How the Dow Jones Industrial Average Is Calculated

How the Dow Jones Industrial Average Is Calculated On the off chance that you read the paper, tune in to the radio, or watch the evening news on TV, you have likely caught wind of what occurred in the market today. Its all fine and great that the Dow Jones wrapped up 35 focuses to close at 8738, yet what does that truly mean? What Isâ the Dow? The Dow Jones Industrial Average (DJI), usually just alluded to as basically The Dow, is a normal of the cost of 30 unique stocks. The stocks speak to 30 of the biggest and most broadly traded on an open market stocks in the United States. The list gauges how these organizations stocks have exchanged throughout a standard exchanging meeting the financial exchange. It is the second-most established and one of the most referenced financial exchange record in the United States. The Dow Jones Corporation, the heads of the list, adjusts the stocks being followed in the list occasionally to best mirror the biggest and most broadly exchanged supplies of the day. The Stocks of the Dow Jones Industrial Average As of April 2019, the accompanying 30 stocks were constituents of the Dow Jones Industrial Average list: Organization Image Industry 3M MMM Aggregate American Express AXP Purchaser Finance Apple AAPL Purchaser Electronics Boeing BA Aviation and Defense Caterpillar Feline Development and Mining Equipment Chevron CVX Oil and Gas Cisco Systems CSCO PC Networking Coca-Cola KO Drinks Dow Inc. DOW Concoction Industry ExxonMobil XOM Oil and Gas Goldman Sachs GS Banking and Financial Services The Home Depot HD Home Improvement Retailer IBM IBM PCs and Technology Intel INTC Semiconductors Johnson JNJ Pharmaceuticals JPMorgan Chase JPM Banking McDonald's MCD Inexpensive Food Merck MRK Pharmaceuticals Microsoft MSFT Purchaser Electronics Nike NKE Clothing Pfizer PFE Pharmaceuticals Procter Gamble PG Purchaser Goods Voyagers TRV Protection UnitedHealth Group UNH Overseen Healthcare Joined Technologies UTX Aggregate Verizon VZ Media transmission Visa V Customer Banking Walmart WMT Retail Walgreens Boots Alliance WBA Retail Walt Disney DIS Broadcasting and Entertainment How the Dow Is Calculated The Dow Jones Industrial Average is cost arrived at the midpoint of implying that it is processed by taking the normal cost of the 30 stocks that contain the list and isolating that figure by a number called the divisor. The divisor is there to consider stock parts and mergers which additionally makes the Dow a scaled normal. On the off chance that the Dow werent determined as a scaled normal, the record would diminish at whatever point a stock split occurred. To represent this, assume a stock on the list worth $100 parts is part or isolated into two stocks every value $50. On the off chance that the executives didn't consider that there are twice the same number of offers in that organization as in the past, the DJI would be $50 lower than before the stock split since one offer is currently worth $50 rather than $100. The Dow Divisor The divisor is controlled by loads set on all the stocks (because of these mergers and acquisitions) and therefore, it changes frequently. For instance, on November 22, 2002, the divisor was equivalent to 0.14585278, however as of September 22, 2015, the divisor is equivalent to 0.14967727343149.â This means in the event that you took the normal expense of every one of these 30 stocks on September 22, 2015, and separated this number by the divisor 0.14967727343149, youd get the end estimation of the DJI on that date, which was 16330.47. You can likewise utilize this divisor to perceive how an individual stock impacts the normal. As a result of the equation utilized by the Dow, a one point increment or abatement by any stock will have a similar impact, which isn't the situation for all records. Dow Jones Industrial Average Summary So the Dow Jones number you hear on the news every night is basically this weighted normal of stock costs. Along these lines, the Dow Jones Industrial Average should simply be viewed as a cost in itself. At the point when you hear that the Dow Jones went up 35 focuses, it just implies that to purchase these stocks (considering the divisor) at 4:00 p.m. EST that day (the end time of the market), it would have cost $35 more than it would have cost to purchase the stocks the day preceding simultaneously.

Deception Point Page 41 Free Essays

Making the furious waterway of air significantly additionally startling to Tolland was the slight downwind grade of the ice rack. The ice was slanted marginally toward the sea, two miles away. In spite of the sharp spikes on the Pitbull Rapido crampons connected to his boots, Tolland had the uncomfortable inclination that any stumble may leave him got up to speed in a storm and sliding down the unending frigid slant. We will compose a custom article test on Trickiness Point Page 41 or on the other hand any comparable subject just for you Request Now Norah Mangor’s two-minute course in ice sheet security presently appeared to be perilously deficient. Piranha Ice hatchet, Norah had stated, securing a lightweight T-formed instrument to every one of their belts as they prepared in the habisphere. Standard cutting edge, banana edge, semitubular sharp edge, sledge, and adze. All you have to recollect is, in the event that anybody slips or becomes involved with a blast, snatch your hatchet with one hand on the head and one on the pole, slam the banana cutting edge into the ice, and fall on it, planting your crampons. With those expressions of affirmation, Norah Mangor had joined YAK belay bridles to every one of them. They all wore goggles, and took off into the evening haziness. Presently, the four figures advanced down the icy mass in an orderly fashion with ten yards of belay rope isolating every one of them. Norah was in the number one spot position, trailed by Corky, at that point Rachel, and Tolland as stay. As they moved more distant away from the habisphere, Tolland felt a developing anxiety. In his swelled suit, albeit warm, he felt like a clumsy space explorer trekking over a far off planet. The moon had vanished behind thick, surging tempest mists, diving the ice sheet into an invulnerable darkness. The katabatic breeze appeared to get more grounded continuously, applying a consistent strain to Tolland’s back. As his eyes stressed through his goggles to make out the sweeping vacancy around them, he started to see a genuine threat in this spot. Excess NASA wellbeing precautionary measures or not, Tolland was astonished the executive had been happy to chance four lives around here rather than two. Particularly when the extra two lives were that of a senator’s little girl and a renowned astrophysicist. Tolland was not astonished to feel a defensive worry for Rachel and Corky. As somebody who had captained a boat, he was accustomed to feeling answerable for everyone around him. â€Å"Stay behind me,† Norah yelled, her voice gulped by the breeze. â€Å"Let the sled lead the way.† The aluminum sled on which Norah was moving her testing gear took after a larger than average Flexible Flyer. The art was prepacked with analytic rigging and wellbeing embellishments she’d been utilizing on the ice sheet in the course of recent days. Every last bit of her rigging including a battery pack, wellbeing flares, and an incredible front-mounted spotlight-was bound under a made sure about, plastic covering. Regardless of the overwhelming burden, the sled skimmed easily on long, straight sprinters. Indeed, even on the practically vague slope, the sled moved downhill voluntarily, and Norah applied a delicate limitation, as though permitting the sled to lead the way. Detecting the separation developing between the gathering and the habisphere, Tolland investigated his shoulder. Just fifty yards away, the pale arch of the vault had everything except vanished in the tempestuous darkness. â€Å"You at all stressed over finding our direction back?† Tolland hollered. â€Å"The habisphere is nearly invisi-† His words were stopped by the boisterous murmur of a flare lighting in Norah’s hand. The abrupt red-white gleam lit up the ice rack in a ten-yard range surrounding them. Norah utilized her heel to dive a little impression in the surface day off, up a defensive edge on the upwind side of the opening. At that point she slammed the flare into the space. â€Å"High-tech bread crumbs,† Norah yelled. â€Å"Bread crumbs?† Rachel asked, protecting her eyes from the abrupt light. â€Å"Hansel and Gretel,† Norah yelled. â€Å"These flares will most recent 60 minutes a lot of time to discover our direction back.† With that, Norah took off once more, driving them down the ice sheet into the obscurity indeed. 47 Gabrielle Ashe raged out of Marjorie Tench’s office and for all intents and purposes thumped over a secretary in doing as such. Embarrassed, all Gabrielle could see were the photos pictures arms and legs entwined. Countenances loaded up with joy. Gabrielle had no clue how the photographs had been taken, however she realized damn well they were genuine. They had been taken in Senator Sexton’s office and appeared to have been shot from above as though by concealed camera. Lord have mercy on me. One of the photographs demonstrated Gabrielle and Sexton having intercourse legitimately on the senator’s work area, their bodies spread over a dissipate of authentic looking reports. Marjorie Tench found Gabrielle outside the Map Room. Tench was conveying the red envelope of photographs. â€Å"I expect from your response that you accept these photographs are authentic?† The President’s senior counsel really appeared as though she was making some acceptable memories. â€Å"I’m trusting they convince you that our other information is precise too. They originated from the equivalent source.