Ascariasis and Trichuriasis

————————————————- OBJECTIVES I. Objectives Within our 3 weeks clinical exposure at San Pedro Hospital at St. Luke’s Ward, we, the proponents of San Pedro College, BSN 3E, group3, subgroup2, will be able to present a comprehensive nursing case analysis regarding the case of our patient who have a Bronchopneumonia in which we can gain more knowledge to understand further our clients condition. In order to achieve the general objective stipulated above, this case analysis aims to: a.Present a rationale discussing the rotation, patient’s medical status, statistics which include the international, national and local statistics about the case and its nursing implications; b. assess patient in a cephalocaudal manner; c. obtain factual information regarding patient’s data base including the biographical data, clinical data, family health history, past health hi story, and history of present illness; d. construct a family genogram to trace the family history that will show us the health status, hereditary diseases, and the present condition of the client and his family ; e. ite at least 2 definitions of the diagnosis from the book and 1 from the internet source f. discuss the specific medical management including drug studies and diagnostics according to the condition of the patient; g. explain the related nursing theory that can apply to the situation of the patient; h. formulate one (1) nursing care plan applicable to the patient; i. compose a comprehensive discharged plan following METHOD. j. list all sources and references used in the making of this case study. ————————————————- ————————————————- INTRODUCTIONII. Intr oduction Oxygenation concept covers the study of different concepts on oxygenation and the nursing care for clients having problems and alterations from the normal process of oxygenation. Oxygenation is the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular. The systems involved in this concept are the respiratory, cardiovascular and hematologic systems. This concept functions to support the different clients in the clinical setting by providing nursing care, providing health teachings, and helping them restore their body’s normal functioning.The group has been clinically exposed in St. Luke’s Ward were we encountered our client N. A , a 6 year old female who was admitted due to fever under the service of Dr. R. Mata on Room 443-2 who has Bronchopneumonia. The group then decided to make him our main subject in our case analysis for the reason that his condition was perfectly related to our oxygenation rotation and also its affected organ is the respiratory system while its affected organ is the lungs.We have chosen her as our patient for our case analysis because of our desire to gain more knowledge and understanding of the disease and the condition in which our patient is experiencing. Bronchopneumonia is an acute inflammation of the lungs and bronchioles, characterized by chills, fever, high pulse and respiratory rates, bronchial breathing, cough with purulent bloody sputum, sever chest pain, and abdominal distension.The disease is usually a result of the spread of infection from the upper to the lower respiratory tract, most common caused by the bacterium Mycoplasma pneumoniae, Staphylococcus pyogenes, or Streptococcus pneumoniae( Mosby,2010) For international statistics according to world health organization children under 5 years of age they have 613,600 cases with 2,044 number of childhood deaths in the year 2004 ( Retrieved from http://whqlibdoc. who. int/publications/2006/92806404 89_eng. df ) While for its national statistics according to Department of health for the age 5-9 years old they got 244 cases of pneumonia for girls and 287 cases for boys with a total of 531 cases for both sexes While for the local statistics according to Department of Health they have 174 cases for every 100000 children with the incidence rate of 253. 16 for the year 2007 only in Davao city. This case study would contribute a lot on the quality of nursing education, practice, and research. First, to nursing education, this case study would keep the group equipped with knowledge, skills, and attitudes on ow to manage future patients with Bronchopneumonia it then nourishes those lessons learned in the scope of our concepts. To the nursing practice, this case study would help those who are practicing their professions as nurses, student nurses and other people who are medically inclined by being able to improve their nursing management and intervention to patients who had Bronchopneu monia. In application, those learned from our lectures can be related more to an actual state thus having a higher understanding, as to improve our skills and thinking.This case is facilitative to nursing research, because all data that we have gathered will help us in understanding the disease process of the patient. This would also help the group identifying the primary needs and health problems that would arise; thus it will help researchers that will encounter the same problem in the future. The group hopes that in the future technology can give the patients a more reliable treatment in an affordable and easy way for the patient. ————————————————- DEFINITION OF DIAGNOSIS BRONCHOPNEUMONIA/ CAP MR Bronchoneumonia can be a primary illness (often called community acquired pneumonia or CAP) or can develop as a complication of another respiratory infection or underlying illn ess. The causes of pneumonia in children vary depending on the season and the child’s age and health status. Pneumonia most likely develops when the body is unable to defend against infectious agents, which could be viruses, bacteria, mycoplasma, fungi, chemicals, foreign substances, or various other organisms or materials. It is also that not all inflammation of the lung is infection in origin. It could be caused by aspiration of foreign substances.Source: Bowden, V. , Greenberg, C. (2008). Pediatric Nursing Procedures Second Edition. Lippincott Williams & Wilkins. * Community acquired pneumonia (CAP) – Occurs either in the community setting or within 48 hours of hospitalization. The agents that most frequently cause CAP requiring hospitalization are Streptococcus pneumoniae, H. influenza, Legionella, Pseudomonas aeroginosa and other gram negative rods Source: Bare, B. , Cheever, K. , Hinkle, J. , Smeltzer, S. (2009). Brunner and Suddarth's Textbook of Medical Surgica l Nursing 12th edition. Lippincott Williams ; Wilkins Moderate risk community acquired pneumonia manifests vital signs that are not within normal range, having symptoms of tachypnea, tachycardia and fever. It can have x-ray findings of multi-lobar involvement, progression of lesion to 50% within 24 hours, abscess and pleural effusion. It is suspected to be prone for aspiration. It can be associated with extrapulmonary findings of sepsis and unstable comorbid condition. Source: http://www. slideshare. net/crisbertc/pneumonia-4775641 ASCARIS LUMBRICOIDES * Ascaris Lumbricoides is also known as the giant intestinal roundworm. Adult roundworms live in the small intestines.Fertilized and unfertilized eggs develop in the soil into embryonated stage which is the infective stage. Soil is commonly contaminated in areas where there are no sanitary toilet facilities or where human feces is used as fertilizer in vegetable garderns. Source: Maglaya,A .. [et. al]. (2009). Argonauta Corporation. M arikina City, Philippines * Ascaris Lumbricoides is a genus of nematode worms; large parasitic intestinal roundworms found throughout temperate and tropic regions. Source: Mosby’s Pocket Dictionary. (2010). Elsevier. Singapore. * Ascaris lumbricoides, giant roundworm, is the most common parasitic worm in humans.According to some estimates 25 % of humans are infected with the disease, ascariasis. Ascariasis occurs worldwide, mostly in tropical and subtropical countries. It has highest prevalence in areas of poor sanitation and where human feces are used as fertilizer. Source:http://www. parasitesinhumans. org/ascaris-lumbricoides-giant-roundworm. html TRICHURIS TRICHIURA * Trichuris Trichiura is also known as the whipworm because the anterior end is highly attenuated and the posterior end is thicker and more fleshy. It is another common intestinal worm and is usually found together with ascaris. Source: Maglaya,A .. et. al]. (2009). Argonauta Corporation. Marikina City, Philip pines * Trichuris Trichiura is a species of whipworms, commonly found in warm,moist regions of the world. Ingestion of whipworm eggs results in infection in humans; the parasits live mainly in cecum or large intestine. Source: Mosby’s Pocket Dictionary. (2010). Elsevier. Singapore. * Trichuris trichiura is a nematode (roundworm) also called the human whipworm. The third most common round worm of humans. Occurs worldwide, with infections more frequent in areas with tropical weather and poor sanitation practices, and among children.It is estimated that 800 million people are infected worldwide. Trichuriasis  (infection with Trichuris trichiura) occurs in the southern United States. Source: http://www. medterms. com/script/main/art. asp? articlekey=12961 ————————————————- PHYSICAL ASSESSMENT A. Physical Assessment Date and time of assessment: September 21,2012, 9 a. m. * GENERAL SURVEY N. A. , six years old, female has a mesomorphic body structure and she weighs 15 kilograms. She is wearing a clean hospital gown. Her hair was black in color and is unkempt. She has a brown-complexion.Upon interview with the watcher, the patient is alert and oriented and in an appropriate mood. * VITAL SIGNS VITAL SIGNS| RESULT| NORMAL VALUES| Blood Pressure| 90/60mmHg| 87/48 – 117/64 mmHg| Temperature| 35. 8  °C| 35. 6 – 37. 5 C| Cardiac Rate| 110 bpm| 60 – 100 bpm| Pulse Rate| 102 bpm| 60 – 100 bpm| Respiratory Rate| 30 cpm| 20 – 25 cpm| I. SKIN, HAIR, NAILS The patient has a brown complexion and is generally uniform in color. The skin is dry, rough to touch and with fair skin turgor. The body’s temperature is uniform all throughout the body and is within the normal range (36-37  °C). no lesions, edema or ulcerations noted.Hair is black in color and in normal distribution. Texture is brittle. Infestations noted such as dandruff and lice. Body hair is variable in amount. The fingerplate has a convex curvature with an angle of 160 °. Nail beds are pinkish reflecting a good circulation. Epidermis surrounding the nail is intact. After performing the blanch test of capillary refill, there is a prompt return of usual color in 3 seconds. II. HEENT * HEAD The patient’s head is normocephalic. Facial features are symmetrical, palpebral fissures equal in size and symmetrical nasolabial folds. Muscle strength of jaw is normal. * EYESEyebrows are evenly distributed and symmetrically aligned. The skin is intact and movements are equal. Eyelashes are equally distributed and slightly curled outward. No lesions or discoloration noted on both eyes. Sclera is clear. The palpebral conjunctiva is smooth and pale. The pupils are black in color, equal in size of about 2mm in diameter, round and have a smooth border. The iris appears brown in color. * EARS The ears have the same color as that of facial skin, symmetrical and aligned with the outer canthus of the eye. It is mobile and not tender. However, the texture is dry. Normal voice tones are audible.No discharges noted. * NOSE External nose is uniform in color and no discharge noted. The nasal mucosa is pink in color. The nasal septum is intact and in midline. * MOUTH AND OROPHARYNX The lips are pinkish and moist and has symmetrical contour. The tongue is in midline without any lesions present. There were twelve upper teeth and ten lower teeth present. Two upper molars have been extracted and one lower molar has cavity. The gums are pink. The oral mucosa has a uniform pink color and moist. Hard and soft palate are pinkish in color. Gag reflex is present. III. NECK Neck muscles are equal in size.Head movements are coordinated and smooth with no discomforts. Trachea is centrally placed in midline of neck and spaces are equal on both sides. The thyroid gland is not visible upon inspection. IV. BACK The skin is uniform in color. No les ions, areas of tenderness, redness or abrasions noted. V. ANTERIOR THORAX AND LUNGS Upon inspection, difficulty of breathing/ tachypnea was observed. The patient used accessory muscles such as shoulders and the abdominal muscles to assist in breathing. Crackles where heard on both lung fields upon auscultation. Pleural friction rub is also present. Chest skin turgor is good. VI. POSTERIOR THORAX AND LUNGSThe anteroposterior diameter of the chest has a ratio of 1:2. The skin is intact, temperature is uniform, chest wall is intact and no masses or tenderness noted. Upon palpation,tactile fremitus is increased when patient is asked to say, â€Å"1,2,3†. VII. CARDIOVASCULAR SYSTEM No pulsations, lifts, or heaves noted on aortic, pulmonic, triscupid and apical areas noted upon inspection. Normal cardiac sounds heard upon auscultation (S1 and S2). Peripheral pulses have full pulsations with symmetrical pulse volumes. Peripheral leg veins are symmetric in size. Limbs are not tender. Capillary refill time of 3 seconds was recorded.VIII. ABDOMEN The skin color is uniform. No lesions, masses or tenderness noted. Audible bowel sounds of 5-10 sounds per minute. IX. EXTREMITIES No nodules or deformities observed on shoulders, arms and elbows. Forearms can be flexed, extended, or put to supine and prone position. Contractures, redness, bone enlargements, nodules, atrophy and tremors were not observed. Fingerplates are of convex curvature and nail beds are pinkish. No pain or tenderness, deformities on hip joints and thigh. A visible scar on right calf is present and measures 2. 