Respiratory free essay sample

It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patient who has just received morphine sulfate for postoperative pain C Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure. Cognitive Level: Application Text Reference: pp. 1799-1800 Nursing Process: Assessment NCLEX: Physiological Integrity ? 2. The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. We will write a custom essay sample on Respiratory or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS). A Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Assessment NCLEX: Physiological Integrity ? 3. When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of a. too-rapid movement of blood flow through the pulmonary blood vessels. b. incomplete filling of the alveoli with air because of reduced respiratory ability. c. decreased transfer of oxygen into the blood because of thickening of the alveoli. Mismatch between lung ventilation and blood flow through the blood vessels of the lung. C Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker, which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid pulmonary blood flow is another cause of shunt but does not describe the pathology of pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and perfusion are matched in pulmonary fibrosis; the problem is with diffusion. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation NCLEX: Physiological Integrity ? 4. A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include? a. Oxygen transfer into your blood is slow because of thick membranes between the small air sacs and the lung circulation. b. Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs. c. Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs.Blood flow though some areas of your lungs is decreased even though you are taking adequate breaths. D Rationale: A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, Oxygen transfer into your blood is slow because of thick membranes describes a diffusion problem. The remaining two responses describe ventilatio n-perfusion mismatch with adequate blood flow but poor ventilation. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation NCLEX: Physiological Integrity ? 5. A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to increased airway resistance A Rationale: The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Diagnosis NCLEX: Physiological Integrity ? 6. When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Monitor the patient every 10 to 15 minutes. b. Notify the patients health care provider immediately. c. Attempt to calm and reassure the patient. d. Assess vital signs and pulse oximetry. The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e. g. , increased oxygen flow if hypoxic). The change in the patients neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patients clinical status and may delay care. Cognitive Level: Application Text Reference: pp. 1804-1805 Nursing Process: Assessment NCLEX: Physiological Integrity ? 7. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern? a. The patient is sitting in the tripod position. b. The patient has bibasilar lung crackles. c. The patients pulse oximetry indicates an O2 saturation of 91%. d. The patients respiratory rate has decreased from 30 to 10/min. D Rationale: A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation. Cognitive Level: Application Text Reference: p. 1804 Nursing Process: Assessment NCLEX: Physiological Integrity ? 8. To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry. A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both. Cognitive Level: Comprehension Text Reference: p. 1805 Nursing Process: Assessment NCLEX: Physiological Integrity ? 9. A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min. B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain. Cognitive Level: Application Text Reference: p. 1806 Nursing Process: Assessment NCLEX: Physiological Integrity ? 10. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patients arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patients oropharynx. d. increase the oxygen flow rate. D Rationale: Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. Cognitive Level: Application Text Reference: pp. 1802, 1807 Nursing Process: Implementation NCLEX: Physiological Integrity ? 11. A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP) B Rationale: The patients lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patients respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patients respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. Cognitive Level: Application Text Reference: pp. 1807-1808, 1810 Nursing Process: Planning NCLEX: Physiological Integrity ? 12. A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patients room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions. D Rationale: The patients assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange. Cognitive Level: Application Text Reference: p. 1809 Nursing Process: Planning NCLEX: Physiological Integrity ? 13. When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowlers position. d. in the tripod position. B Rationale: The patient should be positioned with the good lung in the dependent position to improve the match between ventilation and perfusion. The obese patients abdomen will limit respiratory excursion when sitting in the high-Fowlers or tripod positions. Cognitive Level: Comprehension Text Reference: pp. 1809-1810 Nursing Process: Implementation NCLEX: Physiological Integrity ? 14. When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patients SpO2 is 90%. c. The patient complains of weakness. d. The patients blood pressure is 162/94. A Rationale: Increasing somnolence will decrease the patients respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. Cognitive Level: Application Text Reference: p. 1804 Nursing Process: Assessment NCLEX: Physiological Integrity ? 