Stefan’s Diaries Origins Chapter 22 Free Essays

The seven day stretch of the Founders Ball accompanied a virus spell that subsided into Mystic Falls and wouldn't leave. Women strolled around town in midafternoon in fleece coats and wraps, and the nighttimes were overcast and black. Out in the field, laborers worried about an early ice. We will compose a custom article test on Stefan’s Diaries: Origins Chapter 22 or on the other hand any comparative subject just for you Request Now All things considered, that didn’t prevent individuals from as distant as Atlanta coming into town for the ball. The motel was full, and the whole town had a jamboree like air in the days paving the way to the occasion. Damon was back at Veritas, his strange residency with the detachment over. I hadn’t revealed to him that Katherine and I were going to the Founders Ball, and he hadn’t inquired. Rather, I’d busied myself with work, feeling recharged power about taking over Veritas. I needed to demonstrate to Father that I was not kidding about the bequest and about growing up and accepting my place on the planet. He’d been giving me greater obligation, permitting me to investigate the records and in any event, urging me to go to Richmond with Robert to go to a domesticated animals sell off. I could see my life, quite a while from now. I’d run Veritas, and Katherine would run within the home, facilitating gatherings and playing the incidental game around evening time with Father. The evening of the ball, Alfred thumped on my entryway. â€Å"Sir? Do you require any assistance?† he asked as I swung the entryway open. I looked at my appearance in the mirror. I was wearing a dark since a long time ago followed formal attire, with my hair slicked back. I looked more seasoned, progressively sure. Alfred followed my look. â€Å"Looking savvy, sir,† he permitted. â€Å"Thank you. I’m ready,† I stated, my heart rippling in energy. The previous evening, Katherine had prodded me brutally, not giving me any pieces of information regarding what she was going to wear. I couldn’t hold back to see her. I knew she’d be the most delightful young lady at the ball. Progressively significant, she was mine. I headed down the steps, diminished that Damon was mysteriously absent. I pondered whether he was going to the Founders Ball with a portion of his military companions or maybe one of the town’s young ladies. He’d been far off recently, difficult to track down in the first part of the day and at the bar around evening time. Outside, the ponies were pawing at the drive. I entered the holding up mentor, which cut clopped its way to the carriage house. I looked out the window, and saw Katherine and Emily remaining at the front entryway. Emily wore a straightforward dark silk dress, however Katherine †¦ I needed to press my go into the carriage seat to shield from leaping out of the moving mentor. Her dress was emerald green, nipping in at the abdomen dress was emerald green, nipping in at the midsection before streaming over her hips. The bodice was low and tight and flaunted her rich white skin, and her hair was pulled back on the highest point of her head, uncovering her elegant, swan-like neck. The subsequent Alfred pulled back on the horses’ reins, I opened the entryway of the mentor and bounced out, grinning extensively as Katherine’s eyes got mine. â€Å"Stefan!† Katherine inhaled, lifting her skirts marginally as she floated down the steps. â€Å"Katherine.† I delicately kissed her cheek before I offered my arm to her. Together, we turned and strolled toward the carriage, where Alfred remained with the entryway open. The way to Mystic Falls was loaded up with new mentors of every kind, prompting the Lockwood house on the furthest finish of town. I felt a rush of expectation. This was the first run through I’d ever accompanied a young lady to the Founders Ball. In every single earlier year, I’d burned through the greater part of the nights playing poker with my companions. Constantly a catastrophe occurred. A year ago, Matthew Hartnett had become inebriated on bourbon and had inadvertently unfastened the ponies from his parents’ mentor, and two years prior, Nathan Layman had gotten into a fistfight with Grant Vanderbilt, and both wound up with broken noses. We gradually advanced up to the house, at last arriving at the front walk. Alfred halted the ponies and let us out. I bound my fingers with Katherine’s, and together we strolled through the open entryways of the house and made a beeline for the lounge area. The high-ceilinged room had been freed from all furnishings, and the candlelight loaned a warm, puzzling gleam to the dividers. A band in the corner played Irish reels, and couples were at that point starting to move, despite the fact that the night was youthful. I crushed Katherine’s hand, and she grinned up at me. â€Å"Stefan!