The Writing Rubric For the Beta Essay

<h1><atitle>The Writing Rubric For the Beta Essay</atitle></h1><p>Writing a conventional exposition is sufficiently troublesome, yet when you include the feared composing rubric for the beta article it will appear to be significantly increasingly troublesome. This guide will clarify a few things about the composing rubric and how to approach composing your beta paper. The motivation behind the rubric is to cause the paper to show up progressively proficient composing consistently requires doing your absolute best. Here are a few things you have to remember before getting started.</p><p></p><p>First of all, the composing rubric isn't intended to annoy you or cause you to feel like you are inept. It's a method of deciding if you can compose the exposition or not. In the event that you follow the rules, it won't be hard for you to pass the composing rubric. It should help you on your capacity to compose a decent exposition, it should decide whether you can. The article should be the as a matter of first importance thing you do when you prepare to apply for college.</p><p></p><p>Grammar is significant when composing a postulation. The paper you compose ought to be right in language structure and accentuation. The general purpose of a composing rubric is to decide how much work you can place into your proposal. The most ideal approach to pass the composing rubric is to improve your composing abilities with the goal that your composing will stream better and all the more easily. At the point when you wind up wandering neither here nor there you are attempting to discuss or when you appear to overlook what it is you were attempting to state, you have to return and read over your composing once more. On the off chance that you can improve your composing aptitudes, at that point you can pass the composing rubric.</p><p></p><p>Good composing isn't as troublesome as you w ould might suspect. The composing rubric isn't a prerequisite so as to compose a successful postulation, yet it can assist you with raising your article to an acceptable level so you can breeze through the assessment. It is significant that you take notes all through the creative cycle and you should ensure that you practice your composing abilities while composing your last draft.</p><p></p><p>No matter what sort of thinking of you need to do, there is a layout that will make your composing increasingly sorted out and cleaned. This is the composing rubric and will decide the style of the paper. The creative cycle and tone that the composing rubric put forward are significant in light of the fact that it will influence the manner in which you wind up composing the exposition. On the off chance that you need to compose an article with a solid feeling of structure then the composing rubric is for you.</p><p></p><p>The exposition you need to compose will rely upon the prerequisites you have for the test. In the event that you are taking the SAT, at that point you have to compose an exposition that will grandstand your capacity to investigate data and have the option to communicate your considerations and thoughts in a legitimate manner. The other sort of keeping in touch with you may need to compose is a postulation that will bolster a logical fact.</p><p></p><p>Each sort of composing has a composing rubric for you to follow. The thinking of you do should be firmly composed with legitimate syntax and accentuation. Continuously put the time and exertion into concentrating how to appropriately compose an exposition provided that you need to get high evaluations on the article that you keep in touch with you have to realize how to sort out your musings. Having a decent comprehension of the kinds of composing will enable you to single out the suitable method to introduce your thoughts and facts.& lt;/p><p></p><p>Writing isn't simple, yet with the correct devices, you can transform any composition into an extraordinary one. You needn't bother with a conventional composing rubric for the beta article, yet you do need to comprehend that composing is a craftsmanship and you should invest a great deal of energy into your composing aptitudes. In the event that you need to traverse school, at that point you have to concentrate on your composing aptitudes and ensure that you are doing your absolute best every single time you put pen to paper.</p>

Lucky Charms and Graphing with St. Patricks Day Math

How to Choose the Best Topic For Your Research Paper?

<h1>How to Choose the Best Topic For Your Research Paper?</h1><p>When it comes to wiki points for inquire about paper composing, there are many fascinating alternatives to browse. At the end of the day, there are numerous subjects that you can use as topic for your exploration paper. You should simply choose the best subject. With twin themes for look into paper composing, you can without much of a stretch research the best point for your needs.</p><p></p><p>The first wiki subject for investigate paper composing would be nutrition types. You can inquire as to whether you need to compose an exploration paper on how nutrition types impact the weight reduction diet programs. Or on the other hand maybe you have to compose a paper on how the nutrition classes impacts the customary eating routine of different individuals. The thought is that when we eat healthy, we can really get in shape. It's a basic proclamation yet it truly works.</p>< p></p><p>Another wiki theme for look into paper composing is the possibility of nutrients. You might be thinking about what makes a nutrient a basic piece of your eating routine. All things considered, most nutrient enhancements are not so much required by everybody. Be that as it may, a few of us don't care for the flavor of certain nutrients and they just need some so as to feel much improved. In this manner, these nutrients are considered as essential.</p><p></p><p>Another wiki point for inquire about paper composing would be the various sorts of homeopathic items that can assist us with our issues. The thought is that numerous ailments like diabetes and osteoporosis can be dealt with utilizing homeopathic items. With these nutrients and minerals, you can at present get your ideal results.