James Is Intolerance of the Catholic Faith Essay Example for Free

James Is Intolerance of the Catholic Faith Essay Do you agree with the view that the main cause of the Gunpowder Plot of 1605 was James I’s intolerance of the catholic faith? It was the lack of tolerance in which James showed toward the Catholic faith, but also the large amounts of tolerance to the Protestants in the mean time. James was, almost, too pleasant towards the Protestants and therefore angered the Catholics as he did so, leaving the Catholic’s wanting to display that the intolerance shown towards them was unacceptable. Therefore, historians are able to infer that it was due to James’ attitudes towards the catholic faith that the Gunpowder Plot took place. Source 2 and 3 both agree that the gunpowder plot was due to James dealing with the Catholic faith with a very harsh attitude, also pushing the Catholics into taking measures such as ‘massacres, rebellions and desperate attempts against the King and State’ due to the King driving them to. James ‘dealt severely [..] he took a lot of money’ which he, evidently, didn’t implicate amongst the puritans. James shows a lot of hatred towards the Catholics and their faith through the way he dealt with them. Source 4 supports evidence shown through both source 2 and 3 in the way that it is expressing the ‘utter detestation’ he had of Catholicism and how he was happy to show his ‘hostility against the Catholics in order to satisfy the Puritans’. James states how he couldn’t comply with all the needs of the Catholics which they present to them, however he made no effort to even think about contemplating those needs of the Protestants. The kings hatred towards the Catholics, however, may also have been due to the influence of his inherited chief minister, Robert Cecil, who from Source 3 we can understand himself didn’t enjoy having the Catholic faith around, being warned that if the harshness shown towards them wasn’t to stop then the king would have to intervene in ‘massacres, rebellions and desperate attempts against the king and state’. However, Robert Cecil, down to his own despise of the faith manipulated the situation, applying a larger amount of pressure upon James to continue to treat the Catholics with a harsh manner, shown in source 5, ‘Cecil used every opportunity to infer to James that the popes were rivals to his authority [] something James could not tolerate’. Source 5, unlike source 3, states how Cecil was a ‘staunch protestant’ seeing the Catholics as being ‘tantamount to traitors’ due to their beliefs opposing the king by referring back to the pope, although they both show that Robert Cecil is using his own viewpoint to affect the way in which the King undertake the ‘issue’ of the Catholic faith, just in diverse ways, and therefore a possible cause of the gunpowder plot, which many historians would argue, was due to James’ ministers themselves, influencing the kings beliefs and ideals. Robert Cecil through his influence over the king shown in source 5 can also be supported in source 1 with him stating that the King has been too tolerable of the Catholics and how the king should be harsher towards them and how ‘the King’s excessive kindness’ has resulted to ‘priests preach that Catholics much kill the Kings to help their religion’, and therefore wasn’t James’ intolerance of the Catholics that caused the Gunpowder plot but the tolerance he showed them instead. Many Catholics would say that due to James’ deliberately publicly announcing his ‘utter detestation’ of their faith that James deserved the plot to be against him due to the harshness shown towards their faith and beliefs, which we are able to infer via source 4 telling historians that ‘all priests [] had been expelled and recusancy fines introduced’. Overall through the sources historians are able to infer that James showed a large intolerance towards the Catholic faith, whether it be through him own ideals or influenced by other, which then pushed them into believing that performing the Gunpowder plot upon the Houses of Parliament was for the greater good of their religion, and therefore the main cause of the gunpowder plot of 1604 was King James’ intolerance for the Catholic faith. Amy Poole.

