It Is Not Goodness to Be Better Than the Worst free essay sample

It isn't goodness to be superior to the most exceedingly terrible. ’’ Most individuals, when given a task, will do the least conceivable work required to in any event pass. Clearly, with fresher and more current innovations, individuals have gets sluggish after some time. In the event that one is close to death, it doesn’t imply that they are equivalent to one who is totally fine. There are innumerable models for a statement, for example, this. Understudies may just meet the insignificant prerequisites for a venture only for it to be scarcely enough to pass. Having more work done takes into consideration the general evaluation to surpass what might have been composed at the negligible necessities. I recollect when I was in 6th grade, my instructor alloted the class a 200 word outline of what we found out about during history time. To us this appeared to be a great deal, however we figured out how to have it finished by the due date. We will compose a custom exposition test on It Is Not Goodness to Be Better Than the Worst or on the other hand any comparable theme explicitly for you Don't WasteYour Time Recruit WRITER Just 13.90/page I wound up having an exposition longer than the prerequisites, as did different understudies, however there were a rare sorts of people who decided to compose just 200 words or more. The understudies who composed well over the 200 least were given additional credit. I was content with my additional credit, yet others weren’t upbeat when they got a lower grade because of their synopsis containing numerous missteps, for example, incorrect spellings and syntactic blunders. Now and again, being better than another will majorly affect the two individuals. The better one will act affected and uninformed to the individuals who simply need to support him. As a result of these changes, the lesser individual will comport oneself to accept he is lesser and will continue accepting so for quite a while. Except if he understands that it was only one time, he will keep on accepting his latent capacity isn't as incredible as the more prominent man. This statement is befuddling me now, it is acceptable to not be the most exceedingly terrible however there is a distinction. It’s great to compose long paper and get a decent imprint, however don’t be pompous. In any case, on the off chance that one isn't the most exceedingly awful, yet has gotten a terrible blemish on a similar task, at that point he despite everything has not been acceptable. In â€Å"Mills is most exceedingly terrible performing West African leader† (2012), Fiifi Arhin attests that President Mills has not totally been the most noticeably terrible pioneer, but instead the â€Å"10th most noticeably terrible performing pioneer of 2011†. Arhin records the far more terrible Presidents and states that it couldn't totally have been their shortcomings as â€Å"other factors came into play†. The numerous models utilized in the article are previous Presidents that have accomplished astoundingly mediocre work that President Mills. This article is written in a belittling tone towards the Presidents, and convinces the crowd with realities. With these models, I have at long last settled on a choice to concur with this week’s latin statement. It isn't extraordinary to be the most exceedingly terrible. To be marginally better than that of the most noticeably awful is still observed as poor. It is extraordinary to be the best. In any case, on the off chance that you are not the best nor most exceedingly terrible you are in the center, and that is a confounding spot to be.

Grendel and Cain Essay

In the narrative of Beowulf you get a brief look at a wide range of subjects all through this epic. Those subjects extend from great and malevolence to those of death and greatness. The story itself delineates a period in history when life was lead â€Å"blind† through the lessons of the book of the master and his verbally expressed words. At this equivalent period in history conventional agnostic strict practices and convictions have gradually offered route to the goals and reasoning of Christianity. Huge numbers of the topics held inside the pages of Beowulf originate from the adages and tales discussed and rehearsed in the Old Testament, while simultaneously including agnostic convictions of beasts, evil presences, and numerous divine beings. The most striking of these scriptural correlations is seen between Grendel (the hero, abhorrent opponent of Beowulf) and Cain (the underhanded sibling of Able). In the Old Testament, Cain murders his sibling Abel and is thus rebuffed and exiled from the Garden of Eden by God. His activities demonstrated to dramatically affect the life of Grendel and the decisions he makes for a mind-blowing duration until his epic battle for triumph over the Geats and Beowulf himself. Emblematically and hereditarily, Grendel expect the job of his progenitor Cain in this epic story as a pariah, abandoned from the remainder of society, finding a home just among the obscure (detestable) and the individuals who have trespassed. Benefiting from the fragile living creature and blood of god’s manifestations, Grendel begins a fiery fight to annihilate all that is acceptable and the things he can not have. To the Anglo-Saxons and the makers of Beowulf, one of the most exceedingly terrible wrongdoings an individual could have submitted in life was that of killing ones family (or the murdering of one’s sibling). During the time of this composing the figure of Cain is utilized figuratively to speak to â€Å"the unknown† (disorder, underhanded) and the nearness of malevolence. Cain resists divine beings will thus he disconnects himself to the shades of malice of the encompassing scene just to encourage a disdain of god and a family reviled forever. The period where Grendel and Cain dwelled in was profoundly organized around the book of the ruler (book of scriptures) and accordingly made a general public organized around the lessons and ethics of its accounts. The possibility of kinship and family being spoiled through the demonstration of homicide is one of the most noticeably terrible things an individual can do and the results of that are extreme. Grendel is his very own survivor world and the activities of his predecessors. The general public for which Grendel needs to overcome and deny existenceâ proves to be the maker and destroyer of his shocking being. In the great story of Cain and Able, Cain desirously kills his sibling Able in a horrendous clamor of envy