</p><p></p><p>An significant wiki subject for look into paper composing is vegetarianism. Veggie lovers as a rule abstain from eati ng meat. Despite the fact that you don't view yourself as a veggie lover, you may at present see yourself as a non-meat-eater. With this wiki subject for inquire about paper composing, you can show that you are not all that severe about your eating regimen. You simply need to eat meat in modest quantities as long as you don't deny yourself.</p><p></p><p>Another wiki point for look into paper composing would be lactose narrow mindedness. At times, we can't process the sugar found in milk and natural products. There are a lot of vegetables and natural products that can be processed by lactose-prejudiced people.</p><p></p><p>One wiki subject for inquire about paper composing is work out. A great many people believe that the response for weight reduction lies in works out. In reality, you don't have to practice unnecessarily. Truth be told, you can even set aside time and cash by doing less exercise and eating more food.</p><p> </p><p>Finally, another wiki subject for inquire about paper composing is creatine. Competitors can profit by this enhancement since it causes them recoup quicker from the thorough instructional meetings. It can build the measure of ATP.</p>

US Civil War Research Paper Topics

<h1>US Civil War Research Paper Topics</h1><p>In most US Civil War look into papers, you will go over the subject of administration. For what reason was it so critical to win the war? All things considered, there are a few reasons and on the off chance that you need to study it, you can do some examination and be readied when the time comes.</p><p></p><p>Here are some US Civil War investigate paper points that you can consider to remember for your project:</p><p></p><p>You may have just discovered that the Union Army was prevalent in all regards, yet for what reason was the Army unrivaled as far as military association? The military was better composed on the grounds that it was directed by a General, who was either a popular General or a previous armed force general. They were the ones who were responsible for a military. Be that as it may, another factor that helped the Union win the war was the effect of the media.& lt;/p><p></p><p>Because the troopers were a piece of the media and in this way must be viewed as energetic and solid, the rallying call 'Association or Death' turned into the trademark for the warriors. This guaranteed the resolve of the fighters would rise and become stronger.</p><p></p><p>Research paper on US Civil War may likewise investigate the reasons why most officers bombed in the war. There are a wide range of reasons why most officers flopped in the war. For instance, it could be a result of absence of order, poor authority, or the absence of initiative, or inability to face challenges, which prompted victory.</p><p></p><p>On top of all these, you may likewise need to investigate the way that the US Civil War was not exclusively battled about subjugation and race. It was a multi-factorial war where there were numerous variables, for example, financial aspects, legislative issues, religion, and even sentim ent that likewise assumed their job. Truth be told, it was a contention about cash and how the free States had the option to increase political force and control of their borders.</p><p></p><p>Finally, you might need to join different US Civil War investigate paper subjects like ladies' privileges and woman's rights into your undertaking. Ladies had the option to join the military even before the Civil War. An examination paper can feature the significance of ladies in the Army and the effect of ladies' privileges on the Union and the Confederacy.</p><p></p><p>As you can see, US Civil War inquire about paper points are wide and shifted. You can choose what to concentrate on and consolidate into your task and what not.</p>

Censorship in the Media Essay - 1084 Words

The parameters of the term censorship have been changed and manipulated very much over the years. Television and movie ratings have become more lenient against violence and indiscretion because these things are now seen as entertainment. Is this appropriate for our youth? Should children be exposed to these images so early on? How does censorship in the media affect adolescents? Children are the future of our society and need to have some understanding of real world occurrences. Ultimately, censorship can only be determined by the parents. The media cannot filter every bit of controversial images. What rights does the media have in this situation? How are their First Amendment rights applied here? As an aspiring political science†¦show more content†¦Some see this as the denial of an individual’s freedom of speech. In order to establish a group that censors televisions and movies, the Motion Picture Producers Association (MPAA) was created. Each rating category has a description of the appropriate age at which to view the film and whether or not a parent’s accompaniment is necessary. The Motion Picture Producers Association assesses a film and gives it a rating of G (general audiences), PG (parental guidance suggested), PG-13 (parents strongly cautioned), R (restricted), or NC-17 (no one under seventeen admitted). As the film industry has been changing over time, so have the ratings. More and more parents are having issues with the ratings that some films are issued. â€Å"The man behind the ratings, Jack Valenti, president of the Motion Picture Association of America (MPAA), says the system works just fine. ‘Parents use it and trust it, and thats why its lasted for almost 35 years,’ Valenti says. ‘It warns parents in advance about whats in a particular movie, but ultimately, parents are responsible for the behavior and conduct of their children — not the ratings system’ (Hansen 273).