Philosophy Essay Example | Topics and Well Written Essays - 1000 words - 14

Philosophy - Essay Example Consequences of an action should be important criteria for the people. Velasquez has maintained that various philosophers like Bantham had pursued the philosophy that actions, which result in maximum happiness for maximum number of people, are invariable good and therefore, the end justifies the means if it generates happiness for people. Popularised as act utilitarian theory, the actions, that are designed to benefit or have beneficial cascading effects on others, are morally and ethically right. Morality can only be defined by rationalizing about ‘whether one is inflicting evil on others’. Emmanuel Kant has been emphatic that moral obligations are imperatives and his two Rules define the categorical imperatives: Rules of Universality; and Rules of Respect. The first one makes says that people at all time must act appropriately and the second rules promotes the value of respect and says that well being al all individuals is important and therefore, one should not use others for their own vested interests. Velasquez has preferred the moderated version of Kantian philosophy and believes that people must act in the manner that minimizes harm and promotes happiness amongst maximum number of people. No, ethics are not based on virtues. Virtues can be broadly defined as highly recommending characteristics of moral principles that people aspire for but they are not mandatory code of conduct. Ethics, on the other hand are value based conduct that are needed to lead a worthy life which serves the benefit of the people at large. Therefore, a person may aspire to be generous and honest in his working, but even if he is not generous or honest but he does not harm others by his actions, he will not be considered unethical. The philosophy is part and parcel of every human being and he or she exhibit it through the wisdom and individual perspectives

The Phantom of the Opera Essay Example | Topics and Well Written Essays - 1000 words

The Phantom of the Opera - Essay Example The performers wore colorful and rich costumes. The style of costumes changed depending on the scenes. Some of them represented parts of other operas inside the musical. For example, the rehearsal of the opera Hannibal takes place in the Ancient Rome, and the costumes had a luxury Roman and Carthaginian style. In the opera Il Muto, the performers wore eighteenth-century clothing. The musical offers a great visual interest in the group scenes, specially in the number â€Å"Masquerade†, where the cast showed different costumes, like ballerinas, buffoons, clowns, mythological figures, and the â€Å"Red Mask† of the Phantom. The Phantom of the Opera does not have the traditional concert setting. The audience does not just listen quietly, like in a concert of classical music. The scenario is partly integrated with the rest of the theater. It is important to notice that The Phantom of the Opera is a musical about a theater, which takes place within a theater. In some moments, the public could feel that they belonged to the same fictional audience who witnessed all the events in the Paris Opera. For example, the fall of the chandelier, the appearance of the nobleman Raoul in a balcony, from where he sees Christine singing; the representation of Don Juan Triumphant, the opera written by the Phantom, or in the other opera Il Muto, when the diva Carlotta loses her voice.

Non Medical Independent And Supplementary Prescribing V300 Nursing Essay

Non Medical Independent And Supplementary Prescribing V300 Nursing Essay This essay discusses the evolution of nurse prescribing in the context of legislation and political element, with the consideration of how this has changed and assisted the clinical nurse specialist role, with particularly emphasis on Heart failure. The pathophysiology of heart failure will be discussed and integrated into the relation of drug actions with particular interest into Diuretics. Alongside this; the importance of effective history taking, assessment and consultation skills to treat the patient accurately and at a high standard and quality is discussed. The decision making process and the importance of a shared approach in relation to heart failure is highlighted incorporating the importance of compliance in the maximising the treatment of heart failure. Sources of information and decision support systems that are available will be highlighted with a discussion on the importance of these in principles. Demonstration of ability to prescribe safely, rationally, cost effectively, and in consideration of the public health issues around medicine use are discussed and finally clinical governance through quality assurance and audit of prescribing practice is considered. For the purpose of the essay the following learning outcomes are discussed: Evaluate understanding and application of the relevant legislation and political context of the practice of non-medical prescribing Critically appraise sources of information/advice and decision support systems in prescribing practice and apply the principles of evidence based practice to decision making. Integrate and apply knowledge of drug actions in relation to pathophysiology of the condition being treated Demonstrate the ability to prescribe safely, rationally, cost effectively, and in consideration of the public health issues around medicines use Integrate a shared approach to decision making taking account of patients/carers wishes, values, religion or culture Evaluate effective history taking, assessment and consultation skills with patients/clients, parents and carers to inform working /differential diagnosis. Contribute to clinical governance through quality assurance and audit of prscribing practice and regular continuing professional development The controls of medicines in the UK has undergone a number of regulatory changes since the end of 1800s, climaxing in the Medicines Act (1968). Prior to 1992, doctors, veterinary surgeons and dentists were the only professions legally permitted to prescribe. This situation made the medical profession gatekeepers for medicines, certainly the case for those medicines considered more likely to cause harm or abuse such as controlled drugs i.e. morphine. Cumberledge Report (1986) identified the need for community nurses to prescribe, The Crown Report (1989) published findings of a review to determine the circumstances in which non-medical health professionals could undertake new roles with regard to prescribing, supply and administration of medicines and led to the development of protocols which we now know as Patient Group Directives (PGDs). The Crown Report (1999) recommended that legal authority to prescribe should be extended to include new groups