and outrage. For his transgression, he was ousted from humankind forever and left uniquely to live dislodged from the schedules of typical creatures and compelled to live among the dull and the evil. Cain was the first of a reviled family to be ousted for the wrongdoings he submitted. His discipline demonstrated to drastically affect him and the fate of his blood line. His discipline produced his commitment to holding resentment against god himself and the inaccessible light he has been prevented from securing. Subsequent to being the primary conceived of Adam and eve, Cain proceeded to turn into a rancher of the ground, while his sibling Abel followed the quest for a manager of the sheep. Cain turned into a self-willing, malignant man, insubordinate in his demeanor towards God and his connection to his kinfolk. His interminable sin was submitted on the seventh day or Sunday of the week while the two siblings were introducing contributions to the ruler. Abel’s offering was of the â€Å"firstlings of his run and of the fat† (Gen. 4:4), while Cain’s â€Å"was of the product of the ground† (Gen. 4:3). For Abel’s penance, he gave the best he had thus his contribution was regarded by his older folks while Cain’s offering was despised and excused. It was therefore Cain brood outrage towards his family; the most exceedingly terrible of which was centered around his more youthful sibling Able. After his disfavor towards the ruler and his family, Cain’s aloofness towards his sibling delivered sentiments of dangerous expectation and contempt. Sometime this frantic shock drove him to kill Able in crude uneventful contempt. For his transgression he was ousted from Eden. From that day on he drove the life of an outcast, bound to be â€Å"a criminal and drifter in the earth† (Gen. 4:12) and precluded the rights from securing a typical man, just to exposed the characteristic of a miscreant and cautioning to other people. With this Cain strolled into the place where there is Nod (obscure, insidious, dull), just to leave an inheritance felt by the ages of his posterity. At the point when Cain executed Able, he touched off the unceasing fire of a reviled family. From Cain’s blood came â€Å"the revile of his outcast and sprang monstrosities and mythical beings and abhorrence ghosts and the goliaths too† (Beowulf. Pg. 35), haziness involved is inheritance and insidiousness typified his future. Grendel is a relative of Cain, so he shares Cain’s oust from all that is acceptable and light. Cain may have been theâ first uprooted individual after Adam and Eve, however he was not the last. Grendel shares his ancestor’s discipline, he is banished not just from whatever land or riches he would have had on the off chance that he were â€Å"human†, however he is likewise relinquished by God and all who followed and enjoy his confidence and glory. It is this relinquishment that causes Grendel to devastate and kill. â€Å"The treasure seat, he was shielded from drawing closer; he was the Lords outcast† (Beowulf pg.36), s ince he can't move toward the seat of the Lord like the remainder of humanity, he decides to endeavor to demolish it. He has no affection for God and his kids on the off chance that he can not be with them â€Å"hand in hand†. In any case, in contrast to Cain and his folks, Grendel is bound from his creation by being considered into a blood line stricken by an unfathomable length of time of expulsion from God’s light due to Cain’s sin against his sibling. It is consequently why Grendel slaughters. He can never be in the light since he is continually battling a forlorn war against God and the entirety of his manifestations. In light of his ejection from that which is acceptable, he is besides disposed of by everything that follows in the wake of divine beings will (individuals, society, life, and so on.). The content alludes to him as â€Å"spurned and joyless† (Beowulf pg. 47); it is no big surprise why Grendel was considered so huge. He didn't acknowledge his expulsion without retaliating. Like a great many people who are chafed and detached and afterward positioned between a â€Å"rock and a hard place† he retaliated â€Å"insensible to agony and human sorrow† (Beowulf pg. 35) for those he killed. The purpose for his activities isn't on the grounds that he is a boisterous beast, yet rather, he is overpowered by desire since he can't partake in the riches god has made available to mankind. In view of this, if Grendel can not step into the light and become some portion of the life as saw all things considered. At that point he will devastate it and leave it for nobody. Similarly as Cain did before him, Grendel will never be content with himself as long as he should exposed observer to the celebrating of life and love delighted in by all whom sumptuous in the gleam of Gods hands. Regardless of whether it is Grendel or his progenitor Cain, the two of them experience the ill effects of the misery of attempting to make due in a world as reviled creatures, compelled to opposed around in the edges of the cool night and the forlornness of a sun seared day. In the wake of decimating the ideal picture of a substance individual for the sake of envy and outrage, Cain; illegal to enter the known world forever,â created a range of authority which played into the eventual fate of his kids and his grandchildren’s kids, etc. Despite the fact that the sign of Cain isn't clear on Grendel’s physical qualities, the nearness of his reviled nature is. He like Cain experiences a surrender of confidence and humankind. As outsiders the two of them discover disdain and scorn towards the things they need most, regardless of whether it’s affirmation by god and all that is acceptable on the planet or the capacity to meander unreservedly unafraid of criticism and an tagonistic vibe. To humankind they represent a danger more regrettable then the entirety of most people’s fears. They speak to all that is terrible on the planet and accordingly end up dismissed by everything great the world brings to the table. It is conditions like these that have demonstrated to draw out the most exceedingly awful in an individual, for example, they did in Cain and his later precursor Grendel. What might you anticipate from those compelled to live among the uprooted in a world angry of there presence. Rather than being acknowledged for there mishaps and pardoned for there sins, they where dismissed for what they where and what they had become, bringing about an animal roused by agony and lack of concern exacted by the manager of there being and the crowd of there lives.

