American Infrastructure

American Infrastructure-Now or Never Because of the poor state of the economy the care American infrastructure has been ignored, which poses a danger to everyone that come in contact with it. Recent disasters have reminded many how important the care of American infrastructure is. America’s infrastructure gets a grade of â€Å"D† from the American Society of Civil Engineers (ASCE), which recommends that we spend $2. 2 trillion on repairs and maintenance. â€Å"Much of America is held together by Scotch tape, bailing wire and prayers,† says director of the Fels Institute of Government at the University of Pennsylvania.But with the country no longer swimming but drowning in debt the upkeep of things such as roads and bridges, which we use every day, are easily overlooked. Mike Pagano, an urban planning expert at the University of Illinois at Chicago, said â€Å"We have convinced ourselves that infrastructure is free, that someone else should be paying or that we h ave paid our share. † One must stop overlooking the problems that one knows exist simply because the consequences are not immediate. Crumbling infrastructure has a direct impact on our personal and economic health, and the nation’s infrastructure crisis is endangering our nation’s future prosperity,† D. Wayne Klotz. According to the U. S. Department of Transportation more than one in four of America's nearly 600,000 bridges need significant repairs or are burdened with more traffic than they were designed to carry. A third of the country’s major roadways are also in less than standard condition which data from the National Highway Safety Administration finds plays a factor in a third of more than 43,000 traffic fatalities.Along with the Association of State Dam Safety Officials finding that the number of dams that could fail has grown more that 134 percent since 1999 to 3,346 and more than 1,300 of those being â€Å"high-hazard† meaning their failure would threaten lives. When a council of 28 civil engineers evaluated 15 infrastructure categories on the basis of capacity, condition, funding, future need, operation, maintenance, public safety and resilience water received the lowest grade. ASCE gave U.S drinking water, inland waterways, levees, roads and wastewater infrastructures. The report they generated estimated that leaking pipes lose seven billion gallons of clean drinking water a day â€Å"Infrastructure is the four-syllable jawbreaker that governments use to describe the concrete, stone, steel, wires and wood that Americans rely on every day but barely notice until something goes awry (Kelderman). † Due to the state of the economy many lawmakers put the money need to keep infrastructure properly taken care of into things like defense.The federal Clean Water State Revolving Fund, which makes low interest loans to clean up or protect water supplies, has shrunk from more than $3 billion in 1990 to roughly $1 billion in 2007 (Kelderman). The report also suggests that there is an $11 billion dollar shortfall annually needed to bring facilities up to current federal water regulations. As stated in the article â€Å" The State of the Union-Crumbling’, the nation is spending less than 40 percent of the $225 billion needed annually for the next 50 years to maintain the current system of roads, rails and bridges and build enough transportation capacity for a growing population.In the past ten years there have been many infrastructure failures that make you wonder when the government will get serious about the issue at hand. Not paying attention to the condition of infrastructure has proven to be fatal. The article â€Å"The State of the Union- crumbling† confirms that on Aug. 1 2007 the Interstate 35 bridge in downtown Minneapolis collapsed into the Mississippi river, killing thirteen people. Steam pipe explosions in Midtown Manhattan last summer killed one and disrupted many.In March 2006 the Kaloko Reservoir dam in Hawaii collapsed killing seven and causing $15 million in damages. In 2005 after Hurricane Katrina the levees holding back Lake Pontchartrain gave way killing more than a thousand. Imperative calls have been made to prevent anymore catastrophes due to failing infrastructure but not much has been done. Money is still being put into things like defense which many politicians feel is more important. But if we keep neglecting our own home we may have nothing but half mangled buildings to defend. Our leaders are looking for solutions to the nation’s current economic crisis. Not only could investment in these critical foundations have a positive impact, but if done responsibly, it would also provide tangible benefits to the American people, such as reduced traffic congestion, improved air quality, clean and abundant water supplies and protection against natural hazard. † ASCE President D. Wayne Klotz stated. A report from Kansas City Mi ssouri based HNTB corp. ound that 74 percent of Americans would be willing to spend more on various transportation expenses or taxes if the money was put toward long-term transportation improvements. More than half (58 percent) of Americans would pay more each month, an average of thirteen dollars per month, to reduce the time they spend in traffic by twenty percent. ASCE President D. Wayne Klotz also stated that â€Å"Infrastructure investment at all levels must be prioritized and executed according to well conceived plans that both complement the national vision and focus on system wide outputs.Goals of the plan should center on freight and passenger mobility, intermodality, water use, environmental stewardship and encouraging resiliency and sustainability. The plans must reflect a better defined set of federal, state, local, and private sector roles and responsibilities and instill better discipline for setting priorities and focusing funding to solve the most pressing problems. The plans should also complement our broad national goals of economic growth and leadership, resource conservation, energy independence, and environmental stewardship.Infrastructure plans should be synchronized with regional land use planning and related regulation and incentives to promote non-structural as well as structural solutions to mitigate the growing demand for increased infrastructure capacity. † A long-term infrastructure plan can foster productive growth in our economy, sustainable growth that furthers energy independence and real solutions to climate change and comprehensive growth so that low and moderate-income families have access to opportunity.And studies show that American citizen realize the importance and are willing to pay their fair share of the cost so the only thing missing now is action. Works Cited Kelderman, Eric. â€Å"The Pew Charitable Trusts. † Pew Center on the States. N. p. , 16 Jan. 2008. Web. 29 Oct. 2012. ;http://www. pewstates. or g/projects/stateline/headlines/the-state-of-the-union-crumbling 85899387455;. Failure to Act. Rep. N. p. : n. p. , n. d. 2011 Report Card. American Society ofCivil Engineers, July 2011. Web. 28 Oct. 2012. ;http://www. asce. org/infrastructure/report-card/economic-study/;. â€Å"American infrastructure receives ‘D' grade on ASCE report card. † Clean Water Report 4 Feb. 2009: 2. General OneFile. Web. 2 Nov. 2012 â€Å"Infrastructure, Infrastructure. † Transport Topics. 3967 (2011): 6-. ABI/INFORM Complete. Web. 2 Nov. 2012. â€Å"Americans support infrastructure investment. † American City ; County 1 May 2011. General OneFile. Web 2 Nov. 2012.

