Does Age Really Matter? Essay

Some people may think that age matters in relationship while others say that relationships work best when the male is older, but I do not agree with either ideology. I used to believe that age matters in a relationship but after personally going through an experience that counteracted those beliefs, I finally believed. When my cousin, Mojgun, met the love of their life no one, including myself, ever believed that the relationship would work, especially since she was five years older than him. Usually in the Persian culture, the man is supposed to be older than the female, always, and when that isn’t the case, there is not much hope for the relationship. After being together for six years, they finally married, and now she is expecting their second child, and they are happier than they could ever be. With that, age doesn’t matter in a relationship because it all depends on the individual’s ideals, culture, and what their goal is in that relationship or that point in their life what they’re looking for. Age doesn’t matter in a relationship; as long as they both are mature and they have a same goal in their life and they care about each other. A relationship is like a boat in the ocean if they don’t know where they’re heading too and if they can’t work together, they never can land the boat. The only thing that matters the most in a relationship is the love between couples. If you are in a relationship with a person that takes advantage of you or abuses you, it makes no difference what your situation or age is they will do that no matter what the age is. An example of that is one of my mom’s childhood friends married a man two years younger than here, and since they have been together he has been abusive to her ever since. It has not gotten any better, in fact it has gotten worse, because now she is use to it and thinks that’s what love is. No matter what people try to do, including my mom intervening, she always goes back to him because that ’s how her brain is trained now. That’s what she grew up with, especially with her relationship, and that’s what she is accustomed to. The relationship obviously is not healthy because they both don’t have the same goals in that relationship, which should be including treating each other with respect, not degrading each other. No matter what the age, if she was younger or  older, her husband is the type of person who is abusive, and age would not fix any of it. It would remain the same because that’s how his personality is. Perhaps, if he was actually loving, and really treated her with respect, she would know what real love is, but she does not, and it is sad to see her live with that, thinking that deep down it is love. Love should not hurt, and in her case that’s all she feels on a constant basis from him. Through this example, it clearly shows that age does not take a toll on the end result or on what’s occurring between my mother’s friend and her husband. No matter what the age, everything will still stay the same, and eventually as time passes by things will get worse and w orse, as sad as that is. When people have the same goals on the other hand, like for example, wanting to settle down and have children, relationships are more likely to be successful. When couples have the same goals at the time of meeting or starting a relationship, it plays really vital to the success of that relationship. If one likes to go out and party, and the other does not there is always going to be that friction between them because one is doing something the other does not approve of, and so forth. Regardless of the age, there is always going to be that friction. On the other hand, if both like to stay at home, dine in, and share the same interests it really doesn’t matter what age they are because they share the same interests or common goals. When couples have the same long-term goals in mind, such as having kids or settling down getting married, they will do whatever they have to do to complete that end goal, and both do that to make sure it happens. For example, if a man is not looking to settle down, while the woman is, there is always going to be friction, and most likely that relationship is not going to work out. In my own experience, even though I am only twenty two years old, I have had relationships where girls wanted to become something more serious than I could handle, and I just was not ready for that. As a result it caused a lot of road blocks because we did not see eye to eye on what was going on with the relationship and where it was going, therefore me having to break up with her because it’s not a common goal we shared. I did not plan on marrying her or being in a committed relationship where I knew I wanted to marry her, I just was not ready. Regardless of age, if one is ready to settle, when the other is not, the relationship is most likely not going to work, because it’s in their  mentality, the personality, whether they want to settle down at that point in time or in their life. Anyone could make an argument that if someone was older or younger, it could have an impact, but in the end, it all depends on the individual and age doesn’t necessarily mean that your outlook, personality, or opinions change. As one gets older, you can argue that their opinions become more solidified, and they become more stable with who they are, and what they want in life. Primarily in the Persian culture, women are always treated with the utmost respect. It does not matter how old each partner is in the relationship, because there is always the basic foundation of treating each other with respect, especially Persian men with Persian women. They are like a team, and no matter what, they will do what they have to do to win the game (life), side by side. When a couple sees eye to eye, it does not matter how old they are, it matters that they understand each other, and want their relationship to work. Relationships work if you take the time to get to the know the person you are going to be with. If they don’t share the same ideals, culture beliefs, or goals in life, most likely the relationship is not going to work. It all depends on the type of individuals that are paired together and whether there is chemistry and that drive to make it work, otherwise it’s an uphill battle. When couples who are together share the same interests, goals in life, and beliefs, there’s a higher probability that their relationship will work, regardless of their age.

Ap World Histroy Dbq

DBQ Political, religious, and social factors affected the work of scientist in the sixteenth and seventeenth century in many ways. They were the reasons why natural philosophers questioned, studied, and continued to find new information in their discoveries. Developing a new scientific worldview must have required an abundance of controversy dealing with these important factors. There were people who believed that the discoveries made should not interfere with political power. *Thomas Hobbes, an English Philosopher, certainly believed in many theories’ that scientists had viewed. However he is best known for his political thought.Certainly his political views were included in his scientific works (Doc 7). Louis XVI, a political power, showed interest into the scientific studies. This evidently showed on a drawing to honor Louis XVI’s visit to the French Royal Academy (Doc 10). Clearly, science was encouraged to flourish because people knew the happiness of the country, for not only depending on the arms abroad but for also creating abundances at home (Doc 11). The social factor was furthermost likely to have been more analyzed in scientist works. Many were interested in what people thought of them and their studies.Scientist were even more proficient in removing their experiments completely if people disagreed. Marin Mersenne guaranteed that his experiments had been repeated more than 100 times, but however was willing to change them if someone did not agree. Others however, were confident in their studies and did not care for much criticism (Doc 1). The reason for why natural philosophers were sometimes held back was because they truly did not know what their objective was. This is most likely why they made slight progress in the sixteenth and seventeenth centauries (Doc 4). Religion was unquestionably a factor scientist considered.They took the principles of God into their works. It appeared impossible to them how things could have so much aston ishing features and qualities and still have been created out of nature. They knew these things became to exist from an immeasurable wisdom and power (Doc 8). Just as God governs minds, minds have specific laws which place them above the moments of matter (Doc 12). Bible stories were used as comparisons with scientific views, such as John Calvin mentioning Moses who wrote in a popular style where all ordinary persons gifted with common sense and were able to be understood (Doc 2). He is a French Protestant theologian which may be what leads him to trust that astronomy unfolds the admirable wisdom of God. There were those who were not affected with political, religious, and social factors because they were limited on human rights. Women had certain difficulties in the scientific area. Margret Cavendish would have set her own school of natural philosophy if she would have not have feared the casting of a male school. *Margaret, a natural philosopher, was certainly interested in discov eries however, she understood the complications of having a part in this grouping (Doc 9).Studies should have been allowed from those who wished to learn, as well as those who selected to reject whatever is unidentified to them (Doc2). Both genders could have formed a friendship between intelligent associations; this would have been a great aid to the investigation and education of the truth (Doc 6). Political, religious, and social factors were massive topics. Natural Philosophers certainly were aware of their process of studies and experiments. They all had different views on the three factors causing old and new discoveries to be more interesting.