† I spun around and saw Mr. furthermore, Mrs. Cartwright. I dropped Katherine’s hand right away. Mrs. Cartwright’s eyes were red, and she was decidedly thin contrasted with the last time I saw her. In the mean time, Mr. Cartwright appeared to have matured ten years. His hair was snow-white, and he was strolling with the guide of a stick. Both wore purple branches of vervainâ€a tuft stood out of Mr. Cartwright’s front pocket, and the blossoms were woven into Mrs. Cartwright’s hatâ€but other than that, they were clad altogether in dark, for grieving. â€Å"Mr. also, Mrs. Cartwright,† I stated, my stomach grasping with blame. In truth, I’d about overlooked that Rosalyn and I had been locked in. â€Å"It’s great to see you.† â€Å"Y could have seen us sooner if you’d come ou to approach us,† Mr. Cartwright said. He could scarcely conceal the hatred in his voice when his look arrived on Katherine. â€Å"But I comprehend you more likely than not been in profound †¦ sadness as well.† â€Å"I will come since I know you’re taking visitors,† I said falteringly, pulling at my neckline, which abruptly felt very close around my neck. â€Å"No need,† Mrs. Cartwright said coldly as she ventured into her sleeve to pull out a tissue. Katherine caught Mrs. Cartwright’s hand. Mrs. Cartwright looked down, an appearance of stun all over. A flood of fear went through me, and I battled the desire to step among them and shield Katherine from their displeasure. Be that as it may, at that point Katherine grinned, and incredibly, the two Cartwrights grinned back. â€Å"Mr. what's more, Mrs. Cartwright, I am so upset for your loss,† she said energetically, holding their looks. â€Å"I lost my folks during the Atlanta attack, and I realize how hard it is. I didn’t know Rosalyn well, yet I do realize she will never be forgotten.† Mrs. Cartwright cleaned out her nose loudly, her eyes watering. â€Å"Thank you, dear,† she said respectfully. Mr. Cartwright praised his better half. â€Å"Y thank you.† He went to me, sympathy es, supplanting the disdain that had involved his eyes just minutes sooner. â€Å"And please deal with Stefan. I know he’s suffering.† Katherine grinned as the couple rejoined the group. I expanded in wonder. â€Å"Did you urge them? † I asked, the word tasting harsh in my mouth. â€Å"No!† Katherine set her hand over her heart. â€Å"That was classic, consideration. Presently, let’s dance,† she stated, pulling me toward the enormous dance hall. Fortunately, the move floor was a pound of bodies and the lighting was low, so it was practically difficult to make out explicit individuals. Bloom wreaths dangled from the roof, and the marble floor was waxed to a sheen. The air was hot and cloying, with the fragrance of several contending aromas. I put my hand on Katherine’s shoulders and attempted to unwind into the three step dance. Yet, I despite everything felt jittery. The discussion with the Cartwrights had blended my still, small voice, causing me to feel ambiguously unfaithful to Rosalyn’s memory, and to Damon. Had I deceived him some way or another by not disclosing to him that Katherine and I were at the ball together? Was it wrong that I’d been thankful for his drawn out unlucky deficiencies? The band halted, and as ladies balanced their dresses and got a handle on their partners’ hands once more, I made a beeline for the reward table in the corner. â€Å"Are all of you right, Stefan?† Katherine asked, coasting up close to me, stress lines wrinkling her exquisite temple. I gestured, however I didn’t break my step. â€Å"Just thirsty,† I lied. â€Å"Me too.† Katherine stood eagerly as I spooned the dim red punch into a precious stone tumbler. I passed the glass to her and looked as she drank profoundly, thinking about whether that was what she resembled when she drank blood. At the point when she set the glass on the table, she had the smallest hint of red fluid around her mouth. I couldn’t help it. With my pointer I cleared the drop off the side of her bow-formed mouth. At that point I put my finger in my own mouth. It tasted sweet and tart. â€Å"Are you sure you’re all right?† Katherine inquired. â€Å"I’m stressed over Damon,† I admitted as I presented myself with a glass of punch. â€Å"But why?† Katherine asked, certifiable disarray enlisting all over. â€Å"Because of you,† I said just. Katherine took the tumbler from me and drove me away from the reward table. â€Å"He’s like a sibling to me,† she stated, contacting my temple with her cold fingers. â€Å"I’m like his younger sibling. Y know ou this.† â€Å"But each one of those occasions when I was debilitated? When you and he were together? It appeared †¦Ã¢â‚¬  â€Å"It appeared as though I required a friend,† Katherine said immovably. â€Å"Damon’s a tease. He doesn’t need to be secured, nor would I need to be attached to him. Y ou are my adoration, and Damon is my brother.† Surrounding us, couples whirled in the semi-dimness, dunking so as to the music and snickering merrily at private jokes, apparently cool as a cucumber. They, as well, needed to stress over assaults and the war and grievousness, yet they despite everything chuckled and moved. Why couldn’t I too? For what reason did I al

