Potentially Inappropriate Medication at a Private Hospital

Potentially Inappropriate Medication at a Private Hospital Abstract The use of certain medications in geriatrics when potential risks outweigh the potential benefit and an effective alternative is available is called as Potentially Inappropriate medication. Because geriatrics are more sensitive towards adverse effects of medications. Beers criteria which is updated and reviewed by American Geriatric society list out 53 medications/therapeutic classes of drugs to be avoided in geriatrics. Methodology: A prospective observational study was conducted for 9 months in a 650 bed private corporate hospital, South India. All geriatric patients admitted in the hospital during the study period was included. Beers Criteria 2013 were used to identify potentially inappropriate medications. Result: The prevalence of PIM use (52%) was significantly higher in study population. An avg of 10 drugs were taken by the study population. A total of 215 medications were identified as PIMs. Among them 195(90%) medications should be avoided by the geriatrics independent of th eir condition (category I). 66(60%) of the study population had used more than one PIMs. 91(83%) of the PIM users had atleast one DRPs and the mean DRPs value of the PIM users were 1.59à ¯Ã¢â‚¬Å¡Ã‚ ±1.3. Conclusion: High prevalence of PIMs in the study population signifies the need of monitoring geriatric prescriptions. Key words: PIMs, Beers Criteria, Geriatrics Introduction In recent years proportion of geriatric hospital admission with comorbidity and polypharmacy has been increasing continuously (1, 2). Adverse drug events (ADRs) are the most common reason for hospital admission, but sometimes it’s not identified. Medication errors (MEs) or conventional adverse drug reactions (ADRs) are the common reason for adverse drug events which ends in clinical symptoms. Overall, elderly patients need greater attention to drug therapy and safety parameters (1, 3-5). Greater attention is needed for geriatric population due to age related pharmacodynamics and pharmacokinetic changes. But appropriate pharmaceutical care for elderly are determined on the basis of clinical trial conducted with adult population.(6) The burden of harm resulting due to the use of multiple drugs in geriatric populations is a major health related problem in developed countries. A research study reveals that around one in four geriatrics admitted to hospitals are prescribed with at least one inappropriate medication and potentially preventable adverse drug reactions accounts for nearly 20% of all inpatient deaths (7). The assessment of potentially inappropriate medication (PIM) in geriatric is a challenging work and there is a need for considering many factors which influences the prescribing as well as outcome. Eight well known tools are available to identify the PIMs and studies reports that Beers criteria is the best and easy one to assess the PIMs. Beers criteria also has the advantage over others because it is periodically updated (8).This study therefore aimed to investigate the prevalence of PIM use on geriatric population using Beers criteria 2012 and its association with Drug Related Problems (DRPs) . Methodology Study Site: The work entitled â€Å"A study on prevalence and impact of Potentially Inappropriate Medication use in geriatrics at a private corporate hospital† was carried out in a 640 bedded private corporate hospital, South India. Study Design: Prospective –Observational study. Study Period: Nine months. Inclusion criteria: Patients above age of 65 yrs. Exclusion criteria: The patients who are unwilling to participate in the study and out patients METHOD: A regular ward rounds was carried out in all the wards of General medicine. Each patient’s medication profile was reviewed. Patients who met the inclusion criteria were briefed on the project with the help of patient information form and if they are willing to participate in the study their consent was obtained. The data from medical chart were recorded in customized data entry form. The prescribed drugs were evaluated and PIMs use were identified with the help of Beer’s criteria. The drugs which are identified as PIM are categorized into following: Potentially inappropriate medications /classes to avoid in geriatrics, Potentially inappropriate medications /classes to avoid in geriatrics with certain pathological condition that the listed PIM use can exacerbate Medications to be used with caution in geriatrics. ADRs associated with PIMs use were assessed. Drug interaction and ADR was monitored and reported. DRPs and Drug Risk Ratio (DRR) were calculated for PIMs. DRPs were the sum of ADR, drug interaction and drug allergy.DRR was calculated as the number of DRPs in relation to how often the drug was used (DRPS/number of times used). Results and Discussion In the study period, 212 patients were included in the study as per inclusion criteria and exclusion criteria. 