The declining incidences of strikes in the United States and some Research Paper

The declining incidences of strikes in the United States and some possible explanations - Research Paper Example To understand the extent and causes of this phenomenon, one needs to leaf through the labor history of this country. Once the European settlements grew in America, notions of prosperity based on agricultural development slowly started to be replaced by the mineral wealth mined out from the earth. Gold and silver became the most coveted attributes and mining expeditions often ended up in looting of ancient civilizations like Aztecs and Incas. The American labour class emerged from the Native Americans who were deprived of their godly havens of Mother Nature and left to toil for a living by this new civilization. (Nicholson, 2004, p.4). Expansion of trade succeeded the crusades of 13, 14 and 15th centuries. America along with the whole world was witnessing the birth of the merchant class, the bourgeoisie. Colonies in Africa were established initially to exploit the rich natural resources but eventually the merchants realized that they could make use of the physical capabilities of the black Africans to further their commercial interests. America started importing African slaves who thereby joined the labour forces of the country. When following the civil war, slavery was finally abolished in 1865, all the free slaves got consolidated into a more visible form of working class. Thus it was the ethnic mix of natives and black slaves that formed the labouring masses of this country. Philip Yale Nicholson, writing on the labour history of USA had noted several historians observing that â€Å"the wealth produced by slavery and slave trade provided the economic foundation for the industrial revolution and that plantation slave labour was the precursor to the property-less industrial working class or proletariat.† (Nicholson, 2004, p.6) The working conditions of the early labourers were so inhuman that the human spirit in them often revolted in the form of â€Å"theft of property, flight into the wilderness or other colonies, rebellions, slowdowns, strikes, mutinies

Hydrochloric acid Essay Example for Free

Hydrochloric acid Essay Prediction I predict that the more marble chips there are, the faster the rate of reaction, because there is more marble for the hydrochloric acid to react with, I predict this because in previous experiments when working with the same equipment I found that if you put a lot of marble in the acid, the levels of water in the burette go down very quickly, compared to when you only put a little bit of marble in the acid and the levels of water go down much slower. I also predict that the hotter the temperature of acid, the faster the rate of reaction, because heat often works as a catalyst in experiments with acid. Increasing the temperature of the acid will increase the rate of reaction because particles move faster and collide more vigourously at higher temperatures. Plan I will fill a burette with water, and then turn it upside down in a beaker full of water. I will then put a tube into the bottom of the burette and attach it to another beaker using a bung to stop any air from leaking. I will then calculate the rate of reaction between the marble chips and hydrochloric acid by measuring how much the levels of water in cmi drops every 10seconds. So that it is a fair investigation I will make sure that I always start with 50cmi of water in the burette, and 1000cmi of acid in the beaker. I will also make sure that I take readings every 10 seconds, because otherwise my results would be invalid, or have results missing. The factors that I will investigate to see if they cause change are temperature of the acid, and amount in weight of marble chips. I will test 0. 5g and 1g of marble chips at every temperature, and will try and repeat every experiment twice so that I will be able to see whether any results seem totally inaccurate. I will test the rate of reaction at three temperatures, firstly I will cool the acid to 6i C. I will do this by putting the beaker of acid in a larger beaker of water and ice. This will ensure that no ice comes into contact with the acid so the water wont dilute it. I will then add the marble chips. I will then test the rate of reaction at room temperature, and after that I will test the rate of reaction at 55i C by heating the acid with a Bunsen burner and then adding the marble. I will set up the apparatus as below: Results: The rate of reaction for 0. 5g marble chips at 6 degrees C. Time (seconds) Level of water in burette (cmi ) 0 50 10 49. 4 20 49. 4 30 49. 4 40 48. 5 50 47. 6 60 46. 3 70 44. 1 80 43. 4 90 42 100 41 110 39. 9 120 38. 8 130 37. 6 140 36. 5 150 35. 8 160 34. 9 170 33. The rate of reaction for 0. 5g marble chips at room temperature. Time (seconds) Level of water in burette (cmi ) The rate of reaction for 1g marble chips at room temperature. Time (seconds) Level of water in burette (cmi ) The rate of reaction for 0. 5g marble chips at 55 degrees C. Time (seconds) Level of water in burette (cmi ) The rate of reaction for 1g of marble chips at 55 degrees C. Time (seconds) Level of water in burette (cmi ) 0Conclusion I conclude that my predictions that the hotter the acid, the faster the rate of reaction, because the particles move faster and collide more at higher temperatures, and the more marble chips there are, the faster the rate of reaction, because there is more marble for the acid to react with to be true. I can prove this because using my line of best fit on the averages graphs, I calculated the rate (by using the formula: Level of water/ Time (seconds)), at about 60 seconds in all but the hot acid experiments, where I worked out the rate at 40 seconds. I chose these times because at about these times the experiment was well underway, so the rate would be accurate, and it wouldnt be too late that the reaction was slowing down. I worked out that the rates were: Evaluation I think that the experiment went quite well overall, and we got some quite good results. I think if I did it again I would work with a weight of crushed marble chips instead of just a set weight of random sized marble chips, because the larger the surface area of something, the shorter length of time it takes to dissolve, and this could have effected the results of these experiments because the reactions that took longer may have taken longer because the marble was smaller in surface area than in other experiments. This is because the larger the surface area, the more particles that are in contact with the acid at any one time, so it will be able to react faster. I might also use different strengths of acid to see whether the stronger the acid is, the faster the rate of reaction. A stronger concentration of acid will increase the rate of reaction, because more collisions of molecules are possible in the same amount of time, because there are more particles available in the same volume of acid.