† Gabrielle felt her whole body flushing as she walked a few doors down. Where the damnation is the exit? Tench’s bumbling legs experienced no difficulty keeping up. â€Å"Senator Sexton vowed to the world that both of you are dispassionate partners. His broadcast explanation was entirely convincing.† Tench motioned egotistically behind her. â€Å"In reality, I have a tape in my office if you’d like to invigorate your memory?† Gabrielle required no boost. She recalled the question and answer session very well. Sexton’s forswearing was as determined as it was ardent. â€Å"It’s unfortunate,† Tench stated, sounding not in the slightest degree baffled, â€Å"but Senator Sexton looked at the American individuals in the eye and told an unabashed deception. General society has an option to know. What's more, they will know. I’ll make sure by and by. The main inquiry currently is the means by which the open discovers. We accept it’s best originating from you.† Gabrielle was shocked. â€Å"You truly think I’m going to help lynch my own candidate?† Tench’s face solidified. â€Å"I am attempting to take the high ground here, Gabrielle. I’m allowing you to spare everybody a ton of humiliation by holding your head high and coming clean. All I need is a marked explanation conceding your affair.† Gabrielle held back. â€Å"What!† â€Å"Of course. A marked proclamation gives us the influence we have to manage the representative unobtrusively, saving the nation this appalling chaos. My offer is basic: Sign an announcement for me, and these photographs never need to see the light of day.† â€Å"You need a statement?† â€Å"Technically, I would require an affirmation, however we have a public accountant here in the structure who could-â€Å" â€Å"You’re crazy.† Gabrielle was strolling once more. Tench remained next to her, sounding increasingly furious at this point. â€Å"Senator Sexton is going down somehow, Gabrielle, and I’m offering you an opportunity to escape this without seeing your own stripped ass in the first part of the day paper! The President is a better than average man and doesn’t need these photographs advanced. On the off chance that you simply give me an affirmation and admit to the issue on your own terms, at that point we all can hold a little dignity.† â€Å"I’m not for sale.† â€Å"Well, your competitor positively is. He’s a risky man, and he’s breaking the law.† â€Å"He’s violating the law? You’re the ones breaking into workplaces and taking unlawful observation pictures! Have you ever known about Watergate?† â€Å"We had nothing to do with social event this soil. These photographs originated from a similar source as the SFF crusade subsidizing data. Someone’s been watching both of you very closely.† Gabrielle tore past the security work area where she had gotten her security identification. She ripped off the identification and hurled it to the wide-looked at watch. Tench was still on her tail. â€Å"You’ll need to choose quick, Ms. Ashe,† Tench said as they approached the exit. â€Å"Either present to me an affirmation conceding you laid down with the representative, or at eight o’clock this evening, the president will be compelled to open up to the world about everything-Sexton’s monetary dealings, the photographs of you, the works. What's more, trust me, when the open sees that you sat around and let Sexton lie about your relationship, you’ll go down on fire directly next to him.† Step by step instructions to refer to Deception Point Page 41, Essay models

Know Money, Win Money! Episode 16 Chicago Auto Show

Know Money, Win Money! Episode 16 Chicago Auto Show Know Money, Win Money! Episode 16:  Chicago Auto Show Know Money, Win Money! Episode 16:  Chicago Auto ShowVroom! Vroom! Honk! Get out of the way or get in the car, because we’re on our way to the newest episode of Know Money, Win Money. Yes, we went to the Chicago Auto Show for our latest quiz-em-up.Although they still didn’t have any flying cars, there was a car dressed up to look like an X-Wing from Star Wars, so well take what we can get. Did the attendees have a trunk full of car knowledge, or were they running on empty?Owning a car can be very pricey. Every piece seems to be as expensive as diamonds to replace, without being nearly as indestructibileâ€"hence the need for replacing. Gas can be expensive too, as can car-washes, detailing, and even air fresheners, depending on the scent.But how much does it cost in a year, on average, to own a car? Quite a bit. $8,500, in fact. You could  could certainly  find a used car for much cheaper than that. Well, not necessarily a functioning used car, mind you, but it would definitely be a metal box of some sort, and it would come with at least three wheels.  Either way, it’s enough to make you fall in love with public transportation.Given how much it costs to own a car, one would hope that a majority of American households would find a way to go without an automobile. One would be hoping in vain, howeverWe next  asked what percentage of American households have cars, and the answer is: a lot. Turns out that a whopping 95 percent of American households have a car. Yowzers!Maybe we should grind up some of those cars to build public transportation that stretches from the densest of cities to the most rural of mountain tops. Then again, Mad Max: Fury Road wouldnt really work if all the characters had to  take the bus, so there are pros and cons on both sides.That’s all for now! We’ve gotta  hit the road and get working on the next episode of Know Money, Win Money.If this is your first time  watching Know Money, Win Money, welcome! Here are some other recent epi sodes you can check out:Episode 15: Con Alt Delete (Part 2)Episode 14: Winter BrewfestEpisode 13: Con Alt DeleteWhere would you like to see us go in future episodes? We want to hear from you! You can  email us, or you can find us on  Facebook  and  Twitter

Impacts of Ocean Warming and Acidification on Coral Reefs - Free Essay Example

Sample details Pages: 2 Words: 609 Downloads: 8 Date added: 2019/03/14 Category Ecology Essay Level High school Tags: Global Warming Essay Did you like this example? For many decades, ecosystems in the world have experienced climate changes. These changes include sea levels rising, the increase of temperature, and widespread coral bleaching. Climate change is the change in temperature of our earth that is caused by human activity. Don’t waste time! Our writers will create an original "Impacts of Ocean Warming and Acidification on Coral Reefs" essay for you Create order One of these climate change catastrophes is ocean warming and acidification on coral reefs. Coral reefs are Anthozoa invertebrates of the phylum Cnidaria, made up of calcium carbonate skeletons. Coral reefs range from thousands of different species, making them a unique part of the marine world. Corals reef create symbiotic relationships with other organisms by providing shelter, food, and protection for several organisms even though they risk their own life. Corals are found in tropical islands, surrounded by clear waters which are susceptible to strong tropical storms (Hodgson et al. 560). It is best for coral reefs to be near the sand shore to receive sunlight to make photosynthesis. This allows corals to grow, as well as avoid strong water movements (Hodgson et al. 560). Coral reefs are rich with nutrients, which makes them a vital ecosystem. A vital ecosystem is a system that contains benefits to other environments. These benefits include ecological and economic benefits. Some economic benefits are commercial fisheries, tourism, and protection of shorelines. Commercial fisheries examples reside in Hawaii, an island that benefits from coral reefs due to food security, primary and secondary consumers, and cultural practices. Hawaiian fisheries provide the land $10.3 to $16.4 million annually, which is then broken down into commercial sales (Grafeld et al. 2017). An ecological benefit with tourism industries resides in the Maldives. In the Maldives, tourism is highly attracted due to its beautiful beaches which contain coral reefs. At least one million tourists are received in the Maldives, which gives them an increase in gross domestic products annually. With ecological benefits, coral reefs produce final coral sand and protect shorelines from wave energy and erosion. (Reguero et al. 147). The ocean acidification in coral reefs is caused by carbon dioxide that dissolves in water, products of human activity and release of carbon dioxide in the atmosphe re. PH levels are affected, which changes their environment since they require a certain amount of pH for the ecosystem to function. If the pH levels are not met, corals run out of zooxanthellae algae that provide oxygen (Manzello et al. 521). This affects the growth of coral reefs since too much of the pH levels in the water will cause a strong acidity, making the corals vulnerable to growth. Carbon dioxide also causes ocean warming. Ocean warming negatively impacts coral reefs since heat pressure consumed by the coral reefs result in a release of the zooxanthellae algae (Carilli et al. 2012). When the algae is released, the color of the coral reef changes known as coral bleaching. If greenhouse gas effects were not associated with the carbon dioxide in the atmosphere, the earth’s atmosphere would not accelerate global warming as it is today. Most global warming issues can be avoided if every individual was determined to make a change. Some of the steps that we can contribute to saving our planet are to use LED light bulbs for our home, reduce the excessive amount of food containing meats, maintaining your car tires, and reduce the excessive use of water. These steps help our surrounding maintain healthy, as well as respect nature for what it is. Even though this may be difficult to always think about in our daily routines, small changes in behavior can make a huge difference during our lifetime. As for coral reefs, it is best to recycle and pick up trash during beach vacations so that we do not add more stress to their environment.

