Wednesday, October 30, 2019

AFTER THE FACT ASSIGNMENT Example | Topics and Well Written Essays - 250 words

AFTER THE FACT - Assignment Example The prologue of the account, however, narrated Deane’s close connection with his personal aide, Edward Bancroft and Deane’s partnership with Bancroft in their sort of gambling escapades when he was exiled. Deane was alleged to have known of Bancroft being a double spy to both Britain and the U.S., and so, when Deane decided to come back to his country, he died aboard a ship. Though a conjecture, some evidences gathered by historians can link Bancroft’s fear of being revealed as a traitor and his thorough knowledge in poisons. With this account, truth is defined as a product of careful analysis of evidences, and the apparent connections of them in order to make a logical and coherent conclusion. Top rail bias means that writing history is mired by prejudices and bias of affluent history authors who are the producers of most history books. Bottom rail means citing, for instance, a slave as a source of a historical research. It is difficult to be used as a reliable source of information knowing the biases present in every slave’s dependence to their lords (Davidson and Lytle 206). Good sources are diverse, meaning they come from two different people, and must be first-hand. Moreover, any freedman’s point-of-view should not be taken by face-value. Sack’s method of investigation could have worked better because it did not employ any form of deceit, and it is an accuracy-driven method. An outside factor, such as race and inherent prejudices, plays a crucial role in a historical researching. Sack’s approach that entails thorough research and comparison of accounts works best. Meanwhile, the case of the colorblind painter depicted a historical approach in finding a solution to blindness problem. This is equally true with historical research. Treating every reader as blind from history and the historian as well could make a history research free from biases and prejudices and will be even more

