How does Steinbeck present three characters who are outsiders? Essay

The novel â€Å"Of Mice and man† wrote by Steinbeck. Steinbeck in 1930s he trying to say how was 1930s in the America .In 1930s John Steinbeck is trying to explain how people were migrating from place to place. The reason why people migrated was because people need money as a result of â€Å"economic depression†. Just for that reason the people are moving to another place to get money. Can you imagine every time you migrating to place to place .The novel is full outsiders .What is an outsider? An outsider is when somebody who is excluded from the community for a reason or for reasons. The reason why this so significant is because in those days there was great amount of depression, massive unemployment and migrant workers. At that time friendship was the only key to get people together or love each other. This is same situation we have in this novel which includes everything I have already mentioned. Firstly example â€Å"curley’s wife† is an outsider from novel. Stein Beck shows that by not giving her a name. He shows in this 1930s America women did not have their own identify .if they have not got an identify they cannot get a name .In 1903s women were used, only for cooking , house work and many other horrible things †¦.. When she talks to crooks she is saying â€Å"I could get you strung up on a tree so it easy it ain’t even funny â€Å"in sentence we can see curley’s wife is racist to crooks because crooks is black that’s right she hates him. She I s saying how easy it is to get crooks â€Å"strung up† We can see through crooks the racism in America .Another example Steinbeck includes Curley ‘wife to show the sexism in America in the 1930s.Where she grew up there was lots of fight because he husband curley is doubting man . For example: On day curley looking his wife because she is not in the house. So he came bunk house ask to every body in the bunk house they said no then curley asked where is slim they said he went to do some work .Then he get angry and shut the door hardly .Because he is always doubt with her wife so he thing she go with slim because he is wife is actual sexual life-she had none of except with curley and there has probably been no consummation there since .Curley would not consider her gratification and would probably be suspicious if she had any. Consequently she is little starved. She wants a friend to be respected .Her different kind of girl. Secondly Lennie is an outsider because he is a mentally disabled, he has like a child’s mind and he don’t understand when somebody talking to him. Am saying this because when George before killed him, he was saying this â€Å"How long, how long it will take to have a home and to have rabbits? â€Å"we can see from this sentence he has like child’s mind because he is saying† how long, how long?† he asking like a child.Lennie like to touch soft things .Lennie â€Å"now I won’t get to tend the rabbits†. This shows us when lennie touch the soft things that will die!!! Because lennie is too strong but he doesn’t know how strong he is. Another example for lennie when he takes the, mice dies in that time. He always dreams to get so many rabbits and to have a nice home with his best friend George . Some times he gets angry† suddenly his anger rose God damn you â€Å"he cried.† Why do you get killed? You ain’t as mice. This shows us he can’t tend the rabbits because George said if you do bad thing you can’t get tend the rabbit and land because if lennie do bad things he can’t live on a place. Lennie before kill Curley’s wife Lennie was stroking her hair because lennie likes to touch soft things .When Curley’s wife said† let go† and shout to lennie and lennie gets angry but lennie doesn’t want to let her because her hair is so soft. Then lennie trying to stop her to shouting and shut her mouth but by accident he broke her neck and she died. Steinbeck foreshadows this. He is a big man, in contrast to his name. He has limited intelligence, so he relies on George to look after him. He copies George in everything George does and trusts George completely. â€Å"Behind him(George)walked his opposite, a huge man, shapeless of face, with large, pale eyes, with wide, sloping shoulders; and he walked heavily, dragging his feet a little, the way a bear drags his paws. His arms did not swing at his sides, but hung loosely.† He shares a dream with George to own a piece of land. Lennie’s special job would be to tend the rabbits .He likes to pet soft things, like puppies and dead mice. We know this got him into trouble in Weed when he tried to feel a girl’s soft red dress: she thought he was going to attack her. He can be forgetful – George continually has to remind him about important things. He is very gentle and kind, and would never harm anyone or anything deliberately. He is extremely strong: he can work as well as two men at bucking barley. He is often described as a child or an animal – he drinks from the pool like a horse and his huge hands are described as paws. Thirdly crooks is the only black person in the ranch it makes him an out sider.He is the lowest of the lowest and we can see this when Curley’s wife say bad things crooks using her status as a white woman over him. Crooks always left out and woman love to have a friend. These shown when lennie comes into his ranch and let him sit down. He also takes his anger out on lennie by saying George won’t come back. He is trying to make him feel how crooks has been feeling all his life crooks have some dreams but it can’t be really but his dream is to have good family and to have children and his other dream is not racism black and white†¦.Crooks physically disabled . Crooks black stable worker. He is disfigured and is out sider as well as candy. He has a place of his own and stays there by him self .He doesn’t want a company. He also want to part of George and Lennie’ dream. He said that he would work out. He is only new who understands lennie, be sides George, and be friends him. He looks past lennie mental handicap and lennie looks past crook’s physical handicap. Crooks are the black stable hand or buck. He is the only permanent employee at the ranch, since he injured his back in an accident. His back gives him constant pain. He is the only black man around and is made to be isolated by his colour – he can’t go into the bunk-house or socialise with the men. He is always called the ‘nigger’ by the men, which shows how racism is taken for granted. The men don’t mean to insult Crooks every time they call him this, but they never think to use his name All this has made him proud and aloof. He is lonely â€Å"S’pose you didn’t have nobody. S’pose you couldn’t go into the bunk house and play rummy ’cause you were black†¦A guy needs somebody-to be near him†¦.I tell ya a guy gets too lonely an’ he gets sick.† The only time he mixes with the ranch hands socially is when they pitch horseshoes – and then he beats everyone! He has his own room near the stables and has a few possessions. He has books, which show he is intelligent and an old copy of the California Civil Code, which suggests he is concerned about his rights. He has seen many men come and go, all dreaming of buying a piece of land, but is now cynical, as no one has ever achieved it.

