Show how the provision of education before 1833 Essay Example for Free

Show how the provision of education before 1833 Essay Show how the provision of education before 1833 depended upon personal wealth. Education before 1833 did depend upon personal wealth along with other factors, (fully explained later on. ) Different classes of people attended different types of schools, and the costs that the schools charged would have a great impact on the types of people attending them. A governess would look after the wealthy children, and the boys governess would be replaced by a tutor, until they were old enough to attend school. This tutor would teach Greek and Latin. But in order for the boys to be taught mathematics, and French a visiting master must be hired. The girls, on the other hand, were taught accomplishments, which included music, drawing and dancing. The womens role was to be elegant and to entertain as a wife, not to be educated and working outside of the home. This was where the education stopped for the females; though, the upper class young boys went on to attend a public school, such as the ones at Eton, Harrow and Winchester, which taught classics, such as Latin and Greek, classical History and sport. Though these schools were well known for bullying, including fagging, strict corporal punishments and really bad teaching. These types of schools were very inefficient, and many parents knew these schools taught mainly manly habits, such as fighting and bullying. There was a range of schools for middle class children depending on the wealth of their families. Upper middle class children (still of wealthy parentage) would attend a private school; these were for mainly boys though some girls did attend these types of schools. The boys would be taught Classics and Maths, and the girls would be taught manners, singing, dancing, painting and embroidery. These were usually boarding schools, though the same types of subjects were taught, these would have been the cheaper of the two schools. Another middle class school was the grammar schools, to attend these schools you must have been followers of the Church of England, a protestant, Christian. These schools were for only boys and taught Classics, Maths and following later Languages. Grammar schools were usually in wealthy towns such as Wolsingham, Bishop and Durham (at the time,) these were for only for middle class children. Another type of school only for middle class children were the dissenting academies, these only taught none Church of England children, but again only took boys. These dissenting academies had the most up to date curriculum, teaching Maths, Science, Geography, Languages and accounting. These schools were the best at the time, and were highly popular among the middle classes. Charity schools were aimed at the lower middle classes, and/or working class children. Few of these schools did give working class children a proper education. (Internet. ) These schools were for the male and female children. They taught the three Rs, Religion, Crafts (Weaving and shoe making. ) These were only very small schools, charging small fees, but to the parents paying them these fees would seem extremely high. These schools were usually in villages such as Willington, the average pay a week for a typical working class person is around 10d, and out of this 2d would be spent on a Childs education. This is an extremely high proportion. The last school that is aimed at lower middle class children or working class children are the dame schools. These taught Reading, sewing, knitting or nothing. These kinds of schools were more of a child minding service rather than a school, and what was taught depended upon the person that ran the school. Its not much they pay me, so its not much I teach them. One Dame said (Culpin) Without wealth, to pay for an education, children werent educated enough to get good jobs, these children ended up down the pit. Not surprisingly most of these children were lower or working class children. People needed money to get an education, if they didnt get an education they would end up with a bad paying job, going nowhere in life. As Ive already said, it isnt the only factor though; Wealth is probably the largest factor, though as you can see males had a much better, fuller education than the females. And religion also determined what type of school you attended in these times. Of course personal wealth determined what type of school a person attended, though so did other factors. But to me the best type of schools at the time were the dissenting academies, though these were for the middle classes.

Implementing an Electronic Health Record System

Implementing an Electronic Health Record System Implementing Electronic Health Record System Based on HL7 RIM -Reusing the RIM Model Archetypes Nancy Mittal Abstract: It is difficult to exchange healthcare information between different HealthCare Systems. Health Level Seven is a universal standard to facilitate the communication between different HealthCare Systems. Electronic Health Record System is a software platform that store patient health data which maintained by hospital and medical practice. Health Level 7 Reference Information Model was studied to provide the interoperability between different HealthCare Systems. In this paper, we studied about the various version of Health Level Seven standard including HL7 v2.x, HL7 v3.0, HL7 RIM. This paper focused on how the existing structure of HL7 is improved by reusing the HL7 RIM classes such as Act, Role, and Entity etc each are associated with set of attributes. It explains to modify the existing structure of HL7, need to modify the HL7 RIM because HL7 RIM model provide the structure of HL7. This paper also explained the role based queries are performed by the interested stakeholders like pati ents, doctors and hospitals. In this new structural form, role based information is maintained in the centralize database. This research fills the gap between skilled and semi-skilled users and query is performed on role base. Keywords: HL7, RIM, Role, Archetypes 1. Introduction: With the continuous development of health records, maintain and exchange the information in different HealthCare systems has become unavoidable. So, the communication between different hospitals or between different HealthCare system need to improved. Electronic Health Record is a repository of health information in a digital format about an individual patient or population managed by hospitals or medical practice that shared across different HealthCare Systems. It reduces the chances of data replication. More organizations adopt EHR; physicians, nurses and clinicians have greater access to patient information which helps in accurate diagnosis and complete data helps to ensure the best possible care. Electronic Health Record (EHR) system is needed to focus on two requirements: dynamic involvement of different hospitals, patients and HealthCare Systems And the way of maintaining the information. Standard compliant EHR provide facility of communication and to exchange information of patients between different hospitals, doctors, HealthCare systems. Each patient has his own queries respective to their role in the system. The query interface is designed to provide the effective knowledge among different kind of patients, hospitals. Health Level Seven: Heath Level Seven is a standard developing organisation accredited by ANSI (American National Standard Institute) founded in 1987. HL7[1] name refers the top layer of the OSI (Open System Interconnection) layer protocol for the health environment. HL7 specifies a number of various standards health information and also provide communication between different HealthCare System. Standard are the set of rules that allow information to be shared in standardized and reliable manner. HL7 messaging standard: There are two main HL7 messaging standard HL7 v2.x and HL7 v3.0. HL7 v2.x is also called as pipe hat. This standard provides the interoperability specification for health and medical transaction. HL7 v2.x message format are in human readable ASCII and non XML encoding syntax. It supports administrative, logistical, financial as well as clinical messages. HL7 v3.0 provides the interoperability specification for health and medical transaction based on RIM (Reference Information Model). HL7 v3.0 message format based on XML encoding syntax and also on HDF (formal methodology) and object oriented principle. It supports only clinical data. Movement from HL7 v2 to HL7 v3 is that v3 would be model driven methodology means v3 standard support healthcare workflows through modelling; the end result maximize reuse and increase consistency in HL7 specification. Another[2] HL7 v2.7 supports all HealthCare department data for exchange between different HealthCare systems. It reduces the custom interface programming. But it is not plug and play; and not support transaction processing feature. Table1.Difference between HL7 v2.x and HL7 v3.0 HL7 RIM[3] (Reference Information Model): The HL7 Reference Information Model provides the structural information of HL7 in the form of information classes. HL7 RIM is an object oriented model to make compatible the HL7 specification interoperability to all domains. It is important part of the HL7 v3.0 development model. It increases precision and reducing implementation costs. HL7 RIM is based on UML (Unified Modelling Language). Reference information model has five components: Subject Area (major part of am model), class (about which information is collected), Relationship (relation between classes), attribute (information about class), and data type (specification of the format of an attribute). RIM has six main important classes: Act- It represents actions that are executed by entity. Entity: These are the physical things that take part in health care. Role: Role that entity plays as they participate in health care Participation: It represent context for an act such as who perform, for whom and where. ActRelationship: It represents the relationship between actions. RoleLink: It represents the relationship between roles. 