Principles of Acid Base Balance

Principles of Acid Base Balance The purpose of this handout is to educate the student on basic principles of acid base balance. To give a systematic approach to interpretation and understanding of arterial blood gases and appropriate care for the patient who is having a blood gas taken. It is intended that the student will learn from this package but also be encouraged to source other material to broaden their understanding of acid base balance. It is intended that this learning packet will complement their experiences with help of an understanding mentor, who will assist them with questions raised both within themselves and within the book. An arterial blood gas measures the acidity of the blood, the levels of carbon dioxide and levels of oxygen. The blood is taken from an artery prior to the blood distributing the oxygen from blood cells to the body tissues. The values the gas will show are: Partial pressure of oxygen (PaO2) this measures the pressure of oxygen dissolved in the blood Edwards (2009) say this can indicate how good respiratory system is functioning. This can indicate oxygen saturation and how well oxygen can move from the lungs to the blood Partial pressure of carbon dioxide (PaCO2) this measures how much CO2 is dissolved in the blood and how well it can move from the blood to the lungs (and out of the body). Foxall (2008) explains that co2 mixed with water turns in to carbonic acid that the lung must excrete to prevent an acidosis. Bicarbonate (HCO3) Bicarbonate is the form in which a large amount of acid is removed from the cells Schilling (2008) says about 70% is removed from tissues and bicarbonate can be measured as either actual or standard bicarbonate. The standard which is the more important value is obtained by using a PCo2 of 5.6 kPa as a reference for the amount of CO2 in the body. Base excess (B.E.) Springhouse (2008) explains that the base excess indicates the amount of excess or lack of bicarbonate in the circulatory system it can be a negative number indicating too much acid or a positive number indicating too much base. It normal range is -2 to +2 Introduction Skinner (2005) and Adam (2009) concur in that arterial blood gas analysis is an essential part of diagnosis and management a patients ventilation therapy and their acid base balance. Skinner continues to say the usefulness of this intervention is dependent on the ability of the health professional to analyse and interpret the individual aspects of the gas. The intention of this learning packet is to introduce the learner to the individual aspects of a blood gas, and there meaning. Additionally it hopes to show how to bring these values together to formulate a decision on the patients condition and suggest options for treatment. Common reasons for blood gas analysis are: To diagnose and assess existing lung function. To review treatment for lung disease and evaluate its effectiveness. To assess if extra oxygen is required for a patient or if further support is required (CPAP, BIPAP or PPV). To measure the acid base level in patients where it is compromised. Patient would include renal patients, patient with heart failure, severe infected patients uncontrolled diabetes or individuals who have taken an overdose. Preparing the patient. Explain to the patient that they are having a blood test from their artery. It is likely to be taken from a radial artery. Nettina (2005) Describes a test to assess the puncture site prior to puncture called the Allens test procedure. This will evaluate the blood circulation in the hand and whether it is appropriate to use the radial artery for puncture. The site will be cleaned with alcohol and allergy status permitting anaesthetic agents will be applied to reduce discomfort, and increase possibility of success. Dougherty (2008) suggests that the patient should be encouraged to breathe normally through the procedure and the doctor may ask for cessation of supplementary oxygen prior, to give a better understanding of the patients present condition. After the syringe is full, place gauze over the puncture site and apply pressure until bleeding has stopped. This may be some time if the patient is on blood thinners or has coagulopathy. Once bleeding has stopped apply a dry dressing but monitor for any further bleeding. After the procedure there is a possibility of bruising although the longer pressure is kept on the puncture site the lower the risk. Some light headedness or nausea may occur during or after the blood draw. On rare occasions the needle may damage the artery or a nerve causing it to become blocked. As a result care must be taken with the wrist once blood draw has taken place. How it feels Dougherty explains that collecting arterial blood from a patient is a procedure that is often painful. It is more painful than the routine venous phlebotomy your patient may be used to. There are a number of reasons for this, arteries are often deeper than veins and surrounded by nerves. Ideally the patient is given a local anaesthetic and the patient feels just a sting as the needle punctures the skin. Otherwise there is a sharp pain as the needle enters the artery. If the procedure becomes protracted either by the practitioner having difficulty finding the artery or the artery is narrow the pain may more than brief. It is important to note that both pain and fear would cause the arteries to narrow so reassurance is important and if the practitioner continues to have difficulty you must advocate on the patients behalf since fear would impact on future successful arterial blood gas collection. Questions What other sites could a patient have blood gases taken from? Can only arterial blood be used for blood gases? What values would be markedly different in a venous sample blood gas. Why would a patient emotional response make blood draw difficult how can we reduce the affects of this to cause a positive outcome What medications or disease process would make a patients bleeding time prolonged after sampling? Further reading Royal Marsden clinical procedures manual 2008, Dougherty etal Overview The measurement of a blood gas will show a pH value. PH is a value the can range from 1 to 14 and is a measure of acidity or alkalinity of a substance. Springhouse(2008)explains in the blood stream the pH value is inversely proportional to the number of hydrogen ions in the blood. The fewer ions the higher the number (alkalosis) and vica versa, more ions would mean a lower number (acidosis). A solution with a pH of 1 is acidic and a solution of pH 13 would be alkalotic. A solution of pH 7 is called neutral since it is in the middle, it is neither acidic nor alkalotic, and water has a pH of 7. Adams (2009) explains that the normal PH of the body ranges from 7.35 to 7.45. In order for normal metabolism to take place the body must maintain this fine balance at all times. He clarifies that if the pH level rises the blood is said to be alkalotic or acidic if it drops below 7. Hall (2009) says the ability of the body to function normally is impaired if the pH moves from these parameters. Hall also concludes that in acidosis the bodys response to medication is muted, cardiac function is impaired since contractility and vascular response to catecholamines is reduced. If the patients pH is raised then oxygenation is effected which interferes with neurological and muscle function. Adams points out that severe changes in pH that is above 7.8 or below 6.8 will interfere with basic cell function and respiration and if not corrected will result in death. Below is a discussion on how the body regulates this delicate balance. We will elaborate on the processes the renal and respiratory systems use to buffer the bodys processes to keep this fine balance. The respiratory buffer system Hinds (2008) explain that carbon dioxide (CO2) is a normal by product of cellular metabolism. Carbon dioxide is carried in the blood to the lungs where excess CO2 combines with water (H2O) to form carbonic acid (H2CO2) in the blood. The blood pH will change according to the level of this acid in the blood. This fluctuation triggers either a rise or fall in respiration until the level of CO2 is returned to the patients base line. Hinds explain that this system is fairly rapid and can be triggered in a short space of time a few minutes in most cases. The renal buffer system Henessey (2007) simplifies the metabolic system explaining that the kidneys also maintain acid base balance by the excretion or retention of bicarbonate (HCO3). As the pH rises HCO3 is excreted and in return as the pH decreases HCO3 is retained. Although an effective system the renal system is slow to respond to imbalances, requiring hours or days to attend altered pH. Questions If neutral pH is 7 why does the body require a mean of 7.4 a slightly alkalotic environment to operate? The notes above indicate the bodys response to catecholamines is muted what are these and why are they important? Normal values pH 7.35 to 7.45 PO2 11 to 13.3 kPa PaCO2 4.8 to 6.0 kPa HCO3 21 to 28 mmol/l Acid Base Disorders Respiratory acidosis. Henessy (2007) discussion on respiratory acidosis is defined as a pH less than 7.35 with a Pco2 greater than 6.0 kPa. This type acidosis is caused by a build up of CO2 which combines with water in the body to produce carbonic acid thus lowering the pH of blood. Driscoll (1997) says any condition that results in a reduction in ventilation can cause this type of acidosis. Head trauma, which has inflicted damage to the respiratory centre leading to respiratory depression. Sedatives, narcotics, neuromuscular blocking agents or anaesthesia, which can cause central nervous system depression. Impaired respiratory muscle function related to spinal cord injury or neuromuscular disease. Poor lung function such pneumothorax, pneumonia, atelectasis or bronchial obstruction. Hypo inflation due to pain chest injury or abdominal distension. Hasan (2009) simplifies the presentation of the signs and symptoms of respiratory acidosis are centred within the respiratory, cardiovascular and nervous systems. These symptoms can range from shallow breathing or dyspnoea to headaches or altered consciousness and irritability. If left unchecked these symptoms deteriorate towards drowsiness and coma. Increasing ventilation support will correct this type of acidosis. The specifics of how this will be done is dependant on the mode of insult to the respiratory system. Edwards (2009) suggests ventilator support could be oxygen via a face mask, non invasive ventilation (N.I.V.) or positive pressure ventilation (P.P.V.). If medications are inhibiting respiratory function then reversal agents can be deployed whilst supporting the patients respiratory needs. Pneumothorax and pain are problems that can be reversed promptly once the patients condition allows. Marino (1997) say that if the patients symptoms or condition, cannot easily be resolved then it may be appropriate to ventilate the patient mechanically. Commonly patients with respiratory acidosis are hypo ventilating, as a result they will benefit from supplemental oxygen but this only improves the quality of respiration; it does not in fact remedy the problem. Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2 less than 4.8 kPa. Any condition that causes hyper inflation can result in respiratory alkalosis. These conditions include, Pain Anxiety fear or panic Medications which stimulate the respiratory system Lesions in the brain affecting the respiratory centre Increased metabolic demands such as fever sepsis or pregnancy. Alkalosis will present cardiovascular or central nervous system disorder. Springhouse (2008) illustrates that presentations can be dysrhythmias and palpitations to numbness and confusion. Additional symptoms are dry mouth, blurred vision and titanic spasms of the arms and legs. To resolve the alkalosis the cause of the hyper ventilation must be attended to. These patients are at risk of suddenly deteriorating, they have tachypnea and must be supported to reduce fatigue. If they become tired their own ability to ventilate adequately will be impaired leading to respiratory failure. Questions What would be the signs and symptoms of a patient with a respiratory caused imbalance? Which kind of medications can cause an acidotic condition and what would be the reversal agents? In respiratory alkalosis why do patients suffer with tetany? What are the signs and symptoms of respiratory failure? Metabolic acidosis Metabolic acidosis is defined as a bicarbonate level less than 21mEq/L with a pH of less than 7.35. Schilling (2008) explains metabolic acidosis is caused either by a deficit of base in the blood stream or an excess of acids other than CO2. Excessive bowel action such as diarrhoea and intestinal fistulas may cause decreased levels of base. Increased acids can be caused by a number of factors such as: Renal failure Diabetic ketoacidosis Anaerobic Metabolism Starvation Salicylate intoxication Hall (2009) Signs and symptoms of metabolic acidosis are varied affecting numerous systems. The nervous system presents with headaches, dizziness leading to confusion or later coma. Dysrhythmias are common as conduction pathways are affected and low blood pressure due to desensitivity to catecholamines such as epinephrine. Marino (1997) elaborates to say the respiratory system will attempt to correct imbalances by breathing out more CO2. Kussmaul respirations these are deep and laboured breaths. In the gastro intestinal tract nausea and vomiting is noted as well as warm flushed skin. The Hinds (2008) says treatment of the metabolic acidosis is to resolve the cause, this invariably means an initial review of body systems and their function. By assessing each function and its efficiency, underperfused or hypoxic