Monday, October 28, 2019

Ultrasonic transducers

Ultrasonic transducers 1.1 Introduction Transducer is a device which converts energy of one form to that of another. With reference to ultrasonic transducer the ultrasonic energy is to be converted to electrical, mechanical, or other energy form. A reversible transducer transforms energy in both directions with equal efficiencies. The transducers can be classified as follows: 1. Piezoelectric oscillators: Principle of piezoelectric effect is used and this is reversible. The possible frequency range is from 20 kHz to well over 10 GHz. 2. Magnetostrictive oscillators: Employs the phenomenon of magnetostriction, a reversible form of conversion. Can be made to operate at mega-hertz and even gigahertz frequencies. 3. Mechanical transducers: Includes whistles and sirens (mechanical oscillators) and radiometers, and are irreversible. Mainly used for high-power applications. 4. Electromagnetic transducers: Applied for high-intensity applications at low frequencies, in the audible range. They have been used for low-intensity work at frequencies of up to 50 kHz and, also as receivers at megahertz frequencies. 5. Electrostatic transducers: Used as generators at low intensities with an upper frequency limit of a few hundred kilo-hertz. Reversible in conversion and used as receivers at frequencies as high as 100 MHz. 6. Miscellaneous transducers: Includes thermal, chemical, and optical transducers. Ultrasonic receivers are categorized into two 1. Receivers terminating acoustic beams: The cross-section of the receiver embraces the whole or a large proportion of that of the beam and its dimensions extend from several to a large number of wavelengths. The presence of the receiver materially affects the configuration of the acoustic field, to give rise to regular reflections of the beam. 2. Receivers acting as probes: ultrasonic probe receivers are used for mapping out acoustic fields and for measurement of local intensities. the use of probe receivers is restricted to lower frequencies (e.g. in the kilo-hertz range)., as their dimensions need to be small enough, not to upset the characteristics of the field,( to be less than about one-tenth of a wavelength). 1.2 Piezoelectric transducers 1.2.1 General considerations Piezoelectric transducers employ the piezoelectric effect, discovered by the Pierre and Jacques Curie in 1880. The effect occurs naturally in certain single crystals with polar axes, (e.g. quartz, tourmaline, lithium sulphate, cadmium sulphide, and zinc oxide.) When mechanical stress is applied to the surfaces of piezoelectric crystals, coated with silver or gold, equal and opposite electric charges will be induced on them and a voltage will be observed. This is the direct piezoelectric effect, and the crystalline axis perpendicular to the coated faces is the relevant polar axis. When a voltage is applied across the electrodes to produce an electric field, a converse effect is observed, resulting in a mechanical strain. These effects are associated with compressions and shears, in quartz, for example, the principal polar axes are called the X- and Y axes, there is three of each. The X-axes are oriented at angles of 120Â ° apart, and with corresponding Y-axis perpendicular to it. The electrodes lie at right angles to an X-axis for X-cut quartz crystals, and are associated with compressions, and Y-cut quartz crystals with shears. The Z-axis, is known as the optic axis and lies perpendicular to the planes containing the X- and Y-axes. Optic is a non-polar axis for which the piezoelectric effect is not observed. A piezoelectric transducer oscillates at the applied frequency with amplitude of the order of 10-6 times its thickness, on applying an alternating voltage across its electrodes,. If, the transducer is excited at one of its resonance frequencies the amplitude is considerably increased, e.g. to about 10-4 times the thickness at the fundamental frequency Artificially induced piezoelectric transducers are of polycrystalline structure. They are made up of large numbers of minute crystallites bonded together, to the required shape and size. The final product is in the form of a ceramic. Prior to polarisation, these ceramic transducers do not require to be cut with reference to any particular axis, as they are isotropic. So it is possible to have a shape in any convenient form by adding small quantities of other materials, the transducers properties can be improved or adjusted. The piezoelectric effect is measured by the d coefficient, which can be expressed in one or two ways. (i) If the crystal is subjected to a mechanical stress, at the same time, the electrodes are short-circuited by a wire, charges induced by the stress will flow through the wire until the potential difference across the crystal is reduced to zero. Considering, q is the value of the total charge flowing and F the force producing the stress, then d coefficient can be given as d=q/f coulombs per Newton 3.1 (ii) When a voltage V is applied across the crystal, on which no load is applied e.g. vacuum, a displacement l is produced due to the resultant strain, then volts per metre 3.2 The electromechanical coupling coefficient is defined as Both d and k vary with temperature and reduce to zero at the Curie temperature Tc. The frequency response of a transducer depends on its Q factor. If the characteristic impedances of transducer and medium are R1 and R2, then Q can be represented as where K is a dimensionless constant. Ceramic transducers have higher d coefficients and electromagnetic coupling coefficients compared to the quartz crystals. But quartz crystals are highly stable. 1.2.2. Coupling of Piezo electric transducers A suitable liquid must be provided to avoid an air gap , for efficient coupling of ultrasound between the transducer and a solid. To generate longitudinal waves at normal temperatures, a film of oil is usually enough, but, at low temperatures a high-vacuum grease is used to prevent loss of continuity of characteristic impedance. While working with high temperatures, a couplant which does not evaporate, should be chosen. .For transverse wave propagation, it is necessary to use adhesive such as epoxy resin, so as to ensure the couplant has enough strength to withstand the application of the shear stresses without collapsing. Canada balsam or even nail varnish , on some occasions will provide good coupling for shear waves, depending on the temperatures. 1.2.3 Ultrahigh frequency (u.h.f.) piezoelectric transducers An early method of generating u.h.f. ultrasonics was to place one end of a single-crystal quartz rod inside an electromagnetic cavity resonator Ci (see Figure ). The surface was excited at the required frequency, and waves were propagated along the rod. Initially the method was applied only for producing ultrasound in single-crystal quartz , due to difficulty of coupling other materials to the free end of the rod. Another electromagnetic cavity resonator C2 at the other end of the rod acted as a receiver. In later stages the free ends of the rod and solid specimen was coated with thin film of indium. 1.2.4 Piezoelectric sandwich transducers To generate waves at the frequencies ranging from 40 kHz down to 20 kHz.frequency, for High-intensity applications ,with a piezoelectric ceramic, the thickness should exceed 100 mm. A ceramic block of this thickness is both expensive and is highly absorbent. Due to this, absorbed acoustical energy being converted into heat, results in a rapid increase of temperature and the Curie temperature is soon reached, with a consequent disappearance of the piezoelectric effect. To avoid this sandwiching of the piezoelectric transducers can be applied. A sandwich transducer consists of a comparatively thin piezoelectric plate located between two thicker metal plates.They have high compressive strengths and by compressing the sandwich permanently using high tensile bolt damage can be prevented. (see Figure 3.7); the transducer is said to be mechanically biased. 1.2.5 Surface wave piezoelectric transducers Surface waves can be generated by using mode conversion with a longitudinal wave transducer as the primary source, but it is also possible to propagate them directly. Surface waves are produced by placing an ordinary longitudinal wave transducer in contact with the edge of the material and inclined at an angle of 45Â ° (Fig 3.4) and are received in same fashion. Another method of generating and receiving surface waves is by coating two electrodes on the surface of a piezoelectric material and applying the exciting voltage at the required frequency across them (see Figure 3.5). This technique was used for delay line applications 1.2.6 Operation of piezoelectric transducers A quartz crystal mounted at its nodes, is an ideal one for propagating continuous waves over a narrow frequency band. Electrical connections must be made to the electrodes and additional damping caused by them should be kept minimal. Nodal mounting is not advisable for very thin transducers and where contact with a solid medium has to be maintained. For cases like these, the transducer is held in position by means of a light spring against a solid surface. Then the solid surface provides one electrical contact with the transducer electrode and the other is provided by the spring. To have maximum efficiency, the impedances of the exciting and receiving electrical circuits should be correctly matched to the electrical impedance of the transducer. For pulsed wave operation it is essential that the pulses are kept sufficiently short to prevent their overlapping. No stationary waves are to be produced in the medium. To produce very short pulses and where a narrow frequency band is not needed, transducer material, such as a ceramic is used. The transducer is backed by a block of a material having a very high acoustic absorption coefficient and of sufficiently large electrical conductivity to provide contact with that transducer surface. A mixture of tungsten powder and Aroldite is used for this purpose. A high direct voltage (typically from 300 V to 600 V) of instantaneous duration is applied periodically to the transducer electrodes at the required pulse repetition frequency. At each electrical impulse, the transducer experiences a high initial strain after which it oscillates over about two or three cycles, the amplitude decreasing rapidly.. Thus, for a transducer operating at a frequency of 6 MHz to produce pulses each of thre e wavelengths, the pulse duration is about only 0.5ÃŽ ¼ for propagation into most metals. The relation between pulse-length (PL) in seconds and the frequency bandwidth can be given as: PL= 1.3/ Frequency Bandwidth 3.4 1.3 Magnetostrictive transducers Magnetostrictive transducers are made of ferromagnetic materials, which can easily be magnetised and displays magnetostriction or the Joule effect. When a bar or rod of one of these materials is placed in a magnetic field, it suffers a change in length, either an increase or decrease, depending on the nature of the material and the strength of the field, immaterial of the sign of strain. Hence, when the direction of magnetic field is reversed, there is no change in the sense of the strain. Figure 3.11 shows the relationship between mechanical strain and the magnitude of the field strength for a few ferromagnetic materials. The graph imples, the variation is not a linear one, in general. Nickel is found to be the most satisfactory material for magnetostrictive transducers, having an electromechanical coupling coefficient of 31 per cent and a Curie temperature of 358Â °C. Permendur, an alloy, has a higher Curie point (about 900Â °C) and low electromechanical coupling coefficient. Though ferrites (non metals) has an advantage of being poor conductors and not being heated by eddy currents, and exhibit magnetostrictive effect are not often used as transducers due to their poor mechanical properties. There is a converse magnetostrictive effect, in which a mechanical stress applied to a ferromagnetic rod lying in a magnetic field gives rise to a change in the magnetic flux density. This is known as the Villari effect. Magnetostrictive transducers are in the forms of rods surrounded by coil windings (see Figure 3.7). An alternating magnetic field of the same frequency is induced by an alternating current through the coil ; giving rise to longitudinal oscillations of the rod. These oscillations take place at a twice the frequency of the field and take on the form of unsmooth, rectified alternating current, resulting in unwanted frequencies. As in the case of ceramic transducers. This disadvantage is avoided by polarisation, as in ceramic transducers. It is not possible to obtain a high polarising field by permanent magnetisation, and a steady direct field of suitable magnitude is provided by passing a direct current through another coil wound round the transducer. So, the oscillations occur about some other point instead of taking place about the origin of the curve. If the amplitude of the applied alternating field is low for changes to take place along the linear portion of the curve, and, is less than the value of the polarising field, then sinusoidal oscillations occur at the applied frequency. The resonance frequency inversely proportional with the length of the transducer rod. The frequency is increased by decreasing the length, but, simultaneously , there is a intensity is lowered for a rod of given cross-sectional dimensions , which results from the reduction in size of the vibrating mass. So, at frequencies more than 100 kHz ,the output from this type of transducer becomes vanishingly small. The considerable leakage of magnetic flux is observed , which is a disadvantage of using rod-shaped oscillators . Transducers designed to form closed magnetic circuits are used for high-intensity applications The window-type transducer is clamped nodally, and the vibrations produced are longitudinal. In ring-type transducer, vibrations are in a radial manner, and hence ultrasonic energy is focused at the centre resulting in high acoustic intensity. Absorption of ultrasound by induction of Eddy currents and Hystersis results in increased amount of eating. Though there are a number of ferromagnetic materials with low hysteresis losses, their magnetostrictive properties are poor. The losses due to eddy current can be reduced by using laminated stacks consisting of alternating sheets of the metal and of some insulating material such as mica. Since the rise in temperature may result in loss of magnetostrictive properties, it is necessary to cool the transducer during its operation. By using velocity transformer, an increased intensity, distributed over a smaller area, can also be obtained with both rod and window types of transducers. This consists of a tapered coupling rod and provides an increase in the value of the particle velocity at the end remote from the transducer. For maximum efficiency, the transformer is designed to resonate by making it one wavelength long and supporting it at a nodal point, i.e. at a distance of a quarter-wavelength from the transducer. The diagram illustrates the application of the velocity transformer to the construction of the ultrasonic drill Magnetostrictive oscillators being reversible can be used as receivers. An example of a magnetostrictive probe receiver consists of a nickel rod held vertically in a fluid in which ultrasound is radiated in an upward direction. The rod is contained in a plastic tube so that only the free end is exposed to the waves which are then transmitted along its length. A current is induced by the Villari effect in the pick-up coil placed near the upper end of the rod. Another coil carrying a direct current provides the polarising field. The formation of stationary waves is prevented by placing an absorbent material at the top of the rod. Nickel film transducers are used for producing and receiving ultrasound of very high frequencies ranging from 100 MHz to 100 GHz in solids. A thin film of nickel, of thickness corresponding to one half-wavelength at the resonant frequency, is deposited on the end-surface of the specimen into which sound is to be passed. The rod is located with its plated end inside a microwave electromagnetic cavity resonator, excited at the required frequency. The receiver may consist of a similar film coated on the opposite surface of the specimen and also located in a cavity resonator. Instead a single nickel film can act as both source and receiver, using reflection method. No coupling material is required and no special technique is necessary for coating the nickel film. 1.4. Mechanical Transducers Mechanical ultrasonic generators are used for high-intensity propagation in liquids and gases at frequencies of up to about 25 kHz .They exist mainly in the forms of whistles and sirens. They are powerful and less expensive than piezoelectric and magnetostrictive transducers, but with limited scope of applications. Ultrasonic whistles are of two types, the cavity resonator, used mainly for gases, and the wedge resonator, employed for both gases and liquids. . 1.4.1. Cavity Resonators Galton whistle (see Figure 3.12) consists of a cylinder terminated by the end-surface of a piston which can be adjusted to provide resonance at the required frequency The fluid, flows through an annular slit at high speed and strikes the rim of the tube where vortices appear and produce edge-tones. The frequency of the edge-tones depends on the velocity of the fluid which can be adjusted until the cavity resonates. For air, at a frequency of 20 kHz, fundamental resonance takes place for a cavity length of approximately 4 mm. The second type of cavity resonator is the Hartmann generator, similar in design to the Galton whistle, except that the annular slit is replaced by a conical nozzle (see Figure 3.13). The fluid is forced through the nozzle and emerges at a supersonic velocity to produce shock waves, which cause the cavity to be excited at a high intensity. Resonance is achieved by adjusting the fluid velocity. 1.4.2. Wedge Resonator The wedge resonator consists of a rectangular plate with wedge-shaped edges, mounted on nodal supports and placed in a fluid jet stream.(Figure 3.14). The wedge is set up into flexural vibrations having an intensity comparable with that attained by the Hartmann generator. Operating frequencies are of the order of 20 kHz. Sirens also are used for generating high-energy ultrasound in fluids. The siren consists of a rotor disc with a number of identical holes spaced evenly around the circumference of a circle slightly smaller than the disc. The rotor turns concentrically in front of a similar disc (the stator), which is kept at rest whilst fluid jets are directed through the holes. The frequency of the emitted ultrasound is equal to the frequency of interruption of the jet flow, as the holes move relatively to one another, and is calculated as the product of the number of holes in the rotor and the speed of revolution. The tone emitted by the siren is not a pure one but this is unimportant for the applications for which it is used. One advantage of this instrument is that by altering the speed of rotation the frequency can be varied in a continuous manner. The use of mechanical receivers has been restricted to measurements of intensities in liquids and gases. The two principal types of mechanical receivers are the Rayleigh disc and the radiometer. The Rayleigh disc consists of a thin circular disc suspended vertically in the ultrasonic field by means of a torsion fibre. Initially the disc is positioned, with its plane surfaces parallel with the direction of propagation. In the presence of ultrasound, the sound waves exert a couple on the disc, which rotates until brought to rest in a steady position as a result of an opposing couple exerted by the suspension. The angle of rotation required to reach the state of equilibrium depends on the the acoustic intensity. A radiometer is a device which measures directly the pressure of radiation, a quantity which is proportional to the acoustic intensity. The simplest form of radiometer is a tiny solid sphere suspended in the sound field. It is deflected horizontally in the direction of propagation when the ultrasound is present. The device is calibrated by subjecting it to known fluid pressures and then measuring the resulting displacements. The torsion balance radiometer is designed for waves travelling in a horizontal direction and the common balance type for vertically directed waves(Fig 3.15 a and Fig 3.15b) 1.5 Electromagentic Transducers A lightweight electromagnetic transducers have been used for low-intensity ultrasonic measurements in poorly conducting solids and liquids. But the method requires constant application of a steady magnetic field m which is a major disadvantage 1.5.1. Giacominis method: A bar of poorly conducting solid is coated with a thin conducting strip of negligible mass over opposite halves of the upper and lower surfaces and the end-face. It is supported horizontally at the nodal positions by electrically conducting wires, and the coated end is subjected to a horizontal magnetic field at right angles to the axis. When an alternating current is passed through the conducting strip, the bar vibrates longitudinally, in accordance with Flemings left-hand rule of electromagnetism. Because electromagnetic transducers are reversible, vibrations in the bar are picked up by the conducting strip which, in the presence of a steady magnetic field, will have induced in it an alternating e.m.f. in accordance with Flemings right-hand rule of electromagnetism. This e.m.f. is related to the acoustic intensity. Thus the device can be used as both a transmitter and a receiver of ultrasound. 1.5.2. Filipczynskis Method: An aluminium film in the form of a continuous and winding narrow strip is evaporated on to a perspex block to provide a coil of negligible mass. The block is then immersed in the liquid and located inside a gap between the pole-pieces of a permanent magnet which supplies a steady magnetic field of high intensity. Ultrasonic waves pass from the liquid into the block, giving rise to oscillations of the aluminium coil which induce in it an e.m.f. related to the intensity in the block. 1.6 Electrostatic transducers An electrostatic transducer consists essentially of two parallel plates of a conducting material placed close to one another to form an electrical capacitor. One plate is fixed and the other is free to vibrate in a direction at right angles to the surface of the plates. A high resistance is placed in series with the capacitor and steady charges on the plates maintained by a direct potential difference of several hundred volts (Fig 3.18). For operation as a transmitter, a signal at the desired frequency, is fed to the plates , output voltage of amplitude not exceeding the direct potential difference. The periodic variation of the charges induces vibrations of the movable plate. For use as a receiver, the movable plate is placed in position to receive the sound waves and its consequent vibrations give rise to periodic variations of the electrical capacitance of the transducer, producing an alternating current which flows through the high resistance; the resulting alternating voltage proportional the intensity of the received sound. The electrostatic transducer in the form of the condenser microphone has long been used at audible frequencies. Diaphragm being light , inertial effects are negligible and the sensitivity remains constant over a wide frequency range. It can be used for gases and liquids as both a receiver and a transmitter at frequencies of up to about 300 kHz. 1.7 Miscellaneous Transducer Other methods of generating and receiving ultrasound involve the uses of thermal, chemical, and optical devices. The chemical changes observed in materials irradiated with ultrasound, is used as a means of detection. It is also possible to generate ultrasonic waves in a transparent medium by the crossing of two laser beams originating from a common source. There are a number of applications which make use of thermal transducers. One thermal type of transmitter is the spark-gap generator, which radiates ultrasound as a result of periodic temperature changes taking place when a high alternating voltage of a given frequency is discharged across a gap in a circuit. The hot-wire microphone, is a receiving thermal transducer,consisting of a thin wire, made from platinum and heated to just below redness. When sound waves strike the wire, it cools down by an amount directly dependent on the intensity. This is indicated by a decrease in its electrical resistance. The hot-wire microphone has been used successfully for gases at frequencies of up to 600 kHz. Ultrasonic intensities can also be measured from the rise in temperature within the beam, as shown in Figure 3.19. The heat produced by the ultrasound is absorbed by the liquid in the thermally insulated flask. Expansion of the liquid results in a rise in the level of the liquid in the graduated capillary tube, calibrated by supplying a measured amount of heat from the heating coil. The waves transmitted through the liquid are finally absorbed by the glass wool placed at the end of the vessel. Acoustic powers of from 50 mW to 30 W can be measured to an accuracy of better than 10 per cent with this device.

