Human Resources in Riordan Manufacturing Essay

When people think of the responsibilities of a human resources department, they may say they are responsible for the hiring and firing of employees. The truth of the matter is that a human resources management is responsible for much more than just hiring and firing. The human resources management is responsible for hiring qualified people, training employees to do their jobs according to company policies, motivate their employees and be able to support productive employees. Riordan Manufacturing has a good human resources department, which maintains an innovative and team-oriented work environment. Riordan Manufacturing mainly recruits employees outside the company via entry –level positions. There is also an internal job posting for employees to take advantage of new job opportunities. The method Riordan Manufacturing uses to recruit qualified employees is through online advertisements via Monstor.com, local newspapers, employee referrals, temp agencies, and job conferences. The plant in China uses contract workers for engineering, and IT positions. Riordan Manufacturing seeks qualified people for jobs, but the company does not conduct reference test as well as drug testing of potential employees. When concerning training and development, Riordan Manufacturing has a mandatory training program for employees within their 90 days of hire. New employees have to attend orientation on their first day on the job. For production and shipping and quality employees, they have to go through Six Sigma training. New supervisors are required to go through training workshops within 12 months of becoming a supervisor. Such workshops include interviewing guidelines, preventing EEO claims as well as workplace sexual harassment, and finally performance reviews. Riordan Manufacturing also has incentive programs for outstanding employees. There are three types of programs Riordan Manufacturing use to recognize outstanding employees. 1. Outstanding Employee Award 2. Employee Suggestion Program 3. Seniority Awards Riordan Manufacturing HR system Riordan Manufacturing implemented it’s HRIS (Human Resource Information Systems) in 1992. This system manages employee information such as the following: 1. Personal information 2. Pay rate 3. Personal exemptions for tax purposes 4. Hire dates 5. Seniority date 6. Organizational information 7. Vacation hours If an employee has to make any changes to his or her information, he or she has to submit it in writing on a special form. That information is entered later by a payroll clerk. The training and development specialist kept track of training and development records via Excel worksheets. In order for recruiters to maintain applicant’s information, all resumes are filed in a central storage area and are track via an Excel spreadsheet. Riordan Manufacturing employs a third party provider to keep track of workers’ compensation. Individual managers keep track of employee’s files and are also responsible for tacking FMLA absences as well as requests for accommodation. A compensation manager keeps results of job analyses, salary surveys and individual compensation decisions via Excel spreadsheet. Complaints, grievances, harassment complaints, as well as ethical issues are managed and tracked by employee relations specialists. HR Needed Systems Riordan Manufacturing’s current HRIS needs an up-to-date face lift. Instead of having different individuals managing employee’s vital information, Riordan Manufacturing needs to invest in human resources software. Implementing the software would increase the efficiency of their current HRIS. It would ease the burden of keeping track of all the employees’ information. References University of Phoenix (2012). Riordan Manufacturing Virtual Organization. Retrieved from BSA/500 – Business Systems II course website.

Visual Merchandising

Visual Merchandising: Visual Merchandising is very important because the first impression of the product or store on the customer is by visualizing. If the impression is positive then customers attract to the store. A store must have the inviting appearance to the customers. Objectives of Visual Merchandising: Objective of visual merchandise is to attract the customers to your business in order to sell the merchandise. The main objective is to make the customers feel comfortable and eager to buy. Essential of Visual Merchandising: * Interior Floor  Design  and Display. * Space and Signage. * Window Display. Tools Use for Visual Merchandising: Audio-Visual Displays. * Decoration and Props. * Signage and Graphics. The presentation in visual merchandising falls into two categories mainly: 1. Exterior Presentations. 2. Interior Presentations. Exterior Presentations: The outlook of a store is a major determinant for a customer. Good exterior presentation attracts attention, creates in terest and invites the customer into business. It involves exterior signs, banners and window display. Exterior Signs: A store sign is its â€Å"signature† which tells the customers that what type of the business and what it sells. In less than 10sec the sign must attract attention.Banners: Banners are used to sales promotion. It should be very colorful and eye catching. Window Display: Some products should be placed on a store’s window. Window display should attract attention, create interest and invite people into the store to purchase goods. New displays indicate new up-to-date merchandise is available. Interior Presentations: Another way of the merchandising is through interior display that effectively show merchandise to the customers. The purpose of doing this is to develop interest for the merchandise. It involves color theme and images, lighting, props and fixtures. Researchers found that 64. % of all purchase decision was made inside a store. Three goals of st ore are- 1. Motivate the customers to spend money 2. Protect the image of the store 3. Keep expenses to minimum Color and Lighting: Color in a display can catch eye and make people pause and look. The overall color combination can affect the atmosphere of a store. Lighting is essential in calling attention to merchandise in a display. Customer’s eye is drawn automatically to the brightest area. Props and Fixtures: A display prop is not for sale, it is just used with a product in a display to clarify the function of the product being sold.Merchandise and Fixture Display Recommendations: Goods can be effectively displayed on a variety of fixtures such as tables, cubes, racks and other display cases. Movable shelves from all sides used in self-service retail stores to display merchandise. They can be lined up in stores as grocery or hardware stores. Errors Commonly Occurring in Display: * Too much merchandise * Too little merchandise * Too many props * Poorly selected props * Di splay changed to seldom * Limited or no display budget * Lack of attention to detail

An Emergency Management Coordinator and Their Responsibilities

An Emergency Management Coordinator and Their Responsibilities The Emergency Management field is a rather unique and at times a very stressful field. An Emergency Management Coordinator may have many different roles within the emergency service community. An Emergency Management Coordinator has to create plans such as mitigation, and how to prepare the community for a potential catastrophe. Successful emergency management requires specialized skills. EMCs help communities by assessing potential hazards and training emergency response teams, they also work together with government entities that deal with cleanup efforts and medical aid after a natural disaster, hazardous accident or terrorist attack has occurred. As society has become more integrated, those skills include coordinating an increasingly complex array of organizations, resources and personnel. Add to this the high expectations that citizens tend to place on emergency mangers, and the challenge can seem very overwhelming. Now that we have a basic understanding of who and what an Emergency Management Coordinator is I want to take a look at the realities of their duties in the face of disaster/emergency situations. Whether they may be faced with hurricanes, earthquakes or bomb threats, emergency management coordinators (EMCs) must assess the situation quickly, brainstorm possible solutions and delegate duties accordingly. Some of the major duties for EMCs include supervising search and rescue, obtaining food and shelter for survivors and organizing other relief efforts. And depending on your geographical location this job can mean different things in relation to the amount and severity of such threats. An EMC is not off the clock when things are calm and there is no emergency situation to tend to. The laundry list of duties and responsibilities that an EMC much take on is quite extensive and includes, but is not limited to the following: Supervises, coordinates, and maintains the daily operations of the local Emergency Management Agency (EMA). Maintains the Emergency Operations Center (EOC) in a continuous state of readiness. Maintains coordination with local and state governmental departments and agencies, utilities and industry during any type of emergency. Prepares and revises the county Emergency Operations Plan (EOP). Assists local government departments/agencies in the preparation of the departments SOPs in support of the EOP. Reviews and makes recommendations to businesses, industry, hospital, and nursing homes on the preparation of their emergency plans to ensure they are workable within the framework of the local and state plans. Develops and coordinates mutual aid agreements with other agencies and adjacent counties. Prepares and manages the local EMA budget. Prepares the required budget and staffing patterns paperwork for GEMA, which qualifies the local EMA for GEMA and FEMA funds. Organizes and coordinates local training for public safety and volunteer first responders. Supervises and monitors the actions of the Volunteer Search and Recovery Squad. Prepares scenarios and procedures and coordinates training for local government officials, industry, utilities, and volunteers in conjunction with the exercising of emergency plans. Ensures the EOC is staffed with knowledgeable qualified personnel and makes training and exercises available to these personnel. Through newspaper articles, radio programs, television, speaking engagements, and seminars, makes the public aware of the emergency plans and procedures that are in place and the publics part in making these plans and procedures work. Working with the Red Cross and DFACS, ensures that adequate facilities are available to shelter citizens should the need arise. Coordinates with the school system officials for the development of tornado warnings and school shelter plans. On a 24 hour basis, responds to hazardous material incidents, bomb threats, severe weather alerts, and other natural or man-made emergencies. Manages the daily operations of the Local Emergency Planning Committee (LEPC) and answers citizen inquiries concerning hazardous materials. Responds to water and land search and recovery efforts utilizing the EMA Volunteer Search and Recovery Squad. Interprets and applies all federal and state directives that apply to emergency management and departments supporting EMA. Answers inquiries from citizens concerning emergency plans and procedures. Ensures that all special needs citizens, registered with the Department of Health, are evacuated if the need arises. Also coordinates the transportation needs of the nursing homes. Utilizing computer models and various weather service products, stays abreast of current weather conditions and advises city/county administrators and/or department heads of any action that may be needed. The amount of responsibility that and EMC has is pretty substantial, and it is because of them that when disaster strikes we have the ability to get the help and services that re needed to start the processing of cleaning up and rebuilding. Because of the importance of this position I believe that the individual tasked with having to develop emergency plans has to be one of focus and drive with the best interest of the community at heart. But other than having a focus and drive there are other qualities that make for a really good EMC. One of the most essential qualities an emergency manager must have is professionalism. According to Federal Emergency Management Agency (FEMA) training, professionalism is imperative because emergency managers must work with a wide variety of people to coordinate, organize and get things done in a crisis situation. They must treat other people fairly and kindly, and find the balance between cordiality and a sense of urgency. Emergency managers must als o be able to have empathy but follow the rules and federal guidelines regarding emergency assistance (FEMA). Another important quality is to have great communication and organizational skills. Being a great listener is also important so that they may quickly understand all the facts pertaining to an emergency situation, and be able to efficiently communicate and delegate tasks to subordinates and community leaders. This may also entail using a wide variety of communication mediums appropriately and effectively. These types of leaders must perform well in high-stress situations, and remain calm at all times. This is not an ideal position for someone who loses his temper quickly. Along with the essential professional and personal qualities, the emergency manager must understand and be proficient at the actual management activities. For example, he must plan and coordinate the emergency procedures with local contacts, such as the police and fire department. He must also know the process of contacting state or national officials for more help if necessary. Other types of emergency management ac tivities include working with weather bureaus, transportation authorities and criminal law agencies, (EHow). The way an EMC responds to a disaster is highly dependent upon the source of the disaster and the level of damage it has caused. Natural disasters, such as earthquakes, floods or hurricanes, demand actions and solutions vastly different from those caused by warfare. Spills of toxic or hazardous materials or nuclear power plant malfunctions require different approaches to minimize negative effects. No one disaster will be entirely the same as another, so the response may not be able to be handled them same way. The key concept of an EMC is PPRR which stands for: Prevention/Mitigation- Assessing and reducing disaster risks. Activities include researching natural and man-made disasters, constructing physical mitigation works (such as levees and firebreaks), establishing warning systems, land use planning (e.g. stopping people from building on floodplains) and building codes (e.g. mandating fire-proof building materials). Preparedness- Preparing the emergency services and the community ready for disasters. Activities include preparing emergency plans, training first responders, educating the community on how to prepare and what to do in a disaster. Response- Actually responding to a disaster and ensuring that the emergency services have the right resources (equipment and people) to do their job. Emergency management professionals arent usually in charge of responding to a disaster, but act as an executive officer, providing expert advice to someone with the decision making authority Recovery- Getting a community that has been impacted by a disa ster back on its feet. Activities include, collecting and distributing donations and goods, distributing government relief payments, assisting with reconstruction tasks and much more. There is no single model for emergency management, either in organization or in size. Nationwide, there is great variety. For example, emergency management may function as a separate organization. In an ideal situation, the emergency manager answers directly to the jurisdictions chief executive, giving the executive direct access to unfiltered information from the emergency manager. In many communities emergency management is a function within the fire/rescue, public safety, or law enforcement department. Often it is part of a volunteer department. Staff size may run the gamut from a single part-time or shared position, to a full-time employee, to a full-time director with a large staff, each with assigned areas of responsibility. In any community no matter what the size people look to emergency management for certain things. For example, they expect: A safe and resilient community. In most jurisdictions this entails communitywide preparedness; up-to-date emergency plans, and a training and exercise program to support those plans; and strategies for preventing, protecting against, and mitigating the effects of disasters. Effective response and recovery when incidents do occur. Information about the risks the population faces and the actions they should take. Ethical conduct (FEMA). Because the emergency manager takes on a higher profile during emergencies, a common perception is that all emergency management responsibilities are related to responding to emergencies. In reality, emergency management is not just about the core functions involved in response. It includes a broad array of program functions, and much of the work is of a nonemergency nature. Core functions are those that are critical to a successful emergency response (FEMA). Emergency managers are responsible for the following core functions: Direction, control, and coordination Communications Warning External affairs/Emergency public information Population protection Mass care, emergency assistance, housing, and human services Public health and medical services Logistics management and resource support In addition to the emergency core functions, the emergency manager directs the day-to-day emergency management program that enables the jurisdiction to build and sustain needed capabilities and maintain a state of preparedness. Examples of nonemergency program activities include: Ongoing monitoring of threat/hazard information. Developing and updating plans. Recruiting and training staff. Planning and coordinating exercises. Budgeting, accounting, and grant writing. Building relationships across the community. Educating the public. Organizing for hazard mitigation. Soliciting public input on recovery planning. Documenting, reporting, and managing information. (FEMA) As you can see the amount of responsibility that an EMC takes on is great, the reality is that no matter what is going on from one day to the next the job of an EMC doesnt just revolve around the time of a disaster taking place. Each and every day there is a job to be done and people to keep in the loop and make sure that everyone is doing their job so that when disaster does strike everyone can be ready. The Emergency Management field is a rather unique and at times a very stressful field. An Emergency Management Coordinator may have many different roles within the emergency service community. An Emergency Management Coordinator has to create plans such as mitigation, and how to prepare the community for a potential catastrophe. Successful emergency management requires specialized skills. EMCs help communities by assessing potential hazards and training emergency response teams, they also work together with government entities that deal with cleanup efforts and medical aid after a natural disaster, hazardous accident or terrorist attack has occurred. As society has become more integrated, those skills include coordinating an increasingly complex array of organizations, resources and personnel. Add to this the high expectations that citizens tend to place on emergency mangers, and the challenge can seem very overwhelming.

