Book Report on The Giver

How do you get teens thinking about fundamental issues of life? Experience shows that plain old rhetoric does little good; children (and, as a matter of fact, every one of us) should put their minds to the problem in question and arrive at a viewpoint as a result of conscious choice. Lois Lowry’s novel The Giver provides much food for thought in this respect. Plot Overview The protagonist, Jonas, is a twelve-year-old boy who lives in a society of absolute peace and quiet. Horrors of warfare, disease and privations are things long forgotten by everyone except the Receiver of Memory who stores knowledge of the days past in all its variety in case the Community has to make a decision for which it lacks experience. As it turns out, memories of the Community members are limited to everyday life; they are not aware of what came before. Neither do they know natural beauty and fine art; furthermore, their lives are emotionally barren because strong feelings are regarded as a threat to stability and prevented. The Community advisors administer all civil and even private matters (from appointing to jobs to choosing spouses) to keep people from wrong choices and upsetting experience. As Jonas is appointed the Receiver and gets the knowledge from his predecessor (who is now The Giver), he becomes restless with confusion; and when he learns about the true nature of some realia, he cannot bear to let the Community remain the way it is. He plans to escape to the world outside (the Elsewhere), while the Giver intends to spread the memories among the citizens and see to it that they are not crushed by the overwhelming knowledge. Living Consciously as a Key to Freedom Although the book became an object of controversy and debate (on the pretext that it contains implications and themes too unsettling for children aged 8-12), it is definitely worth reading. The story is skillfully narrated and captivating, and the subject matter is more than relevant to children: what is freedom? The author dwells upon numerous aspects of this issue: Is freedom a means of creation and a vehicle for progress, or does it lead to chaos and destruction? Is turning a blind eye to painful experience a sound way to deal with sorrows of life? Can we really sacrifice individuality to eliminate the differences which provoke conflicts among people? Should the authorities impose their control over people’s deeds and thoughts for the sake of order, or is it the dead end of human society? These questions are undoubtedly difficult (and not only for teens, by the way); but ignoring such ‘adult topics’ serves only to bring up naà ¯ve and helpless human beings, just like it was done in the community described in the novel. The Giver is, in fact, a good reminder for parents and teachers of what a wise adult should be – a Giver of knowledge who helps the young handle troubling experiences by building up strength of mind, and not by hushing up awkward or unpleasant issues.

Blind Obedience - 2109 Words

Name: Andraie Lewis Eng. 122 May 8,2013 Blind obedience Society often view obedience as a good quality or trait to have; employers want obedient employees and parents often wish for obedient children. Being obedient means that an individual shows respect for an authority figure and will carry out the instructions they are given; when someone is obedient they are widely accepted by society, because they do whatever it is that society asks of them. But obedience carried too far can have disastrous consequences to both the individual and society; this is referred to as blind obedience. Blind obedience is when a person follows authority without even thinking about the†¦show more content†¦A lot of people argued that Milgram’s experiment was unethical, but made sense logically. His †experiment was carried out in the shadow of the Holocaust. The trial of Adolf Eichmann had the world wondering how the Nazis were able to persuade so many ordinary Germans to participate in the murder of innocent people† (Cohen A24). During world war two (WW II), Adolf Hitler, the leader of the Nazis’ came to power through his dictatorship which ultimately led to the demise of millions of Jews in order to create a master race. With the obedience of the militia, he rose to power annihilating any freedoms Jewish people had. His tactics were brutal and irreconcilably fatal for all who disobeyed him. We can only assume that the Germans followed Hitler’s’ gruesome orders out of fear or just out of ignorance but as Tod Hoffman mentioned in his article from the â€Å"Gazette,† †How ordinary Germans were transformed into Nazi butchers remains a compelling historical and sociological question† (I12). Those Germans blindly obeying Hitler’s inhumane orders is only apart of the widely astonishing scale of people obeying authority and following orders without even thinking for themselves. †Even among those who were not rabid National Socialists, faith in, and support for, Hitler was blind and boundless. Whether this was genuine or a function of having lived for years under a totalitarian regime that valued obedience above all otherShow MoreRelatedThe Blind Obedience in â€Å"the Lottery†2459 Words   |  10 PagesThe Blind Obedience in â€Å"The Lottery† â€Å"The Lottery† by Shirley Jackson written and published in 1948, takes place on June 27th in a small town of three hundred people. Villagers gather together at around ten o’clock for one of the main rituals called ‘the lottery‘, which takes place in the central square. â€Å"The lottery was conducted as were the square dances† (Jackson 31) illustrating the timely scheduled event. It is a normal day with â€Å"the fresh warmth of a full summer day† (Jackson 1). The menRead MoreThe Blind Obedience And Authority1237 Words   |  5 PagesBlind Obedience to Authority Millions of people were killed in Nazi Germany in concentration camps however, Hitler wouldn’t have been able to kill them all, nor could just a handful of people. Obedience is when society influences where/ when an individual acts in response to a direct order from another individual, who is usually the authority figure. It is assumed that without such an order the person would not have acted in this way. In order to obey authority, the obeying person has to acceptRead MoreEssay about Blind Obedience700 Words   |  3 Pages Blind Obedience nbsp;nbsp;nbsp;nbsp;nbsp;While sitting in church on Sunday going through the same motions of every Sunday, my son leans over to ask, â€Å"Why do we have to stand up for this prayer?† My response â€Å"because we are supposed to†. Reading â€Å"The Children’s Story† by James Clavell, made me think a little more about this question that I had no answer for. A person needs to be able to explain why he does what he does. Children are innocent and unknowing; they are like a blank piece of paperRead MoreAnalysis Of Just Do What The Pilot Tells You831 Words   |  4 PagesDalrymple, is a British physician who discusses why blind obedience is discouraged. His article, â€Å" Just Do What the Pilot Tells You†, was first published in the New Statesman. In this specific article, he touches on points in our lives when we are supposed to do what we are told. Disobedience is when a person chooses to disobey some sort of order they were directed to do. The main point that the author is trying to make is that neither obedience or disobedience should be more prominent than the otherRead MoreAuthority Is A Fundamental Part Of Life Essay2069 Words   |  9 Pagesuse authority to maintain order and obedi ence throughout communities. Parents possess characteristics of authority in order to teach children right from wrong. As well as, teachers are considered authority figures since they need to control and maintain obedience in the classroom. Authority cannot exist without obedience. Society is developed on this notion. Without authority, and its required obedience, disorder and disruption would occur. But how much obedience to authority is necessary? When isRead MoreBlind Obedience in Shirley Jacksons The Lottery1059 Words   |  5 Pages The author of â€Å"The Lottery† wrote this story â€Å"to shock the story’s readers with a graphic demonstration of the pointless violence and general inhumanity in their own lives† (Jackson 211). This story reflects human behavior in society to show how although rules, laws or traditions do not make sense, people follow them. Throughout the story the three main symbols of how people blindly follow senseless traditions were the lottery itself, the color black, and the hesitation that people had towardsRead MoreBlind Obedience in Shirley Jacksons The Lottery Essay2503 Words   |  11 PagesJames Evans believes that since the story was written in the immediate aftermath of World War II and the holocaust, it raised (and can still raise) important questions concerning ‘the power of mass psychology, the possibility that blind adherence to tradition will forestall judgment, and the ease with which responsibility can be denied.’† (J. Stark qtd. in Evans 119) Other critics simply focus on man’s inhumanity to man. Helen Nebeker notes: Numerous critics have carefullyRead More Essays on Jacksons Lottery: Dangers of Blind Obedience Exposed684 Words   |  3 PagesDangers of Blind Obedience Exposed in The Lottery      Ã‚  Ã‚  Ã‚   Most of us obey every day without a thought. People follow company dress code, state and federal laws and the assumed rules of courtesy. Those who do disobey are usually frowned upon or possibly even reprimanded. But has it even occurred to you that in some cases, disobedience may be the better course to choose? In her speech Group Minds, Doris Lessing discusses these dangers of obedience, which are demonstrated in Shirley JacksonsRead More Essay on Shirley Jacksons The Lottery - Blind Obedience Exposed954 Words   |  4 PagesBlind Obedience Exposed in The Lottery    The annual ritualistic stoning of a villager in Shirley Jacksons The Lottery parallels tradition in American culture.   This paper will inform the reader of the effect tradition has on characters in the short story The Lottery and how traditions still strongly influence peoples lives in america.      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Christian weddings hold many traditions and superstitions that seemingly defy logic.   Although most couples no longer have arrangedRead MoreEssay on Obedience1004 Words   |  5 PagesErin Poulsen ACP W131 Mr. Scanlan 19 October, 2015 Comparative Critique Obedience and Disobedience has been a part of key moments in history. Many have studied forms of obedience to learn how it affects people and situations. For example, Stanley Milgram conducted a well-known experiment in which the subject, named the â€Å"teacher† must shock the â€Å"learner† every time he doesn’t remember a word pair from a memory test. The focus of this study is on the teacher, and whether they will administer