Friday, October 25, 2019

Essay Of Eukaryotic Organelles :: Biology, Health, Human Body

The mitochondria has an eggshape structure. The mitochondria consists of an inner and outer membrane. The outer membrane is what shapes the organelle to its egglike shape. The inner membrane which folds inward makes a set of "shelves" or cristae that allow the reactions of the mitochondria to take place. The more the mitochondria makes these reactions the more the inner membrane folds. This happens because the mitochondria now has more surface area connecting it to its surroundings. The processes that the mitochondria make are to break down the high energy organic molecules into smaller more useful packages. The endoplasmic reticulum is a network of tubes and channels that transport and with the help of ribosomes produce proteins. The rough endoplasmic reticulum contains ribosomes which are not present in the smooth endoplasmic reticulum. The rough endoplasmic reticulum allows the cell to produce proteins. The smooth endoplasmic reticulum is used in the detoxification processes in the cell and the transitional endoplasmic reticulum is used to breakdown glycogen to glucose. The endoplasmic reticulum is versatile and grows and shrinks according to the cell's activities. Chloroplasts which are found in plant cells are used in the process of photosynthesis. They fall into the category of plastids but they are differentiated in that they contain chlorophyll. These organelles produce chemical reactions from the energy that the sun gives them. The Golgi complex's structure is made up of many flattened membranes sacs that are surrounded by tubules or vesicles. These are called the cisternae. The golgi complex accepts vesicles from the endoplasmic reticulum and modifies them for usage in the cell.