† The main issue in censorship today is responsibility. Who is essentially responsible for properly censoring and controllingShow MoreRelatedCensorship And The Media Of Censorship1407 Words   |  6 Pagesthe same can be said about censorship. Censorship and privacy do not solely revolve around leaks and personal intrusions from foreign entities. The advent of social media and cell phones have created new avenues for people to communicate and share information; The internet provides people a new and global way to spread information that can be considered worthy of censorship. Many people I know argue that censorship should not be commonplace in the media, in social media, or even in the entire InternetRead MoreMedia Censorship1427 Words   |  6 PagesApril 30, 2011 Media Censorship in the United States Censorship has existed for longer than we could ever imagine. One of the first acts of state sponsored censorship occurred in 399 B.C. when Socrates, was executed for the â€Å"supposed common good of the people† (Guarding Public Morality, 2010, p.1). Socrates was a teacher and a philosopher in ancient Greece. His teaching methods were controversial for the time, and he was charged with corrupting the youth and drawing them away from the GreekRead MoreCensorship in the Media1115 Words   |  5 PagesIs Censorship necessary? â€Å"Once a government is committed to the principle of silencing the voice of opposition, it has only one way to go, and that is down the path of increasingly repressive measures, until it becomes a source of terror to all its citizens and creates a country where everyone lives in fear. -- Harry S Truman Thesis: Although some people believe that censorship is adequate to select what things does the society will be good and can live around it while others believe that thereRead MoreCensorship of Media1064 Words   |  5 PagesSurprises of Censorship In today’s world of technology and high finance children learn and do different activities. Video games, television shows, and the internet all have effect on our society. These items take away from moral values, and it also undermines the instruction parents give to their children. We need a healthier world with fewer restrictions, and if negative commodities are prohibiting children from recreational play parents should be the regulators in what content their childrenRead MoreThe Censorship Of The Media1542 Words   |  7 PagesBut while the larger media corporations may be hesitant to allow these other conceptions of the human to be represented in the mainstream, there is no such hesitation in fan communities. The fans are not and do not have to be concerned with â€Å"securing the well-being of our present ethnoclass† (Wynter). Rather, they are considered with their own well-being and their own representation and thus they are able to tell the stories that th ey want to be told and there is nothing preventing them from doingRead MoreThe Censorship Of The Media1665 Words   |  7 Pages Privacy in the Media In addition, the media is in an especially complex situation regarding the current concept of privacy regarding the proper use of technology and due to the numerous ethical issues, that arise from sensationalist media practices. First, the invasion of privacy can be justified by uncovering vital information that serves public interest to be considered ethical journalistic practice (Plaisance, 2014, p. 187). However, while there is less ethical merit in providing the publicRead MoreThe Censorship Of The Media939 Words   |  4 Pagesongoings of the world inform American policy and economics. Yet Americans remain ambivalent because other countries are not debated in the news. The news media implicitly apply filters to their coverage of news stories to inform the public thereby creating a narrative skewed by political or financial gain to influence their viewers. Because the media is privatized, it is difficult to recognize this propaganda system. Careful dissection of the time and sp ace dedicated to each story covered by the anchorsRead MoreCensorship and Indecency in Media928 Words   |  4 PagesCensorship and Indecency in Media Although indecent speech is protected by the First Amendment speech in broadcast media has been restricted because of its accessibility to children. In Federal Communications Commission’s (FCC) current policy, indecent speech is defined as the â€Å"language that describes, in terms patently offensive as measured by contemporary community standards for the broadcast medium, sexual or excretory activities and organs, at times of the day when there is a reasonable thatRead More Censorship in Media Essay2359 Words   |  10 Pagesviewing audience. Censorship is defined as Policy of restricting the public expression of ideas, opinions, conceptions, and impulses, which are believed to have the capacity to undermine the governing authority or the social and moral order which authority considers itself bound to protect? (Abraham 357). Political, religious, obscenity, and censorship affecting academic freedom are all equal in their destructiveness towards free speech. ?There are two different forms that censorship takes; prior, whichRead MoreCensoring The Censorship Of Media3205 Words   |  13 PagesCesar Ortega Mrs. Martinez English, Period 8th 11/28/2014 Censoring In the 21st century the censoring of media should be scarce but in the contrary it’s being reinforce by countries. For instance, the act of censoring gay media hurts all those individuals who are members of the LGBT community and those who wish to learn more about the LGBT community and its history. It prevents people who wish to find more resources and information that might be able to change their life for the better. Censoring

Security Plan free essay sample