5 inches. Lesions, edema, inflammation and deformities are absent.NEUROLOGIC ASSESSMENT * Mental Status * Language Client can talk and is able to express himself by speech and gestures. She can articulate clearly. * Orientation The client was able to recognize other persons such as her relatives, nurses on duty and his physician. She is oriented of the time of the day and was aware of where sh e is at the present moment. * Memory The client was able to recall the meal she had for breakfast. She also remembered some of the hospital personnel that were assigned to her. * Attention span and calculation The patient has a short attention span as she is easily distracted by her surroundings.Her ability to calculate was done through giving simple arithmetic questions (addition and multiplication). Her answers are correct. CRANIAL NERVES Cranial Nerve| Type| Function| Assessment| Olfactory| Sensory| smell| We covered the client’s eyes and she was able to identify the smell of milk and peanuts. | Optic| Sensory| Vision and Visual Fields| The patient does not know how to read but sees clearly the prints on the paper given to her. | Oculomotor| Motor| EOM, movement of sphincter of pupil, movement of ciliary muscle of the lens| The patient was able to see through the 6 extraocular movements.The pupil size was 2mm at both left and right eye, was briskly reactive to light and ac commodation. It constricts and dilate in response to light. | Trochlear| Motor| EOM, specifically moves eyeball downward ; laterally | The patient was able to move her eyes from left to right and right to left without moving her neck. | Trigeminal| Sensory ; Motor| Sensation of cornea, skin of face and nasal mucosa| When the patient clenched her jaw, her temporal and masseter muscles felt equally strong. Jaw movement was normal. The patient blinked as the wisp of cotton touched the lateral sclera of the eye.She also felt the cotton as it touched her left and right cheeks. | Abducens| Motor| EOM, specifically, moves eyeballs laterally| The patient as able to rotate her eyes in a circular manner from top to left to bottom and to right and back to top as instructed. | Facial| Sensory ; Motor| Facial expression, taste (anterior two-thirds of the tongue)| The patient has symmetrical facial features when instructed to smile, frown, close eyes and puff cheeks. | Vestibulocochlear| Sensory| Hearing ; balance| The patient was able to hear the student nurses properly during normal voice conversation. Glossopharyngeal| Sensory ; Motor| Swallowing ability, tongue movement| Gag reflex was present by touching the posterior part of the using using a tongue depressor. | Vagus| Sensory ; Motor| Swallowing, vocal sord movement| The student nurses asked the patient to open her mouth widely and observed during inspection that the palate and uvula rises in the midline as patient says â€Å"ahh†. | Accessory| Motor| Head movement, shrugging of shoulders| The patient was able to move his head to her left and right against the hand as a resistance and has equal strength.She was able to move her head up and down freely. Her sternocleidomastoid and trapezius muscles were equal in size upon inspection and palpation. | Hypoglossal| Motor| Protrusion of tongue from side to side, up ; down| The patient was able to move her tongue to his left and right, up and down and was able to pr otrude her tongue. | ————————————————- ————————————————- ————————————————- HISTORY ————————————————- TAKING PERSONAL DATA Name: N. A Age: 6 years old Gender: femaleHome Address: Davao City Birth date: January 16, 2006 Nationality: Filipino Religion: Christian Civil Status: Child CLINICAL DATA Hospital Institution: San Pedro Hospital Ward: St. Luke’s Ward Room and Bed no: 443-2 Date Admitted: August 19, 2012 Time Admitted: 1:00am How admitted: Per ambulatory Chief Complaint: Fever Attending Physician: Dr. Richard Mata Family Health Histo ry In the maternal side of our client, both of the grandparents of N. A died, her grandmother M. B. died at the age of 62 because of myoma, she had a history of asthma, while its grandfather died for unknown reason also had asthma.The couple was blessed with 7 children including the mother of our client Amy and Aladin who also has a history of asthma, their siblings Archie and Arnold both have asthma and fond of smoking and drinking alcoholic beverages. While Ariel died at the age of 35 and also had asthma. For the paternal side, the grandmother of our client had a history of asthma while its grandfather has TB and fond of smoking. They were blessed with 5 children including the father of our client R. A who also likes to drink and smoke, his sister M.A died at the age of 7 because it drowned on the beach, while its brother aldrin had a history of asthma and was also a smoker and drinker, their brother Renante died at the age of 26 due to stab wound and was a smoker and drinker befo re. Our client N. A was used to be asthmatic as well as its brother J. A ————————————————- ————————————————- GENOGRAM Past Health History According to the mother of our client when she was pregnant for our client she always go to their barangay for prenatal check up, she said she gave birth of N.A at the age of 16 in full term at their house here in Davao City with the help of her trusted midwife in a normal spontaneous vaginal delivery, she said that she first noticed a blood in her underpants and started to feel pain following a ruptured bag of water after an hour, she said that she labored not less than 8 hours. The mother of our client also shared that during the childhood days of her daughter it had chicken pox, tonsillitis, sore eyes and asthma when she it was 2 years old, her mother also stated that her daughter N.A completed her immunizations such as BCG, DPT, OPV, Measles, HIV, and Hepa B. Per interview to the mother, she stresses that her daughter had her first hospitalization when she was just months and was admitted at Regional now called SPMC due to diarrhea and vomiting, but then after 5 days of admission, the Doctor had given the family a list of medications but forget their names , the mother shared that the moment they got home after 5 days the mother of our client noticed a stainless earrings in her daughter’s feces, When our client N.A was 3 or 4 years of age she was then again admitted at San Pedro Hospital under the service of Dr. Lubo in due to swelling of its right lower extremity , according to the parents their daughter underwent a minor surgery just enough to remove the bacteria or some kind of microorganism present. They describe the leg of their daughter with a redness surrounding its puss unfortunately th ey cannot remember what’s the case was but they shared that during that admission N.A was also diagnosed with Pneumonia with the used of chest X-ray, its third hospitalization was the present. Our client has no allergy to any kind of food nor medications, according to N. A’s mother her daughter stop breastfeeding when she was 2 while according to its father his daughter was a picky eater in terms of vegetables, he said she could only count the number of vegetables her daughter ate, according to our client she prefer pork, fish or fruits than vegetables.Per interview to our client she said she eliminates once a day, and urinates at least 2-3 times per day and sometimes urinates when asleep. N. A also shared to us that she usually sleeps after watching Lorenzo’s Time and wakes up at 6 am to prepare for school, she was a kinder student in one of the project hope here in Davao City, according to her she had lots of friends in school and they usually play, hide and s eek, Dampa, Chinese Garter and the like. Present Health History Our client N.A had an on and off fever for 4 days, her mother gives their trusted paracetamol neo-kiddielets yet they decided to admit their daughter last September 19, 2012 at 1:00 am under the service of Dr. Mata on room 443-2, he was then ordered to have CBC,Urinalysis , CXR and fecalysis. The result of CXR indicates that our client has bronchopneumonia and was also positive of ascaris and trichuris, he was given medications and one of them is antiox to get rid of the parasite inside our patient. ————————————————-MANAGEMENT Radiologic Findings Procedure| Rationale| Impression| Nursing Responsibilities| X-ray of the chest and abdomen| Test done to visualize the internal structures using the x-ray| Hazy infiltrates seen in the inner lung zones. Heart and great vessels are not unusual. Diaphragm and costophren ic sulci are intact. The rest of the included structures are unremarkable. Bronchopneumonia| * Let the patient wear the prescribed hospital gown * Remove other garments and other accessories * Transport patient to the X-ray room. Provide safety and privacy| Hematology: Complete Blood Count provides a fairly complete evaluation of all formed elements in blood. It can supply a great deal of the information necessary to diagnose a hematologic disorder, help to identify disease states not directly related to hematopoietic system, and help to evaluate the stages and prognosis of certain diseases. It helps to detect the abnormality of the component of the blood that shows underlying diseases in the patient condition before performing a surgery or operation.Date| Component| Rationale| Results| Clinical Significance| Interventions| SEPTEMBER19,2012| Hemoglobinmale 140-180g/dlfemale 120-160g/dl| Hemoglobin is a protein in red blood cells that carries oxygen. A blood test can tell how much he moglobin you have in your blood and determine the ectent of Anemia. | 110g/dl| Elevated Values:Polcythemia, DehydrationDecreased Values:Many cancers, Hodgkin’s disease, Lymphosarcoma, Anemia, and malutrition and as a side effect of chemotherapy| Pretest Patient Care for CBC, Hemogram: * -Explain to the patient or watcher the procedure, process and purpose of the test to be done. Inform them that the test requires a blood sample and slight discomfort may be felt when skin is punctured. * * – Avoid stress if possible because altered physiologic status influences and changes normal hemogram values. * – Select hemogram components ordered at regular intervals. These should be drawn consistently at the same time of day for reasons of accurate comparison; natural body rhythms cause fluctuations in laboratory values at certain times of the day-Dehydration or overhydration can dramatically alter.The presence of either of these states should be communicated to the laborat ory. -Fasting is not necessary. However, fat-laden meals may alter some tests results as a result of lipidemia. Intra:-Inform the patient that venous blood is to be collected-Venipuncture should be performed in an aseptic technique as well as the collection of sample. Posttest Patient Aftercare for Hemogram, CBC:-Apply manual pressure and dressings to the puncture site on removal of the needle. -Monitor the puncture site for inflammations or hematoma formation.Maintain pressure dressings on the site if necessary. Notify physician of unusual problems with bleeding. -Resume normal activities and diet. -Bruising at the puncture site is common. Signs of inflammation are unusual and should be reported if the inflamed area | | Erythrocytesmale 4. 5-5. 0female 4. 0-5. 0x10^12/L| The number of red blood cells per cubic millimeter of blood. erythrocyte indices,n. pr the standard values of red blood cell numbers, morphologic characteristics, and behavior in comprehensive hematologic laborator y testing. | 4. 3 x10^12/L| Decrease in value means hemorrhage, hemolysis anemias, cancer, over dehydrationIncrease in value meas polycythemia, dehydration, living at high altitude| | | MCHMean Corpuscular Hemoglobin27 – 33picograms/cell| is the average mass of hemoglobin per red blood cell in a sample of blood. It is reported as part of a standard complete blood count. | 26. 0picograms/cell| MCH less than lower limit of normal: hypochromic anemia MCH within normal range: normochromic anemia MCH greater than upper limit normal: hyperchromic anemia| | | MCVMean Corpuscular Volume80 – 96femtoliter| is a measure of the average red blood ell volume that is reported as part of a standard complete blood count. | 80Femtoliter| MCV less than lower limit of normal: microcytic anemia MCV within normal range: normocytic anemia MCV greater than upper limit of normal: macrocytic anemia| | | MCHCMean corpuscular hemoglobin concentration32 to 36 grams/deciliter| The MCHC is a measure of the concentration of hemoglobin within a red blood cell. This measurement is useful in evaluating the clinical response of an anemic patient to therapy. | 32. 6grams/deciliter| Decreased: microcytic anemiaIncreased: hereditary spherocytosis| | | Leukocytes(5. -10. 0x10^9/L)| A useful guide in determining the severity of disease process. It will identify certain persons with increase susceptibility to infection through measuring total amount of WBC in the body| 3. 7 x10^9/L| Elevated Values:. An increase in the number of circulating leukocytes is rarely due to an increase in all five types of leukocytes. When this occurs, it is most often due to dehydration and hemoconcentration. In some diseases, such as measles, pertussis and sepsis, the increase in white blood cells is so dramatic that the picture resembles leukemia.Decreased Values:Aplastic anemia, bone marrow depression, pernicious anemia, some infectious or parasitic disease| | | Neutrophils(0. 55-0. 