tissue beds can be identified. Hypoxemia can lead to generalised anaerobic metabolism, but hypoxia of a specific tissue bed will produce metabolic acids even if oxygenation (PaO2) is normal. To reverse this acidosis perfusion must be restored which in turn will cease the anaerobic metabolism. Hinds warns that other causes of metabolic acidosis should be addressed after the possibility of hypoxia and poorly perfused tissue beds have been resolved or ruled out. Metabolic alkalosis Metabolic alkalosis is defined as a bicarbonate level of 28mEq/L with pH greater than 7.45. Metabolic alkalosis obviously is the reverse of the previous condition deriving from an excess of base or a deficit of acid. Adam (2009) suggests that excessive base comes from ingestion of antacids, excess use of bicarbonate or lactate in dialysis. Low amounts of acid come from overuse of diuretics, gastric suction or protracted vomiting. It presents through neurological signs and symptoms varying from light headedness to seizures and coma or musculoskeletal symptoms of weakness, muscle cramps and tetany. Other associated signs might be nausea and vomiting and respiratory depression. This is a relatively uncommon presentation and presents a challenge in treatment. Bicarbonate can be stimulated thought the kidneys by drugs such as Acetazolamide but it is a protracted therapy. Severe cases I.V. administration of acids may be used Questions Which other value is closely linked with the metabolic state of the body? What does it signify? What signs and symptoms would a patient show who presented with a metabolic acidosis? In a very severe alkalosis state what I.V. acids could be administered? Steps to Arterial Blood gas interpretation There are simply 3 steps to interpreting a blood gas result and each must be done in order to prevent confusion and misdiagnosing your patient. The components are pH PaCO2 and HCO3 below are three steps and following are examples to assist you in interpreting them. Step One Review the pH initially is this normal or abnormal? If the pH is above 7.45 it is alkalotic if it is below 7.35 then it is acidotic. Step Two If the blood sample pH is altered then we must consider how this is being affected. Initially assess the PaCO2 this value will move in the opposite direction to the pH when there is a insult to the respiratory system. That is as the pH falls out of normal values the PaCO2 rises from its normal limits. The reverse is true if the PaCO2 falls then the pH will rise. Step Three The third step is to assess the HCO3 value. If there is an altered metabolic function the HCO3 will alter in a similar direction to the pH. As the HCO3 value rises so will the pH and as one decreases so will the other. Examples: Using the table above and your knowledge you have gained try and diagnose the problems below. Example 1 Mr Brown is a 72 year old man admitted with recent chest infection to the assessment unit. He is quite short of breath and has a strong cough his blood gas show the following information Patient: John Brown D.O.B.01:01:38 PH 7.30 PaCO2 8 HCO3 25 Step one, assess the pH is it normal? It is not, it is low therefore it is acidotic. Step two, assess the PaCO2 is it normal? It is not, it is raised which is the opposite direction of the movement of the pH. Step three, assess the HCO3, is that normal? Yes it is within its normal range. Reviewing the grid it can be seen the pH being low, the PaCO2 raised and the HCO3 normal shows a respiratory acidosis. Example 2 Maria 29, who has a long history indigestion and reflux, has come to the drop in clinic with vomiting unresponsive to her usual medications and cramp in her hands. A routine blood gas shows the information below. Patient: Maria Goode D.O.B.: 01:01:1981 pH 7.51 PaCO2 5.5 HCO3 35 Assess the pH, is it normal? It is high indicating alkalosis Assess the PaCO2 is it normal? It is normal Assess the HCO3 is it normal? It is raised, moving in the same direction as the pH. Looking at the chart above a raised pH and a raised HCO3 would indicate a metabolic alkalosis state Discussion on compensation So far we have only looked at a simple blood gas scenarios, with only one system failing. As Hasan (2009) indicates that often if one system fails or falls out of normal range altering the pH the second system will activate and work harder to compensate to bring the pH back in to normal limits. This activity is called compensation. Foxall (2008) describes that when a patient develops an imbalance over a period of time the body will naturally attempt to compensate. The lungs and the kidneys are the primary response mechanisms and so the body will try to resolve any metabolic or respiratory imbalance to return the pH to normal There are varying degrees of compensation initially uncompensated, an altered pH with only one value out of normal range. Partially compensated blood gas, an altered pH value with both values out of normal range. Compensated blood gas, a normal pH value with possibly both values out of range. Previous examples we looked at were simple uncompensated blood gases. Now lets look at more advanced gases such as partial compensation. To review these gases as before break the interpretation down in to three simple steps Assess the pH, is the gas acidotic or alkalotic Assess the PaCO2; is the PaCO2 a normal value? As reviewed before respiratory imbalances will move the pH in the opposite direction to which the PaCO2 moves when causing a primary imbalance. If the PaCO2 is moving in the same direction that is either increasing, or decreasing in value, then this would be a compensatory behaviour and it would indicate the primary insult is coming from the kidneys (metabolic). In a compensatory environment a decreasing PaCO2 would show the lungs are buffering by excreting excess acid by blowing off Co2 in order to equalise the balance of acids and return the pH to normal. Conversely a raised pH and raised PaCO2 would indicate a buffering response by the lungs which would reduce acid excretion in an effort to return to homeostasis. In summary, if there is evidence of compensation, but the pH has not yet arrived back into normal limits then it is only partial respiratory compensation. Assess the HCO3. In our original uncompensated examples the pH and the HCO3 moved in the same direction when the primary insult was metabolic. Following our discussion above in compensatory behaviours the values will work counter to their normal presentation. So if the pH is decreasing when the HCO3 is increasing or decreasing when the pH is increasing this is a compensatory action therefore the primary insult is a respiratory one. The kidneys will hold on to or release HCO3 in response to the abnormal pH to equalise the acid in the body to return the bodys pH to normal The essential difference between these two states is that they are on a journey towards normal from possibly uncompensated , to partially compensated, to fully compensated environment (normal pH). The body is always trying to correct the imbalance however successful, but the body will never over compensate. As can be seen from the above table the pH in fully compensated states is normal. Knowing which side of 7.40 will help in determine the original imbalance that is now compensated. More technical questions Example 1 A patient enters the AE who is known to the renal team. He has been having dialysis 3 times a week for a year but missed his last appointment. He is complaining of being unwell. A Routine blood gas show the following results Using the same 3 steps we have used before: Patient : George Philip D.O.B. : 01:01:50 pH 7.31 PaCO2 3.9 HCO3 18 Is the pH normal? The answer is no it is low therefore it is acidotic Is the PaCO2 Normal? No this is also low. If the PaCO2 was causing the primary insult we would expect it to move in an opposite direction to the pH in this case it is not. We must conclude therefore that the primary insult is metabolic and the paCo2 is out of range in a compenstatory role. The lung are excreting CO2 to reduce the PaCO2 whereby return equilibrium and return the pH to normal. Is the HCO3 normal? It is not it is low moving in the same direction as the pH. Therefore confirming what has already been said that the primary problem is metabolic. If you review the tables above it can be seen that the primary problem is metabolic but the full diagnosis would be a partially compensated metabolic acidosis Example 2 A lady walks in to her local surgery complaining of shortness of breath she is a long term smoker. A routine blood gas shows the following results Patient: Jane OBrien D.O.B. : 01:01:62 pH 7.35 PaCO2 7.2 HCO3 29Assess the pH is it normal? Yes it is, but the low side of neutral Assess the PaCO2 is it normal? No it is raised an acidotic condition. If this is the primary problem we would expect the pH to move in opposite direction to the PaCO2. Assess the HCO3 is it normal? No it is also high which is representative of an alkalotic state. Although the pH is normal both elements are out of range showing there is full compensation being achieved. The pH is lower than 7.40 which shows it is moving in the opposite direction as the HCO3 which show the initial insult was respiratory and that the kidneys are compensating by retaining bicarbonate Her arterial blood gas would be interpreted as fully compensated respiratory acidosis Example 3 A 42 year old man on the surgical unit with history of bowel obstruction has had N.G. on free drainage has become unwell. Routine labs were sent and the blood gas below: Patient: Tom Jones D.O.B. : 01:01:47 pH 7.44 PaCO2 7.1 HCO3 34 Is the pH normal? Yes Raised within normal limits Is the PaCO2 normal? No this value is also raised, so therefore even if this is a fully compensated state it was a metabolic imbalance in origin. Is the HCO3 normal? No this is raised with two value out of range and the pH with in normal limits this is fully compensated gas with the pH raised in normal limits and the HCO3 raised this was an initially a metabolic alkalosis This is a fully compensated metabolic alkalosis. Example 4 David has arrived from a nursing home with altered consciousness into the AE department. His initial labs showed a raised white cell count and this blood gas was taken Patient: David Hawcroft D.O.B. : 01:01:72 pH 7.32 PaCO2 8.2 HCO3 32 Is the pH normal? No it is low therefore it is acidotic. Is the PaCO2 with in normal limits? No it is raised which indicates that respiratory system is causing the primary insult. Assess the HCO3 is that normal? No this is raised also indicating that because it is moving in an opposite direction to the pH it must be in compensation, confirming the insult is respiratory in nature. Since both elements are out of normal limits there is evidence of compensation but since thepH is not achieved normal values it is considered only partial compensation, so this gas is a partially compensated respiratory acidosis Primarily this book has been to discuss the relationship between respiratory and renal systems is maintaining the bodys acid base balance. Arterial blood gases are used also to interpret blood oxygenation using the Po2 value. This value indicates the partial pressure of oxygen, the ability of oxygen to bind to haemoglobin and transfer to tissues, this ability can be affected by the acid state of the body. Below is a discussion on the Oxyhemoglobin Dissociation Curve which is a graph that plots the behaviour of oxygen in the blood comparing saturation against partial pressure and how acid base can affect it. Oxyhemoglobin Dissociation Curve The Oxyhemoglobin curve is a tool used to show the relationship between oxygen saturation and Pao2. Marino (1997)points out that the strength at which oxygen binds to the haemoglobin can vary depending on the disease state of the body. This in turn can affect the oxygenation of tissue beds or end organ perfusion. Adam(2009) simplifies the principle explaining that oxygen can bind too tightly which would which would inhibit of transfer of oxygen to tissues that needed oxygen or alternatively not bind tightly enough an oxygen is lost before it reaches these target cells. This relationship between the affinity of oxygen and the saturation is illustrated below with the Oxyhemoglobin curve. As mentioned above there are a number of conditions or states than can affect this relationship essentially moving the graph left or right. A fever, acidosis or elevated PCo2 levels can cause reduced adhesion of the O2 molecule therefore the graph and its values appear to move to the right (A right shift). Where as if the body is alkalotic, hypothermic or a low PCo2 the graph will shift to the left which would indicate the blood is failing to release the oxygen through increased affinity The curve can be used to assess Pao2 if the oxygen saturation is known. Shown in the illustration is a person with a saturation of 82%. If the curve has not shifted then that persons Pao2 would be 51mm Hg. A value of 80mmHg could indicate hypoxemia. Correction of the patients oxygen level may be facilitated by improving oxygen delivery and resolving conditions affecting the curve. Revision Questions What number indicates extreme acid on the pH scale? What is the range for pH in the blood? The kidneys compensate for acid base imbalances by excreting what substance? Which A.B.G value indicates an excess or insufficiency of sodium bicarbonate? What two values are compared on the Oxyhemoglobin curve? Interpretation revision pH 7.33 PaCO2 8.0kPa HCO3 31 pH 7.49 PaCO2 5.9 kPa HCO3 34 pH7.37 PaCO2 5.3 kPa HCO3 25 pH 7.44 PaCO2 4.0 kPa HCO3 16 pH 7.27 paCO2 5.5 kPa HCO3 15 Further reading Mays DA (1995). Turn ABGs into childs play R.N. 58:1: 36-40 Foxall Kesley (2008) Arterial Blood Gas Analysis: an easy learning guide M K Publishing Keswick Cumbria U.K.

