Old Company Case Essay

We are a very old company, but we recognise that our customers are changing, so we continually develop new products to reflect this. David Lee, managing director, Lee Kum Kee Company2 The problem with a lot of family-controlled local brands that have a long history behind them is that it’s very easy to become old and run out of steam. – Antony Chow, vice-president for Greater China, RSCG (an advertising agency)3 The sauce company Lee Kum Kee, one of the best known Hong Kong brands, certainly did not have the problem mentioned above, although it did have a long history that began in 1888, and was run by the same family through four generations. The company was founded by Lee Kam Sheung as a small oyster-sauce manufacturer in Guangdong Province, China. It relocated to Macau in the early 1900s, moved once more to Hong Kong after World War II, and was based there in the decades afterwards. Lee Kum Kee was already expanding beyond the Guangdong-Macau-Hong Kong distribution network in the 1920s to North America, when it was also making shrimp paste. In the 1970s and 1980s, after the torch passed to thirdgeneration leader Lee Man Tat, there was a diversification of geographical markets as well as products at a very quick pace. Lee Man Tat’s sons, who were educated in the West, inherited the leadership from their father in the 1990s, and the pace of modernisation and diversification continued while the Company’s marketing strategy remained as vigorous and Vincent Mak prepared this Case under the supervision of Dr. Chi Kin (Bennett) Yim for class discussion. This case is not intended to show effective or ineffective handling of decision or business processes. This Case is part of the Trade & Industry Department SME case series funded by the Hong Kong Special Administrative Region Trade and Industry Department SME Development Fund. Any opinions, conclusions or recommendations expressed in this material/event (by members of the project team) do not reflect the views of the Government of the Hong Kong Special Administrative Region, Trade and Industry Department or the vetting committee for the SME Development Fund.  © 2003 by The Centre for Asian Business Cases, The University of Hong Kong. The Company moreover overcame a consumer-confidence crisis — called 3-MPCD crisis — in the late 1990s and early 2000s and continued to thrive. By early 2003, Lee Kum Kee had already developed more than 200 sauces. Its distribution network covered 60 countries in five continents, and its products were available in more than 80 countries. What lessons about strategic brand management can we learn from the way Lee Kum Kee developed, maintaine d and expanded the reach of its products over a whole century? What lessons about crisis management does the Company’s handling of the 3-MPCD crisis offer? Lee Kam Sheung was born in 1868 in Qibao, a village in Xinhui, Guangdong Province, China. Threat from local gangsters forced him to leave his farming life and move to a small island called Nam Shui in the same province, where oysters were abundant. Lee opened a small restaurant there, often using oysters as stock for soups. One day, while cooking oysters, he absent-mindedly walked away for a long time, so that when he remembered the oysters and looked at the soup, it had already become a thick, strongly aromatic liquid, which he found delicious. Hence the birth of Lee’s oyster sauce, which he began producing under the brand name of Lee Kum Kee in 1888 (â€Å"Kee† meaning â€Å"company† in local Cantonese). In 1902, a fire destroyed Lee Kam Sheung’s manufacturing plant, and he moved to nearby Macau, where oysters were also abundant. He began to sell shrimp paste as well as oyster sauce, and his business soon covered Guangdong, Macau and Hong Kong. Of Lee Kam Sheung’s three sons and two daughters, the eldest son died young, and the family business passed to his two remaining sons, Lee Shiu Tang and Lee Shiu Nan. The former was responsible for marketing while the latter took up product quality and improvements to production procedures. The Company’s products were already selling successfully among the Chinese immigrant population in North American cities at that time. The company opened a Hong Kong branch in 1932 while expanding to meet the increasing demands of overseas markets. In 1946, after the Second World War, the two brothers moved their headquarters to Hong Kong, where the prospering economic climate was more conducive for businesses. The 1970s and 1980s5 Lee Man Tat, son of Lee Shiu Tang, took over as Company chairman in 1972, taking the Company to new heights. His era was marked by agile and flexible marketing; production enhancements through the automation and modernisation of production techniques; further expansion of geographical markets and sales networks, and large-scale diversification of sauce products. One of Lee Man Tat’s important early moves was to launch a new brand called Panda Oyster Sauce, capturing the hype caused by the Chinese government’s gift of a pair of pandas to US President Richard Nixon during his visit to China in 1971. The Panda brand was created as a result of slow growth in the Company’s traditional product, premium oyster sauce, which was too expensive for many families. Panda Oyster Sauce was reasonably priced and was expected to have stronger market penetration power. The brand, however, did not secure a good foothold at once, but after some effective marketing efforts it became a hit and outperformed the old labels.   Lee Man Tat learned from the success of the Panda brand that he needed to cater to different market segments. He soon launched a string of new products and brands at different prices and for different tastes, such as chilli sauce, sweet and sour sauce, chicken marinade and curry sauce. These products did well particularly in North American Chinese restaurants. In 1980, the Company, which was still quite small, with only 25 staff, began exploring the Mainland Chinese market. It was extremely difficult for them at the start, as they knew little about the market. Everything they exported to the Mainland was wrong, from the products themselves to packaging and prices, according to Lee Man Tat’s son Eddy Lee Wai Man, who joined the Company in 1980.6 The Company then reduced the number of products for the Mainland market from 50 to 15, in order to focus its promotional efforts. The products gradually became well-received in the Mainland, although delayed payment from retailers emerged as a problem. In the 1980s, Lee Man Tat’s four sons — Eddy, David, Charlie and Sammy — returned with different US degrees to Hong Kong within a couple of years of each other and joined the Company as interns.7 They all started their stints with low-level duties but as their managerial involvement increased, they began to introduce more and more new concepts from the West. When Lee Kum Kee celebrated its first 100 years in 1988, the Company changed its logo to symbolise its vision of â€Å"building a cultural bridge between East and West with our sauce products†. The Company underwent still greater changes after the 1980s. As Eddy Lee took on more and more leadership responsibility, becoming managing director and then chairman of the group, he and his brothers unleashed new initiatives that combined the flexible strategic approach of their father with Western business thinking. Quality and modernised branding were emphasised, as was an up-to-date information technology system. New Products, Brand Building and Market Expansion In 1992, the Company launched a super premium gourmet sauce called XO sauce, which was made from dried scallop, ham and dried shrimp, and had a variety of applications on noodles, porridge, dim sum, sushi, stir fry dishes and other dishes. The sauce’s popularity was a great triumph for the Company. The sauce was later diversified into additional variants such as XO Seafood Sauce and Premium XO Sauce with Abalone. In 1994, the Company started selling soy sauce, a generic product for which there were established competitors. As a result, sales were slow at the beginning.9 The Company then observed that, in most homes, the amount of soy sauce used for dipping was fairly low, both in frequency and in volume. For the Hong Kong market, however, steamed fish was popular among the Chinese, and housewives wanted to make their home-cooked steamed fish taste like those in the restaurants. Lee Kum Kee saw that it could develop a soy sauce that was sweeter than normal soy sauce, specifically for seafood. The strategy led to success, and the Company went on to develop variants including chilli soy sauce, sweet soy sauce, saltreduced soy sauce, mushroom-flavoured dark/light soy sauces, etc. Lee Kum Kee did not invest significantly in its brand until the early 1990s.10 In 1994, it scrapped its old product labels — as David Lee himself said, the old product labels were boring to him.11 The arch of the company logo became a â€Å"Golden Plaque† that implied a guarantee of product quality, while a detail of the traditional Chinese window frame at the border of the plaque reflected the Company’s Hong Kong heritage. By the late 1990s, the Company aimed to use its name and history in Asia and the many Chinese communities around the world to penetrate the general US and European household market.12 On the industry side, the Company capitalised on its status as a premier Asian food brand to expand its network of retailers, restaurateurs and other manufacturers in the West. Most importantly, to make its products even more consumer-friendly and to appeal to young families that did not wish to spend too much time on cooking, the Company continuously widened its product line. Examples included single-use sauce packets with instructions on how to prepare specific dishes, and a larger variety of ready-made sauces that could be used with a range of ingredients. Even its oyster sauce products came in variants such as Premium, Panda Brand, Choy Sun, Vegetarian and others with added dried scallops and mushrooms. In 1998, the Company launched its first five varieties of sauce packets; in the following year, it added 11 more to include dishes such as sweet-and-sour fish, black-bean chicken and spicy tofu. These lines of products became popular in Asia and were then introduced to the West. Throughout the process of geographical diversification, for new as well as old products, the Company observed the different needs of different regional markets. As David Lee said:13 We †¦ have different packaging and tastes to suit different markets, so a chilli product in Japan will come in smaller bottles and be sweeter and less thick, for instance, than it would be in Ho ng Kong. Development in China14 Lee Kum Kee built its first factory in China in 1990; the plant was located in the southern province of Guangdong. Its sales expansion also started with the Guangdong Province but gradually moved north; in 1998, the company began to sell its products in Beijing. In 2002, the Company’s sales in Beijing had already increased more than 10-fold since it entered the market there, while its sales in Guandong were also growing at a double-digit annual rate. The Company had three factories in the Guangdong Province and was considering setting up new ones in northern China. Lee Kum Kee was turning its market development focus back from overseas to the Mainland in the early 2000s. The potential for the development of this obviously huge market could also be seen in the fact that, of the 200-odd products of Lee Kum Kee, only about 60 were sold in the Mainland. As with other markets, Lee Kum Kee was sensitive about different customers’ tastes, so that a Lee Kum Kee sauce in Beijing might taste a little differently from a similarly named sauce in Shanghai. By 2002, the Company had more than 500 distribution networks in the Mainland, and was ranked fourth in total sales in the sauce market, but it had not yet expanded fully into secondary cities in provinces such as Szechuan and Guangxi. In an interview in 2002, Eddy Lee said it would already be great if Lee Kum Kee could secure one per cent of the Mainland market, which was very fragmented.