65%)| Neutrophils are p roduced in huge numbers in response to infection, trauma, infarction (cell death due to lack of blood supply), emotional distress or other stimuli. They cruise around the blood stream waiting to be called to a site where damage is happening. Once there, they kill the invading bacteria and other noxious substances, usually dying in the process themselves. The method they use to kill invaders is called phagocytosis which involves engulfing and digesting the â€Å"enemy† cell. 0. 48 %| Elevated Values:Elevated in bacterial infection, Hodgkin’s disease, Decreased Values:Decreased in Leukemia and malnutrition and as a side effect of hemotherapy, Infection, drug reaction, autoimmune neutropenia, maternal antibody production, aplastic anemia. | | | Lymphocytes(0. 25-0. 40%)| Lymphocytes consist of the B cells and T cells. The B cells make antibodies and the T cells regulate the immune response. Lymphocytes secrete products (lymphokines) that modulate the functional activities of many other types of cells and are often present at sites of chronicinflammation. 0. 41 %| Elevated Values:Elevated in lymphocytic leukemia, Hodgkin’s disease, multiple myeloma, viral infections, and chronic infections, cytomegalovirus infection, petussis, brucellosis, tuberculosis, syphilis. Decreased Values:Decreased in malnutrition, cancer, and other leukemias and as asdie effect of chemotherapy. Human Immunodeficiency Virus Infection, Miliary Tuberculosis, Renal failure, Terminal Cancer| | | Monocytes(0. 02-0. 06%)| Monocyte is a type of white blood cell, part of the human body's immune system.Monocytes have several roles in the immune system and this includes: (1) replenish resident macrophages and dendritic cells under normal states, and (2) in response to inflammation signals| 0. 09 %(High)| Elevated Values:Elevated in Acute infection, monocytic leukemia and cancer. , chronic myeloid leukemia, acute monocytic leukemia, myelomonocytic leukemia, lupus erythematosus, p olyarteritisnodosa, rheumatoid arthritis| | | Eosinophils(0. 01-0. 05%)| Eosinophils contain toxic substances that kill foreign cells in the blood. An absolute eosinophil count is a blood test that measures the number of white blood cells called eosinophils.Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. | 0. 01%| Elevated Values:Elevated in cancer of bone, ovary, testes and brain. Skin diseases, trichonosis, Scarlet fever, Chronicmyelogenous leukemia, Myeloproliferative diseases. Decreased Values:Allergies, Pyogenic infection, Shock, Postsurgical response| | | Basophils(0. 000-0. 005%)| A type of white blood cell in the circulation which is characterized by its ability to uptake certain dyes when stained for examination under the microscope (basophils appear blue).Basophils play a part in the allergic response as they have IgE on their surface, and release chemical mediators causing allergic symptoms when the IgE binds to its specific allergen. | 0. 01 %| Elevated Values: Elevated in leukemia and healing stage of infecion. Hypersensitivity reactions, ulcerative colitis, chronic hemolytic anemia, Hodgkin’s disease, myxedema, chronic myelogenous leukemia, polycythemia veraDecreased Values:Hyperthyroidism, Pregnancy, Stress, Cushing syndrome| | | Hematocrit(0. 40-0. 48%)| Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells.This measurement depends on the number of red blood cells and the size of red blood cells. | 0. 34%(Low)| a danger sign of an increased risk of dengue shock syndrome. Polycythemia vera (PV) is associated with elevated hematocrit. PV is a myeloproliferative disorder in which the bone marrow produces excessive numbers of red cells, and reflects excessive numbers of RBC precursors in the bone marrow, as well as some abnormal forms. This condition is called erythroid hyperplasia. Lowered hematocrit can imply signi ficant hemorrhage. | | | Thrombocyte(150-300 x10^9/L)| Thrombocytes are important for normal blood clotting.If there are not enough thrombocytes, the risk of uncontrolled or prolonged bleeding increases. When there are too many thrombocytes in the blood, abnormal blood clot formation, a serious and life-threatening condition, can occur. Looking at the numbers, size, and health of thrombocytes is a part of a Complete Blood Count (CBC) test. | 27610^9/L| Increased values:Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and post operatively; about 50% of pt. with unexpected increase of platelet count will be found to have a malignancy.Decreased values : thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy. | | Urinalysis: The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and urinary tract and kidney disorde rs. Date| Component| Definition &Normal range| Rationale| Result| Interpretation &Significance| Nursing Responsibilities| SEPTEMBER19,2012| Color| Mainly a result of the presence of the pigment urochrome, (produced through endogenous metabolic processes).N: Light yellow to amber| The urinalysis is a routine screening test which is usually done as a part of a physical examination, during preoperative testing, and upon hospital admission. The results of UA are used to diagnose, treat, and provide follow-up for a variety of conditions, such as infections of the kidneys and urinary tract and also in the diagnosis of diseases unrelated to the urinary system. | Light Yellow| A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin.If the sample contained| PRE-PROCEDURE * Explain to the patient the purpose of the routine urinalysis and the need for a urine sample to be obtained. †¢ No fasting is require d prior to the test. | | Appearance/Turbidity| Generally refers to the clarity of the urine sample. N: Clear to slightly hazy| | Clear| Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator.Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of turbidity. | INTRA-PROCEDURE * Testing the first morning urine specimen, when the urine is concentrated, is preferred. * A minimum sample of 15 mL of urine is required. * A clean-catch midstream technique to obtain the urine sample is recommended to prevent contamination of the specimen. * Give instructions to the client on how to catch urine. * Instruct patients to avoid touching the inside of the specimen container and lid. For the portions of the urinalysis which involve use of dipstick testing, a reagent strip is dipped into the urine specimen. After a period of time specified by the manufacturer of the dipstick, the color of the reagent pad is compared with a color chart provided by the manufacturer. * Gloves are worn throughout the procedure. POST-PROCEDURE * Label the urine specimen and transport it to the laboratory immediately. The urine needs to be examined within 2 hours. * If urine is collected via an indwelling urinary catheter, a syringe and needle is used. Remove the needle prior to transferring the urine to the specimen cup to avoid damage to any microscopic sediment which may be present. Report abnormal findings to the primary care provider. | | Specific Gravity| Indication of the kidney’s ability to reabsorb water and chemicals from the glomerular filtrate. N: 1. 010 – 1. 025| | 1. 005| If it is below 1. 003 after a 12 hour period without food or water, renal concentrating ability is impaired and the patient either has generalized renal impairment or nephrogeni c diabetes insipidus. In end-stage renal disease.Having over 1. 035 is either contaminated, contains very high levels of glucose, or the patient may have recently received high density radiopaque dyes intravenously for radiographic studies or low molecular weight dextran solutions| | | Glucose| Glucose is virtually absent from the urine. Less than 0. 1% of glucose normally filtered by the glomerulus appears in urine (< 100 mg/24 hr). N: 0-100mg/dL| | (-)Negative| Presence or Excess sugar in urine means, Glycosuria, generally means diabetes mellitus. | | | Protein| Urine normally contains only a scant amount of rotein, which derives from both the blood and the urinary tract itself. N: 0-30mg/dL| | (-)negative| Trace positive results (which represent a slightly hazy appearance in urine) are equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of normal). 1+ corresponds to about 200-500 mg/24 hours, a 2+ to 0. 5-1. 5 gm/24 hours, a 3+ to 2-5 gm/24 hours, and a 4+ repres ents 7 gm/24 hours or greater. More than 150 mg/day is defined as proteinuria. Proteinuria > 3. 5 gm/24 hours is severe and known as nephrotic syndrome. | | WBC| Usually, the WBC's are granulocytes. White cells from the vagina, especially in the presence of vaginal and cervical infections, or the external urethral meatus in men and women may contaminate the urine. N: 0- 17 / UL| | 3| Pyuria occurs if the presence of leukocytes is abnormal or increased which may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis. | | | RBC| finding of red blood cells in the urine (hematuria) is considered abnormalN:0- 11 / UL| | 1| RBC in urine is slightly higher than normal.Significantly high RBC number in urine may point to acute tubular necrosis, benign familial hematuria, calculi, hemophilia, hemorrhagic cystitis, pyelonephritis, renal trauma, renal tuberculosis, renal tumor, or UTI. | | | Epithelial Cells| Renal tubular epithelial cells, usually lar ger than granulocytes, contain a large round or oval nucleus and normally slough into the urine in small numbersN: 0- 17/UL| | 5| If the number sloughed is increased nephrotic syndrome and in conditions leading to tubular degeneration,| | | Cast| Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron).The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation. Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells. N: 0-1/ UL| | 0| Presence of protein cast formation is often caused by low flow rate, high salt concentration, and low pH, all of which favor protein denaturation and precipitation. blood cell cast are indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage.White blood cell casts are most typical for acute pyelonephritis, but they may also be present with glomerulonephritis. Their presence indicates i nflammation of the kidney, because such casts will not form except in the kidney. | | | Bacteria| Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms.N: 0- 278/ UL| | 3| More than 278/ UL of one organism reflects significant bacteriuria. Multiple organisms reflect contamination. | | STOOL ANALYSIS: It is the evaluation of the characteristics of the clean catch fecal specimen. The physical characteristics as well as the contents of the feces are evaluated for the presence of gastrointestinal abnormalities such as infections. SEPTEMBER19,2012| Color| Brown| | | Consistency| Coarse| Unusualities in the stool consistencies may indicate GI abnormalities such as malabsorption and infection.Co arseness or excessive dryness may result from poor hydration status or presence of parasites in the GIT. | | Parasite ova| Trichuris TrichiuraAscaris Lumbricoides| Presence of ova in the stool indicates positive parasitic infection in the gastrointestinal system| | Pus Cells| 2-4/hpp| Pus production is an indicator of GIT infection as a defense mechanism activated by the immune system| Medical Order Order| Rationale| 9/19/121:15am > Please admit under the service of Dr. R.Mata (PC) >Secure consent for admission & mgt >Diagnostics:-CBC c PC-U/A-CXR – APC>Therapeutics:Cefuroxime (100_ 500mg IVTT q 8 hours (ANST)Paracetamol 250mg/5ml, 3ml q 4 hours RTCSalbutamol neb, I neb q 6 hrs>DAT c SAP>IVF : D5IMB 500cc to run @ 55 cc/hr >encourage pt to increase oral fluid intake>TSB for fever>VS q 4 hrs & record pls>I & O q shift, record>will inform AP of this admission>refer PRN, thanks! >Cont. meds & ebulization>fill up official CXR result 8am>Fecalysis3pm(+)LBM X 3>Erceflora I vial BI D >Increase rate of IV to 60cc/hr9. 20pm(+) trushing(+) ascarisStool exam>stat mebendazole (antiox) 50g/ml ,10ml on single dose9/20/128am>cont. meds(-) fever3pm Afebrile >cont. meds>refer for unusualities9/21/128am(-) fever>cont. meds| -To be able to accommodate the patient’s needs for optimum health care and to be able to refer any unusualities immediately and to continue patient monitoring. – This consent legalizes the acceptance and trust of the client to the health practitioner. With this laboratory test, the patient’s condition will be determined. – These medicines have different action thereby treating the client’s symptoms manifested by the client from her present condition-Maintain healthy diet within normal range and since the patient can tolerate any food he desires that is nutritious. Strict aspiration precaution since the patient was a child should be carefull and prevent aspiration-Is a hypertonic solution , for slow administration ess ential to prevent overload (100ml/hr)- To prevent dehydration-To help relieve fever- To obtain baseline data of VS and monitor condition of patient until stable. These measures excessive loss or retention of water in the body. – These medicines have different action thereby treating the client’s symptoms manifested by the client from her present condition. – to analyze the condition of a person's digestive tract in general -To Promote normalization of intestinal flora. -Besides of becoming asource of nutrition it also help replace the water loss by patient due to LBM-An antihelmintics , treatment of parasites present in the patient- These medicines have different action thereby treating the client’s symptoms manifested by the client from her present condition.These medicines have different action thereby treating the client’s symptoms manifested by the client from her present condition. – For the physician to be informed immediately, facilit ating attendance of the unusuality at hand- These medicines have different action thereby treating the client’s symptoms manifested by the client from her present condition. | ————————————————- ————————————————- ————————————————-DRUG STUDY GENERIC NAME: Acetaminophen BRAND NAME:   paracetamol CLASSIFICATION: Antipyretics, Non opiod analgesic MODE OF ACTION: Inhibits the synthesis of prostaglandins that may serve as mediators of pain ; fever, primarily in the CNS. Has no significant anti-inflammatory properties or GI toxicity. THERAPEUTIC EFFECTS: Analgesia. Antipyresis. ORDERED DOSE: 250 mg/ 5 ml, 3ml q 4 (RTC) DATE ORDERED: 9-19-12 SUGGESTED D OSE: 10-15 mg/kg/dose q 4-6 hr as needed INDICATIONS: Mild pain. Fever.CONTRAINDICATIONS: Contraindicated in: Previous hypersensitivity; Products containing alcohol, aspartame, saccharin, sugar, tartrazine (FDC yellow dye #5) should be avoided in patients who have hypersensitivity or intolerance to these compounds. DRUG INTERACTIONS:Drug-Drug: Chronic high dose acetaminophen may increase risk of bleeding with warfarin. SIDE EFFECTS: GI: hepatic failure, hepatotoxicity (overdose) GU: renal failure (high doses/ chronic use Derm: rash, urticaria NURSING RESPONSIBILITIES: 1. ) Monitor blood studies. 