A Separate Peace Themes

A Separate Peace by John Knowles concerns itself about a young adult named Gene who decides to visit his old school Devon years after the war and recollects his memories of his friend, Phonies. Most of the story is a flashback about the hardships Gene and Phonies had to face growing up in high school during a war. During this flashback, Gene grows through the phase where he must let go of his childhood and mature to adulthood. Throughout the book, Phonies symbolizes childhood and innocence, revealing the main theme of the book: innocence versus maturity.Gene's Journey through his years at Devon shows how he matures and gains a bigger understanding of the world around him. At the beginning of the book, both Gene and Phonies were childish at the beginning of the book. For example, Phonies would wear pink clothing and a school tie as a belt to a headmaster's gathering. â€Å"In his haste that morning Finny had not unexpected used a tie for a belt. But this morning the tie at hand had b een the Devon School tie† (20). This shows a level of disrespect of self-image and school-image that usually rash, young children have.Phonies even believes that the war is Just a scam made up by adults to get a profit. There's the bad, there's the good; Just pure black and white. He was even able to rationalize this illogical belief to Gene, and Gene easily gives in. Just like how a child sticks to her favorite blanket or comforting teddy bear to protect her from the nasty in life, Phonies is Gene's way of clinging on to a more immature view to explain life simply. As Gene begins to mature through his years at Devon, he loses Phonies for a while as Phonies recovers from his leg injury.This opens the door to Gene as he sees a new view point on life. He has a sense of guilt that he was the one who trounced Phonies out of the tree, but cannot explain his actions. This new sense of guilt make question if he is truly evil or still innocent. It raises the question that there may be something more than Just cruelly evil or purely good that Phonies seemed to believe earlier. However, Phonies, symbolizing Gene's childhood, tries to pull Gene back to a world of innocence with winter carnivals and games – games where there are no losers and everyone wins.Affected by Phonies' tempting simple ideals, Gene finds himself hard to let go of the innocent outlook on life. Still, this prodding question further develops when Gene meets Leper after the effects of the war. â€Å"The army has the perfect word for everything, did you ever think of that? †¦ And the perfect word for me†¦ Psycho. I guess I am. I must be. Am I though, or is the army? Because they turned everything inside out† (141 , 149). This quote summarizes the scene when Gene learns about harsh cruelties of war, and begins to realize that the world is bitterer than he had originally thought.Human beings can be evil. This completely transforms his original innocent view on the world. At t he end of the novel, when Gene is of age to be recruited into the war, Gene has learned much about the harsh truth of reality. He begins to move into an acceptance state. When Phonies realizes that it was Gene who had originally trounced the branch, Gene is able to explain that there are certain evils, certain impulses that earlier in the novel. â€Å"No, I don't know how to show you, how can I show you, Finny? Tell me how to show you.It was Just some ignorance inside me, some crazy thing inside me, something blind, that's all it was† (191). Gene accepts that humans are neither fully good nor evil, but normal beings with natural impulses. Knowles shows throughout the book that as one ages and matures, one must lose that innocent childish mentality. Gene slowly pulls apart from Phonies' ideals and moves onto a more complex understanding of human behavior. However, as Gene reaches young adulthood, Knowles cleverly has Phonies pass away, as only to show that in order for Gene to fully mature and reach adulthood, the innocent childhood must completely disappear. Did not cry then or ever about Finny†¦. ‘ could not escape a felling that this was my own funeral, and you do not cry in that case† (186) The quote even shows that Gene feels that Phonies was part of himself. This is referring to the naive childhood part of Gene. Knowles consistently expresses the theme of innocence versus maturity. He tells us that in order to achieve maturity and achieve the fuller, complex view on life, one has to lose the innocent outlook that usually the young has. Gene moved from a young naive child to a developed young adult.

What Does Nursing Mean To Me?

It is important to me that nursing is identified as an honorable and essential profession. I believe that nursing is a status that reflects the two equally important parts of nursing knowledge: Empirical knowledge and Esthetical knowledge. â€Å"It is the artful nurse's interactions that can bridge the gap introduced by technology and science, thereby creating integrity and engagement rather than detachment in the personal encounter† (Johnson, 1994). Even when I am not at work, I sub-consciously carry that status with me all the time; and am ready to demonstrate it.For example, at a family gathering, if someone asks me a health-related question, I not only provide the scientific answer and explanation in simple language, but will also give him or her health teaching related to that question in a caring, compassionate way. I can relate carrying this status with me just like how celebrities carry the glamorous status with them all the time and, how they are always ready to face the camera. Therefore, for me, nursing is a status that can only be maintained by the right combination of science and art.It is important to me that nursing is identified as an honorable and essential profession. I believe that nursing is a status that reflects the two equally important parts of nursing knowledge: Empirical knowledge and Esthetical knowledge. â€Å"It is the artful nurse's interactions that can bridge the gap introduced by technology and science, thereby creating integrity and engagement rather than detachment in the personal encounter† (Johnson, 1994). Even when I am not at work, I sub-consciously carry that status with me all the time; and am ready to demonstrate it.For example, at a family gathering, if someone asks me a health-related question, I not only provide the scientific answer and explanation in simple language, but will also give him or her health teaching related to that question in a caring, compassionate way. I can relate carrying this status with me just like how celebrities carry the glamorous status with them all the time and, how they are always ready to face the camera. Therefore, for me, nursing is a status that can only be maintained by the right combination of science and art.

Analysis of the Process Description of the Property Assignment

Analysis of the Process Description of the Property - Assignment Example   Demand for inspection is required to comply with Form 24 of the Appendix to the Federal Rules of Civil Procedure. (Federal Rules of Civil Procedure) A motion is an application to a court for relief, guidance, protection or assistance and can be made either orally or in writing at any time during a trial. However, if a motion is an originating process it must be made in writing. By its very definition and nature, a motion contains four relevant parts despite the fact that there is no real statutory provision mandating these four requisite parts. (Blanchard, p. 463) The most obvious part of the motion begins with a statement of the relief or assistance and the actual order the party moving the courts wishes to obtain by way of the motion. This part of the motion should be followed by a statement of the legal authority for which the application by way of motion can be made. The legal authority is typically contained in the Rules of Civil Procedure. For example, the applicant can make a motion to dismiss on the grounds that the complainant fails properly state a claim contrary to Rule 12 of the Federal Rules of Civil Procedure. (Blanchard, p. 464) The third part of the motion will usually state the grounds upon which the applicant is moving the court as well as the court’s authority to entertain the motion. The grounds relied upon are no more than the reasons for making the application and the court’s authority to grant the relief based upon the reasons stated. The fourth and final part of the motion will provide the court with the e vidence giving rise to the grounds for the motion. This evidence will consist of relevant affidavits and exhibits. (Blanchard, p. 463)   

Genetic Health information Critical thinking questions Assignment - 1

Genetic Health information Critical thinking questions - Assignment Example 4). The genetic code found in our DNA, has many potential insights for individual resistances and susceptibilities to diseases. The HGP is quite distinct from other biomedical research because it has been defined by a series of very quantifiable and concrete goals. For example, it has been used to construct physical and genetic maps. These maps have been used as vital research tools and have proved to be invaluable in determining more than 100 genes involved in diseases such as achondroplasia, breast cancer, colon cancer, and Huntington disease. HGP has simplified the human genetic code as well as animals and plants in a four-letter alphabet. These chemical constituents of each DNA molecule are A (adenine), C (cytosine), G (guanine) and T (thymine). The project has been able to explain that there are 23 pairs of chromosomes in each human cell, and each contains millions of these nucleotides. Through the project, it has been proved that there are 3 billion nucleotides. Studies on these chromosomes have been used clinically to explain to expectant mothers if they are going to give birth to a baby boy or girl. HGP has led to improved techniques of genetic screening for various diseases before birth. A genetic library has been created. This library contains genetic information of relatively homogeneous regions in human DNA. Therefore, individuals do not have considerable variability at this locus. If it is found out that a genetic disease is produced from a specific allele or mutation being present, screening can be done to identify who the individuals are. It is now possible to determine the chances that a child might inherit genetic disorders associated with parents by analyzing the parental gamete DNA. This has allowed genetic disorders to be corrected before birth. Research is also being carried on rapid selection and insertion of DNA into human individuals; these may soon lead to reproduction

Strategic Management Essay Example | Topics and Well Written Essays - 1500 words

Strategic Management - Essay Example Why is it this so? It is clear that the globalization of markets has led to a paradigm shift in how organizations-and especially multinationals-conduct their business operations. The deregulation of national and regional markets has led to eradication of bottlenecks to cross border trade leading to increased competition for the vast and diverse, global markets. Porter’s competitive model was build based on the prevailing economic conditions of the eighties. It assumed the classical perfect market conditions of intense competition and a relatively stable market structure that is subject to cyclical developments. Therefore, by design, this model loses significance in the modern global market. Modern global business is characterized by dynamic markets where industries have complex and multiple relations and product groups (Have, 2003). The upsurge of internet technology and e-business platforms has meant that the effectiveness of the model is in providing a still image of the ind ustry. This is as opposed to providing holistic projections of future trends and developments that can be ably translate into strategy for the particular market segment. The model assumes the idea of competition based on a need for profitability and market survival only loses relevance in modern markets. It wrongly approaches some of the five factors i.e. suppliers and customers as a threat to the organization that needs to be addressed. Modern economics postulate that business strategies should be focused in incorporating, as opposed to reacting to these particular factors (Miles, 2011). The Boston Consulting Group (BCG) matrix was developed with a focus on the efficient allocation of resources within business enterprises. It adopts an evaluative criteria based on two prime factors i.e. market share and market growth has been widely used as a tool for portfolio planning, marketing and business strategy development. The basic principle in risk management is in diversification of ass ets through portfolio investments. The BCG model provides a useful pictorial comparison of the firm and its products versus the leading competitor and its products in the same market. The model, therefore, becomes a critical tool for implementing a firm’s short to medium-term profitability and growth objectives by providing forecast solutions of the market as it is now and as expected in the near future. In the short-run, the model is capable of providing strategies that are designed to provide quick-fix solutions to a firm. The disposal and optimization of loss making assets or ventures can be easily identified using this model. On the down side, the model, the model’s application is often limited to a scope of a year. The model lacks the ability to provide a long-term picture of the market conditions and thus strategy development towards achieving the firm’s overall long-term goals becomes very challenging. The BCG assumes a direct relationship between market shares, seems irrelevant in the current global market. There are small businesses in the small market segments especially within the information technology segment that have surpassed even the largest multinational corporations in profitability (Kaplan & Norton, 2000). The model also places an inaccurate reliance in market growth as a dominant factor in determine the attractiveness of a market segment. There are other factors such as aggregate market risk and regulation that equally influence

Were the Puritans Puritanical (Carl Degler) Essay

Were the Puritans Puritanical (Carl Degler) - Essay Example believed it would anger God if one dressed differently to their station in life; it would be like lying to God to dress extravagantly when one was a member of a lower class. Many of the people who were in the upper-class of Puritans could and would wear gold, silver, and lace. Whilst this is true, most of the other restrictions on dress were to preserve the modesty of the wearer, although it was not as dull, plain and conservative as the stereotype. Women were expected to cover their head and most of their body. As previously mentioned, the Puritans placed a great value on the pure things in life, and part of this belief was an understanding of the Bible as more-or-less literal. In this case, they believed that man should not have too much fun, enjoyment or laughter in this life in case it hinder his ability to experience these things in the next, and sex was part of this. Sex was part of this, but it did not mean that sex was banned in society. The Puritans knew that people of both genders have sexual desires, and they also knew that these needed to be fulfilled. All the Puritans asked was that sexual intercourse be undertaken prayerfully with recognition that it is God that has bestowed these pleasures on them. However, it is worth noting that they did believe in having sex with respect and not enjoying it to excess. The central view of human nature in the Puritan faith is that it is prone to sin and this is an inescapable factor of life. Everything that comes from the body is sinful or disgusting. They believed that because of this tendency to sin, they must be controlled by a strong hand that helped them to curtail these sinful lusts and become more like God and live a purer life. The reason that they broke off from the English church is that they believed that this was corrupt, and they needed to escape this to try and counterbalance some of the things that human nature provoked. In life, the Puritans were expected to avoid sin as much as possible and