2. Related Work: Electronic health record system based on health level seven, and HL7 used to provide the communication between different HealthCare systems, most of the research studies show perplexing which is further discussed in this paper review. Tung Tran, Hwa-Sun Kim[[1]] studied the research on,†A Development of HL7 Middleware for Medical Device Communication† to developed HL7 compliant middleware. Researcher used HL7 as a middleware to facilitate data transfer to information system in hospitals. Middleware has capability of receiving data from monitoring device and converting into HL7 data type format. It receive raw data from medical devices and convert to HL7 data and passed to HIS based on HL7 interface engine. Li-Fan Ko, Jen-Chiun Lin, Chi-Huang Chen, Jie-Sheng Chang, Faipei Lai[[2]] concluded the research on,†HL7 Middleware Framework for Healthcare Information System. Researchers introduce HL7 and web services standard into framework which is basically Service Oriented Architecture (SOA). HL7 directly transmitted data over transport layer protocol TCP/IP: for small application HL7 message over TCP are simple and easy to implement; for larger application, system become complex and attacker increases. This research solved that problem by introducing web services which provide interoperation between software systems. Jennifer Munnelly[[3]] in his research study on, HL7 Healthcare Information Management Using Aspect-Oriented Programming focused the modification in application department without the requirement modification into complete structure by using HL7.Researcher suggested introduce HL7 functionality into exiting application without any modification through AOP. Wooshik Kim[[4]] studied the research on, Integration of IEEE 1451 and HL7 Exchanging Information for Patients’ Sensor Data showed the IEEE 1451 concerned with smart transducer and having plug –play capabilities. Patients wear sensors that measure the patient’s status in real time and transmitted these data to remote sites such as hospital. HL7 accepted this kind of data and interpreted with various online sensor data. Pasquale De Meo[[5]] studied on, Integration of the HL7 Standard in a Multiagent System to Support Personalized Access to e-Health Services. In this paper, he presented a system which has multi agents to maintain patients in seek of health related services in e-health care by using various algorithms PPB, DS-PPB, AB. This proposed system increases the quality service and effectiveness. Maqbool Hussain[[6]] concluded his research on, Healthcare Applications Interoperability through Implementation of HL7 Web Service Basic Profile studied all phases of web service component that implement HL7 Web Service Basic Profile. It is branch of the transportation subsystem progressed at NUST School of Electrical Engineering and Computer Science, Pakistan. Naeem Khalid Janjua[[7]] in research study presented work on, Digital Health Care Ecosystem: SOA Compliant HL7 based Health Care Information Interchange and proposed Service Oriented Architecture (SOA) based HL7 system design for patient information and showed the translation from HL7 V2 to V3 and mapping between database and user query. Sara Gaion[[8]] researched on, Design of a Domain Model for Clinical Engineering within the HL7 Reference Information Model. This paper develop a DIM (Domain Information Model) by providing the HL7 RIM to clinical engineering in a particular domain. This paper represent clinical engineering information in the HL7 RIM (Reference Information Model) with the reason of developing a HL7 v3 RIM model based on DIM (Domain Information Model) dedicated to CE(Clinical Engineering) by reuse of standard healthcare information models and show the process of repairing and maintenance of device used in hospital. N.A. Mamani Macedo[[9]] studied the research on, Electronic Health Record: Comparative Analysis of HL7 and Open EHR Approaches. This paper showed the comparison between HL7 and openEHR to automatism a Patient’s Record in any hospital which adopted: HL7 and OpenEHR. The method includes analyzing each way, defining some criteria of evaluation, design a comparative chart. 3. Design model: The work is defined with the specification of the hospital and the relative attributes and the functional specification. It defines the role and requirement to specify the functional dependencies and its requirements. The role is defined for all the interested patients and hospitals and all interested users are connected to it along with their specified roles. The hospital is responsible for the information updating as well as to generate the query that queried by patients to obtain the information access about the patient, disease or diagnose. Complete information is defined in the form of centralized repository. Model is in the form of a query interface in which the communication to the system and different hospitals maintain the information in different way so that the mapping is required between the query set and the hospitals. To establish this mapping, the structural constructs for the system are defined so that the functional based information transition will be take place. Steps in implementation model First step is role identification and analysis: Users in this system are patients and hospitals(health organization). Role is defined for all the interested users ,patients and hospitals and they are coonnected to it along with their hospitals. Second step is role specific query generation: Hospitals is reasponsible for the information updating as wel as to generate the query that queried by patients to obtain the information access about the patient,disease and diagnose. Third step is query filteration and mapping done by RIM model: Complete information is defined in the form of centralized dataset.Model in the form of query interface in which the communication to the system and diff hospitals maintain the information in diff way. So that mapping is required between query set and hospitals. Last step query result are extraced. 4. Conclusion: In changing the structure of HL7 and increasing the reusability over existing HL7 RIM model by reuse the RIM model archetypes. HL7 standard facilitate to exchange and sharing the healthcare information among different hospitals or in between different healthcare systems. We concluded that we extract the existing HL7 RIM model and improve the reusability over existing model by reusing the classes of RIM model and implement the user interface to accept request from different users and process the role base Queries. References: [1] Health Level Seven (HL7), http://www.hl7.org. [2] Explorative study of healthcare data Interchange standards [3]http://www.openhre.org/local/rim202/rim.htm#Acts-sbj [[1]] Tung, Kim, Cho,† A Development of HL7 Middleware for Medical Device Communication†, Fifth International Conference on Software Engineering Research, Management and Applications [[2]] Li-Fan Ko, Jen-Chiun Lin, Chi-Huang Chen, Jie-Sheng Chang, Faipei Lai,† HL7 Middleware Framework for Healthcare Information System†. Basically framework is service oriented architecture (SOA)†. [[3]] Jennifer Munnelly, HL7 Healthcare Information Management Using Aspect-Oriented Programming, International Symposium on Computer-Based Medical Systems, pp 1 – 4 ¸2009 [[4]] Wooshik Kim, Integration of IEEE 1451 and HL7 Exchanging Information for Patients’ Sensor Data, J Med Syst, pp 1033–1041, 2010 [[5]] Pasquale De Meo, Integration of the HL7 Standard in a Multiagent System to Support Personalized Access to e-Health Services, IEEE Transactions on Knowledge and Data Engineering, pp 1244 1260, 2011 [[6]] Maqbool Hussain, Healthcare Applications Interoperability through Implementation of HL7 Web Service Basic Profile, Sixth International Conference on Information Technology: New Generations, pp 308 313 ¸2009 [[7]][7] Naeem Khalid Janjua, Digital Health Care Ecosystem: SOA Compliant HL7 based Health Care Information Interchange, 3rd IEEE International Conference on Digital Ecosystems and Technologies, pp 329 – 334, 2009 [[8]] [8] Sara Gaion, Design of a Domain Model for Clinical Engineering within the HL7 Reference Information Model, IEEE Workshop on Health Care Management, pp 1 6 , 2010 [[9]] N.A. Mamani Macedo, Electronic Health Record: Comparative Analysis of HL7 and Open EHR Approaches, Pan American Health Care Exchange, pp 105 – 110, 2010