Written Critique of Drug Therapy in Nursing Practice

According to Wayne K. Anderson, Dean, State University of New York, School of Pharmacy, â€Å"statistically, if you take six different drugs, you have an 80% chance of at least one drug-drug interaction. † The drug regimen of Mrs. Brown includes six drugs that may interact with each other if not administered and monitored carefully. This is the reason why healthcare providers should be aware of the possible adverse affects that may happen related to her drug regimen. Necessary precautions should be observed to get the full benefits of the needed drugs and minimize possible drug-drug interactions. Nursing Management Mrs. Brown has a history of seizure, therefore, necessary measures should be provided to ensure the patient's safety. It is also known that seizure is one of the many side effects of the drug metronidazole (Drugs. com, 2010). To prevent injury to patient, the nurse should provide comfort and safety measures if the CNS effect occurs such as siderails, and assistance with ambulation if dizziness and weakness are present† (Karch, 2006, p. 170). Since Mrs. Brown has numerous risk factors and health conditions, the nurse should â€Å"monitor for drug-drug interactions to arrange to adjust dosages appropriately† (Karch, 2006, p. 47). The drug regimen of Mrs. Brown may present several adverse effects that should be observed, the nurse â€Å"monitor adverse effects and provide appropriate supportive care as needed to help patient cope with these effects† (Karch, 2006, p. 347). To achieve therapeutic effects, it is also important that the nurse is aware how to â€Å"administer the drug as prescribed in appropriate relationship to meals† (Karch, 2006, p. 572). The nurse should provide supportive management to the drug regimen so she should â€Å"monitor the patient's clinical status closely especially during the initial stages of treatment† (Karch, 2006, p. 34). This includes daily monitoring of serum lithium and phenytoin levels, blood glucose, prothrombin time (PT) and hepatic functioning. It is essen tial to promote compliance to the patient. The nurse should â€Å"provide thorough patient teaching, including drug name and prescribed dosage, as well as measures for avoidance of adverse effects, warning signs that may indicate possible problems and the need for monitoring and evaluation to enhance patient knowledge about drug therapy† (Karch, 2006, p. 347). Some of the teaching points that should be included are any sign of blood loss ( petechiae,bleeding gums, bruises, dark colored stools, dark colored urine) to evaluate the effectiveness of warfarin and symptoms of phenytoin toxicity, including drowsiness, visual disturbances, change in mental status, nausea, or ataxia. Indications and Actions The indications and actions of Mrs. Brown's regimen is presented to help verify the purpose of the drugs and their effects on the overall condition of the patient. Metronidazole (Flagyl, MetroGel, Noritate) Metronidazole is used for the treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease, H. pylori infection causing peptic ulcers, bacterial vaginosis, and anaerobic infections and perioperative prophylaxis in colorectal surgery† (Kee & Hayes, 2006, p. 470). In this case, it is also used to treat abscesses in the pelvis caused by susceptible anaerobic bacteria. It is classified as â€Å"an antiprotozoal agent that acts to inhibit DNA synthesis in susceptible protozoa, leading it to unable to reproduce and subsequent cell death† (Karch, 2006,p. 169). Paracetamol (Acetaminophen) Acetaminophen is indicated for the treatment of pain and fever associated with a variety of conditions, including influenza; for the prophylaxis of children receiving diptheria-pertussis-tetanus (DPT) immunizations; and for the relief of musculoskeletal pain associated with arthritis† (Karch, 2006, p. 241). Paracetamol was prescribed for the presence of pain in the client's perineal area. Metformin (Glucophage) â€Å"Metformin is a biguanide compound used for the management of type 2 diabetes† (Kee & Hayes, 2006, p. 787). In this case, the patient was known to have diabetes. This medication could be considered as a new mechanism for the management of her type 2 diabetes. This oral diabetic agent â€Å"acts by decreasing hepatic production of glucose from stored glycogen† (Kee & Hayes, 2006, p. 787). It is said to diminish the increase in serum glucose after meals and lessen the degree of postprandial hyperglycemia. Phenytoin (Dilatin) â€Å"Phenytoin is the protoype hydantoin used in the treatment of tonic-clonic seizures and status epilepticus, as well as in the prevention and treatment of seizures after neurosurgery† (Karch, 2006, p. 342). Since the patient has a history of seizure disorder, this medication was prescribed for maintenance. It acts as â€Å"an anticonvulsant drug that works by suppressing sodium influx through the drug binding to the sodium channel when it is inactivated, thus prolonging the channel inactivation and thereby preventing neuron firing† (Kee & Hayes, 2006, p. 341). Warfarin ( Coumadin) â€Å"Warfarin (Coumadin) is an anticoagulant drug in oral form that is used to maintain a state of anticoagulation