Nursing Care Plan Free Essays

Nursing Care Plan Assessment equals Data Collection + Analysis| Nursing Diagnosis – Actual/Potential| Nursing Goal(SMART)| Nursing Interventions/ActionsInclude Rationale/Reference| Evaluation| Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker, Hypertension, Fall at home, Bradycardia, Hyperlipidemia. Neurological: Alert, Oriented x 4. We will write a custom essay sample on Nursing Care Plan or any similar topic only for you Order Now Diet as ToleratedActivity as tolerated. Does not want to do physiotherapy. Would prefer to remain in bed. Will only move her arms and legs and adjust as needed. | Activity Intolerance related to weakness, bed rest and immobility as evidenced by client verbalizing lack of interest/desire in activity. Risk for falls related to generalised weakness and impaired mobility as evidenced by client having a history of fall in the past. Hopelessness related to failing or deteriorating physical condition as evidenced by client stating â€Å"Why god is not calling me to him†. | 1. Client will participate in daily activity with vital signs within limit in a week’s time. 2. Client will perform ADLs with some assistance, e. g. , toilets with help ambulating to bathroom, by discharge. 1. Client will not experience a fall by identifying risks that increase susceptibility to falls by the end of the day. 2. Client and caregiver will apply tactics and ways to increase safety and provide a safe home environment. 1. Client will initiate behaviours that may reduce feeling of hopelessness by the end of week. 2. Client will be hopeful verbalizing optimistic plans after she is discharged and reaches home. | 1. Record client’s vitals before and after any activity. Rationale: Variation can be caused by temporary insufficiency of blood supply (Ackley Ladwig, 2008, p 119). 2. Administer pain medications prior to activity. Rationale: Pain restricts client from performing maximum activity and may worsen the movement (Ackley Ladwig, 2008, p 120). 3. Encourage client to change position gradually, dangle, sit, stand and ambulate as tolerated. Rationale: Performing activities slowly at client’s pace and for shorter periods minimizes fatigue (Kozier, 2010, pg. 1126). 4. Teach the client systematic performance of active ROM exercises to maintain and improve joint mobility. Rationale: These activity increases muscular strength and active movement (Kozier, 2010, pg. 1147). 5. Encourage client plan activities with alternate periods or rest and activity. Rationale: Assistance in planning daily routines that maintain a balance between activity and rest may be necessary to conserve energy (Day, 2010, pg. 1744). 6. Reinforce importance of progressive exercise, emphasizing that joints are to be exercised to the point of pain and not after that. Rationale: Pain occurs as a result of joint or muscle injury. Continued stress on joints or muscles may lead to more serious damage and limit ability to move (Gulanick Myers, 2010, pg 136). 1. Place objects used by the client within her reach. Rationale: Client can lose balance and might fall when she is trying to get items that are out of reach (Kozier, pg 775, 2010). 2. Emphasize and educate client about the importance of nutrition especially vitamin D supplementation in relation to reducing fall risk. Rationale: Proper diet along with Vitamin D supplement raises calcium which reduces falls and falls related fractures (Best Practice Guidelines, 2005, Rec. 05). 3. Consult with other health care team members such as OT/PT to help resolve mobility issues. Rationale: Interprofessional collaboration results in a sharing of expertise to enhance the quality of patient care (Kozier, pg 776, 2010). 4. Encourage client to do exercises and activity as tolerated to maintain muscle strength and joint flexibility. Rationale: A routine of exercises such as Tai chi can enhance balance and improve overall muscle strength (Best Practice Guideline, Rec. 2. 1, 2005). 5. Educate client to stay in the lower level of house such as bedroom/washroom or everything in one floor. Rationale: Having all daily required amenities nearby will reduce client’s risk of falling. (Kozier, pg 774, 2010). 6. Increase client’s awareness by highlighting the risk factors associated with falls within home; removing unsafe objects. Rationale: Risk factors such as clutter, unsecure rugs, extra loose tripping clothing and inadequate lighting hampers the motivation for mobility (Kozier, pg 774, 2010). 1. Creating a therapeutic nurse-client relationship by listening attentively and increasing her positivity by talking about her past pleasant experiences. Rationale: Encourage client to share feeling and reflecting on past accomplishments, positive memories and significant milestones (Day, 2010, pg. 434). 2. Encourage client to become involved in activities on the unit like interacting with staff, other clients, participating in therapy and recreational activities. Rationale: This will help distract her mind from a preoccupation with her illness (White, 2005, pg. 1326). 3. Provide things to do when client is feeling down, like, crossword puzzle, reading books, watching TV. Rationale: This provides time to shift her attention to more creative activities, and will see the situation not so utterly and hopeless (White, 2005, pg. 1326). 4. Teach client to substitute negative self-talk with positive self-talk. Rationale: Focusing on individual’s strengths and abilities enables and support hope (Day, 2010, pg. 434). 5. Encourage client to spend increased time with family and loved ones. Rationale: Clients who live alone with no family support are more prone to hopelessness (Carpenito-Moyet, 2008, pg. 329). 6. Encourage client to engage in creative activities to tap their resources. For example, music, art, storytelling, quilting etc. Rationale: Expressive arts are framework for identifying personal strengths (Kozier, 2010, pg. 1440). | 1. Client performs activities within daily limits of vital signs. 2. Based on the pain scale verbalized by client, pain medication is administered 30 minutes prior to the start of daily activity. 3. Client demonstrates changing of positions within her tolerance limits. 4. Client understands and demonstrates ROM exercises to improve her mobility. 5. Client discussed importance of activity and rest patterns to manage energy and prevent fatigue. 6. Client understands importance of exercise and looks forward to physiotherapist appointment and also does regular exercise at home as tolerated. 1. Nurse makes sure that client has all the necessary things in within reach before leaving the room. 2. Client understands importance of nutrition in reducing risk for fall and eats appropriately. 3. Client looks forward to Occupation/Physical Therapy appointments. 4. Client understands importance of exercise and also does regular exercise at home as tolerated. . Client verbalized a plan to make changes at home to ensure safety. 6. Client is aware of potential risk for falls and keeps home clutter free and safe. 1. Client seems positive about her life talking to health care team. 2. Client socializes with other people on the floor and looks forward to any recreational activity. 3. Client sets target to finish some part of her magazines and puzz les book before a certain time of day like before breakfast or lunch comes. 4. Client understands and verbalizes the improvement in her health rather than her initial diagnosis. 5. Client makes plans to meet with family and friends every one or two week as per everyone convenience. 6. Client keeps herself occupied either by reading books, watching TV, listening to music or knitting etc. | References (Day,R. A. , Paul, P. ,Willaims, B. , Smeltzer, S. C. , Bare, B. (2010). Textbook of Canadian Medical-Surgical Nursing (pp. 982-983). Williams Wilkins. White, L. (2005). Foundations of nursing. Australia United States Clifton Park, NY: Delmar Learning. Carpenito-Moyet, L. J. (2008). Nursing care plans documentation, nursing diagnoses and collaborative problems. 5 ed. ). Philadelphia, PA: Lippincott Williams Wilkins. Ackley, B. J. , Ladwig, G. B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed. ). St. Louis: Mosby Elsevier. Kozier, B. , Erb, G. , Berman, A. , Synder, S. , Bouchal, S. R. , Hirst, S. (2010). Fundamentals of canadian nursing, concepts, process and practice. (2 ed. ). Toronto: Pearson Canada. Gulanick, M. , Myer s, J. L. (2010). Nursing care plans, diagnoses, interventions, and outcomes. (7 ed. ). PA: Mosby. How to cite Nursing Care Plan, Essay examples Nursing Care Plan Free Essays ASSOCIATE DEGREE NURSING NURSING PROCESS FORM: PART I – ASSESSMENT Student: Date of Care: 3/4/13 Client’s Initial: WB Room # 1011 Occupation: Teacher Age: 59 Sex: F Race: Black Religion: Christian Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband Stage in Life Cycle: Generativity vs. StagnationSurgery date(s) this admission: N/A Chief complaint: Brain Dysfunction/Traumatic, closed injury Admission Diagnosis: Post Blunt Force (Head) Trauma Additional Diagnosis: Type 2 DM; HTN; DM related Neuropathy Past Medical/Surgical History (dates) 11/29/10 Dx w/ Pancreatitis Hep B Current Medical History: 59 y/o female AA pt w/ PMH of Type 2 DM; HTN; DM related Neuropathy, suffering from closed injury head trauma caused by basketball hoop and backboard falling on her head. A CAT scan of her head cervical spine came back negative for fractures. We will write a custom essay sample on Nursing Care Plan or any similar topic only for you Order Now She was scheduled for DC from ED but b/c of her ? vision; gait problems; and persistent headache, she was admitted to West Towerfor inpatient rehab and continued med evaluation. Psycho-Social History: No Hx of tobacco, alcohol or illicit drug use. Lives in own one-story home. Widowed for 5 yrs. Has 25 yrs as a school teacher, Has family support (daughters). NURSING PROCESS FORM: PART I PATHOPHYSIOLOGY OF CURRENTDIAGNOSIS FROM TEXTBOOK Diagnosis and Definition of Diagnosis: Dx: Post Blunt Force (Head) Trauma Definition: a usually serious injury caused by a blunt object or collision with a blunt surface (as in a vehicle accident or fall from a building) Etiology: While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma. Motor vehicle accidents account for almost half of the TBIs in the United States, and in suburban/rural settings, they account for most TBIs. In cities with populations greater than 100,000, assaults, falls, and penetrating trauma are more common etiologies of head injury. The male-to-female ratio for TBI is nearly 2:1, and TBI is much more common in persons younger than 35 years. Diagnostic Procedures: The physical examination and the history of the exact details of the injury are the first steps in caring for a patient with head injury. The patient’s past medical history and medication usage will also be important factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is more important to assess brain function than to look at the bones that surround the brain. Plain X-ray films may be considered in infants to look for a fracture, depending upon the clinical situation. Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and patients suffering axonal shear injury may be comatose with a normal CT scan of the head. Numerous guidelines exist to give direction as to when a CT should be completed in patients who present awake after sustaining a minor head injury. The Ottawa CT head rules apply to patients age 2 to 65. High Risk †¢Glasgow Coma Scale less than 15, two hours after injury ? †¢Suspect open or depressed skull fracture ? †¢Sign of basilar skull fracture ? †¢Vomiting more than once ? †¢Older than 65 years of age Medium Risk †¢Amnesia before impact greater than 30 minutes? †¢Dangerous mechanism of injury Signs, Symptoms, and Course of the Disease/Disorder: It is important to remember that a head injury can have different symptoms and signs, ranging from a patient experiencing no initial symptoms to coma. A high index of suspicion that a head injury may exist is important, depending upon the mechanism of injury and the initial symptoms displayed by the patient. Being unconscious, even for a short period of time is not normal. Prolonged confusion, seizures, and multiple episodes of vomiting should be signs that prompt medical attention is needed. In some situations, concussion-type symptoms can be missed. Patients may experience difficulty concentrating, increased mood swings, lethargy or aggression, and altered sleep habits among other symptoms. Medical evaluation is always wise even well after the injury has occurred. Treatment and Prognosis: The treatment of head injury may be divided into the treatment of closed head injury and the treatment of penetrating head injury. While significant overlap exists between the treatments of these 2 types of injury, some important differences are discussed. Closed head injury treatment is divided further into the treatment of mild, moderate, and severe head injuries. Mild head injury Most head injuries are mild head injuries. Most people presenting with mild head injuries will not have any progression of their head injury; however, up to 3% of mild head injuries progress to more serious injuries. Mild head injuries may be separated into low-risk and moderate-risk groups. Patients with mild-to-moderate headaches, dizziness, and nausea are considered to have low-risk injuries. Many of these patients require only minimal observation after they are