Case Study – Appendicitis

I. DEFINITION/PREVALENCE Acute disease of the GI tract may be caused by the pathogen itself or by a bacterial or other toxin. Acute inflammatory disorders such as appendicitis and peritonitis result from contamination of damaged or normally sterile tissue by a client’s own endogenous or resident bacteria (Lemone and Burke, 2008, page 766). Appendicitis is the inflammation of the vermiform (wormlike) appendix; the appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve, which is the beginning of the large intestine.It is usually located in the right iliac region, at an area designated as McBurney’s point. McBurney’s point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant. It is the usual site for localized pain and rebound tenderness due to appendicitis during later stages of appendicitis. The function of the appendix is not fully understood, although it reg ularly fills and empties digested food. Some scientists have recently proposed that the appendix may harbor and protect  bacteria  that are beneficial in the function of the human colon.Appendicitis  is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present.The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign may be elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens.The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. It is the most common reason for emergency abdominal surgery, affecting 10% of the population. Although appendicitis affects a person at any age, the peak incidence is between the ages of 20 and 30 years old in which the vast majority of clients are most common in adolescents and young and slightly more common in males than females. About 7% of the population will have appendicitis at some time in their lives (Lemone and Burke, 2008 page 766).The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal Pyle phlebitis , which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37. 7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. II. TYPES/CLASSIFICATIONAppendicitis can be classified as simple, gangrenous, or perforated, depending on the stage of the process. In simple appendicitis, the appendix is inflamed but intact. When areas of tissue necrosis and microscopic perforations are present in the appendix, the disorder is called gangrenous appendicitis. A perforated appendix shows evidence of gross perforation and contamination of the peritoneal cavity (LeMone & Burke, 2008 page 766). Peritonitis can be primary or secondary. Primary peritonitis is an acute bacterial infection that is not associated with perforated viscus, or organ.Bacterial infection is the usual cause and may be associated wi th an infection by the same organism somewhere else in the body, which reaches the peritoneum via the vascular system. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in the body, is a type of primary peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a perforated organ, often manifest peritonitis, which may be due to leakage of bacteria through the wall of the intestine. Secondary peritonitis is usually caused by bacterial invasion as a result of perforation, or rupture of an abdominal viscus.It can also result from severe chemical reactions to: pancreatic enzymes, digestive juices, or biles released into the peritoneal cavity (Gould & Dyer, 2011). III. DEMOGRAPHIC PROFILE Patient’s name is Mr. Ruptured Acute Appendicitis, 24 years old, male, residing at 820 General Kalentong, Daang Bakal, Mandaluyong City. He is the second child among 3 siblings, a Roman Catholic, single, a 3rd year college Information Technology student. IV. FAMILY MEDICAL HISTORY (Family Genogram)COD: TB COD: TB A: 83 -S, -D A: 83 -S, -D Not Recalled Not Recalled c c A: 20 +S, +D A: 20 S, +D A: 24 +S, +D A: 24 +S, +D A: 27 -S, -D Skin allergy A: 27 -S, -D Skin allergy A: 42 +S, +D A: 42 +S, +D A: 64 +S, +D HPN, Stroke A: 64 +S, +D HPN, Stroke c c A: 46 -S, +D Asthma A: 46 -S, +D Asthma A: 51 -S, +D A: 51 -S, +D patient patient LEGEND: LEGEND: male male married married deceased male deceased male S- smoker D- drinker COD- cause of death S- smoker D- drinker COD- cause of death female female deceased female deceased female V. PAST MEDICAL HISTORY He was first hospitalized last 2006 due to dengue at the same hospital: Mandaluyong City Medical Center (MCMC).He has no other further illnesses except the typical fever, cough and cold. Other than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 week prior to admission patient experienced abdominal pain all over abdomen. He consulted at ER MCMC si gned out AUPD (Acute Peptic Ulcer Disease) and was given Omeprazole & HNBB (Buscopan). Whole abdominal ultrasound done and revealed tiny cholecystolethiasis. He was given Diclofenal and HNBB tab and eventually discharged. Few days prior to consultation, the patient still experienced abdominal pain.He consulted at Emergency Room and was opted for surgical intervention – EXPLORATORY LAPAROTOMY APPENDECTOMY under the service of Dr. Abram Del Valle, M. D. VII. GORDON’S PHYSICAL ASSESSMENT i. Health Maintenance – Perception Pattern Before admission: The patient used to smoke cigarette 3 sticks per day. And he also drinks alcohol daily specifically beer of more than 2 bottles per session. He was not using drugs and he has no allergies at all. During time of care: The patient is not smoking cigarette or drinking alcohol. ii. Nutritional – Metabolic PatternBefore admission: The patient was on a high protein diet because he was used to go to the gym 2-3 times a we ek. He was also taking vitamins (CENTRUM). He has normal appetite and has no difficulty swallowing. He usually eats 3 times a day (breakfast, lunch and dinner) and most of the time he also has his snacks. He also usually drinks 2-3 liters of water a day. e During time of care: The patient is on NPO (nothing per orem) for 5 days due to post-operative appendectomy and he was on his 2nd day of NPO status when we cared for him. He has also NGT lavage connected. ii. Elimination Pattern Before admission: The patient’s normal bowel movement was 3 BM a day and has no difficulty in bladder habits. His last bowel movement was last July 17, 2012. He usually urinates 6-7 times a day without difficulty. During time of care: The patient has absence of bowel movement and even flatus and has no bowel sounds upon auscultation. He has foley catheter and with urine output of 480 cc per shift. iv. Activity and Exercise Before admission: The patient could do his activities independently without a ssistance.He usually goes to gym 2-3 times a week. During time of care: The patient’s functional level or self-care ability level is 2 which mean he requires help from another person for assistance. v. Sleep/Rest Pattern Before admission: The patient usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no difficulty in sleeping and he feels rested after sleep. During time of care: The patient has regular sleeping habits. He sleeps at 10 am, wakes up at 6 am with uninterrupted sleep. vi. Cognitive – Perceptual PatternBefore admission: The patient was alert and coherent, has normal speech, with mild level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. During time of care: The patient is alert and coherent. He has normal speech (Filipino as his spoken language), he has moderate level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. He also complained of acute pain and described it as a cramping pain. Pain management (Tramadol) was given. vii. Role – Relationship Pattern Before admission: The patient was a student and single.His support system was his family, relatives & friends. During time of care: The patient’s support system is his mother who is always at his bed side assisting him in whatever he needs. Upon asking his mother if she has any concerns regarding hospitalization, she said that she is more concern about the fast recovery of her son. viii. Sexuality – Reproductive System Before admission and during the time of care: The patient still didn’t have his testicular exam. ix. Coping – Stress Tolerance/Self – Perception/Self – Concept Pattern The patient’s major concern regarding his hospitalization is s all about self-care.Due to the contraptions attached to him, he cannot independently do his activities. His major loss was his stepfather when he died of kidney failure. His rated his outlook on future as 5, 1 being poor and 10 being very optimistic. He further explained why he rated 5 because he is not sure if when he finished college he can be able to find a job suited for him. x. Value – Belief Pattern Our patient is a Roman Catholic and he always goes to church every Sunday together with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK| THEORIST| STATUS| Intimacy vs.Isolation * Develops commitments to others and to a life work (career)(Daniels, et. al. , 2010). | Erikson| The patient had a relationship with his opposite sex but he said that they just broke up a week before he was hospitalized due to some personal and private reasons. Currently, he is in 3rd year college, an IT student. | Genital * Emergence of sexual interests and development of relationships with potential sexual partners (Daniels, et. al. , 2010). | Freud| As what had written above, the patient had a relationship with his opposite sex but because of some reasons they decided to end u p their relationship. Formal Operations * Able to see relationships and to reason in the abstract (Daniels, et. al. , 2010). | Piaget| He perceived that relationships (any kind of relationship) are important especially at his age. He can also reason out in an abstract way. He can express his opinions intellectually and precisely. | Early Adulthood * Select a partner, learn to live with a partner, start a family, manage a home, establish self in a career/occupation, assume civic responsibility, and become a part of a social group (Daniels, et. al. , 2010). Havighurst| According to our patient, he didn’t expected that something like that will happen to them (referring to his girlfriend). He was really expecting that they are really meant for each other and that she (his gf) will be his future wife. He is also establishing himself to a future career, that’s why he is studying in preparation for his future. During our time of care also, his ‘barkadas’ visited him and he said that they were his ‘tropa’. | Postconventional * Individual understands the morality of having democratically established laws (Daniels, et. al. , 2010). Kohlberg| Upon asking the patient if he is familiar with the democratically established laws in the Philippines, he immediately responded with a yes. He also said that these laws help us, Filipinos, to have safe and secure country though there may come a time that we may experience something unexpectedly. | IX. PHYSICAL ASSESSMENT * Vital Signs TIME| Initial 8AM (07/24/12)| 10 AM| 12 NN| 8 AM (07/25/12)| 12 NN| Last 8AM(07/26/12)| T| 36. 3| 37. 3| 37. 4| 36. 4| 37. 3| 36| P| 83| 84| 71| 75| 81| 68| R| 23| 25| 21| 19| 19| 20| BP| 120/80| 120/80| 120/80| 120/80| 120/80| 110/80| Sequence: BY SYSTEMS NORMAL FINDINGS| BOOK FINDINGS| PATIENT FINDINGS| SIGNIFICANCE| I. NEUROLOCIGAL SYSTEM Alert and coherent; with normal body temperature of 36. 3 °C – 37. 6 °C| * Fever (usually >38 °C although hypo thermia may be present w/ severe sepsis); chills * Thirst * Pain| * Complained of pain in the incision site (lower longitudinal midline of the abdomen)| Pain results from the increased pressure of fluid on the nerves, especially in enclosed areas, and by the local irritation of nerves by chemical mediators such as bradykinins (Gould, et al. 2011). | II. RESPIRATORY Normal respiration with a rate of 12-20 breaths per minute| * Tachypnea; shallow respirations| * RR: 23 bpm w/ shallow respiration| Acute pain usually initiates physiologic stress response with increased respiratory rate (Gould & Dyer, 2011). | III. INTEGUMENTARYPink or brown and in uniform color, no edema, no lesions, moistSkin temperature is normally warmIntact skinWhen pinched, skin springs back to previous state| * Dry lips and mucous membranes * Swollen tongue * Poor skin turgor| * Dry lips and mucous membranes * Skin turgor:3-5 seconds * Presence of surgical incision at lower longitudinal midline of the abdomen * Sk in is warm to touch and is reddened| Dry mucous membrane and poor skin turgor are signs of dehydration (Gulanick, et al. 1994). Redness may indicate inflammation (Weber & Kelly, 2007). Redness and warmth are caused by increased blood flow into the damaged area (Gould & Dyer, 2011). | IV. CARDIOVASCULAR Normal pulse rate of 60-100 bpm| * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissue edema| * Pulse rate: 83 bpm| Acute pain usually initiates a physiologic stress response with increased heart rate (Gould & Dyer, 2011). | V. MUSCOLOSKELETALAbility to do Activities of Daily Living (ADL)| * Difficulty ambulating * Weakness| * Difficulty ambulating due to post-op condition * Weakness| Constant pain frequently affects daily activities and may become a primary focus in the life of an individual (Gould & Dyer, 2011). | VI. GENITO-URINARY Normal urine output of 30cc/hrColor: Amber, transparent, clear| * Decreased urinary output * Dark color urine| * Dark color urine * Urine output: 480 mL/shift * Specific gravity: 1. 