BUSINESS ASSIGNMENT Essay Example | Topics and Well Written Essays - 1250 words

BUSINESS ASSIGNMENT - Essay Example The division has been finished by utilizing socioeconomics and conduct techniques. The objective market has been picked in the wake of distinguishing the size and gainfulness of the portions. In the wake of building up the situating technique, the showcasing blend has been made for the objective market. At long last, a diagram of the money related arrangement of Manga Cafe has been talked about. Recognized PROBLEM The field-tested strategy of propelling Manga Cafe in London seems, by all accounts, to be a one of a kind thought as there is as of now not such bistro in London be that as it may, in light of the forceful rivalry among the universal brands in the UK Cafe industry; Manga Cafe needs a very efficient and effective advertising plan. INDUSTRY COMPETITION Various espresso brands are working in London; nonetheless, the three biggest market pioneers incorporate Starbucks, Costa Coffee and Nero. The accompanying situating map shows the situating of significant bistro suppliers in London dependent on their nature of administrations and costs. Starbucks being the market head is offering normal quality however at exceptionally significant expenses, in this manner, portions of Starbucks are declining in UK as well as in the vast majority of its significant markets (Bishopric, 2011). Costa is extending all through UK in light of its sensible costs and better quality and in 2010/2011, organization intends to open 130 additional outlets in the UK (Bakeryinfo, 2010). Nero is considered as a modest brand which offers an incentive through great items and administrations. Situating Map THE PRODUCT/SERVICE DESCRIPTION Manga Cafes are well known among the Japanese people group. The expanding number of Japanese inhabitants in the UK fabricates a solid interest for Manga Cafes in the UK, European and outside business sectors. Since there is no Manga Cafe in London yet, along these lines, dispatch of Manga Cafe in London has all the earmarks of being a possible business alt ernative. This bistro will satisfy the expanding request of Japanese funnies in Europe. The bistro will offer a stage to the individuals where they can come and appreciate perusing Japanese funnies. In addition, extra administrations will likewise be offered to engage the guests, for example, Japanese food, web office, games and DVDs. The guests will be charged dependent on their term of remain in the bistro. Advertising PLAN Market Segmentation To portion the market, socioeconomics and conduct division methodologies have been utilized. In socioeconomics division, the buyers have been sectioned dependent on their age, calling and nationality. Age: The age bunch structure of London in 2001 is given underneath (Office for National Statistics, 2002). Age Structure of People in London Source: Office for National Statistics Profession: The second segment variable is calling and in London individuals having a place with various callings, for example, instruction, laborers, experts, jobles s dwell. Nationality: The third segment variable is nationality and since Manga Cafe is a Japanese bistro along these lines, just Japanese nationals will be legitimately focused on. In any case, the all out populace of London in 2009 was 7,686,000 and it incorporates around individuals with 34 distinct nationalities (London.gov.uk, 2010). Table: London Population by Nationality Source: London.gov.uk In social division, the buyers who will have information, intrigue and uplifting mentality towards Japanese culture will be