Concert Report Essay Example | Topics and Well Written Essays - 500 words - 8

Concert Report - Essay Example In readiness for the concert, I enjoyed a special dinner prepared for the audience. More specifically, LA Phil staffer introduced us to the evening classical concert amidst cheers from the audience. It was such a refreshing and joyous feeling to be part of this audience. The pianist and concert conductor, Christian Zacharias opened the Los Angeles Philharmonic Classical Music concert with a fascinating performance that left the audience in party mood and in happy feelings. The conductor manifested his creativity and perfection in playing neo-classical Danses concertantes to the enjoyment of the audience that kept their clapping and cheers for the longer part of his performance. The rhythm and the matching beats were resoundingly entertaining and seemingly derived the destined message in a light yet refreshing tone. The Concertmaster who played the Bach violin with immense energy and fun derived a sweet feeling as the audience enjoyed every tone, beat, and the rhythmic movement of his body. Indeed, Martin Chalifour left the audience craving for more of artistic expertise despite playing numerous sets of refreshing music. At some point, the band sought to remember the depressing feelings that Robert Schumann felt during their performance. This led to a sad feeling as the audience identified with the band’s expression of Schumann’s sad encounters. Nevertheless, Christian Zacharias led the band in clear beats, swift body movement, and rhythmic music flow to the amazement of the audience, which exhibited deep feelings towards the message communicated by the performers. Furthermore, the Walt Disney Concert Hall offered a resounding bass response, which completed a sweet tonal variation with the joyous violin. As such, I was able to identify and enjoy every tone, beat, and rhythms from the performers. However, at some point, the resounding bass response led to a booming sound, which disturbed my hearing thus creating a disturbing feeling. At the same time,

Paper 2 Essay Example | Topics and Well Written Essays - 1250 words - 1

Paper 2 - Essay Example For instance, Lauren Slater’s Metaphorical Memoir ‘Lying’, she chronicles her youth, how she struggled with epilepsy until she was cured through psychotherapy and medication; however, Slater also narrates how, when after being diagnosed with epilepsy, she developed the irresistible compulsion to lie. On the other hand, in her Autobiographical Memoir titled â€Å"The Kiss†, Kathryn Harrison reveals how, due toan unhealthy relationship with her mother, she became a victim of an incestuous relationship with her father. In this respect, we can posit that both Slater and Harrison had devised alternative ways of seeking attention to fill the emptiness from being neglected while growing up- compulsive lying and incestuous relationship respectively. Lauren Slater’s metaphorical memoir ‘Lying’ is an outright lie right from the title where she boldly and loudly announces that the contents of the book do not represent a true account of her life. As if that is not enough, Lauren Slater advertently imposes upon the reader a need to redraw the lines between factual truth and metaphorical truths; she achieves this by cunningly confusing facts and fiction throughout the book thus undermining the very essence of a memoir, which naturally is supposed to be a true account of events in one’s life. ... uring her adolescence, Lauren too begins lying, stealing and faking seizures as alternative ways of seeking attention from the people around her; this shows how neglected she was and how desperately she craved for the much needed attention. Later in her life, Slater begins an affair with a married man who was much older than she was but the relationship ends badly; Slater resorts to attending Alcoholics Anonymous sessions even though she was not alcoholic. However, Slater tells her story with so much conviction that even when she later confesses that she was not an alcoholic, everyone dismisses her true story as denial (Slater 207). The interplay between literal/factual with the Metaphorical/fictional is heightened even further when Slater suggests that epilepsy affects the memory thus, by confusing her emotional memory and factual memory, Slater raises concerns about the fundamental assumptions of the Memoir genre and all narrative self-disclosure. Kathryn Harrison develops an inces tuous relationship with her father as a way of courting the much needed attention due to her being neglected by her mother while growing up. In her autobiographical novel, â€Å"The Kiss†, Harrison reveals how her distant father figure coupled with the unhealthy relationship with her mother translates into a four-year incestuous affair; growing up, Harrison had close to no clue of her father until she recreates him in her own mind as someone bigger, faster and stronger than all other dads do. Harrison is raised by her grandparents because her parents divorced when she was only six months old (Harrison 5); her father appears ghostly, almost mythical because she is not allowed to discuss or talk about him. This causes the young Harrison to become extremely curious about her absent father, the

How terrorism affect our economy Essay Example for Free

How terrorism affect our economy Essay Terrorism and terrorist activates are never intended to target an economy directly, instead it is designed to scare people who, overwhelmed by there trepidation destroy there own economy. The pliant economy of United States was misjudged in contrast with the September 11 terrorist attacks. Despite an estimated $120 billion of damage and a great deal of anxiety, one year following the 9/11 attacks considerable recovery was recorded in U. S economy. A disagreement between the Economists world wide has been shaping up over the affects of terrorism on the economy of USA, many feel that because acts of terrorism are usually aimed towards small portions of the stock of capital of a country so effect on economic activity are not very large(Enders and Sandler 2006). On the other hand, consciences of terrorism on the economy under pragmatic estimation suggest large and long term affects (Terrorism and the World Economy 40). If we review the federal budgets between FY 1998 and FY 2001 $ 48. 3 billion where available in surplus. Attacks of September 11 originated a blow to the economy of Manhattan, but not to that of Boston or Chicago. Terrorism creates a pessimistic affect on industries like air travel, hotels and insurance at large, but if we review economys overall performance, investment and demand shifted to other industries-especially when Federal Reserve eased credit in order to calm post-Sept. 11 markets. The immediate and the fore most impact that originate due to terrorism is the development of Paranoia attitude towards the economy through restrictive air travel and raising uncertainty, economy is drifting into a phase of recession. U. S economy has been diminishing even further after U. S invasion in Afghanistan and Iraq. Another way terrorism affected our economy is the lift in oil price which proved to be an economic jolt over the American nation who is now linking this oil situation with the upcoming elections and political agenda of American presidential candidates. The most direct damage that terrorism brought to our financial system is the deficit of U. S. government budget, which was a record of 413 billion dollars in 2004. A slight drop of $198 billion in deficit is being predicted by CBO for FY 2009 which is expected to increase moderately by 2010. If we analyze the reports released by CBO we will realize the shocking increase in the expenditure of war on terrorism over the last few years, federal finances for the department of home land security, and ever mounting cost of government beneficial social sachems such as medical health care and social security has halted economical development. Economists are predicting an inevitable increase in red ink taxation; this is resulting in an increasing cost of housing and other basic amenities which is ultimately decreasing the consumption power of an American. (CBO) Terrorism creates a general sense of insecurity, this brings a huge expanse on U. S federal budget in shape of home land security dept, Congressional Budget Office (CBO) estimates that federal resources devoted to homeland security activities were a total of about $41 billion in 2004, roughly double the amount allocated to those activities before September 11, By 2007 Spending for the Department of Homeland Security increased by about 6 percent, to $42. 7 billion this money was required to further strengthen the borders and aviation security. General Seance of insecurity also slowed the pace of economic growth in 2007; economists strongly feel that it will slacken further in 2008. According to CBO, the consistent problems in the housing and financial markets and the high price of oil has curbed spending on household and businesses this is also ensuing decrease in the growth of GDP. Laws and policies developed to control terrorism has overwrought federal resources to a total of $2. 9 trillion for 2008, while the revenue will total $2.7 trillion, which will result in budget deficit of $219 billion, this situation will be worsening with the additional $30 billion required to sustain military activates in Iraq and Afghanistan. (CBO 10) As a consequence American nation is facing a decline in funds allocation for national health dept, education, and Environment protection, the 2007 financial budget favored spending on defense which brought an overall decline in resources allocated for developing U. S social welfare programs Another worrying line of attack in which terrorism is affecting U. S economy is the current decline of the U. S dollar. By 2007, an 8% decline was recorded in U. S dollars performance in index compared to its six largest trading partners. According to the predictions made by Stephen Malyon, (a currency strategist at Scotia Capital in Toronto) the current weakness in dollar should persist for the first two quarters of the current financial year, while a rise of $1. 55 in Euro against dollar was also anticipated by him. (Ellis 2008) Terrorism creates an anxiety in the midst of American people who quite frequently hear about terrorist threats and the on going war on terrorism, while a general sense of insecurity has detained the business community, and this has created a lack of confidence among the main stream investors. Terrorism has also put the burden of humongous expense that the nation had to face in shape of Dept of home land security, ever since Sept 11, while this dept controls almost all issues related to national security and U. S intelligence, an increase in the federal resources and funds devoted towards this department, and as a consequence every year a considerable decline is recorded in social benefits such as education and national health care. Other affects of terrorism on American economy at large are the red ink taxes, increase in oil cost and the decline in dollar value; all of this is contributing towards decreasing the purchase power of an average American. Economists worldwide agree that the negative aspects and the decline in U. S economy is the cost that USA is paying for the war on terrorism. More over a large number of political economical analyst feel that the issue of terrorism is being propagated by the American presidential candidates in there political agendas which is a major cause of nervousness among the nation. Many argue today about United States aggressive strategy to counter terrorism has been a mistake and think that a defensive strategy would have been a more appropriate choice in terms of the affects of terrorism on U. S economy. Work Cited; †¢ Enders Walter and Todd Sandler. The Political Economy of Terrorism. 1st ed. Cambridge, England: Cambridge University, 2006. †¢ Abadie, Gardeazabal. Terrorism and the World Economy. (2007): 40. †¢ Orszag, Peter R. United States, CBO. The Budget and Economic Outlook:Fiscal Years 2008-2017. Washington, DC: CBO, 2007. †¢ Ellis, David. Dollars slide. Its the economy, stupid (2008 )