Introduction to Baby Thesis Essay

Heavy metals such as lead, zinc, copper, can often be found in industrial wastewater and their discharge to the environment poses a serious threat due to their acute toxicity to aquatic and terrestrial life which includes humans. As a result of increasing industrialization more heavy metals are continually released to the environment and this has prompted environmental engineers and scientists to think of better methods by which heavy metal-bearing wastewaters can be treated effectively and economically. The most used way of removing heavy metals in wastewater is through the use of activated carbon which is used as an adsorbent. This is due to the adsorptive properties of activated carbon(Cecen & Aktas, 2011). Agricultural by-products represent a considerable quantity of harvested commodity crops. The use of by-products as precursors for the production of widely used adsorbents, such as activated carbons, may impart a value-added component of the overall biomass harvested. In most developing countries, the activated carbon is imported at high cost, limiting the quantities of safe drinking water available to the people (Gray, 2010, p. 72). In recent years, there has been research focusing on the use of appropriate, low cost technology for the treatment of drinking water in the developing world. Research has also been focused on the indigenous production of water treatment chemicals using locally available raw materials. Generally, the raw materials for the production of Activated Carbon are those with high carbon but low inorganic contents such as wood, lignite, peat and coal. Activated carbons form a large and important class of porous solids, which have found a wide range of technological applications. The characteristics of activated carbon depend on the physical and chemical properties of the precursor as well as on the activation method. In addition to the starting material and the oxidizing agent, activation time and temperature affect the structural properties of the resulting activated carbon (Hassler, 2009). A wide range of carbonaceous materials can be used as the carbon precursors such as coal, peat, wood and various agricultural by-products. Recently, agricultural by-products have received an increasing attention for the production of activated carbon due to their low-cost, renewability and wide prevalence (March & Reinoso, 2006). The production of value-added products such as activated carbon will enlarge its application, reduce waste materials and generate income to rural communities in Valenzuela. Heavy metal contamination exists in aqueous waste streams of many industries such as metal plating facilities, mining operations and tanners. Activated carbons were used as adsorbent materials because of their extended surface area, microporous structure, high adsorption capacity and high degree of surface reactivity. Furthermore, the presence of different surface functional groups on activated carbon, especially oxygen groups, leads to the adsorption of ions of heavy metals (Ilango, 2012, p. 22). One of the fastest growing research areas is the environmental applications of activated carbon, such as wastewater treatment. In the treatment of wastewater, it is used for purification, decolorization and the removal of toxic organics and heavy metal ions. year Chernicharo and Sperling (2005) stated that the demand of activated carbon increased over the years and the market growth was estimated at 4. 6 % per. This demand can be satisfied considering the large number of raw material available for the production of activated carbon (Bansal, & Goyal, 2005). The aim of the study was to produce activated carbon from local agroforestry wastes and assess the efficiency of the produced carbons in removing dyes and metal ions from wastewater. The researchers decided to use corncobs as the source of activated carbon to be used in the adsorption of heavy metals present in the waters of Manila Bay, this is because corncobs are widely available and inexpensive macromolecular waste in the agriculture in the Philippines. Bandosz (2006) studied the thermochemical reaction between corncob and CA and obtained a modified corncob, which had a large cation exchange capacity than natural corncob. Chemical analysis of the corncobs showed that it mostly consisted of 38. 4%, cellulose; 40. %, hemicelluloses; and 9. 1%, lignin. Modified ground corncobs using either 0. 6 M CA or phosphoric acid have improved natural adsorption capacity. Physical and chemical agents generated by human activities may often have various adverse effects on both aquatic and terrestrial Iife. Lead is an ubiquitous material in the environment and its presence in varying concentrations can be found in diverse locations. The Water Environment Federation (2010) reported that human exposure to lead has harmful effects on kidney, central nervous and reproductive systems. Air, food and water generally do not usually contain large amounts of lead, however excessive contamination of these natural sources by industrial activities can result in continuous toxic levels of exposure and consequently clinical poisoning (Ilango, 2012). In order to develop poisoning from organic lead, one has to be continuously exposed to concentrations higher than those in the general environment for some week or months. Lead exposure has both acute and chronic effects (Hassler, 2009). Another pertinent health problem of lead is bioaccumulation or magnification, which may elevate its concentration to toxic levels (Ilango, 2012). National Research Council Canada reported that fish could absorb lead through their body surface and the food they consume. As a case study the liver of sea bass caught near California Coast at Los Angeles was found to contain about 22 ppm Pb which is considerably higher than the permitted level of 10 ppm for human consumption and twice as high as the concentration in fishes found 300 km away; the major* of the lead was attributed to automotive aerosol (Bandosz 2006).

Why the drinking age should be lowered to 18 Research Proposal

Why the drinking age should be lowered to 18 - Research Proposal Example Based on this assumption we argue that the age for drinking should be lowered to 18 years old. We will begin with evidence that opposes the lowering of the drinking age and then argue the benefits of it. Gordie Bailey Jnr had been drinking in order to impress some frat house members at his college. The boy drank until her was unconscious and it was assumed that he had 'passed out'. However, Gordie Bailey did not wake up (Roan 2008). This is an example of what terrifies the public and parents in particular. While this may not be an isolated case, and may occur more frequently but to a lesser degree, there is little control even with legislations over such situations. The 2006 Archives of Pediatrics & Adolescent Medicine conducted research to determine the dangers of underage drinking. The results showed that drinking from the age of around 14 leads to a 47% chance of developing a life-time dependency as opposed to only 9% after the age of 21 (Roan 2008).There appears to be rather conclusive evidence damning the use of alcohol at a young age. However, the first set of information requires the age of 14 upwards to use alcohol in order to develop dependencies, which is a whole 4 years b elow the 18 year cut off for legal alcohol use. Even if the legislature legalized the use of alcohol at age 18, the 14 year age group would still drink illegally. The Juvenile Justice Center identifies 18 years old as a critical age for mental growth and change. This period is where the brain discards tissue it has accumulated during the teenage years that is no longer necessary. This is in order to regulate and balance brain functions (JJC 2004: 2). Drug and alcohol dependencies can be developed during this time and it is noted to be critical in brain development. Despite this, teenagers evidently still use dependence forming drugs such as alcohol and crystal methamphetamines (and other drugs) illicitly. Cracking down on the drinking age does not appear to be a suitable or practical solution to the problem in any event. Some psychoanalytical studies believe that alcoholism is predisposed in people. Theorists such as Sigmund Freud and Melanie Klein relate dependencies to the oral stage of development. This is the stage where the infant is supposed to derive feelings for orally manifest articles. If this stage is deprived or not completed fully, the child develops fixations that carry to adulthood. Other arguments based on psychiatric evidence realte depression and family genetics to alcoholism rather than purely having it available for use. The DSM-IV Sourcebook is the American Psychiatric Association reference sourcebook used for diagnosis of disorders states: "The morbid risk rates for alcoholism in antisocial personality were significantly higher for relatives of patients with nonendogenous/nonmelancholic depression" (DSM-IV 1996: 217). While this does evidently not rule out the effects of underage drinking, it does explain why some youth may become dependent faster than others, if at all. There is a co-dependency of a number of variables that have to be present before a person can formally be called 'alcoholic'. A study done by Marlatt, Demming and Reid also challenged the hypothesis that alcohol abuse was pathological. Their study showed that when

Alexander Hamilton and Thomas Jefferson Essay Example | Topics and Well Written Essays - 250 words

Alexander Hamilton and Thomas Jefferson - Essay Example As the President he worked on reversals of a number of Federalist policies like the removal of the excise tax on whiskey, the cut back on military budget and reduction of the national debt, secured repeal of the Naturalization Act, and also worked on getting the Alien and Sedition Act to expire and pardoned anyone affected by it (Wright, 2008). Alexander Hamilton on the other hand was born very simple however he grew to become a very strong and recognised figure in the powerful central government. He as well joined the Cabinet as the secretary of the treasury when Washington became the first President in 1789. He has proved to be very productive and has secured in the creation of the national bank and dealing with the government debts (DiLorenzo, 2008). Although he had been very helpful to the country and proved to be a very successful leader, he was in a scandal of adulterous affairs which led him to be public ridiculed. Both these leaders were equally good politically and with the amount they provided to the public, however Alexander Hamilton was the only one who was faced with a lot of public ridicule. Later Alexander needed to choose between two political opponents for the presidency and this is when the two, Hamilton and Jefferson worked on the same side to win over Adam Burr, who was considered to be unprincipled. Both Hamilton as well as Jefferson were to extremely principled and focused (Wright,