Digital Education

Essay On Online Vs Traditional Education Working adults and stay-home parents looking to further their education may use online education as a resourceful tool to extract a better learning environment. In today’s society, online education is designed specifically for working adults and stay home parents with busy schedules and social responsibility. Some employers are now demanding more education from their employees along with in field experience than ever before and the job market is increasing competitive for those who want to succeed in their career.Traditional Learning provides the oldest method of education. Allowing the student to see the professor face to face and ask pertinent questions concerning their classes. Students have the ability to meet with other students for study groups and friendship. During my research, students who choose the traditional method of education believed that the face-to-face students enjoy the ability to learn with others, allows for class instruction, presentations, live speaking and they love the ability to get to know their instructors. Relevant materials: How Businesses Can Learn From Text MiningStudents in the face-to-face courses are able to get together in study groups that help them achieve better in testing. On-line Learning provides new age technology to widen the educational scope. With new age technology, I sense enormous excitement about the promise of online learning to prepare today’s students to succeed in an increasingly technology-driven global economy. Prospective students are facing a new kind of college experience — online education. It employs portable devices, computers and PDA’s to facilitate learning.With advances in information technology, portable devices, computers and PDA’s have traditionally been seen as a way of carrying information in a more convenient format, with longer battery life than a laptop computer and less weight than a bag full of reference books. Virtual classroom settings and message boards offer a variety of learning techniques. A setting usually contains an electronic whiteboard. The instructor presents instruction and interacts with students in real-time. Virtual classrooms include chat functions and often the ability for participants to speak to one another.It also, it allows student to learning without having to commute. For those students who are not able to attend their regular classes and colleges can easily carry with their higher education through online education mode of study. Students can create study environment of their like, they can make their own schedule; they can carry education while on the move, along with business they can pursue with their higher education. Best practices, a sustainable effort to extract and establish the best learning environment.Online is a quickly growing means of education for all students. It allows students to work and learn at their own pace without the unyielding time restrictions of traditional learning. Online education provides access to learning materials at any time. This allows students the flexibility to schedule their learning around families, jobs and other activities. Technology also provides accessibility and time management. Working while going to school is the potential applicability that studies may have on your job.In other words, it’s one thing to go to class and learn about something in theory, and it’s another to take that theory and put it into practice. Students who work can apply their newly acquired knowledge immediately to their jobs; they can also focus their studies on the kinds of real-world problems that professionals face daily in the workplace. It collaborates both students and teachers just alike from across the globe. No technological invention in the history of man has connected the people of the world like the Internet.While there is still a huge disparity between those who have access to the Internet and those who don't, the mere fact that any of us can communicate across the globe speaks to the importance of this medium. Many times the web sites we visit in a course are based in another country. What better place to find out about the works of Michelangelo than to go to Italy (virtually, of course)? What better way to learn about the Amazon rain forest or the history of China or the customs of islanders in the South Pacific than to visit those places online?And if you participate in global learning days or other online events, you may even meet and make friends with someone in another country. It is a small world, after all. The point is that we live in a diverse-changing world that is ripe with new possibility. The ability to learn new information or a new skill whenever you want and wherever you want offers far greater opportunities for education than ever before. The scope and reach of education broadens to far greater horizons that perhaps ever imagined. ______________________________________________REVIEW I'd like to begin, if I may, by just clearing up a couple of things. Onlin e education is not a tool to extract a better learning environment. Learning environments aren't extracted with tools. A spade, however, is a tool that can be used to extract a potato from the ground. The important thing to know about potatoes, however, is that whether they are good or blighted is independent of the specific tool of extraction. Online education is also not one thing. The Khan Academy provides free educational videos.Stanford provides free online educational courses. EssayJudge. com provides brilliantly insightful reviews. (Honest! ) Then there's a galaxy of pseudo-educational sites and lousy overpriced university sites and fraudulent degree mills for the gullible and the desperate and the cheaters and the pretentious and the ne'er-do-wells. So if you want to compare online education with traditional education, you need to be clearer about what exactly you mean by online education. Online education facilitates plagiarism.For instance you can go to sites that list the seven benefits of online education or the ten advantages of online courses and then cut and paste into your own essay, without attribution, vapid sentences like: â€Å"What better way to learn about the Amazon rain forest or the history of China or the customs of islanders in the South Pacific than to visit those places online? † or â€Å"Students who work can apply their newly acquired knowledge immediately to their jobs; they can also focus their studies on the kinds of real-world problems that professionals face daily in the workplace. â€Å"

PROBLEMS FACING HIGH SCHOOL SCIENCE TEACHERS AND THEIR SOLUTIONS Essay

PROBLEMS FACING HIGH SCHOOL SCIENCE TEACHERS AND THEIR SOLUTIONS - Essay Example However, these teachers tend to experience some challenges and this discourse focuses on such. Science is a very dynamic field and this means that high school science teachers must adopt emerging technologies to enable their students remain marketable or viable in the job markets. However, this tends to be a great challenge in low income high schools where science teachers are forced to rely on outdated technologies. Technology, in this scenario, refers to the machinery, computer hardware and software, lab equipment, and lab manuals (Baker 32). Some teachers in such institutions handle the theoretical parts of the advanced technologies without necessarily arranging for practical sessions due to lack of required facilities. At the end of the day, students lack the practical experience and this is a huge setback as they graduate and join the job market. The solution is the administration of such schools should liaise with local authorities so that some fund could be set aside to purchase the right equipment in the institutions. The schools could also seek funds or donations from the community, organizations, and even willing individuals to purchase the required equipment (Geisler 209). Meanwhile, the school could make arrangements with institutions with such facilities so that students could make arranged visits and learn from their facilities. However, this should be in a manner that both students from both facilities are not inconvenienced. Science teachers could use assimilated modules to guide their students as the administration seek funds to purchase such facilities. Science oriented subjects require more lesson hours compared with social and humanity related subjects. However, a majority of high schools allocate the same hours for all subjects. Due to this, a majority of teachers end up not completing the required syllabus as the school closes. However, their counterparts handling social and humanity lessons