Recent Applications of Keratin

Ongoing Applications of Keratin Theoretical This survey examines the ongoing utilizations of keratin and keratin-based materials. Keratin-Based Materials The keratin-based materials are created from keratin filaments, for example, human hair, skin, hooves, plumes, mouths, feet and horns (18). For biomedical and pharmaceutical purposes, human hair is a favored significant wellspring of keratin for a few reasons. In the first place, it is accessible promptly from hair stylist and excellence salons. Additionally, human hair is less inclined to cause undesired unfavorably susceptible or insusceptible responses in a human. At long last, a determined keratin material can be produced using the hair of an individual for whom the keratin-based material will be utilized (13). Creature quills are additionally significant assets for keratin extraction. Consistently, there are 5 million tons of chicken quills delivered from chicken meat as a waste stream (8). Along these lines, plumes are rich wellspring of keratin that can be effectively acquired. There are various techniques to extricate the keratin-based material from the keratin sources. One technique incorporates incomplete oxidization of some disulfide linkages of the keratin with an oxidizing operator, for example, peracetic corrosive, while remaining disulfide linkages are left unblemished. The halfway oxidized hair is powdered and the staying flawless disulfide linkages are cut with a diminishing operator. An insoluble piece of keratin part is, at that point, expelled by centrifugation (3, 15). The dissolvable part, including alpha keratin, is sanitized and oxidized to change disulfide linkages between protein spines (3, 19). The oxidized solvent part is effortlessly broken up and can shape keratin arrangements with controlled focuses (19). The created keratin strong can be utilized in a sinewy structure when destroyed, in a powder structure when finely ground, in a hydrogel or viscoelastic hydrogel when hydrated by including water, or might be utilized in specific epitomes (13). These materials are utilized for biomedical, pharmaceutical, biosorbent, and mechanical applications. Wound Dressing The ideal injury dressing secures the harmed tissue, keeps up dampness while being water porous, is anything but difficult to apply, and conveys powerful recuperating operators to the injured tissue (15). The keratin-based material goes about as a non-antigenic injury mending material (3). The keratin-based film is suitable to be utilized as an injury dressing. The permeable wipe frameworks of keratin can assume a significant job in retaining wound exudates and in keeping up a sound and damp condition for mending a physical issue (16). Likewise, a hydratable keratin strong powder that is additionally utilized in a type of a keratin hydrogel when included water is utilized as an injury dressing (13). These exceptionally spongy keratin strong fiber and powder furnish an additional advantage alongside the water retentiveness. This advantage incorporates recuperating or mitigating peptides related with the keratin (18). Blanchard et al. (3) tried the keratin power, which would be utilized to create a keratin hydrogel when hydrated, as wound mending operator with a few benefactor destinations. The cleaned keratin powder is applied on a portion of a benefactor wound site and the other half is treated with a standard treatment. The outcome shows the parts treated with the keratin powder develop quicker and epithelialize all the more quickly. Likewise, the patients with the injuries have essentially less agony with the keratin power treatment (3). Than et al. (4) directed an investigation concentrating on the impacts of the keratin dressing on constant injuries of various cases. For one of the examined cases, a negligibly exudative injury, which had been existed for 11.5 months, was treated with a lattice dressing delivered from freeze-dried keratin protein. This dressing permits the quick development of new tissue by reabsorbing into the created tissue. The injury was mended following 30 weeks (Figure 2). Additionally, the patient had encountered the rehashed leg ulcers; yet, the patient stayed sans ulcer after the treatment (4). Figure 1 (1A) Ulcer under keratin-determined lattice dressing treatment at Day 0; (1B) Healed ulcer under keratin-inferred grid dressing treatment at Day 99 (4) Pharmaceutical Siller-Jackson et al. (13) and Van Dyke et al. (18) proposed an innovation of the keratin material joined with nonwoven film, which can be utilized in a few unique applications. One of the applications is that the strong keratin with nonwoven film can frame a gainful medication conveyance framework when it is joined with dynamic pharmaceutical specialists. These pharmaceutical operators, including the aggravates that may permit particle trade with sulfonic corrosive gatherings of keratin, can be detailed as hydrochlorides, polar specialists, protein specialists, polypeptide operators, and peptide operators (18). Polypeptide operators incorporate both local and recombinant polypeptides (13). Table 1 gives the rundown of the classes and kinds of pharmaceutical operators (13, 18). Table 1 Classes and Types of Pharmaceutical Agents (13, 18) The creation of Van Dyke et al. (18) proposes that the use of the medication conveyance framework with strong keratin gives a few huge points of interest. In this framework, the properties of the measurement type of a medication can be dictated by the substance and material properties of the keratin, while with most conveyance frameworks, the degree of a medication is kept up at a reliable focus with supported or controlled discharge. Additionally, the nonwoven film sedate conveyance framework is acted in non-watery media, which is an unmistakable favorable position in light of the fact that non-water solvent medications are normally problematic to plan into helpful measurement structures. Moreover, keratin can assume a double job of wound dressing and medication conveyance framework all the while, permitting a less nosy treatment than discrete medicines (18). Hemostat Aboushwareb et al. (7) exhibited the hemostatic qualities of the human hair keratin hydrogel with the capacity to retain liquid and tie cells effectively. The examinations assess the adequacy of human hair keratin hydrogel in a deadly model of liver injury in a hare model, contrasted with other business hemostats. The investigation demonstrated the adequacy of the keratin biomaterials in capturing drain and expanding the survivability in a model of liver injury, comparably to the thought about business products.