assessed carefully, and many do not require radiographic evaluation. These patients may be discharged if a reliable individual can monitor them. Patients who are discharged after mild head injury should be given an instruction sheet for head injury care. The sheet should explain that the person with the head injury should be awakened every 2 hours and assessed neurologically. Caregivers should be instructed to seek medical attention if patients develop severe headaches, persistent nausea and vomiting, seizures, confusion or unusual behavior, or watery discharge from either the nose or the ear. Patients with mild head injuries typically have concussions. A concussion is defined as physiologic injury to the brain without any evidence of structural alteration. Concussions are graded on a scale of I-V. A grade I concussion is one in which a person is confused temporarily but does not display any memory changes. In a grade II concussion, brief disorientation and anterograde amnesia of less than 5 minutes’ duration are present. In a grade III concussion, retrograde amnesia and loss of consciousness for less than 5 minutes are present, in addition to the 2 criteria for a grade II concussion. Grade IV and grade V concussions are similar to a grade III, except that in a grade IV concussion, the duration of loss of consciousness is 5-10 minutes, and in a grade V concussion, the loss of consciousness is longer than 10 minutes. As many as 30% of patients who experience a concussion develop postconcussive syndrome (PCS). PCS consists of a persistence of any combination of the following after a head injury: headache, nausea, emesis, memory loss, dizziness, diplopia, blurred vision, emotional lability, or sleep disturbances. Fixed neurologic deficits are not part of PCS, and any patient with a fixed deficit requires careful evaluation. PCS usually lasts 2-4 months. Typically, the symptoms peak 4-6 weeks following the injury. On occasion, the symptoms of PCS last for a year or longer. Approximately 20% of adults with PCS will not have returned to full-time work 1 year after the initial injury, and some are disabled permanently by PCS. PCS tends to be more severe in children than in adults. When PCS is severe or persistent, a multidisciplinary approach to treatment may be necessary. This includes social services, mental health services, occupational therapy, and pharmaceutical therapy. After a mild head injury, those displaying persistent emesis, severe headache, anterograde amnesia, loss of consciousness, or signs of intoxication by drugs or alcohol are considered to have a moderate-risk head injury. These patients should be evaluated with a head CT scan. Patients with moderate-risk mild head injuries can be discharged if their CT scan findings reveal no pathology, their intoxication is cleared, and they have been observed for at least 8 hours. Moderate and severe head injury The treatment of moderate and severe head injuries begins with initial cardiopulmonary stabilization by ATLS guidelines. The initial resuscitation of a patient with a head injury is of critical importance to prevent hypoxia and hypotension. In the Traumatic Coma Data Bank study, patients with head injury who presented to the hospital with hypotension had twice the mortality rate of patients who did not present with hypotension. The combination of hypoxia and hypotension resulted in a mortality rate 2. 5 times greater than if neither of these factors was present. Once a patient has been stabilized from the cardiopulmonary standpoint, evaluation of their neurologic status may begin. The initial GCS score provides a classification system for patients with head injuries but does not substitute for a neurologic examination. After assessment of the coma score, a neurologic examination should be performed. If a patient has received muscle relaxants, the only neurologic response that may be evaluated is the pupillary response. After a thorough neurologic assessment has been performed, a CT scan of the head is obtained. The results of the CT scan help determine the next step. If a surgical lesion is present, arrangements are made for immediate transport to the operating room. Fewer than 10% of patients with TBI have an initial surgical lesion. Although no strict guidelines exist for defining surgical lesions in persons with head injury, most neurosurgeons consider any of the following to represent indications for surgery in patients with head injuries: extra-axial hematoma with midline shift greater than 5 mm, intra-axial hematoma with volume greater than 30 mL, an open kull fracture, or a depressed skull fracture with more than 1 cm of inward displacement. In addition, any temporal or cerebellar hematoma that is larger than 3 cm in diameter is considered a high-risk hematoma because these regions of the brain are smaller and do not tolerate additional mass as well as the frontal, parietal, and occipital lobes. These high-risk temporal and cerebellar hematomas are usually evacuated immediately If no surgical lesion is present on the CT scan image, or following surgery if one is present, treatment of the head injury begins. The first phase of treatment is to institute general measures. Once appropriate fluid resuscitation has been completed and the volume status is determined to be normal, intravenous fluids are administered to maintain the patient in a state of euvolemia or mild hypervolemia. A previous tenet of head injury treatment was fluid restriction, which was believed to limit the development of cerebral edema and increased ICP. Fluid restriction decreases intravascular volume and, therefore, decreases cardiac output. A decrease in cardiac output often results in decreased cerebral flow, which results in decreased brain perfusion and may cause an increase in cerebral edema and ICP. Thus, fluid restriction is contraindicated in patients with TBI. Another supportive measure used to treat patients with head injuries is elevation of the head. When the head of the bed is elevated to 20-30 °, the venous outflow from the brain is improved, thus helping to reduce ICP. If a patient is hypovolemic, elevation of the head may cause a drop in cardiac output and CBF; therefore, the head of the bed is not elevated in hypovolemic patients. In addition, the head should not be elevated (1) in patients in whom a spine injury is a possibility or (2) until an unstable spine has been stabilized. Sedation is often necessary in patients with traumatic injury. Some patients with moderate head injuries have significant agitation and require sedation. In addition, patients with multisystem trauma often have painful systemic injuries that require pain medication, and many intubated patients require sedation. Short-acting sedatives and analgesics should be used to accomplish proper sedation without eliminating the ability to perform periodic neurologic assessments. This requires careful titration of medication doses and periodic weaning or withholding of sedation to allow periodic neurologic assessment. Intravenous lidocaine administered along with rapid sequence induction before endotracheal intubation is not associated with significant hemodynamic changes in traumatic brain injury patients. [9] The use of anticonvulsants in patients with TBI is a controversial issue. No evidence exists that the use of anticonvulsants decreases the incidence of late-onset seizures in patients with either closed head injury or TBI. Temkin et al demonstrated that the routine use of Dilantin in the first week following TBI decreases the incidence of early-onset (within 7 d of injury) seizures but does not change the incidence of late-onset seizures. [10] In addition, the prevention of early posttraumatic seizures does not improve the outcome following TBI. Therefore, the prophylactic use of anticonvulsants is not recommended for more than 7 days following TBI and is considered optional in the first week following TBI. After instituting general supportive measures, the issue of ICP monitoring is addressed. ICP monitoring has consistently been shown to improve outcome in patients with head injuries. ICP monitoring is indicated for any patient with a GCS score less than 9, any patient with a head injury who requires prolonged deep sedation or pharmacologic relaxants for a systemic condition, or any patient with an acute head injury who is undergoing extended general anesthesia for a nonneurosurgical procedure. ICP monitoring involves placement of an invasive probe to measure the ICP. Unfortunately, noninvasive means of monitoring ICP do not exist, although they are under development. ICP may be monitored by means of an intraparenchymal monitor, an intraventricular monitor (ventriculostomy), or an epidural monitor. These devices measure ICP by fluid manometry, strain-gauge technology, or fiberoptic technology. Intraparenchymal ICP monitors are devices that are placed into the brain parenchyma to measure ICP by means of fiberoptic, strain-gauge, or other technologies. The intraparenchymal monitors are very accurate; however, they do not allow for drainage of CSF. Epidural devices measure ICP via a strain-gauge device placed through the skull into the epidural space. This is an older form of ICP measurement and is rarely used today because the other technologies available are more accurate and more reliable. A ventriculostomy is a catheter placed through a small twist drill hole into the lateral ventricle. The ICP is measured by transducing the pressure in a fluid column. Ventriculostomies allow for drainage of CSF, which can be effective in decreasing the ICP. A risk of symptomatic hemorrhage exists with entriculostomy placement, and Bauer et al report from a retrospective study that an international normalized ratio (INR) of 1. 2-1. 6 is an acceptable range for emergent ventriculostomy placement in patients with TBI. [11] Once an ICP monitor has been placed, ICP is monitored continuously. No absolute value of ICP exists for which treatment is implemented automatically. In adults, the reference range of ICP is 0-15 mm Hg. The normal ICP wavef orm is a triphasic wave, in which the first peak is the largest peak and the second and third peaks are progressively smaller. When intracranial compliance is abnormal, the second and third peaks are usually larger than the first peak. In addition, when intracranial compliance is abnormal and ICP is elevated, pathologic waves may appear. Lundberg described 3 types of abnormal ICP waves, A, B, and C waves. [12] Lundberg A waves, known as plateau waves, have a duration of 5-20 minutes and an amplitude of 50 mm Hg over the baseline ICP. After an episode of A waves dissipates, the ICP is reset to a baseline level that is higher than when the waves began. Lundberg A waves are a sign of severely compromised intracranial compliance. The rapid increase in ICP caused by these waves can result in a significant decrease in CPP and may lead to herniation. Lundberg B waves have a duration of less than 2 minutes, and they have an amplitude of 10-20 mm Hg above the baseline ICP. B waves are also related to abnormal intracranial compliance. Because of their smaller amplitude and shorter duration, B waves are not as deleterious as A waves. C waves, known as Hering-Traube waves, are low-amplitude waves that may be superimposed on other waves. They may be related to increased ICP; however, C waves can also occur in the setting of normal ICP and compliance. When treating elevated ICP, remember that the goal of treatment is to optimize conditions within the brain to prevent secondary injury and to allow the brain to recover from the initial insult. Maintaining ICP within the reference range is part of an approach designed to optimize both CBF and the metabolic state of the brain. Treatment of elevated ICP is a complex process that should be tailored to each particular patient’s situation and should not be approached in a â€Å"cookbook† manner. Many potential interventions are used to lower ICP, and each of these is designed to improve intracranial compliance, which results in improved CBF and decreased ICP. Acute treatment of increased intracranial pressure The Monro-Kellie doctrine provides the framework for understanding and organizing the various treatments of elevated ICP. In patients with head injuries, the total intracranial volume is composed of the total volume of the brain, the CSF, intravascular blood volume, and any intracranial mass lesions. The volume of one of these components must be reduced to improve intracranial compliance and to decrease ICP. The discussion of the different treatments of elevated ICP is organized according to which component of intracranial volume they affect. The first component of total intracranial volume to consider is the blood component. This includes all intravascular blood, both venous and arterial, and comprises approximately 10% of total intracranial volume. Elevation of the head increases venous outflow and decreases the volume of venous blood within the brain. This results in a small improvement in intracranial compliance and, therefore, has only a modest effect on ICP. The second component of intracranial vascular volume is the arterial blood volume. Hypocapnia is capable of reducing cerebral blood flow 4% for each mm Hg change in PaCO2. The control mechanism is probably extravascular pH changes in fluid bathing cerebral resistor vessels, which alter smooth muscle intracellular calcium concentrations. This may be reduced by