in situations in which the patient is susceptible to potentially dangerous clot formation† (Karch, 2006, p. 38). The patient was given this medication since she has a history of atrial fibrillation that makes her susceptible to thrombus and embolus formation. The drug Warfarin inhibits the formation of thrombus and embolus formation by decreasing certain clotting factors. â€Å"Warfarin causes a decrease in the production of vitamin K-dependent clotting factors (II [prothrombin], V II, IX and X) in the liver† (Karch, 2006, p. 740). Lithum Carbonate â€Å"Lithium is used as a mood stabilizers which is used to treat bipolar affective disorder† (Key & Hayes, 2006, p. 399). Mrs. Brown has a bipolar mood disorder so this drug was prescribed to control her periods of mania and depression. It is said to function in several ways, â€Å"it alters sodium transport in nerve and musle cells; inhibits the release of norepinephrine and dopamine, but not serotonin, from stimulated neurons; increases the intraneuronal stores of norepinephrine and dopamine slightly; and decreases intraneuronalcontent of second messengers† (Karch, 2006, p. 330). Common Drug Interactions Drug to Drug Interactions Metronidazole (Flagyl, MetroGel, Noritate) This drug is known to produce interactions with phenytoin, oral coagulants and lithium. â€Å"Coadministration with a nitromidazole may increase the serum concentration of phenytoin† (Drugs. com, 2010). It is known to induce microsomal liver enzyme activity such as phenytoin that may accelerate the elimination of metronidazole resulting in reduced plasma; impaired clearance of phenytoin has been reported† (DailyMed, 2009). In this case, pharmacologic responses and serum phenytoin should be checked frequently whenever metronidazole is being administered to the patient. The drug dosage should be adjusted as necessary. Another thing to do is to educate the patient the signs and symptoms of phenytoin toxicity for immediate physician notification. â€Å"Metronidazole has been reported to potentiate the anticoagulant effect of warfarin and other oral coumarin anticoagulants, resulting in a prolongation of prothrombin time† (DailyMed, 2009). Mrs. Brown should be advised to report any signs of bleeding to her physician. INR should be checked frequently for adjustments in warfarin dosage, specifically after starting or discontinuing metronidazole. And lastly, lithium is said to produce interactions when administered with metronidazole. â€Å"Concurrent use of metronidazole with lithium may provoke lithium toxicity due to reduced renal clearance† (Rxlist, 2010). Since Mrs. Brown has a bipolar mood disorder, lithium is a long drug regimen. The serum lithium and creatinine levels should be monitored after the initiation of metronidazole. Phenytoin (Dilantin) Besides the impaired clearance of phenytoin with the use of metronidazole, there are other drug interactions that can happen in reference to Mrs. Brown's drug regimen. It is said that Phenytoin can increase the effects of anticoagulants. â€Å"The hydantoins displace the anticoagulants and aspirin, causing more free drug and increasing their activity† (Kee & Hayes, 2006, p. 342). Still, it is important to check on the prothrombin time (PT), phenytoin level and prothrombin time of the patient during the administration of both drugs. â€Å"Signs of an active bleed include coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea-colored urine (hematuria), and black, tarry stools (hemoccult positive)†. Brown should be observed and notified to the physician. It is also said that the use of phenytoin can lead to â€Å"increased hepatotoxicity with acetaminophen† (Karch, 2007, p. 952). Lithium interacting with Phenytoin â€Å"may either increase or decrease the effectiveness of lithium or increase or decrease the effectiveness of the drug† (Raber, 2010). Phenytoin level and lithium serum level should be checked frequently to monitor the effectiveness of these drugs. Warfarin (Coumadin). Aside from the drug interactions of warfarin to both Metronidazole and Phenytoin, there is an existing interaction between Metformin and Warfarin. It is said that Metformin â€Å"oral hypoglycemic drugs for diabetes can displace warfarin or dicumarol from the protein-bound site, causing more free-circulating anticoagulant† (Kee & Hayes, 2006, p. 663). Due to this possible interaction, it is important to monitor the blood glucose level and prothrombin time (PT). The patient should be informed of the signs and symptoms of hypoglycemia and bleeding so that she could report it to the health care team immediately. Warfarin also interacts with paracetamol (acetaminophen); it said that â€Å"some investigators advise that the hypothrombinemic response to warfarin can increase when acetaminophen is taken in a dosage of more than 2 g per day for longer than one week† (Ament, Bertolino & Liszewski, 2000). Since Mrs. Brown has a prescription of 1000mg to be taken four times a day, her dosage is more than 2g per day. â€Å"If acetaminophen therapy is needed, the dosage should be as low as possible, and the drug should be taken for only a short period. In addition, the INR should be monitored closely† (Ament et al. 2000). Metformin (Glucophage) Meformin has moderate drug interaction with the drug Phenytoin. It is said to diminish the efficacy of oral diabetic agents and insulin. â€Å"These drugs may interfere with blood glucose control because they can cause hyperglycemia, glucose intolerance, new-onset diabetes mellitus, and/or exacerbation of preexisting diabetes† (Drugs. com, 2010). There should be close monitoring of Mrs. Brown's blood glucose level in order to observe hypoglycemia in the patient. Lithium (Eskalith) Lithium has drug interactions with Metronidazole and Phenytoin. It is also established that lithium may diminish the therapeutic effects of insulin and oral anti-diabetic agents. â€Å"In one study, 10 psychiatric patients treated with lithium carbonate for 2 weeks demonstrated elevated blood glucose levels and impaired glucose tolerance tests. There have also been isolated case reports of hyperglycemia, impaired glucose tolerance, or diabetes mellitus in patients on lithium, although a causal relationship has not been established† (Drugs. com, 2010). The blood glucose level should be checked frequently after starting or discontinuing lithium therapy. Drug to Food, Drug to Herbal, Drug to OTC drugs Interactions Metronidazole Metronidazole has a significant interaction with ethanol. â€Å"Use of alcohol or products containing alcohol during nitroimidazole therapy may result in a disulfiram-like reaction in some patients† (Drugs. com, 2010). Necessary precautions should be made in relation to use of ethanol and ethanol-containing products. Mrs. Brown should be instructed not to take alcohol beverages and alcohol-containing products. It is said that â€Å"alcohol beverages should not be consumed for at least a day after completion of metronidazole therapy† (Drugs. om). Metronidazole has an interaction to the herb milk thistle. â€Å"Milk thistle has been reported to protect the liver from harm caused by some prescription drugs. While milk thistle has not yet been studied directly for protecting people against the known potentially liver-damaging actions of metronidazole, it is often used for this purpose† (Morazz oni & Bombardelli, 1995). Phenytoin Phenytoin has moderate interaction with alcohol and food. The effects of alcohol on the therapeutic level of Phenytoin depend on the duration of its consumption. â€Å"Acute consumption of alcohol may increase plasma phenytoin levels. Chronic consumption of alcohol may decrease plasma phenytoin levels† (Drugs. com, 2010). Phenytoin (oral drug) could be given with or without food in a consistent manner. Give with food if patient complains of GI upset ( Karch, 2007). The bioavailability of Phenytoin is said â€Å"to decrease to subtherapeutic levels when the suspension is given concomitantly with enteral feedings† (Drugs. com, 2010). Antacids containing calcium may decrease the blood level of phenytoin while aspirin (more than 1500 mg/dl) may increase the blood level of phenytoin (Epilepsy. om, 2010). Phenytoin also will lower the blood levels of other types of medication like acetaminophen (Epilepsy. com, 2010). Warfarin Patients taking Warfarin should not take Vitamin K-rich foods like â€Å"liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and other green leafy vegetables† (Drugs. com). There are also particular medicines that should not be taken for they m ay cause serious bleeding problems in the stomach and intestines and alterations in blood clotting. These particular medicines are as follows: â€Å"acetaminophen (Tylenol), aspirin, and NSAIDs including celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Motrin, Advil), indomethacin, naproxen (Aleve, Naprosyn),and others† (Drugs. com, 2010). It is also said that the patient should â€Å"avoid eating cranberries, drinking cranberry juice, or taking cranberry herbal products† (Drugs. com, 2010). Warfarin can interact with the following herbal products: â€Å"garlics, gingko biloba, ginseng or St. John's wort†. (Drugs. com, 2010). Metformin Drugs that can raise the blood sugar affecting the use of Metformin include medicines to treat colds and allergies while drugs that lower blood sugar include some nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and sulfa drugs (Bactrim)† (Drugs. com, 2010). Alcohol should also not be taken concomitantly with this drug. â€Å"Alcohol lowers blood sugar and may increase the risk of lactic acidosis while taking this drug† (Drugs. com, 2010). There could be increased risk for hypoglycemia if the drug is taken with â€Å"juniper berries, ginseng, garlic, dandelion root and celery† (Karch, 2007, p. 58). Lithium Patients taking lithium carbonate should â€Å"avoid drinking large amounts of coffee, tea, or cola, which can cause dehydration through increased urination† (Drugs. com, 2010). Besides having interactions with other drugs in the patient's regimen, lithium also interacts with over-the-counter drugs. â€Å"If Eskalith is taken with certain other drugs, the effects of either could be increased, decreased, or altered such as nonsteroidal anti-inflammatory drugs† (Drugs. com, 2010). â€Å"Patients being treated with lithium should be encouraged not to use the herbal therapy psyllium. If combined with lithium, the absorption of