15. The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patients temperature is 101. The patients SpO2 has dropped to 90%, although the O2 flow rate has been increased. D Rationale: The patients dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patients blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Assessment NCLEX: Physiological Integrity ? 16. When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patients family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. The infection spread through the circulation from the urinary tract to the lungs. b. The urinary tract infection produced toxins that damaged the lungs. c. The infection caused generalized inflammation that damaged the lungs. d. The fever associated with the infection led to scar tissue formation in the lungs. C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever. Cognitive Level: Application Text Reference: p. 1813 Nursing Process: Implementation NCLEX: Physiological Integrity ? 17. All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg C Rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Implementation NCLEX: Physiological Integrity ? 18. After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. positioning the patient for a chest radiograph. b. drawing blood for arterial blood gases. Obtaining a ventilation-perfusion scan. d. inserting a pulmonary artery catheter. D Rationale: Pulmonary artery wedge pressure will remain at normal levels in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Implementation NCLEX: Physiological Integrity ? 19. Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patients PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields. A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Assessment NCLEX: Physiological Integrity ? 20. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. PEEP will prevent fibrosis of the lung from occurring. b. PEEP will push more air into the lungs during inhalation. c. PEEP allows the ventilator to deliver 100% oxygen to the lungs. d. PEEP prevents the lung air sacs from collapsing during exhalation. D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. Cognitive Level: Comprehension Text Reference: p. 1817 Nursing Process: Planning NCLEX: Physiological Integrity ? 21. When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The skin on the patients back is intact and without redness. b. Sputum and blood cultures show no growth after 24 hours. c. The patients PaO2 is 90 mm Hg, and the SaO2 is 92%. d. Endotracheal suctioning results in minimal mucous return. C Rationale: The purpose of prone positioning is to improve the patients oxygenation as indicated by the PaO2 and SaO2. The other information will be  collected but does not indicate whether prone positioning has been effective. Cognitive Level: Application Text Reference: pp. 1817-1818 Nursing Process: Evaluation NCLEX: Physiological Integrity ? 22. A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patients family members are anxious about the patients condition and are continuously present at the hospital. In addressing the familys concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patients chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility. d. provide hope and encouragement to the family because the patients disease process has started to resolve. A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process. Cognitive Level: Application Text Reference: p. 1814 Nursing Process: Implementation NCLEX: Psychosocial Integrity ? 23. The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101. 2 ° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patients vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg. B Rationale: The patients increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient. Cognitive Level: Application Text Reference: pp. 1813-1814 Nursing Process: Implementation NCLEX: Physiological Integrity ? 24. Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures C Rationale: Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

Trinity Church and John Hancock Skyscraper in Copley Square essays

Trinity Church and John Hancock Skyscraper in Copley Square essays Copley Square in Boston is a historic landmark of Boston, Massachusetts, that remains to be one of the defining features of the city, both due to its historical and architectural significance, but also in part because of its unique open-space setup filled with trees, flowers, and grass. The incredible architecture of Copley Square that spans the style and history of many decades, combined with the park-like atmosphere of the plant life, is able to transport any visitor to a different state of mind, and it serves as a great escape from the dark alleys and traffic pollution of Boston. One of the fascinating things about the Copley Square area is that it was once a tidal marsh unable to support any buildings until the Back Bay was filled. (Wieneke.) Two of the defining landmarks of Copley Square are the Trinity Church and the John Hancock skyscraper. The original Trinity Church in Boston was was built by John Indicott in the 1700's. (Norton) However, in 1860 the Vestry voted to move the church to a new location. In January of 1872, a 24,800 square foot plot of land was purchased in Boston, having been carefully chosen as the site for the church, and soon after committee meetings began to review architectural plans for the building. Gambrill and Richardson, a firm of H. H. Richardson, was commissioned to design the church. Additional funds were set aside for the building, allowing for an additional plot of land to be purchased, adding nearly 15,000 feet to the original plan. The church is surrounded on all sides by streets, not other buildings which would restrict the view of the church. In April of 1873, engineers began driving wooden pilings, most of which were completed from July to September of this year. However, the Vestry became discouraged by the building cost estimates ranging from a soaring $355,000 to $640,000 and they halted work on the building unt...