1970 - 1980 Essay -- Essays Papers

1970 - 1980 During the 1970’s, the United States experienced "Watergate," the most famous political scandal in American History. It was a scandal that began with a break in and ended in resignation. On June 17, 1972 five intruders were caught and arrested for illegally entering the rooms of the Democratic National Committee headquarters in Washington’s Watergate Complex. "The investigation of the break-in lead directly to the reelection campaign of President Richard M. Nixon and unraveled a web of political spying and sabotage, bribery and the illegal use of campaign funds" (Washingtonpost.com). Two-and-a-half-years later along with a number of court hearings led to the 1974 resignation of Richard M. Nixon. Nixon became the first President in U.S. History to resign. During all the political drama the United States brought an end to an unpopular war and made great strides in space exploration. The Vietnam War finally came to an end on January 27, 1973 when the United States and North Vietnam signed the Paris Peace Accords. Under its terms, U.S. troops would with drawl from Vietnam. Even though this ended many years of warfare, the "Vietnam War badly burdened the American economy" (Bondi 125). Turning away from the problem of increased debt, America saw technology at its best. On November 16, 1973 NASA gave us Skylab, our country’s first space station: "Skylab offered is an opportunity to do what none had done before – to study the Sun from space" (Eddy xiii). Despite the happenings of Watergate and the weight of the Vietnam War, this ground- breaking space exploration brought excitement and opportunity to the United States. During the 1970’s the world experienced many events, however, there were a few that made history. On... ...od of the piece captured my imagination, and my thoughts for several days" (Michaels 1). Along with Tim O’Brien another popular author during the 1970’s was Alice Walker. Alice Walker was involved in the Black Nationalism movement in the early 1970’s. This group fought to bring economic equality to the African American community. They also wanted to promote a separate identity and a sense of pride. One of their slogans was "Black is Beautiful". This is seen in Walker's short story "Everyday Use." In this story, she involves characters from both sides of the African-American culture. Some represent "new black" and others remain "traditional." Walker is trying to show that African Americans should not be ashamed of their culture or their African American heritage (Raz). In other words they should follow the slogan of the Black Nationalism movement "black is beautiful."

Cultural context of the play Essay

How does Miller use the character of Alfieri to involve the audience and illustrate the cultural context of the play? Alfieri is used in a multitude of ways by Miller to help the play at various stages. He is a character in the play, which other characters interact with, however, he is displaced somewhat because he comments on the goings on of the play, expands on what has happened to make it clearer to the audience, links scenes together and to a certain extent takes the role of a narrator. The character of Alfieri as a lawyer is wisely chosen. Lawyers at that time were seen as a sign of bad luck as with priests, because they were symbols of the law and â€Å"law has not been a friendly idea since the Greeks were beaten†. This shows that Alfieri does not always bring good news and often brings about the things that people do not want to hear, like when Eddie goes to him and asks what he can do to get rid of Marco and Alfieri tells him that there is nothing he can do. The majority of characters in this play are immigrants who have tried to make a living by living in America so at one point or another they would have wanted to avoid the law. Alfieri being a lawyer also shows us how he is above the other immigrants as they are still uneducated, living lives of hard labour using colloquiums such as â€Å"yiz† which indicates a lack of control or status. However, Alfieri is educated and now has status. The language he uses is so much more formal than that of Beatrice or Eddie. Although Alfieri have status he may not have real respect, just the grudging respect for his status. Others do not see him as one of them , â€Å"see how uneasily they nod to me†. Realistically, Alfieri is the only one of them who has achieved the American Dream, worked his way form poverty to having a good life. Arthur Miller himself was the son of an immigrant and he supported himself through college by working on the docks, so he knew where to come from when writing about the hardships and unreliability of living a life like Eddies. In the area and time that the play is set, the rules of community, the code of honour, is more important than the state laws. Disobeying these unwritten laws and betraying the community could result in ostracization. As with Romeo and Juliet this play features people breaking the family laws, then being suitably punished for it. The issues in this play are ones that have been studied before and will be used again due to the fact that they are still relevant. You will always have people that want to do something that is not against the law but going against traditions in their communities and will often cause them a worse fate then if they were breaking a state law. People can relate to disobeying these community rules. Alfieri’s prologue introduces the play. He sets the scene and tells us a bit about the history and culture of where the play is set, where men where â€Å"justly shot by unjust men†. He also says in his epilogue that people now â€Å"settle for half†¦ we are quite civilized, quite American†. With statements like that you can tell that uncivilized things are going to happen. The opposite of how people are now will come out, the real them. Alfieri also tells us that what we are about to see is not just an ordinary one of his cases, and not simply the â€Å"petty troubles of the poor†. Not only in Alfieri’s prologue does he give us hints to what will happen in the play. Ina act one when Eddie goes to Alfieri and asks what he can do to get Rodolpho out, Alfieri says that Eddie must let go of Catherine and let her live her own life â€Å"because after all -what other way can it end? † he is almost predicting that if Eddies protective behaviour continues then it shall end in a bad way. The epilogue, also delivered by Alfieri helps us to understand things better as well. After all the commotion and high emotions of Eddies death, Alfieri is there, calm and collected as ever and gives us enough of an explanation to get us thinking, but also one that lets us make our own minds up. It offers a sense of rounding off. Alfieri reminds us f why we first liked Eddie, and talks of what a good character he was and how we will all like him far more than Alfieri’s â€Å"sensible clients†. Eddie died because he did what he wanted to and Alfieri can see the strength in this action, however, believes it is â€Å"better to settle for half† in order to survive and for there to be peace. Once again, as in the prologue Alfieri is at ease with us the audience. He is relaxed and allowing himself to be honest, to say what he really thinks. Alfieri comments are almost like what you would do to yourself in your head when analyzing or thinking something over. He is going through his thoughts in an almost soliloquy type way. When I went to see the play A View form a Bridge in the Questors theatre in Ealing the role of Alfieri was show to just as much the boob that he was in the svincter . if your happy and you know it clap your hands (clap clap) alice the camel had 95 humps†¦. ride alice ride du du dum cheesh. Im but a little bit bit bit bit show but a little bit bit bit shame but a little bit bit bit , bit bit bit. Peters pepper picked another pickle bearing pussy pepper raaah!!! Vivadixiesubmarine transmitionplot I think that Alfieri is a very good character to have in the play as he manages to fill in all the gaps where extra explanation is needed, such as after scenes. He also acts as an unofficial scene changer, and marks when time has passed or the setting is different. As well as all of this he also points people in the direction of doing things. If it was not for him telling Eddie that the only way he could get rid of Rodolpho was to phone immigration then he would not of thought of it.