Thursday, October 24, 2019

Principles of marketing Essay

1. Introduction   1.a What is marketing? Elements of marketing: Marketing is a business philosophy that seeks to address customers wants and needs by either determining what a customer wants or anticipating customer demands and then producing goods and services that meet these requirements. The marketing concept therefore differs significantly from the selling and the production concept, where it was what the firm produced that was sold. The production concept believed that all production sells and what is needed is a selling effort. In marked contrast, the marketing concept works first at determining what the customer needs and then producing the same so that the customer is satisfied. The elements of marketing include the customer, the product, the value of the product and the want it addresses. 1.b Advantages of marketing and criticism: The marketing approach ensures that the seller does not make mistakes in determining what the market demands. There is thus that much efficiency in the marketplace as production capacities are built depending on market feedback and what customers want. Also, as the marketing department knows what the customer wants, it is able to provide an efficient answer and design, at a cost that the customer is willing to pay. The marketing approach has also been criticized for its attempt at forecasting and determining personal choices. It is also criticized for influencing customers towards goods and services that they may actually not need, but are driven to these products through clever strategies that convert simple desires into burning needs. Marketing also has been criticized for using external influences through advertising and promotions to make people demand goods that they would otherwise not have found useful. Leveraging customer psychology to get people influenced by imaginary reference groups that they aspire to belong to, also is another tool used by marketing that is often criticized for its ability to attract customers. Modern marketing, with all available technology and databases that track customer behaviour, is a weapon that can be used by firms wanting to grab large market shares. It therefore tends to be unethical at times and needs string regulatory mechanisms. 1.c The marketing function The marketing function is a function that includes all activities that contribute to the marketing strategy and the marketing process. This function therefore covers all aspects of identifying customers, determining their needs, estimating wants, calculating total demand, building supply chains and constructing marketing promotion strategies through all available marketing channels. This also includes marketing controls and control systems that ensure that all activities undertaken by marketing departments are consistent with and in line with the objectives of the firm. The marketing planning and control mechanism tracks the various activities undertaken by the firm, and determines if the process is going as per plan. 1.d Marketing management: Monitoring and evaluating its marketing processes regularly, a firm is able to take corrective action. The monitoring of marketing activities is a specialized task that ensures the entire chain of activities is checked regularly, constant feedback taken and corrective measures instituted that bring the plan back to the path desired so the firm’s overall objectives are met and are not deviated from. The marketing function starts with a marketing plan that is a written statement of objectives and processes that the firm would undertake to meet its goals. This plan is constantly recalled to ensure the control system and the action plan sticks to the strategy that has been drafted. The plan takes into account the economic environment the firm exists in, the regulatory framework, and the demographic characteristics of the population, competitive forces and product characteristics. The marketing mix   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Product: The marketing mix is central to any marketing plan that a marketing strategy evolves. The marketing mix primarily looks at the four components that have defined marketing strategy. These four major components of a marketing plan are the Product, Place, Price and Promotion. The first – product, focuses on making the firm’s product something that is of value for the customer, is constantly redefined to meet changing tastes and is what is actually something that meets market demand. The product that is marketed is defined by its quality, its functionality, the appearance, the service that comes with the product and the support provided to the customer. It is important for the firm to produce a product that is of high quality. In a competitive market, it is no longer possible to sell a product that is not of high quality as there are several substitutes available and competitors are always ready to improve quality. Hence the product is defined by it functionality and the brand that is built around the product. The brand defines product quality and provides customers with information about the product even before the product is bought and used. Additionally, the product is defined by what the firm provides by way of after sales support and service. Modern brands provide products with warranties that cover the risk of failure after the product is sold to the customer. Brands are built around the various facets of the product sold. A brand carries an inbuilt guarantee of the usefulness of the product. Brand building is essential to marketing management and defines the product part of the marketing mix. Products are also made so as to acquire certain niches in the market and this can be either done through specific functionalities or through product differentiation. Place: The second component is place and this focuses on the fact that the product would be made available to the customer at the right time and at the right place. It also includes the aspect that the product should also be available in the right quantities. Non-availability will move customers away to another substitute while too large a stick will increase inventory costs. So the correct balance needs to be struck. The place component of the marketing mix depends on the logistics that go into supplying the product to the customer at the right place and at the right time. The logistics department must identify appropriate locations, the appropriate channels of distribution, the channel partners that take the product to the customer and ensure maximum coverage. The place also defines the point of contact with the customer, the point of purchase advertising and the support locations. Modern technology has added a new dimension to place by way of providing Internet and mobile access to marketers. Using mobile phones and online marketing, customers are able to access distant locations at the click of a mouse and check out the product in a virtual environment. Delivery is quick because of the developments in transportation and travel. Support and service can now be provided through distant, centralized locations that are accessible through support centers and call centers. Successful marketing in today’s environment is a function of how well the marketer leverages modern technology by way of online brochures, online advertising and payment gateways.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Price: The price of course is a critical component of the marketing mix. In a competitive market where goods are homogenous and perfectly substitutable, it is price that would ensure some buyers for a new product. On the other hand, in similar situations, a product that is priced high could occupy the position of a superior good and guarantees a premium only because it attracts prestige and value to the product. In goods and services that are price elastic, price can e used as a strategic tool to increase margins, whereas in price inelastic markets, prices need to be kept stable. A large number of marketing strategies focus on the price range a product offers and the income levels and consumption characteristics of the customer in the neighborhood.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Pricing is also a strategy that incorporates list prices and how they are estimated. The list price takes into account the competition and the channel margins. Where the marketer is using a push strategy, pricing must include incentives to retailers and wholesalers that enable them to push the product among the customers. Pricing also includes the strategy that involves using discounting and discounting sales to increase volumes periodically. Today pricing strategies also have to keep in mind leasing options and installment based payments. They must therefore allow for various financing options.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Promotion: The other important component of the marketing mix is the promotion package that is used by the marketer. Especially in a new market, where a product is being launched and introduced, it is critical for the market to accept the new product. Here is where the promotional aspect acquires a new dimension compared to the promotional strategy of a product that is entering a competitive market. Promotional strategies need to be carefully defined depending on the nature of the product and the market characteristics. The most important promotional tool used worldwide is advertising and this in the modern world is a strategic decision that must take into account the advertising mix that calculates what amounts of money and effort be spent on television, print media, internet advertising, bill boards, radio stations and mail brochures.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Also, in the days of consumer movements and regulatory mechanisms, it is important for promotion to concentrate on public relations. Most brands today spend a lot of effort in maintaining public relations through regular contact with the consumers and the media. Also promotion in specific goods and services is carried out through a direct sales network that requires a great amount of coordination and networking. It is also important to remember that, given its scope and coverage, promotion is an activity that requires scientific budgeting and monitoring. Promotion as an activity needs to cover the target audience, the end customer, the opinion makers and the potential buyers and channel members that could be part of the future supply chain.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The 4 P marketing mix model has been the one most used by various marketers all over the world and ensures that each of the marketing function gets covered and focused on. There have been those who have argued for a 5 P and even a 7 P marketing mix, especially to cover service products. The one extra P that is most often talked about is People, the human resource component that actually makes the efforts in tackling the 4 Ps. In any marketing firm, where customers need to be convinced and must trust the product, it is the people handling the product, the promotion and the supply chain that need to be extremely well trained, motivated and understanding of customer demands. Therefore it is often argued that the marketing mix must give an equal emphasis on its people and their training and incentives. However the 4 Ps discussed above are the most critical and need to be focused on to be able to successfully compete at the market place. Buyer behaviour   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   3.a Purchase decision: Purchase decision is a complex mechanism that involves a .large number of steps. The buyer behaves differently for high involvement and low involvement products. Products that are expensive and are in the nature of assets are high involvement products where the consumer takes time and makes efforts to look at various possible substitutes and competitors before making the purchase decision. The purchase decision is therefore sees to go through the various steps. There is a need recognition phase where the marketing begins. Here the buyer defines what his needs are the starts exploring possibilities that would solve the need. High involvement products there fore need great amounts of research before the buyer is able to decide. On daily consumables like soaps and toothpaste the buyer may not be as highly involved and easily makes decisions. Therefore after the need recognition process, the buyer then goes of ran information search through which a set of alternatives emerge. These are then weighed against various constraints and then the actual purchase decision is made. What follows is the post purchase behaviour and in this the buyer may actually regret making the decision or may go away satisfied. Marketers need to understand what is referred to as post purchase dissonance to be able to ensure good word of mouth promotion from existing customers.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   3b. Reference groups, culture: Of course buyer behaviour depends a great deal on the cultural background where the market exists. In savings oriented societies buyer behaviour is quite different form societies marked by conspicuous consumption. Also buyers in certain societies are bound to make far more careful decisions than in certain other cultural frameworks. Also groups tend to alter behaviour is different settings. The reference group is a major decision maker for most customers who would like to reach a group that they aspire to belong to through similar buyer behaviour. This is why a large number of celebrities are used to sell products and promote them. To influence buyers who consider these celebrities as these reference groups and inspirational groups. 4. New product development   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Market plans and market strategies therefore are complex mechanism that must look at various aspects of buyer behaviour, product characteristics and promotional strategies. Very often in such mechanisms, it becomes critical for firms to make decisions regarding innovation and new product development,. It could sometimes to easy for a firm to simply provide a market with existing demand and give the same product that exists at a better price and better place. However this might not work as the first mover ahs an advantage. Also the demand levels keep changing as culture changes and incomes change.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Therefore new products must be offered and innovations required both in developing new products, in new segmentation strategies, in product differentiation, in defining new niche markets and in being able to design both push and pull promotional strategies. Innovation is the name of the game as markets become more competitive and the customer more demanding. Market strategy demands that innovative strategies and products be designed keeping the basics in mind – that of the need to study and satisfy customer demand. Marketing is a science that attempts at assessing demand and developing products and promotions that meet this demand at appropriate prices and places. Innovation in marketing must keep this design in mind and develop new processes and products that work at the market place. References Moorman C. and Rust T. R., (1999) The Role of Marketing, Journal of Marketing, Fundamental Issues and Directions for Marketing Webster F. E., (1992) The Changing Role of Marketing in the Corporation, Journal of Marketing Borden, N. H., (1964) The concept of the marketing mix, Journal of Advertising Research Howard, J and Sheth N. R. (1969), The theory off buyer behavior, John Wiley and Sons. Peter P. J. and Olson J. C., (2004) Consumer behavior and marketing strategy. Irwin/McGraw-Hill Grà ¶nroos C, (1991)The Marketing Strategy Continuum: Towards a Marketing Concept for the 1990s,   Journal: Management Decision Hooley G, Saunders J and Nigel Piercy N., (2004), Marketing Strategy and Competitive Positioning FT Prentice Hall Wind Y, Robertson TS., (1983) Marketing Strategy: New Directions for Theory and Research,   Journal of Marketing Fill C, (1995) Marketing communications: frameworks, theories and applications, Prentice Hall Mela CF, Gupta S, Lehmann DR, (1997) The Long-Term Impact of Promotion and Advertising on Consumer Brand Choice, Journal of Marketing Research