of healthcare professionals, this also bought about the differentiation between Independent and Supplementary prescribers. This report noted that a doctor often rubber stamps a prescribing decision taken by a nurse, which is demeaning to nurses and doctors. (Cooper et al,2008) The Medicinal Products Act (1992) permitted qualified District Nurses and Health Visitors to independently prescribe, and this was only a limited number of medicines from a Community Practitioners Formulary. Over the next few years legislative changes occurred which involved, non community qualified nurses to train as prescribers, together with an increase in medications added to the Nurses Formulary. In 2003, nurses and Pharmacists were permitted to prescribe from the whole of the British National Formulary (BNF) as supplementary Prescribers, except controlled and unlicensed drugs. Controlled Drugs were prescribable by nurses and pharmacists using supplementary prescribing from 2005. During this time other allied Healthcare professionals such as physiotherapists, Radiographers, Podiatrists and optometrists were also able to become supplementary prescribers. (DOH, 2005) These rapid changes in the development of non medical prescribers in the United Kingdom were a contrast to the gradual introduction to prescribing rights in the United States of America. (Armstrong,1995). The UK now has the most extended non medical prescribing rights in the world. (Armstrong, 1995) In 2006, DOH (2006) permitted trained nurses and pharmacists to independently prescribe all medicines within their clinical competence. The most recent changes have occurred to the Misuse of Drugs Regulations (2012) which now means that appropriately qualified nurses and pharmacists will be able to prescribe controlled drugs like morphine, diamorphine and prescription strength co-codamol. Currently there are more than 50,000 Non medical prescribers in the UK, around 19,000 nurses and almost 2,000 pharmacists are qualified as Independent and/or supplementary prescribers (Carey, 2011) The changing legislation of Non medical Prescribers has changed alongside with the environment of the NHS services. This is recognised in the guide produced by NMC (2010) stating that the services delivered by the NHS become more challenging and complex as there is an ever increasing need for improved productivity without the compromising of quality. Coronary Heart disease, puts great pressure and demands on the National Health Service (NHS). Hospital admissions for Chronic heart failure have increased markedly, chronic heart failure accounts for about 5% of all medical admissions and approximately 2% of total health care expenditure. Despite improvements in medical management, under treatment for heart failure is still common. (Mcmurray et al, 2002) In 2002, The British Heart Foundation (BHF) piloted a scheme and funded with the help of Big Lottery Fund ninety two Heart failure nurses throughout the United Kingdom. The results were shown in the final report BHF (2008) showing an average reduction in heart failure admissions of 43% and an average estimated saving, per heart failure patient of  £1, 826. Increasing the role of the Non medical prescribers therefore increasing the skills and knowledge of nurses/pharmacists only enhances the vital role within the field these nurses have in todays current fight to provide the highest quality care possible. It has been shown that registered nurses are extending their roles and responsibilities to work in new ways (Furlong + smith, 2005). Crowther et al (2003), Gattis et al (1999), Paniagua (2011) Lambrinou et al (2012) and Jaarsma (2010) have all shown that Heart failure nurse specialists are optimal providers to assist physicians with Heart failure care for this complex and time-consuming patient population. The management of heart failure is complex involving both pharmacological treatments and strategies to improve patients functional status and quality of life (Palmer et al, 2003) Heart failure can be defined as an abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues. (ESC, 2012) Clinically patients present with typical symptoms; breathlessness, ankle swelling and fatigue. And signs; elevated JVP, pulmonary crackles and displaced apex beat. Diagnosis of heart failure relies on a detailed history and accurate physical examination (NICE, 2010). These symptoms can be related to either a reduction of cardiac ourput (fatigue) or to excess fluid retention (dysapnea, orthopnea and cardiac wheezing) fluid retention also results in peripheral oedema and occasionally an increasing abdominal girth secondary to ascites. Symptoms and signs are often non-specific and could be related to other conditions. Knowledge on the use of other diagnostic services is necessary: Echocardiography, Electrograph, Chest Xray, Blood tests all contribute to the confirmation of diagnosis. Case study One demonstrates a typical presentation of a patient presenting with first presentation of heart failure symptoms; typically compromised and in need of expert medical treatment; Pharmacological and non pharmacological therapies. This patient presented with clear signs of congestion and volume retention of which a diuretic therapy plays a central role in the treatment (Felker and Mentz, 2012) As the heart fails, there is a reduction in both blood pressure and cardiac output, in response to this the body conserves water which results in oedema. Diuretics act at different sites of the kidneys, they then eliminate sodium and water through enhanced excretion from the kidneys so are able to relieve the symptoms of fluid congestion. Different classes of diuretics work at different points within the kidney tubules. (Davies et al, 2000) Appendix two shows the diuretics available. This patient was treated with Furosemide intravenously (IV), most patients receive a loop diuretic as first line treatment for heart failure (Faris et al, 2012.) Loop diuretics are the most frequently used diuretic in treatment of Chronic heart failure despite their unproven effect on survival, their indisputable efficacy in relieving congestive symptoms makes them first line therapy for most patients. (Bruyne, 2003) Appendix three shows how loop diuretics work. As already stated first line treatment for acute decompensated heart failure is intravenous diuretic therapy either as a bolus or via continuous infusion. Despite being available for decades, few randomized trials exist to guide dosing and administration of this drug. In 2011, the Diuretic Optimization Strategies Evaluation (DOSE) trial used a prospective, randomized design to compare bolus versus continuous infusion of IV furosemide, as well as high-dose versus low-dose therapy. The study found no difference in the primary end point for continuous