There is no check in/check out points for any of the employees which can be easier for them to steal. The furnace of the building prevents the fire protection system. The building does not have any fire extinguishers systems only alarm switches. The sprinkler system can only be activated by pulling one of the alarm switches located along the production line. My first recommendation for this plant is to have the property more closed to stop anybody from trying to burglarize or vandalize. For example they can have all the plant ensured with high security fence which won’t allow anybody to jump over the fence. The fence that has swirled wire on top so if anybody tries jumping it, it will cut their hands. I know that this fence can’t be 100 percent to stop them from jumping but it can deter them from jumping it and this can give the security guard some time to notice anybody trying to jump over. We will write a custom essay sample on Security Plan or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page It should have fence even around the parking lot and the parking spaces should be closed with a gate not allowing any one to come in or come out until their working hours are over. Their should also be a security guard at the ront gate just in case if anybody from work has to leave early he can open the gate and check him for any property stolen from inside the company. Another thing this plant would have to be stricter with their employees. Like for example to don’t let them get out of the premises until their job is finished. Allow them to take their lunch so they won’t have to leave the property this can help stop any employees from stealing. Also after leaving having them stop at a check point by a security officer were he can check if they have stolen any property from the plant. Since theirs 800 employees their should be more than one security guard checking at the check point and not all should get checked only randomly because that would just deter them from leaving to their house since theirs 800 of them. There should only be one entrance and exist to the parking lot and plant. They should also have an ID from the company just to double check they are currently working in the plant and its no one else just trying to get in easy. Every time they go into work they should present that ID to the security officer. Without that ID they shouldn’t be allowed in the plant even if they are workers who forgot it. Every business or building has security cameras and I believe this plant should have way more security cameras than any other business. There should be a couple hundred cameras inside the large valve plant even in the blind spots. In the small valve plant there should be less since it’s smaller but definitely the same security measure for both plants. Some cameras outside the plant would be a good idea too. For example the parking lots around the building making sure no ones trying to jump over the fences or cause property damage. Of course their should also be a couple of security officers watching the security cameras making sure everything is going good. Im sure that these cameras can help save the company more money when it comes to loss prevention. Security officers are very important to the business when it comes to safety. This plant only has one security officer patrolling the premises. I think that is irresponsible just to have one security officer for the whole plant. That’s why I believe more security officers should be hired to patrol the plant, to stand by the gate, to monitor the security cameras. At least four to five officers patrolling the plant and one or two standing near the gate. Another four inside monitoring the security cameras. I understood that at night time the plant was only lighted by four mercury vapor street lights located at the corners of each intersection. They should add the new L. E. D lights all around the premises to keep everything well lighted in the night time. This will help the security officers in their job and also doing a better job because if they can see better they can spot an intruder easier. When the business tries to prevent any accidents they should prepare for the worst accidents that can occur. The plant isn’t very well protected against fires because the fire protection system consists of a dry pipe sprinkler system that can only be activated by pulling one of the alarm switches located along the production line. It only affects the building in which the switch is pulled. The alarm activates a signal which is transmitted to the fire department. The building does not have any type of fire extinguisher system, only alarm switches. This plant should have the best sprinkler system which can detect any fire and it should activate by itself. Once the sprinkler system activates by itself it should notify the fire department without anybody having to pull any switch. There should also be fire extinguishers all around the plant. Like I said the owners should have everything prepared for the worst accident that can happen. Im sure the company can afford all this. It’s also great to apply all these security measures. Fence around the Plant L. E. D lights for the plant lightning

Complete Heart Block Case Study free essay sample

It is an empirical inquiry that investigates a phenomenon within a real life context. It provides a systemic way of looking at events, collecting data, analysis information and reporting the result. It tends to be selective, focusing on one or two issues that are fundamental to understanding the system being examined. Cardiac cases are under typical category of case studies where symptoms are described, probable causes are suggested, treatment is recommended and prognosis is recorded till the hospital stay of the case. So it is the complete study of the case and about the diseased condition from which the case is suffered. Objectives of case study 1. To collect data related to the etiology and predisposing factors causing diseases. 2. To identify the manifestations of medical/surgical conditions from the underlying patho physiological changes. 3. To correlate the principles of physical, biological and behavioral sciences in application of nursing process in care of the patients with specific conditions regarding Medical/Surgical treatment. We will write a custom essay sample on Complete Heart Block Case Study or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page 4. To conduct health educations for individuals and groups. 5. To provide comprehensive nursing care according to the need of the patient. 