Why We Celebrate Womens History Month In March

On February 28, 1980, President Jimmy Carter wrote: From the first settlers who came to our shores, from the first American Indian families who befriended them, men and women have worked together to build this Nation. Too often, the women were unsung and sometimes their contributions went unnoticed. These words, part of his message establishing the first Womens History Week in 1980, marked the beginning of a new chapter in American history; one in which recognition of women and their work, and the promotion of their rights became a more explicit concern. That initial effort was expanded in 1987, when March was designated as Womens History Month. The Beginning: Womens History Week In 1978 in California, the Education Task Force of the Sonoma County Commission on the Status of Women began a Womens History Week celebration. The week was chosen to coincide with International Womens Day, March 8. The response was positive. Schools began to host their own Womens History Week programs. The next year, leaders from the California group shared their project at a Womens History Institute at Sarah Lawrence College. Other participants not only determined to begin their own local Womens History Week projects, but agreed to support an effort to have Congress declare a national Womens History Week. Three years later, the United States Congress passed a resolution establishing National Womens History Week, which had ample bipartisan support. This recognition encouraged even wider participation in Womens History Week. Schools focused on special projects and exhibitions honoring women. Organizations sponsored talks on womens history. The National Womens History Project began distributing materials specifically designed to support Womens History Week, as well as materials to enhance the teaching of history through the year, to include notable women and womens experience. Womens History Month In 1987, at the request of the National Womens History Project, Congress expanded the week to a month, and the U.S. Congress has issued a resolution every year since then, with wide support, for Womens History Month. The U.S. President has issued each year a proclamation of Womens History Month. To further extend the inclusion of womens history in the history curriculum (and in everyday consciousness of history), the Presidents Commission on the Celebration of Women in History in America met through the 1990s. One result has been the effort towards establishing a National Museum of Womens History for the Washington, D.C., area, where it would join other museums such as the American History Museum. The purpose of Womens History Month is to increase consciousness and knowledge of womens history: to take one month of the year to remember the contributions of notable and ordinary women, in hopes that the day will soon come when its impossible to teach or learn history without remembering these contributions. Sources National Womens History Week Statement by the President. February 28, 1980.

Soyuz 11 Disaster in Space

Space exploration is dangerous. Just ask the astronauts and cosmonauts who do it. They train for safe space flight and the agencies who send them to space work very hard to make conditions as safe as possible. Astronauts will tell you that while it looks like fun, space flight is (like any other extreme flight) comes with its own set of dangers. This is something the crew of Soyuz 11 found out too late, from a small malfunction that ended their lives.   A Loss for the Soviets Both American and Soviet space programs have lost astronauts in the line of duty. The Soviets biggest major tragedy came after they lost the race to the Moon. After  the Americans landed  Apollo 11  on July 20, 1969, the Soviet space agency turned its attention towards constructing space stations, a task they became quite good at, but not without problems.   Their first station was called  Salyut 1 and was launched on April 19, 1971. It was the earliest predecessor for the later Skylab and the current  International Space Station missions. The Soviets built Salyut 1 primarily to study the effects of long-term space flight on humans, plants, and for meteorological research. It also included a spectrogram telescope, Orion 1, and gamma-ray telescope Anna III. Both were used for astronomical studies. It was all very ambitious, but the very first crewed flight to the station in 1971 ended in disaster. A Troubled Beginning Salyut 1’s first crew launched aboard Soyuz 10 on April 22, 1971. Cosmonauts Vladimir Shatalov, Alexei Yeliseyev, and Nikolai Rukavishnikov were aboard. When they reached the station and attempted to dock on April 24, the hatch would not open. After making a second attempt, the mission was canceled and the crew returned home. Problems occurred during reentry and the ship’s air supply became toxic. Nikolai Rukavishnikov passed out, but he and the other two men recovered fully. The next Salyut crew, scheduled to launch aboard Soyuz 11, were three experienced fliers: Valery Kubasov, Alexei Leonov, and Pyotr Kolodin. Prior to launch, Kubasov was suspected of having contracted tuberculosis, which caused the Soviet space authorities to replace this crew with their backups, Georgi Dobrovolski, Vladislav Volkov and Viktor Patsayev, who launched on June 6, 1971. A Successful Docking After the docking problems that Soyuz 10 experienced, the Soyuz 11 crew used automated systems to maneuver within a hundred meters of the station. Then they hand-docked the ship. However, problems plagued this mission, too. The primary instrument aboard the station, the Orion telescope, would not function because its cover failed to jettison. The cramped working conditions and  a personality clash between the commander Dobrovolskiy (a rookie) and the veteran Volkov made it very difficult to conduct experiments. After a small fire flared up, the mission was cut short and the astronauts departed after 24 days, instead of the planned 30. Despite these problems, the mission was still considered a success. Disaster Strikes Shortly after Soyuz 11 undocked and made an initial retrofire, communication was lost with the crew far earlier than normal. Usually, contact is lost during the atmospheric re-entry, which is to be expected. Contact with the crew was lost long before the capsule entered the atmosphere. It descended and made a soft landing and was recovered on June 29, 1971, 23:17 GMT. When the hatch was opened, rescue personnel found all three crew members dead.   What could have happened? Space tragedies require thorough investigation so that mission planners can understand what happened and why. The Soviet space agencys investigation showed that a valve which was not supposed to open until an altitude of four kilometers was reached had been jerked open during the undocking maneuver. This caused the cosmonauts oxygen to bleed into space. The crew tried to close the valve but ran out of time. Due to space limitations, they were not wearing space suits. The official Soviet document on the accident explained more fully:   At approximately 723 seconds after retrofire, the 12 Soyuz pyro cartridges fired simultaneously instead of sequentially to separate the two modules .... the force of the discharge caused the internal mechanism of the pressure equalization valve to release a seal that was usually discarded pyrotechnically much later to adjust the cabin pressure automatically. When the valve opened at a height of 168 kilometers the gradual but steady loss of pressure was fatal to the crew within about 30 seconds. By 935 seconds after retrofire, the cabin pressure had dropped to zero...only thorough analysis of telemetry records of the attitude control system thruster firings that had been made to counteract the force of the escaping gases and through the pyrotechnic powder traces found in the throat of the pressure equalization valve were Soviet specialists able to determine that the valve had malfunctioned and had been the sole cause of the deaths. The End of Salyut The USSR did not send any other crews to Salyut 1. It  was later deorbited and burned up on reentry.  Later crews were limited to two cosmonauts, to allow room for the required space suits during take-off and landing. It was a bitter lesson in spacecraft design and safety, for which three men paid with their lives.   At latest count, 18 space fliers (including the crew of Salyut 1) have died in accidents and malfunctions. As humans continue to explore space, there will be more deaths, because space is, as the late astronaut Gus Grissom once pointed out, a risky business. He also said that the conquest of space is worth the risk of life, and people in space agencies around the world today recognize that risk even as they seek to explore beyond Earth. Edited and updated by Carolyn Collins Petersen.