2. ) Monitor liver function studies. 3. Monitor renal function studies. 4. ) Check I ; O ratio. (decrease output may indicate renal failure) 5. ) Assess for fever ; pain. 6. ) Assess allergic reaction. 7. ) Assess hepatotoxicity: dark urine, clay colored stools, jaundice, itching, abdominal pain. 8. ) Assess for chronic poisoning : rapid, weak pulse; dyspnea : cold extremities; 9. ) Give dru g with food or milk to decrease gastric symptoms 10. )Tell patient that urine may become dark brown as a result of phenacetin (metabolite of acetaminophen) GENERIC NAME: Cefuroxime BRAND NAME:   Ceftin, ZinacefCLASSIFICATION: Anti-infectives MODE OF ACTION: Bind to bacterial cell wall membrane, causing cell death. ORDERED DOSE: 500 g IVTT q 8 ANST (-) DATE ORDERED: 9-19-12 SUGGESTED DOSE: INDICATIONS: Treatment of following infections caused by susceptible organisms: respiratory tract infections, bone ; joint infections, urinary tract infections, meningitis, gynecologic infections, lyme disease, perioperative prophylaxis CONTRAINDICATIONS: Contraindicated in: Hypersensitivity to cephalosporins, Serious hypersensitivity to penicillins. DRUG INTERACTIONS:Drug-Drug: Probenecid decrease excretion ; increase blood levels. Concurrent use of aminoglycosides or loop diuretics may increase risk of nephrotoxicity. SIDE EFFECTS: CNS: seizures, GI: pseudomembranous colitis, diarrhea, cramps, nausea, vomiting DERM: rashes, urticaria Local: pain at IM site, phlebitis at IV site Misc: anaphylaxis, serum sickness, superinfection NURSING RESPONSIBILITIES: 1) Observe ten rights of administering medication 2) Assess for infection. 3) Observe patients for signs of anaphylaxis. (rash, pruritis, laryngeal edema, etc) 4) Monitor Vital signs specially Temperature ) Advise patient to report signs of superinfection ; allergy. 6) Instruct patient to notify health care professional if fever ; diarrhea develop especially if stool contains blood, pus, or mucus, 7) Advise patient not to treat diarrhea without consulting health care professional. 8) Monitor patient for life threatening adverse effects, including anaphylaxis, steve-johnson 9) Monitor kidney and liver function test results and intake and output 10) Instruct patient to take drug with food GENERIC NAME: Bacillus Clausii BRAND NAME:   Erceflora CLASSIFICATION: antidiarrhealsMODE OF ACTION: Contributes to the recovery of the i ntestinal microbial flora altered during the course of microbial disorders of diverse origin. It produces various vitamins, particularly group B vitamins this contributing to correction of vitamin disorders caused by antibiotics ; chemotherapeutic agents. Promotes normalization of intestinal flora. ORDERED DOSE: q 1 vial BID DATE ORDERED: 9-19-12 SUGGESTED DOSE: Children 2-11 years 1-2 vials of 2  billion/5 mL susp INDICATIONS: for acute diarrhea with duration of ;14 days due to infection drugs or poisons. Chronic or persistent diarrhea with duration of ;14 days.CONTRAINDICATIONS: Contraindicated in: not for use in immunocompromised patients (cancer patients on chemotherapy, patients taking immunosuppressant medications) SIDE EFFECTS: No known side effect or adverse effect. NURSING RESPONSIBILITIES: 1. ) Observe ten rights of administering medication 2. ) Shake Drug well before administration 3. ) Monitor patient for any unusual effects from drug. 4. ) Administer drug within 30 mi nutes after opening container. 5. ) Dilute drug with sweetened milk. , orange, tea. 6. ) Administer drug orally. GENERIC NAME: mebendazole BRAND NAME: VermoxCLASSIFICATION: antihelmintics ORDERED DOSE: 50g/ml DATE ORDERED: 9/19/12 INDICATIONS: Treatment of whipworm, pinworm, roundworm, hookworm, infections. CONTRAINDICATIONS: Contraindicated in: Hypersensitivity. DRUG INTERACTIONS: Drug-Drug: Use with potassium-sparing diuretics or ACE inhibitors or angiotensin ll receptor antagonists may lead to hyperkalemia. Anticholinergics may increase GI mucosal lesions in patients taking wax-matrix potassium chloride preparations. SIDE EFFECTS: CNS: seizures, dizziness, headache GI: abdominal pain, diarrhea, increased liver enzymes. Nausea, vomiting Neuro: numbnessMisc: fever NURSING RESPONSIBILITIES: 1. Observe ten rights of administering medication 2. Administer with food. 3. Disinfect toilet facilities after patient use. 4. Arrange daily for daily laundry of bed linens, towels, undergarment s 5. Assess for temperature, bowel sound ; output 6. Culture for ova ; parasites 7. Monitor hematologic and hepatic studies 8. Advise patient to wash hands before and after eating 9. Teach patient to maintain strict hygiene to prevent reinfection 10. Advise patient that dietary restrictions, fasting, and laxatives aren’t necessary GENERIC NAME: albuterolBRAND NAME:   salbutamol CLASSIFICATION: Bronchodilators MODE OF ACTION: Binds to beta-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase ; increased levels of cyclic-3’, 5’ ORDERED DOSE: 1 neb q 6 DATE ORDERED: 9-19-12 INDICATIONS: Used as bronchodilator to control ; prevent reversible airway obstruction caused by asthma or COPD. CONTRAINDICATIONS: Contraindicated in: Hypersensitivity to adrenergic amines; Hypersensitivity to fluorocarbons. DRUG INTERACTIONS: Drug-Drug: Concurrent use with other adrenergic agents will have increase adrenergic side effects.Use with MAO inhibit ors may lead to hypertensive crisis. SIDE EFFECTS: CNS: nervousness, restlessness, tremor, headache, insomnia CV: chest pain, palpitations, angina, arrhythmias, hypertension GI: nausea, vomiting Neuro: tremor NURSING RESPONSIBILITIES: 1. ) Observe ten rights of administering medication 2. ) Inform patient that albuterol may cause an unusual or bad taste. 3. ) Advise to rinse mouth with water after each inhalation to minimize dry mouth 4. ) Instruct to notify health care professional if no response to the usual dose. 5. ) Chest tapping after each nebulization. . ) Position patient on high back rest position 7. ) Advise to consult physician before taking OTC med, natural/ herbal products, or alcohol with this therapy. 8. ) do not give a food immediately it can cause vomiting 9. ) Monitor serum electrolyte levels 10. )Monitor for hypersensitivity reactions and paradoxical bronchospasm. ————————————†”———- ————————————————- ————————————————- RELATED NURSING THEORY ————————————————- Florence NightingaleShe stated in her nursing notes that nursing â€Å"is an act of utilizing the environment of the patient to assist him in his recovery† , that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development The factors posed great significance during Nightingale's time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. Also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient.This theory was applicable to our client because of that the disease of our client is related to its environment. Our client has brochopneumonia which can be afflicted with our environment plus a weak immune system which initiates the disease process. Our client was also positive to Ascaris Lumbricoides and Trichuris Trichiura in which we could really tell that they are having a problem in terms of taking care of themselves like paying attention to their personal hygiene and the like in their community,. Environment is such a big factor to use and all other disease process that is done to our client. Envir onment provides the things that we that may do good or bad to us.Environment is also not always defined by the things around you but also the things that we can provide such as silent and soothing environment which is initially the best type of prevention for us. Know regarding to our client the factors that initiate healing status of our client is that the concern for sanitation it shows that having been infected with ascaris and trichuris is affected by unsanitary environment and other factors such as place of living, lifestyle etc. We must provide a sanitary environment to help boost immune system and ease the way for recovery and also we must initiate a supportive atmosphere to enhance the capabilities of client to rely to boost self confidence in having good prognosis and having a healthy and not anxious set of mind set. ———————————————— ———â€⠀Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€- NURSING CARE PLAN ————————————————- DISCHARGE ————————————————- PLAN Medication * Explain to the patient and significant others the reason why the drugs were prescribed by the doctor.  ® Providing sufficient information about treatment aids patient and family education as well as gains cooperation. * Encourage patient and family not to miss a dose during the whole duration of therapy. It is important to take your medicine exactly as you are told.  ® Medications taken full course give full therapeutic effects to the patient.In addition, this would also prevent the development of antibiotic resistant microorganisms. * Instruct the family to immediately stop medic ations if adverse reactions occur and refer immediately to the physician.  ® This prevents the occurrence of further progression of life-threatening adverse reactions. * Advice patient’s significant others to ask before taking any food or herb supplements, vitamins, or medicine that he/she bought at the store.  ® Some of these may negatively interact with the drugs that are being taken. Exercise * Instruct the family to provide adequate rest and sleep.  ® This aids the patient’s recovery and helps him regain strength. Tell client to continue deep breathing exercises, also instruct family for the exercise needed.  ® This is to promote good blood circulation and relaxation. * Encourage ambulation and active range of motions.  ® It mobilizes and loosen secretions. Treatment * Encourage the patient to follow the doctor’s orders  ® It is important to take your medicine and follow instructions exactly as what they are told. * Instruct patient and family to follow-up check-up as indicated by the physician.  ® Follow up check-up can help in monitoring the progress, reassessment, and evaluation of patient’s condition. * Encourage the family to comply with the treatment regimen for the patient. This helps by improving the recovery rate of the patient. Hygiene * Encourage the patient and significant others to wash hands more often especially when after using the bathroom.  ® To deter spread of microorganisms which cause various illnesses. * Encourage bathing daily.  ®This is to prevent spread of microorganism and promote self esteem. * Instruct the patient to promote good oral hygiene especially after eating.  ® This lessens the occurrence of dental caries. * Encourage patient to incorporate in his habit the proper way of washing her hands and covering her mouth when coughing.  ® This prevents the spread of microorganisms and further contamination. Out-Patient Advise patient and family to go back to the hospital in a spec ific date for follow-up check-up after discharge.  ® This enables the physician to reassess and evaluate the health status of the patient. * Consult a doctor if there are any problems or any complications encountered.  ® This calls for immediate action or interventions which may prevent furthermore complications. Diet * Diet as tolerated as much as possible.  ® To meet the daily requirements of the body as well as to have an optimum nutritional diet. * Encourage patient to drink 8 glasses of fluids a day.  ® To improve hydration as well as to excrete wastes accordingly. * Encourage to ensure safe water sources or if necessary, boil water for drinking. This is to eliminate the risk of any bacterial or parasitic infection. * Encourage to avoid eating raw foods such as raw meat. If dealing with fresh vegetables, wash it thoroughly with water.  ®This is to avoid microorganisms which could be present that can cause illnesses * Encourage the family to provide nutritious foods su ch as fruits and vegetables.  ® Fruits and vegetables are rich in essential vitamins and nutrients, which aid in supplying the optimum nutrition for the patient. ————————————————- ————————————————- REFERENCE (s) Reference (s) : * Bare, B. , Cheever, K. , Hinkle, J. , Smeltzer, S. (2009).Brunner and Suddarth's Textbook of Medical Surgical Nursing 12th edition. Lippincott Williams ; Wilkins * Bowden, V. , Greenberg, C. (2008). Pediatric Nursing Procedures Second Edition. Lippincott Williams ; Wilkins. * Maglaya,A .. [et. al]. (2009). Argonauta Corporation. Marikina City, Philippines * Mosby’s Pocket Dictionary. (2010). Elsevier. Singapore. * http://www. slideshare. net/crisbertc/pneumonia-4775641 * http://www. parasitesinhumans. org/ascaris-lumbricoides-gi ant-roundworm. html * http://www. medterms. com/script/main/art. asp? articlekey=12961 * http://whqlibdoc. who. int/publications/2006/9280640489_eng. pdf * Department of Health * World Health Organization