mild-to-moderate hyperventilation, in which the PCO2 is reduced to 30-35 mm Hg. This decrease in PCO2 causes vasoconstriction at the level of the arteriole, which decreases blood volume enough to reduce ICP. The effects of hyperventilation have a duration of action of approximately 48-72 hours, at which point the brain resets to the reduced level of PCO2. This is an important point because once hyperventilation is used, the PCO2 should not be returned to normal rapidly. This may cause rebound vasodilatation, which can result in increased ICP. Below a PaCO2 of 25-30 Torr, CBF falls much less rapidly, presumably because of severe enough vasoconstriction to induce hypoxemia in brain tissues, limiting oxygen delivery. PaCO2 tensions less than 25 Torr are sufficient to change brain metabolism into anaerobic, which increases acidosis. Low arterial O2 tensions influence CBF but to a lesser degree than PaCO2. No measurable changes in CBF occur during hypoxemia until the PaO2 drops below 50 Torr, at which time CBF gradually increases. In addition to reducing CBF, the resultant respiratory alkalosis may reverse local tissue acidosis, which develops in cerebral edema, benefiting cellular respiration and restoring autoregulation. Within 48-72 hours, renal mechanisms for handling bicarbonate excretion compensate for altered PaCO2 tensions, thereby normalizing cerebral pH and returning CBF to baseline values. There are 3 paradoxes to hyperventilation therapy for the control of ICP. †¢Since cerebral vasospasm is a serious concern in subarachnoid hemorrhage (SAH), attempts to create further vessel constriction by hyperventilation in order to decrease concomitant cerebral edema are rarely indicated unless the amount of edema is clinically emergent. †¢Vessels in the damaged area of the brain have lost their autoregulatory control. While unaffected brain regions would vasoconstrict normally to the stimulus of decreased PaCO2, damaged areas might vasodilate in response to diminished cerebral blood flow. This can create a â€Å"reverse steal† phenomenon, where blood and nutrients are diverted away from â€Å"normal† areas of the brain and into â€Å"damaged† areas. This diversion would feed the increased metabolic requirement of damaged tissues, but the sum total effect may cause more harm to the rest of the brain. In addition, the increased hydrostatic pressure combined with the capillary permeability damage might, in some cases, paradoxically increase ICP in damaged areas. †¢Sudden increases in PaCO2, as a result of ventilator changes, often result in dramatic increases in CBF, and rapid deteriorations in the patient’s condition. During hyperventilation, the cerebral bicarbonate level gradually adjusts to offset the lower level of CO2, maintaining normal pH. If the pCO2 is allowed to rise suddenly, the excess CO2 rapidly crosses the blood-brain barrier, but the bicarbonate level in the brain increases much less rapidly. The result is cerebral acidosis, with attendant cerebral vascular dilatation, increased cerebral blood volume, and elevated ICP, usually resistant to further hyperventilation. Unfortunately, little objective evidence exists that treatment by hypocapnia has significantly improved mortality or survival. At best, it seems to be a temporary stop-gap measure until some other curative measure, such as surgery, might be attempted. Patients with the most prompt response to hyperventilation generally have the best prognosis for recovery. No evidence exists that hyperventilation therapy produces benefit in hypoxemic-anoxic encephalopathy. CSF represents the third component of total intracranial volume and accounts for 2-3% of total intracranial volume. In adults, total CSF production is approximately 20 mL/h or 500 mL/d. In many patients with TBI who have elevated ICP, a ventriculostomy may be placed and CSF may be drained. Removal of small amounts of CSF hourly can result in improvements in compliance that result in significant improvements in ICP. The fourth and largest component of total intracranial volume is the brain or tissue component, which comprises 85-90% of the total intracranial volume. When significant brain edema is present, it causes an increase in the tissue component of the total intracranial volume and results in decreased compliance and increased ICP. Treatments of elevated ICP that reduce total brain volume include diuretics, perfusion augmentation (CPP strategies), metabolic suppression, and decompressive procedures. Diuresis and brain edema Diuretics are powerful in their ability to decrease brain volume and, therefore, to decrease ICP. Mannitol, an osmotic diuretic, is the most common diuretic used. Mannitol is a sugar alcohol that draws water out from the brain into the intravascular compartment. It has a rapid onset of action and a duration of action of 2-8 hours. Mannitol is usually administered as a bolus because it is much more effective when given in intermittent boluses than when used as a continuous infusion. The standard dose ranges from 0. 25-1 g/kg, administered every 4-6 hours. Because mannitol causes significant diuresis, electrolytes and serum osmolality must be monitored carefully during its use. In addition, careful attention must be given to providing sufficient hydration to maintain euvolemia. The limit for mannitol is 4 g/kg/d. At daily doses higher than this, mannitol can cause renal toxicity. Mannitol should not be given if the patient’s serum sodium level is greater than 145 or serum osmolality is greater than 315 mOsm. Other diuretics that sometimes are used in patients with TBI include furosemide, glycerol, and urea. Mannitol is preferred over furosemide because it tends to cause less severe electrolyte imbalances than a loop diuretic. Interestingly, mannitol and furosemide have a synergistic effect when combined; however, this combination tends to cause severe electrolyte disturbances. Urea and glycerol have also been used as osmotic diuretics. Both of these compounds are smaller molecules than mannitol and, as a result, tend to equilibrate within the brain sooner than mannitol; therefore, they have a shorter duration of action than mannitol. Urea has the additional problem that it can cause severe skin sloughing if it infiltrates into the skin. Hypertonic saline (3%) has generated some interest in the treatment of intracranial hypertension secondary to brain edema because it is thought to be less disruptive to fluid and electrolyte balance than other diuretic agents. Boluses of mannitol can generate a dramatic diuresis, resulting in rapid intravascular depletion and potential kidney damage. Mannitol can cause as much as 1500 cc of fluid to diurese in the space of 2 hours, as intravascular fluid depletion occurs, hematocrit can rise, blood viscosity can increase, and cloning is enhanced. This makes the area of brain irritation much more amenable to stroke. Saline 3% or 7. 5% administered in continuous infusion generates a more predictable and gentle osmotic flow of brain intracellular water into the interstitial space. The maximum effect occurs after the end of infusion and is visible over 4 hours. Hypertonic saline hydroxyethyl starch (HS-HES) seems to effectively lower ICP but does not increase CPP as much as does mannitol. Therapeutically, the limits of serum sodium and osmolality are in the range of 155-320. More research is needed to elucidate the exact method of action of hypertonic saline and the contraindications. Other supportive treatments While awaiting possible operative therapy, other supportive treatments are as follows: †¢Early extraventricular drainage of CSF is sometimes of value in controlling brain edema if there is a suspicion that the ventricles will progressively diminish in size because edema cannot be cannulated from a burr hole. †¢Coughing and straining increase venous pressure, restricting drainage and backing up blood into the head, thereby increasing ICP. Neuromuscular paralysis may decrease ICP by preventing sudden changes related to coughing or straining and by promoting systemic venous pooling that increases venous drainage from the head. Any other restrictions to jugular blood drainage, such as a kinked neck from positioning in bed, increase ICP by retarding jugular drainage, transmitting pressure back into the brain. †¢Trying to differentiate a drug-induced coma from an increased ICP–induced coma with a trial of naloxone (Narcan) is contraindicated, as it invariably induces agitation if the stupor is narcotic induced. Agitation increases catecholamine response, increases cardiac output, and increases blood flow to the head, thereby increasing hydrostatic pressure and ICP. Decreased serum protein (albumin) from malnutrition causes a decreased serum osmolality compared to the osmolality in the surrounding tissues. This allows intravascular water to flow along the increased osmotic gradient into the tissues, increasing edema. Hyperalimentation should be initiated as soon as possible if the course is likely to be protracted. †¢Boutique intravenous stabilizing cocktails have been said to maintain homeost asis of intravascular and extravascular fluid compartments, avoiding rapid fluid shifts that might adversely affect cerebral metabolism and edema. Composed of an albumin, bicarbonate, and Lasix solution, the albumin increases intravascular colloid content, resisting fluid flow into the brain substance, the bicarbonate buffers pH changes, and the Lasix tends to promote a stable, consistent urine output, resisting intravascular fluid changes from renal compensations. This may be useful in diffuse brain edema to protect against further damage from vascular compartment shifts, but body physiology probably adapts to it rapidly, thereby limiting its effect. These cocktails have not been proven to be effective as a treatment of SAH since they tend to promote diuresis and intravascular depletion. †¢Use of positive end-expiratory pressure (PEEP) for mechanical ventilation is controversial in TBI patients with acute lung injury/acute respiratory distress syndrome. Zhang et al found that PEEP can have a varied impact on blood, intracranial, and cerebral perfusion pressure in patients with cerebral injury. When applying this technique, mean arterial and intracranial pressure monitoring appears beneficial. [13] Management of cerebral perfusion pressure CPP management involves artificially elevating the blood pressure to increase the MAP and the CPP. Because autoregulation is impaired in the injured brain, pressure-passive CBF develops within these injured areas. As a result, these injured areas of the brain often have insufficient blood flow, and tissue acidosis and lactate accumulation occur. This causes vasodilation, which increases cerebral edema and ICP. When the CPP is raised to greater than 65-70 mm Hg, the ICP is often lowered because increased blood flow to injured areas of the brain decreases the tissue acidosis. This often results in a significant decrease in ICP. Metabolic therapies are designed to decrease the cerebral metabolic rate, which decreases ICP. Metabolic therapies are powerful means of reducing ICP, but they are reserved for situations in which other therapies have failed to control ICP. This is because metabolic therapies have diffuse systemic effects and often result in severe adverse effects, including hypotension, immunosuppression, coagulopathies, arrhythmias, and myocardial suppression. Metabolic suppression may be achieved through drug therapies or induced hypothermia. Barbiturates are the most common class of drugs used to suppress cerebral metabolism. Barbiturate coma is typically induced with pentobarbital. A loading dose of 10 mg/kg is administered over 30 minutes, and then 5 mg/kg/h is administered for 3 hours. A maintenance infusion of 1-2 mg/kg/h is begun after loading is completed. The infusion is titrated to provide burst suppression on continuous electroencephalogram monitoring and a serum level of 3-4 mg/dL. Typically, the barbiturate infusion is continued for 48 hours, and then the patient is weaned off the barbiturates. If the ICP again escapes control, the patient may be reloaded with pentobarbital and weaned again in several days. Hypothermia may also be used to suppress cerebral metabolism. The use of mild hypothermia involves decreasing the core temperature to 34-35 °C for 24-48 hours and then slowly rewarming the patient over 2-3 days. Patients with hypothermia are also at risk for hypotension and systemic infections. Another treatment that may be used in patients with TBI with refractory ICP elevation is decompressive craniectomy. In this surgical procedure, a large section of the skull is removed and the dura is expanded. This increases the total intracranial volume and, therefore, decreases ICP. Which patients benefit from decompressive craniectomy has not been established. Some believe that patients with refractory ICP elevation who have diffuse injury but do not have significant contusions or infarctions will benefit from decompressive craniectomy. Management of elevated ICP involves using a combination of treatments. Each patient represents a slightly different set of circumstances, and treatment must be tailored to each patient. Although no rigid protocols have been established for the treatment of head injury, many published algorithms provide treatment schemas. The American Association of Neurologic Surgeons published a comprehensive evidence-based review of the treatment of TBI, called the Guidelines for the Management of Severe Head Injury. In these guidelines, 3 different categories of treatments, standards, guidelines, and options are outlined. Standards are the accepted principles of management that reflect a high degree of clinical certainty. Guidelines are a particular strategy or a range of management options that reflect a high degree of clinical certainty. Options are strategies for patient management for which clinical certainty is unclear. Prognosis: The outcome of TBI is related to the initial level of injury. While the initial GCS score provides a description of the initial neurologic condition, it does not correlate tightly with outcome. Various methods have been used in an attempt to predict the outcome of TBI, and these are beyond the scope of this discussion. However, one simplified model uses 3 factors, that is, age, motor score of the GCS, and pupillary response (ie, normal, unilateral unresponsive pupil, bilateral unresponsive pupils), to provide a probability of outcome. The Traumatic Coma Data Bank analyzed 780 patients with head injuries and identified 5 factors that correlated with a poor outcome, as follows: (1) age older than 60 years, (2) initial GCS score of less than 5, (3) presence of a fixed dilated pupil, (4) prolonged hypotension or hypoxia early after injury, and (5) presence of a surgical intracranial mass lesion. An examination of the Crash Injury Research Engineering Network database found a significantly higher mortality rate among elderly motor vehicle accident victims (age 60 years) compared to their younger counterparts. 