ã‚â Also, it was demonstrated that the keratin hydrogel doesn't deliver unfriendly cell and tissue reactions (7). Embed Filler The keratin hydrogel can likewise be utilized as an enlargement of delicate tissue, remembering increase of vocal harmonies for request to reestablish flexibility, and growth of bosoms, lips, jawline, gluteal zone, and wrinkled or skin break out scarred skin so as to improve the presence of a subject (25). The biocompatible viscoelastic keratin hydrogel is utilized as an embed filler (25). Such keratin hydrogel gives a characteristic showing up and safe embed for remaking or filling the human bosom, and different tissues. The embed might be utilized in a few different ways. One way is that the strong hydrogel embed antecedent is hydrated before putting the filler into an embed envelope. Another way is that tissue expanders are contained in an envelope with the keratin hydrogel. This technique permits the embed to assimilate the body liquids through the envelope and expanding in a volume at a controlled rate, giving an increasingly helpful and agreeable embed contrasted with customary inserts (18). The keratin hydrogel inserts are less poisonous than the silicone inserts, if there should be an occurrence of the danger of a spillage. Likewise, the keratin fillers give more normal appearance and feeling than saline inserts do. Also, the keratin inserts don't require a second intrusive technique to collect tissue as fat cells do (18). Biosorbent The enthusiasm for the utilization of biomass for the broke up metal expulsion from watery arrangements has been expanding a direct result of the generally significant expense of the customary water treatment materials, the complex operational set-up, and the wellbeing safety measures (9). The keratin-based material can be utilized as the cleansing technique for common and waste water assets polluted with metal (8). The keratin protein fiber is utilized to sanitize substantial metal-defiled water. The fleece keratin has been accounted for to take-up mercury, copper, silver, cadmium, lead, chromium, and aluminum. Additionally, mohair keratin has been accounted for to evacuate copper (9). Khosa and Ullah (10) have as of late introduced the utilization of the keratin biopolymer for the expulsion of arsenic. Additionally, Saucedo-Rivalcoba et al. (11) have proposed the utilization of polyurethane-keratin half breed films so as to ingest and expel hexavalent chromium from water. Elastic Hergenrother et al. (12) has proposed the usage of keratin as a filler in elastic pieces. This utilization of keratin related to coupling specialists expands dynamic stockpiling modulus (G) while not influencing the physical properties of the mixes. The keratin filler utilized is gotten from avian plume or quill supper, which has higher mass thickness than ground quill. The mixes of the filler are affordable and simple to process. Likewise, these are naturally agreeable in light of the fact that even a modest quantity of avian quill utilized will permit the diminished measure of non-inexhaustible fillers, for example, carbon dark, to be utilized (12). The keratin filler utilized for elastic is beta-keratin-based and water-insoluble. Keratin from quills is generally monetary, is non-harmful, has a high liquefying point, is light-weight, and is a biodegradable inexhaustible material. Subsequently, the strengthening keratin filler will help produce maintainable items that utilizations elastic, for example, tires. Diapers/Feminine Hygiene Products The spongy materials are fit for retaining body liquids, for example, pee and menses. Subsequently, the spongy materials are remembered for the items that are utilized close to the skin. Such materials can be gotten from wood mash, cellulosic strands, or artificially delivered superabsorbent (13, 18). An internal center of diapers and female cleanliness items is intended to retain water

Role of the Government Essay - 825 Words

Market Structure and the Role of the Government (Essay Sample) Content: Market Structure and the Role of the GovernmentNameInstitutionMarket Structure and the Role of the GovernmentAn industry is comprised of all firms making identical or similar products (Dewar, 2010). The kind of market structure existing in an industry depends on the number of firms and nature of competition in that industry. The four primary market structures include perfect competition, monopoly, oligopoly, and monopolistic competition (Dewar, 2010). In a perfect competition market, there are many sellers and many buyers. In this case, no particular sellers decision will impact on the market prices. In this kind of market structure, firms are price takers and products are homogeneous. A monopoly market structure exists when a single producer is the sole provider of a given product that has no close substitutes. In this kind of market, the firm is the price maker and entry and exit by other firms is blocked. In a monopolistic competition market situation, there is a l arge number of sellers offering similar but differentiated products. In this kind of industry, each firm represents just a small percentage of the total market. In addition, there market entry and exit is easy. In an oligopolistic market situation, there are few firms that produce similar or differentiated products. These firms are mainly large corporations that dominate the market. Entry into this kind of market is hard since the few existing firms enjoy great economies of scale (Dewar, 2010).A monopolistically