110 (52%) patients were found to be prescribed with PIMs listed in Beers criteria (fig no: 01). A similar study conducted by Birader K et al (2013) (9) reported that PIM prevalence were 38% in their study population. Increased anxiolytics use as a prophylaxis for hospital related anxiety might be the reason for high prevalence of PIM than the later study. The total number of patients in study population were 110. Among them 62(56%) were males and 48(44%) were females.The study result reveals that PIMs user are mostly males. A similar study conducted by Birader K et al (2012) (9) reported that prevalence of PIM use is more among males than females. The age categorization of PIM users was done. The maximum age of PIM users was 93 years and mean age of PIM users was found to be 70.2 ±5.77. The median age for PIM users was 68.5 years. The result indicated that age group of (65-69) were commonly prescribed by PIMs. This results compared with a previous study carried out by Birader K et al (2012) (9) which also reports that PIMs were frequently prescribed in the age group of 65-69 years. The social habit of the PIM users shows that 8(7%) patients were smokers and alcoholics, 14(13%) patients were alcoholics, 21(19%) patients were smokers and 67(61%) patients were teetotalers in PIM users. The comorbidities of the PIM users was analyzed. There were 52 (47%) suffering from hypertension and 32(29%) were suffering from DM. The results shows that most of the study group had comorbidities of hypertension followed by DM and CVDs. A similar study conducted by Fouquet A (11) also reported that most common diagnosis among their study population was hypertension and diabetes. The number of drugs prescribed for the PIM users were calculated (fig no: 2). The mean number of drugs per prescription was 9.9 ±2 with the maximum of 16 drugs and minimum of 5 drugs prescribed. The above results signifies that all prescriptions were in polypharmacy category. A similar study conducted by Blozik E (12) concluded that one of the main factor for PIM use is â€Å"polypharmacy†. The number of PIM drugs per prescription in the study population was calculated (Fig no: 3). The result reveals that 44(40%) were using one PIM drug, 50(45%) were using two PIMs, 14(13) were using three PIMs, 1(1%) were using 4 PIMs and the maximum of 5 PIMs use were found in 1(1%) of the study population. 66(60%) of the study population consumed more than one PIM. The mean was found to be 1.8 ±0.78 and an avg of 2 PIM was used by the study population. A similar study conducted by Dormann H (2013) (13) were reported that 87% of the study population consumed at least one PIM. Among the PIM users the total number of PIM drugs was calculated and it was found to be 215 drugs. PIM users were categorized into three groups according to Beers criteria. (Table no: 2) There were 195(90%) belongs to category I, 12(6%) were in category II and 8(4%) were in category III. The individual categories of PIM was analyzed. It was found that alprazolam 57(52%), clonazepam 17(15%), hyocyamine 10(9%), Lorazepam 10(9%), hydroxyzine 10(9%), zolpidem 10(9%), ketorolac 10(8%) were prescribed in category I (table no: 3). A similar study conducted by Birader K et al (2013) (16) reported that alprazolam and cimetidine were frequently used PIM among their study population. Use of hyocyamine in constipation 3(25%) accounts for the most frequent inappropriate drug use in category II (table no: 4). Hydroxyzine in constipation 2(17%), cyproheptidine in constipation 2(17%), ketorolac in PUD 2(17%), clonazepam in frequent fall 1(8%), ketorolac in CHF 1(8%) and theophylline in insomnia 1(8%) were other category II inappropriate medication use. Use of escitalapram 3(40%), mirtazapine 2(30%), fluoxetine 1(10%), sertraline 1(10%) and Duloxetine 1(10%) were the category III PIMs (table no:5). The DRP among the PIM users were analyzed (fig no: . It was found that 19(17%) of the PIM users were free from DRPs. Majority of the study population had at least one drug related problems. The mean value of DRP in the study population was found to be 1.59 ±1.3. The minimum observed number of DRP per patient was one and maximum observed number of DRP per patient was six. The ADR use was monitored in the study population. A total number of 40 ADR associated with PIM use (Fig no:5) and 14 ADR associated with nonPIM use were identified. The study result reveals that one among three PIM users were found to have at least one ADR. A similar study conducted by N. Nixdorff et al (2008) were also reported that PIM users were found to experience ADR most frequently than nonPIM users. As a part of our study, screening of drug interactions were done. A total number of 131 major drug interactions were identified, in that 111 were unique. Among the drug interactions found 16(12%) were PIM-PIM drug interactions, 39(30%) were PIM-other drugs drug interactions and 76(58%) were caused by non PIM drugs (table no: 6). Drug risk ratio were calculated for the study population (table no:7). It was observed that prochlorperazine had the highest DRR (4) followed by phenobarbitone (2), digoxine (2), pentazocine (2) and duloxetine (2). The statistical analysis of obtained results has been done using statistical tools. The association of different variables are analyzed using à ¯Ã‚ Ã‚ £2 test. On assessment of association between â€Å"number of comorbidities† with â€Å"number of drugs† and â€Å"number of PIMs† (table no:8), the result proved that â€Å"number of comorbidies† are statistically associated with â€Å"the number of drugs† at 0.001 level of significance and â€Å"number of PIMs† at 0.05 level of significance. It means that as number of comorbidity increases polypharmac and PIM use also increases. On assessment of association between â€Å"number of drugs† and â€Å"number of PIMs† (table no: 9), the result proved that â€Å"number of drugs† are statistically associated with â€Å"number of PIMs† at 0.05 level of significance. This result proves that polypharmacy is one of the reason for PIMs. On assessment of association between â€Å"number of DRPs† with â€Å"number of drugs† and â€Å"number of PIMs† (table no:10), the result proved that â€Å"DRPs† are statistically associated with â€Å"number of PIMs† at 0.01 level of significance but not associated with â€Å"number of drugs† at 0.05 level of significance. This result proves that DRPs is more associated with PIMs than polypharmacy which means it not the number of drugs contributing to DRPs but the use of PIMs. Conclusion Our study identified a high prevalence of PIMs use and associated DRPs in the study population. DRPs due to PIMs is preventable. Development and implementation of new criteria or modification of already existing criteria such as Beers criteria, START STOPP criteria which will helps in safe prescribing practice can reduce the PIMs use. References Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011; 365: 2002–12. Budnitz DS, Shehab N, Kegler SR, Richards CL: Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007; 147: 755–65. Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG: Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 2005; 165: 68–74. Pirmohamed M, James S, Meakin S. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329: 15–9. Chrischilles EA, VanGilder R, Wright K, Kelly M, Wallace RB. Inappropriate medication use as a risk factor for self-reported adverse drug effects in older adults. J Am Geriatr Soc 2009; 57: 000–6 Avorn J, Shrank WH. Adverse drug reactions in elderly people: A substantial cause of preventable illness. BMJ. 2008;336:956–7 Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework. Ian A. Scott, MBBS, MHA, MEd,a Leonard C. Gray, MBBS, MMed, PhD,b Jennifer H. Martin, MBChB, MA (Oxon), PhD,c Charles A. Mitchell, MBBSd Opondo D. Inappropriateness of Medicationth Prescriptions to Elderly Patients in the Primary Care Setting: A Systematic Review, plos one, aug 2012, volume 7, issue 8 Biradar K; assessment of potentially inappropriate medication in elderly patients at Basavehwar teaching hospital;IJPP 2012dec, vol 5,issue 4, 73-5 Denys TL (2011) Functional Decline Associated With Polypharmacy and Potentially Inappropriate Medications in Community-Dwelling Older Adults With Dementia, Am J Alzheimers Dis Other Demen. 2011 December ; 26(8): 606–15. doi:10.1177/1533317511432734 Fouquet A, Zegbeh H, Krolak-Salmon P, Mouchoux C. Detection of potentially inappropriate medication in a French geriatric teaching hospital: A comparison study of the French Beers criteria and the improved prescribing in the elderly tool. J Eurger 2012 3: 326-29 Blozik E, Rapold R, von Overbeck J, Reich O. Polypharmacy and potentially inappropriate medication in the adult, community-dwelling population in Switzerland. Drugs aging. 2013;30:561-8 Dormann H, Sonst A, Mà ¼ller F, Vogler R, Patapovas A, Pfistermeister B, Plank-Kiegele B, Kirchner M, Hartmann N, Bà ¼rkle T, Maas R. Adverse drug events in older patients admitted as an emergency the role of potentially inappropriate medication in elderly people (PRISCUS). Dtsch Arztebl Int 2013; 110(13): 213–9. DOI: 10.3238/arztebl.2013.0213 N. Nixdorff et al. Potentially inappropriate medications and adverse drug effects in elders in the ED. AJEM 2008 26: 697–700 Tables and figures NO. of PIM/prescription Number of patients N=110 Percentage 1 44 40 2 50 45 3 14 13 4 1 1 5 1 1 Table no:1 Number of PIM per Prescription sl no category no. of PIMs percentage 1 PIM drugs/classes to be avoid in geriatrics (category I) 195 90 2 PIM to be avoided in certain pathological condition (category II) 12 6 3 PIMs to be used with caution (category III) 8 4 Table no:2 Categories of PIM sl no Drugs No. of Patients sl no Drug No. of Patients 1 Alprazolam 57 (29%) 16 Nitrofurentoin 3(1.5%) 2 Clonazepam 17(9%) 17 Mirtazapine 2(1%) 3 Hyocyamine 10(5%) 18 Cyproheptidine 2(1%) 4 Lorazepam 10(5%) 19 Diazepam 2(1%) 5 Hydroxyzine 10(5%) 20 Piroxicam 2(1%) 6 Zolpidem 10(5%) 21 Prochloperazine 2(1%) 7 Ketorolac 10(5%) 22 Chlorphemiramine 2(1%) 8 Aceclofenac 9(4.5%) 23 Trihexylphenedine 2(1%) 9 Propoxyphene 8(4%) 24 Digoxin 2(1%) 10 Diclofenac 7(3.5%) 25 Phenobarbitone 1(0.5%) 11 Spironolactone 6(3%) 26 Naproxen 1(0.5%) 12 Prazosin 5(3%) 27 Clinidium-chlordiazepoxide 1(0.5%) 13 Clonidine 5(3%) 28 Indomethacin 1(0.5%) 14 Chlordiazepoxide 3(1.5%) 29 Metachlopramide 1(0.5%) 15 Amitriptyline 3(1.5%) 30 Pheniramine 1(0.5%) 31 Pentazocine 1(0.5%) Table no: 3 Category 1(PIM drugs/classes to be avoid in geriatrics) Sl no Drug Disease No. Patients Percentage 1 Ketorolac CHF 1 8 2 Hydroxyzine Constipation 2 17 3 Hyocyamine Constipation 3 25 4 Ketorolac PUD 2 17 5 Cyproheptidine Constipation 2 17 6 Clonazepam Frequent Fall 1 8 7 Insomnia Theophyllin 1 8 Table no: 4 Category II (PIM to be avoided in certain pathological condition) sl no Drug No of Patients percentage 1 Mirtazapine 2 30 2 Fluoxetine 1 10 3 Sertraline 1 10 4 Duloxetine 1 10 5 Escitalapram 3 40 Table no: 5 Cateegory III (PIMs to be used with caution) NO OF INTERACTION PERCENTAGE PIM-PIM 16 12 PIM- OTHER DRUGS 39 30 OTHER DRUGS 76 58 Table no:6 Categories of Drug Interactions Sl No Drug DRPs Total Drug Risk Ratio 1 PROCLORPERAZINE 8 2 4.00 2 PHENOBARBITONE 2 1 2.00 3 DIGOXIN 4 2 2.00 4 PENTAZOCINE 2 1 2.00 5 DULOXETINE 2 1 2.00 6 NAPROXEN 2 1 2.00 Table no.7 Drug Risk Ratio Sl no Varience No. of comorbidities Chi squire value P value 1 2 ≠¥ 3 1 No. of PIMs 1 5 21 13 12.76* 0.05 2 10 12 15 ≠¥ 3 7 15 12 2 No. of drugs 6-8 13 16 4 26.77* 0.001 9-11 8 25 17 ≠¥ 12 1 7 19 Table no:8 Association of no. of comorbidities with no. of drugs and PIMs . varience No. of Drugs Chi squire value P value 6-8 9-11 12-14 ≠¥15 No. of PIMs 1 16 21 4 3 21.76* 0.001 2 14 24 8 4 ≠¥ 3 2 5 5 4 Table no: 9 Association of no. drugs and no. PIMs Sl no Varience No. of DRPs Chi squire value P value 0 1 2 ≠¥3 1 No. of PIMs 1 11 21 10 2 21.76* 0.001 2 7 23 8 12 ≠¥ 3 1 4 2 9 2 No. of drugs 6-8 9 15 11 1 11.77 0.05 9-11 4 25 6 12 ≠¥ 12 6 8 3 10 Table no:10 Association of DRPs with no. of drugs and PIMs Fig no:1 Prevalence of PIMs Fig no:2 Number of Drugs Prescribed per Patient Fig no:3 Number of PIM per Prescription Fig no: 4 Adverse Drug Events and Its frequency Fig no:5 Adverse Drug Events and Its Frequency