versus bolus infusion. High-dose diuretics were more effective than low dose without clinically important negative effects on renal function. Although no difference was found between IV and bolus dose there are benefits to both elements so clinical judgement would be made on the specific patient needs and requirements, for example, immobilization, duration of therapy requirements, haemodynamic status. The aim of using diuretics is to achie ve and maintain euvolaemia (the patients dry weight with the lowest achieveable dose. (ESC, 2012). Case study two identifies a patient whom is another example of heart failure but offers a different presentation; this accentuates the importance of a careful physical examination and valuable accurate history taking. The absent breathe sounds over the right base of lung field along with the history was an indication of pleural effusion and initiated the prescription of a radiograph chest to be performed. Absent or diminished breath sounds strongly suggest an effusion (Kalantri et al, 2007) unfortunately Congestive heart failure is the most common cause of a pleural effusion. (Enrique, 2008) Again, Pleural effusions from heart failure are managed with diuretic therapy, initially with a loop diuretic, intravenously titrated in response to clinical signs, daily weights and renal function to avoid excessive volume depletion. (Light, 2002) Non-compliance in patients with heart failure (HF) contributes to worsening HF symptoms and may lead to hospitalization. (Van der wal, 2006). Using skills that were taught during basic nursing training is imperative in conducting a beneficial and effective clinical examination, these interpersonal skills may dictate how the patient and carers perceive and acknowledge there diagnosis and may have an influence on the approach the patient has on his/her own health. Over the past 3 decades, the biopsychosocial model of health has become increasingly important in the effective practice of medicine. Central to this model is an emphasis on treating the patient as a whole person, including the biological, psychological, behavioral, and social aspects of their health (Engel, 1980). The American Heart Association (AHA) in collaboration with other professional societies has issued a new scientific statement for the management of patients with advanced heart failure. It emphasizes shared decision making and is designed to help physicians and other health professionals align medical treatment options with the wishes of the patients. Allen (2012) recognises the complexity of heart failure and complexity of the treatment options can be a barrier to shared decision making, but this only emphasizes why such a patient-centred approach should be undertaken in Advanced heart failure. Shared decision making has received particular emphasis in relation to the pre scribing of drug treatments. Traditionally, studies have identified 50% of patients with chronic conditions do not take their treatment as prescribed, with major reasons being because they do not share the doctors views, or they are worried about side effects. (REF QUOTE?) Therefore the aim is to explore these issues by adopting a shared decision making approach and reach a concordance between doctor and patients. Therefore getting patients involved in the planning and management of care, being sensitive to the individuals need, spending time figuring out what is important to them, will hopefully reduce some of the confusion and complexities concerning heart failure. Although knowledge alone does not insure compliance, patients can only comply when they possess some minimal level of knowledge about the disease and the health care regimen. (Van der wal, 2006). The National Prescribing Centre (2012) designed a competency framework which can be seen in appendix 3. One of the three domains is the consultation which highlights three areas of importance 1; Knowledge; pharmacological and pharmaceutical. 2; Options; concerning the diagnosis and management 3; Competency; involving shared decision making with parents, patients and carers. The data is clear that for the benefit of the patient and success with the treatment regimen it is vital to consider wishes of the patient/carer, ethical, cultural opinions, lifestyle of the patients. Also contributing factors which may cause non-complicance whether intentional or not for example: polypharmacy, complicated dose regimens, unpleasant side effects, and cognitive problems or physical disability preventing the patient taking the medicines. A large number of factors need to be incorporated into the thought process prior to getting to the point and writing a prescription. Surrounding issues that directly and indirectly support patient orientated prescribing Sources of information are on number of levels. In a hospital ward, for example, immediate sources of information include the British National Formulary (BNF) and ward pharmacist. The role of both is, at least in part, to assist in ensuring that, for any prescription, the correct dose and timing of administration are correct and appropriate for the indication. The BNF is widely available and accessible and can and should be used to assist in prescribing whenever there is any doubt about dose and timing. The Pharmacist provides an additional safety netting, by checking prescriptions before providing the medications. In addition, the pharmacists role includes ensuring that medications prescribed are available for administration. Further afield, but still within the hospital, local policies give guidance on what drugs are available and recommended for a particular indication. These policies may be produced by the hospital or by regional bodies, including SHA, Network PCTs, for example, local arrangement may mean that a particular statin is used for primary prevention of coronary heart disease, due to local procurement agreements or cost effectiveness analyses. Beyond the hospital setting, a number of sources provide guidance on what should actually be prescribed, or considered, for a given condition. Such sources might include national bodies, in particular National institute of clinical excellence (NICE) and specialist societies. The latter may be national and or international. For example, in the field of heart failure, NICE has given guidance on what medications should be administered and at what stage of the disease and symptoms. For all patients ACEI: should be given. There are many different ACE I. The guidelines recommend using only those which have actually been proven to be of benefit in heart failure; these [emailprotected]@@@@@@. For those who are intolerant of ACE; ARB should be used. Again, NICE recommends thoses that have shown efficacy in clinical trials, and these [emailprotected]@@@@@@. Beta-blockers