15] Many methods exist for evaluating the outcome of TBI. A simple and commonly used method is the Glasgow outcome scale. This divides outcome into 5 categories, as follows: (1) good, (2) moderate disability, (3) severe disability, (4) vegetative, and (5) dead. The scale can be divided further into good outcomes (eg, good plus moderate disability) and poor outcomes (eg, severe disability, vegetative, dead). Refere nce (with page numbers, should be in the last 5 years and must be from a med-surgical textbook): Crippen, D. W. (2011, September 26). Head trauma treatment management. Retrieved from http://emedicine. medscape. com/article/433855-treatment WORKSHEET INFORMATION Description *Vital signs frequency: 3/3/13, 1220: pain 6/10; BP 136/67; HR 63; Temp 97. 4 F/36. 3 C; Resp 18bpm; SpO2 97% 3/4/13, 0900: pain 0/10; BP 142/70; HR 62; Temp 97. 2 F/36. 2 C; Resp 17bpm; SpO2 97%; pre-brkfst glucose 103 Weight 118 Kg/BMI 40. 9 *IO (not charted) Intake this shift 3/4/13: 3-6 oz. cups of water = 540mL; 2-4 oz. cups of tea = 240mL; 1-6 oz. cup of juice = 180mL; Total of 960mL; Avg. 120mL/hr *Urinary Elimination Continent, (not charted) *Bowel Elimination Continent, LBM was 3/3/13 NG tube N/A *Diet Lo Cal 1800, Diabetic *Positioning or Turn self w/ bedrails and mod assist *Bath Type self w/ mod assist of bed transfer and gaiting *Activity Level gaiting 30 ft w mod assist Dressing Change/Site N/A Orthopedic Device/Care N/A Scheduled Procedures CT Scan (head) 3/3/13 O2 at L/Min via: Room Air I. V. Fluid Type N/A I. V. Site/rate (Hep Lock IV) N/A *Allergies NKA Code Status Full Isolation Status None Standard Precaution *Required Critical Information NURSING PROCESS FORM: PART I – REVIEW OF SYSTEMS/NURSING HEALTH Subjective and Objective Data General Appearance (Posture, expression, first impressions) Pt is obese (BMI 40. 9) AA female, grooming appropriate, sitting up in wheelchair, is responsive and has a pleasant manner, getting ready to eat brkfst, I feel the pt has some anxiety as she stated â€Å"I am worried about my injury and if I can go back to work. I think I may have to retire. † Neurological (pain and its perception, last hearing or visual check, LOC, papillary response, signs of conduction deficits, speech pattern, orientation): Pain 0/10 but pt states â€Å"I have a headache whenever my pain medication wears off. Pt can’t remember last visual but she is wearing an ordered eye patch for her diplopia blurred vision; Pt can’t remember last hearing check but no sign of hearing impairment while talking to pt; GCS (15) E-4, V-5, M-6; Orientation positive to person, place, day; PERRLA; Speech pattern normal; Musculo-skeletal (mobility, safety, range of motion, atrophy or edema, prosthetic): Mobility w/ mod assist; Transfers w/ mod assist; Gaiting w/ mod assist from two attendants; ? ROM and muscle weakness R-side extremities; Edema R ankle +3 pitting; no atrophy; no prosthetics; Cardiovascular (rate, rhythm, quality of pulses, PMI, capillary refill, bedside monitoring device, 12 Lead ECG report): HR 67; Rhythm regular; Radial pulse +3, Dorsalis +1; BP 124/74 L upper arm; Cap refill 3 sec. ; no bedside monitoring; Pulmonary (tobacco history, shortness of breath, breath sounds, rate, rhythm, cough): No tobacco, mild SOB; Breath sounds clear; Rate 17 bpm; Rhythm even; No cough; Gastrointestinal (bowel sounds, appetite, weight gained or lost, elimination pattern, nutritional supplements, date of last bowel movement): Normal bowel sounds x4 quads; appetite good (intake 100% of brkfst lunch); elimination pattern continent LBM 3/3/13; Lo Cal 1800 diet diabetic diet; Reproductive (last breast or testicular self-examination, mammogram, pelvic or prostate exam, LMP, pain): N/A Endocrine (diagnosed at what age, last HgbA1c or associated lab work): DM type 2 Dx’ed at 41 y/o; glucose finger-stick pre-brkfst 103, pre-lunch 113, no glucose required. EENT (eyes, nose or sinus problems, swallowing difficulties, dental or oral problems) Blurred vision LR eyes diplopia; hearing slight ringing x2; had some epistaxis upon admission to ED on 3/1/13 but not in last 24 hrs; no difficulty swallowing; no dental or oral problems; Renal (current urinalysis, urinary devices, voiding pattern, urgency, burning, pain, etc. ): No urinalysis; no urinary devices; voiding pattern continent, no urinary retention; no urgency, burning, or pain; IO’s not charted; Integumentary (skin undertone, turgor, edema, temperature, etc. ): Skin warm dry; no lesions; tugor good How to cite Nursing Care Plan, Essay examples Nursing Care Plan Free Essays Health ProblemFamily Nursing ProblemsGoal of CareObjectives of CareIntervention Plan Nursing InterventionsRationaleMethod of Nurse-Family ContactEvaluation Unhealthful lifestyle and personal habits specifically cigarette smoking as a health threat. 1. Inability to recognize the presence of the problem due to Inadequate knowledge 2. We will write a custom essay sample on Nursing Care Plan or any similar topic only for you Order Now Inability to make decisions with respect to taking appropriate health action due to fear of consequences of action, specifically physical consequences 3. Inability to provide adequate nursing care to the at-risk member of the family due to: A. Inadequate knowledge about the disease or health condition B. Lack of the necessary facilities, equipment and supplies for care 4. Inability to provide a home environment conducive to health maintenance due to lack of knowledge of preventive measures 5. Failure to utilize community resources for health care due to inadequate knowledge of community resources for health care After nursing intervention, Rusty Cacal with the help of his family members will be able to lessen the cigarettes he smokes from 10 sticks to 15 sticks a day to gradual cessation of smoking Objectives 1. After discussing the definition of cigarette smoking, the family will be able to state the meaning of cigarette smoking accurately within 3 minutes. 2. After 10 minutes of discussion, the family will be able to enumerate the components of cigarette completely in 5 minutes. 3. Given the components of cigarette, the family will be able to state at least 8 out of 11 effects of nicotine in 8 minutes. 4. Given the components of cigarette, the family will be able to state the effects of tar completely in 5 minutes 5. After discussing the effects of nicotine and tar, the family will be able to distinguish the effects of addiction in cigarette smoke within 5 minutes. 6. After 15 minutes of discussion, the family will be able to discuss 7 out of 9 management on how to reduce the # of cigarette smoked per day within 8 minutes. 7. Given a sample of a time table, the family will be able to formulate a schedule on the reduction of # of sticks of cigarette smoked per day within 20 minutes. 8. In a day-to-day basis, the clients will be able to practice the formulated schedule plan in 1 month and 2 weeks. Developmental 1. The health care provider will discuss the meaning of cigarette smoking. 2. The health care provider will enumerate the components of cigarette. 3. The health care provider will discuss the effects of nicotine. 4. The health care provider will discuss the effects of tar. 5. The health care provider will distinguish the effects of addiction in cigarette smoking. 6. The health care provider will discuss the different management on how to reduce the # of cigarette smoked per day 7. The health care provider will provide a sample of a time table. She will guide the client in formulating her schedule for 1 month 8. The HCP will monitor the clients’ compliance to the formulated schedule 1. Discussing the meaning of cigarette smoking will enable the clients to have a wide understanding about this habit and be aware that smoking contributes significantly to diseases that shortens life and is leading cause of death like heart attack, stroke, respiratory diseases which make smokers â€Å"pulmonary cripples† as in asthma, emphysema, bronchitis, recurrent infections, and cancer. *Ref: http://doh. gov. ph/tobacco/aboutsmoking. tm 2. Discussing the components of cigarettes will enable the clients to be aware of the possible effects of the listed components *Ref: http://www. knowledgebasescript. com/ emo/article-393. html 3. Discussing the effects of nicotine will enable the clients to know the medical consequences of nicotine exposure *Ref: Psychology Today Staff Originally published by Psychology Today:2002/10/10 4. Disc ussing the effects of tar will enable the clients to know how it affects their respiratory tract. *Ref: Janice A. Dye and Kenneth B. Adler; http://www. pubmedcentral. nih. ov/pagerender. fcgi? artid=475133 pageindex=1#page 5. Discussing the effects of smoking addiction give the conclusion that there are many health effects of smoking cigarettes products and not one of them are beneficial. It’s not an exaggeration; it is reality that smoking tobacco does unquestionably not only destroy client’s well being but also health of acquaintances and family around her. *Ref: Winn, Jackie (2008), â€Å"No Positive Effects From Smoking Can Be Found†. September 28, 2008, from http://ezinearticles. com/? No-Positive-Effects-From-Smoking-Can-Be-Foundid=1290284 6. Discussing the different management on how to reduce the use of cigarette smoke per day increases quit rates by 30 percent. Every person who uses cigarettes should be offered at least brief advice to quit smoking. More intensive counseling and medications are even more effective and should be provided to all cigarette users willing to use them. *Ref:CORINNE G. HUSTEN, ABBY C. ROSENTHAL, MICAH H. MILTON, The Gale Group Inc. , Macmillan Reference USA, New York, Gale Encyclopedia of Public Health, 2002 7. Providing sample time table will help the clients to guide the client in making a checklist or schedule on reducing and quitting smoking. Ref: The lung Asssociation; http://www. lung. ca/protect-protegez/tobacco-tabagisme/quitting-cesser/how-comment_e. php#list 8. Monitoring clients’ compliance to the formulated schedule will able the clients to apply their schedule and reduce the number of cigarettes thrysmoked per day *Ref:http://www. healthline. com/adamcontent/smoking-tips-o n-how-to-quit? utm_source=z_smoking_cessationutm_medium=googleutm_campaign=adamutm_term=how%20to%20quit%20smoking Home VisitEffectiveness: 1. Was the family able to define cigarette smoking? Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? __ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 2. Was the family able to enumerate the components of cigarette? Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? __ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 3. Was the family able to discuss the effects of nicotine Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? __ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 4. Was the family able to discuss the effects of tar Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? __ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 5. Was the family able to discuss the effects of addiction in cigarette smoking? Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? _ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 6. Was the family able to discuss the different management on how to reduce the # of cigarette smoked per day Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ Why no? __ Adequacy : Was the no. of intervention sufficient? Yes__ No__ Why no? __ Appropriateness: Was the no. of intervention, setting, time table, realistic to client situation? Yes__ No__ Why no? __ Acceptability: Was the intervention suitable to client situation? Yes__ No__ Why no? __ Effectiveness: 7. Was the family able to formulate a schedule on the reduction of # of sticks of cigarette smoked per day Yes__ No__ Why? Efficiency: Was the time, materials, human resources used economically? Yes__ No__ How to cite Nursing Care Plan, Papers