History Research Paper - Lincoln and Zinn's Point of View about Essay

History Research Paper - Lincoln and Zinn's Point of View about Slavery - Essay Example Lincoln lived at central Illinois until he became the United States president in the year 1861. At the time of his birth, more than one fifth of the population of Kentucky consisted of slaves. Most of these slaves worked on the Ohio River or on small farms. At this time, Kentucky was a significant crossroads of the slave trade. Lincolns’ farm was located along the road connecting Nashville and Louisville, along which peddlers, slaves and settlers regularly passed. Therefore, he grew up in an environment where slavery existed and where racism and all forms of antislavery sentiments thrived. It is since this time that Lincoln developed a negative attitude towards slaves. He pointed out that he is naturally anti-slavery. He argued that if slavery is not wrong as proclaimed by other people, then there was nothing wrong in the entire world. When he grew up and became a famous politician in Illinois, the collective experiences of his life contributed to his occasional critic of slav ery. Lincoln’s real encounter with slavery was in the year 1828 and 1831 when he assisted in transporting farm products for sale in the area of New Orleans. Their trip clearly showed the division that existed between slaves and those societies which are free. There were various economic activities taking place in the entire region. The slave system of trade was on the rise since people needed them to work in plantations. The clash between the societies due to slave and free labor dominated the American life and this extremely shaped Abraham Lincoln’s political career. Lincoln was not happy when the Congress passed the Kansas Nebraska Act in the year 1854. By passing this legislation, there was a possibility of increasing slavery in the lands where it had been discouraged. Lincoln considered the legislation immoral. He held the view that America’s founders through their efforts to stop slavery had prevented its spread to other regions. Stephen Douglas who was a D emocratic Senator had sponsored this act which did not go on well with Lincoln (Holzer 57). In his speech in acceptance of the senatorial nomination on 16th June 1858, he pointed out that Douglas, Franklin Pierce (a former president), and Chief Justice Taney Roger among others had agreed to nationalize slavery. In his speech, he also pointed out that their country would become all slaves if they are not careful with the decisions of a few individuals. He urged his listeners to fight it since if they are divided then they could not win the war against slavery. In 1830s, Joshua Speed and Lincoln met in Springfield, Illinois. Even though, they separated when Speed returned to Kentucky which was his native land, they remained close friends throughout life. Lincoln differed with Speed concerning slavery even though Speed had been brought up on a plantation with slaves. They communicated on several occasions and in his letter to Speed in the year 1855, Lincoln pointed out several reasons to why he disliked slavery. He was responding to Speed’s letter of 22nd May 1855. He reminds Speed of their trip from Louisville to Ohio in the year 1841, when there were a dozen of slaves on board. He points out that that sight was a torment to him, and he always sees something of the same kind when he goes to Ohio and any other slave border. Slavery makes Lincoln miserable, and he can not afford to avoid rebuking it in the strongest

Sequential Injuries and Timing of Injuries Assignment

Sequential Injuries and Timing of Injuries - Assignment Example The body is photographically documented. Evaluation of the injury is carefully traced. In the case of injury in vagina, sexual activity kit is needed (Rutty, 2007). X-rays are done on the injuries in order to identify the existence of remained weapons or portions of weapons. An X-ray on the chest can be done to assess the possible air embolism. After taking x-rays and collecting suitable trace evidence, the body is washed so that the documentation of photography and injuries can take place (Rutty, 2007). For example, sharp force injuries are classified as incised wounds, stab wounds or chop wounds and blunt force injuries produce lacerations. The types of the victims who are categorized with sequential injuries are those subjected to any type of trauma. There are several categories of traumatic deaths classified as mechanical, chemical, electrical or thermal. Mechanical trauma when a force is exerted on a tissue such as bone or skin. Sharp and blunt force injuries are classified in t his category. Chemical trauma refers to destruction and death resulting from the chemical interactions with the person’s body. Thermal trauma results from hyperthermia and hypothermia. Electrical trauma results from electric shocks. Clear photograph of the injury is taken to estimate the wound at perpendicular to the injury with a suitable scale. It is essential in case microscopic findings contradict with the expected era of the injury. Subsequently, specimen tissues of the wound can be taken from the wound edges or the entire injury excised for more processing (Rutty, 2007). If a large skin surfaces are involved or some parts of the injured tissue are not required to be represented in wound estimation, then the representative samples are supposed to be potted for the rest of the wound if the entire wound was not microscopically analyzed. Samples are put four percent formalin and processed for regular histological analysis namely Estastica van Gieson (EvG),

Approaches To Crime Prevention Assignment Example | Topics and Well Written Essays - 1000 words

Approaches To Crime Prevention - Assignment Example Government takes these prevention measures in order to reduce the ratio of crimes in the society, enforce the law and thus maintaining the environment of justice and peace in the society. The application of these crime preventive measures is very important for any community. These criminals actually use negative ways in order to harm the community people and thus gain advantage of their own. There should be strict rules and regulations and then a strong control system on the implementation of these rules will definitely help community people. There are different approaches of crime prevention that can be used in different situations. These different situations may be based on the difference in the activities, difference in focus of intrusion and the difference in the effects of those crimes. Various models have been identified so far (Morgan et. al., 2012). Everything has been systematic now. Same is the case with our criminal justice system. It has developed into a better and beneficial system now, just because of the scientific changes made in it (Geoffrey, 2012). The variety in the crime preventive approaches is the result of all the strategically changes made in it. These approaches may include community prevention approach, family prevention approach, situational environmental approach and developmental environmental approach. The analysis of all these four approaches is given below in detail. Law enforcement was the best policy by the Court in order to take preventive measures against the crimes but as there are several reasons behind crime commitment, so there must be several techniques in order to stop them. Only law enforcement would not be enough for them. Therefore in addition to law enforcement the above four approaches were introduced within different periods. There are some approaches, which actually involves citizens and the community in order to enhance the effectiveness of the crime prevention measures

A Legal, Ethical, Global, and Corporate Environment in Business Research Paper

A Legal, Ethical, Global, and Corporate Environment in Business - Research Paper Example Therefore, she had a prima facie case against her employer because the employer was unable to prove that Tiano’s leave affected the business adversely (Clarkson et.al, 2012). In this case, Meads owned Citibank a credit-card debt amounting to $5,000 of which he could not be able to settle at that moment because of his health issues. He officially informed the creditor about his predicament and together with his attorney they informed the creditor that in future the creditor should contact Meads’ attorney. However, Citicorp who was working as Citibank agent made numerous calls at Meads home and place of work. Meads sued â€Å"CCSI for causing emotional distress.† According to Fair Debt Collection Practices Act, the CCSI did not anything to warrant the charge against unfair debt collection. However, the manner in which they collected the debt would attract a charge against â€Å"cause for distress† because they should have contacted Meads’ attorney considering the health condition of the debtor and directives by the attorney to contact him on behalf of his client (Clarkson et.al, 2012). In this case, Hoffman had entered into an agreement with Red Owl without any consideration. The contract was based on the verbal promise. Hoffman can successfully sue Red owl Stores under the promissory estoppels because the defendant made a promise to the plaintiff and never fulfilled it. In order for Hoffman to succeed in the legal claim, Hoffman should be able to convince the jury that they relied on Red Owl Store’s pledges and that upon the reliance on those promises, they suffered certain adversities. However, Hoffman should be prepared to get compensation for the actual loss suffered. The court may stop the agreement between the plaintiff and the defendant if by continuing with the agreement will result in unfairness between the parties (Clarkson et.al, 2012).   