This has always been a major part of my identity

I am Korean.   This has always been a major part of my identity, even though I was born in America.   Being a member of another culture in America means that the way I have always viewed life, and success, is different than the way most Americans view it.   My mother, who was born and raised in Korea, contributed to this significantly.   She did not understand American culture, and never fully adapted to American life.   Living in a new country was confusing for her, which is why she clung so strongly to her native culture.   She passed this culture and way of thinking on to me. My mother was a typical Korean mother – prideful, overbearing, and she always had the attitude of â€Å"I’m always right no matter what you think.†Ã‚   Her attitude was maddening at times, especially when she remained completely calm despite telling me I was wrong and she was right.   However, it was this very attitude that shaped who I turned out to be, in many different ways. Traditional Korean values and American jobs do not mix well.   It was because of my mother’s strong Korean views that she could not keep a steady job in America.   This put us at a real economic disadvantage, but my mother remained strong no matter what.   She would find another job, and continue to provide for us somehow.   Even when money was tight, she was not discouraged.   My mother remained strong and did what she had to do. Watching her strength tore me apart sometimes.   I saw how hard she had to work, just to help us get by.   When I was 14, after having lost another job, my mother was forced to work for my aunt’s cleaning business.   She was assigned to clean a building that was within walking distance of our home, because she often had car troubles.   She made only minimum wage doing this, which I knew was not enough to support us. I asked my aunt if I could work with my mother in order to make extra money to help with bills.   While I can’t say I was thrilled at the prospect of working at the age of 14, I knew I needed to do this.   At first, my aunt resisted letting me, and my mother wasn’t happy either.   She did not want me to work.   However, within a week, both realized how serious I was about working, and they relented.   Already I had picked up from my mother’s attitude that I needed to do what had to be done, even if I did not want to. When we were not working, my mother and I talked sometimes.   Every chance that we had, it would always be about the same dreaded topic — my future. Being so deep inside of the grave, as I liked to call our financial situation, there was only one direction to look – up and out of the hole. I never admitted to myself that I wanted to leave her to go to college; how could I? Life was hard enough with both of us working, so it didn’t seem possible for her to do it on her own.   However, my mother had other ideas about my future.   She wanted what was best for me, and not the life that she had raised me in. I always protested when she told me this, because I wanted to stay and help her.   But she would tell me then, in her serious, don’t-argue tone that I needed to go to college to make my life better.   Our conversations had an enormous effect on my work ethic and my sense of responsibility.   I wanted to receive my degree and help my mom so that she could retire, because she was so selfless in taking care of me, and pushing me towards a brighter future. My mother’s quiet, hard-working attitude left a major impression on me. She taught me never to give up, to always do what is necessary, and to continually strive to do better.   I will not relent in the face of life’s struggles. I will be strong, I will work hard, and I will dream of a future that would not have been possible if it were not for my mother.