the lithium may be blocked and the patient will not receive therapeutic level† (Karch, 2006, p. 333) Possible Adverse Reactions and Nursing Interventions Metronidazole â€Å"Convulsive seizures have been reported in patient treatment with metronidazole† (DailyMed, 2009). Necessary seizure precautions should be implemented. Mrs. Brown has a history of seizure; this is why the healthcare team should take necessary adjustments to the dosage of metronidazole. Aside from this major adverse reaction, the patient can develop â€Å"unpleasant metalic taste, nausea, vomiting and diarrhea† (Karch, 2007, p. 86). Nursing care for strange metallic taste should be â€Å"frequent mouth care, sucking sugarless candies†, and for nausea, vomiting and diarrhea, the patient should be advised to â€Å"eat frequent small meals† (Karch, 2007, p. 786). In the case of Mrs. Brown, complains of discomfort in her buttocks, pain in per ineal area and offensive odor could mean that she developed cadidiasis as â€Å"known or previously unrecognized candidiasis may present more prominent symptoms during therapy with metronidazole† (DailyMed, 2009). Treatment with candidicidal agent should be instituted to the patient. Other adverse effect can be â€Å"disulfiram-like interaction with alcohol† (Karch, 2007, p. 786). The patient should be always reminded of precautions on ingesting alcohol and alcohol-containing products. Phenytoin â€Å"Nausea,vomiting, diarrhea, constipation and gingival hyperplasia† (Karch, 2009, p. 951) could be present in patients taking Phenytoin. The nurse should â€Å"arrange instruction in proper hygiene technique for long-term patients to prevent development of gum hyperplasia†, â€Å"take drug with food, eat frequent small meals† (Karch, 2007, p. 953). Among the other common adverse effects are â€Å"dizziness ,drowsiness, confusion and headache†. The patient should be advised to â€Å"avoid performing tasks requiring alertness and visual acuity† (Karch, 2007, p. 953). Warfarin The common adverse effects of Warfarin are â€Å"nausea, vomiting, abdominal cramping, diarrhea and hemorrhage† (Karch, 2007,p. 1216). Nurse should advise the patient to â€Å"avoid any situations in which she could be easily injured. † Necessary care should be provided to avoid bleeding in the patient like â€Å"not giving any IM injections† (Karch, 2007, p. 1217). The patient should also be asked to â€Å"report unusual bleeding (from brushing teeth, excessive bruising), black or bloody stools, cloudy or dark urine† (Karch, 2007, p. 1218). Metformin The most significant possible adverse effects of this drug are â€Å"hypoglycemia and lactic acidosis† (Karch, 2007, p. 758). The nurse should â€Å"monitor blood for glucose and ketones† or â€Å"should ask the client any sign of hypo- or hyperglycemic reactions† (Karch, 2007, p. 758). There could also be â€Å"signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat† (Drugs. om, 2010). In this case, it is necessary to â€Å"stop the medication and report to the physician† (Drugs. com, 2010). Lithium The common side effects of Lithium involves CNS manifestions such as â€Å"lethargy, slurred speech, muscle weakness and fine hand tremor; GI manifestions such as nausea, vomiting , diarrhea, thirst; GU effect is polyuria† (Karch, 2007, p. 704). It is important to instruct the client to â€Å"report any signs of toxicity such as diarrhea, vomiting, tremor, drowsiness, muscle weakness† (Karch, 2007, p. 705). The patient should also be prohibited or â€Å"avoid driving or performing tasks requiring alertness† and should be instructed to â€Å"eat frequent small meals† (Karch, 2007, p. 705). Health Education Metronidazole It is impotant to instruct the client to â€Å"not drink alcohol (beverages or preparations containing alcohol, cough syrups)† (Karch, 2007, p. 786). The nurse should also mention to the client that she may experience â€Å"urine with darker color , dry mouth with strange metallic taste, nausea, vomiting and diarrhea† (Karch, 2007, p. 786). Intervention to relieve these side effects should be taught like â€Å"frequent mouth care, sucking sugarless candies for dry mouth; eating frequent small meals for nausea, vomiting and diarrhea† (Karch, 2007, p. 786). Phenytoin Patients taking Phenytoin should be advised to â€Å"take this drug exactly as prescribed with food to reduce GI upset or without food — but maintain the consistency† (Karch, 2007, p. 953). Mrs. Brown should be advised to â€Å"not discontinue this drug abruptly or change dosage, except on advice of health care provider† (Karch, 2007,p. 953). Since Mrs. Brown has diabetes, it should be advised that she should â€Å"monitor blood or urine sugar regularly, and report any abnormality to health care provider† (Karch, 2007, p. 953). She should be advised that she should â€Å"maintain good oral hygiene to prevent gum disease and arrange frequent dental checkups† (Karch, 2007, p. 953). Warfarin It should be advised to the patient to â€Å"not start or stop taking any medication without consulting her health care provider† (Karch, 2007, p. 1217). She should â€Å"carry or wear a medical ID tag to alert emergency medical personnel about the drug† (Karch, 2007, p. 218). She should be instructed to â€Å"avoid