Indian Fiscal Policy Impacts - 9621 Words

LOVELY PROFESSIONAL UNIVERSITY Term Paper School of Business Department of Management Name of the Student: Azhar Shokin Regd. No.: - 11000968 Course Code: MGT511 Course Title: Business Environment Course Instructor: Vishwas Chakranarayan Course Tutor: Vishwas Chakranarayan Class: MBA Semester: 1st Section: S1001 Batch 2010-12 Student’s Signature Azhar Shokin Topic: - Impact of Fiscal Policy on Indian Economy Contents * Introduction * Literature Review * Research * Article * Analysis * Data and Methodology * Main Findings * Conclusion * Recommendations * References Impact of Fiscal Policy on Indian Economy Introduction In economics, fiscal policy†¦show more content†¦This can be used in times of recession or low economic activity as an essential tool for building the framework for strong economic growth and working towards full employment. In theory, the resulting deficits would be paid for by an expanded economy during the boom that would follow; this was the reasoning behind the New Deal. Governments can use a budget surplus to do two things: to slow the pace of strong economic growth and to stabilize prices when inflation is too high. Keynesian theory posits that removing spending from the economy will reduce levels of aggregate demand and contract the economy, thus stabilizing prices. Economists debate the effectiveness of fiscal stimulus. The argument mostly centers on crowding out, a phenomena where government borrowing leads to higher interest rates that offset the simulative impact of spending. When the government runs a budget deficit, funds will need to come from public borrowing (the issue of government bonds), overseas borrowing, or monetizing the debt. When governments fund a deficit with the issuing of government bonds, interest rates can increase across the market, because government borrowing creates higher demand for credit in the financial markets. This causes a lower aggregate demand for goods and services, contrary to the objective of a fiscal stimulus. Neoclassical economists generally emphasize crowding out while Keynesians argue that fiscalShow MoreRelatedFiscal Policy And Fiscal Policies1046 Words   |  5 PagesFiscal Policy Generally fiscal policy is the set of strategies that government implements or plans to use with certain activities such as the collection of revenues and taxes and expenditure that can influence the overall economic condition of the nation. A well written or planned fiscal policy can lead the nation to the steady path of the strong economy, increase employment and also maintains healthy inflation. Every country needs fiscal policy as fiscal policy plays a vital role on monitoringRead MoreConventional and Unconventional Tools Used by Central Banks, A Basic Study Guide1320 Words   |  5 Pageshas to have a certain amount of reserves with them from the total deposits that have come in the bank. The central bank decides on the percentage of those reserves that the banks hold from the individuals’ deposits. During Expansionary Monetary Policy: a. Change the reserves requirements: The reserve requirement is lowered by the Central Bank as the Central Bank wants to increase the money supply in the economy. b. Open Market Operations: The Central bank buys the financial assets from the banksRead MoreCurrency Depreciation1580 Words   |  7 PagesWe discuss the currency depreciation vs. devaluation. Also, discuss the impact of currency depreciation from Indian economy perspective. Currency Depreciation amp; Impact Rajesh Kanjani (34473) rajesh.kanjani@hotmail.com SIBM Exe. MBA (2011-2014) Currency Devaluation vs. Depreciation The devaluation and deprecation of currency go more or less hand in hand. Currency depreciation is an economic result, whereas devaluing a currency is an act that results in currency depreciation. Many a timesRead MoreTerm Paper649 Words   |  3 Pages | |Post Recession Recovery: Indian Context|-----do------- | |5 | |ITC e-chaupal: Strategic Advantage of |-----do------- | | | |CSR | | |7 | |Foreign Investment in Indian economy - |-----do------- | | | Read MoreModi s Policy And Trump Win : Top 8 Economic Changes Expected Essay816 Words   |  4 PagesModi Demonetization Policy and Trump Win: Top 8 Economic Changes Expected In Coming Months In the past 15 days, we have witnessed some unbelievable things happening in India and the USA. On November 8, 2016, the Prime Minister of India announced that all currency notes of 500 and 1000 denominations will no longer be valid after four hours from the announcements. 