Importance of Debt Management-Free-Samples-Myassignmenthelp.com

Question: How debt management will improve the expected profit of the Commonwealth Bank. Answer: Introduction In the modern world, management of debt has been one of the key issues for the organizations that are performing in the global economy. The debt management is helpful in determining the level of profit for any organization. In the current aspect to time, the basis of finance is the initial step in the functioning of an organization or business. The basic and the fundamental financial source are inclusive of equity and debt financing which is even called the capital structure of financing (De Jonghe, ztekin 2015). In accordance to equity financing, the common fund can be increased by issuing the Initial Public Offering (IPO) to the common people and the issuance of the ordinary shares. On the other hand, debt is explained as the agreement among two parties where the borrower has to assure to make payments of certain amount of interest with the treaty to make payment for the principle value in the coming future (De Mooij, Keen 2016). The process of debt financing is regarded as a key aspect of the financial strategy of the organization because of the fact that debt are of numerous kinds that includes the issuing of the bonds, debentures, trade credits and loans etc. On the other hand, profit is explained as the financial advantage or the rewards that have been achieved when the revenue value is more than the costs of the business operations. As the profit is associated directly with the process of decision making of an organization and therefore has an effect on the selection of the equity or debt financing (Alshatti, 2015). Problem Statement Different kinds of organisations has the option of selecting in between the equity financing and debt financing for the activities of the business which is associated directly to the growth and profit of the organization (Allegret et al., 2016). It can be explained that debt financing has the benefit over the tax savings or the tax intentions over the financing related to equity and debt financing is not a complex process with respect to the equity financing in the process of debt management and the lender is eligible only to undertake repayment of the principle of the loan that has been agreed on and additionally the rate of interest. Therefore, most of the organizations have the intention of undertaking debt financing (Alessandri, Nelson 2015). It is due to this reason that this thesis paper has looked to discuss about the management of debt variables that have an impact on the anticipated profits of the firm, the process of research planning that are going to be utilised in order to compare and compute the variables that can be exploited in order to assess the various kinds of ratios, leverage and the amount that can be used in order to undertake a comparison of the outcome in the present scenario (Bennett et al., 2015). This paper has therefore looked to determine the debt management process and its impact on profit of Commonwealth Bank of Australia. Research Aims and Objectives The objectives of the paper has been constructed in order to have an idea about the process that would be undertaken and the factors that would be taken into consideration in order to have an idea about the result that would be obtained in this paper. The research aims and objectives are as follows: Determine how profitability has an impact on the operations of a bank Ascertain how debt management improves the level of profit in the bank Research Questions The researcher looks to frame the research questions in order to create a path in accordance to which the research paper would move ahead and thereby would be able to answer to the issues that are pertinent to this research paper. The research questions are as follows: Q1. How does profitability have an impact on the activities of Commonwealth Bank? Q2. How does debt management improve the profit level of Commonwealth Bank? Literature Review The anticipated profit and the capital structure of the organizations are dependent on the numerous decisions associated with the capital structure that are undertaken by them. In the current period, several researches have been explained that capital structure has been swelling but there are empirical evidences has been key even today (Waemustafa, Sukri 2015). There have been several studies and reports that have discovered that positive tax has an impact on the extent of debt financing (Subrahmanyam et al., 2017). There has been several numbers of studies that have revealed a negative impact on of tax on the extent of leverage. Therefore, it needs the Meta assessment of the impact of marginal tax on the debt ratio (Barth et al., 2017). The tax benefit is seen to be one of the most significant pieces of information for the purpose of financial decisions in accordance to the capital structure. It is due to this fact that development in the capital structure has been suggested as a c entral principle as the companies have been making use of extreme utilisation of the debt in order to damage the level of profit for an organization. DeAngelo, Stulz (2015) have undertaken the tax advantages of debt making use of the rate of the marginal tax at various degrees of interest. As the taxable income after the subtraction of the rate of interest is lower than the past financing, the process expressed by Calomiris, Carlson (2016) has a good chance of estimating the lower rate of marginal tax than the one predicted by Ball et al., (2015). The development in the capital structure with the assistance of the debt to equity ratio will raise the profitability of the firm (Ashraf et al., 2016). The extent of debt or the debt to equity ratio themselves does not specify whether the organizations have been using increased amount of debt or not but on the other hand, the companies that are operating outside Australia has faced the transformations in the usage of debt after the fina ncial crisis in accordance to the financial decisions from the point of view of the tax advantages and costs (Van Bekkum, 2016). There have been other papers as well who have concentrated on the agency issue that has a direct impact on the capital framework of an organization (Chan-Lau et al., 2015). The agency issues come out when there is supposed to be the probability of disputes among the owners of the company and the lenders which may limit the optimal capital ability decision of the company (Panizza, Presbitero 2014). In this case, the capital investment will look to explain the agency issues with the help of debt financing. On the other hand, cost associated with bankruptcy is looked upon to be comparative to the value of liquidation of the company where the concentration is given on the assessment of the decisions of the organizations that are associated with the capital investment in accordance to the external debt financing along with the bankruptcy threats (Alshatti, 2015). Therefore, the companies will look to select the extent of optimality in order to mitigate the increased expense of borrowing and bankruptcy. But in certain scenario, the agency cost can be existent even when the estimated cost of bankruptcy is terminated. Furthermore, when the rate of the corporate tax is raised, the agency expense will reduce but the optimal level of capacity will rise with the rise in the extent of borrowing (De Jonghe, ztekin 2015). Research Methodology This segment of the research paper has the intention of revealing the process of collecting the authentic data that would the helpful in taking the paper forward and answering the issues that have been identified by the researcher previously. In order to discover the effective capital structure that is related to debt financing and equity financing that will be helpful in finding out the anticipated profit of Commonwealth Bank, the researcher has looked to collect quantitative data. Data collection process The main objective of the data gathering process has been to reveal the impact of debt management on the on the anticipated profit of Commonwealth Bank. In accordance to this research, the researcher has looked to undertake descriptive research design in order to explain the data that has been gathered by the researcher from several sources (Borisova et al., 2015). The paper has tried to collect the data with the assistance of the secondary data methods so that critical level of analysis can be attained (Black et al., 2016). In order to gather the data in an effective and swift manner, the researcher has utilised the most general methods of gaining the secondary data. This kind of data has been gathered by taking assistance of the sources like the websites and even website journals. The other sources include the journals, relevant books, and articles, reports from the governments and the annual reports of the banks that have been taken into consideration (Greenwood et al., 2015). The researcher has even taken assistance of the researches that have been taken previously by other researches in order to link them with the current researches and have a clear idea about the result that needs to be accomplished. The collection of the data with the help of these sources will be reducing cost for the researcher and thereby this method is looked upon as cost efficient. The secondary data even addresses the current concern by not taking assistance of any other sources that are available to the researcher. The information related to Commonwealth Bank and the other banks that have been selected for the assessment in this paper has even gathered from the Australian Statistics Bureau (ABS) as this website contains all the data that are associated with any organization that are functional in the Australian economy (Gomariz, Ballesta 2014). However, as this paper mainly concentrates on the financial aspects of the banks, effective level of information has been available from the annual reports of the concerned banks and thereby effective results can be attained. Data Analysis The researcher has looked to collect quantitative data as the paper is concerned with assessing the financial figures that are associated with the transactions that have taken place in Commonwealth Bank and the other banks that have been selected in order to gain the outcome that is required in order to complete the paper. The data that has been attained needs to go through several software tools in order to get the results out of them (Hasan et al., 2017). Excel software and tool has been used in order to evaluate the data and the internal aspect of the data that would explain the impact of debt management on the expected profit for Commonwealth Bank can be obtained. The leverage ratio of the selected banks will be taken into consideration in order to attain the results that are associated with the research aims and questions. Data Analysis and Findings This segment of the paper has been framed in order to have an idea about the process and the measures that have to be taken in order to critically evaluate the financial figures and break them down in an effective manner in order to have an idea about debt management and their impact on the expected profit of Commonwealth bank in Australia in comparison to the ANZ Bank and Westpac. The values that are in relation to Return on Equity, Return on Asset and the Financial Leverage have been compared of each of the banks in order to have an idea about their operational activities. The analysis has been given as follows: Descriptive Statistics Commonwealth Bank Commonwealth Bank 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Mean 13.5667 12.8667 12.4567 12.5967 12.5367 11.9533 11.9133 11.88 10.9667 10.8633 Standard Error 6.26346 6.10346 5.79784 5.81498 5.76262 5.46916 5.43391 5.40705 4.97982 4.91503 Median 19.76 17.07 17.53 18.17 17.91 16.77 16.21 16.65 15.5 15.46 Standard Deviation 10.8486 10.5715 10.0422 10.0718 9.98115 9.47287 9.4118 9.36529 8.6253 8.51309 Sample Variance 117.693 111.757 100.845 101.442 99.6234 89.7352 88.582 87.7087 74.3957 72.4726 Skewness -1.7317 -1.5064 -1.6932 -1.7276 -1.7205 -1.6965 -1.6262 -1.6974 -1.7118 -1.7214 Largest(1) 19.9 20.69 18.95 18.65 18.68 18.05 18.41 17.9 16.38 16.09 The descriptive statistics of Commonwealth Bank explain that the mean value of the bank in accordance to the variables that have been taken into consideration has their value in between 10.86 to 11.56. The values have been very close to each other. The median for the variables for the past 10 years have ranged from 15.46 to 18.17. The standard deviation on the other hand has been around 8.5 to 10.8. The figures explain that there have been slightest of changes in the financial scenario in accordance to the debt management and profitability. ANZ Bank ANZ Bank 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Mean 11.05 8.65 10.27 10.7367 10.4833 10.47 10.86 10.21 8.79 8.96667 Standard Error 5.29878 4.26738 4.72902 4.89934 4.80181 4.77838 4.93603 4.67128 4.42123 4.30678 Median 14 10.19 13.91 15.21 14.61 14.75 15.62 14.19 9.92 10.97 Standard Deviation 9.17775 7.39132 8.1909 8.4859 8.31698 8.2764 8.54946 8.0909 7.65779 7.45956 Sample Variance 84.2311 54.6316 67.0908 72.0105 69.1721 68.4988 73.0933 65.4627 58.6417 55.645 Skewness -1.297 -0.8969 -1.6048 -1.713 -1.6831 -1.7048 -1.7288 -1.678 -0.6496 -1.1214 Confidence Level(95.0%) 22.7988 18.3611 20.3473 21.0801 20.6605 20.5597 21.238 20.0989 19.023 18.5306 The values in regards to ANZ Bank indicate that the mean value has been in between 8.7 to 11.05 and the median on the other hand has been 9.92 and the highest value has been 15.62. On the other hand, the standard deviation explains that value has been in between 7.4 to 9.1. These figures have lower values in accordance to the ones that have been observed for Commonwealth Bank. Westpac Bank Westpac 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Mean 16.1467 10.27 11.5567 11.5267 10.0033 10.31 10.95 10.6933 9.57333 9.40333 Standard Error 7.61549 4.93026 5.26551 5.23509 4.57405 4.66003 4.96 4.84357 4.34745 4.23443 Median 22.86 13.12 16.19 16.02 13.87 14.94 15.91 15.3 13.38 13.37 Standard Deviation 13.1904 8.53947 9.12014 9.06745 7.92248 8.07141 8.59097 8.3893 7.53 7.33425 Sample Variance 173.987 72.9225 83.1769 82.2186 62.7657 65.1477 73.8048 70.3804 56.7009 53.7912 Skewness -1.697 -1.3346 -1.6961 -1.6824 -1.6731 -1.7319 -1.7321 -1.7259 -1.6935 -1.7219 Confidence Level(95.0%) 32.7668 21.2132 22.6557 22.5248 19.6805 20.0505 21.3412 20.8402 18.7056 18.2193 The descriptive statistics in relation to Westpac indicates that the mean value ranges from 9.4 to 16.14. The median for the financial figures of Westpac are 13.37 to 22.86 and the standard deviation has a range of 7.33 to 13.19. Correlation The process of correlation refers to the understanding of the relationship among the variables that have been taken into consideration. This paper has looked to undertake a correlation among the financial leverage and the net profit margin of the banks that have been chosen. The correlation of all the banks have been explained as follows: Commonwealth Bank Correlation -0.786950463 MSE 0.940482382 The correlation of Commonwealth bank has been constructed by taking help of the financial leverage figures and the net profit of the company. The figures indicate that the correlation is negatively correlated explaining that financial leverage and net profit margin are not associated to each other for Commonwealth Bank. The mean squared deviation has a value of 0.9404. This addresses that debt management does not improve the profit of the bank. ANZ Bank Correlation -0.156814712 MSE 1.48335 The figures for ANZ Bank has been similar to Commonwealth Bank as it is seen that the values for the past ten years are negatively correlated and the two variables are not associated to each other. The mean squared deviation of ANZ Bank comes to 1.48335 Westpac Bank Correlation -0.203415414 MSE 1.727055587 The correlation for Westpac is negatively correlated as well and thereby explaining that debt management is not having improving the level of profit for the bank. The mean squared deviation for the bank is 1.727055587. Discussion Descriptive Statistics The figures that have been attained for the three banks indicate that the performance of the banks have fallen with the advent of time for all the three banks. The fall in the leverage ratios have indicated that there has been an impact on the profit of the companies (Greenwood et al., 2015). The values of all the three banks have decreased significantly for the past 10 years and there has been an observation that out of the three banks the performance of Commonwealth Bank has been the best. The assessment therefore has been able to explain that debt management has an impact on the estimated profit and the same has been observed in the analysis of Commonwealth Bank. Correlation The values that have been obtained for the correlation analysis of all the three banks have addressed that all the variables that have been compared for the banks are not closely related to each other for all the 10 years. Westpac, ANZ Bank and Commonwealth Bank have their profit and financial leverage not associated closely to each other as the obtained value is negative. This explains that debt management may not improve the estimated profit of the banks especially in the case of Commonwealth Bank as it has the highest negative value. The outcome is positively related to the constructed literature review. Conclusion Addressing the aims and the questions The paper has been extensively able to answer the research aims and objectives as the results that have been collected explain that management of debt has the capability to improve the expected profits of a bank. The result has been able to signify that leverage may not have an impact on the profitability of Commonwealth Banks and debt management cannot improve the profit level of the banks. The results even indicate that debt management and level of profit are indirectly associated to each other and therefore steps has have been undertaken by the management of the banks to improve the level of profit. Limitation The limitation that is existent with this research paper has been that the secondary data that has been collected for the completion of the paper may not be accurate as the transactions that have been disclosed by the companies may not be true. The other limitation that has been observed is the time limitation and therefore the researcher could not construct a much better result. Recommendation Every research paper has certain aspects in accordance to which suggestions can be given in order to improve financial position of the banks and thereby improve the operational activities as well. The management of the banks can take steps in improving the debt management process of the banks with the help of which the level of profit can be enhanced. The banks can even look to undertake partnerships with other financial institutions who would look and control the debt management processes of the banks which can be effective in maintaining the profit level they desire. Reference List Alessandri, P., Nelson, B. D. (2015). Simple banking: profitability and the yield curve.Journal of Money, Credit and Banking,47(1), 143-175. Allegret, J. P., Raymond, H., Rharrabti, H. (2016). The Impact of the Eurozone Crisis on European Banks Stocks Contagion or Interdependence?.European Research Studies,19(1), 129. Alshatti, A. (2015). The effect of credit risk management on financial performance of the Jordanian commercial banks.Investment Management and Financial Innovations,12(1), 338-345. Alshatti, A. (2015). The effect of credit risk management on financial performance of the Jordanian commercial banks.Investment Management and Financial Innovations,12(1), 338-345. ANZ Personal Banking | Accounts, credit cards, loans, insurance | ANZ. (2018). Anz.com. Retrieved 5 February 2018, from https://www.anz.com Ashraf, D., Rizwan, M. S., LHuillier, B. (2016). A net stable funding ratio for Islamic banks and its impact on financial stability: An international investigation.Journal of Financial Stability,25, 47-57. Ball, R., Li, X., Shivakumar, L. (2015). Contractibility and transparency of financial statement information prepared under IFRS: Evidence from debt contracts around IFRS adoption.Journal of Accounting Research,53(5), 915-963. Barth, M. E., Gomez-Biscarri, J., Kasznik, R., Lpez-Espinosa, G. (2017). Bank earnings and regulatory capital management using available for sale securities.Review of Accounting Studies,22(4), 1761-1792. Bennett, R. L., Gntay, L., Unal, H. (2015). Inside debt, bank default risk, and performance during the crisis.Journal of Financial Intermediation,24(4), 487-513. Black, L., Correa, R., Huang, X., Zhou, H. (2016). The systemic risk of European banks during the financial and sovereign debt crises.Journal of Banking Finance,63, 107-125. Borisova, G., Fotak, V., Holland, K., Megginson, W. L. (2015). Government ownership and the cost of debt: Evidence from government investments in publicly traded firms.Journal of Financial Economics,118(1), 168-191. Calomiris, C. W., Carlson, M. (2016). Corporate governance and risk management at unprotected banks: National banks in the 1890s.Journal of Financial Economics,119(3), 512-532. Chan-Lau, J. A., Liu, E. X., Schmittmann, J. M. (2015). Equity returns in the banking sector in the wake of the Great Recession and the European sovereign debt crisis.Journal of financial stability,16, 164-172. De Jonghe, O., ztekin, . (2015). Bank capital management: International evidence.Journal of Financial Intermediation,24(2), 154-177. De Jonghe, O., ztekin, . (2015). Bank capital management: International evidence.Journal of Financial Intermediation,24(2), 154-177. De Mooij, R. A., Keen, M. (2016). Debt, taxes, and banks.Journal of Money, Credit and Banking,48(1), 5-33. DeAngelo, H., Stulz, R. M. (2015). Liquid-claim production, risk management, and bank capital structure: Why high leverage is optimal for banks.Journal of Financial Economics,116(2), 219-236. Gomariz, M. F. C., Ballesta, J. P. S. (2014). Financial reporting quality, debt maturity and investment efficiency.Journal of Banking Finance,40, 494-506. Greenwood, R., Hanson, S. G., Stein, J. C. (2015). A Comparative?Advantage Approach to Government Debt Maturity.The Journal of Finance,70(4), 1683-1722. Greenwood, R., Landier, A., Thesmar, D. (2015). Vulnerable banks.Journal of Financial Economics,115(3), 471-485. Hasan, I., Hoi, C. K., Wu, Q., Zhang, H. (2017). Social capital and debt contracting: Evidence from bank loans and public bonds.Journal of Financial and Quantitative Analysis,52(3), 1017-1047. Panizza, U., Presbitero, A. F. (2014). Public debt and economic growth: is there a causal effect?.Journal of Macroeconomics,41, 21-41. Personal banking including accounts, credit cards and home loans - CommBank. (2018). Commbank.com. Retrieved 5 February 2018, from https://www.commbank.com Subrahmanyam, M. G., Tang, D. Y., Wang, S. Q. (2017). Credit default swaps, exacting creditors and corporate liquidity management.Journal of Financial Economics,124(2), 395-414. Van Bekkum, S. (2016). Inside debt and bank risk.Journal of Financial and Quantitative Analysis,51(2), 359-385. Waemustafa, W., Sukri, S. (2015). Bank specific and macroeconomics dynamic determinants of credit risk in Islamic banks and conventional banks.International Journal of Economics and Financial Issues,5(2). Westpac.com. (2018). Westpac.com. Retrieved 5 February 2018, from https://www.westpac.co