Autonomy and Responsibility in Nazi Germany - 1435 Words

Autonomy and Responsibility in Nazi Germany Throughout history, the struggle of people finding their rights in society has played a major role, especially in the Nazi ideology. During this struggle, societies tried to determine who had rights, what a person owed to society and the duties of an individual. Nazis believed in the Volk, which meant people in the sense of a race, not individuals. Nazis saw the Volk as the major component in society, and therefore based the rest of their beliefs on a persons place in the society on the idea of preserving the pure Volk. The rights a person obtained were based on achieving this goal of preserving the Volk as well. The Nazi view of autonomy and responsibility of the individuals in†¦show more content†¦Thus, they eliminated all rights these non-citizens had in the nation, including the right to exist. The extermination of the non-Germans was seen to them as a way of preventing contamination of the German culture. They were afraid that Jews wanted to take over the world and that would destroy the platforms of the nations. They believed that à ¬Jews destroy the peoples both in religion and moralsà ® and exterminating them was the only way to keep German power.3 In order to exterminate these people, the Final Solution was enacted in 1935. The Final Solution began with the Nuremberg Laws. These laws denied citizenship to Jews, based a persons race on their ancestry, prohibited Jews from marrying Germans, ended exemptions on restrictions for Jewish veterans, prohibited the employment of Germans by Jews, and required that all Jews wear the star of David at all times for easy identification.4 The second step came in 1938 when Jews, Gypsies, Communists, and Socialists were shipped to concentration camps and the real extermination began in the gas chambers.5 The Nazis saw peo ple not of the main volk as nothing and therefore did not even think that they had the right to live. 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Once WWI ended one of the biggest side effects of WWI was the physical destruction, besides millions of people died or got injuredRead MoreEuthanasia And Physician Assisted Suicide918 Words   |  4 Pages Opponents of active euthanasia and physician-assisted suicide contend that doctors have a moral responsibility to keep their patients alive as reflected by the Hippocratic Oath. A sample of the Oath states, Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not playRead MoreTo What Extent Was Hitler a Weak Dictator? Essay1855 Words   |  8 PagesTo what extent was Hitler a ‘weak dictator’? 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Since the beginning of the twentieth century, Iran has been embroiled in a struggle to maintain its own autonomy against western influences as mentioned by Shiva Balaghi in her work entitled â€Å"A Brief History of 20th-Century Iran† (Balaghi). Western involvement has plagued the Middle East for a long time, especially upon Iranians. Much of this is due to Iran being situated in such a strategic position in the Middle East.

The Implementation of Total Quality Management - Two Key Alternatives Case Study - 2

Essays on The Implementation of Total Quality Management - Two Key Alternatives for Lots of Vital Issues Case Study The paper â€Å"The Implementation of Total Quality Management - Two Key Alternatives for Lots of Vital Issues" is an outstanding example of a case study on management. The ever-increasing international business competitiveness has mandated companies to build up approaches to turn into low-cost producers and to make different their goods and services from their trading rivals. Total Quality Management is one approach that has been praised globally given the impact it had in turning around Japanese Companies into key competitors.Today’s organizations are surrounded by a rising dealing global environment where numerous essentials have developed into a custom that may not have been of distress to organizations in the earlier times. This includes the emergence of computers and telecommunication and information channels such as the internet. For organizations, these are fresh aspects they have to mull over and apply Total Quality Management into.Today, the implementation of Total Quality Management is vital. However, putting Total Quality Management into operation is not easy and poses a key challenge to the present day top management of most organizations. This forms the basis of this research. The research employs a case study approach.The research reveals that top management commitment to Total Quality Management execution is crucial. However, the top management has to deal with deep-rooted issues such as lacking adequate human resources, choosing the best quality method, modeling techniques, and the most fitting technology mix.To deal with some of these issues, the top management must be committed to Total Quality Management implementation. Also, they ought to consider the opinion of several experts in implementing Total Quality Management, be problem-focused and engage all stakeholders.The ever-increasing international business competitiveness has mandated companies to build up approaches to turn into low-cost producers and to make different their goods and services from their trading rivals. These approaches include Total Quality Management, Self-Directed Work Teams, Total Productive Maintenance, Just-in-Time, Business Process Re-engineering, and Manufacturing Resources Planning. However, the leading confrontation of all businesses is finding a holistic management approach that will get better their competitiveness in international trade. Total Quality Management is one approach that has been praised globally given the impact it had in turning around Japanese Companies into key competitors (Yusof Aspinwall, 2000a).Product Quality is a management concept that has its roots in Japan. The concept was founded by Americans working there in the late 1940s and 1950s: They are Feigenbaum, Juran, and Deming. These three Americans set the fundamentals of Total Quality Management. According to Magutu (2010), Total Quality Management progressed from a lot of dissimilar management practices and upgrading processes. Essentially, Total Quality Management evolved through several stages starting with Inspection/Supervision, Quality Control, and Quality Assurance to the present Total Quality Management. Different authors have defined Total Quality Management in several ways. In this paper, Total Quality Management simply entails a management plan that involves each one member of an organization, at all levels, in producing better standards of product or services that they offer in the marketplace. This essentially entails the administration and control of quality all over a whole organization.Different researches and authors have too identified various dimensions of Total Quality Management but the key dimensions take account of top management support, personnel management, employee involvement, customer rapport, supplier rapport, teamwork, product design process, quality assurance as well as process flow management. Total Quality Management generally lays emphasis on customer focus and satisfaction (Dahlgaard et al 1998).