Cultural Geography Essay Topics

Cultural Geography Essay TopicsThe most important part of a cultural geography essay is the beginning. If your first paragraph doesn't stand out from the rest, it will be hard to create a topic for the rest of the essay. Even if you do have some ideas for starting the essay, remember that it should build upon those ideas. Find a way to draw readers into your subject, and keep them interested by following these guidelines:After your first paragraph, you should continue to build on the topic in the second paragraph. The second paragraph should be all about the introductory statement, what the purpose of the essay is, and how it relates to your topic. Remember that your goal is to draw readers into your subject, and then to continue to make them curious and interested.You should make sure your essay looks as realistic as possible, without resorting to anything that could happen in the real world. It's a great idea to follow the example of real geographic subjects. For example, if you're studying the American West, start your essay by talking about the weather. This is a good way to start off if you're writing about a natural setting.Map your topic as accurately as possible. This means that you should think about the geography of your area and map your subjects on maps or notations, and give references where you've researched the subject. This can be a valuable tool for determining what topics you need to avoid.Next, you need to give examples of essays you've read or heard about. Consider using excerpts from these essays. Read the entire essay through again, then use the examples to determine what kinds of subjects you should avoid in your essay. Remember that every essay is different, so be sure to write a culturally-sensitive essay.You should start with a list of questions for yourself before writing your essay. This will help you determine what types of topics are suitable for your essay and will also allow you to better evaluate your own writing. Do the same fo r your readers.Finally, you need to go back and edit your essay. It's important to focus on proofreading and fixing any mistakes you find. Having a good article for research can help you write an essay that will be appealing to readers.The end result of a cultural geography essay is a well-written, well-researched piece of work that can attract readers. Follow these tips and you'll be able to write an essay that will inspire students.

Poor Prognosis Experience - 851 Words

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A Research Study On Breast Cancer - 1308 Words

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Individualism and the Cold War - 1513 Words

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This team spurred much needed national pri de to our country and restored our faith even during the darkest of timesRead MoreThe Political System Of The United States1053 Words   |  5 Pagesfactors that attributed to America’s success, such as liberty, equality, individualism, nationalism, and capitalism. The political culture during the 1830s has changed over the years, yet in many ways it has stayed the same. On the other hand, the characteristics of American society has changed throughout the years. For example, in the 1960s the main characteristics were conformity, prosperity and fear of communism(6). The Cold War was a big issue in the 1960s, the U.S. was a big industrial country atRead MoreThe Civil War Has Changed The Country987 Words   |  4 PagesThe history of America, as a nation is connected through the wars it has entered and how these wars have irreversibly changed the country. â€Å"The Civil War made modern America†¦ [and] we remain connected to this war† (Suri, Lecture 1). This is bec ause the Civil War was an establishment of our nation’s beliefs and freedoms; fought to preserve the Union, this war shaped what America was and would become. The Civil War changed the notion of what liberty was, the transition from negative freedom to positiveRead MoreThe Is The Atomic Bomb Signaled Not Only The Commencement Of The Cold War1461 Words   |  6 PagesThe atomic bomb signaled not only the commencement of the Cold War, but also a political divide between the communist ideologies of the Soviet Union and the democracy of the Western world. A fear of communism behind the Iron Curtain and nuclear annihilation spread throughout the US, while existential views regarding the meaning of life arose. Through their texts, composers subverted dominant Cold War paradigms to †¦Ã¢â‚¬ ¦.. ATQ†¦Ã¢â‚¬ ¦. Samuel Beckett’s modernist existential play ‘Waiting for Godot (Godot) (1953)’

White Lies free essay sample

I am a weird kid. Not weird in the colloquial â€Å"hipster† sense, just genetically weird. I have red-green colorblindness, congenital insensitivity to pain, an extremely irrational fear of bees, and a 148 IQ that makes me come across as egocentric when others would be perceived as sincere. Considering the aforementioned, I would not have it any other way. Every person has little weird nuances and intricacies that make them who they are; most people do not cherish these oddities. I cannot fathom a world in which everyone is alike, it would be worse than if every channel was reality TV (oh wait†¦). My individualistic nature is pertinent if you hope to understand my take on white lies. I am a firm believer in white lies; without them, our society would be so brutally honest that every achievement would be instantaneously subjected to the jealousy that percolates throughout the undertones of human nature. We will write a custom essay sample on White Lies or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page In short, white lies are healthy. Just so were not confused, I am using white lie as a euphemism for such lies that one finds convenient to tell, and excuses himself for telling. The infamous, â€Å"the dog ate my homework†, is as subtle as William Shatner’s toupee, but effective nonetheless. White lies are important for businesses as well. I evidence the typical â€Å"the table will be ready in five minutes†- because customers would prefer to be lied to than told they are not going to eat for a half-hour; the hope of food conquers the reality of no-food every time. Moreover, if white lies were illegal, Olive Garden would be serving a life-sentence. I cannot count how many times I was longing for endless breadsticks and salad bowl, only to be delicately, yet meticulously deceived into believing that my craving would come to fruition in the near-future. Unfortunately, two hours is not in the near-future according to a hormonal teenager’s appetite. Despite all that, I find myself saying â€Å"thank you† at every instance in which polite manners are obligatory. What exactly am I thanking them for? Am I thanking them for making me linger in a six square foot area, where, despite the laws of physics, twenty-seven human beings manage to cluster to the point where everyone just marinates in the anguish of waiting? The answer is yes. Political correctness is becoming a division of white lies before our very eyes. â€Å"You look great in that dress† and â€Å"it’s not you, it’s me† immediately come to mind. I mention political correctness because it is the subject of my favorite quote. It goes as follows, â€Å"Political Correctness is a doctrine fostered by a delusional, illogical minority, and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end.† I think it is regressive when people listen intently to your every word hoping that you utter something politically incorrect, so they can fulfill their duty as a â€Å"Good-Samaritan† and rebuke you. Political correctness has its place in formal atmospheres, just the way white lies have their place in informal atmospheres. So only use a white lie when it is not at the expense of someone else.