30| Decreasing output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). | VII. GASTROINTESTINAL Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elementsAbdomen is free of lesions or rashesA series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minuteNormally no tenderness or pain is elicited or reported by the clientNo rebound tenderness is presentAbdomen is non-tender and soft.There is no guarding| * Loss of appetite * Nausea & vomiting(usually projectile) * Constipation of recent onset * Diarrhea(occasional) * Sudden, severe, generalized abdominal pain * Abdominal distention; rigidity * Decreased/absence of bowel sounds * Inability to pass stool/flatus * Muscle guarding (abdomen) * Psoas’ Sign (flexion of or pain on hyperextension of the hip due to contact between an inflammat ory process & the psoas muscle) * Obturator Sign (the internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee and a resultant tightening of the internal obturator muscle may ause abdominal discomfort) * Rovsing’s Sign (pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant) * Rebound tenderness (a sign of inflammation of the peritoneum in which pain is elicited by the sudden release of the fingertips pressing on the abdomen) | * Board-like abdomen * Sudden, severe, generalized abdominal pain * Absence of bowel sounds in all four quadrants * Absence of flatus/stool * Presence of surgical incision| Signs indicating the onset of peritonitis include a rigid â€Å"board-like† abdomen (Gould & Dyer, 2011).Pain recurs as a steady, severe abdominal pain as peritonitis develops (Gould & Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or paralytic ileus (Weber & Kelly, 2007). When inflam mation persists, nerve conduction is impaired, and peristalsis decreases, leading to obstruction of the intestines (paralytic ileus) (Gould & Dyer, 2011). | X. DIAGNOSTIC TESTS DIAGNOSTIC TEST| NORMAL| RESULT| SIGNIFICANCE| WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) | The organs examined appear normal (Cosgrove, et al. , 2008). | Liver is not enlarged.It has homogenous echopattern with smooth border. The intrahepatic ducts are not dilated. No evident focal mass lesion seen. CD measures 3. 9mm. Gallbladder is normal in size and wall thickness. There are multiple tiny echogenic shadowing foci seen within the gallbladder lumen. Pancreas & spleen are normal in size & echopattern. No focal mass lesion seen. Both kidneys are normal in size & echopattern. Right kidney measures 10. 1Ãâ€"4. 2Ãâ€"5. 46cm with cortical thickness of 1. 7cm while the left kidney measures 10. 5Ãâ€"4. 8Ãâ€"4. 1cm with thickness of 19cm. No evident caliectasis, lithiasis, seen bilaterally.Urinary bladder is unf illed. Impression:Tiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot dilated biliary tree | Abdominal ultrasound is the most effective test for diagnosing acute appendicitis (LeMone & Burke, 2007). | HEMATOLOGY REPORT/COUNT (July 21, 2012)| RBC: 4. 2-5. 6 M/uLPlatelets: 150-400 x 10/LWBC: 3. 8-11. 0 K/mm3Hemoglobin: 135-180g/LHematocrit: 0. 45-0. 52DifferentialNeutrophils: 0. 50-0. 81Lymphocytes: 0. 14-0. 44Monocytes:0. 02-0. 06Eosinophils: 0. 01-0. 05Basophils:0. 00-0. 01| WBC Count: 12. 6 K/mm3RBC: 4. 1 M/uL (normal)Hematocrit: 0. 45 (normal)Hemoglobin: 153g/L (normal)Differential Count:Neutrophils 0. 90Lymphocytes 0. 10 (normal)| Elevated WBC is seen in acute infection (LeMone & Burke, 2007). Neutrophils: elevated in bacterial infection (LeMone & Burke, 2007). | URINALYSIS (July 21, 2012)| Color: Light straw to amber yellowAppearance: ClearOdor: AromaticpH: 4. 5-8. 0Specific gravity: 1. 005-1. 030Protein: 2-8mg/dLGlucose: NegativeKet ones: NegativeRBCs: RareWBCs: 3-4Casts: Occasional hyaline| Color: Dark YellowTransparency: TurbidUrine pH: 6. 0 Specific gravity: 1. 30Sugar: NegativeProtein: +4Microscopic examPus cells 4-6/HPFRBC 1-2/HPFCrystals: Amorphous Sulfate Moderate| A dark yellow to brownish color is seen with deficient fluid volume (LeMone & Burke, 2007). Hazy or cloudy urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates (LeMone & Burke, 2007). | CLINICAL CHEMISTRY (July 21, 2012)| Sodium (Na): 135-142 mmol/LPotassium (K): 3. 8-5 mmol/L| Sodium: 132 mmol/LPotassium: 4. 02 mmol/L| Sodium is decreased in SIADH & vomiting (LeMone & Burke, 2007). | XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE)The large intestine, which is about 1. 5 m (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum. Structurally, the four major regions o f the large intestine are the cecum, colon, rectum, and anal canal. The opening from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal sphincter (valve), which allows materials from the small intestine to pass into the large intestine. Hanging inferior to the ileocecal valve is the cecum, a small pouch about 6 cm (2. 4 in. ) long.Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 in. ) in length, called the appendix or vermiform appendix (vermiform = worm-shaped; appendix = appendage). The mesentery of the appendix, called the mesoappendix, attaches the appendix to the inferior part of the mesentery of the ileum. The open end of the cecum merges with a long tube called colon, which is divided into ascending, transverse, descending colon are retroperitoneal; the transverse and sigmoid colon ascends on the right side of the abdomen, reaches the inferior surface of the liver, and turns abruptly to the left to form the right colic (hepatic) flexure.The colon continues across the abdomen to the left side as the transverse colon. It curves beneath the inferior end of the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac crest as the descending colon. The sigmoid colon begins near the left iliac crest, projects medially to the midline, and terminates as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is called the anal canal.The mucous membrane of the anal canal is arranged longitudinal folds called anal columns that contain a network of arteries and veins. The opening of the anal canal to the exterior, called the anus, is guarded by an internal anal sphincter of smooth muscle (involuntary) and an external anal sphincter of the skeletal muscle (voluntary). Normally these sphincters keep the anus c losed except during the elimination of feces (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, inflammation of the vermiform appendix, is a common cause of acute abdominal pain.It is the most common reason for emergency abdominal surgery, affecting 10% of the population (Tierney et al. , 2005). Appendicitis can occur at any age, but is more common in adolescents and young adults and slightly more common in males than females (LeMone & Burke, 2007). The development of appendicitis usually follows a pattern that correlates with the clinical signs, although variations may occur because of the altered location of the appendix or underlying factors (Gould & Dyer, 2011). Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices.The obstruction is often caused by fecalith, or hard mass of feces. Other obstructive causes include a calculus or stone, a foreign body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Following obstruction, the appendix becomes distended with fluid secreted by its mucosa and microorganisms proliferate. Pressure within the lumen of the appendix increases, impairing its blood supply because blood vessels in the wall are compressed thus the appendiceal wall becomes inflamed and purulent exudate forms.Within 24 to 36 hours, the increasing congestion and pressure within the appendix leads to ischemia and necrosis of the wall, resulting in increased permeability. Bacteria and toxins escape through the wall into the surrounding are. This breakout of bacteria leads to abscess formation or localized peritonitis. An abscess may develop when the adjacent omentum temporarily walls off the inflamed area by adhering to the appendiceal surface. In some cases, the inflammation and pain subside temporarily but then recur. Localized infection or peritonitis develops around the appendix and may spread along the peritoneal membranes.Increas ing pressure inside the appendix causes increased necrosis and gangrene in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perforates, releasing its contents into the peritoneal cavity. This leads to generalized peritonitis and would lead to septicemia and into septic shock and will result to death (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Risk Factors Non-modifiable: * Age (Adolescents & young adults) * Gender (Male) Modifiable: * Fecalith * Calculus/Stone * Foreign body * Inflammation * Tumor * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid inside the appendix Buildup of fluid inside the appendix Proliferation of microorganisms Proliferation of microorganisms Abdominal pain Abdominal pain Increased pressure within the lumen of appendix Increased pressure within the lumen of appendix Compression of blood vessels Compression of blood v essels * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness Decreased blood flow into the appendixDecreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid Ischemia & necrosis of the wall Ischemia & necrosis of the wall Increased permeability Increased permeability Bacteria and toxins escape through the wall Bacteria and toxins escape through the wall Abscess formation/localized bacterial peritonitisAbscess formation/localized bacterial peritonitis Proliferation of localized peritonitis around the appendix and peritoneal membranes Proliferation of localized peritonitis around the appendix and peritoneal me mbranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Increased necrosis and gangrene in the wall Increased necrosis and gangrene in the wall Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak out into peritoneal cavity Intestinal bacteria leak out into peritoneal cavity * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESSProblem #1: ABDOMINAL PAIN – July 24, 2012 * Subjective Cues: * â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps,† patient verbalized while having a conversation with him. How does it feel like: Abdominal cramping Precipitating factor: â€Å"Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit† (â€Å"Whenever wound cleaning is performed but oftentimes it just suddenly happened†) Relieving factor: Pain reliever (but not all the time pain reliever is being given) Does it radiate to the other parts of the body (back, legs, chest, etc): No Duration of pain: â€Å"Paiba-iba din eh.Minsan sobrang tagal mga 2-3 minutes, minsan naman mga ilang Segundo lang† (â€Å"It differs, sometimes it’s too long (2-3 minutes) and sometimes it just happened for a second†) * Patient rated the pain as 8/10 where 0 signifies no pain and 10 signifies unbearable pain. * Objective Cues: * Facial grimace * Guarding of the incision site * Rigid (board-like) abdomen * Abd ominal distention * Location of pain: Surgical site * RR: 25 bpm * Nursing Diagnosis Acute Pain related to inflammation of the tissues secondary to post-op surgical incision.Inflammation or nerve damage gives rise to changes in sensory processing at peripheral and central level with a resultant sensitization. In relation, prostaglandins are chemotactic substances drawing leukocytes to the inflamed tissue. It plays a vasoactive role; it is also a pain and fever inducer (Lemone and Burke, 2007). Acute Pain related to infection & inflammation of the peritoneal membranes secondary to peritonitis The peritoneum consists of a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdominal cavity.This peritoneal structure provides a mean of rapid dissemination of irritants or bacteria throughout the abdominal cavity. Abdominal distention is evident, and the typical rigid, board-like abdomen develops as reflex abdominal muscle spasm occurs in response to invol vement of the parietal peritoneum (Gould & Dyer, 2011). * Goal/NOC: Pain Control Outcomes Short Term: After 30 minutes of nursing intervention the patient will report a decrease in pain from pain scale of 8/10 to 4-5/10. Long Term:After 8 hours of nursing intervention the patient will demonstrate an understanding about the proper way of controlling pain as evidenced by proper splinting and deep breathing exercise and will report a decrease or most probably will be free from pain from pain scale of 4-5/10 to 1-2/10. * NIC: Pain Management Independent: * Assessed pain including its character, location, severity, and duration. Both preoperatively and postoperatively, the client’s pain provides important clues about the diagnosis and possible complications.Abdominal distention and acute inflammation contribute to the pain associated with peritonitis. Surgery further disrupts abdominal muscles and other tissues, causing pain (LeMone & Burke, 2007). * Monitored vital signs every 2 hours. Vital Signs, especially respiratory rate (RR), are usually altered in acute pain. (Sparks and Taylor, 2005). * Kept the client at rest in semi-Fowler’s position. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position (Doenges et al. , 2006). * Provided diversional activities (texting, sound trip, etc).Refocuses attention, promotes relaxation, and may enhance coping abilities and diverts attention from pain (Doenges et al. , 2006). * Taught post-op health teaching (e. g. , proper splinting & deep breathing exercises). The use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications (LeMone & Burke, 2007). * Encouraged early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). Give hot and cold compress. Hot , moist compresses have a penetrating effect. The warm rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. (Doenges et al. , 2006). Dependent: * Administered analgesic as prescribed (TRAMADOL 50 mg/IV Q 8 ° x 3 doses) Time given: 8 AM. Post-operatively, analgesics are provided to maintain comfort and enhance mobility (LeMone & Burke, 2007). * Kept on NPO. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting (Doenges et al. 2006). * Evaluation Short Term: Goal partially met. After 30 minutes of nursing intervention the patient reported of a decrease in pain from a pain scale of 8/10 to 6/10 in which 4-5/10 was the expected outcome. Long Term: Goal met. After 8 hours of nursing intervention the patient displayed control of pain as evidence by deep breathing exercise and proper splinting. He also reported of a decrease in pain with a pain scale of 2/10 from 6/ 10. Pain reliever – TRAMADOL was given @ 8 am via IV. Problem #2: ABSENCE OF FLATUS– July 24, 2012 * Subjective Cues: â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping),† patient verbalized while having a conversation with him. * Pain scale of 8/10 * Objective Cues: * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sounds upon auscultation of all four quadrants * Nursing Diagnosis Dysfunctional gastrointestinal motility related to inflammatory process of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis often draws large amounts of fluid into the abdominal cavity and the bowel.In addition, peristaltic activity of the bowel is slowed or halted by the inflammation, causing paralytic ileus, impaired propulsion of forward movement of bowel contents (LeMone & Burke, 2007). * Goal/NOC: Ambulation Outcomes Short Term: After 8 hours of nursing intervention the client wil l report/experience flatus and will understand and demonstrate the need for early ambulation following abdominal surgery. Long Term: After 2 days of nursing intervention the client will report/experience either flatus or bowel movement or both. * NIC: Impaction Management; PositioningIndependent: * Assessed abdomen including all four quadrants noting character to determine increased or decreased in motility; Assessed for further abdominal tenderness & auscultated for any abdominal sounds. To help identify the cause of the alteration and guide development of nursing intervention (Sabol & Carlson, 2007). * Monitored and recorded (intake) and output every hour or 2 hours. Intake and output records provide valuable information about fluid volume status (LeMone & Burke, 2007). * Encouraged early ambulation.Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). * Assisted in moving from side to side o r up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. (Gulanick, et. al. , 1994). Dependent: * Administered antacid as ordered (RANITIDINE 50g/IV Q 12 °. Antacids either directly neutralize acidity, increasing the  pH, or reversibly reduce or block the secretion of acid by gastric cells to reduce acidity in the stomach (Gabriely, et al. 2008). * Evaluation Short Term: Goal partially met. After 8 hours of nursing intervention the patient didn’t experience flatus or even bowel movement but was able to have an understanding with regards to early ambulation as evidenced by letting his mother assist him in moving up in bed going to the chair but refused to walk because of complaint of having a lot of contraptions attached to him which causes him to have difficulty in moving. Long Term: Goal met. After 3 days of nursing intervention the patient reported of a flatus fo r 3 times.Problem #3: RISK FOR DEHYDRATION – July 24, 2012 * Subjective Cue: * â€Å"Nanghihina na ako kasi limang araw ako hindi pwede kumain pati tubig bawal din kaya nagnunuyo na yung labi ko,† as verbalized by the patient. * Objective Cues: * NPO for 5 days * Dry mucous membrane * Dry lips * Capillary refill= 2 seconds * Skin turgor= 3-5 seconds * Urine output/shift= 480 mL * Urine color: Dark Yellow * Urine specific gravity: 1. 030 (Normal value: 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP: 120/80 mmHg * PP: 83 bpm * Nursing DiagnosisRisk for deficient fluid volume related to postoperative restriction secondary to NPO for 5 days Inflammation of the peritoneum with sequestration fluid and NPO status can lead to dehydration and electrolyte imbalance (Doenges, et al. , 2008). * Goal/NOC: Knowledge: Treatment Regimen; Hydration; Oral Hygiene; Tissue Integrity: Skin & Mucous Membranes Outcomes Short Term: After 30 minute s of nursing intervention patient will have an understanding with regards to maintaining fluid balance as evidenced by willingness of following the prescribed regimen given by the medical staffs. Long Term:After 3 days of nursing intervention the patient will be able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, and individually adequate urine output. * NIC: Fluid Management; Fluid Monitoring; Vital Signs Monitoring Independent: * Monitored BP & Pulse. Variations help identify fluctuating intravascular volumes, or changes in vital signs associated with immune response to inflammation (Doenges, et al. , 2006). * Inspected mucous membranes; assessed skin turgor and capillary refill. Indicators of adequacy of peripheral circulation and cellular hydration (Doenges, et al. 2006). * Monitored intake and output; noted urine color/concentration, specific gravity. Decreasing urine output of concentrated urine with increasing s pecific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. Noted passing of flatus, bowel movement. Indicators of return of peristalsis, readiness to begin oral intake (Doenges, et al. , 2006). * Provide clear liquids in small amounts when oral intake is resumed, and progress diet is tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss (Doenges, et al. 2006). * Stressed the importance of having him on a NPO status and provided the necessary information with regards to his condition and the medications being administered (e. g. , IVF). It provides the patient a full understanding with regards to his condition thus encouraging him to participate and work hand in hand with the staff (Gulanick, et al. , 1994). * Gave frequent mouth care with special attention to protection of the lips. Dehydration results in drying and painful cracking of the lips and mouth (Doenges, et al. , 2006). Dependent: * Maintaine d gastric suction as indicated.Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperatively phase to decompress the bowel, promote intestinal rest, and prevent vomiting (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8 ° or 30 gtts/min) and electrolytes (D5 Balanced Multiple Maintenance Solution w/ 5% dextrose 1L x 8 ° or 30 gtts/min). The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances (Doenges, et al. , 2006). * EvaluationShort Term: Goal met. After 30 minutes of nursing intervention the patient was able to have a full understanding with regards to maintaining fluid balance as evidenced by verbalizing, â€Å"So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. † Long Term: Goal met. After 3 days of nursing intervention th e patient was able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor (1-2 seconds), stable vital signs (please see page __ ), and adequate urine output of 620 mL with an appearance of amber yellow. Problem #4: RISK FOR INFECTION – July 24, 2012 Subjective Cues: â€Å"Nurse, sobrang kailangan ba talaga ang paghuhugas ng kamay bago linisan o hawakan sugat niya? †, asked by the mother. * Objective Cues: * Post-operative condition – presence of surgical incision * Surgical site is warm to touch and reddened * Temp: 36. 3 °C * Nursing Diagnosis Risk for infection related to inadequate primary defenses secondary to post-operative surgical incision It is risk to be invaded by pathogens especially if surgical site is near at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, et al. 2006). * Goal/NOC: Risk Control (For Infection) Outcomes Short Term: After 30 minutes of nursi ng intervention the patient will be able to have partial understanding about infection control and will verbalize understanding of and willingness to follow up prescribed regimen. Long Term: After 3 days of  nursing intervention  the  patient will be free of sign and symptom r/t infection. * NIC: Incision Site Care; Infection Control; Wound Care Independent: * Monitored vital signs. Noted onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.Suggestive of presence of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected incision and dressings. Noted characteristics of drainage from wound/drains, presence of erythema. Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis (Doenges, et al. , 2006). * Instructed proper hand washing. Practiced aseptic wound care. Reduces risk for infection (Doenges, et al. , 2006). * Encouraged adequate nutr itional intake after the NPO status of the patient and when the patient is allowed to eat.Adequate intake of protein, Vitamin C and minerals is essential to promote tissue and wound healing (Sparks and Taylor, 2005). Dependent: * Administered antibiotics (CEFUROXIME 750mg TID Q 8 ° x 2 doses & METRONIDAZOLE 500g/IV Q 8 ° x 2 doses) as ordered. Therapeutic antibiotics are given if the appendix is ruptured or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with incision and drainage (I&D) if indicated. May be necessary to drain contents of localized abscess (Doenges, et al. , 2006). * Evaluation Short Term:Goal met. After 30 minutes of nursing intervention the patient was able to have an understanding about infection control as evidenced by verbalizing, â€Å"Para maiwasan ang pagkaroon ng impeksyon kailangan kong maghugas ng kamay palagi at kinakailangan din ang araw-araw na paglilinis ng sugat ko kahit na sa tuwing nililinisan ito makirot s a pakiramdam. † Long Term: Goal met. After 3 days of  nursing intervention  the  patient was free of sign and symptom r/t infection. Problem #5: INABILITY TO PERFORM ACTIVITY/IES OF DAILY LIVING (ADL) – JULY 24, 2012 * Subjective Cues: â€Å"Hirap talaga ako gumalaw, maglakadlakad, o kahit man lang umupo dahil sa mga nakakabit na ito sa akin,† as verbalized by the patient. â€Å"Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko,† he added. * Objective Cues: * Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage & IV fluid @ left hand) * Nursing Diagnosis Impaired physical mobility related to body weakness, presence of surgical incision, pain, & presence of contraptions attached Physical immobility can be usually associated with post-operative conditions (Gulanick, et al. 1994). * Goal/NOC: Activity Tolerance Outcomes Short Term: After 30-45 minutes of nursing intervention the pat ient will be able to have a clear understanding with the use of identified techniques to enhance activity tolerance and to apply it as well as evidenced by participating in ROM exercises, lower leg & ankle exercise, ambulation, or even moving up in bed. Long Term: After 2-3 days of nursing intervention the patient will be able to continually participate in a simple form of activity and will report an improvement with regards to his activities. * NIC: Exercise Therapy: BalanceIndependent: * Performed passive ROM exercises. ROM exercises and good body mechanics strengthen abdominal muscles and flexors of spine (Gulanick, et al. , 1994). * Encouraged lower leg and ankle exercises. Evaluated for edema, erythema of lower extremities, and calf pain or tenderness. These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation (Gulanick, et al. , 1994). * Noted emotional and behavioral responses to immobility. Provided diversional activities. Forced i mmobility may heighten restlessness and irritability.The Cardiovascular SystemDiversional activity aids in refocusing attention and enhances coping with actual and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, progressive ambulation, and therapeutic exercises. Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance (Gulanick, et al. , 1994). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. Gulanick, et al. , 1994). * Noted client reports of weakness, fatigue, pain and difficulty accomplishing tasks. Symptoms may be result of/or contribute to intolerance of activity (Gulanick, et al. , 1994). Dependent: * Administered pain medication (TRAMADOL 50 mg/IV Q 8 ° x 3 doses, time given: 8 AM) as prescribed and on a regular sch edule. Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivation to increase activity (Gulanick, et al. , 1994). * Evaluation Short Term:Goal partially met. After 30-45 minutes of nursing intervention the patient was able to have a clear understanding with the use of identified techniques to enhance activity tolerance and was able to use all of the techniques except for the ambulation. He refused to walk because he complained of pain whenever the catheter tube slipped into his legs. Long Term: Goal partially met. After 2-3 days of nursing intervention the patient was able to continually participate in all of the identified techniques but still refused to participate in ambulation.He also reported of an improvement with regards to his activities as evidence by his verbalization, â€Å"Medyo natotolerate ko na rin yung mga activities kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad p ero pagnaalis na siguro yung catheter baka kayanin ko na. † XV. BIBLIOGRAPHY * Cosgrove DO, Meire HB, Lim A, & Eckersley RJ. (2008). Grainger & Allisonn's Diagnostic Radiology: A Textbook of Medical Imaging (5th edition). New York, NY: Churchill Livingstone * Doenges M. , Moorhouse, M. ; Murr, A. (2006).Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span (7th Edition). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. ; Murr, A. (2006). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P. , Barky, N. (2008). Clinical problem-solving, back to basics. New England Journal of Medicine * Gould, B. ; Dyer, R. (2011). Pathophysiology for the Health Professions (4th Edition). Saunders Elsevier Inc. * Gulanick, M. Klopp, A. , Galanes, S. , Gradishar, D. ; Puzas, M. (1994). Nursing Care Plans Nursing Diagnosis and Intervention (3rd Edition). Mosby-Year Book, Inc. * LeMone P. ; Burke, K. (2007). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (4th Edition). Pearson International Edition * LeMone P. ; Burke, K. (2008). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (5th Edition). Pearson International Edition * Mosby’s Pocket Dictionary of Medicine, Nursing ; Allied Heath (4th Edition) 2002, Mosby Inc. Palma G. ; Oseda A. (2009). G;A Notes Clinical Pocket Guide for Medical and Allied Health Professionals (2nd edition). G;A Notes Publishing Co. , Philippines * Sabol, V. K. ; Carlson, K. K. (2007). Diarrhea: Applying research to bedside practice. AACN Advanced Critical Care * Tortora G. ; Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Biological Sciences Textbooks, Inc. * Weber J. ; Kelley J. (2007). Health Assessment in Nursing (3rd Edition). Lippincott Williams ; Wilkins

