Assessment of Vulnerability and Adaption to Climate Change

ASSESSMENT OF THE VULNERABILITY AND ADAPTION TO CLIMATE CHANGEQUESTIONNAIRE No.INTERVIEWEE NAMEINTERVIEWED DATE____/____/2014Part A: Family Information 1. Name of interviewee: ____________________________________________________Male ___ Female____ 2. Relation to the family held: ____________________________________ Telephone: ____________________ 3. Religion a. Islam _______ b. Christian__________ c. Others _______ 4. Name of small town: 1. Kipini _______________ 2. Ozi ___________________ 3. Kilelengwani ____________ Part B: Composition OF HOUSEHOLD AND HUMAN CAPITALFamily memberPresently present ( P/A )Gender ( M/F )Age ( old ages )Marital position ( 1. Married 2. Unmarried 3. OthersEducation degree 0 – none 1. Primary 2. Secondary 3. High school 4. Certificate/Diploma 5. Bachelor 6. MaestroCondition of wellnessTechnical accomplishmentsNumber of yearss in the past 12 months unable to transport out support activitiesNameNumberPart C. PHYSICAL AND NATURAL CAPITALName of Rhizophora mangle related physical capitalMeasureValue at market monetary valueObservations/ notesPart B. ( PRODUCTION ACTIVITIES ) OF YOUR FAMILY ( KEY NATURAL RESOURCE DEPENDENT LIVELIHOOD ACTIVITIES ) 1. What is your family’s chief beginning of income? ( What is your family’s cardinal support? ) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — – — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — – 2. Could you delight name the other beginnings of income, in order of importance?Livelihood/jobWhereRating3. Calendar of support activities:Support activitiesJanFebMarAprMayJunJulAugSeptOctNovDec4. Please rate the importance ( value ) of natural resources ( Rhizophora mangles ) in to your support and day-to-day life:Natural resourceImportance5. Changes ( e.g. , Total country, location and quality ) of natural resources that relate to your support from 2000 up to nowNatural resourceChanges in 2000 – 2011AreaLocationQuality6. Make your family own a house? 1. Yes 2. No 7. If yes, what is the current market value ( Kshs ) _________ 8. How many roomw does the house have _______________ Family ACTIVITIES AND ASSOCIATED FINANCIAL CAPITALFamily memberBeginning of incomeEstimate of clip invested ( days/ twelvemonth )Estimate of income degree ( Kshs/yr )1.2.FisheriesAgribusinessAgricultural labourerCattle/ domestic fowl rise upingBusinessOccupationSelling firewood3. OthersInterest from deposited moneyInterest from money loaningRentSocial security benefitsOthers ( relations, contribution )OtherSocial capital C. NATURAL HAZARD RISKS, HUMAN IMPACTS AND RESPONSE 10. Make you retrieve, in the past 10 old ages, that your local community experienced any natural jeopardies or unusual conditions conditions ( delight grade X on the months that it happened ) ?JanFebMarAprMayJunJulAugSeptOctNovDecHigh temperature ( warm )DroughtsFloodTidal inundationLow temperature ( cold )Other unusual jeopardies11. Compared to the past 10 old ages, how have the usual conditions conditions changed?JanFebMarAprMayJunJulAugSeptOctNovDecHigh temperature ( warm )DroughtsFloodTidal inundationLow temperature ( cold )Other unusual jeopardies12. In the past 10 old ages, did your community experience any troubles ensuing from authorities ordinances on land/crops/hydro-construction or were there any self-generated activities of local occupants that affected the area’s support ( please list in the tabular array below ) ?Factors/ causesLivelihood/agricultural production theoretical accountDamage13. Loss in production and day-to-day life due to unusual conditions conditi ons in the past 10 old ages,JanFebMarAprMayJunJulAugSeptOctNovDecPoor harvestsLack of imbibing H2OCattle diseasePlant diseasesHuman diseasesHouse harmLosing occupationPlease explicate harm causes? _________________________________________________________ _________________________________________________________ 14. Loss in production and day-to-day life due to presently unusual conditions conditions?JanFebMarAprMayJunJulAugSeptOctNovDecPoor harvestsLack of imbibing H2OCattle diseasePlant diseasesHuman diseasesHouse harmLosing occupationPlease explicate harm causes? _________________________________________________________ _________________________________________________________ Respondents will be asked to name the types and Numberss of conditions and clime events impacting them and so name down their impact degrees. Three different impact degrees will be used: Increased, Stable and Decreas C. HOUSEHOLD HISTORY 1. Is the above reference family head’s birth topographic point? Yes ( 1 ) / No ( 0 ) If no go inquiry 2 ; if yes go inquiry 4. 2. When have your family migrated? 3. From where have you come here? ( Village: Union: Upazila: ) 4. Why did your family move to this small town? 5. When did your ain family start? 6. Please reference all the old economic activities of your familyYear ( from, to )Previous economic activitiesReason for altering occupation/activitiesObservation/notesAppendix B – Checklists for Oral History Interviews Purpose Oral history interviews were used to garner in-depth information on impacts, responses ( both short- and long-run ) and restraints to responses to climatic dazes and emphasiss of families and their supports in each community. Common checklists for the families of all three survey communities How climatic dazes and emphasiss impact your family ( negatively or positively ) both inland and at sea? Dazes and emphasiss include: – cyclones – inundations – sea degree alterations – land eroding, and – fluctuations in temperature and rainfall – others Impacts on – support capital assets, – substructure, societal services, markets, transforming constructions and procedures, – support activities and schemes ( piscaries or non-fisheries related ) and – overall supports. How you tackle these, both in the short-run and in the longer-term? What things facilitate or constrain while undertaking these? What things help most while undertaking these and how? What things constrain most while undertaking these and how? What are the tendencies ( both frequence and strength ) in the above dazes and emphasiss? What have you learned from the above? In future how are you traveling to undertake these? How can others, outside your families, aid undertake these? – 229 – Extra checklists for the families of Kutubdia Para Why and how did your family migrate? Why did you migrate to Kutubdia Para? Why did you non migrate to other topographic points? Which factors influenced you to travel? Was there any support from non-government beginnings? Was there any support from authorities? How did migration impact your life? What things and how helped or constrained you go oning or bettering your life here? Can you state whether migration is/was a successful or unsuccessful scheme? How is your life traveling to be here in future? Extra checklists for the families of Kutubdia Island Could you speak about the history of your colony here? Why did your family non migrate? Which factors influenced your family non to travel from Kutubdia Island to Kutubdia Para or to other mainland countries? What have been the impacts of non traveling on supports / flights / passages taking topographic point? Do you believe that your family has taken the right determination non to migrate? Is your family more or less successful in relation to livelihood than the families who hold migrated? What are your household’s future programs – migration or remaining on the island? If staying, so how will your family tackle future climatic emphasiss and dazes? How could your current supports be improved? If migration, so how will your family overcome the limitations of migration? How can others, outside your household aid you in migration?

Are Literature Circle Effective

Literature circles are mostly used during a classroom to expand the view of the book and really see the details in each others opinion, but are they effective? Multiple students find literature circles helpful in understanding the book and they all have their own job when it comes to coming together and discussing what they read. In a certain way literature circles are helpful when it comes to comprehending the book everyone in your group is reading. You also get to bond more with the other people in your group, increase your discussion skills and vocabulary as well. Everyone in the group has their own opinion so when a question is asked about a certain paragraph or page, you can all discuss why you answered what you did. â€Å"Literature circles are effective for team building abilities, discussion skills, and reading comprehension†¦Ã¢â‚¬  (Matt) Even though staying on task is one of the tricky parts of literature circles, they truly are helpful. Literature circles are a great way for students to read and enjoy a book, especially high school students because most teenagers now a days do not read as much as they should. It’s a wonderful tool as well, so they can learn to work effectively together. When your in your group you can have a discussion director, summarizer, vocabulary reporter, and a passage master. Discussion directors create questions about the passage they read and take notes during the discussion. Summarizers are the ones that summarize the passage. Vocabulary reporters look for significant words in the passage that caught their eyes and discuses them with the group. Passage master find passages in the reading that everyone should notice, remember, or think about. Everyone in a literature circle has a job so they can all work together and compare thoughts. This is an important tool when comprehending a book. Everyone has a way to contribute, and work together. Literature circles are very helpful when it comes to your reading, vocabulary, and discussion skills. You get to hear others opinion about the reading so you can understand how they felt. So sincerely literature circles are very effective.