International Human Resource Management Essay Example | Topics and Well Written Essays - 3000 words - 1

International Human Resource Management - Essay Example The HRM policies therefore ran into several bottlenecks caused by these prevailing differences which resulted in a review of some of the policies. Since there was still a need to maintain some kind of general standard of HRM policies that applied across the board, the idea of International HRM came up. This need was further enhanced by the process of globalization which enabled organizations to do business all over the globe, including in places they could not dream of reaching before (Beardwell & Claydon 13). This paper explores the extent to which standardization of HRM policies has taken place across the globe. This will be done by examining the contribution of globalization to HRM policy standardization, the comparison of two different regions of the globe to gauge the extent of this globalization and a projection into the future of HRM practices. Globalization and Standardization of Human Resource Management The management of employees at all levels in a multinational company or conglomerate is referred to as strategic human resource management [SHRM] (K’Obonyo & Dimba 3). ... America is a liberal society that is fully focused on such things as human rights, open market policies, equal opportunities and gender equity among other things. The environment in Saudi Arabia is more religion oriented with a massive influence of Islam on day to day life. Issues such as equal opportunity and equity are just emerging but are not as important as the Islamic influence (K’Obonyo & Dimba 3). Consequently, successful human resource management policies in America may not work so successfully in Saudi Arabia. Emphasis on gender equity in the latter may raise more friction than it would in the former since certain roles are regarded as male roles that women cannot successfully handle. Attitudes are changing very slowly on the role of women as CEOs for example (Delery & Doty 802). SHRM therefore comes in to take into account such disparities in culture so as to enable effective and successful policy frameworks for human resources in diametrically different cultural en vironments. Policies are shaped according to the cultural environment rather that against them. In any case it is not the aim of businesses to change the prevailing political environment but to adapt as much as possible for the smooth running of the business and maximal output in terms of profitability (Delery & Doty 803). SHRM takes into account Cultural Value Dimensions. This term is used to refer to the empirical criteria used to determine the extent to which national cultures differ. There are four such dimensions: power distance paradigms, uncertainty avoidance mechanisms, individualism-collectivism factors and masculity-feminity issues (Hofstede 42). Power distance is the terminology for the extent to which the lower cadre

Business Systems Analysis and Design Coursework - 1

Business Systems Analysis and Design - Coursework Example Performance appraisals build effective habits among members such as employees are able to clearly understand the organisational goals and identifying the best way forward to meeting these goals. Managers ensure that they evaluate the best process that will be able to improve the performance of their employees (Jones, 1997). In this process managers should be capable of ensuring that the team members achieve their goals and objectives. Team members should also be improving constantly and developing in their skills to become in order to become a great asset to the organisation. Managers should ensure that the hindrances to improvement are addresses by having a personal conversation with team members and listening to every issue. The issues and concerns raised should be solved immediately and in the most effective manner in order to avoid major issues in the future. Managers should also be in a position of asking themselves whether their employees are achieving the desired expectations of the business and whether they have the potential to achieve these goals. Finally managers should be able to gauge how much the employees have improved since the previous appraisal or the value they have added to their development since the manager started supervising. Once the above goals are well focused, then managing people will become an easy process. Kate (2011) describes that effective management include assessing the current situation of a team member, setting effective goals and working together to ensure that member achieves those goals. The first step in managing people is to have a clear vision. The managers should be able to be precise on the expected performance by analysing the role of every team member. These expectations should then be communicated to the team members informing them to be accountable of their activities. The second step of effective people management is to make the expectations clear to the team members. The objectives should be discussed in a pos itive way to the members and the manager should communicate the ongoing basis for the team member to know exactly what they have achieved and what is remaining to attain their target. The third step involves letting the team members be aware that their work is of value to the entire organisation. Richard et al. (2009, p. 50) shows this involves a short brief to everyone reminding them of the purpose of the organisation, the purpose of the team and the benefits to other departments. Managers should make sure that the team members are aware that they play a major part in achieving the entire output of the organisation. This should be a continuous assessment that the supervisor has to show to their members. This makes the employees feel valued therefore making them motivated to performing better. The forth step involves getting to know each team member basing on their abilities, skills and personal behaviour. This will make you understand them well and it also improved mutual respect. 2. Rich picture Rich pictures represent processes, structures and issues within an organization that are relevant to the problem definition. These also provide a thinking model about the system, how to think about the system and also how to group pertinent issues. Rich pictures also enable an

