Barriers to Effective Pain Management Essay

Nurses have a unique role in alleviating the pain experienced by their patients. With their professional knowledge and regular close contacts with patients, they are ideally placed to listen and respond to any concerns. Taking time to assess the individual will allow for the development of a thrusting relationship between the nurse and patient. Accurate assessment and documentation can help to chart the multi- dimensional nature of the pain, aiding decision making and patient care planning (Mcguie 1992). Adequate control of pain is only achieved in 50% of patients in Western societies. This emphasizes that pain control is a serious problem for a great number of patients. Health care professionals, patients and the health care system itself all contribute to this problem. Other factors that add to this undesirable situation include the following: – Poor decision making on part of health care professionals – myths and misconceptions about pain and opoids – patients non compliance with treatment and their reluctance to report pain – Problems within the organization of health care Pain assessment and management is an integral part of the daily nursing routine. Health care professionals must strive to overcome the barriers to effective pain management in practice. The tendency to under medicate older adults may be related to several factors, including misguided beliefs, fears regarding complications, and a failure to assess ant treat confused older adults. It is imperative that nurses don’t act upon false misconceptions in delivering patient care. The management of pain in the elderly represents a considerable nursing challenge. This is because the elderly are more likely to experience both acute and chronic pain than their younger counterparts. Age related factors may also complicate the assessment and management of the individual’s pain. Failing sight and hearing, cognitive impairment, confusion and dementia create communication difficulties and therefore pose significant barriers to pain assessment particularly in the use of the measurement tools. Lack of knowledge of the Doctor and nurse / poor communication: An individuals pain is complex, the management should not rely on one professional clinical judgment and action. The pain control process should be interwoven between numerous health care professionals. The nurse must strive to exercise their communication skills in discussing aspects of patient care with the MDT team. A lack of confidence and knowledge are the common reasons for poor communication and teamwork. There is ample evidence to demonstrate that both nurses and doctors have poor knowledge about pain and its management. It is also known that contemporary nursing and medical education programs do not equip health care professionals with significant information on the nature of pain, the methods of pain assessments and the principles of pain management. With a lack of knowledge and basic fundamental management skills, nurses may feel unprepared to care for patients suffering from pain, and consequently make incorrect decisions regarding the management of patient’s pain. Poor decision making on behalf of the nurse can reflect on the following: âž ¢ Underestimation of the severity of the illness âž ¢ Overestimation of the effectiveness of the interventions âž ¢ Reluctance to administer parental analgesia âž ¢ Administering a low dose of opoid rather than the required dose needed to control the severity of patient’s pain. âž ¢ Nurses rarely employing non pharmacological strategies In addition, the lack of knowledge and confidence of the nurse may interfere with his or her ability to effectively communicate aspects of patient care to other health care professionals. The under educated nurse has a tendency to underestimate the MDT and doctor’s involvement in pain assessment and management. However, it is imperative that the doctor carriers out a physical examination of the patient on admission to identify the pathological causes of the patients pain. This is an imperative part of pain management and is much needed to facilitate the planning of care. The more experienced the nurse is the more inclined they are to underestimate severe pain. The less experienced nurse is more inclined to overestimate an individuals pain. The doctor’s lack of confidence and knowledge may result in him or her avoiding discussions relating to analgesia and changing the drug or dose of the opoid, irrespective of the nurse’s belief that it for the best interest of the patient. Doctors that are lacking in knowledge have a tendency to prescribe analgesia below the therapeutic level of the pain and are often reluctant to act upon the nurse. This is a serious issue that must be addressed as the nurse is often the person who knows the most information about the patient as they provide a 24 hour round the clock care to the patient. It is clear that these poor practices arise from a number of inter- related reasons. However the lack of knowledge and effective team work seems to be the central issue. In order to assure effective communication is brought to the clinical practice, efforts to increase group learning and confidence of health care professions is much needed. Role play may improve health care professional’s knowledge and collaboration skills. Interpersonal education may be effective at allowing health care professionals understand each others roles in practice. Regular education sessions in the hospital with numerous health care professions from different specialties may be a great opportunity for nurses and other health care professionals to learn together. Communication Barriers The collection of information at assessment is dependent on the nurse’s ability to communicate effectively. However, nurses commonly lack the skills required in this area. Health care professionals often expect the patients to complain spontaneously of pain and patients often assume the nurse will enquire about their pain. This is one significant issue within communication that is commonly demonstrated in practice. Certain nurses don’t even ask the patient if they are experiencing pain. This is a serious issue as patients may be reluctant to report their pain because they don’t want to appear unpopular or don’t want to distract the health care professionals from treating their condition. The omission of verbal assessment may result in these patients suffering unnecessary pain for a prolonged period of time. This can have devastating long term consequences to an individual’s health. A quantity of nurses may employ some form of verbal communication to the patient’s pain assessment. However, they usually confine the assessment to asking one question only, such as, are you experiencing any pain at present? This can be misinterpreting as the patient may be pain free lying still in bed, yet the patient may be experiencing pain on activity. In order to improve the management of pain in practice, continuous education of improving communication skills must be enforced into the clinical setting. A number of communication barriers such as deafness, blindness, and disorientated, confused and cognitive impaired persons can further complicate the assessment process. It is important to compensate for the auditory and visual impairments that the individual may have. While assessing and monitoring the patient, the nurse must position her/his face in view of the patient, speak in a slow and normal tone of voice, use large print size, and provide written instructions and aids such as glasses or hearing aids. Pain assessment should be considered a greater challenge amongst the elderly as these patients more commonly present with communication barriers. Such barriers include deafness, blindness, and cognitive impaired, unconscious and disorientated individual. Pain assessment tools are designed to suit patients with various communication barriers. Health care professionals must choose the appropriate assessment tool that would best suit the individual in pain. For example, a visual analogue scale may be more suitable for a deaf individual. The abbey scale is specially designed for the cognitive impaired individual. The nurse must validate the pain and believe that the pain is as bad as the patient reports it to be. Nurses have a tendency not to validate the patient’s pain. They tend to overestimate lower levels of pain and underestimate more severe pain. If the nurse places him or herself in the role of the family member, they may become more sensitive to the patients needs and his or her experience of pain. Commonly the nurses distance themselves from the patient which results in the nurses failing to recognize the patient’s needs. Nurses have a tendency to block communication with patients who are terminally ill or patients who have chronic pain. This is because they believe they cannot do much for the patient. Efforts to improve professionals collaboration skills with the terminally ill patients and chronically ill is fundamental. Clearly continuing education that integrates helping nurses become more sensitive to patient pain may have an important role in facilitating nurses to develop better assessment skills. Health care professional’s poor pain assessment A good assessment is the cornerstone of good control of distressing symptoms. Yet, current pain assessment practices leave much to be desired. The underestimation of the patient’s pain seems to be problematic in current practice. Nurses have developed a tendency to interfere about a person’s pain on a basis of what they observe. This may be acceptable if they confirm the validity of the interferences with the patient, however this is not happening. Poor use of verbal cues Health care professionals frequently observe patients behaviors and activities when assessing pain and consider non verbal cues as being reliable indicators of pain intensity. However, it is easy to misinterpret non verbal cues. For example the nurse tends to only regard pain as intense or severe if the patients show real intense behavioral signs. The nurse assumes the patient is pain free if such intense behavior signals are absent. Nurses need to take into account that each patient will have a unique response to pain which will be influenced by many factors including cultural beliefs and religious morals. Such patients will exhibit expressive pain behaviors such as crying and moaning, where others may adapt a stoical approach and will not express their suffering outwardly. The presence of pain is therefore not always obvious from the patient’s facial expression and non verbal cues should not be regarded as reliable indicators of pain. If health care professionals place emphasizes on non verbal cues and make interferences on the basis of what they observe, it is not surprising that they yet tend to underestimate the intensity of patients pain and over estimate the effectiveness of interventions. The use of measurement tools which provide patients with a means of quantifying their pain experience is one way of overcoming this problem in practice. However, the under use of assessment tools is a problem that needs to be addressed. Interviewing the patient who is experiencing pain is a critical component of assessment since it provides patients with an opportunity to express not only intensity of their pain but also what it means to them and the effect it has on their lives. Constraints to developing a therapeutic relationship with the patient Pain assessment should be viewed as a unique opportunity for the nurse to use effective communication skills and spend time to build a relationship with the patient. This may encourage patients to express their fears or concerns, enhancing patient assessment and therefore improving the overall goals of care. However, staff shortages and time constraints often make it difficult for the nurse to spent time with the patient and hence it is difficult to build a thrusting relationship with the patient. The fact that there is a high turnover of patients in the hospital means that nurses have little opportunity to establish and sustain a good therapeutic relationship with the patient and family.