are recommened but not any betablocker. Only those with proven @@@ in heart failure should be used; these are Aldosterone A ntagonists should also be used for patients with advanced heart failure (NYHA III/IV). Guidance recommends spironolactone, or eplernone if not tolerated (most usually due to gynaenomastia in men) From the above, it may be seen that the National guidance indicates which drugs from each class should be considered for each purpose. This leaves room for local policies and prescribers to decide which of the available agents is suitable for a particular individual. Pursuing the example of heart failure further, international guidelines are issued by a number of bodies. The principle of these is the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) and the American Heart Association (AHA). Of these, the ESC guidelines are most applicable to the United Kingdom. Societal guidelines tend to focus more on a particular disease and the available evidence to provide best treatment, whereas NICE guidelines have greater emphasis on appraisal of cost-effectiveness, which is of greater relevance to the local health economy in the UK. Furthermore, ESC guidelines give a strength of recommendation for a particular treatment (Class I, IIa, IIb) and an indication of the level of evidence behind the recommendation. (A, B, C) Ultimately, the source of information which informs societal guidelines comes from research, in the form of clinical trials, performed on the back of pre-clinical research. Therefore, the doses of drugs which are recommended for use usually reflects the dose and frequency of a drug or used in a clinical trial which demonstrated benefit. There are therefore numerous levels of information and advice which support prescribing practice. For many conditions, these are ultimately based on evidence derived from clinical trials, in some areas these will be the gold standard RCT. However, some trials provide softer evidence, such as observations data or even anecdotal. Understanding of these various trials and guidelines is important to understanding how local guidelines and daily prescribing practice come about and are supported by evidence. The trials/guidelines all mentioned above have provided convincing evidence that clinically significant improvements can be achieved in heart failure by appropriate drug treatment. Moynihan et al (2002) recognises that the adoption of more effective and/or safer drugs, new technologies are usually more expensive, aging of the population leads to increased morbidity and drug therapy, all play a role in increasing drug expenditure. Medicines are regarded an expenditure, but can also be an investment, if they are used rationally. Rational prescribing means cost effective use of safe and effective drugs. Specialist clinics for heart failure are a tool for delivering care according to clinical guidelines and providing diagnostic treatment. They provide optimal management of the condition, education of patient and carers about the signs and symptoms of worsening disease and medication compliance. Advances in medication and technology for heart failure are vast, which again strengthens the need and importance of such clinics to enable patient treatment to change accordingly and appropriately. Studies have shown that if patients are treated by Cardiology clinicians or Heart failure specialist nurses, clinical guidelines are more likely to be followed and readmission rates are lower for these patients. (Reis et al, 1997) An example of prescribing within heart failure is an investment for the patient and the NHS is the use of Angiotensin-converting enzyme inhibitors (ACE I). These have been shown to improve symptoms, survival and slow progression of heart failure. (Luzier et al, 1998). ACE I are one of the essential therapies for all heart failure patients, if tolerated. Treatment should be maximised and in maximising the dose quite often you can reduce or stop the use of loop diuretics due to improved symptoms and clinical signs. (Hoyt et al, 2001) Therefore patients who are appropriately treated and titrated to maximal therapy therefore benefit clinically, may reduce other medicines and they can overall reduce the chances of hospital admission with decompensated heart failure which is beneficial to the patient and the NHS finances. A recent study by Dharmarajan et al (2013) covering three million hospitalizations showed that more than a third of readmissions (within 30 days of discharge) were for heart failure. Their thought was that many of these could have been preventable, with greater input from pharmacists, physicians, nurse specialists, and greater consideration to social elements; reducing readmission also reduces other risks involved in exposing patients to hospitalization. The National Heart failure Audit (2012) conducted by NICOR is an audit to monitor progress, clinical findings and patient outcomes of patients with heart failure. It is an essential audit for each NHS trust to comply and complete. ++. It provides critical information on management and outcomes which then provides data essential to drive future improvements. Conclusion: CASE STUDY ONE Description of clinical setting: Patient was an inpatient on the Cardiology ward; he was admitted the day before and had been referred to Heart failure clinical nurse specialist for review. Case history: An 84 year old retired postman was admitted from home with progressive worsening shortness of breath over the last 6 weeks. He had been to see the General Practitioner two weeks ago who treated him for a chest infection with a course of oral antibiotics (Amoxycillin). He denies any chest pain, however he complains of palpitations at times of exertion and a productive cough. Patient had not experienced any syncope, dizzy spells; only other complaint was loss of appetite and poor quality sleep. Patient has been sleeping with 4 pillows, waking regularly due to struggling for breathe and resulted to sleeping in the chair downstairs. Exercise tolerance had drastically reduced to 50 metres before having to stop due to breathlessness. On examination the patient was tachypnoeic, pulse was 95 and regular, sitting blood pressure was 110/62 standing 105/55. Weight 97kg. Oxygen Saturations on air 94%. Inspiratory crackles were clearly heard on both lung bases, no heart murmur could be auscultated and apex beat was misplaced to the anterior auxiliary line. JVP was raised +4. Pitting peripheral oedema up to thighs and a large distended abdomen, which was soft and not tender on palpation. ECG confirmed Sinus tachycardia with Q waves in antero lateral leads. Chest x-ray also confirmed cardiomegaly and interstitial oedema. Drug treatment pre admission: Aspirin 75mg once a day (OD) Blood pressure control Past