An Analysis of the Plot of True Grit Essay Example | Topics and Well Written Essays - 750 words

An Analysis of the Plot of True Grit - Essay Example III. Maddie begins for her search for Chaney A. Marshall Cogburn tries to discourage her from joining the quest but she refuses to be dissuaded from doing so. B. Marshall Cogburn and Maddie begin looking for clues to Chaney’s wherea\bouts 1. They discover that Chaney used one of Frank’s gold pieces in the Indian territory. 2. They meet Quincey and Moon and encounter the Pepper Gang. IV. Maddie comes face to face with Chaney who tries to kill her. A. Chaney gets killed B. Maddie gets bitten by a snake but Cogburn saves him The movie â€Å"True Grit† is the story of a young girl’s determination to seek justice for the death of her father. The viewer learns this immediately from the girl named Maddie Ross who explains at the beginning of the film how her father was killed by a man named Tom Chaney. The succeeding segment of the film show the steps taken by Maddie as she goes on a quest to find her father’s killer. One of the important things that she d oes is find a person like Marshall Cogburn to help her in bringing Tom Chaney to justice. At the onset, it appears that it is only Maddie who is on a quest to seek her father’s killer. The viewer discovers however that a Texas Ranger named Le Bouef is also looking for Tom Chaney who murdered a senator in Texas. ... One of the important elements of the film that was significant was the characters themselves. The quest for Tom Chaney brought out the best in Maddie, Marshall Cogburn, and the Texas Ranger LeBouef. Maddie was able to demonstrate that in spite of her age, she acted with great courage and wisdom. She knew where she was going and what she had to do. It is for this reason that Cogburn, who thought of her as a child acting on impulse, could not easily get rid of her. One must remember that the reason why she bought a horse and went along on the quest was to make sure that she’s going to get her money’s worth. Marshall Cogburn who was portrayed as a drunk showed that he has some decency left in him when he decided to forget all about the reward money and honor the deal he and Maddie made. He also showed his displeasure for cruelty when he stopped LeBouef from spanking Maddie and when he knocked off two Indian boys who were hurting a mule. Above all, he showed true grit when he carried the wounded Maddie for several miles to get her to a doctor. LeBouef also lived up to his being a Texas Ranger when he came back for Maddie who almost got killed by Tom Chaney. The pattern followed by the film involves an incident that takes place and forces the leading character to go on a quest. Knowing that the quest is difficult, the leading character recruits others to help him or her succeed in achieving his or her goal. In the case of Maddie, she gets help from Cogburn and LeBouef. The characters encounter several challenges that tend to derail them from achieving their goal but they are able to overcome these obstacles. Maddie for instance failed to be dissuaded by Cogburn and LeBouef,

Eduardo Bonilla-Silvas Book, Racism Without Racists Essay -- Color Bl

Race has been an issue in North America for many years. Eduardo Bonilla-Silva discusses the new racism in his book, Racism without Racists. Bonilla-Silva classifies the new racial discrimination as color blind racism. Color blind racism is then structured under four frames (26). Color blind racism is believed to have lead to the segregation of the white race from other minorities called white habitus. Color blind racism and white habitus has affected many people, whom don’t even realize that they are, have been or will be affected. Color blind racism is an â€Å"ideology, which acquired cohesiveness and dominance in the late 1960s, explains contemporary racial inequality as the outcome of nonracial dynamics,† according to Bonilla-Silva (2). In order to analyze color blind racism, Bonilla-Silva relies â€Å"mostly on interview data (11)† through a 1997 Survey of Social Attitudes of College Students and a 1998 Detroit Area Study (DAS) (12). Bonilla-Silva then breaks down the analysis of color blind racism into four central themes to convey how whites explain a world without racial issues: abstract liberalism, naturalization, cultural racism, and minimization. Abstract liberalism is â€Å"ideas associated with political liberalism and economic liberalism† (28). Abstract liberalism is used for a wide range of issue therefore Bonilla-Silva gives a few different examples of when this frame is used. Rationalizing Racial Unfairness in the Name of Equal Opportunity was used when asking white students â€Å"if minorities should be provided unique opportunities to be admitted into universities† (31). Most whites will state that everyone should have an equal opportunity. Those whites, â€Å"ignored the effects of past and contemporary discrimination on... ...with other races and eventually it will become second nature. Obviously, the government cannot make those integrated communities communicate but I believe that with time neighbors will start to talk to one another or if nothing else some type of promotion for community block parties, similar to when I was a kid, would assist in the communication process. That is how I remember meeting the neighbors. Community block parties are non-existent now days but I believe they are beneficial to everyone! With a little effort from everyone, we can make it happen, a life without racism! References Bonilla-Silva, Eduardo (2003). Racism without racists. Lanham, Maryland: Rowman & Littlefield Publishing Group. Charles, Camille (2003). The dynamics of racial residential segregation. Annual Review of Sociology, 167. Retrieved from http://jstor.org/stable/30036965.