6. To assist individual in different diagnostic investigations. . Controls the infection by applying recommended Infective prevention measures. HISTORY TAKING Demographic Data Name: Nutan Govinda Joshi Age: 82 years. Sex: Male Marital Status: Married. Religion: Hindu. Education: Literate (Bachelor in Pharmacology) Occupation: Retired Address: Jhamsikhel Ward:CCU Bed no: 10 Hospital No. :51974 Diagnosis: Complete heart block with hypertension with type 2 DM Date of admission: 2069/09/02 Date of discharge: 2069/09/11 Unit:1 ‘A’ Dr. Murari Dungana and Dr. Pranita Dhakal. Chief complaints At the time of admission: * Generalized weakness since 3pm * Altered sensorium since 5pm At the time of assessment: * Pain at pacemaker implanted site History of Present illness: According to the patient, he was in his usual state of health then he suddenly developed generalized body weakness since today 3pm associated with two episodes of vomiting. Patient also gave history of altered sensorium for few minutes. ECG done at Kathmandu Hospital show Complete Heart Block at rate of 42 bpm for which he received 4ml of atropine and isoprenaline was started. Patient referred here for TPI. No history of loss of consciousness, SOB, palpitation, chest pain, burning micturation, constipation and passage of loose stool. History of past illness: * Known case of Hypertension and type 2 DM and under medication. Personal History: No history of any drugs or food allergy. He is non-vegetarian and he used smoke in past about 2-3 sticks/day since 16 years and he left smoking 35 years back. He is non-alcoholic. Bowel : Has not passed stool since 2 days Appetite: Normal Sleep : Decreased Urine : Normal Socio-economic status: * Income source: Pharmacy and Son * Road and electricity facilities : Present * Drinking water : boiled water * Excreta disposal: Toilet * Health facilities : Nearby hospital: Kathmandu Hospital * Waste disposal : Manure 9yrs Family tree67 yrs 83 yrs 78 yrs 80 yrs 76 yrs 80 years 82 yrs 5 Male: Female: Patient: Marriage 49 yrs 42 yrs 55 yrs 62 yrs 37 yrs 61 yrs 58yrs 56 yrs 60yrs His father had history hypertension. Died at 67 yrs age due to some cardiac problems. Mother had suffered from hemiparalysis for about 6 years and later died at 79 yrs. PHYSICAL EXAMINATION: On date:2069/09/03 Hi s general condition is weak. He is well oriented to time, place and person. General appearance: Looks ill. Level of consciousness: Conscious. Cleanliness: Maintained. Gait : Balanced Weight : 50 kg. VITALS: * Temperature: 98 F Pulse: 88 beats per min * Respiration: 20/min * Blood Pressure: 90/70 mmHg * PILCCOD: nil HEAD TO TOE EXAMINATION: * Head and face Hair: whitish and short with no dandruff present No any scars and injuries. Face : wrinkled face and looks tiered. * Eyes Pupil: React to light Vision: Decreased. Opacity of lens: Transparent. Blurred vision: Not present Anemia: Not present Jaundice: Not present * Ears Normal shape and size, and No any discharge. Condition of mastoid area: No any sign of Inflammation External ear canal: Normal * Nose Normal shape and size, and no any bleeding. Nasal deviation absent. * Mouth, Throat and Neck Lips: Pink, no cracks Gums: Normal Tonsils: Not enlarged. Palate: Normal Uvula: Normal. Thyroid: Not enlarged and palpable. * Chest and Lung Inspection Shape : Normal Movement of chest: Moving equal during respiration Palpation : Non tender Percussion : Resonant sound felt on Percussion. Auscultation Breath sound: Normal Vesicular Breathing Sound Bilateral Equal Air Entry No wheezing or crept. Respiration: Normal 20/minute. * Cardiovascular System Chest pain: complains of pain at incision site on movement Pulse : 88/minute Blood pressure: 110/70 mm of Hg Incision on left side of the chest made for Permanent Pacemaker implantation. Auscultation Heart sound: Normal (lub and dup) Murmur: absent. * Gastro-intestinal system Bowel habit: has not passed stool since 3 days Vomiting: Absent Loss of appetite: Absent Palpation Liver: Not palpable. Spleen: Not palpable. Kidney: Not palpable. Any abnormal masses: No. Auscultation for bowel sound: 3-4 times per minute. Tenderness : Absent * Genito Urinary System No any abdominal pain present Pain on micturation: No Blood in urine: No Color of urine: Light yellow. (Straw) Patient was on indwelling catheter No any signs of UTI seen (fever, lower abdomen pain, foul smelling urine, frequency in urination etc) * Musculoskeletal system Normal body posture. No any deformity * Nervous System Convulsion: No. Level of conscious: Conscious. Gait balance: Well balanced. Orientation : Oriented to time, place and person. Speech problem : No. Problem of rest and sleep : not present. Findings of physical examination * Looks ill. * Has not passed stool since 3-4 days * On the left side of his chest there was a surgical incision done for the permanent pacemaker implantation. Patient complains of pain on movement. * Patient on indwelling urinary catheter. ANATOMY AND PHYSIOLOGY OF CONDUCTIVITY OF HEART: The SA node is situated at the junction of the superior venacava and RA. It comprises specialized atrial cells that depolarize at rate influenced by the automatic nervous system and by circulating catecholamine. During normal (sinus) rhythm, this depolarization wave propagates through both atria via sheets of atrial myocytes. The annulus fibrosus forms a conduction barrier between atria and ventricles, and the only pathway through it is AV node. This is midline structure extending from right side of inter atrial septum, penetrating the annulus fibrosus anteriorly. The AV node conducts relatively slowly, producing a necessary time delay between atrial and ventricular contraction. The His-Purkinje system is comprised of the bundle of His extending from AV node into interventricular septum, the right and left bundle branches passing along the ventricular septum and into the respective ventricles, the anterior and posterior fascicles of left bundle branch, and the smaller Purkinje fibers that ramify through ventricular myocardium. The tissues of His-Purkinje system conduct very rapidly