The goal of the present paper is to discuss the different and shared properties

The goal of the present paper is to discuss the different and shared properties of photography and film with reference to the use of photographs in the film Paris qui dort (also known as Le rayon de la mort in France, and Paris asleep or The crazy ray internationally) by Renà © Clair (shot in 1923, the premier in France took place in 1925, in the United States – in 1926).Anne Friedberg once characterised this particular movie as â€Å"a narrative built around the shift from photography to film.†[1]   This quote indicates a channel for the discourse on the topic, how the French filmmaker synthesised photographic and cinematographic means to create a complex visual tissue.To remind the plot of this earlier example of cinematic science fiction, the main hero of the film called Albert (Henri Rollan), who is the watchman at the Eiffel Tower, awakens one perfect day to discover that the whole city of Paris has been fallen asleep. While he strolls down the streets of the bu siest European metropolis, the character observes people having been paralysed in their routine affairs. During his journey Albert meets five persons who have just arrived to Paris by airplane: Hesta (Madeleine Rodrigue), a self-made young traveller, a multi-millionaire who came to visit his bride (Antoine Stacquet), a hook and a police detective (Marcel Vallà ©e and Louis Prà © Fils), and a pilot (Albert Prà ©jean).These six occasional fellows in misery spend the night on the top of the Eiffel Tower and swoop into the city the next day to amuse themselves at their best.Having returned back to their shelter with precious loot, Albert and company catch the SOS-signal on the radio. In result of a purposeful search, the adventurers arrive at the cellar laboratory of Dr. Crase, a talented yet frenzied scientist (Charles Martinelli). Miss Crase, the professor's niece and assistant, meets the newcomers and tells them an interesting story.It appears that Dr. Crase has invented a wonderf ul machine that could arrest time by its rays. When the scientist tested his invention, all the six heroes enjoying the moment â€Å"happened to be, at three twenty-five, the moment of immobilization, at an altitude beyond its reach.†[2] Dr Crase was talented enough to design the formula for freezing the course of life but forgot to devise an antidote. Upon persuasion, he corrects his mistake, and Paris is permitted to return back to the usual mode of life.The members of the warm company separate from each other. Albert finds himself accompanying Miss Crase. The young man likes the girl and decides to see her back to her place but finds no cash to pay for the cab. He decides to immobilise the city one more time to stock up on money for the rest of his life. Albert rushes to Dr. Crase’s laboratory and struggles with the professor over the machine’s levy. Depending on their movements, the life in Paris is either set still or resumed in mobility. The battle ends up with an explosion.The heroes of the movie try to explain to the police what has happened. Nobody believes them so far as the rest of the Parisians, who have fallen asleep, do not remember the period of immobilisation. Finally, Albert is almost persuaded that Dr. Crase and his invention have been just his nightmares. However, upon return to the Eiffel Tower hand-in-hand with Miss Crase, the hero finds a diamond ring in the aperture between the girders. It was one of the trophies that the merry gang brought from the journey across the frozen city. The ring makes Albert believe once again in the existence of immobilising rays.[3]Before deciphering Friedberg’s idea about Clair having synthesised the performative possibilities of photography and cinematography, and before sharing some original ideas, the author feels obliged to analyse the technical and cultural backgrounds of these two interrelated media.Researchers started investigating the semiotic value of photography as the precedent to cinematography as early as in the mid-19th century. At the dawn of invention, photography was perceived as a technique to make light â€Å"exert an action †¦ sufficient to cause changes in material bodies.†[4] The idea was expressed by Fox Talbot in a book The pencil of nature, published in 1844. Rosalind Krauss chose the treatise as a field for analysis to discuss a dynamics of symbolic complexity associated with photography throughout its development. Her discourse is especially interesting so far as it explores the earlier metaphysical values ascribed to photography in the 1840s and the most recent semiological explanations of this art.To summarise the section of Krauss’ article dealing with the earlier representations of photography, the latter was perceived as a complex phenomenon existing both at the physical and metaphysical layers. On the one hand, it was often compared to â€Å"the footprint that is left on sand.†[5]To put it different ly, a well-known light spectrum was refracted inside a photographic camera so that the representations of people and other animate and inanimate objects were imprinted on the plates and photographic paper. On the other hand, Talbot and his contemporaries were intrigued by â€Å"certain invisible rays† which let â€Å"the eye of the camera †¦ see plainly where the human eye would find nothing but darkness.†[6][1] A. Friedberg, Window shopping: cinema and the postmodern, Berkeley and Los Angeles, CA, USA, University of California Press, 1993, p. 102. [2] Miss Crase’s words, cited in A. Michelson, Dr. Crase and Mr. Clair, October, 11: Winter, 1979: p. 34. [3] A detailed summary of the movie plot is provided by Michelson, pp. 33-34. [4] W. Fox Talbot, The pencil of nature, facsimile edition, New York, Da Capo Press, 1969, introduction, n.p., cited in R. Krauss, Tracing Nadar, Photography, 5: Oct. 1978: p. 39. [5] Krauss, Tracing Nadar, p. 33. [6] Talbot, cited in Krauss, Tracing Nadar, p. 41.

Cultural Awarness on Venezuela Essay Example | Topics and Well Written Essays - 1000 words

Cultural Awarness on Venezuela - Essay Example Apart from its stunning scenery, Venezuela moreover is abundant with natural wealth that the rest of the worldwide public is hurried to get at. Inappropriately latest bullying to the land-living, folks, and administration have overpowered the republic into close devastation (Duarte et al). Venezuelas countrywide populace is almost comparable to that of most other South American nations, with a blend of primary aboriginal inhabitants, a huge Spanish arrival, and noteworthy residents of African descent. There have also been distinguished Latin American and European immigrations in the past two epochs. Even with these diverse inhabitants, conversely, Venezuela has one of the greatest established state identities in the landmass. This state firmness is almost certainly due to dual factors: Venezuela has an enormously lesser fashionable manifestation of native groups to challenge the national solidity, and secondly up until the 1990s Venezuela boasted an unbelievably sturdy national budget. Venezuela has a federalist government, which comprises of policymaking, jurisdictive, and legal branches. The policymaking branch is led by a generally chosen president who remains in power for five years. The jurisdictive branch encompasses Congress that is separated into a Chamber of Deputies and a Senate. The Chamber of Deputies mirrors the nations provincial picture, whereas the Senate comprises of two legislatures from every state and the capitals centralized locality. Venezuelas uppermost justice body is that of the Supreme Court, whose fellows are picked out by the legislative body of Assembly. The Venezuelan military contains an expected eighty thousand fellows alienated into the army, air force and navy. The country has by tradition upheld stumpy levels of security expenses, be an average of only 1.5 percent of its GDP. Venezuela has had enduring significant skirmishes with adjacent Colombia and Guyana, which further heightened in the 80s. From the time

Memorandum on Public Adminstration Case Study Example | Topics and Well Written Essays - 1250 words

Memorandum on Public Adminstration - Case Study Example The level of infant mortality is an important indicator of health status of a community. Health People 2010 consensus document stated the reduction of infant mortality rate as one of its objectives. Numerous documentaries reveal the existence of racial disparities in infant mortality rate (IMR). African Americans and other racial minority groups experience a slightly higher IMR as compared to the IMR experienced by the whites. The disparities in neonatal mortality occur due to factors influencing the birth of extremely preterm infants and the access to specialized pediatric and obstetric care. Neonatal mortality accounts for about 67 percent of the national IMR (Khanani et al., 1). Therefore, the risk of preterm birth is a fundamental factor to assess when seeking to decrease the infant mortality. Infant death rate is a key gauge of a nation’s health. It measures the number of infants that die before they reach the age of one year. Most studies on the impacts of WIC on infant’s health have methodological limitations. In most of these studies, the independent measure is often eligibility rather than participation and measure of the results being cause of infant death or timing of those deaths. Population based surveys including WIC program participation are limited. Besides studies examining the effects of timing of WIC are very rare. Evidence on the effects of interventions such as nutritional and prenatal care on birth weight and other features of infant’s health in US populations is variegated. This makes it uncertain on how the WIC program might affect infant mortality. Since its founding in 1974, the WIC program has gained the reputation of being a successful federal funded nutrition program in the US. Numerous findings of previous studies reviews and reports show that WIC program is cost effective in nurturing and improving the health and nutritional status of

Recent Advances in Mechanical Micromachining Essay

Recent Advances in Mechanical Micromachining - Essay Example There are much considerations to be taken when machining small pieces due to the imperfections per unit volume that are due to the size effect of the work piece and the strain effect that is caused by the size effect during machining of the small pieces of work pieces (Dornfeld & Takeuchi, 2006). An example is energy dissipation that has been neglected or along time in micro machining that resulted to significant subsurface plastic flow to the shear zone under the machined surface. 2. One of the micro geometries created through micromachining is the fabrication of multi level mold inserts for micro molding of a microwave system. This involved combination of micromachining with deep etches X-ray lithography that resulted to creation of micro molds with features in the range of 60Â µm in height and 50Â µm wide. This portrayed the possibility of stacking several mold so high aspect ratio parts (Dornfeld & Takeuchi, 2006). 3. Micro tooling refers to using the correct tools in micromachining. The cutting edge of radius of a crystal sharpened diamond for example is on the order of 10nm and the depth of such a tool is in the submicron range. Micro tools are fabricated by ion beam process. An example is the gallium focused ion beam that generates a number of cutting edges and tool end clearance and machined surface with the same as eh diameter of the tool. The use of wire electric discharge grinding (WEDG) (Dornfeld & Takeuchi, 2006) is also common in tool fabrication. WEDG involves a sacrificial wire that replaces the turning tool in conventional turning. Material is then eroded from the rotating tool with electrical discharges. The sacrificial wire in this case is fed around a reel and takes up system that would prevent discharges from worn out regions and this increases the accuracy of the tool shape (Dornfeld & Takeuchi, 2006). Micro tools are usually made from tungsten wire due to

Personal Statement to apply preparatory course of graduate school in

To apply preparatory course of graduate school in UK - Personal Statement Example Fortunately, I enjoy family support, especially from my father who works as an Electrical and Automation engineer. He is interested in providing both moral and financial support in my pursuit for engineering knowledge, either at home or abroad. Prior to providing detailed description of my personal life and career plans, I would like to categorically explain my specific choice of wanting to study at a UK college. First, I was born and raised in China. I have undertaken all my academic programs within the People’s Republic of China, up to my undergraduate level. As a result, I would wish to pursue further learning within a different environment away from the monotonous Chinese institutions. I choose United Kingdom because it features as one of the most culturally diversified society in Europe. UK is known for its cultural tolerance and warm accommodation to people from diverse religious backgrounds. In addition, the UK offers friendly and homely residential settings to visitors. Therefore, I believe that learning institutions within the country offers me with an opportunity to study within a culturally rich and diverse environment free from the Chinese way of learning and thinking. Apart from cultural diversity, it is undeniable that the UK education system is renowned and respected across the world. Its learning institutions like yours are known to offer quality and standardized education system that meet and even exceed expectations within the labor market. Actually, preparatory courses from UK enjoy international recognition. They have sophisticated learning infrastructure with qualified teaching staff (Smith 67). Consequently, students undertaking and completing their preparatory studies within the UK are not only highly regarded by stakeholders within the education sectors but also by employers around the world. Apart from enabling me to gain substantial knowledge, such recognition and high regards to UK