medical history: Anterior lateral Myocardial infarction 7 years ago (2005) followed by Angioplasty to the right coronary artery. No further operations or admission to hospital. Blood results: Chemistry: Sodium 128mmol/l, Potassium 4.8 mmol, Urea 9 mmol/l, Creatinine 145 mmol/l, LFTs, HB and clotting was all unremarkable. Echo: severe left ventricular dysfunction, with minor tricuspid regurgitation. Social background: Patient lives with wife in a two bedroom bungalow, they are both normally well and independant. He has no allergies and takes no over the counter medications or recreational drugs in the past or present. Drug chart to date in hospital: Aspirin 75mg OD Frusemide 80 mg OD Ramipril 2.5 mg OD Discussion: Patient was fortunate enough to have had Echocardiography that morning, which offered me the definitive diagnosis. This gentleman presents with a common clinical presentation of progressive systolic dysfunction of an ischemic cause. The patient was comfortable and stable enough for a steady and methodical examination and history taking. On construction of a management plan for this patient, clearly first line treatment is diuretic therapy, T Effective dieresis and consequent adjustment of the loading conditions of the failing heart is generally regarded as essential (Raftery, 1994) This patient went on to be prescribed Intravenous Diuretics, instructions for Daily weights, Fluid balance, advice and rehabilitation for heart failure. Then longer term plan for titration of Heart failure medications to achieve maximum therapy suitable for this patient. Allen, L.A., Stevenson, L.W., Grady, K.L., Goldstein, N.E., Matlock, D.D., Arnold, R.M., Cook, N.R., Felker, G.M., Francis, G.S., Hauptman, P.J., Havranek, E.P., Krumholz, H.M., Mancini, D., Riegel, B. and Spertus, J.A., for the American Heart Association; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia, 2012. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), pp.1928-1952. Armstrong, P., McCleary, K. J. and Munchus, G., 1995. Nurse practitioners in the USA their past, present and future. Some implications for the health care management delivery system. Health Manpower Management, 21(3), pp.3-10. Avery, A.J. and Pringle, M., 2005. Extended prescribing by UK nurses and pharmacists. British Medical Journal, 331, pp.1154-1155. Bruyne, L.K., 2003. Mechanisms and management of diuretic resistance in congestive heart failure. Postgraduate Medical Journal, 79(931), pp.268-271. Carey, N. and Stenner, K., 2011. Does non-medical prescribing make a difference to patients? Nursing Times, 107(26), pp.14-16. Cooper, R., Guillaume, L., Avery, T., Anderson, C., Bissell, P., Hutchinson, M., Lynn, J., Murphy, E., Ward, P. and Ratcliffe, J., 2008. Non medical prescribing in the United Kingdom: developments and stakeholder interests. Journal of Ambulatory Care Management, 31(3), pp.244-252. Crowther, M., 2003. Optimal management of outpatients with heart failure using advanced practice nurses in a hospital-based heart failure centre. Journal of the American Academy of Nurse Practitioners, 15, pp.260-265. Davies, M.K., Gibbs, C.R. and Lip, G.Y., 2000. ABC of heart failure. Management: diuretics, ACE inhibitors and nitrates. British Medical Journal, 320(7232), pp.428-431. Department of Health and Social Security, 1986. Neighbourhood nursing a focus for care (Cumberledge report) London, HMSO. Department of Health, 1989. Report of the Advisory Group on Nurse Prescribing (Crown report) London, HMSO. Department of Health, 2000. National Service Framework for Coronary Heart Disease. London, HMSO. Department of Health, 2005. Supplementary prescribing by nurses, pharmacists, chiropodists/podiatrists, physiotherapists and radiographers within the NHS in England. A guide for implementation. London, HMSO. Department of Health, 2006. Improving patient access to medicines: A guide to implementing Nurse and Pharmacists independent prescribing within the NHS in England. London, HMSO. Dharmarajan, K., Hsieh, A.F., Lin, Z., Bueno, H., Ross, J.S., Horwitz, L.I., Barreto-Filho, J.A., Kim, N., Bernheim, S.M., Suter, L.G., Drye, E.E. and Krumholz, H.M., 2013. Diagnosis and timing of 30 day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Journal of American Medical Association, 309, pp.355-363. Diaz-Guzman, E. and Budev, M., 2008. Accuracy of the physical examination in evaluating pleural effusion. Cleveland Clinic Journal of Medicine, 75(4), pp.297-303. Faris, R.F., Flather, M., Purcell, H., Poole-Wilson, P.A. and Coats, A.J., 2012. Diuretics for heart failure. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD003838. DOI: 10.1002/14651858.CD003838.pub3. Felker, G.M., Lee, K.L., Bull, D.A., Redfield, M.M., Stevenson, L.W., Goldsmith, S.R., LeWinter, M.M., Deswal, A., Rouleau, J.L., Ofili, E.O., Anstrom, K.J., Hernandez, A.F., McNulty, S.E., Velazquez, E.J., Kfoury, A.G., Chen, H.H., Givertz, M.M., Semigran, M.J., Bart, B.A., Mascette, A.M., Braunwald, E., OConnor, C.M., for the NHLBI Heart Failure Clinical Research Network, 2011. New England Journal of Medicine, 364(9), pp.797-805. Felker, G.M. and Mentz, R.J., 2012. Diuretics and ultrafiltration in acute decompensated Heart failure. Journal of the American College of Cardiology, 59(24), pp.2145-53. Furlong, E. and Smith, R., 2005. Advanced nursing practice. Policy, education and role development. Journal of Clinical Nursing, 14, pp.1059-1066. Gattis, W.S., Hasselbied., V., Whellan, D.J. and OConnor, C.M., 1999. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team. Archives of Internal Medicine, 159, pp.1939-1945. Hawkins, N.M., Petrie, M.C., Jhund, P.S., Chalmers, G.W., Dunn, F.G. and McMurray, J.J., 2009. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. European Journal of Heart Failure, 11, pp.130-139. Hoyt, R.E. and Bowling, L.S. 2001. Reducing readmission for congestive heart failure American Family Physician, 63(8), pp.1593-1598. Hunt, S.A., Baker, D.W., Chin, M.H., Cinquegrani, M.P., Feldman, A.M., Francis, G.S., Ganiats, T.G., Goldstein, S., Gregoratos, G., Jessup, M.L., Noble, R.J., Packer, M., Silver, M.A., Stevenson, L.W., Gibbons, R.J., Antman, E.M., Alpert, J.S., Faxon, D.P., Fuster, V., Gregoratos, G., Jacobs, A.K., Hiratzka, L.F., Russell, R.O. and Smith, S.C. Jr; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure); International Society for Heart and Lung Transplantation; Heart Failure Society of America, 2001. ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in collaboration with the International S ociety for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation, 104(24), pp.2996-3007. Jaarsma, T., 2010. Multidisciplinary approach in heart failure: evidence, experiences and challenges. Journal of Cardiac Failure, 16(9), pp.1071-9164. Kalantri, S., Joshi, R. and Lokhande, T., 2007.