Statistical Methods in Economics and Business Essay

Statistical Methods in Economics and Business - Essay Example A standard made by the institution. Now the conductors of the study have thought of using British Studies Program to see whether or not students will excel in the said aspect. Students form 10 institutions have attended to participate in the study and together with them, the faculty gets to supervise and coordinate with what are being offered by the Program. As a brief background of the British Studies Program, it offers business courses such as accounting and economics and non - business courses like the Legend of King Arthur and the Geography of Great Britain. The objective of the program regarding the study is that students are to be: As what can be observed from the design formulated form the study, we can clearly and able to see the changes or improvements made by the subject students so we can say that it is an appropriate design. A very systematic approach to the study and almost no subjectivity involved. At the beginning, those who conduct the study, of course, hypothesized that the program gives some significant positive effect on the students, but in conforming with technicality of using statistics to assess the subject to see any progress made, they just gave a hypothesis th

Interpretive Analyses essay on edward abbey book desert solitaire

Interpretive Analyses on edward abbey book desert solitaire - Essay Example and in your own, the flavor of an apple, the embrace of a friend or lover, the silk of a girls thigh, the sunlight on rocks and leaves, the feel of music, the bark of a tree, the abrasion of granite and sand, the plunge of clear water into a pool, the face of the wind" (p. xiii) Travelling in the sand of the desert and the rocky barren land are like conducting the excavations in the goldmine which bring forth new hopes and experiences from the author’s perspective. This book is like the oases in the desert. Abbey has no hesitation in stating categorically, "... I have personal convictions to uphold. Ideals, you might say. I prefer not to kill animals. Im a humanist; Id rather kill a man than a snake" (p. 20) and the reader will understand why Abbey makes such a hard observation as he turns the pages of the book! The content of the book is the summing up of Abbey’s benevolence. He intensely likes the silence and the grandeur of the wild desert and the quiet life of its inhabitants. The beliefs and practices of this naturalist are the need of the time when artificiality dominates in every area of the human activities. When human being, enamored of the scientific achievements, acts as if the nature is the permanent enemy, its exploitation is the birth right and one must be ever at war with it. Abbey sees paradise in canyons and the Colorado River and resents industrial tourism. In every small detail, in the oscillating blade of grass and the mighty roar of the river, Abbey relishes the mesmerizing beauty of Nature! He pleads that environmentalism should not be the view but the way of life. Condemnation of the defilers of Nature is not his literary pastime, but a strong conviction. The contents of the book are not the official annual report of the ranger who is posted in the part for one year. This one is not an ordinary ranger! For the exploiters, the bounties of Nature are the monetary rewards—it’s their commission. For Abbey it is the mission!

War Through the Media Essay Example | Topics and Well Written Essays - 750 words

War Through the Media - Essay Example The writer pays much of his attention to the problem of information gaps. The question †what would happen if the Axis powers won the war?†(p. 51) illustrated the fear that people felt. So newspapers used this state of fear and unknowing in order to control the emotional state of the public. Also because of economic competition that existed then between newspapers, every of them tried to outdo the opponent. This caused that truth in headlines disappeared in the content. â€Å"The nation’s newspapers published according to the dictates of their own consciences and interests and printed what they wanted to print, attacked who they wanted to attack, and reported with accuracy or distortion—that is, they acted like a free press†.The government had to find a solution to this problem, so it had to control the information. So the only way out was to form an agency devoted to propaganda. There were several of them only the Office of War Information (OWI), esta blished by President Roosevelt on June 13, 1942, continued its existence. Its mission was to inform public of happening abroad and to counteract enemy propaganda. Jordan Braverman give the definition of the OWI`s objectives, he says that the goals of the OWI were to record, clear, and approve all proposed radio and motion picture programs that federal agencies sponsored and to serve as a contact for the radio broadcasting and motion picture industries in their relationships with federal departments and agencies and concerning these governmental programs†¦Ã¢â‚¬ ¦The OWI was to form

Violence in Sports - an Ethical Perspective Essay Example for Free

Violence in Sports an Ethical Perspective Essay Violence in sport has become far too commonplace. Aggressive sports such as football and hockey involve many aggressive tactics; however far too often do these aggressive tactics become overshadowed by deliberate acts of violence with the intent to cause bodily harm to an opponent. Many professional and non-profession athletes, as well as coaches, have adapted the mentality that winning is the common goal that all who participate in sport strive for and therefore feel that engaging in violent acts while competing should be permitted in achieving this goal. In sport winning is what each athlete strives for and seemingly they will consign in harmful acts of violence to achieve their goal. Former Boston Bruins player David Forbes was quoted â€Å" I just don’t see, no matter how wrong the act is, how anything that happens in an athletic contest be criminal†, (Gillespie). The mentality of being above the law that most professional athletes possess does not only affect the game in which they are playing. Many athletes who execute physical acts of violence while competing are more prone to committing such violent acts in their everyday lives, most commonly domestic violence. Harvard Law Review). Spectator violence and hooliganism are also primarily linked to the violence fans observe during sporting events. (Williams). Also, professional and amateur sport has become an integral part of our culture and society. Sports can be seen or heard, in one form or another, at any time of day or night. Professional athletes are amongst the most publicized people in the world. Thus, the words and actions of these athletes have been commonly mistaken as notions of acceptable conduct. Therefore, people, especially children, who view these acts of excessive and dangerous violence often imitate the aggressive acts they too frequently observe from professional and amateur athletes. The core of these on going problems is the lack of, or far too feeble disciplinary actions assigned to players who commit unlawful acts of violence while competing in sport. League officials must enforce harsh penalties for acts of violence during a sporting event. In more severe cases violence in sport should be treated as a criminal matter, where perpetrators can be tried and convicted in civil court. This paper will discuss the affects that violence in sport has on our society by discussing the sub branches of the Social Conflict Theory of sociology. In understanding the sociological affects of violence in sport it is possible to discuss how violence in sports affects our present day society, which closely follows Socrates’ pattern in achieving an ideal state. In applying Socrates’ pattern in achieving an ideal state along with the psychological aspects of Plato’s cardinal virtues it will be possible to come to an understanding on how to eliminate violence in sport. In conclusion, the paper will discuss why athletes, conscious of their actions or not, commit violent acts while competing by applying Psychologist Immanuel Kant’s Theory of Command Given by Reason. Unpunished acts of violence that occur while competing that goes without punishment ultimately leads to violence acts while not competing. There have been numerous accounts of athletes performing physical assault while not competing. The most prevalent form of violence carried out by athletes off the playing field is domestic violence. Football coach Joe Paterno of Penn State University was quoted â€Å"I’m going to go home†¦.. nd beat up my wife† after a pre-season loss (Harvard Law Review [HLR], 1996 p. 1048). Many people have speculated about why athletes are like likely to commit acts of domestic abuse. One of these speculations is that players such as enforcers â€Å"train to use violence and intimidation on the field and may have difficulty preventing these lessons from carrying over into their personal relationships†, (HLR, 1996 p. 1050). Another, more logical speculation is that â€Å"sport has had a kind of sanctuary atmosphere to it in terms of the legal system and police have kept their distance†, (Lapchick, 2000 p. ). For an athlete to be above the law simply because he or she is an athlete is irrational. However, â€Å"the public has gotten fed up with athletes crossing the violent lines, both on and off the court, and that may contribute to police entering the sanctuary†, (Lapchick, 2000 p. 1). If indeed the police begin to get involved when acts of violence are performed by athletes on and off the court, violence and physical aggression may not be as commonplace in the future as they are today. Irrational as it may be for sport to have its own sanctuary atmosphere in terms of the legal system, we as a society must question why we ultimately allow for this to occur. During the 2003- 2004 National Hockey League season Todd Bertuzzi of the Vancouver Canucks viciously attacked unsuspecting Colorado Avalanche forward Steve Moore. The attack left Moore with a broken neck which ultimately ended his NHL career. Although Bertuzzi was suspended for the remainder of the season and his team was fined $250,000 no criminal charges were laid. One can only wonder how an unprovoked attack on an unsuspecting victim which ultimately ended a career due to a broken neck cannot be treated as a criminal offense. The Bertuzzi incident is an ideal example which illustrates how our society allows professional athletes to advocate themselves above the law. The problem of violence in sport can be discussed using the sub branches of the Social Conflict Theory of sociology. The Social Conflict Theory of sociology deals with the ideology that the problems that society faces are the result of the way that society, as well as the economics of that society are organized. The sub branch of Social Conflict Theory that gives support to the explanation to why we as a society put professional athletes above the law is The Marxist Theory. The Marxist Theory can also be broken down even further into Instrumental Marxism and Structural Marxism theories. The general premises behind the two Marxist theories however are quite similar. Marxist sociologists view crime as an outcome of Capitalism. The upper class, or the Bourgeoises, control all modes of production. It is this system that creates the division between the classes. The upper classes have all they need; they are the wealthy class as well as the most powerful and influential. The lower class, or the Proletariat, on the other hand has virtually nothing. These are the people left with no power no influence and virtually nothing. The general concepts of the Marxist theory are: that the laws are set up to protect the interests as well as maintain their financial standing while nothing is given to the lower classes or the poor. In our society we view our professional athletes as the upper class or the Bourgeoises. Professional athletes are indeed wealthy, powerful and influential. Thus our current laws, according to the Marxist theories, are set up in a way to protect the interest of the upper class (including professional athletes) as well as not to ruin their social status. The Marxist Theories provide an explanation of how professional athletes, such as Todd Bertuzzi, can carry out intentional acts of violence and not be prosecuted while if others who are not part of the upper class (the Proletariat) were to carry out the same act of violence would be prosecuted in a civil court. Therefore, to eliminate violence in sport our society must not allow subcultures, hockey for an example, to follow a different set of laws than the rest of society. Today our society is divided into many different classes. There is the upper class, the upper-middle class, middle class and so forth. Our present day society closely follows Socrates’ pattern in achieving an ideal state. Socrates’ pattern divides society into three classes. The first of the three are the workers, craftsmen, farmers, shopkeepers ect. Another class is the auxiliaries or warriors, and the third class is the guardians or rulers. Each man in the state belongs in one or another of these classes. However to simply divide a society into three classes in an attempt to achieve an ideal state seems somewhat implausible. Plato believed that every man must possess the cardinal virtues to live a good live. These virtues: wisdom, temperance, justice and courage are essential in living a good life and therefore are essential in achieving an ideal state. These virtues however can be applied not only to everyday life, but also to subcultures, such as hockey or football. Plato believes for a state to be ideal it must possess wisdom. The concept of wisdom is understanding ones self and controlling self. If professional or amateur athletes were to possess the virtue of wisdom they ultimately possess self control. To say an athlete committed an act of violence unintentionally or because he or she was â€Å"caught up in the game† is absurd. To commit an act of violence with the intent to cause injury is premeditated. If all athletes were to possess the virtue of wisdom they would have complete control over one self. All athletes should also possess the virtue of courage. Courage can be defined by Plato as â€Å"preserving things which may rightly be feared† (Plato 31). In professional and amateur sport athletes need to respect and obey the rules and regulations. In other words athletes must fear the possible punishments, whether criminal or not, for violence to ultimately be terminated from sport. If athletes begin to feel that they are not above the law or that their subculture must follow the same laws as the remainder of society violence in sport will ultimately decrease. In the republic Plato describes temperance, the third virtue, as: â€Å"†¦ within man himself, in his soul, there is a etter part and a worse; and that he is his own master when the part which is better by nature has the worse under control† (Plato 32). Clearly the virtue of temperance is important to possess for violence to diminish in sport. To master oneself and have the worse under control would definitely decrease the amount of violence in sport. Also, for athletes to have temperance would make for a more exciting game. To have control over one’s self in a team game means putting the team before the individual. Doing so will lead to less violent acts and a more exciting team oriented style of play. The final and most important virtue is justice. Plato believes that if a community were to follow and obey the three previous virtues of wisdom, courage and temperance justice will automatically exist. This can also be applied to the subculture of sport. If all people within the subculture of sport such as the General Managers, league officials and athletes were to possess the three virtues of wisdom, courage and temperance justice would automatically exist and therefore violence in sport would be a criminal matter where perpetrators can be tried and convicted in civil court. In society there are two types of command given by reason; hypothetical and categorical imperatives. Immanuel Kant describes hypothetical imperatives as â€Å"an action that must be done to justify a means or reach a set goal†, (Kant 2). Categorical imperatives are â€Å"actions that are done because of their necessity to morality†, (Kant 2). Hypothetical and categorical imperatives are also present in subcultures. Athletes who commit violent acts while competing follow the hypothetical imperative command. They are driven by hopes of winning and will do whatever it takes to achieve this goal. This is a key factor in giving an explanation to why some athletes find reasoning in committing a violent act while competing in a sporting event. Also this gives explanation to why some athletes fell that no matter how wrong the act is, how anything that happens in an athletic contest be criminal. Following the hypothetical imperative is described as performing an action to justify a means or reach a set goal. If this action is violent many athletes will argue that it should not be considered criminal because it was a justified action executed to reach a set goal; a goal which they are entitled and expected to carry out. However, Kant would argue against this stating that the only ethical principle is universal, and therefore categorical, is â€Å"to treat oneself, always as an end, never as a mean†. For example in hockey a hypothetical imperative could be â€Å"if you don’t obey the rules you go to the penalty box†. A categorical imperative would be â€Å"Obey the rules, it is your duty†. If athlete’s were to take on a categorical imperative way of life sport violence would come to an end, not because it is right or wrong, but because it would be the athletes duty to treat oneself, always as an end, never as a mean. Nonetheless, it is illogical to assume that violence in sport will one day be non existent. It is not illogical to assume that if the subculture of sport and those who are in command adapt the categorical imperative ways that violent acts in sport will be considered a criminal matter. To live a good life it is essential to possess the cardinal virtues. The cardinal virtues are essential in achieving an ideal state. In achieving an ideal state Kant would argue that the only ethical principle is universal and therefore categorical is to treat oneself, always as an end, never as a means. By treating oneself always as an end, never as a means true justice in present day society will prevail and everyone who commits a violent act will be prosecuted in civil court regardless if they belong to a subculture or not.