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Managing and developing people - Essay Example Usually, big organizations could have thousands of employees. To manage such a magnitude of employees requires expertise, skill and a deep knowledge of principles of management. Regardless of the size of the organization, human resources are what keep a company moving. This paper discusses the role of motivation in getting work done and especially in increasing employee job performance. The following is a report on the factors that affect motivation in an given organization. The report highlights different technique and human resources theory, which different organizations use to give rewards and maintain a well-motivated workforce. This section of the report analyzes the techniques and theories with an aim of evaluating their effectiveness as strategies made to assist the organization in achieving its goals. It is evident that the task of motivating workforce in an organization is not an easy one and requires that organizations evident enormous resources in the process. Cranny, Smith, and Stone, (1992), defines motivation as the process of empowering an individual to continue acting in a certain positive behaviour. Motivation in organizations is aimed at encouraging employees to take initiative in execution of their duties at the work place. Motivated employees exhibit self-drive and desire to willingly perform their tasks in accordance to the organization’s objectives (Cranny, Smith, & Stone, 1992). According to the Maslow’s theory, employees’ behaviour is influenced by wants and desires which unless satisfied, they continue to determine and influence how an employee will act. In a business organization, employees have their needs and wants, which make them to work. However unless their expectations are fulfilled they may under perform or function in less effective manner. Business organizations have come up with different ways of fulfilling human resource needs. The most important of them is the motivation of workers. Unless workers are

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Microeconomics - Essay Example This essay discusses free market, and how the price serves in it as the rationing mechanism. Pricing strategies and effects are also explained, as well as sellers and the way they can sell all they want at the equilibrium price. Two outcomes are probable when the government entails a price floor: if the price floor is lower than the equilibrium price, it is not binding and has no effect on the price or quantity sold, and if the price floor is higher than the equilibrium price, the floor is a binding constraint and a surplus is formed. The quantity supplied surpasses the quantity demanded. In this essay author refers to how buyers’ demands for the good or service must in several ways be rationed among sellers. This essay explaines such a thing using a significant example of a price floor, that is the minimum wage. Minimum wage laws order the lowest price for labor that any employer may pay. The economy nowadays includes not a single labor market, but many labor markets for various types of workers. The impact of the minimum wage was explained as well as workers and their skills and experience that were needed. The Advocates and the Opponents of the minimum wage give their opinion on the topic. While the Advocates consider the procedure as one way to increase the income of the working poor, the Opponents consider that high minimum wage triggers unemployment, encourages teenagers to drop out of school, and prevent several unskilled workers from getting the on-the-job training they need.

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What difference does it make that production is capitalist production - Essay Example The term "Capitalist" was first used in 1848 by Karl Marx and Frederick Engels in the Communist Manifesto in the famous sentence: "Modern Industry has converted the little workshop of the patriarchal master into the great factory of the industrial capitalist"1. According to the Houghton Mifflin Company, capitalism can be defined as follow: "An economic system in which the means of production and distribution are privately or corporately owned and development is proportionate to the accumulation and reinvestment of profits gained in a free market."2 The capitalist production is a system where the owners of money capital - referred as capitalists - hire labor to work in the production process. The capitalists gather within a corporation where they own shares. The decision process can be made by only one of them - commonly the one that owns the largest amount of shares - or they can appoint a manager who will take the decisions regarding the production for them. The output produced as well as the fixed and circulating capital goods used in the production and the residual of the value of output over total costs, including labor costs belong to the capitalists. As the capitalist process is based on the amount of capital, if the capitalists need additional capital - more than what they own - they can borrow from lenders and retain a part of the profit from previous years to use it as capital this year. Cooperative Production Even though Karl Marx was historically the first opponent to capitalism, he's the one in the Capital3 who gave the best explanation of its mechanisms. He also provided an alternative to the capital based mode of production: cooperatives. He did not actually present this alternative as we know it today but gave the main grouds of its creation. It is why usually cooperatives are associated with socialist and communist regimes. It is Robert Owen, a Welshman, who is the known creator of the cooperative movement in the nineteenth century. The most common definition of a cooperative is an organization which is owned by and operated for the benefit of those using its services.4 In other words a group of workers gather in order to set up a production process. Each of them participates in the production process, has shares and voting rights. In a cooperative, workers make common decisions or choose a manager to take the decisions regarding the production process. As in the capitalist production, the members of a cooperative can borrow money from lenders if they can not provide a sufficient amount of capital to the production process or retain a part of the net income from previous years to use it as capital this year. The main difference between capitalist production and a cooperative one is that the owners of the cooperative participate in the production process. They are not separated from the activity which is the case in the capitalist model. And mainly, they benefit from the entire production. They are not only paid for their labor but

Decision support System Essay Example | Topics and Well Written Essays - 2250 words

Decision support System - Essay Example Information technology experts are investing heavily in finding out the trends of IT uptake in the business world and utilize this information in key decision making for the organization (Albert & Kenneth, 2004). The demand for IT in businesses increases when customers realize there are programs in the market which are meant to help them avoid errors in decision making which affect their organization negatively through the losses incurred. Application of computers especially for decision support services is broad. There is no area in human existence where right decisions are not important. Whether it is health care settings, not for profit organizations, profit organizations, learning institutions, business organizations and any other place or institution where there is spending or cost incurred, all these require making decisions to strengthen the sustainability of the organization. Whether these are individual or corporate owned, there is need to gather information from consumers d irectly so as to offer products and services which will satisfy them (Albert & Kenneth, 2004). There is no business which operates within a vacuum. It is not very difficult to witness more than one organization which provides similar services, or companies selling goods within the same geographical area. Sometimes there goods which are originating from different companies present in retail outlets and customers do choose one item and leave the other. These decisions which customers make are based on several factors which attract them. In order to attract customers and influence their decisions to buy one product and leave another of the same type manufacturers spend so much in advertising their products to many people (Basil, 2010). The outcome of those promotional efforts is the large number of customers who demand for their products, thus boosting their capital base and profit. The quality of products or services also contributes much on the customers’ demand of those servi ces or products. It is important that clients take their time to provide goods and services which will be able to meet the basic standards in a given setting since every country has a board which oversees the sale and distribution of goods and services to ensure that consumers are protected from counterfeit products and services. Other external factors which affect a business organization include the political, legal and social systems in a particular country. It is important to understand the preferences of people you expect to be your customers for the products and services you offer. The behaviors, habits, customs and practices of people usually have a strong foundation which is sometimes very difficult to change. Therefore before you decide to invest in certain products while having a certain population in mind as your target population; it is important to consider the social nature of these people since it influences the purchasing habits of these people. The legal system is al so important in a given country since it lays a framework under which a business should operate. When investing in a foreign country it will be important to gather information on the laws which exist in that country so as to ensure you don’t incur unnecessary costs which come as fines due to breaking of business laws. These are some of the factors which aff

Analysis of Marketing plans for Forever Charge Assignment - 8

Analysis of Marketing plans for Forever Charge - Assignment Example This identifies a comprehensive basis for understanding the marketing environment and helps in ensuring a detailed marketing plan. Organization and precision of contents of each of the areas are however not adequate for an effective marketing plan. The environmental analysis fails to discuss customer factors and this means missing links in the plan. Other factors such as recession, competition, and technology advancements are just mentioned but are not discussed. Environmental factors, as used under environmental analysis, are also not specific because even technological factors, recession, and competition are environmental factors. Such organization of the section into external, internal, and customer factors and a discussion of aspects of each of the group of factors would have been appropriate. Even though SWOT analysis appears organized (Ferrell and Hartline 38, 39), its contents are not accurate. Helping to promote business, for example, is more of an objective than an opportuni ty, and if an opportunity exists for promoting business then that should be discussed with clarity. The marketing plan is for Forever Charge, a product of BKSK Inc. The product is a wireless charger that is new in the market and is being marketed for a new company. The objective of the plan is to win consumers’ trust towards sales and profits. Below is the analysis of aspects of the plan. The marketing plan is detailed and this allows for consideration of factors to the success of plan implementation. Each of the sections of the plan is organized into subsections in which details are discussed. Analysis of the marketing environment, for example, includes discussion on technological, competitive, economic, socio-cultural, legal, and social factors to the marketing environment. This ensures effective decisions on the explored areas.  

The Mysterious Forest Essay Example | Topics and Well Written Essays - 750 words

The Mysterious Forest - Essay Example I bet you will worship me after you see them for yourself. I know how much you love a mystery†, he said, tugging at her hands. Keira looked up at her best friend and seeing how earnest he was, she decided that he was not pulling her leg. She got up from the comfortable hammock in her house’s patio and headed off after Daryl towards the forest. Before leaving, she called out to her white shepherd dog, Snow, who she knew was aching for a walk since a long time. As she and Daryl trudged along, Keira wondered how she could have forgotten how far the forest was from her home. It certainly has been long since Daryl and I used to play there as kids, she thought. Aloud, she said, â€Å"Do not leave me in suspense, Dar. At least tell me what those markings look like. Is it related to a UFO or what?†. â€Å"I myself do not know for sure. I saw them in the morning when I went to take some leaves for my sister’s science project†, answered Daryl with a look of co nfusion on his face while he fed Snow some biscuits he had brought along. When they finally reached the edge of the forest, Snow suddenly started barking and tugging at the chain. â€Å"Whoa! Easy girl†, Keira murmured, â€Å"What has got into you?†. Looking around, Keira noticed that it was getting pretty dark outside as they had left for the forest just before night started to fall in. She was just about to suggest coming back the next day, when Snow broke loose of the chain and bounded off into the forest. â€Å"SNOW!†, Keira and Daryl shouted at the same time and ran behind her. Branches and leaves whipped at their hair and faces while Daryl and Keira dashed blindly through the forest. They could hear Snow’s barking in the distant, but no matter how far they ran or how loud they called her name; her barks seemed to be going farther and farther. Daryl started slowing down and whispered, â€Å"Wait wait!†. Keira reluctantly stopped, waiting impat iently for him to catch his breath. The moon was right above their heads by now, allowing Keira to clearly make out the fright on Daryl’s face. In fact, the whole forest was lit up by the moonlight, making the tall trees cast eerie shadows everywhere. Keira felt a pang of fright herself; Snow’s barking had stopped by now which meant that Daryl and she were all alone in an unfamiliar area of the forest. Suddenly, she heard Snow yelp in pain and then everything was silent again. Before she could even react, Daryl started muttering, â€Å"No no no no it cannot be. The markings were on the other side of the forest† , backing away from her. The moon was about to get covered by clouds, but before everything went dark, Keira caught a glimpse of Daryl’s eyes- they were wide with fear and staring past her. She quickly turned around and squinted into the dark clearing ahead of her. But before she could make out anything, she heard the rustling of leaves and the cru nching sound of someone heavy walking towards them from the clearing. Daryl let out a startled cry and took off into the forest, away from her. However, Keira was rooted to the spot with fear. All sorts of things went through her mind, especially the recent news reports on television about children going missing and ending up dead. The snap of a twig brought her back to her senses, causing her to whip around and start running like crazy. Keira did not know where her feet were leading her to because the only thing on her mind was to get away from this place or rather, this ‘presence’. Suddenly, she slipped on the wet floor and losing her balance, fell hard on the ground. While struggling to get up, her hands bumped against something cold and clammy. She jolted with fear, but before she could let out a scream, Daryl’