APWH Chapter 14 Flashcard

APWH Chapter 14

SummaryCritique essays

SummaryCritique essays #___________ COURSE#_______ SECTION/TIME______ REFERENCE: Darley, J. M., , B. (1968). Bystander intervention in emergencies: Diffusion of responsibility in R. Hock (Ed.), Forty Studies That Changed Psychology (295-303). Upper Saddle, N. J.: Prentice Hall. SUMMARY: Society dictates that we take action to help others in emergency situations, but often, we do not. In the famous case of Genovese, where 38 bystanders watched a woman get brutally murdered, only one person called the police. Darley and Latane analyzed the bystanders reactions. They believed that the reason no one took steps to help Kitty Genovese was a phenomena they called diffusion of responsibility. As the number of bystanders in an emergency increases, the greater the belief that someone else will help. With 3 different groups of subjects, Darley and Latane measured the percentage of subjects in each condition who helped the alleged troubled student. They also measured the amount of time it took them to respond. After four minutes, the experiment was terminated. Their findings supported their hypothesis as the amount of delay in helping was greater when more by-standers were present. They also considered the role of social influence in the study. What was it a bout the presence of others that was so influential? Beyond their specific findings, Darley and Latanes ground-breaking research on helping behavior and diffusion of responsibility, continues to influence many studies on very topical issues. CRITIQUE: Darley and Latane contributed greatly to explaining a perplexing human behavior. Hopefully, as more people learn about the bystander effect, they will become aware of the need to act in any emergency situation, even if others are present. Research has demonstrated that when people have learned about the bystander effect, their participation level is higher in emerge ...

Law Essay Example | Topics and Well Written Essays - 250 words - 7

Law - Essay Example uring all the computers are password protected, installation of antivirus, and firewalls in all the computers at home is one of the most important facets that must be adhered to reduce this vice. In addition to this securing VIOP networks helps in controlling e-crime. On the other hand it is important to understand that e-crime can easily be detected through installation of cookies which provides information about any illegal users of the network currently in use. Although it is always difficult to detect hackers, the field of computer forensic helps in detecting this vice. Apart from the basics of computer protection like passwords and firewalls, computer forensics can detect any sound and digital information that may have been routed out or into the computer system. It is important to understand that e-crime is punishable by the federal state. According to the office of Maine AG e-crimes are felonies which are punishable by up to six months incarcerations and $ 1,000

Article critics Essay Example | Topics and Well Written Essays - 250 words

Article critics - Essay Example mization to receive 40 infusion of 500ml chelation solution or a placebo 40 infusion to an oral vitamin and chelation solution or oral placebo (Research Grant, 2012). Researchers found that patients receiving the chelation solution had fewer serious cardiovascular events than the control group 26% vs. 30%, and the trail was conducted in 134 sites in the United States and Canada from 2002-2012. However the article fails to report that there was high drop out in the placebo group than in the chelation. They were getting a placebo and the side effects of it. The Chelation group was significantly different in life outcomes measured with the assessment, as opposed to the Placebo group. According to the cnn analysis, the four percentage point difference between was â€Å"barley statistically significant†. The difference may have been by chance not because chelation actually works or they necessarily have bad side effects. The high dropout contributed to less accuracy in the study. It is less

The Role of WTO in the Liberalization of Trade Literature review

The Role of WTO in the Liberalization of Trade - Literature review Example International monetary affairs and trade are interlinked due to the fact that monetary and fiscal areas are also associated with exports and productivity growths. Integration of evolving economies into the international economy facilitates competition for capital and aid. It is evident from capital flow from expanding markets by commercial banks, private investors and multinational enterprises. The recent financial crisis has highlighted the risks involved in this process. Therefore, IMF and World Bank actively play their roles as financer or as a watchdog.WTO plays a critical role in drawing funds through trade and foreign investment liberalization. International trade is imperative for economic growth; therefore, it is essential for emerging economies to accelerate economic reforms (Hoogmartens, 2004, p.9). The fundamental objectives of WTO as well as its predecessor GATT, as Hoogmartens (2004) observes are to serve as a forum to negotiate trade liberalization, to monitor and develop better measures for transparency and to work for resolve issues between trade participants. In addition to that, the fundamental objective includes raising living standards, working towards providing full employment, production and trade expansion, and ultimately, optimal utilization of the world’s resources. In order to achieve these objectives, WTO/GATT work towards fixing or limiting the impact of trade barriers, for instance, quotas, customs process, tariffs, state trading and subsidies in addition to paving the way for trade liberalization(p.10). Hoogmartens (2004) further states, â€Å"Tariffs are generally believed to distort competition and to attribute monopoly rents to producers in countries that uphold them. Quotas are also believed to distort competition, but usually, do not yield more p rofit for domestic producers. Furthermore, their administration may yield corruption, just as discriminatory licensing may†. (p.10)  

