Unit 1 DB Essay Example | Topics and Well Written Essays - 500 words

Unit 1 DB - Essay Example The regulatory environment within the region is uniform and it presents a relatively stable political as well as economic environment. To run a business in EU would have important implications. It will not prove to be more predictable and stable but it will also involve lesser complications as for as running the business in the country. EU not only provide a bigger market however it is bit regulated too that might prevent us from fully exploring the market. Further, the regional protection policies will also be a substantial barrier to our proposed entry into the market through the proposed acquisition. The most important advantage of making an acquisition offer to the firm working in the EU region will be the availability of developed infrastructure as well as readily available market. Further, this will also provide ACME an opportunity to tap the new markets of the EU region also. With the passage of time as ACMA gain knowledge of the market and understand the local dynamics, it will be able to get an access to the more formal, regulated and bigger market once it make an acquisition of the firm working in the EU

Immigration from Mexico to the Us Essay Example for Free

Immigration from Mexico to the Us Essay Introduction When you think about the US you think about immigration, both the legal and the illegal immigration. The United States of America is a country buildup around immigration. Ever since the possibility of fleeing chaotic and poverty hit Europe had become a reality, many chose to take the jump and take the long journey against the possibilities country, America. Since the 16th century, where the country was discovered, it has been connected with The American Dream and a new start on life and a possibility to be able to create a better life for yourself, better than the one you knew from your home country and many immigrated for that chance. The only Native Americans are the Indians all others are immigrants, most often more generations old. The US also has the largest and most technologically powerful economy in the world, this means that a lot of people still believe in â€Å"The American Dream† and therefore try to immigrate into the US. We will explain the illegal immigration to the US from Mexico in our task. After that we will look at the pros and cons of the illegal immigration financially. Subsequently we want to analyze which influence the illegal immigration has on the United States economy. Finally wed like to see on what the present president, Obama thinks of the subject and reckon which possibilities it opens up for in the future among other things the Dream act. Country portrait USA The United States of America is a democratic federal republic with more than 9,6 billion km2 and a population of 310 million people. This makes them the third largest and third most populated country in the world. The US gained their freedom from the British Empire in 1776, and had first there been recognized as a nation. Ever since the breakaway from Brittan the US had a lot of issues on the national level. Among other things the civil war in the middle the 19th century. Up through the 19 and 20 century 37 new states was added to the republic, this resulted in the 50 states we know as the United States of American today. It was not until after the Second World War the US took place as a superpower of the world and it has since been the all-dominant power both political and military, which has created the university-polar world community that we know today. The US has one GNP at 15.29 trillion $ which is the largest economy for a single country in the world, GNP growth was in 2011 on 1.7 % which ranks as a no. 162 in the world. The US has a complete workforce on 153.6 million (2011) and GNP per inhabitant on 49,000 USDS (2011) this gives a little misleading picture, since the difference between rich and poor is huge compared countries with less GNP per inhabitant. The US has an unemployment rate on 9 % (2011) and an incredible 15.1 % of the population live under the poverty threshold (2010) the US is the result of a country with large immigration from many different countries over several hundred years, therefore the US is among the top of the countries in the world with most ethnic groups. The main spoken language in the US is English/American 82, 1% of the population speaks that while a staggering 10,7 % of the population only speaks Spanish this creates a lot of barriers and challenges for the country. Issue – Illegal immigration from Mexico Definition The border between the United States and Mexico stretches more than 2.000 miles and has become a symbol of a boiling bowl of political issues between the two countries. It is especially the illegal immigration from Mexico to the United States that are causing problems. Facts * Mexico experienced economic turmoil in 1994, and there has been a large influx of Mexican immigrants ever since * Some 1.1 million people tries to cross the border and gets arrested every year * The Gini-coefficient (which is a measure of statistical dispersion that measures the inequality among values) illustrates the difference between living standards in the US and in Mexico. Where zero is complete equality, 100 is perfect inequality. Mexico has a gini index on 54,6 compared to the US which has a gini index around 46. Push / Pull factors This difference between the two countries might not be clear from the gini index. But there is a huge difference in living standards and possibilities of doing something grater with their lives than what is possible in Mexico. * GDP per capita * Mexico $14.800 * US $49.000 Push factors * Unemployment rate in Mexico may be as high as 25 % * Crime with especially drugs and gun trafficking * 51, 3 % of the population are living below the poverty line * Difficult to develop a higher standard of living Pull factors * Unemployment rate in the US is about 9 % * 15,1 % of the population are living below the poverty line * There are work for the Latinos in the South * Its hard work in the hot sun. Americans just dont want to do it anymore, said Betty Perez, a local rancher. * Noticeable difference in the quality of life between the two countries * Immigrants are chasing the â€Å"American Dream† Future immigrants * Despite a recent report from the Pew Hispanic Center * There will always be immigrants trying to immigrate to a better life * Pull factors are getting lower and this might have an effect / still a huge push factor Issue Linguistic Challenges Definition The linguistic challenges that arise because of the Mexicans’ immigration, have a huge effect on the us. By 2050 the United States will be the biggest Spanish-speaking country in the world. Analyzes * Education system loses quality, because of more Spanish talking students. Dropout rate for Hispanics is increasing. * Hispanic get substandard health care * Available jobs, but the language cause problems * Spanish can be a gateway The education systems lose quality, because of more Spanish talking students. The dropout rate for Hispanic between 16 and 19 years old who have poor English language skills is 59 percent. The Hispanic dropouts in educational institutions results in Hispanics with high an unemployment rate and low paying jobs. Hispanic Immigrants get substandard health care, because they cannot speak English well and not all hospitals have Spanish translators. Some places in the us there’s is actually jobs available for Hispanics, but manufacturing and retail employers can’t hire the immigrants, because of their bad English level, the immigrants aren’t able to be trained and placed in the jobs as well as the job safety requirements. You have to speak English on the job, so nobody has to be around you to tell you what the boss wants or translate out of an instruction manual, said Jose Adame of Horn Lake, Miss. He came from Mexico nine years ago for work, but said he was not able to find a steady job as a machine operator until he improved his English. The growing standard of living among Spanish-talking countries affects the trading. South-America is a way more important country now to trade with, than it was before. Some places it’s actually good to speak Spanish, and can it can be a gateway for a job if you speak Spanish. Issue – Economical ups and downs from immigration Definition The constant wave of immigrants to the US presents some difficulties and some advantages. We will now try to uncover some of the economical ups and downs that have come as a result of immigration in the US. Analyzes Are there economic and social consequences of illegal immigration? Some say Illegal immigrants have cost billions of taxpayer-funded dollars for medical services, others say that they are an asset to the society. * One of Mexicos largest revenue streams (after exports and oil sales) consists of money sent home by legal immigrants and illegal immigrants working in the U.S. * â€Å"All empirical study of illegals economic impact demonstrates that illegal immigrants contribute more than they cost.† – Francine J Mipman, Professor of Law, Business and Economics at Chapman University * Many small cities in the south, close to the Mexican border, wont function without the immigrants. * Recent estimate from the Council of Economic Advisers is that immigrants as a whole (not just illegal immigrants) add about $37 billion a year to the U.S. economy, on net. * It’s typically young uneducated men who immigrate to the US, so they don’t really contribute that much. * Illegal immigration from Mexico caused a 3.6 percent reduction in the wages of non-high school graduates in the U.S. during 1980-2000. Issue – President Obamas immigrations plans for the future Definition In November 2010 the Democrats lost the House and much of their Senate majority, which made it complicated for president Barrack Obama to successfully get his immigration politic reform through the senate. What is Barrack Obama’s immigrations plan for the next 4 years? Facts In 2008 president Obama ran for the president post with immigration as one of his main issues, but there has been a lack of progress on immigrations reforms, which Obama explains with a large Republican opposition, as well as a shift in priorities given the global financial crisis. Even though Barrack Obama admits that the lack of immigrations reforms are the greatest failure of his time as president. One of the main issues of immigration in USA is the deportation of young hard working people, who were brought to the country by their parents. Obama will stop these deportations, and help those young men get an education and be a part of the society. Since the beginning of his time in office, President Obama has worked to build a consensus for Congress to pass comprehensive immigration reform. He plans to continue his efforts to work with Congress to pass a bipartisan immigration reform, and has promised to make it a priority of his second term as president. The President understands the challenges that immigrants face. That’s why he proposed a new rule to keep families together by allowing undocumented spouses and children of U.S. citizens to stay in the country while they begin the legal immigration process. Conclusion / estimate It is incredibly hard to draw any conclusions on the illegal immigrations part, mainly because they are illegal and no one keeps track of them. Some studies shows that the immigrants push the wage level down on certain jobs, but the overall picture is that they contribute to the US economy. The illegal immigrants are not allowed any social services, therefore the cost of having them in the country is low while they take jobs that most Americans aren’t interested in. The legal immigrants pose a different issue, they are eligible to social services, and often ship their money to Mexico to their families, but they also use a steady flow of money in the country, it is more of a 50/50 saturation with the legal immigrants. Obama is going to continually try and make the US better for immigrants, and cut down on deportation of young people who were brought to the country by their parents. Obama will try to get a lot of reforms through the senate, but its going to be hard, depending on how the votes in the house goes at the election. The linguistic challenge presented by the Hispanic speakers in the US is something to take serious. The costs that public institutions in the US have to spend, to please all the Spanish speakers in the US, are huge. The educational challenge is also present here, the standards of the US education system has been dropping as a result of the Spanish speaking students. Method Most of the used statistics have been found online by using CIA, the world factbook. We have used the quantitative method and compared the two countries (Mexico and the US) statistics with each other looking at both economic and social problems. While looking at the numbers and statistics we have been critical and double checked the statistics that we found on different sites both Danish and American. In addition to that we have looked at several articles that have spoken about the issue of immigration both looking at pros and cons. We also watched a film during class in which there where some useful information about immigration from Mexico.

The Cay :: essays research papers

The plot tells of a young boy named Phillip and an old black man named Timothy. Phillip and his mom are on a boat to the United States. Their family has always looked down on black people. Then during the night there was a rumble a Phillip fell of his bunk. A German sub-marine hit their boat. They got up put on their close and life jackets and got in the lifeboat. Then while the life boat was being launched it tipped and everyone fell in the water. Phillip was swimming frantically for his mother but before he knew it he was knocked unconscious by something big. When he woke up he was in a life boat with a old, ugly, black-skinned man. The man said that he got knocked on the head really bad and he was happy to see that he was awake. The sun was really hot so the black man told him to give him his close so he did. Then the man tore some wood from the boat and made a shelter with the close. Phillip said wear are w wears my mom but the man said she’s not here but she’s probably in a different life boat. Phillip was really thirsty so the man opened a hatch in the boat and took some water out of a keg. He only gave Phillip a half a cup so Phillip asked for more. The man said they must spare as much water as possible. It was almost dark when the man said maybe some flying fish will jump in our boat for us to eat. Phillip didn’t like the idea of eating raw fish but he was hungry. The next day Phillip woke up and his eyes were blurry he hey there’s something wrong with my eyes. So the man took a wet towel and put it on his head it started to get better. Then Phillip fell back asleep and when he woke up it was dark. Phillip screamed what time is it the man said ten then Phillip its nighttime right the man laughed no its morning. Phillip screamed I’m blind the man was shocked he said here look at the sun, and he pointed Phillip to the sun Phillip said its still dark. During that night he asked what his name is the man said my name is Timothy. Phillip said do you have a last name the man said no Phillip was shocked at this then Timothy said lets get some sleep we have a long day tomorrow. The Cay :: essays research papers The plot tells of a young boy named Phillip and an old black man named Timothy. Phillip and his mom are on a boat to the United States. Their family has always looked down on black people. Then during the night there was a rumble a Phillip fell of his bunk. A German sub-marine hit their boat. They got up put on their close and life jackets and got in the lifeboat. Then while the life boat was being launched it tipped and everyone fell in the water. Phillip was swimming frantically for his mother but before he knew it he was knocked unconscious by something big. When he woke up he was in a life boat with a old, ugly, black-skinned man. The man said that he got knocked on the head really bad and he was happy to see that he was awake. The sun was really hot so the black man told him to give him his close so he did. Then the man tore some wood from the boat and made a shelter with the close. Phillip said wear are w wears my mom but the man said she’s not here but she’s probably in a different life boat. Phillip was really thirsty so the man opened a hatch in the boat and took some water out of a keg. He only gave Phillip a half a cup so Phillip asked for more. The man said they must spare as much water as possible. It was almost dark when the man said maybe some flying fish will jump in our boat for us to eat. Phillip didn’t like the idea of eating raw fish but he was hungry. The next day Phillip woke up and his eyes were blurry he hey there’s something wrong with my eyes. So the man took a wet towel and put it on his head it started to get better. Then Phillip fell back asleep and when he woke up it was dark. Phillip screamed what time is it the man said ten then Phillip its nighttime right the man laughed no its morning. Phillip screamed I’m blind the man was shocked he said here look at the sun, and he pointed Phillip to the sun Phillip said its still dark. During that night he asked what his name is the man said my name is Timothy. Phillip said do you have a last name the man said no Phillip was shocked at this then Timothy said lets get some sleep we have a long day tomorrow.

