Effective Organizational Transformation Essay Example | Topics and Well Written Essays - 500 words

Effective Organizational Transformation - Essay Example Hence, it is imperative for the organizations to be cognizant of the inherent complexity of an organizational transformation, to avoid any confusion or possible frustrations. Organizational transformation mostly affects an entire organization and do brings in ample confusion and chaos in its wake. Therefore, the involved stakeholders need to be willing and prepared to act and operate in an environment defined by ample change, amorphousness and uncertainty. Besides, there aught to be an optimum awareness at all the levels within and organization regarding the multiple phases of change and the knowledge, attitude and expertise required to manage each specific phase. In the given context, an acknowledgement of some key elements involving organizational transformation does help. Vision- Any successful organizational transformation largely is dependent on a clear and lucid vision. A flawless vision does happen to be an essential ingredient of any well-managed organizational transformation.

Infomatics Essay Example | Topics and Well Written Essays - 750 words

Infomatics - Essay Example Caregiver, educator, and advocacy roles of a nurse identify need for computer competency towards knowledge development. As a caregiver and an educator, a nurse must develop knowledge that can then be conveyed to the audience for intended purposes and computer applications such as online searches from databases and libraries and communication applications aid these. Caregiver role requires greater competence for applications such as evidence-based research and evidence-based practice that the dynamic nursing environment necessitates. Competence into computer-based applications for data collection, analysis, and interpretation are necessary (McGonigle & Mastrian, 2011) and are my areas of weakness. Undergraduate and graduate students are competent in basic computer skills and have positive attitude towards informatics but parity in competencies between the two levels suggests need better skills at the higher levels (Choi & Martins, 2013) that can be inferred to needs at longer experien ce as mine. Nursing informatics competency is also necessary for improving effectiveness of self-care and for developing strategies for better self-care approaches (Knight & Shea, 2014), and this identifies need for improving my competency level. Use of research software for the application is the greatest weakness. Some software use commands for customization of worksheets to accommodate specific data sets, such as creation of headings for data sets. This remains my challenge and without it, input data lack meaning, and may rely on memory for an understanding. Similarly, specific commands or steps for executing in-built commands are necessary for conducting data analysis using statistical software and I lack the required competence. Results from my PATCH assessment identify my ability to realize the needs through learning to use computer and associated applications. My confidence in learning computer use for professional and creativity tasks, and my

The Social Concept in Terms of Culture and Norms Research Paper

The Social Concept in Terms of Culture and Norms - Research Paper Example To begin with, it is imperative to define the exact nature and importance of these strategies in the context of the concert hall. Interpretive strategies spring from that aspect of a field’s study which seeks to define the same in the context of an individual’s life and link the same with various factors at a regional, international and global level. (Norberg - Schulz,1996; P 414 – 428) The role of an interpretive strategy in the case of the two concert halls discussed here is to bring out a variety of features in the structural implications of the building. These features have been further discussed below. One of the major features of an interpretive strategy lies in its ability to transform a space and transport an individual to a place beyond the structure where the building and the individual in question are in perfect tandem as far as everyday activities and a sense of drama in this everyday life are concerned. This has been termed as Hermeneutics. (Hale, 20 00; P 213 – 233) On a more technical grid, the term hermeneutics adheres to the play of a person’s sense of aesthetics when regarding the two concert halls discussed in this paper. The finer point shows that the hermeneutic tradition helps create a platform where a person may experience the concert hall as an extension of his or her daily living. This is an important point made by the term ‘modern aesthetics’, which cater to more than a marriage of fine art and engineering for positive structural implications in the concert hall.

Alternative-Fuel Vehicles Essay Example for Free

Alternative-Fuel Vehicles Essay Atmospheric pollution is a major problem nowadays. So it is important that we should immediately find alternative fuel sources for petroleum and reduce the emission of harmful gases in the atmosphere. This has been the dream of many scientists because this will significantly reduce the emission of carbon dioxide, a green house gas, to the atmosphere. Most of these fuels can be manufactured domestically so I cut the costs of importing from other countries. Some are even derived from renewable sources. Electric cars are now being manufactured globally. Unknown to many, electricity-powered cars came into the automotive scene before its diesel and petroleum counterpart. But due to the limitations of the technology in the past, its development was stopped and diesel cars became the standard car. Most of the problems electric cars faced points to the battery. Batteries were heavy and required recharging. But there are new developments in this technology. A battery now has longer life and comes in much lighter forms. The main drawback of this car is the distance it can travel before the batteries run out. If there are enough recharging stops, like gas stations, the electric car will prove itself as a fuel-efficient and environment-friendly car. Natural gas cars are also gaining popularity. The promise of being able to fuel the car at one’s own home is hard to deny. Honda calls it a personalized solution to the fact that gasoline stations don’t sell natural gas. The Honda model Civic GX is coined as the cleanest internal combustion engine-powered vehicle ever tested by Environmental Protection Agency. However, natural gas is not renewable. A potential advantage of Hydrogen cars is that it can be used over and over again by the process of electrolysis. Although the supply hydrogen is not limited as fossil-fuels, production of such cars doesn’t come at a cheap price. Hydrogen has many advantages if used to fuel cars, but currently it is very expensive. Some car companies offer to convert diesel cars into hydrogen cars, but most of the time the price of conversion is much more expensive than the original price of the car. Also, hydrogen in normal temperature is gas and to be used as fuel it should be squeezed in high pressures so it is somewhat difficult to contain. Fuel cell cars are definitely a technology to watch for. It has the potential to minimize the use of energy while reducing harmful emissions at the same time. What sets it above the others is that it can make its own energy through certain chemical processes. Also, fuel cell cars don’t emit pollutants. But the price is almost the same for hydrogen cars, if not higher. The developments in fuel cells is rather young, it is not yet tested as compared to other alternative fuels, so it would be a risk if we utilize this technology right away. Among these alternative sources of energy, I choose natural gas. The other alternatives may score a higher grade in terms of energy advantage and minimal emission, but they are too expensive. The economy will suffer as we save the environment using Hydrogen, Electric, and Fuel Cell cars. Natural gas is widely distributed around the world. New natural gas reserves are discovered as time pass, it is just waiting for us to harness fuel from it. Most countries will be able to tap their own resources and strengthen one’s economy. The production of cars and fuel supply for natural gas cars is also very feasible compared to the other alternatives. Atmospheric pollution is increasing during each day. And since natural gas is the cheapest, we can immediately put it to use. This is the realistic approach concern the threat of global warming. We put into use something that works and will be a benefit for both the economy and environment. And after we became successful in harnessing natural gas, and the economic condition permits it, it is the time to upgrade to hydrogen or fuel cells and completely eliminate harmful emissions from vehicles.