Elastic Clause of the US Constitution Assignment

Elastic Clause of the US Constitution - Assignment Example â€Å"Implied† powers are â€Å"those powers given to Congress by Article 1, Section 8, clause 18, of the Constitution that is not specifically named but is provided for by the necessary and proper clause† (p. 45). Accordingly, the necessary and proper clause exists to afford these implied powers to Congress in order to make sure the federal government has the power to carry out the laws â€Å"which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States† (p. 44). This clause is problematic for many because it falls along the Federalist/Anti-Federalist divide and the contemporary Conservative/Liberal divide. However, the problem with the necessary and proper clause is not with its controversial and contentious nature, but with the fact that it is vague, ambiguous, and is designed for subjective interpretations and applications of Constitutional law.The phrase â€Å"necessary and proper† in clause 18 of Article 1, Section 8 entitles Congress to make laws that extend beyond what the Constitution enumerates in the previous 17 clauses of that Section. This is taken to be a relationship between an end-goal and the means of achieving that goal (Engdahl, 2011). The end-goal must be a necessity for the achievement of the purpose of a government, which include the formation of â€Å"a more perfect Union† and the establishment of â€Å"Justice† (US Constitution, 1787). These ends are the explicit goals of the enumerated powers; in a similar vein, the implied powers are given only as they are necessary and proper to exercise the enumerated powers. This interpretation of the â€Å"necessary and proper† clause is based on the context in which it appears. Coming after 17 enumerated powers, the final clause specifies that the Congress is able to make laws that ensure the foregoing powers (namely, the enumerated powers ) can be exercised sufficiently. In other words, the eighteenth clause of Section 8 does not give a blank check to Congress to make any rules or regulations it feels like passing. Rather, the expansion of implied powers must always be taken in necessary and proper reference to one of the enumerated powers.

Changes brought on by blogging and social media on public relations Research Paper

Changes brought on by blogging and social media on public relations - Research Paper Example Public Relations (PR) is the act of managing the informational flow that occurs between a business/company or organization and the public (Stuart, 2012). It is an essential part of business operations, and any successful company requires this part of business in order to maintain a relationship with its target market which in this case can be referred to as the audience. The introduction of blogging to the business world has affected the public relations sector in a number of ways, and it can be said that it has become an essential factor in this part of business as its popularity has continued to rise over the years (Fraser, 2007). Companies have developed the need to integrate blogs and blogging into their PR system as its growth has made it a medium of importance. There are various changes that have been brought on by blogging on Public relations as it has affected various areas related to this practice. Some of these areas and the changes that have been to them include: Communication can be said to be the sector that has been mostly affected by the introduction of blogging to Public Relations. The mode of communication has developed as a result of the introduction of blogs to the internet as the traditional methods can be said to have been surpassed as a result of this new activity (Bruns & Jacobs, 2006). Whereas in the past most companies depended on the more traditional mediums such as TV, Radio and Print media to pass on their information to the public, the introduction of blogs has brought on a new trend where these mediums are no longer a necessity for those organizations who may wish to pass on certain information to the public (Fraser, 2007). The internet has spread throughout the world like wild fire, and as a result there is a large demographic population that have turned to the World Wide Web as a source of information thus

Comparison of Literature Respecting Fascism during the Nazi Party Era Essay

Comparison of Literature Respecting Fascism during the Nazi Party Era - Essay Example Fascism is: ''A form of political behavior marked by obsessive preoccupation with community decline, humiliation or victim hood and by compensatory cults of unity, energy and purity, in which a mass-based party of committed nationalist militants, working in uneasy but effective collaboration with traditional elites, abandons democratic liberties and pursues with redemptive violence and without ethical or legal restraints goals of internal cleansing and external expansion.''1 Fascism is generally associated with mysterium inguitatis, or sin. There are similarities with fascism and terrorism, which unfortunately citizens of the United States are concerned about more than ever since the events that occurred on September 11, 2001, which was an example of inspiring intimidation through force. While there are unfortunately many fascist leaders in the world today, many may recall most of all a fascist leader named Adolph Hitler, who was a leader of Germany before and during World War II. Over the past few years, two books have been published addressing fascism that focused in large part on Hitler and World War II. One book, "Austerlitz", which is a fictional book whose main character's last name is the title of the book, was written by W. G. Sebald, who is a knowledge expert of the Holocaust in particular2. Basically, the book focuses on one man's journey through this part of European history and its fascist leaders. The other book, "The Anatomy of Fascism", by Robert O. Paxton, is a non-fiction book that dissects the components of fascism quite thoroughly, such as the history and cause of fascism, past fascist leaders and how they operated, and predicts the future of fascism in the world3. So, what exactly is fascism and how was it overtly demonstrated by Adolph Hitler Fascism is also correlated with evil. One accepted definition of fascism is a political paradigm that involves the implementation of a militaristic and autocratic government. Fascists are also creators of right wing authoritarian regimes. Why is it correlated with evil Because historically the citizens of fascist leaders, such as Hitler, experience the same consequences and human emotions of evil, such as calamity, suffering, sorrow, and distress. This evil delivered by fascist leaders typically and initially develops the perception of total innocence and assurance of prosperity of these citizens when they follow their objectives. Yet on every occasion of fascist leaderships, mercilessness occurs if not coerced by the fascist leaders eventually, such as Hitler, whose Holocaust deaths are believed to be by many as a true definition of evil. These leaders typically use the same tactics as those who desire to brainwash others, such as: 1. Keeping their citizens unaware and ignorant of certain events and knowledge. 2. Fascist leaders attempt to control their citizen's time and environment as much as they can. 3. These leaders create dependency and fear among their citizens. 4. The leaders suppress if not outlaw the ways things were done in the past. 5. Fascist leaders instill new beliefs that they claim are necessary for the

Gay Marriage and its Legalities Essay Example | Topics and Well Written Essays - 1000 words

Gay Marriage and its Legalities - Essay Example For proponents of the human rights issue, the matter would appear to be rather open and shut in terms of challenging constitutionality and this issue impacts decision-making at the social level, even if this practice is discouraged in the rule of law. This division seems to maintain the gay marriage and its constitutionality while this divisional approach exists. â€Å"Consistent with the rule of law, however, the Department of Justice has long followed the practice of defending federal statutes as long as reasonable arguments can be made in support of their constitutionality, even if the Department disagrees with a particular statute as a policy matter, as it does here." (lawlib.state.ma.us, 2). In defense of those who uphold the constitution as a foundation on which to mold new social policy, leadership recognizes that policy on gay marriage stands and will remain defended providing there are no significant grounds on which to proclaim the act unconstitutional. Federal support for the program without claims of unconstitutionality put this issue much into state-level hands, with federal level support in the objective if the goal is to uphold this civil rights matter. The mid-tier court system that governs and shapes these policies is currently made up of very conservative judges and a blend of more liberal decision-makers (Chemerinsky, 3). Division at this level and lack of solid ground on which to claim opportunity for repealing federal policy halts the progress of ensuring adequate legal protection for gay marriage. Under this system, challenges to decisions made at the district level are put forward to the Supreme Court in the pursuit of discretionary review. In general, gay marriage will likely be decided at the highest levels of judicial scrutiny providing that a resolution (either for or against) is determined at the inferior levels of justice. States that allow gay marriage include California, though its momentum is continuously challenged.  