Accounting Gross Revenue Calculation and Net Revenue Calculation

Question: Discuss about theAccountingfor Gross Revenue Calculation and Net Revenue Calculation. Answer: Depicting the Accounting Policy that Might be use by CGC for Recording the Revenue at Gross Amount or Net Amount when FB Credit Agreement Becomes Active: The current scenario mainly states that an effective recoding keeping method could be used by CGC to effectively maintain the transactions conducted on the virtual world. In addition, the scenario effectively depicts that Facebook with CGC will provide the relative credits for purchase of products in the virtual world. Moreover, the scenario also states that Facebook takes the actual cash and provides virtual credited to its users. In addition, Facebook only keeps 30% of the cash that are collected from the users and sends the other 70% to CGC. Radebaugh (2014) stated that companies mainly use different type of accounting method for their virtual, which could in turn help in segregating virtual profits from actual profits. On the other hand, Slemrod (2013) criticises that companies dealing in online shopping system are not able to comprehend the changing business environment. Gross revenue calculation and net revenue calculation is mainly stated, which could be used by CGC for effectively recording. However, the income of CGC has effectively divided its revenue in 70% (CGC) and 30% (Facebook). However the income that is been generated by the company is mainly provided by Facebook after sale of credits. Thus, the company might effectively us the net revenue system to depict its financial statement and portray the overall income that is been generated from sale of Facebook credits. In this context, Cooper, Edey and Peacock (2013) stated that net revenue method is mainly used by companies that have a fixed commission on its sales. On the other hand, Bucheli et al. (2013) criticises that net revenue system mainly loses its friction if the company does not operate under commission method. The scenario also depicts that Facebook, while receiving payment from its clients incurs a financing cost. The financing cost mainly occurs from PayPal, which is 3.5% of the gross amount paid by its customers. However, the fees that is been given to PayPal is effectively paid by Facebook as the cash transaction is the companies responsibility. However, the service charge is mainly deducted from the gross income that is generated from sales of Facebook credits. In addition, charges are only conducted on credit cards and PayPal transactions, which could change the overall net revenue that is been generated by both Facebook and CGC. Weil, Schipper and Francis (2013) mentioned that net revenue method does not allow the company to adjust the overall expenses that is been incurred from online payments. Thus, after the effective evaluation of the scenario CGC needs to use the gross revenue method to depict the exact expenses incurred of the transaction that is been conducted from PayPal and credit cards. The use of gross revenue calculation method could help CGC to segregate the expenses of 3.5% for each transaction and divide the exact amount of net revenues. In addition, as per the evaluation 2014 revenue should be recorded based on gross amount to depict the exact net revenue generated from transactions after the FB credits agreement have been active. Reference: Bucheli, M., Lustig, N., Rossi, M. and Ambile, F., 2013. Social Spending, Taxes, and Income Redistribution in Uruguay.Public Finance Review, p.1091142113493493. Cooper, R., Edey, H.C. and Peacock, A.T., 2013.National income and social accounting. Routledge. Radebaugh, L.H., 2014. Environmental factors influencing the development of accounting objectives, standards and practices in Peru.The international Journal of Accounting Education and Research. Urbana,11(1), pp.39-56. Slemrod, J., 2013. Buenas notches: lines and notches in tax system design.eJournal of Tax Research,11(3), p.259. Weil, R.L., Schipper, K. and Francis, J., 2013.Financial accounting: an introduction to concepts, methods and uses. Cengage Learning.

The Digital Divide free essay sample

To what extent is there a global dimension to this divide? Is the divide narrowing or widening? The digital divide marks the gap between those who have access and utilize Information communication technologies and those who lack access or ability (reference). Causes for this division have traditionally stemmed through economic circumstance. Due to the existing disproportions between countries economic situations, a large global dimension exists within the digital divide. Socio-demographic factors also significantly affect ones positioning on the spectrum of the digital divide. Through examination it becomes clear that the gap in some senses is showing signs of narrowing. On the other had however, these factors are enhancing the gap and widening the divide for some. The increasing advancements within Information communication technologies and explosion of Internet possibilities within developed countries are leaving developing nations behind. The 21st century has not hindered concern surrounding this digital divide within international agencies such as the United Nations Development Program (Norris 2000). The disparities between developing societies and advanced are considered to be increasing and gap widening. This lends itself to putting countries at an economic advantage or disadvantage, leading to many flow-on effects. Poorer nations such as India, Africa, and southern parts of Asia have been in large, unable to invest in the internationally growing technologies, which would allow their nation to have and maintain Internet access, due to the initial start up investment necessary (Reference). A country not having Internet access in today’s digital age leads to a number of economic consequences. This can be highlighted through; schools being unable to educate or teach students IT skills, preventing them from taking advantage of the huge amounts of information accessible through the web. Therefore people are not growing up with the skills required to get ahead or keep up with this digital era. Ultimately this lack of IT skills results in the inability to compete within the global market or at an international level. Contrasting to this, richer countries are taking advantage of these advancing ICTs, benefiting from more highly trained people who will ultimately lead to higher economic growth (reference). At a fundamental level, this concept illustrates the significant consequences for countries without access to the ICTs and the way in which the revolution of these has allowed developed countries to gallop ahead of those developing who still lack access. In correlation to this divide, at the disadvantage of the poor, the rich get richer. The digital divide works along side other forms of social inequality and is effecting people not only globally but with in a national sense also (Korupp amp; Szydlik 2005). It has been indicated that groups that are the most venerable in society are those who lack access to a computer. They run the risk of being excluded from possible social, educational, cultural and economic benefits. This may have adverse effects on their educational outcomes, employment prospects and other aspects of wellbeing (Australian Bureau of Statistics, 2003). These marginalized people have been deemed to fall into categories of; low income, elderly, lacking in education, and minorities (Winter 2000). The flow on effects of this proves to become more complex than one might initially perceive. Those who are able to afford access to the most advanced technologies and efficient versions are able to capitalize on their existence. Findings support, in 1998, households with an income of $75,000 and above, were nine time as likely to have computer access, and twenty times more likely to have internet access than those of lower income levels (Norris 2000). This disparity can lead to increasing divides in an economic sense as mentioned, but also in a social context. For example, a West German, well educated male has a significantly higher chance of being on the favorable side of societies digital divide, in comparison to the likes of a Turkish women with a lower income and