Barbie s Role Models Represent The Unobtainable Physique

Growing up, I played with Barbie. Barbie had her own house, car and airplane. She had clothes and shoes for every occasion. She was independent and successful. She was tall, blonde and beautiful. She was everything I hoped to be as an adult. Barbie continues to be a role model for many little girls today. Little boys have their own role model, G.I. Joe. He is strong, a warrior, the good guy. Unfortunately, these iconic role models represent the unobtainable physique. Their body shapes are unrealistic. Perceiving these toys as physical role models has become detrimental to the health of children because when they fail to size up, or down, to these figures, serious illnesses, disease and even death can occur. Children are†¦show more content†¦However, these measurements are based upon a woman with a height of 6’1†. When I was a child, some 40 years ago, the average height of a woman was approximately 5’3.5†, as determined by the Centers f or Disease Control and Prevention (CDC). That average height has not changed much through the decades. Today, it is approximately 5’4† (Ogden, 10). It should be noted, the average weight for a woman with a height of 5’4† ranges from 115 to 140 pounds, well above Barbie’s weight of 100 pounds at 6’1†. The average weight for a woman of Barbie’s height of 6’1† ranges from 145 to 190 pounds. Table 1. Barbie doll Real Life Measurements Barbie doll real life measurements Type of doll Modern Vintage Body shape: Super-skinny type of hourglass (explanation) Dress size: 0 0 Breasts-Waist-Hips: 32-22-33†³ (81-56-84cm) 35-22-32†³ (89-56-81cm) Bra size: 30B 32C Cup size: B C Height: 6’1†³ (185 cm) 6’1†³ (185 cm) Weight: Both about 100 lbs (45 kg) Natural breasts or implants? Could be natural (how do we know this?) Source: Barbie doll. Body Measurements. The South Shore Eating Disorders Collaborative (SSEDC), through the National Eating Disorder Association (NEDA), contradicted these findings and created the Get Real Barbie campaign based upon the writings of Margo Maine, Ph.D. They utilized Barbie’s measurements and related them to a human woman. Based upon a height of 5’9†, which is still well above the average, Barbie would have a waist of 18†,

Case Study †Appendicitis Free Essays

I. DEFINITION/PREVALENCE Acute disease of the GI tract may be caused by the pathogen itself or by a bacterial or other toxin. Acute inflammatory disorders such as appendicitis and peritonitis result from contamination of damaged or normally sterile tissue by a client’s own endogenous or resident bacteria (Lemone and Burke, 2008, page 766). We will write a custom essay sample on Case Study – Appendicitis or any similar topic only for you Order Now Appendicitis is the inflammation of the vermiform (wormlike) appendix; the appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve, which is the beginning of the large intestine. It is usually located in the right iliac region, at an area designated as McBurney’s point. McBurney’s point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant. It is the usual site for localized pain and rebound tenderness due to appendicitis during later stages of appendicitis. The function of the appendix is not fully understood, although it regularly fills and empties digested food. Some scientists have recently proposed that the appendix may harbor and protect  bacteria  that are beneficial in the function of the human colon. Appendicitis  is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign may be elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. It is the most common reason for emergency abdominal surgery, affecting 10% of the population. Although appendicitis affects a person at any age, the peak incidence is between the ages of 20 and 30 years old in which the vast majority of clients are most common in adolescents and young and slightly more common in males than females. About 7% of the population will have appendicitis at some time in their lives (Lemone and Burke, 2008 page 766). The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal Pyle phlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37. 7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. II. TYPES/CLASSIFICATION Appendicitis can be classified as simple, gangrenous, or perforated, depending on the stage of the process. In simple appendicitis, the appendix is inflamed but intact. When areas of tissue necrosis and microscopic perforations are present in the appendix, the disorder is called gangrenous appendicitis. A perforated appendix shows evidence of gross perforation and contamination of the peritoneal cavity (LeMone Burke, 2008 page 766). Peritonitis can be primary or secondary. Primary peritonitis is an acute bacterial infection that is not associated with perforated viscus, or organ. Bacterial infection is the usual cause and may be associated with an infection by the same organism somewhere else in the body, which reaches the peritoneum via the vascular system. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in the body, is a type of primary peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a perforated organ, often manifest peritonitis, which may be due to leakage of bacteria through the wall of the intestine. Secondary peritonitis is usually caused by bacterial invasion as a result of perforation, or rupture of an abdominal viscus. It can also result from severe chemical reactions to: pancreatic enzymes, digestive juices, or biles released into the peritoneal cavity (Gould Dyer, 2011). III. DEMOGRAPHIC PROFILE Patient’s name is Mr. Ruptured Acute Appendicitis, 24 years old, male, residing at 820 General Kalentong, Daang Bakal, Mandaluyong City. He is the second child among 3 siblings, a Roman Catholic, single, a 3rd year college Information Technology student. IV. FAMILY MEDICAL HISTORY (Family Genogram)COD: TB COD: TB A: 83 -S, -D A: 83 -S, -D Not Recalled Not Recalled c c A: 20 +S, +D A: 20 S, +D A: 24 +S, +D A: 24 +S, +D A: 27 -S, -D Skin allergy A: 27 -S, -D Skin allergy A: 42 +S, +D A: 42 +S, +D A: 64 +S, +D HPN, Stroke A: 64 +S, +D HPN, Stroke c c A: 46 -S, +D Asthma A: 46 -S, +D Asthma A: 51 -S, +D A: 51 -S, +D patient patient LEGEND: LEGEND: male male married married deceased male deceased male S- smoker D- drinker COD- cause of death S- smoker D- drinker COD- cause of death female female deceas ed female deceased female V. PAST MEDICAL HISTORY He was first hospitalized last 2006 due to dengue at the same hospital: Mandaluyong City Medical Center (MCMC). He has no other further illnesses except the typical fever, cough and cold. Other than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 week prior to admission patient experienced abdominal pain all over abdomen. He consulted at ER MCMC signed out AUPD (Acute Peptic Ulcer Disease) and was given Omeprazole HNBB (Buscopan). Whole abdominal ultrasound done and revealed tiny cholecystolethiasis. He was given Diclofenal and HNBB tab and eventually discharged. Few days prior to consultation, the patient still experienced abdominal pain. He consulted at Emergency Room and was opted for surgical intervention – EXPLORATORY LAPAROTOMY APPENDECTOMY under the service of Dr. Abram Del Valle, M. D. VII. GORDON’S PHYSICAL ASSESSMENT i. Health Maintenance – Perception Pattern Before admission: The patient used to smoke cigarette 3 sticks per day. And he also drinks alcohol daily specifically beer of more than 2 bottles per session. He was not using drugs and he has no allergies at all. During time of care: The patient is not smoking cigarette or drinking alcohol. ii. Nutritional – Metabolic Pattern Before admission: The patient was on a high protein diet because he was used to go to the gym 2-3 times a week. He was also taking vitamins (CENTRUM). He has normal appetite and has no difficulty swallowing. He usually eats 3 times a day (breakfast, lunch and dinner) and most of the time he also has his snacks. He also usually drinks 2-3 liters of water a day. e During time of care: The patient is on NPO (nothing per orem) for 5 days due to post-operative appendectomy and he was on his 2nd day of