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These measures are: †¢ Fiscal measures: To reduce the fiscal and revenue deficit the government of India has a strong control over its own expenditure. In 1984, the government announced a package program to curtail public expenditure and to postpone fresh recruitments to government jobs. †¢ Monetary measures: The monetary policy of RBIRead MoreUnion Budget Review1366 Words   |  6 PagesUNION BUDGET 2012-2013 ANALYSIS SAJILAL.N.S Roll No: 8, SIES EMBA 2012 CONTENTS Overview of Indian Economy Approach to Budget Key Attributes of 2012-2013 Budget Challenges Going Forward OVER VIEW OF INDIAN ECONOMY The Indian economy had left behind the low-growth track of the early 1980s, following the bold economic reforms initiated in 1991-93. India began to appear as a significant player in the global economy. India’s exports began to climb, its foreignRead MoreThe Effects Of Fiscal Policy On Inflation Essay1321 Words   |  6 Pages 2.3.3 The evidences of the effects of fiscal policy on inflation Blejer and Cheasty (1988) hold the view that base on the the inflationary-financing model, a decrease of fiscal deficit will leads to reductions in inflation as deficits are assumed to be financed by the inflation tax. After that, more scholars e.g. Buiter (1987), Fischer (1980) and Pfajfar (2014) believe that fiscal deficits will lead to inflation. The reason is that the central government to finance the deficit can be carried outRead MoreGlobal Crisis1656 Words   |  7 PagesThe Major concern in India today is global financial crisis is leading to severe recession, In the real economy. It started showing in the effects middle of 2007 and it to 2008. Various sectors like steel, fertilizers, financial things, banking. Now Indian Government was taking considerable step for this global crisis in the next year i.e; 2010. We can see 9% rises in global economy. TATA MOTORS: In June 2008, Tata motors has acquired the Jaguar land Rover business from ford motor Company

Censorship and Material Selection Policies Essay - 863 Words

A book is a door into a new world. When someone writes, they choose their words carefully so that the story flows, makes sense, and goes along with what they are writing about. Everything from the scenery, to the way a certain character talks is thought about and brought to life by a few simple scratches on a page. Some people want to suppress the writings of geniuses just because of an image, idea, or phrase on the grounds that they are morally objectionable by the standards applied by a censor. It has been like this for ages. As long as someone has something to tell, another will be there to try and prevent them. Schools have been doing this for quite a while now and there is a need to stop it. Censorship of books in schools should not†¦show more content†¦Promoting student power in the choice of high school literature can prove uncomfortable, wild, and touchy. Without the right amount of preparation, research, and reading, teachers may find language, content, and themes t o be more mature than they really wanted. Young adults’ choices in literature can make teachers cringe at the very thought. However, instead of censoring texts, the focus should shift to students ability to read beyond what society has marked as â€Å"inappropriate.†(Denzin) For multitudes of children, teens, and even some adults, Harry Potter is a hero. He fights wickedness and stands up for his friends and the entire wizarding world. However, not everyone agrees. Instead, he is perceived as a threat by quite a few groups. DeMitchell and Carney discusses how some adults on a school board reacted to this perceived threat. Over half of a school board voted to restrict access to Harry Potter books in the public school library. The resulting legal battle over the boards actions helps to define not just Harry Potters place in the public school library but the rights of students alike. (eric.ed.gov) There are States who still censor practically everything that goes through their school libraries. Long Island has remained quiet with respect to the censoring of books in public schools. The rest of the country, as the National Library Association has made all too clear. Throughout the United States, every day books fall victim to theShow MoreRelated Censorship and Selection Essay1595 Words   |  7 PagesIntroduction Censorship is a dirty word to information professionals. Attempts by individuals or groups to restrict the public from reading, hearing or viewing certain materials due to their content, is enough to send librarians and organizations such as the American Library Association, to the proverbial battle field. However, information professionals from all fields have to make choices about what to include and what not to include in their particular librarys collection. How are these selections madeRead MoreKey Elements Of Collection Development Policy1100 Words   |  5 Pages1.0 Introduction Collection development policy is a blueprint for developing collections. The policy is a written document and the policy is a guideline for libraries in acquisition and maintenance collections. According to Johnson (2009 cited