Emerging Themes in Marketing Essay Example | Topics and Well Written Essays - 2500 words

Emerging Themes in Marketing - Essay Example Independent research has been carried out on topics such as online shopping, its evolution and current scenario, a brief highlight on the online retail industry of UK and the current issues this industry is facing. The literature review also highlights the consumer behaviour and patterns during online shopping. Findings – Apart from an analysis of the benefits of innovation in online shopping, the paper also highlights the benefits and rising issues of online shopping sites. Originality/value –This paper also expands the literature on the various emerging issues in the field of online retailing and recommends strategies to improve the technological and overall innovations in online shopping, creating a better customer experience. Keywords - Online shopping, innovation, retail, sustainable growth, sales. Contents Contents 3 Introduction 4 Literature Review 5 Critical review 5 Online Shopping and Changing Retail Environment 6 Consumer Buying Behaviour and Drivers of Onlin e Shopping 7 Online Shopping In UK- Emerging Issues 9 Figure 2- Online Retailing As Percent Of UK Shopping. 10 Conclusion and Future Recommendations 11 Reference List 13 Introduction Innovation can be described as establishing ideas in order to create new solutions to meet the requirement of the business or organisation. There is a widespread belief that innovations leads to exploitation of ideas which in turn are responsible for a sustainable and profitable economic growth. However, the exact practices, measurements and course of directions for the innovative activities of an organisation depend largely on their situation. Innovation varies widely in services sector, compared to any other physical or tangible sector. Innovation in retail also requires more support from the government, compared to other sectors (Brown, 1990). But it should also be noted that innovation retailing sector has provided with largest number of value added services and employment opportunities within UK. R etailing can be considered as a cross-functional economic activity acting as a bridge between consumption and production. Online retailing is a sector where organisations bring together products and services relevant to the requirements of the customers (Doherty and Ellis-Chadwick, 2010). Retailers from UK have become more active in terms of supply chain and innovation. Most of the big organisations in retail industry are managed by professionals and have widespread reach in the developed markets. Now these organisations are stepping into emerging markets to increase their market share. Most of the big retailers have earned a brand name for themselves with some of them having in-house brands which are levelled with branded manufacturers. While it is not possible for these brands to establish brick and mortar shop in every corner of the city or country of target, online retail shopping has given them eminent opportunities which have helped in the overall growth of the market share, p rofits and overall revenue generation for these online retailers. The present article will find useful insights on the present online retail industry; its nature and scope and forces which drive innovation in the online retail industry. Literature is gathered to find out the typology and behaviour of the online shoppers and the

Romeo and Juliets Changes Essay Example for Free

Romeo and Juliets Changes Essay By the end of act 2 Romeo and Juliet have changed considerably from how they were first presented to us. By the end of Act 2, Romeo and Juliet have changed in different ways. It is not evident that the changes they have made are that considerable. Juliet becomes much more mature and less like a young girl. Romeo on the hand, doesn’t seem to have changed as much as Juliet. He does become more responsible and seemingly more mature, but his impulsive behaviour leads to his death. Romeo changes by the end of Act Two in the case of his maturity. He is first presented as a â€Å"lovesick puppy† over Rosaline, although he hardly knew her. He states â€Å"sad hours seem long† which shows him pining over Rosaline, whom he apparently ‘loved’. When he attends the Capulets’ party however, he then claims to have fallen in love with Juliet. This shows that he is a rather â€Å"fickle† character who perhaps doesn’t know the meaning of love. However by the end of Act Two, it seems that he remains firmly in love with Juliet, which shows that he has matured and no longer â€Å"loves only with his eyes†. He also shows more courage and bravery to love Juliet no matter the consequences. His attitude towards his friends changes as well and he is no longer as crude and jovial as them. He shows a more serious outlook on life. Although he does perhaps mature as the play progresses, his immature and impulsive behaviour remains as it was before. This recklessness is what leads to his banishment and death. Juliet is first portrayed to us as mild-mannered and obedient. The images Shakespeare presents us are of Juliet as a young child who is very innocent. As the play progresses however, she is shown to be falling in love with Romeo. This shows that she is maturing and she is now portrayed as a young women and not a little girl. She also defies her parents in marrying Romeo which shows that she now changed from the mild, innocent girl that we first see. She is brave enough not to trust her Nurse after she â€Å"betrayed† her. Her Nurse was previously her best friend and she had trusted her with everything, so the fact that she was able to lie to the nurse and defy her shows that she is no more strong-willed and independent. She advances from an dutiful child to a more mature woman who defies her parents and is braver by the end of act two. Throughout the play, the characters change in maturity and in their attitudes towards their parents and friends. Romeo and Juliet appear to love each other deeply and this is what makes them more mature, rebellious and strong-willed. Although they change in these ways, Romeo still remains impulsive and reckless and this leads to his downfall.