competitive market consist a large number of small firms making similar but differentiated products (Dewar, 2010). These firms have a relatively large and flexible resource base, with extensive market knowledge. In this case, each firm depicts some kind of market control thus facing a demand curve that is negatively sloped. In the short run, firms in a monopolistically competitive market are making economic profit. The condition of free entry and exit in this market allows o ther firms to enter the market thus driving economic profits to zero in the long run. In the presence of many firms, every seller in the monopolistically competitive market pursues maximum profits by adjusting the long-run plant size and short-run production (Schotter, 2009). In this pursuit, the quantity produced equals the marginal revenue. That is, marginal cost is equal to marginal revenue. Economic profit and loss are the major driving forces for the entry and exit of firms in a monopolistic industry. In this way, the economic profits earned by firms induce the entry of other firms that in turn drive the profits to zero (Schotter, 2009).A public good refers to a product whose consumption by any one individual does not reduce its availability to another person and from which no one is excluded (Schotter, 2009). Public goods exhibit two major characteristics. These are non-excludability in use and non-rivalry in consumption. A good is non-rivalrous if one individuals consumption cannot hamper or reduce other peoples ability to consume the product. A good is non-excludable if it counterproductive and expensive to exclude some people from using it (Schotter, 2009). The failure to consider the marginal social cost of consumption usually leads to congestion of a public good. In addition, a public good is said to be indivisible. That is, a public good cannot reasonably be divided into smaller units. Public goods are mainly provided through public policies. This condition usually leads to conflicts between the interest of individual consumers and different groups. The conflict between group interest and self-interest results to an outcome, the prisoners dilemma. The prisoners dilemma kind of utility outcome corresponds to the Pareto-inferior allocation of goods in an economy (Dewar, 2010).Product differentiation exists in two types. These are artificial product differentiation and real product differentiation (Dewar, 2010). Artificial product differentiation occ urs when products provided in a market setting are the same. However, consumers are influenced through packaging, sales techniques, advertising, and other marketing activities, to perceive the products as different. Producers and manufacturers create differences in the product packaging, brand name, size, shape, and design in order to persuade the consumers. In front of artificial product differentiation, sellers exhibit some degree of monopoly power where they manipulate a product in the process of searching or making their own prices (Schotter, 2009). In the process, consumers choice of preference is affected. That is, a consumer will be willing to pay for a product depending on the sellers marketing strategy, price, and the consumers perception of a given s...

Maintaining Proper Time Management Skills - 975 Words

It is known that maintaining proper time management skills will constitute into leading a successful personal and professional life. Time management is important but is often a struggle amongst professionals; me being one of many who are struggle. After carefully analyzing my routine, I’ve noticed that I often struggle with making it to appointments in a timely manner, completing assignments long before the due date, and committing to multiple engagements at the same time. At first, I would conclude that I was just overwhelmed with my duties but later found out that my time management skills were suffering. As a working graduate student, the procrastination on given assignments and appointments increased tremendously; as expected. According to Nonis and Hudson, today’s college students are less prepared for college level work than their predecessors. (2010) Once students get to college, they tend to spend fewer hours studying while spending more hours working. (Nonis and Hudson, 2010) As years passed, many college students have more responsibilities hence the need to work while in school. With increased responsibility, priorities tend to be rearranged and an area of your life may be neglected. Both Nonis and Hudson believe that due to outside obligations, the students’ would be negatively affected academically. (Nonis and Hudson 2010) Nonis and Hudson tested they’re hypothesis by connecting the direct relationship between the time spent on academics outside of the classroomShow MoreRelatedDriven Special Competencies In The Mechanics Of Leadership703 Words   |  3 Pagesand search customer account information. Acquainted with the tensions and stages of organizational challenges during tough economic times and the need to reform and build sustainable processes. 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Chinua Achebe s Things Fall Apart Essay - 1804 Words

Cultural Things Some would say that the essential element of Chinua Achebe s Things Fall Apart is that of the struggle. The role of customs and traditions are incredibly important and decides the fate of men, women, and children. The main character Okonkwo is at odds with himself, the world, and his future throughout the story. This book deal with the obstacles arising from the conflicts of man vs. self, and man vs. society. Throughout the story Okonkwo gains morals and life lessons that change him on his journey of personal growth. Tradition Things Fall Apart is set in the 1890s, at a point when the Europeans started to colonize Africa and in particular Nigeria. This novel explorers the traditions of European literature of Africans that describe them as primitive and savages. The attitudes in novel this are rooted into our insight that the District Commissioner in the book seems familiar with most people perspectives. He