Mobile report Coursework Example | Topics and Well Written Essays - 2000 words

Mobile report - Coursework Example (Ahonen and Melkko, 2008, 44-99) PhyÃ'•ically, itÃ'• very Ã'•imilar to the iPhone 3G, much more Ã'•o than the Diamond, complete with Ã'•lim, candybar form factor, a large Ã'•creen dominating the front panel and minimaliÃ'•t controlÃ'•. Compare the phoneÃ'• Ã'•ide by Ã'•ide and youll find that dimenÃ'•ionÃ'• are remarkably Ã'•imilar too, though the Omnia iÃ'• a little Ã'•limmer, narrower and Ã'•horter than the iPhone 3G, at 12.5 x 112 x 56.9mm compared to 12.3 x 115.5 x 62mm. Ð…o how exactly doeÃ'• it Ã'•tack up elÃ'•ewhere? Well, aÃ'• youd expect from a modern WindowÃ'• Ã'•martphone, thereÃ'• a pile of featureÃ'• and many of theÃ'•e appear to match or outÃ'•trip the iPhone 3G equivalent. It haÃ'• a five-megapixel camera on the rear with an LED flaÃ'•h and a VGA video call camera on the front - the iPhoneÃ'• iÃ'• three megapixelÃ'• leÃ'•Ã'• and it haÃ'• no video call feature. It alÃ'•o haÃ'• HÐ…DPA of up to 7.2Mb/Ã'•ec, a 624MHz proceÃ'•Ã'•or, Bluetooth, Wi-Fi, a GPÐ… receiver and an FM radio. PluÃ'• it comeÃ'• with a decent helping of Ã'•torage – either 8GB or 16GB with microÐ…D expanÃ'•ion aÃ'• well. ItÃ'• Ã'•creen, however, at 3.2 incheÃ'• iÃ'•nt quite aÃ'• luxuriouÃ'•ly Ã'•paciouÃ'• aÃ'• the iPhoneÃ'• and itÃ'• 400 x 280 reÃ'•olution iÃ'• alÃ'•o inferior. ThereÃ'• alÃ'•o no 3.5mm headphone Ã'•ocket and though a converÃ'•ion dongle iÃ'• included in the box, wed Ã'•ooner not have to carry an adapter around juÃ'•t to liÃ'•ten to muÃ'•ic and it Ã'•eemÃ'• a needleÃ'•Ã'• overÃ'•ight given the capaciouÃ'• Ã'•torage on offer. (Ahonen and Melkko, 2008, 44-99) The camera, however, iÃ'• the main highlight here. ItÃ'• reÃ'•olution iÃ'• the main headline: five megapixelÃ'• iÃ'• the higheÃ'•t reÃ'•olution Ive Ã'•een in a WindowÃ'• Mobile device, but it alÃ'•o haÃ'• image Ã'•tabiliÃ'•ation, which meanÃ'• you dont have to rely on the leÃ'•Ã'•-than-ideal LED flaÃ'•h in difficult lighting. The reÃ'•ultÃ'• are impreÃ'•Ã'•ive. Inevitably given the pinhole lenÃ'• Ã'•hotÃ'• are a little noiÃ'•y in low light

Case study on Nokia Essay Example | Topics and Well Written Essays - 3000 words

Case study on Nokia - Essay Example Situation Analysis Market Analysis According to Informa Telecoms & Media, the global mobile phone sales are going to decline sharply in the next 5 years. The forecast says that total sales will be down by as much as 14% all around the world. Previously the expectation was that 7.43 billion devices would be purchased between 2011 and 2013; however that figure was lowered down to 6.39 billion. This downturn in the sales of mobile devices will be a major reason for handset manufacturers to turn their attention to the smartphone market, in order to maintain and increase the targeted sales value. Company Analysis Nokia provides cellular phone communication apparatus for all critical market, including WCDMA, GSM and CDMA. Its recent venture into the smartphone industry has been somewhat mediocre. However, the organisation began as a manufacturer of pulp, rubber and cable. The organisation was founded by Fredrick Idestam in the year 1865. The company has strong research and development activities in over 10 countries and device manufacturing units in nine countries. The company sells its products in more than 150 countries around the globe. Product Line Analysis The current product line analysis of Nokia is: Nokia Lumia Nokia Lumia is an innovative new venture of Nokia in partnership with Windows. The UK market currently has the models 800 and 710. The models have features like instant updates, super-fast mobile internet and innovative design. Smartphones Nokia’s Smartphones consists of business tools, social tools and navigation systems. It includes real time emails, calendar and document sharing features, sharing files in social networking sites, and most importantly GPS navigation systems. Symbian Belle The Nokia 700 and 600 are categorised under the Symbian Belle consisting of eye catching design, NFC sharing, faster browsing, six home screens, live widgets and pull down taskbar. Mobile Phones Other than Smartphones the general products can be typed based on features like touch, type, touch and type and keyboard. There is the E series, Asha range, C series, X series and N series. Accessories This consists of NFC sharing Bluetooth, cases and covers and travel in-car equipment. Customer Analysis Nokia is the largest manufacturer of mobile phones in the world. The success of handset manufacturers amidst this high rate of competition depends on successful market segmentation. Following are the segmentation variables of Nokia: Hi-fliers-This segment is concerned with the business executives and corporate honchos for whom cell phones are a device to co-ordinate and increase efficiency and productivity if business. In most cases

Enlightenment and the French Revolution Essay Example | Topics and Well Written Essays - 1000 words

Enlightenment and the French Revolution - Essay Example Enlightenment promoted the ideas of natural law and progress in societal aspects as evident from the writings of Voltaire, Montesquieu and Rousseau. Themes from the enlightenment that contributed to the French revolution include; liberal government, constitutional monarchy, the monarchy, division of power, the Declaration of the Rights of Man, popular sovereignty, The Social Contract and Enlightened Absolutism1. The crumple of the previous establishment contributed to social unrest, economic problems and conflicting ambitions which led to the French Revolution. In the unfolding of the French revolution, the thoughts, ideas, and expressions rose from the enlightenment theorists. The themes of the enlightenment did not share a common idea, and it was not activated by a solitary revolutionary plan. Unlike the other revolutions, the French Revolution occurred in phases, with each amounting to a revolution in itself. The revolutionists repudiated one theme to pursue another. The initial p hase of the French Revolution occurred on the basis of the themes expressed by Montesquieu. This theme recognized a liberal constitutional monarchy as an elaborate government system for people who pursued freedom. This theme proposed the dividing of the sovereign state between many centers of power. This provided a balance from any center turning despotic. The English achieved this model by devolving sovereignty between the parliament, law courts and the Crown. Montesquieu suggested that the French should use their familiar estates such as the aristocratic courts, the crown, chartered cities, church and the landed nobility to advance these themes2. Montesquieu ideas gave a conspicuous share of the power to the aristocrats, a class he belonged to, both in courts and on land. The aristocrats actively took part in the revolution during the early stages. They identified themselves with the cause of national freedom and the interests of their estates. Louis the 16th took the revolution a s an enterprise for his privileged subjects to emulate what the English did by replacing an absolute ruler with a constitutional monarch3. The French Revolution had three main principles; fraternity, liberty and equity. The enlightenment advanced these principles by targeting aspects that did not include institutions such as the church, monarch and feudalism. The enlightenment gave people the power to rule, without, compulsion to operate within reason, interests or logic. This meant that citizens had acquired rights, powers and respect. The enlightenment themes of nationality, patriotism and absolute rights led to the achievement of the objectives of the French Revolution. The French national assembly has the same principles, and it represents the people and restores the nation to the citizens. This had a positive effect on the national assembly by supporting a democratic nation. The enlightenment gave people believe that they could control and comprehend the universe by empirical r esearch and reason. The natural law dominated the physical world, with the likelihood of the social world also dominating the physical world. The enlightenment emphasized the rejection of beliefs in traditional authority because they found the traditional institutions values as irrational. The enlightenment found the institutions as an obstacle for human development and growth. Their mission required them to

Discuss whistle-blowing in nursing. (Please cover the pros and cons of Research Paper

Discuss whistle-blowing in nursing. (Please cover the pros and cons of whistle blowing and it's relevance to nurse empowerment) - Research Paper Example Furthermore, a nurse might also act as a health advisor for the patients’ future well being. The American Nursing Association (ANA) states, â€Å"nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations† (What is Nursing 2012). Despite the level of input required, the reward for this profession mostly shows up as a bully. Majority of the nurses face social demons at work such as discrimination, over exploitation and verbal or even in some cases, physical abuse. Through a survey conducted of 612 nurses, 67.5% have, at some point or the other suffered inappropriate behavior from their managers. American Nursing Association has stated that 56.9% have either been threatened or been abused verbally at work. (Malcolm 2006; Spence, Leiter, Day, & Gilin 2009; ANA 2001). Whistle blowing is a terminology used when an employee of an organization who objects over illegal or unethical practices that takes place within the business. Depending upon the nature of the management style, whistle blowing can have its advantages but, in some cases quite severe repercussions. Many within a firm might consider whistle blowing no less than an act of treachery while for some companies or organizations, whistle blowing is just another form of collaborative and collective ideas to cut costs and improve efficiency from all areas of the firm. Encouraging employees from all levels of hierarchy to step up and contribute towards the betterment of the institution, collectively. However, fact is, such an attitude is rare to be found. News reports and surveys represent clearly that healthcare institutions are not in favor of such an activity and view whistle blowing as cynical criticism that diminishes its public image. Nurse practitioners have suffered the most, socially an d