Paper Ib

REVISION 2 (56 Marks) IB Standard level Biology Dulwich College Shanghai Topic 3: Chemistry of Life 3. 1Chemical elements and water 3. 1. 1State that the most frequently occurring chemical elements in living things are carbon, hydrogen, oxygen and nitrogen. 3. 1. 2State that a variety of other elements are needed by living organisms, including sulphur, calcium, phosphorus, iron and sodium. 3. 1. 3State one role for each of the elements in 3. 1. 2. 3. 1. 4Draw and label a diagram showing the structure of water molecules to show their polarity and hydrogen bond formation. 3. 1. Outline the thermal, cohesive and solvent properties of water. 3. 1. 6Explain the relationship between the properties of water and its uses in living organisms as a coolant, medium for metabolic reactions and transport medium. 3. 2Carbohydrates, Lipids and Proteins 3. 2. 1Distinguish between organic and inorganic compounds. 3. 2. 2Identify amino acids, glucose, ribose and fatty acids from diagrams showing their structure. 3. 2. 3List three examples of each of monosaccharides, disaccharides and polysaccharides. 3. 2. 4State one function of glucose, lactose and glycogen in animals and of fructose, sucrose and cellulose in plants. . 2. 5Outline the role of condensation and hydrolysis in the relationships between monosaccharides, disaccharides and polysaccharides; between fatty acids, glycerol and triglycerides; and between amino acids and polypeptides. 3. 2. 6State three functions of lipids 3. 2. 7Compare the use of carbohydrates and lipids in energy storage. Paper 1 Multiple Choice (7 Marks) 1. Which is not a primary function of protein molecules? A. Hormones B. Energy storage C. Transport D. Structure 2. Which of the following could be a function of a membrane protein? A. Energy storage B. Enzymatic activity C. Oxygen uptake D. Thermal insulation 3.What is the maximum number of fatty acids that can be condensed with glycerol? A. One B. Two C. Three D. Four 4. What is a role of carbohydrates in animal cells? A. As channels for passive transport B. As enzymes C. As energy storage D. As components of the animal cell wall 5. Which of the following terms correctly describe the molecule below? I. Monosaccharide II. Ribose III. Carbohydrate A. I only B. I and III only C. II and III only D. I, II and III 6. What causes water to have a relatively high boiling point? A. Hydrogen bonds between water molecules B. Hydrogen bonds between hydrogen and oxygen within water molecules C.Cohesion between water molecules and the container in which the water is boiled D. Covalent bonds between hydrogen and oxygen within water molecules 7. Identify the atoms and ions from the table below. AtomsIons A. H+Na+OH–Cl– B. FeKCH3COO–H2O C. FeH2OCa2+N3 – D. NaCI–NO3 – Paper 2 Section A Data Analysis (7 marks) 1. Scientists have long been concerned about the effect of heavy metals in foods that we eat. Aquatic filter feeders including bivalves, such as musse ls and oysters, are especially prone to accumulation of heavy metals. Calcium is taken into bivalves through protein channels, but other non-essential elements may also be taken in.To investigate the relationship between the uptake of calcium and other elements, the bivalves Hyridella depressa and Velesunio ambiguous were placed in solutions containing ten times the normal level of calcium (Ca). The elements manganese (Mn), lead (Pb), cadmium (Cd) and cobalt (Co) were also present in the solutions at normal concentrations. The results are shown below. [Source: Reprinted from Markich Scott J. and Jeffree Ross A. , â€Å"Absorption of divalent trace metals as analogues of calcium by Australian freshwater bivalves: an explanation of how water hardness reduces metal toxicity†, Aquatic Toxicology (August 1994), vol. 9, issue 3–4, pp. 257–290,  © 1994 with permission from Elsevier] ? (a)(i)Outline the effect of increasing calcium levels in the water on calcium level s in the tissue of the bivalves. (1) (ii)Outline the effect of increasing calcium levels in the water on metals other than calcium in the tissue of the bivalves. (1) (b)Suggest reasons for the effects of calcium on the levels of the other metals in the tissues. (2) (c)Evaluate the implications of these results for monitoring water quality in regions where bivalves are harvested. (3) Paper 2 Section A Short Structured (20 Marks) 1.The complex structure of proteins can be explained in terms of four levels of structure, primary, secondary, tertiary and quaternary. (a)Primary structure involves the sequence of amino acids that are bonded together to form a polypeptide. State the name of the linkage that bonds the amino acids together. (1) (b)Beta pleated sheets are an example of secondary structure. State one other example. (1) (c)Tertiary structure in globular proteins involves the folding of polypeptides. State one type of bond that stabilizes the tertiary structure. (1) (d)Outline th e quaternary structure of proteins. (2) 2.State one named example of a fibrous protein and one named example of a globular protein. (2) 3. State two functions of proteins with a named example of each. (2) 4. Lipids are essential nutrients that must be included in the diet. (a)State one food rich in lipids suitable for a vegan diet. (1) (b)Outline two functions of lipids in the body. (2) (c)Discuss the possible health problems associated with diets rich in lipids. (4) 5. Living organisms produce a wide variety of organic compounds. (a)Define the term organic. (1) Organic compounds are made of chemical elements, which are therefore essential to living organisms. b)State the three most commonly occurring elements. (1) (c)Some organic compounds contain other elements. State one substance, or group of substances, that contains (i) nitrogen, (ii) phosphorus. (2) Section B Extended Response (22 Marks) 1. Outline the role of condensation and hydrolysis in the relationship between amino acid s and dipeptides. (4) 2. Explain the secondary and tertiary levels of protein structure. (4) 3. Describe why carbohydrates and lipids are used as energy stores. (6) 4. Explain, with reference to its properties, the significance of water as a coolant, a means of transport and as a habitat. (8)

Patch Essay Example | Topics and Well Written Essays - 500 words

Patch - Essay Example pete their products and prices, which relatively benefit consumers in the way that they will be able to find everything online with lowest price as they mention in their mission. Excluding all other matters, the huge number of customers proves it all about Amazon’s excellent prices and products. Currently, people not only see Amazon as a platform for e-commerce, but also as a famous company for its own products. Amazon recently released many products such as Kindle Fire, TV Fire, and Fire Phones, which took the sale of e-books, e-music and e-movies to another level. It has contributed many benefits to the content creators and consumers. Content creators are happy when they are able to directly publish their products through Amazon with lower cost, while consumers are satisfied with the huge number of e-books with cheaper prices compared to physical ones. Fulfillment by Amazon (FBA) is quite an outstanding service. Amazon claims to help third-party sellers â€Å"to pick, pack, ship and provide customer services.† Consequently, such sellers only need to provide their products. With FBA program, Amazon uses robots to reduce the need of workers, and boost the efficiency of selling. However, while focusing on new technology Amazon fail on providing safe work environment to its employees who are their important stakeholders. The current U.S Supreme Court about Amazon warehouse working condition clearly illuminates this weakness. According to Bloomberg Reports, there have been more than dozen cases filed against Amazon since 2010. Although, the company can manage to get high profit, they still have some problem in communicating with the employees. After doing some research and analyzing the business, it became apparent that Amazon is doing well by successfully putting people together in a joint performance to achieve a common goal. However, we still maintain that the company also has some downsides. Its excellent prices and services are not the only measurement to

Writing121 Essay Example | Topics and Well Written Essays - 1250 words

Writing121 - Essay Example One of the questions asked is whether women and men should be permitted by law to dress as they wish in any society or should restrictions be placed on the ways in which people dress in public. It should be a freedom for people to wear as they please regardless of their gender or race. Giving the people this kind of freedom is going to make them feel free to wear as they please. They will feel that they are not restricted by the laws and will be a happy people. However, dictating or putting limitations on how the people of the nation will wear may make them uncomfortable and hinder them from feeling free to do as they wish. Men should be allowed to wear as they please and women as well in order to strengthen the bond within a nation. Restrictions will have more negative effects on the society than positive effects. Individuals that are better to a point are not usually cooperative. They face the challenge of needing a way to have unique identity and how to experiment on different things. However, due to the restrictions, they end up bottling it up which may with time make them bitter; especially is they do not agree with the reasons behind the restrictions. This does not m atter whether the individual is male or female. The mode of dressing in a nation where the people are free is also the freedom to express one self. The way on dresses is a reflection on their individuality as long as it is their own choice. Therefore, when women and men are given the freedom to dress as they please, they are also awarded the freedom of expression not only in speech but in dressing. They will be free to show what they believe in and dress in a manner that makes them feel comfortable. The individuals in such a nation will not feel obliged to act in a certain manner that suits their dressing code even if they do not believe in it; putting restrictions on the dressing code will force them to act in a

Innovating Essay Example | Topics and Well Written Essays - 3000 words

Innovating - Essay Example The broad nature of ideas in the definitions of innovation and skills, the hardship in the ability to relate innovative outputs and outcome with human capital, and the limitation in the availability of innovation-specific information have made it difficult task for firms to accurately come up with innovative means of operations in order to maximize their potential in performance. This study aims at exploring the link that exists between the desired innovations and skills necessary for the management of an enterprise (Acharya, 2012). In both managerial and individual levels, one needs to acquire and develop certain skill in order to become efficient in the smooth running of his/her business operations. Some of these basic skills include; academic skills, reading and writing, generic skills in problem solving, multicultural openness, technical skills, and leadership skills. These are some of the skills one will need to add in his/her portfolio as a manager and an individual. Skill assessment exercise helps one measure his level of skills and realize the need to add more skills necessary for effective management (Acharya, 2012). In creativity design, the managers will also be required to acquire the managerial and entrepreneurship skills in order to be able to foresee future opportunities and threats in their managerial operations. Individuals need to acquire the skills that will enable them to; learn from their work place the new ideas and opportunities that can be explored at an individual level for their development of skills and knowledge (Aghion, 2013). The required set of skills in an organization is determined by certain factors such as the type of innovation and industry structure, as well as the stage of the innovation. Some of the problems foreseen in group exercise are on how the group will be able to draw different skill mixes in different times to come up with

Computational Biology The Serine Protease Active Site Essay - 1

Computational Biology The Serine Protease Active Site - Essay Example Chymotrypsin belongs to the trypsin family of serine proteases and is usually secreted in inactive form (zymogen) in the small intestine. The structure of chymotrypsin was elucidated via the X-ray crystallography.Below is the structure of chymotrypsinogen (see Error: Reference source not found) The active site is the catalytic unit of an enzyme. The determination of the three-dimensional structure of chymotrypsin by X-ray crystallography was the basis of greater insight into the mechanism of action of serine proteases. The Swiss-PDB Viewer software available at http://spdbv.vital-it.ch/disclaim.html was used to manipulate the coordinates of chymotrypsin and subtilisin serine proteases retrieved from the protein data bank (PDB available at www.rcsb.org). The catalytic site of most srine peptidaeses including chymotrypsin is composed of a catalytic traid of serine, histidine and aspartic acid residues. The ezyme the experimnt dealt with are are serine proteases and they have been known to exhibit similar spatial arrangements. However, the residues of the enzymes may adopt different order in the amino acid sequence. Catalytic triad is composed of Ser195 on one side and Asp102 and His57 on the other side inside the active site cleft. An extensive hydrogen bonding network exists in the triad for instance NÃŽ ´1-H of His57 and OÃŽ ´1 of Asp102 and also between OH of Ser195 and the NÃŽ µ2-H of His57. However in the event that His57 is protonated the latter bond is lost (Hedstrom, 2002). Figure 8: The positions of the backbone nitrogens are shown; the residues are Ser195 and Gly193 and the distances from these nitrogens to the peptide carbonyl oxygen. This brings the two residues closer for interactions to occur The catalytic triad in subtilisin contains residues 32, 64 and 221; the oxyanion hole comprises the side chain of Asn155 and the backbone NH of Ser 221; the mouth of the specificity

The relationship between transformational leadership and innovation in Literature review

The relationship between transformational leadership and innovation in the Bahraini banking system - Literature review Example The intention of this study is innovation as a quality which has become increasingly important to the survival of all kinds of companies in the fast changing and globalised world of today. The many articles in the media following the death of Steve Jobs in late 2011 have reminded businesses of the competitive advantage that innovation brings to a company, but at the same time there is much discussion about the type of leadership style that this innovator inflicted upon his colleagues. Some theorists claim that there is such a thing as an â€Å"innovation leader†: â€Å"Innovation leaders are senior executives –whatever their functions or positions – who spontaneously instigate, sponsor and steer innovation in their organizations.† This view suggests that the job of innovation one that belongs at the top of the organisational hierarchy. Other theorists, leaning on the earlier work of Weber, stress the importance of charisma, theorizing that some individuals have personal traits that mark them out as special, and allow them to play a particularly dynamic and effective leadership role, athough there have been some debates about how to define this elusive quality. Charismatic leadership engages the emotions in a positive way, making the members of the organisation feel that they belong, and in a best case scenario also increasing their motivation and efforts towards the corporate aims. It does this by building trust, creating shared beliefs, engendering positive feelings about the leader, and getting workers and managers alike to feel involved in the project. (Yukl, 1981) It has been pointed out that there is also a downside to the