Memory :: essays research papers fc

I. Introduction   Ã‚  Ã‚  Ã‚  Ã‚   II. Dementia   Ã‚  Ã‚  Ã‚  Ã‚  Senility is a misused term for the loss of ability to think, reason, and remember in older persons. Senility is not a medical condition; it is not normal, natural, or inevitable with aging; it is not limited to older people either. The term senility is replaced in most of my pertinent research by the medical term dementia, which seems to describe a group of symptoms that represent a change or deterioration from an individual's previous level of functioning (Tueth, 1995). Dementia has specific causes, which impair long-term memory and quite relevantly;: language, judgment, spatial perception, behavior, and often personality, interfering with normal social and occupational functioning. Most dementias are evidently both progressive and irreversible. According to Cummings (1995) after the age of 60, the frequency of dementia in the population statistically doubles every 5 years: that is to say it affects only 1% of 60-64-year-olds but 30-40% of those over age 85 (Cummings, 1995).   Ã‚  Ã‚  Ã‚  Ã‚  The most common causes of dementia are Alzheimer's Disease (Tueth, 1995), and vascular problems or problems related to a stroke (Yoshitake et al., 1995) . Depression, believed to cause some symptoms of dementia, may be as common in early dementia as it is by itself and may improve with prompt treatment even in people with dementia. The risk of dementia increases with age. Although statistics concerning those who have dementias worldwide are not known, it is known that most dementias are not reversible but that people with dementia can function better with treatment of other medical or sensory problems , and optimal social and environmental support. From what I have learned, stimulation and activity can also help people with dementia. It is very important to note that minor memory problems in older people previously attributed to senility may have other causes, such as distraction, fatigue, grief, stress, alcohol, sensory loss, difficulty with concentration or inability to remember many details at once, illness, or medications (Cummings, 1995). Confusion and disorientation caused by these problems may apparently be reversible though. III. Examining Alzheimer's Disease By definition, Alzheimer's disease (AD) is an incurable degenerative disease of the brain. AD is a progressive dementing illness in which the core symptom is long-term memory loss (Tueth, 1995). Other associated symptoms include impairments in language, abstract reasoning, and visual spatial abilities as previously described in dementia. Personality changes are common and range from apathy to restless agitation. These are said to be directly related to memory difficulties (inferred from Elias, 1992). Psychiatric symptoms, including depression, delusions, and hallucinations, may also occur during the course of AD resulting somewhat from the severe loss of memory.