situations that may cause injury and have periodic blood tests to check on drug action† (Karch, 2007, p. 1218). Lastly, the patient should be instructed to â€Å"report unusual bleeding, black or bloody stools and cloudy or dark urine† (Karch, 2007, p. 1218). Metformin Some of the instructions t hat should be given to the patient are â€Å"not to discontinue the medication without consulting health care provider and avoid using alcohol while taking the drug† (Karch, 2007, p. 758). She should also be advised to â€Å"monitor blood for glucose and ketones and report any hypo-or hyperglycemia reactions† (Karch, 2007, p. 758). Lithium Health teaching about this drug should include the following: â€Å"take the drug exactly as prescribed, after meals or with food or milk; eat a normal diet with normal salt intake and maintain adequate fluid intake and arrange for frequent checkups including blood tests† (Karch, 2007, p. 705). Mrs. Brown has numerous risk factors and health conditions that may produce drug interactions that may worsen her health. It is known that Metronidazole can produce seizures as its side effect. Considering this, safety precautions should be made since she has a history of seizure. This drug can also impair the clearance of the drug Phenytoin in her system and potentiate the anticoagulant effects of Warfarin. These things should be monitored by the healthcare team for them to make necessary adjustments. Phenytoin can also increase the anticoagulant effect of Warfarin and may either increase or decrease the efficacy of lithium. Necessary drug dosage adjustments should be made to minimize these interactions. Daily blood glucose monitoring should be done and symptoms of hypo- or hyperglycemia should be reported. This is necessary because Warfarin can increase the effects of oral diabetic agents such as Metformin. However, Phenytoin and Lithium can diminish the efficacy of this drug. Thus, it is really important to monitor the client's clinical status and the possible adverse effects of the drug regimen. It is also important to â€Å"offer support and encouragement to help the patient cope with the drug regimen† (Karch, 2006, p. 334).

Existentialism and Human Nature Essay

Absolute individuality and absolute freedom: the basis of all existentialist arguments. The existentialist’s conceptions arise from their held views that since we are all ultimately alone, we have absolute freedom over our nature. Existentialists emphasize the â€Å"free and conscious self† which opponents constantly attack, exclaiming that there is a â€Å"higher power† enabling our consciousness. But are humans so simple? Can things be explained solely on blaming ourselves or another being for our nature? The existentialist generally believes in a sole existence; meaning that we are alone in the world, and that we have no one but ourselves. They also believe in the human being’s capacity to feel more than one kind of pain, and that there are three different levels to our pain, physical, psychological, and emotional. All of these types of pain can cause us to become irrational and anxious. But are we really anxious because of this pain, or is it because we ultimately feel alone? And if we are all individuals, can we really feel the same kind of pain as someone else? Existence precedes essence is also dominant in the mind and thoughts of the existentialist. That is, the idea that we are born into this world without a predetermined nature, and only later in life do we shape out nature through actions and choices. This opposes the traditional view that is that essence precedes existence, according to which we are seen as having a purpose, and values, all of which is determined before birth. (I personally think that the idea of essence preceding existence is rather obscure. There is no way that our values and purpose can be determined by genetic code. DNA is what we are, not who we are. ) Existentialists pose another question to the opposition: how can we be happy in a world devoid of significance and meaning? The loss of external values allows us to derive value from within ourselves. This value is greater than any imposed by outside forces, and thus cannot be taken away from said sources. Although many human beings live a life devoid of true happiness, it does not mean that we are incapable of attaining such a goal. If a person finds the meaning for their life, whether it be one meaning, or many, there is a large chance that they can achieve such a utopia without recognizing outside influences. People of different viewpoints follow different methods, as well as believe in different forces that shape our nature. It is in my opinion, as well as that of the existentialist, that we shape our own nature through decisions and actions made by our own free will; that we are ultimately free to act independently from the influences of outside forces. That we can ultimately ignore the views imposed on us, and achieve a sustainable level of happiness in the process. Human nature is a frail thing; people are just looking for someone else to blame for their actions and for who they are, even when there isn’t any. Therefore, there is no one to blame for who we are, but ourselves.