Samsung Company

Introduction to Business Samsung Company From a small export business created in Daegu, Korea, Samsung has grown and become one of the world’s leader in the electronics industry. The main specialization of Samsung is digital appliances and media, semiconductors, memory and system integration. The market segmentation of Samsung is giving them a firm commercial advantage. Samsung is segmented according to demographic segmentation, that consists of dividing the market in groups based on different criteria.The most important criterias used by this company is age, income and occupation. Using this criteria they tend to become a leader in technology market as they offer products for each group of customers. Also they are using psychographic segmentation that is the science used to better understand consumers, according to their lifestyle, personality and the main values they have.Another process used by this company is Positive market segmentation that consists of studying the rival goods that are demanded in the market and to compare the quality and price, to understand what the customers need and what products could they insert in the market to satisfy the customer and to increase the confidence of customers in the company. This strategy is one of the strengths of the company as they study the activity of Apple Corporation and other rivals.Using the collected datas they know better what kind of products could they offer to different groups of consumers. The motto of the company is â€Å"Inspire the World, Create the Future†, from it we can deduce that the main purpose for them is to satisfy the customers desires and to achieve a high revenue. Another strength that keeps Samsung in the top world’s brands is the fact that Samsung is totally dedicated to give their customers a wealth of opportunities to rich their full potential. The globalization process for Samsung’s technology businesses started in the early 1980s.So they became a part o f The digital age that has brought new changes and opportunities to global business and Samsung has responded with competitive products and constant innovation. This can be proved by studying the worldwide demand for different goods. For example the worldwide demand for mobile phones was staggering 1. 5 billions in 2011, Samsung accounted for 330 million of those units. This proves the strength of the company as a worldwide leader for different goods as notebooks, mobile phones or digital cameras.Investing directly in activity that spurs economic growth helps Samsung to achieve greater income potential and maintain Samsung brand as one of the most popular in the world. Their position in the market gives them the opportunity to achieve new heights, one of them is their plan of reaching $400 billion in revenue and become one of the world’s top five brands by 2020. Samsung’s Chairman Lee considers that Globalization is the key for future growth, using this idea he created a new strategy to accelerate Samsung’s globalization through developing a pool of global managers as strategic advisors for Samsung Group.Samsung strategies varies for each trade market. In India their strategy is to be a nationwide distributor and retail presence in the domestic consumer durables market. Also they use different advertising tactics to promote their products, for example Samsung has been associated with the Lakme India Fashion Week for its Mobile Phones. The company used this platform in 2005 to launch a new version of mobile phone the D-500, that became after World’s best mobile phone in the Indiam market.Another strategy is the strategic alliances between Samsung and other worldwide recognized organisations, for example in 2007, Samsung established a joint venture with Limo for developing a Linux platform, also they Co-developed for handsets and DVB-H standardization solutions with Nokia. Samsung is also investing money in different companies that co uld help them to provide better technology to consumers, for example investments in shares of US based firm specializing in HDD technology (Integral Peripherals), or investments in operator of telecomunications systems in Chile (Entel).Other strengths of Samsung are the design, effective advertisement and market communication, an actively coming out with newer models and branding as Samsung is ranked 17th among global companies in 2011. A strong point for Samsung is that consists from various business units, the most important is Electronic Industry the one that brings the most revenue for the group (65% in 2011), Engineering and Heavy Industry and Financial Services.When Samsung Electronics rushed its first smartphone to market as a response to the debut of the Apple iPhone, some customers burned the product on the streets or hammered in to the bits in public displays of disaffection. Complaints ranged from dropped calls and heavy touchscreen to frequent auto-rebooting and a lack o f applications. This is weakness for Samsung that they can not keep up with the innovations from Apple and other rivals, even if they try to show the opposite.The biggest threat for Samsung is the global patent battle, between them and Apple,as Apple considers that Samsung copied its iPad and iPhone. Another threat is the fact that Samsung created a big variety of phones into the market so that could lead to a decrease in the demand for new goods in future. Samsung has a different market approach as it offers to customers a much bigger diversity of products. As their previous accomplishments, they look further to explore and develop new activities, as health, medicine, biotechnology. References 1.Kim Youngsoo, 1997, â€Å"Technological Capabilities and Samsung Electronics† 2. Bloom Martin, 1992, „Technological Changes in the Korean Electronics Industryâ€Å" 3. Yu Sengjae, 1989, „Korean Electronics Enterprises : Growth and Strategiesâ€Å" 4. Samsung Global Stra tegy – http://sgsg. samsung. com/Introducing_Samsung_GSG_final. pdf 5. Samsung Business Review -http://www. samsung. com/uk/aboutsamsung/corporateprofile/download/2011_4_Business_Overview. pdf 6. Samsung Financial Highlights – http://www. samsung. com/hk_en/aboutsamsung/corporateprofile/ourperformance/samsungprofile. html