The Dead :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  The Dead   Ã‚  Ã‚  Ã‚  Ã‚  When Gabriel Conroy delivers his wordy yet incredibly moving speech to the gaggle of Dubliners gathered together for the Holidays, he worries, possibly even fears, death. He talks of the future, making it sound cold and inhospitable. He lays compliments on his aunts one after the other about their â€Å" perennial youth’ (pg.166) and their kid ways. Gabriel addresses both the future and the present using a compare and contrast method, making one seem comforting and homey, the other dark and unknown. This comparison adds the aspect of death to Gabriel’s speech because of impermanence of his Aunt Julia and Aunt Kate; the impermanence of good old Irish hospitality, warmth and love.   Ã‚  Ã‚  Ã‚  Ã‚  The reader is also a sense of Gabriel’s desperate fear of death when he speaks of his Aunt Kate and Aunt Julia. He seems defiant of the fact that they are both old and won’t be around to throw parties like these much longer. Gabriel constantly harps on their energy and youthfulness. At first, he sounds simply like a polite young man fiercely complimenting his elder family members as many people do. But as his speech continues and he begins to discuss the attributes of each aunt and how they effect everyone else in the room, Gabriel begins to sound more and more like he is trying to grab and hold on to something completely intangible. And I think that â€Å"thing† is youth. He is trying to preserve his aunts, and every wonderful thing that they represent, forever. He sees that once they perish, there will be no one to throw these parties anymore, no one to extend a warm welcome to anyone who enters their home. In the future, without Gabrielâ₠¬â„¢s aunts, everything they know today will gone; all because of death.   Ã‚  Ã‚  Ã‚  Ã‚  Gabriel starts out his speech with talk of the ideas, both political and scientific, that are beginning to sprout out of young people’s minds as they speak. He fears that these young, educated people will not look back on parties like they are holding at this moment and recognizes the â€Å" qualities of humanity, of hospitality, of kindly humour† (pg. 165) that run rampant through each and every room. He seems to realize the importance of these qualities and he fears that when his generation dies out, so will the mannerisms of the Old Irish ways, the comfort these ways bring him, and mostly, life as he knows it.

Big Foot Research

Cornell Notes Topic: Sasquatch Page _1 & 2_ of _5_. | Lesson 21 Monster Research| Main Idea: Origins of the Sasquatch. Where they are. What they eat. Any predators? | * Notes: Sasquatch, also known as Bigfoot, is an ape-like creature said to live in the United States and Canada. Although sightings have been reported in numerous states, most reports come from the Pacific Northwest region of the United States. Numerous Bigfoot sightings have also been reported in British Columbia, Canada. In Wisconsin, the Lakota Indians call the creature â€Å"Chiye-tanka†, a word meaning â€Å"Big Elder Brother. Sasquatch is described as a large, hairy bipedal hominoid. Many people think that Bigfoot's relatives can be found in different areas of the world under different names, such as the â€Å"Yeti† in Nepal and Tibet. The Sasquatch’s footprints can be twenty-four inches long and up to eight inches wide. People who have reported seeing a Sasquatch, that in addition to resembl ing an ape, it has large eyes and facial structures that bear a resemblance to a male gorilla. The most common color of a Sasquatch's hair is black.However, several colors have been reported such as dark brown, reddish brown, light brown, gray, and in rare instances, white. Most sightings have reported that the hair on Sasquatch is quite wiry and appears to be matted to the creature. Sasquatches are foragers. A few cases to support this statement are that they have been seen washing and eating wild onions in a stream. Crouching over a water hole washing edible grass roots. There were two piles, one washed and the other unwashed. Walking through a forested area stripping spruce buds off the trees and eating the seeds. It would also pull down branches to eat the buds.Head lights of a car caught a Sasquatch eating apples in front of a house. Many trees had the fruit stripped off higher than a human could reach. Stealing corn and turnips from a vegetable garden, chickens and turkeys als o missing. A bedding area was found in an abandoned mine shaft, there were many brussel sprout stalks were found near the entrance. A thousand 16 inch tracks were found, they showed a Sasquatch stripping the bark from trees to look for insects. Two deer hunters witnessed two dark brown Sasquatches 7 to 9 feet tall reaching down under rocks to find insects and worms.Two Sasquatches in a creek turning over rocks and eating something, possibly insects or small fish. A witnessed an animal digging up clams on the shore. They shot at it thinking it was a bear it stood up, screamed and ran away on two legs. Twenty people on two commercial fishing boats approached the shore, a Sasquatch on a mud flat stood up and ran away. They checked the spot where the creature stood and realized it was digging clams. Two adults and one juvenile witnessed digging up hibernating ground squirrels and feeding on them. Scavenging on road kill.Stealing game animals from hunters. Stealing fish from nets. The li st goes on. As you can probably guess they have no predators. | | | Cornell Notes Topic: Sasquatch Page _3 & 4_ of _5_. || Main Idea: Body structure. Sightings. Proof? Any attacks on humans? How long have they been around? | Notes: Over the last two hundred years there have been thousands of reported sightings of Sasquatch and Possibly thousands of unreported sightings as well. Hundreds of footprints have been found and cast all over North America. Wide shoulders and a deep chest.Arms are longer than legs and hang down below the knee. Short thick neck or the appearance of no neck. This is due to the fact that the spine connects to the back of the skull and the Trapezius muscles are more developed. Pointed head, a unique anatomical characteristic of the Gorilla. This is attributed in the adult male to a prominent sagittal crest overlaid with a pad of fibro fatty tissue. This characteristic is less pronounced in females and smaller bodied adult males. Extreme muscularity. Broad, flat face. Jaw that protrudes beyond the nose.This anatomical feature (prognathism) is distinctly ape-like. Prognathism is due to the need for large jaws and teeth for mastication. Brow-ridges, above the eyes is a huge shelf of bone. Hair color is most often described as light brown, dark brown or black. Other colors that have been reported are grey, light, white, silver-tipped, and red to reddish-brown. Hair length is longer on the head, shoulders, and arms, than anywhere else on the body. Hair distribution, body is completely hair covered except for patches of bare black skin on the face, chest, soles of feet, and palms of hands.There have been reported attacks on humans but they cannot be proved. Stories of an ape like creature roaming the forests of North America have been around as long as some of the Native Americans tribes started in certain areas, due to the finding of cave painting of sasquatches. However, the earliest written account was made in 1811. | | | | Cornell Notes Topi c: Sasquatch Page _5_ of _5_. | | Main Idea: Life span. How do they survive in the winter? | * Notes: Based on Bigfoot sightings, researchers believe that Sasquatch does not migrate far distances.They do shift their patterns of movement and can move deeper into forests when they need to. Researchers concluded this by the fact that there are less Bigfoot sightings in the winter. Their life expectancy is right around 50 years. | | | | Summary/Questions: All of this information is very useful and will help me a great deal. All of my questions were answered. I have more than enough information to do a research paper on the Sasquatch. | cryptidz. wikia. com/wiki/Sasquatch www. exploringtheunexplained. com/sasquatch. htm www. bigfootproject. org/articles/eval_sas_photos. html sasquatch. net/