Anatomy and Physiology Case Study

Anatomy and Physiology Case Study Case #1: A 60 year old man with long-standing type II diabetes that has been untreated with insulin is admitted to the hospital after reporting noticeably bloody urine. Bilaterally, he has no feeling in the bottoms of his feet and decreased sensitivity mid-shin, while sensation at the knees is normal. Upon examination the clinician notices that the patient’s lenses are cloudy, and the patient is having a difficult time reading his admissions paperwork. The patient’s blood pressure is also elevated. Why might this patient have blood in his urine? The patient may be suffering from a bladder or kidney infection. What other abnormalities would typically be found in such a patient’s urinalysis? Urinalysis may show High Blood Sugar. What is causing the bilateral desensitization of the lower limbs? It is possible that the patients diabetes is not controlled causing damage to the nerves and hardening of the arteries which can cause decreased sensation and poor blood circulation in the feet. Why are this patient’s lenses cloudy? The patient may be suffering from glaucoma, or cataracts. Why might this patient have difficulty reading his admissions papers? The patient may be suffering from Presbyopia, in which the lens of the eye loses its ability to focus, making it difficult to see up close. How is the elevated blood pressure related to the other symptoms? H causes all these symptoms so there is a chance that the high blood level may be the problem of why there was urine in the blood, numbness, and vision impairment. Case #2: Julie Turner, a 27 year old non-pregnant female, has grown increasingly anxious about changes in both her behavior and body recently. She consults her physician and complains of insomnia, gastrointestinal instability, feeling excited, and weight loss. She also reports that even though she has lost weight, her â€Å"double chin† has not gone away. Upon examination, the physician notes that, while not pronounced, Julie’s eyes seem larger, and her reflexes are excitable. The physician decides to send Julie to an endocrinologist for a consultation. What does an endocrinologist specialize in? Diagnose and treat diseases related to hormones. Define hyperthyroidism. Hyperthyroidism or â€Å"Overactive Thyroid†, is a condition in which the thyroid gland makes too much thyroid hormone. Which of Julie’s signs an symptoms are compatible with hyperthyroidism? Weight loss Does Julie show signs and symptoms specific to Grave’s disease? Yes, Grave’s disease actually causes most hyperthyroidism. Why might Julie be mistakenly thinking she has a â€Å"double chin†? Julie may be mistaken by the fact that her â€Å"double chin† is actually her swollen thyroid. What is the doctor concerned with when they notices that Julie has â€Å"large eyes†? Julie may be tired and not getting enough rest. If Grave’s disease is confirmed, what is the most likely treatment? First beta blockers will be prescribed and once all the results are confirmed they will either give Julie Radioactive iodine or Anti-thyroid medicine. Case #3: George is a 50 year old man that had a severe motorcycle accident 12 years ago. As a result of the accident, George had one kidney and part of his small intestine removed because they were hemorrhaging. Immediately following recovery, George had some weight loss that he was told to expect because of malabsorption caused by having his intestine removed. George has never returned to work due to his injuries, and mostly sits inside and watches TV and reads. Recently, however, George broke his wrist trying to catch himself from falling. When he was examined, he was told that his bones had become weak. Define osteopenia and osteoporosis. Which does George seem to have? Osteopenia refers to bone mineral density (BMD) that is lower than normal peak BMD but not low enough to be classified as osteoporosis.Osteoporosis is a progressive disease that causes bones to become thin and brittle, making them more likely to break. George seems to have Osteoporosis. What is the most common type of fracture of the wrist in a person of George’s age? Explain how Vitamin D, calcidiol, and calcitriol are synthesized? Calcidiol, or 25-hydroxyvitamin D, is the main storage form of vitamin D, Low calcidiol levels in the blood indicate a vitamin D deficiency, which can lead to weak bones. Your kidneys convert calcidiol into calcitriol, or 1, 25-hydroxyvitamin D, the active form of vitamin D that promotes calcium absorption. How could George’s missing kidney be related to his decreased bone strength? The lack of vitamin D and calcium absorption which having a vitamin D deficiency will cause bone weakness. How could George’s partial small intestine be related to his decreased bone strength? It could decrease the calcium you eat from being absorbed into your blood causing your blood calcium to become and stay low. If George has a decreasing density of his bones due to his previous injuries, what is the classification of his condition? George is suffering from Osteoporosis. Could George’s lack of time outside be a factor in his weak bones? It’s part of one of the factor’s the other is based on the fact of George laying around and not doing anything which is causing his bones to weaken. Case #4: Pete is a 250 lb man that played 15 years of professional football. Pete quit football at that age of 38 when his hips and knees became too painful to play. He has tried to manage the pain with OTC antiinflammatory drugs for the past 20 years. Now 58 years old, Pete has a severe limp on his right side and gone to the doctor in hopes to get stronger pain medication. His general doctor orders X-rays, which reveal bilateral narrowing of both hip and knee joints. The right acetabulum shows bony projections extending toward the femoral head. What does Pete suffer from? Pete is suffering from Osteoarthritis. What are Pete’s risk factors? Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. As the cartilage deteriorates, tendons and ligaments stretch, causingpain. If the condition worsens, the bones could rub against each other. Explain whether or not the 20 years of OTC antiinflammatory medications has really helped anything? OTC may have helped with the swelling and mild pain but that’s as far as they help. What are the bony projections of the acetabulum called? The acetabulum is the socket of the ball-and-socket hip joint. The top of the thigh bone (femur) forms the ball, and the socket (acetabulum) is part of the pelvic bone. Does Pete need to see an orthopedic surgeon, or can the general doctor treat Pete’s condition? Pete would have to go see an Orthopedic Surgeon for his case. Is Pete a candidate for joint replacement surgery? One of the alternatives Pete may want to look into is Total hip Arthroplasty (THA) is one of the most successful surgical interventions that leads to improvement in quality of life and provides significant improvements in both pain and function. Case #5: A 67 year old African-American male presents to his family physician for a checkup. It has been more than 5 years since his last checkup. A thorough examination including a digital rectal examination and history is unremarkable for a man of his age. The physician orders several different blood tests, including a prostate-specific antigen (PSA) level. Why would a physician order several blood tests for a person with no apparent problems? PSA is detected through a man’s blood and also the patient has not been to a checkup for 5 years. Does this man have any risk factors for anything in particular? Yes, he is at risk of prostate cancer. What is a digital rectal exam used to test for? The Rectal exam helps to detect growths or enlargements of the prostate gland in men. Why is a PSA level an important test for this man? This exam measures the amount of prostate-specific antigen in the blood. What would an elevated PSA level indicate? Elevated levels would mean inflammation of the prostate gland or prostate cancer. If this man has elevated PSA, how would it be treated? Depending on the level that the test comes back a urine test may be provided to check for a UTI that may be causing the levels to be elevated if not a biopsy may be suggested to confirm if and where the cancer is. Case #6: A 26 year old women presents at the clinic with a complaint of infertility. She and her husband have tried unsuccessfully for over one year. She reports irregular menses since menarche at age 13. She has never been pregnant, and has always had Pap smears. She reports at least a dozen sexual partners and was treated for gonorrhea 6 years ago. He husband has had normal semen analysis results. What are the risk factors for female infertility? Irregular menstrual cycle, age, can be risk factors as well as sexually transmitted diseases such as gonorrhea can cause fallopian tube damage. Which of these risk factors may be involved in this case? In this case Gonorrhea is the biggest risk factor. What hormone levels would be appropriate to ascertain? If the problem is a pituitary hormone imbalance, which hormone(s) might be involved? The hormone Hyposecretion would be involved. If the problem is an ovarian hormone imbalance, which hormone(s) might be involved? Polycystic Ovarian Syndrome: PCOS is a disruption in communication between the brain, the pituitary gland and the ovaries. PCOS is characterized by irregular or lack of ovulation, irregular or lack of menstrual periods. Define pelvic inflammatory disease. Pelvic inflammatory disease is a general term for infection of the uterus lining, fallopian tubes, or ovaries. If a pelvic exam is performed and PID is involved, what might be noticed? Tenderness and possibly a lump next to the uterus may be noticed. How might laparoscopy be useful for a definitive diagnosis? It will give a clearer picture of the abdomen and pelvis. Case #7: A 21 year old female presents to the ER complaining of lethargy, a stiff neck, and a headache. Initial examination reveals a high grade fever, sensitivity to light, and withdrawal from neck flexion. A history uncovers that she is a daycare worker and many students have been absent recently. What do the symptoms suggest? The Symptoms suggest that the female has Meningitis. Is this patient at particular risk for the suggested illness? People of any age can get meningitis, but because it can be easily spread among those living in close quarters, teens, college students, and boarding-school students are at higher risk for infection. What test needs to be done? Laboratory tests and a possible spinal tap will be done. How is this test performed? Taking a needle and collecting a sample of spinal fluid from the lumbar. What are the two most likely microorganisms to be found with the test from question #3? This test will show any signs of inflammation and whether a virus or bacteria is causing the infection. Does the daycare need to be notified? Yes immediately and any children that may be exposed or feel like they are sick should seek professional care right away. Case #8: A 68 year old African-American male is transported to the ER with rapid onset left sided weakness. He was watering his lawn when he suddenly dropped the hose and fell to the ground. His speech was slurred when EMS personnel arrived. The man has a history of high blood pressure and hypercholesterolemia. His exam shows left facial areflexia and drooping. CT scan of the head shows no hemorrhage. What is the diagnosis? Ischemic Stroke What is the likely location of the pathology in this instance? Location would be in his brain. What are the risk factors for this condition? Hypercholesterolemia, high blood pressure, atrial fibrillation diabetes, family history of stroke, age, and race might all be factors. What are the possible mechanisms of pathology in this case? Possible mechanisms of pathology are Thrombotic Stroke and Embolic Stroke. Which is the more likely mechanism of the pathology in this case? The Thrombotic Stroke is more likely. What is the underlying problem in this case? Hypercholesterolemia and Blood Pressure are the underlying problem. How did the underlying problem lead to this incident? High blood pressure and hypertension can lead to thickening of the arterial walls making the passage way narrow. Case #9: A 36 year old man is seeing his physician because he is becoming increasingly weak. He reports that the weakness progresses throughout the day. He has a desk job and can hardly keep his eyes open and head up by the end of the day. Other history is unremarkable. Cranial nerve examination shows weak facial muscles, inability to repeat movements, and bilateral ptosis. The patient’s shoulders droop with a very poor posture. What is the likely diagnosis? Ocular Myasthenia What is the pathogenesis of this disease? Ocular Myasthenia is a disease of the neuromuscular junction resulting in hallmark variability in muscle weakness and fatigability. What other deficits might present if untreated? If left untreated it may cause acute respiratory failure. Why do the symptoms seem to worsen later in the day? Symptoms seem worse later in the day due to physical activity throughout the day. Symptoms aren’t as bad once the person has rested. What other conditions should be ruled out? Early symptoms can be confused with Psychiatric disorders. What