How to Successfully Expand your Business into the Africa

Import and export figures are also significantly higher for emerging markets and developing economies compared to advanced economies. Looking at these projections as an business or investor should have you seriously considering expanding your business or portfolio into these regions and tap into these revenue. Introduction Today world is becoming less and less defined by its boundaries, the words â€Å"Global Village† and used to reference this evolution. Business is at the fore front of breaking these boarders.Technological advances in communication especially via the World Wide Web have broken down the barriers enabling a business in America to sell rodents in a consumer in China, England, Brazil, Kenya†¦. Anywhere the internet is present can now be included in a business's target market. Not only can businesses sell goods and services anywhere in the world, the can also have operation there and be able to communicate and collaborate with colleagues and other partners m ore efficiently and affordable than even before. Given these facts then why do businesses choice to do trade with one country over another and not both or as many as possible?We the simple answer to this question is that there many other barriers to read with foreign countries that will make it hard or even impossible for foreign business to expand into those regions. African countries have been one of those that many businesses in developed countries have refrained from doing business with. And in their defense it's not without merit. Despite African being blessed with an abundance of natural resources, it has been plagues with wars, and political instability leading to high levels of poverty, lack of education and poor infrastructure.However over the last two decades, many of these countries have made strides in utter there economies, and have registered high economic growth during this period. However even with these changes, not many foreign business have taken note of these reg ion as potentially significant part of the market. Even with slow economic growth rates among developed countries. Africa is poised to be the next big market, especially as things slowly wind down in Asia notably China. The purpose of this project is to establish a successful strategy for American Businesses to expand into the African Market Is this a profitable market?The African economy has seen a significant economic growth of the past two cascades. The economic growth rate is two to three times that of developed countries and still significantly higher than that of other emerging economies like Asia and Latin America. The middle class has shown a sharp rise over the last decade, raising the amount of people with discretionary income thus driving the economy. This growth spike is driven by the growth of the middle class. The middle class growth has happened as Africa makes strides in education, infrastructure, and political stability in many countries.Compared to Just about 10 ye ars ago, a huge economic growth can be noticed. From a similar research project conducted written in 2004 titled † The experience of South African Firms Doing Business in Africa' we can see Just how the economy and other factors have changed. In June 2003, the International Monetary Fund (MIFF) observed that macroeconomic policies in Africa had improved considerably in recent years, although inflation remained a source of worry in a number of countries such as Zombie, Angola, Somalia and Nigeria.In its April World Outlook, the MIFF maintained that the central challenge for Africa remained the establishment of those conditions necessary to achieve the Millennium Development Goals, most notably a sustained reduction in poverty. However, to achieve these goals, an overall growth rate of 7% per annum is required. Far from reaching that goal, Africans economic growth slowed to 3. 1% in 2002, compared with 4. 3% the previous year. (Games 2004) Fast forward to 2013 that goal of 7% gr owth is being attained by several African countries.If you look at the latest MIFF data for economic growth in table 1. MIFF 2013 The average growth for many of the African countries, is at 6. 9% in 2013 and raising up to 7. 9 in 2014. The map further shows where parts are recording these phenomenal growth rates. A 7% average annual growth rate is too significant to Just be ignored. This growth creates an increased demand for goods and services that usually cannot be meet by current businesses and government. Deutsche Bank said the number of households with discretionary income would reach 130 million by 2020 from 85 million now. Cape Argus [South Africa] 14 Novo. 2013) What industries are most profitable? A developing counties or emerging economies the African market has opportunities for business in every industry. This region is playing catch up with developed countries thus means the opportunities for foreign businesses who have already one it can bring with them experience and expertise to contribute to this growth will turning a profit. Retail is one of sub-Sahara Africans hottest sectors, fuelled by expanding populations and fast growing economies.In east Africa, the economies of several nations are growing around 7 percent a year. Real income growth in Africa is averaging 2. 3 percent a year and consumer spending accounts for 60 percent of economic output, the World Bank said in April. Deutsche Bank said the number of households with discretionary income would reach 130 million by 2020 from 85 million now. That's really good news for shops. Daily News [Colombo, Sir Lankan] 14) Africans tourism growth was faster than the average for emerging economies. More than half of Africans tourists arrived by air.International tourist arrivals in Africa had grown almost fivefold since 1990 at a rate of 6. 3 percent a year. International tourist arrivals rose from 15 million a year in 1990 to 50 million in 2011. The growth rate in sub-Sahara African tourism arrival s was nearly 8 percent a year between 1990 and 2011. It is estimated that tourism injects more than $30 billion (Rabin) into the continent a year. Airbus said there had been some positive improvements across the egging despite continued impediments to growth. (Cape Times [South Africa] 1 Novo. 013) What are the barriers? These are: Low levels of development and insufficient investment in people as resources; Political and fiscal risk. A weak private sector, coupled with a strong government presence in the economy; High dependency on donors and other financial mechanisms for aid and the funding of projects; High business costs owing to the lack of basic services, facilities, infrastructure, development, competition and resources; Insufficient air and road links; Poor leadership and bad governance; Corruption at all levels of government;High costs of finance due to high risk and weak economies Currency fluctuations. (Games 2004) This list of barriers to doing business in Africa are fr om a decade ago, at present not all of them have been corrected but significant steps have been taken to fix reduce or eliminate them. In Africa, foreign investors beware: business is often a family affair. Just ask Wall-Mart , the world's largest retailer. Daily News [Colombo, Sir Lankan] 14) Political climate Tunis: The eighth annual African Economic Conference concluded today, calling on development and business leaders to turn Africa into a hub of business and development excellence. The conference, Jointly organized each year by the African Development Bank (BFD), the United Nations Economic Commission for Africa (ACE) and the United Nations Development Programmer (UNDO), brought together 500 decision-makers and development practitioners. Daily the Peak Banker 2013) Infrastructure SCALING up infrastructure investments and adopting modern methods of management have been identified as significant benchmark in releasing potentials in the business sector to contribute immensely to economic growth of the East African Community (EACH) partner states. (Tanzania Daily News 2013) â€Å"We need investment n infrastructure, our roads and ports,† (African news service 2013) Countries to avoid Why sub-Sahara Africa and not north?Growth will weaken in north Africa dues to slow down among oil exporters (miff pop) Sub-Sahara Africa is expected to continue growing at a strong pace during 2013-14, with both resource-rich and lower-income economies benefiting from robust domestic demand (Figure 2. 15). The external environment is the main source of risks to growth, particularly for middle- income and mineral-exporting economies. Given the still-uncertain global environment, countries whose policy buffers are thin and here growth is strong should seek to rebuild fiscal positions without undermining productive investment. miff pop) The generally strong per- performance is based to a significant extent on ongoing investment in infrastructure and productive capacity, con tinuing robust consumption, and the activation of new capacity in extractive sectors. (MFC pop) . In sub-Sahara Africa as a whole, inflation is projected to fall further to 7 percent in 2013 (miff pop) The frequency of growth takeoffs in low-income countries (Lies) has risen markedly during the past two decades, and these takeoffs have lasted longer than those that took place before the sass.Economic structure has not mattered much in sparking takeoffs-?takeoffs have been achieved by Lies rich in resources and by those oriented toward manufacturing. A striking similarity between recent takeoffs and those before the sass is that they have been associated with higher investment and national saving rates and with stronger export growth, which sets them apart from Lies that were unable to take off and confirms the key role of capital accumulation and trade integration in development.However, recent takeoffs stand out from earlier takeoffs in two important aspects. First, today's yeoman Lies have achieved strong growth without building macroeconomic imbalances-?as reflected in declining inflation, more com- appetite exchange rates, and appreciably lower public and external debt accumulation. For resource-rich Lies, this has been due to a much greater reliance on foreign direct invest- meet (FED). For other Lies, strong growth was achieved despite lower investment levels than in the previous genera- Zion.Second, recent takeoffs are associated with a faster pace of implementing productivity-enhancing structural reforms and strengthening institutions. For example, these Lies have a lower regulatory burden, better infrastructure, higher education levels, and greater political stability. Looking for- ward, there remain many challenges to maintaining strong growth performance in today's dynamic Lies, including the concentration of their growth in only a few sectors and the need to diversify their economies, and ensuring that growth leads to broad- based improvements in l iving standards.Still, if these countries succeed in preserving their improved policy foundation and maintaining their momentum in structural reform, they seem more likely to stay on course and avoid the reversals in economic fortunes that afflicted many dynamic Lies in the past. miff 97) In particular, the follow- ins have become more important: a more competitive exchange rate, deeper export links with other Modes, higher human capital levels, initial levels of income per capita, and overall economic size.Indeed, as global trade and competition increase, greater external competitiveness, export diversification, and productive- itty improvements may raise Lies' chances of takeoff relatively more than when the global economy is less integrated. The baseline results suggest that the chances of take- off more than tripled during the sass compared with the period before 1990 (Figure 4. 11). The predicted (miff Pl 10) How can barriers to entry be overcome?He said that in order to kick-s tart a major investment drive on the continent, these banks should partner with institutions such as the Bank Guest Francine De Development, the Africa Finance Corporation and Cairo-based Brinkman. Pressed on whether he had considered the Industrial Development Corporation and the Development Bank of Southern African, he said these too should be considered for partnering and leveraging with bigger commercial banks. (Cape Times [South Africa] 1 Novo. 2013) â€Å"Business on the continent is a relationship, not Just a transaction.If you miss the relationship you will have endless trouble with the transaction. † Building relationships in Africa is an important part of doing business, particularly for South Africans who have to work at countering the perception that they are the new colonizers, the bully boys who have taken over markets, pushing out local businesses. (Games 2004) Are other countries already doing business in this region successfully? About 80 business people have been given advice about increasing exports to Africa. The event, held yesterday in Quern, was hosted by Government agency I-J Trade and Investment (KIT).Susann Hutting, of the East Midlands office, said most of the delegates had already traded with Africa and were looking for ways to increase their sales to the continent. â€Å"Lots of people were looking for different information about exporting more,† she said. (Leister Mercury Novo. ) Which developed countries are doing business here? Asks, who was born in South Africa, said â€Å"everyone is keen on Africa†, including investment banks in the EX. and North America. They had billions of dollars available to invest on the continent but did not know the regulatory terrain and the pitfalls of coal investment markets.He had been in discussions with many of the international banks. â€Å"They are all asking†¦ Are you [Airbus] formulating a strategy for Africa? † (Cape Times [South Africa] 1 Novo. 2013) Marrio tt International, the New York Stock Exchange-listed international hospitality group, is planning to acquire the brands and management business of Protean Hotels in South Africa and sub-Sahara Africa. The US group confirmed yesterday that it had signed a letter of intent with Cape Town-based Protean Hospitality Holdings to acquire Protean Hotels' brands and its management business.Protean Hotels operates or franchises 116 hotels across three brands with 10 184 rooms in South Africa and six other sub-Sahara African countries. (cape times 2013) How are other business from other foreign countries doing? Natural growth of African-based aviation would see the number of aircraft needed to serve the markets for flights to, from and within the continent rising from 618 at the start of 2012 to a projected 1 453 by 2031. It was projected that 122 aircraft of the existing 618 would have to be replaced, while 823 would have to be brought on stream. This meant nearly 1 000 new aircraft would be needed in the next 20 years.

Brigadier General John Hunt Morgan in the Civil War

Brigadier General John Hunt Morgan in the Civil War John Hunt Morgan - Early Life: Born June 1, 1825, in Huntsville, AL, John Hunt Morgan was the son of Calvin and Henrietta (Hunt) Morgan. The eldest of ten children, he moved to Lexington, KY at age six following the failure of his fathers business. Settling on one of the Hunt family farms, Morgan was schooled locally before enrolling in Transylvania College in 1842. His career in higher education proved short as he was suspended two years later for dueling with a fraternity brother. With the outbreak of the Mexican-American War in 1846, Morgan enlisted in a cavalry regiment. John Hunt Morgan - In Mexico: Traveling south, he saw action at the Battle of Buena Vista in February 1847. A gifted soldier, he won promotion to first lieutenant. With the conclusion of the war, Morgan left the service and returned home to Kentucky. Establishing himself as a hemp manufacturer, he married Rebecca Gratz Bruce in 1848. Though a businessman, Morgan remained interested in military matters and attempted to form a militia artillery company in 1852. This group disbanded two years later and in 1857, Morgan formed the pro-South Lexington Rifles. An ardent supporter of Southern rights, Morgan often clashed with his wifes family. John Hunt Morgan - The Civil War Begins: As the secession crisis loomed, Morgan initially hoped that conflict could be avoided. In 1861, Morgan elected to support the Southern cause and flew a rebel flag over his factory. When his wife died on July 21 after suffering from several health problems, including septic thrombophlebitis, he decided to take an active role in the coming conflict. As Kentucky remained neutral, Morgan and his company slipped across the border to Camp Boone in Tennessee. Joining the Confederate Army, Morgan soon formed the 2nd Kentucky Cavalry with himself as colonel. Serving in the Army of Tennessee, the regiment saw action at the Battle of Shiloh on April 6-7, 1862. Developing a reputation as an aggressive commander, Morgan led several successful raids against Union forces. On July 4, 1862, he departed Knoxville, TN with 900 men and swept through Kentucky capturing 1,200 prisoners and wreaking havoc in the Union rear. Likened to American Revolution hero Francis Marion, it was hoped that Morgans performance would help sway Kentucky into the Confederate fold. The success of the raid led General Braxton Bragg to invade the state that fall. Following the invasions failure, the Confederates fell back to Tennessee. On December 11, Morgan was promoted to brigadier general. The next day he married Martha Ready, the daughter of Tennessee Congressman Charles Ready. Later that month, Morgan rode into Kentucky with 4,000 men. Moving north, they disrupted the Louisville Nashville Railroad and defeated a Union force at Elizabethtown. Returning south, Morgan was greeted as a hero. That June, Bragg gave Morgan permission for another raid into Kentucky with the goal of distracting the Union Army of the Cumberland from the upcoming campaign. John Hunt Morgan - The Great Raid: Concerned that Morgan might become too aggressive, Bragg strictly forbade him to cross the Ohio River into Indiana or Ohio. Departing Sparta, TN on June 11, 1863, Morgan rode with a select force of 2,462 cavalry and a battery of light artillery. Moving north through Kentucky, they won several small battles against Union forces. In early July, Morgans men captured two steamboats at Brandenburg, KY. Against orders, he began transporting his men across the Ohio River, landing near Maukport, IN. Moving inland, Morgan raided across southern Indiana and Ohio, causing a panic among the local residents. Alerted to Morgans presence, the commander of the Department of the Ohio, Major General Ambrose Burnside began shifting troops to meet the threat. Deciding to return to Tennessee, Morgan headed for the ford at Buffington Island, OH. Anticipating this move, Burnside rushed troops to the ford. In the resulting battle, Union forces captured 750 of Morgans men and prevented him from crossing. Moving north along the river, Morgan was repeated blocked from crossing with his entire command. After a brief fight at Hockingport, he turned inland with approximately 400 men. Relentlessly pursued by Union forces, Morgan was defeated and captured on July 26 after the Battle of Salinesville. While his men were shipped to the Camp Douglas prison camp in Illinois, Morgan and his officers were taken to the Ohio Penitentiary in Columbus, OH. After several weeks of incarceration, Morgan, along with six of his officers managed to tunnel out of the prison and escaped on November 27. Proceeding south to Cincinnati, they managed to cross the river into Kentucky where Southern sympathizers aided them in reaching Confederate lines. John Hunt Morgan - Later Career: Though his return was lauded by the Southern press, he was not received with open arms by his superiors. Angry that he had violated his orders to remain south of the Ohio, Bragg never fully trusted him again. Placed in command of Confederate forces in eastern Tennessee and southwest Virginia, Morgan attempted to rebuild the raiding force that he had lost during his Great Raid. In the summer of 1864, Morgan was accused of robbing a bank in Mt. Sterling, KY. While some his men were involved, there is no evidence to suggest that Morgan played a role. While working to clear his name, Morgan and his men encamped at Greeneville, TN. On the morning of September 4, Union troops attacked the town. Taken by surprise, Morgan was shot and killed while attempting to escape from the attackers. After his death, Morgans body was returned to Kentucky where he was buried in Lexington Cemetery.

MASS CUSTOMIZATION AND ONE-ON-ONE MARKETING essays

MASS CUSTOMIZATION AND ONE-ON-ONE MARKETING essays The Internet supports mass customization and one-on-one marketing as Mass customization - The capacity of the Internet is found in the use of information technology (IT), data storage and data processing instead of the traditional approach of relying on physical location and employees. Both products and services can be customized to meet specific individual needs at leves that could not be accomplished without these benefits of IT. Dell sells computers by allowing customers to select components according to individual needs. Instead of simply accepting what the manufacturer includes in the package, Dell's approach allows consumers to select their own components, and Dell builds-to-suit. The use of technology allows this mass customization to be offered in a cost-effective manner. Many other mass customization services exist on the Internet, such as news services, home-page customization and floral purchases, by allowing consumers to select options that meet personals preferences. One-on-one marketing - The Internet facilitates direct marketing because personal data can be collected and stored from both existing and potential consumers. Data collection is achieved through simple data-gathering methods such as when consumers place orders, visit websites, enter contests or request information. Key demographic information (name, address, sex, age, education, income) and other relevant data (interests, intents, willingness to receive additional information) is collected and stored. This data can be retrieved and used to tailor marketing campaigns to persons found within the database by sorting relevant fields to match targeted consumer profiles. The data to support this type of targeted marketing is ...