Home care division at unilever

Home care division at unilever This report tries to analyse a very important situation the Home Care Division at Unilever found itself during the late 1990s in Brazil. Unilever, with an 81% market share is the market leader in the detergent powder business. This report is based on the findings of project Everyman a market research carried out in Brazil in order to understand the regional divide in terms of the income, culture, consumption pattern or usage of detergent powder between the consumers of North East and the South East areas of the country. The research also takes into account the competitors of Unilever in Brazil and also its sales and performance in the detergent market. And finally a recommendation is made on what would be the best marketing strategy which the company should adopt to penetrate into the largely unexplored low-income consumer segment in the Fabric wash business thereby expanding its market share and also increasing the profitability for the company. The economic recovery of 1995-1996 was beneficial for the low-income consumers, which meant that the purchasing power of the poorest 10% of the population grew by 27% per year during the period. Our main focus remains on the two main regions of Brazil, the Northeast and the Southwest, especially the lower income consumers of Northeast of Brazil. Consumer behaviour is the process individuals or groups go through to select, purchase, use and dispose of goods, services, ideas or experience to satisfy their needs and desires. (Solomon, Marshall, Stuart, Barnes, Mitchell, 2009). The Decision to buy the detergent for a consumer in both the regions NE and SE is Habitual and hence lacks complexity. It is seen that the level of involvement of the consumer in the decision making process is very low. Also, the consumer is well aware of various brands of detergent or laundry soap which are on offer in the market. Moreover, considering the fact that the risk associated with the purchase of the detergent or laundry soap is minimal, the consumer spends lesser time in evaluating or deciding the brand of purchase. There are various influences which affect the ultimate choice of a consumer. In this case, the various categories of influences which are affecting the consumers choice while buying the detergent powder or laundry soap are shown in Figure 1: There are various different ways in which a consumer tends to internalise any available information to make an informed decision. The key internal influences which are affecting the decision making of the consumers are: Perception: It can be defined as the process of selection, organising and interpreting any information in form of sensation. The consumers perceive Omo as an ideal detergent having all the qualities required to fulfil their washing needs. According to the consumers as given in Exhibit 5, an ideal detergent should demonstrate the following qualities or aspects: Power of the detergent (its ability to clean and whiten the clothes with small quantity of product). Smell/Fragrance (Strong, pleasant smell associated with softening power and gentleness to fabric and hands). Ability to remove stains without laundry soap or bleach The ease with which the powder dissolves and absence of residue (consistency and granularity of the powder). Interestingly, the perception regarding the usage of bleach also differs between the women of the Recife Northeast, where majority of the women prefers using bleach after washing clothes to remove tough stains, whereas only 18% of the women in Sao Paulo Southeast prefer doing so. Learning: It can be defined as the change in buyer behaviour caused due to available information or experience. The consumers in general are well aware of the various brands of washing detergents and soaps available in the market. From the data given regarding Brand Knowledge, market penetration and Top of the mind awareness in Exhibit 8 it is evident that the consumer across regions in Brazil have either the knowledge or have seen or used one or all washing products at some point in time. Lifestyle: Reflects the value, tastes and preferences of people depending on their pattern of living which is determined by how they choose to spend their money, time and energy. The way the clothes are washed differs in both regions since the women in NE attach great value and take pride in keeping themselves and their families spotlessly clean whereas the women in SE consider it as daily chores, less important for self-esteem and social status. Another factor influencing the choice of detergent or soap is the number of households which owns washing machine 28% in Northeast and 73% in Southeast. Social Class: The rank or the status of the people or group in the society can be defined as a Social Class. People are considered to be in the same class who either work in same occupations, having similar level of incomes, or share similar tastes. Exhibit 2 highlights the social class composition in the Southeast and the Northeast of Brazil. The divide is evident with more than 45% of the population in Southeast forming the top 3 Tiers (A, B, C) as compared to the Northeast where more than 53% of the total population form the bottom 2 Tiers (E+ E-). This is one of the major reasons for the difference in the consumption pattern of the detergent powder and laundry soaps in both the regions, although the penetration of both detergent powder and the laundry soap is almost the same. Majority of the population in the north-eastern region use a lot more soap and less detergent as compared to their counterparts in the southeast. Another very interesting fact to note is the frequency at which the clothes are being washed in both the regions. The washing of clothes in the Northeast happens more frequently as compared to the Southeast since the low income group of Northeast have fewer clothes to wear. In the year 1996, the detergent powder and the washing soap market in the Northeast of Brazil was worth a whopping $208 million and growing. As shown in Figure 2 there are 3 key players in the fabric wash market in Brazil with Unilever, the market leader with an 81% market share, close behind is PG with a 15% share in the market and the remaining 4% of the market is captured by local Brazilian companies. The market can be broadly classified based on the type of washing products offered. The detergent powder industry which sells around 42,000 tons of washing powder in the Northeast is growing at an exceptional rate of 17% per annum. And the dominance of major multinationals like Unilever and PG has been because of the capital intensive nature of the of the manufacturing process requiring massive manufacturing and RD costs. Following are some of the key players in the market. Unilever: Unilever has been a dominant force in the detergent powder market in the Northeast with a 75% market share. With a 52 % market share Omo is the most popular and the most dominant brand of detergent powder in the Unilever stable. Minerva is the only brand offered by Unilever in both the detergent powder and the laundry soap with a market share of 17% and 19.1% respectively. And finally Campeiro holds 6% of the total detergent powder market. PG: Although PG entered the Brazilian market in 1988, it has come a long way in becoming the second most successful manufacturer with a 15% share in the detergent powder market. The primary reason for this success can be given to the large amount spend on making manufacturing improvements in the businesses acquired by PG to develop better products for the Brazilian market and the RD and marketing expertise is a direct threat to Unilever. Ace is its the flagship brand which has 11% market share, a direct competitor of Omo with features like superior whiteness, dirt removing capability and fabric protection is priced at 2.35/Kg. Followed by the other brands offered by PG viz. Bold competing against Minerva and with focus on softness sells at 2.50/Kg and Pop is an alternative for Campeiro selling at 1.70/Kg together occupies 6% of the detergent powder market. Others: Invicto owned by local Brazilian company ASA with 5% share of the market which competes against Campeiro is sold at 1.70/Kg. The remaining 3 % of the detergent powder market is currently being held by local Brazilian companies. The Laundry soap market in the Northeast of Brazil is equally big as compared to the detergent powder industry with revenues of $ 102 million, selling around 8,125 tons per year; however its growth rate at just 6% is far slower than its rival. Unlike the detergent powder market where Unilever and PG were the dominant forces, this market is being dominated by brands manufactured by local Brazilian companies; surprisingly PG offers no products in this segment. As shown in Exhibit 7 the local companies hold a major chunk 69.6% of the market share (including others and Flora). Bem-te-vi is extremely popular and is positioned with emphasis on traditional and regional values targeting the low income consumers of Northeast holding 11.3% of the market. Minerva which is the only Unilever brand is considered to be one of the best laundry soaps with an impressive total share of 19.1%. Marketing Mix Strategies help in identifying how a companys marketing would accomplish the objectives by using the following factors; It is a strategic planning method used in evaluating the Strengths, Weaknesses, Opportunities and Threats involved in a business. The details of the SWOT analysis for Unilever are evident in Figure 4. 5.1 Growth Strategy Unilever fabric wash products enjoy immense respect and recognition across different regions of Brazil due to its diverse range of products, dependable in-house marketing capabilities and excellent advertising campaigns. However, the ignorance and indecisiveness in adopting a strategy to tap in the huge potential of the low income group of Northeast has been an area of concern for the company. The Product-market Growth Matrix in Figure 5 helps us analyse various growth strategies and identify the most suitable strategy the company should follow to expand their current market. New Products Existing Products Product Emphasis New Markets Existing Markets MKT Emphasis Extension of the current entry level brand Campeiro is the most ideal strategy and hence we need to adopt the Product development strategy model. The new product would be rightly called Campeiro Dazzle. We will further analyse and discuss the targeting, segmentation and positioning strategy which Unilever should follow to achieve its goals. The STP strategy in Northeast for Campeiro Dazzle would be influenced by the following variables: Segmentation: Demographic: More than 53% of the population, approximately 26 million in the Northeast lives on less than two minimum wages. Illiteracy rate at 40% is very high. Psychographic: Bleach is very important to remove fat stains. Washing clothes has a symbolic value for the women and they take pride in keeping their family clean. Considered to be one of the pleasurable activities of the week, hence washing in public laundry, river or pond is considered to be an opportunity to meet and chat with friends. Behavioural: Clothes are washed frequently (5 times a week in Recife). Target marketing strategy: Since Omo and Minerva is already targeted towards the High and middle income group respectively, the new Campeiro Dazzle will be focusing on the low income consumer segment in the Northeast using Differentiated targeting strategy. Positioning: Success of Target marketing strategy is contingent on the identification and selection of most appropriate market segment. Keeping the current positioning of the 3 detergents (Omo, Minerva and Campeiro) unchanged; our primary focus would be to strategically position the new Campeiro Dazzle. The ideal positioning of Camperio Dazzle should be such that it falls between Minerva and Campeiro which fits it in the top left quadrant above the perceived Quality and Price index 100. Unilever can establish Campeiro Dazzle as one of its most sought after and affordable BRAND of CHOICE for the low income consumers by developing a Marketing Mix as mentioned below; The most important concern internally at Unilever Brazil is the issue of cannibalisation of existing premium brands like Omo or Minerva due to shift in strategy following the introduction of the new brand extension Campeiro Dazzle. The concern I believe is a legitimate one and if things do go wrong as feared by many, the results could be devastating for Unilever and could tarnish its image as being the best and most dependable, inviting competitors like PG to take maximum advantage of the situation and eat into Unilevers market share across regions in Brazil. The level of income, however, is the key factor which would avoid any such adverse situation since our new brand is targeted at the low income consumers of the northeast and is not positioned to compete against Omo and Minerva which is targeted at the high income and middle income consumers respectively. Extension of the entry level brand Campeiro is justifiable considering the time and cost constraints faced by Unilever. The process of creating and introducing a new brand involves immense RD, marketing advertising and distribution costs and will also take a long time to develop and Unilever cannot afford at this point in time since its main rival PG has the potential and the expertise to capture the massive detergent low income consumer market by either extending or repositioning one of its own existing products. Based on the Segmentation, target marketing, positioning and marketing mix strategies discussed earlier, it is strongly recommended that Unilever follows a quick growth strategy (3 year) to capture maximum market share of the low income consumers in the northeast by getting them to use Campeiro Dazzle. The Bottom-up budgeting technique would be most helpful since the new strategy requires Unilever to spend more on the promotion of Campeiro Dazzle Push strategy in the first 3 years of its introduction. This would be gradually reduced in the fourth and fifth year once the product eats into the market share of the competitors and demand for product increases Pull Strategy. Æ’Â   Push strategy: Unilever can follow the same 70/30 ratio for ATL BTL communication which it does currently. Emphasis should be more on ATL because of its high reach and low cost-per-contact especially TV advertisements hoardings (Knowledge about the availability of the new product). On the other hand BTL techniques like in-store promotions and improved visibility of the product in the small stores. The biggest factor that can contribute to an instant success of Campeiro Dazzle is if Unilever builds confidence in its secondary, small local wholesalers and specialized distributors by running a high incentive/commission through sales programme. This is one primary reason why 0.50 cents/k.g has been earmarked towards promotional cost. Resulting in our products reaching 75,000 small outlets where most of the low income consumers shop. Æ’Å ¸ Pull Strategy: Promotion is one of the most important and inseparable part of the marketing mix. However for Unilever, assuming the success and the overwhelming acceptance of Campeiro Dazzle over the first three years by the low income consumers the promotion strategy would then have to shift to improve the profit margin. This would be a challenge considering the fact that reversal of the distribution channels is difficult. However, increasing demand for Campeiro Dazzle amongst low income consumers due to effectiveness, high brand value and recognition (thanks to a new TV promotion/advertisement by a well known celebrity or a popular music band which would act as a stimulant) will force the retailers to respond to this demand by stocking more Campeiro Dazzle in their stores. Conclusion: The aforementioned analysis clearly indicates that the existing detergent products and the strategy adopted by Unilever to capture the market share and satisfy the needs of the low income consumers hasnt been very successful. Project Everyman, however, has come as a ray of hope for the company helping it understand the enormous potential of this group of consumers. The implementation of the new strategies mentioned in this report would certainly help Unilever to expand its market share and profitability and most importantly help them implement this business model to gain success in other developing economies of the world and immense respect in the industry.