Contempory business issues-sub-prime lettings Essay

Contempory business issues-sub-prime lettings - Essay Example In September 2007, Northern Rock, the UKs fifth largest mortgage provider, was forced to seek an emergency funding from the Bank of England, the UKs central bank as a result of problems in international credit markets attributed to the sub-prime lending crisis. Not only that, even the IMF has warned the UK housing market about the mortgage scenario in the country. According to IMF, the UK market is even more overpriced than its US equivalent before the current decline. Consequently, IMF has downgraded its forecast for 2008 growth to 2.3%. They attribute the dangers to higher lending standards than in the US as well as strong immigration combined with constrained supply. Recently, Morgan Stanleys David Miles described himself as ‘relatively pessimistic’ about the UK housing market. According to him, it is in a worse shape than its European counterparts. He further warned that limited supply wont continue to hold up prices into the future. In this context, I would also like to state the perplexing figures release by ‘Shelter’. According to which more than a million people used high-cost credit card loans to meet rental or mortgage demands in the last 12 months. Out of the 2,000 households polled, 6% had relied on a card, and when payments were made by young people aged between 18 and 24 that figure rose to 7.5%. Just few days ago, the Chairman and CEO of the global financial giant, Citigroup, had to resign owing to almost $5-billion write-off in mortgage due to the sub-prime crisis. These are certainly worrying signals of times to come. At this point, let us try to understand the root causes of the subprime crises in US. The subprime mortgage lending problems actually began almost three years ago when mortgage companies started giving out loans to consumers without asking for any documentation or verification. As a

Promoting recovery in mental health (case study) Essay

Promoting recovery in mental health (case study) - Essay Example The concept of psychiatric rehabilitation was introduced in mid-1970s and the concept slowly evolved to absorb more fresh air and democracy through the next decades (Pratt, Gill and Barret, 2007, p.13 of the preface). A more recent development that happened to this concept has been the notion of psychiatric recovery, which evolved in late 1980s (Deegan, 1988). Pratt, Gill and Barret (2007, p.111) have expressed the essence of this concept by saying, â€Å"the idea of recovery represents optimism about the future.† Recovery model in psychiatric treatment has been the product of the brave research work undertaken by persons who had walked through the dark alleys of mental illness, and had come out of them with a new spirit of freedom and self-determination (for e.g., Anonymous, 1989; Ralph, 2004; Unzicker, 1989; Deegan, 1988). It was based on the models of â€Å"recovery from physically handicapping conditions, a number of researchers and scholars have helped to develop a conce pt of recovery for severe mental illness† (Pratt, Gill and Barret, 2007, p.111). ... he mentally ill person is assisted to take command of his/her own situation and he/she is no more totally at the mercy of others, whether they be psychiatric professionals, friends, relatives or institutions. This is the first step towards accepting a mentally ill person as a person having equal rights with a ‘normal’ person. And this is where the recovery concept of social inclusion comes in as the most important factor. Brown (1981), Chamberlin (1984), Jacobson and Curtis (2000), and Everett (1994) have been the major theoreticians who had developed the concept of recovery into a practical psychiatric practice. The basic tenet, to which this concept owes its emergence, is the idea that human interaction, love and mutual understanding are the core values of existence. In curing a mental illness of a person, his/her friends, family, neighborhood, community and the society have a responsibility to share (Ramon, Healy and Renouf, 2007). Deegan (1988) has drawn attention to the fact that the notion of recovery from mental illness is now a twofold intervention where, the patient has to take up one’s own responsibility and all the same, professional help is available for him/her to further the recovery. In particular, customer involvement has been the most important segment of the concept of recovery. This customer-first theory was an outcome of an era when mentally ill patients were victims of superstition and where they were deprived even of the basic human rights (Jacobson and Curtis, 2000). Out of this bleak situation, the mentally disabled persons gradually learned to raise their voice and to initiate a social movement (Jacobson and Curtis, 2000). The collaboration approach is also part of the recovery model. The scope of this concept includes, â€Å"education,

The Presence of Horror and Fear in ‘the Monkey’s Paw’ Story Essay Example for Free

The Presence of Horror and Fear in ‘the Monkey’s Paw’ Story Essay This essay is an analysis of ‘The Monkey’s Paw’, a horror short story by William Wymark Jacobs. This story is about a talisman that shapes like monkey’s paw which has magical powers. It grants three wishes to its owner. It’s given to one family, husband, wife, and their son. They wish for some money, and that wish also become true, they get the money, the exact amount they wished for. But actually that money was the compensation for the death of their son that caused by the accident. Torturing by the sadness of the dead of her only son, the wife wishes for her son back to life again. When knocking is heard at the door, the husband feels scared about what will happened. And before the wife can opened the door, the husband used the last wish. The knocking stop and when the wife opened the door, no one is there. The essay will be focused on how the speaker brings the horror and fear in this story. There are many ways how the horror and fear is delivered in this story, but this essay will only take and explain three of them. The first thing that brings horror and fear is the background of the Sergeant-Major Morris as the previous owner of the talisman, how he could get that talisman. The reader can feels that the talisman has a mysterious background from how the Sergeant-Major feels uncomfortable when telling about the talisman. â€Å"The soldier regarded him the way that middle age is wont to regard presumptious youth. †I have,† he said quietly, and his blotchy face whitened. † It can be seen that the Major seems too quiet and too afraid for the man that wants to tell the story about the talisman that can granted wishes. Second, the horror and fear come up to the climax through the action or response the husband and wife after the death of their son. The fight between the husband and the wife about the wish to revive their only son also bring the reader feels the horror and fear. â€Å"The old man turned and regarded her, and his voice shook. â€Å"He has been dead ten days, and besides he – I would not tell you else, but – I could only recognize him by his clothing. If he was terrible for you to see then, how now? †Ã¢â‚¬  it brings the readers get the imagination how scary in looks if the son come back to life. The last thing that is, how the narration also supports to create a horror and fear atmosphere in the story. The best example can be seen from the last event. But her husband was on his hand s and knees groping wildly on the floor in search of the paw. If only he could find it before the thing outside got in. A perfect fusillade of knocks reverberated through the house, and he heard the scraping of a chair as his wife put it down in the passage against the door. He heard the creaking of the bolt as it came slowly back, and at the same moment he found the monkey’s paw, and frantically breathed his third and last wish. † The narrations which explain about the setting, the situation and condition also take an important role to raise the tension of fear in this short story. In sum, there are many ways of how the speaker is delivered the horror and fear of this short story. Three of them are: The background of the Sergeant-Major Morris as the previous owner of the talisman, The action or response from the husband and wife about the wish to revive their son, How the narration explain the setting, situation, and condition in this story with a ‘spooky’ ways. There are still many others ways how the speaker brings the horror and fear in this story that make this story become a good horror story.