Freud’s Psychoanalysis in Art: Frida Kahlo’s Surrealism

One of the most influential social scientists of his time, Sigmund Freud and his theories on psychoanalysis remains relevant today in the study of human personality and the influence of the subconscious on human thinking and behavior.Freud’s ideas on the significance of dreams, which was seen by him as the expression of human being’s innermost desire, were in fact borrowed by artists ascribing to surrealism who sought to imprint the subconscious. Surrealist paintings are thus characterized with the use of symbols and often have a dreamlike quality to them, where cannot always be taken at face value or by literal translation.It is no wonder then that Freud’s ideas have been widely used in the interpretation of works of art or even of character sketches. Freud’s theory on how personalities are developed which revolves around the main ideas of id, ego, and superego, have, for instance, been used to explain how sex and libido may be transformed into other form s of energies, or how particularly traumatic life events may have a negative effect on both adults and children when not properly processed.Likewise, Freud’s ideas of sexual repression and displacement were influential in the growth and development of the surrealist school, which drew on the rich imagery of one’s dreams, wishes, and fantasies to create their art. (West 185)One of the most notable surrealist painters, Frida Kahlo, has been a classic example of an artist whose works could be interpreted using Freudian concepts and ideas. Kahlo’s tumultuous life, characterized by wild sexual affairs with both male and female lovers, a devastating divorce, and her inability to conceive children due to a series of back operations were mostly found in the bulk of her work which were fraught with symbolisms. (West 185)In her painting entitled Self Portrait with a Necklace, Kahlo painted herself wearing a necklace of thorns and a dangling humming bird, which alludes to her suffering from divorce (as symbolized by the thorns) and to her quest for new love (as shown by the humming bird which is a traditional Mexican love amulet). (Erickson, 2005). In these self portraits,Kahlo’s entire life was depicted in her paintings. She drew her own birth, for instance, and many other events including those connected with her pain and frustration. (Levine 273) Her husband Diego Rivera was also depicted in many of her paintings in different ways: in Frida and Diego Rivera (1931) which is supposed to be a painting of their marriage, she paints him as a father-figure and herself as his daughter, which is reminiscent of Freud’s Electra complex and reveals Kahlo’s insecurity at her own husband’s authority.In another painting Retablo (1943), she captures the scene of the accident that left her under intense pain for most of her life (Kahlo and Kettenman 32) which she later depicts in Broken Column (1944) that â€Å"graphically expresses h er physical agony.† (West 184)Psychoanalysis therefore plays an important role in understanding and unlocking many surrealist artwork. In Kahlo’s case, the artist has rendered her own physical suffering in the metaphoric sense, mostly through the use of portraiture, to something that is haunting and beautiful, and one which outlasts even the pain and suffering of Kahlo’s troubled soul.Works Cited:Erickson, R. (2005). Freudian thought and the surrealist world. Downloaded from Associated Content, The People’s Media Company on March 16, 2007 Kahlo, F. & A. Kettenman. (2000). Frida Kahlo 1907-1954: Pain and Passion. Taschen.Levine, M. P. (2000). Analytic Freud: Philosophy and Psychoanalysis. United Kingdom: Routledge.West, S. (2004). Portraiture. United Kingdom: Oxford University Press.   

History of the Miraculous Apparition of the Virgin of Guadalupe

istory of the Miraculous Apparition of the Virgin of Guadalupe In the year 1531, early in the month of December a miracle happened in Tepeyacac, it was said that the miracle illustrious Virgin, Blessed Mary, Mother of God, Our Lady, appeared to a man named Juan Diego. He was a humble Indian who lived in Quahutitlan but was from Tlatilolco. The way the author narrates the beginning of the story is really good. He uses a really sincere tone that makes the story look real and really respectful attitude. The author has a sincere way of telling the story.He knows how to engage every scene with another one and the setting he describes makes this story so real that the readers get involved really easily on this story. Many readers become part of the story through their imagination and this is a wonderful gift someone can have because being able to feel the story like part of your real life is not easy. He keeps on telling the story and this part is gorgeous. He describes the land and it see ms that it looks like wonderland. It is so marvelous and this place is where Juan is going through.It was a Saturday morning when he was on his way to divine worship based on his custom, when he starts hearing birds singing. The way these birds sing was so beautiful that he thought he was dreaming. He was so amaze about what was happening to him. He makes an exact description of all the setting of this story; imagine every single thing that he was saying. It was stunning. He mentions that she was shining as the sun and that all around her was so bright, all of these are the things that really matters in a story, all the emphasis he puts on it makes it really reliable.I really enjoy this part because I feel like if I was in the story, like if I was looking at the flowers and the sun. All the sounds of the birds and the wind were really fantastic and help to imagine how was the land where he was because he even explains that the sounds were coming from the top of the hill, he was grea tly rejoiced with all these beautiful sounds that make a wonderful song, suddenly he heard a sweet voice saying: â€Å"Juan†, he was so scared and confuse because he was hearing a lot of different noises and even this voice mentions his name so he did not dare to climb to the mountain.He was just standing looking to the top where he was hearing all these things. He finally decided to climb the hill. He wanted to know who was calling him and why or for what. When he reached the hill he saw on the very top of the hill a beautiful lady. All around her was shining like the sun, there were stones, caves everything was so bright and even the rainbow clothed the land so that the cactus and all other plants that grew there seem like precious gold, Juan Diego was really excited about it, but at the same time he was wondering why that lady did was calling him.As it is mentioned before the author does a really good narrative of this story by describing all the scenes with a wonderful se tting. When he finally got to the top of the hill and talked to this wonderful lady. He was surprised about her and the things that she was telling to him because she talked to him like she loved him. This is one of the parts that should recall because in here the author has a tone he is using is like nostalgia but at the same time he tries to describe how the virgin was talking to Juan like when a mother talks to her son or daughter.This entire scene was nice, as the author mention Juan felt that this lady loved him, and sure she did because she even says â€Å"You must know, and be very certain in your heart, my son, that I am truly the eternal Virgin, holy Mother of the True God†. With this quote we can see how the author tries to sensitize the reader to get the idea that she really loves him and that she is a good person. The author wants us to know how the virgin was a really nice lady. Then they finally started talking and the virgin told Juan what she wanted from him, what she expected him to do, and what she wanted was a church on that hill, exactly where she was.She wanted a church in where she could show and may make