Substitution Industrialization Essay Example | Topics and Well Written Essays - 1500 words

Substitution Industrialization - Essay Example Even though ISI led to the industrialization of Brazil where agriculture products dominated the economy, it has some bad effects also like increasing rates of inflation and debts. ISI did not resolve the balance of payments problems. On the other hand ISI marked the golden period of Brazilian economy from the years early 1950's and early 1960's. Promotion of other sectors also resulted from ISI such as steel, petrochemicals, fuels, automobiles, transport infrastructure and electricity. Portuguese were the first people to come to Brazil and discover its potential resources. The first attraction for them was the Brazil wood. This wood was exported by them to the European countries. However, the real breakthrough was the sugar cane production. Sugar was in high demand in Europe and an opportunity for the people to make huge profits out of its export. African slaves were used for the production of sugar. But unfortunately after a period of time sugar supply became far more than the demand due to excessive production in the Caribbean and hence prices declined significantly. In the nineteenth century, another important development in the Brazilian economy was the escalation of coffee exports. By the year 1929 coffee contributed to around 73% of the total exports. Tremendous growth of coffee exports led to the development of transport infrastructure like railways and ports. As the movements for the abolition of slavery gained momentum, the only other alternative for the employers was the free wage labour in form of immigrants from the extremely poor rural lands of European countries like Italy, Portugal and Spain. Millions of people immigrated to Brazil from Europe. Only few of them worked on plantations due to miserable conditions and others opted to move to the cities and set up their own workshops. On the other hand there was an overproduction of coffee in the country without many takers. Decline of coffee exports and the labour immigration from Europe formed the basis for the origin of industrialization. As a consequence of the Great Depression and t he Second World War there was an enormous fall off in the exports of coffee. Availability of the goods imported to Brazil also declined. As a result most of the products were needed to be produced in the country itself that led to forced import substitution industrialization. Financial crisis in the country led to the rise of populism on the political front. The newly elected president Getulio Vargas was backed by military. Landowners lost their monopoly and a centralized system was setup. The president being conscious about the present and future prospects of the coffee export trade concentrated the resources on the industrial development of the country. New policies and changes in support of the industries were formulated. Initial steps like providing the basic inputs, cultivation of energy sources and so on were taken by the administration. The period after the Second World War saw Brazil heading towards a growing and sound industrial foundation, the main sectors being food, textile, leather and wood. After the end of Vargas's reign, the new president Dutra opted for the free trade policy and the market opened to the US imports. Major part of the foreign exchange was lost in the import of luxury consumer

Shakespeares Purpose in Subverting the Moral Universe in Hamlet Essay Example for Free