Syntactic Development of Children Essay Example for Free

Syntactic Development of Children Essay Language developmentphonology, semantics, syntax and pragmaticsplays a key role in child development; whereas it acts as an indicator for the important facets of child progression, its’ more important function is that it facilitates the child’s course of learning in terms of linguistics and cognitive abilities.   The pattern and capacity of the child learner for language developmentthe acknowledgement of morphemes and the use of syntax-is normally referred to as â€Å"First Language Acquistion.† Chomsky (1975), one of the major proponents of Nature’s role in acquisition, contended that there exist a universal grammar and that the child-learners (/infants/growing child) have innate, language-specific abilities that facilitate and constrain language learning. Children are said to develop an almost innate or automatic synaptic rules without explicit instruction from their surroundings/environment. The generative language and the transformation adopts a minimalist approach wherein there is economy in terms of derivation and representation in grammar and syntax.   Chomsky (1959;65) suggested the Bare Phase Structure wherein sentence building is derivational, not pre-conceived, binarily-branched, and no recognizable head and terminal parts. Up to now, such notion is vague and problematic. Basically, language development starts from two-word utterances during the early stage of the child’s life to a rule-governed system of language at ages three to four. Past four years old, the child starts to explore and learn morphology ‘creatively’. Concomitant to this is the development of Mean Length Utterances (MLUs) from simple telegraphic morphemes to grammatical morphemes. Grammatical morphemes refer to the inflection of content (e.g. number and tenses) and function of words (e.g. preposition and articles) (Brown 1973). Acquisition of grammatical morphemes follows a certain order which is dependent on the complexity of the (set of) words. Prepositions, plural forms and present progressive tenses are easily acquired compared to contractible copula and auxiliary forms of the words. Such order is determined by semantic and syntactic complexity. Learners from pre-school and first grade have the capacity to correctly apply grammatical morphemes to novel words. Dulay and Burt (1978;82) constructed the acquisition hierarchy for 13 English grammatical morphemes for Spanish-speaking- and Cantonese-speaking children which is summarily describes as follows: Group 1 (Nominative/Accusative: simple declarative sentences), Group II (singular copula, s/p auxiliary, progressive), Group III (Past Irregular, possessive, 3rd person singular, conditional auxiliary, long plural) and Group IV (perfect auxiliary and past participle). The problem with such assumption on interlanguage is that the theory is too reduced or oversimplified. While it is true that syntactic development follows a process, the major problems involved are the different comparison groups used for the study, the progression is not systematically defined, and of course, there exist the language variation. Such language variation is real and must be accepted as a challenge for future research on the subject. To fully understand interlanguage, future researchers should consider a wider scope in cognitive and linguistic aspects correlated to early learning. Works Cited Brown, R. A First Language: The Early Stages. Cambridge, Mass.: Harvard UP,1973. Chomsky, N. Reflections on Language. NY: Pantheon Books, 1975. Chomsky, Noam. 1959. Review of Verbal Behavior by B.F. Skinner. Language 35, 26-58. Chomsky, Noam. Aspects of the Theory of Syntax. Cambridge, Mass.: MIT Press, 1965 Dulay, H., and M. Burt.. Errors and strategies in child second language acquisition. TESOL Quaterley 1974, 8, 129-136. Dulay, H., and M. Burt. Some remarks on creativity in language acquisition. In William C. Ritchie (ed.). Second Language Acquisition Research, NY: Academic Press, 1978. Dulay, H.,M.Burt, and S. D. Krashen. Language Two. New York: Oxford UP, 1982. Dulay, H., E. Hernandez-Chavez, and M. Burt. The process of becoming bilingual. In S. Singh and J. Lynch (ed). Diagnostic Procedures in Hearing, Speech and Language. Baltimore: University Park Press, 1978, 251-303.

Company Communication Issue

Company Communication Issue Intro. Since 2013 the company has received reports that some consumers may not be pleased with Huggies diapers because they felt scary due to a supposed chemical burn on the skin. I as the chief communication director have instructed the public relations department to do a media content analysis in order to determine the real situation or impact. Through content analysis, we will be able to do a qualitative research focusing on the interpretation of some editorials, magazines, websites, blogs, social media, forums, etc. Content analysis is the systematic and objective categorizing of information, in public relations, this is used to measure the amount of media coverage and the nature of that coverage (Wilcox, Cameron, Reber, 2014). Content analysis enables public relations departments to reinforce responsive communication by including some factors such as the percentage of favorable, neutral, negative mentions about a company, a brand or service, the overall tone of mention, the percentage of articles that contain a key message point that some organization wants to communicate (Wilcox, Cameron, Reber, 2014). Body. After a study carried out through different sources, the public relations department took a sampling of media data categorized by type as follows. Conclusions. The problem is that there are reports of some websites that express complaints from some customers that the honeycombs are causing burns due to some chemical component. Actually, according to the media content analysis made, no conclusive evidence has been found this is really happening. Instead, the findings show that the brand has been gaining the trust of the final consumers over time. Kimberly-Clark Corp has been interested in innovation, earning some awards. The brand has educational programs for the use of the product in order to prevent misuse. They enforce the campaign about their passion for helping all babies, especially the smallest and most fragile like premature ones. The findings reaffirm that the company is doing a great positive publicity job for the brand, raising it to the second level of popularity in the United States. This work is reflected in sales portals such as diapers.com in which consumer feedbacks reflect an 85% satisfaction with the brand. I do not think these complaints will affect the brands prestige or its positioning in the market, I think the brand is strong enough to deal with it. I would recommend to the CEO to keep the eyes on these forums so that we follow up the possible increase of these complaints, and can proactively prevent any damage to the brand. At the moment it is not recommended to invest more than what is done so far in some positive image campaign to counter these rumors. Reference sources page Wilcox, D. L., Cameron, G. T., Reber, B. H. (2014). Public relations: Strategies and tactics (11th ed.). Boston, MA, United States: Pearson College Div. Huggies snug and drydont use!! (2015, February ). Retrieved February 16, 2017, from What to Expect, http://www.whattoexpect.com/forums/february-2015-babies/topic/huggies-snug-and-dry-dont-use.html Home. (2013, May 11). Chemical burns from huggies.. Retrieved February 16, 2017, from Baby Center Community, http://community.babycenter.com/post/a45616222/chemical_burns_from_huggies. Huggies launches pull-on diaper. (2011). Nonwovens Industry, 42(8), 12. Huggies continues efforts to diaper babies in needs. (2012). Nonwovens Industry, 43(1), 14. PR, N. (2017, February 1). New Huggies Brand Diaper Innovation to Help the Smallest Babies. PR Newswire US. Kimberly-Clark, Skymark Develop Huggies Four-Pack. (2016). Nonwovens Industry, 47(12), 21. Huggies Pull-Ups get potty training liner. (2015). Grocer, 238(8204), 37. tiffanyg. (2013, July 18). Huggies little movers diapers. Retrieved February 16, 2017, from Diapers.com, https://www.diapers.com/p/huggies-little-movers-diapers-331811?sku=KC-856qid=4105292032sr=1-2 PEOPLE. (2015). Caribbean Business, 43(26), 42.