Internationalization Strategies: European Car Makers

Internationalization Strategies: European Car Makers The Automobile industry is one of the truly most global industries in the world today. The automobile has changed the lives, culture, and economy of the people and nations that manufacture and demand them. Ever since the late 1800s when the first modern car was invented by Benz and Daimler in Germany, the industry has grown into a billion dollar industry affecting so many aspects of our lives. It covers a global community catering needs which may be common among the entire community or specific to a particular community. Its challenging for the Managers and their companies to develop a strategy that outrun their competitors and serve their global customer base. Automotive Industry in Europe at a Glance The automotive industry is a major industry in the European economy involving a few vehicle manufacturing firms and about 2/3 of the production is outsourced to a substantial number of independent suppliers. The produce includes cars, light trucks and vans, buses and coaches, medium and heavy trucks, motorcycles and agricultural and forestry tractors. A lot of mergers and acquisitions have been the routine of the automotive industry. Currently DaimlerChrysler, Volkswagen (VW), BMW, Ford Europe, General Motors (GM) Europe, Renault, PSA (Peugeot-Citroà «n), Fiat and Porsche comprise the main EU car industry. Beside them, there are a good number of small manufacturers apart from some Japanese manufacturers production facilities in the EU. The Internationalization strategies by European car makers The car industry as a whole is much internationalised as it is easy to do business in different parts of the world. To an extent, a lot of multinational corporations of the industry are heavily based in their domestic markets for several reasons, such as cheaper labour and creating jobs for the local inhabitants. When it comes to sales, the industry is perhaps more global, for example in the USA, one of the top three leading cars Toyota is a Japanese company that has much of its production facilities and technical development in Japan but according to Data monitor- industry profile. The internationalisation of the industry has a long history as the car industry itself is old and prolific. The American car industry is said to date back to 1908 when the first automobile was built. Internationalisation is slightly older and has been linked with the ending of world war two for the majority of developed countries; however it is a fairly newer concept in emerging markets. Institutional differences are apparent as many companies entered emerging markets, such as Ford, an American manufacturer, entered many emerging markets such as the Japanese and Chinese. There are still trade barriers in many parts of the world but not many affect the selling of cars. The speed of internationalisation depends on the country where the car originates. In more economically developed countries it makes sense that the speed of internalisation is fast and furious, for example many countries aspire to live life in the American lifestyle, therefore the sale of American cars in emerging markets occurs at a faster rate than the other way round. Although recent events suggest this is no longer true, as now Japanese cars are outselling American cars in the USA industry. Japanese internationalisation occurred at a slower rate at first but then it took off as soon as other continents industries slowed and so Japan were able to capitalise. Volkswagen- volume and diversity model (Boyer and Freyssenet, 1999) Toyota- Profit Strategy (Keeping the total cost low, no matter in what market they are operating) Honda practiced Profit Strategy based on innovation and flexibility. Producing models with distinct features and launching them quickly before the competitors could copy them Companies such as GM and Fiat have reactivated a strategy based on volume and diversity by increasing the commonalisation of platforms; by re-engineering their equipment-making subsidiaries in such a way as to regain control over the value chain; and by developing employee polyvalence. PSA tried to implement a strategy based on the permanent reduction, irrespective of output, of costs, but the French group had to abandon this orientation when its employees took industrial action, and it has reverted to its previous emphasis on volume and diversity. Ford, which had pursued the same line, shifted towards a volume based strategy, and tried to design and sell world cars, each of which with its own platform. Chrysler was at first unclear about the direction to take, but then made the decision to modify its profit strategy so as to emphasise innovation and flexibility .For Renault and Rover, quality became the top priority and each firm has tried to upgrade its market presence, repositioning itself in its segments top half. Renault subsequently focused on innovation, but has progressively discovered that such an approach would require the complete re-organisation of its corporate structures. (Boyer and Freyssenet, 1999) Geographical characteristics of Internationalisation About 20 yrs back one can argue that the automobile industry was just concentrated in U.S, Europe and Japan. But Due Globalisation and aggressive Internationalisation strategies used the manufactures, the market is moving towards the developing the economies. Due to recession and saturated market in U.S and Japan the more sales are happening in the developing economies. Within the EU the top five Automobile producing countries are Germany, France, Italy, Spain and U.K and in the world the top five are Japan, U.S, China, Germany and France. The European market is the largest markets in terms of production (33%) followed by Japan (20%). Though ACEA 2010 reports states that China will soon overtake Japan and the U.S in terms of Production and sales of Automobiles. The stats also shows that big markets that once accounted for most of the production and sales are now saturated and diminishing. Manufactures has now moved into the emerging economies to reap the high growth rate and economic conditions prevailing in many of these economies. An e.g. for this is the growing number of production and assembly plants in countries like Brazil, China, India, Mexico, South- Korea, Poland. Entry strategies by European carmakers The European drive into central Europe has been spearheaded by Volkswagen and Fiat, both of whom see the region as a vital part of their global strategies, even if managerial resources are being strained in an effort to obtain a return on investment. Eastern Europes market can be split into two distinct areas: the Central European Free Trade Area (CEFTA) consisting of Poland, the Czech Republic, Hungary, Slovenia and Slovakia and the rest. Naturally, it is the former that is attracting Western attention, especially as sales in the CEFTA are running at around 600,000 per annum and are likely to rise at 10 per cent a year for several years to come, with VW and Fiat each commanding 25 per cent of the market. Fiats main interest lies in Fiat Auto Poland which it acquired in 1992 through its purchase of Fabryka Samochodow Malolitrazowich (FSM) and since then has exported 50 per cent of output to Western European markets. At the time of purchase FSM was riddled with the inefficiencies comm only found in state-owned automakers in Central and Eastern Europe, but Fiat pledged to invest $2 billion in Poland by the year 2000, and part of this at the time of writing is being used to finance production of its Palio models which it hopes to sell worldwide. Turning to Russia, Fiat in 1997 embarked on an $850 million project with ZAO Nizhegorod Motors, owned by GAZ of Nizhy Novgorod to produce 150,000 Palio units a year. Fiat and ZAO each have 40 per cent of the equity with the remaining 20 per cent funded by the European Bank for Reconstruction and Development (JustAuto.co. 2000; Automotive News, 1996b). Volkswagen holdings in the East are due to its acquisition of Skoda and the taking over of former Trabant plants in the former East Germany. VW has already diversified and modernised Skodas model range and will use these to drive into emerging markets in the area, including Russia, Poland and Belarus. Despite the workforce being well educated and skilled, VW did not always find it easy to persuade Eastern workers to adapt to Western production methods and this is best illustrated in its former Trabant plant at Zwickau. The plant was modernised to produce the Polo and Golf models, but workers experienced severe cultural difficulties in adjusting to modern production methods despite being given extensive training. Building a Trabant involved considerable physical effort just to get the body parts to fit together and this gave a sense of achievement for the workers. Though modern technology and lean production methods removed the physical effort, it also took away the sense of pride and it took VW a considerable time to persuade the workforce of the virtues of modern technology. Nevertheless, both Fiat and VW are firmly installed in Eastern Europe and are about to be joined by Renault which has signed an agreement joining forces with the Moscow City Authorities to build cars in an old Moskvich plant. Of the European producers, VW and Fiat are clearly the most dominant in Eastern Europe and, provided resources are not overstretched, will probably gather a considerable harvest in the future compared to their rivals. But the European arms of both Ford and GM are moving in the same direction, too. Besides being established in Belarus and Poland, Ford has formed a joint venture with Bankirski Dom, near St Petersburg and GM have entered into a similar arrangement with AvtoVAZ at Togliatti, 1,000 kilometres south east of Moscow (Automotive News, 1996b). Finally, stretching beyond the frontiers of Eastern Europe, European firms are currently attempting to establish themselves in China. It was Peugeot that made the initial running when, in the early 1980s, it formed a joint venture in Guangzhou to produce its 404 and 505 models. Neither vehicle was suited to the Chinese market. They were too large, unsuitable for the roads and considered old fashioned by the Chinese when compared to other Western models. In the end, no more than 20,000 units were produced in any one year, and in 1998 Peugeot were forced to withdraw from the market. As Peugeot withered in the market, its other arm, Citroen, prospered in a new joint venture at Wuhan where a stripped down version of the ZX is produced in approximately 15,000 to 20,000 units per annum, a figure that will rise sharply in the coming years (Donnelly and Morris, 1997). Volkswagen by contrast have been far more successful in its joint ventures with the Shanghai Automobile Industrial Corporatio n and the First Auto Works at Changchun in Jilinn Province in the north east of the country. Since the mid-1980s, VW has produced its Santana model in China with frequent updating and has recently introduced its more modern Jetta, Passat and Bora models. These ventures have proved successful in that VW have roughly 50 per cent of the taxi market in China, but have yet to obtain any return on their capital as they, like other multinationals in other countries, have discovered the Chinese market is no crock of gold (Donnelly and Morris, 1997, JustAuto.co., 2000c). While other European firms such as Mercedes and Renault have signed declarations of intent with the Chinese and are waiting to see how the market develops, both Ford and GM have moved further down the road and have begun production at Changan and Guangzhou respectively. Similarly, Chinese hostility to Japanese producers has waned and both Suzuki and Toyota have begun to compete in the market. Current opinion is that the Chin ese market will grow steadily in the coming century and that it is better to enter this market in its infancy than to hesitate. The ball is firmly in the European court and firms must either gamble now on the prospects of return in the future or they might be too late. An outline of the main foreign market entry modes and An overview of the enterprise structures and controls used by firms Ford of Europe was founded in 1967 on a merger between the British and German divisions of the Ford Motor company. Founded in Detroit, Mich., in 1903 by Henry Ford and a group of investors, the company introduced the hugely successful Model T in 1908 and by 1923 was producing more than half of all U.S. automotive vehicles. Through the Lincoln Motor Co. (acquired in 1922), Ford produced luxury Lincolns and Continentals. After years of declining sales, the Model T was succeeded by the Model A in 1927; other companies such as General Motors took the opportunity to make serious inroads into Fords dominance. The company was reincorporated in 1919, with Ford and his family acquiring full ownership. Later acquisitions included Aston Martin and the Land Rover brand of sport utility vehicles. Ford also owns a significant share of the Mazda Motor Corp. Because of financial struggles at the beginning of the 21st century, the company sold off Aston Martin in 2007 and both Jaguar and Land Rover i n 2008. However, Ford occasionally outsells Toyota in shorter periods (most recently, during the summer months of 2009). As of 2008, Ford has become the second largest automaker in Europe (only behind Volkswagen), with sales that occasionally exceed those in the United States and large markets in Germany, Italy, and the United Kingdom. ( PaddockTalk). Ford Motor Co bought into China as a quick and low-cost way of entering the market. In contrast to Chrysler and GMs JV approach in China, Ford chose to acquire 20% of Jiangling Motor, a relatively small local auto producer. This helped in establishing their presence much quicker than their competitors and removed most of the barriers their competitors were facing such as management control and conflict. The European drive into central Europe has been spearheaded by Volkswagen and Fiat, both of whom see the region as a vital part of their global strategies, even if managerial resources are being strained in an effort to obtain a return on investment. Eastern Europes market can be split into two distinct areas: the Central European Free Trade Area (CEFTA) consisting of Poland, the Czech Republic, Hungary, Slovenia and Slovakia and the rest. Naturally, it is the former that is attracting Western attention, especially as sales in the CEFTA are running at around 600,000 per annum and are likely to rise at 10 per cent a year for several years to come, with VW and Fiat each commanding 25 per cent of the market. Fiats main interest lies in Fiat Auto Poland which it acquired in 1992 through its purchase of Fabryka Samochodow Malolitrazowich (FSM) and since then has exported 50 per cent of output to Western European markets. At the time of purchase FSM was riddled with the inefficiencies comm only found in state-owned automakers in Central and Eastern Europe, but Fiat pledged to invest $2 billion in Poland by the year 2000, and part of this at the time of writing is being used to finance production of its Palio models which it hopes to sell worldwide. Turning to Russia, Fiat in 1997 embarked on an $850 million project with ZAO Nizhegorod Motors, owned by GAZ of Nizhy Novgorod to produce 150,000 Palio units a year. Fiat and ZAO each have 40 per cent of the equity with the remaining 20 per cent funded by the European Bank for Reconstruction and Development (JustAuto.co. 2000; Automotive News, 1996b). Volkswagen holdings in the East are due to its acquisition of Skoda and the taking over of former Trabant plants in the former East Germany. VW has already diversified and modernised Skodas model range and will use these to drive into emerging markets in the area, including Russia, Poland and Belarus. Despite the workforce being well educated and skilled, VW did not always find it easy to persuade Eastern workers to adapt to Western production methods and this is best illustrated in its former Trabant plant at Zwickau. The plant was modernised to produce the Polo and Golf models, but workers experienced severe cultural difficulties in adjusting to modern production methods despite being given extensive training. Building a Trabant involved considerable physical effort just to get the body parts to fit together and this gave a sense of achievement for the workers. Though modern technology and lean production methods removed the physical effort, it also took away the sense of pride and it took VW a considerable time to persuade the workforce of the virtues of modern technology. Nevertheless, both Fiat and VW are firmly installed in Eastern Europe and are about to be joined by Renault which has signed an agreement joining forces with the Moscow City Authorities to build cars in an old Moskvich plant. Of the European producers, VW and Fiat are clearly the most dominant in Eastern Europe and, provided resources are not overstretched, will probably gather a considerable harvest in the future compared to their rivals. But the European arms of both Ford and GM are moving in the same direction, too. Besides being established in Belarus and Poland, Ford has formed a joint venture with Bankirski Dom, near St Petersburg and GM have entered into a similar arrangement with AvtoVAZ at Togliatti, 1,000 kilometres south east of Moscow (Automotive News, 1996b). Finally, stretching beyond the frontiers of Eastern Europe, European firms are currently attempting to establish themselves in China. It was Peugeot that made the initial running when, in the early 1980s, it formed a joint venture in Guangzhou to produce its 404 and 505 models. Neither vehicle was suited to the Chinese market. They were too large, unsuitable for the roads and considered old fashioned by the Chinese when compared to other Western models. In the end, no more than 20,000 units were produced in any one year, and in 1998 Peugeot were forced to withdraw from the market. As Peugeot withered in the market, its other arm, Citroen, prospered in a new joint venture at Wuhan where a stripped down version of the ZX is produced in approximately 15,000 to 20,000 units per annum, a figure that will rise sharply in the coming years (Donnelly and Morris, 1997). Volkswagen by contrast have been far more successful in its joint ventures with the Shanghai Automobile Industrial Corporatio n and the First Auto Works at Changchun in Jilinn Province in the north east of the country. Since the mid-1980s, VW has produced its Santana model in China with frequent updating and has recently introduced its more modern Jetta, Passat and Bora models. These ventures have proved successful in that VW have roughly 50 per cent of the taxi market in China, but have yet to obtain any return on their capital as they, like other multinationals in other countries, have discovered the Chinese market is no crock of gold (Donnelly and Morris, 1997, JustAuto.co., 2000c). While other European firms such as Mercedes and Renault have signed declarations of intent with the Chinese and are waiting to see how the market develops, both Ford and GM have moved further down the road and have begun production at Changan and Guangzhou respectively. Similarly, Chinese hostility to Japanese producers has waned and both Suzuki and Toyota have begun to compete in the market. Current opinion is that the Chin ese market will grow steadily in the coming century and that it is better to enter this market in its infancy than to hesitate. The ball is firmly in the European court and firms must either gamble now on the prospects of return in the future or they might be too late.