Language Structures Experience Essay Example | Topics and Well Written Essays - 2250 words

Language Structures Experience - Essay Example This sense of belonging springs from one’s immediate environment where there is focus on the language one speaks along with complementary elements like accent, nuances and other such features that form the general social and cultural terrain of the particular place. Language offers people first hand knowledge of a variety of symbols that one comes to associate with a place. This in turn generates a more enriching quality to one’s experiences. (Mercer, 1996) In knowing and learning a language, whether by birth or subsequent settlement, there is a certain amount of satisfaction that helps contribute to one’s sense of identity. This also has certain mental implications as it shows the person’s basic aptitudes, besides brining him or her face to face with the challenges of implementing the language. This makes a person draw from experiences of the past, learn from present experiences and contribute to future experiences, which will shape his or her overall life experiences. This also renders a certain amount of creative and communicative competency to a person and his or her sense of confidence with which he or she carries out interactions with people. In this regard, it is necessary to shift focus to the process of learning of a language and garnering communicative competency. This process is important in every individual’s life as the knowledge comes only after learning. The very process of learning is a journey throughout which an individual is brought face to face with experiences. These experiences form his or her general perspective on things. In this way, there is a certain level of competency which in turn, springs from the areas and experiences that a person finds comfortable to deal with. Learning a language is a crucial part of describing how a language shapes a person's experiences. (Girvin, 2000) Learning a language has always been a great challenge. While this is a matter of creating awareness, it is also a matter of creating certain comfort level that will trigger communicative competency in that language. To be more precise, the teaching of a language can take place on the basis of the communicative approach - i.e., through reading, listening and repeating exercises that will prompt greater teacher - student interface and thus help correct any deviations on the spot. A vital element of this approach or model is communicative competency which is the goal that a language learner strives to achieve. (Johnson, 1996) This communicative competency becomes the very fabric of a person's life when it comes to understanding circumstances, people and cultures. This fact has special importance in the area of cognitive development. The cognitive development is the most basic and important sensor that differentiates between kinds of experiences. This sensor has to be honed right from the beginning of an individual's life so that there is an affiliation in the child's mind towards a language, a culture and a place. In honing this part of one's cognitive development, there is scope to increase his or her competency. The power of language and being able to communicate with someone plays a large role in the cognitive development. This helps the person develop in terms of trusting the teacher and sharing with the family. The ways and means of teaching or learning a language can be formal or informal depending on the person's stage in life. (Mercer, 1996

Challenges of special needs education Essay Example for Free

Challenges of special needs education Essay Efforts involved in implementation of Special needs education in Uganda today have got challenges that are facing them. These challenges are Handling the problems of an inclusive classroom. The concept of having classrooms that contain both special needs students and students who are developing typically is becoming a popular one. This type of education poses new challenges for a special education teacher. For example, many students who have no disabilities are unaccustomed to dealing with those who do. Teachers in these classes are charged with eliminating cruelty and insensitivity from among  their students and ensuring that those with special needs are treated with respect. Professional Isolation. The nature of a special education teacher’s work is very different from that of traditional teachers; the result of this is that standard classroom teachers may not view them as colleagues. There may be a professional stigma attached to the work of teaching â€Å"slow† students. Special education teachers often work with smaller groups and may focus on skills rather than content, thereby leading to the perception that their work is easier or less important. Lack of support from parents. Some parents of special needs children are disinterested in the welfare of their children and fail to provide them with adequate care. Alternatively, they may be overly protective. Both can be problematic for the child and for their teacher. Disinterested parents may have no involvement with their child’s education or interaction with their teachers, WHEREAS OVERPROTECTIVE PARENTS MAY HAVE UNREALISTIC EXPECTATIONS FROM THE CHILD AND THE CHILD’S teachers. Both attitudes can shape children in negative ways. Parental disinterest may make special needs students less motivated and parents who are overprotective often diminish their  child’s confidence and make it harder for them to learn. 2 [emailprotected] com The difficulty of discipline in a special needs classroom. Disabled children may have behavioral issues including restlessness and moodiness. They may also exhibit problems like a short attention span or an inability to understand what is being taught. Special education teachers have to learn how to deal with these problems as well as how to take appropriate disciplinary measures. Budget problems. Across the nation, special education programs are facing increasing enrollment and decreasing budgets. The result is that there are fewer teacher assistants available, which results in a greater workload for special education teachers. They may also face shortages of essential resources and equipment for delivering effective lessons. Shortage of teachers to handle learners with special needs. Most of the teachers refuse to offer a hand once told to handle a class and later identify that learners in that class are disabled in one way or the other. Many teachers like to teach only learners who are able to do things without any difficulty. They fail to understand that ability is not to everyone. Shortage of teaching materials. Some schools in Uganda today support the learners with special needs but they are faced with a problem of the materials they are to use to teach the learners for example having brails for the blind. This poses a challenge to special needs education in Uganda today. Statistics about the number of the children with special needs. There is no correct statistical approximation of the number of the children with special needs in Uganda today. Supplemented by the enumeration of people taking place after a long period. With miss appropriated number of  children with special needs, there comes a challenge to the state to budget for them in terms of the resources like human resource available. 3 [emailprotected] com Rigid curriculum. Rigidity of the curriculum is also a challenge as it does not clearly show how to handle people with disabilities. The curriculum provides the content but not the pedagogy. This poses achallenge to the teachers who handle learners with special needs on how to handle and present or deliver the content. There are few schools that offer special needs education in Uganda today. They are faced with  a problem of handling the whole multitude of learners all over the country. The population of learners in those schools is high becoming a challenge to teaching and special needs education in general. There are few training institutions for those who would wish to understand the necessary basics of handling learners with disabilities. Assumptions tend to be taken that it is automatic that an individual cannot fail to handle a person with any form of disability. This is a real misconception as for example a person may just think that he knows but when a disabled person asks him for some help, he directs him to specialists. Despite the fact that Special needs education is faced with a number of challenges. Some of those challenges can be mitigated. I suggest the following ways that can be used to act as solutions t the number of challenges above are:- Comprehensive review of state laws, regulations and policies should be done to in cooperate policies for efficient implementation of special needs education in Uganda today. In addition government policies should be put in place with clearly well-defined measures to the rights of the disabled and what is expected from the community as far as providing special needs education is concerned. This will enable the learners to be helped in whatever form the help may be but not being isolated and thus their presence in society thought of as being useless. 4 [emailprotected] com Tertiary institutions that train teachers should in cooperate into their curriculum courses that train teachers to handle learners with special needs. This will help increase the human resource that handle learners with special needs eliminating the challenge of the shortage of teachers with skills of handling learners with special needs. Sensitization of stake holders of their roles regarding the support they should render to people  with disabilities. This will make parents not to keep their children at home rather send them to schools where they may be fully partially included in regular classes thus will end up having achieved their right to education. Parents should made aware of the consequences of not rendering a hand in the education of their children. The government should consider the special needs education sector on their budget. This will make them cater for the materials that the students need to learn. With these materials like the brails available, the implementation of education of learners with special needs will not have  much trouble. Review of the curriculum to check where people with various forms of disabilities can be infused into the system needs to be done as this will help teachers have at least some basics of handling the disabled not leaving everything tothose whom they claim to be experts inthat field. With maximum cooperation of teachers in the school, all the students will thus be catered for. REFERENCES Fanning, B. , Veale, A. , OConnor, D. (2001). Beyond the pale: Asylum seeking children and social exclusion in Ireland. Dublin: Irish Refugee Council. Farrell, P. (1997). The integration of children with severe learning difficulties: A review of the recent literature. Journal of Applied Research in Intellectual Disabilities, 50(2), 26-31 Ferguson, D. L. (2008). International trends in inclusive education: The continuing challenge to teach each one and everyone. European Journal of Special Needs Education, 23(2), 109-120 Gutman, L. M. , Midgley, C. (2000). The role of protective factors in supporting the academic achievement of poor African American students during the middle school transition. Journal of Youth and Adolescence, 29(2), 223-248.