Client Directed Outcome Informed Therapy (CDOI) Analysis

Client Directed Outcome Informed Therapy (CDOI) Analysis Taryn Slaughter Throughout the years, therapies have transitioned through different theories of change, model development and extensive research. For decades evidence based models of therapy were argued to be the best treatment for clients. Whilst therapy programs continued and expanded the rates of success did not. Slowly the perception of traditional models and treatments began to change and therapists began looking for alternatives to best suit the needs of their clients. Gradually the roles of therapist and client have changed and the client now has more involved in their treatment process. The client is no longer just a recipient of treatment; they are a partner in the planning, implementing and the outcomes. This essay will describe client directed outcome informed therapy and how it benefits clients with consistent positive treatment outcomes. The concept of Client Directed Outcome Informed therapy (CDOI) was developed through collaboration between Scott Miller and Barry Duncan (Duncan, Miller Sparks, 2004). After reviewing years of outcomes research, CDOI therapy was created in an attempt to meet the needs of individuals who had not responded to traditional models of therapy (Duncan, Miller Sparks, 2004; Duncan Moynihan, 1994). Through further studies and collaborations other forms of outcome and client directed models emerged. These other forms of therapy have been called Feedback Informed Therapy (FIT) and Partners for Change Outcome Management System (PCOMS) (Miller, Duncan, Sorrell Brown, 2004). All three forms of therapy focus on the same principle of providing treatment for clients that is best suited to their individual needs. CDOI therapy has no fixed treatment, model, practice or intervention. The client directed aspect of CDOI therapy ensures that the differences between individuals are understood (Duncan, Miller Sparks, 2004). Practitioners performing CDOI therapy with clients acknowledge that each individual is different by structuring treatments to meet the needs of each client (Duncan Moynihan, 1994). The process of structuring treatment for each individual requires an understanding of the client’s strengths weaknesses and resources to obtain the best possible outcome (Norcross Wampold, 2010). Once these are understood, the client and therapist are then able to outline the desired goals of the client and implement treatments best suited to the client. The relationship between client and therapist enables the process of establishing goals and treatment options in any therapy. The relationship (or alliance) is built early in the initially stages of therapy (Barber, Connolly, Crits-Christoph, Gladis, Siqueland, 2000). The strength of the alliance is determined on the ability of the client and therapist to work together in a mutually respective, trusting and supportive environment (Klee, Abeles Muller, 1990). A therapist must be able to overcome any early resistance to therapy or formation of alliance to ensure the treatments being provided will meet the needs of the client. Research has shown that the strength of the alliance is a significant indicator to the outcomes of treatment. A meta-analytical review conducted by Martin, Garske and Davis (2000) examined a number of studies which observed alliance and outcomes of treatment. It was found that the alliance formed between therapist and client was the most significant indicator of outcome. These findings are consistent with the other alliance focused research (Klee, Abeles Muller, 1990; Krupnick et al., 1996; Meier, Barrowclough Donmall, 2005) which shows that a strongly built alliance results in more positive outcomes then those client/therapist relationships with inconsistent or weakly formed alliances. The outcome informed aspect of CDOI therapy involves the process of compiling feedback throughout treatment. This process provides indicators on whether the selected treatment is affective for the client and meeting their needs (Duncan, Miller Sparks, 2004). A number of studies have shown the effectiveness of ongoing feedback between counsellor and client and positive outcomes of treatment (Claiborn, Goodyear Horner, 2001; Lambert Shimokawa, 2011). Therapists can use the information gathered through feedback to either continue with current treatments or make adjustments where required to continue to work towards treatment goals (Duncan, Miller Sparks, 2004). The most important aspect of this process is that the client is the one expressing how the treatment is working for them, maintaining to the principle of CDOI therapy. There are many different terms used in professional practise when collecting feedback. There are also a number of different methods used when compiling information transmitted between therapist and client. In CDOI and other client and outcome focused therapies many therapists use the Outcome Ratings Scale (ORS) and Session Rating Scale (SRS) (Miller, Duncan, Sorrell Brown, 2004). Both scales allow the therapist to gain an understanding on the level of alliance formed and the success of the treatment being utilised. Consistent feedback from the client ensures that the alliance is still strong and the treatment is being effective in reaching the clients goals (Shaw, 2014). Other models of treatment and therapies such as Counselling and Medical models have more specific structures and guidelines. These models of therapy use the process of diagnosing a problem and then utilising a specific therapy to treat that problem (Mozdzierz, Peluso Lisieki, 2011). Through evidence based practise, problems and therapies are linked together from previous studies and research in the areas where there have been previous successful outcomes. Therapies such as Cognitive Behaviour Therapy (CBT) are linked with previous results in treating diagnosed disorders such as anxiety and depression (Butler, Chapman, Forman Beck, 2006; Tolin, 2010). These therapies are classified under the medical model of treatment and would be used by therapists after diagnoses of anxiety or depression has been made. The difference between these models and the CDOI therapy model is that there is no distinct diagnoses and treatment structure. Each client is evaluated on their own strengths, weaknesses and ideas about treatment. Goals and treatment options are set by both the client and the therapist to ensure all needs of the client are being met, not just the symptoms of a disorder that may be present resulting in a diagnoses (Duncan, Miller Sparks, 2004). Other models of therapy are more restricted in the types of treatments provided and do not allow for individual characteristics of each client. When adopting the CDOI method there is no need to completely discard other models such as the Counselling Model of treatment. CDOI therapy can draw from these different models and modify the structure to suit the client, instead of following the guidelines that may not be appropriate in every case (Duncan Moynihan, 1994). There have been many cases of successful outcomes for clients using evidence based therapies in the past (Butler, Chapman, Forman Beck, 2006; Tolin, 2010). However CDOI therapy is an alternative to these therapies that can be structured to meet the needs of any client by minimising the risk of negative outcomes. There are a number of strategies that can be used by a professional counsellor to improve their outcomes when using CDOI therapy. The importance of alliance between client and therapist has been proven to be a significant indicator of outcome. To build an alliance a professional needs to build a strong, safe and trusting relationship with the client (Norcross Wampold, 2010). A professional counsellor needs to understand the processes involved to build and maintain a strong alliance throughout treatment. Building strong interpersonal skills is one way a professional can achieve a strong alliance. To assess interpersonal skills, a professional can use the Social Skills Inventory (SSI) and the Facilitative Interpersonal Skills (FIS) Performance task questionnaires (Anderson, Ogles, Patterson, Lambert Vermeersch, 2009). These questionnaires measure social and emotional aspects of individual’s interpersonal skills. These aspects are important in building a successful alliance between professional and client which has shown to be a strong indicator of positive outcome. Building on interpersonal skills can be achieved through continuing regular training and education. By continuing education, a professional counsellor can remain current with ongoing research, therapies and treatments and build on existing skills (Norcross Wampold, 2011). By utilising further education a professional can use new ideas to improve outcomes in future cases. One other strategy relates to the feedback process between therapist and client. A successful indicator of outcome, the feedback process is important (Claiborn, Goodyear Horner, 2001). A professional counsellor needs to use a simple and quick system of collecting feedback so that the process doesn’t become overwhelming for the client (Lambert Shimokawa, 2011). This process can only lead to positive outcomes for the professional and client. Conclusion- No one model has proven superiority over another References Anderson, T., Ogles, B M., Patterson, C. L., Lambert, M. J., Vermeersch, D. A. (2009). Therapist Effects: Facilitative Interpersonal Skills as a Predictor of Therapist Success. Journal of Clinical Psychology, 65(7), 755-768. Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., Siqueland, L. (2000). Alliance Predicts Patients’ Outcome Beyond In-Treatment Change in Symptoms. Journal of Consulting and Clinical Psychology, 68(6), 1027-1032. doi: 10.1037/0022-006X.68.6.1027. Butler, A. C., Chapman, J. E., Forman, E. M., Beck, A. T. (2006). The empirical status of cognitive-behavioural therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. doi:10.1016/j.cpr.2005.07.003. Claiborn, C. D., Goodyear, R. K., Horner, P. A. (2001). Feedback. Psychotherapy:Theroy, Research. Practise, Training, 38(4), 401-405. doi:10.1037/0033-3204.38.4.401. Duncan, B. L., Miller, S. D., Sparks, J. A. (2004). The Heroic Client. A revolutionary way to improve effectiveness through client-directed, outcome informed therapy. Sanfrancisco, California: John Wiley Sons. Duncan, B. L., Moynihan, D. W. (1994). Applying Outcome Research: Intentional Utilization Of The Clients Frame Of Reference. Psychotherapy, 31(2), 294-301. doi: 10.1037/h0090215. Johnson, L., Brown, J., Anker, M. Becoming Outcome Informed. In Duncan, B. L., Miller, S. D., Sparks, J. A. (2004). The Heroic Client. A revolutionary way to improve effectiveness through client-directed, outcome informed therapy (pp. 81-118). Sanfrancisco, California: John Wiley Sons. Klee, M. R., Abeles, N., Muller, R. T. (1990). Therapeutic Alliance: Early Indicators, Course and Outcome. Psychotherapy: Theory, Research, Practise, Training, 27(2), 166-174. doi: 10.1037/0033-3204.27.2.166. Krupnick, J. L., Sotcky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., Pilkonis, P. A. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal Of Consulting And Clinical Psychology,64(3), 532-539. doi: 10.1037/0022-006X.64.3.532. Lambert, M. J., Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48(1), 72-79. doi:10.1037/a0022238. Martin, D. J., Garske, J. P., Davis, M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytical review. Journal of Consulting and Clinical Psychology, 68(3), 438-450. doi: 10.1037/0022-006X.68.3.438. Meier, P. S., Barrowclough, C., Donmall, M. C. (2005). The role of the therapeutic alliance in the treatment of substance misuse: a critical review of the literature. Addiction, 100(3), 304-316. doi: 10.1111/j.1360-0443.2004.00935.x Miller, S. D., Duncan, B. L., Sorrell, R., Brown, G. S. (2004). The Partners for Change Outcome Management System. Journal of Clinical Psychology, 61(2), 199-208. doi: 10.1002/jclp.20111. Mozdzierz, G. J., Peluso, P. R., Lisieki, J. (2011). Evidence-Based Psychological Practices and Therapist Training: At the Crossroads. Journal of Humanistic Psychology, 51(4), 439-464. doi:10.1177/0022167810386959. Norcross, J. C., Wampold, B. E. (2010). What Works for Whom: Tailoring Psychotherapy to the Person. Journal of Clinical Psychology, 67(2), 127-132. doi. 10.1002/jclp.20764. Norcross, J. C., Wampold, B. E. (2011). Evidence based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98-102. doi: 1037/a0022161. Shaw, S. W. (2014). Monitoring Alliance and Outcome with Client Feedback Measures. Journal of Mental Health Counselling,36(1), 43-57. Tollin, D. F. (2010). Is cognitive-behavioural therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30(6), 710-720. doi:10.1016/j.cpr.2010.05.003.

Looking at the opening scenes Of Mice and Men. :: English Literature

Looking at the opening scenes Of Mice and Men. The scene opens on George and Lennie's feet running through the grass, the grass is dripping wet with dew and whipping their feet as they run. Their shoes are old and tattered as if they have not been able to afford new ones for a very long time. Through the silence you can hear the beating of Lennies heart, he can sense the fear in George and this makes him panic as well, rapid music gradually joins in with the beating of his heart. The camera slowly drifts up George's body, it is out of focus slightly, as it gets to the face it gradually gets back into focus and you can see the sheer terror on his face. His eyes are moving from side to side, scouting the area for anybody that poses a threat. It suddenly switches to a flashback. We open in the middle of a field , for miles all you can see is red poppies, swaying in the gentle breeze, the camera slowly starts to rotate to show that the field is empty. As it gets back to where it started from a young pretty girl appears, she has a dreamy expression on her face as if she is thinking of something, we are left guessing at what it is. She gently plucks one of the poppies out and tenderly peels off the petal's one by one, while she continues to do this she starts to stroll towards the camera, the camera focuses on Lennie in the distance. There is an expression of curiosity on his face, his eyes are very wide and his head is a little tilted to the side. He starts to walk very slowly towards her; still with the same curious expression upon his face. The music is slow and calm; suddenly Lennie's expression changes it becomes more determined and eager to capture a closer glimpse, his pace picks up and so does the music, it becomes more rapid and dramatic. As soon as Lennie reaches the girl, the music stops, she is humming and gazing up at the sky looking as if she doesn't have a care in the world. You can hear her breathing getting g slow and shallow as Lennie runs his fingers through the soft material of her dress, it slips through his fingers like water. She withdraws a deep gasp of air. The scene changes to a farmyard full of young men , whistling and laughing with each other; suddenly, an ear-piercing scream echoes around the small farmyard, birds fly from all the near by trees, and

Forty Years in the Wilderness Essay -- Personal Narrative Nature Essay

Forty Years in the Wilderness Clouds of dust billowed behind our jeep like a filthy veil. Scrawny boys in underwear left their jacks to chase us. Seconds later, they trailed off calling "gringos." A bachata blared in the distance as we pulled up to the palm hut that doubled as a ranger station. Two shirtless rangers leaned against grimy cases displaying ceramic idols and shards of bowls. Sitting around over cups of steaming coffee, one ranger amused us with cuentos while Mom bartered with the other for a guide. Crabs scurried across the trail. My family and I tromped behind the ranger, eager to see caves decorated by Taino Indians. We were confident that this hike into a National Park would be an exciting challenge like our vacations in previous years to other forests in the Dominican Republic. Partially buried coconuts and fragments of brain coral created an obstacle course to scramble over on our way to the caves. James and Sarah raced ahead of the guide, while David and I meandered behind looking for lizards. Grandma won at "I spy," spotting tropical birds and brightly colored orchids dangling in the canopy quicker than any of us. Prickly underbrush and cacti engulfed the path in a sinister tangle. When we stopped for a drink, Grandpa grabbed a cactus to steady himself. His face contorted into a grimace as blood channeled between wrinkles and spines on his hand. Using my sleeve, I gently wiped Grandpa's hand and wrapped it in a handkerchief to stop the bleeding. We hiked on in silence, s hattered only by chattering parrots and humming wasps. The trail fed into the gaping mouth of a cave, surrounded by razor sharp stalactite and stalagmite teeth. We sprawled on damp boulders, munching on peanuts and hesitantly shinin... ... gone for six hours but it felt like years. Grandma carefully measured out even amounts of water from the thermos for each of us to wet our parched throats. When we piled into the jeep, it reeked of sunscreen, insect repellant, and body odor. Ignoring her usual rules, Mom let us hang out the windows as she sped to the nearest colmado. We sat in the shade of an almendra tree and guzzled a crate of pop and a five-gallon drum of water. I could smell hot grease from the corner fried foods stand, but the thought of food turned my stomach. All I wanted was to drink until I felt I might burst. Back at our cabin, I raced to the only bathroom and slammed the door. I stepped in the shower with my clothes still on and let the cool water pour over my body in an overwhelming sense of relief. The only coherent thought I could form as I stood there was: "Thank you God for water."