Analysis of “Nuances of a Theme by Williams”

Analysis of â€Å"Nuances of a Theme by Williams† The title of Wallace Stevens’ poem â€Å"Nuances of a Theme by Williams† implies that he intends to comment on, possibly celebrate, and almost certainly explore the potential distinctions and variations available in the poem by William Carlos Williams titled â€Å"El Hombre.† Stevens includes â€Å"El Hombre,† in its entirety minus the title, in the opening four lines of his poem with the implication (again based on the, at worst, neutral title of Stevens’ poem as well as the seemingly tributary inclusion of â€Å"El Hombre†) that his re-workings and explorations of his colleague’s piece will maintain its essence and, presumably, not bear it much, if any, antipathy. The title, however, proves to be misleading and Stevens’ subsequent lines appear to be less of a nuanced exploration of Williams’ poem than a criticism of what he sees as its faults: namely the sentimentality, anthropomorphizing, and romantic detachedness of t he narrator that is present especially in the first two lines. It is particularly the first stanza of Williams’ poem that Stevens takes issue with and he does so, at least in part, by way of its second stanza. Stevens attaches himself to two phrases, â€Å"shine alone† (3) and â€Å"lend no part† (4), that bookend the second stanza of Williams’ poem and uses them as his access points to the poem. He quotes the two phrases directly, elevating them to the opening words of both of his subsequent stanzas, though in doing so he also very purposefully changes their meaning. The first line of Stevens’ composition, â€Å"Shine alone, shine nakedly, shine like bronze† (5) seems, appropriately, to satisfy the expectations of the title while also being characteristic of Stevens’ playful perspectivist aesthetic tendencies (reminiscent, perhaps, of â€Å"Thirteen Ways of Looking at a Blackbird†); beginning with the two-word phrase taken directly from Williams’ piece, Stevens’ proceeds to stretch it into a richer, more textured imperative description of the same â€Å"ancient star† (2) addressed in Williams’ poem. Nonetheless, the succeeding two lines that make up the rest of Stevens’ first stanza diverge from mere variation into what seems to be an invective response to the opening lines of Williams’ poem: â€Å"It’s a strange courage/you give me, ancient star† (1-2). Stevens appears to be concerned with the fact that Williams sort of anthropomorphizes the star, which seems to be the rising sun, and instills it with the ability to give courage. He says of the sun that it must shine like something that â€Å"reflects neither [his] face nor any inner part/of [his] being† (6-7) and, ultimately, â€Å"like fire, that mirrors nothing† (7). Stevens’ deliberate dissociation with the sun (as a stand-in for nature) reflects his belief that one should apprehend nature without embellishing it; that the things of nature should not be used as means to access the triumphs or despairs of humanity. Where in Stevens’ â€Å"The Snowman† it is only with â€Å"a mind of winter† (1) that one can hear â€Å"the sound of the land† (10) without being distracted by â€Å"any misery in the sound of the wind† (8), so must Williams’ sun, in Stevens’ conception, mirror â€Å"nothing that is not there† (The Snowman, 15) if it is to be truly apprehended. With the entirety of Stevens’ first stanza in mind, the variations in his first line (that continues and concludes in the third with â€Å"shine like fire†) read less playfully and more like a slow, deliberate distancing from the humanness of the word â€Å"alone.† For â€Å"alone† is rarely used to describe the state of an inanimate object by itself, which wouldn’t require the recognition of being outside of a society of similar objects since society is limited to animate creatures. So Stevens re-forms the description as â€Å"nakedly.† That first step, though, is only a small step away from animation since it evokes the idea of being without clothes. But the adverb â€Å"nakedly† is, in fact, more commonly used to describe the nature of concepts or ideas, as in â€Å"plainly† or â€Å"blatantly,† and less the physical state of one’s dress. With the second transformation, â€Å"like bronze,† however, the le ss subtle split with animation begins. With â€Å"like bronze† Stevens has reformulated an idea of the sun as merely resembling something. Though it is a man-made something, which, therefore, maintains an inevitable if convoluted connection to the human realm. So, Stevens’ necessarily searches for one more angle, â€Å"like fire,† and the split with humanity is complete; the sun is reduced to something natural, independent of human existence, but, more importantly, it is reduced to precisely what it is. The sun is precisely something that in Stevens’ view should â€Å"lend no part to any humanity that suffuses/[the sun] in its own light† (8-9) as Williams does. For like Stevens declares in his later poem â€Å"Things of August†: â€Å"The rich earth, of its own self made rich,/Fertile of its own leaves† (51-52), so must the shining sun, of its own self shine. It appears that Stevens’ wishes to forget all human history of sun worship and mythology and relish the sun as it is perceived in the moment, in the present, by an individual person. Yet, in communicating his point, Stevens’ says that the sun should â€Å"be not chimera of the morning† (10). â€Å"Chimera† carries the meaning of â€Å"illusion† or â€Å"daydream† as if warning against being tricked into seeing the sun as more than it is, or as something that it is not. But â€Å"chimera† also carries the connotation of the mythical creature that was made of various animal parts and had an intelligence. So in this moment, while Stevens’ argument is ostensibly sustained, he undermines it slightly by constructing it around such a contradictory notion, even if only as a means to negate it. The final three lines of the poem continue in this vein of ridding the sun of any ancient residual meaning. He ironically says the star should â€Å"Be not an intelligence/Like a widow’s bird/Or and old horse† (12-15). These comparisons are ironic simply because Stevens would not grant intelligence to a bird or horse, but he knows that they are often thought of that way. A lonely widow gives more meaning and power to her avian companion and a farmer may attribute wisdom to a horse that has weathered much. Stevens slyly insults the romantic sentimentality of Williams’ poem by putting it on the same level as the foolish and uneducated figures suggested in his closing lines. It seems that Stevens sees Williams’ poem as weak and sentimental. Stevens’ poem is an exercise of his mind on Williams’ theme, enacted to deliberately and systematically gain control over the emotional preoccupations of the poem. I would suppose that, ultimately, Williams would not only have appreciated the criticisms of Stevens, but also would have agreed with them. I feel as though â€Å"El Hombre† is, at least on a basic level, an immature poem of Williams that would not have fit into his later, more distinctly formulated views.