education (Korupp amp; Szydlik 2005). Whilst there currently is lacking evidence to indicate a decline in other forms of social disparity due to computer and Internet access, these members at the adverse end of social classes are not benefiting through this digital emergence. Thus their position is remaining the same. On the other end of the spectrum however, there are indicators suggesting this emergence is helping to secure or even increase the favorable social position of these in higher social classes. Thus the digital divide is arguable contributing towards further divisions among social classes, enhancing not only economic division, but social hierarchy on a national and international scale. Research suggest the environment in which a person is born into and raised, determines ones attitudes towards new technologies (reference). This is globally and most certainly influenced through geographic positioning, however also through the era in which one grew up. Sackmann and Weymann (1995), developed an approached, depicting four ideal types; the pre-technical generation (born before 1939), the generation of household revolution (born between 1939 and 1948), the generation of advanced household technology (born between 1949 and 1964), followed by the computer generation (born after 1964). Evidence suggests those who were born in the computer generation are considerably more inclined to advance with these new information communication technologies, enhancing potential to benefit both socially and economically. According to a 2008 survey, ninety percent of adults between the ages of eighteen to twenty nine use the internet, contrasting to this only thirty five percent of those over sixty five use the internet (Hwang 2008). This highlights the way the digital divide has widened as those from the pre-technical generation and generation of household revolution have fallen further and further behind (Korupp amp; Szydlik 2005). As a result, the division has worked at the advantage to those catorgised within the younger generation. It has enabled them with a potential competitive edge in the global market place. Through efficient use of these information communication technologies it is now easier than ever before to compete on an international scale (reference). Incorporating these devices into ones lifestyle so readily has equipped younger generations with empowering opportunities. The gap between age groups within countries is still a dividing factor within digital usage, however it must be noted that the significance of this is declining (Chen, Wellman 2004). People are now being born into a world where the digital technologies such as the Internet are considered a tool for daily life, more intergraded than ever before. Flow on effects of this have resulted in people incorporating a range of technologies into their lifestyle from a very young age, through this they are able to adopt with advancements made within technologies more readily (the children’s article). This the gap between digital divide within age groups is bridging as more and more people are being brought up surrounded by the concept, thus the divide in this sense can be seen to be narrowing. At the other end of the divide are those developing countries which lack access altogether. As mentioned earlier, the gap here has been widening and continues to do so, however It can be argued that ultimately these digital technologies could in fact be of the most benefit to these currently missing out. They have the abilities to provide them with the opportunity to strengthen the voice of such minorities. For example, the Internet offers broader communication, which could enable small businesses from the likes of Africa or India to sell their products directly to customers internationally. This would exclude the current costly middlemen necessary for these products to be exchanged. In turn, creating larger economic revenue and wider exposure with the opportunity to grow. In order for these countries to gain these potential benefits, a basic level of access is required which is still lacking, thus until this is occurs the gap will continue to widen (Norris 2000). Statistics do however show hope for these countries, which have initially been left with adverse effects of the digital divide. As Information communication technologies advance, basic assess becomes cheaper and more widely accessible. An example of this can be illustrated through the likes of South America. During the year of 2000 South America had a approximately only one in ten people online. This is contrasting to 2012’s figures, which estimate 48. 2% on the population engaging with Internet penetration (http://www. internetworldstats. com/stats2. htm 2012). Furthermore, worldwide Internet users jumped from 1 billion in 2005, to approximately 2 billion in 2010. This trend is through numerous factors including; the spread of mobile phones with web capabilities, cheaper technologies, the growth and range of internet providers, and adoption of government investments within digital industries (reference). Though there are still countries with entrenched digital exclusion such as Africa, which has a mere 15. 6%, online penetration, changes shown through the likes of South America, confirm that accessibility enhancement is occurring in a global dimension. The divide in this sense is continuing to widen between countries without access but narrowing in relation to the amount of countries and regions in which this is happening to. In summary a degree of causes, consequences on both global dimensions and national levels surrounding the digital divide are highlighted. There are of course further factors and consequences that are effecting this division, however at a basic level the above provides understanding to the factors surrounding the digital divide. Through these analogies it is fair to say that whilst the digital divide can be seen as narrowing in a domestic sense, on wider global sense the gap will continue to widen until access is more readily available for all.

Principles of Management Multi Organ Failure Essay Example

Principles of Management : Multi Organ Failure Essay * Day 6 – 7 /ABC * ABC Principles of Management : Multi Organ Failure /MODS * PRINCIPLES OF MANAGEMENT : ABC / Multi Organ Failure (MODS) * Multiorgan dysfunction syndrome (MODS) is the progressive dysfunction of more than one organ in patients that are critically ill or injured. * It is the leading cause of death in intensive care units (ICUs). * The initial insult that stimulates MODS may result from a variety of causes including, but not limited to, extensive burns, trauma, cardiorespiratory failure, multiple blood transfusions, and most commonly, systemic infection. Schumaker, 2006) * The term MODS has been referred to interchangeably as systemic inflammatory response syndrome (SIRS) and multisystem organ failure (MSOF). (Schumaker, 2006) * A. Determination and Management Multi Organ Failure: Etiology and Risk Factors * Causes of MODS include: * dead tissue * injured tissue * infection * perfusion deficits * persistent sources of inflammation such as pancreatitis or pneumo nitis * High Risk for developing MODS : * Impaired immune responses such as older adults clients with chronic illnesses * clients with malnutrition * and clients with cancer * Clients with prolonged or exaggerated inflammatory responses are at risk, including victims of severe trauma and clients with sepsis * Multi Organ Failure: Classification * 1. Primary MODS – * results directly from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. â€Å" * The direct insult initially causes a localized inflammatory response that may or may not progress to SIRS. An example of primary MODS is a primary pulmonary injury, such as aspiration. * Only a small percentage of clients develop primary MODS. * Multi Organ Failure: Classification * 2. Secondary MODS * is a consequence of widespread systemic inflammation, which develops after a variety of insults, and results in dysfunction of organs not involved in the initial insult. * Th e client enters a hypermetabolic, state that lasts for 14 to 21 days.. * During this body engages in autocatabolism : which causes changes in the bodys metabolic processes. rocess can be stopped,. the outcome for the death. * Secondary MODS occurs with condition septic shock and ARDS. (Black,2005 , p2474) * Multi Organ Failure: Clinical Manifestations * There is usually a precipitating event to MOD: * aspiration, * ruptured aneurysm * Septic shock which is associated with resultant hypotension. * The client is resuscitated; the cause is treated; and appears to do well for a few days. * The following possible sequence of events often develops. * Multi Organ Failure: Clinical Manifestations The client experiences SIRS before MODS Within a few days * there is an insidious onset grade fever, tachycardia, increased numbers and segmented neutrophils on the different count (called a left shift), * dyspnea with the diffuse patchy infiltrates on the chest x-ray client * often has some deteri oration in mental reasonably normal renal and hepatic laboratory results * Multi Organ Failure: Clinical Manifestations * Dyspnea progresses, and intubation and mechanical ventilation are required. * Some evidence of agulopathy (DIC) is usually present. * The client is usually stable hemodynamically and has relative polyuria, n increased in cardiac index (greater than 4. 