28 Argumentative Essay Topics on AIDS Prevention Organization

28 Argumentative Essay Topics on AIDS Prevention Organization If you are tasked with writing an argumentative essay on AIDS prevention organizations, your goal by the end of your argumentative work is to convince the other side that the evidence you presented adequately supports your thesis, or that the evidence presented by the opposing side is false or insufficient. Some writers prefer explaining the flaws in the opposition while others prefer presenting evidence enough to not just disprove the opposition, but to prove their side in things. When writing on such a topic, you have to first select certain facts that support whatever claim you make. Below you will find a list of facts that might help you support your claims: Since the year 2000, over thirty eight million people have been infected with HIV. Since the year 2000, twenty five million people have passed away due to AIDS-related illnesses. Around the world AIDS remains one of the top three leading causes of death. Around the world AIDS remains the leading cause of death for women who are of reproductive age in lower income countries and middle income countries. Out of the total number of people who are living with AIDS today, roughly nineteen million of them do not realize they are HIV positive or have AIDS which roughly equates to one out of every two people who have HIV not knowing they have it and therefore not seeking out treatment. Right now roughly fifteen million people are getting treatment for HIV around the world. Right now 8.1 million of the people getting treatment for HIV are doing so through a program supported by the group Global Fund. AIDS no longer results in death as the only final option today, and in fact, with proper medication those with HIV can live the same length of time as someone without. Today HIV treatment consists of what are called antiretrovirals, or AVR’s which stop the virus from replicating inside of an infected individual and also helps to prevent the breakdown of the body’s immune system. Antiretrovirals, or AVR’s help to prevent the transmission of HIV in someone who is infected. An infected individual taking antiretrovirals, or AVR’s can reduce the likelihood of transmitting HIV by ninety seven percent. HIV can spread through the transfusion of blood which is infected. HIV can spread through sharing of infected needles which have been exposed to infected blood. HIV can spread through the exchange of all bodily fluids such as sex. HIV can spread from an infected mother to her child during pregnancy and/or birth. Prevention strategies for HIV have reduced the rate of infection around the world by thirty five percent since the year 2000 alone. The most impactful and effective prevention tool is the prevention of HIV spreading from mother to child during pregnancy and child birth which is done with antenatal care, HIV testing, ARV’s as necessary, and support after birth. Harm reduction services for those who inject drugs is a useful prevention tool for HIV. Distributing condoms to prevent the spread of sexually transmitted diseases including AIDS is a viable tool for prevention. AIDS prevention strategies must be rooted in a human-rights approach in order to meet with the needs in key demographics. Data over the last decade rating to HIV has become focused on key demographics beyond men who have sex with other men and on sex workers, migrants, prisoners, youths, and those who inject drugs. The populations who are at the highest risk for the transference of HIV/AIDS are the people who have the highest discrimination and lack of available health services within a reasonable distance. Some organizations such as the Global Fund offer treatment and medication free of charge. Discussions about sex and the disease itself are the first steps to prevention, treatment, and care. The encouragement of behavioral changes such as reducing the number of sexual partners can be useful in prevention. Increasing the use of condoms will reduce the spread of AIDS. Delaying the age at which sexual activity begins can be used to reduce the spread of AIDS. Rates of infection in girls between the age of 15 and 24 are double compared to the rates of infection for men of the same age. It is important to note that there is often fear and prejudice in any frank discussion or argument revolving around AIDS. There remains a strong stigma surrounding not only the disease itself but those people who are living with it. It is a result of this stigma that many people lack any basic knowledge about it and why the rate of infected who are unaware of their infection remains so high. Even if people have access to the information about the disease, they are often reticent to get a test officially because of fear, stigmas, and discrimination. Other forms of discrimination can also result in people not receiving access to the health services they need which results not only in a lack of treatment but in the continual spread of the disease. Refusing to acknowledge or write about the facts, no matter how unpleasant, will only perpetuate the prejudice and death. Overall, remember that these are merely facts which you can use as evidence to substantiate your argument. If you have troubles making up topics for your AIDS prevention essay, use ours that are prepared for you. You want to avoid using facts that you have twisted to support your claims and should instead rely only upon accurate information relevant to your topic. In some cases you might find a plethora of items you want to include, but if space or word limits are an issue, be sure to only rely upon those items which are the most relevant. The references included at the end are not only the sources from which these facts originate, but serve as viable resources for additional material, data, and perspectives for potential argumentative essays on AIDS prevention organization. Moreover, you can use our guide on writing an excellent argumentative essay and youll not be disappointed. References: AIDS 2012. AIDS 2012 Home.  AIDS 2012 Home. N.p., n.d. Web. 10 Nov. 2015. AIDS Crusades.  Uberpreneurs  (2013): n. pag. Web. Cherkerzian, Diane. Ray Carney Hacks Up Hollywood.  The Revolution Is Within. N.p., 06 Oct. 2009. Web. 08 Nov. 2015. Mayaud, P. et al. 1997. â€Å"STD rapid assessment in Rwandan refugee camps in Tanzania,† Genitourinary Medicine 73(1) International AIDS Society. Towards an HIV Cure.  Towards an HIV Cure. International AIDS Society, n.d. Web. 10 Nov. 2015. Office of National AIDS Policy. Office of National AIDS Policy.  The White House. The White House, n.d. Web. 10 Nov. 2015. Stratton, Stephen E., and Sarah Watstein.  The Encyclopedia of HIV and AIDS. New York: Facts On File, 2012. Print.