Ionic vs Covalent Bonds - Understand the Difference

Ionic vs Covalent Bonds - Understand the Difference A molecule or compound is made when two or more atoms form a  chemical bond, linking them together. The two types of bonds are ionic bonds and covalent bonds. The distinction between them has to do with how equally the atoms participating in the bond share their electrons. Ionic Bonds In an ionic bond, one atom essentially donates an electron to stabilize the other atom. In other words, the electron spends most of its time close to the bonded atom.  Atoms that participate in an ionic bond have different electronegativity values from each other. A polar bond is formed by the attraction between oppositely-charged ions.  For example, sodium and chloride form an ionic bond, to make NaCl, or table salt. You can predict an ionic bond will form when two atoms have different electronegativity values and detect an ionic compound by its properties, including a tendency to dissociate into ions in water. Covalent Bonds In a covalent bond, the atoms are bound by shared electrons. In a true covalent bond, the electronegativity values are the same (e.g., H2, O3), although in practice the electronegativity values just need to be close. If the electron is shared equally between the atoms forming a covalent bond, then the bond is said to be nonpolar. Usually, an electron is more attracted to one atom than to another, forming a polar covalent bond. For example, the atoms in water, H2O, are held together by polar covalent bonds. You can predict a covalent bond will form between two nonmetallic atoms. Also, covalent compounds may dissolve in water, but dont dissociate into ions. Ionic vs Covalent Bonds Summary Heres a quick summary of the differences between ionic and covalent bonds, their properties, and how to recognize them: Ionic Bonds Covalent Bonds Description Bond between metal and nonmetal. The nonmetal attracts the electron, so it's like the metal donates its electron to it. Bond between two nonmetals with similar electronegativities. Atoms share electrons in their outer orbitals. Polarity High Low Shape No definite shape Definite shape Melting Point High Low Boiling Point High Low State at Room Temperature Solid Liquid or Gas Examples Sodium chloride (NaCl), Sulfuric Acid (H2SO4 ) Methane (CH4), Hydrochloric acid (HCl) Chemical Species Metal and nometal (remember hydrogen can act either way) Two nonmetals Do you understand? Test your comprehension with this quiz. Key Points The two main types of chemical bonds are ionic and covalent bonds.An ionic bond essentially donates an electron to the other atom participating in the bond, while electrons in a covalent bond are shared equally between the atoms.The only pure covalent bonds occur between identical atoms. Usually, there is some polarity (polar covalent bond) in which the electrons are shared, but spend more time with one atom than the other.Ionic bonds form between a metal and a nonmetal. Covalent bonds form between two nonmetals.

Domain Name Dispute Assessment Task Essay Example | Topics and Well Written Essays - 2000 words - 2

Domain Name Dispute Assessment Task - Essay Example lso argues that the respondent has no right or legitimate interest in the domain name, and that the domain name is used by the respondent in bad faith.3 The complainant is seeking the only remedy available under the Policy, namely transference of the domain name in question. The respondent denies that the complainant has a common law tradename and argues that in the event that the complainant proves otherwise, the complaint is denied in its entirety. The arbitration decisions rests on determining whether or not the complaint substantiates a case of ‘cybersquatting.’4 The term cybersquatting refers to a situation in which a domain name belonging to one party is subsequently used for nefarious purposes by another,5or rather, a case of ‘abusive registration.’6 Essentially, in order to prove cybersquatting, the complainant must satisfy three elements: the domain name used by the respondent is identical or confusingly similar to either a trademark or ‘service’ to which the complainant has an interest or rights; the respondent does not have a legitimate interest or right in the domain name; and the respondent is using the domain name in bad faith.7 Before dealing with the three elements necessary for substantiating the complainant’s case, it is necessary to deal with the trademark issue raised by the respondent. What distinguishes the Uniform Dispute Resolution Policy (UNDRP) from the au. Policy is that under the au. Policy, it is not necessary for the complainant to have a registered trademark. All that the complainant is required to prove under the au. Policy is that he or she have acquired a common law trademark through ‘sufficient evidence of use or reputation in the trademark to justify reliance on a common law trademark’.8 The complainant has provided sufficient evidence of its common law trademark through evidence indicating that Quickileaks has been operating as a well-recognised and accessed online media outlet prior to the respondent’s

Water in Africa Research Paper Example | Topics and Well Written Essays - 1500 words

Water in Africa - Research Paper Example s economy that was worth $35 billion in 2012 and estimated to grow by 8 percent in 2013(more than sub-Saharan African average for sixth year straight) will not continue to grow at the estimated rate without modern water network(Dzawu). In sub-Saharab Africa, cost of water shortages and lack of sanitation is estimated to be 5 percent of its annual GDP (Dearn).This research paper examines Africa’s water and sanitation crisis and major reason behind it and finds that Africa’s water crisis is the precursor of global water crisis, as a result, privatization may seem to be the only solution, but long term management and planning is the key to regulate it. It is interesting to note that Ghana is now politically stable and conducting peaceful elections since 1992. Its economic strengths are associated with gold, cocoa, and oil, yet Ghana’s President, John Dramani Mahama, accepted that Ghana is facing a major energy and water crisis. Some of the major problems with water supply system are aging water pipes, some of which were installed in 1914.Moreover, even those pipes doesn’t reach expanding suburbs of Accra. The supply is not adequate for ever increasing demand. Due to the lack of investment in water sector for 50 years, state only deals with emergency situations. State-owned Ghana Water can’t explain for 55 percent of the water it produces because either water is illegally siphoned from pipes or pipes bursts due to damage by erosion or construction (Dzawu). Water shortages brought nationwide crisis in electricity production. Though the water shortages have always been there, but electricity production needs were met by gas, electricity crisis started when the West African Gas Pipeline collapsed in August 2012 which reduced the natural gas supply to fire thermal power plants. Water Company also needs electricity in order to maintain its treatment operations (Dzawu). According to Ghanaian a researcher, In order to run their operations, other companies often

International Human Resource Management Assignment - 2

International Human Resource Management - Assignment Example 2) A draft job analysis for the position of an expat role would contain a minimum level of education, qualifications, and personality (Pilbeam & Corbridge, 2006). The last of these three is the most important factor in this type of role because it will determine if the prospective employee will adapt to the local culture. Once the candidates are whittled down based on this prerequisite, education and qualifications would then determine who was better placed to take the job according to the job requirements. 3) There are some methods of attracting candidates that would have to be altered to suit a local country where the job is. For example, some third world countries have very little Internet access, so advertising on the Internet would likely not succeed. These types of countries rely more on job referrals from somebody already established in the job market. 4) Psychometric testing would be ideal for potential expat employees because it would measure how they would fit into the company based on their cognitive abilities and personality or behavioral style (PsychPress, 2012). I would interview an expat’s partner because how they adapt to the local culture will determine whether the expat is committed to the job or

The Role of Motivation in Project Management Dissertation

The Role of Motivation in Project Management - Dissertation Example Engineering and construction is one of the primary factors of human evolution and therefore, the evolution of the society through construction depends on success of project management. Consequently, project management depends on the ability of the project managers to generate, nurture, and maintain high levels of motivation in all levels of project management. Although motivation on the base level where practical work happens is usually taken as the most fruitful target for motivation, other levels of project management including the highest project managerial levels needs to be equally motivated. The proposed study is overwhelmingly important to the author and the primary focus will be on the role of motivation in success of project management in the construction industry. Much of the insight on role of motivation in project management can be found on authentic books and authoritative internet sources. Different theorists and researchers have exhaustively explored theories of motivation in different aspects. Various definitions of motivation theories will be explored in the light of motivation and its influence on success of project management. However, only motivational aspects relating to motivation in construction industry will be discussed. ... Objectives 1. To make a profound research on literature discussing the field of motivation and correlate the information that will be obtained to success in project management in the construction industry. Key areas of consideration to achieve the above objective will include a) Theories of motivation b) Motivation factors c) Motivation as it applies to project teams d) Project management and teams 2. To ascertain the role of motivation in project management by looking at practical case studies. Key areas to be considered are a) How the project was carried out b) Motivation issues within the case study c) How the motivation issue was addressed d) Outcome of the motivation in relation to success or failure of the project Hypotheses 1. Motivation has a direct effect on the success of project management initiatives in the construction industry 2. Construction companies that adopt proficient motivation strategies record increased success in their project objectives Purpose of Study Effic ient management of construction projects is increasingly becoming more important as competition in the construction industry increases. The modern world is presenting more challenges for construction industry thereby increasing performance pressure on construction project managers. This increases the need for project managers to increase the output of project teams by any possible means. Since motivation is one of the greatest tools of meeting the objectives of project teams, a clear understanding of the relationship between the two concepts becomes overwhelmingly important. It is therefore, the purpose of this study to make profound investigation into the relationship between motivation and success of project teams with the purposes of shedding

Discuss the art work in the Cantor Arts Centre in Standford University Essay

Discuss the art work in the Cantor Arts Centre in Standford University - Essay Example This means that some of the artworks in the museums are obtained freely from the people who made them, and who have the full rights. People are in some cases driven to present artworks in museums by the desire to promote their cultures or represent the general coexistence of creatures in their environment. Through this, people understand and keep information about the culture that is represented by a work of art and are able to explain some information. In describing the work of art in a museum, it is important to identify the piece of work represented, the artist and the issues that prevailed during the time of production. This is important in understanding the work in different dimensions as well as getting the understanding of the feeling of people concerning the work (Payne and Picasso 8). The Lion Reclining in a Landscape The Lion Reclining in a Landscape is an artwork that is exhibited in Cantor Arts Center in Stanford University as part of the pieces of art that are representi ng the nature through a lion in an environment. The artwork was created as an original artwork by an artist, Antonie Luios Barye, who lived in America between the year 1796 and 1875, to represent the correlation between animals and their environment. This image was presented to different museums for exhibitions under the authority of the Barye who owned the piece of art and is availed to all the people who visit such museums for the viewing. This image is presented as a drawing that is made on a paper and is placed in the shelves for viewing by all the interested visitors in such museums. One of the places where Barye presented this image is the Cantor Arts Center in Stanford University where it is presented to the public for viewing. Through the work of art, people are able to understand different issues and this is in accordance to the views of the people concerning Barye and his piece of art. The piece of art that was presented in the 19th century as a primary creation but it has undergone reproduction with time so as to keep it in the records. The Lion in a Landscape image, although old and replicated by other people by copying the original image, is accepted favorably by the people who view it from the different museums in which it is exhibited. In the event of painting the image, the artist was presented was affected by different circumstances in the environment that made the different features to be prevalent in the image (Payne and Picasso 29). Antonie Luios Barye lived under his father who worked as a goldsmith and familiarized himself with the work of making sculptures and his skills were perfected by his working with different companies and training in different institutions. He continued in his work to demonstrate his interest in animals and that led him to production of images that were representing them in different ways. This means that all his production was designed according to his preferences in animals within the environment (Payne and Pica sso 59). During the time of production of Lion in a Landscape, the political environment was dominated by the Roman Empire who valued sculptures and drawings of their images. Economically, Barye produced his artworks during the time of gold