Music Intervention as Anxiety and Stress Relief

Music Intervention as Anxiety and Stress Relief Evelyn Neville Music Intervention as Anxiety and Stress Relief during Minor Medical Procedures Introduction This concept analysis will address the anxiety and stress relief effect of music on patients during routine medical procedures. Music can have a calming effect on patients which can greatly reduce the anxiety and stress the patients may be feeling while enduring procedures such as blood draws or IV insertions (Mok Wong, 2003). The anxiety felt by many patients can provide many obstacles throughout the appointment such as the inability to listen effectively due to the inability to focus (Baldwin, 2016), a negative impact on seeking out further medical treatments in the future (Detz, Lopez Sarkar, 2013), and a general increase in muscle tightness, heart rate, blood pressure and respirations (Bandelow, Boerner ,Kasper, Linden, Wittchen Mà ¶ller, 2013). The alleviation of some of this anxiety and stress may have a powerful impact that could contribute to a patients overall health and continue to build a strong foundation for the relationship between the patient and their health care provider. It is significant that the concept of using music for anxiety relief is studied further as this could provide a new involvement for patients in their own healthcare. It could also provide cost effective ways for the healthcare providers to ensure patients are comfortable, are relaxed and walk away feeling better about their relationship with their health care provider. Music is a universal language that we can all relate to and we should use it to our advantage in the medical field. Music has been successfully used to reduce anxiety in dental procedures (Lahmann et al., 2008), the use of music may be a simple and inexpensive way for hospitals, clinics or doctors offices to make the patients experience better and less stressful. It has been found that music may even be have sufficient anxiety and pain relief in postoperative settings that it may be used as a substitute for adverse effect causing opioid medications (Allred, Byers Sole, 2008). Therefore it is significant that health care professionals should attempt to use the benefits of this non-pharmacologic intervention while treating their patients. The specific use of personally chosen music will ensure that the patient feels they have control over the situation and are involved in their own care (Erlang, Nielsen, Hansen Finderup, 2015). Assumptions The underlying assumptions of this concept analysis include that inherently people like music and it can aid in anxiety reduction as shown by lowered blood pressure, heart rate and respiratory rates (Bandelow, Boerner, Kasper, Linden, Wittchen Mà ¶ller 2013). It has also been used in therapy and other medical practices such as dentistry to assist patients in coping with stress, pain and anxiety (Lahmann et al., 2008). Even though everyone copes differently with stress, it can be assumed that many people use music to reduce stress for physiological, cognitive and emotional processes (Thoma, La Marca, Bà ¶nnimann, Finkel, Ehlert Nater, 2013) Preview In the following section of this concept analysis the reader will be presented with a review of literature reviews that describe the concept in different disciplines. Using the Walker and Avant (2005) method, the concept analysis will include a discussion of the concept and its attributes, antecedents and consequences. Lastly, Empirical referents will also be discussed. Literature Review The literature review for this concept analysis was done with materials found on the following databases: Cumulative Index of Nursing and Allied Health (CINAHL), DePaul Library Book Circulation, UptoDate and Google Scholar. The databases were searched between 1990 and 2017, focusing on articles published after 2000. The CINAHL database produced 1 result for nursing theory music, 11,857 results for music, 333 for music anxiety, 1,531 results for generalized anxiety disorder, 61 results for previous pain experience, and 52 results for music procedure. UptoDate was searched for generalized anxiety disorder with an undisclosed amount of total results. Google Scholar produced 908,000 results for music therapy, 46,200 results for music calming, 597,000 results for music preference, 102,000 results for music therapy anxiety reduction, 1,100,000 results for trust anxiety, 268,000 results for nursing theory music, 1,890,000 results for nurse patient relationship, 976,000 results for patient n urse communication long term, 1,990,000 results for music psychology, 749,000 results for music anxiety and 70,400 results by searching music social bonding. Two additional sources were used, 2 books about music found in the DePaul University Library Book Circulation database when searching for music medicine and music philosophy. Music Therapy According to Oxford dictionary music can be defined as vocal or instrumental sounds (or both) combined in such a way as to produce beauty of form, harmony, and expression of emotion (Oxford Dictionary, n.d.). As music is an abstract form of art, it is able to relate the composers and musicians feelings and intention through direct imitation, approximate imitation and symbolization (Cooke, 2001). With this ability to convey emotion and feelings, music is able to stimulate a heightened emotional response from its creators and listeners (Sloboda, 1991), creating a framework for therapists to create an enriched environment through the use of music. Within music therapy the terms music and music therapy have been used interchangeably, this was especially common practice at that time when the profession was not yet established (Horden, 2000). Music in and of itself is defined as the use of music and/or musical elements (sound, rhythm, melody, and harmony) within the music therapy discipline. To describe music therapy the World Federation of Music Therapy goes one step further and defines it as a process designed to facilitate and promote communication, relationships, learning, mobilization, expression, organization and other relevant therapeutic objectives, in order to meet physical, emotional, mental, social and cognitive needs. (Horden, 2000). Music therapy has been used for anxiety reduction in the past including in a study about the effects of music therapy on patients anxiety while undergoing a flexible sigmoidoscopy. The results of this study confirmed that patients who listened to self-selected music tapes during the procedure had significantly decreased scores for State-trait anxiety inventory, heart rates and mean arterial pressures compared to the control group. Within this study it was concluded that music is an effective anxiolitic adjunct for the flexible sigmoidoscopy procedure (Palakanis, DeNobile, Sweeney, Blankenship, 1994). Psychology Music psychology is a branch of psychology that focuses on the production, creation and perception of music. Within music psychology, music is defined as patterned action in time which appears communicative, complex, generative and representational (Hallam, Cross Thaut, 2009). Music psychology can be applied to individual preferences, arguably due to personality, and the way music is perceived. Studies exploring influence of personality on musical preferences such as the study performed by Stephen J. Dollinger in 1993 have shown that overall personality does have an influence on the types of music individuals prefer. Dollinger, for example, showed that the personality trait openness had a positive correlation to enjoyment of a variety of different kinds of music (Dollinger, 1993). Anxiety has been linked to experiencing additional stressors in childhood, an environmental factor, according to Wiedemann (2013). He points out that personality traits are another factor that can predispose people to experiencing anxiety and how strongly they experience it. Age can also be a factor in the expression of anxiety, with adolescents having a higher incidence rate of anxiety overall (Wiedemann, 2013). Lastly, Wiedeman discusses that anxiety when due to a life event is adaptive, however once the perceived danger passes and the anxious state lasts, this may be due to a pathologic type of anxiety. These anxiety causing events may also cause the patient to experience lasting bouts of anxiety in the future during similar traumatic events (Wiedemann, 2013). Biology Within biology, music can have a neurobiological role. There music is regarded in biological terms as originating in the brain, so that most explanations concentrate on the ways in which brains process information (Freeman, 1998).   As explained by Freeman in his study, music is defined by deeply personal experiences of individuals which are made unique by the separation of information within the brain as it learns more and goes through epistemological solipsism or isolation of uniqueness of knowledge (Freeman, 1998). As sounds pass through the inner ear, along excited sensory neurons into the primary auditory cortex, musical experience is still a neurobiological experience deprived of emotion. However, as explained by Freeman: as the information is processed through neighboring cortical areas concerned with speech and song the information is passed between the newer brain and older part of the forebrain and can generate memories evoked by listening to music, and arouse the em otional states that have become associated with now familiar songs through previous experiences (Freeman 1998). As this information is continuing to pass through the brain, a sense of social bonding is felt by the subject through the perception, creation and sharing of music and dance (Freeman 1998). This social bonding leads to trust, and is related to a social aspect as well as a release of neurochemicals. It is therefore a plausible assumption that music can create neurobiological stimuli that create an environment of bonding and trust building. This can be an important aspect of a patient-nurse/healthcare professional relationship. Lastly, genetics is another factor when discussing anxiety in patients. In recent studies it has been shown that genetics explained about half of the variance when it comes to the predisposition of anxiety in familial cases (Wiedemann, 2013). Concept Maturity This concept has gained some traction within the last few years, especially in other disciplines besides nursing. Dentistry has used music to assist patients during dental exams and procedures for several years and more studies have been done recently in using music to assist in stress and anxiety relief. Generally the concept has been researched in specific instances such as children in the ED receiving IVs or patients receiving a flexible sigmoidoscopy. A longer term study within the nursing discipline needs to be performed to ensure a complete concept analysis can be done. Analysis Defining attributes The defining characteristics that are repeated in the literature include anxiety, music and a positive effect on decreased heart rate. Anxiety encompasses a general feeling of worry and concern about future events which may have an uncertain ending. This can be very well translated to patients worry and fears about medical procedures that may cause them pain and discomfort as well as feeling a lack of knowledge and control over the situation. It has been confirmed that anxiety can manifest itself in things such as increased heart rate, feeling of tightness, and muscle tension (Bandelow, Boerner ,Kasper, Linden, Wittchen Mà ¶ller 2013). The effect of music on heart rate as a relaxation technique has been studied in a clinical setting. It has been proven that a patients preferred music can have a positive effect on lowering the heart rate post procedure (Vaajoki, Kankkunen, Pietilà ¤ Vehvilà ¤inen-Julkunen, 2011). The heart rate is defined as a clinical value measured as a full heart contraction for the duration of a full minute. The ability to lower heart rate allows us to empirically measure the effects of music on the patients during and after their procedures. The patient will have sole control over their choice of music in this concept. Giving the patient the ability to control the type of music has also shown to provide patients with a sense of choice and involvement in the procedure (Erlang, Nielsen, Hansen Finderup, 2015). The musical choices of the patients will be songs played by instruments that are kept in a key with harmonies and rhythm. The patient has full control over the genre of music which may include rock, classical, pop and acoustic. Antecedents Most adult patients will have previously experienced a blood draw and therefore will know what to expect. This knowledge may range from a feeling of impending doom and anxiety over the pain and discomfort they may experience. Though blood draws may not always be painful, previous experiences influence a patients expectations and can translate into higher anxiety and stress when the previous experience was negative (Reicherts, Gerdes, Pauli Wieser, 2016). The travel to the medical facility and the identification of music to be played are also antecedents to the impending procedure. Consequences Consequences of the attempt to relieve anxiety during a blood draw can include a positive experience due to relieved anxiety as well as improved rapport with the nurse or other health care professional which will result in return of the patient for future screenings and preventative care (Detz, Lopez, Sarkar, 2013) . This in turn will result in the patient seeking out healthier long term behavior as well as a decrease in emergency service use (Weiss Blustein, 1996). Additionally, the patient may feel more relaxed and not tense up as much making the nurses job to perform the blood draw much easier. As illustrated in a study by Hartling, Newton, Liang, Jou, Hewson, Klassen and Curtis (2013) a significant amount of health care providers reported that it was easier to perform IV placement on children admitted into the Emergency Department who listened to music than those who were not listening to music. It was also noted that the health care providers were happier with the placement whe n patients were listening to music than if they were not (Hartling et al., 2013) The opposite experience may also occur, creating a negative consequence. The patient may not have found the music they wanted to listen to and may have not experienced anxiety relief during the blood draw. If the nurse was unsuccessful in performing the blood draw by having to start over, puncturing or fishing for the vein resulting in pain, the patient may reflect on this being a bad experience and will not want to return and may even feel the relationship with the nurse has been damaged which may result in the patient not seeking out medical care in the future. Empirical Referents The attribute of anxiety can be measured through a number of Anxiety scales such as the Generalized Anxiety Disorder seven-item scale (GAD-7) or The Hospital Anxiety and Depression Scale (HADS) (Baldwin, 2016). These measurements can be done before and after the procedure, as well as across a population of patients who did listen to music as well as those that did not. A similar comparison between heart rate, blood pressure and respiration rate should be done for everyone involved in the study. A general Patient Satisfaction Survey may also be done for all patients to get an overall sense of the experience and to ask specifics on the patient-nurse relationship after the procedure. A study that may be emulated can include the study performed by Hartling et al. (2013) which looked at pediatric patients response to having music played while having an IV placed in an Emergency Department setting. Within the study an Observational Scale of Behavioral Distress-Revised was used to measure behavioral distress, as well as child-reported pain, heart rate and parent and health care provider satisfaction, ease of performing procedure and parental anxiety were measured. This takes into account a variety of different types of data (qualitative vs. quantitative) while measuring success from more than 1 angle. Nursing Application The following two cases will outline how anxiety can lead to a positive and negative experience while experiencing a blood draw. The model case will show a positive experience of how music is able to reduce anxiety while the contrary case will portray a case in which anxiety is high for the patient. Model Case Jane Doe is coming in for a routine physical with the instruction of fasting as she will have blood drawn for a routine blood panel. Jane has an established rapport with the doctors office she is attending including the nurse who will be performing the blood draw today. Since Jane has had good experiences with this nurse before she is feeling calm prior to her appointment; she knows what to expect. When the nurse arrives she explains that they have added a new feature of having music played while the blood is being drawn. She is given a tablet with a music app where Jane is able to choose what music she would like to listen to. This gives Jane a sense of control and involvement in the situation and feels she can relax while the nurse is drawing her blood. As Jane relaxes the nurse is able to easily insert the needle and draw the blood quickly on her first attempt. Janes ability to relax her muscles and lowered anxiety ensured that she would not flinch and potentially disrupt the bloo d drawing process. After the appointment Jane leaves happy with the interaction with the nurse and feels the music helped in keeping her anxiety at bay in a natural way reinforcing her positive view of this doctors office. Contrary Case Jane Doe is coming in for a routine physical with the instruction of fasting as she will have blood drawn for a routine blood panel. Jane has never been to this doctors office before and is feeling some anxiety about this new environment. As the nurse gets ready to perform the blood draw, Janes anxiety intensifies as she recalls previous needle sticks. She feels as though she has no control over the situation and is starting to tense up as the nurse begins prepping her arm. The nurse is unable to accurately place the needle into the vein and has to start over. Jane is now feeling more anxious than ever as the first attempt was very painful and now the nurse will attempt to reinsert the needle again. After the appointment, Jane leaves the office not being confident in the ability of the nurse nor her desire to want to continue making appointments with this doctors office. Discussion and Conclusion The purpose of this concept analysis was to analyze the effects of music on patient anxiety during blood draws.   Through the lens of music therapy, psychology and biology it is concluded that music may act as a cost effective and non pharmacological solution to anxiety reduction while also improving patient-nurse relationships and encouraging patients to further seek medical intervention and preventative care in the future. Musical intervention may even encourage patients to seek a more long-term relationship with their nurse or other Healthcare provider which will ensure better health outcomes in their lifetimes. A practical application of this concept would be a very real possibility at the Japanese American Service Committee. Here, older adults are provided with a place to go while their families are at work to provide a stimulating environment as well as ensuring they are safe. Most of the clients suffer from some type of age related difficulties in performing activities of daily living effectively and on their own. Some may have dementia while others are no longer able to ambulate safely on their own without an assistive ambulation device. Though JASC does have a nurse on staff, they do not have a need to perform blood draws, though the use of music may come in handy while giving vaccines or administering other types of injection medications. Often clients become anxious towards the end of the day as they worry they will not make it home or that their families have forgotten them. The use of music may be a simple and cost effective way for JASC to engage the clients while reducing their worry. The care takers may also teach the clients about the use of music during stressful medical procedures as many of the clients do see their doctors quite often. The education may also be given to the clients families who may be able to put the concept into use and therefore assist in making these doctors visits less stressful for everyone. Implications for further research include a more comprehensive study across all ages, genders, settings, socioeconomic and insurance status, various procedures and patients who are predisposed to anxiety disorders. There are many factors that can influence a patients anxiety level and it is important to distinguish between musics effectives versus a persons inability to effectively deal with anxiety. References   Ã‚   Allred, K. D., Byers, J. F., Sole, M. L. (2010). The Effect of Music on Postoperative Pain and Anxiety. Pain Management Nursing, 11(1), 15-25. doi:10.1016/j.pmn.2008.12.002 Baldwin, D. (2016). Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. In M.B. Stein R. Hermann (Eds.). UptoDate. Available from https://www-uptodate-com.ezproxy.depaul.edu/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis?source=search_resultsearch=generalized%20anxiety%20disorder%20diagnosisselectedTitle=1~128 Bandelow, B., Boerner, J. R., Kasper, S., Linden, M., Wittchen, H. U., Moeller, H. J. (2013). The diagnosis and treatment of generalized anxiety disorder. Deutsches Aerzteblatt International, 110(17), 300-309. doi:10.3238/arztebl.2013.0300 Cooke, D. (2001). The language of music. London: Oxford University Press. Detz, A., Là ³pez, A., Sarkar, U. (2013). Long-Term Doctor-Patient Relationships: Patient Perspective From Online Reviews. Journal of Medical Internet Research, 15(7). doi:10.2196/jmir.2552 Dollinger, S. J. (1993). Research Note: Personality and Music Preference: Extraversion and Excitement Seeking or Openness to Experience? Psychology of Music, 21(1), 73-77. doi:10.1177/030573569302100105 Erlang, A. S., Nielsen, I. H., Hansen, H. O., Finderup, J. (2015). Patients Experiences Of Involvement In Choice Of Dialysis Mode. Journal of Renal Care, 41(4), 260-267. doi:10.1111/jorc.12141 Freeman, W. J. (1998). A neurobiological role of music on social bonding. In N. Wallin, B. Merkur, S. Brown   (Eds.), The Origins of Music. Cambridge MA: MIT Press. Hallam, S., Cross, I., Thaut, M. (2016). The Oxford handbook of music psychology. Oxford: Oxford University Press. Hartling, L., Newton, A. S., Liang, Y., Jou, H., Hewson, K., Klassen, T. P., Curtis, S. (2013). Music to Reduce Pain and Distress in the Pediatric Emergency Department. JAMA Pediatrics, 167(9), 826. doi:10.1001/jamapediatrics.2013.200 Horden, P. (2014). Music as medicine: the history of music therapy since antiquity. Aldershot: Ashgate. Lahmann, C., Schoen, R., Henningsen, P., Ronel, J., Muehlbacher, M., Loew, T., . . . Doering, S. (2008). Brief Relaxation Versus Music Distraction in the Treatment of Dental Anxiety. The Journal of the American Dental Association, 139(3), 317-324. doi:10.14219/jada.archive.2008.0161 Mok, E., Wong, K. (n.d.). Effects of Music on Patient Anxiety. Aorn Journal, 77(2), 396-410. http://dx.doi.org/10.1016/S0001-2092(06)61207-6 Palakanis, K. C., Denobile, J. W., Sweeney, B. W., Blankenship, C. L. (1994). Effect of music therapy on state anxiety in patients undergoing flexible sigmoidoscopy. Diseases of the Colon Rectum, 37(5), 478-481. doi:10.1007/bf02076195 Reicherts, P., Gerdes, A. B., Pauli, P., Wieser, M. J. (2016). Psychological Placebo and Nocebo Effects on Pain Rely on Expectation and Previous Experience. The Journal of Pain, 17(2), 203-214. doi:10.1016/j.jpain.2015.10.010 Sloboda, J. A. (1991). Music Structure and Emotional Response: Some Empirical Findings. Psychology of Music, 19(2), 110-120. doi:10.1177/0305735691192002 Thoma, M. V., Marca, R. L., Brà ¶nnimann, R., Finkel, L., Ehlert, U., Nater, U. M. (2013). The Effect of Music on the Human Stress Response. PLoS ONE, 8(8). doi:10.1371/journal.pone.0070156 Vaajoki, A., Kankkunen, P., Pietilà ¤, A., Vehvilà ¤inen-Julkunen, K. (2011). Music as a nursing intervention: Effects of music listening on blood pressure, heart rate, and respiratory rate in abdominal surgery patients. Nursing Health Sciences, 13(4), 412-418. doi:10.1111/j.1442-2018.2011.00633.x Weiss, L. J., Blustein, J. (1996). Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. American Journal of Public Health, 86(12), 1742-1747. doi:10.2105/ajph.86.12.1742 Wiedemann, K. (2015). Anxiety and Anxiety Disorders. In International Encyclopedia of the Social Behavioral Sciences (2nd ed., Vol. 1, pp. 804-810). Amsterdam: Elsevier.