Opioid Substitution Treatment Barriers Health And Social Care Essay

ISSUES. Opioid permutation intervention is internationally recognised as the most effectual intercession available to handle opioid dependance. There is concern that capacity at public clinics and pharmaceuticss is deficient to run into high demand, ensuing in a cohort of opioid-dependent patients left untreated. Research has focussed on pharmaceutics barriers to OST bringing but small is known about the public clinic sector. APPROACH. A narrative reappraisal was conducted by thorough scrutiny of relevant literature in electronic databases ; Medline, CINAHL and Cochrane. Cardinal FINDINGS. Despite the enlargement of OST and vacancies in pharmaceuticss, some opioid-dependent patients continue to confront barriers that block entree to intervention. These barriers are varied and multi-faceted. For the patient, stigma and a compulsory dispensing fee are important deterrences to pharmacy dosing. For the druggist, negative behaviors associated with OST patients such as debt, larceny and aggressive behavior and full capacity are grounds that impede proviso of OST. In public clinics, the backlog of stable patients non being transferred to pharmacy dosing is a suspected barrier that has non been extensively investigated. IMPLICATIONS. Research has explored pharmaceutics and patient barriers to OST entree but less is known about the public clinic barriers. More research is warranted into public clinics to clarify possible barriers of all grades of the OST system. CONCLUSION. This reappraisal emphasises the dearth of research into OST bringing in public clinics. Further probe into the processs of OST in clinics is necessary and should concentrate on patient appraisal, referral and direction. Keywords: opioid permutation intervention, pharmaceutics, clinic Word count: 246 Researching barriers to opioid permutation intervention in pharmaceuticss and public clinicsIntroductionOpioid dependance carries a scope of important inauspicious wellness, economic and societal jobs to the person and wider community, including the hazard of overdose, the spread of infective diseases ( HIV/AIDS, hepatitis B and C ) , psychological jobs, drug-related offense, wellness impairment and household break [ 1, 2 ] . Opioid permutation intervention ( OST ) is internationally recognised as the most good and cost-efficient pharmacological intercession available for the intervention of opioid dependance [ 3, 4 ] . In response to an addition in the Australian population of heroin-dependent users in the 1990s [ 5, 6 ] the authorities introduced OST as a injury minimization scheme to understate these inauspicious effects [ 7 ] . Since so OST bringing has steadily increased under the National Pharmacotherapy Policy and National Drug Strategy [ 7, 8 ] . The figure of patients has ri sen in surplus of 2,000 clients per twelvemonth since 2007 and at the clip of authorship, there are presently over 46, 000 clients having intervention in Australia entirely [ 8 ] . In Australia, OST involves supervised day-to-day dosing of one of three long-acting opioid replacing medical specialties ( dolophine hydrochloride, buprenorphine or buprenorphine/naloxone ) . Most new patients are initiated into intervention by the doctor at a public clinic under the supervising of a nurse or instance director. In this scene they have entree to single instance direction, reding and specialist medical support at no charge. Once they become stabilised on intervention, patients are encouraged to reassign their dosing to a community pharmaceutics [ 2 ] , thereby emancipating their dosing topographic point at the public clinic for a new patient. There is a concern that this tract is non every bit smooth as it appears. As at June 2008, an estimated 41,000 opioid dependent people in the community were still unable to entree intervention and the job is declining [ 9 ] . Confusing the job is the fact that there is no bing agencies of measuring the precise demand for intervention and no systematic monitoring of waiting times in the pharmacotherapy system [ 9 ] . Proposed accounts for this issue are varied and multi-faceted. It is believed the system capacity at both the populace clinics and the community pharmaceutics degrees may non be sufficient to suit the high demand for OST, therefore the ground why an estimated 50 % heroin-users are non in intervention. Previous surveies have investigated the pharmaceutics barriers to OST but at that place appears to be a deficiency of research into the drug and intoxicant clinics [ 10, 11 ] . This reappraisal aims to research the literature refering to OST in Australia. In peculiar the reappraisal will look into the grounds for the â€Å" unmet demand † [ 9 ] of opioid dependant patients necessitating these services and the bing barriers to the proviso, entree and consumption of OST faced by both patients and healthcare suppliers.MethodA narrative literature reappraisal was conducted by thorough scrutiny of the literature in 3 electronic databases Medline, CINAHL and Cochrane. The undermentioned keywords and phrases were searched: â€Å" opiate ( opioid ) permutation ( replacing ) intervention ( therapy ) † , â€Å" referral † , â€Å" dolophine hydrochloride † , â€Å" buprenorphine † , â€Å" pharmaceutics † , â€Å" drug and intoxicant clinic † , â€Å" drug wellness clinic † and â€Å" harm minimization † . The