Evaluate the current uses of 3D printing. Discuss the potential future Essay

Evaluate the current uses of 3D printing. Discuss the potential future of 3D printing based on current issues identified in the literature - Essay Example 3D technologies include building images layer by layer using powder and raw materials such as resins, plastics and super alloys rather than multi-coloured ink as in conventional printers (Berman 2012, p. 155). 3D printing presents many future possibilities, albeit some clearly not for the foreseeable future, including the manufacturing of final objects closer to consumers or even by the consumers themselves, with significant implications for both the society and economy. On the other hand, there are also issues ranging from social to practical, legal and economic aspects. This paper will evaluate the current uses of 3D printing and discuss its potential future based on the issues associated with them. 3D printing has evolved since the first functional 3D printer was created in 1984. The 3D printing or additive manufacturing process is a form of rapid-prototyping that fabricates three-dimensional objects using the technology of ink-jet printing. The process joins materials from three-dimensional model data to make or ‘print’ objects, usually placing layer upon layer unlike subtractive manufacturing that include cutting and moulding raw materials into objects (Stahl 2013, p. 3). Further, it mainly uses systems of 3D scanning and computer-aided design (CAD) models for production. Objects printed using the 3D technology are fabricated after successive layers of materials are solidified, fused or deposited on top of each other, whereby each layer corresponds to the objects’ cross-sectional shapes. FDM (fused deposition modeling) and SLS (selective laser sintering) are currently the most common 3D printing technologies. Technological developments have made the conce pt more accessible and affordable, widening the range of current and potential users beyond the previous rapid prototyping systems that fundamentally targeted engineering and industrial applications. According to Stephens, Orch & Ramos (2013, p. 334), 3D printing may better be understood by viewing what

Organisations and people Essay Example | Topics and Well Written Essays - 2500 words

Organisations and people - Essay Example This is a debatable reason because normally universities offer much more than colleges, however, due to the amount of enrollment, Ohio Dominican University cannot compete with many schools. I also feel the choice of extra curricular activities is also far more interesting at Columbus State Community College because since there are more students. I will get more specific as to why I chose Columbus State Community College in the following paragraphs. Body Ohio Dominican University is quite small which means that its programs have a home feel to them however in terms of providing opportunities for future job prospects, it is limited because of its weak enrollment numbers and small size of the campus. Some people feel that a small school is exactly what they want and need and a small size can actually improve the quality of life for people in school, however, it would be better if this school were larger like Columbus State Community College is. There is nothing wrong with a small school however it cannot compete with the large variety of experiences a larger school can offer. Once again, not everyone would agree about this however it is the stance I have chosen. Ohio Dominican University has the ability to provide a sense of comfort and a more relaxed atmosphere since it is very small but resources and quality are limited when larger schools exist because brighter students enroll in larger schools because of the many more choices of academic programs offered. A larger school means more programs, more opportunity, more competition, and a higher quality of education. Ohio Dominican University would be better in my opinion with a larger enrollment because they have a strong position with their Catholic affiliation and they offer many degree and post degree programs that are not offered in Columbus State Community College or any other college for that matter. Ohio Dominican University has a plan to achieve growth however if it does not achieve this goal, then it would be considered a worse school than many others that have attracted more students. The general look of their websites do not really speak of their distinctiveness or whether one is better than the other. Unfortunately only key factors like enrollment or programs offered allow me to make my comparisons. Completing a degree at a university in North American would allow for more job prospects though and allow a much greater chance to compete in the real world. College programs are able to provide great introductions to programs and provide a much more practical and hands on approach that is not involved in the university experience. Ohio Dominican University oddly has such a small number of students enrollment that the people who want to look into going there would most likely wonder why the enrollment is so small. There are small cities but the number attending there is extremely small. Many people in rural communities that are much happier with rural life, feel like attending a small school with few people is the greatest experience and they also feel they can get a much better quality education from these schools since enrollment is so low. One might also be able to take a stance that would suggest that no one school is better than any other because all colleges that are public are the same and all universities are the same. One might criticize lack of job prospects or the differences that one school may offer more opportunities

Psychological study of man Research Paper Example | Topics and Well Written Essays - 1250 words

Psychological study of man - Research Paper Example For many years, the psychologists have limited their work to the study of women psychology. However, with the passage of time and in-depth analysis of various aspects in the field of psychology, the professionals have realized that there are certain behaviors which are associated with men that need to be studied in detail (Blazina and David, 21). In order to make sure that there is sufficient evidence of work on psychological study of man, the experts have undertaken various initiatives to make valuable contributions in the world of psychology. Previously, the psychologists studied the gender roles by comparing them across various cultures (Lavent and William, 70). But recent developments in the research of these gender roles highlighted that the male behave in certain ways not on the basis of biological or social constructs but rather on socially and psychologically constructed entities (Carothers and Harry, 386). Joseph Pleck was the person who developed â€Å"The gender role strain paradigm† in 1981. According to this paradigm, a man has to deal with various strains to live up to the expectations of the society. It was even the starting point for the development of an additional branch of psychology for men (Lavent and William, 2). The gender role is defined as the set of behaviors, actions, attitudes and self-perception methods which are ascribed to all members of the particular biological sex i.e. male or female. There is a specific CPGR (Culturally Preferred Gender Role) which varies according to the cultures. Every male is encouraged to show compliance with CPGR and even forced to adopt it (Lavent and William, 132). According to Szukalowski, a man is generally nurtured on a way that the rules of masculinity are engrained in his personality (45). The three main areas of masculinity are strength (courage, rationality, self-reliance and aggression), action (ambition, dominance, risk-taking and competitiveness) and honor

Animation Critique Essay Example | Topics and Well Written Essays - 250 words - 4

Animation Critique - Essay Example Fred Moore was different from the other animators because of his style of drawing. He was ranked in a different league because he gave charm, emotion and appeal to his characters. By doing this his characters looked more substantial while performing their actions. Fred had the 14 points of animation which he kept in check while working. He concluded that the character should have appeal, interesting depiction, entertaining, presence of creator in character, advancement of character, two-dimensional clarity, three-dimensional solidity and four-dimensional drawing (Duggan, 99). Moore was famous for portraying womanhood with great flair. His drawing of Snow White did not impress Walt hence he was given the responsibility to create the dwarfs. Moore designed the look and personalities of the seven dwarfs and also animated the famous scene of Snow White kissing Grumpy dwarf (Lenburg, 342). Animation history is full of world class animators. Another famous individual known in field is Pete Burness, who is well known for creating the character of Mr. Magoo (Lenburg, 39). The most famous character in the world of animation is Walt Disney. He was a legend who gave us Mickey Mouse, Donald Duck, Snow White and Bambi. He was known for his innovative thinking and perfection. His animated characters have and will always be alive among us (Krasniewicz,

Flamingo Essay Essay Example for Free

Flamingo Essay Essay Bonny Sim Flamingo Essay July 12, 2012 Did you know that flamingos were the inspiration for the phoenix? Pheonicopterus is another name for flamingos in Latin, which means crimson wing. Flamingos live in warm places like South Africa. They are usually near salty lakes or rivers. Flamingos are one of the most amazing creatures on Earth. Flamingos’ bodies are mostly pink. Their beaks are brownish black and the inside parts of their wings are black feathers. However, their eyes, legs, and feet are all pink. They have long, pink chopstick like legs, and big, webbed feet. Flamingos are usually 120cm in height, and weigh 2~5 kg, with an average wingspan of 140cm. Flamingos are pretty tall, mostly because of their long legs and neck. What do flamingos eat? What eats the flamingos? Flamingos have a very special tool for eating: their beaks. They stamp their large feet in the mud of the lake or river to stir up food from the bottom. They usually eat brine shrimp and blue-green algae, filter fed. Also, flamingos are very sociable birds that group in communities that can reach into the thousands. Flamingos group together for predator avoidance maximizing food intake, and finding the best nesting sites. They can be eaten by mongooses and marabous. The unique thing about flamingos is that they are crimson colored. However, the baby flamingos are born with grey feathers. There are carotenoid proteins in aqueous bacteria and beta carotene that causes this pink and reddish coloration. Female flamingos are more attracted to vividly colored, healthy, and enchanting males, when they are finding their mates. The flamingo dance, as we call it, is for finding a mate. They raise their neck high, and twist their heads from side to side. Randomly, they flap their wings. First, the flamingos divide themselves into groups of 15~50 birds. When they find their mate, their female chooses a spot for the nest. Next, they build the nest out of mud and salt. Another pair sometimes tries to steal the other couple`s nest spot if they want it. The female flamingo lays the egg, and it hatches after a month. Thee chicks are born gray, with spots of white. Because the flamingos have a hormone called prolactin, they create crop milk to feed their chicks. The crop milk contains red and white blood cells. The family stays in the nest with the chicks for six days, but after 7~12 days, the chicks venture around. Two weeks later, the chicks become a part of microcreches, and their parents leave them in these groups. Soon, the microcreches come together to form creches, which can consist of thousands of chicks. Creches are meant to protect the chicks from getting eaten by the predators. In conclusion, the life cycle of flamingos, is so awe-inspiring. The way they filter feed, and how they group themselves, is so unbelievable. Did you know that flamingos were the inspiration for the phoenix? The chicks that learn to walk really fast are amazing, too. Let`s protect them from being endangered, by keeping the lakes and rivers clean. Also, it might help the flamingos if we stop the global warming.