is superior acting and very dismissive of people calling them savages, and totally unaware of the rich of Igbo life. Digression is at tool that Achebe s uses in abundance in the novel. The novel s central story is the tragedy of Okonkwo, to Achebe The novel is a documentary, but the energy of Achebe s narrative protects the book from reading like an anthropology text. The reader is allowed to see the Igbo people through their own eyes, as they celebrate rituals and holidays that mark important moments in the year and in the people sShow MoreRelatedChinua Achebe s Things Fall Apart1719 Words   |à ‚  7 PagesThings fall apart is a classic novel written around the turn of the century, the novel focuses on the protagonist who we can also call a hero, Okonkwo. Okonkwo is a wealthy and respected leader within the Igbo tribe of Umuofia in eastern Nigeria. Strong individual with a passionate belief in all the values and traditions of his people. 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Chronic Obstructive Pulmonary Disease System

Question: Discuss about the Chronic Obstructive Pulmonary Disease System. Answer: Introduction Chronic- obstructive pulmonary disease (COPD)is a condition that is characterized bythe air-flow limitation, which is not completely reversible (GOLD, 2010). It includes airflow obstructive diseases such as chronic- bronchitis and emphysema. In-spite of effective COPD control, the patients may experience many episodes of exacerbations affecting their physical as well as mental health. Additionally, COPD exacerbations incur a high cost and affect the pulmonary function and quality-of-life (Toy, 2010). This case study discusses about Mr. Bill McDonald, a 65 year old male who has got admitted in the hospital with chief complaints of dyspnea even at rest, increased lethargy, wheezing with chronic- productive cough producing excessive purulent- sputum and was diagnosed to have acute exacerbations of COPD. He is found to smoke one pocket of cigarettes per day for 35 years and has history of recurrent- bronchial infections. This essay discusses in detail about the pathophysiology, medical a nd nursing management for Mr. Bill with acute exacerbations including home-care considerations, community resources available and educational plan. Pathophysiology of acute and chronic COPD COPD is a condition in which the airway is obstructed by chronic bronchitis and emphysema or a combination of both (Hinkle, 2014). Any damage or inflammation in the larger airways of lungs can result in chronic- bronchitis which is referred to as a condition in which an excessive production of sputum with recurrent cough persisting for at-least three months/year for two consecutive years due to chronic smoking (Lewis, 2013). As, Mr. Bill is a chronic smoker for 35 years, the cigarette smoke has irritated the walls of bronchioles causing hyperplasia of mucous-secreting glands (including goblet cells) in the bronchi leading to increased mucus production. Moreover, the hyperplasia of cells has reduced the diameter of the airway resulting in reduced clearance of mucus. Smoking has reduced the ciliary movements causing reduced clearance of secretion resulting in sputum accumulation leading to the multiplication of micro-organism bronchiolar infections (Barnes, 2014). Because of inadequate clearance, Bill has experienced chronic cough with production of purulent sputum. Because of recurrent bronchiolar infections, more number of neutrophils with macrophages were released, which in-turn has released proteolytic enzymes leading to the destruction of alveolar tissues that again increases inflammation, edema and infectious process causing formation of exudates. More frequently, the micro- organisms have colonized in Bill leading to recurrent bronchial- infections causing excessive mucus accumulation resulting in occlusion of smaller bronchioles (Hinkle, 2014). This has increased resistance to airflow that in-turn has increased the effort of breathing leading to decreased oxygen supply to tissues causing hypoxemia. Additionally, there was a diminished respiratory drive with increased tendency to hypo-ventilate and retain CO2. Because of this, most of the lung areas are not ventilated and so oxygen diffusion could not occur leading to dyspnea both at rest and activities. Hence, Bill with chronic bronchitis requires oxygen both at rest and activities as the disease progresses. As Bill is a smoker, bronchospasm develops frequently that adds to the already existing airway resistance results in further increase in work of breathing and impaired gas exchange which is manifested by dyspnea and lethargy than usual. On auscultation, because of increased CO2 retention in lungs, the lung sounds such as scattered crackles, ronchi and wheezes were heard (Lewis, 2013). Because of smoking, an acute exacerbation of COPD has occurred in Bill, which is an event in the course of COPD that is characterized by the acute- changes in the usual clients dyspnea, cough and sputum production (Hurst, 2009, Eisner, 2010). Its severity has been ranked as level-I (treated at home), level-II (needs hospitalization), level-III (results in respiratory failure) in which Bill lies in level-II (Ghoshal, 2012). Medical management The first step to treat acute-exacerbations involves increasing the dose and frequency of short-acting bronchodilators. If it is unresponsive, bronchodilators with oral corticosteroids should be given. Short-acting 2- agonist (e.g. Salbutamol- 100-to-200 mcg) with nebulizer and Tab. Prednisolone (30mg) OD was administered for 7 days for Bill (Hurst, 2009). If there are changes in the characteristics of sputum, antibiotics should be added based on the causative bacterial-pathogen. Antibiotics should be started only for patients with sputum (Garvey, 2012). In regard to Bill, Levofloxacin (500mg daily) was administered for 11days because of the presence of Pseudomonasspp. in his sputum specimen (Currie, 2009). Theophylline might be administered in patients who are unresponsive to treatment which is not administered for Bill. Oxygen should be