mentions of relevant literature were besides searched. Documents were eligible for inclusion if they were written in English and published between the old ages 2000 and 2012. Documents were excluded if they chiefly focused on detoxification plans, naltrexone intervention, dolophine hydrochloride for hurting alleviation or if they pertained to patients other than big opioid-dependent patients. A comprehensive hunt of Australian cyberspace resources was besides conducted. The primary sites were Australian national and province authorities wellness policy and statistics sites ( hypertext transfer protocol: //www.druginfo.nsw.gov.au/ , hypertext transfer protocol: //www.aihw.gov.au/ , hypertext transfer protocol: //www.health.nsw.gov.au/ , hypertext transfer protocol: //www.nhmrc.gov.au ) and the UNSW National Drug & A ; Alcohol Research Centre ( NDARC ) .RESULTS AND DISCUSSION:Several surveies have shown OST to be associated with benefits including reduced illicit opioid usage, lower associated offense rates and improved wellness results [ 3, 12, 13 ] . It has besides been demonstrated to be more extremely cost-efficient than detoxification or rehabilitation [ 4 ] . In response to increasing demand, the figure of dosing sites in Australia has increased from 2,081 ( 2005-06 ) to 2,200 ( 2009-10 ) with the major addition being in the figure of new pharmaceuticss taking to offe r OST services [ 8 ] . Community pharmaceuticss are the chief suppliers of OST in Australia, accounting for 43 % of OST patients in NSW. This is in line with other states such as the UK, France, Germany and New Zealand where pharmaceutics is emerging as a head of OST proviso [ 14-16 ] . Although pharmacy proviso of OST has expanded, there are still people who can non entree these dosing sites, restricted by certain barriers. The lone solid grounds of these people is on waiting lists, but presently in Australia there is no official demand to supervise waiting lists or capacity [ 9, 17-19 ] . Factors explicating the inability of OST plans to run into current demand are multifaceted and interconnected and scope from deficient figure of intervention topographic points depending on location to barriers faced by patients in accessing OST such as rural location or restricted dosing hours. Much research has focussed on the challenges faced by suppliers of OST services, viz. community pharmaceuticss, GPs and public clinics.OST in community pharmaceuticsCommunity pharmaceutics histories for 43 % of OST patients in NSW. Most surveies on OST proviso are survey-based. In a study of NSW public clinic patients, 80 % of participants preferable pharmaceutics dosing over the clinic [ 20 ] . Benefits of pharmaceutics that have been cited in patient studies include greater community integrating, a more stable dosing environment, flexible dosing hours, less travel clip and cost ( the patient may be referred to a pharmaceutics closer to their reference ) and the chance for regular takeout doses [ 20-22 ] . Takeouts are extremely valued by opioid dependent patients as they facilitate the standardization of life [ 21 ] . Patients can devour their dosage unsupervised and the decreased frequence of dosing attending allows clients to prosecute employment and instruction chances and fulfil household duties. Sing they are merely routinely given to stable patients in community pharmaceuticss and non by and large in public clinics, takeouts are a major inducement to pharmaceutics dosing. Although demand and patient penchant for pharmaceutics dosing is high, patients may still confront barriers that deter them from come ining into pharmaceutics intervention. Stigma Whilst patients on OST reported high degrees of satisfaction, a common issue in dosing sites was the presence of negative staff opinion and stigma [ 10, 21, 22 ] . When Deering et Al. ( 2011 ) asked New Zealand OST patients how intervention could be improved, an overpowering bulk identified ‘better intervention by staff ‘ [ 10 ] . The position that staff behavior could be improved was supported in a study by Kehoe et Al. ( 2004 ) nevertheless contrastingly 80 % of respondents besides reported that staff intervention was satisfactory or first-class [ 21 ] . This disagreement suggests that whilst patients were overall satisfied with staff intervention, they still felt the demand for betterment. Financial load Another common hindrance to OST identified in the literature is the fiscal load of intervention faced by patients [ 11, 20, 22, 23 ] . Whilst intervention costs in NSW public clinics are to the full subsidised by the province authorities, pharmaceutics dosing incurs a hebdomadal dispensing fee runing from about $ 30- $ 35 [ 22 ] . In one survey, 32 % of public clinic patients surveyed claimed they could non afford the pharmaceutics distributing fees perchance explicating their involuntariness to reassign to pharmacy [ 20 ] . The balance were merely able to pay an mean $ 10 a hebdomad, an sum well lower than $ 33.56, the average hebdomadal dispensing fee reported by Lea et al [ 22 ] . The fact that 23 % pharmaceutics clients owed the pharmaceutics money for dosing [ 22 ] confirms that a significant figure of OST clients struggle to afford pharmaceutics distributing fees. The theoretical account used in Canberra in which 50 % of the distributing fee is subsidised, [ 24 ] is intended to ease the pecuniary load and act as an