NPO status when we cared for him. He has also NGT lavage connected. ii. Elimination Pattern Before admission: The patient’s normal bowel movement was 3 BM a day and has no difficulty in bladder habits. His last bowel movement was last July 17, 2012. He usually urinates 6-7 times a day without difficulty. During time of care: The patient has absence of bowel movement and even flatus and has no bowel sounds upon auscultation. He has foley catheter and with urine output of 480 cc per shi ft. iv. Activity and Exercise Before admission: The patient could do his activities independently without assistance. He usually goes to gym 2-3 times a week. During time of care: The patient’s functional level or self-care ability level is 2 which mean he requires help from another person for assistance. v. Sleep/Rest Pattern Before admission: The patient usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no difficulty in sleeping and he feels rested after sleep. During time of care: The patient has regular sleeping habits. He sleeps at 10 am, wakes up at 6 am with uninterrupted sleep. vi. Cognitive – Perceptual Pattern Before admission: The patient was alert and coherent, has normal speech, with mild level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. During time of care: The patient is alert and coherent. He has normal speech (Filipino as his spoken language), he has moderate level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. He also complained of acute pain and described it as a cramping pain. Pain management (Tramadol) was given. vii. Role – Relationship Pattern Before admission: The patient was a student and single. His support system was his family, relatives friends. During time of care: The patient’s support system is his mother who is always at his bed side assisting him in whatever he needs. Upon asking his mother if she has any concerns regarding hospitalization, she said that she is more concern about the fast recovery of her son. viii. Sexuality – Reproductive System Before admission and during the time of care: The patient still didn’t have his testicular exam. ix. Coping – Stress Tolerance/Self – Perception/Self – Concept Pattern The patient’s major concern regarding his hospitalization is s all about self-care. Due to the contraptions attached to him, he cannot independently do his activities. His major loss was his stepfather when he died of kidney failure. His rated his outlook on future as 5, 1 being poor and 10 being very optimistic. He further explained why he rated 5 because he is not sure if when he finished college he can be able to find a job suited for him. x. Value – Belief Pattern Our patient is a Roman Catholic and he always goes to church every Sunday together with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK| THEORIST| STATUS| Intimacy vs. Isolation * Develops commitments to others and to a life work (career)(Daniels, et. al. , 2010). | Erikson| The patient had a relationship with his opposite sex but he said that they just broke up a week before he was hospitalized due to some personal and private reasons. Currently, he is in 3rd year college, an IT student. | Genital * Emergence of sexual interests and development of relationships with potential sexual partners (Daniels, et. al. , 2010). | Freud| As what had written above, the patient had a relationship with his opposite sex but because of some reasons they decided to end up their relationship. Formal Operations * Able to see relationships and to reason in the abstract (Daniels, et. al. , 2010). | Piaget| He perceived that relationships (any kind of relationship) are important especially at his age. He can also reason out in an abstract way. He can express his opinions intellectually and precisely. | Early Adulthood * Select a partner, learn to live with a partner, s tart a family, manage a home, establish self in a career/occupation, assume civic responsibility, and become a part of a social group (Daniels, et. al. , 2010). Havighurst| According to our patient, he didn’t expected that something like that will happen to them (referring to his girlfriend). He was really expecting that they are really meant for each other and that she (his gf) will be his future wife. He is also establishing himself to a future career, that’s why he is studying in preparation for his future. During our time of care also, his ‘barkadas’ visited him and he said that they were his ‘tropa’. | Postconventional * Individual understands the morality of having democratically established laws (Daniels, et. al. , 2010). Kohlberg| Upon asking the patient if he is familiar with the democratically established laws in the Philippines, he immediately responded with a yes. He also said that these laws help us, Filipinos, to have safe and se cure country though there may come a time that we may experience something unexpectedly. | IX. PHYSICAL ASSESSMENT * Vital Signs TIME| Initial 8AM (07/24/12)| 10 AM| 12 NN| 8 AM (07/25/12)| 12 NN| Last 8AM(07/26/12)| T| 36. 3| 37. 3| 37. 4| 36. 4| 37. 3| 36| P| 83| 84| 71| 75| 81| 68| R| 23| 25| 21| 19| 19| 20| BP| 120/80| 120/80| 120/80| 120/80| 120/80| 110/80| Sequence: BY SYSTEMS NORMAL FINDINGS| BOOK FINDINGS| PATIENT FINDINGS| SIGNIFICANCE| I. NEUROLOCIGAL SYSTEM Alert and coherent; with normal body temperature of 36. 3 °C – 37. 6 °C| * Fever (usually 38 °C although hypothermia may be present w/ severe sepsis); chills * Thirst * Pain| * Complained of pain in the incision site (lower longitudinal midline of the abdomen)| Pain results from the increased pressure of fluid on the nerves, especially in enclosed areas, and by the local irritation of nerves by chemical mediators such as bradykinins (Gould, et al. 2011). | II. RESPIRATORY Normal respiration with a rate of 12-20 breaths per minute| * Tachypnea; shallow respirations| * RR: 23 bpm w/ shallow respiration| Acute pain usually initiates physiologic stress response with increased respiratory rate (Gould Dyer, 2011). | III. INTEGUMENTARY Pink or brown and in uniform color, no edema, no lesions, moistSkin temperature is normally warmIntact skinWhen pinched, skin springs back to previous state| * Dry lips and mucous membranes * Swollen tongue * Poor skin turgor| * Dry lips and mucous membranes * Skin turgor:3-5 seconds * Presence of surgical incision at lower longitudinal midline of the abdomen * Skin is warm to touch and is reddened| Dry mucous membrane and poor skin turgor are signs of dehydration (Gulanick, et al. 1994). Redness may indicate inflammation (Weber Kelly, 2007). Redness and warmth are caused by increased blood flow into the damaged area (Gould Dyer, 2011). | IV. CARDIOVASCULAR Normal pulse rate of 60-100 bpm| * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissue edema| * Pulse rate: 83 bpm| Acute pain usually initiates a physiologic stress response with increased heart rate (Gould Dyer, 2011). | V. MUSCOLOSKELETAL Ability to do Activities of Daily Living (ADL)| * Difficulty ambulating * Weakness| * Difficulty ambulating due to post-op condition * Weakness| Constant pain frequently affects daily activities and may become a primary focus in the life of an individual (Gould Dyer, 2011). | VI. GENITO-URINARY Normal urine output of 30cc/hrColor: Amber, transparent, clear| * Decreased urinary output * Dark color urine| * Dark color urine * Urine output: 480 mL/shift * Specific gravity: 1. 