Wednesday, October 23, 2019

Case Study – Appendicitis

I. DEFINITION/PREVALENCE Acute disease of the GI tract may be caused by the pathogen itself or by a bacterial or other toxin. Acute inflammatory disorders such as appendicitis and peritonitis result from contamination of damaged or normally sterile tissue by a client’s own endogenous or resident bacteria (Lemone and Burke, 2008, page 766). Appendicitis is the inflammation of the vermiform (wormlike) appendix; the appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve, which is the beginning of the large intestine.It is usually located in the right iliac region, at an area designated as McBurney’s point. McBurney’s point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant. It is the usual site for localized pain and rebound tenderness due to appendicitis during later stages of appendicitis. The function of the appendix is not fully understood, although it reg ularly fills and empties digested food. Some scientists have recently proposed that the appendix may harbor and protect  bacteria  that are beneficial in the function of the human colon.Appendicitis  is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present.The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign may be elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens.The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. It is the most common reason for emergency abdominal surgery, affecting 10% of the population. Although appendicitis affects a person at any age, the peak incidence is between the ages of 20 and 30 years old in which the vast majority of clients are most common in adolescents and young and slightly more common in males than females. About 7% of the population will have appendicitis at some time in their lives (Lemone and Burke, 2008 page 766).The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal Pyle phlebitis , which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37. 7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. II. TYPES/CLASSIFICATIONAppendicitis can be classified as simple, gangrenous, or perforated, depending on the stage of the process. In simple appendicitis, the appendix is inflamed but intact. When areas of tissue necrosis and microscopic perforations are present in the appendix, the disorder is called gangrenous appendicitis. A perforated appendix shows evidence of gross perforation and contamination of the peritoneal cavity (LeMone & Burke, 2008 page 766). Peritonitis can be primary or secondary. Primary peritonitis is an acute bacterial infection that is not associated with perforated viscus, or organ.Bacterial infection is the usual cause and may be associated wi th an infection by the same organism somewhere else in the body, which reaches the peritoneum via the vascular system. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in the body, is a type of primary peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a perforated organ, often manifest peritonitis, which may be due to leakage of bacteria through the wall of the intestine. Secondary peritonitis is usually caused by bacterial invasion as a result of perforation, or rupture of an abdominal viscus.It can also result from severe chemical reactions to: pancreatic enzymes, digestive juices, or biles released into the peritoneal cavity (Gould & Dyer, 2011). III. DEMOGRAPHIC PROFILE Patient’s name is Mr. Ruptured Acute Appendicitis, 24 years old, male, residing at 820 General Kalentong, Daang Bakal, Mandaluyong City. He is the second child among 3 siblings, a Roman Catholic, single, a 3rd year college Information Technology student. IV. FAMILY MEDICAL HISTORY (Family Genogram)COD: TB COD: TB A: 83 -S, -D A: 83 -S, -D Not Recalled Not Recalled c c A: 20 +S, +D A: 20 S, +D A: 24 +S, +D A: 24 +S, +D A: 27 -S, -D Skin allergy A: 27 -S, -D Skin allergy A: 42 +S, +D A: 42 +S, +D A: 64 +S, +D HPN, Stroke A: 64 +S, +D HPN, Stroke c c A: 46 -S, +D Asthma A: 46 -S, +D Asthma A: 51 -S, +D A: 51 -S, +D patient patient LEGEND: LEGEND: male male married married deceased male deceased male S- smoker D- drinker COD- cause of death S- smoker D- drinker COD- cause of death female female deceased female deceased female V. PAST MEDICAL HISTORY He was first hospitalized last 2006 due to dengue at the same hospital: Mandaluyong City Medical Center (MCMC).He has no other further illnesses except the typical fever, cough and cold. Other than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 week prior to admission patient experienced abdominal pain all over abdomen. He consulted at ER MCMC si gned out AUPD (Acute Peptic Ulcer Disease) and was given Omeprazole & HNBB (Buscopan). Whole abdominal ultrasound done and revealed tiny cholecystolethiasis. He was given Diclofenal and HNBB tab and eventually discharged. Few days prior to consultation, the patient still experienced abdominal pain.He consulted at Emergency Room and was opted for surgical intervention – EXPLORATORY LAPAROTOMY APPENDECTOMY under the service of Dr. Abram Del Valle, M. D. VII. GORDON’S PHYSICAL ASSESSMENT i. Health Maintenance – Perception Pattern Before admission: The patient used to smoke cigarette 3 sticks per day. And he also drinks alcohol daily specifically beer of more than 2 bottles per session. He was not using drugs and he has no allergies at all. During time of care: The patient is not smoking cigarette or drinking alcohol. ii. Nutritional – Metabolic PatternBefore admission: The patient was on a high protein diet because he was used to go to the gym 2-3 times a we ek. He was also taking vitamins (CENTRUM). He has normal appetite and has no difficulty swallowing. He usually eats 3 times a day (breakfast, lunch and dinner) and most of the time he also has his snacks. He also usually drinks 2-3 liters of water a day. e During time of care: The patient is on NPO (nothing per orem) for 5 days due to post-operative appendectomy and he was on his 2nd day of NPO status when we cared for him. He has also NGT lavage connected. ii. Elimination Pattern Before admission: The patient’s normal bowel movement was 3 BM a day and has no difficulty in bladder habits. His last bowel movement was last July 17, 2012. He usually urinates 6-7 times a day without difficulty. During time of care: The patient has absence of bowel movement and even flatus and has no bowel sounds upon auscultation. He has foley catheter and with urine output of 480 cc per shift. iv. Activity and Exercise Before admission: The patient could do his activities independently without a ssistance.He usually goes to gym 2-3 times a week. During time of care: The patient’s functional level or self-care ability level is 2 which mean he requires help from another person for assistance. v. Sleep/Rest Pattern Before admission: The patient usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no difficulty in sleeping and he feels rested after sleep. During time of care: The patient has regular sleeping habits. He sleeps at 10 am, wakes up at 6 am with uninterrupted sleep. vi. Cognitive – Perceptual PatternBefore admission: The patient was alert and coherent, has normal speech, with mild level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. During time of care: The patient is alert and coherent. He has normal speech (Filipino as his spoken language), he has moderate level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. He also complained of acute pain and described it as a cramping pain. Pain management (Tramadol) was given. vii. Role – Relationship Pattern Before admission: The patient was a student and single.His support system was his family, relatives & friends. During time of care: The patient’s support system is his mother who is always at his bed side assisting him in whatever he needs. Upon asking his mother if she has any concerns regarding hospitalization, she said that she is more concern about the fast recovery of her son. viii. Sexuality – Reproductive System Before admission and during the time of care: The patient still didn’t have his testicular exam. ix. Coping – Stress Tolerance/Self – Perception/Self – Concept Pattern The patient’s major concern regarding his hospitalization is s all about self-care.Due to the contraptions attached to him, he cannot independently do his activities. His major loss was his stepfather when he died of kidney failure. His rated his outlook on future as 5, 1 being poor and 10 being very optimistic. He further explained why he rated 5 because he is not sure if when he finished college he can be able to find a job suited for him. x. Value – Belief Pattern Our patient is a Roman Catholic and he always goes to church every Sunday together with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK| THEORIST| STATUS| Intimacy vs.Isolation * Develops commitments to others and to a life work (career)(Daniels, et. al. , 2010). | Erikson| The patient had a relationship with his opposite sex but he said that they just broke up a week before he was hospitalized due to some personal and private reasons. Currently, he is in 3rd year college, an IT student. | Genital * Emergence of sexual interests and development of relationships with potential sexual partners (Daniels, et. al. , 2010). | Freud| As what had written above, the patient had a relationship with his opposite sex but because of some reasons they decided to end u p their relationship. Formal Operations * Able to see relationships and to reason in the abstract (Daniels, et. al. , 2010). | Piaget| He perceived that relationships (any kind of relationship) are important especially at his age. He can also reason out in an abstract way. He can express his opinions intellectually and precisely. | Early Adulthood * Select a partner, learn to live with a partner, start a family, manage a home, establish self in a career/occupation, assume civic responsibility, and become a part of a social group (Daniels, et. al. , 2010). Havighurst| According to our patient, he didn’t expected that something like that will happen to them (referring to his girlfriend). He was really expecting that they are really meant for each other and that she (his gf) will be his future wife. He is also establishing himself to a future career, that’s why he is studying in preparation for his future. During our time of care also, his ‘barkadas’ visited him and he said that they were his ‘tropa’. | Postconventional * Individual understands the morality of having democratically established laws (Daniels, et. al. , 2010). Kohlberg| Upon asking the patient if he is familiar with the democratically established laws in the Philippines, he immediately responded with a yes. He also said that these laws help us, Filipinos, to have safe and secure country though there may come a time that we may experience something unexpectedly. | IX. PHYSICAL ASSESSMENT * Vital Signs TIME| Initial 8AM (07/24/12)| 10 AM| 12 NN| 8 AM (07/25/12)| 12 NN| Last 8AM(07/26/12)| T| 36. 3| 37. 3| 37. 4| 36. 4| 37. 3| 36| P| 83| 84| 71| 75| 81| 68| R| 23| 25| 21| 19| 19| 20| BP| 120/80| 120/80| 120/80| 120/80| 120/80| 110/80| Sequence: BY SYSTEMS NORMAL FINDINGS| BOOK FINDINGS| PATIENT FINDINGS| SIGNIFICANCE| I. NEUROLOCIGAL SYSTEM Alert and coherent; with normal body temperature of 36. 3 °C – 37. 6 °C| * Fever (usually >38 °C although hypo thermia may be present w/ severe sepsis); chills * Thirst * Pain| * Complained of pain in the incision site (lower longitudinal midline of the abdomen)| Pain results from the increased pressure of fluid on the nerves, especially in enclosed areas, and by the local irritation of nerves by chemical mediators such as bradykinins (Gould, et al. 2011). | II. RESPIRATORY Normal respiration with a rate of 12-20 breaths per minute| * Tachypnea; shallow respirations| * RR: 23 bpm w/ shallow respiration| Acute pain usually initiates physiologic stress response with increased respiratory rate (Gould & Dyer, 2011). | III. INTEGUMENTARYPink or brown and in uniform color, no edema, no lesions, moistSkin temperature is normally warmIntact skinWhen pinched, skin springs back to previous state| * Dry lips and mucous membranes * Swollen tongue * Poor skin turgor| * Dry lips and mucous membranes * Skin turgor:3-5 seconds * Presence of surgical incision at lower longitudinal midline of the abdomen * Sk in is warm to touch and is reddened| Dry mucous membrane and poor skin turgor are signs of dehydration (Gulanick, et al. 1994). Redness may indicate inflammation (Weber & Kelly, 2007). Redness and warmth are caused by increased blood flow into the damaged area (Gould & Dyer, 2011). | IV. CARDIOVASCULAR Normal pulse rate of 60-100 bpm| * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissue edema| * Pulse rate: 83 bpm| Acute pain usually initiates a physiologic stress response with increased heart rate (Gould & Dyer, 2011). | V. MUSCOLOSKELETALAbility to do Activities of Daily Living (ADL)| * Difficulty ambulating * Weakness| * Difficulty ambulating due to post-op condition * Weakness| Constant pain frequently affects daily activities and may become a primary focus in the life of an individual (Gould & Dyer, 2011). | VI. GENITO-URINARY Normal urine output of 30cc/hrColor: Amber, transparent, clear| * Decreased urinary output * Dark color urine| * Dark color urine * Urine output: 480 mL/shift * Specific gravity: 1. 