Alpine Avalanche in Austria in 1999

The Avalanche in Austria that had killed more or less 31 people in February 1999 has been considered as the worst natural disaster during the past 30 years. The Alpine avalanche smashed into the Ischgl ski resort near the village of Galtuer. What is avalanche? Why it is happening?These two questions provide understanding on the natural disaster that most of us are not aware or are concerned. Snow Avalanche is the speedy downslide movement of snow ice associated with assorted debris such as rocks and vegetation (Definition and Characteristic-Avalanche). Avalanche happens when a bunch of snow becomes unstable; it then releases and speedily down slides either over an open or concerted area in an avalanche path. Its speed even reaches up to two hundred miles an hour and can wield a force strong enough to uproot or snap big trees or even destroy concrete structures. An avalanche may be preceded by an â€Å"air blast† that may also be capable of damaging buildings. Snow avalanche is a natural hazard along with rock avalanche, landslides, debris torrents that are all known as mountain slope hazards (McClung, David & Schaerer, Peter 2006, p. 14). These hazards presents serious problems for visitors and dwellers in mountainous terrain though mountain slope hazards are not as destructive as the so-called â€Å"big five† of the natural disasters such as earthquake, floods, tropical storms, drought, and volcanic eruptions. However, the Austrian avalanche in February 23, 1999 that claimed thirty-one lives mostly tourist from neighboring countries were said to be the worst alpine disaster in the world. Rescuers said aside from the 31 people dead, they rescued twenty-three of which eight were injured. Wendelin Weingartner, governor in the western province of Tyrol commented saying, â€Å"this is a catastrophe such as we have not had for centuries. † Eyewitness of the scene stated automobiles were trampled by big walls of snow or tossed like toy cars by the force of the avalanche. One house was sliced off its top floor as if by a giant razor blade. The disaster stranded up to seven hundred tourists in Galtuer but they were eventually flown out by the Austrian army to safety as well as the more or less 1000 foreign tourists. The impact of this avalanche was heavily felt in the village of Galtuer, which was reach, by the raging fast moving snow avalanche in a matter of only fifty seconds destroying seven modern buildings and burying fifty-seven people. The families of the victims were outraged as the village were supposed to be safe from the threat of avalanche. Galtuer was situated two hundred meters from the base of the mountains and is considered safe from avalanche based on the computerized stimulated test showing one in one hundred-fifty year event, would not reach the village. However, the massive built up of snow and the accumulation along the way as it slid down the mountain slope has grown so large at one hundred meters high when it trampled on the village. Investigation about what made the February 1999 Austrian avalanche so much worse than anything previously recorded revealed that from January 20 onwards series of severe storms brought warm, moist air from the Atlantic, which upon meeting with ice cold arctic air, resulted, to a record snowfalls of up to four meters. This was followed by very strong winds of up to one hundred-twenty kilometer per hour, which had increased the depth of snow on the mountains above Galtuer. David Waugh (2000) explains that as snowfalls, â€Å"it often forms two layers separated, as in sandwich, by a weaker layer† (p. 127). The warmer weather at Galtuer at the end of January caused melting and re-freezing until there was a much greater accumulation of snow. Although avalanche higher warning was given three times in the area, but it was quite impossible to predict the exact locations of avalanche with all the thousands slopes in the region. The build up of snow under a weak ground have made that very strong avalanche force that has brought enormous destruction on lives and properties. The February 1999 avalanche, which began at four in the afternoon of the twenty-third with a dry snow slab avalanche, fractured with a width of approximately four hundred meter. Scientist studying the nature of February 1999 avalanche discovered through a controlled experiment that avalanche increased in volume considerably as it moved downhill (Waugh 2000, p. 127). The scientist findings revealed that that the weight of snow that hit Galtuer was up to 400,000 tones and that the avalanche was one hundred meters in height and had traveled at the speed of three hundred kilometer per hour. The disastrous 1999 alpine avalanche has shown clearly that it is fundamental to have proper land use planning to protect mountain villages from the destructive effects of the snow avalanches. Walter J. Ammann, Stefanie Dannenmann, and Laurent Vulliet stated that proper planning of land use â€Å"requires a correct risk analysis procedure which implies the evaluation of the two essential components of risk: hazard and vulnerability† (Ammann, Dannenmann, & Vulliet 2006, p. 227). The vulnerability of Austrian structures and buildings against avalanche has been directly correlated to the impact pressure. However, the vulnerability component of avalanche risk is more difficult to assess because of the scarcity of suitable data to evaluate the effects of avalanches on people and properties. Despite of the efforts of the Austrian government to prevent the build up of snow in the mountain area, the incident that challenged the human capacity of creating safety standards against natural disasters prove to be no much against a simple actions of nature. The February 1999 avalanche in the village of Galtuer perhaps can be attributed to the human shortcomings despite of the prior efforts made to ensure the safety of everyone in the area, tourist and local people alike. Based on available literature, comprehensive studies were done on the characteristic and nature of avalanche only after the Galtuer incident happened. This suggest that the village of Galtuer which were assured of safety from the threat of avalanche were constantly in danger as studies done previously were not really sufficient to determine the true characteristic of avalanche. Besides, hazard zoning was inefficient as most of the destroyed houses were within green zoning which dangerous to the threats of avalanche. In this case, the February 1999 avalanche came as a big surprise costing lives and damages to properties. It was apparent that weather was particularly severe in the region with non-stop snowfalls over the duration of seven days accumulating up to 270cm. Local feedbacks about the weather condition estimates that strong winds, which are around eighty to ninety kilometer per hour, produced 10-20 tones of snow in an hour. The testimonies from survivors indicate that they were not at all expecting such tragedy would happen. A British survivor described the scenario as incredible and â€Å"absolutely terrifying† stating that a â€Å"huge cloud of snow† enclosed the village. In his article entitled, â€Å"Lessons Learnt from Avalanche Disasters† Alessandro Colombo stated that people ignored the warning believing that the situations were improbable. The 1999 Austrian avalanche was not a single disaster that happened that particular year as more avalanche occurred although not as disastrous as what happened in February 23 of that year. The two avalanches that successively and unexpectedly occurred have left many people dead and threats of new avalanches continues to bring fears and worries to people leaving in the area and tourist alike. The responsibility of the Austrian authorities is to make protect the safety of the people by enforcing necessary measures that will guarantee their safety. It is clear from this point that the authorities had not done enough to protect the people from the threat of the avalanche. Indeed, the Austrian authorities have been criticized for doing the evacuation earlier. Televisions and newspaper stated that that government should have taken more safety measures for the sake of the safety of the people, even at the cost of tourist business. Conclusions What happened in February 1999 in Austria is grim reminder that man cannot underestimate the forces of nature, which usually strike in an unexpected situation. The case of the sinking of Titanic during a very peaceful condition of sea is a further reminder that authorities cannot afford to be complacent about his accomplishment particularly when it comes to keeping the safety of the people. While the Austrian authorities admit shortcomings, the disaster had already claimed lives and wrought enormous destruction to properties. Although these events happened almost a decade ago, it is important that government take advance precautionary measures that will guaranty the safety of the people even at the expense of tourist industry. While Austrian mountain slopes continues to attract tourist from the around the world, the danger from the threats of avalanche remains. However, it is perhaps safe to assume that the lessons from the 1999 avalanche were already imbedded in the hearts and of the Austrian people. In other words, similar disasters may never happen again with the same magnitude of destruction both in humans and in properties. Reference List Ammann, J. ,W. Dannenmann, S. & Vulliet, L. (2006) Risk 21- Coping with Risk Due to Natural Hazards in the 21st London: Taylor and Francis Group Definition and Characteristic-Avalanche http://geosurvey. state. co. us/Default. aspx? tabid=399 Hopes fade to Find more Survivors from Austrian Avalanche (posted February 25, 1999) http://www. cnn. com/WORLD/europe/9902/25/europe. snow. 01/index. html McClung, D. & Scaerer, (2006) P. The Avalanche Handbook. USA: The Mountaineers Books Waugh, D. (2000) Geography: An Integrated Approach UK: Nelson Thornes