Assessment of Pressure Ulcers and Reliability of Risk Assessment Tools

Assessment of Pressure Ulcers and Reliability of Risk Assessment Tools The purpose of this assignment, is to identify a patient, under the care of the district nursing team, with a Grade 1 pressure ulcer, to their sacral area. To begin with, it will give a brief overview of the patient and their clinical history. Throughout the assignment the patient will be referred to as Mrs A, in order to protect the patients identity and maintain confidentiality, in accordance with the guidelines set out by the Nursing and Midwifery Council (NMC 2008). A brief description of a Grade 1 pressure ulcer will be given, along with a description of the steps taken in assessing the wound, using The Waterlow Scale (1985). This assignment will discuss the literature review that was carried out, along with other methods of research used, to gather vital information on wound care , such as the different classifications of wounds and the different risk assessment tools available. This assignment, will include brief overviews, of some the other commonly used pressure ulcer risk a ssessment tools, that are put to use by practitioners and how they compare to the Waterlow Scale. This assignment will also seek to highlight the importance of using a combination of clinical judgement, by carefully monitoring the patients physical and psychological conditions, alongside the at risk score calculated from the Waterlow Scale, in order to deliver holistic care to the patient. Mrs A is a 84 year old lady who has been referred to the district nurses by her General Practitioner, as he has concerns regarding her pressure areas . Following a recent fall she lost her confidence and is now house bound. She now spends more time in her chair as she has become nervous when mobilising around the house and in her garden. She has a history of high blood pressure and occasional angina for which she currently takes Nicorandil 30mg b.d. as prescribed by her General Practitioner , Nicorandil has been recognised as an aetiological aspect of non healing ulcers and wounds (Watson, 2002), this has to be taken into consideration during the assessment and throughout the management of her wound. Mrs A has no history of previous falls or problems with her balance. She has always been a confident and independent lady, with no current issues surrounding continence or diet. She has always enjoyed a large network of friends who visit her regularly. It is recommended by National Inst itute for Health and Clinical Excellence (NICE) that patients should receive an Initial assessment (within the first 6 hours of inpatient care) and ongoing risk assessments and so referrals of this nature are seen on the day, if it is received if not within 24 hrs. In order to establish Mrs As current risk of developing a pressure area, an assessment must take place. An initial holistic assessment, looking at all contributing factors such as mobility, continence and nutrition will provide a baseline that will identify her level of risk as well as identifying any existing pressure damage. A pressure ulcer is defined as, a localised injury to the skin and / or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing, or confounding factors, are also associated with pressure ulcers. According to the European Pressure Ulcer Advisory Panel (EPUAP 2009). Mrs A is more vulnerable to pressure damage, as her skin has become more fragile and thinner with age (NICE 2005). There are risk factors associated to the integrity of the patients skin and also to the patients general health. Skin that is already damaged, has a higher incidence of developing a pressure ulcer, than that of healthy skin. Skin that becomes too dry, or is more moist due to possible incontinence, is also at higher risk of developing a pressure ulcer than healthy skin. An elderly persons skin is at increased risk, because it is more fragile and thinner than the skin of a younger person. Boore et al (1987) identified the following principles in caring for the skin to prevent pressure damage, skin should be kept clean and dry and not left to remain wet. The skin should also not be left to dry out to prevent any accidental damage . Due to Mrs A spending more time sitting in her chair, she has become at a higher risk of developing a pressure sore, as she is less mobile. The reason being It becomes difficult for the blood to circulate causing a lack of oxygen and nutrients to the tissue cells. Furthermore, the lymphatic system also begins to suffer and becomes unable, to properly remove waste products. If the pressure continues to increase and is not relieved by equipment or movement. The cells can begin to die, leaving an area of dead tissue resulting in pressure damage. Nelson et al (2009) states, pressure ulcers can cause patients functional limitations, emotional distress, and pain for persons affected. The development of pressure ulcers, in various healthcare settings, is often seen as a reflection of the quality of care which is being provided (Nakrem 2009). Pressure ulcer prevention is very important in everyday clinical practise, as pressure ulcer treatment is expensive and factors such as legal issues have become more important. EPAUP (2009) have recommended strategies, which include frequent repositioning the use of special support surfaces, o r providing nutritional support to be included in the prevention. In order to gather evidence based research, to support my assignment. I undertook a literature review of the Waterlow Scale and Classifications of Grade 1 pressure sores. The databases used were the Culmulative Index to Nursing and Allied Health Literature (CINAHL) and OpenAthens. I used a variety of search terms including pressure sores, Grade 1 classification, Waterlow Scale, and How pressure sore risk assessment tools compare. Throughout the literature review the information was gathered from sources using a date range between the years of 2000 2011, although some references were found from sources of information that are from a much later date. This method of research ensured a plethora of articles and guidelines were collated and analysed. The trust guidelines in wound care were used, to show how we implement theory into practise in the community, using the wound care formulary. There was a vast amount of information available, as pressure area care is such a broad subject. The search criteria had to be narrowed down, in some cases to ensure the information gathered was relevant and not beyond the scope of the assignment. The evidence used throughout this assignment, is based on guidelines and recommendations given by NICE (2001), EPUAP (2001) and articles sourced from The Journal of Community Nursing (JCN). This was the most accurate information and guidance on pressure ulcer classifications and assessment although, some articles may not have been the most recent. The assessment tool used throughout my area of work, is the Waterlow Scale. The Waterlow Scale was developed by Judy Waterlow in 1985, while working as a clinical nurse teacher. It was originally designed for use by her student and is used to measure a patients risk of developing a pressure sore. It can also be used as a guide, for the ordering of effective pressure relieving equipment. All National Health Service (NHS) trusts have their own pressure ulcer prevention policy, or guidelines and practitioners are expected to use the risk assessment tool, specified in their trusts policy. NICE (2003), guidance states, that all trusts should have a pressure ulcer policy, which should include a pressure ulcer risk assessment tool. However, it reminds practitioners that the use of risk assessment tools, should be thought of as an aid to the clinical judgement of the practitioner. The use of the Waterlow tool enables, the nurse to assess each patient according to their individual risk of dev eloping pressure sores (Pancorbo-Hidalgo et al 2006). The scale illustrates a risk assessment scoring system and on the reverse side, provides information and guidance on wound assessment, dressings and preventative aids. There is information regarding pressure relieving equipment surrounding, the three levels of risk highlighted on the scale, and also provides guidance, concerning the nursing care given to patients. Although the Waterlow score is used in the community setting, when calculating the risk assessment score, it is vital that the nurse is aware of the difference in environment the tool was originally developed for. The tool uses a combination of core and external risk factors that contribute to the development of pressure ulcers. These are used to determine the risk level for an individual patient. The fundamental factors include disease, medication, malnourishment, age, dehydration / fluid status, lack of mobility, incontinence, skin condition and weight. The external factors, which refer to external influences which can cause skin distortion, include pressure, shearing forces, friction, and moisture. There is also a special risk section of the tool, which can be used if the patient is on certain medication or recently had surgery. This contributes to a holistic assessment of a patient and enables the practitioner to provide the most effective care and appropriate pressure relieving equipment. The score is calculated, by counting the scores given in each category, which apply to your patients current condition. Once these have been added up, you will have your at risk score. This will then ind icate the steps that need to be taken, in order to provide the appropriate level of care to the patient. Identification of a patients risk of developing a pressure sore is often considered the most important stage in pressure sore prevention (Davis 1994). During the assessment a skin inspection takes place of the most vulnerable areas of risk, typically these are heels, sacrum and parts of the body, where sheer or friction could take place. Elbows, shoulders, back of head and toes are also considered to be more vulnerable areas (NICE 2001). When using the Waterlow tool to assess Mrs As pressure risk, I found she had a score of 9. According to the Waterlow scoring system she is not considered as being at risk as her score is less than 10. As I had identified in my assessment, she had a score of 2, for her skin condition due to Grade 1 pressure ulcer to her sacrum. I felt it necessary, to highlight her as being at risk. A grade 1 pressure ulcer on her sacral area, maybe due to her recent loss of confidence and reduced mobility which has left Mrs A spending more time in her chair. Pressure ulcers are assessed and graded, according to the degree of damage to the tissue. The National Pressure Ulcer Advisory Panel (NPUAP), classifies pressure ulcers based on the depth of the wound. There are four classifications (Category/Stage I through IV) of pressure damage. In addition to these, two other categories have been defined, unstageable pressure ulcers and deep tissue injury (EPUAP, 2009) Grade 1 pressure damage is defined, as a non-blanchable erythema of intact skin. Indicators can be, discolouration of the skin, warmth, oedema, induration or hardness, particularly in people with darker pigmentation (EPUAP, 2003). It is believed by some practitioners, that blanching erythema indicates Grade 1 pressure damage (Hitch 1995) although others suggest that, Grade 1 pressure damage is present, when there is non-blanching erythema (Maklebust and Margolis, 1995; Yarkony et al, 1990). The majority of practitioners, agree that temperature and colour play an important role, in identifying grade 1 pressure ulcers (EPUAP, 1999) and erythema, is a factor in alm ost all classifications (Lyder, 1991). The pressure damage usually occurs, over boney prominences (Barton and Barton 1981). The skin in a Grade 1 pressure ulcer, is not broken, but it requires protection and monitoring. At this stage, it will not be known how deep the pressure damage is, regular monitoring and assessment is essential. The pressure ulcer may fade, but if the damage is deeper than the superficial layers of the skin, this wound could eventually develop into a much deeper pressure ulcer over, the following days or weeks. A Grade 1 pressure ulcer, is classed as a wound and so I have commenced a wound care plan and also a pressure area care plan. I will also ensure, Mrs A has regular pressure area checks in order to prevent the area breaking down. The pressure area checks will take place weekly until the pressure relieving equipment arrives, this will then be reduced to 3 monthly checks. Dressings can be applied to a Grade 1 pressure ulcer. They should be simple and offer some level of protection. Also, to prevent any further skin damage a film dressing is often used, or a hydrocolloid to protect the wound area (EPAUP, 2009) . These dressings will assist in reducing further friction, or shearing, if these factors are involved. It is considered the best way to treat a wound, is to prevent it from ever occurring. Removing the existing external pressure, reducing any moisture, which can occur if the patient is incontinent and employing pressure relief devices, may contribute to wound healing. Along with adequate nutrition, hydration and addressing any underlying medical conditions. The advice given to practitioners, on the reverse of the Waterlow tool is to provide a 100mm foam cushion, if a patients risk score is above 10. As Mrs A has an at risk score of 9, with a Grade 1 pressure sore evident, I feel it appropriate to provide the pressure relieving mattress and cushion to prevent any further pressure damage developing. All individuals, assessed as being vulnerable to pressure ulcers should, as a minimum provision, be placed on a high specification foam mattress with pressure relieving properties (NICE, 2001). As I am providing a cushion and a mattress, it is not felt