in Gregory 2014, p.33), the libraries need a master plan to develop their collections. The absence of planning document leads into misleading for selection, deselection and decision making. As a result, the libraries may lose many opportunities in developingRead MoreThe Library Functions On The Concept Of Intellectual Freedom Essay1057 Words   |  5 Pagesscaring her child. She later asks that the book removed to the library and with threats to sue. After calmly listening to her complaint, I proceeded to explain the policies and procedures for challenging a book. I explained the library functions on the concept of intellectual freedom. Mrs. Green was given a copy of the district challenge/ban policy and a pamphlet on the steps for filing a challenge. Additionally, Mrs. Green was made aware that even though I listened to her complaint, she needed to put theRead MoreSchool Librarians Case Study1076 Words   |  5 PagesOne of the new AASL Shared Foundations: Engage (2017) is that librarians â€Å"implement organizational policies and practices related to censorship, materials challenges, library records, and responsible use of information resources† (Shared Foundations Engage sect. para. 4). Subsequently, librarians demonstrate their leadership capabilities through implementing and disseminating information to their school on guidelines for students’ use of digital tools and library resources. Furthermore, librarian sRead MoreThe Effect of Shared Culture of Journalists on the Selection and Presentation of News737 Words   |  3 PagesThe Effect of Shared Culture of Journalists on the Selection and Presentation of News News is formed through a selective process which is controlled by media professionals such as journalists correspondents and editors. Agenda setting, a theory created by Stephen Lukes, sees how journalistrs select news that is projected through the media. Agenda setting also sees bias in the media, which is most commenly dominated in the political broadcasts. The Glasgowuniversity mediaRead More Censorship in the Classroom Essay2774 Words   |  12 Pageswant controversial materials out of the classroom? In this look at the language of censorship, we must first define censorship, who does the censoring, and why. These will be the first three spotlights for looking at the language of censorship. Then, we will look at how teachers, especially teachers of literature and the language arts are affected by censorship. Finally, we will preview how censorship can be taught in the classroom, to prevent some of tomorrows censorship cases. I neverRead More Banned Books Essay1279 Words   |  6 Pagesemployer but parents themselves. The main objetcive of libraries are to maintain a family-oriented institution.The libraries offer a broad selection of reading materials for everyone to use including parents, teachers, young adults, and children. Many public libraries facilities have special areas for children and teens with materials that appeal to those particular ages and particular interests. Libraries also offer programs for children and young adults to assist them with learningRead MoreThe Adventures Of Huckleberry Finn By Samuel Langhorne Clemens1325 Words   |  6 PagesAll schools and educational institutions of any sort have a policy regarding the selection of instructional materials. The Denali Borough School District in Alaska is a school system that opened up to talk about their policy. Alaska is one of the few states in the United States that allows schools to more or less govern themselves, giving them soft standards that must be met but giving the freedom to pick and choose any instruct ional material that is desired, many schools do not have this privilegeRead MoreEssay on Censorship and Book Banning1838 Words   |  8 Pages Censorship is a concept with several different meanings. To each individual censorship has its own meaning. Is it a violation of our rights or is it a protection for our well being? Censorship in the generic sense refers to the suppression of information, ideas, or opinions. It occurs in all forms of communication from technological media to print media. Each society, culture, or individuals belief is violated by the codes of censorship that our society instills. Book banningRead More Internet Censorship - Just Say No1369 Words   |  6 PagesInternet Censorship: Just Say No    In December of 1994, a young college student named Jake Baker posted one of his fiction pieces in an alt.sex newsgroup. Usually, his contributions to this widely-read site consisted of short stories about rape, torture, and murder of women. In this particular newsgroup post, he continued with his usual contributions; however, he took it a bit further by writing about one of his fellow classmates, using her name and identity in the piece. Faculty members at

Analysis Of Producing A Six Supplied Line 180 Second Drama...