administered at any stage of exacerbation in the presence of hypoxemia to improve his base-line oxygenation to at-least 60 mmHg and to maintain oxygen saturation of at-least 90% (Garvey, 2012). Bill was administered with 2 liters/min of oxygen through nasal-cannula and his O2 saturation was 88% and PaO2 55 in ABG. Non-invasive positive-pressure ventilation could be used to reverse acute- respiratory failure which was not used for Bill. Nursing management As Bill was having COPD exacerbation, he was monitored for PaO2, PaCO2 with pH, at the time of admission, treatment and at the time of changes in patients condition. Pulse oximeter was connected to monitor the oxygen saturation. Oxygen was administered to Bill at the rate of 2 liters/min through nasal-cannula to maintain normal oxygen-saturation thereby to prevent occurrence of respiratory acidosis/hypercapnia. Mechanical ventilation should be started only when pH 7.35 (Ghoshal, 2012). He was monitored carefully to prevent increased CO2 washout that may lead to respiratory depression as CO2 act as a respiratory-drive for Bill (Lewis, 2013). Therefore, oxygen should be given at lower rate to prevent CO2-narcosis. Upright position was provided to expand the lungs to promote oxygenation. Bill was demonstrated to perform pursed-lip-breathing that was helpful to increase expiration so as to prevent bronchiolar-collapse with air-trapping (Lewis, 2013). He was guided to practice abdominal-breathing that helped him to use diaphragm in-stead of accessory-muscles so as to promote maximal inspiration as well as to reduce the respiratory rate. In case of abdominal-breathing, the abdomen will protrude at inspiration and contract at expiration, where the diaphragm pushes the air outside the lungs and promotes control over Bills breathing especially during dyspnea and exercises. Deep-breathing with coughing-exercise was demonstrated to promote expulsion of lung secretions so as to promote normal breathing. His position was changed once in 2 hours to prevent aspirations. Chest physiotherapy (bronchial tapping) was performed to remove excess lung secretions (Hinkle, 2014). Bill has experienced difficulty in breathing and consuming food simultaneously and hence small and frequent diet (six meals) was encouraged (Seo, 2014). He was encouraged to drink 3 liters of fluid/day to promote hydration so as to liquefy the lung secretions and promote mucus expulsion (Hanania, 2010). The fluid was given only in-between the meals but not with meals to avoid abdominal distention that might increase his dyspnea. Gas-forming and carbonated foods were avoided as they will cause abdominal distention causing dyspnea. Very cold and hot foods were avoided as it may cause coughing spasms. Home-care considerations The role of nurse is crucial in educating home-care considerations to COPD patients (Zakrisson, 2011). Bill is discharged with portable oxygen to prevent hypoxemia as he is a chronic COPD patient. Nasal-cannula (2 liters/min) was arranged for Bill as it is safe and simple to use at home and is comfortable and acceptable. It will not interfere with eating, talking, coughing, walking or moving. But, its position should be maintained to avoid dislodgement. Long-term oxygen therapy (LTOT) will help to improve neuro-psychological function, increase activity- tolerance, reduce hematocrit and decrease pulmonary-hypertension. As, Bill was stable with PaO2 of 55 mmHg and SaO2 (less than 88%), LTOT was allowed. Regular nasal-cannula was arranged to deliver O2 from central source at home. He was given with liquid O2 as it is portable and holds 6-8 hr O2 supply at 2 L/min and the reservoir will lasts for 7-10 days (Lewis, 2013). He was instructed about the methods of using oxygen at home, its importance, advantages, disadvantages and precautions to be followed. He was instructed to put the nasal straps properly and not to be too tight. Observe the ear-tops for skin breakdown and pad it, if needed (Hanania, 2010). Bill was educated to assess oral as well as nasal mucous membrane for 2-3 times/ day and advised to apply water-based gel over the nasal membrane and lips (Lewis, 2013). Encouraged to wash mouth frequently and use humidifier to avoid dryness in skin resulting in skin breakdown and infection. He was advised to remove the nasal-cannula and clean it with water for 2-3 times/ day and clean the skin carefully and observe for bruises, scratches and cuts. He was instructed to change disposable equipments regularly and to remove sputum that is coughed-out. He was advised to post No Smoking boards at home and not to use electric razors, open flames, mineral oils, blankets (wool) or portable- radios near the oxygen area and not to allow smoking in home (Lewis, 2013). He was encouraged to remain active and travel normally. Oxygen could be arranged by private companies at the destination point. If, he wishes to travel by bus, train or flight, notifications should be given to make O2 reservations. High-altitude stimulation-test should be performed in a hospital to determine the amount of O2 needed for traveling in flight. Resources available In Government, COPD National-Program as well as Lung-cancer programs are the major programs available within Lung- Foundation. They are supported by the Information with Support-Centre of Lung- Foundation which operates a toll-free telephonic number for COPD patients, care-takers and physicians to make a call and speak with team member (who can guide them to get resources and get link to the support- services) or to talk to a Lung-Care Nurse. There are other foundation areas as Respiratory-infectious diseases, Bronchiectasis registry, Multi-centre clinical-trial network, telephonic support- group and community- awareness events (Harper, 2013). Usually, home oxygen- systems are also rented from a private company, which sends a pulmonary nurse and/or respiratory therapists to the patients home. These therapists will teach about the method of using O2 system, method of caring O2 system and how to identify, when the system is getting low and needs to re-order (Lewis, 2013). The