Basic resource for any organisation

Basic resource for any organisation Introduction: Information is basic resource for any organisation to its management. If the information is available on time its really effective for the management in its operations. The term information system usually refers to a system based on computer which is designed to support the operation, management and decision function. Management information system collects, transmit, process, store information and the system convert this data for management to make decisions and the strategy in the organisation. Reason for information system strategy First let me clear the misunderstanding for those who dont understand that whatever we do we have a strategy.im sure everything we do we have an objective to achieve that plan we make a plan that plan is strategy. Problem is strategy can be good or it can be bad or we may not have spotted that we can do much better if take the opportunity and environment into account. But there can be certain things give us a push to adopt a strategy and to achieve the better results for our business. There are two distinct phases, the first one is quantitative and the second one is qualitative. The first part we talk about the research of different organisations. In each organisation we will talk about different key stake holders in formulation of strategy process. This phase of the research will be started when different stakeholders will be interviewed over 100 interviews have been conducted so far. For the second phase the potential sample size will be every HEI in the UK. The first method tool which is being used to get samples in the first part is based on interviews and observation from which case studies are being created. The case studies created in part one will then be used to enlarge and increase upon present theory to grow a survey. This will be directed, using the results already recognized in qualitative research and different other organisations. This will bring the experimental sample to lots of other organisation which is adequate to learn any main defects in the survey. The second data-gathering tool will be a organized survey. The small size of the real people means that the survey can be given in all the organisations to at smallest three key stake holders or alliance frontrunners. Earl suggests a multiple methodology to formulate an information systems strategy. Earls multiple methodologies Earls multiple methodology provides a means of: Clarification of the business needs and strategy in information systems terms. Evaluation of current information systems provision and use. Innovation of new strategic opportunities. 1. Top down clarification Earls definition of a suitable method to clarify business needs in IS terms: ‘A methodology that is easily understood and used by line and general managers, it can cope with varying robustness of business strategy, it does not consume too much time or resource, it can be repeated as circumstances inevitably change and, as a result of these needs and because it could not achieve anything else, it points to directional IS needs and not detailed specifications. The ‘Critical Success factors approach meets many of the requirements of the definition. There are otherssee ‘Strategic Management and Information Systems Wendy Robson See ‘IT Strategy for Business Joe Peppard 2. Bottom Up evaluation Most organisations only have a vague understanding of the potential and capacity of their present IT systems. The technical perspective and backroom perception of IT may create a barrier. To understand the present systems a bottom up analysis is carried out. This involves an audit or survey. As well as the technical detail the user/specialist interface is examined. The value of the system to the organisation must also be ascertained. In this evaluation the following questions must be asked: How reliable is the system? How easy is it to maintain? How cost effective is it? What is the impact on the business? How easy is it to use? How often is it used? What is the state of our specialist user relationship? Other considerations might be the interactivity of the systems. These interactions and the evaluation can be shown graphically using systems maps or other means. The present systems can then be examined for strengths and weaknesses. The top-down business approach and the bottom-up systems approach do not provide an opportunity to exploit radical new ideas for exploiting the competitive advantage of IT. The business approach examines the ‘what and does not examine the ‘hows. The bottom-up approach is constrains radical thinking by the presence of the evaluation process and the strengths and weaknesses of the existing systems. A more detached approach is needed. 3. inside out thinking lateral thinking It is often inspiration and creativity that produces the bright spark ideas that can produce the beginnings of an IS strategy for competitive advantage. Ideas brought from unrelated sectors can often be successfully applied. The right atmosphere must be nurtured to produce this creativity. Runge suggests the following six characteristics associated with IT innovation|: The idea often emanates from a commercial manager. The idea was backed by a senior manager who became the project champion. The competitive advantage was added to an existing system; evolutionary process. The idea was developed outside of the IT control constraints. Customers were involved in the development. The application was given a high profile and was marketed. External Analysis The three legs of Earls multiple methodologies have considered IS strategy from an internal perspective. It is important to also view this strategy from an external point of view i.e. competitors, customers, consumers etc. There are techniques that can help clarify this approach. The SWOTmethod is a suitable candidate that explores both internal and external perspectives. A technique such as SWOT is useful when considering an external view of the three legs of the multiple strategies. Porters five forces model is a useful model for considering the external perspective on IS strategy. Boddy et al suggest that Porters model can be used to construct an IS strategy. Considerations when using the multiple methodologies. The use of methodologies does not mean a ‘cookbook attitude should be taken the implementation of strategies. Methodologies are useful overall frameworks but the context in which they are used needs consideration as well as experience. Experience suggests that: Significant differences existed in different firms; IS strategy formulation inherently seemed a more complex matter in some firms than others; and approaches in practice did not always match either the popular prescriptions or the accounts in case documented articles. Infrastructure-led may emphasise leg 2 bottom-up approach. Business-led may emphasise leg 1 top-down approach. Opportunity-led may emphasise leg 3 inside-out. Alternative approaches There are many other approaches in structuring IS strategy. One such approach is Porters five forces model. This is also useful in conjunction with Earls methodology. The following is reproduced from Body et al. IS changes the basis of competition: opportunities and threats Computer-based information systems are changing competitive conditions in many Indus-tries. There are many tools and techniques which can be used to analyse the relationship between strategy and information systems, depending on their purpose. In this book we can only illustrate one of these approaches, and the Five Forces model originally developed by Michael Porter seems the most appropriate to introduce. It can be used at the level of the individual firm to assess the possible impact of information systems on the competitive position of the firm. A comprehensive account of the many other perspectives on the topic will be found in Robson (1997). Figure 4.5 is based on Porters framework, and a show that IS represents an opportunity to secure a strategic advantage by using it to strengthen one or more of these forces. Similarly, it represents a competitive threat, if other organisations are able to use IS more effectively in these ways. Information systems and the threat of new entrants Managers can use IS on this force by using it to reduce the threat from new entrants by raising barriers, or by using it themselves to enter new markets. Using information systems to raise entry barriers The Caterpillar case illustrates that the manufacturer of the machine links the customer electronically with the service organisation. Because of that electronic link, it is not easy for a customer to go to another service organisation for repair and maintenance. This strengthens Caterpillars position as a manufacturer and as a service provider. The system is so complicated, advanced and expensive that it is hard for existing competitors to imitate. It is even more difficult for new entrants in this market to develop a similar system. The box gives two other examples. In the IS industry itself ‘setting the standard is very important to gaining a strong position. Most customers want to use equipment that has become established as the industry standard. Examples are Microsoft word-processing software, Intel computer chips and Netscape Internet browsers. It is very hard for new entrants to overcome these entry barriers, leading to a winner takes all situation in many sectors of the market. Using IS to enter markets more easily The Caterpillar case illustrates how the company uses its information system to attain a stronger position in the maintenance market. The system can strengthen the relationship with buyers of Caterpillar equipment and provide them with a broad after-sales service. Caterpillar becomes a stronger competitor of independent maintenance companies in new markets. Information systems and the threat of substitutes Companies can use information systems to alter this force by differentiating their products, or by creating new ones which they can use to threaten competitors. Using information systems to differentiate products and services The Caterpillar case shows the company using the information system mainly to improve the speed and quality of customer service. When the system notes deterioration the service starts immediately and the very capital-intensive machine will be repaired soon. This saves the customer a great deal of money. Other companies use the Internet to create and orchestrate active customer communities. Examples include Kraft (www.kraftfoods.com), Intel (www.intel.com), Apple (www.apple.com) and Harley Davidson (www.harley-davidson.com). Through these communities the companies become close to their customers. They can learn and innovate with product or service improvements that would otherwise be impossible. The research summary box below explains why it is essential for information service providers to differentiate their products. Using information systems to create new products and services Telephone and Internet banking are relatively new phenomena which have only become possible with new systems. The same is true of companies that use the power of database technology to offer new services in customer relationship management and direct market-in. Wide Internet access has generated a huge increase in businesses offering new services. These include electronic auctions, search engines, electronic retailers, electronic hubs (Data and Segev, 1999; Timmers, 2000; Kaplan, 2000), and Internet providers. Caterpillar created new maintenance services, and the next box gives another example. Information systems and the bargaining power of suppliers Increasing power of suppliers can increase their power by using information systems to track much more closely the costs of providing services to customers. They can set prices accordingly, or decide that they do not want a particular piece of business. For example, airlines use yield management systems to track actual reservations against traffic forecasts for any flight, and then adjust prices for the remaining seats to maximise revenue. Stepanekz (1999) reports how Weyerhaeuser Doors uses an Internet-based system to, amongst other things; manage orders from its distributors. This allows the company to manage its internal processes more efficiently, but also to assess much more accurately the value of each order, and the overall performance of its distributors. This enables it to refuse unprofitable orders, and to be more selective about the distributors which it supplies. Customer relationship management systems are a currently popular example of suppliers ability to track customers requirements more accuratel y, thus increasing the suppliers power over the customer. Decreasing power of suppliers Information systems can also be used the other way around. Customers can use information systems to strengthen their position in the marketplace at the expense of suppliers power. Ford and General Motors have set up electronic marketplaces and urge their suppliers to use that system to match their supply with the demand of Ford and GM. The Economist (6 November 1999) commented: Ford and GMs e-business revolution will not be confined to them alone. Their decision to go online will ripple through the 50,000 or so firms they trade with. The car makers are careful to say that none of their suppliers will be compelled to use their new portals, preferring simply to express that the benefits-cost savings, the access to new customers, the faster time to market, the sheer value of the information will make it an obvious choice. But the reality is different. Ford and GM are investing a lot in their e-business infrastructure and great hopes are riding on it. Suppliers that want to continue to do business the old way will rapidly become ex-suppliers and before long ex-companies. The next section about the use of information systems to change the power of buyers explores this theme further. This illustrates that information systems are increasingly inter-organisational phenomena, rather than hidden back-office systems. Inter-organisational systems can be used to co-operate as well as to compete with business partners, whether suppliers or customers. Powerful parties tend to urge less powerful ones to adopt their systems. Information systems and the bargaining power of buyers a good example of the balance of power being altered is when retail chains use modern communication technologies to make electronic links with their suppliers. Such systems reduce inventory costs and warehouse expenses and improve fulfilment time and information flows. For instance, they encouraged the further concentration of retailing firms which then had much more power over their suppliers. The retailers computer continually monitors its suppliers finished goods inventories, factory scheduling, and commitments against its schedule. The purpose is to ensure the stores always have adequate stocks. A supplier that is unwilling to join the system is likely to lose business. The box illustrates how Wal-Mart used this idea. More generally, buyers can use the web to access more suppliers, and to compare prices for standard commodities much more widely than was practical with earlier technologies. Information systems and the intensity of rivalry two ways of using information systems in the process of competitive rivalry are by reducing costs and through more effective management. Using IS to reduce costs On-line inventory systems make it possible to make radical changes in manufacturing supply systems. This greatly reduces inventory levels, and the costs associated with them. Car manufacturers are only invoiced for components when the completed assembly leaves the factory. When the system knows that X headlamps have been used, it passes the information to the component supplier. They send an (electronic) invoice for the components used, and supply replacements. There are similar systems in retailing, where suppliers like Unilever and Procter Gamble manage the inventory of their biggest customers. These inter-organisational systems reduce inventory costs but not only through lower inventory levels. They also reduce the need for working capital and allow a (smaller) purchasing department to focus on non-routine orders and strategic supply matters. The Internet enables large companies to transfer their purchasing operations to the web. Secure web sites connect suppliers, business partners and customers all over the world. This makes it easier for new suppliers to bid for a share of the available business, makes costs more transparent, and improves the administrative efficiency of the supply process. Using IS to enable more effective management A travel agents branch accounting system can now provide detailed patterns of business to managers, enabling them to monitor trends more closely, and to take better-informed pricing and promotional decisions. Another example is Ahold, a Dutch retailer, which achieved much greater performance in the supply chain by using its data-mining capability and knowledge extraction in its customer database. Management information systems can expand the span of control of individual managers, which can support the flattening of organisations. These examples show that information systems may become opportunities for creating, supporting or changing generic strategies. On the other hand competitors have similar opportunities there are also costs and risks associated with using information systems in this way. IS can also be a threat New entrants in the financial services sector have been able to introduce telephone bank-in through call centres very quickly. They were able to take advantage of the fact that they did not have an established branch network, and so could use the new technology very quickly. The technology worked to the disadvantage of established banks with many local offices. They found it costly to close branches. The technology was an advantage to the new, a disadvantage to the old. This illustrates a more general point that, for all the potential opportunities, IS can also be a threat. Information systems enable new competition Computer-based information systems represent opportunities for one business and threats to another company. In retailing, large chains have benefited at the expense of smaller shops, large suppliers have benefited at the expense of smaller ones, and large retailers have more power over suppliers. Any use of IS by one company to enter a new market, reduce costs and so on, is a potential threat to a competitor. They lose out if they have not seen the possibility, or have managed implementation less effectively. The London Stock Exchange is threatened by the fact that modern technology allows major institutions to trade shares directly, rather than use the market institution. The problem is increased by the fact that competing exchanges have implemented new information systems more effectively. They are likely to gain a larger share of a smaller market. Information systems place new demands on management time Implementing a major system takes a great deal of management time a cost that managers rarely include when evaluating investments. They require managers to look inward at (important) operational problems of staff, system design, and security. The danger is that they do not look at (even more important) issues of how to use the systems for strategic advantage. In other words: managers are often balancing between a ‘problem orientation and an ‘opportunity orientation. Senior management frequently underestimates the resources required to implement new information systems, especially of managing the many organisational implications. Implementing an information system successfully is difficult many research reports comment on the difficulties of implementing information systems. This is especially true of systems which involve many stakeholders with different interests or those which are innovative in other respects. They often take place in an uncertain environment, from a competitive as well as from a technological point of view. These uncertainties make it difficult to plan a change over a longer time. At the same time, the stakes are getting higher in terms of costs, people and other resources. Even when applications work, there may be downsides Managers often buy in expertise for development, operations and consultancy. These suppliers become the main experts of a companys IS resource. This dependency can be misused. Their lack of knowledge and insight in the organisation causes major problems. They have difficulty in negotiating successfully with the external providers and crucial company knowledge becomes the asset of other companies. References Achterberg, J.S., Gerrit, A. and Heng, M.S.H. (1991) Information systems research in the post-modern period. In Nissen, H.E., Klein, H.K. and Hirschheim, R. (eds.) Information Systems Research: Contemporary Approaches and Emergent Traditions. Elsevier Science Publishers BV, North Holland. Anderson, M. (1992) Implementing an information infrastructure strategy: the University of Edinburgh experience. University Computing Antill, L. (1991) Selection of a research method. In Nissen, H.E., Klein, H.K. and Hirschheim, R. (eds) Information Systems Research: Contemporary Approaches and Emergent Traditions. Elsevier Science Publishers BV, North Holland. Baroundi, J.J. and Orlikowski, W.J. (1988) A short form measure of user information satisfaction: pychometric evaluation and notes on use. Journal of Management Information Systems Boaden, R. and Lockett, G. (1991) Information technology, information systems and information management: definition and development. European Journal of Information Systems Breaks, M. (1991) Information systems strategies. British Journal of Academic Librarianship Burrell, G. and Morgan, G. (1979) Sociological Paradigms and Organisational Analysis: Elements of the Sociology of Corporate Life. Ashgate Publishers. Campbell, W.G. and Fiske, D. (1959) Convergent and discriminant validation by the multitrait- multimethod matrix. Psychological Bulletin Creswell, J.W. (1994) Research Design: Qualitative and Quantitative Approaches. Sage Publications.Return to text Fitzgerald, E.P (1993) Success measures for information systems strategic planning. Journal of Strategic Information Systems Galliers, R.D. (1991) Strategic information systems planning: myths reality and guidelines for successful implementation. European Journal of Information Systems