Lawyers, Scientists Urge Ethics in Biological Advances

In this news article, the concerns of scientists toward an amoral approach to the advances of biological sciences and engineering are examined. Much of the article centers on a keynote address delivered by Harvard Law School professor Einer Elhauge where the professor states â€Å"The issue is that people tend not to focus on the consequences of certain forms of human re-engineering.†The professor goes on to comment that the great strides in biological science may yield a great number of advances in helping humanity overcome a number of diseases and afflictions, but he also acknowledges that there is great potential for abuse. Examples of such abuse include issues such as altering the sex of a child in the womb or even a deaf family biologically engineering the deafness of their offspring.Ultimately, the Elhuage’s focus is to convince the scientific community that, even though it has biological technology to alter evolution, it should use ethical standards before embark ing on the proverbial â€Å"playing God† concept that Mary Shelly warned science about 250+ years ago.To a great degree, the article is accurate in terms of its presentation and call for moral and ethical consciousness. Just because science reaches the technological or biological advances of a highly evolved society does not mean that science can now re-orchestrate what is considered morally acceptable in the hearts and minds of the population. As such, science should understand the limits of ethical and moral behavior and not approach advancements with total mindlessness and amorality.Congressman Calls out Tech Firms on China Ethics.The bulk of the purpose of this article is to put the onus on American and international businesses to reconsider their actions when empowering China by conducting extensive business with the nation.In the article, it is reported that Congressman Chris Smith has taken internet companies such as Yahoo, Google, Sysco Systems, etc to task for going along with China’s internet censorship program. This may not seem like an entirely important issue, but one needs to keep in mind that China is primarily a military-industrial complex dictatorship that has a horrible record for human rights violations. As Smith points out, when American businesses work in tandem with nations with such abominable track records they enable such dictatorships and help perpetuate significant human rights violations.Furthermore, it is noted that journalists in China have been censured and punished and imprisoned for exercising their free speech. Smith suggests that American businesses that contribute to such a scenario should be fined and sanctioned.What Smith is essentially doing here is he is compelling American companies to conform to ethical standards of behavior and that is commendable. However, these companies have limited ability in terms of being able to shape domestic Chinese law. Furthermore, in such a highly competitive international bu siness environment, it is difficult to impose ethics as defined by one nation onto another nation, no matter how noble the cause. Smith’s statements are commendable, but it is not entirely clear if they will be successful.Ethics board fines Dow for giving state workers airplane rideAs the title of the article infers, the center of the ethics controversy this article deals with is a fine levied at Dow Chemicals to the tune of $2,500.00 for flying three state college employees to an out of state training program. At the time of the issue of contention, Dow was launching a co-operative training program with the state college (Louisiana Community and Technical College) and provided free airline tickets to employees for meeting purposes. This, however, was a violation of state ethic laws, hence the fine.This scenario strikes one as, well, silly. For Dow to compensate the airline tickets of three state workers so all parties can hash out a co-operative venture hardly seems like une thical behavior, although it is defined as such under state ethics laws. While the whole scenario comes off as much ado about nothing (actually, $2500 to a multi-billion dollar company such as Dow is basically nothing), it technically is a violation of state laws and the levied fine is valid. However, it does not seem like any real, serious ethical violations actually took place.If anything, the situation appears more like an error as the result of an oversight as opposed to a deliberate ethical violation. Oversights, however, are not an excuse for not following directions. In that regard, the decision against Dow was valid and the fine levied justified.BibliographyAnon. (2007, February 9) Ethics board fines Dow for giving state workers airplane ride.The Associated Press.   Retrieved February 12, 2007 fromhttp://money.aol.com/news/ articles/_a/ethics-board-fines-dow-for-giving-state/n20070209095709990003Schwankert, Steven.   (2007, February 12) Congressman Calls out Tech Firms o nChina Ethics. IDG News Service, Retrieved February 12, 2007, fromhttp://www.infoworld.com//07/02/12/HNcongressmanchinaethics_1.html/article/ sourcedomain =www.dailyfreepress.com&MIIHost=media.collegepublisher.comZerey, Ralpha. (2007, February 12) Lawyers, Scientists Urge Ethics in BiologicalAdvances. The Daily Free Press. Retrieved February 12, 2007, fromhttp://media.www.dailyfreepress.com/media/storage/paper87/news/2007/02/12/News/Lawyers.Scientists.Urge.Ethics.In.Biological.Advances-2712941.shtml?

Free Essays on A Dream Come True

My nights consisted of sweat beads falling down my fore head and fears of drifting back into sleep. I don’t think that my parents really ever understood how frightened I was when I woke up from one. I can specifically tell you how it smelled in some of my dreams, or what I might have been wearing. But every nightmare was the same, a dark bridge I’d fall from into murky rapids underneath. My hands would become clammy when I drove over a bridge. I’d clench onto the steering wheel and pray that I didn’t lose control. I wouldn’t dare change the direction of my eyes; for a single glimpse of the muddy waters below would fire pains to shoot threw my chest. Flashbacks of those thoughts swelled in my throat and the air passing through my lungs would become thinner and thinner. I would never consider myself a wimp. Ever since I could walk I had bruises and band-aids decorated in an assortment of colors on my legs, elbows and arms. I was a tomboy at its best w hen I was young, and still have a tendency to walk away from a game with the most amount of dirt on them. But when it came to a day on the river, I would have rather given a limb than surround myself with its terrifying pressure. It took a lot for me to give in to the invitation, but I decided to finally tag along one Sunday afternoon. I knew as soon as we got there I had overdressed. I had my swimsuit on underneath my wrinkled-free clothes, even though I was hoping a miracle would occur so that it would never saturate in river water. As we got closer to the dock, the sounds of rushing water rocked against the river bank. Just crossing over the walkway into the dock had my heart beating like a hollow drum. My friend’s hands held securely onto my own as I slowly, balanced my way onto the boat. Shocked by its swaying tranquility, I proceeded to find my seat and hold onto dear life, since Russ was known for showing off in his boat. As the day continued the pre-mature sunburn was ... Free Essays on A Dream Come True Free Essays on A Dream Come True My nights consisted of sweat beads falling down my fore head and fears of drifting back into sleep. I don’t think that my parents really ever understood how frightened I was when I woke up from one. I can specifically tell you how it smelled in some of my dreams, or what I might have been wearing. But every nightmare was the same, a dark bridge I’d fall from into murky rapids underneath. My hands would become clammy when I drove over a bridge. I’d clench onto the steering wheel and pray that I didn’t lose control. I wouldn’t dare change the direction of my eyes; for a single glimpse of the muddy waters below would fire pains to shoot threw my chest. Flashbacks of those thoughts swelled in my throat and the air passing through my lungs would become thinner and thinner. I would never consider myself a wimp. Ever since I could walk I had bruises and band-aids decorated in an assortment of colors on my legs, elbows and arms. I was a tomboy at its best w hen I was young, and still have a tendency to walk away from a game with the most amount of dirt on them. But when it came to a day on the river, I would have rather given a limb than surround myself with its terrifying pressure. It took a lot for me to give in to the invitation, but I decided to finally tag along one Sunday afternoon. I knew as soon as we got there I had overdressed. I had my swimsuit on underneath my wrinkled-free clothes, even though I was hoping a miracle would occur so that it would never saturate in river water. As we got closer to the dock, the sounds of rushing water rocked against the river bank. Just crossing over the walkway into the dock had my heart beating like a hollow drum. My friend’s hands held securely onto my own as I slowly, balanced my way onto the boat. Shocked by its swaying tranquility, I proceeded to find my seat and hold onto dear life, since Russ was known for showing off in his boat. As the day continued the pre-mature sunburn was ...

Personal Virtues Essay Essays

Personal Virtues Essay Essays Personal Virtues Essay Paper Personal Virtues Essay Paper I went over the list a twosome of times and I am non certain if I even put them into the right order or non of how I feel. I had changed them a few times. I am surprised at a twosome of picks that I made. I was non certain of how to rate reputability and self-respect. I know I can esteem a individual but that individual does non esteem me so I in bend do non desire to esteem that individual. I do hold dignity and I do hold pride in myself but I do non believe it is of import as my first five picks. My most of import pick was truthfulness. The one thing that I hate is when person lies to me. Small white prevarications does non trouble oneself me excessively much. I think everyone has told a white prevarication sometime or another. I like to be honest with myself and with others. When person lies the truth normally comes out and sometimes it is non good. Wholesomeness is another 1 that is of import to me. I know that if I am healthy I will be able to take attention of my kids and take attention of the demands of my household. I make certain that my house. kids and myself are cleaned. I do non like sources and when people do non take that safeguard it drives me brainsick. I am hardworking. I am a difficult worker. I get truly dedicated to my occupation particularly if it deals with kids. I am certain that my dedication and difficult work comes from my male parent. He still works at the age of 72 and likely will until he can no longer do so. I believe I am mercy now. I used to be high strung and had a pique but after holding kids I have calmed down. I think I am mild. I do non acquire huffy to easy any longer and I am really soft. The 1 that I like is humour. I am friendly with merely about everyone. I like to be unfastened and honest with people. For the most portion I am courtesy towards other people. Now for my bottom five. sternness is my 11th pick. My self-denial is non every bit good as it should be. There are times that I should command it but I merely give in to enticement. I think doggedness is something I have problem with. I have a wont of non gluey to what I have said or wanted to make. I know I need to truly work on this facet of my life. Prudence is another 1 I was non certain about where to put it. Most of the clip I do non be after for things it normally merely happens by the goad of the minute. Guess you could state that I do non believe foremost before moving and sometimes that is a job. Dutifulness was a tough 1. I am really loyal and am devoted to people. I believe in GOD and I pray every twenty-four hours but I am non truly spiritual. One thing I do non care excessively much for is political relations even though I know it is all around us. I have neer voted during any of the election but have decided to register so that I can vote for the first clip this twelvemonth. Frugality was my last pick. I love to pass money even though I have small of it. The economic system is non good right now but that does non halt me from passing money. Sometimes I walk out of the shop believing why did I purchase some of the points and why did I spend every bit much as I did but the comforter goes off rapidly. Over all I did believe this was hard to believe of an order that best tantrum me. After completing this essay I am still non certain how I feel about it. The 1 that will stay my top pick is truthfulness.

Jean Rouch and David MacDougall Assignment Example | Topics and Well Written Essays - 750 words

Jean Rouch and David MacDougall - Assignment Example Despite Rouch and MacDougall being both proficient filmmakers, whose work is highly valued in the cinema industry, their styles in making the film are divergent and variant. Firstly, Rouch employee’s a filmmaking style known as, ethnic-fiction, in making his films. Rouch style of filmmaking was influenced by the unearthing of surrealism. In these films, there is a thin line between fiction and documentary. In comparison, MacDougall ethnographies were purely documentaries. Secondly, David often used handheld cameras to capture his films while Rouch used light handheld cameras in his direct cinemas. Rouch used Pilot-tone connected to a 16mm camera using a prototype of Nagra III to shoot, Chronicle of a summer, in 1960. This was used in place of the heavy sound recording machinery that was very unreliable. Before the pilot-tone, the documentary sound was recorded before, during interviews or much later on location. The sounds that were recorded were later synchronized during soun d editing hence providing the documentary with sound. In conclusion, it is clear that there different approaches in filmmaking considering Rouch and MacDougall main difference is in the style of making the film. Rouch focuses on fiction films while MacDougall shoot documentaries. It is also clear that the advances in the film industry have been greatly contributed by technology. For example, in this day and age it is possible to shoot videos and record quality sound at the same time. In, as much as, Rouch and MacDougall differ in the choice of cinematic styles, they uphold a number of common aspects. The first one is that both of their cinematic styles incorporated aesthetic art. Aestheticism is an art movement supporting art nature and beauty values more than social-political themes portrayed in a film.