Journeys- Robert Frost

â€Å"It's the journey not the arrival that matters† as journeys are often a metaphor for that which transcends the physical realms of one's travels. It is the medium for arrival that allows for the opportunity for self-discovery. The complexities of life as revealed throughout Robert Frost's poetry, use ordinary, physical journeys in nature to demonstrate how journeys often reach beyond the physical sense in which they are composed. Similarly, the novel Thirteen Reasons Why by Jay Asher and the short film, â€Å"Harvie Krumpet,† present the plight of ordinary people and the life changing possibilities of journeys.An equally prominent theme is the occurrence of the need for changing paths as obstacles arise and the effect such change has upon the arrival. These texts demonstrate how the intended destination is often not the final destination. The composers, through the use of a variety of literary and filmic techniques show these similar themes throughout the texts. Con sequently, the composers are able to present their understanding of the concept of journeys Frost's poem, â€Å"The Road Not Taken,† is an extended metaphor for lost possibilities or missed opportunities.The persona reflects upon the impacts of a decision and, perchance, what may have been. This is evident in, â€Å"I shall be telling this with a sigh/ Somewhere ages and ages hence. † Thus, the responder can conceive the persona is dubious as to whether the right decision has been made. Furthermore, the text contains repetition of the image of two roads diverging. This symbolises the arising of pivotal moments where decision are required. This aids the responder to connect with the persona as in every part of life decisions are required and choices are often difficult to arrive at.Frost also conveys the idea that journeys have a tendency to flow smoothly whether the outcomes are positive or negative. This is portrayed through the consistent rhyme scheme throughout the stanzas. The flowing rhyme scheme enables the reader to become immersed within, and to concentrate heavily upon, the hidden meanings within the text. Balanced against this is Asher’s novel, Thirteen Reasons Why, which portrays the notion that journeys are impacted upon by the decisions that individuals make, altering the course rather than sailing smoothly along the original path.Asher suggests that the final destination constantly changes as obstacles arise and are overcome, consequently allowing for self-discovery along the path. Asher demonstrates how journeys are not a solo venture. Often journeys commence within an individual but are impacted upon by the actions of others. For instance, Hannah Baker commits suicide after constant mistreatment by her peers. Her journey commenced trying to find a sense of belonging. Unfortunately, this didn’t occur and dire consequences were to be the result.This is evident in the use of ellipses to represent hesitation, reflection and the severity of consequence when Hannah states, â€Å"Do not take me for granted†¦ again,† and, †A lot of you cared, just not enough. And that†¦ that is what I needed to find out. † As a result, the responder can connect with Hannah through empathy and the understanding that self-discovery relies heavily upon the journey and the events throughout rather than arriving at the destination. Similarly, the short film, â€Å"Harvie Krumpet,† exhibits the similar theme that obstacles will be required to be overcome.Harvie’s journey is one of self-discovery that transcends the physical realms of the loss of his parents, his migration and the development of Alzheimer’s. On the contrary to Thirteen Reasons Why, Harvie retains a positive outlook on life and this enables him to constantly strive for success. Every person is unique, thus, people undertake their own unique journeys. The responder is immediately informed Harvie is unique throug h the use of subtitles at the commencement of the film. â€Å"Some are born great, some have greatness thrust upon them – others are just different. †Harvie’s life experiences are juxtaposed with his near always-cheerful attitude. Harvie must adapt to a foreign lifestyle after migrating to Australia yet his spirit never dies. This forces the responder into self-reflection, considering things transcending the physical realms and discovering the inner strength to continue the journey. However, Harvie’s unfortunate circumstance isn’t permanent unlike the impermanency of nature as revealed in Frost’s poem, â€Å"Nothing Gold Can Stay. † Frost uses this text to demonstrate that nature’s beauty can never remain when, â€Å"Nature’s first green is gold/ Her hardest hue to hold. The effect of this couplet is to inform the responder that often what is desired can’t last. Contained within the third couplet is an allusion t o the Bible and the Garden of Eden, â€Å"Then leaf subsides to leaf/ So, Eden sank to grief. † This demonstrates how the perfection the Garden of Eden was impermanent and shows the responder that change is inescapable. The extremely simple diction of monosyllabic words throughout the entire eight-line poem helps the text to flow smoothly in the same way as â€Å"The Road Not Taken. †Frost also uses â€Å"Nothing Gold Can Stay,† to reveal how innocence changes as self-discovery occurs. Self-discovery transforms the individual and Frost uses the symbolism of a flower to demonstrate the changes occurring during life. â€Å"Her early leaf’s a flower/ But only so an hour. † Ultimately, all the composers demonstrate complimentary themes that demonstrate how it is the journey not the arrival that matters. Journeys are the medium that allows for the transcendence of physical realms and the development as an individual in the process.

Variable Costing and Samanta Shoes Research Paper

Variable Costing and Samanta Shoes - Research Paper Example Transportation costs are directly proportional to production cost. Transportation of raw materials from one area will affect the shoe price. Materials that are outsourced from remote locations will, therefore, increase the price of the shoe. Research and development costs are directly proportional to the production cost of shoes. Increased research and development will lead to higher shoe prices. Manufacturing of new shoes based on intensive research will also lead to increased shoe prices. 2. Founders’ decision making is mainly influenced by the variable costing method that is mainly affected by production levels. Variable costs are directly proportional to production levels. Absorption costing allows incomes to increase as production levels rise. Use of absorption costing by the management artificially inflates the incomes of the company (Horngren, Datar, & Rajan. p 45). Absorption costing in the period of production depicts that fewer costs are incurred and more income for the

Science Essay Example | Topics and Well Written Essays - 1000 words - 1

Science - Essay Example The results also show that there is a mix community of methicillin resistant staphylococci on the keyboards since methicillin resistant S. Epidermidis and S. haemolyticus were isolated from the computer keyboards. The investigators then concluded that even though there is low prevalence of methicillin resistant Staphylococcus aureus, their presence, coupled with high volume of traffic on these student computer terminals is a demonstration of higher risk. The public access computers have potential to act as reservoirs for Staphylococcus aureus. The hypothesis in this study was that; the prevalence of methicillin resistant Staphylococcus aureus on computer rooms and public access computers was high and the keyboards contains strains implicated in disease outbreaks. The research question was that is there high prevalence of methicillin resistant Staphylococcus aureus on computer keyboards of public access student computer terminals. The dependent variable in this study was prevalence rate of methicillin resistant Staphylococcus aureus (MRSA) while the independent variable was the specimen collected from computer terminals used by the students in secondary and post secondary school. The dependent variable which is the prevalence of MRSA was controlled by following the standard procedure in the collection, handling, inoculation and isolation of Staphylococcus aureus. In this regard the prevalence rate was only read after the growth and isolation. It is important to note that there could be many bacterial growth from samples collected from computer terminals, however, through the use of selective media, mannitol salt agar (MSA), only Staphylococcus aureus could grow. Specimens that are the independent variables were controlled by ensuring that all specimens were collected from the computer keyboards alone and a standard procedure was used to collect, label, prepare and preserve the specimen. The

Competitive Advantage at Louis Vuitton and Gucci Case Study

Competitive Advantage at Louis Vuitton and Gucci - Case Study Example This research is the best example of comparison of two brands. Both LVMH and Gucci host a number of luxurious brands which have their own individuality in terms of designing, inbound and outbound logistics, marketing and value to these companies. The most important success factor for these companies has been the valuable brands they serve. These brands have a long established history for delivering products which have been appreciated and accepted as the source of luxury. By luxury we mean products or services which have high economic value and have a limited market of the richest and elites. Both companies have cultivated strong marketing tools to ensure that their brands remain active in the market and are not renounced at any times. Furthermore, their presence and major fashion shows in major cities including New York, Paris, Milan, London, Singapore and Berlin creates a real impact for these companies. The overall impact of rejuvenating brand is increasing demand for prestigious products even at higher prices than market average. The second most important success factor is that these companies have constantly engaged in the process of evolving. From just being single business line entities they have not been hesitant to explore opportunities available in the market. This is mainly due to the inspirations and charisma of the groups’ creative directors who had long term vision for making their brands as household name. The companies have grown as conglomerate of brands with product lines in different market segments however keeping in view the value in terms of the extravagance and luxury for their users. The companies have been able to differentiate from their competitors in many ways. Most importantly is that these companies have kept a unique culture and control over the use of their brands. They have not allowed excessive franchising and licensing of their brand which would dilute their brands as experienced by some of the leading fashion brands su ch as Pierre Cardin which lost its presence in the luxury market because of the overuse of the brand in 1980s for over 800 products (Lynch, 2005). The consideration of the companies' value chains indicate that both companies aim to work with controlled suppliers

Obesity Health Advocay Campaign Research Paper Example | Topics and Well Written Essays - 750 words

Obesity Health Advocay Campaign - Research Paper Example Despite these concerns, the rate of social expenditure in alcoholic drugs and narcotics has subsequently increased and are regarded as the major factors contributing to obesity. Due to the poor health and dietary habits of most Americans, there have been campaigns developed to stop the effect of this disease. To be an effective advocate campaigner it is important first to have clear objectives on how you wish to attain your goals. For this reason it is important to get powerful individuals who have high score chances of standing against a large opponent. It is important also to understand working under the public eye involves constant scrutiny and criticism. Provision 8.1 of ANA code of ethics requires that the nursing profession be committed in promoting health and welfare and safety of all people. Our aim is to reduce the number of people suffering from obesity from current 35.7% to less than 5% in the next 10 years. This will be done through health programs aimed at promoting good diet for the community and the public in general. This will be conducted through advertisements and home visits in areas where the cases of obesity are highly prevalent. We target schools and other institutions as we aim at providing guidance on how to end up with a healthy life. We will also get the community support by making three lists of our allies, opponents and unsure people to help us identify our target audience. Before doing this it will be necessary to acquire an IRB approval since we shall be dealing with human subjects. This research will provide hotlines to all the subjects to freely report on incompetent, unethical, illegal, or impaired practice behaviors or situations. However, during this time ethical dilemmas usually arise. One can be in a dilemma on whether to launch attacks on those who are on the opponent side or not. We shall also constantly remind our nurses that each one of them is accountable for individual practice according to the

Role Of A Lawyer In Business Essay Example | Topics and Well Written Essays - 750 words

Role Of A Lawyer In Business - Essay Example Provision of ideas to the client- The lawyer may provide the necessary ideas and the advice to the client. However, the nature and the type of advice may differ depending upon the type of the client. In certain areas, the client may be extremely knowledgeable exhibiting complete mastery over the particular issue. In those cases, the advice may be limited to certain trivial and core operational areas. On the other hand, there are certain businesses where the lawyer assumes a much larger role when compared to the current role. As for example, in the areas where the business is dependent on the IPR (Intellectual Property Rights), the legality of the case become increasingly important. Thus, in cases like this, the lawyer basically plays the role of a business advisor. Other areas that can be included in the following gamut are the businesses that run out of multiple countries or sell products in multiple countries. Implementation of the determined business objectives- The successful operation of any business is dependent on the achievement of the stipulated business objectives. The attainment of those business objectives is a function of proper business decisions in the relevant areas. The lawyer has to get a fair idea about the long term goals, the mission, the vision and the objectives of the business. This may help in the determination of proper steps towards the outcome. The financial implication can also be better understood if the lawyer devises the proper strategy and the roadmap for the same. This will help the businesses to determine what is important, what is relevant and what could be used to achieve those objectives. The lawyer should help in demarcating the business issues from the legal issue so that the necessary steps could be taken without any problem. The lawyer could also look into the possible alternatives for running any business. Thereby, all the stop gap arrangements coul d be done to ensure that the business keeps on running. Protection of the interests of the client- The first and the foremost responsibility of all the lawyers is to protect the interest of the clients. The interests of the clients are varied and different. Therefore, the necessary areas of the contention are also different. The lawyer must always ensure that the proper directions are given to the client. Limitation of risk to the client- One of the most important activities of the lawyer is to ensure that the risk to the business is mitigated at all costs. All the measures should be taken by the lawyer to see that at any point of time, the business does not suffer any kind of loss. The lawyer and the business head must be able to develop a consensus on the business needs. This includes two steps, looking at the ability to diminish the effects of the quantitative risk and the effects of the risk on the business. Therefore, this complete procedure ensures that the clients and the ind ividuals are on the same page in terms of the proliferation of business.