and allow near simultaneous depolarization of entire ventricular myocardium. The heart rate is determined by the myocardial cells with the fastest inherent firing rate, under normal circumstances, the SA node has highest inherent rate (60-100impulses per minute), the AV node has second highest inherent rate (40-60 impulses per minute, and the ventricular pacemaker sites have the lowest inherent rate (30-40 impulses per minute). If SA node malfunctions, AV node generally takes over the pacemaker function of the heart at its inherently lower rate. If both the SA node and AV node fail in their pacemaker function, the pacemaker site in ventricle will fire its inherent rate at 30-40 impulses per minute. DESCRIPTION OF DISEASE – COMPLETE HEART BLOCK * It is the medical condition in which the impulse generated in the SA node in the atrium does not propagate to the ventricles. * When AV conduction fails completely, the atria and ventricles beat independently. Ventricular activity is maintained by an escape rhythm arising in the AV node or bundle of His (narrow QRS complexes) or distal purkinje tissues (broad QRS complexes). Distal escape rhythms tend to be slower and less reliable. Complete heart block produces a slow (25-50/min), regular pulse that, except in the case of congenital complete heart block, does not vary with exercise. There is usually compensatory increase in stroke volume with a large volume pulse and systolic flow murmurs. * Rate: atrial rate is measured independently of the ventricular rate, usually normal b ut the ventricular rate is usually very slow. * Rhythm: each independent rhythm will be regular, but they will bear no relationship to each other * P wave: present but no consistent relationship with the QRS * PR interval: not really measurable QRS complex: depends on the escape mechanism (ie, AV nodal will have normal QRS, ventricular will be wide and the rate will be slower) * T wave: normally conducted Aetiology of complete heart block * Congenital * Acquired * Idiopathic fibrosis * Myocardial infarction/ischemia * Inflammation * Acute (e. g. aortic root abscess in infective endocarditis) * Chronic (e. g. sarcoidosis, chagas disease) * Trauma (e. g. cardiac surgery) * Drugs (e. g. digoxin, Beta blockers) Clinical features In book | In my patient | Bradycardia | Present (43 beats per minute) | Hypotension | Present (90/70 mm of Hg)| Hemodynamic instability | Present (semi-conscious, dizziness, altered body sensorium)| Fatigue | Present | Shortness of breath | Present | Exercising may be difficult | Present | Test and diagnosis In book | In my patient | Remarks | ECG | Done | Heart rate= 43bpm, Complete heart block| Complete blood count | Done | WBC elevated | Echo | Done | Mild MR and mild TR| Electrolytes | Done | Electrolyte imbalances present. Sodium level decreased. And others; urea, creatinine, RBS elevated. | Cardiac enzymes| Not done| | Chest x ray | Done | Normal | Types: 1) Temporary pacemaker 2) Permanent pacemaker Temporary pacemaker This is an artificial device used to stimulate or pace the heart for short term treatment. The pulse generator containing the circuit and batteries is located outside the body and the pacemaker lead is fixed in right ventricle Purpose: * To initiate and maintain the heart rate when the natural pacemaker of heart is unable to do so. * To prevent circulatory failure * To slow rapid arrythmia not responding to drugs or cardioversion Indication: * Complete heart block * Symptomatic sick sinus syndrome Anterior or inferior wall infarction with second or high AV block * Tri fascicular block * Post cardiac surgery * Prior to permanent pacemaker generator change Complications: * Infection and phlebitis * Cardiac temponade * Pulmonary embolism/pneumothorax * Battery failure * Lead dislodgement * Diaphragmatic stimulation * Venous thrombosis Medical and nursing management (TPI) Before: patient preparation * Explain the pr ocedure and type of pacemaker to the patient. * Obtain written consent from the patient and patient party * Clean and shave the area (both groin) Check the vital signs * Mental support * Maintain the room temperature at 24 to 26 deg centigrade * Check serology: HIV, HbsAg, HCV and others * Start an IV line with 5% dextrose solution or normal saline solution * Prepare isoprenaline drip * Check battery in pulse generator * Prepare the emergency cart, the defibrilator and ECG monitor * Set up all the equipment for insertion of pacemaker * The nurse should know about the pacemaker generator including the power switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial, and their proper setting. During the procedure * Assist the doctor and scrub nurse during procedure step by step * Scrub hands thoroughly and put on sterile gloves aseptically * Assist during the insertion of temporary pacemaker lead * Observe vital signs and observe ECG monitor carefully for arrythmias and other complications * The pacemaker lead can be inserted through the femoral, sub clavian or internal jugular vein and fixed into the right ventricular apex. The lead and generator should be connected and fixed properly to avoid pacing failure. * Record the pacing parameters After the procedure * Observe the patient and check vital signs. Continue ECG monitor for arrythmias, pacing function for at least 24 hours * Watch for the symptoms of nausea, palpitation, rigor and pain for next 3-4 hours. Asses the pacing parameters, battery, wire connection and take a 12 lead ECG. * Confirm inserted position of wire, rate and output. * Use elastoplast to immobilize hands and legs of the pacemaker implant site. Then allow gradual mobilization after 48 hours with sterile dressings. * Assist the technician to take chest X ray Cover the dial of pacemaker to prevent accidental disconnection * Record and report about the patient’s condition. Permanent pacemaker * An artificial device used to stimulate the heart for long term treatment. The pulse generator is permanently implanted in the body. It is most commonly used in patient with complete heart block. Purpose: * To initiate and maintain the heart rate when