treatment should be sought? A blood test measuring antibodies to acetylcholine receptors; 80-90 percent of Myasthenic people show these antibodies in their blood. Case #10: Tim and Leanne are rushed to the hospital after a car accident. Tim was driving as the car was hit in the driver side door. He sustained a broken humerus from the direct impact. His arm was immobilized and he is resting in his room. Leanne, who was in the front passenger seat sustained a ruptured spleen and four adjacent broken ribs on the left side. Her wounds are from striking the middle console of the car. She is in the ICU with her chest wrapped. What are the factors that affect wound production? The wound-healing process consists of four highly integrated and overlapping phases: hemostasis, inflammation, proliferation, and tissue remodeling or resolution Which factor is the main difference causing Tim and Leanne to have such different injuries? The main factor that causes the difference in injury here is the fact the driver side door was the one hit in the accident. What is the mechanism that caused the rupturing of Leanne’s spleen? Leanne struck the middle console of the car. What is the name of the condition in which several adjacent ribs is broken? Flail Chest Due to her broken ribs, what is Leanne at risk of developing? Rib Stress If Leanne’s lung is bruised, what other condition may develop? Leanne may develop a pulmonary contusion or bleeding of the lungs.

Child With Failure To Thrive Health And Social Care Essay

Child With Failure To Thrive Health And Social Care Essay In this review article, the definition, aetiology, evaluation, differential diagnoses, management, prevention and prognosis of failure to thrive are discussed. Failure to thrive (FTT) is a common problem in paediatric practice, affecting 5-10% of under-fives in developed countries with a higher incidence in developing countries. Majority of cases of FTT are due to a combination of nutritional and environmental deprivation secondary to parental poverty and/or ignorance. Many infants with FTT are not identified. The key to diagnosing FTT is finding the time in busy clinical practice to accurately measure and plot a childs weight, height and head circumference, and then assess the trend. In the evaluation of the child who has failed to thrive, three initial steps required to develop an economical treatment-centred approach are: (i) A thorough history including itemized psychosocial review, (ii) Careful physical examination and (iii) Direct observation of the childs behaviour and of parent-child interaction. Laboratory evaluation should be guided by history and physical examination findings only. Once FTT is identified in a particular child, th e management should begin with a careful search for its aetiology. Two principles that hold true irrespective of aetiology are that all children with FTT need a high-calorie diet for catch-up growth (typically 150 percent of their caloric requirement for their expected, not actual weight) and all children with FTT need a careful follow up. Social issues of the family must also be addressed. A multidisplinary approach is recommended when FTT persists despite intervention or when it is severe. Overall, only a third of children with FTT are ultimately judged to be normal. Keywords: Failure to thrive, growth deficiency, undernutrition. INTRODUCTION Although the term failure to thrive (FTT) has been in use in the medical parlance for quite some time now, its precise definition has remained debatable1. consequently, other terms such as undernutrition1 and growth deficiency2 have been proposed as preferable. FTT is a descriptive term applied to young children physical growth is less than that of his or her peers.3 The growth failure may begin either in the neonatal period or after a period of normal physical development.4 The term FTT is not, in itself, a disease but a symptom or sign common to a wide variety of disorders which may have little in common except for their negative effect on growth.5 In this regard, a cause must always be sought. Often, the evaluation of children who fail to thrive pose a difficult diagnostic problem. Some of the difficulties result from the numerous differential diagnoses, the definition used or misdirected tendency to search aggressively for underlying organic diseases while neglecting aetiologies based on environmental deprivation.6 In addition, early accusations and alienation of the childs parents by the health-care provider will make the evaluation and management of the child who has failed to thrive more difficult.7 In general, factors that influence a childs growth include: (i) A childs nutritional status; (ii) A childs health; (iii) Family issues; and (iv) The parent-child interactions.3,8,9 All these factors must be considered in evaluation and management of child who has failed to thrive. This paper presents a simplified but detailed approach to the evaluation and management of the child with FTT. DEFINITION The best definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time using a standard growth chart, such as the National Center for Health Statistics (NCHS) growth chart.10 All authorities agree that only by comparing height and weight on a growth chart over time can FTT be assessed accurately.11 So far, no consensus has been reached concerning the specific anthropometric criteria to define FTT.11 Consequently, where serial anthropometric records is not available, FTT has been variously defined statistically. For instance, some authors defined FTT as weight below the third percentile for age on the growth chart or more than two standard deviations below the mean for children of the same age and sex1-3 or a weight-for-age (weight-for-hieght) Z-score less than minus two.1 Others cite a downward change in growth that has crossed two major growth percentiles in a short time.3 Still others, for diagnostic purposes, defined FTT as a disproportionate failure to gain weight in comparison to height without an apparent aetiology.6 Brayden et al.,2 suggested that FTT should be considered if a child less than 6 months old has not grown for two consecutive months or a child older than 6 months has not grown for three consecutive months. Recent research has validated that the weight-for-age approach is the simplest and most reasonable marker of FTT.12 Pitfalls of these definitions: One limitation of using the third percentile for defining FTT is that some children whose weight fall below this arbitrary statistical standard of normal are not failing to thrive but represent the three percent of normal population whose weight is less than the third percentile.5,6 