Diabetes Mellitus Study Guide

DIABETES MELLITUS * Chronic multisystem dz , abnormal insulin production / impaired utilization * Disorder of glucose metabolism related to absent/ insuff insulin supply or poor utilization of inslin that’s available * 7th leading cause of death * leading cause of blindness, ESRD, lower limb amputation * contributing factor for heart dz/ stroke risk 2-4 x higher than without DM * INSULIN – hormone produced by cells in islets of Langerhans of pancreas.Normal – continously into bloodstream ( basal rate), or increased w/ meals (bolus) * Normal glucose range 70-120 mg/dL, average insulin secreted daily 40-50 U 0. 6 U/kg * Glucagon, epinephrine, GH, cortisol oppose effects of insulin counterregulatory hormones they blood glucose lebels, stimulate glucose production by liver, movement of glucose into cells. Insulin released from cells – as precursor / proinsulin thru liver enzymes form insulin & C-peptide ( C-peptide in serum & urine indicator of cell function) * in plasma insulin after meal storage of glucose as glycogen in liver/ muscle, inhibits gluconeogenesis, fat deposition, protein synthesis * Nl overnight fasting release of stored g;ucose from liver, protein from muscle, fat from adipose tissue * Skeletal muscle & adipose tissue receptors for insulin insulin-dependent tissues Type I Diabetes Juvenile onset, insulin-dependent, s/s abrupt but dz process present for several yrs, 5-10%, absent or minimal insulin production, virus/toxins, under 40, 40% before 20 yr * s/s thirst( polydipsia), polyuria, polyphagia ( hunger), fatigue, wt loss, Kussmaul respirations * immune mediated dz; T-cells attack & destroy cells * genetic predisposition & exposure to virus * Idiopathic diabetes – not atoimmune, strongly inherited, in small # pt w/ type I DM , African/Asian * Predisposition HLAs human leukocyte ntigens when exposed to viral infection cells destroyed * Long preclinical period, s/s develop when pancreas can no longer produce suffi cient insulin to maintain nl glucose levels * Req. insulin from outside source exogenous insulin eg. injection * No insulin diabetic ketoacidosis (DKA) life threatening, results in metabolic acidosis * â€Å"honeymoon period† – newely diagnosed pts, tx initiated pt experience remissions req little insulin because cells produce suff amount of insulin lasts 3-12 mths then req permanent insulin Prediabetes * risk for developing diabetes glucose levels high but not high enough for diabetes diagnosis * impaired fasting glucose IGF 100-125 mg/dL * 2 hr oral glucose tolerance test OGTT 140-199 mg/dL * HgB A1C – 5. 7%-6. 4% risk for diabetes * Increased risk for developing DM type II – if no preventive measures develop DM in 10 yrs * Long term damage to body heart, blood vessels occur in prediabetes * Usually no symptoms * Maintain healthy weight, exercise regularly, healthy diet risk of developing diabetes Type II Diabetes * Adult onset, non-insulin dependent, 9 0% * > 35, overweight, tendency to run n families * African Am, Asian, Hispanics, Amerian Indians Some insulin is produced but either insufficient for body needs / poorly utilized * Gradual onset, many yrs undetected hyperglycemia, 500-1000mg/dL * Early usu. asymptomatic; high risk pt screen annually * Fatigue, recurrent inf, vaginal yeast inf, candida inf, prolonged wound healing, visual changes * Risk factor obesity ( abdominal/ visceral ) * 4 major metabolic abnormalities * insulin resistance > tissue no response to insulin / unresp receptors – receptors are located on skeletal muscles, fat & liver * ability of pancreas to produce insulin – fatigued from compensatory prod of insulin, ell mass lost * inappropriate glucose by liver – too much glucose for body needs – type II * altered prod. of hormones & cytokines by adipose tissue ( adipokines) role in glucose & fat metabolism – type II. Two adipokines ( adiponectin & leptin ) affect insulin sens itivity altered mechanism in type I & I * Metabolic syndrome > risk for type II & cardio dz, cluster of abnormalities, insulin resistance, insulin levels, triglycerides, HDLs, LDLs, HTN * Risk factors for metabolic syndrome central obesity, sedentary lifestyle, urbanization, westernization Gestational Diabetes During pregnancy, 7% of pregnancies * High risk – severe obesity, prior hx of gestational DM, glycosuria, polycystic ovary syndrome, family hx of DM II screened at 1st prenatal visit * Average risk OGTT at 24-28 wks of gestation * Higher risk of cesarean delivery, perinatal death, neonatal complications * Will have nl glucose levels within 6 wks postpartum but risk of DM II in 5-10 yrs * Nutritional therapy – 1st line , if doesn’t work insulin therapy Other specific types of diabetes * Due to other medical condition or treatment causes abn blood glucose levels * Damage , injury, destruction of cell function Cushing’s, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, TPN * Meds > corticosteroid (prednisone), thiazides, phenytoin(Dilantin), antipsychotics – clozapine * Tx underlying condition, stop meds Diagnostic studies * A1C > 6. 5 % ; greater convenience, no fasting req, less day to day alterations during stress/ illness * FPG >126 – no caloric intake for 8 hrs prior testing ; confirmed by repeated testing another day; if has s/s and FPG>126 further testing OGTT not req * 2 hr OGTT >200, glucose load 75g accuracy depends on pt preparation, and factors that influence results.False negative > impaired GI absorption, falsely elevated> severe restrictions of carbs, acute illness, meds corticosteroids, contraceptives, bed rest * IFG impaired fasting glucose & IGT > prediabetes, 100-125 mg/dL, IGT 2 hr > 140-199 * Glycosylated HgB – HgB A1C > amount of glucose attached to HgB molecules over lifespan ( RBC 90-120 days ) DM pts should check it regularly, done to monitor success of tx / make chang es to tx < 6. % – risk of retinopathy, nephropathy, neuropathy dz affecting RBCs – can affect A1C results Treatment * Goals > s/s, promote well being, prevent acute complications, prevent/ delay onset/ progression; met when pt maintain glucose level as near to nl, daily decisions about food intake, blood glucose testing meds, exercise * Rapid acting insulin – lispro (Humalog), aspart (NovoLog) – onset 0-15 min, peak 60-90 min, dur. -4 hrs , clear, give 15 min before meals ; bolus * Short acting – Regular (Humulin R, Novolin R) onste ? -1 hr, peak 2-3hr, dur 3-6 hrs, injected 30-45 min before meals; bolus * Intermediate acting – NPH, basal insulin, onset 2-4hrs, peak 4-10hrs can result in hypoglycemia, dur. 10-16 hrs, can be mixed w/ short & rapid, cloudy, must be agitated before adm. Long acting – glargine (Lantus), detemir ( Levemir) addition to mealtime insulin, type I, to control glucose between meals & overnight, without it risk of developing DKA, no peak – risk of hypoglycemia , not diluted or mixed, clear; onset 1-2 hrs, dur. 24hrs +, basal * Combination > pt don’t want 2 separate injections, 2 type of insulin mixed together, not same control of glucose levels as with basal-bolus; ahort/rapid mixed w/ ntermediate provide both mealtime & basal coverage * Storage > vials room temperature 4 wks, heat & freezing alter insulin, between 32-86 F; avoid direct exp to sunlight, extra insulin in fridge/ traveling-thermos, Prefilled syringes – sight impaired, manual dexterity; syringes w/ c;udy solution in vertical position needle up to avoid clumping of suspension, rolled gently, warm before injection. * Injection > abdomen fastest absorption arm, thigh, buttock, rotate within 1 particular site; never into site that’s about to be exercised (heat = absorption & onset), vial 1ml=100U, SQ 90 degrees * Needles ? 