Atmosphere in Macbeth, by Shakespeare

Atmosphere in Macbeth, by Shakespeare The word atmosphere usually means the air around us. When using the word in the sense of a play it means a certain mood around a certain area at a certain time. Tension usually means emotional or mental stress. Act 2 Sc 2 is the climax of tension that has been built up all the way through Act 1. Act 1 is building up to the murder of Duncan and it is a sinister atmosphere because of the tension and atmosphere in the play as a whole. In Act 2 Scene 2 Macbeth has killed the king, Duncan. This decision comes after the witches come to him after the battle in Act 1 Sc 3 and give him the prophecy that he will be King. In the Elizabethan era people were rather superstitious and believed that witches and anything to do with the witches were bad news. So to be seeing them in real life or so they thought was really bad news. Because of the superstitions of the Elizabethan folk, this tends to be a rather evil sight in their eyes. He is further tempted to kill the King when his wife persuades him to do so. He does this with the help of his wife, who has drugged the Kings guards so as to put them to sleep. Going back to the scene, Macbeth kills the King and is very remorseful for what he has done and his power greedy wife tries to remove any thoughts of remorse from his mind. However, in his hastiness to leave the scene of murder, he forgets to smear blood onto the guards daggers but Macbeth didnt want to go back there so his wife goes and does the deed. Meanwhile, Macbeth is hearing sounds and we would think that he is going mad. This is the beginning of many sounds and visions that Macbeth will see and hear. At the beginning of Act 2 Sc 2 tension is created as Lady Macbeth is waiting and nervous, so she has taken a drink and that has given her confidence. She says: That which hath made them drunk hath made me bold. This creates tension because Lady Macbeth is tense and so the audience will also be tense. In this scene the tension is created by the exclamation of Lady Macbeth when she fears that all has gone wrong. This is when she says: Alack! I am afraid they have waked, and tis not done: thattempt and not the deed ¦ This scene creates a sense of tension and suspense because it creates a feeling as to what the consequences of this failed plan will be if not carried out properly. We get to know all the emotions at this point of the character in the scene, Lady Macbeth. The atmosphere is also created by the natural sounds of animals in the night. Lady Macbeth says: I heard the owl scream, and the crickets cry ¦ This creates the sort of atmosphere of suspense as if something is about to happen. She is awaiting the arrival of Macbeth, so obviously shes listening extra hard to try to hear anything going on in Duncans room. The audience would know that this event took place at night, under the cover of darkness. We know this because Lady Macbeth says that she hears the owl scream, and owls only come out at night as they are nocturnal. In this scene, the atmosphere is also created by the silence of the night. We can deduce this from the way Lady Macbeth refers to the way she did not hear a sound when asked by Macbeth, except:  ¦the owl scream, and the crickets cry. The silence leaves the audience in a state of suspense as to what is going to happen next and eagerly awaiting the next course of action the actors will produce on stage. In this scene the tension is created when Macbeth has brought the daggers back with him when he should have left them with the servants. .Lady Macbeth says: Why did you bring these daggers from the place? This creates tension because if Macbeth is seen with the daggers he will be accused straight away of murder. This creates a cliff hanger as it is a race against time to get the daggers away and them back into safety. The tension in the scene is created when Macbeth and Lady Macbeth are having a fast paced conversation. This is said in the conversation: Didst thou not hear a noise? Did you not speak? When? As I descended?. This causes tension because shes trying to establish what happened, however she does this quickly, which shows that there is no time to waste. In this scene, tension is also created when Macbeth starts to hear sounds. We can deduce this from the text when Macbeth says: Methought I heard a voice cry Sleep no more! Macbeth does murder sleep; innocent sleep ¦ This creates tension because people in the Elizabethan era were rather superstitious and would start to think that either the demons have come to get Macbeth, or he has gone mad. Also, the religious people from the Elizabethan era would interpret that Macbeth has murdered eternal sleep. Some people would interpret sleep as rest and when people are resting they are at their most innocent and vulnerable, they have no control over what they say, do or dream. Therefore they would interpret it like Macbeth has murdered innocence and some would interpret it that Macbeth has lost control. In the scene the atmosphere is also created when Lady Macbeth tries to remove any thoughts of remorse from the mind of Macbeth. We can deduce this from when Macbeth says: Macbeth: This is a sorry sight. Lady Macbeth: A foolish thought, to say a sorry sight. We see that Lady Macbeth takes control when she treats Macbeth like a child and puts him in his place. We see that Lady Macbeth has turned from a normal woman, to something cold hearted and cruel. She is turning away from any kind of emotion and creating a cold feeling into the hearts of the Elizabethan audience. In Elizabethan times a woman was considered to be lower than a man in the world order at the time. However, as we see in the play, that Shakespeare has changed the order as Lady Macbeth asks to the demons to be unsexed. We see that, even though that the worlds order at the time put women below men, Lady Macbeth is the one who takes the pivotal role that Macbeth should be taking. Also, tension is created by the way that Macbeth has been so strong and noble, yet after killing the king his bravery and chivalry seems to desert him. We see this in the sentence: Why, worthy thane, you do unbend your noble strength, to think so brainsickly of things This is one of those things that the Elizabethan era could speculate about. Some superstitious people would say that Macbeth has been punished by the gods/demons/angels. Less superstitious people would say that the drain of having to kill someone who you have paid oath of fealty to and thinking about the consequences would drain your bravery out of you. This is one place where Shakespeare has let the audience do the thinking. Finally, tension is also created in the scene when the knocking starts. Whence is that knocking? This creates tension because people in the audience were not expecting it. In conclusion, there are many ways that this scene creates atmosphere and tension and I have only mentioned a few. Shakespeare has created the character of Macbeth in such a way that you dont know whether to be sorry for him or to accuse him. Shakespeare has created the character of Lady Macbeth as a normal woman at first, and then becomes a cruel cold blooded character later on. The Elizabethan audience can decide for themselves if Macbeth is guilty or was persuaded by the witches and his wife Lady Macbeth.

George Orwells 1984 Essay -- Essays Papers

Orwells 1984 1984 as an Anti-Utopian Novel A utopia is an ideal or perfect community. While some writers have created fictional places that embody their ideals societies, other writers have written satires that ridicule existing conditions of society, or anti-utopias, which show possible future societies that are anything but ideal. In 1984 , George Orwell presents a terrifying picture of future as life under the constant surveillance of â€Å"Big Brother.† This book 1984 is an anti-utopian novel. The main character Winston Smith lives in the large political country Oceania, which is eternally at war with one of two huge countries, Eurasia and Eastasia. At any moment all existing records show either that Oceania has always been at war with Eurasia and allied with Eastasia, or that it has always been at war with Eastasia and allied with Eurasia. Winston knows this, because his work at the Ministry of Truth involves the constant correction of news. â€Å"Who controls the past controls the future: who controls the present controls the past,† the party slogan reads. Basically, Winston takes real news and twists it to what â€Å"Big Brother† wants the people to know. In the grim city and terrifying country, where â€Å"Big Brother† is always watching you and the Thought Police can practically read your mind, Winston is a man in great danger for the simple reason that his memory still functions. He knows the party controls people by feeding them lies and taking away their imaginations. The Pa...

An Investigation Into The Effect Of An Electric Current On Copper Sulphate Solution :: GCSE Chemistry Coursework Investigation

An Investigation Into The Effect Of An Electric Current On Copper Sulphate Solution Aim In this experiment my aim is to enforce and develop ideas about the investigation into the effect of an electrical current through copper sulphate solution. Safety - Electricity is dangerous - Aware of coppers sharp edges - Long hair tied back - Use of acids in experiment Diagram 1) Weigh the cathode 2) Set up apparatus below 3) After a minute, remove the copper and shake off the excess copper sulphate solution. Wipe the copper with acetone and waft in the air to remove as much of the solution as possible. 4) Weigh the cathode again and record results. Repeat this procedure for the other currents. The anode does not need to be changed Prediction I predict that as you increase the voltage the mass of the cathode will increase. However much the cathode increases in mass the anode will increase in mass proportionately. I also think that the change in mass will be directly proportional to the charge giving a straight line that passes through the origin. Justification Of Prediction I think the increase of voltage will result in the increased mass of the cathode. This is because the higher the voltage, the more electrons are 'pulled' off the anode therefore more can be deposited onto the cathode resulting in a higher mass. Theoretically as you double the voltage the mass should double giving us a graph, which goes through the origin. Using the equation Cu ² - 2e Cu (s) we know that 1 mole of copper ions requires 2 moles of electrons to produce 1 mole of copper metal. We can also use the equation to predict how much copper should be deposited. The formula is:  ½ x I x T --------- 95600 Next I will show a results table of predicted results, based on the formulas I have given. This will be useful when I have my actual results as I can compare these to what the ideal results should be, and then evaluate whether I have valid results. GRAPH GRAPH Analysis By using the equation, 'Cu ² - 2e’ Cu (s)' and the formula Q = I x T / 95600 we can work out how much copper should have been deposited. An Investigation Into The Effect Of An Electric Current On Copper Sulphate Solution :: GCSE Chemistry Coursework Investigation An Investigation Into The Effect Of An Electric Current On Copper Sulphate Solution Aim In this experiment my aim is to enforce and develop ideas about the investigation into the effect of an electrical current through copper sulphate solution. Safety - Electricity is dangerous - Aware of coppers sharp edges - Long hair tied back - Use of acids in experiment Diagram 1) Weigh the cathode 2) Set up apparatus below 3) After a minute, remove the copper and shake off the excess copper sulphate solution. Wipe the copper with acetone and waft in the air to remove as much of the solution as possible. 4) Weigh the cathode again and record results. Repeat this procedure for the other currents. The anode does not need to be changed Prediction I predict that as you increase the voltage the mass of the cathode will increase. However much the cathode increases in mass the anode will increase in mass proportionately. I also think that the change in mass will be directly proportional to the charge giving a straight line that passes through the origin. Justification Of Prediction I think the increase of voltage will result in the increased mass of the cathode. This is because the higher the voltage, the more electrons are 'pulled' off the anode therefore more can be deposited onto the cathode resulting in a higher mass. Theoretically as you double the voltage the mass should double giving us a graph, which goes through the origin. Using the equation Cu ² - 2e Cu (s) we know that 1 mole of copper ions requires 2 moles of electrons to produce 1 mole of copper metal. We can also use the equation to predict how much copper should be deposited. The formula is:  ½ x I x T --------- 95600 Next I will show a results table of predicted results, based on the formulas I have given. This will be useful when I have my actual results as I can compare these to what the ideal results should be, and then evaluate whether I have valid results. GRAPH GRAPH Analysis By using the equation, 'Cu ² - 2e’ Cu (s)' and the formula Q = I x T / 95600 we can work out how much copper should have been deposited.

Courthouse Visit

After calling the Calendar Department and scheduling my visit for May 7, 2014 at 9 am, went to the Santa Clara County Superior Civil Court on 191 N SST SST, San Jose, CA 951 13. SSL entered the building, was greeted by several court officials wearing badges. Proceeded to empty my pockets, remove my watch and belt and then walked through a metal detector. There's something about putting your belt on in a public setting that is fascinating. The bulletin board indicated that the trial I was to attend was taking place in Department 8 on the third floor of the building. Seed the elevator to get to the third floor and walked through the double doors into the courtroom. The bailiff immediately recognized me as a student. Judge Maureen A Flan was the presiding judge for the trial. Further research for the case showed that the case (#1 JOVANOVICH) was filed on November 2, 2010 by Austria Limited against several different people and entities in the matter of fraud. From ha TTL gathered, both t he plaintiff and defendants were in business together attempting to build a company that specializes in hosting data centers on ships for security purposes.There was a lot of money involved and the plaintiff may or may not have been siphoning money from the company's capital funds. Two witnesses were called to the stand during my visit, Mr.. Kenneth Choc and Ms. Lillian Valued. Each spent a lot of time reviewing exhibits. Mr.. Choc is one of the defendants who owns one of the businesses involved in the case. He was being asked about a lot of different p paperwork he did and emails he sent. Ms. Valued is the Assistant Branch Manager for CitiBank in Saratoga.She reviewed bank statements and wire transfer documents that involved both pa reties. Honestly, it was hard not to fall asleep. I was very uncomfortable sitting for the entire two hours Of questioning. Also felt bad for the attorneys who had to stand awkwardly because they were also trying to lean closer to the microphone so they could be heard. At first, I didn't even think the judge was paying attention. It looked like she was doing her own thing as the witnesses were questioned, but occasionally she would chime in and it was then clear that she was busy taking notes of her own. Hint the biggest upset to me was the lack of gavel usage. Overall, it was a good experience. Not only does a courthouse visit give a person more motivation to keep their nose clean but it was also an eye opener for anyone, like myself, who would like to go into business for themselves. Choose your partners wisely and always keep everything documented. Court Official Interview Name and title of person interviewed: Robert Mencken, J. D. , Attorney at Law How long have you served the courts? Almost 6 years Where did you go to school?Baylor University School of Law What was your most memorable moment on the job? Would say when recently I helped a couple that was being sued get an agree meet from the other side that dropped the case. I t is what they wanted from the beginning Eng, and I was really glad to get it for them. What was your most challenging moment on the job? When had a client lie to me, to which I put my own reputation on the line for, and then found out about the lie (that he had not done drugs, when in fact he had, and he drug test confirmed it).It was a learning experience, which makes me much more care u', but also less trusting. It's both a good thing that it happened, and a shame that it had t o. How has the court system changed in the past few years? In my state it has changed significantly because of tort reform and politics. Tort reform has affected the way that lawyers analyze cases, what cases they take, and who at the future Of the profession is going to be. Politics is always a force Of change where Jud gees are either appointed or elected, because politics ultimately are what get them into office.And the practice of law changes based upon the beliefs of the judges that are info arcing an d interpreting that law. What recommendations would you make to students who want to become De actuated? If you mean students that might want to be lawyers, I would say make sure the tatty really do want that. Observe how lavaÐ’Â »years act and what they do in court. Make sure t hat you want to do all of the things that lawyers do, not just the â€Å"fun† or â€Å"glamorous† ones. And of course, study hard, and make good grades. It makes a huge difference whew n you're applying for law schools.