My Philosophy of Education Essay -- Philosophy of Teaching Statement

Philosophy of Education If I had to pick one view that is most compatible with my own view and learning and teaching it would have to be Constructivism. If I got to choose another one I would go with Cognitive. Constructivism is a view that focuses on the active role of the learner and a Cognitive view sees learning as an active mental process of receiving, remembering, and using knowledge. Both of these views see the role of students as an active role; an involved role. I believe that we learn knowledge and change our behavior based upon this knowledge; instead of the other way around. I used to be somewhat of a behaviorist in that I put too much of the teachers focus on the behavior of the students. I have began to stray away from the idea that teachers are to teach there students morals and ethics. One of the major changes in my philosophy is the student/teacher relationship. The relationship that students and teachers have now is one that really doesn’t allow for the teacher to teach thin gs like morals and ethics. I see that this relationship is becoming more and more impersonal. This goes beyond the classroom though; for some reason this is just the general direction that our culture seems to be heading; impersonal relationships. My philosophical view on education was most closely related to Progressivism. I realize that having a pure Progressivism point of view, or any pure philosophy for that matter, is a dangerous perspective to have. My belief that Progressivism is 100% correct would be a pure Progressivism philosophical view. This was straight from my original philosophy and as you can see it really reveals a constructive view of learning. All educators as well as students should constantly be open ... ...r of today’s teachers for the job to be taken lightly. Our future President is in a classroom right now. Realizing this, teachers should have a desire to teach children and to prepare them for the future, and if this takes completely changing my style because it isn’t compatible with my students then so be it. A lack of this desire to do whatever it takes will no doubt show in a classroom and in the world we will live in. Teachers are the ones who need to go through a rigorous education in order to be better equipped to do the job efficiently. Trust and respect should be maintained and teachers should always encourage their students. It is a teacher’s job to help young men and woman obtain the knowledge they will need to be successful adults. No one can dispute the fact that teachers affect the future. What students are being taught today will effect tomorrow.

Strong Shadows :: essays research papers

1. I believe that Dr. Zuger chose the people she did because she was trying to get a large amount of differences of infections the patients could contract and also show the patients' similarities in lifestyle and the similarities in the way in which they grew up to try and educate people on the lifestyle one must live to put oneself at higher risk for contracting this terrible disease. The characters all seemed to have come from a home without much love from their family members, or they had something major missing in their life that could have caused a great amount of stress not normally experienced in an average person's life. All of them were uneducated and careless leading us to believe that Dr. Zuger was trying to show that education and responsibility are the best ways to prevent one's contraction of this disease. Some of them got HIV from reckless lifestyles such as drug use involving needle sharing to prostitution while others got it merely by having sex with casual partners. The decision to pick this array of patients again strengthens the fact that Dr. Zuger is trying to tell us that it is possible to get AIDS in many ways and that just because one is having casual sex does not mean that he is immune from its effects. These are probably a few reasons why Dr. Zuger chose them for her book. 2. The human frailty that Deborah Sweet possessed was that she was untrustworthy, she was always trying to get Dr. Zuger to get something for her such as prescriptions for drugs that would sell on the street or get her to write her a note to be allowed to miss court. The human frailty that Michael Soto has was when he first got the HIV virus and when he was using drugs. He is a very nice and willing patient and does not want to burden others with his problems. This shortcoming was very hard to decide on because he was such a good person. Cynthia Wilson's human frailty was that she needs help and that she is uneducated. She thinks that they should just be able to fix her problem without a problem and without delay. She seems to be very ungrateful for all the help she is receiving. She also does not know how to teach her children how to avoid becoming like her.