5 l/min), * Systemic vascular resistance of less 600 dynes cm-5 Clients often have increased blood glucose level in the absence of diabetes * Multi Organ Failure: Clinical Manifestations * Between 7 and 10 days: * Bilirubin level increases and continues to increase, followed serum creatinine. * Blood glucose and lactate level continue to increase because of the hypermetabolic state. * Other progressive changes include nitrogen and protein combined with decrease level of serum albumin, pre-albumin, and retinol binding protein * Multi Organ Failure: Clinical Manifestations Between 7 and 10 days * Bacteremia with enter ic organism is common and infection from candida viruses such as herpes and cytomegalovirus are common. * Surgical wound fail to heal, and pressure ulcer may develop. * During this time, the client needs increasing amounts of fluids and inotropic medications to keep blood volume and cardiac preload near normal and to replace fluid lost through polyuria * Multi Organ Failure: Clinical Manifestations * Between day 14 and day 21: * The client is unstable appears close to death. * The client may lose consciousness Renal failure worsens to the point needs dialysis. * Edema may he present because of low serum protein levels. * Mixed venous oxygen level may increase because of problems with tissue uptake of oxygen caused by mitochondrial dysfunction. * Lactic acidosis worsens, liver enzymes continue to increase, and coagulation disorders become impossible to correct. * Multi Organ Failure: Prognosis * If the process of MODS is not reversed by day 21, it is usually evident that the client w ill die. * Death usually occurs between days 21 and 28 after the injury or precipitating event. Not all clients with MODS die; however, MODS remains the leading cause of death in the intensive care unit with mortality rates from 50% to 90% despite the development of better antibiotics, better resuscitation, and more sophisticated means of organ support. * Multi Organ Failure: Prognosis * For those clients who survive, the average duration of intensive care unit stay is about 21 days. * The rehabilitation, which is directed at recovery of muscle mass and neuromuscular function, lasts about 10 months. * Multi Organ Failure: Medical Management * Restrain the Activators: Manifestations of potential infection must be quickly treated to restrain the activators of MODS. * If the agent is known, antibiotics to which the organism is sensitive should be administered. * If the organism is not -known, broad-spectrum antibiotics are given * If the severity of the sepsis is identified early and d rotrecogin alfa (Xigris) is ad ministered, progression to MODS may be prevented * Multi Organ Failure: Medical Management * If there is progression, the lungs are often the first organs to fail and so require special attention. Aggressive pulmonary care is needed in all clients who are at risk of MODS. * Interventions may be as simple as coughing and deep breathing or ambulation. * The clients oxygen saturation should be monitored as well. * Malnutrition develops from the hypermetabolism and the GI tract often seeds other areas with bacteria, some clinicians require the client to be fed enterally. * They believe that feeding enhances perfusion and decreases the bacterial load and the effects of endotoxins * Multi Organ Failure: Nursing Management Care of the client with MODS is multifaceted, balancing the needs of one system against the needs of another while trying to maintain optimal functioning of each system * Nursing diagnoses appropriate for the client with MODS * The number of independent nursing interventions for the client with MODS is limited. * Multi Organ Failure: Nursing Management * The overall goal for nursing is effective client and family coping: * Nurses must remain sensitive to the needs of the family. Caring for the family of critically ill clients is a challenge in that understanding, predicting, and intervening with families in crisis is less exact, than the calculation of oxygen needs. * There are no easy formulas to use to provide hope, courage, coping, and caring. * Nurses must remain alert to the needs of the family as well as the client during this stressful time. * B. Life saving and Intervention * Detailed discussion and return demo will be discussed on EDN and Vines laboratory. * 1. First Aid Measure * 2. Basic Life Support * 3. Advance Cardiac Life support * First aid measures Is an immediate care given to a person who have been injured or suddenly taken ill. * It includes self help and home care when medical assistance is delayed or not available. * Roles of First Aid: * Bridge that fills the gap between the victim and the physician. * It is not intended to compete with nor take the place of the services of the Physician. * It ends when medical assistan ce begins. * Basic Life Support ( BLS) * An emergency procedure that consists of recognizing respiratory arrest and cardiac arrest or both and the proper application of CPR to maintain life or until a victim recovers or advanced life support is available. C-A-B steps : * Circulation restored * Airway opened * Breathing restored * ADVANCE CARDIAC LIFE SUPPORT (ACLS) * Refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. [1] * ADVANCE CARDIAC LIFE SUPPORT (ACLS) * Extensive medical knowledge and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers * (e. g. hysicians, paramedics, nurses, respiratory therapists, clinical pharmacists, physician assistants, nurse practitioners * and other specially trained health care providers) can provide ACLS, as it requires the ability to manage the patie nts airway, initiate IV access, read and interpret electrocardiograms, and understand emergency pharmacology. * Fluid Resuscitation (Study) * The infusion of isotonic IV fluids to a hypotensive Pt with trauma; aggressive FR may disrupt thrombi, ^ bleeding, and v  survival * Intravenous literature: Boyd, J. H. , Forbes, J. , Nakada, T. A. , Walley, K. We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Principles of Management : Multi Organ Failure specifically for you FOR ONLY $16.38 $13.9/page Hire Writer R. and Russell, J. A. (2010) * Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical Care Medicine. 2010 Oct 21 * FLUID RESCUCITATION * Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or pathologic processes. * Fluids can be replaced via oral administration (drinking), intravenous administration, rectally, or hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously. * FLUID RESCUCITATION * Procedure * It is important to achieve a fluid status that is good enough to avoid oliguria (low urine production). * Oliguria has various limits, a urine output of 0. 5mL/kg/hr In adults is adequate and suggests adequate organ perfusion. * The parkland formula is not perfect and fluid t herapy will need to be titrated to hemodynamic values and urine output. * The speed of Fluid Replacement may differ between procedures. * The planning of fluid eplacement for burn victims is based on the Parkland formula (4mL Lactated Ringers/kg/% TBSA burned). * The parkland formula gives the minimum amount to be given in 24 hours. * Half of the value is given over the first eight hours after the time of the burn (not from time of admission to ED) and the other half over the next 16 hours. * In dehydration, 2/3 of the deficit may be given in 4 hours, and the rest during approx. 