The Role of Motivation in Project Management Dissertation

The Role of Motivation in Project Management - Dissertation Example Engineering and construction is one of the primary factors of human evolution and therefore, the evolution of the society through construction depends on success of project management. Consequently, project management depends on the ability of the project managers to generate, nurture, and maintain high levels of motivation in all levels of project management. Although motivation on the base level where practical work happens is usually taken as the most fruitful target for motivation, other levels of project management including the highest project managerial levels needs to be equally motivated. The proposed study is overwhelmingly important to the author and the primary focus will be on the role of motivation in success of project management in the construction industry. Much of the insight on role of motivation in project management can be found on authentic books and authoritative internet sources. Different theorists and researchers have exhaustively explored theories of motivation in different aspects. Various definitions of motivation theories will be explored in the light of motivation and its influence on success of project management. However, only motivational aspects relating to motivation in construction industry will be discussed. ... Objectives 1. To make a profound research on literature discussing the field of motivation and correlate the information that will be obtained to success in project management in the construction industry. Key areas of consideration to achieve the above objective will include a) Theories of motivation b) Motivation factors c) Motivation as it applies to project teams d) Project management and teams 2. To ascertain the role of motivation in project management by looking at practical case studies. Key areas to be considered are a) How the project was carried out b) Motivation issues within the case study c) How the motivation issue was addressed d) Outcome of the motivation in relation to success or failure of the project Hypotheses 1. Motivation has a direct effect on the success of project management initiatives in the construction industry 2. Construction companies that adopt proficient motivation strategies record increased success in their project objectives Purpose of Study Effic ient management of construction projects is increasingly becoming more important as competition in the construction industry increases. The modern world is presenting more challenges for construction industry thereby increasing performance pressure on construction project managers. This increases the need for project managers to increase the output of project teams by any possible means. Since motivation is one of the greatest tools of meeting the objectives of project teams, a clear understanding of the relationship between the two concepts becomes overwhelmingly important. It is therefore, the purpose of this study to make profound investigation into the relationship between motivation and success of project teams with the purposes of shedding

Program Evaluation Paper Part III - smoking cessation Term - 1

Program Evaluation Part III - smoking cessation - Term Paper Example The program is extensively large since the target population is the entire populace of smokers in the US (Goel , 2008). This is however not a shortfall since the subject of smoking itself does not require a lot of study since the outcomes of a small comparison group will suffice. The subject being an addiction means that what will be displayed in one smoker will most likely be homogenous among all other smokers. Obtaining information would be considered rather easy. The records of those who have previously been enrolled in smoking cessation programs in health facilities will be found to be useful. Smokers would also voluntarily provide information. As mentioned before that the programs have been in place for some time, information from previous evaluations that were done on a smaller scale will be used as a baseline for this evaluation. This approach of employing surveys will involve distribution of questionnaires to people who smoke or are affected by smoking. The main components of the questionnaires will be finding out how many people admit to being a smoker. Another question would be to find out those who have considered quitting and also to find out what is the biggest challenge that they face when trying to stop smoking. The respondents will be samples collected from different geographical locations to ensure that the sample population is representative of the whole population. It will also be important to have questionnaires designed differently to be filled out by health providers. These questionnaires will be primarily used to find out professional opinions that will be crucial in developing and implementing the smoking cessation program. (Auxin, 2006) Examination of archival documents will also be a vital source of information. These types of source will be used mostly where information like national smoking prevalence is required. Existing records will have to be the latest and most credible. An important

A Literature Review About Mecication Errors Essay Example for Free

A Literature Review About Mecication Errors Essay Introduction An error rate of 5% is acceptable in most industries, however, in the health care industry; one single error can result in death. (Berntsen, 2004, p5) This paper discusses medication errors in relation to pharmacology and drug treatment. It will summarize three academic peer reviewed journal articles, followed by general information in relation to medication errors, the impact of medication errors on client care, strategies to prevent medication errors  and conclude with the relationship to nursing. Summary of Articles Related to Medication Errors. The first article is by Karin Berntsen, 2004, and is entitled How Far Has Health Care Come Since To Err is Human? Exploring Use of Medical Error Data. This is a review of what changes have been made since a medication error report written by the Institute of Medicine was published in 1999. This article depicts how the health care system has changed since this 1999 report was written, and how the information was utilized for our benefit. They concluded that in the USA, medical errors were one of the top 8 leading causes of death. They reported the cost for these errors was between $17 Billion to $29 billion dollars. Until a new report is completed, health care providers will be unaware whether their goals in increasing patient safety were accomplished. The article finalizes that there has been progress in regards to prevention of medication errors and health care leaders feel passionate about increasing patient safety. (Berntsen 2004) The second article is by William N. Kelly, 2004, and is titled Medication Errors: Lessons Learned and Actions Needed and highlights the death of a one year old child who was diagnosed with cancer. She subsequently died, not from the cancer, but from receiving an incorrect dosage of a drug that she was being treated with. This report indicates that medications are systematically checked and balanced and errors are usually caught before a drug is administered to a patient. The article states that problems are not being solved in a timely manner since the industry has been putting band aids on problems that need major surgery.(Kelly 2004). In conclusion, the article questions whether or not they are taking the right approach in preventing errors. Many people are trying to fix this problem however; errors are still made too frequently. (Kelly 2004) The final article is by Rosemary M. Preston, 2004, and is titled Drug Errors and Patient Safety: A Need for Change in Practice. This article presents that errors continue to happen for many reasons. It concentrates upon calculations errors, lack of knowledge of drugs, over/under dosing drugs,  interactions with drugs and food, and legalities regarding drug administration. It also presents recommendations to minimize the risk of drug errors with good communication and honesty. The article closes by stating that nurses should never estimate the skills needed for safe administration of medicines. (Preston 2004) Key aspects: medication errors and their causes. To understand the impact that medication errors have on a patient, we have to understand what a medication error is. According to Health Canada online, a medication error is defined as: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. [Developed for use by the National Coordinating Council on Medication Error Reporting and Prevention]( http://www.hc-sc.gc.ca/english/index.html) Medication errors occur for a variety of reasons. An error can affect all areas of a health care facility from health care management, staff, physicians, pharmacy and especially patients. Studies have indicated that errors will usually occur when the staff demonstrates signs of fatigue, stress, are over-worked or encounter frequent interruptions and distractions. When physicians display bad handwriting, ineffective communication with patients, and do not educate staff and patients effectively, a medication error is more likely to happen. Poor management can result in more medication errors when there is an emphasis on volume, over service quality. This results in inadequate staffing and disorganization. Medication errors affect all components of the health care environment. (http://www.napra.org/docs/0/95/157-/166.asp) Impact on client care. As disturbing as it sounds, one miniscule error can result in a patients injury or can even lead to their death. According to the American Journal of Medicine, statistics reveal that more than two million American hospitalized patients suffered a serious adverse drug reaction in relation to injury within the 12-month period and, of these, over 100,000 died as a result. http://www4.nationalacademies.org/news) Death and injury is a sad reality to any single error. The government established six rights of drug administration to prevent medication errors and ensure accuracy. These six rights include: Right drug, right dose, Right client, right route, right time and right documentation. (Kozier Erb 2004) Injuries that result from a medication error are called adverse drug events. Usually, these unpleasant effects can be eliminated and injury can be avoided. However, every drug produces harmful side effects, but the severities of these effects vary from individual to individual. These side effects also depend on the drug and the dose given. (Kozier Erb 2004) Health care professionals must report all errors and are accountable for their actions. No matter how insignificant, nurses are taught to document and report all mistakes. When statistics show what types of errors are made, an analysis can be done. This analysis can be used to plan ways to prevent them medication errors. (Berntsen, 2004)When a nurse does not report a mistake, the probability that it will happen again will increase. Medication errors have a huge impact on client care. They can result in death, injury, and result in unwanted effects of drugs. It is our responsibility as nurses to comply with the clients six rights of drug administration, to prevent errors from taking place. Strategies to prevent medication errors. There are many efficient ways to prevent nurses from making an error. To ensure patient safety in all aspects of client care, nurses are taught to think critically, and to problem solve. Nurses use critical thinking to ensure safe, knowledgeable, nursing performance and they must be able to keep up with updated health facts by constantly educating themselves with new information. (Kozier Erb 2004) Critical thinking assists in the prevention of medication errors. The six rights in drug administration help prevent medication errors from occurring. It is important to maintain the highest standards of practice of these rights for a drug to be prepared properly. Failure to adhere to any one of these rights will definitely result in a medication error. (Clayton Stock, 2004) Take your time when preparing medications and research any unknown drugs. Rushing should be avoided when preparing, administering and reading medication labels. Proper research must be done before an unfamiliar drug is administered it to a client. Even when in a rushed emergency situation, drugs should be looked at carefully to know the correct concentration and name of the drug, to prevent injury. (http://www.hc-sc.gc.ca/english/index.html) Labels should be read carefully and accurately. Before a drug is given to a patient, three checks should be done to ensure you are giving the proper drug and dose. In a situation where you are unsure of a drug order, you are expected to refuse the order and clarify it by law. If an individual is unfamiliar with a particular drug, the drug should not be given. (http://www.napra.org/docs/0/95/157-/166.asp) When a label is unclear, do not try not to examine the drug order yourself. Do not ask an associate, or ask for anyone elses interpretation of the drug. To get the correct information, contact the individual who ordered the drug to clarify the label. In order to decrease the chances of error, verify all unclear hand writing, abbreviations, decimal points, decimal places and dosages. (http://www.napra.org/docs/0/95/157-/166.asp) Use of dosage abbreviations should not be used to avoid drug miscalculations. Dosage abbreviations are misinterpreted more often, than any other type of abbreviation. Using standardized abbreviations, would assist in preventing misinterpretation of abbreviations. (Preston 2004) A drug check should be done three times prior to the administration of a drug. The drug label should correspond with the physicians orders. The three checks should be done; Before removing the drug from the shelf or dosage cart, before preparing or measuring the actual prescribed dose, and before replacing the drug on the shelf or before opening a unit dose container, just before administering a dose to a patient. (Clayton Stock, 2004) Do not make assumptions regarding drugs. Physicians, pharmacists, make mistakes and other parts of the health system may be flawed. For example, when documentation shows the patient has no drug allergy, it is wrongful to assume the patient will have no adverse reaction to a new drug. This could result in detrimental results to a clients health. Therefore no assumptions should ever me made. (http://www.ismp.org-/ToolsAllina-Orientation.html) A quiet environment for preparing medications will prevent prescription errors from occurring. Sometimes, nurses are repeatedly interrupted when preparing a medication. Distractions interfere with processing information and decision making. Errors will least likely occur when preparations are done when there are no distractions. (http://www.ismp.org-/ToolsAllina-Orientation.html) When preventing errors, staff must be certain all dosage calculations are correct and clarified. It may be beneficial to ask a colleague to assist you in checking doses, to minimize the chance of miscalculations. Other suggestions to minimize error include; making pre-calculated conversion cards, always use a leading zero before a decimal, never use a zero after the decimal and include indications whenever possible. Miscalculations are preventable if proper methods of inspecting calculations are used. (Preston  2004, p.72) Assess for the effects of drugs to avoid harming a client. A client must be assessed before and after a drug is given. For instance, before giving an oral medication, assess whether the client can swallow or feels nauseated. An appropriate follow up should be done after a medication is administered. It is important to check if the client experienced the desired effect of the drug. Significant abnormal responses to drug should be reported to the physician. (Kozier Erb 2004) Conclusion. To finalize this assignment, medication errors are mistakes that can cause harm to patients and can even result in death. The articles that have been summarized illustrate situations where medication errors have occurred and review what the health care industry is doing to prevent errors. A medication error is preventable and errors can be caused by a variety of reasons. This paper has discussed the impact medication errors have on client care and strategies of how to prevent errors from occurring. As a nurse, this knowledge will assist me in keeping beneficence a priority for client care. References Clayton, Bruce D., BS, RPh, PharmD, and Yvonne N. Stock, MS, BSN, RN. Basic Pharmacology for Nurses. 13th ed. United States of America: Mosby, 2004. Government of Canada Online. (2004, Summer). Retrieved July 18, 2004, from Health Canada Web site: (http://www.hc-sc.gc.ca/english/index.html) Kelly, William N. Medication Errors. Professional Safety 49: 35. Academic Search Elite. EBSCO. Assiniboine Community College. 22 July 2004 . Government of Canada Online. (2004, Summer). Retrieved July 18, 2004, from Health Canada Web site: (http://www.hc-sc.gc.ca/english/index.html) Kozier Erb, Barbara, et al. Fundamentals of Nursing. 7th ed. Upper Saddle River, New Jersey: Pearson Prentice Hall, 2004. Minimizing Medication Errors. (n.d.). In NAPRA: National Association of Pharmacy Regulatory Authorities. Retrieved July 17, 2004, from NAPRA: National Association of Pharmacy Regulatory Authorities Web site: http://www.napra.org/docs/0/95/157/166.asp Preston, Rosemary M. Drug errors and patients safety: the need for a change in practice. British Journal of Nursing (BJN) 13: 72. Academic Search Elite. EBSCO. Assiniboine Community College. 22 July 2004 .