30| Decreasing output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). | VII. GASTROINTESTINAL Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elementsAbdomen is free of lesions or rashesA series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minuteNormally no tenderness or pain is elicited or reported by the clientNo rebound tenderness is presentAbdo men is non-tender and soft. There is no guarding| * Loss of appetite * Nausea vomiting(usually projectile) * Constipation of recent onset * Diarrhea(occasional) * Sudden, severe, generalized abdominal pain * Abdominal distention; rigidity * Decreased/absence of bowel sounds * Inability to pass stool/flatus * Muscle guarding (abdomen) * Psoas’ Sign (flexion of or pain on hyperextension of the hip due to contact between an inflammatory process the psoas muscle) * Obturator Sign (the internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee and a resultant tightening of the internal obturator muscle may ause abdominal discomfort) * Rovsing’s Sign (pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant) * Rebound tenderness (a sign of inflammation of the peritoneum in which pain is elicited by the sudden release of the fingertips pressing on the abdomen) | * Board-like abdomen * Sudden, severe, generalized abdominal pain * Absence of bowel sounds in all four quadrants * Absence of flatus/stool * Presence of surgical incision| Signs indicating the onset of peritonitis include a rigid â€Å"board-like† abdomen (Gould Dyer, 2011). Pain recurs as a steady, severe abdominal pain as peritonitis develops (Gould Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or paralytic ileus (Weber Kelly, 2007). When inflammation persists, nerve conduction is impaired, and peristalsis decreases, leading to obstruction of the intestines (paralytic ileus) (Gould Dyer, 2011). | X. DIAGNOSTIC TESTS DIAGNOSTIC TEST| NORMAL| RESULT| SIGNIFICANCE| WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) | The organs examined appear normal (Cosgrove, et al. , 2008). | Liver is not enlarged. It has homogenous echopattern with smooth border. The intrahepatic ducts are not dilated. No evident focal mass lesion seen. CD measures 3. 9mm. Gallbladder is normal in size and wall thickness. There are multiple tiny echogenic shadowing foci seen within the gallbladder lumen. Pancreas spleen are normal in size echopattern. No focal mass lesion seen. Both kidneys are normal in size echopattern. Right kidney measures 10. 1Ãâ€"4. 2Ãâ€"5. 46cm with cortical thickness of 1. 7cm while the left kidney measures 10. 5Ãâ€"4. 8Ãâ€"4. 1cm with thickness of 19cm. No evident caliectasis, lithiasis, seen bilaterally. Urinary bladder is unfilled. Impression:Tiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot dilated biliary tree | Abdominal ultrasound is the most effective test for diagnosing acute appendicitis (LeMone Burke, 2007). | HEMATOLOGY REPORT/COUNT (July 21, 2012)| RBC: 4. 2-5. 6 M/uLPlatelets: 150-400 x 10/LWBC: 3. 8-11. 0 K/mm3Hemoglobin: 135-180g/LHematocrit: 0. 45-0. 52DifferentialNeutrophils: 0. 50-0. 81Lymphocytes: 0. 14-0. 44Monocytes:0. 02-0. 06Eosinophils: 0. 01-0. 05Basophils:0. 00-0. 01| WBC Count: 12. 6 K/mm3RBC: 4. 1 M/uL (normal)Hematocrit: 0. 45 (normal)Hemoglobin: 153g/L (normal)Differential Count:Neutrophils 0. 90Lymphocytes 0. 10 (normal)| Elevated WBC is seen in acute infection (LeMone Burke, 2007). Neutrophils: elevated in bacterial infection (LeMone Burke, 2007). | URINALYSIS (July 21, 2012)| Color: Light straw to amber yellowAppearance: ClearOdor: AromaticpH: 4. 5-8. 0Specific gravity: 1. 005-1. 030Protein: 2-8mg/dLGl ucose: NegativeKetones: NegativeRBCs: RareWBCs: 3-4Casts: Occasional hyaline| Color: Dark YellowTransparency: TurbidUrine pH: 6. 0 Specific gravity: 1. 30Sugar: NegativeProtein: +4Microscopic examPus cells 4-6/HPFRBC 1-2/HPFCrystals: Amorphous Sulfate Moderate| A dark yellow to brownish color is seen with deficient fluid volume (LeMone Burke, 2007). Hazy or cloudy urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates (LeMone Burke, 2007). | CLINICAL CHEMISTRY (July 21, 2012)| Sodium (Na): 135-142 mmol/LPotassium (K): 3. 8-5 mmol/L| Sodium: 132 mmol/LPotassium: 4. 02 mmol/L| Sodium is decreased in SIADH vomiting (LeMone Burke, 2007). | XI. ANATOMY PHYSIOLOGY OF APPENDIX (LARGE INTESTINE) The large intestine, which is about 1. 5 m (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum. Structurally, the four major regions of the large intestine are the cecum, colon, rectum, and anal canal. The opening from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal sphincter (valve), which allows materials from the small intestine to pass into the large intestine. Hanging inferior to the ileocecal valve is the cecum, a small pouch about 6 cm (2. 4 in. ) long. Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 in. ) in length, called the appendix or vermiform appendix (vermiform = worm-shaped; appendix = appendage). The mesentery of the appendix, called the mesoappendix, attaches the appendix to the inferior part of the mesentery of the ileum. The open end of the cecum merges with a long tube called colon, which is divided into ascending, transverse, descending colon are retroperitoneal; the transverse and sigmoid colon ascends on the right side of the abdomen, reaches the inferior surface of the liver, and turns abruptly to the left to form the right colic (hepatic) flexure. The colon continues across the abdomen to the left side as the transverse colon. It curves beneath the inferior end of the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac crest as the descending colon. The sigmoid colon begins near the left iliac crest, projects medially to the midline, and terminates as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is called the anal canal. The mucous membrane of the anal canal is arranged longitudinal folds called anal columns that contain a network of arteries and veins. The opening of the anal canal to the exterior, called the anus, is guarded by an internal anal sphincter of smooth muscle (involuntary) and an external anal sphincter of the skeletal muscle (voluntary). Normally these sphincters keep the anus closed except during the elimination of feces (Tortora Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, inflammation of the vermiform appendix, is a common cause of acute abdominal pain. It is the most common reason for emergency abdominal surgery, affecting 10% of the population (Tierney et al. , 2005). Appendicitis can occur at any age, but is more common in adolescents and young adults and slightly more common in males than females (LeMone Burke, 2007). The development of appendicitis usually follows a pattern that correlates with the clinical signs, although variations may occur because of the altered location of the appendix or underlying factors (Gould Dyer, 2011). Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices. The obstruction is often caused by fecalith, or hard mass of feces. Other obstructive causes include a calculus or stone, a foreign body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone Burke, 2007). Following obstruction, the appendix becomes distended with fluid secreted by its mucosa and microorganisms proliferate. Pressure within the lumen of the appendix increases, impairing its blood supply because blood vessels in the wall are compressed thus the appendiceal wall becomes inflamed and purulent exudate forms. Within 24 to 36 hours, the increasing congestion and pressure within the appendix leads to ischemia and necrosis of the wall, resulting in increased permeability. Bacteria and toxins escape through the wall into the surrounding are. This breakout of bacteria leads to abscess formation or localized peritonitis. An abscess may develop when the adjacent omentum temporarily walls off the inflamed area by adhering to the appendiceal surface. In some cases, the inflammation and pain subside temporarily but then recur. Localized infection or peritonitis develops around the appendix and may spread along the peritoneal membranes. Increasing pressure inside the appendix causes increased necrosis and gangrene in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perforates, releasing its contents into the peritoneal cavity. This leads to generalized peritonitis and would lead to septicemia and into septic shock and will result to death (Gould Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Risk Factors Non-modifiable: * Age (Adolescents young adults) * Gender (Male) Modifiable: * Fecalith * Calculus/Stone * Foreign body * Inflammation * Tumor * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid inside the appendix Buildup of fluid inside the appendix Proliferation of microorganisms Proliferation of microorganisms Abdominal pain Abdominal pain Increased pressure within the lumen of appendix Increased pressure within the lumen of appendix Compression of blood vessels Compression of