An inconvenient truth (Movie report) Movie Review

An inconvenient truth ( report) - Movie Review Example Some men heeded Marsh’s call and forest reserves were established soon after. Meanwhile, John Muir, founder of the Sierra Club helped in the establishment of the Yosemite and Kings Canyon National Park because he believed that all living things had a part to play in the subsistence of the whole world, and must be preserved because they exist. From these early efforts sprung worldwide environmental organizations calling for a more ethical use of the earth’s resources. By 1972, out of the United Nations Conference on the Human Environment, the Stockholm Declaration was born The Declaration recognized man as both a â€Å"creature and molder† of his environment, acknowledged the role of the environment in the sustainability of mankind, and mandated man to protect his environment (United Nations Conference on the Human Environment). It demanded accountability in all citizens and communities, enterprises and institutions to shape the future of the environment. From the early awareness of the importance of nature to man’s survival came an understanding that the Earth is a living being. In 2010, the Earth Declaration (World People’s Conference on Climate Change and the Rights of Mother Earth) afforded Mother Earth with equal rights as humans. It was perhaps the first document to compel nations to reco gnize the interdependence of life on the planet and that â€Å"in an interdependent living community it is not possible to recognize the rights of only human beings without causing an imbalance within Mother Earth† (World People’s Conference on Climate Change and the Rights of Mother Earth). I mention these developments in the environmental movement because I wish to believe that climate change will not end the world, instead, it will help man discover who he truly is. George Mash once said, The fact that, of all organic beings, man alone is to be regarded as essentially a destructive power, and that he wields energies to resist which,

Liberal Democracy Fostering Development Essay Example | Topics and Well Written Essays - 2250 words

Liberal Democracy Fostering Development - Essay Example This report declares that the civil societies are useful in fostering development. They are responsible for setting the priorities of the most vulnerable in the society. With liberal democracy, according to Sen, civil societies can play their roles effectively. Democracy will allow civil societies expand their choices in the way they make the needs of the most vulnerable people in the society know. This will enable the vulnerable individuals in the society to promote their freedom from poverty, fear, and violence. Sen’s argument is that, with democracy, there would be a climate where people can complain, speak out and argue. There would be promotion of transparency. Things will we be happening in the government and individuals will be aware of. This paper makes a conclusion that from Sen's perspective, liberal democracy such as the focus on rights has proven to be important. However, in some cases such as China and South Korea, this is not the case. The most important thing to note is how liberal democracy can foster development. For example, in developing countries that are democratic, how has democracy assisted the people both socially and economically? There is a need for more participation by people in movements that advocate change of political and economic system. This paper partially agrees with Sen’s views that liberal democracy fosters development, economically, either politically or socially. Nonetheless, there is growing attack on liberal democracy because it does not allow participation and co-operation at its centre.

Military History Essay Example | Topics and Well Written Essays - 1000 words

Military History - Essay Example A Short History of the NCO is dedicated to the foundation of the NCO, its evolution, history, educational system; includes explanatory photos and tables. NCO Duties, Responsibilities, and Authorities Study Guide is a list of the main UCO duties and responsibilities which is shown in the form of questions and answers. B. The purpose of this paper is to show the role of the NCO corps and staff in the postwar history. The question demanding the answer: has the NCO played the active and appreciable role in the postwar U.S. Army history 2. A. After the World War II the constant growth of military technologies led to the necessity of new educational programs development: "Emphasis on NCO education increased to the point that by 1959 over 180,000 soldiers would attend NCO academies located in the continental United States. In addition to NCO academies, the Army encouraged enlisted men to advance their education by other means" (1). In 1950 the U.S.A. sent soldiers in Korea. The NCO soldiers took part in the war, and some of them were real heroes: "Near Surang-ni, Sergeant Ola L. Mize led the defense of "Outpost Harry." Learning of a wounded soldier in an outlying listening post, during an artillery barrage, Mize moved to rescue the soldier. Returning to the main position with the soldier, Mize rallied the troops into an effective defense as the enemy attacked in force" (2). During the war in Vietnam the NCO took a large part in combat leadership: "Needing large numbers of NCOs for combat, the Army created the Noncomm issioned Officers Candidate Course. Three branches were established at Fort Benning, Fort Knox, and Fort Sill" (2). There were also many cases of heroism among the NCO soldiers during the war: "Five times, Ashley and his newly-formed unit attacked enemy positions, clearing the enemy and proceeding through booby trapped bunkers. Wounded by machine gun fire, Ashley continued on, finally directing air strikes on his own position to clear the enemy. As the enemy retreated, he lapsed into unconsciousness" (2). B. In 1971 the NCO Educational System was introduced. Firstly it consisted of three training levels: "Basic Noncommissioned Officer Course (to provide basic leadership skills and a knowledge of military subjects needed at the squad and team level), Advanced Noncommissioned Officer Course (to provide the student with advanced technical and leadership skills), and the Sergeants Major Academy (which prepared senior NCOs to perform duties as sergeants major at the division and higher headquarters)" (2). The next rather important step of the NCO reforming took place in 1986, when was "established the Primary Leadership Development Course as a mandatory prerequisite for promotion to staff sergeant. This was the first time an NCOES course actually became mandatory for promotion" (2). In 1987 a new Sergeant Major Academy was build: "This 17.5 million dollar, 125,000 square foot structure allowed the Academy to expand course loads and number of courses" (2). Today the NCO Education

The themes and issues in Arthur Millers Essay Example for Free

The themes and issues in Arthur Millers Essay Whenever playing the part of Proctor you would have to get across to the audience that he is obviously outspoken and blunt in his view of witchcraft, but he chooses to downplay the significance of Abigails accusations. He has a tendency to remain apart from the rest of Salem, which is shown through his decision not to attend church, his rows with Parris and his facing up to the officials of the court. When acting therefore, a strong independence of character has to be shown. His tendency to remain apart from the group could be shown by the actor placing himself far away from the rest of the characters on the stage, except for Elizabeth who he truly loves and wants to please. There are individuals nowadays who, just like John, also remain far apart from todays society. These people are looked upon as being strange and odd as they question original ideas and produce their own. For example, people who think that abortions are wrong as seen as strange and peculiar. Some think it is wrong for people to have opinions for themselves and that they should stick to the rules but I think it is people like John, who stand out and get listened to, that keep our communities strong. Another side of Proctor, which would be difficult to portray on stage, is one of his greatest strengths: his manliness. I would consider this as being a challenge because although it is one of his strengths, it is also one of his weaknesses as it leads him to his affair with Abigail. The guilt he feels over this act of betrayal prevents him from speaking out soon enough and contributes to his eventual imprisonment and death. Hence, he dies a death engendered by his own strength, which gains in significance due to the weakness of others. Guilt is an emotion which most of us feel today and often affects decisions we have to make, just like the conflicts, which Proctor had to overcome. We can tell Proctor is a good man as he does what his conscience told him to do tear up the confession, which leads to his death. We also see Elizabeths actions when guilt overcomes her too. In act three she lies because she feels partly responsible for Johns looking elsewhere for love. Elizabeth is a woman who never lies but she is prepared to lie to defend Proctor because her love for him and her guilt over not treating him as well as she could. This is a good comparison on how guilt can make you react in different situations. When acting the part of Elizabeth a difference of attitude would have to be shown between act two and three. Is act two she is very suspicious of Proctor and it is obvious that she doesnt trust him which could be shown in her finding it hard to make eye contact with him and not being very affectionate towards him. In act three she feels so sorry about the way she had acted before and it is clear that she loves her husband very much.