Five Year Career Development Plan Research Paper

Five Year Career Development Plan - Research Paper Example This is because of the training programs I will have to attend in order to achieve the desired educational level. I will have to complete my Masters level education before proceeding onto my Doctorate degree. There are several promotion opportunities that will come my way due to the advances I make in my education. After acquiring my Master’s and Doctoral degrees, I intend to get a permanent job in a company where the employers will consider my skills level in granting me a promotion. While working for the company, I will apply my creativity and other personal initiatives in assisting the company to augment its efficiency (Brown, 2002). This will enable the management to take notice of my good work and recommend me for the promotion. The growth of my business in the next five years will enable me to expand the business to other areas. This will increase my power in the company since I will be dealing with a greater variety of products, workers and customers (Patton & McMahon, 2001). This expansion will prompt the expansion of the business management team. I will be the acting chief executive for the business and charged with the responsibility of making all the major decisions. There are several methods that I intend to use for managing my career. These include the use of tools for assessment such issuing questionnaires for gauging my performance within the business (Bohlander & Snell, 2009). The development of processes allowing me to investigate my competence will be vital in developing my career. They will enable me to determine whether my skills conform to the company’s goals and objectives. I also intend to use appropriate methods in setting and planning the actions I will take. The above methods are achievable through the development of strategies applicable to my circumstances. I will assist in rolling out these strategies in the course my duties to ensure they conform to the set plans (Brown, 2002). Currently, I am a degree holder in the f ield business administration and very proficient in using computers. I am an internationally certified accountant having achieved the qualifications after completing the required courses in a college within my neighborhood over the last year. I happen to have very good inter personal and communication skills. I can work for long hours and under minimum supervision while taking care of the equipment I am using. The education I have achieved throughout my school work assists me in very many fields. This is because I was enrolled into a curriculum that equips students with skills in diverse fields. I have also been trained in computer maintenance processes. This skills equip me with the ability to work independently when dealing with various types of technology. The attributes that will indicate satisfaction at my work place will include pay increases, promotions and adequate allowances to cater for my requirements. Satisfaction at the job place will be indicated by the levels of effic iency with which the above three features will be implemented (Bohlander & Snell, 2009). It will involve working towards achieving my goals and objectives without distracting the routine operations in my duties. The achievement of my goals and objectives will largely depend on the action steps I take. In order to attain my objectives, I intend to use efficient time management strategies to avoid the wastage of time and

Create Writing Assignment and Grading Rubric for it Coursework

Create Writing Assignment and Grading Rubric for it - Coursework Example The main character was hugely affected by the process of confinement and torture. What role does psychology play in the analysis, understanding and relationship of the main character? During this era of feminism, John, the character’s husband contributed towards the attitude of men towards women. How does this attitude of machismo affect the character? How does it define the role of the character after the tumultuous relationship is observed? The paper should be 3 pages maximum. All the queries should be answered in precise and concise judgments that draw clear examples from the short story. American Psychological Association (APA) format, 6th edition should be effectively utilized in this written assignment. A succinct thesis statement will form the backdrop of the assignment. It is crucial to ensure that the thesis statement adequately maps out the direction of the written responses at each and every step. The essay should be as descriptive as possible, analyzing all written facts and presented evidences in line with the paper instructions. The main short story to be used in this analysis is Yellow Wallpaper. No other text other than the one mentioned should be used. Ensure accurate use of APA (6th edition), and in-text citations that include page

Generation X Essay Example | Topics and Well Written Essays - 1250 words - 1

Generation X - Essay Example urdles as well as stereotypes, the strong, appealing characteristics from the particular events, issues and people stem individuals born in generation X, making them extraordinary. Generation X is defined as the generation born in the years 1965 to 1980, immediately apparent in this generation after the baby boomers. This generation was named ‘X’ as the letter itself represents an unknown, mystery. This generation is better educated and more ethnically diverse (Rosen 4). In addition, this generation was raised at a period of increasing divorce rates, faltering economy, and two income families. From all generations, this is the only one that was pushed into early adulthood. The aspect of women liberation from traditional roles as only homemakers is broken in this generation. This is evident by several women joining the work force, leaving behind their infants. During this era women broke the traditional characteristic of being dependent to a man to being independent and self sufficient. The con of this move was the commencement of latchkey kids who had no choice, but to take care of themselves whilst their parents worked (Zustiak 32). I am a clear example of such children; both my parents worked, being the first born, I had the responsibility of taking care of my siblings. I can say that I took the role of my parents, and disciplined my siblings when they made a mistake. I lacked the emotional needs from my parents and turned out into an autonomous, self-reliant individual. The situation at home forced me to grow up faster, and also adapt parenting skills. This was a challenge, as I was struggling the balance of being a child, sibling and at the same t ime ‘a parent. This explains why individuals who are in this generation like I, demonstrate the values of resourceful, autonomy and contribution, attributes of the command of authority and structured work hours. I was raised at a time where there was the emergence of personal computers, television, and Atari

Identify time management techniques Essay Example | Topics and Well Written Essays - 500 words

Identify time management techniques - Essay Example In addition, one needs to incorporate a motivational factors within the goal setting activity that would enable the generation of a rewards for fulfilling or accomplishing the goals that were set within the identified time frame. One affirms that by looking forward to availing of a benefit or reward, the achievement of goals are facilitated since one’s focus would be re-directed to the positive outcome, and not on the challenges that could be encountered on the way to attaining the identified goal. Another important aspect of goal setting and time management is learning the skill of prioritization. One’s score in this area is 24 out of 35 or 69%. Given a set of activities or endeavors, one must be able to identify and classify the tasks according to urgency: which needs to be done within the shortest possible time frame. As such, making a list of the activities for the day, or for the week, would assist in developing prioritization skills. Likewise, one must also recognize which tasks are more tedious and comprehensively encompassing in details. If there are endeavors that require much preparation and planning, the strategies for prioritization should include accurately identifying tasks in minute details, or broken down into sub-tasks, so that one would not perceive the activity as burdensome in holistic form. In addition, tasks that entail prior research, collection of data, or extensive studying could be scheduled intermittently, as one’s spare time would allo w. The third relevant aspect in time management is managing interruptions. The score generated in this area is 12 out of 20 or 60%. It could be deduced that there are more rooms for improvement in this aspect. One must be able to discern which types of interruptions prevent me from completing scheduled tasks or responsibilities in an effective manner according to prescribed time frame. The interruptions in one’s daily routine

Business assessment Assignment Example | Topics and Well Written Essays - 3000 words

Business assessment - Assignment Example Recommendations 15 8. References 16 9. Appendix 19 1.0 Introduction Purpose of the Report The purpose of this report is to provide a critical comparative analysis of two organisations in the way they are operated and managed. This is to help us in discovering what causes success or failure for organisations and how different organisations adapt to dynamic environment. Organisations not flexible enough to adapt to the environment are unable to attract and retain talented employees or take advantage of available opportunities hence cannot achieve organisational effectiveness. Scope of the Report To analyse the operation and management of the two organisations the report will consider how they are structured and designed so as to show the interrelationships between roles and departments and lines of authority. Secondly, report will cover organisation of work especially the use of teams and team working. Thirdly, it will analyse the approaches to leadership and management adopted by the organisations as this determines their success or failure. The report will then analyse the organisational culture and its impact on the organisations operations and lastly, conclusions and recommendations will be made on how to improve operations and management. Organisations Background Biogenta is a manufacturing company producing crop-protection products and whose mission is to be the most trusted provider of crop-protection products in the world. It has manufacturing facilities in 10 countries and employees in over 80 countries. Contrary to popular belief that large size companies are bureaucratic in nature, Biogenta has an organic structure and a matrix design where individuals belong to a functional area and a project team. The chief executive officer, Jane Morgan is an effective leader and manager whose encouragement of creativity and innovation has pushed the company to greater heights. The company has a very strong culture which emphasizes on learning and development, diver sity and corporate social responsibility. Outback Inc is a traditional organisation run by family members. It offers tourism services to wide range of clients and operates in a very turbulent environment. Being a small organisation, it is expected to have an organic structure but instead, it is bureaucratic in nature with a functional design and little or no teamwork. Creativity and innovation is hindered by its autocratic leadership style. The company has no vision or mission and has a high turnover culture due to lack of opportunity for advancement and employee voice. 2.0 Organisational Design and Structure Benowitz (2011, p.70) defines an organization structure as â€Å"the configuration and interrelationships of positions and departments†. An organisation design on the other hand, is the change of an organization structure to enable it to respond effectively to environmental changes. A poor organization design and structure can lead to lack of co-ordination among function s, slow decision making, and role confusion (Corkindale, 2011). Types of Organisation structure An organisation structure is determined by the degree of complexity, formalisation, and centralisation. Complexity reflects the amount of differentiation in an organisation; formalisation shows the degree to which an organisation uses rules and procedures to direct behaviour while centralisation reflects how power and authority is distributed in an organisation. Gitman and McDaniel (2008) recognise two kinds of

Generation X Essay Example | Topics and Well Written Essays - 1250 words - 1

Generation X - Essay Example urdles as well as stereotypes, the strong, appealing characteristics from the particular events, issues and people stem individuals born in generation X, making them extraordinary. Generation X is defined as the generation born in the years 1965 to 1980, immediately apparent in this generation after the baby boomers. This generation was named ‘X’ as the letter itself represents an unknown, mystery. This generation is better educated and more ethnically diverse (Rosen 4). In addition, this generation was raised at a period of increasing divorce rates, faltering economy, and two income families. From all generations, this is the only one that was pushed into early adulthood. The aspect of women liberation from traditional roles as only homemakers is broken in this generation. This is evident by several women joining the work force, leaving behind their infants. During this era women broke the traditional characteristic of being dependent to a man to being independent and self sufficient. The con of this move was the commencement of latchkey kids who had no choice, but to take care of themselves whilst their parents worked (Zustiak 32). I am a clear example of such children; both my parents worked, being the first born, I had the responsibility of taking care of my siblings. I can say that I took the role of my parents, and disciplined my siblings when they made a mistake. I lacked the emotional needs from my parents and turned out into an autonomous, self-reliant individual. The situation at home forced me to grow up faster, and also adapt parenting skills. This was a challenge, as I was struggling the balance of being a child, sibling and at the same t ime ‘a parent. This explains why individuals who are in this generation like I, demonstrate the values of resourceful, autonomy and contribution, attributes of the command of authority and structured work hours. I was raised at a time where there was the emergence of personal computers, television, and Atari

Business assessment Assignment Example | Topics and Well Written Essays - 3000 words