Immigration and Asylum Law Essay Example | Topics and Well Written Essays - 2500 words

Immigration and Asylum Law - Essay Example In the House of Lords decision in Islam (A.P.) v. Secretary of State for the Home Department and Regina v. Immigration Appeal Tribunal and Another Ex Parte Shah (A.P.) [1999] 2 W.L.R. 1015 (Conjoined Appeals), Lord Steyn set out a four point criteria that one claiming refugee or asylum status must meet. He opined that under Article 1A(2) of the Refugee Convention, an asylum seeker must be able to prove that, firstly he/she has a well founded fear of persecution; secondly, that the reason for persecution is as a result of race, religion, nationality, membership of a particular social group, or political opinion; thirdly, that he/she is not within the country of his/her nationality; and fourthly, that he/she is either unable or unwilling to lay claim to protection from his/her country of nationality due to the fear of persecution. Consequently, having a well founded fea... Another decided case that buttresses the argument set out in Lord Steyn opinion is Januzi v. Secretary of State for the Home Department and Others [2006] UKHL 5. In Januzi Lord Bingham held that the use of the provision "owing to a well-founded fear of being persecuted " in Article 1A(2) of the Refugee Convention constitutes a causative condition upon which all the other conditions for claiming a refugee status hinge on. Thus a person claiming refugee status can claim to be persecuted because of his/her race, religion, nationality, membership of a particular social group, or political opinion, but if this fear is not a well-founded one, the claim to refugee status would be denied. In the Islam and Regina cases (cited above) for instance, two Pakistani women - Islam and Shah - had left their native country of Pakistan to the UK and were seeking asylum due to fear of persecution because of being part of a particular social group. Both of them had been physically abused by their husbands and had been accused of infidelity, a crime that carried the penalty of being flogged publicly or being stoned to death under Shariah Law. The two women had also received threats from neighbours after they fled from their husbands' homes and sort refuge with family members. In establishing whether the Islam and Shah had a claim to asylum due to a well founded fear of persecution, Lord Steyn quoted from an Amnesty International Report on the human rights abuses of women in Pakistan. The report stated inter alia that: ". . . several Pakistani laws explicitly discriminate against women. In some cases they allow only the evidence of men to be heard, not of women. In particular, the Evidence

Critical Reasoning (The Personal Characteristics that enable leaders Essay

Critical Reasoning (The Personal Characteristics that enable leaders to be Effective ) - Essay Example Thesis: effective leadership is based on different features and not only professional features are important, but also personal characteristics matter a lot. Employees are members of a team, who are able to implement innovative and creative ideas of a leader. Consequently, there is a need for stable and trustful relations between them. Taking into account modern researches and studies in business filed, it is evident that the main attention of researchers and scientists concerns effective leadership. Elving (2005) claims that effective leader can establish changes by means of communication. Basically, the employees are not ready for changes and perceive innovations or changes from a negative perspective. It is on behalf of the effective leader to enable employees to accept organizational changes. In accordance with Elving, there are five basic steps to be taken by leaders: a humane attitude to employees; communication in a friendly and a simple atmosphere; individual treatment for every employee; joking and easy-going manner of communication. In this case, changes and innovations in organizations are perceived â€Å"as is†, because organizational changes will be perceived as self-evident (Bovey 2001, p. 536). Caldwell (2003) claims that â€Å"leaders are transformed managers† (Caldwell 2003, p. 285). Change managers embody ideas and practices of change leaders. Actually, effective leaders invent and embody organizational changes and effective managers have implemented these actions at different organizational levels. Nevertheless, there are different leaders in the Western and the Eastern worlds. Consequently, in order to determine the effective leadership and change management in the Eastern world and Western world, it is relevant to take into account cultural and social peculiarities of different businesses, which are rooted in historic contexts of

The Role of Iron in Attenuating Tooth Deterioration Coursework

The Role of Iron in Attenuating Tooth Deterioration - Coursework Example onally, it is a transmissible, multifactorial, and dietobacterial disease, and the presence of iron in the diet plays a role in the clinical and development features of the infection. Despite the fact that this disease is complex and as such a grave threat to toddlers, it is preventable. From their research, the authors were able to deduce that those with low serum iron content had a higher risk of having dental caries. According to the article, ECC is generally believed to be directly related to the establishment of S. mutans in the early stages of tooth deterioration. In this, iron has an inhibitory role, which prevents the growth of the microorganism, thus, preventing tooth deterioration. Nevertheless, it is worth noting that the authors suggest that there is a need to assess the level of iron in children with ECC. Schroth, Robert, Levi, Jeremy, Kliewer, Eleonore, Friel, James  and   Moffatt, Michael. "Association between iron status, iron deficiency anemia and severe ealry childhood caries: a control study." BMC, (2013): 13:22. Similarly, from the research by Schroth et al. (13-22), one is able to deduce the role of iron in attenuating teeth deterioration. In their article, the authors noted that tooth decay generally affect the well-being of children. They noted this through their studies that included the assessment of differences in regard to the nutritional status between children with and those without Severe Early Childhood Caries (S-ECC). From their finding, which young children with S-ECC have a low ferritin status compared to those with no caries. Additionally, they reported that children with S-ECC are characterized with low haemoglobin level than those who are dental caries-free. The former had a high level of iron deficiency as compared to those children who are cavity free. In regard to the above, it is important to note that in most cases low hemaglobin is considered a sign of low iron levels in the blood leading to anemia. With the above