Conflicts in Elizabeth Stuart Phelps The Angel Over the Right Shoulder

Conflicts in Elizabeth Stuart Phelps' The Angel Over the Right Shoulder      Ã‚  Ã‚   "The Angel Over the Right Shoulder" is fascinating because of the conflict it uncovers between a woman's need to fulfill her domestic role and her need to develop as an individual. The story was published in 1852, when the American people were struggling with the role of women in society. The author, Elizabeth Stuart Phelps, introduces two opposing possibilities for this role. One is the woman whose entire being revolves around her domestic sphere and who has no individual identity. The other is an individual who, although fulfilling the role of mother and wife, takes time to cultivate and develop her own interests and person. This essay will focus on discussing the social and historical concepts intertwined with these two opposing viewpoints concerning the role of women in the middle 19th century rather then evaluating them in terms of the story. This will give the reader information necessary to better understand and analyze the events of the text.    The first possibility of woman's ideal social role, revolving entirely around her domestic responsibilities, has its origin in the past. Women of white middle class standing had historically taken on the responsibilities of clothing, feeding and caring for all members of the family, while the men had ensured that the raw materials for these duties existed. Stereotypically, the husband would work the farm cultivating the crops and caring for the animals, while the wife would turn these raw materials into the necessities of life, including food and clothing. When industry began to take over in the early 1800's the specific tasks of gender shifted, but the general spheres d... ...ideas about the new role of women in society while reading "The Angel Over The Right Shoulder", and to consider the ways in which Phelps encourages or discourages each one. I also encourage the reader to delve more deeply into the wealth of information surrounding this very important time period in the history of the United States, to understand where Phelps' ideas were generated and why she may have seemed to favor of one role of women over another.    Works Cited Graves, A.J., Mrs. Woman in America: Being an Examination into the Moral and Intellectual Condition of American Female Society. New York: Harper, 1847,c1841 Melder, Keith. Beginnings of Sisterhood: The American Woman's Rights Movement, 1800-1850. New York: Schocken Books, 1977. Phelps, Elizabeth Stuart. The Angel Over the Right Shoulder. Andover: Warren F. Draper, 1852.   