Dystopia and Lowry the Giver Essay

Dystopia and Lowry the Giver Essay Dystopia and Lowry the Giver Essay Jonathan Williams-Estevez Mrs. Kimball English 8-6 12-15-13 The Giver by Lois Lowry The Giver by Lois Lowry is a science fiction novel. (Sci-fi means it’s from the future or time travel or advanced technology.) The sci-fi novel is about Jonas and the Giver (the two main characters of the novel.), the story is about when Jonas was an eleven he had a normal life (in the community's way) but when he turned to a twelve he got his assignment as being the new Receiver of Memories, because he has the sense to see from beyond and the previous giver is getting old and weak. * My theme is about how rules make some places a utopia but too many can make the utopia the into a dystopisa because of how all the rules the committee have are controlling the lives of the people. The Giver becomes the teacher of Jonas when he gets assigned to being the Receiver of Memories because the Giver was the last Receiver of Memories. When the Giver starts to transmits the memories to Jonas, he is not just giving him memories from the community but from the whole world when there were floods, starvation, poverty, and even war. When the Giver is giving Jonas those memories he is also giving him awareness, feelings like loss, sadness, and love. The community citizens unquestioningly follow the rules, because over time killing has become a regular part of their lives, the horrible actions they do, it doesn't emotionally upset them. Just as the Giver says of Jonas's father killing the lighter twin newborn â€Å"It’s what he was told to do, and he knows nothing else.†(lowry ) As Jonas is getting those feelings he is also starting to realize the perfect **utopia he calls home, is actually a ***dystopia because of the rules. The rules that the committee made was to make everyone the same because the people didn't/couldn't see color, they have to do what they're told to do or you were released and they didn't have feelings like love or sadness. One of the rules is that they have to use precise language (accurate language.) and when Jon as was little he said he was starving and he got smacked because the workers that worked there said that â€Å"He isn’t starving he’s hungry.† (lowry ) They also have a rule about your spouse. If you want one you will have to apply for one