added inducement for intervention keeping or entryway. No surveies have yet evaluated the consequence of lower fees on patient keeping times. From the druggist perspective client debt likewise serves as a deterrence against the bringing of OST or uptake of new patients. Other jobs related to behavioral disinhibition, aggression, larceny and the negative impact on concern and other clients have all been identified as grounds impacting druggists ‘ proviso of OST [ 25, 26 ] . In contrast to pharmacist concerns, one survey in the UK interviewed pharmaceutics clients and found the bulk to be overall supportive of pharmaceuticss presenting drug user services [ 14 ] , with the specification that privateness was necessary. The demand for equal privateness is in line with OST patient positions [ 22 ] . However qualitative informations was sourced from interviews which may be skewed by interviewee disposition to give socially desirable replies. Role of the GP prescriber Another common job experienced by community druggists is the trouble reaching prescribers and the prescribing of takeout doses to unstable patients [ 26 ] . Pharmacists identified the hazard of recreation of takeout doses and hapless appraisal of stableness as issues that required improved interprofessional coaction with prescribers. Interestingly in one survey a bulk of druggists agreed that prescriber communicating was equal, nevertheless little sample size and the rural location which tends to further closer interprofessional relationships may be accountable [ 27 ] . Winstock et Al. ( 2010 ) recommends the public-service corporation of standardized resources such as the NSW Department of Health ‘Patient Journey Kits ‘ to steer multidisciplinary attention of OST patients [ 26, 28 ] . Another facet lending to system capacity is the reduced supply of prescribers for OST. GPs are frequently the first point of contact for opioid-dependent people. They are required to set about extra preparation to go commissioned opioid pharmacotherapy prescribers [ 29 ] . GPs play an intrinsic function in the initial showing, appraisal and on-going feedback and monitoring of OST clients. The issue lies in the ripening work force and the retirement of commissioned prescribers, thereby cut downing intervention entree [ 17 ] . Public clinics are the lone prescribing option but considerable barriers including full system capacity and the deficiency of motion of stable patients out of clinics into pharmaceuticss besides limit the public clinics ability to suit excess patients. Unexplained vacancies Despite grounds of an â€Å" unmet demand † [ 9 ] , a survey conducted by the National Drug and Alcohol Research Centre ( NDARC ) found that more than half of OST-providing pharmaceuticss reported an norm of 7 vacancies to dose extra patients. Data extrapolation of to all NSW pharmaceuticss registered to present OST suggests that there are about 3000 vacant dosing topographic points across NSW. Whilst a 3rd of pharmaceuticss in the survey were runing at full capacity, some pharmaceuticss reported functioning no clients [ 18 ] . This spectrum of clients across registered pharmaceuticss and the being of current vacancies exemplify the underutilisation of community pharmaceutics dosing topographic points. However the fact that these vacancies may non ever be located where the demand is highest has to be taken into consideration. For illustration patient entree to intervention in rural locations is frequently restricted due to limited pharmaceutics Numberss and longer going distan ces [ 25 ] . From the literature, it appears NSW pharmaceuticss have the capacity to increase consumption of clients, with a possible 70 % of pharmaceuticss capable but non willing to supply OST services. Factors identified that would promote druggists to increase client Numberss include the stableness of the patient, higher fiscal additions per client and the option to instantly return unstable patients to public clinics [ 18 ] . However some public clinics expressed concern about taking back unstable patients, proposing there was no warrant of available dosing capacity, one time a new patient had been inducted [ 18 ] .OST in public clinicsEntree to OST is determined by both the handiness of pharmaceuticss supplying OST every bit good as the capacity of public clinics to take on extra clients [ 19, 26 ] . However harmonizing to an expansive NSW state-wide study on OST by Winstock et Al. ( 2008 ) , there appears to be an underutilisation of available pharmaceutics dosing sites and limited capacit y in public clinics [ 19 ] . Whilst the bulk of literature has focussed on pharmaceutics proviso of OST, relatively less research has been conducted into the public clinic grade of the OST system despite representing 19 % of dosing patients in NSW [ 8 ] . Public clinics have become an increasing country of involvement driven by studies that the motion of stable patients through the clinics out to community pharmaceuticss appears to be dead [ 17, 19 ] . This is ensuing in a backlog of patients barricading new patients from accessing intervention at the clinics. The proportion of stable patients transferred from the clinics to pharmaceuticss is estimated to be really low at 3-15 % a month [ 18 ] . Surveyed patients have cited a reluctance or inability to afford a dispensing fee and feeling dying about reassigning [ 20 ] as grounds against