5/16 inch (short – children, thin adults); gauges 28,29,30,31 – hi gher gauge = smaller diameter = more comfortable injection * Recapping done only by person using syringe, never recap syringe used by pt; alcohol swabs in health care facility before inj to HAI, at home soap & water * Insulin pump – continuous subq insulin infusion 24 hr/d basal rate , loaded w/ rapid acting insulin via plastic tubing to catheter in subq tissue.At meal time – bolus . (+) tight glucose control, similar to nl physiologic pattern, nl lifestyle, more flexibility (-) infection at site, risk of DKA, cost Problems w/ insulin therapy * Hypoglycemia * Allergic rxn – itching, erythema, burning around inj. site, may improve w/ low dose antihistamine ; rxns to Zinc, protamine, latex , rubber stoppers on vials * Lipodystrophy – atrophy of subq tissue if same inj site used Somogyi effect – rebound effect, overdose of insulin induces undetected hypoglycemia in hrs of sleep, produces glucose decline in response to too much insulin s/s headaches, n ight sweats, nightmares ; if in morning glucose – adcised to check glucose levels at 2-4am if hypoglycemia present at that time.If it is insulin dosage in affecting morning blood glucose is reduced TX : less insulin * Dawn phenomenon – hyperglycemia on awakening in the morning due to release counterregulatory hormones in predawn hrs ( possibly GH/cortisol) adolescence/ young; TX: adjustment in timing of insulin adm. or in insulin. Predawn fasting glucose levels insulin production from pancreas , s. ff > wt gain, hypoglycemia * Meglitinides repaglinide(Prandin) insulin prod, less likely cause hypoglycemia because more rapidly absorbed/eliminated, cause wt gain, take 30 min before meal, not if skipped * Biguanides – Metformin > glucose lowering, first choice DM II/prediabetes, obese & â€Å"starch blockers† slow down carbs absorption, taken with â€Å"first bite†, effectiveness> check 2 hr postprandial glucose levels * Thiazolidinediones – Ava ndia > â€Å"insulin sensitizers†, for pts w/ insulin resistance, don’t insulin Production, not cause hypoglycemia; risk of MI, stroke , not for pt w/ HF * DPP4 inhibitor – Januvia > new class, slow inactivation of incretin hormones; DDP4 inh are glucose dependent = risk of hypoglycemia, no wt gain * Incretin mimetics – exenatide (Byetta) > stimulate incretin horm which are in DM II, stim. of insulin, Suppress glucagon, satiety = caloric intake, slows gastric emptying; prefilled pen * Amylin analog > Amylin hormone secreted by cells, co secreted w/ insulin Pramlintide (Symlin) is Synthetic , type I & II when glucose level not achieved w/ insulin at mealtimes , subq thigh or abdomen NOT arm , not mixed w/ insulin – cause severe hypoglycemia ! * blockers — masks s/s of hypoglycemia, prolong hypoglycemic effects of insulin * Thiazide / loop diuretic — hyperglycemia, K Nutrition Type I > meal planning, exercise, developed w/ pt’s e ating habits & activity pattern in mind, day to day consistency in timing & amount of food eaten * Type II > wt loss = improved insulin resistance, total fats & simple sugars = calorie & carbs intake; Spacing meals , wt loss 5-7% = glycemic control, regular exercise * Carbohydrates > sugar, starches, fiber whole grains, fruits, veggies, low fat milk included min 130g/d * Glycemic index GI > describe blood glucose levels 2 hrs after carb meal , GI of 100 = 50g glucose * Fiber intake 14g/1000 kcal * Fats 7% of total calories , < 200mg/d cholesterol & trans fats * Protein same for diabetes / normal renal function / gen. population, high proein diet not recommended * Alcohol > inhibits gluconeogenesis ( breakdown of glycogenglucose) by liver; severe hypoglycemia in pt on insulin / oral hypoglycemic dx.Moderate alcohol consumption < 2 drinks men, track carbs w/ each meal & daily, set limit for max amount ( depends on age, wt, activity level) usu. 45-60g /meal ; also My Pyramid & plate me thod ( ? nonstarchy veggies, ? starch, ? protein, nonfat milk & fruit * Exercise > 150 min/wk moderate intensity aerobic; DM II resistance training 3 x wk, most adults should 30 min moderate intensity activity 5 x most days * Exercise > insulin resistance, blood glucose, wt loss which insulin resistance ( may need less meds), triglycerides, LDL, HDL, BP, circulation * Start slowly w/ progression. Insulin, sulfonylureas, meglitinides >risk of hypoglycemia with increase physical activity esp if exercise at peak of dx or no food intake.Effect may last 48 hrs post exercise Exercise 1 hr after meal, have 10-15g carb snack every 30 min. during exercise (prevent hypoglycemia). Before exercise glucose immediate info about glucose levels – can make adjustments diet, activity, meds * Recomm. for all insulin-treated pts * Multiple insulin injections – 3 or more x day, done before meals, before & after exercise esp in type I, whenever hypoglycemia suspected, when ill (stress), 2 h rs after start of meal – if effective Pancreas transplantation * For pt w/ ESRD, plan to have kidney transplant * Pancreas transplanted following kidney transplant, pancreas alone –rare * Pancreas alone only if hx of severe metabolic complications, emotional roblems w/ exogenous insulin, failure of insulin-based management * Improve quality of life, no exogenous insulin need, no dietary restrictions * Only partially able to reverse renal & neurologic complications * Need lifelong immunosuppression to prevent rejection * Pancreatic islet cell transplantation in experimental stage, islets from deceased pancreas via catheter into abdomen portal vein Nursing management * Pt active participant in management of diabetes regimen * Few/no episodes of acute hyper/hypoglycemic episodes, maintain glucose level near nl * Prevent/ delay chronic complications * Adjust lifestyle to accommodate DM regimen w/ min. stress Nursing assessment Past hx mumps, rubella, viral inf, recent trau ma, stress, pregnancy, infant>9lbs, Cushing, acromegaly, family hx of DM * Meds > compliance w/ insulin, OA; corticosteroids, phenytoin, diuretics * Eyes > sunken eyeballs, vitreal hemorrhages, cataract * Skin > dry, warm, inelastic, pigmented lesions on legs, ulcers(feet), loss of hair on toes * Respiratory > Kussmaul – rapid, deep * Cardio > hypotension, weak rapid pulse * GI > dry mouth, vomiting, fruity breath * Neuro > altered reflexes, restlessness, confusion, coma * MS > muscle wasting * Also electrolyte abnormalities, fasting glucose level >126, tolerance test> 200, leukocytosis, BUN, creatinine, triglycerides, cholesterol, LDL, HDL, A1C 45yrs without risk factors for diabetes Acute intervention * Hypoglycemia, DKA, HHS – hypersmolar hyperglycemic syndrome * Stress f acute illness/ surgery > counterregulatory hormones > hyperglycemia ( even minor upper resp infection or flu can cause this) * Continue regular diet, noncaloric fluids (broth, water, diet gelatin, decaffeinated), take OA/insulin as prescribed, monitor glucose Q4H * Acutely ill DM I , glucose>240 test urine for ketones Q3-4H , medium/large report to MD * Ill > eat than normal > continue OA meds/ insulin as prescribed + carbohydrate containing fluids (soup, juices, decaffeinated) * Unable to keep fluids/ food down MD * Don’t stop insulin when ill counterregulatory mechanisms will glucose level * Food intake important body needs extra energy to deal w/ stress Extra insulin may be needed to meet this demand, prevent DKA in DM I * Intraoperative > IV fluids & insulin before, during, after sx when there’s no oral intake In DM II w/ OA – explain it’s temporary measure, doesn’t mean worsening of DM * If contrast medium (w/iodine) > Metformin discontinued 1-2 days before sx, resumed 48 hrs after sx risk of acute renal failure.Resume after kidney function nl ( creatinine checked & is nl) * Insulin adm > teach proper administration, adjustments, side e ffects, assess response to insulin tx, if new to insulin assess ability to manage tx safely, cognitive status, ability to recognize/ tx hypoglycemia, if cognitive skill another responsible person must be assigned; diff to self inject/ afraid of needles * Follow ups > inspect injection sites ( lipodystrophy ) * Short term memory deficit > OA or short acting OA cuz doesn’t cause hypoglycemia * OA w/ diet & activity, not take extra pill when overeating * Diligent skin care & dental > aily brushing/ flossing, inform dentist about DM * Foot care !!! scrapes, burns treated promptly & monitored > nonirritating antiseptic ointment > dry sterile pad> not start to heal in 24 hrs or infection > MD * Regular eye exams * Travel – sedentary > walk Q2H to prevent DVT & prevent glucose , carry snacks, extra insulin COMPLICATIONS Diabetic Ketoacidosis DKA * Diabetic coma Profound deficiency of insulin > hyperglycemia, ketosis, acidosis, dehydration * Most likely in DM I pts, but someti mes in DM II ( severe illness/ stress) * Causes > illness, infection, undiagnosed DM I, inadeq insulin dosage, poor self management, neglect * Insulin – glucose cant be properly used for energy fat broken for fuel ketones (by product) serious when excessive in blood alter pH, cause metabolic acidosis ketonuria (in urine) & electrolyes depleted; impaired protein synthesis, nitrogen lost from tissues * Untreated depletion of Na, K, Cl, Mg, phosphate hypovolemiarenal failure/ retention of ketones & glucose shockcoma (result of dehydration, lytes & acidosis)death * s/s > dehydration, poor turgor, dry mm, HR, orthostatic hypotension, Kussmaul , abdominal pain, sunken eyeballs, acetone fruity odor, early s/s > lethargy,weakness * blood glucose >250, arterial blood pH IV access begin fluid/ electrolyte replacement NaCL 0. 