Accessible Virtual Classroom For Visually Impaired Students Literature review

Accessible Virtual Classroom For Visually Impaired Students - Literature review Example It is easy to see why the concept of a virtual classroom appeals to a lot of people. It’s usually much cheaper than the regular schooling system and provides much more flexibility when it comes to learning and applying the knowledge. A common complaint levied against the traditional schooling system is that the students have no flexibility in following the curriculum, ie, all students are expected to follow at the same pace as that set by the teacher. However, each student has his or her own learning style and speed, which is especially marked for students who are at the either extreme of the IQ spectrum. Virtual classrooms remove this restriction by letting each student access and process the information according to their unique customized rate. Also, every pupil receives a fair amount of individual attention, which is not possible in a traditional classroom environment. The concept of a virtual classroom is also valuable to people who are in geographically or economically inaccessible parts of the world. It might not be possible to have a school for a community of a few people that are perched in a mountainous area or a desert region. Further, students who are physically disabled such as paraplegics or the mentally challenged can often still experience a conventional education as part of a virtual classroom setup. It is also seen that virtual classrooms are becoming popular for higher education purposes – where this was initially developed.... However, the purpose of this paper is to explore and study if these classrooms are also tailored to meet the demands of the visually challenged population. The visually impaired are traditionally at a disadvantage when it comes to computers and online resources such as the internet – because the mode of data transfer in these media is through sight. If this handicap can be overcome, online classes can be a great resource for the blind as they can empower themselves through the wealth of online educational resources available. Much is yet to done, but several important progresses have already been achieved to this extent. Tactile and Haptic devices have made great inroads into the education of the blind. It needs to be explored in greater detail how several of the successful virtual classrooms have addressed the specific needs of this community. Virtual classrooms are a multimodal information transfer environment. It combines the features of a web conference and video – audio conference. The device applications and multimodal sensitivity are the results of the combined benefits of several web applications such as email, chat, screen sharing, polling, web conference rooms, video – audio chats, telephone conference and so on. Before the question of the usability of virtual classrooms for the visually impaired in analyzed, it would be instrumental to analyze the specific features of a virtually information transfer environment. This is attempted in the next section where each of these features are considered in some detail. Features of a Virtual Classroom The following are the key features of a virtual classroom. 1) Real time audio and video Real time audio and

Economics (Answer 2 questions) Essay Example | Topics and Well Written Essays - 750 words

Economics (Answer 2 questions) - Essay Example For instance, the procurement price for wheat and rice rose to 170 and 240 by 1980 (taking the base at 100 in 1970). Thus, there has been a substantial rise in the procurement prices of these commodities with a view to placate the rich farmers who form one of the dominant groups. Next, the license and control mechanism called by many derisively as the â€Å"Inspector Raj† placed undue emphasis on stifling the innovative and entrepreneurial tendencies to favor the few industrial houses that controlled the economy. The resulting contraction in industrial output has been shown as a result of these policies by Bardhan. The third dominant group, the professionals have managed to retain their supremacy in knowledge and allied interests by making sure that they have high â€Å"scarcity value† in a country where the overwhelming majority are illiterate. They have done this by making sure that resources are diverted from initiatives that provide for mass education to higher education schools and colleges where the elite minority can get admission. However, it is not always the case that these dominant groups act in unison or are hand in glove with each other. There have been instances where the rich farmers have found themselves in opposition to the bureaucrats and the professional class particularly when it came to the distribution of largesse by the government in the form of subsidies and the like. Thus, there have been conditions where the dominant groups have found themselves in conflict with each other. 2) It a long held belief pioneered by Jean Dreze and Amartya Sen that social indices of development are a better guide to the overall development of an economy than purely economic indicators. This fact has been reinforced by many studies that point to the emergence of so-called â€Å"Tiger Economies† of South East Asia by investing in human and social capital. Dreze and Sen argue that even in India,