Business assessment - Assignment Example Recommendations 15 8. References 16 9. Appendix 19 1.0 Introduction Purpose of the Report The purpose of this report is to provide a critical comparative analysis of two organisations in the way they are operated and managed. This is to help us in discovering what causes success or failure for organisations and how different organisations adapt to dynamic environment. Organisations not flexible enough to adapt to the environment are unable to attract and retain talented employees or take advantage of available opportunities hence cannot achieve organisational effectiveness. Scope of the Report To analyse the operation and management of the two organisations the report will consider how they are structured and designed so as to show the interrelationships between roles and departments and lines of authority. Secondly, report will cover organisation of work especially the use of teams and team working. Thirdly, it will analyse the approaches to leadership and management adopted by the organisations as this determines their success or failure. The report will then analyse the organisational culture and its impact on the organisations operations and lastly, conclusions and recommendations will be made on how to improve operations and management. Organisations Background Biogenta is a manufacturing company producing crop-protection products and whose mission is to be the most trusted provider of crop-protection products in the world. It has manufacturing facilities in 10 countries and employees in over 80 countries. Contrary to popular belief that large size companies are bureaucratic in nature, Biogenta has an organic structure and a matrix design where individuals belong to a functional area and a project team. The chief executive officer, Jane Morgan is an effective leader and manager whose encouragement of creativity and innovation has pushed the company to greater heights. The company has a very strong culture which emphasizes on learning and development, diver sity and corporate social responsibility. Outback Inc is a traditional organisation run by family members. It offers tourism services to wide range of clients and operates in a very turbulent environment. Being a small organisation, it is expected to have an organic structure but instead, it is bureaucratic in nature with a functional design and little or no teamwork. Creativity and innovation is hindered by its autocratic leadership style. The company has no vision or mission and has a high turnover culture due to lack of opportunity for advancement and employee voice. 2.0 Organisational Design and Structure Benowitz (2011, p.70) defines an organization structure as â€Å"the configuration and interrelationships of positions and departments†. An organisation design on the other hand, is the change of an organization structure to enable it to respond effectively to environmental changes. A poor organization design and structure can lead to lack of co-ordination among function s, slow decision making, and role confusion (Corkindale, 2011). Types of Organisation structure An organisation structure is determined by the degree of complexity, formalisation, and centralisation. Complexity reflects the amount of differentiation in an organisation; formalisation shows the degree to which an organisation uses rules and procedures to direct behaviour while centralisation reflects how power and authority is distributed in an organisation. Gitman and McDaniel (2008) recognise two kinds of

KTG leader ship Essay Example for Free

KTG leader ship Essay Introduction An environmental analysis in strategic management plays a very important  role in businesses by pinpointing current and potential opportunities or threats outside the company in its external environment. The external environment includes political, environmental, technological and sociological events or trends that can affect the business directly or indirectly. The main objective in this report is an environmental analysis using all the factors and analyzing tools , generally conducted as part of an analysis of strengths, weaknesses, opportunities, and threats (SWOT) when a strategic plan is being developed. Managers practicing strategic management must conduct an environmental analysis quarterly, semi-annually, or annually, depending on the nature of the businesss industry focusing on the followings: Analyzing factors effectiveness on our organization as one of the biggest group in the healthcare services in the region. Organization sources and competitors. Organization values chain construction. SWOT analysis evaluation. Ref: http://www.wisegeek.com/what-is-the-role-of-environmental-analysis-in-strategic-management.htm , 2014 3.ANALYSING FACTOR EFFECTIVENESS: 3.1 Macro Environment Analysis: One of the best tools for considering trends in the Macro environment is the PESTEL analysis. (Figure 1) Figure 1 3.1.1Political factors: Since we are located here in the UAE, we have no taxation and this is one of the strength point we are depend on. but at the same time our administration team not recognizing that the minimum wages should be increased comparing with the other facilities and hospitals in our region as a big competitors. 3.1.2Economic: Economic factors include economic growth, interest rates, exchange rates and the inflation rate. These factors have major impacts on how businesses operate and make decisions. For example, interest rates affect a firms cost of capital and therefore to what extent a business grows and expands. Exchange rates affect the costs of exporting goods and the supply and price of imported goods in an economy. And since our organization as privet health care facility, based on the profit rate it takes in the consideration all these factors especially after it involved in the stock market last year. Beside that the new plan is to minimize the expenses that related to the interest exchange rate by following the centralization policy. ex. making one laboratory for all branches with a very controlled transportation system for sending the patients samples to the centralized laboratory instead of having a separate laboratory in each branch 3.1.3Social: Our organization as one of the privet hospitals in the region , is giving all the healthy activities, health care providing, never giving any changing as a demographic trends. We are doing outside activities supporting some certain people those who have a chronic disease like the diabetic patients to have more and more knowledge about themselves and how to take care about it. Ref(CBS course , topic 2 , page # 5) 3.1.4Technology: We are depending on the development of new technology to maintain competitiveness. Ex(opening new department of the Nuclear medicine for early Cancers diagnostics ) 3.1.5 Environment: factors include ecological and environmental aspects such as weather, climate, and climate change, which may especially affect industries such as tourism, farming, and insurance. Furthermore, growing awareness of the potential impacts of climate change is affecting how companies operate and the products they offer, both creating new markets and diminishing or destroying existing ones. Ref http://en.wikipedia.org/wiki/PEST_analysis According to our national regulations and environmental roles ,we are following the EHSMS(Emirates Health Safety Management System). 3.1.6 Legal  include discrimination law, consumer law, antitrust law, employment law, and health and safety law. These factors can affect how a company operates, its costs, and the demand for its products. The services in the hospital is the same for all patients and the priority is only for the urgent and emergency cases only not according to the nationality, color or any other discrimination issues. And on the other side there is a special track for the VIP patients ,giving the best quality to be the first choice in the region as a privet hospital. 3.2 Micro Environment Analysis: One of the best tools for considering trends in the Micro environment is the porter analysis. (Figure 2) Figure 2 Porter five forces analysis is a framework for industry analysis and business strategy development. It draws upon industrial organization (IO) economics  to derive five forces that determine the competitive intensity and therefore attractiveness of a market. Attractiveness in this context refers to the overall industry profitability. An unattractive industry is one in which the combination of these five forces acts to drive down overall profitability. A very unattractive industry would be one approaching pure competition, in which available profits for all firms are driven to normal profit. This analysis is associated with its principal innovator Michael E. Three of Porters five forces refer to competition from external sources. The remainder are internal threats. 3.2.1 Threat of Substitute Products or Services: A substitute is a product that performs the same or similar function as another product. Microeconomics teaches that the more substitutes a product has, the demand for the product becomes more elastic. Elastic demand means increased consumer price sensitivity which equates to less certainty of profits. For example, public-transportation is a substitute for driving a car, and e-mail is a substitute for writing letters. Conditions that increase the threat of substitutes are: 1.2.1.1 An attractive price of substitutes: Our organization as a privet health care facilty depends on the insurance companies in how much they are fixing the prices of the services and products, but they are trying to do some marketing using special prices for the labors in some company by doing full checkup examination for those people who don’t covered by insurance. 1.2.1.2 Increased quality of substitutes: Our facility is trying to give the best quality to be the first choice in the region in the privet health care sector. Focusing more and more to follow the highest international standards like the JCIA (Joint Commission of international accreditation) ,CAP(Collage of American Pathologist) and the ISO ..Etc 1.2.1.3 Low switching costs to consumers: our Administration is not switching the cost to the consumers since they are covered by health insurance. But sometimes they are switching the costs to the staff by minimizing the staff without enough study to the work load or stopping the annual increments. 3.2.2 . Threat of Entry: Profitable markets that yield high returns will attract new firms. This results in many new entrants, which eventually will decrease profitability for all firms in the industry. Unless the entry of new firms can be blocked by incumbents (which in business refers to the largest company in a certain industry, for instance, in telecommunications, the traditional phone company, typically called the incumbent operator), the abnormal profit rate will trend towards zero (perfect competition). The following factors can have an effect on how much of a threat new entrants may pose: The existence of barriers to entry (patents, rights, etc.). The most attractive segment is one in which entry barriers are high and exit barriers are low. Few new firms can enter and non-performing firms can exit easily. Government policy Capital requirements Absolute cost Cost disadvantages independent of size Economies of scale Economies of product differences Product differentiation Brand equity Switching costs or sunk costs Expected retaliation Access to distribution Customer loyalty to established brands Industry profitability (the more profitable the industry the more attractive it will be to new competitors) Rivalry Between Established competitors: Rivalry refers to the degree to which firms respond to competitive moves of the other firms in the industry. Rivalry among existing firms may manifest  itself in a number of ways- price competition, new products, increased levels of customer service, warranties and guarantees, advertising, better networks of wholesale distributors, and so on. The degree of rivalry in and industry is a function of a number of interacting structural features: Rivalry tends to intensify as the number of competitors increases and as they firms become more equal in size and capability. Market rivalry is usually stronger when demand for the product is growing slowly. Competition is more intense when rival firms are tempted to use price cuts or other marketing tactics to boost unit volume. Rivalry is stronger when the costs incurred by customers to switch their purchases from one brand to another are low. Market rivalry increases in proportion to the size of the payoff from a successful strategic move. Market rivalry tends to be more vigorous when it costs more to get out of a business than to stay in and compete. Rivalry becomes more volatile and unpredictable the more diverse competitors are in terms of their strategies, their personalities, their corporate priorities, their resources, and their countries of origin. Rivalry increases when strong companies outside the industry acquire weak firms in the industry and lunch aggressive, well-funded moves to transform their newly-acquired firms into major market contenders. Two principles of competitive rivalry are particularly important: (1) a powerful competitive strategy used by one company intensifies competitive pressures on the other companies, and (2) the manner in which rivals employ various competitive weapons to try to outmaneuver one another shapes the rules of competition in the industry and determines the requirements for competitive success. Since our hospital is the biggest hospital in the area, it depends in the competition on increasing the branches in all areas inside and outside the city for more than 8 branches directed by the corporate office in the Capital. 3.2.4 Bargaining Power of Customers: 3.2.4.1 Markets for Outputs: Selling goods or services to customers (distributors, customers or other manufacturers) Customers’ influence dependent upon importance of products to them their bargaining power We have a marketing team of 4 members working under the supervision of the corporate office , handling all the outputs issues like : the chronic patients disease health care activates offering free of charge checkup (ex. diabetic patients..) 3.2.4.2 Markets for Inputs: Purchasing raw materials, components and financial labor services. The same team also cooperating with the purchasing department together working to get the best quality materials for the lowest prices in order to minimize the costs. And that will allow the hospital to give more best services more than the other competitors. 3.2.5 Bargaining Power of Suppliers: The power balance between organization and supplier is similar to the relationship between organization and customer The organization becomes the customer and the producer of the inputs it requires are the suppliers Some small groups of suppliers may form cartels or cooperatives to increase their bargaining strength Suppliers use leverage such as threats to raise prices or reduce quantity or quality of goods they supply We are depending on the process comparison in the market and to services the suppliers will provide to us. In the opposite side, we are a customer for the suppliers and since we are the biggest customer in the privet sector we can manage the deal according to our needs. 3.3 Formulating: Formulating is phase one in the strategic planning process and according to  the diagram below We can see that it plays a very important in taking the best decisions and actions to achieve the objective of the organization. In our hospital there are many plans in how to make all these decisions become a real. At the beginning of each new year , we are making our plan projects for the next 12 months And everyone have to achieve his planed objectives as individual under the umbrella of the administration and corporate office objectives. And at the end of the year will have an assessment to check how many objectives he reached , according to his work assessment will get his increment , so that will let him work harder during the year to achieve the organization objectives. Figure 3 Ref(CBS course , topic 1 , page #12). 3.3.1 Organization sources and competitors : Our hospital sources is strong enough to be a strong competitor in the market depending on: Best medical companies as materials providers.  Best marketing plans based on the corporate marketing plans. Patients (as a customers ): Accepting all the insurance cards at the time that some other hospitals don’t accepting all patients. 3.3.2 Organization value chain construction Value chain is a template that identifies the activities of a company from raw materials to customer, the value added by each activity and the cost of each activity, and that facilitates implementation of business-level strategy . Ref ( CBS Strategic Management Topic 3 Page#6) The axiom is true that you never get a second chance to make a good first impression, and hospitals have many opportunities to do so. Or not. At several junctures along the trek of accessing services, the patient confronts a series of opportunities to continue in the system or not, based on the success of the interaction. These touchpoints are not created equal, and it is important to know which has the greatest impact. Here, we can focus the Service Line Growth strategy. As a tool to understand the impact  of each touchpoint, value-chain service analysis maps the process to help us decide where to focus strategic intent. Hospital business planning adapts a model developed by Michael Porter, who defines the value chain as a means to analyze an organization’s strategically relevant activities to understand how to influence performance and cost. He breaks the activities of the firm into primary and support activities. Primary activities—which, for most firms involves inbound and outbound logistics, operations, sales and marketing—are supported by an infrastructure of underlying support activities, including HR, IT, and purchasing. How the product or service is ultimately developed and delivered to the customer depends on the effective interaction of these variable activities. The hospital value chain is diverse and complex. Our service offerings are far from clear cut, varying sharply between service lines. Each specialty and disease category has a distinct value chain to be flowcharted and analyzed prior to understanding where we can impact choice by creating value. In most cases this is at the physician referral point where patients make initial decisions. This may be a primary care physician or a specialty care physician who is directly involved in managing the hospital encounter. In most cases, it is the loyalty of the physicians and their attitude towards the hospital that determines the direction of the process. This analysis is a good tool for getting stakeholders on the same page. It helps focus planning efforts and gets to the key issue of where to go and what to do. This leads us to the question—what business are we in, and where do we strategically want to focus our efforts, which is the essence of strategy. Figure 4 4.1 Strengths (Internal Factors) The hospital key strengths are the following: Long Standing Reputation – was the previous monopoly Company in the industry Government Affiliated – trusted in the Market Most skilled employees in the industry – generated good client relations 4.2 Weaknesses (Internal Factors) The main functional areas of weakness are the following: Production Costs in comparison to competitors Profit Margins – in comparison to competitors Service Delivery – poor operational functions Loss of Contracts – lack of continual Contract retention Company Culture – disconnected, divided, tall organisation structure HR Policies Procedures – poor employee retention, lack of career development, low morale Lack of MIS – no common management information systems in place across functions. Brand Identity/Image – lack of Marketing department Conclusion: The main objective is the consideration of the external and internal analyzing factors, using all the analyzing tools and studies like: PORTER, SWOT and all other analyzing international methods. This report explained clearly the essential required methods for analyzing using the practical example of my organization (Privet Hospital), how to make the competitive advantages and how to use all the efforts to get the best analyzing results. After the analyzing how can we use our strength points to be the first choice in the market and how to correct the weakness points to avoid any problem in the future. In the light of the above there are essential factors which might be affecting in any organization , so we have to cover all the points that I mentioned about it before like : Analyzing factors effectiveness on our organization as one of the biggest group in the healthcare services in the region. Organization sources and competitors. Organization values chain construction. SWOT analysis evaluation. 6. References http://www.wisegeek.com/what-is-the-role-of-environmental-analysis-in-strategic-management.htm , 2014 (http://en.wikipedia.org/wiki/PEST_analysis) , 2014 CBS course , topic 2 , page # 5 , 2014 http://en.wikipedia.org/wiki/PEST_analysis , 2014 http://www.oshad.ae/en/sectors/healthsector/Pages/ehsmsrequirements.aspx, 2014 http://www.dineshbakshi.com/igcse-business-studies/external-environment/revision-notes/63-external-environment-factors, 2014 http://en.wikipedia.org/wiki/Porter_five_forces_analysis ,7 March 2014) http://en.wikipedia.org/wiki/Porter_five_forces_analysis#Threat_of_new_entrants, 2014 http://www.strategy-formulation.24xls.com/en114 CBS course , topic 2 , page #17 , 2014 CBS course , topic 2 , page #20 , 2014 CBS course , topic 1 , page #12 , 2014 CBS Strategic Management Topic 3 Page#6 , 2014 http://healthcarestrategicadvantage.blogspot.ae/2007/11/value-chain-analysis.html , 2014 Strategic Management Unit 306 (CBS) , 2014