Individual Analysis For the assignment of producing a six supplied line 180-second drama short film I was tasked as the 1st Assistant director in our production ‘Hidden’. In my role analysis I shall be examining my role as 1st AD going into depth of preparation, research and contributions I made towards the short film. The main roles of the 1st AD is to creating a shooting schedule, working with the director to decide a shooting order, give directions to crew and actors and be aware of health and safety whilst on set. As the 1st AD I was the right hand person to the director, I had found out through basic research that my role required me to help decide a shooting order and how long each scene will take to film, creating a shooting†¦show more content†¦[1] The shooting schedule itself included all the necessary information needed to be organised and to hopefully keep on track, these were timings, scene number, night or day, location (Forest or House), short scene description, any props needed. The printed schedule allowed space underneath for any notes to be added if timings or schedules changed, this way I could alert the director of any required information. On day one we did fall behind by two hours but I had told the group before hand that I had schedule it so we could overrun by 2.5 hours if need be, even though we didn’t keep to schedule I still let the director and the crew know how behind on time we were, what scenes were coming up and progress reports of the day. With regards to lunch I checked with everyone on set for it to be pushed back a little to fit in the morning scenes, even though it’s annoying they were still happy that I had checked with them beforehand adding to the approachable aspects of my role. However when I found out we would be reshooting I should have created a second shooting schedule so we could keep organised on day two, doing this would allow the director to be certain on what shots needed to be re-filmed and if any audio needed to be captured. I did have notepad with some notes on shots but a shooting schedule would have been more ordered and precise so we could have been there for as little time as possible. Next time

Nursing Care Plan Essay Example For Students

Nursing Care Plan Essay Course: NUR 1210LInstructor: Dates of Care: 12, 13, 19 20 Sept 96Date Submitted: 11/15/96Student Names: Anthony Bernardi, SN/SPJCHOLISTIC NURSING CARE PLANSTUDENT Anthony BernardiGRADEDATE November 15, 1996Client’s Clinical Picture (5)(Initial Cephacaudal assessment)Textbook Description of Diagnosis (5)Summary of Client’s Progress (5)Completion of Holistic NCP Tool (30)NURSING DIAGNOSIS (15)GOALS (10)INTERVENTIONS (10)RATIONALES (5)EVALUATIONS (10)REFERENCES (5)TABLE OF CONTENTSSUBJECT PAGE #? Cover Page 1? Grading Point Scale 2? Table of Contents 3? Summary Page 4? Client’s Clinical Picture (Cephacaudal Assessment) 5? Medical Diagnosis 6? Textbook Description of Disease 6-12? Treatments and Procedures 13? Summary of Caregiver Progress Notes 14? Diagnostic Values Out Of Normal Range Clinical Implications 16? Radiology 17? Medications 18-52? Holistic Nursing Care Plan Form 53-62? List of Nursing Diagnosis 65? Five Nursing Diagnoses 66-70? References 71CLIENT CLIN ICAL PICTURE:Please see attached Cephacaudal Assessment (Pages 5)MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia, cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI, Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma TEXTBOOK DESCRIPTION OF DIAGNOSIS:See attached Disease Process Description (pages 6-12-)SUMMARY OF CAREGIVER PROGRESS NOTES: See attached Caregiver Progress Notes (page 14-15)CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for â€Å" atypical chest pain and hemoptysis†. V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit. Pt. is able to do all his ADL’s with limited assistance. He wants to get better and leave the HSP. Pt. Stated’ 90 days is to long to be here†. Pt. States that he is concerned about caring for his tube site when he goes home and does not feel that his wife can do this for him. Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC lineMEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and depression. PATHOPHYSIOLOGY HEMOPTYSIS: Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi or lungs (Tabor’s, 17th ed. 1989 p.879)CACHEXIA SECONDARY TO MALNUTRITION/INFECTION : The state of ill health, malnutrition, and wasting It may occur in any chronic diseases, certain malignancies and advanced pulmonary tuberculosis. (Tabor’s, 17th ed. 1989 p.287)NECROTIZING PNEUMONIA: Aspiration pneumonia. Aspiration pneumonia is frequently called necrotizing pneumonia because of the pathologic changes in the lungs. It usually follows aspiration of material in the mouth into the trachea and subsequently the lungs. The aspirated material. Either food, water, or vomitus, is the triggering mechanism for the pathology of this type of pneumonia. If the aspirated material is an inert substance (e.g. barium or nonacid stomach contents), the initial manifestation is usually caused by obstruction of airways. When the aspirated materials contain gastric acid, there is chemica l injury to the lung parenchyma with infection as a secondary event usually 48 to 72 hours later. The infecting organism is usually one of the normal