Technology of Ultrasound Scans

Technology of Ultrasound Scans 2.1 Ultrasound 2.1.1 Physics of Ultrasound Sound is a mechanical wave that travels through an elastic medium. Ultrasound (US) is sound at a frequency beyond 20 000 Hz, the limit of human hearing. Bats orientate themselves with the help of US waves at 100 000 Hz. Ultrasound at frequencies of 200 000 Hz is used for navigation. The frequency range of diagnostic US is between 1 and 20 MHz. When sound encounters a boundary between two media of different densities some of the sound bounces back as an echo, a phenomenon called reflection. The rest of the sound continues through the medium but is deflected from its original path, this is called refraction. Acoustic impedance is the resistance of a medium to the propagation of sound and decides how much sound will be reflected at the interface between the media. Some of the energy of the sound is converted by friction into heat when propagating, this loss of energy is called absorption. When ultrasound waves encounter a surface, a small part of their energy is scattered away in random directions while most of the sound continues to propagate, a phenomenon called scatter. Reflection, refraction, impedance, absorption and scatter are all phenomena important for image formation in diagnostic ultrasound use. Artifacts, echoes that do not correspond to an anatomic structure but result from the physical properties of ultrasound propagation in the tissues, are also important to be aware of when using ultrasound. This phenomenon can also be of diagnostic help. One example is the acoustic shadowing of a gallstone, caused by total absorption of the sound by the stone. Diagnostic ultrasound is based on the pulse-echo principle. The smallest functional units of the transducer are the piezoelectric crystals. The crystals are embedded in the probe, and each crystal has a specific frequency. A pulse is initiated from each crystal in the probe and a longitudinal sound wave propagates through the body. Some of the energy is absorbed in the tissue and some is reflected. The reflected energy is received by the probe, which calculates the depth of the interface by measuring the time taken to return. We can say that the human body is composed of three basic materials differing in acoustic impedance: gas with a very low impedance, bone with a very high impedance and soft tissue with an impedance somewhere in between. The large mismatch between air and bone and tissue (â€Å"impedance mismatch†) causes 100% of the sound to be reflected at air/tissue interfaces and almost all the sound at bone/tissue interfaces. There is a small mismatch between different soft tissues in impedance, a fact that is the basis for diagnostic ultrasound. Different frequencies of ultrasound are used for different diagnostic examinations. Higher US frequencies (7-16 MHz) have higher resolution but are strongly absorbed by soft tissue and are therefore used for superficial structures. Very high frequencies (16- 20 MHz) will only travel for a few millimeters within tissue and are limited to intravascular and ocular examinations. Lower frequencies (3-7 MHz) are used for deeper structures, being less strongly absorbed and of lower resolution. There are different modes of displaying the amplitude of reflected sound waves: A- mode, M-mode and B-mode. A-mode (amplitude) calculates only the depth of the interface and is mainly of historical interest. M-mode (motion) is used to display moving structures and is used in cardiac ultrasound. B-mode (brightness) is the routine US image for most surgical applications. Here the returning echoes are displayed as shades of grey with the echo amplitudes represented by a grey level ranging from black to white. The individual image lines are stored, assessed and assembled on the monitor to create a two-dimensional B-mode image. Doppler ultrasound uses the Doppler effect. When US is reflected from a moving structure (i.e. blood) the frequencies of the waves change and the amount of frequency change is determined by the speed and direction of blood flow. The use of Doppler is obvious in vascular US but is also of use in other areas of diagnostic ultrasound. 2.1.2 History of Ultrasound Scientists, including Aristoteles, Leonardo da Vinci, Galileo Galilei, Sir Isaac Newton and Leonard Euler, have been studying the phenomena of acoustics, echoes and sound waves for many centuries. It was though not until 1877 that John William Strutt, also known as Lord Rayleigh, published a description of sound as a mathematical equation in â€Å"The theory of sound† which became the foundation for the science of ultrasound. Some years later, 1880, Jaques and Pierre Curie discovered the piezo-electric effect; that an electric potential is generated when mechanical pressure is applied to a quartz crystal, an important discovery that eventually led to the development of the modern- day ultrasound transducer which contains piezoelectric crystals. The first study of the application of ultrasound as a medical diagnostic tool was published by the Austrian brothers Karl and Friedrich Dussik in 1942. They attempted to locate brain tumours and the cerebral ventricles by measuring ultrasound transmission through the skull and concluded that if imaging of the ventricles was possible, the interior of the human body could also be visualized using ultrasound. Unfortunately it was later determined by Guttner, in 1952, that the images produced by the Dussiks were variations in bone thickness. Nevertheless, their scientific work marked the beginning of diagnostic ultrasonography in the medical field and Dussik wrote in an article a decade later: †As knife and forceps in surgery, the chemical agent in chemotherapy, the high frequency electric field in diathermy and X-ray application, so has medicine taken on a new physical tool in the last decade: the ultrasonic field†. George Dà ¶ring Ludwig, working together with Francis Struther, was the first scientist to visualize gallstones, implanted in the muscles and gallbladders of dogs, with ultrasound. His studies also resulted in the finding that the mean velocity of ultrasound in soft tissue is 1540 m/sec, a discovery that was to prove very important for future research. Much of his work was however considered restricted information, because he was employed by the military, and therefore not published in medical journals. John Julian Wild and Douglass Howry were also important pioneers in the ultrasound field. Wild was a surgeon who was able to visualize bowel wall thickness with ultrasound, and he also discovered a difference in echogenicity between benign and malignant tissue. Wild also developed transrectal and transvaginal transducers and a scanning device for screening patients for breast cancer. Howry built the first B- mode scanner in 1949 and, together with the two engineers Bliss and Posanky, he also developed the first linear contact scanner. The somascope, the first circumferential scanner, built in 1954, was also developed by Howry. The problem with these scanners was that the patient had to be immobilized and immersed for a long time. In the period 1957-58 an ultrasound scanner was developed by Howry and his colleagues where the patient was strapped to the plastic window of a semicircular pan filled with saline solution. Although not immersed, the patient had still to be immobilized for a long time. Finally, in the early 1960s, Howry developed the first hand-held contact scanner, together with Wright and E Myers. During the same time Ian Donald was carrying out ultrasound research in England and 1958 he published an article that came to be a landmark, (â€Å"Investigation of abdominal masses by pulsed ultrasound†), where he describes how ultrasound changed the treatment of a woman diagnosed with advanced gastric cancer dramatically by diagnosing a cystic mass with ultrasound; the mass was later resected and found to be a benign ovarian cyst. Donald contributed significantly to the field of obstetric and gynecological ultrasound for example by discovering the urinary bladder to be a natural acoustic window for the pelvic organs and by measuring the biparietal diameter of the fetus for the first time. A century earlier the Doppler effect had been discovered by the famous Austrian scientist Christian Andreas Doppler and presented in 1842 in a paper called ÃÅ"ber das farbige Licht der Doppelsterne und einiger anderer Gestirne des Himmels (On the colored light of the double stars and certain other stars of the heavens). In Lund, Sweden, the principal pioneers of echocardiography Inge Edler and Carl Hellmuth Hertz, developed the first echocardiogram in October 195323 . Subsequently Hertz and Ã…sberg invented the first two-dimensional real-time cardiac imaging machine 1967 and Edler and Lindstrà ¶m registred the first simultaneous M-mode and intracardiac Doppler blood flow recordings at about the same time. Ultrasound has in the last decades developed quickly and the first digital scanners were released onto the market in 1976, providing better and reproducible images. Interventional ultrasonography dates back to 1969 when Kratochwill proposed the use of ultrasound for percutaneous drainage. Regarding ultrasound for trauma the first report of the method for evaluating blunt trauma was dated 1971, by Kristenson in Germany. The development is still going