necessary to apply a dressing at this point. However, the area will need regular monitoring, as at this stage it is unknown how deep the pressure damage is. If proactive care is given in the prevention and treatment of pressure ulcers, with the use of risk assessments and providing pressure relieving resources, the pressure area may resolve. Pressure ulcers can be costly for the NHS, debilitating and painful for the patient. With basic and effective nursing care offered to the patients, this can often be the key to success. Bliss (2000) suggests that the majority of Grade I ulcers heal, or resolve without breaking down if pressure relief is put into place immediately. However, experiences in a clinical settings supports observations, that non-blanching erythema can often result in irreversible damage (James, 1998; Dailey, 1992). McGough (1999) during a literature search, highlighted 40 pressure ulcer risk assessment tools, but not all have be considered suitable, or reliable for all clinical environments. As there are many different patient groups this often results in a wide spectrum of different patient needs. The three most commonly used tools in the United Kingdom (U.K.) are, The Norton scale, The Braden Scale and The Waterlow Scale. The first pressure ulcer risk assessment tool was the Norton scale. It was devised by Doreen Norton in 1962. The tool was used for estimating a patients risk for developing pressure ulcers by giving the patient a rating from 1 to 4 on five different factors. A patients with a score of 14 or more, was identified as being at high risk. Initially, this tool was aimed at elderly patients and there is little evidence from research gathered over the years, to support its use outside of an elderly care setting. Due to increased research over the years, concerning the identification and risk of developing pressure ulcers, a modified version of the Norton scale was created in 1987. The Braden Scale was created in the mid 1980s, in America and based on a conceptual schema of aetiological factors. Tissue tolerance and pressure where identified, as being significant factors in pressure ulcer development. However, the validity of the Braden Scale is not considered to be high in all clinical areas (Capobianco and McDonald, 1996). However, EPAUP (2003) state The Braden Risk Assessment Scale is considered by many, to be the most valid and reliable scoring system for a wide age range of patients. The Waterlow Scale, first devised in 1987, identifies more risk factors than the Braden and the Norton Scale. However, even though it is used widely across the U.K., it has still be criticised for its ability to over predict risk and ultimately result in the misuse of resources (Edwards 1995; McGough, 1999). Although there are various tools, which have been developed to identify a patients individual risk, of developing pressure sores. The majority of scales have been developed, based on ad hoc opinions, of the importance of possible risk factors, according to the Effective Healthcare Bulletins (EHCB, 1995). Franks et al, 2003; Nixon and Mc Gough, 2001, challenged the predictive validity of these tools, suggesting they may over predict the risk, cause expensive cost implications, as preventative equipment is put in place, when it may not always be necessary. Or they may under predict risk, so a patient maybe assessed as not being at high risk, develops a pressure ulcer. Although the Waterlow scoring system, now includes more objective measurements such as Body Mass Index (BMI) and weight loss after a recent update. It is still unknown, due to no published information, whether the reliability of the waterlow tool, has improved since the changes that took place. It has been recognised, as a fundamental flaw of these tools and due to this clinical judgement, must always be taken into consideration alongside the results that have been measure, from the use of the risk assessment. This is clearly recognised by NICE, as they advise their use as an aide-mà ©moire (2001). The aim of Pressure ulcer risk assessment tools, is to measure and quantify pressure ulcer risk. To determine the quality of these measurements the evaluation of validity and reliability would usually take place. The validity and reliability limitations, of pressure ulcer risk tools are widely acknowledged. To overcome these problems, the solution that is recommended is to combine the scores of pressure ulcer risk tools, with clinical judgment (EPAUP 2009). This recommendation, which is often seen in the literature, unfortunately is inconsistent as Papanikolaou et al (2007) states: If pressure ulcer risk assessment tools have such limitations, what contribution can they make to our confidence in clinical judgment, other than prompting us about the items, which should be considered when making such judgments?. Investigations of the validity and reliability, of pressure ulcer risk tools are important, in evaluating the quality, but they are not sufficient to judge their clinical value. In the research of pressure ulcer tools, there have been few attempts made to compare, the different pressure ulcer risk assessment strategies. Referring to literature until 2003, Pancorbo Hidalgo et al (2006) identified three studies, investigating the Norton scale compared to clinical judgment and the impact on pressure ulcer incidence. From these studies, it was concluded that there was no evidence, that the risk of pressure ulcer incidence was reduced by the use of the risk assessment tools. The Cochrane review (2008), set out to determine, whether the use of pressure ulcer risk assessment , in all health care settings , reduced the incidence of pressure ulcers. As no studies met the criteria, the authors have been unable to answer the review question. At present there is only weak evidence to support the validity, of pressure ulcer risk assessment scale tools and obtained scores contain varying amounts of measurement error. To improve our clinical practise, it is suggested that although tools such as the Waterlow Scale are used to distinguish a patients pressure ulcer risk, other investigations and tests, may need to be carried out to ensure a effective assessment is taking place. Practitioners may consider, various blood tests and more in depth history taking, including previous pressure damage and medications. Patients lifestyle and diet should also be taken into consideration and where appropriate, a nutritional assessment should be done if recent weight loss, or reduced appetite is evident. Nutritional assessment and screening tools are being used more readily and appear to be becoming more relevant in managing patients who are at risk of or have a pressure ulcer. The assessment tools should be reliable and valid, and as discussed previously with other risk assessment tools they should not replace clinical judgement. However, the use of nutritional assessment tools can help to bring the nutritional status of the patient to the attention of the practitioner, they should then consider nutrition when assessing the patients vulnerability to pressure ulcer development. The nutritional status of the patient should be updated and re-assessed at regular intervals following a assessment plan which is individual to the patient and includes an evaluation date. The condition of the individual will then allow the practitioner to decide how frequent the assessments will occur. The EPUAP (2003) recommends that as a minimum, assessment of nutritional status should include regu lar weighing of patients, skin assessment, documentation of food and fluid intake. As Mrs A currently has a balanced diet, it is not felt necessary to undertake, a nutritional assessment at this point. Her weight can be updated on each review visit, to assess any weight loss during each visit. If there is any deterioration in her condition, an assessment can be done when required. Continence should also be taken into consideration and where necessary a continence assessment should take place. Incontinence and pressure ulcers are common and often occur together. Patients who are incontinent are generally more likely to have difficulties with their mobility and elderly, both of which have a strong association with the development of pressure ulcers (Lyder, 2003).   The education of staff, surrounding pressure ulcer management and prevention, is also very important. NICE (2001) suggest, that all health care professionals, should receive relevant training and education, in pressure ulcer risk assessment and prevention. The information, skills and knowledge, gained from these training sessions, should then be cascaded down, to other members of the team. The training and education sessions, which are provided by the trust, are expected to cover a number of topics. These should include, risk factors for pressure ulcer development, skin assessment, and the selection of pressure equipment. Staff are also updated on policies, guidelines and the latest patient educational information (NICE 2001). Education of the patient, carers and family, is essential in order to achieve optimum pressure area care. Mrs A is encouraged to mobilise regularly, in order to relieve the pressure as a Grade 1 pressure sore has been identified, she is at a significant risk of developing a more severe ulcer. Interventions to prevent deterioration, are crucial at this point. It is thought, that this could prevent the pressure sore from developing into a Grade 2 or worse. NICE (2001) have suggested, that individuals vulnerable to or at elevated risk of developing pressure ulcers, who are able and willing, should be informed and educated about the risk assessment and resulting prevention strategies. NICE have devised a booklet for patients and relatives, called Pressure Ulcers Prevention and Treatment (NICE Clinical Guidance 29), which gives information and guidance on the treatment of pressure ulcers. It encourages patients to check their skin and change their position regularly. As a part of good practise, this booklet is given to Mrs A at the time of assessment, in order for her to develop some understanding of her pressure sore. This booklet is also given to the care givers or relatives so they can also gain understanding, regarding the care and prevention, of her pressure ulcer. An essential part of nursing documentation, is care planning. It demonstrates the care, that the individual patient requires and can be used to include patients and carers or relatives in the patients care. Involvement of the patient and their relative, or carer is advisable, as this could be invaluable, to the nurse planning the patients care. The National Health Service Modernisation Agency (NHSMA 2005) states clearly that person centred care is vital and that care planning involves negotiation, discussion and shared decision making, between the nurse and the patient. There were a number of improvements that I feel could have been made to the holistic care of Mrs A. I feel that one of the fundamental factors that needed to be considered , were the social needs of the patient. As I feel they are a large contributing factor, towards why the patient may have developed her pressure sore. The patient was previously known to be a very sociable lady, who gradually lost her confidence, resulting in her not leaving the house. There are various schemes and services available, which are provided by the local council or volunteer services, to enable the elderly or people unable to get around. For example, an option which could of been suggested to Mrs A are services such as Ring and Ride, or Werneth Communicare. Using these services or being involved in these types of schemes, may have empowered Mrs A to leave the house on a more regular basis. This would enable her to build up the confidence, she lost following her fall. This would have also lead to positive impact on the patients psychological care, as Mrs A would have been able to overcome her fears of leaving the house, enabling her to see friends and gain communications lost. As previously mentioned in this assignment, although Mrs A had a score of 9, which is not considered an at risk score. I still felt it necessary to act on this score, even though the wound was a not considered to be critical. If it is felt the patient is at a higher risk than that shown on the assessment tool, the practitioner should use their clinical judgement, to make crucial care decisions. It should also be considered, by the practitioner that risk assessment tools such as The Waterlow scale, may not have been developed, for their area of practise. Throughout the duration of Mrs As wound healing process, a holistic assessment of her pressure areas and general health assessment were carried and all relevant factors, were taken into consideration. The assessment tool used to assess her pressure areas, is th e most common tool used currently in practise and the tool recommended by the Trust. To conclude, there is evidence to prove that pressure ulcer risk assessment tools are useful, when used as a guide for the procurement of equipment. However, they cannot be relied upon solely to provide holistic care to a patient. It has been highlighted, that to ensure a holistic assessment of patients, it is necessary to complete a variety of assessments, to create a complete picture. Although The Waterlow scale covers a number of factors that need to be considered, throughout the assessment, it has become evident that the at risk score, can often be over or under scored depending on the practitioner. Clinical judgement has proved to be, a very important aspect of pressure ulcer prevention and treatment. The education of the patient, carer and relatives has also been highlighted, as an important aspect of care. Empowering the patient with information regarding their illness, may decrease the healing time and help prevent has further issues.