oropharyngeal flora. The clinical manifestations proceed as those of a classic pneunococcal or streptococcal pneumonia. Fungi may also be a cause of pneumonia. These infections are not transmitted from person to person, and the patient does not have to be placed in isolation. The clinical manifestations are similar to those of bacterial pneumonia. Skin and serology tests are available to assist in identifying the infecting organism. However, identification of the organism In a sputum specimen or in other body fluids is the best diagnostic indicator. (Lewis, S.M. Collier, p. 643-644)ASPERGILLOSIS INFECTIONS : There are several forms of Aspergillosis infections. All are caused by one or more of the many different Aspergillus fungus species; only a few of these organisms are capable of producing disease in humans. These species are sprea d through the air and can be found almost any place in the world. Because these spores are inhaled, they usually affect the lungs or other airway passages such as the bronchial tubes, nose and sinuses. The fungi can be invasive, affecting any tissue, mucous membrane or vital organ of the body. Allergic Bronchopulmonary Aspergillosis (ABPA) is an immune disorder that occurs in people with asthma or chronic obstructive pulmonary disease (COPD) infected with Aspergillosis fungi. It causes an excess of certain white blood cells (eosinophils), an infiltration of the lungs, and impaction of the bronchial tubes with eosinophils and Aspergillus organisms. Symptoms of this disease may consist of fever, shortness of breath (dyspnea), chest pain, wheezing, a cough with sputum (with or without blood) or a generalized feeling of ill-health (malaise). This form of Aspergillosis is not usually invasive, but it can lead to a chronic dilation of the bronchial tubes (bronchiectasis). Pulmonary Mycetoma, also known as Aspergilloma or fungus ball, is a form of Aspergillosis that often occurs as a result of the Aspergillus fungus growing together (colonization) in a cavity of the lungs. These cavities are usually caused by other pulmonary diseases such as tuberculosis, sarcoidosis, histoplasmosis or coccioidomycosis. The fungus ball can be seen on x-rays. This form of Aspergillosis is characterized by a chronic cough, weight loss, a generalized feeling of ill-health (malaise) and the spitting up of blood (hemoptysis). Fulminative or Invasive Aspergillosis is another form of this disorder that can cause distribution of the Aspergillus fungus to other parts of the body. This disease can progress from a localized infection to a widespread erosion and ulceration of the bronchial system and an inflammation of the vascular system (vasculitis). Vasculitis is a narrowing of the inside of a blood vessel that can obstruct the flow of blood to the tissues. This lack of blood can cause damage to the tissues (necrosis), and a possible formation of blood clots (thrombosis). Invasive Aspergillosis is usually first confined to the lungs but it can spread through the blood to other organs especially the liver, brain, kidneys, skin, gastrointestinal tract and other sites. This can be a very serious disease which can have a slow or rapid course. It is seen in those whose immune system has been weakened by other illnesses, especially people with cancer (e.g., Leukemia, Hodgkins Disease), kidney transplant patients or those undergoing certain drug therapies. Occasionally, Aspergillosis can cause Infective Endocarditis which is an infection of the inner lining of the heart muscle (endocardium). A type of infective endocarditis, prosthetic valvular endocarditis (PVE), may develop in patients who have previously had artificial (prosthetic) heart valve replacement. This infection may occur as a result of contamination of the operating room area by the Aspergillus spores. Drug addicts are also more susceptible to this form of Aspergillosis. Mycetoma, also known as Madura Foot, is a chronic infection produced by Aspergillosis as well as several other fungi. It is a progressive fungal disease that is characterized by lesions of the foot, face, trunk, hand or leg. These lesions can cause swelling, hardening, pus formation, sinus drainage and abscesses that can lead to bone destruction and deformities. It is more commonly seen in tropical climates. Aspergillosis is a group of infectious diseases that are caused by the inhalation of the Aspergillus fungus. The spores that cause these infections can be found in decaying vegetable matter, grains, grass, leaves, soil, wet paint, air conditioning systems, on refrigerator walls and in construction and fireproofing materials. It is not known why most people resist infection from this common fungus, and why others are more susceptible to infection. A weakened immune system, or an abnormal immune response to the fungus, may cause the fungus to proliferate and become a threat to ones health. Aspergillosis is a rare disorder that affects males and females in equal numbers. It is seen more often in those people who have chronic respiratory problems or whose immune system has been weakened by other serious illnesses or drug therapy. DEPRESSION: Depression is the most common functional disorder. Signs of depression include sadness, low energy, diminished memory and concentration, sleeping disturbances, appetite