In the first 2 years of life, the childs weight changes to follow the genetic predisposition of the parents height and weight.13,14 During this time of transition, children with familial short stature may cross percentiles downward and still be considered normal.14 Most children in this category find their true curve by the age of 3 years.6,14 When the percentile drop is great, it is helpful to compare the childs weight percentile to height and head circumference percentiles. These should be consistent with the position of height and head circumference percentiles of the patient.5 Another limitation of the third percentile as a criterion to define FTT is that infants can be failing to thrive with marked d eceleration of weight gain, but they remain undiagnosed and therefore, untreated until they have fallen below the arbitrary third percentile.6 These normal small children do not demonstrate the disproportionate failure to gain weight that children with FTT do.6 This approach attempts not only to prevent normal small children from being incorrectly labeled as failing to thrive, but also excludes children with pathologic proportionate short stature.14 Having excluded these easily distinguishable disorders from the differential diagnosis of FTT, simplifies the approach to evaluation of the child who has failed to thrive.6 A more encompassing definition of FTT includes any child whose weight has fallen more than two standard deviations from a previous growth curve.3,15,16 Normal shifts in growth curves in the first 2 years of life will result in less severe decline (i.e, less than 2 SD).13 Some authors have even limited the definition of FTT to only children less than 3 years old17,18 A precise age limitation is arbitrary. However, most children with FTT are under 3 years of age.6,8 EPIDEMIOLOGY In young children, FTT which does not reach the severe classical syndrome of marasmus is common in all societies.19 However, the true incidence of FTT is not known as many infants with FTT are not identified, even in developed countries.20-22 It is estimated to affect 5 10% of young children and approximately 3 5% of children admitted into teaching hospitals.3,5,23 Mitchell et al,24 using multiple criteria found that nearly 10% of under-fives attending primary health care centre in the United States showed FTT. About 5% of paediatric admissions in United Kingdom are for FTT.4 The prevalence is even higher in developing countries with wide-spread poverty and high rates of malnutrition and/or HIV infections.3,19 Children born to single teenage mothers and working mothers who work for long hours are at increased risk.22 The same is true of children in institutions such as orphanage homes and homes for the mentally retarded5,22 with an estimated incidence of 15% as a group.5 Under-feed ing is the single commonest cause of FTT and results from parental poverty and/or ignorance.19,22,24 Ninety five percent of cases of FTT are due to not enough food being offered or taken.25 The peak incidence of FTT occurs in children between the age of 9 24 months with no significant sex difference.22 Majority of children who fail to thrive are less than 18 months old.3 The syndrome of FTT is uncommon after the age of 5 years.3,22 AETIOLOGY Traditionally, causes of FTT have been classified as non-organic and organic. However, some authors have stated that this terminology is misleading.27 They based their opinion on the fact that all cases of FTT are produced by inadequate food or undernutrition and in that context, is organically determined. In addition, the distinction based on organic and non-organic causes is no longer favoured because many cases of FTT are of mixed aetiologies.3 Based on pathophysiology (the preferred classification), FTT may be classified into those due to: (i) Inadequate caloric intake; (ii) Inadequate absorption; (iii) Increased caloric requirement; and (iv) Defective utilization of calories. This classification leads to a logical organization of the many conditions that cause or contribute to FTT.10 Non organic (psychosocial) failure to thrive In non-organic failure to thrive (NFTT), there is no known medical condition causing the poor growth. It is due to poverty, psychosocial problems in the family, maternal deprivation, lack of knowledge and skill in infant nutrition among the care-givers5,11. Other risk factors include substance abuse by parents, single parenthood, general immaturity of one or both parents, economic stress and strain, temporary stresses such as family tragedies (accidents, illnesses, deaths) and marital disharmony.6,8,22 Weston et al,28 reported that 66% of mothers whose infants failed to thrive has a positive history of having been abused as children themselves, compared to 26% of controls from similar socioeconomic background. NFTT accounts for over 70% of cases of FTT.6 Of this number, approximately one-third is due to care-givers ignorance such as incorrect feeding technique, improper preparation of formula or misconception of the infants nutritional needs,29 all of which are easily corrected. A cl ose look at these risk factors for NFTT suggest that infants with growth failure may represent a flag for serious social and psychological problems in the family. For example, a depressed mother may not feed her infant adequately. The infant may, in turn, become withdrawn in response to mothers depression and feed less well.10 Extreme parental attention, either neglect or hypervigilance, can lead to FTT.10 Organic failure to thrive It occurs when there is a known underlying medical cause. Organic disorders causing FTT are most commonly infections (e.g HIV infection, tuberculosis, intestinal parasitosis), gastrointestinal (e.g., chronic diarrhoea, gastroesophageal reflux, pyloric stenosis) or neurologic (e.g., cerebral palsy, mental retardation) disorders.6,19,22 Others include genitourinary disorders (e.g., posterior urethral valve, renal tubular acidosis, chronic renal failure, UTI), congenital heart disease, and chromosomal anomalies.6,7 Together neurologic and gastrointestinal disorders account for 60 80% of all organic causes of under nutrition in developed countries.30 An important medical risk factor for under nutrition in childhood is premature birth.1 Among preterm infants, those who are small for gestational age are particularly vulnerable since prenatal factors have already exerted deleterious effect on somatic growth.1 In societies where lead poisoning is common, it is a recognized risk factor for p oor growth.5,31 Organic FTT virtually never presents with isolated growth failure, other signs and symptoms are generally evident with a detailed