Patient Diagnosis: Lack of Energy Presentation

Patient Diagnosis: Lack of Energy Presentation Summary This dissertation is based on two patients who presented to medical services with a presenting complaint of a lack of energy?. My first patient, Mrs W, 61 years, has Diabetes Mellitus, type 2 and my second patient, Mr H, 59 years, has severe anaemia from unknown lower Gastrointestinal blood loss. I shall begin by focusing on the clinical aspects and basic medical sciences of their diseases and then go on to discuss psychosocial aspects, management, investigations and the role of professionals involved in their health care. I will then look at research and evidence based trials to explore the scope of their conditions and look at any current research that is being carried out. Throughout my dissertation I aim to reflect and convey what I have learnt and how I felt about my experiences. From writing this report I have developed as an individual and have gained personal advancements that I didnt expect to achieve. I have been able to widen my understanding of diseases and patients experience of their disease. Furthermore, I have gained an appreciation for research and evidence based medicine and developed a respect for other health care professionals. I have learnt the vital importance of taking on a holistic approach when dealing with a patient, rather than just looking at the basic science behind a disease. All in all, writing this dissertation has enabled me to truly understand how a disease can affect a patient and I now appreciate that it is not always about curing a patient, but about treating, advising and working towards a better quality of life for the patient and their family. 1. Introduction In my dissertation I aim to explain, explore and reflect on my experience of the People and Disease course. In particular I will focus on my experience of meeting with two individual patients with the same presenting complaint a lack of energy?. Both patients seem to be concerned with the prognosis of their disease but from very different points of view. My first patient wants to overcome her diabetes and not let it worsen; whereas, my second patient does not wish to know the cause of his anaemia, but is worried about the associated symptoms of his condition and how they will progress. Before contacting my first patient, Mrs. W, I felt apprehensive and quite anxious about the idea of having my own patient. I was worried about what she would think of me, how we would be able to build a rapport and what sort of questions I would ask her. In all honesty, I had naturally stereotyped her as a typical old lady?, but on meeting her, my initial thoughts were soon corrected. From this I have learnt that when given details about a patient you shouldnt necessarily stereotype and categorise them into a certain group in society. When asking her the initial questions that I had prepared I felt that it made the conversation very informal, so to adapt to the situation I just literally let her speak and tell me whatever she wanted to. This was very helpful to me as she had a lot of things she wanted to tell me and talk about. However, I do realise from communication skills seminars that not all patients will be as open as this in the future and therefore I do need to have the ability to speak to patients that are perhaps a bit more reluctant and unwilling to share their problems and thoughts. For example, you can use a lot of open questions to allow the patient to answer what they feel is comfortable for them and just gradually develop the conversation from what they say, rather than chit chatting?, which is what I found with my first patient. After asking Mrs.W about her recently diagnosed diabetes she seemed very unsure how to explain to me what she thought was wrong with her, she seemed to resent the fact she has a disease and questioned what she had done to deserve becoming ill. She said that even though the Doctor had explained everything to her, she was unsure of what to expect in the future and seemed quite worried about the aspect of not being able to care for herself. From telling me all of this, I felt quite overwhelmed and unsure of how to reassure her. Even though I wanted to help, I found myself in a situation where I physically couldnt, which was very frustrating. On my second and third visits I asked a bit more about her family situation, her social activities and her thoughts, ideas and feelings (psychological factors). From taking on this broader approach, I began to realise the true picture of Mrs Ws life and how it contributed to the worries of her illness. She told me about her husband leaving her and h er daughter and son becoming quite distant, she explained that she often felt lonely and at times it made her feel quite depressed. This seemed to be more of a concern to her than her actual illness, but it demonstrated why she is concerned about her diabetes worsening because she has very little family support and would have to cope by herself. From the meetings with Mrs W, I have learnt the vital importance of taking on a holistic approach when speaking to a patient. I have learnt that its not just a biological illness that contributes to the wellbeing of a patient; you have to take into consideration the home/family environment and the social and psychological factors. Not only have I had the opportunity to see an illness in the context of real life but I have greatly improved my confidence and patient communication skills by being able to gather information, take family history and cope in a one-to-one based home environment. However, my experience from meeting my first patient contrasted completely with my second patient experience. Initially I had some difficulties finding my second patient, as the consultant I had contacted only ran morning clinics; so I took the initiative to go into the hospital and find a suitable patient myself. Even though I felt quite nervous, I went onto the haematology ward and simply explained to one of the nurses about my course and what had happened so far with trying to find a patient. She was extremely helpful and understanding, which put me at ease and she more or less found me a patient right there and then (which I hadnt expected). However, even though I hadnt really prepared anything I already felt that I had developed some good skills and awareness of communicating appropriately with patients, both from my first patient and communication skills seminars, to be able to build up a good report with my second patient. Mr. H (my second patient) was very different to my first patient in the sense that he wasnt as open when talking about his illness. He is suffering from severe anaemia and has to have blood transfusions every week (so like my first patient, had the presenting symptom of no energy). However, he didnt seem to recall any dates of his illness and didnt want to explain what had caused the anaemia. However, after reading his medical records and meeting with his consultant, I came to realise that Mr. H had had a bad experience with a doctor and had adamantly refused further investigation, so his severe/worsening anaemia remains an unknown cause. Also, in comparison to my first patient, he had a much more considerable loss of energy, so even though he gave consent for me to talk to him, I felt at times he needed a break so I ensured that I did not stay too long and trouble him during my visits. Nevertheless, I found that meeting a patient in a hospital environment is completely different to meeting them in a home environment. In a hospital environment you need to be very aware of everything around you, how you are acting towards other staff and patients and there is a real need to realise certain cues from the patient (as they are in a more severe situation than a patient in a home environment). Overall, the People and Disease course has been a really enjoyable learning curve. Ive been able to put my communication skills to practice and see how to adapt to different situations, which has boosted my confidence enormously. Even though there is much more to learn, I really look forward to doing so and I hope that I will develop the skills needed to become a good doctor in todays society. 2. Clinical Features In this section I aim to discuss clinical features of my patients diseases and differential diagnoses. My first patient was diagnosed with Type 2 Diabetes Mellitus and my second patient suffers from severe anaemia; both of these conditions have similar clinical features and the same presenting complaint of a lack of energy and fatigue. Both of my patients recorded symptoms of lethargy, dizziness, fainting and shortness of breath; exploring these similar symptoms demonstrates the importance and accuracy needed for a diagnosis, as these symptoms could be indicative of a variety of other diseases. It is also vital to have a correct diagnosis, as a misdiagnosis would lead to unnecessary grievance, treatments or investigations which would cause a patient a lot of stress. Fatigue is the common presenting complaint in both of my patients and is clinically difficult to define; it is related to tiredness, exhaustion and a general lack of energy. Fatigue is a very common health complaint and around 20% of people in the United Kingdom claim to have fatigue intense enough to interfere with them having a normal life. Physical causes are estimated at 20-60%, and emotional causes are the other 40-80% (1).The fact that fatigue alone can disrupt ones life so severely indicates the important role of a doctor to be able to make a correct diagnosis for the cause of it. However, my individual patients described their fatigue in very different ways. Mrs W described her lack of energy in relation to feeling lethargic and very tired all the time, whereas Mr Hs fatigue was very much to do with a sudden onset of shortness of breath and chest pain. The symptoms that patients with anaemia normally present with are highlighted in the image below: (2) Mr. H has anaemia with haemoglobin levels often as low as 3.2gm/dL; with the normal range being 13 18 gm/dL for a male and 12 16 gm/dL for a female (2); indicating that his anaemia is very severe and therefore explains why he would experience fainting, chest pain and angina as shown in the image above. And in comparison to Mrs. W, highlights the difference in their experience of their clinical presentation of a lack of energy. Type 2 diabetes was previously referred to as adult onset diabetes and is related to insulin resistance and a relative, rather than an absolute, deficiency of insulin secretion (3). Due to the fact that this type of diabetes is concerned with gradual insulin resistance/deficiency means that individuals do not always (or initially) require insulin to achieve satisfactory diabetic control. The common symptoms associated with Type 2 Diabetes are (4): Polyuria: the need to urinate more often due to the body trying to excrete the extra glucose that is in the blood and in turn creating an osmotic gradient resulting in more urine production. Polydipsia: feeling thirsty more often than usual, due to the loss of fluids (increased urine production). Weight loss: this is due to the fact that glucose is not being taken up by cells due to insulin deficiency/resistance, so the body starts to burn up fat instead, which results in weight loss due to fat storage depletion. The majority of diabetic patients experience lack of energy because the cells in the body are not getting the glucose that they need, resulting in lethargy and tiredness. As type 2 diabetes progresses, patients may also experience blurred vision, yeast infections and prolonged time for wound healing. Mrs W was diagnosed with type 2 diabetes in February 2007; initially only experiencing a lack of energy. Over the months that I met with her she also started to experience polyuria and polydipsia. She was concerned as to how much her diabetes would progress and worsen because it had not been made very clear by her Doctor. This demonstrates the important need for a Doctor to be aware of patients concerns and level of understanding of their disease process. However, when speaking to Mr H about his clinical presentation and symptoms he had a very nonchalant attitude towards the cause of his disease. I later discovered that his anaemia was in fact due to unknown lower Gastro-intestinal (GI) blood loss and on questioning Mr H about this; he explained that he refused investigation to find the cause of the blood loss due to dissatisfaction with the way he was treated. He explained that during a scheduled procedure for a colonoscopy, the doctor carrying out the investigation was extremely rough and caused him a lot of distress and discomfort. And even though Mr H asked for the procedure to be stopped, the doctor proceeded against the patients wishes; this aggravated Mr H and led to violent behaviour towards the doctor and the dispute was later taken to court. I was very shocked to hear of his experience and also felt deeply concerned that he refused future investigations as his symptoms and anemia are very severe and have lead to angina and disabling conditions; with him being unable to walk and get out of bed unassisted due to such severe lack of energy. This emphasizes the crucial need for a good doctor-patient relationship, as shown in this case, without it, a doctor may be unable to make a proper diagnosis and prescribe ideal treatment.   