staff nurse has to make arrangements with the community-health nurse to obtain O2 equipments from an agency and receive follow-up home-care regularly. The agency will make arrangements to receive an O2 concentrator with portable tanks and concentrated O2 with oxygen regulators and supplies (20m of tubing with nasal-cannula). He was educated about basic anatomy with physiology of lung along with pathophysiology, features with complications for COPD through Australian Lung Association videos. Breathing retraining techniques as pursed-lip breathing and abdominal-breathing techniques were demonstrated. Energy-conservation methods as pacing the activities and performing pursed- lip breathing while performing activities was educated. The medication list with all the medications such as oral/ inhalant corticosteroids, antibiotics, -adrenergic receptors and anti-cholinergics was given with instructions for dosage, frequency, route, mode of action and side effects. He was demonstrated about the method of using inhaler (Lewis, 2013). He was educated about method of using oxygen at home with precautions. His family was guided to manage emotional issues as depression, anxiety, panic attacks, dependency, intimacy and interpersonal relationship issues. He was educated about COPD management plan that involves focusing on self-management and knowing features of exacerbations that may exacerbate in winter (Jenkins, 2012, Bruce, 2007). He should be educated with the need to report changes with reasons for flare-ups, recognizing features of respiratory infection and yearly follow-up. He was advised about the support and rehabilitative sources available (Casey, 2011). He was advised to avoid crowds and contact with persons with respiratory infections and to obtain influenza immunization. Conclusion Epidemiologic data indicate that chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Patients with poorly managed COPD are likely to experience exacerbations that require emergency department visits or hospitalizationtwo important drivers contributing to escalating healthcare resource use and costs associated with the disease. Exacerbations also contribute to worsening lung function and negative outcomes in COPD. The aim of this review is to present the perspective of nurse practitioners and physician assistants in terms of providing the pharmacologic and non-pharmacologic modalities needed to treat current and prevent future exacerbations. Major respiratory guidelines recommend treatment of acute exacerbations with short-acting bronchodilators, oral corticosteroids and antibiotics, as appropriate. Supplementary oxygen and/or ventilatory support may also be beneficial to selected patients. Treatments to minimize the risk of future exacerbations should include maintenance pharmacotherapies, risk-reduction measures (e.g. smoking cessation, influenza and pneumonia vaccinations), pulmonary rehabilitation, self-management support and follow-up care. Thus, this case study discusses in detail about chronic and acute COPD. I have learnt about the pathophysiological sequence of acute and chronic COPD that is caused by chronic smoking. I have learnt about the medical as well as nursing management plans of a patient with acute exacerbations of COPD. I understood about the home-care considerations of patient with portable oxygen and community-support services available with discharge plan for COPD patients. Reference Barnes, P.J. (2014). COPD, An Issue of Clinics in Chest Medicine. Retrieved from https://books.google.co.in/books?isbn=0323260918 Bruce, M.L. McEvoy, P. (2007). COPD: your role in early detection.Nurse Prac.32:2434. Casey, D., Murphy, K., Cooney, A. Mee, L. (2011). Developing a structured education programme for clients with COPD:Br J Community Nurs.16:2317. Currie, G. (2009). Chronic Obstructive Pulmonary Disease (COPD). Retrieved from https://books.google.co.in/books?isbn=0199563683 Eisner, M.D et al. (2010). Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly. An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease:Am J Respir Crit Care Med.182:693718. Garvey, C. Ortiz, G. (2012). Exacerbations of Chronic Obstructive Pulmonary Disease: Open Nurs J. 6: 1319. doi:10.2174/1874434601206010013 Ghoshal, A.G, Dhar, R. Kundu, S. (2012). Treatment of Acute Exacerbation of COPD: SUPPLEMENT TO JAPI. 60: 38- 43 GOLD- Global Initiative for Chronic Obstructive Lung Disease. (2010). Global strategy for diagnosis, management, and prevention of COPD.Retrieved from https://www.goldcopd.org/uploads/users/files/GOLDReport_April112011.pdf Hanania, N.A Sharafkhaneh, A. (2010). COPD: A Guide to Diagnosis and Clinical Management. Retrieved from https://books.google.co.in/books?isbn=1597453579 Harper, E. (2013). Lung foundation Australia: promoting lung health and supporting those with lung disease: J Thorac Dis. 5(4): 572577. doi:10.3978/j.issn.2072-1439.2013.08.39 Hinkle, J.L. (2014). Brunners and Suddarths Textbook of Medical Surgical Nursing. (13th ed.). Philadelphia: Lippincott Williams and Wilkins. Hurst, J.R et al. (2009). Temporal clustering of exacerbations in chronic obstructive pulmonary disease:Am J Respir Crit Care Med.179:36974. Hurst, J.R. (2009). Management and prevention of chronic obstructive pulmonary disease exacerbations: a state of the art review:BMC Med.7:40. Jenkins, C.R et al. (2012). Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study:Eur Respir J.39(1):3845. Lewis, S.M., Heitkemper, M. M., Dirksen, S.R. (2013). Medical Surgical Nursing: Assessment and Management of Clinical Problems. (9th ed.). Missouri: Mosby. Seo, S.H. (2014). Medical Nutrition Therapy based on Nutrition Intervention for a Patient with Chronic Obstructive Pulmonary Disease: Clin Nutr Res. 3(2): 150156. doi:10.7762/cnr.2014.3.2.150 Toy, E.L et al. (2010). The economic impact of exacerbations of chronic obstructive pulmonary disease and exacerbation definition: a review:COPD.7:21428. Zakrisson, A.B et al. (2011). Nurse-led multidisciplinary programme for patients with COPD in primary health care: a controlled trial:Prim Care Respir J.20(4):42733.