Letters in Jane Austens Pride and Prejudice Essay -- Jane Austen Prid

Letters in Jane Austen's Pride and Prejudice Pride and Prejudice is one of the great love stories of our time. Its continued popularity shows that its essential story can still be adapted to modern day life. Set in the 1800s, it tells the love story of two people who gradually learn to understand each other and themselves. In the time that the novel is set, modern means of communication, for example telephones and computers were not yet invented. The most effective way of corresponding, especially over long distances, were letters. In this period, when people met in formal circumstances, for instance at a ball, where they were in company and never alone, they could not express their inner thoughts. Letters provided a confidential way to do this. This is also true to the novel; where Jane Austen carefully composes the letters. There is more care and attention paid to their structure and content; as letters are they are a permanent record of thoughts that can be revisited and re-read, were carefully crafted to provide the exact meaning of each letter. The letters used in Pride and Prejudice shows us a glimpse of a character’s personality and their viewpoint. They are a key feature of conveying a new character and developing the plot. It is not an accident that over forty letters or letter extracts are used in Pride and Prejudice. They are an effective means of illuminating characters where dwelling on individual reflections is not a style used much by the author. Also we gain an insight into the recipient of the letter through their response. One of the first letters used in Pride and Prejudice to introduce a new character is Mr Collins’ letter. This letter gives us our first opportunity to assess ... ...tures Lydia Bennet’s character. In this essay I have shown three examples of letters. In each of these letters we have seen how they have introduced, changed perceptions and shown us in depth a character. Letters are an integral part of the novel; they are threaded through the story to add variety, drama and develop character detail. Without letters it would be hard to move plot on and pick up the pace of the novel. They are used as a means of providing drama to the novel. They often reveal dramatic detail and provide an impression of news being discovered immediately. Letters offer a useful structural device to add variety to how the plot is revealed. This in turn shows the variety and imagination of Austen’s style. They also are entertaining additions to the novel on their own, often giving engaging or moving insights into character and situation.

Druids Essay -- essays research papers fc

THE DRUIDS During the Anglo-Saxon period, magic was often practiced among several different classes of people in their own ways. It was considered sinful but its power was always believed in. Their knowledge of magic was first sought out from the biblical story, The Three Wise Men. According to one legend, the men who visited baby Jesus were astrologers who located him by magic use of the stars. The Bible has many ferences to magic, sorcery, and witchcraft. Since religion was valued during the Anglo-Saxon period, the Bible held the laws to their lives. Church authorities tried to ban witchcraft but people in many parts of the world continued to practice witchcraft as a religion. From the Anglo-Saxon period, the most well known of these people were the Druids. The Druids were the priests or ministers of religion among the ancient Celtic nations in Gaul, Britain, and Germany. They combined the functions of the priest, the magistrate, the scholar, and the physician. Druidism is a reconstruction of the beliefs and practices of the ancient Celtic priesthood-professional class. They underwent lengthy training; about twenty years. Druids led all public rituals, which were normally held within fenced groves of sacred trees. They didn't use any images to represent the object of worship. A circle of stones enclosing an area from twenty to thirty yards in diameter, constituted their sacred place. The most sacred of this is the Stonehenge. When privacy was called for, these rituals took place in sacred grooves and clearings hidden deep in the forests. They believed in only one god, to whom they gave the name "Be'al". In modern english this translates to "the life of every thing," or "the source of all beings". It has a connection with the Phoenician Baal. The Druids identified this with the Sun. Fire was referenced as a symbol of the eternal life. In record, most of the leaders were males. It wasn't known whether female Druids were considered of equal part. Two festivals were of great importance to the Druids. The first festival took place in the beginning of May and was called Beltane or "Fire of God". A large fire was heated on an elevated spot, in honor of the sun, whose returning beneficence t hey then welcomed after the winter time. The second festiva... ... Druidism itself was destroyed or continued deeply underground throughout most of the Celtic lands. Though Druidism is not a common practiced religion today, it still does exist even here in the United States. The spirit of the Druids will never die due to the ancient "Druid" altars, beds, rings, stones, stone circles, and temples they have left behind. Other present day religious leaders have followed and adopted the same beliefs as the Druids. Though we are not as familiar with these magicians, their legends and remnants still haunt the European lands. Works Cited BOOK Dersin,Denise. What Life Was Like Among Druids And High Kings. Richmond, Virginia: Time Life Inc., 1998. Encyclopedia Wallis, Wilson D. "Druid." The World Book Encyclopedia. 1970 Edition. INTERNET SOURCES Celtic Druidism. http://www.religioustolerance.org/druid.htm Druids. http://celt.net/Celtic/History/d_overview.html The Druids. http://witchcraft.simplenet.com/druid.html