known and give all her love, her mercy, help and protection. She said she was his and everybody else truth his merciful mother who call upon her. In this scene she is explaining Juan why she wanted a church. He tells him to go to the Episcopal Palace of the Bishop of Mexico and tell them what he just saw and what she just told him. She really desired a church in that place so she command Juan Diego to go and tell them to build her one.He need it to have a lot of confidence on himself in order to convince everybody in the palace of what he was saying, or at least to convince the Bishop. I think that the narrator is really involved in the story but not as a character. The author uses a really good setting because he even portrays real life events and that is what it makes the readers to be involved and interested on the reading. His religion is catholic because of the way he talks about what the virgin want it and what is she going to do with the church.She wants to be built there; he is very reliable and even thought he is just the narrator he is doing a good job on transmitting all what the virgin says along the story. The Virgin of Guadalupe is a very famous character on the catholic religion and this is a really important fact that helps the author because he is not using non-fictional characters instead he is talking about a really known image. She is known as a nice lady, as a sweet lady who helps everyone and who does miraculous and that you can pray her for something and she will conceive almost whatever you want.This is what it makes the story reliable and interesting. Juan Diego went to the palace to talk to the Bishop. He was kind of afraid because he was just a humble Indian and he knew that the Bishop would probably not believe him about what he was going to say, but even though he went there and after so much trouble he went through in order to talk to the Bishop at the end he did and tell him all that he had saw and heard. The Bishop was listening at him carefully and respectfully but at the end the Bishop just tell him to come back other day in where they can talk about it.Juan Diego left sadly and went to see the virgin and explain her everything that had happen on the palace. When the author talks about the way the people in the palace treated Juan he seems to be ironic, because he is saying that Juan was on his way to the palace so that the Bishop could listen to him and do what the virgin wanted to, but we all knew that this would not be able to happen at once, even the author knew that nobody will believe Juan about what he was about tell them. He does not lose his empathy and he tries to keep the story on an interesting point so the readers do not lose track of the story.Juan Diego very sad went back to see the virgin and this time the virgin tell him that he needed to go back to the palace and tell them again what she wanted to. She told him to try to convince him, to try to use the same words that she was telling him so they can believe him. He hope the Bishop to believe him and he said to the virgin not to worry about it that he would find the way to convince him no matter what and he promise her he will come back with good news. In this paragraph the author has a nostalgic tone.He want the readers to be sensitive to what Juan was going through and all the things that he need it to do so they could believe him, but this is also a moral because this is showing us not to give up on whatever we want to do or to obtain if we keep on trying and no matter how many times you try. If you never lose the hope you will obtain what you want, sooner or later but you will have it. Nothing is worthless, if you do it with faith and if you really try hard. This is when god tests you, to see how much you will try to obtain something and if you are really wor king hard on what you want.The author makes a really good writing when the Virgin tells Juan to go back and tell the Bishop what she want it, he tries to makes us feel as part of the story, because what the Virgin said to him was so nice but at the same time nostalgic. Even Juan says that he thinks he is not the appropriate person to do this. He says that still he will try convinced the Bishop no matter what. This part is kind of repetitive, but I guess is the way the story happened and also to make emphasis on the fact that it was not easy for the Juan to accomplish what the virgin wanted him to do.We probably all wonder why the virgin select him to do that, but well we will find out later on the reading. The next day he went there again and the same thing happened, he took forever to get to talk to the Bishop and when he finally did, he told him the same thing. This time one thing change, now he was interested on: when did he saw the Virgin, where and how does she looks like. All of these questions Juan Diego were able to answer him, so he did and with no trouble told him everything that he was seen and heard. The Bishop could not believe what was happening and did not know if he should believe or not.As it was mentioned before all these part of the reading was becoming kind of repetitive. The Bishop was really amazed of what he had heard. He command three of his servants to follow Juan on his way back. He said he was going to talk to the Virgin again, so he need it to be sure that he was not lying. The setting of this part of the story is really good because the author describes how Juan went back home and how those servants were following him but suddenly they lost him. They went back to the palace and said to the Bishop that he was a liar that they did not saw anything wrong.That was not the truth they just wanted to cover themselves because they lost him. As the story keeps on going, the author tries to keeps us engage on the reading. He does an amazing description of each scene that is just becoming more interesting and interesting each time. Sometimes you are reading a story but something happens that you lose the path of the story, and this can become boring and tedious. After that he went back home and found an uncle who was staying there very sick he was burning in fever. He did not know what to do, he call a doctor and the Dr. ame to look at him. He gave him medicine, but he was so sick that noting help him. Bernardino who was his uncle name told Juan to go to Tlatilolco and bring a priest. He wanted to confess; he said that He WAS About to pass away. Juan was so sad and went to look for the priest, on his way to Tlatilolco he did not know which way to go. If he goes straight he would saw the Virgin and she wanted him to go and see the Bishop. Since he was on a hurry to get the priest, he went through a different path, but what he did not know was that the Virgin could see him wherever he went.When he was walking the virgin a sk him: Where are you going this is not the path you follow always, he was so embarrassed that he tell her what was going on about his uncle and everything. The Virgin told him not to worry about it that he was cure already and that now he need it to go and talk to the Bishop. This scene was a moral because it shows us that whatever you do you, god will always know it and in this case the virgin knew everything what Juan Diego did. This teaches us that no matter where we are god will always take care of us. Always try to follow the right path of your life.Sometimes you think that doing other stuff will make you popular or whatever but this is not truth, all bad things will always come up. Finally he went again to see the Bishop. This time he had an evidence of what he was saying and that was what the Bishop wanted. There were these beautiful flowers on his mantle and as soon he shows it to the Bishop they fall on the floor and a suddenly appeared the most pure image of the Virgin. I t was so real that everybody in there knelt down and gazed with wonder. This setting seems real and he always portrays a lot of real life events.