45% or 0. 9% to restore urine output 30-60 ml/hr & BP * glucose level approach 250 5% dextrose added * Incorrect fluid repl > sudden Na & cerebral edema * Obtain K level before insulin started – insulin > further K * Insulin withheld until fluid resuscitation & K>3. 5 * Too rapid IV fluids & rapid lowering of glucose cerebral edema Hypersmolar hyperglycemic syndrome HHS * Life threatening, able to produce insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, ECF depletion * Less common than DKA * Often > 60, in DM II Causes > UTI, pneumonia, sepsis, acute illness, new DM II * Asymptomatic in early stages > so glucose can rise very high >600mg/dL * The higher glucose > in serum osm > neurologic manifestations somnolence, coma, seizures, hemiparesis, aphasia * Resemble CVA (stroke) determine glucose level for correct dx * Ketones absent in urine * Tx similar to DKA * First IV 0. 45% or 0. 9% NS, regular insulin given after fluid replacement * Glucose fall to 250 – add glucose 5% dextrose * Hypokalemia not as significant as in DKA * HHs require greater fluid replacement * Assess VS, I&O, turgor, l abs, cardiac / renal monitoring related to hydration & electrolyte levels, mental status, serum osm Hypoglycemia Low blood glucose glucagon & epinephrine > defense against hypoglycemia * s/s of epinephrine > shaking, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor * brain req constant supply of glucose > when > affect mental functioning > LOC, diff speaking, visual disturbances, confusion, coma, death * Hypoglycemis unawareness > no warning signs until glucose reach critical point > incoherent, combative, LOC > often elderly w/ beta blocker meds * When very high glucose level falls too rapidly, too vigorous management of hyperglycemia * Mismatch in timing of food intake & peak of isulin/ OA * Can be quickly reversed Check glucose levels, if contain fat that glucose absorption; check glucose in 15 min * Still 70 eat regular meal/snack low peanut butter, bread, cheese, crackers, check glucose in 45 min * No significant imptovement after 2-3 doses of 15g carb MD * Pt no t alert to swallow 1mg glucagon IM in deltoid muscle ( nausea, vomiting rebound hypoglycemia) * Hospital setting > 20-50ml of 50% dextrose IV push * CHRONIC COMPLICATIONS OF DM Angiopathy * end organ dz from damage to blood vessels (angiopathy) 2nd to chronic hyperglycemia * leading cause of diabetes-related deaths, 68% deaths due to cardio, 16% strokes * causes: accumul.Of glucose metabolism by products (sorbitol) damage to nerve cells, abnormal glucose molecules in basement membrane of small blood vessels (eye,kidney), derangement in RBCs – oxygenation to tissues * DM I > keep blood glucose levels near to normal – retinopathy & nephropathy (complications of microvascular complications) Macrovascular complications * Dz of large, medium size blood vessels , earlier onset in pt w/ diabetes * W > 4-6x risk of cardiovascular dz, M > 2-3 x * risk factors > obesity, smoking, HTN, fat intake & sedentary lifestyle * Smoking injurious to pt w/DM, risk for blood vessel dz, CV d z, stroke, lower extremity amputations * Maintain BP control – prevention of CV / renal dz Microvascular complication * Thickening of vessel membranes in capillaries/ arterioles in response to chronic hyperglycemia * Are specific to diabetes Eyes ( retinopathy ), kidneys ( nephropathy ), skin (dermopathy ) * Some changes present w/DM II at time of dx, but s/s not appear until 10-20 yrs after onset of DM * Diabetic retinopathy – microvascular damage to retina, most common cause of blindness 20-74 yrs old. Nonproliferative> most common, partial occlusion of small blood vesselin retina microaneurysms, Proloferative> most severe, involves retina & vitreous neovasculization ( form new blood vessels to compensate) if macula involved vision is lost * DM II > dilated eye exam at time of diagnosis & annually, DM I within 5 yrs after DM onset * Laser photocoagulation * Virectomy * Glaucoma Nephropathy – microvascular complication, damage to small blood vessels that supply glomeruli / kidney.Leading cause of ESRD in US; same risk for DM I & II > HTN, smoking, genetic predisposition, chronic hyperglycemia * Screen for nephropathy annually w/ measurement albumin / creatinine ratio * If micro/macroalbuminuria > ACE inh ( lisinopril ) or angiotensin II rec antagonist ( Cozaar ) tx HTN & delay progression of nephropathy * Aggressive BP management & tight glucose control Neuropathy Sensory neuropathy (PNS)– loss of protective sensation in lower extremities amputations * Hyperglycemia > sorbitol & fructose accumulate in nerves damage * Distal symmetric polyneuropathy > hand/ feet bilaterally * Loss of sensation – to touch/ temperature * Pain > burning, cramping, crushing, tearing , at night * Paresthesias > tingling , burning, itching * At times skin too sensitive (hyperesthesia) * Foot injury & ulcerations without having pain TX : blood glucose control, topical creams capsaicin ( Zostrix ) 3-4 X/d pain in 2-3 wks, selective serotonin, norepin ephrine reuptake inh ( Cymbalta ), pregabali ( Lyrica ), gabapentin Autonomic neuropathy – can affect all body systems & lead to hypoglycemic unawareness, bowel incontinence, diarrhea, urinary retention Complications : * Delayed gastric emptying ( gastroparesis ) anorexia, n/v, reflux, fullness, can trigger hypoglycemia by delaying food absorption * Cardiovascular abnormalities , postural hypotension assess change from lying, sitting, standing, painless MI, resting tachycardia HR * Risk for falls * Sexual dysfunction > ED in diabetic men > 1st s/s of autonomic failure * Neurogenic bladder > urinary retention, diff. voiding, weak stream empty bladder Q3H in sitting position, Crede maneuver ( massage lower abdomen) * Cholinergic agonists > benthanechol Feet & lower extremities Risk for foot ulcerations & lower extremity amputations * Sensory neuropathy > major rosk for amputations due to loss of protective sensations LOPS * Unaware of foot injury, improper footwear, stepping on objects w/ bare feet * Screening using microfilament > insensitivity to 10g Semmes-Weinstein > risk for ulcers * Proper footwear, avoid injuries, diligent skin care, inspect feet daily * PAD risk for amputations due to blood flow to lower extremities * PAD s/s > intermittent claudication, pain at rest, cold feet, loss of hair, cap refill, dependent rubor ( redness when extr in dependent position ) * DX : ankle brachial index ABI & angiography * Casting to redistribute weight on plantar surface * Wound control > debridement, dressings, vacuum, skin grafting etc. Charcot’s foot > ankle & foot changes joint deformity need fitted footwear * Acanthosis nigricans – dark, coarse, thickened skin in flexures & neck * Necrobiosis lipoidica diabeticorum – DM I, red-yellow lesions w/ atrophic skin , shiny & transparent revealing blood vessels under the surface – young women * Granuloma annulare – DM I, autoimmune, partial rings of papules, dorsal surface of h ands/ feet Infection Candida albicans, boils, furuncles, bladder infections (glycosuria) antibiotics Gerentologic * reduction in cells, insulin sensitivity, altered carbohydrate metabolism * 20 % > 65 YO * # of conditions treated w/ meds that impair insulin action (

Customer Service Plan Essay