natural pacemaker of the heart is unable to do so * To prevent circulatory failure Indication: * Complete heart block * Symptomatic sick sinus syndrome * Tri fascicular block * Symptomatic Mobitz II AV block Complications: As in temporary pacemaker In addition: Pneumothorax/ hemothorax Pacemaker pocket infection Pacemaker syndrome APPLICATION OF NURSING THEORY VIRGINIA HENDERSON’S INDEPENDENT THEORY OF NURSING According to Henderson, â€Å"The unique function of nurse is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to peaceful death) that he/she would perform unaided if he/she had the necessary strength, will or knowledge and to do so in such a way as to help him/her gain independence as rapidly as possible. †-1996. Since my client was admitted in the CCU with the diagnosis â€Å"Complete Heart Block with known case of hypertension and type2 DM’, there were various changes and problems which were diagnosed on the basis of Henderson’s Unique Function of Nurses. Henderson conceptualized the nurse role as assisting sick or well and gain independence in meeting 14 fundamental needs. Essential Components| Findings in my patient| Breathe normally. | Shortness of breathing and wheezing present (pneumothorax) present. Oxygen at 4lt/min through facemask. | Eat and drink adequately| Appetite was normal. | Move and maintain desirable posture. | Assisted to move and maintain desire posture with support. | Eliminate body wastes| On indwelling urinary catheter later removed and self voiding. No bowel since 3-4 days, passed stool on enema. | Sleep and rest. | Rest and sleep normal, but some difficulty and discomfort due to pain on left chest tube site. | Select suitable clothes-dress and undress. | Able to select suitable clothes-dress and undress. | Maintain body temperature within normal range by adjusting clothing and modifying the environment| Able to maintain body temperature within normal range. Keep the body clean and well groomed and protect the integument. | Patient’s body was clean and well groomed. | Avoid dangers in the environment and avoid injuring others. | Able to avoid dangers. | Communicate with others in expressing emotions, needs, fears or opinions. | Was expressive and cheerful. | Worship according to one’s faith. | Patient worships according to her belie f. | Work in such a way that there is a sense of accomplishment. | he works with a sense of accomplishment. | Play or participate in various forms of recreation. he participates in various forms of recreational activities. | Learning, discovering or satisfying the curiosity that leads to normal development of health using available health facilities. | Try to use available health facilities. | ASSESSMENT Patient was assessed from the 2nd day of admission until day of discharge and continuous nursing care was provided as per the need identified according to Henderson’s Independent theory. FINDINGS Patient problems were: * Restricted left hand movement S/P PPI. * Patient on indwelling urinary catheter. Patient has not passed stool since 3-4 days. * Ineffective breathing pattern; Pneumothorax (left side) PRIORIOTIZED NURSING DIAGNOSIS * Acute pain and discomfort related to chest tube insertion and pleural effusion. * Ineffective breathing pattern related to pain at left sided pl eural effusion. * Activity intolerance related to status post Permanent pacemaker implantation with restriction of left hand movement * Constipation related to impaired physical mobility and change in daily routines. * Risk for infection (UTI) related to indwelling urinary catheter. Risk for infection related to surgical incision for pacemaker implantation. Date| Day| C/O| Vital signs| O/E| S/E| I/O| Plan| 09/02| DOA with diagnosis of Complete heart block with known case of type 2 diabetes mellitus amp; hypertension. S/P Temporary pacemaker implantation at 9:00 pm. | Generalized weakness since 5-6 hoursAltered sensorium since 3-4 hours. | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| Urine nil. Informed to Dr. so Inj. lasix 20 mg stat at 7am . | Monitor vital signs 2 hourly. Watch for arrythmias. Patient to be kept in NPO from 6am tomorrow. Plan for PPI tomorrow. Insulin on sliding scale. | | | | 970F| 62 bpm| 18/min| 90| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 9/03| Ist DOA ;CHB with TPI, K/C/O T2DM amp; HTN. Day of PPI. Received from cath S/P PPI at 12:15pm | Cough | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| 1600/ 3600ml -ve balance 2000ml| Administer Nebulization 8 hourly. Syp. Grillinctus, Inj. levoflox, Inj. Monocef added. Tab Glycomet SR stopped. Oxygen through face maskFoleys continue. | | | 97. 80F| 64 bpm| 20/min| 110| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 09/04| 2nd DOA:CHB with PPI, K/C/O T2DM amp; HTN. | Shortness of Breathing Pleural effusion done : C/O pain at chest tube site | 97. 80F| 72 bpm| 24/min| 90| Ill | Nil | RS: wheezing present | 1770/ 1360 ml + ve balance | Chest X-Ray. Pneumothorax present so left pleural drainage done. Post c hest X-ray. Continue O2 at 4 lt/min. Blood for WBC,DC, RFT tomorrow. Tab codomol SOS added. Inj, Lantus added today. | | | | | | 60| | | CVS: S1 S2 and no murmur| | | | | | | | | | | | PA: soft, non-tender and no organomegaly, BS 3 to 5 times per 10 mins. | | | 09/05| 3rd DOA:CHB with PPI, K/C/O T2DM amp; HTN| Not passed stool since 4 days. Severe pain at left pleural drainage site. | T| P| R| BP| GC| PILCyCOD| RS: wheezing present | 1400/1500ml-ve balance100ml| Nasal cannula at 3lt/min. Dressing at PPI site. Chest X-Ray done and Seen by Dr, left pleural drain to be clamped on from tomorrow 6am. Perform chest X-Ray while clamping. Sliding scale insulin stopped and regular started,blood sugar testing tomorrow. | | | 960F 0F 0F 0F. 80F| 80 bpm| 20/min| 100| Ill| Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non tender and no organomagaly, BS=3-5/10m| | | 09/06| 4th DOA:CHB with PPI, K/C/O T2DM amp; HTN| None | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added so und| 1600/ 1400 ml | Drain tube clamped. Chest X-ray at 9 am FBS, pre dinner, post dinner to be done daily by