Shakespeares Purpose in Subverting the Moral Universe in Hamlet Essay he inverted moral universei in Shakespearean drama was a demonstration of the increased reality that ancestral and collective foundations were losing their sanctified nature. Key upheavals were taking place and the world of Shakespeare was evolving from a time where the earth was still the center of the universe,ii towards a life of societal instability. Like all playwrights, Shakespeares ideas for plot were partly a reflection of the world in which he lived. The enlightenment was a time where religion was giving way to science and economic gain. It would be unreasonable for such a reflective dramatist to omit the implications and limitations of the times in his work. The regulations and boundaries for human conduct are not always clear, especially in times of fluctuation. While I would not maintain moral universe is a dominant theme in Shakespeares work, I do argue that it is a somewhat significant current running through many of his plays. To define any one moral universe in the work is folly, each play deserves many separate definitions. Collective morality goes through an alteration according to the circumstances of each group of characters. Situational ethics play a role in determining the behavior of Shakespeares characters, especially in the history plays. To ascribe one particular moral universe to any work does not take into account the perspectives of all the major characters. While we are not privy to the thoughts of all characters, some plays reveal them more clearly. The Moral Universe In Hamlet Hamlet shows Shakespeares belief in the potential of human beings to achieve spiritual and moral transcendence and social harmony through reasoned thought and proper action. The play presents the individual as trying to make choices in shaping his or her own fate.iii This quote, taken from a lecture by Maria Simms, identifies Shakespeares intentions in the character of Hamlet. The play presents a parallel of the playwrights objective. Mad or no, Hamlet knows the difference between ethical and unethical and is committed to shaping his moral universe to that end. Shakespeare, torn between the dark ages of Elizabethan traditions and the glow of enlightenment, uses this indecision in the makeup of the character of Hamlet. The inversion of the moral universe takes place in the murders within the family, the unnaturalness of the mother remarrying the uncle, and old friends turning traitor. The quote, My two schoolfellows. Whom I shall trust as I will adders fangs, is a clear example of Hamlets world. His father is dead, his mother is lost to him, he is seeing ghosts, and he cannot trust those around him. Shakespeares purpose in subverting the moral universe was to accentuate the unnaturalness of the acts and the appearance of the ghost. In the first act of Hamlet, the appearance of the ghost character is problematic. When Shakespeare wrote it; English religious theology was not recognizing the state of purgatoryiv. Granted, the locale of the play is in Denmark, however, it is a sensitive point and conceivably that is why after Hamlet sees the ghost, Shakespeare permits his character go wholly round the bend. The spirit becomes the influence that upsets the balance of the moral universe. It is the most unnatural character in the play. The accusation of murder is the real moral question, from the ghosts viewpoint. If it were that Gertrude had remarried too soon, the ghost would have been seeking revenge for that transgression as well. The purgatory in Shakespeares play is a blatant upset in the conventional universe of that era. Hamlet furthermore has a dilemma, he has to believe the manifestation and the charge made by the spirit, and he cannot have absolute belief without sufficient evidence. One can assume that the audience was also questioning the likelihood of a ghost. Only when Hamlet establishes confirmation can the play advance; otherwise, we are trapped in purgatory along with the ghost. Other instances of inverted moral universe are: the mother marrying the uncle in haste, friends betraying each other, the wrongful murder of Polonius, and the King sentencing Prince Hamlet to death. These situations proceeded from the act of murder of Hamlet Senior. The inversion happens as the result of an unacceptable or un-natural act. What often happens in Shakespearian plays (and tragedies in particular) is the disordered universe exists because of injustice, wrong choices by the protagonist, and un-natural acts of murder. When the inversions transform back to natural order, resolution can take place. The transformations emphasize the redemption of the hero and the moral universe. The advancement of Hamlet marches through a troubled equilibrium of the natural world to a resolution where Fortinbras restores the element of order. An inversion of the moral universe back to order is a manifestation of the same journey that the protagonist had to go through. For example: Henry IV dies and order is restored through his son, Hamlet is killed and Fortinbras restores order, Romeo and Juliet both die and order is restored through the prince. Each of their fatalities see all of them ascend beyond themselves: that is, to become righteous. Simply put, the inversion serves for the dramatic representation of the salvation of the central character and the moral universe. The Moral Universe in the Henriad In Richard II, the moral universe still based its identity upon kingship predicated by God. Richard II is considered a moral character because of his divine rights. It would not necessarily matter if he were a proficient ruler, because his appointment as king is firmly grounded in absolutism. According to Wayne Jackson of The Christian Courier, This concept affirms that there is an absolute, objective standard of right and wrong. v When Richard II usurps the line of succession as set forth in Biblical tones, the moral universe starts to wobble. The Duke of York cautioned Richard II that there were, in fact, limits to what he could justify to his people, You lose a thousand well-disposed hearts, he warned. After Richard II disregards this good council and proceeds on his course of action, he begins to doubt himself. This hesitation is the opening Shakespeare provided for Bullingbrook and his character had limitations as well. In this moral universe, Bullingbrook cannot cleanly seize the throne. When Richard came down to the base court, he essentially abdicates the supremacy of the throne and provided Shakespeare with a moral universe that spins out of control. Nihilism became the new order and rules for behavior were vague from that point on. The Henriad is the clearest illustration of situational ethics in the works of Shakespeare. In his plays, the act of killing a king or subverting a kings power (A Midsummer Nights Dream) destabilizes the universe. In addition, each character feels justified in his or hers own actions. There is a lack of a conventional biblical moral universe in Henry IV, I and II; the persistent motif in these plays is that most of the characters are bent on servicing their own ends. The reality that an archbishop would consent to a revolt against the ruler is an obvious indication that the state of the moral universe is on its head. This might not have happened had Henry IV been a ruler by divine right. As the head of state, he set the tone of the universe. Since he interrupted the lines of succession; he left himself open to more of the same when his own past came back to haunt his rule. The constant uprisings are also taking place in Shakespeares sector. During the performance of the plays, Elizabeth was fending off rebellions of her own. The characters in the Henriad also are deficient in morality. As in Measure for Measure, most of the characters are flawed, not just the hero. Both Hotspur and Henry fail to see their moral shortcomings. Integrity crumbles because the idea on which it is based is shallow. In Henry IV, part II, the moral universe is political in nature. The moral criterion of the crown is not only the progress back to proper succession, but political effectiveness as well. The individual weakness of a figure vital in the public sphere has great repercussions in society. Hal cared about his image and coldly calculated when he would show his true nature. He was trickster, deceiver, and deliverer based upon the situational moral principles. It is ironic that he was revered as The Ideal Christian King, clearly he broke the law during his illegal activities with Falstaff. Like his father before him, he was artful in the use of his friends and then shed them when they no longer served a valuable purpose. In the Henriad, Shakespeare allows the audience to decide upon each characters moral behavior and whether or not it was justified. There are many facets and differing moral universes in this group of histories. Hals youthfulness is the agent of change Shakespeare uses in the Henriad. It is only when he sheds his youthful friends, immoral activities, and shallow ideals that he can move forward and re-unite his country in battle against the French. This is the true restoration of the moral universe. If he had simply assumed the crown when his father died, without the journey of shedding his past, the moral universe could not have reverted to its natural state. Shakespeare also used the device of character conflict when depicting the many conflicting moral universes. Characters feel the pull in different ways. It is easy to imagine Hal as that gentleman with the angel Henry IV, on one shoulder (tarnished though is fathers image is) and the devil Falstaff on the other. Indeed, it is only through Henry IVs realization that he has taken the crown illegally that resolution is possible. Shakespeare used this kind of introspective journey as a theme in many plays. Without his fathers epiphany, Hal would undoubtedly been easily swayed to the dark side. Henry IV achieves redemption through his understanding and remorse and that sets the moral universe in enough order that Hal is in a position to make his choice. Hal serves as the equilibrium between the two contradictory characters of Henry IV and Falstaff. Comparison of the Moral Universe in the Henriad, Hamlet, and Measure for Measure In both Measure for Measure and Henry V, the rulers are not about to let social immorality be part of their rule. Shakespeare deals with Angelo and Falstaff in a like manner. It is clear that these men, who once enjoyed the ear of royalty, are going to be Shakepeares scapegoats for people who have strayed morally in life and in rule. The character of Falstaff is a thorny one, He is a disgrace to knighthood, and one might say that his code of honor is simply, CHEERS! He receives the penalty by Henry V for his transgressions with Hal during his youth. His sideways attempt to grasp power by ingratiating himself with Hal does not serve him well. His character is a discordant note in the rule of Henry IV, and moral harmony is restored when this note is silenced in Henry V. Again, in Henry V we see a lack of moral consciousness, or at the very least a bid for moral right. Henry V will not invade without the archbishops proof with right and conscience, that his claim to France is valid. Nevertheless, this supposedly moral outlookvi is tainted by the truth that lies beneath, in order to keep order in his country (forestall uprisings); he needs to get his subjects to focus on issues abroad.vii Shakespeares characters deviate from their expected social roles. In Measure for Measure the characters are trying to either save their own skins or their virtue. Similar to the Henriad, it is all blurred confusion over what actually constitutes a collective moral universe. There is further complexity of characters in Measure for Measure, we observe how they each wrestle for justice in their individual ways. Measure for Measure and Hamlet differs from the Henriad because there is more at stake ethically. The war in Measure for Measure is the fight to restore the values of the citizens, the justice they feel they deserve, and proper rule to the society. Each character is concerned with justice in his or her own moral universe. Aleksander Bobko, at a conference on Unjust Structures at the Von Hugel Institute in Cambridge noted, Justice, then, is a kind of the objective measure of things, its ultimate basis being Logos which, contrary to Chaos, sets the world in order. In Measure for Measure, when each character receives justice, the moral universe is set to rights. Shakespeare neatly ties up at the end of the play, with no problematic threads left out. Hamlet also seeks justice for the death of his father and receives it when he kills his uncle. CONCLUSION The overturned moral universe in Shakespearean performances of Measure for Measure, Hamlet ,and the Henriad was a display of evolution from an established religiously sanctioned rule to an enlightened time. Shifting expectations created moral ambiguity and a shared moral universe was hard to ascertain. Shakespeare used his plays as a mirror of the change his society was going through in the choice of his plots, character conflict, and moral inconsistencies. Humanity was moving away from absolutism to relativism and nihilism. Situational ethics played a strong role in his work in the lives and choices of his characters. Instead of using magic as the weight to unbalance the universe, he used morality and ethics as literary devices to throw his created worlds into chaos. When the moral universe was out of order, the rules of society became indistinct. Shakespeare forced certain characters to undertake journeys for enlightenment to restore the moral universe. His function in destabilizing the moral universe was to emphasize the unnaturalness of the actions of his characters. i Term moral universe introduced by Professor Tomkins, Fall 2003 ii Donahue conversation iii Simms lecture Effect of the Reformation on the Renaissance in England iv Tom Bishop http://www.shaksper.net/archives/1998/1276.html SHAKSPER, the international electronic conference. v A Critical Look at Situation Ethics by WayneJackson. vi How moral is war, consider who gains, a few titled men are the only people who will actually benefit along with a host of knights, who fight for glory and pay in their protected Armour. But the reality is that the serfs will be the one to pay- their lands taxed, their farms and villages burnt and the men killed. All because they live in the region of certain lords, they will fight, no matter what the cost. Their situation remains static no matter who wears the crown, until they get a king who knows how to avoid war, restore a collective moral universe, and rule as a political leader instead of a barbarian. (Wendt) vii Tomkins lecture, November 2003. Works Cited Oxford English Dictionary. Second Edition. 1989 (ed. J. A. Simpson and E. S. C. Weiner), Additions 1993-7 (ed. John Simpson and Edmund Weiner; Michael Proffitt), and 3rd ed. (in progress) Mar. 2000- (ed. John Simpson). OED Online. Oxford University Press. http://dictionary.oed.com Hacker, Diane A Writers Reference. 5th ed. Boston New York: Bedford/ST. Martins 2003 Murfin, Ross and Ray, Supryia The Bedford Glossary Of Critical and Literary Terms: Second Edition. Boston and New York: Bedford/St. Martins. 2003 The Riverside Shakespeare: Second Edition. Houghton Mifflin Company: Boston New York, 1997. Jackson, Wayne. A Critical Look at Situation Ethics 1999. 1 Mar. www.christiancourier.com/feature/March99.htm Simms,Maria. Introduction to Shakespeare lecture. http://www.scu.edu.au/schools/hmcs/human/writing/introwrittext/lectureNotes/Topic2Hamlet.html Christian Courier A Critical Look at Situation Ethics: Second Edition. Houghton Mifflin Company: Boston New York, 1997. Donahue, William. Personal interview. 15 November. 2003 Tomkins, Ken. Shakespeare Lectures. Sept. Nov. 2003 Bobko, Aleksander. Evolution of the concept of justice-from objective measure to aesthetic evaluation. June 2003 Conference. Transforming Unjust Structures: Capabilities and Justice. Von Hugel Institute St Edmunds College, Cambridge.