Essay --

The 3G+GPS shield uses the 3G module, SIM5218E from SIMCOM, which enables the connectivity to high speed WCDMA and HSPA cellular networks. It is a single board which can handle high speed wireless communication. The 3G module has an internal GPS with the help of which it is possible to locate the device outdoors as well as indoors. It combines the standard NMEA frames with mobile cell ID triangulation for accuracy and uses both assisted-mobile (A-GPS) and mobile-based (S-GPS) modes. A video camera can be connected to the shield which enables recording photo and video in high resolution (640x480). It is also possible to connect a microphone to the module and a SD socket to save directly all the data coming from the 3G network or recorded from the video camera. Since the 3G+GPS shield supports the above mentioned features with all the hardware on board, it became the first choice for the implementation of the prototype. Described below are the important components of the 3G+GPS shield that we have used. 3.1.1 Hardware 3.1.1.1 3G Module (SIM5218E) Figure ‎3 2: SIM5218E Sim5218E is a quad-band GSM/GPRS/EDGE and UMTS engine that works on frequencies of GSM 850 MHz, EGSM 900 MHz, DCS 1800 MHz, PCS 1900 MHz, and WCDMA 2100M/1900M/900M [28]. Sim5218E provides interfaces for Serial communication, GPS, Camera, USIM Card as well as an audio interface. These are described briefly below. Detailed information about these is present in the â€Å"Hardware Design† document of SIM5218E [29]. Serial interface Sim5218E has an asynchronous serial port. Sim5218E is designed as a Data Connection Equipment. It can be connected to any Data Terminal Equipment using standard DCE-DTE connection. Serial port can be used for sending AT commands ... ...verage problems are experienced, then two antennas are used, where the second antenna is connected to the sub-antenna connector. 3.1.1.2 Electret Microphone We have used electret microphone for the prototype. It is a small microphone useful in acoustic and audio applications. Figure ‎3 3: Electret Microphone 3.1.1.3 Camera The camera used for the prototype is a VGA Sensor Camera module. This camera is a very compact size. It uses a GC0309 CMOS sensor. It is 0.3MP (VGA) camera with a maximum resolution of 640 x 480 dpi. Figure ‎3 4: VGA Sensor Camera 3.1.1.4 Arduino Mega 2560 Figure ‎3 5: Arduino Mega 2560 Arduino Mega 2560 is a microcontroller board based on the ATmega2560. It has 4 UARTs (hardware serial ports), which will be very useful in interfacing various components. It has a 16MHz crystal oscillator with a flash memory of 256KB and SRAM of 8KB.

Jane Matilda Bolin

Bolin became the first Black woman to serve as a U. S. Judge. She was the youngest of four children born to Gaius and Matilda Bolin. Her mother, Matilda Emery, was an English immigrant. She died when Jane was only eight years old. Her father, Gaius Charles Bolin, was an African American and, also, part Native American. G. Charles owned a successful law practice in Poughkeepsie, NY. He was the first African American graduate of William College in Western Massachusetts and he was, also, the first African American of the Dutchess County Bar Association. As a child, Jane often shared passionate conversations with her father about law and his profession. She spent a great deal of time in his law office afterschool and on weekends. This helped Jane to determine early on that she wanted to follow in her father’s footsteps and become a lawyer. Having lived a sheltered lifestyle, she was further motivated to pursue a law career when she discovered the hardships of Blacks in America at that time. She became exposed to this through her father’s involvement in the NAACP and by reading the NAACP bi-monthly magazine, The Crisis. The violence, racism, and prejudice that she uncovered was very much unlike the lifestyle in which she grew up, where her father was respected by both blacks and whites. After graduating from high school at the age of 15, she attended Wellesley College in Massachusetts, where she was one of only two black students. Both students were picked on and embarrassed daily. This became Jane’s first racism experience. She graduated in 1928 as one the top 20 graduates in her class. Because she did not receive much support from her professors, she knew what to expect when it was time for seniors to speak to an advisor about career options. Her advisor told her that she would never be able to make it as a black female attorney. However, Jane was determined to attend Yale Law School. Jane’s father wanted to protect her from the prejudice that he endured while trying become a lawyer. He tried to persuade her to become a teacher and inspire other young black minds. However, once he learned that she was accepted to Yale Law School, he gave her all of his support. That year she was one of only three women and the only black woman enrolled in Yale. She became the first African American to receive a law degree from Yale. She returned home, passed the New York State Bar exam, and began practicing law in her father’s law firm. In 1933, Jane married Ralph Mizelle. They moved to New York City and opened their own law practice. Jane began a career in public service in 1937 as an Assistant Corporate Counsel for the City of New York. After two years of serving in this position, Mayor Fiorello LaGuardia swore Jane in as the Judge of the Domestic Relations Court (Family Court) on July 22, 1939. This made her the first African American to be the judge of any U. S. court. As a judge, she made several monumental changes. She made it illegal to place individuals with probation officers based on race. She, also, required childcare agencies that received public funds to accept all children, regardless of race. She later founded an integrated center for trouble youth. Jane served as a judge for 40 years. She retired at age 70 in January of 1979. Jane Bolin died on January 8, 2007. She was 98 years-old. Bibliography http://blackhistory. com/cgi-bin/blog. cgi? blog_id=133098&cid=54