Reflective Practice in Nursing Communication

Reflective Practice in Nursing Communication This assignment looks at the study of theoretical reflection in conjunction with how effective communication skills can be developed to expand our knowledge. To achieve this I will explain what reflection practice is using models of reflection; evaluate theories of personal development what they are and how they are used. Discuss how reflective practice benefits communication skills and in turn influence our knowledge of nursing care. What is reflection? In scientific terms reflection is seen as light, heat or sound striking a surface to give off a reflection (Darlene 2006). Reflection is also seen as philosophical understanding of how one can gain knowledge through experience and use different approaches to the same scenario (ref). Reflection can be described as; meditation, deep thinking and or giving careful considerations to possibilities and opinions of a given situation (Mcferran and Martin 2008). The novel idea of reflection rose from a theorist John Dewey (1859-1952); his proposed view on reflection is described as persistent, active thinking and taking into consideration the supporting evidence that forms knowledge to the given situation. This theorist suggests that the person uses their mind and emotions to facilitate reflection (Bulman and Schutz 2008). This suggests that John Dewey describes reflective individuals has being open-minded, responsible and wholehearted (Vaugn and Leblanc 2011). Deweys perception of reflection was a platform for many authors to elaborate on in terms of understanding reflective practice. Johns and Freshwater (2005) propose that health professionals should find the meaning of reflection through description rather than definition because to define reflection is to suggest the author has authority over its meaning. This in turn allows reflections models and frameworks to be used intuitively giving a more holistic approach, it can be subjective and purpose driven (Johns and Freshwater 2005). Mann et al (2007) describes Schons (1983) view that reflection can happen in two ways: reflecting upon activities whilst they are happening called reflection in action (present reflection) and reflecting upon activities once they have happened (reflecting on the past). Reflection can also be seen as the engine that facilitates superficial learning into finding a deeper understanding that enables the practitioner to transform what is known to knowledge in action (Boud et al 1985 cited in Rolfe et al 2011). Reflection (Broad overview) Describe some of the different theories and models of reflection that are available and how they are used. Explain how reflection can aid personal development. Schon, reflection on and in action Models of reflection, Driscolls, Atkins and Murphy, Gibbs, Johns, Kolb. 750 words Reflection Model and frameworks There are many different models of reflection which seem to have similar philosophical theories attached to each approach. Rolfe et al (2011) asserts models are methodologies and frameworks are methods used to understand and give guidance on how use the chosen reflective model and models therefore are ontological this mean they have formal specifications for representing ideas and concepts that aim to improve personal growth and development. Models of reflection developed by Schon and Argyris (1992) involves three elements: (1) knowing-in-action (2) reflection-in-action and (3) reflection-on-practice (Ghaye and Lillyman 2010). Ghaye and Lillyman (2010) have extrapolated Schons work to include knowing-in-action; they propose that practitioners customise and tailor their own knowledge or theories to the situation presented. Knowing in action is described further by Carper (1978) who identifies five approaches to knowing in action; empirical, personal, ethical and aesthetic knowing ( Newton and McKenna 2009). Empirical knowing is the formation of knowledge organised into general laws and theories for the describing and predicting phenomena pertaining to nursing practice (Averill and Clements 2007). Empirical means of knowledge tends to seek out theoretical explanation which can be replicated and be publicly verifiable (Newton and McKenna 2009). Newton and McKenna (2009) further suggest that empirical knowledge can only be effective when it is interpreted within the context of given clinical situation and how it is assimilated into practitioners personal knowledge. Personal knowing described by Carper (1978) is about finding out how much we know about ourselves when faced with clinical challenges and that health care professionals may not necessarily know about the self but do strive to know about the self. Newton and McKenna (2009) state that Caper (1978) does reiterate that it is difficult to master however it is an essential in understanding nursing care. Newton and McKenna (2009) suggest that personal knowing demands a deeper level of understanding and awareness to communicate and interact with ourselves and others. This type of knowing requires the nurse to be empathic, nurse attempt to do this by developing a personal yet professional relationship between the patients as opposed to viewing a patient as an object (Newton and McKenna 2009). Moral actions and ethical choices are intertwined with personal knowing to which Carper (1978) suggests presupposes personal maturity and freedom. Ethical knowing is about the moral aspect of nursing that is concerned with making choices, making justifiable actions and judging outcomes (Newton and McKenna 2009). The main focus of ethical knowing is trained towards issues of obligations that would require rationalisation and deliberate reasoning (Carper 1992). Chinn and Kramer (2004) suggest that rational can be expressed through codes, moral rules and decision-making. Newton and McKenna (2009) assert that having knowledge of moral issues is not isolated to ethical codes of nursing disciplines for example the Code of Conduct written by the NMC (2010). Newton and McKenna (2009) assert that ethical knowing is only partly learnt through applying codes and moral rules but is more through experiencing situations that initiate reflection upon what is or has happened and how this affects patient care. Gibbs( date) Driscoll(dates)and Kolb ( date)all conjured reflective models which are each similar to one another; they are all cyclical reveals that learning through reflection about what is or what has happened is continuous cycle. Gibbs et al (1988) model please see appendix 1 (a) Do you know of any other models that perhaps dont take on such a cyclical approach†¦ consider the work of Chris Johns, Mezirow, Boud et al also†¦. How do they compare and contrast with each other? Why might one model of reflection suit one situation or context better than another?Think about which models promote single loop or double loop learning if you can. Reflective practice (Specific) Give an overview of how reflection is used in nursing. Explain its relevance to nursing and how and when it is used. Explore the concepts of reflective practice and critical incident analysis. Introduce use of reflection for personal development. CPD, self regulation. Identify the different situations where reflection can be used. Skills V critical Incidents what is a critical incident. 750 words Reflective practice is seen has using reflective techniques to improve, maintain change in clinical procedures and influence guidelines to encourage greater safety of patients in all areas of health organisations (Bulman and Schutz 2008). Health care organisations in the UK have undergone and still continue to undergo changes to how it is regulated (Rolfe et al 2011). The emphasis is largely associated with increasing patient safety and risk reduction (Rolfe et al 2011). The four main bodies in the UK; Royal College of Nursing (RCN), Nursing Midwifery Council (NMC) and General Social Care Council (GSCC) and General Medical Council (GMC) which are concerned with the controlling, training and regulating of the healthcare system in UK (Rolfe et al 2011). Evidence-based studies have taught the NHS and regulatory bodies how to change practices and procedures to create better outcomes for patients, they have also encompassed further development for staff to promote a better use of resources through continuing professional development CPD (Ghaye and Lillyman 2010). An example of this could be the pressure sore nurses taking on the responsibility of giving guidance to non-specialist nurses to take care of patients with such conditions. This could not have been achieved if it was not for reflective thinking being part of the learning process (ref). How do we use reflective practice within our day to day practice? Consider the approaches that mentors take when supporting students, look at the principles involved in preceptorship and clinical supervision†¦ Communication skills (Application) Discuss and analyse how reflection can be utilised to improve your communication skills in practice. Explore how and when you would use it. What practical steps would you take and what resources would you utilise and why. Link reflection in and on action to communication situations giving information (in), breaking bad news (on), then use of journals, models, writing, peer support. 750 words Conclusion Sum up 500 words You have made a solid start at this assignment so far and have introduced many ideas which are relevant to the topic. These themes now need to be explored in greater detail . You have a slight tendency to introduce theoretical concepts ( not all of which are uncomplicated) without fully explaining their meaning†¦. Take care to avoid this as just mentioning them does not mean that you understand them and we will be looking for evidence of understanding. You also need to pay attention to your sentence construction as there are several poorly constructed sentences noted so far†¦. Make sure that when you lift them from the text you have referred to , that you do adapt them to make sense in the context that you are trying to use them. I would like to have a look at this piece when it has been developed a bit more. You are definitely heading in the right direction though and overall have made an effective start.

The Two Willy Lomans in Arthur Millers Death of a Salesman Essay

The Two Willy Lomans in Arthur Miller's Death of a Salesman    There are two Willy Lomans in The Death of a Salesman. There is the present broken, exhausted man in his sixties, soon to end his life. And there is the more confident, vigorous Willy of some fifteen years before, who appears in the flashbacks. One actor portrays both, readily shifting from one representation to the other. To some extent, of course, the personality remains constant. The younger Willy, although given to boastful blustering, does admit misgivings to Linda and loneliness to Biff. And the shattered older man, in turn, occasionally reverts to his former manner of jaunty optimism. Yet the changes are great and significant. The earlier Willy could never have been the idol of his teen-aged sons had he behaved in the perverse, distracted fashion of his older self. Willy's agitation during his last days stems from a twofold sense of failure. He has not been able to launch successfully in the world his beloved son Biff, and he no longer can meet the demands of his own selling job. Although not altogether ignoring Linda and Happy, he is primarily concerned about the once magnificent young football star who at thirty-four drifts from one temporary ranch job to the next. Willy cannot "walk away" from Biff'sproblem, as Bernard suggests, nor can he accept Linda's view that "life is a casting off." Being over sixty, Willy is doubtless tiring physically. The sample cases are heavy. The seven-hundred-mile drives are arduous. And many business contacts, developed over the years, are vanishing as the men of his era die or retire. Yet the worry over Biff has obviously accelerated his collapse. Actually, Willy's attitude toward Biff is complex. On the one hand, t... ...ledge. But Happy is still determined to "beat this racket"and come out "number one man." On the day of the big game, Charley ruefully asks Willy when he is going to grow up. In some ways Willy never does. His boyish enthusiasm is, of course, part of his appeal. But his persistent refusal to face facts squarely drives him at last to a violent death. Ironically, his suicide, to him the ultimate in magnificent gestures, merely leaves Linda woefully bereft and Biff more than ever sure that "he had the wrong dreams. All, all wrong." Works Cited Eisinger, Chester E. "Focus on Arthur Miller's 'Death of a Salesman': The Wrong Dreams," in American Dreams, American Nightmares, (1970 rpt In clc. Detroit: Gale Research. 1976 vol. 6:331 Gordon, Lois "Death of a Salesman": An Appreciation, in the Forties: 1969) rpt in clc. Detroit: Gale Research. 1983 vol. 26:323   