the yellow wallpaper -- essays research papers

How Passivity and Submissiveness lead to madness by Charlette Perkins Gilman and Henrik Ibsen â€Å"He told me all his opinions, so I had the same ones too; or if they were different I hid them, since he wouldn’t have cared for that† (Ibsen 109). As this quote suggests Charlotte Perkins Gilman, in â€Å"The Yellow Wall-Paper† and Henrik Ibsen, in A Doll House dramatize that, for woman, silent passivity and submissiveness can lead to madness.   Ã‚  Ã‚  Ã‚  Ã‚  The narrator of â€Å"The Yellow Wall-Paper† is driven to madness after she withdraws into herself. â€Å"I am alone† (Gilman 44), she tells us. Desperately trying to express her feelings to John, she says â€Å"I told him that I really was not gaining here and that I wish he would take me away†(Gilman 46), but â€Å"I stopped short; for he sat up straight and looked at me with such a stern reproachful look that I could not say another word.† Instead the narrator â€Å"keeps quiet.† She settles into quiet submission: I â€Å"am much more quiet than I was. John is so pleased† (Gilman 48). She is â€Å"afraid† to â€Å"irritate† John or â€Å"to make him uncomfortable† (Gilman42). She makes herself believe that as a â€Å"physician† he knows what’s best for her and, therefore, acts passively, letting John control her even though she gets â€Å"unreasonably angry with† him (Gilman40). Writing in her journal is the only thing that keeps her sane; yet John takes that away from her: â€Å"I must put this away-he hates to have me write† (Gilman 41). The narrator yearns to confess to John how she really feels, but she prefers to keep her feelings bottled up: â€Å"I think sometimes that if I were to write a little it would relieve the pressure of ideas and rest me† (Gilman 42). Instead, she is passive and hides her emotions. â€Å"I cry at nothing and cry most of the time. Of course I don’t when John is here, or anybody else,† only â€Å"when I am alone† (Gilman 44). She tells us that â€Å"John doesn’t know how much I really suffer† (Gilman 41). Even when the narrator tries to communicate with him, he immediately dismisses her: â€Å"I tried to have a real earnest reasonable talk with him,† but â€Å"John wouldn’t hear of it† (Gilman 40). Instead of speaking her mind and standing up for herself, she withdraws and does â€Å"not say another word†(Gilman 47). Convincing herself that John is always â€Å"right,† she obeys whatever â€Å"John says,† which only causes her condition to â€Å"worsen† despite the fact ... ...y Torvald: â€Å"He used to call me his doll-child, and he played with me the way I played with my dolls†¦I went from Papa’s hands into yours. You arranged everything to your own taste, and so I got the same taste as you-or I pretended to†¦ Now when I look back it seems I have lived here like a beggar-just from hand to mouth† (Ibsen 109). Rather than be â€Å"sheltered† (Ibsen 108) by him unlike Gilman’s character, Nora is able to speak up for herself and confront her past.   Ã‚  Ã‚  Ã‚  Ã‚  Both Nora and the narrator of â€Å"The Yellow Wall-Paper† suffer from their silent passivity and submissiveness. Nora Helmer, who nearly â€Å"lost [her] mind† (Ibsen ), is able to save herself by being assertive and speaking out, confronting Torvald, her past, and her need to educate herself in the ways of the world. Unfortunately Gilman’s character keeps her feelings inside, and, as a result withdraws into herself and becomes insane. The narrator asserts her disjunction from reality as she tells John: â€Å"I’ve got out at last†¦in spite of you and Jane...and you can’t put me back† (Gilman 53), sloughing off the person she once was, â€Å"Jane† to become the â€Å"woman† in the paper.   Ã‚  Ã‚  Ã‚  Ã‚  