Customer service and commitment to our customers has been the driving force behind our brand. Widget strive to get it right first time, everytime.Incases where things don’t come out right we believe our professional workers will strive to correct the problem and our customers have the right to know what level of service they can expect from us all the time even in these times when we fall short of the very high standards we have set ourselves. Through our Vision and mission statement we make a commitment to our customers both internal and external. Mission Statement Passionate about exceeding the delivery of our customers’ service expectations by providing the very best in professional, value engineered widgets through our ever growing nationwide team of professional, caring staff. Vision Statement To be Australia’s number one national provider of quality widgets by empowering our staff to deliver our customers with the very best in quality, value and service. Our Product standards Our product is manufactured in strict accordance with the Australian quality standards and also taking into account the use of which our customers will subject our product. Our internal policies and quality standards support the high quality standards set in our vision and mission statement.Our product specifications are clearly presented in all our packaging materials and tested during the production process to ensure all tolerance limits are adhered to. Our main product is 12 mm black hole plugs which are made of plastic to cover ,conseal and decorate 12 mm diameter holes in cabinets,furniture,window frames,vinyl fences and elsewhere.Fits any 12mm diameter holes. These hole cover widgets practically work anywhere indoors and out .These are made from our factory with high –impact injection molded  plastic. These can come from different sizes as requested by our customers. All our products have a small tolelance limit of +1% or -1%. Specifications. Our product range will have the following features. Color:it will come in the range of black ,white or grey Fits hole size :12mm or as requested by customer Diameter:12 mm Length: 6mm Top diameter:15 mm Material:Polypropylene. Tolelance limit:plus or minus 1% Widgets outlines its description of its product in the policy and communicated to the customer to allow the customer to make any queries or complaints incase the product received its off specification. Pricing Widget ensures that its products are properly priced so that customers are able to afford the goods as well as profitability is maintained to allow the company invest in the quality and standards initiatives of the products. Widgets pricing is well thought as we do in other sectors of the business like marketing and branding, the price the customer sees on display is the price customers pay. There are no hidden costs. Our standard product 12 mm fits hole size will cost 12AUD /dozen and customers are requested to enquire from the customer service team for prices of any changes requested to the standard product. Delivery of goods Widgets aim to deliver all orders made either online or face to face within three days of the order being made.We aim to have a delivery process which ensures a reliable, secure and efficient service. If delays occur during deliveries and extra time may be required, customers will be contacted urgently to alert them of the next delivery times or else they can call our Despatch department directly on 1300 880 370. One day prior to your delivery we will SMS all of the important delivery information about your order to your mobile. If all the information is correct you will only need to text back OK. If there are any details that are not correct or you wish to change your delivery date please ring us on 1300 880 370. In order to offer our customers a better delivery service these terms and conditions replace any delivery and pickup conditions stated on your order form. TERMS & CONDITIONS: 1. It is important that someone is at the receaving end to receive delivery of your purchase on the designated day. No specific time of delivery can be provided. A four hour time frame will be advised but cannot be guaranteed. 2. A minimum delivery fee of $75 (outside the Metropolitan area) is payable separately to the Carrier in cash or bank cheque. Delivery is free inside the Metropolitan area 3. Cash or bank cheque must be used to pay any balance of monies owing at time of delivery. Personal/Company cheques will NOT be accepted. For your convenience we can accept credit cards in store 48 hours prior to delivery, surcharges may apply. 4. Once arrangement for a delivery day is confirmed, there will be a minimum re-delivery charge of $75 if no person is at the delivery address on the day of delivery or the delivery is cancelled by the customer on day of delivery. 5. When receiving goods, please inspect thoroughly before signing â€Å"Received in good order† as any claims for scratches, marks, dents or other damages will not be accepted once signed. 6. Failure to collect or take delivery of the goods beyond 21 days from the date of contact by our despatch department will result in the sales order being cancelled and all monies paid will be forfeited. 7. All original packing & wrapping will be left at the premises (delivery address). CUSTOMER PICK UPS Customer collection of goods purchased from Widgets stores can also be  collected by the customer in any of our distribution centres.. The customer must contact the Delivery department prior to pick up on 1300 880 370 to make an appointment. Same day pickup is not available. Pickup times at Distribution Centers Customers: Monday to Thursday – 10:00am – 12:30pm & 1:30pm – 3:00pm Carriers: Friday ONLY Other Policies and Procedures Customer needs Widget believes that it is important that customers needs are regularly reviewd to ensure that its products are inline with the changing times. Therefore time and again Widget carries out research to identify these needs and implement changes identified. Widget uses the RATER model to identify its customers needs since customers when assessing what they want will consider the reliability, assurance, tangibles, empathy and responsiveness as they are being assisted. Using the RATER guide Widget will use the following techniques to gather customer needs Informal face to face discussions for its key customers Telephone interviews Email surveys Suggestion boxes Internet surveys. All information gathered for customers is protected by the Privacy act 1988 including how the information is collected,used and disclosed,its accuracy and how securely it is kept and general rights to access that information. Widget has a dedicated Customer service research officer who is responsible for ensuring that all customer data collected is securely kept and used for  its intended purpose only. Complaints and feedback If you have a complaint or if there is anything we can help you with, please let us know.Widget values feedback and appreciate the opportunity to follow up. Widget deals with all people from diversi background and does not discriminate anyone on the basis of age ,race,disability or sex. Our policy take into account the Age discrimination act 2004,Australian Human Rights Commission Act 1986,Disability Discrimination ACT 1992,Racial discrimination Act 1975 and Sex Discrimination Act 1984. There are a number of ways you can contact us to lodge your complain and includes our Email at Widget123.gmail.com or phone at 08100300 or mail at Widget Australia,3/77 Manning street ,Bentley ,6102. Or you can also connect with us via Twitter or facebook Complain resolution process and timeframes Once we receive your complaints, we may ask you to provide supporting or documentation to aid us in investigations. This may include proof of identity, statutory declaration, receipts and so on. We aim to resolve complaints within 5 working days, however please note that some complaints may take longer to investigate especially matters to do with international orders. Managing records and data. Widgets collects alot of data of customers including physical addresses, names,date of birth and many more information. The Customer service research officer is responsible for keeping the data securely and is sorted by our secure information technology section. The Privacy Act 1988(â€Å"the Act†)  governs the obligations and responsibilities of companies in relation to the management of official records. Under this Act, each company has an obligation to maintain official records in its custody in good order and condition. This obligation applies not only to the capture, storage, maintenance and disposal of physical records, but also to records in electronic format. Widget policy is governed by this act and all measures necessary are taken to ensure that compliance is maintained.