Earls Top 5 Filipino Traits Essay Example for Free

Earls Top 5 Filipino Traits Essay 1. Adept Filipinos are very flexible at surging any difficulty and hardship 2. Craftsmanship Filipinos are very crafty 3. Obsessive Filipinos wish to improve their lives and those around them and are willing to go through great hardships and efforts, but dont always know when to stop or how to balance it all. 4. Mimicry Filipinos tend to copy or gain that which others have. In this respect, thats why you see groups of Filipinos in foreign countries that are so similar (like in LA every Filipino seems to have a piano at home that no one buys, or in Japan every Filipino on a military base seems to own rose wood. But if they move to a new group, then they easily wish to change and copy the new styles. Kind of like following a fad. 5. Short memories No I dont mean their dumb or something, I mean they forget the past or let go of the past easier. They dont hold grudges quite so bad. Filipinos are not more family oriented than in other cultures, but what makes them Filipinos is they think they are. No offense. But many people have strong relations with their families. I lived in a home for six months and had to listen to my Brother in law tell me how family oriented they are as he yells at his father, and puts down his dead mother. I watched as just about every male member of the family had girlfriends, and the wives knew and ran those girls out of town when they got pregnant. I watched families that lived across the street visit each other once a year. I had a Filipino tell me that my daughter (half Filipino isnt Filipino enough to live in his house with my 2nd wife for a short time). So in any respect, Im not say they are less family oriented, but that we all have our issues with getting along, and Filipinos are no more family oriented than other cultures. This is according to the yahoo answers dot com. Well I agree with these because most of the Filipinos come from poor families and they can survive any trials becsuse they are already used to it. They are already down, so they on;y way to go is up. In the Philippines the most common thing that is talked about is the government. This is because this is the largest contributor of the poverty in the Philippines.

Comparison between Female Characters in Beowulf Essay -- Beowulf Compa

Comparison between Female Characters in Beowulf   Ã‚  Ã‚  Ã‚  Ã‚  Beowulf, the Old English epic tells the story of one brave hero and his battles against evil monsters. The poem deals with mostly masculine elements like fight descriptions, depictions of armor and long inspiring speeches. However, the women characters in the epic also have important roles and they are far from being superficial, as it may seem at first. There are several female figures in Beowulf; this paper will focus on three of them- queen Wealhtheow of the Danes, queen Hygd of the Geats and Grendel?s mother. These characters have many parallels between them but in a way some are the ?alter-ego? of the others.   Ã‚  Ã‚  Ã‚  Ã‚  Wealhtheow is the perfect hostess and devoted queen and wife. Her first appearance in the poem demonstrates her official duties as the queen: ?Wealhtheow came in, Hrotgar?s queen, observing the courtesies. Adorned in her gold, she graciously saluted the men in the hall, then handed the cup first to Hrotgar?So the Helming woman went on her rounds, queenly and dignified, decked out in rings, offering the goblet to all ranks, treating the household and the assembled troop (lines 612-623). As a queen, Wealhtheow has a role to fulfill and she does it with grace. She welcomes the guests; offers mead and creates a peaceful atmosphere in the mead-hall. The figure of Grendel?s mother is quite the opposite in this aspect- she is the ?anti- hostess? and far from being graceful. This creature does not greet the man who arrives to her dwelling; she fights Beowulf desperately and only a divine interference saves his life: ?It was hard-fought, a desperate affair that could have gone badly; if God had not helped me, the outcome would have been quick and fatal? (lines1657-1658). One can claim that these manners of Grendel?s mother are quite masculine. We find that she fights well and has the qualities of a great warrior if she was almost able to overcome Beowulf and she takes upon herself the manly duty of avenging her dead son. Beowulf himself says to Hrotgar that: ?It always better to avenge dear ones than to indulge in mourning? (lines 1384-1385). Taking vengeance for warrior?s death is noble but Grendel?s mother?s attentions are condemned by the poet ? she cannot be noble and she cannot act upon warrior?s code of honor; this notion comes from the fact that she is not really human and more impor... ...at queen does not trust her son to be a successful sovereign and she does not try to secure his future on the throne. Unlike Wealtheow and Grendel?s mother Hygd?s primary concern is to her people, not her son: ?There Hygd offered him throne and authority as lord of the ring-hoard: with Hygelac dead, she had no belief in her son?s ability to defend their homeland against foreign invaders? (lines 2369-2372). After a closer look in Beowulf one will find that the women roles in the poem are quite central and significant. They enrich the narrative by developing the plot and enlighten their men?s intentions. Nevertheless the women in the poem have their own will and power- political or physical. Thought some share similar qualities women characters are not patterned or superficial; these women are defined by dominant male figures but nonetheless they have their own significant features and depth. Works Sited: Anonymous. Beowulf. The Norton Anthology of English Literature. 7th Edition. Vol. I. (pp.32-99). Ed. Abrams, M.H., New York: W.W. Norton & Company, 2000. ?Germanic History and Culture?, Germanic Heritage Page, The Anglo-Saxon Domain www.anglo-saxon.demon.co.uk .

Case Study – Appendicitis

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