history and physical examination.32 Organic disorders accounts for less than 20% of cases of FTT.6 Mixed failure to thrive In mixed FTT, organic and non organic causes coexist. Those with organic disorders may also suffer from environmental deprivation. Likewise, those with severe undernutrition from non-organic FTT can develop organic medical problems. FTT with no specific aetiology Review of the literature on FTT indicate that in 12 32% of cases of children who have failed to thrive, no specific aetiology could be established.23,33-34 Causes of failure to thrive A. Prenatal cases: (i) Prematurity with its complication (ii) Toxic exposure in utero such as alcohol, smoking, medications, infections (eg rubella, CMV) (iii) Intrauterine growth restriction from any cause (iv) Chromosomal abnormalities (eg Down syndrome, Turner syndrome) (v) Dysmorphogenic syndromes. B. Postnatal causes based on pathophysiology: A. Inadequate caloric intake which may result from: i. Under feeding Incorrect preparation of formula (e.g. too dilute, too concentrated). Behaviour problems affecting eating (e.g., childs temperament). Unsuitable feeding habits (e.g., uncooperative child) Poverty leading to food shortages. Child abuse and neglect. Mechanical feeding difficulties e.g., congenital anomalies (cleft lip/palate), oromotor dysfunction. Prolonged dyspnoea of any cause B. Inadequate absorption which may be associated with: Malabsorption syndromes e.g. Celiac disease, cystic fibrosis, cows milk protein allergy, giardiasis, food sensitivity/intolerance Vitamins and mineral deficiencies e.g., zinc, vitamins A and C deficiencies. Hepatobiliary diseases e.g., biliary atresia. Necrotizing enterocolitis Short gut syndrome. C. Increased Caloric requirement due to Hyperthyroidism Chronic/recurrent infections e.g., UTI, respiratory tract infection, tuberculosis, HIV infection Chronic anaemias D. Defective Utilization of Calories Inborn errors of metabolism e.g., galactosaemia, aminoacidopathies, organic acidurias and storage diseases. Diabetes inspidus/mellitus Renal tubular acidosis Chronic hypoxaemia Clinical manifestations of FTT3,22 Commonly the parents/care-givers may complain that the child is not growing well or losing weight or not feeding well or not doing well or not like his other siblings/age mates. Usually FTT is discovered and diagnosed by the infants physician using the birthweight and health clinic anthropometric records of the child. The infant looks small for age. The child may exhibit loss of subcutaneous fat, reduced muscle mass, thin extremities, a narrow face, prominent ribs, and wasted buttocks, Evidence of neglected hygiene such as diaper rash, unwashed skin, overgrown and dirty fingernails or unwashed clothing. Other findings may include avoidance of eye contact, lack of facial expression, absence of cuddling response, hypotonia and assumption of infantile posture with clenched fists. There may be marked preoccupation with thumb sucking. EVALUATION A. Initial evaluation It has been proposed that only three initial investigations are required to develop an economical, treatment-centred approach to the child who presents with FTT and this include:35 (i) A thorough history including an itemized psychosocial review; (ii) Careful physical examination including determination of the auxological parameters; and (iii) Direct observation of the childs behaviour and of parent-child interactions. The Psychosocial Review: The psychosocial history should be as thorough and systematic as a classic physical examination Goldbloom35 suggested that the interviewers should ask themselves three questions about every family: (i) How do they look; (ii) What do they say; and (iii) What do they do? a. HISTORY (1) Nutritional history Nutritional history should include: Details of breast feeding to get an idea of number of feeds, time for each feeding, whether both breasts are given or one breast, whether the feeding is continued at night or not and how is the childs behaviour before, after and in between the feeds. It would give an idea of the adequacy or inadequacy of mothers milk. If the infant is on formula feeding: Is the formula prepared correctly? Dilute milk feed will be poor in calorie with excess water. Too concentrated milk feed may be unpalatable leading to refusal to drink. It is also essential to know the total quantity of the formula consumed. Is it given by bottle or cup and spoon? Also assess the feeling of the mother e.g., ask how do you feel when the baby does not feed well? Time of introduction of complementary feeds and any difficulty should be noted. Vitamin and mineral supplement; when started, type, amount, duration. Solid food; when started, types, how taken. Appetite; whether the appetite is temporarily or persistently impaired (if necessary calculate the caloric intake). For older children enquire about food likes and dislikes, allergies or idiosyncracies. Is the child fed forcibly? It is desirable to know the feeding routine from the time the child wakes up in the morning till he sleeps at night, so that one can get an idea of the total caloric intake and the calories supplied from protein, fat and carbohydrate as well as adequacy of vitamins and minerals intake. (2) Past and current medical history The history of prenatal care, maternal illness during pregnancy, identified fetal growth problems, prematurity and birth weight. Indicators of medical diseases such as vomiting, diarrhoea, fever, respiratory symptoms and fatigue should be noted. Past hospitalization, injuries, accidents to evaluate for child abuse and neglect. Stool pattern, frequency, consistency, presence of blood or mucus to exclude malabsorption syndromes, infection and allergy. (3) Family and social history Family and social history should include the number, ages and sex of siblings. Ascertain age of parents (Down syndrome and Klinerfelter syndrome in children of elderly mothers) and the childs place in the family (pyloric stenosis). Family history should include growth parameters of siblings. Are there other siblings with FTT (e.g., genetic causes of FTT), family members with short stature (e.g. familial short stature). Social history should determine occupation of parents, income of the family, identify those caring for the child. Child factors (e.g., temperament, development), parental factors (e.g., depression, domestic violence, social isolation, mental retardation, substance abuse) and environmental and societal factors (e.g., poverty, unemployment, illiteracy) all may contribute to growth failure.5 Historical evaluation of the child with FTT is summarized in Table 1. (b) PHYSICAL EXAMINATION The four