Reflective Summary On Prescribing Practice Learning Nursing Essay

Reflective Summary On Prescribing Practice Learning Nursing Essay The author, a nurse practitioner based in an Emergency Department (ED), from here on in will be referred to as the practitioner. The practitioner is currently employed in a development role with the view, following training, of becoming an acute care practitioner. This will entail working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. This plan of care could well include a number of prescribed medications. Hence it is in the practitioners job description (as it is increasingly in many specialist/autonomous nursing roles) to become a Nurse Independent and Supplementary Prescriber (NISP). The Cumberlege Report (1986) suggested that nurses should be able to prescribe independently and highlighted that patient care could be improved and resources used more effectively by doing so. It identified that nurses were wasting their time requesting prescriptions from Doctors. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (DoH 1989, 1999, 2006 2008; Luker et al 1994; Latter et al 2011) and is still under constant review. The aim of this portfolio is to: Reflect on practice as a means of on-going personal and professional development. Demonstrate a capability of integrating learning into practice. Submit a range of material mapped against the module learning outcomes, NMC 2006 prescribing standards, domains of practice and core competencies. Establish an evidence-based approach to practice competence as a safe independent supplementary prescriber. This prescribing practice portfolio will be a reflective portfolio using Rolfe et al (2001) model of reflection to aid learning from experience and close the gap between theory and practice. This model has been chosen as it is something the practitioner is familiar with and has used before. The portfolio will conclude with a reflective summary on prescribing practice learning which will draw together the evidence used to support achievement of the competences identified. After discussing with colleagues who have already completed the NISP course, the practitioner is aware of the complex nature and volume of work that is required over the duration of it. There is a feeling of nervousness due to this but also a feeling excitement over what will be learnt. If successful the practitioner believes her practice will be enhanced significantly as she will have the ability to give patients seamless care. References Department of Health. (1986) Neighbourhood Nursing: A Focus for Care. (Cumberlege Report). London: HMSO Department of Health. (1989) Report of the Advisory Group on Nurse Prescribing. The Crown Report). London: HMSO Department of Health. (1999) Review Of Prescribing, Supply And Administration Of Medicines. (The Crown Report Two) London: HMSO. Department of Health. (2006) Medicines Matters. London: HMSO Department of Health. (2008) Making Connections: Using Healthcare Professionals to Deliver Organisational Improvements. London: HMSO Latter, S. Blenkinsopp, A. Smith, A. Chapman, S. Tinelli, M. Gerard, K. Little, P. Celino, N. Granby, T. Nicholls, P. Dorer, G. (2011) Evaluation of nurse and pharmacist independent prescribing. Faculty of Health Sciences, University of Southampton; School of Pharmacy, Keele University on behalf of Department of Health [Online] Available at http://eprints.soton.ac.uk/184777/ [Accessed 15th Sept 2012] Luker, K. Austin, L. Hogg, C. Ferguson, B. Smith, K. (1998) Nurse-Patient Relationships: The context of Nurse Prescribing. Journal of Advanced Nursing. (28) 2: 235-242 Rolfe, G. Freshwater, D. Jasper, M. (2001) Critical Reflection in Nursing and the Helping Professions: a Users Guide. Basingstoke: Palgrave Macmillan. Consultation Holistic Assessment Case Study In this case study the consultation, diagnosis, prescribing options and decisions of a 35 year old female seen in the ED will be discussed. This case study will aim to improve the practitioners knowledge of conducting a consultation and its relationship with making a diagnosis and treatment options. To maintain confidentiality, in line with the code of professional conduct, the patient will be referred to as Mrs A (Nursing and Midwifery Council (NMC), 2008). Consultation Examining the holistic needs of the patient is the first of seven principles of good prescribing (National Prescribing Centre (NPC), 1999) and must be undertaken before making a decision to prescribe (NMC Practice Standard 3, 2006). Holistic assessment takes into consideration the mind, body and spirit of the patient (Jarvis, 2008). Traditionally consultation and making a diagnosis has been completed by Doctors. However, nurse diagnosis would appear to have been formally acknowledged since The Crown Two Report (DoH, 1999) as part of the independent prescriber role. Horrocks et al, (2002), found greater patient satisfaction with nurse consultations than with GP consultations. Jennings et al, (2009) and Wilson Shifaza, (2008) also found this to be true of nurse practitioners working in emergency departments. Importantly, they also found no significant variation in other health outcomes. Most of these studies found that consultations with nurses were to some extent longer, they offered more advice on self-care and self-management and that nurses gave more information to patients. Although there are various consultation models that have been described (Byrne Long, 1976; Pendleton et al, 1984; Neighbour, 2005; Kurtz et al, 2003; Stott Davis, 1979), these are based upon observation of doctor, not nurse consultations. Nevertheless, the consultation models and skills described in the medical literature are relevant to all practitioners (Baird, 2004). Consultation models help the practitioner centre the consultation around successful information exchange and try to provide a theoretical structure. Consultation models can also be used to help make maximum use of the time available at each consultation (Simon, 2009). Traditionally the medical model is used to assess patients however; it does not take into account the social, psychological, and other external factors of the patient. The model also overlooks that the diagnosis (that will affect treatment of the patient) is a result of negotiation between doctor and patient (Frankel et al, 2003) In this case study, the practitioner has used Roger Neighbours model of consultation. This was found by the practitioner to be simple and easy to remember, whilst covering all areas needed to make an effective consultation and assessment. He describes a 5 stage model which he refers to as a journey with checkpoints along the way: Connecting establishing a relationship and rapport with the patient. Summarising taking a history from the patient including their ideas, expectations, concerns and summarising back to the patient to ensure there are no misunderstandings. Handing over negotiating between the practitioners and patients agenda and agreeing on a management plan. Safety netting the consideration of what if? and what the practitioner might do in each case. Housekeeping reflecting on the consultation. (Neighbour, 2005) Connecting Mrs A was called through to the Rapid Assessment and Treatment area in the ED. It was apparent from Mrs As facial expression and limp that walking caused her pain. Silverman Kinnersley, (2010) state that non-verbal communication is extremely important and can often provide clues to underlying concerns or emotions. The practitioner had never met the patient before so had no previous relationship with her but was aware that she may have pre-conceived ideas about the ED which may have caused her anxiety. The practitioner introduced herself to Mrs A, explained her job role, the process that was about to be undertook and consent obtained. During this time eye contact was maintained and the practitioner also asked Mrs A how she would like to be addressed. This was done to try and build up a rapport with Mrs A, to help her feel at ease and reassure her. Simon, (2009) and Moulton, (2007) agree and state that rapport is essential to effective communication and consultation. Mrs A was also of fered a trolley to sit on to make herself comfortable and the curtains pulled around for privacy and dignity. On reflection the practitioner was aware that the environment was a busy and noisy assessment area and this can have a negative impact on the consultation (Silverman et al, 2005). Identifying this with Mrs A and apologising may have re-assured her further and gained trust and respect. Summarising The practitioner began with an open ended question and did not interrupt the patients response. Neighbour, (2005) and Moulton, (2007) advise this to open the consultation. Gask Usherwood, (2002) found that if a practitioner