on and in the light of advances in technology leading to smaller available machines combined with the prices of machines decreasing rapidly speculations have been made about the possibility that doctors in the future will routinely be equipped with their own ultrasound stethoscope for use in their daily clinical work. 2.1.3 Ultrasound Instruments It is important to have a basic knowledge in which an ultrasound image is produced. The components of scanner include Transmitter: Emits electrical impulses that strike the transducer piezoelectric crystals and cause them to vibrate thus producing ultrasound wave. Transducer: Transducer is one which converts one form of energy to another. In ultrasound it converts electric energy to mechanical energy and viceversa. It converts the electrical energy provided by the transmitter to the acoustic pulses directed into the patient. It serves as the receiver of reflected echoes, converting weak pressure changes into electric signals for processing. Receiver: When returning echoes strike the transducer face,minute voltages are produced across the piezoelectric elements. The receiver detects and amplifies these weak signals and provides a means for compensating for the differences in echo strength which result from attenuation by different tissue thickness by control of time depth compensation. Another important function of receiver is the compression of the wide range of amplitudes returning to the transducer into a range that can be displayed to the user. Scan Processor: Processor detects and amplifies the back scattered energy and manipulates the reflected signals for display. Control Console Display: Display presents the ultrasound image or data in a form suitable for analysis and interpretation. Over the years imaging has evolved from simple A mode display to high resolution real time gray scale imaging. Recording Device: Interpretation of images and archival storage of images may be in the form of transparencies printed on film by optical or laser cameras and printers, videotape or through use of digital picture archiving and communications system (PACS). Increasingly digital storage is being used for archiving of ultrasound images. 2.1.4 Transabdominal Ultrasound, Use and Limitations Transabdominal ultrasound of the female pelvis has been the conventional approach in imaging of the female pelvis. With this approach) a full urinary bladder is required to provide a window for imaging and to displace bowel gas. Transabdominal scanning (TAS) therefore required deeper penetration and a lower frequency transducer, usually 3 -5 MHz, must be used. The resolution of images is limited by the relatively lower frequency transducer that is required, and it also has great limitations in the obese lady, especially in the elderly who often cannot hold a full bladder. In the study of uterine hemodynamics in patients who are pregnant, these disadvantages may not be very significant, because the uterine arterial signal from these patients are usually strong. However, in the non-pregnant state, especially in postmenopausal ladies, studies of uterine hemodynamics with TAS could be very difficult. 2.1.5 Transvaginal Ultrasound, Advantages and Disadvantages Widespread availability of ultrasound imaging in the past two decades has dramatically changed the practice of obstetrics and gynecology. These specialists rely heavily upon this technology to make major decisions about management of their patients. Transabdominal sonography (TAS) images the pelvic organs through the anterior abdominal wall in the supra-pubic region. A distended urinary bladder is essential to displace the bowel loops and to provide an acoustic window. There are two major limitations of TAS. First is the need to use lower frequencies for imaging due to the longer distance between the transducer and the pelvic organs. Other disadvantage is the beam degrading effect of the anterior abdominal wall especially in obese patients. Both these limitations lead to degradation in image quality. To overcome these limitations of TAS special transducers, which could be introduced in the vagina, were designed in 1985. The vaginal approach reduces the distance between the probe and the pelvic structures allowing the use of higher frequencies. Trans-vaginal sonography (TVS) produces greatly improved resolution as compared to TAS, primarily due to the higher frequencies employed and also due to the absence of beam deformation by the anterior abdominal wall, Major advantages of TVS over TAS are better image quality and avoidance of patient discomfort due to full urinary bladder. Comparison of TVS and TAS is given in Table 2.1. 2.1.5.1 Indications of TVS TVS is indicated whenever a better look at the pelvic structures is required. Common indications include the following Early pregnancy Lower uterine segment in late pregnancy Ectopic pregnancy Pelvic masses Retroverted or retroflexed uterus Obese or gaseous patient Emergency cases when bladder is empty Follicle monitoring Oocyte retrieval Endometrial study to assess suitability in IVF ET techniques Cervical canal mucous Doppler examination of pelvic organs Interventional procedures The list is not exhaustive and newer indications are continuously being added. TVSTAS Full bladder Not essential Essential Probe frequency 5-7.5 MHz 3-5 MHz Resolution Very high Moderate Field of view Small Large ContraindicationsVirgins, Vaginal obstruction Premature rupture of membraneNone interventional uses Many usesLimited role Table 2.1 Comparison of TAS and TVS 2.1.5.2 Scan Technique Once the probe and the patient have been prepared, the transducer is gradually inserted while monitoring the ultrasound image. The urinary bladders normally consistent position in the pelvis relative to much more variable position of the uterus and the ovaries makes it a good landmark to use when making initial assessment of the transducer orientation. Three basic scanning manoeuvres of the probe are useful to scan the pelvic organs comprehensively: Sagittal imaging with side to side movements, 90 ° rotation to obtain semi-coronal images with angulation of probe in vertical plane, Variation in the depth of probe insertion to bring different parts within field of view/focal zone. A pelvic survey should be done first to ascertain quickly the relative position of the uterus and ovaries as well as to identify any obvious masses. This is obtained by slowly sweeping the beam in a sagittal plane from the midline to the lateral pelvic side walls followed by turning the probe 90 degrees into corona plane and sweeping the beam from cervix to the fundus. In multi-frequency probes proper selection is important for best results. Setting of appropriate focus in electronic arrays is equally important. In mechanical sector fixed focus probes the organ of interest is brought in the focal zone by changing the depth of insertion of the probe. Proper selection of frame averaging is also important. It should be low for fast moving structures like foetal heart and high for studying solid immobile tissues. For Doppler studies a steady probe position is essential and it helps if the examiners forearm is well supported. 2.1.5.3 Dynamic uses of the TVS probe The ultrasonographic examination can be enhanced by placing a hand over the lower abdomen to bring pelvic structures within the field of view/focal range of the probe. Localisation of the point of maximal tenderness by the probe will help in identifying the cause of pain. Dense pelvic adhesions can be diagnosed by the sliding organ sign. In the absence of adhesions, the organs move freely past each other and the pelvic wall in response to pressure by the TVS probe tip. Absence of this free movement may suggest pelvic adhesions. 2.1.5.4 Interventional uses of TVS There are many interventional uses of transvaginal sonography. Newer indications are constantly being added to the list. Some of the more common ones are given below:- aspiration of ova for in vitro fertilisation (IVF) aspiration of ovarian cyst drainage of pelvic collection multi-foetal pregnancy reduction non-surgical etopic pregnancy management early amniocentesis chorion villous sampling transvaginal embryo transfer sonohysterosalpingigraphy 2.1.5.5 Limitation of TVS It should be remembered that TVS provides a more limited field of view than TAS. A survey trans-abdominal scan usually be performed prior to the TVS to rule out the possibility of overlooking a mass lying outside the field of view of the TVS transducer. To avoid the need of a full bladder it has been suggested that a TVS examination may be followed by a TAS scan with bladder empty. The rationale behind this approach is that a mass lying outside the field of view of the TVS probe will be sufficient in size to be seen trans-abdominally even if the bladder is empty. The advent of the transvaginal sonography in 1985 has had a tremendous impact on the practice of obstetrics and gynaecology. The pelvic organs can now be imaged with a resolution not possible earlier. The management of infertility due to female factors depends mainly on the TVS. Addition of Colour Doppler to TVS now gives added information about the vascular supply of various pelvic organs. Details of foetal anatomy that can be depicted by TVS are far superior to that shown by TAS. As a new technique TVS has proved very useful and has a bright future.