Presidencial Election Essay -- American Government, Politics

Every four years, the presidential election cycle sparks a renewed interest into American politics. While the candidates debate on what seems like a weekly occurrence, the public itself is in a struggle to find out who best suits their interests. Rhetoric resembling that of Kennedy and Reagan reappears and talk of â€Å"Change† invokes a sense of optimism. However, many fear that the nominees are simply attempting to win over the electorate, and what began as a promise on the campaign trail will evolve into the status quo in Washington. Examining the past can provide insight into the future and provide direction for a political party. I am choosing to compare the positions of four distinct groups: Colorado Democrats, Libertarians, as well as the ’28,’68, and 2008 platforms of the Democratic Party. State Party vs 2008 National Party (Health Care Reform) One of the most intriguing core values of the Colorado Democratic Party is its stance on Healthcare. They believe that the health of its citizens is of the utmost priority. The State party has indicated that the healthcare system â€Å"should be focused proactively on wellness, preventive medicine, public health, and disease prevention, as well as primary care† (CO Democratic Party, 2010). Additionally, the party supports President Obama’s healthcare reform legislation â€Å"as a first step toward a quality universal single-payer health care system, independent of employment† (CO Democratic Party, 2010). On the national level, the Democratic Party platform for 2008 bares a strong resemblance to that of Colorado. President Obama campaigned on the promise of increasing coverage while reducing the cost and social burden. Affordable, quality healthcare for all Americans was a cornerstone of... ...rtion can be defined as a wedge issue: â€Å"policy concerns that may divide the voter bloc of the opposing party† (Liscio et. al. 256). Typically, a pro-choice stance is one that is supported by Democrats, however Libertarians tend to vote Republican and are fiscally conservative. In the past, minority parties have pursued wedge issues to regain control (Liscio et. al 256). During the 1950’s and 1960’s, the Republicans were pushed to the fringe. In 1968, Richard Nixon campaigned on restoring â€Å"law and order†, attracting conservative white Democrats who were unhappy with their party’s position on race (Liscio et. al. 257). In essence, Libertarians are a faction of the Republican party. Every party has a group that branches off and is contradictory, however, they â€Å"have been fairly successful at submerging their differences in order to win office and govern† (Reiter 43).

Jorge Borges Life Seen In The Secret Miracle Essay -- Jorge Luis Borg

In 1944, Jorge Luis Borges published â€Å"The Secret Miracle†, a short story describing Jaromir Hladik, a Jew living in the Second World War. Jaromir Hladik is taken away by the Germans to a jail by the Germans to be executed shortly after. While in jail, he ponders on all the ways he could be killed and later realizes that he still has yet to finish his play â€Å"The Enemies†. He prays to God, begging for a year to be granted to him so that he can complete his last masterpiece. In a dream, he is granted that year. When the Germans pull the trigger, the world freezes for a full year so he can finish his play. At a first glance, â€Å"The Secret Miracle† appears to be merely a fictioness story. However, Borges included so much of his own life in the character of Jaromir Hladik that the story no longer seems to be so made up. â€Å"Borges writing was impelled and shaped by experience† (Williamson 296). Borges grew up loving books from the very start of hi s life. His father was always a reader, so he had a room set up like a library that housed hundreds of books. Borges also grew up in a family with colorful war history, which allowed him to be introduced to interesting stories early on. At the age of 56, he was completely blind, causing him to see literature in a different way. He no longer thought literature was a reality. For instance, he believed that although an apple is called an â€Å"apple†, it may not actually have that name. Yet he continues to write in this unreality for he feels that it is a writer’s duty to speak out against Juan Peron through literature. In spite of Borges’ belief that literature is not reality, there is evidence of Borges’ life embedded in it which clearly shape the issues and concerns of his work. Borges was always one ... ...ss, which is difficult and requires strategy to succeed. This would fit in with Borges struggle to succeed in his work. In addition, Borges states that, â€Å"No one could any longer describe the forgotten prize, but it was rumored that it was enormous and perhaps infinite† (Borges 166). This could be referring to the prize of life. Many speak of life as being grand, yet no one actually knows whether life on Earth is a prize or not. It goes on to say that Hladik does â€Å"not remember the chessmen or the rules of chess† (Borges 166). In other words, Borges no longer remembers how to live his own life. Borges was first introduced to the game of chess by his father who â€Å"presented him with mathematical theories and philosophical puzzles† (Sickels 4) while teaching him how to become a better chess player. Perhaps this was Borges’ first encounter with the philosophy of life. Jorge Borges' Life Seen In The Secret Miracle Essay -- Jorge Luis Borg In 1944, Jorge Luis Borges published â€Å"The Secret Miracle†, a short story describing Jaromir Hladik, a Jew living in the Second World War. Jaromir Hladik is taken away by the Germans to a jail by the Germans to be executed shortly after. While in jail, he ponders on all the ways he could be killed and later realizes that he still has yet to finish his play â€Å"The Enemies†. He prays to God, begging for a year to be granted to him so that he can complete his last masterpiece. In a dream, he is granted that year. When the Germans pull the trigger, the world freezes for a full year so he can finish his play. At a first glance, â€Å"The Secret Miracle† appears to be merely a fictioness story. However, Borges included so much of his own life in the character of Jaromir Hladik that the story no longer seems to be so made up. â€Å"Borges writing was impelled and shaped by experience† (Williamson 296). Borges grew up loving books from the very start of hi s life. His father was always a reader, so he had a room set up like a library that housed hundreds of books. Borges also grew up in a family with colorful war history, which allowed him to be introduced to interesting stories early on. At the age of 56, he was completely blind, causing him to see literature in a different way. He no longer thought literature was a reality. For instance, he believed that although an apple is called an â€Å"apple†, it may not actually have that name. Yet he continues to write in this unreality for he feels that it is a writer’s duty to speak out against Juan Peron through literature. In spite of Borges’ belief that literature is not reality, there is evidence of Borges’ life embedded in it which clearly shape the issues and concerns of his work. Borges was always one ... ...ss, which is difficult and requires strategy to succeed. This would fit in with Borges struggle to succeed in his work. In addition, Borges states that, â€Å"No one could any longer describe the forgotten prize, but it was rumored that it was enormous and perhaps infinite† (Borges 166). This could be referring to the prize of life. Many speak of life as being grand, yet no one actually knows whether life on Earth is a prize or not. It goes on to say that Hladik does â€Å"not remember the chessmen or the rules of chess† (Borges 166). In other words, Borges no longer remembers how to live his own life. Borges was first introduced to the game of chess by his father who â€Å"presented him with mathematical theories and philosophical puzzles† (Sickels 4) while teaching him how to become a better chess player. Perhaps this was Borges’ first encounter with the philosophy of life.

Influence of Media on Society

Name: ____________________________________________ Adjectives An adjective is a word that describes a noun. example: The tall man went into the restaurant. The word tall is an adjective. It describes the noun, man. Directions: In each sentence, circle the adjective that describes the underlined noun. 1. 2. 3. 4. 5. Leroy and Jenna walked up to an old castle. Maddie put the golden key in the lock. Today is the fifth day of January. The baby birds flew from the nest. Joe's truck has a flat tire. Circle the adjective in each sentence. Underline the noun that it describes. Directions: . 7. 8. 9. 10. I am holding a marker in my left hand. Patricia played beautiful music on her guitar. Has anyone read Caitlyn's latest story? The sly fox outsmarted the chicken. Miguel ordered a large Coke. Super Teacher Worksheets http://www. superteacherworksheets. com Name: ____________________________________________ Adjectives – ANSWER KEY An adjective is a word that describes a noun. example: Th e tall man went into the restaurant. The word tall is an adjective. It describes the noun, man. Directions: In each sentence, circle the adjective that describes the underlined noun. . 2. 3. 4. 5. Leroy and Jenna walked up to an old castle. Maddie put the golden key in the lock. Today is the fifth day of January. The baby birds flew from the nest. Joe's truck has a flat tire. Circle the adjective in each sentence. Underline the noun that it describes. Directions: 6. 7. 8. 9. 10. I am holding a marker in my left Patricia played beautiful hand. music on her guitar. latest story? Has anyone read Caitlyn's The sly fox outsmarted the chicken. large Coke. http://www. superteacherworksheets. com Miguel ordered a Super Teacher Worksheets

The Duke of Delirium: Duke Orsino Analyzed Through Structuralism

Orsino, the Duke of Delirium: Why Our Leaders Will Never Be Self-Aware Shakespeare adorns Orsino, the Duke of Illyria, with numerous character faults: narcissism, capriciousness, impatience; even Olivia finds the Duke repulsive in his â€Å"embassy† (1. 5), and Feste dubs him â€Å"a foolish wit† (1. 5). It is not until Viola enters that Orsino is painted in a new brighter light, and even then, the Duke acts entitled, shallow, and overly masculine (2. 4). Although â€Å"Twelfth Night† is not a tragedy, Orsino’s circumstance is tragic. He is trapped in a vicious hierarchy: a noble wall that separates him from others, protecting his off-putting persona. Because of his status, citizens cannot communicate to him his flaws. Because they cannot communicate, he is left stagnant at the end of the play. When analyzed via structuralism, Orsino’s character articulates the Ur Code that all noble men, protected by a thriving kingdom, act entitled and superior. Interestingly enough, the opposition: ‘Orsino’s perception of self’ verses ‘Other’s perception of Orsino’ (shown below) displays the only common attribute shared between the personal view and the outsider’s view of Orsino: nobility. While this may seem obvious, it explains the lack of communication between the governed and Orsino. The title, â€Å"Duke,† ultimately determines all of the opinions, and also prevents the presentation of these faults to Orsino. When it comes to Orsino, the fact that he holds power is what makes him feel entitled to constant entertainment from Feste, undying love from Olivia, and continuous approval from those he rules. Orsino is oblivious to his changeability and narcissism, which develops the irony of this situation. Orsino’s Perception of Orsino| Illyria’s Perception of Orsino| Great lover/ Romantic | Impatient | Constant | Fickle | Noble | Noble | Masculine | Insincere | Entitled/ Superior | Vainglorious/ Narcissistic| Shakespeare may have inserted this irony into â€Å"Twelfth Night† to further the theme ‘He/She is not what it appears. ’ In the same way as Viola is perceived as a man, but is really a woman, Orsino is perceived as a jerk, but considers himself brilliant. The only difference is that Viola’s perception of self is correct and Orsino’s is incorrect†¦that is, if we are allowed to judge! This question, perhaps, is the largest piece of Shakespeare’s message. The constant switches between gender (Viola/ Cesario), standing (Feste/ Sir Topas), and identity (Sebastian/ Viola) turn the audience’s perceptions upside down and make us question simple things like whether Orsino is good or bad. The Duke wins the heart of Viola in the end, but remains a stagnant ruler. Though they are to be married, he still views himself as being in control of her: â€Å"And since you call’d me master for so long,/Here is my hand: you shall from this time be/Your master’s mistress† (5. ). A female ruler would never have this level of authority, for it is not considered dignified or proper, further proving the point that only males in power possess an overwhelming sense of entitlement. Male entitlement, sadly, is a pattern established in many other portrayals of leaders from Caesar to King George III. Our culture and hierarchies prevent accurate communication, leaving rulers in a state of delirium, a state which Shakespeare’s play s intended for us to be in all along.