How to Be Successful Business Manager

How to be successful Business Manager Introduction Everyone desired to success. In the business field, becoming a successful manager is what the majority long for . No body changes into a well-rounded manager overnight. Learning is necessary for everyone during this process. â€Å"People learn to manage by managing under guidance of a good manager†Ã¢â‚¬â€-Michael Armstrong. Experiences can undoubtedly be an excellent tutor for success, but having a good guide can further allow one to make use of his or her experiences into the largest extent. Being a successful manager requires a huge amount of skills and knowledge.In this paper, not all elements will be mentioned, but the five essential elements have been chosen to be discussed: work smart , risk management, interpersonal talent and skills, Self-management and Leadership skills. Work Smart – Work Effectively and Efficiently To express how to work smartly, Susanne Madsen, a PRINCE2 and MSP practitioner and a qualified Corporate and Executive coach, tells us her tale of success. Work smarter, not harder, as explained by Susanne, means working less and accomplishing more by increasing the working quality. (2)To get things done wisely, she highlights the significance for correcting one’s internal persuasion and attitude towards his or her task that it is not a burden. One could , then, get the vigor for working again. According to the writer’s own experience, she shows that self-assessment and continuous self-adjustment are the paramount importance for success. She also suggests two key points: first, is deputation. A manager should depute the less vital jobs to the others and use those times to communicate more with the major person associated to the project for developing a better linkage with them.Second, is initiative. A manager should get a more well-round plan at the beginning instead of responding the incident or risk when it has been occurred. I am glad to read the inspirationa l article written by a top leader in the world. She gives a great arousal to me. Her sharing and skills are useful, not only at the workplace, but also at the senior academic level. I believe that many college students, just like me, are having the improper belief that the project is burdensome. Why can’t I alter my mindset to abandon the constraints and step up to success smartly?Just try it! Self-management Walter Vieira (2005) proves that people refuse to face realistic self-image and idealistic self-image is biased,(p. 33) and so to evade the results of their SWOT analysis which about their advantages, disadvantages, opportunities and threat environment. (p. 34) However, people do not understand their strength and weakness, will not be able to strengthen and improve , they cannot develop their abilities. In addition, they need to assess that whether they have the basis element include a positive goal, ambition and energy .They also need to know whether they have clearly a ware of their thoughts adaptable ,witty and creativity. He said that people have two reason of requesting an identity, one is for higher living standards, and another is satisfying others' expectation. He agreed with Cyrus Vance that people always evaluate their progress with friends. They were unhappy because their achievements are worse than the others. (p. 35) Therefore he reminded that people not to compare and assess their progress with others, because different people do different things ,will have different progress, as long as compliance with their own plans on the line. p. 35-36) But learning from observing others ,and the through others to observe their own, then the combined best quality of themselves and others. (p. 36) In my opinion, successful managers need to have a correct plan; in order to achieve their positive goals. I think Walter Vieira missed this important point. Therefore, they should know how to assess whether their plan is feasible under environment efforts . For example, their plan need to change when financial crisis. Leadership skills Leadership is the central factor to influence a general manager's success.In the book Successful Management, Neville (1995) believes that leadership has five main dimensions: first, defining a vision is the preliminary stage. The best leaders are adroit at thinking the unique and picking up creativity . They are not faint-hearted of change. When the vision has been ascertained, leaders should be attain it (17-8). Second, he said that commitment to success is not only about eagerness, drive and the will to win, it is also about the interminability of preparation (18). Third, he believes that leader should communicate unabashedly and frankly.Because communicate can let the team learn more experiences from each other (18). Fourth, is challenging in status quo. Young managers should find more innovative solutions in the business market (19). Finally, is about the personal characteristics which are found in extraordinary leaders. He highlights that flexibility, enthusiasm, integrity, willingness to experiment, ability to inspire others, to build relationship, to inspire trust, to communicate and to delegate, those are most routinely emphasize in outstanding leaders(19).He concludes that intellect is missing from these five dimensions, it is not nonessential, just because the role of leadership is too wide and it is not always necessary to have high intellect (19). To a large extent, I agree with Neville that the five main dimensions of leadership. I believe that communication is the most important part of the leadership, it permeates every aspect of the business. All managers, especially those leading teams, they communicating with the workforce is a demanding and rewarding task. Interpersonal talent and skills A successful businessman must possess good communication skills.He should provide different channels for the staff to express opinions which helps understandings of companyâ₠¬â„¢s objectives. Effective communication with employees can ensure thorough understandings of leader’s decisions and expectations on their work. Maintaining a comfortable working environment can  encourage staff to be more willing to talk to their senior level (219). Reduced status difference (219) and enhanced staff morale help collection of employees’ feedbacks and  suggestions, which contributes to company improvements and also help ensure all staffs are working towards same goals.I believe a successful businessman should be a good leader and team player. It is very important that a person can share his knowledge and experience with his employees. He should ensure his messages and decisions can be effectively convey to them. To build up a good relationship with staff, he should respect and encourage them to participate in production and provide new ideas in work. Appreciation of work participation creates good staff morale and motivates them to work towards sam e organizational goals. A person will not be successful if he cannot work well with his subordinates and employees.Even if he has lots of marvelous ideas but no one is willing to work with him, he will only be a talented individual instead of a successful leader in the company. Risk management skills Living with, and challenged by risks, Nick Jackson believed that risk has tightly stick onto the business management agenda. Just as the key, people who learn for robust the risk management can succeed in their business. No matter what risk are the leaders facing, the major challenge is that how to identify, tackle and monitor the risk, and to plan for understandable, maintainable and applicable contingency plan.Not much people could reach this in industry today, he thought, they can recognize the risks whereas fail to observe the dormant influence or lost the sight of controlling systems. There are only less than 30% organizations can manage the risk well even not in effective way. (p. 38) Moreover, Nick stated that the ‘risk’ would be in some positive terms instead of negative. He regarded that people should not only keep improving in the way they manage the difficulties, but also focus on how to avoid from the negative impacts of self-satisfied when they are in advantages. (p. 42)I have been reminded by Nick Jackson that in every single moment, we cannot slack off from supervise the risk in any format. It required the all-round critical thinking. We cannot stop monitor the business from tackled one risk. It is hard and tough to handle this section in the business. And it is a great challenge to all businessman or administrator. g Conclusion â€Å"The productivity of work is not the responsibility of the worker but of the manager. † – Peter F. Drucker, Expert Management Consultant. All in all, the five abilities which stated on the above passages are inseparable.These five categories has shown that how can the manager strengthen the pr oductivity and competitiveness in the industry. They can end up this topic with one sentence, â€Å"Manage yourself well then lead the team to work with communication and risk management plan smartly. † Within this project, we recognized that these skills are not only applicable in the business related industry, but also in different criteria of different industries. In 21st Century, people deserve better quality of services and the bosses deserve higher efficiency of works from their staff. As the result, this paper will be valuable to majority of worldReference Bain, Neville. , â€Å"Management or leadership? † Successful Management. 1st ed. London: Macmillan Press Ltd,14-9. Print C. N. Cheng. â€Å"Communication in Business. † Introduction to Business Studies. (Revised Edition). 1st ed. Hong Kong: Hong Kong Educational Publishing Co, 2009. 212-231. Print Kinicki, Angelo. , and Williams Brian K. â€Å"The nature of leadership. † Management: A Practical Introduction. 4th ed. Americas, New York: McGraw-Hill/Irwin, 2009. 436-38. Print. Nick, Jackson. â€Å"Risk is on the corporate agenda, but where does it fit? †Managing Business Risk. 3rd ed.Great Britain: Kogan Page Ltd,2006. Print Samson, Danny. , and Richard L. Daft. â€Å"Leadership in organisation. † Fundamentals of management. 2nd ed. South Melbourne, Victoria, Australia: Thomson Learning Australia, 2005. 427-31. Print. Susanne Madsen. â€Å"My Story:Work smarter not harder†Projectsmart. co. uk. Projectsmart ,10 September 2011. Web. 10 April 2012 Walter Vieira. Manager to CEO :corporate wisdom for survival and success. New Dehli/Thousand Oaks/London:Tejeshwar Singh for Response Book -stage Publications Inc,2005. print