Porters 5 Forces Analysis Of Communications Industry Essay

The wireless communications industry is one of the world’s sectors of the economy that is experiencing high competition due to challenges of globalization, advance in technology and diversity of customer needs. The main services that are offered in this business are; internet access, cell phone service or mobile communication, messaging, music, ring tone and video distribution among others. There are about 600 companies that are actively involved in this industry and they constitute combined annual revenue of over 110 billion US dollars. However, there are four major companies that have dominated this concentrated market fro some time and they include; Verizon, Sprint Nextel, T-mobile and AT&T. Wireless communication services owe its demand to an increase in consumer income and only those with good income can actually utilize or receive such services. Most businesses also utilize the technology and therefore the profitability of the wireless companies depends on how best they can attract these businesses, their marketing skills and their ability to come up with new innovative technologies. Porters five forces analysis has been used by many companies to analyze their position in the industry and therefore strategically position itself to handle the issue of competition. Since the issue has been identified as a major threat to the existence of the companies industry, this kind of analysis is thus suitable for companies which would like to understand their competitors, their customers, buyers, sellers, suppliers, and other stakeholders in the business.   (Porter, 1985) Threat of New Entrants Previously established wireless communication firms pose a big challenge to new companies in the market which try to exploit the new markets. Although substitute services are being offered in smaller companies, they still have to ‘beat’ one another in either way in order to create a better market share.   With known brand names and higher customer loyalty, established firms to push customers to start using their new products in the market since they have a name in the market. The new entrants need to assess the market effectively and ensure that they learn their customers very well although very few for a start and also ensure that they position themselves strategically to compete more successfully to remain in business. The established firms on the other hand need to maintain good relationships with their customers so that the competitors i.e. the new entrants may not take away their customers. This way, they rest assured that they will remain in the market for a longer time (McGahan, 2004) Power of Suppliers Due to the bargaining power of suppliers, customers in this industry have started to become sensitive to the monopoly imposed by some suppliers and also the changes in prices that affect the way they receive services or products. In most cases, suppliers tend to utilize all unique ways in order to bargain for what they want. First, they would like a company such as T-Mobile to offer hem better prices before they manipulate the customer’s price therefore ending up with huge prices. In some companies, they have become a competitive threat because when they raise their prices, the customers will tend to look for substitute services which can still satisfy their needs but a lower cost. In this industry however, the suppliers have little to influence although they can maneuver their way in the market price for certain services. (Porter, 1985) Competitive Rivalry Competition is almost everywhere today but in the wireless communication industry, it is worse. Given an improved world economy and globalization of businesses, there is rush for new customers by every company. Due to the high concentration of companies in this industry, it requires very competitive minds to venture in his business. Verizon and other companies are experiencing intensive rivalry that has benefited the consumers (Lovelock, 2006). In order to effectively handle the issue of rivalry, some companies such as verizon have resorted to joint ventures for them to increase their market potential. AT&T had a gross profit margin of 60.7% while its closet rival Verizon had 59.50%, Qwest had61.8% and Sprint Nextel had 57.60%. All these four companies, everybody will agree, face competitive rivalry amongst themselves in the business. Although AT&T has a superior value on its market capitalization, it must keep its toes in order to meet the challenge offered by Verizon. (McGahan, 2004) Power of Buyers Buyers are the most sensitive lot in any business because they influence demand, supply and even distribution. In addition, they rely mostly on quality services that satisfy their needs. Due to changes in technology, customers would like to have fast communication services, reliable internet access, accurate and reliable billing among other needs. When either the suppliers or manufacturers increase their products, they will most probably go for substitute products. Many companies allow their customers to bargain for their prices but take into consideration the competitor’s prices. When prices are low and services are of high quality, it is better for the companies. It is widely acknowledged that about 95% of wireless services go directly to the consumers and a mere 5% goes to resellers and suppliers. This indicates that, the market is getting saturated quickly and sooner or later, the companies will have no one to subscribe. It is with this in mind that companies have been employing unique marketing strategies such as the media, internet and other local stores. Since the market is easily saturated, some operators are devising ways to get customers from other companies and subscribe them. This is however difficult because it requires that the services be superior, prices are low and quality is supreme. (Lovelock, 2006) Availability of Substitutes Those alternative products that have the ability to satisfy related needs and give solutions to customers for what they want are referred to as substitute products. They reduce the potential returns for many businesses since they place a ceiling on the prices offered for services. Companies that realize that services being offered do not much the substitutes, and then they adjust their quality and prices. Fro example, AT &T can be able to challenge the service that is offered by smaller mobile phone companies that include messaging by offering high speed voice messaging. (McGahan, 2004) Customers will always be tempted to try new products to see whether they are more effective and are made to believe that the newest services on the market are the best since they are current and tested. In order to counter substitute products, a majority of the companies tend to at least market their products as effectively as possible and thereby meet their market demand. The most worrying trend in the business is the fact that substitutes products come with other services that outweigh the quality of the other ones thus cause a threat to the company. Substitutes give the sellers and the users a variety of choices to choose from and making it very hard for some services to be entrenched into the market.      Reference Grant, R. (2005): Contemporary Strategy Analysis: – Blackwell Publishing Ltd., Oxford pp 56-98 Lovelock, J. (2006): Services Marketing, People, Technology, and Strategy. New York, Prentice Hall, pp 30-33 McGahan, A. (2004): How Industries Evolve: – Principles for Achieving and Sustaining Superior Performance. Harvard Business School Press, pp 3-8 Porter, M. (1985): Competitive Advantage:-Techniques for Analyzing Industries and Competitors. The Free Press, New York, pp 19-43

Analysis of the Poem: Sa Babaye Nga Naghubo Didto Sa Baybayon Sa Obong Essay

In the poem â€Å" Sa Babaye Nga Naghubo Didto Sa Baybayon Sa Obong† , Renee Amper takes us to a scene on a beach through his eyes. It tells the emotional experience of the persona while looking at the girl naked. The writer uses rich imagery, symbolism and figures of speech to communicate the speaker’s emotional state, a metaphor he develops in a variety of ways to describe exactly how the persona in the poem is affected by the scene he is seeing. The poem centers on a memorable visual image. It asks the readers to focus on and take in a striking sight, as of the persona in the poem ,â€Å" nahitimbakuwas akong panan-aw† , which suggests the scene demands abrupt and continuous attention although the girl in the poem doesn’t want anyone to see her â€Å"†¦ nagpanglingi ka kung wa bay naka-ambit sa imung pagpabaya†. If you let it, the central image will etched itself in the memory starting association activating thought and feeling. On the first part of the poem, the readers are given the implication that the persona is in the act of voyeurism but on the later part he reveals a deep concern to his object of observation which is the girl ,â€Å" kaayong ikinto sa balikhaw, kaayong isinggit paghinay!, kaayong ikapakapa sa hilom†.These lines also suggests that the persona is in a deep struggle or he is in a brawl of his own self to do or not to, but clearly he didn’t. Then the lines †nagbingkil ang mga dahon, gitukmod sa lunhaw ang laya aron mutipon sa yuta; nasaag ang huyohoy† evokes dynamism and constant action making the scene alive in the readers mind. The sudden gush of the wind destroys the tranquil observation of the persona impelling him to move as suggested by the lines â€Å" miong-ong akong mga mata, ilawm sa gamot sa kahoy† , which also tells the readers that he clearly doesn’t want the girl to know his whereabouts. The lines â€Å" madailos pagsamot ang imong patadyong , napasapasa ang imong kanindot†, suggest a constant action and that the scene of the girl removing her garments continues to unfold in the eyes of the persona. â€Å" gisapnay ka sa mga balud† implies the girl is now swimming in the sea. However, the poem does not stop there. The lines â€Å" gihulad kang walay kaindig, sa mga tinguha sa daman ug damgo†¦ gipasangil ko sa langit ang akong himaya† , describes the persona’s way of expressing his ineffable ecstasy of watching the enchanting  unadulterated beauty of the girl . Moreover, â€Å" taga â€Å" on the last line of the poem act as a symbolic image for the deep emotion or feelings of the persona for the girl. The hook there is the emotional attachment that has developed in the persona towards the girl. As a reader, i was just mystefied with the nonchalant attitude of the girl. In the province, people most go to the baybayon most of the times even at dawn. And in contrast with other sensuous interpretation, why can’t the persona be viewed as someone who appreciates the beauty of the girl and nothing else?And he was enchanted because of the beauty of the girl thus he developed an attraction to her . Nonetheless, the poem’s value and significance resonates in the readers frame of mind. How we interpret it, how it touches the core of our reason and values, how it activates thought and feelings. I commend the writer and as the girl etched in his memory, this poem has made quite an impression on me. The experience of reading the poem ends as follows

Vascular Sounds, Abdominal,

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