Diabetes Mellitus Study Guide

DIABETES MELLITUS * Chronic multisystem dz , abnormal insulin production / impaired utilization * Disorder of glucose metabolism related to absent/ insuff insulin supply or poor utilization of inslin that’s available * 7th leading cause of death * leading cause of blindness, ESRD, lower limb amputation * contributing factor for heart dz/ stroke risk 2-4 x higher than without DM * INSULIN – hormone produced by cells in islets of Langerhans of pancreas.Normal – continously into bloodstream ( basal rate), or increased w/ meals (bolus) * Normal glucose range 70-120 mg/dL, average insulin secreted daily 40-50 U 0. 6 U/kg * Glucagon, epinephrine, GH, cortisol oppose effects of insulin counterregulatory hormones they blood glucose lebels, stimulate glucose production by liver, movement of glucose into cells. Insulin released from cells – as precursor / proinsulin thru liver enzymes form insulin & C-peptide ( C-peptide in serum & urine indicator of cell function) * in plasma insulin after meal storage of glucose as glycogen in liver/ muscle, inhibits gluconeogenesis, fat deposition, protein synthesis * Nl overnight fasting release of stored g;ucose from liver, protein from muscle, fat from adipose tissue * Skeletal muscle & adipose tissue receptors for insulin insulin-dependent tissues Type I Diabetes Juvenile onset, insulin-dependent, s/s abrupt but dz process present for several yrs, 5-10%, absent or minimal insulin production, virus/toxins, under 40, 40% before 20 yr * s/s thirst( polydipsia), polyuria, polyphagia ( hunger), fatigue, wt loss, Kussmaul respirations * immune mediated dz; T-cells attack & destroy cells * genetic predisposition & exposure to virus * Idiopathic diabetes – not atoimmune, strongly inherited, in small # pt w/ type I DM , African/Asian * Predisposition HLAs human leukocyte ntigens when exposed to viral infection cells destroyed * Long preclinical period, s/s develop when pancreas can no longer produce suffi cient insulin to maintain nl glucose levels * Req. insulin from outside source exogenous insulin eg. injection * No insulin diabetic ketoacidosis (DKA) life threatening, results in metabolic acidosis * â€Å"honeymoon period† – newely diagnosed pts, tx initiated pt experience remissions req little insulin because cells produce suff amount of insulin lasts 3-12 mths then req permanent insulin Prediabetes * risk for developing diabetes glucose levels high but not high enough for diabetes diagnosis * impaired fasting glucose IGF 100-125 mg/dL * 2 hr oral glucose tolerance test OGTT 140-199 mg/dL * HgB A1C – 5. 7%-6. 4% risk for diabetes * Increased risk for developing DM type II – if no preventive measures develop DM in 10 yrs * Long term damage to body heart, blood vessels occur in prediabetes * Usually no symptoms * Maintain healthy weight, exercise regularly, healthy diet risk of developing diabetes Type II Diabetes * Adult onset, non-insulin dependent, 9 0% * > 35, overweight, tendency to run n families * African Am, Asian, Hispanics, Amerian Indians Some insulin is produced but either insufficient for body needs / poorly utilized * Gradual onset, many yrs undetected hyperglycemia, 500-1000mg/dL * Early usu. asymptomatic; high risk pt screen annually * Fatigue, recurrent inf, vaginal yeast inf, candida inf, prolonged wound healing, visual changes * Risk factor obesity ( abdominal/ visceral ) * 4 major metabolic abnormalities * insulin resistance > tissue no response to insulin / unresp receptors – receptors are located on skeletal muscles, fat & liver * ability of pancreas to produce insulin – fatigued from compensatory prod of insulin, ell mass lost * inappropriate glucose by liver – too much glucose for body needs – type II * altered prod. of hormones & cytokines by adipose tissue ( adipokines) role in glucose & fat metabolism – type II. Two adipokines ( adiponectin & leptin ) affect insulin sens itivity altered mechanism in type I & I * Metabolic syndrome > risk for type II & cardio dz, cluster of abnormalities, insulin resistance, insulin levels, triglycerides, HDLs, LDLs, HTN * Risk factors for metabolic syndrome central obesity, sedentary lifestyle, urbanization, westernization Gestational Diabetes During pregnancy, 7% of pregnancies * High risk – severe obesity, prior hx of gestational DM, glycosuria, polycystic ovary syndrome, family hx of DM II screened at 1st prenatal visit * Average risk OGTT at 24-28 wks of gestation * Higher risk of cesarean delivery, perinatal death, neonatal complications * Will have nl glucose levels within 6 wks postpartum but risk of DM II in 5-10 yrs * Nutritional therapy – 1st line , if doesn’t work insulin therapy Other specific types of diabetes * Due to other medical condition or treatment causes abn blood glucose levels * Damage , injury, destruction of cell function Cushing’s, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, TPN * Meds > corticosteroid (prednisone), thiazides, phenytoin(Dilantin), antipsychotics – clozapine * Tx underlying condition, stop meds Diagnostic studies * A1C > 6. 5 % ; greater convenience, no fasting req, less day to day alterations during stress/ illness * FPG >126 – no caloric intake for 8 hrs prior testing ; confirmed by repeated testing another day; if has s/s and FPG>126 further testing OGTT not req * 2 hr OGTT >200, glucose load 75g accuracy depends on pt preparation, and factors that influence results.False negative > impaired GI absorption, falsely elevated> severe restrictions of carbs, acute illness, meds corticosteroids, contraceptives, bed rest * IFG impaired fasting glucose & IGT > prediabetes, 100-125 mg/dL, IGT 2 hr > 140-199 * Glycosylated HgB – HgB A1C > amount of glucose attached to HgB molecules over lifespan ( RBC 90-120 days ) DM pts should check it regularly, done to monitor success of tx / make chang es to tx < 6. % – risk of retinopathy, nephropathy, neuropathy dz affecting RBCs – can affect A1C results Treatment * Goals > s/s, promote well being, prevent acute complications, prevent/ delay onset/ progression; met when pt maintain glucose level as near to nl, daily decisions about food intake, blood glucose testing meds, exercise * Rapid acting insulin – lispro (Humalog), aspart (NovoLog) – onset 0-15 min, peak 60-90 min, dur. -4 hrs , clear, give 15 min before meals ; bolus * Short acting – Regular (Humulin R, Novolin R) onste ? -1 hr, peak 2-3hr, dur 3-6 hrs, injected 30-45 min before meals; bolus * Intermediate acting – NPH, basal insulin, onset 2-4hrs, peak 4-10hrs can result in hypoglycemia, dur. 10-16 hrs, can be mixed w/ short & rapid, cloudy, must be agitated before adm. Long acting – glargine (Lantus), detemir ( Levemir) addition to mealtime insulin, type I, to control glucose between meals & overnight, without it risk of developing DKA, no peak – risk of hypoglycemia , not diluted or mixed, clear; onset 1-2 hrs, dur. 24hrs +, basal * Combination > pt don’t want 2 separate injections, 2 type of insulin mixed together, not same control of glucose levels as with basal-bolus; ahort/rapid mixed w/ ntermediate provide both mealtime & basal coverage * Storage > vials room temperature 4 wks, heat & freezing alter insulin, between 32-86 F; avoid direct exp to sunlight, extra insulin in fridge/ traveling-thermos, Prefilled syringes – sight impaired, manual dexterity; syringes w/ c;udy solution in vertical position needle up to avoid clumping of suspension, rolled gently, warm before injection. * Injection > abdomen fastest absorption arm, thigh, buttock, rotate within 1 particular site; never into site that’s about to be exercised (heat = absorption & onset), vial 1ml=100U, SQ 90 degrees * Needles ? 5/16 inch (short – children, thin adults); gauges 28,29,30,31 – hi gher gauge = smaller diameter = more comfortable injection * Recapping done only by person using syringe, never recap syringe used by pt; alcohol swabs in health care facility before inj to HAI, at home soap & water * Insulin pump – continuous subq insulin infusion 24 hr/d basal rate , loaded w/ rapid acting insulin via plastic tubing to catheter in subq tissue.At meal time – bolus . (+) tight glucose control, similar to nl physiologic pattern, nl lifestyle, more flexibility (-) infection at site, risk of DKA, cost Problems w/ insulin therapy * Hypoglycemia * Allergic rxn – itching, erythema, burning around inj. site, may improve w/ low dose antihistamine ; rxns to Zinc, protamine, latex , rubber stoppers on vials * Lipodystrophy – atrophy of subq tissue if same inj site used Somogyi effect – rebound effect, overdose of insulin induces undetected hypoglycemia in hrs of sleep, produces glucose decline in response to too much insulin s/s headaches, n ight sweats, nightmares ; if in morning glucose – adcised to check glucose levels at 2-4am if hypoglycemia present at that time.If it is insulin dosage in affecting morning blood glucose is reduced TX : less insulin * Dawn phenomenon – hyperglycemia on awakening in the morning due to release counterregulatory hormones in predawn hrs ( possibly GH/cortisol) adolescence/ young; TX: adjustment in timing of insulin adm. or in insulin. Predawn fasting glucose levels insulin production from pancreas , s. ff > wt gain, hypoglycemia * Meglitinides repaglinide(Prandin) insulin prod, less likely cause hypoglycemia because more rapidly absorbed/eliminated, cause wt gain, take 30 min before meal, not if skipped * Biguanides – Metformin > glucose lowering, first choice DM II/prediabetes, obese & â€Å"starch blockers† slow down carbs absorption, taken with â€Å"first bite†, effectiveness> check 2 hr postprandial glucose levels * Thiazolidinediones – Ava ndia > â€Å"insulin sensitizers†, for pts w/ insulin resistance, don’t insulin Production, not cause hypoglycemia; risk of MI, stroke , not for pt w/ HF * DPP4 inhibitor – Januvia > new class, slow inactivation of incretin hormones; DDP4 inh are glucose dependent = risk of hypoglycemia, no wt gain * Incretin mimetics – exenatide (Byetta) > stimulate incretin horm which are in DM II, stim. of insulin, Suppress glucagon, satiety = caloric intake, slows gastric emptying; prefilled pen * Amylin analog > Amylin hormone secreted by cells, co secreted w/ insulin Pramlintide (Symlin) is Synthetic , type I & II when glucose level not achieved w/ insulin at mealtimes , subq thigh or abdomen NOT arm , not mixed w/ insulin – cause severe hypoglycemia ! * blockers — masks s/s of hypoglycemia, prolong hypoglycemic effects of insulin * Thiazide / loop diuretic — hyperglycemia, K Nutrition Type I > meal planning, exercise, developed w/ pt’s e ating habits & activity pattern in mind, day to day consistency in timing & amount of food eaten * Type II > wt loss = improved insulin resistance, total fats & simple sugars = calorie & carbs intake; Spacing meals , wt loss 5-7% = glycemic control, regular exercise * Carbohydrates > sugar, starches, fiber whole grains, fruits, veggies, low fat milk included min 130g/d * Glycemic index GI > describe blood glucose levels 2 hrs after carb meal , GI of 100 = 50g glucose * Fiber intake 14g/1000 kcal * Fats 7% of total calories , < 200mg/d cholesterol & trans fats * Protein same for diabetes / normal renal function / gen. population, high proein diet not recommended * Alcohol > inhibits gluconeogenesis ( breakdown of glycogenglucose) by liver; severe hypoglycemia in pt on insulin / oral hypoglycemic dx.Moderate alcohol consumption < 2 drinks men, track carbs w/ each meal & daily, set limit for max amount ( depends on age, wt, activity level) usu. 45-60g /meal ; also My Pyramid & plate me thod ( ? nonstarchy veggies, ? starch, ? protein, nonfat milk & fruit * Exercise > 150 min/wk moderate intensity aerobic; DM II resistance training 3 x wk, most adults should 30 min moderate intensity activity 5 x most days * Exercise > insulin resistance, blood glucose, wt loss which insulin resistance ( may need less meds), triglycerides, LDL, HDL, BP, circulation * Start slowly w/ progression. Insulin, sulfonylureas, meglitinides >risk of hypoglycemia with increase physical activity esp if exercise at peak of dx or no food intake.Effect may last 48 hrs post exercise Exercise 1 hr after meal, have 10-15g carb snack every 30 min. during exercise (prevent hypoglycemia). Before