Nutritional Assessment Essay

I have sympathise and understand the plagiarism policy as outlined in the syllabus and the sections in the IWU Catalog relating to the IWU Honesty/Cheating Policy. By affixing this statement to the second page of my paper, I present that I have non cheated or plagiarized in the surgical procedure of completing this assignment. I also certify that the work submitted is original work specialized for this course and to my program. If it is found that cheating and/or plagiarism did take place in the writing of this paper, I understand the accomplishable consequences of the act/s, which could include expulsion from indium Wesleyan University.Kristine Davis June 9, 2013 NameDate JW is an 86 year previous(a) man who lives at home with his married woman of 31 long time. He is in fair-good health. He has a history of prostate cancer, angina, and coronary artery disease. He has had 5 stents fructify in his heart over the proceed 10 year. He recovered vigorous up from the surgeries. He has always been athletic and fit. He played racquet ball and flocculent ball until he was 68 years old. He had his first Angina firing at 68. He had radiation seen implants in 2010, which successfully eliminated the prostate cancer.His vital signs be as follows 130/82 line of reasoning pressure, 72 pulse, 20 respirations, 98. 4 spoken temperature, and 96% oxygen saturation. JW weighs 178 pounds and is 5 feet 11 inch in height. His BMI (Body Mass Index) is 24. 7. JW is bustling and oriented. He seems very sharp for his age. He lives with his wife and 2 mouse clicks. He attends to his periodical living needs without assistance. He has a routine of preparing his musics and meals quotidian. His current medications consist of a multivitamin, Omega Fatty Acids, Asprin, Nitroglycerin, Coumadin, and stool softner.JWs nutritionary assessment is as follows he maintains a fixture dieting, eating 3 meals a day. JW wears partial dentures, but does non require any assistance with victuals himself. He has a balanced diet with all essential food groups. He state that he drinks 8 specs of peeing daily as instructed by his physician. He also en feels a film over of wine every night. He has had a 3-5 pound weight loss in the last 3 months. He give tongue to he changed his diet regime to wintry dinners because his wife had surgery 3 months ago.She was uneffective to make his meals on a regular basis until recently. JW is ambulatory and self-sufficient. He state his wife keeps him active and on his toes. He enjoys going to dinner once per week. He admits that he is happy that his wife is recovered from her surgery and fundament to cooking for him. He tries to stay active and assist her with family work and folding laundry. JW wooly his dog of 14 years, two months ago. She had to be frame to sleep due to cancer. He said the loss of his dog had a prodigious impact on his emotional state, and his daily routine.He said he would paseo with his dog, Lucy, every morning and night if the brave permitted. After several(prenominal) weeks of grieving, his wife strike him with a new puppy. JW feels that this puppy has brought back a sense of the companionship and joy that he lost when he lost his dog. He is back to his daily walking with the puppy. JW seems well adjusted to the new puppy. thither are no psychological concerns noted. His cognitive functioning seems up to par. He spends several hours a day reading and working on crossword puzzles in hostelry to maintain his cognitive functioning.JWs grate is dry and warm. His mucous membranes are wet and pink. There are no obvious lesions or pain noted. He does not report any difficulty chaw or swallowing. He said he moves his bowels 1-2 times daily without discomfort. JWs MNA (Mini nutritionary Assessment) reveals that he is at risk for malnutrition. His note was 11. He was informed of the importance of overpowering adequate portions of the foods from the basic food groups includ ing fruits, vegetables, grains, dairy, and proteins. He knows that he must avoid the membranous fats and cholesterol in his diet.However, he was boost to eat a heart rosy-cheeked diet including more vegetables and fruits. JW will reach out to drink the 8 glasses of water per day and take daily walks for exercise. He was encouraged ask his physician if the even out glass of wine was permitted, especially considering his medication regime. JWs goal is to be at adequate weight and BMI for his size, as well as maintain good nutritional status. He continues to be monitored by his particular physician, Cardiologist, Oncologist, and a nutritionist quarterly. He maintains annually dental exams.

Dutch Disease

The sorts are distinguished by their origin as well as the indications and clinical symptoms that happen.Later on 1970, when oil price soured by 4 times; UK was tempted to invest in North Sea oil industry in Scotland.Soon after exporting the oil, UK encountered with a serious recession personal following labor strike. Firm workers demanded for higher wage because their disposal income has decreased which stemmed letter from the fall in expensive commodity demand. UK has become a net export of oil and worth Pound got appreciated.Dutch disease is merely arithmetic.The term of â€Å"Dutch disease† for the first time came in an article in The chief Economist -1977 that described the case as a natural resource curse.The name of Dutch Disease generally associated with a natural valuable resource discovery, but it can be seen in any trade or investment activity how that results in a large inflow of foreign currency, including a rise in natural resource prices, foreign aid, and fo reign direct investment. The inflow of American treasures into Spain in 16th and gold discoveries in Australia in the 1850s are other two example of Dutch Disease diagnosis. By 1978, how this story repeated in Iran.