interrupts, patients then rarely disclose new information, which could lead to not finding out the real reason for the consultation. Mrs A revealed that she received an insect bite to her right lower leg 5 days ago, since then the surrounding skin had become swollen, increasingly red, painful and hot to touch. She explained that the redness was spreading up her leg and the pain was getting worse. Mrs A explained that she was concerned that it was not going to get better and was very worried that it had got worse during the last 3 days. Upon questioning Mrs A also complained of malaise and that she had been feeling very hot and cold and at times. She had been managing to eat and drink as normal. Mrs A lived with her husband, was a non smoker and drank alcohol occasionally. She had no past medical history and took no prescribed or over the counter (otc) medications. It was also elicited that she was allergic to Penicillin which she had an anaphylaxis reaction to. Taking a medical, social, medication and allergy history is important as it can be relevant to the presenting complaint, makes sure key information has not been overlooked and is essential in preventing prescribing errors (Bickley, 2008; Young et al, 2009). The practitioner actively listened to what Mrs A was saying by maintaining eye contact, using open questions and by summarising the history back to clarify points and to make sure nothing was missed. On reflection the practitioner feels this also gave the opportunity for Mrs A to add any further information not disclosed so far. Closed questions were then used to gain specific information related to the initial information given, this is advised by Young et al, (2009) and Moulton, (2007). Effective communication is important as Epstein et al, (2008) explains that a precise history can supply at least 80% of the information necessary for a diagnosis. Upon examination there was obvious erythema. Light palpation revealed that the area was very warm and tender. Neurovascular assessment was performed and was unremarkable. Mrs As chest was clear, heart sounds normal and her abdomen was soft, non tender. Physical examination is important as it is used to detect physical signs that the patient may not be aware of and can be used to confirm or disprove a possible diagnosis. It also suggests to the patient that their illness is being taken seriously. (Bickley, 2008, Charlton, 2006). Observations were taken including blood pressure, heart rate, temperature, respiratory rate and oxygen saturations. All were within normal parameters except her temperature which was 38.2 degrees Celsius. Venous blood was taken to check haematological, biochemical and coagulation status. Mrs A white cell count (WCC) and C-reactive protein (CRP) levels were raised, all other blood results were normal. Handing Over Before making a final diagnosis, it is important that differential diagnoses are excluded (Nazarko, 2012). The practitioners differential diagnoses were deep vein thrombosis (DVT) or venous eczema. However, Mrs A had a straightforward history (insect bite) that together with her observations (raised temperature), examination findings (redness, heat, swelling and pain) and blood results (raised WCC and CRP) indicated an alternative diagnosis, so DVT and venous eczema were ruled out. The practitioners working diagnosis was cellulitis. This was discussed with Mrs A and she appeared reassured that a diagnosis had been made. The practitioner explained that she would like to discuss this with a senior Doctor to help decide on a treatment plan. The practitioner presented the patient to an ED Registrar who agreed with the diagnosis. Diagnosis, treatment and prescribing options were then discussed to aid the practitioners learning. Cellulitis is a bacterial infection of the skin and subcutaneous tissue which is potentially serious (Epstein et al, 2008). It is caused by one or more types of bacteria, most commonly streptococci and staphylococcus aureus (Nazarko, 2012). Cellulitis usually occurs on the lower legs, arms and face but can arise anywhere on the body (Bickley, 2008). Patients with cellulitis present with signs of inflammation, distinctively heat, redness, swelling and pain (Nazarko, 2012). Inflammation is localised initially but increases as the infection progresses. Patients can be systemically unwell (pyrexial, tachycardic, hypotensive) and white cell count and C-reactive protein levels will be markedly raised (Beldon, 2011, Wingfield, 2009, Nazarko, 2012). It appears there is a general lack of evidence based literature surrounding the treatment of patients with cellulitis. The practitioner could only find one national guideline on the management of cellulitis in adults, which was published in 2005 by the Clinical Resource Efficiency Support Team (CREST, 2005). However, to the practitioners knowledge, these have not been validated by a clinical study. Morris, (2008) found in his systematic review that antibiotics cure 50-100% of cases of cellulitis but did not find out which antibiotic regime was most successful. Kilburn et al, (2010) also could not find any definitive conclusions in their Cochrane review on the optimal antibiotics, duration or route of administration. Eron, (2000) devised a classification system for cellulitis and its treatment which CREST used in their guidelines. This system divides people with cellulitis into four classes and can serve as a useful guide to admission and treatment decisions. However Koerner Johnson, (2011) found in their retrospective study, comparing the treatment received with the CREST guidelines, that patients at the mildest end of the spectrum were over treated and at the more severe end undertreated. They also found a significant variation in antibiotic regimes prescribed for patients with cellulitis. Marwick et al, (2011) questioned whether classes I and II could actually be merged to improve treatment. The practitioners trust has antibiotic guidelines (updated yearly) which also include a classification system. This aids the prescriber in choosing the correct antibiotic, dose, route and duration for certain conditions, cellulitis being one of them. After discussion with the Registrar it was determined that Mrs A was in Class I or non-severe which meant she could be managed with oral antibiotics on an outpatient basis. The practitioners trust and CREST, (2005) guidelines advise first line treatment for non-severe or class I cellulitis as oral Flucloxacillin 500mg, three times a day. Flucloxacillin is a moderately narrow-spectrum antibiotic licensed for the treatment of cellulitis. However, Flucloxacillin was contra-indicated for Mrs A as she had a severe penicillin allergy (British National Formulary, (BNF) 2012). Clarithromycin is a macrolide which has an antibacterial spectrum that is similar but not identical to that of penicillin; they are thus an alternative in penicillin-allergic patients (BNF, 2012). Clarithromycin is licensed and recommended by CREST, (2005), and by the practitioners trust, as an alternative to Flucloxacillin in cellulitis for patients with a Penicillin allergy. It is indicated in the BNF, (2012) for the treatment of mild to moderate skin and soft-tissue infections. It demonstrates suitable pharmacokinetics, with good distribution into skin and soft tissues, and is effective against the large majority of staphylococcal and streptococcal bacteria that cause cellulitis (Accord Healthcare Limited, 2012), (See drug monologue page 21-28). There were no contraindications in prescribing Clarithromycin for Mrs A. The option of not having any medication was discussed with Mrs A however, she wanted treatment so the benefits and side effects of Clarithromycin was explained, and consent obtained from Mrs A to prescribe the antibiotics and to be discharged, (NMC Practice Standard 5, 2006). Dose and duration were then also clarified and the importance of taking the antibiotics as prescribed and to complete the full course. On reflection, by discussing and deciding on the best treatment together this would hopefully promote concordance. Negotiating with patients and agreeing on a management plan is very important aspect of reaching patient centred care (Neighbour, 2005). Using an FP10 Clarithromycin tablets 500mg twice a day was prescribed by the Registrar (as the practitioner was not a licensed prescriber, NMC Practice Standard 1, 2006), as per trust guidelines, for 7 days. Paracetamol tablets 1g four times a day was also prescribed for its analgesic and anti-pyretic properties (BNF, 2012). A stat dose of both were prescribed and the practitioner asked the nurse to administer the first dose (NMC Practice Standard 9 14, 2006), and was aware that by delegating this task the prescriber remained accountable. The FP10 was given to the patient to take to the