main goals of physical examination include (i) identification of dysmorphic features suggestive of a genetic disorder impeding growth; (ii) detection of under lying disease that may impair growth; (iii) assessment for signs of possible child abuse; and (iv) assessment of the severity and possible effects of malnutrition.36,37 The basic growth parameters such as weight, height / length, head circumference and mid-upper-arm circumference must be measured carefully. Recumbent length is measured in children below 2 years of age because standing measurements can be as much as 2cm shorter.36,37 Other anthropometric data such as upper-segment-to-lower-segment ratio, sitting height and arm span should also be noted. The anthropometric index used for FTT should be weight-for-length or height. Mid-parental height (MPH) should be determined using the formula.40 For boys, the formula is: MPH = [FH + (MH 13)] 2 For girls, the formula is: MPH = [(FH 13) + MH] 2 In both equations, FH is fathers height in centimetres and MH is mothers height in centimetres. The target range is calculated as the MPH Â ± 8.5cm, representing the two standard deviation (2SD) confidence limits.14 Assessment of degree FTT The degree of FTT is usually measured by calculating each growth parameter (weight, height and weight/height ratio) as a percentage of the median value for age based on appropriate growth charts3 (See Table 3) Table 3: Assessment of degree of failure to thrive (FTT) Growth parameter Degree of Failure to Thrive Mild Moderate Severe Weight 75-90% 60 -74% Height 90 -95% 85 89% Weight/height ratio 81-90% 70 -80% Adapted from Baucher H.3 It should be noted that appropriate growth charts are often not available for children with specific medical problems, therefore serial measurements are especially important for these children.3 For premature infants, correction must be made for the extent of prematurity. Corrected age, rather than chronologic age, should be used in calculations of their growth percentiles until 1-2 years of corrected age.3 Table 2: Physical examination of infants and children with growth failure. Abnormality Diagnostic Consideration Vital signs Hypotension Hypertension Tachypnoea/Tachycardia Adrenal or thyroid insufficiency Renal diseases Increased metabolic demand Skin Pallor Poor hygiene Ecchymoses Candidiasis Eczema Erythema nodosum Anaema Neglect Abuse Immunodeficiency, HIV infection Allergic disease Ulcerative colitis, vasculitis HEENT Hair loss Chronic otitis media Cataracts Aphthous stomatitis Thyroid enlargement Stress Immunodeficiency, structural oro- facial defect Congenital rubella syndrome, galactosaemia Crohns disease Hypothyroidism Chest Wheezes Cystic fibrosis, asthma Cardiovascular Murmur Congenital heart disease(CHD) Abdomen Distension hyperactive Bowel sound Hepatosplenomegaly Malabsorption Liver disease, glycogen storage disease Genitourinary Diaper rashes Diarrhoea, neglect Rectum Empty ampulla Hirschsprungs disease Extremities Oedema Loss of muscle mass Clubbing Hypoalbuminaemia Chronic malnutrition Chronic lung disease, Cyanotic CHD Nervous system Abnormal deep tendon Reflexes Developmental delay Cranial nerve palsy Cerebral palsy Altered caloric intake or requirements Dysphagia Behaviour and temperament Uncooperative Difficult to feed. Adapted from Collins et al 41 Growth charts should be evaluated for pattern of FTT. If weight, height and head circumference are all less than what is expected for age, this may suggest an insult during intrauterine life or genetic/chromosomal factors.2 If weight and height are delayed with a normal head circumference, endocrinopathies or constitutional growth should be suspected.2 When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation.2 Physical examination in infants and children with FTT is summarized in Table 2. Failure to thrive due to environmental deprivation Children with environmental deprivation primarily demonstrate signs of failure to gain weight: loss of fat, prominence of ribs and muscles wasting, especially in large muscle groups such as the gluteals.6 Developmental assessment It is important to determine the childs developmental status at the time of diagnosis because children with FTT have a higher incidence of developmental delays than the general population.36 With environmental deprivation, all milestones are usually delayed once the infant reaches 4 months of age.42 Areas dependent on environmental interactions such as language development and social adaptation are often disproportionately delayed. Specific behavioural evaluations (e.g., recording responses to approach and withdrawal), have been developed to help differentiate underlying environmental deprivation from organic disease.43 Assess the infants developmental status with a full Denver Developmental Standardized test.44 Parent-child interaction: Evaluate interaction of the parents and the child during the examination. In environmental deprivation, the parent often readily walks away from the examination table, appearing to easily abandon the child to the nurse or physician.6 There is little eye contact between child and parent and the infant is held distantly with little moulding to the parents body.6 Often the infant will not reach out for the parent and little affectionate touching is noted.6 There is little parental display of pleasure towards the infant.6 Observation of feeding is an integral part of the examination, but it is ideally done when the parents are least aware that they are being observed. Breast-fed infants should be weighed before and after several feedings over a 24-hour period since volume of milk consumed may vary with each meal. In environmental deprivation, the parents often miss the infants cues and may distract him during feeding; the infant may also turn away from food and appear distressed.6 Unnecessary force may be used during feeding. Developing a portrait of the child-parent relationship is a key to guiding intervention.11 LABORATORY EVALUATION The role of laboratory studies in the evaluation of FTT is to investigate for possible organic diagnoses suggested by the history and physical examination.33,34 If an organic aetiology is suggested, appropriate studies should be undertaken. If history and physical examination do not suggest an organic aetiology, extensive laboratory test is not indicated.6 However, on admission full blood count, ESR, urinalysis, urine culture, urea and electrolyte (including calcium and phosphorus) levels should be carried out. Screen for infections such as HIV infection, tuberculosis and intestinal parasitosis. Skeletal survey is indicated if physical abuse is strongly suspected. In