Impact of Prejudice and Discrimination in Canadian Society

Impact of Prejudice and Discrimination in Canadian Society Arjun Pasricha Introduction Words like prejudice and discrimination have become common terms and they are referred often in our daily life, such as media, books, news, casual conversations, and political discussions. Prejudice and discrimination have been in focus since 1960s and these issues have been researched extensively since the last few decades. This surge of interest to understand the impact of prejudice and discrimination in Canadian society has defined the purpose for this report and the report attempts to explore and examine a complete picture of prejudice and discrimination in the contemporary Canadian society. The report is built on sociological, anthropological and psychological perspectives and aims to examine prejudice and discrimination issues that emerge in Canadian social situations because of social interactions (Eriksen, 2010). The conceptualization of prejudice and discrimination, two forms of social bias have evolved over a period of time and are acknowledged as one of the greatest societal challenges because of their dreadful negative effects on the Canadian society. Presently, there is a universal consensus among all that prejudice and discrimination are one of the serious social issues in Canada and they typically appear together, prejudice is considered as the thought, while discrimination is the action (Dovidio, 2010). According to Driedger and Palmer (2011) prejudice and discrimination is always seen to intersect each other and manifests in many forms. For example, people may have prejudices against some groups and end up engaging in a discriminating manner with them. For instance, social pressures may subject prejudices against women and marginalized population and discriminate them in employment, education, or social services (Chin, 2009). Prejudice is defined as a construction of negative preconc eived beliefs, notions, feelings, attitudes, and opinions about a group of people or individuals, that may be felt or expressed, usually because of ethnicity, religion or race (Chin, 2009). On the other hand discrimination is defined as discouraging or negative treatment towards others because of their sex, gender, race, disability, sexual orientation, religion or belief and age (Dawson, 2013). The discrimination construct not only involves biased treatment , but also unacceptable and inequitable behaviour towards some individuals or some group members, that are excluded from society because of prejudice (Dovidio, 2010). Ageism and Society Ageism is considered as one of the most prevalent prejudices in the society and can be defined as the denial of basic human rights to elderly population (Gutman Spencer, 2010). Sociologists are of the view that people have stereotype prejudice view of older population in the society because of their age, which leads to discrimination. Often aging population experience prejudice in their workplace and typically society holds negative stereotypes for aging population. They commonly presume that old adults are senile, sad, lonely, incompetent, have poor physical or mental health, have conservative thinking, and rigid ideas or opinions. Employment discrimination against old age manifests in different ways, old adults who worked for the company in their younger years are pushed out as they grow older, on the other hand, companies may refrain from hiring old adults, and aging population are unable to get similar employment opportunities as younger population (Gunderson, 2003). Moreover, younger population have negative stereotype thinking that aging population have massive medical expenses and they are a drain on the Canadian system. (Edwards, 2002). Therefore, these negative stereotypes and discriminations can have detrimental effects on aging population. They feel they are being unreasonably blamed for being a burden on health care systems, the Canada Pension Plan and Old Age Security. Therefore, these negative impressions of society foster discrimination against aging population (Mei, et all, 2013). It is time for all of us as individuals to increase our awareness and question our negative stereotype thinking, relook at our assumption about aging and older population. We need to take extra care to reach out to them with an open mind and treat them as valued and important contributors of our Canadian society. Employers too need to value them and make efforts to understand diverse needs of aging population. Moreover, Canadian government has a continued focus on expanding their age inclusive policies that facilitate aging population to have a choice to lead their life to the fullest. Thus, there is a great need for our society as a whole to address the societal issue of ageism. Although, change may not happen overnight, but we all can take the responsibility to collectively build an age-inclusive society. Social Anthropology Perspective on History of Immigrants Immigration to Canada led to an increase in population of diverse cultures. Immigrants were from varied economic and ethnic backgrounds. However, this led to rise in disagreements regarding aspects such as economic benefits or employment for immigrants. This report focuses on social anthropological point of view to describe impact of prejudice and discrimination on immigrants on basis of their ethnicity and culture. Historically, early Canadian immigration policies were largely discriminative Prejudice and discrimination emerged in 17th and 18th centuries in Canada between Aboriginals, and French and European colonizers. Europeans and French viewed those Aboriginals as uncivilized and uncouth. In the 19th century Canada opened its immigration policy and a number of immigrants from other origins were seen. However, Canadians shared prejudices concerning the capabilities of the immigrant groups. During the late 19th and early 20th centuries, whites considered themselves superior in front of nonwhite groups and nonwhites faced a great deal of social prejudice (Driedger Palmer, 2011). In the late 1800 and early 1900, Asian immigrants faced anti-Asian sentiments in British Columbia. They were considered inferior and were discriminated because of their willingness to work for lower wages than whites. Moreover, discriminatory social practices in British Columbia made Asians refrain from voting, practicing law, or careers with civil service. Numerous attempts were made by anti-Asians to prohibit Asians from studying in public schools (Driedger Palmer, 2011). Black Canadians also were subjected to extensive patterns of discrimination in the late 1900 and early 2000s in Nova Scotia and Ontario. They were forced to study in segregated schools, faced discrimination in housing, employment and use of public services. Moreover, on various occasions they were refused to be served in hotels or restaurants. Additionally, whites expressed prejudice toward Black Canadians and saw them as backward, ill-mannered, unaware, dishonest, violent, and law breakers (Driedger Palmer, 2011). After the Second World War, in response for human concern, Canada signed the United Nations charter on Universal Declaration of Human Rights in the year 1948 and The Canadian Bill of Rights was adopted in the 1960. This brought in new tolerance policies and helped to weaken the rigid relationships of prejudice and discrimination. The shift resulted in introduction of more unbiased immigration laws and by the 1970s globalization helped in greater inflow of multicultural immigrants (Driedger Palmer, 2011). Thus immigration policies and regulations have changed, mostly to eradicate overt discrimination on the basis of immigrants’ race or culture. Today Canadians are proud of being a tolerant society, where people of all different racial, ethnic, and national backgrounds live together harmoniously (Dion, 2002). An Ethnic Diversity Survey conducted in 2003 examined the ethnic and cultural backgrounds of Canadians and concluded that 93 per cent of population had never, or rarely, encountered discrimination or prejudice because of their ethnicity or cultural attributes. Nevertheless, some new immigrants did sometimes feel discriminated in personal, economic, social, or political situations (Driedger Palmer, 2011). References Chin, J. L. (2009). The psychology of prejudice and discrimination: A revised and condensed edition. Santa Barbara: ABC-CLIO. Dawson, C. (2013). Prejudice: Reed Business Information Ltd. Dovidio, J. F. (2010). The Sage handbook of prejudice, stereotyping and discrimination. London: SAGE. Driedger, L. , Palmer, H. (2011). Prejudice and Discrimination. The Canadian Encyclopedia. Retrieved on July 12, 2014, from http://www. thecanadianencyclopedia. ca/en/article/prejudice-and-discrimination/ Edwards, A. (2002). Its about time: A new campaign by the ontario human rights commission aims to advance rights for older citizens. Marketing Magazine, 107 (32), 12. Eriksen, T. H. (2010). Ethnicity and nationalism: Anthropological perspectives. New York; London: Pluto Press. Gunderson, M. (2003). Age discrimination in employment in canada. Contemporary Economic Policy, 21 (3), 318-328. doi: 10. 1093/cep/byg013 Gutman, G. , Spencer, C. (2010). Aging, ageism and abuse: Moving from awareness to action. San Diego: Academic Press. Mei, Z. , Fast, J. , Eales, J. (2013). Gifts of a Lifetime: The Contributions of Older Canadians. Retrieved on July 13, 2014, from http://www. rapp. ualberta. ca/~/media/rapp/Home/Documents/Gifts_of_a_Lifetime_2013Sep23. pdf Novak, M. W. , Campbell, L. D. (1993). Aging and society: A Canadian perspective. Scarborough, Ontario: Nelson Canada. Retrieved on July 12, 2014 from http://www. nelsonbrain. com/content/novak0043x_017650043x_02. 01_chapter01. pdf Lozen, J. C. Barratt, J. (2012). Revera report on ageism. Revera Inc. in partner-ship with Leger Marketing. Annotated Bibliography Chin, J. L. (2009). The psychology of prejudice and discrimination: A revised and condensed edition. Santa Barbara: ABC-CLIO. Dawson, C. (2013). Prejudice: Reed Business Information Ltd. Dovidio, J. F. (2010). The Sage handbook of prejudice, stereotyping and discrimination. London: SAGE. Edwards, A. (2002). Its about time: A new campaign by the ontario human rights commission aims to advance rights for older citizens. Marketing Magazine, 107 (32), 12. Eriksen, T. H. (2010). Ethnicity and nationalism: Anthropological perspectives. New York; London: Pluto Press. Gunderson, M. (2003). Age discrimination in employment in canada. Contemporary Economic Policy, 21 (3), 318-328. doi: 10. 1093/cep/byg013 Gutman, G. , Spencer, C. (2010). Aging, ageism and abuse: Moving from awareness to action. San Diego: Academic Press.