pharmacy of her choice for them to dispense (NMC Practice Standard 10, 2006), (See mock prescription page 29). The practitioner did not initially contemplate cost effectiveness but on reflection it has been recognised that this needs to be taken into consideration when prescribing (NPC, 1999). Intravenous antibiotics may have been prescribed, which may have meant an admission into hospital or administration by nurses on an outpatient basis; thus would have increased the cost of treatment significantly. Admission to hospital can also be overwhelming and can put the patient at risk of hospital acquired infections and increased risk of antibiotic resistance (Wingfield, 2008). Safety Netting The erythematous border was marked, with the patients consent, with permanent pen to monitor for any improvement or additional spread of infection (CREST, 2005, Beldon, 2011). The practitioner advised Mrs A that she should return or see her GP if she had worsening symptoms or if by the completion of the course of antibiotics symptoms had failed to resolve. Mrs A was also advised that, if a similar incident occurred, she should seek medical assistance early so that treatment could begin as soon as possible to reduce the risk of severe and long-term complications. In addition it was recommended that she should drink plenty of fluids to prevent dehydration, elevate the leg for comfort and to help reduce the swelling (CREST, 2005, Beldon, 2011). Mrs A was warned that there could be an increase in erythema in the first 24-48 hours of treatment (CREST, 2005). This advice and information empowered Mrs A and made sure that her discharge was as safe as possible. The practitioner brought the consultation to a close by asking Mrs A if she had any questions or if there was anything else she would like to discuss. This gave Mrs A the opportunity of clarifying any information given by the practitioner and the opportunity to divulge any information or concerns not previously mentioned. This re-assured the practitioner that she had addressed her problem appropriately. Housekeeping The practitioner made sure there was clear concise documentation of the consultation and choice of prescription in Mrs A notes (NMC Practice Standard 7, 2006). A discharge letter was also produced to send to her GP NMC Practice Standard 6, 2006). Once the prescription was ready, Mrs A was discharged. This case study has shown the practitioner the importance of effective communication in consultation. By following Neighbours consultation checkpoints it gave structure to the consultation and will be used by the practitioner in future practice. It has also helped the practitioner to gain an understanding of different prescribing options and how to explore these further. For example, the practitioner did find when reading around the subject that there has been some research on the use of corticosteroids in cellulitis to increase resolution, however, to the practitioners knowledge, this is not currently advised in any guidelines and further research is needed. The practitioner would also like to be involved in the development of a cellulitis pathway at her place of work. This could include an algorithm to aid practitioners to differential diagnosis so patients can receive appropriate treatment and reduce the incorrect prescribing of antibiotics. As there are no National Institute for Health and Clinical Excellence (NICE) guidelines on the treatment and management of cellulitis, treatment of patients is not standardised and consequently quality of care could be affected. The optimal choice for antimicrobial therapy requires review and definitive study in clinical trials. References Accord Healthcare Limited (2012) Summary of Product Characteristics for Clarithromycin Capsules 500mg. [online]. Electronic Medicines Compendium. Datapharm Communications Ltd. Available from: http://www.medicines.org.uk/EMC/medicine/25914/SPC/Clarithromycin+500mg+Tablets/ [Accessed 21ST September 2012] Byrne, P. Long, B. (1976) Doctors Talking to Patients. London, HMSO. Baird, A. (2004) The Consultation. Nurse Prescriber. (1) 3: 1-4 British National Formulary: No. 64 (2012) London: BMJ Group and Pharmaceutical Press. Bickley, L. (2008) Bates Guide to Physical Examination and History Taking. 6th Ed. London: Lippincott, Williams and Wilkins. Beldon, P. (2011) The Assessment, Diagnosis and Treatment of Cellulitis. Wound Essentials. (6): 60-68. Clinical Research Efficiency Support Team (2005) Guidelines on the Management of Cellulitis in Adults. Belfast: Clinical Research Efficiency Support Team. Charlton, R. (2006) Learning to Consult. Abingdon: Radcliffe. 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Name of Drug Clarithromycin Drug Classification Macrolide Therapeutic Uses(s) Clarithromycin film-coated tablets are indicated in adults and adolescents 12 years and older for the treatment of the following bacterial infections, when caused by clarithromycin-susceptible bacteria. à ¢Ã¢â€š ¬Ã‚ ¢ Acute bacterial exacerbation of chronic bronchitis à ¢Ã¢â€š ¬Ã‚ ¢ Mild to moderate community acquired pneumonia. à ¢Ã¢â€š ¬Ã‚ ¢ Acute bacterial sinusitis à ¢Ã¢â€š ¬Ã‚ ¢ Bacterial pharyngitis. à ¢Ã¢â€š ¬Ã‚ ¢ Skin infections and soft tissue infections of mild to moderate severity, such as folliculitis, cellulitis and erysipelas Clarithromycin film-coated tablets can also be used in appropriate combination with antibacterial therapeutic regimens and an appropriate ulcer healing agent for the eradication of Helicobacter pylori in patients with Helicobacter pylori associated ulcers Dose range and route(s) of administration Adults and adolescents (12 years and older) à ¢Ã¢â€š ¬Ã‚ ¢ Standard dosage: The usual dose is 250 mg twice daily. à ¢Ã¢â€š ¬Ã‚ ¢ High dosage treatment (severe infections): The usual dose may be increased to 500 mg twice daily in severe infections. Children younger than 12 years: Use of Clarithromycin film-coated tablets is not recommended for children younger than 12 years. Use Clarithromycin paediatric suspensions. Clinical trials have been conducted using clarithromycin pediatric suspension in children 6 months to 12 years of age. Elderly: As for adults Dosage in renal functional impairment: The maximum recommended dosages should be reduced proportionately to renal impairment. In patients with renal impairment with creatinine clearance less than 30 mL/min, the dosage of clarithromycin should be reduced by one-half, i.e. 250 mg once daily, or 250 mg twice daily in more severe infections. Treatment should not be continued beyond 14 days in these patients. Patients with hepatic impairment: Caution should be exercised when administrating clarithromycin in patients with hepatic impairment Administered orally. Pharmacodynamics Mode of Action Clarithromycin is a semi-synthetic derivative of erythromycin A. It exerts its antibacterial action by binding to the 50s ribosomal sub-unit of susceptible bacteria and suppresses protein synthesis. It is highly potent against a wide variety of aerobic and anaerobic gram-positive and gram-negative organisms. The 14-hydroxy metabolite of clarithromycin also has antimicrobial activity. The MICs of this metabolite are equal or two-fold higher than the MICs of the parent compound, except for H. influenzae where the 14-hydroxy metabolite is two-fold more active than the parent compound. Side Effects Dyspepsia, tooth and tongue discoloration, smell and taste disturbances, stomatitis, glossitis, and headache; less commonly: arthralgia and myalgia; rarely: tinnitus; very rarely: dizziness, insomnia, nightmares, anxiety, confusion, psychosis, paraesthesia, convulsions, hypoglycemia, renal failure, interstitial nephritis, leucopenia, and thrombocytopenia Interactions Aprepitant Clarithromycin possibly increases plasma concentration of aprepitant Atazanavir Plasma concentration of both drugs increased when Clarithromycin given with atazanavir. Atorvastatin Clarithromycin increases plasma concentration of atorvastatin. Cabazitaxel Avoidance of clarithromycin advised by manufacturer of cabazitaxel. Calcium-channel Blockers Clarithromycin possibly inhibits metabolism of calcium-channel blockers (increased risk of side-effects). Carbamazepine Clarithromycin increases plasma concentration of carbamazepine. Ciclosporin Clarithromycin inhibits metabolism of ciclosporin (increased plasma concentration). Colchicine Clarithromycin possibly increases risk of colchicine toxicity-suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment). Coumarins Clarithromycin enhances anticoagulant effect of coumarins. Disopyramide Clarithromycin possibly increases plasma concentration of disopyramide (increased risk of toxicity). Dronedarone Avoidance of clarithromycin advised by manufacturer of dronedarone (risk of ventricular arrhythmias). Efavirenz Increased risk