Survival Outcome Neonates Early Sepsis Health And Social Care Essay

Survival Outcome Neonates Early Sepsis Health And Social Care Essay A Retrospective Comparative Study on the Survival Outcome of Neoates with Early -Onset Sepsis with Sclerema Given Fresh Frozen Plasma at Davao Medical Centern Nursery-A One Year Review Objectives: To determine and compare the survival outcome of patients with early onset neonatal sepsis with sclerema given fresh frozen plasma plus standard therapy of neonatal sepsis to those who were only given standard therapy alone. Fresh Frozen plasma contains immunologic factors which is deficient in a neonate. This study would help us validate the role of FFP transfusion in a sick neonate with sclerema. Design: Cohort Study design Setting: Tertiary care hospital Participants:All neonates presenting with clinical signs of neonatal sepsis with sclerema admitteded at Davao Medical Center nursery for the year 2008. Results and Conclusion: INTRODUCTION Neonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs and symptoms of infection in the first month of life1. It has taken so many lives of newborn babies. The mortality rate continuously increases especially in the third world countries like the Philippines so that early recognition, diagnosis and treatment of infection is important because it is largely a preventable disease. Neonatal Sepsis can be divided into two main classes depending on the onset of symptoms related to sepsis- early-onset and late-onset neonatal sepsis2. Early onset is mainly due to antepartum infections vertically transmitted while late-onset is the combination of the former and nosocomial infection. The incidence of neonatal sepsis varies from one institution to another with higher rates in developing countries. In the United States , the incidence of a culture-proven sepsis is approximately 2 per 1000 livebirths and increases to 25 per 1000 livebirths in infants with birthweight less than 1500 grams3. It is considered to be a major cause of fatality during the first month of life contributing to 13-15% of all neonatal deaths with highest rates seen in premature infants and in small for gestational age infants. The mortality rate in neonatal sepsis may be as high as 50% for infants who are not treated3. A local study conducted at MCU-FDTMF Hospital nursery found the incidence of neonatal septicemia to be 9.6 %4 as compared to other studies at UP PGH which is 5.5%. At Davao Medical Center the incidence and the case fatality rate of neonatal sepsis for the year 2008 are about 5/1000 livebirths and 1.3% respectively5. Considering the nonspecificity of the early clinical signs of neonatal sepsis and the neonates relative state of immunosuppression, early diagnosis and treatment is of utmost important. The mainstay of treatment is antibiotic. Supportive management is geared towards thermoregulation to prevent hypothermia or hyperthermia, ensuring good ventilation/oxygenation to vital tissues, provision of optimal nutrition preferably with enteral feeding or TPN, prevention of hypoglycemia and electrolyte imbalance by administration of parenteral fluids and vasopressors for hypotension. Adjunctive therapy includes fresh frozen plasma transfusion, exchange transfusion, immunoglobulin therapy, granulocyte-macrophage colony stimulating factor, and granulocyte transfusion. Sclerema is the uniform hardening of the skin and subcutaneous tissues to the extent that the skin could not be pitted nor picked up or pinched into a fold6.It is considered as a sign of a potentially fatal underlying disease process like neonatal sepsis especially gram- negative sepsis. Neonatal septicemia is invariably fatal when associated with sclerema7. Its reported mortality rates range from 67-88% with death occurring hours to days after onset8. Although literature about the benefits of Fresh Frozen Plasma transfusion in septic neonates with sclerema is scarce, our experienced at SPMC nursery suggests improved outcome from neonatal sepsis with sclerema when given FFP. We do not give FFP to septic neonates without sclerema. We are doing this study to validate if indeed our perception is correct and if this practice is valid. The study will be limited to comparison of septic patients with sclerema only. This preselects the most seriously ill patients. By limiting the study to early onset neonatal sepsis, opportunistic infections from less virulent pathogens like candida and staphylococcus epidermides are likely to be excluded and infection is most likely vertically transmitted and not nosocomial. This is to limit the varaiables due to etiologic agents that may affect outcome and interpretation of the result. Review of Related Literature The defense system of the human body consists of three components: physical , cellular and humoral. Neonates are particularly deficient in all three so that a more aggressive management is mandatory to improve survival outcome when neonates develop septicemia. The physical and chemical barriers to infection in the human body are present in the newborn but are functionally deficient. The skin of a preterm infant is only a few cell-layers thick and is poorly cornified hence can easily be damaged paving the way for infection. The protective fatty acid production is also low making them more vulnerable. At 23 weeks gestational age the fetus possesses T and B lymphocytes, macrophages, monocytes, polymorphonuclear cells and the capacity to synthesize all known immune factors. The ability of the T and B lymphocytes to produce cytokines is less in comparison to adults, however neonates are capable of generating appropriate adaptive immune responses. Langerhans cells are important in local infection and are present in the neonate at 18 weeks gestation. Phagocytes from preterm neonates show normal activity when suspended in normal adult serum, however neonatal serum is deficient in immunoglobulin and complement so there is a marked reduction in adherence and chemotaxis. The neonatal neutrophil or polymorphonuclear (PMN) cell, which is vital for effective killing of bacteria is deficient in chemotaxis and killing capacity. Also neonatal PMNs are less deformable therefore they are less able to move through the extracellular matrix of tissues to reach the site of inflammation and infection. The limited ability of neonate for phagocytosis and killing of bacteria is further impaired when the infant is clinically ill. Lastly neutrophil reserves are easily depleted because of the diminished response of the bone marrow especially in the premature infant. The neonate is capable of synthesizing IgM in utero at 10 weeks gestation, however IgM levels are generally low at birth unless the infant was exposed to an infectious agent during the pregnancy, thereby stimulating increased IgM production. During pregnancy IgG is transported actively and passively across the placenta from about the 20th week of gestation and at full term the neonates IgG levels are higher than his mothers levels. The IgG in an infants plasma has a half-life of about three weeks.Until the infant is able to generate his own IgG, IgM and IgA there is a period of postnatal hypogammaglobulinemia. In a preterm neonate of 26 weeks gestation the plasma IgG levels are markedly lower and diminish to ineffective levels very quickly, increasing the risk of infection. Complement protein production can be detected as early as 6 weeks gestation; however the concentration of the various components of the complement system widely varies among individual neonates. While some infants have had complement levels comparable with those in adults, deficiencies appear to be greater in the alternative pathway than in the classic pathway. The terminal cytotoxic components of the complement cascade that leads to killing of organisms, especially gram-negative bacteria are deficient. The deficiency is more marked in preterm infants. Mature complement activity is not reached until infants are aged 6-10 months. Neonatal sera have reduced opsonic deficiency against GBS, E. coli, and S pneumoniae because of decreased levels of fibronectin, a serum protein that assists with neutrophil adherence and has opsonic properties. Most common organisms causing early- onset neonatal sepsis include group B streptococci, gram -negative enteric organisms like E. coli. Listeria monocytogenes and Klebsiella are also a common isolates. Less common organisms include staphylococcus, other streptococci, anaerobes, and Haemophilus influenza9. The host-defence mechanism of neonates are immature. They have a markedly decrease levels of C3, Cy properdin and factor B which are very important in the alternative pathway of complement. Levels of IgM and IgA are also low at birth. Although IgG levels may be normal in term neonates, it is low in preterm infants. These relative deficiency of the neonates immune system complicated by low birthweight and decreasing age of gestation makes them more susceptible to life threatening infections10. Sadana,et al mentioned that the incomplete development of the host defense system of the neonate is largely responsible for the high mortality in neonatal sepsis11.In his study an increase in the levels of IgG, IgM, IgA andC3 was noted after exchange transfusion.Exchange transfusion offers removal of bacteria and toxins, improves oxygenation and perfusion as well as decreases hemorrhagic complications. The relative immunodeficiency state and susceptibility to sepsis and complications is the impetus for exploring treatment modalities other than antibiotics. There was an increase in the levels of IgG antibodies in septicemia patients with coagulase negative staphylococcus after FFP administration in the study made by Krediet, et al12 The neonate being deficient in both humoral and cellular immunity is more vulnerable to infection. There are literature that suggests the usage of Fresh Frozen Plasma in patients with neonatal sepsis to compensate for the immunologic deficiencies. FFP improves neonatal chemotaxis, provides humoral or cellular factors13 and increases the levels of immunoglobulin such as IgG, IgA and IgM. FFP remains the only approved source of factors V,XI, protein C, protein S and plasminogen14 and basically all the clotting factors. Others would say that FFP transfusion in neonatal sepsis is good because it increases levels of IgG, IgA and IgM15 that will increase chances of survival. FFP contains immunoglobulins anc complement factors16. Fresh frozen plasma, the plasma separated from a unit of whole blood and frozen at -18 oC within 8 hours of collection. It is a platelet-poor plasma17.Each bag has a volume of 175 to 250 ml and contains between 1 and 2 units of each coagulation factor per ml and 400 to 800 mg fibrinogen. It contains fibrinolytic and complement factors. It carries the same risks of viral transmission as other blood components and can cause allergic reactions and fluid overload. Indications for fresh frozen plasma, once used routinely in the support of critically ill-infants and children, have become more specific as evolving evidence has confirmed or disproved the efficacy of plasma in various circumstances. Fresh frozen plasma is currently indicated to treat the coagulopathies of massive hemorrhage, liver failure, disseminated intravascular coagulation and sepsis18. In an infant the fat has a higher saturated- to-unsaturated fatty acid ratio compared to adult fat and thus a higher melting point. Prematurity, hypothermia and shock and anatomic abnormalities have been postulated to further increase this ratio,possibly as a result of enzymatic alteration allowing precipitation of fatty acid crystals within the lipocytes. This condition has been suggested to result in the dramatic clinical findings in the affected skin. Xray diffraction techniques have confirmed that infants with sclerema have an increase in saturated fats and that the crystals within the fat cells are composed of triglycerides. The exact incidence of sclerema neonatorum is unknown . All studies describe SN as extremely rare. The number of reported case in recent years have declined, probably as a result of a better neonatal care. Because sclerema neonatorum invariably is associated with serious underlying disease process, the mortality rate is high. In different series, the reported mortality rates range from 67-88%, with death occuring hours to days after onset. If the underlying disease is treated successfuly, the skin softens and returns to normal. Sclerema neonatorum shows a slight male preponderance, with an estimated male-to-female ratio of 1.5:1. Sclerema neonatorum is a disease confined to the newborn period. It can present at birth, but onset within the first week of life is more common. The oldest reported infant presented with Pseudomonas septicemia is 106 days old. According to literature one half of the affected infants are premature, , and the others are full term but have a serious underlying disease. They are often of low birth weight and have cyanosis and low apgar scores.In one series, 75% of the mothers were healthy, while 25% had preeclampsia, placenta previa, or infection. Labor is usually normal and the delivery is spontaneous and nontraumatic. Physical findings appear suddenly, first on the thighs and on the buttocks and then spreading rapidly often affecting all parts of the body except the palms and the soles and the genitalia. The involved skin is pale, waxy, and firm to palpation. The skin cannot be pitted or pinched up because it is bound to the underlying tissues. The affected infant often dispalys flexion contractures at the elbows, knees and hips, temperature instability, restricted respiration, difficulty in feeding and decrease in spontaneous movement.17 Recognition and the prompt institution of therapy specific to the underlying disease process are mandatory such as antibiotics, steroids, exchange transfusions and FFP transfusion. Definition of Terms Neonatal sepsis- It is a clinical syndrome of bacteremia characterized by systemic signs and symptoms of infection in the first month of life. Neonatal sepsis encompasses systemic infections of the newborn including septicemia, meningitis, pneumonia, arthritis, osteomyelitis and urinary tract infection of the newborn19. Associated factors for early onset neonatal sepsis include lowbirthweight, PROM, foul smelling liquor, multiple vaginal examinations and maternal fever20 Early onset neonatal sepsis- It usually presents within the first 48 hours of life. In severe cases, the neonate may be symptomatic in utero, (fetal tachycardia, poor beat to beat variability) or within the first few hours after birth. The source of the infection is generally in the maternal genital, gastrointestinal, urinary tract . Clinically neonates usually present with respiratory distress and pneumonia. Presence of some perinatal risk factors has been associated with an increased risk of early onset sepsis. Frozen Frozen Plasma It is the plasma removed from a unit of whole blood and frozen at or below 55 degrees Fahrenheit within 8 hours of collection. It contains all the coagulation factors in normal amounts and is free of red cells, leukocytes and platelets. It is not a concentrate of clotting factors. Sclerema Neonatorum- It is derived from the Greek word sclerosmeaning hard. It is considered best as a sign of a potentially fatal underlying disease process in the newborn period. Physical findings appear suddenly first on the thighs and buttocks and then spreading rapidly, often affecting all parts of the body except the palms, soles and genitalia. The involved skin is pale, waxy and firm to palpation. The skin cannot be pitted or pinched up because it is bound to the underlying tissues.It can present at birth but onset within the first week of life is more common. Associated underlying conditions include septicemia, pneumonia, hypothermia, metabolic acidosis, respiratory distress syndrome, congenital heart defects, gastroenteritis and intestinal obstruction. Clinical Signs of Neonatal Sepsis: (At least 2 clinical signs supported by laboratory findings) 1.sclerema 2.hypoglycemia/hyperglycemia 3.temperature instability 4.tachypnea/respiratory distress 5.Apnea 6.Poor perfusion Laboratory findings: 1..I/T ratio> 0.2 2.leukopenia 3.Neutropenia 4.Thrombocytopenia Research Question Will FFP transfusion improves the survival outcome of the sick neonates with early onset neonatal sepsis with sclerema given the standard therapy plus FFP? Is the use of FFP justifiable in the treatment of neonatal sepsis with sclerema in terms of cost and survival outcome? Significance of the study Many studies have been done to improve the survival outcome of neonates with septicemia. The progress in terms of the available adjuctive therapies in the treatment of neonatal sepsis entail a higher cost which is an issue to our marginalized patients who cannot afford such expensive add on treatment hence inspired the researcher to study fresh frozen plasma transfusion which is much more affordable and readily available to the neonates with septicemia particularly with sclerema. FFP contains immunologic factors helping the immunologically deficient neonate in fighting serious infections. This study aims to evaluate the effects of FFP transfusion in the subset of neonates with high case fatality rate. They are the candidates that would benefit from the terminal cytotoxic complement with the coagulation cascade that FFP may provide. OBJECTIVES OF THE STUDY General Objective: To determine and compare the survival outcome of patients with early- onset neonatal sepsis with sclerema given the standard therapy (antibiotic + supportive care ) plus fresh frozen plasma to those with early -onset neonatal sepsis given only the standard therapy (antibiotic + supportive care ) at Southern Philippines Medical Center- Nursery for the year 2008 . Specific Objectives: Determine the incidence of sclerema in early onset neonatal sepsis in SPMC. Determine the rate of early onset neonatal sepsis with sclerema in SPMC. Determine the mortality rate of neonates with early onset sepsis with sclerema. Identify the possible the maternal fetal/neonatal factors related to early neonatal sepsis with sclerema Compare the outcome 1.resolution of sclerema Chapter 2 METHODOLOGY Study Design This paper will be an observational descriptive and comparative study on the survival outcome of patients with neonatal sepsis with sclerema admitted at Southern Philippines Medical Center for the year 2008 using a Cohort study design. Population This study will include all neonates with early-onset neonatal sepsis with sclerema admitted at Southern Philippines Medical Center -Nursery for the year 2008. Inclusion criteria: All neonates admitted at Southern Philippines Medical Center -Nursery who presents with the clinical signs of early- onset neonatal sepsis with sclerema. Exclusion criteria: 1.All neonates presenting with clinical signs of neonatal sepsis with sclerema occurring beyond 48 hours of life. 2. All non-institutional deliveries presenting with early onset neonatal sepsis with sclerema. 3. All neonates admitted at the NICU with obvious congenital anomalies like syndromic features, cleft lip and palate etc. Data Collection Data will be collected by the researcher through a retrospective chart review. The researcher will scan and evaluate each chart of the patient with neonatal sepsis for the presence of sclerema in the progress notes. A data sheet will be use for each patient.Research consultant will be asked for validation of diagnosis. Independent variable -Fresh Frozen Plasma transfusion Dependent variable- survival outcome of neonates with early onset sepsis with sclerema Sample Size: All neonates admitted at Southern Philippines Medical Center-Nursery who fulfilled the inclusion criteria for the year 2008 will be used as a sample in this study. Data Analysis: correlation coefficient and odds ratio will be used to summarize the data for the comparative part. Means and standard deviation for the descriptive part and percentage and rates as per standard definition. Ethical Consideration The approval of the hospital research committee and the ethics committee will be sought before the conduct of the study. No identification data or marks will be placed in each patient included in the study. The data will be kept by the researcher for 5 years. Table 1.Patient clinical profile Name: AGA___SGA___LGA___ Age: Weight: AOG: Sex: Medical record number: length of stay in the hospital: Date of admission : Date of discharge: Diagnosis upon admission: Final diagnosis: OUTCOME: [ ] died [ ]survived [ ] HAMA [ ] transferred [ ]transout to blue area Cause of death: Age at onset of sepsis(hours) Age at onset of sclerema(hours) Antibiotics Ampicillin/Gentamycin Cefotaxime/Amikacin Piperacillin + Tazobactam/Amikacin Meropenem Cefepime Neonatal risk factors Birthweight 1.VLBW 2.LBW 3.normal weight 4.LGA APGAR SCORE (5 minute) 0-3 4-6 7-10 Ballard Scoring 34-37 >37 Comorbidities Neonatal pneumonia Meconium aspiration Intubation Pulmonary hypertension Pneumothorax Others (specify) MATERNAL RISK FACTORS Premature labor and delivery Prolong Rupture of membrane Antenatal Steroid Chorioamnionitis Manipulative Operative Delivery Maternal infection within 2 weeks of delivery UTI RTI Preeclampsia/eclampsia Placenta previa/ abruptio Others (specify) SCLEREMA Hours first noted FFP transfusion Yes /hours before transfusion No Resolution of sclerema post FFP Yes- number of hours first noted resolution No- OUTCOME Died Survived COMPLICATIONS NOTED Table 2. ANTIBIOTICS Standard care+FFP Standard care Total No. % No. % No. % Ampicillin+Gentamycin Cefotaxime +Amikacin Piptazo+Amikacin Meropenem Cefepime Total Table 2.BIRTHWEIGHT Standard care+FFP Standard care Total No. % No. % No. % VLBW LBW AGA LGA Total Table 3. APGAR SCORE(5 MINUTE) Standard care+FFP Standard care Total No. % No. % No. % 0-3 4-6 7-10 Total Table 4. BALLARDS SCORE Standard care+FFP Standard care Total No. % No. % No. % 34-37 weeks >37 weeks Total Table 5. Comorbidities Standard care+FFP Standard care Total No. % No. % No. % Neonatal pneumonia Meconium aspiration Intubation Pulmonary hypertension Pneumothorax Others (specify) Total Table 6. Maternal Risk Factors Antibiotic+Standard care+ FFP Antibiotic +Standard care Total No. % No. % No. % Preterm labor/delivery RBOW Antenatal Steroid Chorioamnionitis Operative Delivery Maternal infection UTI RTI Preeclampsia/eclampsia Placenta previa /abruptio Others (specify) Total Table 7. Onset and Resolution of Sclerema Antibiotic+Standard care+ FFP Antibiotic +Standard care only Onset resolution Total time of sclerema Table 8. Outcome Survived Dead Total No. % No. % No. % Antibiotic+Standard care+ FFP Antibiotic +Standard care Total Conceptual framework: Babies admitted at DMC nursery 2008 No sepsis Compare results Sepsis with sclerema Antibiotic+Standard care+ FFP Antibiotic +Standard care Sepsis without sclerema Early-onset neonatal sepsis COST/BUDGET: COUPON BOND.P.400.00 PRINTINGP700.00 RESEARCH MATERIALS ..1,000.00 ______________________ P 2,100.00 TIME TABLE (May 2009- December 2010) May PRESENTATION TO RESEARCH COMMITTEE AND ETHICS June -October DATA GATHERING November PRESENTATION OF RESULTS December SUBMISSION OF HARD COPIES