30| Decreasing output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). | VII. GASTROINTESTINAL Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elementsAbdomen is free of lesions or rashesA series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minuteNormally no tenderness or pain is elicited or reported by the clientNo rebound tenderness is presentAbdomen is non-tender and soft.There is no guarding| * Loss of appetite * Nausea & vomiting(usually projectile) * Constipation of recent onset * Diarrhea(occasional) * Sudden, severe, generalized abdominal pain * Abdominal distention; rigidity * Decreased/absence of bowel sounds * Inability to pass stool/flatus * Muscle guarding (abdomen) * Psoas’ Sign (flexion of or pain on hyperextension of the hip due to contact between an inflammat ory process & the psoas muscle) * Obturator Sign (the internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee and a resultant tightening of the internal obturator muscle may ause abdominal discomfort) * Rovsing’s Sign (pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant) * Rebound tenderness (a sign of inflammation of the peritoneum in which pain is elicited by the sudden release of the fingertips pressing on the abdomen) | * Board-like abdomen * Sudden, severe, generalized abdominal pain * Absence of bowel sounds in all four quadrants * Absence of flatus/stool * Presence of surgical incision| Signs indicating the onset of peritonitis include a rigid â€Å"board-like† abdomen (Gould & Dyer, 2011).Pain recurs as a steady, severe abdominal pain as peritonitis develops (Gould & Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or paralytic ileus (Weber & Kelly, 2007). When inflam mation persists, nerve conduction is impaired, and peristalsis decreases, leading to obstruction of the intestines (paralytic ileus) (Gould & Dyer, 2011). | X. DIAGNOSTIC TESTS DIAGNOSTIC TEST| NORMAL| RESULT| SIGNIFICANCE| WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) | The organs examined appear normal (Cosgrove, et al. , 2008). | Liver is not enlarged.It has homogenous echopattern with smooth border. The intrahepatic ducts are not dilated. No evident focal mass lesion seen. CD measures 3. 9mm. Gallbladder is normal in size and wall thickness. There are multiple tiny echogenic shadowing foci seen within the gallbladder lumen. Pancreas & spleen are normal in size & echopattern. No focal mass lesion seen. Both kidneys are normal in size & echopattern. Right kidney measures 10. 1Ãâ€"4. 2Ãâ€"5. 46cm with cortical thickness of 1. 7cm while the left kidney measures 10. 5Ãâ€"4. 8Ãâ€"4. 1cm with thickness of 19cm. No evident caliectasis, lithiasis, seen bilaterally.Urinary bladder is unf illed. Impression:Tiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot dilated biliary tree | Abdominal ultrasound is the most effective test for diagnosing acute appendicitis (LeMone & Burke, 2007). | HEMATOLOGY REPORT/COUNT (July 21, 2012)| RBC: 4. 2-5. 6 M/uLPlatelets: 150-400 x 10/LWBC: 3. 8-11. 0 K/mm3Hemoglobin: 135-180g/LHematocrit: 0. 45-0. 52DifferentialNeutrophils: 0. 50-0. 81Lymphocytes: 0. 14-0. 44Monocytes:0. 02-0. 06Eosinophils: 0. 01-0. 05Basophils:0. 00-0. 01| WBC Count: 12. 6 K/mm3RBC: 4. 1 M/uL (normal)Hematocrit: 0. 45 (normal)Hemoglobin: 153g/L (normal)Differential Count:Neutrophils 0. 90Lymphocytes 0. 10 (normal)| Elevated WBC is seen in acute infection (LeMone & Burke, 2007). Neutrophils: elevated in bacterial infection (LeMone & Burke, 2007). | URINALYSIS (July 21, 2012)| Color: Light straw to amber yellowAppearance: ClearOdor: AromaticpH: 4. 5-8. 0Specific gravity: 1. 005-1. 030Protein: 2-8mg/dLGlucose: NegativeKet ones: NegativeRBCs: RareWBCs: 3-4Casts: Occasional hyaline| Color: Dark YellowTransparency: TurbidUrine pH: 6. 0 Specific gravity: 1. 30Sugar: NegativeProtein: +4Microscopic examPus cells 4-6/HPFRBC 1-2/HPFCrystals: Amorphous Sulfate Moderate| A dark yellow to brownish color is seen with deficient fluid volume (LeMone & Burke, 2007). Hazy or cloudy urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates (LeMone & Burke, 2007). | CLINICAL CHEMISTRY (July 21, 2012)| Sodium (Na): 135-142 mmol/LPotassium (K): 3. 8-5 mmol/L| Sodium: 132 mmol/LPotassium: 4. 02 mmol/L| Sodium is decreased in SIADH & vomiting (LeMone & Burke, 2007). | XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE)The large intestine, which is about 1. 5 m (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum. Structurally, the four major regions o f the large intestine are the cecum, colon, rectum, and anal canal. The opening from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal sphincter (valve), which allows materials from the small intestine to pass into the large intestine. Hanging inferior to the ileocecal valve is the cecum, a small pouch about 6 cm (2. 4 in. ) long.Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 in. ) in length, called the appendix or vermiform appendix (vermiform = worm-shaped; appendix = appendage). The mesentery of the appendix, called the mesoappendix, attaches the appendix to the inferior part of the mesentery of the ileum. The open end of the cecum merges with a long tube called colon, which is divided into ascending, transverse, descending colon are retroperitoneal; the transverse and sigmoid colon ascends on the right side of the abdomen, reaches the inferior surface of the liver, and turns abruptly to the left to form the right colic (hepatic) flexure.The colon continues across the abdomen to the left side as the transverse colon. It curves beneath the inferior end of the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac crest as the descending colon. The sigmoid colon begins near the left iliac crest, projects medially to the midline, and terminates as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is called the anal canal.The mucous membrane of the anal canal is arranged longitudinal folds called anal columns that contain a network of arteries and veins. The opening of the anal canal to the exterior, called the anus, is guarded by an internal anal sphincter of smooth muscle (involuntary) and an external anal sphincter of the skeletal muscle (voluntary). Normally these sphincters keep the anus c losed except during the elimination of feces (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, inflammation of the vermiform appendix, is a common cause of acute abdominal pain.It is the most common reason for emergency abdominal surgery, affecting 10% of the population (Tierney et al. , 2005). Appendicitis can occur at any age, but is more common in adolescents and young adults and slightly more common in males than females (LeMone & Burke, 2007). The development of appendicitis usually follows a pattern that correlates with the clinical signs, although variations may occur because of the altered location of the appendix or underlying factors (Gould & Dyer, 2011). Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices.The obstruction is often caused by fecalith, or hard mass of feces. Other obstructive causes include a calculus or stone, a foreign body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Following obstruction, the appendix becomes distended with fluid secreted by its mucosa and microorganisms proliferate. Pressure within the lumen of the appendix increases, impairing its blood supply because blood vessels in the wall are compressed thus the appendiceal wall becomes inflamed and purulent exudate forms.Within 24 to 36 hours, the increasing congestion and pressure within the appendix leads to ischemia and necrosis of the wall, resulting in increased permeability. Bacteria and toxins escape through the wall into the surrounding are. This breakout of bacteria leads to abscess formation or localized peritonitis. An abscess may develop when the adjacent omentum temporarily walls off the inflamed area by adhering to the appendiceal surface. In some cases, the inflammation and pain subside temporarily but then recur. Localized infection or peritonitis develops around the appendix and may spread along the peritoneal membranes.Increas ing pressure inside the appendix causes increased necrosis and gangrene in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perforates, releasing its contents into the peritoneal cavity. This leads to generalized peritonitis and would lead to septicemia and into septic shock and will result to death (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Risk Factors Non-modifiable: * Age (Adolescents & young adults) * Gender (Male) Modifiable: * Fecalith * Calculus/Stone * Foreign body * Inflammation * Tumor * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid inside the appendix Buildup of fluid inside the appendix Proliferation of microorganisms Proliferation of microorganisms Abdominal pain Abdominal pain Increased pressure within the lumen of appendix Increased pressure within the lumen of appendix Compression of blood vessels Compression of blood v essels * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness Decreased blood flow into the appendixDecreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid Ischemia & necrosis of the wall Ischemia & necrosis of the wall Increased permeability Increased permeability Bacteria and toxins escape through the wall Bacteria and toxins escape through the wall Abscess formation/localized bacterial peritonitisAbscess formation/localized bacterial peritonitis Proliferation of localized peritonitis around the appendix and peritoneal membranes Proliferation of localized peritonitis around the appendix and peritoneal me mbranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Increased necrosis and gangrene in the wall Increased necrosis and gangrene in the wall Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak out into peritoneal cavity Intestinal bacteria leak out into peritoneal cavity * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESSProblem #1: ABDOMINAL PAIN – July 24, 2012 * Subjective Cues: * â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps,† patient verbalized while having a conversation with him. How does it feel like: Abdominal cramping Precipitating factor: â€Å"Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit† (â€Å"Whenever wound cleaning is performed but oftentimes it just suddenly happened†) Relieving factor: Pain reliever (but not all the time pain reliever is being given) Does it radiate to the other parts of the body (back, legs, chest, etc): No Duration of pain: â€Å"Paiba-iba din eh.Minsan sobrang tagal mga 2-3 minutes, minsan naman mga ilang Segundo lang† (â€Å"It differs, sometimes it’s too long (2-3 minutes) and sometimes it just happened for a second†) * Patient rated the pain as 8/10 where 0 signifies no pain and 10 signifies unbearable pain. * Objective Cues: * Facial grimace * Guarding of the incision site * Rigid (board-like) abdomen * Abd ominal distention * Location of pain: Surgical site * RR: 25 bpm * Nursing Diagnosis Acute Pain related to inflammation of the tissues secondary to post-op surgical incision.Inflammation or nerve damage gives rise to changes in sensory processing at peripheral and central level with a resultant sensitization. In relation, prostaglandins are chemotactic substances drawing leukocytes to the inflamed tissue. It plays a vasoactive role; it is also a pain and fever inducer (Lemone and Burke, 2007). Acute Pain related to infection & inflammation of the peritoneal membranes secondary to peritonitis The peritoneum consists of a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdominal cavity.This peritoneal structure provides a mean of rapid dissemination of irritants or bacteria throughout the abdominal cavity. Abdominal distention is evident, and the typical rigid, board-like abdomen develops as reflex abdominal muscle spasm occurs in response to invol vement of the parietal peritoneum (Gould & Dyer, 2011). * Goal/NOC: Pain Control Outcomes Short Term: After 30 minutes of nursing intervention the patient will report a decrease in pain from pain scale of 8/10 to 4-5/10. Long Term:After 8 hours of nursing intervention the patient will demonstrate an understanding about the proper way of controlling pain as evidenced by proper splinting and deep breathing exercise and will report a decrease or most probably will be free from pain from pain scale of 4-5/10 to 1-2/10. * NIC: Pain Management Independent: * Assessed pain including its character, location, severity, and duration. Both preoperatively and postoperatively, the client’s pain provides important clues about the diagnosis and possible complications.Abdominal distention and acute inflammation contribute to the pain associated with peritonitis. Surgery further disrupts abdominal muscles and other tissues, causing pain (LeMone & Burke, 2007). * Monitored vital signs every 2 hours. Vital Signs, especially respiratory rate (RR), are usually altered in acute pain. (Sparks and Taylor, 2005). * Kept the client at rest in semi-Fowler’s position. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position (Doenges et al. , 2006). * Provided diversional activities (texting, sound trip, etc).Refocuses attention, promotes relaxation, and may enhance coping abilities and diverts attention from pain (Doenges et al. , 2006). * Taught post-op health teaching (e. g. , proper splinting & deep breathing exercises). The use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications (LeMone & Burke, 2007). * Encouraged early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). Give hot and cold compress. Hot , moist compresses have a penetrating effect. The warm rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. (Doenges et al. , 2006). Dependent: * Administered analgesic as prescribed (TRAMADOL 50 mg/IV Q 8 ° x 3 doses) Time given: 8 AM. Post-operatively, analgesics are provided to maintain comfort and enhance mobility (LeMone & Burke, 2007). * Kept on NPO. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting (Doenges et al. 2006). * Evaluation Short Term: Goal partially met. After 30 minutes of nursing intervention the patient reported of a decrease in pain from a pain scale of 8/10 to 6/10 in which 4-5/10 was the expected outcome. Long Term: Goal met. After 8 hours of nursing intervention the patient displayed control of pain as evidence by deep breathing exercise and proper splinting. He also reported of a decrease in pain with a pain scale of 2/10 from 6/ 10. Pain reliever – TRAMADOL was given @ 8 am via IV. Problem #2: ABSENCE OF FLATUS– July 24, 2012 * Subjective Cues: â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping),† patient verbalized while having a conversation with him. * Pain scale of 8/10 * Objective Cues: * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sounds upon auscultation of all four quadrants * Nursing Diagnosis Dysfunctional gastrointestinal motility related to inflammatory process of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis often draws large amounts of fluid into the abdominal cavity and the bowel.In addition, peristaltic activity of the bowel is slowed or halted by the inflammation, causing paralytic ileus, impaired propulsion of forward movement of bowel contents (LeMone & Burke, 2007). * Goal/NOC: Ambulation Outcomes Short Term: After 8 hours of nursing intervention the client wil l report/experience flatus and will understand and demonstrate the need for early ambulation following abdominal surgery. Long Term: After 2 days of nursing intervention the client will report/experience either flatus or bowel movement or both. * NIC: Impaction Management; PositioningIndependent: * Assessed abdomen including all four quadrants noting character to determine increased or decreased in motility; Assessed for further abdominal tenderness & auscultated for any abdominal sounds. To help identify the cause of the alteration and guide development of nursing intervention (Sabol & Carlson, 2007). * Monitored and recorded (intake) and output every hour or 2 hours. Intake and output records provide valuable information about fluid volume status (LeMone & Burke, 2007). * Encouraged early ambulation.Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). * Assisted in moving from side to side o r up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. (Gulanick, et. al. , 1994). Dependent: * Administered antacid as ordered (RANITIDINE 50g/IV Q 12 °. Antacids either directly neutralize acidity, increasing the  pH, or reversibly reduce or block the secretion of acid by gastric cells to reduce acidity in the stomach (Gabriely, et al. 2008). * Evaluation Short Term: Goal partially met. After 8 hours of nursing intervention the patient didn’t experience flatus or even bowel movement but was able to have an understanding with regards to early ambulation as evidenced by letting his mother assist him in moving up in bed going to the chair but refused to walk because of complaint of having a lot of contraptions attached to him which causes him to have difficulty in moving. Long Term: Goal met. After 3 days of nursing intervention the patient reported of a flatus fo r 3 times.Problem #3: RISK FOR DEHYDRATION – July 24, 2012 * Subjective Cue: * â€Å"Nanghihina na ako kasi limang araw ako hindi pwede kumain pati tubig bawal din kaya nagnunuyo na yung labi ko,† as verbalized by the patient. * Objective Cues: * NPO for 5 days * Dry mucous membrane * Dry lips * Capillary refill= 2 seconds * Skin turgor= 3-5 seconds * Urine output/shift= 480 mL * Urine color: Dark Yellow * Urine specific gravity: 1. 030 (Normal value: 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP: 120/80 mmHg * PP: 83 bpm * Nursing DiagnosisRisk for deficient fluid volume related to postoperative restriction secondary to NPO for 5 days Inflammation of the peritoneum with sequestration fluid and NPO status can lead to dehydration and electrolyte imbalance (Doenges, et al. , 2008). * Goal/NOC: Knowledge: Treatment Regimen; Hydration; Oral Hygiene; Tissue Integrity: Skin & Mucous Membranes Outcomes Short Term: After 30 minute s of nursing intervention patient will have an understanding with regards to maintaining fluid balance as evidenced by willingness of following the prescribed regimen given by the medical staffs. Long Term:After 3 days of nursing intervention the patient will be able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, and individually adequate urine output. * NIC: Fluid Management; Fluid Monitoring; Vital Signs Monitoring Independent: * Monitored BP & Pulse. Variations help identify fluctuating intravascular volumes, or changes in vital signs associated with immune response to inflammation (Doenges, et al. , 2006). * Inspected mucous membranes; assessed skin turgor and capillary refill. Indicators of adequacy of peripheral circulation and cellular hydration (Doenges, et al. 2006). * Monitored intake and output; noted urine color/concentration, specific gravity. Decreasing urine output of concentrated urine with increasing s pecific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. Noted passing of flatus, bowel movement. Indicators of return of peristalsis, readiness to begin oral intake (Doenges, et al. , 2006). * Provide clear liquids in small amounts when oral intake is resumed, and progress diet is tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss (Doenges, et al. 2006). * Stressed the importance of having him on a NPO status and provided the necessary information with regards to his condition and the medications being administered (e. g. , IVF). It provides the patient a full understanding with regards to his condition thus encouraging him to participate and work hand in hand with the staff (Gulanick, et al. , 1994). * Gave frequent mouth care with special attention to protection of the lips. Dehydration results in drying and painful cracking of the lips and mouth (Doenges, et al. , 2006). Dependent: * Maintaine d gastric suction as indicated.Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperatively phase to decompress the bowel, promote intestinal rest, and prevent vomiting (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8 ° or 30 gtts/min) and electrolytes (D5 Balanced Multiple Maintenance Solution w/ 5% dextrose 1L x 8 ° or 30 gtts/min). The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances (Doenges, et al. , 2006). * EvaluationShort Term: Goal met. After 30 minutes of nursing intervention the patient was able to have a full understanding with regards to maintaining fluid balance as evidenced by verbalizing, â€Å"So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. † Long Term: Goal met. After 3 days of nursing intervention th e patient was able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor (1-2 seconds), stable vital signs (please see page __ ), and adequate urine output of 620 mL with an appearance of amber yellow. Problem #4: RISK FOR INFECTION – July 24, 2012 Subjective Cues: â€Å"Nurse, sobrang kailangan ba talaga ang paghuhugas ng kamay bago linisan o hawakan sugat niya? †, asked by the mother. * Objective Cues: * Post-operative condition – presence of surgical incision * Surgical site is warm to touch and reddened * Temp: 36. 3 °C * Nursing Diagnosis Risk for infection related to inadequate primary defenses secondary to post-operative surgical incision It is risk to be invaded by pathogens especially if surgical site is near at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, et al. 2006). * Goal/NOC: Risk Control (For Infection) Outcomes Short Term: After 30 minutes of nursi ng intervention the patient will be able to have partial understanding about infection control and will verbalize understanding of and willingness to follow up prescribed regimen. Long Term: After 3 days of  nursing intervention  the  patient will be free of sign and symptom r/t infection. * NIC: Incision Site Care; Infection Control; Wound Care Independent: * Monitored vital signs. Noted onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.Suggestive of presence of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected incision and dressings. Noted characteristics of drainage from wound/drains, presence of erythema. Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis (Doenges, et al. , 2006). * Instructed proper hand washing. Practiced aseptic wound care. Reduces risk for infection (Doenges, et al. , 2006). * Encouraged adequate nutr itional intake after the NPO status of the patient and when the patient is allowed to eat.Adequate intake of protein, Vitamin C and minerals is essential to promote tissue and wound healing (Sparks and Taylor, 2005). Dependent: * Administered antibiotics (CEFUROXIME 750mg TID Q 8 ° x 2 doses & METRONIDAZOLE 500g/IV Q 8 ° x 2 doses) as ordered. Therapeutic antibiotics are given if the appendix is ruptured or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with incision and drainage (I&D) if indicated. May be necessary to drain contents of localized abscess (Doenges, et al. , 2006). * Evaluation Short Term:Goal met. After 30 minutes of nursing intervention the patient was able to have an understanding about infection control as evidenced by verbalizing, â€Å"Para maiwasan ang pagkaroon ng impeksyon kailangan kong maghugas ng kamay palagi at kinakailangan din ang araw-araw na paglilinis ng sugat ko kahit na sa tuwing nililinisan ito makirot s a pakiramdam. † Long Term: Goal met. After 3 days of  nursing intervention  the  patient was free of sign and symptom r/t infection. Problem #5: INABILITY TO PERFORM ACTIVITY/IES OF DAILY LIVING (ADL) – JULY 24, 2012 * Subjective Cues: â€Å"Hirap talaga ako gumalaw, maglakadlakad, o kahit man lang umupo dahil sa mga nakakabit na ito sa akin,† as verbalized by the patient. â€Å"Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko,† he added. * Objective Cues: * Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage & IV fluid @ left hand) * Nursing Diagnosis Impaired physical mobility related to body weakness, presence of surgical incision, pain, & presence of contraptions attached Physical immobility can be usually associated with post-operative conditions (Gulanick, et al. 1994). * Goal/NOC: Activity Tolerance Outcomes Short Term: After 30-45 minutes of nursing intervention the pat ient will be able to have a clear understanding with the use of identified techniques to enhance activity tolerance and to apply it as well as evidenced by participating in ROM exercises, lower leg & ankle exercise, ambulation, or even moving up in bed. Long Term: After 2-3 days of nursing intervention the patient will be able to continually participate in a simple form of activity and will report an improvement with regards to his activities. * NIC: Exercise Therapy: BalanceIndependent: * Performed passive ROM exercises. ROM exercises and good body mechanics strengthen abdominal muscles and flexors of spine (Gulanick, et al. , 1994). * Encouraged lower leg and ankle exercises. Evaluated for edema, erythema of lower extremities, and calf pain or tenderness. These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation (Gulanick, et al. , 1994). * Noted emotional and behavioral responses to immobility. Provided diversional activities. Forced i mmobility may heighten restlessness and irritability.The Cardiovascular SystemDiversional activity aids in refocusing attention and enhances coping with actual and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, progressive ambulation, and therapeutic exercises. Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance (Gulanick, et al. , 1994). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. Gulanick, et al. , 1994). * Noted client reports of weakness, fatigue, pain and difficulty accomplishing tasks. Symptoms may be result of/or contribute to intolerance of activity (Gulanick, et al. , 1994). Dependent: * Administered pain medication (TRAMADOL 50 mg/IV Q 8 ° x 3 doses, time given: 8 AM) as prescribed and on a regular sch edule. Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivation to increase activity (Gulanick, et al. , 1994). * Evaluation Short Term:Goal partially met. After 30-45 minutes of nursing intervention the patient was able to have a clear understanding with the use of identified techniques to enhance activity tolerance and was able to use all of the techniques except for the ambulation. He refused to walk because he complained of pain whenever the catheter tube slipped into his legs. Long Term: Goal partially met. After 2-3 days of nursing intervention the patient was able to continually participate in all of the identified techniques but still refused to participate in ambulation.He also reported of an improvement with regards to his activities as evidence by his verbalization, â€Å"Medyo natotolerate ko na rin yung mga activities kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad p ero pagnaalis na siguro yung catheter baka kayanin ko na. † XV. BIBLIOGRAPHY * Cosgrove DO, Meire HB, Lim A, & Eckersley RJ. (2008). Grainger & Allisonn's Diagnostic Radiology: A Textbook of Medical Imaging (5th edition). New York, NY: Churchill Livingstone * Doenges M. , Moorhouse, M. ; Murr, A. (2006).Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span (7th Edition). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. ; Murr, A. (2006). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P. , Barky, N. (2008). Clinical problem-solving, back to basics. New England Journal of Medicine * Gould, B. ; Dyer, R. (2011). Pathophysiology for the Health Professions (4th Edition). Saunders Elsevier Inc. * Gulanick, M. Klopp, A. , Galanes, S. , Gradishar, D. ; Puzas, M. (1994). Nursing Care Plans Nursing Diagnosis and Intervention (3rd Edition). Mosby-Year Book, Inc. * LeMone P. ; Burke, K. (2007). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (4th Edition). Pearson International Edition * LeMone P. ; Burke, K. (2008). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (5th Edition). Pearson International Edition * Mosby’s Pocket Dictionary of Medicine, Nursing ; Allied Heath (4th Edition) 2002, Mosby Inc. Palma G. ; Oseda A. (2009). G;A Notes Clinical Pocket Guide for Medical and Allied Health Professionals (2nd edition). G;A Notes Publishing Co. , Philippines * Sabol, V. K. ; Carlson, K. K. (2007). Diarrhea: Applying research to bedside practice. AACN Advanced Critical Care * Tortora G. ; Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Biological Sciences Textbooks, Inc. * Weber J. ; Kelley J. (2007). Health Assessment in Nursing (3rd Edition). Lippincott Williams ; Wilkins