Observation Performed at Atascadero Lake Park

This paper will include observations of interactions between other children that appeared to be in his respective age group as well as children of the opposite sex and In some cases younger and older. Through the use of Piglet's theory of child development and other resources I will compare the child's development as compared to other children In his age range, as well as ascertaining and conveying the parenting style that I observed during this time.Observation of a 3 Year Old Boy Upon arriving at the Decorator Lake Park I positioned myself at a bench close to the play area. This area Included many of the usual types of equipment that one old expect to see at a park that Is frequented by young children. Clearly most of the play equipment was of modern construction and design and It being a beautiful sunny day, the park was full of children of various ages and stages of development.The child I observed primarily was a male approximately three to four years of age and was very active during the time he was at play. He appeared to be at a normal state of development upon my initial observation and this point was only confirmed as I continued to watch Children between the ages of three and four typically walk more rhythmically and re able to easily go from a walk to a run, they Jump and are more able to throw and catch object much more effectively, essentially there gross motor skills advance (Beer).Children in this age range also exhibit improvement with their fine motor skills that allow them to use zippers and eating utensils much more effectively (Beer). The young boy I was observing displayed an excellent ability to climb and run, his balance and depth perception seemed to be very appropriate for this age range. There were many other children of various different ages and sexes at the park as well as the child that I was observing. He seemed especially adept at interacting with many of the other children.Although there were many different toys and pieces of e quipment to play on I also observed several of the children pretending that they were on a ship at sea or performing in the circus, according to Pigged this is part of the operational stage which represents a stage of development that usually occurs Detente ten ages AT two Ana seven (Plague, EYE). One AT ten most villous attributes of this stage is the extraordinary increase in representational, or symbolic, activity (Pigged, 1951). Pigged felt that make believe play was an excellent way for hillier to strengthen newly acquired representational schemes (1951).The child that I was observing seemed to have excellent manual dexterity, he was able to swing from bar to bar on the Jungle gym with ease. He was able to climb up and down the various ladders and chain ropes, crawl through the many openings of the mock tree house that had been provided by the designers of this particular park. One of the longest periods of time he spent on one task was during his time in the sand box. He focus ed a great deal on building what appeared to be a pyramid or some sort of castle.The focus the he exhibited on the end result, I found to be remarkable, however once he had made the decision that it met his expectations he made it a point to not only destroy what he had been painstakingly working on for the better part of forty minutes he also smoothed over the area that he had been working, almost seeming to be concerned that there was no visible evidence remaining. There was a great deal of interaction between the young man and his peers he seemed to have no issue with the sex of the other child, however I did observe at one point that he was holding the hand of a girl who appeared to be around the same GE as he.He appeared to be attempting to persuade her to Join him on the swings. She however was not interested in that particular activity. She actually looked as if she wanted to leave the sandy area of the playground and move onto the grass which would have involved navigating a small step up. When the girl attempted to step up she tripped, causing the boy made a valiant attempt to stop her from falling, to no avail. He was however successful in aiding her to stand back up and helped to bush of the sand. I will say from that point forward the girl was not as eager to hold his and as she clearly felt that was what had caused her to fall.After observing this boy for some time it became clear that he was there with two other children. One a male that was younger than he and the other a female that looked to be approximately four to five years old. In addition after hearing some discussion I was able to ascertain that these children were there with the boys mother and grandmother. Although I did not witness any direct disciplinary steps taken by either of the adult authority figures it was clear that both of the adults were very engaged in what the children were doing.However they allowed the children to lay on the various types of equipment and really only be came involved with specific instructions if it seemed that any of the children were considering leaving the immediate play area. I really felt that the adults were allowing the children to explore and engage in whatever activity they so choose provided it was not an activity that could potential cause harm. In this particular case on this particular day the parental figure was clearly exhibiting the authoritative method of child rearing.According to Beer the authoritative child rearing style is the most successful approach that involves high acceptance and involvement, which includes adaptive control techniques and appropriate autonomy granting (up. 260-261). Although I had only a few opportunities to hear conversations between the adult figure and the child I was serving It was clear Tanat communication was Tree Tooling In ten sense Tanat when the boy expressed what he wanted to do the parent was very responsive to the idea.The youngest of the three children in this group began to have some sort of issue with being unable to navigate the low hanging swing bridge. Subsequently he began to cry which then turned into a fully fledged protest. The boy that I was observing immediately came to his younger peer's assistance. He was able to hold onto the younger child allowing him to make it across and back. This show of empathy which becomes an important part of proboscis and altruistic behavior, according to Beer empathy becomes more common in early childhood and typically preschoolers rely more on words to communicate empathic feelings. (p. 60). In this particular case it was clear that the older boy was in fact talking the younger child through the necessary steps in order to successfully traverse this bridge. This boy seemed especially adept with social interaction and seemed able to move room situation to situation with ease and was comfortable engaging with children of different sexes, ages and points in development. In some instances he seemed to almost make a point to become involved with all of the groups of children. Additionally he appeared to make a point to try to include some other children that were more focused on solitary activities.This I found to be almost deliberate, it seemed that not only was he concerned that a few of the children were playing alone, he persisted in his invitation to Join the other children even when the â€Å"lone wolf† expressed no or very little desire to participate in any group activity. Comparing the child that I was observing to several of the other children that appeared to be in his approximate age range his development seemed to be at least comparable and in some cases further along that the others.With regards to his ability to communicate with the others as well as his ability to move from group to group with a great deal of ease he exhibited an excellent ability to vacillate between appropriate energy levels and vocal volume that would be appropriate to the circumstances to which he wa s about to enter. This displayed to me that the child was experienced with many different types of play or social situations and was able to differentiate each situation without disrupting the other children's focus.This was in clear contrast to several of the other children of the same approximate age that clearly felt it was necessary to make a grand entrance. The amount of time that I spent observing this child's adeptness to navigate through a fairly complicated social playing field displayed how impressive this ability truly was. During the final thirty minutes of my time at the park I really tried to focus on pavement and physical acuity. The boy tended to focus much of his attention on the â€Å"Jungle gym â€Å"equipment.This particular apparatus offered many types of activities, slides, rope swings, monkey bars, which this particular child seemed especially skilled in, also various ladders of different shapes and moving in multiple directions. I can assure you this was no t the park toys of my younger days. The equipment at this park seemed well designed offering the children many different opportunities to discover any hidden acrobatic skills that they may be harboring.All in all this observation made it clear that this young child, this boy of three or four years old, was agile and energetic, had clearly been exposed to many types of social solutions, Ana parents Tanat succeeded to ten autonomy tattle style Ana was developing both physically and cognitively at an appropriate level. In my opinion in many cases he was a bit advanced compared to other children that I observed during my time at Decorator Lake Park. The one thing that impressed me the most was his ability to socialize, to communicate and yet seem to really enjoy his time at the park.