Differential Diagnosis:- Diabetes:- The process of looking at a differential diagnosis involves weighing the probability of one disease against the possibility of other diseases accounting for a patients illness. For example, Mrs W presented with a lack of energy for her diabetes mellitus, but this complaint could have been diagnosed as any other kind of condition such as, hypothyroidism or Cushings disease as they can also present with fatigue. Differential diagnosis to Diabetes Type II:- Why is the condition considered to be a differential diagnosis How to make the correct diagnosis:- Hypothyroidism Also results in a lack of energy and fatigue. Often diagnosed via a blood test, examining the levels of T3,T4 and TSH in the blood. Cushings Disease Polyuria (and associated polydipsia); insulin resistance (especially common in ectopic ACTH production) (5)which can lead to hyperglycaemia (high blood sugar levels), which can in fact lead to diabetes mellitus. Dexamethasone suppression test or/and a 24hour urinary measurement of cortisol(6). Hyperglycaemia High circulating blood glucose levels this is a symptom of diabetes, but could also be due to physiological stress, critical illness or certain drugs. Blood test which indicates a glucose level of 10+ mmol/L (180mg/dl) also a test for diabetes, therefore, need drug/medical history. Anaemia:- The differential diagnosis of anaemia would be any condition relating to the presenting complaint of a lack of energy?, or any other condition relating to the symptoms of anaemia, as discussed in the clinical features section. In particular relation to Mr Hs lower gastrointestinal bleeding the differential diagnoses are as follows: Differential diagnosis for lower GI bleeding:- Why is the condition considered to be a differential diagnosis? How to make the correct diagnosis:- Haemorrhoids Swelling/inflammation of veins in the rectum commonly due to straining in constipation. These can often rupture and bleed. Physical examination of external haemorrhoids, digital rectal examination for internal haemorrhoids. Colorectal Cancer Cancerous growths in the colon (thought to be adenomatous polyps) can rupture, thus causing a bleed. Digital rectal examination, Fecal occult blood test (testing for blood in the stool), endoscopy (7). Ulcerative Colitis A form of Inflammatory Bowel Disease, includes ulcers and open sores which lead to constant diarrhoea mixed with blood. Endoscopy; involving both colonoscopy and sigmoidoscopy. From exploring the differential diagnosis of my patients conditions it has made me more aware of the vital importance of making the correct diagnosis; as there are a number of conditions that certain symptoms could be caused by. Furthermore, considering Mr Hs anaemia it does highlight the fact that his condition could be a number of quite serious conditions, which shocks me even more as he has chosen not to find out the cause of his worsening anaemia due to his troubled experience with a doctor. 3. Pathophysiology It is quite complex to discuss the aetiology of both my patients conditions as the exact cause of type 2 diabetes is not fully understood, although clear risk factors have been identified. Furthermore, Mr H refused investigation into his GI bleeding, which results in the cause of his anaemia remaining ambiguous. Diabetes Mellitus Type 2:- Diabetes Mellitus is a group of metabolic disorders characterised by chronic hyperglycaemia (high blood glucose concentration), due to insulin deficiency, insulin resistance, or both. There are two main types of diabetes; type 1 and type 2. They can clearly be distinguished by their epidemiology and probable causation, but not always so easily separated clinically. Type 1 diabetes is due to autoimmune destruction of insulin-producing beta cells of the pancreas therefore, causing an increase in fasting blood glucose. However, diabetes type 2 is a disorder that is characterised by high blood glucose due to insulin resistance and relative insulin deficiency (8). Since diabetes is a disease that affects your bodys ability to utilize glucose, it is important to understand what glucose is and how your body would normally control it. Glucose is a monosaccharide (simple) sugar that comes from the food we eat, cells take in glucose from the blood and break it down for energy; brain cells and red blood cells rely solely on glucose for fuel. The Pancreas:- The pancreas (where Insulin is synthesised) has both endocrine and exocrine functions. The exocrine function involves the secretion of digestive enzymes that are secreted from acinar cells and released into the small intestine via a system of ducts. Additionally, the endocrine part of the pancreas consists of millions of clusters of cells called Islets of Langerhans that produce hormones. Within the islets there are four main cell types; cells secrete glucagon, cells secrete insulin, cells secrete somatostatin, and PP cells secrete pancreatic polypeptide (9). Glucagon and Insulin are hormones secreted from the pancreas that work concomitantly to control the level of glucose in our blood. Glucagon is released when blood glucose levels fall, therefore resulting in stored glycogen being converted to glucose and thus increasing blood glucose levels, preventing a hypoglycaemic state. Insulin is a hormone that causes cells to take up glucose from the blood and store it as glycogen, thus a deficiency or resistance of this hormone will result in a high concentration of glucose in the blood. Insulin Release:- Beta cells release insulin via the following process; The glucose uptake takes place through a specific transporter protein called GLUT-2. The pancreatic ?-cell membrane contains several K+ channels, and two of them are directly involved, the K+-ATP channel and the maxi-K+ channel. The hyperglycaemia (high blood sugar level) accelerates the glucose uptake and metabolism and thus increases the ATP/ADP ratio. Increased ATP closes the K+-ATP channels, so the cell depolarises. During deploarisation from the normal resting membrane potential of -70 mV, a threshold is reached at 50 mV, resulting in the opening of Ca2+   channels. The Ca2+ influx triggers exocytosis of insulin and C-peptide containing granules following vesicular fusion with the cell membrane. ne. This process is demonstrated in the diagram below (10): However, in an insulin resistant individual normal levels of insulin that are released (via the process described above), do not have the same effect on muscle, adipose and liver cells, therefore resulting in glucose levels staying higher than normal. Increased levels of glucose in the bloodstream over a sustained length of time result in damage to blood vessels. Poorly controlled glucose levels can lead to complications such as nephropathy, retinopathy, neuropathy and cardiovascular diseases. Even though these complications may take a while to develop, it is important to realise that type 2 diabetes is often diagnosed at a relatively late stage. From looking at the pathophysiology of diabetes, Mrs Ws main symptom of lack of energy/tiredness can be explained. Due to her slow progression of insulin resistance means that more glucose remains in the blood and is not utilised by certain cells, such as muscle cells. Therefore, due to the fact that her cells are not able to use the glucose, she experiences weakness and tiredness. This lack of energy will progressively become worse and she may develop other complications if her diabetes is not controlled appropriately. Anaemia:- Anaemia occurs when there is a decrease in the level of haemoglobin in the blood and occurs when the production rate of red blood cells does not match the loss rate. It is a common condition in which all forms can be defined on the basis of physiological mechanisms. There are three broad categories: decreased/defective red blood cell production; increased destruction of red blood cells; and a mixture where both mechanisms operate simultaneously (11). Haemoglobin:- Haemoglobin is a substance contained within red blood cells and is responsible for their colour. It is composed of haem (an iron-containing porphyrin) linked to a protein, globin (12). Adult haemglobin consists of two and two globin chains. The iron containing porphyrin in the haem group is bound to each globin chain and a ferrous atom that can reversibly bind one oxygen molecule (as shown below (13). The biconcave shape of red blood cells enables a large surface area for the uptake and release of both oxygen and carbon dioxide. Haemoglobin becomes saturated with oxygen in the pulmonary capillaries where the partial pressure of oxygen is high and haemoglobin has a low affinity for oxygen (therefore, binds easily). Oxygen is then released in the tissues where the partial pressure of oxygen is low and haemoglobin has a low affinity for oxygen (therefore, oxygen offloads easily). The haemoglobin molecule itself exists in two conformations, relaxed (R) and tense (T). The tense state is characterized by the globin units being tightly held together by electrostatic bonds; when oxygen binds to the haemoglobin these bonds are weakened and broken, resulting in the relaxed conformation. The binding of one oxygen molecule leads to an increased affinity for the remaining binding sites, this is known as co-operativity, and is the reason for the sigmoid shape of the oxygen dissociation curve (below (14)). The binding of oxygen to haemoglobin can also be influenced by secondary effectors (as seen in the above image) i.e. hydrogen ions, carbon dioxide, and 2-3 diphosphoglycerate. The binding of 2, 3 DPG stabilizes the tense state and therefore, reduces haemoglobins affinity for oxygen (15). In conditions with lowered haemoglobin/oxygen levels, such as anaemia or hypoxia the concentration of 2, 3 DPG increases to raise oxygen availability for tissues. Haemoglobin Synthesis:- Haemoglobin is synthesised in a series of complex steps, it takes place in the mitochondria of the developing red blood cells. The major rate limiting step is the conversion of glycine and succinic acid to ?-aminolaevulinic acid (ALA), this occurs via ALA synthetase. Two molecules of ?-ALA condense to form a pyrrole ring, called porphobilinogen. The pyrrole rings are then grouped together   in fours, to form protoporphyrins. Iron is then inserted into the rings to form haem and then finally, haem is attached to the globin chains to form haemoglobin. Production and removal of red blood cells:- Red blood cells are formed and develop in the red bone marrow of large bones; the process by which they are produced is called erythropoiesis. The organ responsible for turning on the faucet of red blood cell production is the kidney. The kidneys can detect low levels of oxygen in the blood. When this happens, the kidneys respond by releasing a hormone called erythropoietin, which then travels to the red bone marrow to stimulate the marrow to begin red blood cell production. Within the bone marrow there are many stem cells from which red blood cells can be formed. As these cells mature, they extrude their nucleus and fill with haemoglobin, forming reticulocytes which can circulate around the body. After 3/4 months, approx 120 days, red blood cells begin to weaken and their cell membranes become very fragile. The red pulp of the spleen allows mechanical filtration and removal of red blood cells, and any leftover components i.e. iron from the haemoglobin are recycled to form new red bl ood cells (16). There are several different types of anaemia such as B12 deficiency, iron deficiency, diseases of the bone marrow and in relation to Mr H, chronic loss of blood. His severe loss of blood has subsequently led to his anaemia as there is a mismatch in production of red blood cells and loss of blood. Due to his deficiency in circulating reticulocytes, oxygen, via haemoglobin is insufficiently supplied to his body, resulting in severe lack of energy. Complications of his condition have led to shortness of breath and angina.   Angina Pectoris:- Angina pectoris literally means a choking sensation in the chest?. It is an episodic pain that is usually felt in the centre of the chest, often radiating to the neck and left arm. Angina occurs because myocardial oxygen requirement is greater than what it is supplied with. This results in a buildup of metabolites, causing pain (17). Classic angina occurs after exertion, excitation or emotion and is caused by insufficient oxygen supply to meet its demand; however, the pain normally subsides with rest. Due to Mr Hs chronic blood loss, there is insufficient blood supply to the heart and subsequent stress is placed on the organ which has led to his angina. 