Traffic Problems

[pic] A research Report on Traffic problems in Big Cities (Islamabad) [pic] By: Aqsa Shahzadi (100827) Basharat Jamil (100811) Kaneez Amna (100869) Sidra Tul Muntaha (100809) Hamza Ashraf (100803) Submitted to: Mr. Naveed Ahsan Business communication BBA-3B [pic] Air University Islamabad [pic] Table of Content Contents Page No 1. Introduction3 1. 1 Core issue:3 1. 2 Purpose:3 1. 3 Scope3 1. 4 Methodology3 1. 4. 1 Findings5 3. Traffic jams in different areas of Islamabad city8 4. Causes of Traffic Problem. 9 5. Solutions to Traffic Problems10 6. Limitations11 7. References11 8. Interview Questions. 12 [pic] 1.INTRODUCTION 1. 1 CORE ISSUE: Our core issue is traffic problems at the entrance areas of Islamabad. Why mostly traffic jams in these area and how traffic is controlled in those areas by the traffic police. 1. 2 PURPOSE: People suffer a lot of problem due to traffic jam. We must give solutions to control traffic and avoid traffic jams. Students, teachers, office workers face prob lems because sometimes due to coming late they miss their meetings and face other problems as well. 1. 3 SCOPE: We are working at the entrance areas of Islamabad i. e. Barakow and Golra. Sometimes due to heavy protocols people face traffic jams.Major traffic jams are at school and office timings. We also face traffic problem on Friday. We will give solutions to the problems to solve this issue. 1. 4 METHODOLOGY: We adopted two types of methodologies which are as follow: 1. Quantitative methodology. 2. Qualitative methodology. [pic] QUANTITATIVE METHODOLOGY: We collect data through questionnaire. Our sample space is 30. We distributed 30 questionnaires among the students of Air University. We collected data from both male and female students. 15 questionnaires were filled by female students and 15 were filled by male students. We will also give the analysis report of our survey. pic] [pic] 1. 4. 1 FINDINGS After survey the responses of male and female students with percentage is give n below: |Â  Q. NO. |QUESTIONS |MALE |FEMALE | | | | YES | NO | YES | NO | |1. |Buses and trucks creating traffic problem. |93. 33% |6. 67% |86. 67% |13. 33% | |2. |Signals helping to control traffic. |86. 67% |13. 33% |93. 3% |6. 67% | |3. |Traffic police performing his duty well. |80. 00% |20. 00% |53. 33% |46. 67% | |4. |Long routes creating a lot of problems. |33. 33% |66. 67% |46. 67% |53. 33% | |5. |Traffic problems are cause of accidents. |80. 00% |20. 00% |93. 33% |6. 67% | |6. |More roads reduce traffic jam. |80. 00% |20. 00% |80. 00% |20. 00% | |7. |Small roads and number of cars are the causes of traffic |100. 00% |0. 00% |80. 0% |20. 00% | | |problems. | | | | | |8. |Are you satisfied from the process of selecting players for |100. 00% |0. 00% |93. 33% |6. 67% | | |different games? | | | | | |9. |More cars due to bank financing are also causes of traffic |60. 00% |40. 00% |66. 67% |33. 33% | | |problem. | | | | | |10. Old cars and trucks are creating traffic problems. |66. 67% |33. 33% |66. 67% |33. 33% | |11. |Lack of traffic sense among people is also a cause of traffic |100. 00% |0. 00% |93. 33% |6. 67% | | |problems. | | | | | |12. |Government is taking steps to avoid traffic jams. |33. 33% |66. 67% |40. 00% |60. 00% | |13. |Government is creating awareness among people about traffic. |33. 33% |66. 7% |33. 33% |66. 67% | |14. |Civil administrations fail to solve traffic problems. |66. 67% |33. 33% |66. 67% |33. 33% | |15. |Non-custom vehicles contributing to increase traffic. |80. 00% |20. 00% |100. 00% |0. 00% | [pic] The following graph is showing the responses of males in Yes/No and also in percentage. [pic] [pic] The following graph is showing the responses of females in Yes/No and also in percentage. [pic] QUALITATIVE METHODOLOGY: We interviewed one of the police officers at Golra.The questions we asked from him are attached at the end of this report. [pic] 3. TRAFFIC JAMS IN DIFFERENT AREAS OF ISLAMABAD CITY [pic] [pic] [pic] [pic] 4. C AUSES OF TRAFFIC PROBLEMS: 1. Small roads for the number of cars and motor cycles. 2. Broken roads in some areas as people don’t like to move from the broken part so traffic increases on rest of the road. 3. More cars due to bank financing. Now everyone can afford a car so more cars are there on the road. 4. Old cars and trucks. Government doesn’t have a clear policy about old cars and trucks. Even 30 years old cars are still running on roads like foxy & Suzuki. . Lack of traffic sense amongst the people. People don’t have traffic sense. Traffic police and media should play their role in creating traffic sense amongst the people. [pic] [pic] 5. SOLUTIONS TO TRAFFIC PROBLEMS: 1. First we have to use more often the public transport. This is the best solution. Also we would recommend to walk a little more or to ride a bicycle. 2. Have a proper public transport system and it is in our hands to reduce the use of our car every day by using public transport. 3. Make th e conditions of roads good, Make more lanes on the road and making alternative routes. 4.Create traffic awareness amongst the people though media and other sources. 5. Traffic problems can be reduced by either increasing road capacity (supply), or by reducing traffic (demand). 6. Different timing of starting and closings of offices and schools to avoid the rush in the morning, afternoon and evening on roads. 7. Make strict laws make them force able through traffic police. Government should put their best efforts to avoid traffic jams and other traffic problems. 8. Old cars should be scrapped and bank financing should be for commercial cars only. [pic] [pic] [pic] 6.LIMITATIONS: 1. Convince Problems. 2. Non availability of traffic police officer. 3. Hard university scheduled. 4. Police officer was not willing to give interview. 7. REFERENCES: ? www. google. com ? www. wikipedia. com ? Police officer [pic] 8. INTERVIEW QUESTIONS. 1. What difficulties do you face in controlling the tra ffic? 2. Do people follow the rules and regulations? 3. Do people cooperate? How is their behavior? 4. How do you manage the traffic when there is a rout? 5. How do you act when there is accident and what are your precautions? 6. Rush hours create a problem for you. How do you manage?

Students will float to the mark you set

Rose's thesis states that â€Å"Students will float to the mark you set. † † Vocational education has aimed at increasing the economic opportunities of students who do not do well in our schools. Some serious programs succeed in doing that, and through exceptional teachers – like Mr. Gross in Horace's Compromise – students learn to develop hypotheses and trouble shoot, reason through a problem, and communicate effectively – the true job skills. The vocational track, however, is most often a place for those who are just not making it, a dumping ground for the disaffected.† Rose attempts to persuade his readers by showing how dysfunctional the vocational students are and how mediocre or unchallenging their studies are. He also persuades the readers by exemplifying the instructor's poor attempts to care about the quality of learning the vocational education students are receiving. His argument is that the instructors are not inventive in their teaching methods and do not work hard at education through use of their imaginations. â€Å"The teachers have no idea of how to engage the imaginations of kids who were at the bottom of the pond.† I agree with Rose's point stating that † You're defined by your school as â€Å"slow†; you're placed in a curriculum that isn't designed to liberate you but to occupy you, or, if you're lucky, train you, though the training is for work the society does not esteem.† This seems to be the norm at all schools. But, I think at all levels, be it high school or college, the instructors teaching these types of programs should be trained to use more imaginative methods of teaching the vocational level students. Obviously, these students each learn at a different pace, but their minds still need to be challenged. They should receive education that stimulates their minds so they do not lose interest. The vocational education system is used as simply as Rose put it, as a â€Å"dumping ground for the disaffected.† I also understand the point Rose made referring to the fact that if a student is trained in a mediocre way he will do nothing but turn into a mediocre student. Resulting in boredom, indifference, tuning out, ignorance, and finally a lack of job skills society deems necessary. I think Rose was correct in the comment â€Å"Champion the average.† Although that is assuming that every vocational student has the courage to rely on his/her own good sense and put the fear behind him or her. Only most of them lack the courage or self-esteem to stand up for themselves, be it only in their own mind. Moreover, many would not take themselves seriously if they did so. Students Will Float to the Mark You Set Mike Rose is a professor in the School of Education at UCLA , earned multiple awards during his career ; Distinguished Research in the Teaching of English, the American Educational Research Association's Distinguished Lectureship, UCLA’s Distinguished Teaching Award, a Guggenheim Fellowship, the Grawemeyer Award in Education, and the Commonwealth Club of California Award for Literary Excellence in Nonfiction. As a child Rose grew up in a poor family in Los Angeles, during his high school years he was placed on vocational classes on accident, by mixed up test scores from another student with the same last name. In the essay â€Å"I Just Wanna Be Average† by Mike Rose, he describes his observations with his students and teachers during his accidentally placed vocational classes, the teachers were showing no interest in teaching and his class mates were not showing any interest in their education, Rose implies in his essay â€Å"The vocational track, however, is most often a place for those who are just not making it, a dumping ground for the disaffected† (Rose 13) Rose shows how the school system has written off students who have potential, his analysis of the school system specifies multiple reasons for the failure of students that go through high school misunderstood from their difficulties learning, it showed that the students were lacking the effort to learn. In Rose’s essay he talks about one of his classmates Ken Harvey, he describes this open conversation in this classroom, the topic was about working hard and being an over achiever, when in it was Harvey’s turn to talk he answered â€Å"I wanna be average†. Ken Harvey’s â€Å"I just wanna be average† quote immediately picked up Rose’s attention! He later goes revealing how this student was gasping for air in their educational environment, as Rose Mentions in the book â€Å"No matter how bad the school, you’re going to encounter notions that don’t fit with the assumption and beliefs that you grew up with- maybe you’ll hear these dissonant notions from teachers, maybe from other students, and maybe you’ll read them† (Mike Rose 14) Since the vocational track is the dumping ground for those students who can’t make it, Harvey was discouraged because in his school he was labeled â€Å"slow†, as that could’ve lowered his morale, Harvey was rotecting himself from the pressure of school by defying himself as a regular person, and it doesn’t help that the fact that the teachers in the vocational track did nothing to help motivate the student. Rose states that ther e was hardly any who worked hard at their education, however Brother Slattery used his stern voice and his weekly quizzes to engage the imagination of those kids who were at the â€Å"bottom of the pond†. One of my academic weak points is algebraic related activity , during my Senior year I was taking a junior math class Algebra 3-4, my first period class that I would get through in the morning, me a morning person? I would show up half asleep, if I stayed awake I was zoning out. The high school that I graduated from had the block schedule system so the classes would have been two hours and thirty minutes long, I dreaded the block schedule system especially when I had Algebra, as furthermore it would feel like an eternity. I’ve spent a good 75% doing something else that would contradict my learning, doodling on my notes or socializing with the people around me. Every time we would learn a new course I tried to give my full attention to the lesson because it would almost be like a fresh start but in the end it would ended up with me not fully understanding the lesson, so a new course would come up this pattern would repeat itself, so I would get a little frustrated every time that would develop. It got to the point where the requirements of the new course would require the information from the previous course to learn it, that’s how I got stuck along with the interest to care anymore. Unfortunately that type of not caring was labeled as â€Å"Senioritis† it happens to every Senior they say, but I wasn’t going to blame it on â€Å"Senioritis† because I have experience that similar uninteresting feeling for my education before my Senior year. I can’t remember the name of my Algebra 3-4 teacher but I do remember a friend that I made there who sat next to me, his name was Adam he seemed very brilliant and strong academically but he wasn’t so good with the ladies. My algebra teacher never took the time to grade our homework, what she would do was make the student plus the person sitting next to you grade each other’s homework, she would put out the answers on her white board, as she would expect every student to grade the other students homework. Adam and I had an alliance with each other, as we took advantage of that situation, I would scratch his back and he would scratch mine by writing the correct answers down or just filling out the homework right there, sometimes I didn’t even take the time to do my homework I would let Adam fill out the paper for me. Adam continued to perfectly learn in that class he would sometimes end up with one or two mistakes in his homework, but he really wanted straight A’s, I would correct his mistakes for him as he would do the same for me. That homework grading system seemed to me as a huge flaw for her students learning, if she took the time to look at our answers, study our equations that we wrote down she could’ve traced the mistake, point it out, ask why we messed up and showed us the correct way to solve the problem I think that would’ve helped some people out. So the fourth quarter finally arrives, my Algebra 3-4 grades are on the edge of failing, my counselor advocated that I should stay after school with a tutor, which I hated the fact that I had to stay after school for more math, which the thought in my mind was â€Å"I’m not going to learn anything and just waste time†, that was quite the opposite of what was going to happened, I met a tall man with glasses always seemed full of energy, I think his name was Larry (I can’t remember names). Every day after school I would meet up with Larry in a classroom with a few other kids from every type of different math class ranging from basic math to trigonometry, Larry would sit down and help every single student one by one, he seemed like he was vey content teacher, every time Larry would sit next to me I would actually learn or understand all this gibberish that we call algebra, he would approach me with a different attitude way different compared to my Algebra teacher. Now when I think about that situation I was in, I would sit in my first period class for 2 hours and 30 minutes while having difficulties understanding, but now in my tutoring class I would only sit for 45 minutes and everything seemed clear to me. The situation that those students from Rose’s essay they’re intelligence are not limited, a bad teacher can make school such a frustrating experience student won’t learn much, understanding t a teacher’s teaching style can sometimes not w ork with the students.