transportation. Precedence groups Intensifying the limited capacity of public clinics is the duty of supplying priority entree of vacancies to groups that meet standards stipulated under NSW Health directives [ 2, 7 ] . Cohorts include released captives, pregnant adult females, people with HIV, hepatitis B bearers and those on a recreation plan as ordered by the tribunal. [ 19 ] Similarly clients that show hazardous forms of illicit substance maltreatment such as those with mental unwellness and intoxicant dependance, or those that exhibit aggressive or antisocial behaviors are better managed at the public clinic instead than at a pharmaceutics. As a consequence many patients who do non run into ‘priority ‘ position are forced to wait. Obviously there is a demand to increase the efficient transportation rate of patients out to pharmaceuticss to do infinite for these clients. As antecedently mentioned, there is no consistent systematic process or set guidelines to help clinicians in covering with these iss ues and as of yet, no research has been conducted on their response to pull offing these issues. A 2008 SWAT study of NSW public clinics reported that when unable to offer immediate intervention, clinics either provided injury decrease advice referred to another public clinic, a private clinic or a GP, or offered detoxification. The assortment of actions and the effectivity of each have non been assessed and look to be decided upon at the discretion of the presiding OST practician at the clinic. Recommendations by the SWAT squad include developing a standardised response when a clinic can non offer a intervention topographic point to a client, and systematic monitoring of capacity to explicate more timely intervention in the hereafter [ 19 ] . Stability appraisal and referral processs An obstruction inherent to the pharmacotherapy system is the clinical appraisal of patient stableness and referral process. The triage function of stableness appraisal is usually coordinated by Nursing Unit of measurement Managers ( NUMs ) or a cardinal stakeholder in the public clinic and involves reexamining patient dosing history and behavior and placing those suited for transportation [ 30 ] . Currently no surveies into the clinical function or preparation of NUMs in OST proviso have been conducted. Soon determinations are guided by clinical opinion. The lone available counsel is limited to authorities policy, instead than scientific grounds and no standardized guidelines exist [ 30 ] . Whilst there are over 300 hazard appraisal instruments available to mensurate results of patients in drug and intoxicant intervention, no individual standardised attack has been nationally adopted or endorsed for OST [ 30 ] . A survey by Winstock et Al. ( 2009 ) found that execution of a province broad preparation plan improved client stableness appraisal with 25 % of staff increasing the figure of clients transferred out to community pharmaceutics [ 31 ] . However the objectiveness of this survey was affected as the method involved clinicians self-reporting cognition and accomplishments prior to and after preparation. However the survey provides preliminary grounds that acceptance of standardized appraisal processes increases the transparence of clinical determinations and can better entree to O ST [ 19, 31 ] . As above-named there appears to be underutilisation of community pharmaceutics OST services with some dosing at full capacity, whilst at the other terminal of the spectrum, some pharmaceuticss serve no patients. The bulk of pharmaceuticss reported vacancies. Whilst 75 % of clinics reportedly monitored available capacity within local pharmaceuticss, it is possible that the remainder are directing clients to overfilled dosing sites [ 18 ] . No formal survey has as of yet explored how clients refer and allocate patients to pharmaceuticss and how pharmaceuticss are selected.DecisionFrom the reappraisal of the literature, there is grounds to propose that the current opioid permutation intervention capacity may non be sufficient to run into demand for intervention. Several barriers have been identified that restrict patient entree to intervention. Pharmacy barriers include the minority of community pharmaceuticss that opt in to present dosing, pharmacist reluctance to take on new patients due to perceived associated negative behaviors and old experiences and patient involuntariness or inability to pay the dispensing fee. The deficiency of prescribers is another aspect contributing to the decreased entree to available intervention. An country of involvement is the part of the public clinic grade of the OST system, nevertheless there is an evident dearth of research conducted into the direction of OST entree in public clinics. The dead flow of stable patients reassigning dosing from the public clinics to community pharmaceuticss is suspected to be impacting entree to intervention for new patients who do non run into precedence standards and are forced to wait. There is preliminary grounds to propose that a standardized attack to stability appraisal may ease stable patient transportation and liberate dosing sites in clinics for non-priority groups. Further research needs to be conducted into the stableness appraisal and referral processs of OST, the bing tools and processs and how effectual they will be in shuting the spread between demand and supply of OST.