Health Benefits of Alternative Therapies

Health Benefits of Alternative Therapies The popularity of alternative therapies in the past two decades has been accompanied by a proliferation of sociological works in investigation different aspects of this phenomenon. A major strand of the literature in the sociology of alternative medicine, which concerns three social actors: users of alternative therapies, practitioners of alternative therapies; and physicians (the orthodoxy). Research on users of alternative medicine has mainly investigated the causes of peoples use of these modalities and has focused on why people use alternative medicine? Research suggests the one reason people use alternative therapy, such as Occupational Therapy, is that they are dissatisfied with the health outcomes of orthodox medicine (Holden, 1978; West, 1988; Sharma, 1996; Spiegel et al., 1998). It is argued that conventional medicine has been unable to cure degenerative and chronic illness and has failed to alleviate pain associated with conditions such as arthritis, and back and neck injuries (Ingliss and West, 1983; Anyinam, 1990). Sharmas (1992) qualitative study of 30 users of various alternative therapies in Britain, including Occupational therapist. Provided support to the idea that patients seek alternative therapies in order to cure an illness that has not been successfully dealt with by GPs. Similarly, Furnham and Smith (1988) and Furnham and Forey (1994) in their British studies compared patients of GPs and patients of alternative practitioners and showed that the latter group was ore sceptical of the efficacy of orthodox medicine. T hey reached this conclusion based on the responses of subjects to statements such as Doctors relieve or cure only a few problems that their patients have, and Most people are helped a great deal when they go to a doctor. Other arguments have been made about the use of alternative therapies, looking at how patients arent necessarily dissatisfied with the health outcome of biomedicine, but rather they are dissatisfied with the medical encounter or the doctor patient relationship (Parker and Tupling, 1976; Taylor, 1984; Easthope, 1993). According to this argument in the literature, doctors spend too little time with, and have little respect for, their patients, who often are not informed of the nature of their illnesses, diagnoses and prognoses. It is argued that doctors have lost their human touch and todays medicine can best be characterised as Fordist medicine which produces alienated and dissatisfied patients. In support of this argument, Sharmas (1992) interviews with alternative therapists clients reveal that they believe GPs spend too little time with patients. Furnham and Forey (1994) also found that users of alternative medicine are more likely to believe that GPs do not listen to what their pa tients have to say. Health Promotion According to Nelson (1997) Occupational therapists understand the potentials of various occupational forms that are meaningful and purposeful to the individual. The therapist hopes and predicts that the occupational form will be perceptually, symbolically, and emotionally meaningful to the person; that the occupational form and the meanings the person actively assigns to it will result in multidimensional set of purposes, and that the person will engage in a voluntary occupational performance. In other words, when therapy is best, the person is full of purpose. Therefore Occupational therapists have a huge concern set around the promotion of health. Thorogood (2004) argues that sociology as a discipline is based on critical analysis and as such, can contribute to health promotion by focusing on questions that go beyond simple definition. In other words sociology can and should engage in debate around why health promotion has evolved the way it has rather then merely trying to establish a static definition of health promotion itself. In this way sociology can help health promotion to be reflective in terms of its role and development. While this means sociology is distinct from health promotion, it is none the less a crucial contributor to the development and practice of health promotion. Ryan et al (2006) approach to health promotion states that it has been hugely influenced by the fact that medicine has been the dominant model within health-service provision and a clear division exists between those who support the medical model of health and those who argue for a more holistic and/ or social model of health. Within health services, models of care are fairly well understood and well established as conceptual entities. Models of Health Care Looking at the bio-medical model, Atkinson (1988) discusses how within this model health is the absence of biological abnormality, it believes diseases have specific causes, that the human body is likened to a machine to be restored to health through personalised treatments that arrest, or reverse, the disease process, and that the health of a society is seen as largely dependent on the state of medical knowledge and the availability of medical resources. Bio-medicine and the health care practices arising from it occupy a paradoxical position in contemporary societies. On the one hand, there is continued enthusiasm for new medical breakthroughs as people seek treatment for an increasing range of conditions. On the other hand, there is also some disillusionment with clinical medicine and growing distrust of doctors etc. despite massively increased investments in medical research and health care, most of the diseases of modern society remain stubbornly resistant to effective treatment, let alone cure. Health professionals and doctors in particular, have been criticised for having a detached, impersonal approach. Some have linked this to the bio-medical model objectifying illness and reducing patients to little or more then a collection of symptoms. Critics such as Oliver (1996) have argued that more attention should be given to the social, psychological and political aspects of illness and disability. Professionals such as Occupational Therapist have responded to this by looking beyond the medical model and adopting a more person-centred approach to patient care. In this context, sociologists are interested in the ways that individual experiences of illness are shaped by wider social contexts, emphasising that the transition from health to illness involves significant changes in social status and therefore the attention of governments and an increasing number of health professionals has turned to the social and environmental influences on health giving rise to a new social- medical model approach to health based on disease prevention and health promotion. Taylor Field (2007) focuses on how health is more than the absence of disease; it is a resource for everyday living. It looks at how diseases are caused by a combination of factors, many of them being environmental. The focus of enquiry is on the relationship between the body and its environment and how significant improvements in health care are mostly likely to come from changes in peoples behaviour and in the conditions under which they live. Occupational therapists draw their attention on this model and it can be understood in there inter-related approaches. The first focuses on individual behaviour and lifestyle choices, the second looks at peoples immediate social environment, and their relationships with others and the third is concerned with general socio-economic and environmental influences. The emergence of a new philosophy sometimes referred to postmodern value system has also led to the rise in alternative therapies (Bakx, 1991; Easthope, 1993; Sharma, 1993). Today most people regard nature as caring, gentle, safe and benevolent; they hold anti-science and anti-technology attitudes (Kurtz, 1994;Park 1996); they believe in a holistic view of health (Anyinam, 1990); they reject authority, especially scientific authority, and demand participation (Taylor, 1984; Easthope, 1993; Riessman, 1994); and they believe in individual responsibility (Cassileth, 1989; Coward, 1989). Alternative practitioners, such as Occupational therapist, commonly use natural and non-invasive treatments, espouse a holistic view of health, allow patients participation in the process of healing (Aaskter,1989), and stress that health comes from within the individual and it is ultimately the responsibility of the individual to achieve a desired state of health. (Coward, 1989) Sussman (p.31) looks at the holistic concept of behaviour stresses an organic and/ or functional relationship, a continuing interaction, and a fundamental interdependence among the traditionally defined parts or areas of human behaviour. Accordingly, the understanding of any aspect of human behaviour or any human problem involves consideration of the potentialities and limitations inherent in human biology; the characteristic ways of feeling, thinking, acting, and relating to other that comprise personality; the nature of physical environment, including natural resources, topographical features, and the man-made environment; the social nature of and the impact of significant social or reference groups; the nature of culture, its potentialities and the limitations it imposes; and the significance of time and mans orientation to time as a key factor in the ordering and regulation of behaviour. In many respects, the holistic philosophy represents a reaction against certain forms of fragmentation and compartmentalisation which have characterised both scientific investigation and the approach to human problems during the first half of the 20th century. Implementation of the holistic approach is seen today in the growing body of research which crosses traditional discipline lines and in the renewed emphasis on comprehensive medicine, comprehensive mental health, and a comprehensive approach to a broad spectrum of human problems including delinquency, alcoholism, unemployment, disability etc. the holistic approach is compatible with an increasing awareness of the tendency for various forms of pathology to occur in clusters. Medical Care and Professionalism Medical care, once dominated by a restricted orthopaedic orientation, is now based on a growing recognition of the basic relationship between the anatomical, physiological, biochemical, and psychological functioning of the human body, and the reciprocal relationship between a disabled persons body functioning manifestation of his personality and his capacity to fulfil basic roles in job, family and community. In contrast, look at the study undergone by à ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦ All participants found that Occupational therapy was being underutilised. One reason provided for this was the lack of understanding about the role of OT by other staff members. Participants of this study felt that the perspective of OT as more of a rehabilitation service and less as a holistic service had an impact on the low use of OT, this being within a hospice setting. They found OT was often defined too much by exercises or functional tasks, and not recognising functional tasks become even more critical to someone who is becoming weaker and weaker and is in the process of dying. The hallmark of professionalism has been accountability for the application of expert knowledge to the service of others (Goode, 1960) Accountability includes both the obligation to answer questions regarding decisions and/or actions and the availability and applications of sanctions for illegal or inappropriate actions and behaviours (Brinkerhoff, 2004) health professionals have historically been accountable to their regulatory bodies for their autonomous exercise of professional judgment in determining services provided (Abbott, 19988). In recent years, the traditional approach to health professional accountability has been called into question for several reasons, one being escalation health expenditures (Degeling, 2000). Because all professional decisions related to health care have financial implications, this control has frequently translated into greater limits on professional practice. Occupational Therapy and Rehabilitation Sussmans (1965) work on the sociology of rehabilitation is well recognised and has the support of the American Sociological Association. The book emerged from a conference on Sociological Theory, Research and Rehabilitation held in Carmel, California in March 1965. According to Sussman, public interest in the concept of rehabilitation has greatly intensified in recent years. The term rehabilitation is being broadly applied to many kinds of disabling human problems, including physical disability, mental illnesses, mental retardation, alcoholism, drug addiction etc. Rehabilitation is used in both a limited and very comprehensive sense. It may refer to services concerned with education, physical functioning, psychological adjustment, social adaptions, vocational capabilities, or recreational activities. Occupational therapy rehabilitation can involve one of several types of therapy, used together or separately, to help patients enter or re-enter the workforce. This can include physical therapy, counselling, and job training. The overall goal of these therapies is to remedy any situation that may cause a patient to fail to perform in both personal and professional environments. Physical occupational therapy rehabilitation may be needed if a patient has been either injured or born with a physical handicap which interferes with everyday living. This can include the re-training of certain major muscle groups as well as education in using a wheelchair or other mobility aid to perform simple and complex tasks. In some more severe cases, employment may never be a possibility due to extreme physical limitations. For these patients, occupational therapy rehabilitation may act to teach them tasks as basic as eating with a fork and spoon or bathing themselves. Counselling for mentally ill, aggressive or depressed patients is also a type of occupational therapy rehabilitation. Often, an employer will require specific workers to undergo this type of treatment to help them interact more efficiently with co-workers, stay motivated on the job, or to fully rehabilitate them after a traumatic experience or depressive episode. This helps patients overcome emotional issues that may hinder job performance or social development, and allows them to effectively express issues and interact with customers or clients. Sometimes occupational therapy rehabilitation involves specific job training courses. This method may be used for mentally handicapped or brain damaged individuals, or those who have lost employment due to emotional or mental issues. Job training helps patients learn specific job related skills including how to perform basic job duties like lifting or typing, as well as how to interact with co-workers and customers. In some cases, an occupational therapist or counsellor may be hired to settle a dispute or problem between colleagues or groups within a workplace. This may include argumentative co-workers who are aggressive to the point of hindered job performance. In these situations, the therapist will teach proper coping methods for dealing with anger and jealously in the workforce in the form of individual counselling sessions, seminars, or group therapy meetings. Therapists and doctors often work together in occupational therapy rehabilitation for their patients. A combination of therapies and medications may be used in order to obtain full rehabilitative results. The primary goal of these tactics is to allow patients to live and work as normal as possible in society. Disability and Rehabilitation When looking at Occupational therapy in terms of rehabilitation, the experts agree that effective rehabilitation of the physically disabled involved helping the client to regain physical and social functions lost through injury or disease. Haber (1973) argues that disability should be conceptualised and measured by functional in capacities. Disability is then the inability to perform usual role activities as a result of a physical or mental impairment (loss of function) of long-term duration (Haber and Smith, 1971) One view of rehabilitation success is taken by Ludwig and Adams (1968) and Diamond et al. (1968) who use patient cooperation and participation in treatment as a measure of outcome. Acceptance of the sick role implies that the patient cooperate and participate in the treatment process as outlined by the experts so that he can get better (Parsons, 1951; 1975). In this context, the good and successful patient is judged to be the person who complies with the sick role. Consequently, rehabilitation success might be an artefact. There is no evidence to show that staff members tend to concentrate their efforts on those patients that they value highly or think have the best chance of demonstrating improvement (Kelman, 1964). However, appearance of patient motivation and cooperation in the rehabilitation settings does not accurately predict independent living after discharge (Kelman and Wilner, 1962). According to Nagi, when trying to define the concept of disabilities looks at the terms impairment and disability. He explores these terms by looking at how every individual lives within an environment in which he is called upon to perform certain roles and tasks. The ability and inability of people can be meaningfully understood and estimated only in terms of the degree of their fulfilment of these roles and tasks, when an individual is described as being unable the description in incomplete till it answers the question, unable to do what?. In this sense, ability-inability constitutes an assessment of the individuals level of functioning within an environment. Two categories of inability can be delineated on the basis of the time of onset. First are congenital inabilities. There are inborn limitations that are the result of anatomical malformations, physiological abnormalities, mental deficiencies, and/or general constitutional inadequacies. To be sure, abilities of all humans are subject tot limitations. Further more, Nagi argues, people differ greatly in degree of ability-inability without nec essarily suffering from an active disorder or a residual impairment. However, although the cutting point between able and unable is hard to distinguish, the more severe conditions are usually recognised. The OASI program have defined disability as the inability to engage in any substantial gainful activity by reason of a medically determinable impairment that is expected to be of long-continues and indefinite duration or to result in death. Potential for rehabilitation indicated a prognostic evaluation of the levels of functioning the individual is capable of reaching under certain circumstances. The assessment of ability-inability is obviously a necessary step toward the evaluation of rehabilitation potential. Occupational therapists ask patients to perform a variety of tasks that would require the use of different types of tools and equipment. Information sought in this evaluation includes an assessment of the following attributes: the quality and quantity of work done, physical and interpersonal work adjustment. Experience and skills, the degree to which the impairment disables the individual in the performance of certain tasks. The rehabilitation potential of the patient. Occupational therapists are informed by the physician when the risk to a patients health precluded certain tasks or the whole occupational evaluation. Criticisms. Throught the mobilisation of the efforts of a highly trained team of medical including occupational therapists, rehabilitation envisions the maximum physical, mental, social, vocational and economic recovery possible. While the goals are attained many very with each individual case, Julius Roth has questioned whether such goals should legitimately be set by the patient or the therapist. The ultimate success of the program rests upon a remarkably intriguing interplay of the biogenic, sociogenic, and psychogenic components of human behaviour The delivery of Occupational Therapy Looking at where and how occupational therapy is delivered, it is delivered in Primary and Secondary Care following the patients journey and is governed by care pathways which include formal and informal carers.  The service is equitable in access and is provided from cradle to graves. Primary care is provided for patients at first contact with the health service. By this very nature it must be generalist, being able to cope with whatever problems arise. General practitioners are the traditional primary care doctors but in recent years we have seen rise to a primary care team, including Occupational Therapist, Physiotherapist and speech therapist to name a few, offering a wider range of health professionals and their respective skills. The World Health Organisation states in its blueprint for Health for All by the Year 2000 that there should be a special emphasis on primary health care services, particularly in developing countries in which funding is even more limited. This recent emphasis on the importance of health care has further improved its status in the medical world. This is particularly true in areas in occupational therapy when there is a focus on for example, elderly in residential care, and other community care related interventions. According to Tussing Wren (2006) literature on primary care indicates a need for the following, all of which are weak or absent in the Irish system: A primary care system which addresses the health needs of a mainly healthy population rather than concentrating on intervention in episodes of illness, an emphases on disease management for the chronically ill, supportive of self-care and home care, stronger evidence-based medicine, with appropriate protocols and guidelines, peer review and quality assurance, primary care infrastructure, supportive institutions, skilled substitutions, and GP interface. On the other hand secondary care is usually specialist services that require beds, and sometimes expensive equipment. Therefore it is usually based in hospitals. For example, stroke patients may be referred to Occupational Therapist by physicians after hospitalisation. Occupational therapist might then work with them in a rehabilitation centre using specific equipment to regain independence. Emerging Services Within recent years, much emphasis has been given to the development and expansion of a variety of out of hospital services for the chronically ill. However, such demonstrations continue to be slow to develop. Among the many issues involved in these attempts are those concerning the roles to be assumed by hospital or by community based agencies in relation to the provision of community care for those disabled patients who no longer require active hospital in-patient treatment. The studyà ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦ was undertaken in order to define a more appropriate hospital role in relation to the continuing needs for rehabilitation care of a chronically ill and disabled population discharge to the community following extended hospital rehabilitation treatment. It evolved against a background of rather pessimistic clinical impressions and retrospective research probes which emphasised this populations failu re to maintain optimum health and social functioning in the community despite the achievement of these level while in the hospital. More specifically, concerns centred on this populations high rate of rehospitalisation, its deterioration in social functioning and its failure to use or to receive needed health and health related services while in the community. Acute Care Occupational therapy plays an essential role in the acute care hospital and in other medically related facilities from the rehabilitation hospital, to sub acute sites, to extended care facilities, to the facilities of the future. Though there are issues when it comes to acute care, Torrance, (1993) states that with increasing technology and quicker discharge, the need for therapeutic occupation increases. Occupational therapists are needed to work with patients in problem solving self-care occupations amidst the constraints of the tubes, monitors and fixators; to activate patients at risk because of the deleterious effects of bed rest; to help patients and caregivers plan realistically from what the patients will do and for how the patients will live and care for themselves after discharge but before healing; and to assess patients quality of life before and after hospitalisation. Nelson (1997:20) gives an example: For an example of the importance of therapeutic occupation in an acute care setting, consider a 5 month old girl born with neuromuscular disease of unknown etiology. The disease is characterised by the total absence of many of the proximal muscles, including those responsible for respiration. Picture her with multiple intubations for respiration and nutrition and with life-support monitors. The occupational therapist carefully removes her from the crib and bounces her gently while talking to her in high-pitched, rhythmical tones. In response to this occupational form, the infants adaptions are to learn to use the muscles controlling her vocal cords as she imitates the therapist; to learn to use the remaining muscles in her left arm as she grabs the therapists keys; and most of all to begin to learn that she too has a legitimate place in the human family. The therapist next places a piece of cloth playfully over the childs face, as in our prior example of the importance of peek-a-boo in healthy development. Like a health baby, this baby too removes the cloth and laughs. Despite the high technology setting, this baby also needs to encounter the occupational form of peek-a-boo in order to develop a sense of self and a sense of other. Therefore Occupational models of practise are needed for the acute care hospital for patients at all points on the lifer span. Since many health problems require a level of medical treatment and personal care that extends beyond the range of services normally available in the patients home, modern society has developed formal institutions for patients care intended to help meet the more complex health needs of its members. Here, much of an occupational therapist work is carried out. Usually in rehabilitation centres within the hospital. Looking at the hospital in more detail, the work of Cockerham (2007) draws on how it is the major social institution for the delivery of health care in the modern world, and how it offers considerable advantages to both patients and society. From the individuals point of view, the injured or sick person has access to centralised medical knowledge and the greatest array of technology within the hospital, and from the standpoint of society, as Renee Fox and Talcott Parsons (1952) argue, that when patients are within the hospital they are protecting their family from many disruptive effects of caring for the ill in the home and operates as a means of guiding the sick and injured into medically supervised institutions where their problems are less disruptive for society as a whole. Many other concepts of Parsons have been criticised, taking his concept of the sick role, it has been argued that Parsons model cannot be applied to chronic illnesses from which patients cannot recover. More significantly, it had been shown that access to the sick role is rather more problematic that Parsons model assumes. It has been suggested that parsons is really talking about a patient role rather then a sick role as there is a distinction between patients subjective experiences of illness and being objectively defined by doctors as having a disease. It is true to say Occupational therapy rejects a lot of Talcott Parons sick role ideas, who believes that when an individual is in the sick role he or she is exempt from responsibility for the incapacity, as it is beyond their control, and is also exempt from normal social role obligations. While this is true to say, Lober (1975:214) observes that while the patient is in the hospital there is an idea of voluntary cooperation , one to one intimacy, and conditional permissiveness, for example, being temporarily excused from normal social activities on the condition of seeking medical advice and care. Coe (1978) has also argued that acceptance is the most common form of patient adjustment to hospital routine and the most successful for short-stay patients, which most patients seeking Occupational therapy are, as the main aim is to get the patients back into society. Chronically Ill and Care According to Oliver (1996), as societies modernise the burden of disease is shifting from acute to chronic long-term illness and disability. While clinical medicine can treat many of these chronic conditions, it cannot cure many of them, and thus more and more people are spending a greater proportion of their lives coping with illness. Occupational therapist deal with many terminally ill patients. According to à ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦.. Individuals with terminal illness face a number of problems related to social, emotional, spiritual and their physical well-being. Some individuals have expressed that the feeling of being a burden to family and friends is more distressing than physical pain (Lloyd, 1989). Carey, 1975 looks at how these individuals with terminal illnesses find the biggest challenges in looking for satisfactory meaning in their new life situation whole facing mortality. Care for these patients has come along way, as in the past the care had primary focus on alleviating only the physical distress of the illness. Kubler-Ross (1997) describes how physicians, who are held back by their own views and feeling on death, are often unable to reach out to their dying patients to provide them with care and comfort. Therefore death in the past was almost seen as a failure of medicine. This ideology began to change with the emergence of the hospice in 1967 by De Cicely Saunfers, who founded St. Christophers hospice. Today we can recognise the hospice as a specialised facility for the care of dying patients that supports them in living life fully and comfortably while confronting death (National Hospice Organisation, 1996). The American Occupational Therapy Association (AOTA) (1998) states the following inn relation to occupational therapy and the hospice: The AOTA affirms the right of a dying person to have access to a caring community within the health care system and believes in the need for personalised care of the dying individual throughout the course of a terminal illness. Occupational Therapy is based on the belief that all individuals engage in occupationsà ¢Ã¢â€š ¬Ã‚ ¦ Occupational therapy practitioners are uniquely qualified to help the dying person continue to engage in meaningful daily occupations within the hospice community of care. (p.872) When a patient who has a terminal illness continues to lose their ability to care for themselves and carryout usual daily activities, fostering the patients independence in self-care, work, and leisure usually becomes a top priority of intervention (Holland Tigges, 1981; Tigges, 1983; Tigges Marcil, 1988). Tigges (1983) explains a framework that looks at the human need of mastery-productive use of tie, energy, interest, and attention, this is also known as the occupational role of performance paradigm (9.163). Although some individuals with terminal illnesses are able to maintain many of their usual roles, its not always true for others. According to Gammage, McMahon, and Shanahan (1976), occupational therapist have a unique role in assisting patients to accept their new role as an individual with an illness and relinquish old occupational roles. Not only do occupational therapists focus on roles los