Phonics: How children learn to read

Phonics: How children learn to read Phonics is probably one of the most important parts on how children learn to read. I will discuss the 12 key concepts from the National Reading Panels report on phonemic awareness and phonics instruction. I will also go over how phonemic awareness and phonics instruction can support a balanced reading program. How sounds are used in words is very important to teach students to learn to read. Students need to know that words are made up of phonemes and that they need instruction to help them learn about phonemes. Students will learn to read when phonemic awareness is taught and student needs to know how to manipulate phonemes by using letters of alphabet. I believe that most students can learn to read using phonemic instruction. There are several ways a student can demonstrate phonemic awareness. When a student can segment words into separate sounds such as /c/ /a/ /t/ is one way. Another way is when the student can identify that a set of words begins with the same sound, such as dog, day and down. These words begin with the letter /d/. Thirdly when a student can isolate and say the first or last sound in a word, such as beginning sound of the word fun is /f/ or the ending sound of fat is /t/. Lastly another way to show awareness is if a student can combine sounds in words like /h/ /a/ /t/ to make the word hat. If students demonstrate these skills they will be way ahead in learning to read and spell. Phonemic awareness and phonic sound like they are the same thing, but I will explain the difference between the two. First, phonics is the relationship between letters and sounds in written language. Phonemic awareness is the sounds of spoken language that work together to form words. But phonemic awareness is taught in phonics instruction, so they do work together. Phonemic awareness students will be able identify and manipulate individual sounds in words while in phonological awareness students will be able to recognize parts of spoken language. This usually will include rhyming, and rime, alliteration, intonation and syllables. Some examples of phonemic awareness are when a student can identify a word such as /h/ /a/ /t/. In phonological awareness students will be able to identify the word frog as /fr/ /o/ /g/ or /fr/ or /og/ When a student can start identifying, making oral rhymes such as, rat and cat, the student is showing they have phonological awareness. Another great example when the student can identify and work with onset and rime in syllables, for example hip and it. Also, a student can clap a word so they can hear the syllables in the spoken word. They can use a word they like or their name, such as Kay-lin. Lastly, a student can identify and work with individual phonemes in spoken words like the first sound in hat. To teach phonemic awareness a teacher can use many techniques. The first example is phoneme isolation. This is where the student will be able to recognize individual sounds in a word. A student will understand that the first sound in hat is /h/. Another example a teacher can use is phoneme identify where a student will be able to recognize the same sound in different words. For example the words tall, talk and toad is /t/. Thirdly is phoneme categorization. This is when a student will be able to recognize a word in a set of words that will have a different sound. In a set of words like, fly, fun and sit, will not fit because the word does not start with /f/. The fourth one I will discuss is phoneme blending. Phoneme blending is when a student will be able to listen to a sequence of separately spoken phonemes, combine the phoneme to make a word, write and read the word. Students who will hear a sound like /f/ /a/ /t/ and will know the word is that as well as write the word. Fifth, is phoneme segmentation. This is where a student will be able to break apart a word into separate sounds. For example the student can tap their foot or count the word out such as /f/ /r/ /o/ /g/. The student will understand that the word frog has four sounds. Then the student will be able to write and read the word. Phoneme deletion is the sixth way. This is when a student recognizes a word that remains when a phoneme is removed to form another word. For example a student given the word small and can recognize that mall is the word remaining when the phoneme /s/ is removed. The seventh is phoneme addition. This is when a student can make a totally new word by adding a phoneme to an existing word. For example, the word an and then told to add the letter /c/ to the beginning and the word now is can. The eighth one is phoneme substitution. This is when a student will be able to substitute one phoneme for another to make a new word. A student may be given a word such as hot and asked to ch ange the /t/ to a /p/. Now the student will say the word, hop. After the above techniques are learned the student will have phonemic awareness. A student will improve their reading and spelling with phonemic awareness instruction. Phonemic awareness will also help increase a students vocabulary knowledge. Segmenting words is one way to have the student learn to read and it will also help them to spell. Being able to read accurately is very important for students to be able comprehend what they just read and the students need to stay focused on the meaning of what they are reading. Phonemic awareness is key for a student to be able to understand what they read. It will also help to reduce the stress of sounding out words and having the student taking too many pauses and losing focus of where they are at when reading. A student being able to manipulate phonemes will show that that he or she is becoming phonemically aware. A student will be able to improve how they spell and read if the student is taught that sounds and letters are used in phonemic awareness to reading and writing. It is very important not to teach several of the methods listed above all at once. As a teacher we do not want to confuse our students. It is a great idea to focus on a couple of the techniques until they can master those and then move on to other techniques if needed. Also, we need to be careful to use techniques that will be at the student literacy level. Again, if we teach above the students level, the student can become very irritated, and if taught below their level they may become bored and their behavior may change. I believe that teaching phonemic awareness is very effective when it is taught in small groups. Students thrive in this type of setting because they like to hear what their classmates are doing or what their classmates think of their work especially if it is positive. Of course phonemic instruction will not guarantee a student will be a successful reader but it sure will help with success. Now I will go over seven key concepts that the NRP has on phonics instruction. Phonics instruction teaches relationship between letters and sounds. This helps students learn and use the alphabetic principals so students will comprehend that there are predictable and systematic relationship between written letters and spoken sounds. This also will help student remember how to read words with phonics instruction. The first and probably the most effective concept is systematic and explicit phonics. Phonics instruction teaches students letter sound relationship. This will aid the students in practicing and applying phonics to materials they can use like books that will have several words. This will help the student to decode letter sound relationships with spelling words or in writing. Secondly, the next concept is that kindergarten and first grade students can be successful with word recognition and spelling will improve with systematic and explicit phonics instruction. When a student uses phonics instruction in early childhood there is a greater chance of success that they will be able to read at their current grade level or above. They will also probably be able to write, thus having students to have better comprehension skills. The third concept is to improve student reading comprehension. This can be done with systematic and explicit phonics instruction. If a student can read with fluency and less stopping, the student will be able to understand what they are reading. If student has to keep stopping to sound out words, the student can lose track of what they just read. Again, the earlier the better The fourth concept is that students from various social economic levels need systematic and explicit phonics instruction. This is basically saying that all students can learn to read this way regardless of their socioeconomically background. I do think it may be more difficult for students to keep up if they do not have guidance at home. The fifth concept is that students who are having difficulty learning to read and who are at risk for developing future reading problems need systematic and explicit phonics instruction. The idea behind this concept that students who are at risk can be benefited from this because words will become automatic helping students to read quickly with more accuracy. The sixth concept is that when systematic and explicit phonics instruction is introduced early that it can be very effective. Teachers need to make sure that phonic skills are introduced at grade level or age appropriateness. For example a student in kindergarten may be using letter shapes and letter sounds. Lastly, the seventh concept is that this is not a complete reading program. Students still need learn and have knowledge in alphabet engaging phonemic tasks and having a teacher read to them so they can gain listening skills as well. I know that my third grade son is just now starting to read books on his own and this is giving him confidence in able to read other materials. His teacher also is still reading to the whole class. He is also writing stories on his own. Now I will go over the five parts of a balanced reading program. They are phonemic awareness, phonics, fluency, vocabulary and text comprehension. These all will help students to understand phonemic awareness if they learn to segment words into syllables. Students will also be able to blend phonemes and manipulate phonemes to form new words, thus helping them to read and comprehend. Hopefully students will be given opportunities to apply what they learn about phonics in everyday living. Phonics will help the student with word recognition, spelling and reading comprehension. I currently work in a 3rd /4th grade classroom and I notice when a student is struggling to read fluently, they are having a difficult time understanding what they are reading. So students need to have this type of behavior modeled for them and students need to practice reading out loud. This way a teacher can evaluate and set goals. The more fluidly they are when they read, the more they will want to read. Vocabulary is very important as well. It is crucial for students to be able to communicate so they can get their ideas and thoughts across clearly. It will also help if they know what the words mean when they are reading them. Students can learn vocabulary in many areas of their lives. They can listen to their peers, their parents and siblings. Teachers and parents can also make sure the student is reading on a daily basis. Also, a teacher can directly teach vocabulary words. Lastly we will discuss text comprehension. This is one area my son struggles with. He is now being able to read faster and this is helping actually understand what he is reading. His teacher has been giving him strategies to help him read his text through cooperative learning, explicit instruction and silent reading. Becoming an educator, when I use these techniques, I will be able to help my students to be successful in reading and writing. After being in a classroom for the last two years I understand that these techniques are imperative and must be implemented in the classroom. Like I tell my children in sports practice if you want to get better. I will make sure my students will have access to interesting reading materials and I will have them doing many writing tasks. The great thing about phonics is that it can be taught individually or in groups. A teacher should take notice though if a student needs more help than other students. Again, the earlier a child begins to use phonics the better chance of a successful reader. Haemophilia: Causes, Symptoms and Treatments Haemophilia: Causes, Symptoms and Treatments Ayman Jomaa Haemophilia is an inherited draining issue in which the blood does not cluster appropriately. This can prompt spontaneous draining and also draining succeeding wounds or surgery, Blood holds numerous proteins called thickening variables that can help to quit dying. Individuals with haemophilia have low levels of either variable VIII (8) or component IX (9). So in simple words haemophilia is an uncommon innate (inherited) draining issue in which blood cant cluster typically at the site of an injury or damage. The issue happens in light of the fact that certain blood coagulating elements are missing or dont work legitimately. This can result in amplified draining from a cut or wound. Spontaneous interior draining can happen too, particularly in the joints and muscles. Haemophilia influences guys considerably more regularly than females. Types of inherited haemophilia: Type A: the most widely recognized sort is brought about by an inadequacy of component VIII, one of the proteins that helps blood to structure clumps. Type B: haemophilia is created by a lack of element IX. Despite the fact that haemophilia is generally diagnosed during childbirth, the issue can additionally be procured sometime down the road if the body starts to prepare antibodies that assault and wreck coagulating components. Notwithstanding, this procured kind of haemophilia is exceptionally uncommon. Causes of haemophilia Haemophilia is brought on by a change or change, in one of the genes, that gives guidelines to making the thickening component proteins required to structure blood coagulation. This change or transformation can keep the coagulating protein from working legitimately or to be missing out and out. These genes are found on the X chromosome. Guys have (XY) and females (XX). Guys inherit the X chromosome from their moms and the Y chromosome from their fathers. Females inherit one X chromosome from each one guardian. The X chromosome holds numerous genes that are not show on the Y chromosome. This implies that guys just have one duplicate of a large portion of the genes on the X chromosome, although females have 2 duplicates. Therefore, guys can have an ailment like haemophilia on the off chance that they inherit an influenced X chromosome that has a transformation in either the element VIII or component IX gene. Females can likewise have haemophilia, however this is much rarer. In such cases both X chromosomes are influenced or one is influenced and alternate is missing or idle. In these females, draining manifestations may be like guys with haemophilia. Despite the fact that haemophilia runs in families, a few families have no former history of relatives with haemophilia. Once in a while, there are bearer females in the family, however no influenced young men, simply by shot. In any case, about one-third of the time, the infant with haemophilia is the first in the family to be influenced with a change in the gene for the coagulating element. Haemophilia can bring about: Draining inside joints that can prompt perpetual joint infection and agony Draining in the head and now and again in the mind which can result in long haul issues, for example, seizures and loss of motion Passing can happen if the draining cant be ceased or on the off chance that it happens in an indispensable organ, for example, the mind. Signs and symptoms Prolonged external bleeding and bruising that happens effortlessly or for no obvious reason, are two significant indications of haemophilia. The side effects of haemophilia fluctuate relying upon whether the individual has the mellow, direct, or extreme type of the issue. For individuals with extreme haemophilia, draining scenes happen all the more frequently and with almost no incitement. For those with moderate haemophilia, delayed draining has a tendency to happen after a more noteworthy harm. Individuals with the gentle manifestation of haemophilia may have irregular draining just after a significant damage, surgery, or trauma. Individuals with haemophilia may have any kind of internal bleeding (inside the body), however regularly in the muscles and joints, for example, the elbows, knees, hips, shoulders, and lower legs. Frequently there is no agony at the outset, yet in the event that it proceeds, the joint may get hot to the touch, swollen, and tormenting to move. Repetitive draining into the joints and muscles can result in perpetual harm, for example, joint disfigurement and decreased versatility (capability to get around). Bleeding in the brain is an intense issue for those with extreme haemophilia, and may be life-debilitating. Indications of bleeding in the brain may incorporate changes in conduct, over the top tiredness, tireless cerebral pains and neck torment, twofold vision, heaving, and seizures. Diagnosis Physical examination is done. If you have symptoms of hemophilia, the doctor will obtain information about your family’s medical history, since this disorder tends to run in families. Blood tests are then performed to determine how much factor VIII or factor IX is present in your blood. These tests will show which type of hemophilia you have, and whether it is mild, moderate, or severe, depending on the level of clotting factors in the blood: People who have 5-30% of the normal amount of clotting factors in their blood have mild hemophilia. People with 1-5% of the normal level of clotting factors have moderate hemophilia. People with less than 1% of the normal clotting factors have severe hemophilia Treatment Hemophilia is a complex issue. Great quality therapeutic consideration from specialists and attendants who know a ton about the issue can help keep a few genuine issues. Regularly the best decision is a far reaching hemophilia medication focus (HTC). A HTC gives consideration to deliver all issues identified with the issue, and additionally training. The group comprises of doctors (hematologists or blood pros), medical caretakers, social laborers, physical advisors and other human services suppliers, who are worked in the consideration of individuals with draining issue Blood Clotting Factors: The most ideal approach to treat hemophilia is to supplant the missing clotting factors with the goal that the blood can clump legitimately. This is carried out by infusing industrially ready clotting factor. There are two main types of clotting factor available are: Plasma-Derived Factor Concentrates: Plasma is the fluid compartment of blood. It is bright yellow and holds proteins, for example, antibodies, egg whites and coagulating variables. A few variable focuses that are produced out of human plasma proteins are accessible. All blood and parts of blood, for example, plasma, are routinely tried for the infections. The clotting proteins are divided from different parts of the plasma, decontaminated, and made into a stop dried item. This item is tried and treated to execute any potential infections before it is bundled for use. Recombinant Factor Concentrates The concentrate is hereditarily designed utilizing DNA engineering. Economically ready variable concentrates are dealt with to evacuate or inactivate blood borne infections. Also, recombinant elements VIII (8) and IX (9) are accessible that dont hold any plasma or egg whites and, subsequently, cant transmit any blood borne infections. The items could be utilized as required when an individual is draining or they might be utilized all the time to keep drains from happening. Today, individuals with hemophilia and their families can figure out how to give their thickening element at home. Giving variable at home implies that drains could be dealt with snappier, bringing about less genuine draining and fewer symptoms. Other treatment products I-DDAVP ® (Desmopressin Acetate) Ddavp ® is a synthetic that is like a hormone that happens regularly in the body. It discharges variable VIII (8) from where it is put away in the body tissues. For individuals with gentle, and a few instances of moderate hemophilia, this can work to expand their component VIII (8) levels so they dont need to utilize thickening variable. This drug could be given through a vein (Ddavp ®) or through nasal spread (Stimate) II-Amicar ® (Epsilon Amino Caproic Acid) Amicar ® is a substance that might be given as a pill or a fluid by veins or mouth. It keeps clusters from breaking down, bringing about a firmer coagulation. It is frequently utilized for draining within the mouth. III-Cryoprecipitate Cryoprecipitate is a substance that originates from defrosting new solidified plasma. It is rich in component VIII (8) and was ordinarily used to control genuine draining previously. In any case, on the grounds that there is no strategy to slaughter infections, for example, HIV and hepatitis, in cryoprecipitate it is no more utilized as the current standard of medicine in the U.s. It is, on the other hand, still utilized within most creating nation Literature sites Bolton-Maggs PH, Pasi KJ. Haemophilias A and B. Lancet. 2003 May 24;361(9371):1801-9. Review.PubMed citation Franchini M. Acquired hemophilia A. Hematology. 2006 Apr;11(2):119-25. Review.PubMed citation Giangrande P. Haemophilia B: Christmas disease. Expert Opin Pharmacother. 2005 Aug;6(9):1517-24. Review.PubMed citation Graw J, Brackmann HH, Oldenburg J, Schneppenheim R, Spannagl M, Schwaab R. Haemophilia A: from mutation analysis to new therapies. Nat Rev Genet. 2005 Jun;6(6):488-501. Review.PubMed citation Oldenburg J, El-Maarri O. New insight into the molecular basis of hemophilia A. Int J Hematol. 2006 Feb;83(2):96-102. Review.PubMed citation Plug I, Mauser-Bunschoten EP, Brà ¶cker-Vriends AH, van Amstel HK, van der Bom JG, van Diemen-Homan JE, Willemse J, Rosendaal FR. Bleeding in carriers of hemophilia. Blood. 2006 Jul 1;108(1):52-6. Epub 2006 Mar 21.PubMed citation