Tuesday, October 22, 2019

School Uniforms Essay

School Uniforms Essay School Uniforms Essay Should School Uniforms be in Public Schools? There has been a debate about children wearing uniforms in public schools. I am a parent of a child that wears a uniform to school. Picking out her clothes is so simple that she does it herself. My youngest daughter attends Sheffield Elementary School here in Lynchburg. She has no problem picking out her favorite jumper, white top, and favorite pair of shoes to start her day. All in all, there is not any fuss about â€Å"what to wear† in the mornings while she is getting ready. With that being said, I think it is a great thing that her school has a uniform policy. I think that all of our schools here in Lynchburg should take on this type of policy. I realize how easy it is getting my daughter ready for school verses my son. He has a slight dress code but nothing like the elementary school. My son goes to Heritage High School. They have a dress code versus a uniform policy. A dress code is a more laid back policy. It typically doesn’t require specific colors to wear. A uniform policy denotes exactly what a student is to wear to school at all times. Sheffield Elementary School has a uniform policy. They are to wear black, blue or kaki bottoms; shorts or pants for boys; shorts, pants, jumpers, skirts, skorts or capris for girls. As far as tops go; red, white, or blue polo’s and/or button up oxford style shirts are to be worn by both male and female students. Neither the shirts nor bottoms are allowed to have any visual logos on them unless they represent the school they are attending (Uniform Policy, LCS). In 2009, there was a school district in the Pocono Mountains, PA where the school superintendent made the decision to have a strict dress code that emulates a uniform. It improved the school tremendously. In fact within the first year of the new dress code program, the school had 1,000 less disciplinary referrals than the previous year (Bouselli). If our own schools would adopt an expanded policy similar to this one, I am sure there will be a decrease of the intolerable behavior in the schools within our community. By wearing uniforms there will be a decrease in bullying, minimize the evidence of gang involvement and reduce the violence that occurs by students being beat up over designer clothing (Fleming). Another huge point is for safety reasons (Fleming). In my own personal experience, when being part of a school field trip, students having the same color tops and bottoms on are great ways to find your group if you are ever separated. Students are more likely to have school spirit as well. This is also a great way to equalize each student (Fleming). Allentown, PA school districts will be enforcing a school uniform policy starting in the 2013/2014 school year (Esack). The assistant principal of Dieruff High School said that the majority of the freshman and sophomores that he questioned told him that they would prefer to have uniforms (Esack). When you have parents, students and faculty wanting to have a policy like this in place, then there will be a better balance to help improve the schools and its students. In the past, I had thought that having a uniform was ridiculous. I didn’t like the extra money I had to spend but, I have realized how wonderful it is. Like I stated earlier, picking out clothes for school is so simple, when you have a uniform there are no questions about what to wear. I can purchase some uniforms at a cheaper price but not one student knows where they came from. I have also come to realize that my daughter seems to make better grades while in this setting. My oldest daughter went to Sheffield and now attends Dunbar Middle School. She still makes good grades but, they were much better when she went to Sheffield. A study from a 1998 thesis at Ohio

Monday, October 21, 2019

9 Hilarious Office Pranks to Pull On Your Coworkers

9 Hilarious Office Pranks to Pull On Your Coworkers Brace yourself:  Blood will be spilled, tears will be shed, and friendships will be broken after you pull these 9 hilarious office pranks on your co-workers. You will get fired. You have been warned.1. Tamper with the Foosball tablevia [giphy.com]Sneak into your office at night while no one is there and super glue the parts  of one side so theyre no longer useable. Sit back and watch your co-workers faces light up with pure rage as you score one goal after another. For further enjoyment, score a goal every time they tell you to stop. Whats that? Stop? Boom! Gooooooal. As a side note, if your place of employment doesnt have a Foosball table, why are you even still working there?2. Impersonate one of your coworkersvia [giphy.com]Make sure to get a similar haircut, and practice your mannerisms. When you come in for work in the morning, sit next to them and proceed to mock them. Depending on their sense of humor, theyll either have a good laugh or grow increasingly frustrated. Hopefu lly its the latter. That way, you can absorb their hatred and anger to sustain your youth.3.   Distort realityvia [giphy.com]When your co-worker comes in, give a confused look  and ask why he or she is there. When they ask you what youre talking about, point to their replacement (who also happens to be a dog dressed in a suit) and mention that they were fired two weeks ago. This prank requires more than just one person on board, but if done correctly, sit back and watch as your co-worker contemplates whether or not theyve just stepped into an episode of the Twilight Zone.4. Act like an assholevia [giphy.com]Okay, Ill admit, this one isnt very creative- but lets be honest, there isnt anything more infuriating to someone than a troll. Pretending to be an asshole is probably the fastest way to get yourself fired, but hey, if youve got nothing to lose, run up behind your co-worker and slap their cup of coffee right out of their hand. If youre feeling especially brave, feel free to g ive them a wedgie or   noogie, or hell- you can do both at the same time.  Come here, nerd!5. Pretend youre possessedvia [giphy.com]Crawl into the office on your back, while chanting the Spongebob Squarepants theme song in a  dark and ominous tone. Bonus points if you can rotate your head 360 degrees.6. Come in dressed as  a zombievia [giphy.com]Possession not your thing? Perhaps youve already scared the shit out of everyone using prank number 5? If so, then its time to dust off your old Halloween costume and have some fun. Hide inside of the fridge or closet and wait for someone to open the door. All those makeup tutorials youve watched on YouTube are finally paying off!7. Fake your death, then resurrect yourselfvia [giphy.com]Have one of your friends call  the office to  let everyone know the bad news- you were hit by an ice cream truck and now are dead. Invite everyone to your funeral; although, after all the pranks youve pulled, its likely no one will show up. The da y of your funeral arrives and everyone is sad and reminiscing about all the good times theyve spent with you, allegedly. As everyone is paying their respects, pop out of your coffin wearing a terrifying mask and lunge at everyone, foaming at the mouth.8. Post pictures of your face everywherevia [giphy.com]Photoshop your face onto the body of a Greek god and print out thousands of copies. Toss them around the office and hang them all over the walls, fridge, and co-workers computers. As an added bonus, send mass emails to everyone in the office of your face photoshopped onto their personal photos.9. Broadcast your mixtapevia [giphy.com]Youve been slaving away in the streets trying to drop the hottest mixtape of 2015 and now its time to share it with the office. Sneak your way into the control room and broadcast it over the intercom to the entire office. Watch as everyone evacuates the office  out of sheer terror.Well there you have it, folks! Be sure to pull these 9 pranks around th e office and you will be on the fast track to becoming the funniest unemployed prankster of all time!