4. Psychosocial aspects of Illness and Disease The impact of chronic illness and disability is far reaching, extending beyond the patient to all those whom the individual has contact. Illness and disability affects all aspects of life, including social and family relationships, economic status, activities of daily living, and recreational activities. Even though several factors influence the extent of impact, every illness or disability requires some adjustment to everyday life. The extent of the impact can depend on (18): The nature of the condition Individuals pre illness/disability personality The meaning of the illness to the individual Individuals current life circumstances The degree of family/social support With reference to my patients, they each had different outlooks on their illnesses as mentioned previously. However, they do have certain similarities when considering the psychological aspect of their diseases. Both patients were shocked to find out their conditions as neither of them had expected to be diagnosed with a lifelong illness. This is known as biographical disruption, which is a key sociological concept as it identifies severe illness or disease as a major disruptive and unexpected experience. The illness/disease leads to a biographical shift from a perceived normal trajectory to an abnormal one, with the development of a new consciousness of the body, fragility of self and grief for a former life. For instance, Mrs W had future intentions to look after and care for her grandchildren and Mr H wanted to carry on working as a HGV driver; but due to their conditions they cannot achieve these former life plans and now have to adapt to a new ones. Additionally, they both explained to me how they experienced the feeling of facing stigma. Stigma refers to the identification and recognition of a negatively defined condition, attribute, trait or behaviour in a person or group of persons (19) . There are different types of stigma, such as enacted or felt. Mr H explained how he felt shunned from his friends and some relatives which refers to enacted stigma; the real experience of prejudice, discrimination and disadvantage as the consequence of his illness. Whereas, Mrs W spoke about her fear of being discriminated against and what people would think/say, which falls under a felt stigma; a fear of enacted stigma, also encompasses a feeling of shame associated with being diabetic?. I feel that this notion of facing stigma is perhaps underestimated in health care because it is not necessarily something a Doctor would automatically think about and therefore, perhaps wouldnt advise the patient on how to deal with such feelings. However, from talking to my patients about how they feel about having an illness they both stressed how psychologically disruptive it is, and how the feeling of being categorised as an ill individual has often led to depressive moods and anxiety. Therefore, from this experience I have learnt the importance of considering the patients thoughts and feelings rather than just focusing on how to treat their disease. Biological-psychosocial Model (Engel, 1977):- This is a model that incorporates psychological, sociological and biological factors in contribution to well being and health of an individual (20). It suggests that all three of these factors together and individually play an important role in relation to health and emphasises the importance of taking on a holistic approach when caring for a patient. The obvious factor of health is the biological factors of disease, the process of the disease and the individuals genetic make-up. Sociological factors include individuals family and friend support network as well as financial status and social class. Psychological factors include peoples disposition, their emotional status, whether they are stressed, depressed or anxious all contribute to ill health. From learning about this model it is important to note what factors affect a patient and how to deal with them accordingly when it comes to management and treatment of their disease. Both of my patients spoke of their psychological and social aspects and how they thought these factors had affected their illness. Mrs W, for example often felt quite depressed and lonely as she recently divorced her husband, and due to her illness often felt too tired to see her grandchildren. She also explained how she felt useless?, as she would get tired grocery shopping and house cleaning and she would get frustrated with herself, which often made her feel worse. This highlights how illness can be affected by more than just a biological aspect, and as a Doctor it is important to recognize other factors that affect a patients life. In comparison to Mrs W, who quite openly spoke about her psychological and social problems, Mr H was much more reluctant to tell me how he felt about his illness and how it was affecting him. However, over time I felt that he became much more comfortable talking to me and we were able to build a good rapport. He later went on to explain how he felt he had to keep a bravado about himself, being an ex army sergeant and that he was embarrassed that he often felt severely depressed and stressed about his worsening condition, but felt that by standing his ground and refusing investigation he Mechanisms Of Granule Formation: Pharmaceutical Industry Mechanisms Of Granule Formation: Pharmaceutical Industry For the production of solid oral dosage forms most fine pharmaceutical compounds require granulation to improve their flowability and processing properties prior to tabletting.    http://www.pharmamanufacturing.com/articles/2008/096.html http://www.scribd.com/doc/6601180/Tablet-Granulation Tablets are the most common drug dosage form today, and thus granulation, which allows primary powder particles to adhere and form granules, is one of the most important unit operations in drug manufacturing. Understanding granulation grows more complex each year. This article reviews the most current methods and mechanisms of pharmaceutical granulation, including factors that can lead to improved control. Particle-bonding Mechanisms a) Adhesion and cohesion forces in immobile films. If sufficient liquid is present in a powder to form a thin, immobile layer, there will be an increase in contact area between particles. The bond strength between particles will increase, as the Van der Waals forces of attraction are proportional to the particle diameter and inversely proportional to the square of the distance of separation [1]. b) Interfacial forces in mobile liquid films. During wet granulation, liquid is added to the powder mix and distributed as films around and between the particles. There are three states of water distribution between particles. At low moisture levels, the pendular state, particles are held together by surface tension forces of the liquid/air interface and the hydrostatic suction pressure in the liquid bridge. ADVERTISEMENT On Pharma Blog Get the latest analysis and commentary on manufacturing and the drug industry at our editors blog. On Pharma looks at the drug industry with a special focus on manufacturing, which is coming into its own as a strategically important area. When all the air has been displaced from between the particles, the capillary state is reached, and the particles are held by capillary suction at the liquid/air interface. The funicular state represents an intermediate stage between the pendular and capillary states. Moist granule tensile strength increases about three times between the pendular and the capillary state. These wet bridges are, however, a prerequisite for the formation of solid bridges formed by adhesives present in the liquid, or by materials that dissolve in the granulating liquid. Solid bridges can be formed in two ways: Hardening binders. When an adhesive is included in the granulating solvent it forms liquid bridges, and the adhesive will harden or crystallize on drying to form solid bridges to bind the particles. Crystallization of dissolved substances. The solvent used to mass the powder during wet granulation may partially dissolve one of the powdered ingredients. When the granules are dried, crystallization of this material will take place and the dissolved substance then acts as a hardening binder. c) Attractive forces between solid particles. In the absence of liquids and solid bridges formed by binding agents, there are two types of attractive force that can operate between particles in pharmaceutical systems, electrostatic forces and Van der Waals forces. Van der Waals forces are about four orders of magnitude greater than electrostatic and add to the strength of granules produced by dry granulation. Mechanisms of Granule Formation a) Nucleation. Granulation starts with particle-particle contact and adhesion due to liquid bridges. A number of particles will join to form the pendular state. Further agitation densifies the pendular bodies to form the capillary state, and these bodies act as nuclei for further granule growth [2]. b) Transition. Nuclei can grow in two possible ways: either single particles can be added to the nuclei by pendular bridges, or two or more nuclei may combine. The combined nuclei will be reshaped by the agitation of the bed. This stage is characterized by the presence of a large number of small granules with a fairly wide size distribution. c) Ball Growth. If agitation is continued, granule coalescence will continue and produce an unusable, over-massed system, although this is dependent upon the amount of liquid added and the properties of the material being granulated [1]. There are four possible mechanisms of ball growth, which are illustrated in Figure 1 [3]: Coalescence. Two or more granules join to form a larger granule. Breakage. Granules break into fragments which adhere to other granules, forming a layer of material over the surviving granule. Layering. When a second batch of powder mix is added to a bed of granules, the powder will adhere to the granules, forming a layer over the surface and increasing the granule size. Abrasion Transfer. Agitation of the granule bed leads to the attrition of material from granules. This abraded material adheres to other granules. Granulation Methods  [4] Dry Granulation. This requires two pieces of equipment, a machine for compressing the dry powders into compacts or flakes, and a mill for breaking up these intermediate products into granules. The dry method may be used for drugs that do not compress well after wet granulation, or those which are sensitive to moisture. Wet Granulation. In this method, the wet mass is forced through a sieve to produce wet granules which are then dried. A subsequent screening stage breaks agglomerates of granules. Organic solvents are used when water-sensitive drugs are processed, as an alternative to dry granulation, or when a rapid drying time is required. Because direct compressing is not the best technology for many active substances, wet granulation is still a preferred method. Even if the active substance is sensitive to hydrolysis, modern equipment (e.g., a fluidized bed) eliminates all problems in wet granulation [2]. http://www.investopedia.com/terms/l/leptokurtic.asp Dawar Qhoraish (k0920236) Nazmul Islam (k) Introduction Granulation can be used to For the production of solid oral dosage forms most fine pharmaceutical compounds require granulation to improve their flowability and processing properties prior to tabletting.    Method and Materials The experiment was carried out as explained in PY2020A practical booklet, without any amendments. Paracetamol (25g), lactose (265g) and sodium starch glycollate (2.945g) and PVP solution 15% (30ml) was used. 1 Erweka AR402 oscillating granulator with the finer sieve was used to granulate the drug without too much force with variables of turns (rpm) and time (minutes). The machine had an emergency switch off button and safeguard on top which turns off machine when you put your hand in. Sieve shaker used was Retsch A5 200 basic was used to separate the particles into different sizes by vibration with variables of amplitude and speed. The top sieve was fixed by parallel bars with screws and bottom of sieves contained rubber bands to control any overflow and stability. Discussion Modal: Low so most particles are fine. (low) Relate to flow rate. Better flow rate. Small IQR-data close to each other. Positive skewness means more particles with finer particles, so flow rate is better. What Does Leptokurtic Mean? A description of  the kurtosis in a  distribution in which the  statistical value is positive. Leptokurtic distributions have higher peaks around the mean compared to normal distributions, which leads to thick tails on both sides. These peaks result from the data being highly concentrated around the mean, due to lower variations within observations. Limitations: 7.9% MC was lost after 45 minutes in 75oC oven compared to 9.51% in 130oC heater balance. Tray was exposed to air for different amount of periods each time, errors as tray was allowed to cool down. Not dried properly Granulators normally used for large quantities. If lubricant used, particle size would be higher. Improvements: More repeats, heat for longer and at high temperature.