Renal Problems And Septic Shock Health And Social Care Essay

Systemic inflammatory response syndrome ( SIRS ) is expressed as febrility or hypothermia, tachycardia, tachypnea which may be associated with leucocytosis or leukopenia. SIRS generates broad spread inflammatory reaction in organic structure in response to external abuse which is protective for an person when its effects are restricted to pathogens, in other state of affairss inflammatory reactions are hurtful when they are directed against normal tissues in add-on to pathogens. [ 1,2 ] SIRS can ensue from legion conditions but termed as Sepsis, merely when infection sets in and morbific agent is detected. Sepsis consequences from an single response to external infection, which begins with systemic redness ab initio, followed by curdling abnormalcies and eventually deranged fibrinolysis. When sepsis causes one or more organ disfunction, the syndrome is termed Multiple Organ Dysfunction Syndrome ( MODS ) or terrible sepsis. [ 3 ] Sepsis-induced hypotension which is furnace lining to f luid boluses is termed Septic daze. Hypothermia associated with infected daze indicates hapless tegument and visceral perfusion, is normally associated with hapless forecast and high mortality rates of up to 30 to 40 % . Several serum biomarkers suggested holding diagnostic or predictive value in infected daze, but a unequivocal biomarker for everyday clinical usage is yet to be identified. One such marker is serum lactate which indicates pronounced hypoperfusion and tissue hypoxia in infected daze. Similarly serum Creatinine should besides be considered as marker of lessening organ perfusion in sepsis and Acute Kidney Injury should be regarded as index of ongoing organ harm and likely possibility of oncoming of infected daze. [ 4 ] AKI is due to sudden and drastic decrease in kidney map ( within 48 hours ) characterized by absolute addition in serum Creatinine ( & gt ; 50 % from baseline ) or a decrease in urine end product ( oliguria of & lt ; 0.5 ml/kg/hour for & gt ; 6 hours ) . Nephritic hypoperfusion and ischaemia during infected daze amendss nephritic tubules taking to acute cannular mortification ( ATN ) and have been demonstrated to be a common etiologic factor for AKI development during sepsis [ 5,6 ] . ATN was found to be a consistent histopathological determination in these patients, this would strongly propose that ischaemia and nephritic tubular cell mortification are likely an of import pathogenetic mechanism. [ 7,8 ] Acute kidney hurt have marked impact on the result of critically sick patients. Disease badness tonss such as the Acute Physiology and Chronic Health Evaluation ( APACHE II ) and Sequential Organ Failure Assessment mark ( SOFA ) both have included nephritic disfunction as forecaster of morbidity and mortality ; on the other manus liver disfunction tonss, coagulopathy, thrombocytes and other critical organ maps are non much stressed in APACHE II hiting system. To set up a unvarying definition of nephritic harm, RIFLE categorization was formulated which characterizes Risk, Injury, Failure, Loss and End-stage Kidney ( RIFLE ) . [ 9 ] An of import facet of the RIFLE categorization is that it grades the badness of acute kidney hurt on the footing of alterations in serum creatinine and urine end product from the baseline status. [ 10 ] Urine end product is an of import physiologic mark of organic structure fluid position, and unstable instability is common in critically sick patients due to extravasation of fluid into extravascular infinite or due to 3rd infinite losingss and eventually the nephritic disfunction. This farther suggest that reduced organ perfusion in infected daze plays a cardinal function in development of AKI taking to cut down creatinine clearance and increased serum creatinine degrees. [ 11,12 ] In this survey we compared increasing serum creatinine degrees with plasma lactates and SOFA tonss to observe oncoming of sepsis and infected daze and to prove the hypothesis that ongoing acute kidney hurt can bespeak reduced organ perfusion and oncoming of infected daze in critically sick patients.Patients and Methods:This survey was carried out to happen a correlativity between lifting serum creatinine degrees and oncoming of infected daze in 115 critically sick patients admitted in ICU and were managed following Surviving Sepsis guidelines. [ 13 ] Human ethical blessing was taken by the institutional moralss commission. Written informed consents were obtained from control topics and patients or their relations. The control groups were the healthy relations attach toing the patient. Entire 90 controls were taken, among them 65 were males and 25 females with a mean ( SD ) age of 36.5 ( 8 ) old ages. Among patient group 67 were males and 48 females with mean ( SD ) age 37.5 ( 6 ) old ages. Patients included in our survey had either of the undermentioned characteristics: ( 1 ) Clinical characteristics proposing infection ; ( 2 ) Core temperature & gt ; 38AÂ °C or & lt ; 35AÂ °C ; ( 3 ) Heart beats & gt ; 100/min ; ( 4 ) Respiratory rates & gt ; 30 breaths/min or demand for supportive mechanical airing and ( 5 ) Inadequate organ map or daze within 12 hours of registration. Patients excluded were: ( 1 ) aged patients older than 75 old ages ; ( 2 ) NYHA category III or IV patients ; ( 3 ) liver inadequacy ( Child C ) ; ( 4 ) HIV, HBsAg positive serology, Cancer patients. Demographic characteristics like age, sex, primary site of infection, morbific beings and disease badness scores including Acute Physiology and Chronic Health Evaluation Scores ( APACHE II ) and Sequential Organ system Failure Assessment mark ( SOFA ) were recorded for each patient ‘s at the clip of admittance in ICU and later. The plasma of these patients was tested for serum creatinine and lactates degrees at the clip of entry in ICU, so after every 24 hours till their stay in ICU. All the samples collected and patient inside informations gathered during the survey were coded to look into for prejudice and patient confidentiality was maintained as per the guidelines for surveies of human patients. Blood sample aggregation: First blood sample was collected prior to get down of antimicrobic, steroid therapy or vasopressors. Blood samples were collected from cardinal venous line ( 9 milliliter ) into sterilized tubings incorporating 1ml trisodium citrate ( TSC ) at the clip of patient admittance I ICU and later. Plasma was separated by extractor at 10,000 revolutions per minute for 15 min. The plasma was stored at -70AÂ °C for farther analysis and repeated freezing melt of samples was avoided in order to forestall debasement of plasma.Statistical analysis:The informations were analyzed by nonparametric analysis of discrepancy ( ANOVA ) with Newman-Keuls multiple comparing post-test. The relation between serum creatinine degrees, plasma lactates and APACHE & A ; SOFA mark was tested by finding the Pearson correlativity coefficient ( R ) . A P-value of less than 0.05 was considered important. All statistical analyses were performed with the Graph Pad InStat 5.0 demo plan ( Graph P ad Software, USA ) .Consequences:Among 115 patients admitted in ICU during the period April 2009 to May 2010, 45 patients were of SIRS, 39 patients were in sepsis and 31 patients in province of infected daze ( Table 1 ) . Sepsis was diagnosed on the footing of specific civilization studies from assorted possible sites of infection, including blood civilization study. Out of 115 patients studied there were 67 male patients and 48 females with a mean ( SD ) age of 37.5 ( 6 ) old ages. Mean serum creatinine degrees in healthy control group was 0.83 AÂ ± 0.26 mg/dl, runing from 0.4 to 1.6 mg/dl. In SIRS group, the average serum creatinine degrees were 3.45 AÂ ± 1.26 mg/dl, runing from 1.2 to 6.2 mg/dl ( Figure 1 ) . The APACHE II and SOFA score correlated linearly with serum creatinine degrees ( r2=0.74, P & lt ; 0.001 for APACHE & A ; r2=0.69, P & lt ; 0.001 for SOFA ; Figure2 ) bespeaking nephritic hurt with badness of redness. In sepsis patients average degrees were 7.15 AÂ ± 1.3, runing from 4.0 to 9.3 mg/dl. Pearson ‘s coefficient showed additive correlativity of serum creatinine and sepsis badness tonss ( r2 = 0.65, P & lt ; 0.001 for APACHE and r2 = 0.62, P & lt ; 0.001 for SOFA ; Figure2 ) . In patients of infected daze with nephritic disfunction really high serum creatinine degrees were observed with mean of 10.31 AÂ ± 2.29 mg/dl with values runing from 6.0 to 15.2 mg/dl, these values were significantly ( P & lt ; 0.01 ) higher than those with sep sis ( 7.01 AÂ ± 1.3 mg/dl ) , SIRS ( 3.49 AÂ ± 1.10 mg/dl ) and the control group ( 0.83 AÂ ± 0.26 mg/dl ) . Detection of metabolic acidosis in arterial blood gas analysis was evaluated farther by blood lactate appraisal ( Figure 3 ) . Blood lactate degrees in SIRS group were ( 5.14 AÂ ± 1.24mmol/L ) with scope from 2.2 to 7.8 mmol/L. Similarly blood lactate degrees in sepsis ( 7.73 AÂ ± 1.4mmol/L ) and infected daze group ( 9.53 AÂ ± 1.2mmol/L ) were significantly high ( 95 % CI in sepsis 7.25 to 8.21 ; daze 8.9 to 10.16 mmol/L ) . In control group mean values were 0.93 AÂ ± 0.39mmol/L ( 95 % CI 0.84 to 1.0 mmol/L ) . In order to detect a relation between extent of nephritic hurt and oncoming of infected daze, creatinine clearance ( taken as step of nephritic map ) was so compared with blood lactate degrees ( taken as index of anaerobiotic metamorphosis and daze ) , Pearson ‘s coefficient showed reverse relation between lifting lactate degrees and Creatinine clearance in patients with terrible sepsis and infected daze ( Figure 4 ; r2=0.48, P & lt ; 0.001in sepsis ; r2=0.56, P & l t ; 0.001in infected daze ) . The patients included in this survey were non given any nephrotoxic drugs and drug dose were modified as per criterion chronic nephritic disease guideline to forestall farther nephritic hurt [ 14 ] .Discussion:Patients come oning to infected daze during their stay in ICU may hold altered sensorium, deranged liver map, malabsorption syndrome or may hold respiratory trouble. It was observed in our survey that all such patients with infected daze have one common characteristic of crazed kidney map with AKI. The pathophysiology of AKI in infected daze is ill understood due to miss of histopathologic information, which in bend requires nephritic biopsy to observe any parenchymal or vascular alterations in nephritic tissue ; such biopsies are non routinely performed in most ICU set up. [ 15,16 ] In absence of such information, we performed an indirect appraisal of nephritic map during oncoming of infected daze. These observations were based on serum creatinin e degrees and creatinine clearance which was so correlated with disease badness tonss ( APACHE II and SOFA ) and serum lactate degrees ( index of anaerobiotic metamorphosis and daze ) . Assorted carnal surveies of AKI have been done which helps in more complex and invasive measurings of nephritic maps. [ 17 ] Most of these carnal surveies were based on either ischemia-reperfusion hurt or drug induced hurt and informations generated from such surveies may assist us in understanding the pathophysiology in a infected patient with AKI. A major paradigm developed from these observations in animate beings and worlds with daze is that AKI is due to nephritic hypoperfusion and ischaemia. This fact supported our position of utilizing AKI as index for decreased organ perfusion and oncoming of infected daze. [ 18 ] Under basal conditions blood flow to kidney is 360 ml/min/100gm of tissue where as blood flow to encephalon ( 50ml/min/100gm ) , bosom ( 70ml/min/100gm ) , lungs ( 25ml/min/100gm ) and liver ( 95ml/min/100gm ) . [ 19 ] Among all the variety meats, kidneys have really high flow rates, approximately three times higher than other critical variety meats, therefore metab olic maps of kidneys were more likely to be affected earliest by decrease in blood flow during infected daze, this may ensue non merely in a decrease in glomerular filtration but besides, in metabolic impairment perchance doing cell decease, acute cannular mortification and terrible AKI. [ 20 ] Glomerular filtration rate ( GFR ) is governed by glomerular filtration force per unit area, which in bend is determined by the relationship between the sensory nerve and motorial arteriolas. When the sensory nerve arteriola constricts due to hypoxia in infected daze, glomerular filtration force per unit area will fall and urine end product and GFR will besides diminish, ensuing reduced creatinine clearance and increased serum creatinine. [ 21 ] Arterial lactate concentration correlates with badness of infected daze and reflects metabolic changes associated with hemodynamic via media. Therefore, the association between high lactate degree and diminishing creatinine clearance are built-in to the badness of the daze and of multi-organ failure. [ 22 ] In add-on, epinephrine extract during infected daze besides enhances lactate production by itself ; the higher adrenaline dosage required in more terrible patients may besides hold contributed to this association. Following the natural history of infected daze in most ICU, it is impossible to happen patients deceasing of infected daze but without nephritic failure, the huge bulk of patients deceasing of multiorgan failure has a outstanding nephritic constituent and requires nephritic replacing therapy during their class in ICU. Renal biopsy during infected daze is non performed routinely because of important hazards owing to azotemic or infected coagulopathy and patient instability. However, this restriction does non impair the relevancy of our observations sing the pathophysiology of infected daze, as kidneys have highest blood flow per gm of tissue and AKI is changeless characteristic of terminal phase multiorgan failure so any via media in nephritic map in critically sick patients should be considered as indicant of decreased organ map and likely oncoming of infected daze.Decision:Kidneies are invariably involved in multiorgan failure of infected daze. Nephritic lesions associated with AKI in infected daze are more complex than the simple ague cannular hurt, so reduced creatinine clearance should be regarded as index of underlying mechanism of decreased organ perfusion and likely possibility of oncoming of infected daze in critically sick patients.