blo od vessels * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness * Fever * Obturator Sign * Psoas Sign * Rovsing’s Sign * Rebound tenderness Decreased blood flow into the appendix Decreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: turbid Ischemia necrosis of the wall Ischemia necrosis of the wall Increased permeability Increased permeability Bacteria and toxins escape through the wall Bacteria and toxins escape through the wall Abscess formation/localized bacterial peritonitis Abscess formation/localized bacterial peritonitis Proliferation of localized peritonitis around the appendix and peritoneal membranes Proliferation of localized peritonitis around the appendix and peritoneal membranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, generalized abdominal pain * Abdominal distention rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, generalized abdominal pain * Abdominal distention rigid â€Å"boardlike† abdomen * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Increased necrosis and gangrene in the wall Increased necrosis and gangrene in the wall Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak out into peritoneal cavity Intestinal bacteria leak out into peritoneal cavity * Low-grade fever leukocytosis * Tachycardia * Hypotension * Vomiting * Low-grade fever leukocytosis * Tachycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESS Problem #1: ABDOMINAL PAIN – July 24, 2012 * Subjective Cues: * â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps,† patient verbalized while having a conversation with him. How does it feel like: Abdominal cramping Precipitating factor: â€Å"Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit† (â€Å"Whenever wound cleaning is performed but oftentimes it just suddenly happened†) Relieving factor: Pain reliever (but not all the time pain reliever is being given) Does it radiate to the other parts of the body (back, legs, chest, etc): No Duration of pain: â€Å"Paiba-iba din eh. Minsan sobrang tagal mga 2-3 minutes, minsan naman mga ilang Segundo lang† (â€Å"It differs, sometimes it’s too long (2-3 minutes) and sometimes it just happened for a second†) * Patient rated the pain as 8/10 where 0 signifies no pain and 10 signifies unbearable pain. * Objective Cues: * Facial grimace * Guarding of the incision site * Rigid (board-like) abdomen * Abdominal distention * Location of pain: Surgical site * RR: 25 bpm * Nursing Diagnosis Acute Pain related to inflammation of the tissues secondary to post-op surgical incision. Inflammation or nerve damage gives rise to changes in sensory processing at peripheral and central level with a resultant sensitization. In relation, prostaglandins are chemotactic substances drawing leukocytes to the inflamed tissue. It plays a vasoactive role; it is also a pain and fever inducer (Lemone and Burke, 2007). Acute Pain related to infection inflammation of the peritoneal membranes secondary to peritonitis The peritoneum consists of a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdominal cavity. This peritoneal structure provides a mean of rapid dissemination of irritants or bacteria throughout the abdominal cavity. Abdominal distention is evident, and the typical rigid, board-like abdomen develops as reflex abdominal muscle spasm occurs in response to involvement of the parietal peritoneum (Gould Dyer, 2011). * Goal/NOC: Pain Control Outcomes Short Term: After 30 minutes of nursing intervention the patient will report a decrease in pain from pain scale of 8/10 to 4-5/10. Long Term: After 8 hours of nursing intervention the patient will demonstrate an understanding about the proper way of controlling pain as evidenced by proper splinting and deep breathing exercise and will report a decrease or most probably will be free from pain from pain scale of 4-5/10 to 1-2/10. * NIC: Pain Management Independent: * Assessed pain including its character, location, severity, and duration. Both preoperatively and postoperatively, the client’s pain provides important clues about the diagnosis and possible complications. Abdominal distention and acute inflammation contribute to the pain associated with peritonitis. Surgery further disrupts abdominal muscles and other tissues, causing pain (LeMone Burke, 2007). * Monitored vital signs every 2 hours. Vital Signs, especially respiratory rate (RR), are usually altered in acute pain. (Sparks and Taylor, 2005). * Kept the client at rest in semi-Fowler’s position. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position (Doenges et al. , 2006). * Provided diversional activities (texting, sound trip, etc). Refocuses attention, promotes relaxation, and may enhance coping abilities and diverts attention from pain (Doenges et al. , 2006). * Taught post-op health teaching (e. g. , proper splinting deep breathing exercises). The use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications (LeMone Burke, 2007). * Encouraged early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). Give hot and cold compress. Hot, moist compresses have a penetrating effect. The warm rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. (Doenges et al. , 2006). Dependent: * Administered analgesic as prescribed (TRAMADOL 50 mg/IV Q 8 ° x 3 doses) Time given: 8 AM. Post-operatively, analgesics are provided to maintain comfort and enhan ce mobility (LeMone Burke, 2007). * Kept on NPO. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting (Doenges et al. 2006). * Evaluation Short Term: Goal partially met. After 30 minutes of nursing intervention the patient reported of a decrease in pain from a pain scale of 8/10 to 6/10 in which 4-5/10 was the expected outcome. Long Term: Goal met. After 8 hours of nursing intervention the patient displayed control of pain as evidence by deep breathing exercise and proper splinting. He also reported of a decrease in pain with a pain scale of 2/10 from 6/10. Pain reliever – TRAMADOL was given @ 8 am via IV. Problem #2: ABSENCE OF FLATUS– July 24, 2012 * Subjective Cues: â€Å"Nurse wait lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping),† patient verbalized while having a conversation with him. * Pain scale of 8/10 * Objective Cues: * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sou nds upon auscultation of all four quadrants * Nursing Diagnosis Dysfunctional gastrointestinal motility related to inflammatory process of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis often draws large amounts of fluid into the abdominal cavity and the bowel. In addition, peristaltic activity of the bowel is slowed or halted by the inflammation, causing paralytic ileus, impaired propulsion of forward movement of bowel contents (LeMone Burke, 2007). * Goal/NOC: Ambulation Outcomes Short Term: After 8 hours of nursing intervention the client will report/experience flatus and will understand and demonstrate the need for early ambulation following abdominal surgery. Long Term: After 2 days of nursing intervention the client will report/experience either flatus or bowel movement or both. * NIC: Impaction Management; Positioning Independent: * Assessed abdomen including all four quadrants noting character to determine increased or decreased in motility; Assessed for further abdominal tenderness auscultated for any abdominal sounds. To help identify the cause of the alteration and guide development of nursing intervention (Sabol Carlson, 2007). * Monitored and recorded (intake) and output every hour or 2 hours. Intake and output records provide valuable information about fluid volume status (LeMone Burke, 2007). * Encouraged early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. (Gulanick, et. al. , 1994). Dependent: * Administered antacid as ordered (RANITIDINE 50g/IV Q 12 °. Antacids either directly neutralize acidity, increasing the  pH, or reversibly reduce or block the secretion of acid by gastric cells to reduce acidity in the stomach (Gabriely, et al. 2008). * Evaluation Short Term: Goal partially met. After 8 hours of nursing intervention the patient didn’t experience flatus or even bowel movement but was able to have an understanding with regards to early ambulation as evidenced by letting his mother assist him in moving up in bed going to the chair but refused to walk because of complaint of ha ving a lot of contraptions attached to him which causes him to have difficulty in moving. Long Term: Goal met. After 3 days of nursing intervention the patient reported of a flatus for 3 times. Problem #3: RISK FOR DEHYDRATION – July 24, 2012 * Subjective Cue: * â€Å"Nanghihina na ako kasi limang araw ako hindi pwede kumain pati tubig bawal din kaya nagnunuyo na yung labi ko,† as verbalized by the patient. * Objective Cues: * NPO for 5 days * Dry mucous membrane * Dry lips * Capillary refill= 2 seconds * Skin turgor= 3-5 seconds * Urine output/shift= 480 mL * Urine color: Dark Yellow * Urine specific gravity: 1. 