michael Collins did the first double rendezvous of two spacecraft in orbit. When the Apollo missions began, Young was immediately tapped to fly the dress rehearsal mission that led to the first Moon landing. That mission was Apollo 10 and took place in May 1969, not quite two months before Armstrong and Aldrin made their historic trip. Young didnt fly again until 1972 when he commanded Apollo 16 and achieved the fifth human lunar landing in history. He walked on the Moon (becoming the ninth person to do so) and drove a lunar buggy across its surface. The Shuttle Years The first flight of the space shuttle Columbia required a special pair of astronauts: experienced pilots and trained space fliers. The agency chose John Young to command the maiden flight of the orbiter (which had never been flown to space with people aboard) and Robert Crippen as the pilot. They roared off the pad on April 12, 1981. The mission was the first manned one to use solid-fuel rockets, and its objectives were to get to orbit safely, orbit Earth, and then return to a safe landing on Earth, as an airplane does. Young and Crippens first flight was a success and made famous in an IMAX movie called Hail Columbia. True to his heritage as a test pilot, Young descended from the cockpit after landing and did a walk-around of the orbiter, pumping his fist in the air and inspecting the craft. His laconic responses during the post-flight press briefing were true to his nature as an engineering and pilot. One of his most-quoted lines answers was to a question about ejecting from the shuttle if there were problems. He simply said, You just pull the little handle. After the successful first flight of the space shuttle, Young commanded only one other mission- STS-9 again on Columbia. It carried the Spacelab to orbit, and on that mission, Young stepped into history as the first person to fly into space six times. He was supposed to fly again in 1986, which would have given him another space flight record, but the Challenger explosion delayed the NASA flight schedule for more than two years. In the aftermath of that tragedy, Young was very critical of NASA management for its approach to astronaut safety. He was removed from flight duty and assigned a desk job at NASA, serving in executive positions for the rest of his tenure. He never flew again, after logging more than 15,000 hours of training and preparations for nearly a dozen missions for the agency. After NASA John Young worked for NASA for 42 years, retiring in 2004. He had already retired from the Navy with the rank of captain years earlier. Yet, he remained active in NASA affairs, attending meetings and briefings at the Johnson Space Flight Center in Houston. He made occasional public appearances to celebrate important milestones in NASA history and also made appearances at specific space gatherings and a few educators meetings but otherwise remained largely out of the public eye until his death. John Young Clears the Tower for the Final Time Astronaut John W. Young died from complications of pneumonia on January 5, 2018. In his lifetime, he flew more than 15,275 hours in all kinds of aircraft, and nearly 900 hours in space. He earned many awards for his work, including the Navy Distinguished Service Medal with Gold Star, the Congressional Space Medal of Honor, the NASA Distinguished Service Medal with three oak leaf clusters, and NASA Exceptional Service Medal. He is a fixture in several aviation and astronaut halls of fame, has a school and planetarium named for him, and received Aviation Weeks Philip J. Klass award in 1998. John W. Youngs fame extends well beyond his flight time to books and movies. He will always be remembered for his integral role in space exploration history.

Marcia J. Citron essays

Marcia J. Citron essays The works of a composer are not the only factor used to determine canonization; culture and gender play a large part in this process. Citron shows how the Western art canon is the result of a complex mixture of opinions, traditions, and interests that often go unacknowledged and unchallenged. The term canon was applied to music in last twenty years, defined as a specified group or body of related works. 1 It is debatable as to whether works are incorporated into the canon as a pre-existent concept or if the canon is only significant through the application of these works into a articulate and expressed repertoire. The canon is restricting in that it set the criterion for works that are to be included or discounted as marked repertoire. There is a categorization process that takes place in the development of the canon. This process places works into an appropriate group and eliminates those that do not fit the mould of what has been deemed culturally acceptable. Much new music is not accepted into reportorial canons, because the canons of the past have set high standards that do not allow for the conception and recognition of new music. These standards of repertoire are defined by cultural groups that are considered dominant on the basis of class, race, gender, age, oc cupation, nationality, and religious orientation. However, the canon is restricted, because the ideals set by one particular social group may not be appropriate for another; therefore, it is not representative of the whole, rather it merely represents the opinion of an individual group. These individuals often change, presenting a change in the standards of the canon as well as a transformation of the value of the canon as a whole. Textbooks and academic curriculum also influence the construction of the canon. Textbooks emphasize specific works and composers on which instructors and students rely on as a source of musical inform...

Social media effects on social & personal behaviors Research Paper

Social media effects on social & personal behaviors - Research Paper Example Increased use of social media in the education will improve students’ social and personal behaviors. Social media is the new mode of communication as well as education. Students of all ages and levels of education have been deeply engrossed with using the different social media to carry out research on school assignments and to communicate with their fellow classmates and their professors. The professors and tutors are also using the platforms to contact their students as far as educational matters are concerned. The continued use of the social media has led to more positive changes in the social and personal behaviors of the students than the negative ones and the research findings indicates that more positive effects can influence the use of social media. It is important to look into more detail about these positive and negative effects of social media use in education because its use is on the increase. Addressing these issues will enable those in the educational field to g et tips on how to engage their students more efficiently and effectively, as well as to assist students to interact and to enhance their classroom skills. Positive effects will be collaborative interaction, communicate with an instructors and peers, and create positive environment in school, whereas the negative effects will include cyber-bullying, stalking, and creating a negative environment in education.

The Role of Mitosis and Miosis In Cancer Tistes Antigen (CTA) Literature review - 1

The Role of Mitosis and Miosis In Cancer Tistes Antigen (CTA) - Literature review Example In this work called "The Role of Mitosis and Meiosis in Cancer Testis Antigen (CTA)" author overviews the connection between differentiation failure and cancer development in patients with testis cancer. Division of germ cells has special features that make this illness distinguished in comparison with the other groups of cancer diseases. It is a well-known fact that the germ cell line derives from the primordial germ cells. These cells basically migrate through the dorsal mesentery of the embryo and then enter the fetal gonad that is developing in the genital ridge. In males, in this genital ridge, the primordial germ cells are enclosed by somatic Sertoli cells and are known as prospermatogonia. These proliferate for a few days and then rest at G0 or G1 of cell cycle until puberty. When the individual attains puberty, the proliferation of the prospermatogonia resumes, thus initiating spermatogenesis. Spermatogonia are the male germline stem cells and they proliferate from puberty al l through the adult life. Two meoitic divisions are involved in this step and a tetraploid of primary spermatocytes are first formed which further undergo meiosis to form haploid sperms. Cancer Testis Antigens or CTAs like MAGE and NY-ESO-1 are basically expressed in these spermatogonia. This tiny investigation is aimed at defining role reasons of CT development in patients, who are included in the high-risk group. Tables, statistics and scientific evidence-based argumentation without any doubt will help you to get the highest A!