addition to being unproductive, blind laboratory fishing expeditions should be avoided for the following reason:5,6 (i) they are expensive; (ii) they impair the childs ability to gain weight in a new environment both by frightening him/her with venepuncture, barium studies and other stressful procedures and the no oral f eeds associated with some investigations prevent him/her from getting enough calories; (iii) they can be misleading since a number of laboratory abnormalities are associated with psychosocial deprivation (e.g., increased serum transaminases , transient abnormalities of glucose tolerance, decreased growth hormone and iron deficiency);21 and (iv) they divert attention and resources from the more productive search for evidence of psychosocial deprivation. In one study, a total of 2,607 laboratory studies were performed, with an average of 14 tests per patient. With all tests considered, only 10(0.4%) served to establish a diagnosis and an additional 1% were able to support a diagnosis.34 Further Evaluation (1) Hospitalization: Although some authors state that most children with failure to thrive can be treated as outpatients,4,5,11,45 I think it is best to hospitalize the infant with FTT for 10 14 days. Hospitalization has both diagnostic and therapeutic benefits. Diagnostic benefits of admission may include observation for feeding, parental-child interaction, and consultation of sub-specialists. Therapeutic benefits include administration of intravenous fluids for dehydration, systemic antibiotic for infection, blood transfusion for anaemia and possibly, parenteral nutrition, all of which are often in-hospital procedures. In addition, if an organic aetiology is discovered for the FTT, specific therapy can be initiated during hospitalization. In psychosocial FTT, hospitalization provides opportunity to educate parents about appropriate foods and feeding styles for infants. Hospitalization is necessary when the safety of the child is a concern. In most situations in our set up, there i s no viable alternative to hospitalization. (2) Quantitative assessment of intake: A prospective 3-day diet record should be a standard part of the evaluation. This is useful in assessing under nutrition even when organic disease is present. A 24-hour food recall is also desirable. Having parents write down the types of food and amounts a child eats over a three-day is one way of quantifying caloric intake. In some instances, it can make parents aware of how much the child is or is not eating.11 Table 4: Summary of risk factors for the development of failure to thrive Infant characteristics Any chronic medical condition resulting in: Inadequate intake (e.g, swallowing dysfunction, central nervous system depression, or any condition resulting in anorexia) Increased metabolic rate (e.g, bronchopulmonary dysplasia, congenital heart disease, fevers) Maldigestion or malabsorption (e.g, AIDS, cystic fibrosis, short gut, inflammatory bowel disease, celiac disease). Infections (e.g., HIV, TB, Giardiasis) Premature birth (especially with intrauterine growth restriction) Developmental delay Congenital anomalies Intrauterine toxin exposure (e.g. alcohol) Plumbism and/or anaemia Family characteristics Poverty Unusual health and nutrition beliefs Social isolation Disordered feeding techniques Substance abuse or other psychopathology (include Muschausen syndrome by proxy) Violence or abuse Adapted from Kleinman RE.1 Table 1: Summary of historical evaluation of infants and children with growth failure Prenatal General obstetrical history Recurrent miscarriages Was the pregnancy planned? Use of medications, drugs, or cigarettes Labour, delivery, and neonatal events Neonatal asphyxia or Apgar scores Prematurity Small for gestational age Birth weight and length Congenital malformations or infections Maternal bonding at birth Length of hospitalization Breastfeeding support Feeding difficulties during neonatal period Medical history of child Regular physician Immunizations Development Medical or surgical illnesses Frequent infections Growth history Plot previous points Nutrition history Feeding behavior and environment Perceived sensitivities or allergies to foods Quantitative assessment of intake (3-day diet record, 24-hour food recall) Social history Age and occupation of parents Who feeds the child? Life stresses (loss of job, divorce, death in family) Availability of social and economic support (Special Supplemental Nutrition Program for Women, Infants and Children; Aid for Families with Dependent Chi

Writing Response To A Short Guide to Writing About Film :: essays papers

Writing Response To A Short Guide to Writing About Film The words â€Å"writing about film†, to my mind, conjure up the Siskel & Ebert-like desiccation of film that one usually finds in a review column. Needless to say, such â€Å"writing† can hardly be found appealing to one who looks for more than the appreciation or dislike of a performance or the absurdity of story. In â€Å"A Short Guide to Writing About Film,† I discovered that writing on film should and can be a far cry from such drivel. It is a staunch review of technique in relation to writing specifically on film. Obvious technique, to be sure, but if approached the proper manner, these reminders can be quite useful in articulating the often hard-to-capture meaning or imagery in film. The author states that the goal of his book is three-fold. The primary two are; that it would be a time-saver for instructors who have difficulty dealing with the common writing problems of their students, and that it would help to alleviate students anxiety about writing by clarifying points that many instructors presume their pupils all know. He does this by setting down guidelines for approaching writing, doing pertinent research, and conveying it, along with analysis, in the medium of stylistic film essays. He provides an abundance of examples of structures, styles, and terms used in this area of writ. The guidelines I found to be extremely useful, for they pertain not just to writing about film, but to any sort of analytical writing. They helped me realize the qualities that my own writing lacks, and I must come to master if I am to articulately present my own subjective experience on paper. The third part of the book’s purpose is that by attaining the first two, â€Å"it would encourage more enjoyable and articulate communication between the two [Professor and pupil]† (pg. X). To do so, Corrigan endeavors to excite readers with the possibilities that lay in writing: sharing experiences, analyzing themes and imagery, and simply writing about the most popular and entertaining medium around.