Vascular Sounds, Abdominal,

The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal authorities. To the best of our knowledge, these procedures reflect currently accepted practice. Nevertheless, they can’t be considered absolute and universal recommendations. For individual applications, all recommendations must be considered in light of the patient’s clinical condition and, before administration of new or infrequently used drugs, in light of the latest package-insert information. The authors and publisher isclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text.  © 2011 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanic al, photocopy, recording, or otherwise—without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher to instructors hose schools have adopted its accompanying textbook. Printed in China. For information, write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 323, Ambler, PA 19002-2756. Derived from American Gothic, 1930 by Grant Wood. All rights reserved by the estate of Nan Wood Graham/Licensed by VAGA, New York, NY. The publishers have made every effort to obtain permission from the copyright holders to use borrowed material. If any material requiring permission has been overlooked, the publishers will be pleased to make the necessary arrangements at the first opportunity. HAIV020410 Library of Congress Cataloging-in-Publication DataHealth assessment made incredibly visual!. —2nd ed. p. ; cm. —(Incredibly visual) Includes bibliographic al references and index. ISBN 978-1-60547-973-6 (alk. paper) 1. Physical diagnosis—Atlases. 2. Physical diagnosis—Handbooks, manuals, etc. I. Series: Incredibly visual. [DNLM: 1. Nursing Assessment—methods— Atlases. 2. Nursing Assessment—methods— Handbooks. 3. Physical Examination— methods—Atlases. 4. Physical Examination— methods—Handbooks. WY 49 H434 2011] RT48. H448 2011 616. 07'54—dc22 ISBN13 978-1-60547-973-6 ISBN10 1-60547-973-X (alk. paper) 2009049443 Staff Publisher Chris Burghardt Clinical Director Joan M. Robinson, RN, MSNProduct Manager Diane Labus Clinical Project Manager Beverly Ann Tscheschlog, RN, MS Editor Jaime Stockslager Buss, MSPH, ELS Copy Editor Karen Comerford Design Coordinator Joan Wendt Illustrator Bot Roda Associate Manufacturing Manager Beth J. Welsh Editorial Assistants Karen J. Kirk, Jeri O'Shea, Linda K. Ruhf Contents iii A work of art iv Contributors and consultants vi 1 Fund amentals 1 2 Skin, hair, and nails 11 3 Eyes and ears 27 4 Nose, mouth, throat, and neck 49 5 Respiratory system 67 6 Cardiovascular system 87 7 Breasts and axillae 113 8 Gastrointestinal system 127 9 Musculoskeletal system 147 10 Neurologic system 171 1 Genitourinary system 193 Selected references 239 Credits 240 Index 242 12 Pregnancy 213 iv Contributors and consultants I’m so excited to be here today! The gallery is opening its new exhibit, Health Assessment Made Incredibly Visual. best picture outside the norm take note I hear it’s a masterpiece that’s guaranteed to inspire top-notch assessment skills. It’s even more extraordinary than I expected. outside the norm take note v The vividly detailed illustrations and photographs of abnormal findings are definitely â€Å"Outside the norm. † And what chiaroscuro! And I’m certainly going to â€Å"Take note† of this piece. You an tell that it captures lifelike charts that illustrate the correct ways to document assessment findings. If this collection were a movie, it would have â€Å"Best picture† written all over it. The graphic depictions of best assessment practices that appear throughout are unique and innovative. All-in-all, I find this a visually stunning and exciting new work. It has certainly inspired me to master health assessment. best picture vi Contributors and consultants Nancy Berger, RN, MSN, BC, CNE Program Coordinator Middlesex County College Edison, N. J. Marsha L. Conroy, RN, BA, MSN, APN Nurse Educator Indiana Wesleyan University MarionChamberlain College of Nursing Columbus, Ohio Roseanne Hanlon Rafter, RN, MSN, GCNS, BC Director of Nursing Professional Practice Chestnut Hill Hospital Philadelphia, Pa. Dana Reeves, RN, MSN Assistant Professor University of Arkansas—Fort Smith Denise Stefancyk, RN, BSN, CCRC Clinical Specialist University of Massachusetts Medical Center Worcester Allison J. Terry, RN, PhD Director, Center for Nursi ng Alabama Board of Nursing Montgomery Leigh Ann Trujillo, RN, BSN Clinical Educator St. James Hospital and Health Centers Olympia Fields, Ill. Rita M. Wick, RN, BSN Simulation Coordinator Berkshire Health Systems Pittsfield, Mass.Sharon E. Wing, RN, PhD(C), CNL Associate Professor Cleveland (Ohio) State University Lisa Wolf, RN, MS, CMSRN Clinical Educator Mount Carmel West Columbus, Ohio Health history 2 Physical assessment 6 Documentation 9 Vision quest 10 Ready. Action! Health history Interviewing tips To make the most of your patient interview, create an environment in which the patient feels comfortable. Also, use the following techniques to ensure effective communication. Fundamentals  ¦ Provided by the patient, or â€Å"subject†  ¦ Verified only by the patient  ¦ Include statements such as â€Å"My head hurts† or â€Å"I have trouble sleeping† Subjective data Are observed  ¦ Are verifiable  ¦ Include findings such as a red, swollen arm in a pat ient with arm pain Objective data The success of your patient interview depends on effective communication.  Select a quiet, private setting.  Choose terms carefully and avoid using medical jargon.  Speak slowly and clearly.  Use effective communication techniques, such as silence, facilitation, confirmation, reflection, and clarification.  Use open-ended and closed-ended questions as appropriate.  Use appropriate body language.  Confirm patient statements to avoid misunderstanding.  Summarize and conclude with â€Å"Is there anything else?         2 Fundamentals All assessments involve collecting two kinds of data: objective and subjective. The health history gathers subjective data about the patient. Health history 3 Components of a complete health history Biographical data Name __________________________________________ Address ________________________________________ Date of birth ____________________________________ Advance directive explained:  Yes  No Livin g will on chart:  Yes  No Name and phone numbers of next of kin: NAME RELATIONSHIP PHONE # ________________________________________________ ________________________________________________Chief complaint History of present illness ________________________________________________ ________________________________________________ Current medications DRUG AND DOSE FREQUENCY LAST DOSE ________________________________________________ ________________________________________________ Medical history Allergies  Tape  Iodine  Latex  No known allergies  Drug: _________________________________________  Food: _________________________________________  Environmental: _________________________________  Blood reaction: _________________________________  Other: _________________________________________ Childhood illnessesDATE ________________________________________________ ________________________________________________ Previous hospitalizations (Illness, accident or injury, surgery, bl ood transfusion) DATE Health problems Yes No Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blood problem (anemia, sickle cell, clotting, bleeding). . . . Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . Eye problem (cataracts, glaucoma) . . . . . . . . . . . . Heart disease (heart failure, MI, valve disease) Hiatal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney problem . . . . . . . . . . . . . . . . . . . . . . . . . Liver problem . . . . . . . . . . . . . . . . . . . . . . . . . . . Lung problem (asthma, bronchitis, emphysema, pneumonia, TB, shortness of breath) . . . . . . . . . . . . Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thyroid problem . . . . . . . . . . . . . . . . . . . . . . . . . Ulcers (duodenal, peptic). . . . . . . . . . . . . . . . . . . . Psychological disorder . . . . . . . . . . . . . . . . . . . Obstetric history (females) Last menstrual period _____________________________ Gravida __________ Para ___________ Menopause Yes No Psychosocial history Coping strategies _________________________________________________ Feelings of safety ________________________________________________ Social history Smoker No Yes (# packs/day _____ # years ___ ) Alcohol No Yes (type ________ amount/day ___ ) Illicit drug use No Yes (type ____________ ) Religious and cultural observances ________________________________________________ Activities of daily living Diet and exercise regimen _________________________Elimination patterns _______________________________ Sleep patterns ____________________________________ Work and leisure activities _________________________ Use of safety measures (seat belt, bike helmet, sunscreen) ______________________ Health mainten ance history DATE Colonoscopy ____________________________________ Dental examination _______________________________ Eye examination _________________________________ Immunizations ___________________________________ Mammography __________________________________ Family medical history Health problem Yes No Who (parent, grandparent, sibling) Ask about the patient’s family edical history, including history of diabetes or heart disease. Ask about the patient’s feelings of safety to help identify physical, psychological, emotional, and sexual abuse issues. Arthritis . . . . . . . . . . . . Cancer . . . . . . . . . . . . . Diabetes mellitus . . . . . Heart disease (heart failure, MI, valve disease) . . Hypertension . . . . . . . . Stroke . . . . . . . . . . . . . Be sure to include prescription drugs, over-the-counter drugs, herbal preparations, and vitamins and supplements. 4 Fundamentals During the final part of the health history, ask about each body structure and syst em to make sure that important ymptoms weren’t missed. Start at the top of the head and work your way down to the toes. Head Psychological status Neck Endocrine system Breasts and axillae Gastrointestinal system Reproductive system General health Neurologic system Eyes, ears, and nose Mouth and throat Skin, hair, and nails Cardiovascular system Respiratory system Hematologic system Urinary system Musculoskeletal system Review of structures and systems Health history 5 Evaluating a symptom Perform a focused physical examination to quickly determine the severity of the patient’s condition. Take a thorough history. Note GI disorders that can lead to abdominal distention.Thoroughly examine the patient. Observe for abdominal asymmetry. Inspect the skin, auscultate for bowel sounds, percuss and palpate the abdomen, and measure abdominal girth. My stomach gets bloated. Your patient is vague in describing his chief complaint. Using your interviewing skills, you discover his pr oblem is related to abdominal distention. Now what? This flowchart will walk you through what to do next. Take a brief history. Intervene appropriately to stabilize the patient, and notify the doctor immediately. Review your findings to consider possible causes, such as cancer, bladder distention, cirrhosis, heart failure, and astric dilation. After the patient’s condition stabilizes, review your findings to consider possible causes, such as trauma, large-bowel obstruction, mesenteric artery occlusion, and peritonitis. Devise an appropriate care plan. Position the patient comfortably, administer ordered analgesics, and prepare the patient for diagnostic tests. Form a first impression. Does the patient’s condition alert you to an emergency? For example, does he say the bloating developed suddenly? Does he mention that other signs or symptoms occur with it, such as sweating and light-headedness? (Indicators of hypovolemia) Yes NoAsk the patient to identify the symptom th at’s bothering him. Do you have any other signs or symptoms? Evaluate your findings. Are emergency signs or symptoms present, such as abdominal rigidity and abnormal bowel sounds? Yes No 6 Fundamentals Physical assessment  ¦ Cotton balls  ¦ Gloves  ¦ Metric ruler (clear)  ¦ Near-vision and visual acuity charts  ¦ Ophthalmoscope  ¦ Otoscope  ¦ Penlight  ¦ Percussion hammer  ¦ Paper clip  ¦ Scale with height measurement  ¦ Skin calipers  ¦ Specula (nasal and vaginal)  ¦ Sphygmomanometer  ¦ Stethoscope  ¦ Tape measure (cloth or paper)  ¦ Thermometer  ¦ Tuning fork  ¦ Wooden tongue blade Assessment toolsAssemble the necessary tools for the physical assessment. Then perform a general survey to form your initial impression of the patient. Obtain baseline data, including height, weight, and vital signs. This information will direct the rest of your assessment. Measuring blood pressure  ¦ Position your patient with his upper arm at heart level an d his palm turned up.  ¦ Apply the cuff snugly, 1 (2. 5 cm) above the brachial pulse.  ¦ Position the manometer at your eye level.  ¦ Palpate the brachial or radial pulse with your fingertips while inflating the cuff.  ¦ Inflate the cuff to 30 mm Hg above the point where the pulse disappears. Place the bell of your stethoscope over the point where you felt the pulse, as shown in the photo. (Using the bell will help you better hear Korotkoff’s sounds, which indicate pulse. )  ¦ Release the valve slowly and note the point at which Korotkoff’s sounds reappear. The start of the pulse sound indicates the systolic pressure.  ¦ The sounds will become muffled and then disappear. The last Korotkoff’s sound you hear is the diastolic pressure. best picture Got your tools? Good. Let’s get to work! Tips for interpreting vital signs  ¦ Analyze vital signs at the same time. Two or more abnormal values may provide clues to the patient’s problem.For example, a rapid, thready pulse along with low blood pressure may signal shock.  ¦ If you obtain an abnormal value, take the vital sign again to make sure it’s accurate.  ¦ Remember that normal readings vary with the patient’s age. For example, temperature decreases with age, and respiratory rate can increase with age.  ¦ Remember that an abnormal value for one patient may be a normal value for another, which is why baseline values are so important. Physical assessment 7 Physical assessment techniques When you perform the physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation.Use these techniques in this sequence except when you perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. 1 Inspection Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Observe for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system. 2Palpation Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails hort and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. Types of palpation Light palpation  ¦ Use this technique to feel for surface abnormalities.  ¦ Depress the skin 1/2 to 3/4 (1. 5 to 2 cm) with your finger pads, using the lightest touch possible.  ¦ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Deep palpation  ¦ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.  ¦ Depress the skin 11/2 to 2 (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed. 8 Fundamentals 3Percussion Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient’s body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. 4Auscultation Auscultation involves listening for various breath, heart, and bowel sounds with a stethoscope. Types of percussion Direct percussion This technique reveals tenderness; it’s commonly used to assess an adult patient’s sinuses. Here’s how to do it:  ¦ Using one or two fingers, tap irectly on the body part.  ¦ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort. Indirect percussion This technique elicits sounds that give clues to the makeup of the underlying tissue. Here’s how to do it:  ¦ Press the distal part of the middle finger of your nondominant hand firmly on the body part.  ¦ Keep th e rest of your hand off the body surface.  ¦ Flex the wrist of your dominant hand.  ¦ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient’s skin.  ¦ Listen to the sounds produced. Getting ready Provide a quiet environment.  ¦ Make sure the area to be auscultated is exposed. ( Auscultating over a gown or bed linens can interfere with sounds. )  ¦ Warm the stethoscope head in your hand.  ¦ Close your eyes to help focus your attention. How to auscultate  ¦ Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient’s skin, enough to leave a slight ring on the skin afterward.  ¦ Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient’s skin, just enough to form a seal.Holding the bell too firmly causes th e skin to act as a diaphragm, obliterating low-pitched sounds.  ¦ Listen to and try to identify the characteristics of one sound at a time. Documentation 9 Documentation Get to know your stethoscope Your stethoscope should have snug-fitting ear tips, which you’ll position toward your nose. The stethoscope should also have tubing no longer than 15 (38. 1 cm) with an internal diameter not greater than 1/8 (0. 3 cm). It should have both a dia phragm and bell. The parts of a stethoscope are labeled below. Ear tips Binaurals (ear tubes) Tension bar Tubing Bell Stem Diaphragm Headset ChestpieceDocumenting initial assessment findings Here’s an example of how to record your findings on an initial assessment form. take note Name Age _______ Sex ______ Height ________ Weight ________ T ______ P ___ R ___ B/P (R) ____________ (L) _____________ Room _____________________ Admission time ____________ Admission date ____________ Doctor ____________________ Admitting diagnosis: __ _________________________ ___________________________ ___________________________ ___________________________ Patient’s stated reason for hospitalization ______________ ___________________________ ___________________________ Allergies ___________________ __________________________ ___________________________ Current medications ________ Name Dosage Last taken _______________________________ _______________________________ _______________________________ _______________________________ General survey _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Henry Gibson 55 M 163 cm 57 kg 37  C 76 14 150/90 sitting 148/88 sitting 328 0800 4 -28-10 Manzel Pneumonia â€Å"To get rid of the pneumonia† PenicillinCodeine None In no acute distress. Slender, alert, and well-groomed. Communicates well. Make s eye contact and expresses appropriate concern throughout exam. C. Smith, RN General information Identify the assessment technique being used in each illustration. Show and tell Unscramble the words at right to discover terms related to fundamentals of assess ment. Then use the circled letters from those words to answer the question posed. My word! Answers: Show and tell 1. Indirect percussion, 2. Deep palpation; My word! 1. Auscultation, 2. Subjective data, 3. Chief complaint, 4. Palpation; Question: Abdomen 10 1. 2. 1. tunicaastolu 2. ivateacub jest 3. place inchmotif 4. aplaintop Answer: Question: Assessment of which body part does not follow the usual sequence? Anatomy 12 Assessment 14 Skin abnormalities 16 Hair abnormalities 24 Nail abnormalities 25 Vision quest 26 Quiet on the set. The assessment is about to begin. Anatomy 12 Skin, hair, and nails SkinSkin, hair, nails The skin covers and protects the internal structures of the body. It consists of two distinct layers: the ep idermis and the dermis. Subcutaneous tissue lies beneath these layers. Epidermis  ¦ Outer layer  ¦ Made of squamous epithelial tissue Dermis  ¦ Thick, deeper layer  ¦ Consists of connective issue and an extracellular material (matrix), which contributes to the skin’s strength and pliability  ¦ Location of blood vessels, lymphatic vessels, nerves, hair follicles, and sweat and sebaceous glands Subcutaneous tissue  ¦ Beneath dermis and epidermis  ¦ Consists mostly of adipose and other connective tissues Stratum corneum Pore of sweat gland Free nerve ending Eccrine sweat gland Hair bulb Sensory nerve fibers Autonomic nerve fibers Artery Vein Anatomy 13 Hair Hair is formed from keratin produced by matrix cells in the dermal layer of the skin. Each hair lies in a hair follicle. Hair shaft Sebaceous gland Arrector pili muscleHair follicle Sensory nerve fibers Hair bulb  ¦ Contains melanocytes Hair papilla  ¦ Consists of a loop of capillaries  ¦ Provides nourishm ent to hair Nails Nails are formed when epidermal cells are converted into hard plates of keratin. Hyponychium Nail plate Lateral nail fold Lunula Eponychium Nail root Nail matrix Hair bulb Matrix cell  ¦ Produces hair Cuticle cells Inner root sheath Outer root sheath Capillary in hair papilla Melanocyte  ¦ Determines hair color What is the matrix? The area of the dermis on which the nail rests. 14 Skin, hair, and nails Assessment To assess the skin, hair, and nails, use inspection and palpation. SkinObserve the skin’s overall appearance. Then inspect and palpate the skin area by area, focusing on color, moisture, texture, turgor, and temperature. Examine the conjunctivae, palms, soles, buccal mucosa, and tongue. Look for dull, dark color. Examine the area for decreased color and palpate for tightness. Palpate the area for warmth. Examine the sclerae and hard palate in natural, not fluorescent, light if possible. Look for a yellow color. Examine the sclerae, conjunctivae, buccal mucosa, lips, tongue, nail beds, palms, and soles. Look for an ashen color. Examine areas of lighter pigmentation such as the abdomen. Look for tiny, purplish red ots. Palpate the area for skin texture changes. Cyanosis Edema Erythema Jaundice Pallor Petechiae Rashes Color Look for localized areas of bruising, cyanosis, pallor, and erythema. Check for uniformity of color and hypopigmented or hyperpigmented areas. Moisture Observe the skin’s moisture content. The skin should be relatively dry, with a minimal amount of perspiration. Be sure to wear gloves during your examination of the skin, hair, and nails. Detecting color variations in dark-skinned people Assessment 15 Texture and turgor Inspect and palpate the skin’s texture, noting its thickness and mobility. It should look smooth and be intact.To assess skin turgor in an infant, grasp a fold of loosely adherent abdominal skin between your thumb and forefinger and pull the skin taut. Then release the skin. Th e skin should quickly return to its normal position. If the skin remains tented, the infant has poor turgor. Temperature Palpate the skin bilaterally for temperature using the dorsal surface of your hands and fingers. The dorsal surface is the most sensitive to temperature changes. Warm skin suggests normal circulation; cool skin, a possible underlying disorder. Assessing skin turgor in an adult Gently squeeze the skin on the forearm or sternal rea between your thumb and forefinger, as shown. If the skin quickly returns to its original shape, the patient has normal turgor. If it returns to its original shape slowly over 30 seconds or maintains a tented position, as shown, the skin has poor turgor. best picture Normal skin variations You may see normal variations in the skin’s texture and pigmentation. Such variations may include nevi, or moles, and freckles (shown below). 16 Skin, hair, and nails Lesion configurations Discrete Individual lesions are separate and distinct. Gro uped Lesions are clustered together. Dermatomal Lesions form a line or an arch and follow dermatome. Confluent Lesions merge so that discrete lesions are not visible or palpable. Lesion shapes Discoid Round or oval Annular Circular with central clearing Target (bull’s eye) Annular with central internal activity Hair When assessing the hair, note the distribution, quantity, texture, and color. Hair should be evenly distributed. Nails Examine the nails for color, shape, thickness, consistency, and contour. Nail color is pink in light-skinned people and brown in dark-skinned people. The nail surface should be slightly curved or flat and the edges smooth and rounded. Lesions When evaluating a lesion, you’ll need to classify t as primary (new) or secondary (a change in a primary lesion). Then determine if it’s solid or fluid-filled and describe its characteristics, pattern, location, and distribution. Include a description of symmetry, borders, color, configuration, diameter, and drainage. Skin abnormalities I know you’ll have these assessment skills nailed in no time! Lesion distribution Generalized — Distributed all over the body Regionalized — Limited to one area of the body Localized — Sharply limited to a specific area Scattered — Dispersed either densely or widely Exposed areas — Limited to areas exposed to the air or sun Intertriginous — Limited to reas where skin comes in contact with itself Skin abnormalities 17 outside the norm Types of skin lesions Fissure A painful, cracklike lesion of the skin that extends at least into the dermis Cyst A closed sac in or under the skin that contains fluid or semisolid material Papule A solid, raised lesion that’s usually less than 1 cm in diameter Vesicle A small, fluid-filled blister that’s usually 1 cm or less in diameter Bulla A large, fluid-filled blister that’s usually 1 cm or more in diameter Ulcer A craterlike lesion of th e skin that usually extends at least into the dermis Macule A small, discolored spot or patch on the skinWheal A raised, reddish area that’s commonly itchy and lasts 24 hours or less Pustule A small, pus-filled lesion (called a follicular pustule if it contains a hair) Nodule A raised lesion detectable by touch that’s usually 1 cm or more in diameter Documenting a skin lesion take note At 0820, pt. c/o right shoulder blade pain, 4/10 on a 0-10 scale. A closed, purulent lesion noted in right upper scapular region of back, approx. 1. 5 cm x 1 cm, with 3 cm surrounding area of erythema. T 100. 2 F. Call placed to Dr. Tomlin’s service at 0830. Angela Kessler, RN 4/15/10 0845 18 Skin, hair, and nails Benign versus cancerous lesionsLesions may be benign, such as a benign nevus, or mole. However, changes in an existing growth on the skin or a new growth that ulcerates or doesn’t heal could indicate cancer or a precancerous lesion. Types of skin cancer outside t he norm  ¦ Abnormal changes in keratinocytes  ¦ Can become squamous cell carcinoma Precancerous actinic keratosis  ¦ Abnormal growth of melanocytes in a mole  ¦ Can become malignant melanoma Dysplastic nevus Note the differences between benign and cancerous lesions.  ¦ Symmetrical, round, or oval shape  ¦ Sharply defined borders  ¦ Uniform, usually tan or brown color  ¦ Less than 6 mm in diameter  ¦ Flat or raisedBenign nevus  ¦ Abnormal changes in keratinocytes  ¦ Can become squamous cell carcinoma  ¦ Abnormal growth of melanocytes in a mole  ¦ Can become malignant melanoma Skin abnormalities 19 More severe Less severe  ¦ Begins as a firm, red nodule or scaly, crusted, flat lesion  ¦ Can spread if not treated Squamous cell carcinoma  ¦ Most common skin cancer  ¦ Usually spreads only locally Basal cell carcinoma  ¦ Can arise on normal skin or from an existing mole  ¦ If not treated promptly, can spread to other areas of skin, lymph nodes, or int ernal organs Malignant melanoma If you suspect a lesion may be malignant melanoma, observe for these haracteristics. memory board ABCDEs of malignant melanoma A = Asymmetrical lesion B = Border irregular C = Color of lesion varies with shades of tan, brown, or black and, possibly, red, blue, or white D = Diameter greater than 6 mm E = Elevated or enlarging lesion 20 Skin, hair, and nails Common skin disorders outside the norm Contact dermatitis is an inflammatory disorder that results from contact with an irritant. Primary lesions include vesicles, large oozing bullae, and red macules that appear at localized areas of redness. These lesions may itch and burn. Contact dermatitis Psoriasis is a chronic disease of marked pidermal thickening. Plaques are symmetrical and generally appear as red bases topped with silvery scales. The lesions, which may connect with one another, occur most commonly on the scalp, elbows, and knees. Psoriasis Occurring as an allergic reaction, urticaria appea rs suddenly as pink, edematous papules or wheals (round elevations of the skin). Itching is intense. The lesions may become large and contain vesicles. Urticaria (hives) Skin abnormalities 21 Mites, which can be picked up from an infested person, burrow under the skin and cause scabies lesions. The lesions appear in a straight or zigzagging line about 3/8 (1 cm) ong with a black dot at the end. Commonly seen between the fingers, at the bend of the elbow and knee, and around the groin, abdomen, or perineal area, scabies lesions itch and may cause a rash. Scabies Herpes zoster appears as a group of vesicles or crusted lesions along a nerve root. The vesicles are usually unilateral and appear mostly on the trunk. These lesions cause pain but not a rash. Herpes zoster Tinea corporis is characterized by round, red, scaly lesions that are accompanied by intense itching. These lesions have slightly raised, red borders consisting of tiny vesicles. Individual rings may connect to form atche s with scalloped edges. They usually appear on exposed areas of the body. Tinea corporis (ringworm) Once I burrow under the skin, I settle down and make myself comfortable. 22 Skin, hair, and nails Pressure ulcers Pressure ulcers are localized areas of skin breakdown that occur as a result of prolonged pressure. Necrotic tissue develops because the vascular supply to the area is diminished. Staging pressure ulcers You can use characteristics gained from your assessment to stage a pressure ulcer, as described here. Staging reflects the anatomic depth of exposed tissue. Keep in mind that if the wound contains necrotic issue, you won’t be able to determine the stage until you can see the wound base. outside the norm Suspected deep tissue injury  ¦ Maroon or purple intact skin or blood-filled blister  ¦ May be painful; mushy, firm, or boggy; and warmer or cooler than other tissue before discoloration occurs Stage I  ¦ Intact skin that doesn’t blanch  ¦ May differ i n color from surrounding area in people with darkly pigmented skin  ¦ Usually over a bony prominence  ¦ May be painful, firm or soft, and warmer or cooler than surrounding tissue Note: This stage shouldn’t be used to describe perineal dermatitis, maceration, tape burns, skin tears, or excoriation.Stage II  ¦ Superficial partial-thickness wound  ¦ Presents as a shallow, open ulcer without slough and with a red and pink wound bed Skin abnormalities 23 Stage III  ¦ Involves full-thickness wound with tissue loss and possibly visible subcutaneous tissue but no exposed muscle, tendon, or bone  ¦ May have slough but not enough to hide the depth of tissue loss  ¦ May be accompanied by undermining and tunneling Stage IV  ¦ Involves full-thickness skin loss, with exposed muscle, bone, and tendon  ¦ May be accompanied by eschar, slough, undermining, and tunneling Unstageable  ¦ Involves full-thickness tissue loss, with base of ulcer covered by slough nd yellow, tan, gray, green, or brown eschar  ¦ Can’t be staged until enough slough and eschar are removed to expose the wound base 24 Skin, hair, and nails Hair abnormalities Typically stemming from other problems, hair abnormalities can cause patients emotional distress. Among the most common hair abnormalities are alopecia and hirsutism. Alopecia occurs more commonly and extensively in men than in women. Diffuse hair loss, though commonly a normal part of aging, may occur as a result of pyrogenic infections, chemical trauma, ingestion of certain drugs, and endocrinopathy and other disorders. Tinea capitis, trauma, and ull-thickness burns can cause patchy hair loss. Alopecia Excessive hairiness in women, or hirsutism, can develop on the body and face, affecting the patient’s selfimage. Localized hirsutism may occur on pigmented nevi. Generalized hirsutism can result from certain drug therapy or from such endocrine problems as Cushing’s syndrome, polycystic ovary syndrome, a nd acromegaly. Hirsutism outside the norm Now â€Å"hair† this: Hair abnormalities may be caused by certain drugs or endocrine problems. Nail abnormalities 25 Nail abnormalities Although many nail abnormalities are harmless, some point to serious underlying problems.Nail abnormalities include clubbed fingers, splinter hemorrhages of the nail bed, and Muehrcke’s lines. outside the norm Splinter hemorrhages are reddish brown narrow streaks under the nails. They run in the same direction as nail growth and are caused by minor trauma. They can also occur in patients with bacterial endocarditis. Splinter hemorrhages Muehrcke's lines or leukonychia striata are longitudinal white lines that can indicate trauma but may also be associated with metabolic stress, which impairs the body from using protein. Muehrcke's lines Clubbed fingers can result from chronic tissue hypoxia. Normally, the angle between the ingernail and the point where the nail enters the skin is about 160 degr ees. Clubbing occurs when that angle increases to 180 degrees or more. Clubbed fingers Normal fingers Normal angle (160 degrees) Clubbed fingers Angle greater than 180 degrees Enlarged and curved nail Answers: Able to label 1. Epidermis, 2. Dermis, 3. Subcutaneous tissue, 4. Hair bulb, 5. Eccrine sweat gland; Rebus riddle The dorsal surface of the hand is most sensitive to temperature changes. 1. 2. 3. 4. 5. Identify the skin structures indicated on this illustration. Sound out each group of pictures and symbols to reveal terms that complete this assessment onsideration. Able to label? Rebus riddle 26 Anatomy 28 Assessment 31 Eye abnormalities 42 Ear abnormalities 46 Vision quest 48 Aye, aye, matey! I best be gettin’ along. They’re filming the eye and ear assessment down on Soundstage 3. 28 Eyes and ears Anatomy EyeEsye and ears The eyes are delicate sensory organs equipped with many extraocular and intraocular structures. Some structures are easily visible, whereas ot hers can only be viewed with special instruments, such as an ophthalmoscope. Extraocular structures The bony orbits protect the eyes from trauma. The eyelids (or pal pebrae), lashes, and lacrimal gland, punctum, canaliculi, and ac protect the eyes from injury, dust, and foreign bodies. Bony orbit Lacrimal gland  ¦ Pars orbitalis  ¦ Pars palpebralis Upper eyelid Lashes Lower eyelid Lacrimal punctum Lacrimal canaliculi Lacrimal sac Nasolacrimal duct Eye muscles Superior oblique muscle Superior rectus muscle Medial rectus muscle Lateral rectus muscle Inferior rectus muscle Inferior oblique muscle Anatomy 29 Intraocular structures The intraocular structures of the eye are directly involved in vision. The eye has three layers of tissue:  ¦ The outermost layer includes the transparent cornea and the sclera, which maintain the form and size of the eyeball. The middle layer includes the choroid, ciliary body, and iris. Pupil size is controlled by involuntary muscles in this region.  ¦ The innermost layer is the retina, which receives visual stimuli and sends them to the brain. Retinal structures: A closer view Superonasal arteriole and vein Optic disk Physiologic cup Arteriole Inferonasal arteriole and vein Vein Superotemporal arteriole and vein Fovea centralis Macular area Inferotemporal arteriole and vein Sclera Choroid Conjunctiva (bulbar) Ciliary body Cornea Lens Pupil Iris Anterior chamber (filled with aqueous humor) Posterior chamber (filled with aqueous humor) Schlemm’s canalVitreous humor Optic nerve Central retinal artery and vein Retina These structures are located in the posterior part of the eye, also called the fundus. They’re visible with an ophthalmoscope. 30 Eyes and ears Ear External ear The flexible external ear consists mainly of elastic cartilage. It contains the ear flap, also known as the auricle or pinna, and the auditory canal. This part of the ear collects and transmits sound to the middle ear. Middle ear The tympanic mem brane separates the external and middle ear. The center, or umbo, is attached to the tip of the long process of the malleus on the other side of the tympanic membrane.The eustachian tube connects the middle ear with the nasopharynx, equalizing air pressure on either side of the tympanic membrane. The middle ear conducts sound vibrations to the inner ear. Inner ear The inner ear consists of closed, fluid-filled spaces within the temporal bone. It contains the bony labyrinth, which includes three connected structures: the vestibule, the semicircular canals, and the cochlea. The inner ear receives vibrations from the middle ear that stimulate nerve impulses. These impulses travel to the brain, and the cerebral cortex interprets the sound. Auditory ossicles  ¦ Stapes (stirrup)  ¦ Incus (anvil) Malleus (hammer) Semicircular canals Vestibule Cochlea Cochlear nerve Eustachian tube Tympanic membrane (eardrum) Helix Anthelix Lobule of auricle External acoustic meatus Assessment 31 Assess ment Eyes Snellen charts The Snellen alphabet chart and the Snellen E chart are used to test distance vision and measure visual acuity. Snellen alphabet chart Snellen E chart Age differences 20 20 In adults and children age 6 and older, normal vision is measured as 20/20. 20 50 For children age 3 and younger, normal vision is 20/50. 20 40 For children age 4, normal vision is 20/40. 20 30 For children age 5, normal vision is 20/30.To measure distance vision: Have the patient sit or stand 20 (6. 1 m) from the chart. Cover his left eye with an opaque object. Ask him to read the letters on one line of the chart and then to move downward to increasingly smaller lines until he can no longer discern all of the letters. Have him repeat the test covering his right eye. Have him read the smallest line he can read with both eyes uncovered to test his binocular vision. If the patient wears corrective lenses, have him repeat the test wearing them. Record the vision with and without correction. Distance vision Recording results Visual acuity is recorded as a fraction.The top number (20) is the distance between the patient and the chart. The bottom number is the lowest line on which the patient correctly identified the majority of the letters. The larger the bottom number, the poorer the patient’s vision. The Snellen E chart is used for young children and adults who can’t read. 32 Eyes and ears Test peripheral vision using confrontation. Confrontation can help identify such abnormalities as homonymous hemianopsia and bitemporal hemianopsia. Here’s how to test confrontation:  ¦ Sit or stand directly across from the patient and have him focus his gaze on your eyes.  ¦ Place your hands on either ide of the patient’s head at the level of his ears so that they’re about 2 apart.  ¦ Tell the patient to focus his gaze on you as you gradually bring your wiggling fingers into his visual field.  ¦ Instruct the patient to tell you as soon as he can see your wiggling fingers; he should see them at the same time you do.  ¦ Repeat the procedure while holding your hands at the superior and inferior positions. Rosenbaum card The Rosenbaum card is used to evaluate near-vision. This small, handheld card has a series of numbers, E’s, X’s, and O’s in graduated sizes. Visual acuity is indicated on the right side of the hart in either distance equivalents or Jaeger equivalents. To measure near-vision: Cover one of the patient’s eyes with an opaque object. Hold the Rosenbaum card 14 (35. 6 cm) from the eyes. Have the patient read the line with the smallest letters he can distinguish. Repeat the test with the other eye. If the patient wears corrective lenses, have him repeat the test while wearing them. Record the visual accommodation with and without corrective lenses. Near-vision Confrontation Does your patient wear glasses or contacts? Remember to test his vision with and without his corrective lens es. Assessment 33 Each upper eyelid hould cover the top quarter of the iris so the eyes look alike. Look for redness, edema, inflammation, or lesions on the lids. Eyelids The corneas should be clear and without lesions and should appear convex. Examining the corneas Examine the corneas by shining a penlight first from both sides and then from straight ahead. Test corneal sensitivity by lightly touching the cornea with a wisp of cotton. The irises should appear flat and should be the same size, color, and shape. Irises Corneas Inspecting the eyes With the scalp line as the starting point, determine whether the eyes are in a normal position. They should be bout one-third of the way down the face and about one eye’s width apart from each other. Then assess the eyelids, corneas, conjunctivae, sclerae, irises, and pupils. 34 Eyes and ears Each pupil should be equal in size, round, and about one-fourth the size of the iris in normal room light. Testing the pupils Slightly darken th e room. Then test the pupils for direct response (reaction of the pupil you’re testing) and consensual response (reaction of the opposite pupil) by holding a penlight about 20 (51 cm) from the patient’s eyes, directing the light at the eye from the side. Next, test accommodation by placing your finger