glucometer. Inj, mixtard dose increased. Plan to transfer out to Single cabin,Drain tube out at 3:15 pm and no any chief complain. O2 at 3lt/min continue. Chest X-ray after tube out. Foleys out. | | | | 980F| 74 bpm| 20/min| 110| Satisfactory | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 80| | | PA: soft, non-tender and no organomeagaly, BS+| | | MEDICATION USED IN MY PATIENT: 2069/09/02 * Inj. Cefazolin 1gm IV 8 hourly TDS * Tab. Glymet SR 500mg PO BD * Inj. humolog 50 S/C 10U morning: HOLD * Inj, levomor 14U S/C evening: HOLD * Tab. Omnitan 50mg PO BD * Inj. insulin sliding scale * 150-200 : 2U, 200-250: 4U, 250-300: 6U, 300-350: 10U, 350-400: 12U, 400 or more then 400: 2069/09/03 * Tab. Augmentin 625mg PO BD Inj Monocef 2gm IV OD * Inj. levoflox 500mg IV OD * Syp Ascril 2tsf PO TDS 2069/09/04 * Syp. Cremaffin 2069/09/05 * Inj. Mixtard 30:70 (12U S/C in morning and 6U S/C in evening : both ? hour before meal) * Tab. Tramadol 50mg PO BD * Inj. Pethidine 25mg IV stat and SOS * Inj Phenargan 25mg IV stat and SOS. * Herbolax 3 cap with warm water HS * Note: NO NSAID: allergy history HEALTH TEACHING TO PATIENT AND FAMILY DURING STAY P atient education about disease condition: The patient and the family were given all the information regarding the disease condition. He and his family members were taught about the possible causes and contributing factors according to book and in comparison with his life to make them know about it. So that they will all be aware of it and follow the necessary consideration. Nutrition: Patient was encouraged to take adequate amount of fluid and fiber diet to prevent from constipation. Patient was encouraged to take low salt diet, decrease intake of fatty diet, decrease cholesterol intake for healthy heart as per antihypertensive medicines suggest. She was advised to avoid red meat and replaced it by chicken or fish that has low fat with high protein. Paient was advised for diabetic diet and regular use of insulin as advised by Doctor. Personal hygiene: Personal hygiene is an important factor for the health recovery of the patient. It brings the sense of self well being and promotes self-esteem. Besides this maintaining oral hygiene promotes appetite and prevents weight loss, vomiting. Daily dressing once a day basis was given to promote wound healing and prevent infection. Medication: Medication is important for restoration of clients health. So, it should be continued as doctor advised. I explained him about the importance of complete dose of antibiotic to be taken to eradicate infection that degrades her disease condition. I also encouraged him to continue the use of antihypertensive medication and antidiabetic medication as per doctor’s advice. I also said about the possible adverse effects of the drug. Daily habit changes: I explained her disease condition and important daily activities to be changed like taking proper rest until she recovers and avoidance of sexual activities for 6 to 8 weeks. She was advised to change her dietary habit into low salt diet, low fatty diet as per hypertensive patient should take. Possible complication: Patient was made aware of possible complication like hemorrhage, retention of urine, bladder injury, rectal injury, vault cellulitis, pelvic abscess, thrombophlebitis, pulmonary embolism, vault prolapse etc were explained resulting from complication of vaginal hysterectomy and Pelvic floor repair. And patient was encouraged to come for F/U immediately with any of the symptoms of underlying complications. Discharge Teaching At the time of discharge, teaching was basically given to the patient and patient’s party. Following things were included in the teaching at the time of discharge. Treatment at Discharge: CONCLUSION Nutan Govinda Joshi, 60 years old female from Kavre was admitted in bed no. 222 in Gynae Ward of Kathmandu Medical College at 11:30 pm on 2068/12/12 and discharged at 3:00 pm on 2068/12/16 with the diagnosis of â€Å"2nd degree Utero-Vaginal Prolapse with cystocele† and â€Å"Vaginal hysterectomy with pelvic floor repair† was done on 2068/12/13. The patient was under my close observation from the 2nd day of admission till the day she was discharged. During her hospital stay, I tried my level best to provide her a quality nursing care based on her needs with the application of Virginia Henderson’s independent theory and I also tried to give suggestion to her and her family members on the management of her disease condition. Though I had very short duration to provide her care, I kept my maximum efforts and help her in any ways that I could. I provided teaching to her, her husband and her mother in laws her present disease condition and treatment she has undergone through. It was very exciting case and I felt very happy to have company with the patient along with her family members so that I could teach and convince them about the care needed. She and her family members were very co-operative and supportive. Even then, it was very educational to study this case. It helped to learn in better way and even helps to practice as well as enhanced my skills to some extent. Bibliography * Burner and Suddharth’s, â€Å"Text book of Medical Surgical Nursing† Volume:2; 12th edition Wolters Kluwer(India) Pvt. Ltd, New Delhi,. * Chaurasia, B. D. (2009). Human Anatomy volume 2 (4th edition). CBS Publishers amp; Distributors Pvt. Ltd. New Delhi, India. * Kozier and Erb’s â€Å"fundamental of Nursing†; 8th edition; Pearson Education, published by Dorling Kindersley (India) Pvt. Ltd. ; 528-43. Lippincot,Manual of Nursing Practice , 9th edition, churchill livinstone * Mosby’s â€Å"Comprehensive Review of Nursing for NCLEX- RN examination† ;19th edition; Elsevier publication; 535-36 * Mosby’s â€Å"Nursing drug reference†; 22nd edition 2009 Elsevier publication;22-23,129-30,1143-44,685-89. * Smeltzer, S. C amp; Bare; 2008. Textbook of Medical-Surgical Nursing, 11thedition. Lippincott Williams amp; Wilkin s. Philadelphia. * Retrieved on 2069/09/10 http://en. wikipedia. org/wiki/Artificial_cardiac_pacemaker#Considerations http://www. nhlbi. nih. gov/health/health-topics/topics/hb/