030 (Normal value: 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP: 120/80 mmHg * PP: 83 bpm * Nursing Diagnosis Risk for deficient fluid volume related to postoperative restriction secondary to NPO for 5 days Inflammation of the peritoneum with sequestration fluid and NPO status can lead to dehydration and electrolyte imbalance (Doenges, et al. , 2008). * Goal/NOC: Knowledge: Treatment Regimen; Hydration; Oral Hygiene; Tissue Integrity: Skin Mucous Membranes Outcomes Short Term: After 30 minutes of nursing intervention patient will have an understanding with regards to maintaining fluid balance as evidenced by willingness of following the prescribed regimen given by the medical staffs. Long Term: After 3 days of nursing intervention the patient will be able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, and individually adequate urine output. * NIC: Fluid Management; Fluid Monitoring; Vital Signs Monitoring Independent: * Monitored BP Pulse. Variations help identify fluctuating intravascular volumes, or changes in vital signs associated with immune response to inflammation (Doenges, et al. , 2006). * Inspected mucous membranes; assessed skin turgor and capillary refill. Indicators of adequacy of peripheral circulation and cellular hydration (Doenges, et al. 2006). * Monitored intake and output; noted urine color/concentration, specific gravity. Decreasing urine output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. Noted passing of flatus, bowel movement. Indicators of return of peristalsis, readiness to begin oral intake (Doenges, et al. , 2006). * Provide clear liquids in small amounts when oral intake is resumed, and progress diet is tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss (Doenges, et al. 2006). * Stressed the importance of having him on a NPO status and provided the necessary information with regards to his condition and the medications being administered (e. g. , IVF). It provides the patient a full understanding with regards to his condition thus encouraging him to participate and work hand in hand with the staff (Gulanick, et al. , 1994). * Gave frequent mouth care with special attention to protection of the lips. Dehydration results in drying and painful cracking of the lips and mouth (Doenges, et al. , 2006). Dependent: * Maintained gastric suction as indicated. Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperatively phase to decompress the bowel, promote intestinal rest, and prevent vomiting (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8 ° or 30 gtts/min) and electrolytes (D5 Balanced Multiple Maintenance Solution w/ 5% dextrose 1L x 8 ° or 30 gtts/min). The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances (Doenges, et al. , 2006). * Evaluation Short Term: Goal met. After 30 minutes of nursing intervention the patient was able to have a full understanding with regards to maintaining fluid balance as evidenced by verbalizing, â€Å"So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. † Long Term: Goal met. After 3 days of nursing intervention the patient was able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor (1-2 seconds), stable vital signs (please see page __ ), and adequate urine output of 620 mL with an appearance of amber yellow. Problem #4: RISK FOR INFECTION – July 24, 2012 Subjective Cues: â€Å"Nurse, sobrang kailangan ba talaga ang paghuhugas ng kamay bago linisan o hawakan sugat niya? †, asked by the mother. * Objective Cues: * Post-operative condition – presence of surgical incision * Surgical site is warm to touch and reddened * Temp: 36. 3 °C * Nursing Diagnosis Risk for infection related to inadequate prim ary defenses secondary to post-operative surgical incision It is risk to be invaded by pathogens especially if surgical site is near at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, et al. 2006). * Goal/NOC: Risk Control (For Infection) Outcomes Short Term: After 30 minutes of nursing intervention the patient will be able to have partial understanding about infection control and will verbalize understanding of and willingness to follow up prescribed regimen. Long Term: After 3 days of  nursing intervention  the  patient will be free of sign and symptom r/t infection. * NIC: Incision Site Care; Infection Control; Wound Care Independent: * Monitored vital signs. Noted onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain. Suggestive of presence of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected incision and dressings. Noted characteristics of drainage from wound/drains, presence of erythema. Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis (Doenges, et al. , 2006). * Instructed proper hand washing. Practiced aseptic wound care. Reduces risk for infection (Doenges, et al. , 2006). * Encouraged adequate nutritional intake after the NPO status of the patient and when the patient is allowed to eat. Adequate intake of protein, Vitamin C and minerals is essential to promote tissue and wound healing (Sparks and Taylor, 2005). Dependent: * Administered antibiotics (CEFUROXIME 750mg TID Q 8 ° x 2 doses METRONIDAZOLE 500g/IV Q 8 ° x 2 doses) as ordered. Therapeutic antibiotics are given if the appendix is ruptured or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with incision and drainage (ID) if indicated. May be necessary to drain contents of localized abscess (Doenges, et al. , 2006). * Evaluation Short Term: Goal met. After 30 minutes of nursing intervention the patient was able to have an understanding about infection control as evidenced by verbalizing, â€Å"Para maiwasan ang pagkaroon ng impeksyon kailangan kong maghugas ng kamay palagi at kinakailangan din ang araw-araw na paglilinis ng sugat ko kahit na sa tuwing nililinisan ito makirot sa pakiramdam. † Long Term: Goal met. After 3 days of  nursing intervention  the  patient was free of sign and symptom r/t infection. Problem #5: INABILITY TO PERFORM ACTIVITY/IES OF DAILY LIVING (ADL) – JULY 24, 2012 * Subjective Cues: â€Å"Hirap talaga ako gumalaw, maglakadlakad, o kahit man lang umupo dahil sa mga nakakabit na ito sa akin,† as verbalized by the patient. â€Å"Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko,† he added. * Objective Cues: * Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage IV fluid @ left hand) * Nursing Diagnosis Impaired physical mobility related to body weakness, presence of surgical incision, pain, presence of contraptions attached Physical immobility can be usually associated with post-operative conditions (Gulanick, et al. 1994). * Goal/NOC: Activity Tolerance Outcomes Short Term: After 30-45 minutes of nursing intervention the patient will be able to have a clear understanding with the use of identified techniques to enhance activity tolerance and to apply it as well as evidenced by participating in ROM exercises, lower leg ankle exercise, ambulation, or even moving up in bed. Long Term: After 2-3 days of nursing intervention the patient will be able to continually participate in a simple form of activity and will report an improvement with regards to his activities. * NIC: Exercise Therapy: Balance Independent: * Performed passive ROM exercises. ROM exercises and good body mechanics strengthen abdominal muscles and flexors of spine (Gulanick, et al. , 1994). * Encouraged lower leg and ankle exercises. Evaluated for edema, erythema of lower extremities, and calf pain or tenderness. These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation (Gulanick, et al. , 1994). * Noted emotional and behavioral responses to immobility. Provided diversional activities. Forced immobility may heighten restlessness and irritability. The Cardiovascular System iframe class="wp-embedded-content" sandbox="allow-scripts" security="restricted" style="position: absolute; clip: rect(1px, 1px, 1px, 1px);" src="https://phdessay.com/the-cardiovascular-system-intrinsic-conduction-system/embed/#?secret=fKNLnNlg3O" data-secret="fKNLnNlg3O" width="500" height="282" title="#8220;The Cardiovascular System#8221; #8212; Free Essays - PhDessay.com" frameborder="0" marginwidth="0" marginheight="0" scrolling="no"/iframe Diversional activity aids in refocusing attention and enhances coping with actual and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, progressive ambulation, and therapeutic exercises. Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance (Gulanick, et al. , 1994). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. Gulanick, et al. , 1994). * Noted client reports of weakness, fatigue, pain and difficulty accomplishing tasks. Symptoms may be result of/or contribute to intolerance of activity (Gulanick, et al. , 1994). Dependent: * Administered pain medication (TRAMADOL 50 mg/IV Q 8 ° x 3 doses, time given: 8 AM) as prescribed and on a regular schedule. Client’s anticipation of pain can increase muscle tension. Medica tions can help relax the client, enhance comfort, and improve motivation to increase activity (Gulanick, et al. , 1994). * Evaluation Short Term: Goal partially met. After 30-45 minutes of nursing intervention the patient was able to have a clear understanding with the use of identified techniques to enhance activity tolerance and was able to use all of the techniques except for the ambulation. He refused to walk because he complained of pain whenever the catheter tube slipped into his legs. Long Term: Goal partially met. After 2-3 days of nursing intervention the patient was able to continually participate in all of the identified techniques but still refused to participate in ambulation. He also reported of an improvement with regards to his activities as evidence by his verbalization, â€Å"Medyo natotolerate ko na rin yung mga activities kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad pero pagnaalis na siguro yung catheter baka kayanin ko na. † XV. BIBLIOGRAPHY * Cosgrove DO, Meire HB, Lim A, Eckersley RJ. (2008). Grainger Allisonn’s Diagnostic Radiology: A Textbook of Medical Imaging (5th edition). New York, NY: Churchill Livingstone * Doenges M. , Moorhouse, M. ; Murr, A. (2006). Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span (7th Edition). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. ; Murr, A. (2006). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P. , Barky, N. (2008). Clinical problem-solving, back to basics. New England Journal of Medicine * Gould, B. ; Dyer, R. (2011). Pathophysiology for the Health Professions (4th Edition). Saunders Elsevier Inc. * Gulanick, M. Klopp, A. , Galanes, S. , Gradishar, D. ; Puzas, M. (1994). Nursing Care Plans Nursing Diagnosis and Intervention (3rd Edition). Mosby-Year Book, Inc. * LeMone P. ; Burke, K. (2007). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (4th Edition). Pearson International Edition * LeMone P. ; Burke, K. (2008). Principles of Medical-Surgical Nursing: Critical Thinking in Client Care (5th Edition). Pearson Internation al Edition * Mosby’s Pocket Dictionary of Medicine, Nursing ; Allied Heath (4th Edition) 2002, Mosby Inc. Palma G. ; Oseda A. (2009). G;A Notes Clinical Pocket Guide for Medical and Allied Health Professionals (2nd edition). G;A Notes Publishing Co. , Philippines * Sabol, V. K. ; Carlson, K. K. (2007). Diarrhea: Applying research to bedside practice. AACN Advanced Critical Care * Tortora G. ; Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Biological Sciences Textbooks, Inc. * Weber J. ; Kelley J. (2007). Health Assessment in Nursing (3rd Edition). Lippincott Williams ; Wilkins How to cite Case Study – Appendicitis, Free Case study samples

Secret Crimes Of Compassion Essays - Euthanasia, Medical Ethics

Secret Crimes Of Compassion Secret Crimes of Compassion To please no one will I prescribe a deadly drug, nor give advice which may cause death. -Oath of Hippocrates This phrase alone supports the very battle cry of those who oppose euthanasia. Their efforts have gone as far as to help make laws forbidding doctor-assisted suicide, including strict procedures for medical staff to determine the competency of an ill patient. But then there are those who wish to make it easier on themselves and even the family and friends, and choose as alternative route the their suffering. Extremely difficult problems arise surrounding the issue of euthanasia: What is the difference between killing someone and letting someone die? Who determines the competency of a terminally ill patient? If a patient is incompetent, who then makes the decisions for him? Most importantly, do we even have the right to die? The question of whether this is a moral battle or a legal battle has yet to be determined. Ever though the issue of suicide may consist of both factors, if one commits suicide successfully, they live neither with the moral guilt nor the face the legal consequences . So then if a second party is involved, it changes the whole story. What is the difference between killing someone and letting someone die? To get a little more technical, these phrases are also known as active and passive euthanasia. If one were to evaluate both of these, he would probably say that letting someone die were a better choice than killing someone. After all, most medical practices in the U.S. allow for the legally. One may be preferred over the other but is that one better than the other? In an example, let's say that a doctor decides to withhold treatment of a patient who is to die in the next couple of days. He does this because he finds it helpless to prolong his suffering. But in actuality, when the doctor withdraws his treatment, the patient takes a lot longer to die and is in more agonizing pain. Once this decision is already made, speeding up his death through active euthanasia looks more preferable over passive euthanasia. So the point is that allowing someone to die may take longer and be more painful, where giving them a letha l injection might be quick and painless (Rachels, 428). Even in today's society, people think it is morally wrong to kill someone rather than letting someone die. But is it really worse? To help answer this question, there is another example that will help illustrate the issue. There was a guy named CJ who was to inherit a lot of money if anything were to happen to his three-year-old nephew. One day his nephew was swimming outside in the pool when CJ came along and drowned him and made it look like an accident. Then there was another guy named Joe who also was to inherit a lot of money if anything was to happen to three-year-old nephew. Well Joe, who decides to kill his nephew, went outside where his nephew was swimming in the pool. To Joe's surprise, he saw that his nephew had slipped, hit his head and fell face first into the water. Joe is excited and stands by to watch him drown and does nothing to save him. Did either one of these guys act any better than the other? If one were to look at it from a moral aspect, one would say that CJ' s actions were morally worse than Joe's because CJ actively killed his nephew. But both of these guys had the same intention, goal and personal gain from the incident. CJ may look like the terrible guy for his actions and Joe may be regarded as a sick individual for watching. But didn't Joe do something? Any way you look at it, these two men committed an act, whether it was passive or active, one is no better than the other. In medical practices today, doctors may not necessarily try to destruct their patients with the same intentions as CJ and Joe. But the possibilities of active and passive euthanasia may be because the doctor may find a patient's life of no use or it