It normally contributes to a countrys currency appreciating in value.Russia is likely to be another innocent victim of this disease. Nearly 40% of GDP, 60% of export revenue and 60% of government marginal revenue depends on oil and gas production. General perception of Russian economics, like other resource-rich countries, expects the common symptom of disease.Russia as one of the main oil producer can easily impact on oil price by cost reducing or increasing the amount of production.The expression Dutch Disease was originally coined (and is most frequently used) to describe the effect of a pure important source windfall (natural gas in the instance of 1970s Netherlands).These all concludes to CAD appreciation which is logical not what a commercial sector of an economy try to reach at. Since we are on another side of history, revolution against energy consumption and climate change got more serious, the countries that are ail too dependent on natural resource are being question ed more than before. Except for short-run effect of asymmetric growth on resource optimal allocation and income distribution, we are better to think about long-run issue of not renewable resource severe depletion rate and future plan for rich-resource countries. 2.

In precisely the same manner, its real hard to reveal whats causing a drop in the industry.Increase in foreign currency 3. Foreign direct investment 4. Foreign aid 5. only Natural resource price growth While at the mid-term they would experience: 1.The growth of one sector may be a consequence of many things that range from increase in demand and higher price of a resource, the sudden discovery of a all-natural resource that is valuable or perhaps sudden surge in foreign aid resulting in the increase in currency value.Become a net import of manufactured goods 6. Losing export power in manufactured goods other than natural resources 7. Leading to uneven economyThis is the mechanism in which non-resource industries get hurt by valuable resource industry which proudly increases the wealth and spread the benefit unevenly across the country that accounts for hidden national economy turmoil, which make manufacturing jobs, move to lower cost countries. Canada logical and Oil Sand Feve r (3.

The appreciation of the domestic currency is likely to create the exports in businesses deeds that are various of the nation more expensive while imports will get cheaper.Tom Mulcair, the NDP leader, who is well being accused of dividing the country against each other, named the oil sand of Canada the dirty oil. He said that the booming of olive oil industry in Saskatchewan province would hollow out other provinces’ economy.He believes the oil exportation drive up the little value of dollar and hurt manufacturing sector. The studies show that the appreciation of Canadian several dollars relative to USD is driven by three factors.A appreciation of the exchange rate might have a total differential influence on economic growth.Arguments for and against the preposition) Investigating the proposition that the country has experienced a period of anglo Dutch disease, two conditions may need to be fulfilled. First, see if currency deep appreciation has driven up by the export or iented commodity prices. Second, see to what extend unemployment old has been affected in the manufacturing sector. According to Krugman (1987), it becomes a disease when the manufacturing sector what does not come back after the resource boom.

Competitiveness is lost by the country.(5. Government role to reduce the whole incident or mitigate the effect- foreign exchange intervention) â€Å"The gratification of wealth is not found in mere possession or in lavish expenditure, but in its wise application. – Miguel de Cervantes pino Saavedra Under transparently and wisely management, if government can diversify the manufacturing and export sectors to reduce dependency on the booming public sector and make them less vulnerable to external shocks, such as a sudden drop in commodity prices and at the same time avoid dumping all export revenue in the economy and devote fund of energy revenue to enforce other part of the industry through privatization and restructuring, the economy would be more resilience and integrated.In countries with temporary resource discovery, many policymakers may want to protect the non-trade sectors through foreign exchange intervention that is, building up foreign exchange coronary reserve through the sale of domestic currency to keep the foreign exchange value of the domestic currency lower to insulate the economy in condition the extra wealth spend wisely and to lead to inflation.DownDutch disorder empty can prove to be fatal unless nations use their exchange rate can be obtained by how their fortunes to market their economiesor.Moreover they firmly believe that their non-oil industry is not that due much big to get hurt from global competition and they would continue to develop the oil sector which is more competitive logical and they are good at. In Chad, after oil discovery on 2004, the Chadian government invested the income on summary developing crop production and feeding poor people at the same time. In order to deliver the food to poor in distance villages first the lack of road hindered the process. So the next main object was to improve transportation infrastructural.

Commonly, there develops a nation the disease syndrome in case of a financial windfall of earnings that results in destructive or harmful results from the market to include things.There are twenty two policies how to spend the money. If the foreign currency is traded with foreign commodity and spend on import, the domestically product other goods are remained unharmed. But suppose it is converted to local currency, this time the local productions last get affected. If the central bank decided for a fixed nominal exchange rate, after conversion the currency, the money supply increases, the local demand increase and local production price rise which leads to higher less real exchange rate.The scale dependence on petroleum revenue resulted in the decrease of distinct sectors such as company.M. and J. P. Neary.

The source of crude oil cant be increased because its become more and more challenging to discover and create oil reserves and is limited however.†¢Coulombe, S. , R. Lamy and S. old Rogers (2007).Second, the petroleum sector infrastructure is in disrepair.htm †¢Ebrahim-zadeh, Christine (March 2003, Volume 40, Number 1). â€Å"Back to very Basics – Dutch Disease: Too much wealth managed unwisely†. Finance and Development, A quarterly magazine of the IMF. IMF.