20 hours * FLUID RESCUCITATION The initial volume expansion period is called the fluid challenge, and may be distinguished from succeeding maintenance administration of fluids. During the fluid challenge, large amounts of fluids may be administered over a short period of time under close monitoring to evaluate the patient’s response. * Fluid challenge, as the procedure of giving large amounts of fluid in a short time, may be reserved for hemodynamically unstable patients, distinguished from conventional fluid administration for patients who are not acutely ill, who receive fluids as part of a diagnostic study, or for less acutely ill patients in whom fluid administration can be guided by fluid intake and output recordings. VARIOUS FLUIDS USED IN FLUID RESCUSITATION * Crystalloids are solutions of mineral salts or other water-soluble molecules. * we are talking about salt (saline) ; Since isotonic fluids have the same concentration as the normal cells of the body and blood, when infused intravenously, they will remain in the intravascular space. * Normal saline (0. 9% NaCl) and lactated Ringers solution are typical isotonic fluids with sugar in (dextr ose) * Hypertonic fluids –( 3% NaCl) have a higher particle concentration than in normal cells of the body and the blood. These agents draw fluid into the intravascular space from cells. * Hypertonic saline (3% NaCl) is a common hypertonic fluid. * Hypotonic fluids * (0. 45 normal saline, 0. 33 NaCl) are composed mostly of free water and will enter the cells rather than remain in the intravascular space. * Normal saline and lactated Ringers are the two balanced salt solutions most commonly used in current fluid resuscitation * Other products * Albumin, * one of the original plasma expanders, is a protein that maintains osmotic pressure in a cell and helps the cell maintain its internal fluid. When we read about protein in urine, especially in diabetics and those with kidney disease, we are talking about albumin. * Blood transfusion is the only approved fluid replacement capable of carrying oxygen * C. Life Maintaining Intervention * C. 1 AIRWAY MANAGEMENT By: Angkana Lurngnat eetape, MD. * Indication for tracheal intubation * ? Airway protection * ? Maintenance of patent airway * ? Pulmonary toilet * ? Application of positive pressure * ? Maintenance of adequate oxygenation * Oral endotracheal tube size guideline During Laryngoscopy ; Intubation * ? Malposition * – Esophageal Intubation * – Bronchial Intubation * ? Trauma * – Tooth damage * – Lip, tongue, mucosal laceration * – Dislocated mandible * – Retropharyngeal dissection * – Cervical spine * ? Aspiration * C. 2 Managing Patients on Ventilators Clinical Nursing Skills * By Sandra F. Smith * Managing Patients on Ventilators * Preparation: * Double check the ventilator settings against those ordered by the physician. * Plug the machine and turn it on. * Familiarize yourself with location of alarm system Connect the ventilator tubing to patient’s endotracheal tube or traheostomy tube * Procedure: * Monitor pt VS every 5 minutes until stable * Obt ain ABG 15 minutes after ventilation is established. * Monitor ventilation setting. * Check humidifier fluid level. * Records I and O and daily weight Positive pressure may cause positive water balance due to humidification of inspired air. * C. 3 Managing Patients on Ventilators * Suspend ventilator tubing from an IV hook or support it on a pillow to reduce traction on the endotrachael tube. Change ventilator tubing every 24 hours. * Check VS and auscultate lungs every hour. Rationale: Positive pressure ventilation may decrease venous return and cardiac output. * Observe and listen for possible cuff leaks around TT or ET. * Empty accumulated water on ventilator tubing. Disconnect tubing and stretch it to release water trapped into corrugated areas and drained to water basin DO NOT drain water back to humidifier. * Provide patient a method of communication. , such as magic slate. * Test nasogastric drainage pH every hour and administer antacid to maintain pH above 5. Test nasogastri c drainage and fecal matter daily for occult blood. * Assess lungs compliance * Implement methods of stress reduction. * Keep ventilators alarms on * C7 Fluid and electrolyte problems By Canthera Cancer Therapy Center * Fluid and electrolyte problems 1. Water retention * Water retention is simply the buildup of excess fluid in tissues. * Swelling of the feet, ankles and hands are generally the first sign of water retention. * But it can also affect other parts of the body such as the abdomen, chest cavity, face and neck. Possible causes include: * Certain medications (some chemotherapy drugs can cause water retention) * Heart, liver or kidney disease * Blockage of veins or lymph system * Fluid and electrolyte problems * Some symptoms to look for and report to your physician include: * Feelings of tightness in the arms or legs. * Difficulty fitting into clothing. * Rings, wristwatch or shoes fit tighter than usual. * Pitting of the lower legs and arms – when you press on your skin with your finger is there an indentation that remains for a few seconds. * A sense of heaviness or weakness in the arms or legs. Skin that feels stiff or taut. * Any redness, changes in skin temperature or pain in swollen areas can be a sign of infection and should be reported immediately. * Fluid and electrolyte problems * Things that you can do to help manage swelling are: * Do not stand for long periods of time. * When sitting or lying keep feet/legs elevated as much as possible. * Avoid tight clothing (including s ocks) * Do not cross your legs when sitting or lying. * Try to reduce your salt intake. Avoid foods that are high in salt content such as chips, tomato juice, cured meats, and canned soups. Weight yourself daily – a weight gain of 5 pounds or more in one week should be reported to the physician immediately. * If your physician has prescribed medications for your swelling take them exactly as prescribed. Do not reduce or increase the dose. * Treatment of fluid retention depends upon the underlying cause. Since some of the causes of water retention can be related to organ disease/damage and are potentially severe, it is important that you speak with your physician or nurse promptly if you are experiencing this problem. * Fluid and electrolyte problems 2 Electrolyte imbalance * Electrolyte imbalance could also be caused by * vomiting, * diarrhea, * sweating, * high fevers, * kidney disease, * medications unrelated to cancer therapy, * certain chemotherapy drugs such as Cisplatin and targeted therapies such as Erbitux. * Fluid and electrolyte problems * Because electrolytes regulate activity of nerves and muscles, their imbalance could lead to malfunctions in multiple organ systems. * It could cause : * muscle spasms, * weakness and twitching; * irregular heartbeat and blood pressure changes; * lethargy, * confusion, and neurological problems. * Severe electrolyte imbalance can result in death. Monitoring for electrolyte imbalance is a simple process and is accomplished through routine lab work. * Fluid and electrolyte problems * Treatment of electrolyte imbalance is based on identifying and treating the underlying problem causing the imbalance, * and actively correcting the imbalance itself. * Treatment may include intravenous replacement of fluids or electrolytes, dietary changes and/or oral replacement of a particular electrolyte. * Fluid and electrolyte problems * 3. Tumor lysis syndrome Tumor Lysis Syndrome is a serious and sometimes life-threatening c omplication of chemotherapy. * . It is caused by release of breakdown products from dying cancer cells and most frequently occurs in patients with leukemia or lymphoma that have a high tumor burden (large tumor). * Patients with pre-existing kidney disease are also at increased risk for this complication * Fluid and electrolyte problems * Symptoms of tumor lysis syndrome include: * Muscle weakness * Paralysis * Heart arrthymias * Seizures * Tetany * Changes in emotional stability * Decreased urine output Changes in electrolyte and uric acid levels. * Fluid and electrolyte problems * Treated prophylatically with hydration and medications which decrease uric acid levels like Allopurinol. * Treatment for tumor lysis is directed toward stabilizing electrolyte and uric acid levels. * Aggressive hydration with IV fluids and use of diuretics may be instituted. In some cases persons have undergone renal dialysis. * C8 NUTRITION BY Schumaker and Chernecky critical Care and Emergency Nursing * Energy expenditure during respiratory failure is high and is caused by the increased work of breathing. The goal of nutritional support is to provide the needed nutrients to maintain the patients current level of : * metabolism * energize the immune system * and maintain end-organ function. * NUTRITION BY Schumaker and Chernecky critical Care and Emergency Nursing * Enteral Gi feeding is the route of choice to provide the calories and nutrients needed and to assist in maintaining normal GI: function. * if the patient is unable to tolerate enteral feedings, then a parenteral (intravenous) route is necessary until the patient can tolerate enteral feedings. * Medical Management of the Client Receiving Parenteral nutrition by Joyce Black * Parenteral Nutrition (PN). PN is indicated to maintain nutritional status and prevent malnutrition when the client has inadequate intestinal function or cannot be fed orally or by . tube feeding. * The PN prescription is guided by the nutritional assessment and the definition of nutrient goals for calories. and protein. The PN solution contains carbohydrates' as glucose, fats, triglyceride, and protein as amino acid levels designed to meet the caloric and protein need of the client. * C 9 Perioperative Problems by Carl Balita, Nursing Review * D. Psychological and Behavioral Intervention * 1. Measure to relieve anxiety * 2. Fear * 3. Depression * 4. Critical concerns life: * a. Immobility * b. Sleep deprivation * c. Sensory overload * d. body image alteration * e. Grieving * f. sexuality * g. spirituality * Psychosocial and Behavioral Intervention http://www. uspharmd. com * Anxiety * Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. * Anxiety * Defining Characteristics Nursing Diagnosis Anxiety * Expressed concerns due to change in life events; * insomnia * Fear of unspecific consequences * Shakiness * Anxiety * Nursing outcome Nursing Care Plans For Anxiety: * †¢ Appear relaxed and report anxiety is reduced to a manageable level. †¢ Verbalize awareness of feelings of anxiety. †¢ Identify healthy ways to deal with and express anxiety. †¢ Demonstrate problem-solving skills. Use resources/support systems effectively. * Nursing Priority Nursing Care Plans   For Anxiety †¢ Assess level of anxiety †¢ Assist client to identify feelings and begin to deal with problems †¢ Provide measures to comfort and aid client to handle problematic †¢ To promote wellness; teaching/discharge considerations * Fear * Fear is a feeling of anxiety and agitation caused by the pr esence or nearness of danger, evil, pain, etc. ; timidity; dread; terror; fright; apprehension respectful dread; awe; reverence a feeling of uneasiness or apprehension; concern: * Interventions. The client needs an explanation of the disease and all treatment options. * Reinforce information to the client as needed. * The client also needs information concerning operative procedures and postoperative interventions (NPO status, NG tubes, other drains, intravenous infusions). * This information helps decrease the clients fear. * Understanding Depression by Health Guide . org * Feeling down from time to time is a normal part of life. But when emptiness and despair take hold and wont go away, it may be depression. * Common signs and symptoms of depression : * Feelings of helplessness and hopelessness. A bleak outlook—nothing will ever get better and there’s nothing you can do to improve your situation. * Loss of interest in daily activities. No interest in former hobbies, pastimes, social activities, or sex. You’ve lost your ability to feel joy and pleasure. * Appetite or weight changes. Significant weight loss or weight gain—a change of more than 5% of body weight in a month. * Sleep changes. Either insomnia, especially waking in the early hours of the morning, or oversleeping (also known as hypersomnia). * Common signs and symptoms of depression : * Irritability or restlessness. Feeling agitated, restless, or on edge. Your tolerance level is low; everything and everyone gets on your nerves. * Loss of energy. Feeling fatigued, sluggish, and physically drained. Your whole body may feel heavy, and even small tasks are exhausting or take longer to complete. * Self-loathing. Strong feelings of worthlessness or guilt. You harshly criticize yourself for perceived faults and mistakes. * Concentration problems. Trouble focusing, making decisions, or remembering things. * Unexplained aches and pains. An increase in physical complaints such as headaches, back pain, aching muscles, and stomach pain. Depression * Depression is a major risk factor for suicide. The deep despair and hopelessness that goes along with depression can make suicide feel like the only way to escape the pain. * Thoughts of death or suicide are a serious symptom of depression, so take any suicidal talk or behavior seriously * Depression * Intervention: * Lifestyle changes are not always easy to mak e, but they can have a big impact on depression. * Lifestyle changes that can be very effective include: * Cultivating supportive relationships * Getting regular exercise and sleep * Eating healthfully to naturally boost mood Managing stress * Practicing relaxation techniques * Challenging negative thought patterns * Critical Concerns life: * Immobility * Sleep Deprivation * Sensory overload * Body image deprivation * Grieving * Sexuality * Spirituality * Immobility * Immobility is complications that are associated with a limited or absolute lack of movement by the patient; various members of the health care team may collaborate to assist the patient in avoiding these problems. * Nurses must -Prevent the complications of immobility, such as :pneumonia , pressure ulcers, with frequent turning or the use of an oscillating bed. Intervention: * Continue to reposition the patient to relieve skin pressure unless the bed provides more, than 40 degrees of rotation. * The eyes may need to be taped closed to avoid corneal abrasion. * Suctioning may be needed to keep the airway clear and prevent pneumonia. * Passive range-of-motion exercises keep joints mobile and minimize muscle wasting. * Position the extremities in correct alignment to prevent contractures. * Use sequential compression stockings to prevent deep venous thrombosis (DVT); low-dose heparin may also be ordered. All these complications are continually assessed for and are treated promptly if they occur. * Sleep Deprivation Sensory overload * Sleep Deprivation is a sufficient lack of restorative sleep over a cumulative period so as to cause physical or psychiatric symptoms and affect routine performances of tasks. * Sensory overload is a condition in which an individual receives an excessive or intolerable amount of sensory stimuli, as in a busy hospital or clinic or an intensive care unit. * Sleep Deprivation Sensory overload * Sleep deprivation is of particular concern for clients in critical care units. Causes of the following: * The noise level * 24-hour lighting * and frequency of caregiver interruptions create sensory overload and sleep deprivation, which is thought to be a major factor contributing to postoperative psychosis (Joyce Black) * Sleep Deprivation * Causes: * Clients who have had surgery are also at risk for sleep pattern disturbance because of disruptions in circadian rhythms. * The cause is unclear, but the disruptions may be related to the length and type of anesthesia, postoperative analgesia, or mechanisms associated with the procedure itself. * Sleep Deprivation Techniques used to promote sleep include : * massage * relaxing music * progressive relaxation techniques * Medications to promote sleep * Body image deprivation * Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. * This attitude is dynamic and is altered through