exercise glucose immediate info about glucose levels – can make adjustments diet, activity, meds * Recomm. for all insulin-treated pts * Multiple insulin injections – 3 or more x day, done before meals, before & after exercise esp in type I, whenever hypoglycemia suspected, when ill (stress), 2 h rs after start of meal – if effective Pancreas transplantation * For pt w/ ESRD, plan to have kidney transplant * Pancreas transplanted following kidney transplant, pancreas alone –rare * Pancreas alone only if hx of severe metabolic complications, emotional roblems w/ exogenous insulin, failure of insulin-based management * Improve quality of life, no exogenous insulin need, no dietary restrictions * Only partially able to reverse renal & neurologic complications * Need lifelong immunosuppression to prevent rejection * Pancreatic islet cell transplantation in experimental stage, islets from deceased pancreas via catheter into abdomen portal vein Nursing management * Pt active participant in management of diabetes regimen * Few/no episodes of acute hyper/hypoglycemic episodes, maintain glucose level near nl * Prevent/ delay chronic complications * Adjust lifestyle to accommodate DM regimen w/ min. stress Nursing assessment Past hx mumps, rubella, viral inf, recent trau ma, stress, pregnancy, infant>9lbs, Cushing, acromegaly, family hx of DM * Meds > compliance w/ insulin, OA; corticosteroids, phenytoin, diuretics * Eyes > sunken eyeballs, vitreal hemorrhages, cataract * Skin > dry, warm, inelastic, pigmented lesions on legs, ulcers(feet), loss of hair on toes * Respiratory > Kussmaul – rapid, deep * Cardio > hypotension, weak rapid pulse * GI > dry mouth, vomiting, fruity breath * Neuro > altered reflexes, restlessness, confusion, coma * MS > muscle wasting * Also electrolyte abnormalities, fasting glucose level >126, tolerance test> 200, leukocytosis, BUN, creatinine, triglycerides, cholesterol, LDL, HDL, A1C 45yrs without risk factors for diabetes Acute intervention * Hypoglycemia, DKA, HHS – hypersmolar hyperglycemic syndrome * Stress f acute illness/ surgery > counterregulatory hormones > hyperglycemia ( even minor upper resp infection or flu can cause this) * Continue regular diet, noncaloric fluids (broth, water, diet gelatin, decaffeinated), take OA/insulin as prescribed, monitor glucose Q4H * Acutely ill DM I , glucose>240 test urine for ketones Q3-4H , medium/large report to MD * Ill > eat than normal > continue OA meds/ insulin as prescribed + carbohydrate containing fluids (soup, juices, decaffeinated) * Unable to keep fluids/ food down MD * Don’t stop insulin when ill counterregulatory mechanisms will glucose level * Food intake important body needs extra energy to deal w/ stress Extra insulin may be needed to meet this demand, prevent DKA in DM I * Intraoperative > IV fluids & insulin before, during, after sx when there’s no oral intake In DM II w/ OA – explain it’s temporary measure, doesn’t mean worsening of DM * If contrast medium (w/iodine) > Metformin discontinued 1-2 days before sx, resumed 48 hrs after sx risk of acute renal failure.Resume after kidney function nl ( creatinine checked & is nl) * Insulin adm > teach proper administration, adjustments, side e ffects, assess response to insulin tx, if new to insulin assess ability to manage tx safely, cognitive status, ability to recognize/ tx hypoglycemia, if cognitive skill another responsible person must be assigned; diff to self inject/ afraid of needles * Follow ups > inspect injection sites ( lipodystrophy ) * Short term memory deficit > OA or short acting OA cuz doesn’t cause hypoglycemia * OA w/ diet & activity, not take extra pill when overeating * Diligent skin care & dental > aily brushing/ flossing, inform dentist about DM * Foot care !!! scrapes, burns treated promptly & monitored > nonirritating antiseptic ointment > dry sterile pad> not start to heal in 24 hrs or infection > MD * Regular eye exams * Travel – sedentary > walk Q2H to prevent DVT & prevent glucose , carry snacks, extra insulin COMPLICATIONS Diabetic Ketoacidosis DKA * Diabetic coma Profound deficiency of insulin > hyperglycemia, ketosis, acidosis, dehydration * Most likely in DM I pts, but someti mes in DM II ( severe illness/ stress) * Causes > illness, infection, undiagnosed DM I, inadeq insulin dosage, poor self management, neglect * Insulin – glucose cant be properly used for energy fat broken for fuel ketones (by product) serious when excessive in blood alter pH, cause metabolic acidosis ketonuria (in urine) & electrolyes depleted; impaired protein synthesis, nitrogen lost from tissues * Untreated depletion of Na, K, Cl, Mg, phosphate hypovolemiarenal failure/ retention of ketones & glucose shockcoma (result of dehydration, lytes & acidosis)death * s/s > dehydration, poor turgor, dry mm, HR, orthostatic hypotension, Kussmaul , abdominal pain, sunken eyeballs, acetone fruity odor, early s/s > lethargy,weakness * blood glucose >250, arterial blood pH IV access begin fluid/ electrolyte replacement NaCL 0. 45% or 0. 9% to restore urine output 30-60 ml/hr & BP * glucose level approach 250 5% dextrose added * Incorrect fluid repl > sudden Na & cerebral edema * Obtain K level before insulin started – insulin > further K * Insulin withheld until fluid resuscitation & K>3. 5 * Too rapid IV fluids & rapid lowering of glucose cerebral edema Hypersmolar hyperglycemic syndrome HHS * Life threatening, able to produce insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, ECF depletion * Less common than DKA * Often > 60, in DM II Causes > UTI, pneumonia, sepsis, acute illness, new DM II * Asymptomatic in early stages > so glucose can rise very high >600mg/dL * The higher glucose > in serum osm > neurologic manifestations somnolence, coma, seizures, hemiparesis, aphasia * Resemble CVA (stroke) determine glucose level for correct dx * Ketones absent in urine * Tx similar to DKA * First IV 0. 45% or 0. 9% NS, regular insulin given after fluid replacement * Glucose fall to 250 – add glucose 5% dextrose * Hypokalemia not as significant as in DKA * HHs require greater fluid replacement * Assess VS, I&O, turgor, l abs, cardiac / renal monitoring related to hydration & electrolyte levels, mental status, serum osm Hypoglycemia Low blood glucose glucagon & epinephrine > defense against hypoglycemia * s/s of epinephrine > shaking, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor * brain req constant supply of glucose > when > affect mental functioning > LOC, diff speaking, visual disturbances, confusion, coma, death * Hypoglycemis unawareness > no warning signs until glucose reach critical point > incoherent, combative, LOC > often elderly w/ beta blocker meds * When very high glucose level falls too rapidly, too vigorous management of hyperglycemia * Mismatch in timing of food intake & peak of isulin/ OA * Can be quickly reversed Check glucose levels, if contain fat that glucose absorption; check glucose in 15 min * Still 70 eat regular meal/snack low peanut butter, bread, cheese, crackers, check glucose in 45 min * No significant imptovement after 2-3 doses of 15g carb MD * Pt no t alert to swallow 1mg glucagon IM in deltoid muscle ( nausea, vomiting rebound hypoglycemia) * Hospital setting > 20-50ml of 50% dextrose IV push * CHRONIC COMPLICATIONS OF DM Angiopathy * end organ dz from damage to blood vessels (angiopathy) 2nd to chronic hyperglycemia * leading cause of diabetes-related deaths, 68% deaths due to cardio, 16% strokes * causes: accumul.Of glucose metabolism by products (sorbitol) damage to nerve cells, abnormal glucose molecules in basement membrane of small blood vessels (eye,kidney), derangement in RBCs – oxygenation to tissues * DM I > keep blood glucose levels near to normal – retinopathy & nephropathy (complications of microvascular complications) Macrovascular complications * Dz of large, medium size blood vessels , earlier onset in pt w/ diabetes * W > 4-6x risk of cardiovascular dz, M > 2-3 x * risk factors > obesity, smoking, HTN, fat intake & sedentary lifestyle * Smoking injurious to pt w/DM, risk for blood vessel dz, CV d z, stroke, lower extremity amputations * Maintain BP control – prevention of CV / renal dz Microvascular complication * Thickening of vessel membranes in capillaries/ arterioles in response to chronic hyperglycemia * Are specific to diabetes Eyes ( retinopathy ), kidneys ( nephropathy ), skin (dermopathy ) * Some changes present w/DM II at time of dx, but s/s not appear until 10-20 yrs after onset of DM * Diabetic retinopathy – microvascular damage to retina, most common cause of blindness 20-74 yrs old. Nonproliferative> most common, partial occlusion of small blood vesselin retina microaneurysms, Proloferative> most severe, involves retina & vitreous neovasculization ( form new blood vessels to compensate) if macula involved vision is lost * DM II > dilated eye exam at time of diagnosis & annually, DM I within 5 yrs after DM onset * Laser photocoagulation * Virectomy * Glaucoma Nephropathy – microvascular complication, damage to small blood vessels that supply glomeruli / kidney.Leading cause of ESRD in US; same risk for DM I & II > HTN, smoking, genetic predisposition, chronic hyperglycemia * Screen for nephropathy annually w/ measurement albumin / creatinine ratio * If micro/macroalbuminuria > ACE inh ( lisinopril ) or angiotensin II rec antagonist ( Cozaar ) tx HTN & delay progression of nephropathy * Aggressive BP management & tight glucose control Neuropathy Sensory neuropathy (PNS)– loss of protective sensation in lower extremities amputations * Hyperglycemia > sorbitol & fructose accumulate in nerves damage * Distal symmetric polyneuropathy > hand/ feet bilaterally * Loss of sensation – to touch/ temperature * Pain > burning, cramping, crushing, tearing , at night * Paresthesias > tingling , burning, itching * At times skin too sensitive (hyperesthesia) * Foot injury & ulcerations without having pain TX : blood glucose control, topical creams capsaicin ( Zostrix ) 3-4 X/d pain in 2-3 wks, selective serotonin, norepin ephrine reuptake inh ( Cymbalta ), pregabali ( Lyrica ), gabapentin Autonomic neuropathy – can affect all body systems & lead to hypoglycemic unawareness, bowel incontinence, diarrhea, urinary retention Complications : * Delayed gastric emptying ( gastroparesis ) anorexia, n/v, reflux, fullness, can trigger hypoglycemia by delaying food absorption * Cardiovascular abnormalities , postural hypotension assess change from lying, sitting, standing, painless MI, resting tachycardia HR * Risk for falls * Sexual dysfunction > ED in diabetic men > 1st s/s of autonomic failure * Neurogenic bladder > urinary retention, diff. voiding, weak stream empty bladder Q3H in sitting position, Crede maneuver ( massage lower abdomen) * Cholinergic agonists > benthanechol Feet & lower extremities Risk for foot ulcerations & lower extremity amputations * Sensory neuropathy > major rosk for amputations due to loss of protective sensations LOPS * Unaware of foot injury, improper footwear, stepping on objects w/ bare feet * Screening using microfilament > insensitivity to 10g Semmes-Weinstein > risk for ulcers * Proper footwear, avoid injuries, diligent skin care, inspect feet daily * PAD risk for amputations due to blood flow to lower extremities * PAD s/s > intermittent claudication, pain at rest, cold feet, loss of hair, cap refill, dependent rubor ( redness when extr in dependent position ) * DX : ankle brachial index ABI & angiography * Casting to redistribute weight on plantar surface * Wound control > debridement, dressings, vacuum, skin grafting etc. Charcot’s foot > ankle & foot changes joint deformity need fitted footwear * Acanthosis nigricans – dark, coarse, thickened skin in flexures & neck * Necrobiosis lipoidica diabeticorum – DM I, red-yellow lesions w/ atrophic skin , shiny & transparent revealing blood vessels under the surface – young women * Granuloma annulare – DM I, autoimmune, partial rings of papules, dorsal surface of h ands/ feet Infection Candida albicans, boils, furuncles, bladder infections (glycosuria) antibiotics Gerentologic * reduction in cells, insulin sensitivity, altered carbohydrate metabolism * 20 % > 65 YO * # of conditions treated w/ meds that impair insulin action (