interaction with other persons and situations and influenced by a ge and developmental level. * As an important part of one’s self-concept, body image disturbance can have profound impact on how individuals view their overall selves. * Body image deprivation In cultures where one’s appearance is important, variations from the norm can result in body image disturbance. * The importance that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. * Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. * Body image deprivation * The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting from bowel or bladder surgery, and head and neck resections are other examples that can le ad to body image disturbance. * Body image deprivation * Defining Characteristics: Verbalization about altered structure or function of a body part * Verbal preoccupation with changed body part or function * Naming changed body part or function * Refusal to discuss or acknowledge change * Focusing behavior on changed body part and/or function * Actual change in structure or function * Refusal to look at, touch, or care for altered body part * Change in social behavior (e. . , withdrawal, isolation, flamboyance) * Compensatory use of concealing clothing or other devices * Body image deprivation * Therapeutic Interventions * Acknowledge normalcy of emotional response to actual or perceived change in body structure or function. Stages of grief over loss of a body part or function is normal, and typically involves a period of denial, the length of which varies from individual to individual. * Help patient identify actual changes. Patients may perceive changes that are not present or rea l, or they may be placing unrealistic value on a body structure or function. Encourage verbalization of positive or negative feelings about actual or perceived change. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth. * Body image deprivation * Therapeutic Interventions * * Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation. * Demonstrate positive caring in routine activities. Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities. * Body image deprivation * Education/Continuity of Care * Teach patient about the normalcy of body image disturbance and the grief process. * Teach patient adaptive behavior (e. g. , use of adaptive equipment, wigs, cosmetics, clothing that conceals altered body part or enhances remaining part or function, use of deodorants). This compensates for actual changed body structure and function. Help patient identify ways of coping that have been useful in the past. Asking patients to remember other body image issues (e. g. , getting glasses, wearing orthodontics, being pregnant, having a leg cast) and how they were managed may help patient adjust to the current issue. * Body image deprivation * Education/Continuity of Care * * Refer patient and caregivers to support groups composed of individuals with similar al terations. Lay persons in similar situations offer a different type of support, which is perceived as helpful (e. g. , United Ostomy Association, Y Me? , I Can Cope, Mended Hearts). http://nursingcareplan. blogspot. com * Grieving by Carl Balita * Sexuality * Sexuality. Sexuality is the behavioral expression of ones sexual identity. * It involves sexual relationships between people as well as the perception of ones maleness or femaleness (gender identification). * Sexuality * Many aspects of sexuality affect health status and are significant to nursing care and client outcomes. * * Aspects include: * (1) physical health problems that affect sexual behavior * (mastectomy, colostomy, skin lesions, venereal diseases, paralysis, physical deformities) * (2) concerns with sexual performance (impotence, premature ejaculation, inability to achieve orgasm, infertility), * (3) issues of sex role function * (homosexuality, bisexuality, sexual ambiguity, transsexual surgery), and * (4) effects of environmental restrictions on sexual performance * (residency in a longterm care facility). * Sexuality * Sexuality and sexual behavior are sensitive topics. * Clients may want to discuss sexuality issues and may look for permission to do so. * Become comfortable with sexuality issues and do not allow personal beliefs and values to interfere with professional care. Accept and interact with clients without judging them or their behavior. * Spirituality * Spiritual beliefs have implications for well-being, such as sustaining hope or assisting with coping during periods of stress. * Include spirituality assessment as part of the, health history and explain the purpose for asking about it * Spirituality * . This portion of the history is usually addressed at the end of the interview after a trusting nurse-client relationship is established. * Because spirituality is personal, respect a clients wishes not to discuss this topic. Ask whether the client prefers to consult someone else wh en spiritual support is needed. * Spirituality * Nurses may be aware that patients have spiritual needs, but in many cases are unable to respond to these needs. * This may result from an inadequacy in nurse education that does not prepare nurses to provide spiritual care. (Michelle Wensley, 2011) * Supportive Management * Supportive Management * (Discussed already on MODS = Medical and Nursing Management on the previous slides) * Preventing Complications * Preventing ICU Complications * Lee-lynn Chen, MD * Assistant Clinical Professor Catheter Related Blood Stream Infection * CRBSI Prevention Bundle : * Hand hygiene * Maximal barrier precautions (mask, gown, gloves and full barrier drapes) and full barrier drapes) * Chlorhexidine skin antisepsis * Optimal catheter site selection, with subclavian vein as the preferred site for non non-tunneled tunneled catheters in adults * Ultrasound guidance * Daily review of line necessity with prompt removal of unnecessary lines * Ventilator Asso ciated Pneumonia * A leading cause of death among hospital acquired infections * Increased length of time on ventilator, in both the ICU and hospital. Estimated cost is $40,000 (2004) * Continuous Aspiration of Subglottic Secretions * Requires intubation with special tube * Separate dorsal lumen that opens in to subglottic area * Aspiration may be continuous or intermittent * Requires frequent monitoring * Pressure Ulcers * Incidence and Cost * Incidence ranging from 0. 4% to 38% * 2. 5 million patients treated annually in US acute care facilities for pressure ulcers related complications * Once pressure ulcer develops, mortality is increased by 2-6 fold with 60,000 deaths * Total annual cost $11 billion * Pressure Ulcers Definition: Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear or friction. * Identifying patients at risk and identifying early skin changes can allow early intervention to pr event a pressure ulcer from developing * Pressure Ulcers: Sites * Sacrum -most common site (30%)Slouching in bed or chair * Higher risk in incontinent pts * Heels-2ndmost common (20%)Immobile or numb legs * Higher risk with PVD diabetes neuropathy * Trochanter * Device related * Minimize pressure * Frequent small position changes (every 1. to 4 hrs) * Keep reclining chair and bed below 30 degree angle to decrease pressure load * Sitting: may need hourly position changes * Increase mobility/Consult PT/OT * Order air mattress if turning protocols are ineffective * Reposition off of any know ulcers * Use pillows to pad bony prominences * Float heels with pillow lengthwise under calves * Minimize friction and shear * Use draw sheet under patient to assist with moving * Do not drag over mattress when lifting up in bed * Avoid mechanical injury-use slide boards, turn sheet, trapeze, corn starch * Manage Moisture Cleanse skin at time of soiling and use absorbent * Provide a non-irritating surface * Barrier ointments and pads * Utilize appropriate fecal/urinary collection devices * Nutrition/hydration * Skin condition reflects overall body function * Skin breakdown may be evidence of general catabolic state * Increase hydration caloric needs * Nutritional goals: ^protein intake1. 2-1. 5 gm/kg body weight daily—unless contraindicated * Consider vitamin supplementation * Rehabilitation * Rehabilitation will be properly coordinated with the Physical Therapy Department