disturbance, with withdrawal, irritability, alcohol abuse, expressed feelings of helplessness and hopelessness, apathy, impaired attention span, and expression of suicidal wishes. Depression is often treatable and reversible through use of antidepressant medications and counseling. (Brunner/ Suddarth, 1988)HYPERTENSION: Hypertension can be defined arbitrarily as persistent levels of blood pressure in which the systolic pressure is above 140 mm Hg and the diastolic pressure is above 90 mm Hg. In the elderly population, hypertension is defined as systolic pressure above 160 mm Hg and diastolic pressure above 90 mm Hg. Hypertension is a major cause of heart failure, stroke, and kidney failure. It is called the â€Å"silent killer† because the person who has it is often symptom free. Gerontological Cons iderations: Changes in the peripheral vascular system are responsible for the changes in blood pressure that occur with age. As the age related process of atherosclerosis evolves, the ability of the vessels to distend and recoil is reduced. Consequently, the aorta and large arteries are less able to accommodate the ejected stroke volume, and a decrease in cardiac output and increase in peripheral resistance result. Systolic blood pressure increases as a result of the increased peripheral resistance, and pulse pressure widens subsequent to the diastolic fall that accompanies reduced distensibility of the aorta. The risk factors for high blood pressure that are present in the population in general continue into old age. These are approximately the same for elderly men and women. (Brunner/ Suddarth, 1988)CHRONIC OBSTRUCTIVE PULMONARY DISEASE : Chronic obstructive pulmonary disease (COPD) is the most common cause of death and disability due to lung disease in the United States. COPD is a broad classification that includes a group of conditions associated with chronic obstruction of air flow entering or leaving the lungs. Airway obstruction is diffuse airway narrowing, causing increased resistance to air bronchiectasis, emphysema, and asthma. Basically, the person with COPD has (1) excessive secretion of mucus within the airways not due to specific causes (bronchitis or bronchiectasis), (2) an increase in the size of the air spaces distal to the terminal bronchioles with loss of alveolar walls and elastic recoil of the lungs (emphysema), and (3) narrowing of the bronchial airways that varies in severity (asthma). As a result there is a subsequent derangement of airway dynamics for example, loss of elasticity and obstruction of air flow. There is often an overlap of these conditions. (Brunner/ Suddarth, 1988 )ASTHMA : Asthma is an intermittent, reversible, obstructive airway disease characterized by increased responsiveness of the trachea and bronchi to various stim uli. This results in narrowing of the airways, causing dyspnea This narrowing of the airway changes in degree, either spontaneously or because of therapy. Asthma differs from other obstructive lung diseases in that it is a reversible process, and patients may exhibit no symptoms for a prolonged period of time. Asthma is a reversible diffuse airway obstruction. The obstruction is caused by one or more of three developments: (1) contraction of muscles surrounding the bronchi, which narrows the airway (2) swelling of membranes that line the bronchi and (3) filling of the bronchi with thick mucus. In addition, there is bronchial muscle enlargement, mucous gland enlargement, thick, tenacious sputum, and hyperinflation or air trapping in the alveoli but most of what is known involves the immunologic system and the autonomic nervous system. (Brunner/ Suddarth, 1988 ATRIAL FIBRILLATION: Atrial fibrillation (disorganized and uncoordinated twitching of atrial musculature) is usually associate d with atherosclerotic heart disease, rheumatic heart disease, CHF, thyrotoxicosis, or pulmonale, or congenital heart disease. Atrial fibrillation is characterized by the following- lowing: Rate: An atrial rate of 350 to 600 beats per minute ventricular response usually 120 to 200 beats per minute. P waves: No discernible P waves: irregular undulation, termed fibrillary or â€Å"f† waves, is seen; PR interval cannot be measured. QRS complex: Usually normal. Conduction: Usually normal through the ventricles. Characterized by an irregular ventricular response, because the AV node is incapable of responding to the rapid atrial rate. Impulses that are transmitted cause the ventricles to respond irregularly. Rhythm: Irregular and usually rapid, unless controlled. Irregularity of rhythm is due to concealed conduction within the AV node. A rapid ventricular response reduces the time for ventricular filling and hence the stroke volume. The atrial kick, which is 25 to 30% of the cardi ac output, is also lost. Congestive heart failure frequently follows. There is usually a pulse deficit, the numerical difference between apical and radial pulse rates. Treatment is directed toward eliminating the cause, decreasing the atrial irritability, and decreasing the rate of the ventricular response. In patients with chronic atrial fibrillation, anticoagulant therapy may be used to prevent thromboemboli from forming in the atria. Drugs of choice to treat atrial fibrillation are similar to those used in the treatment of paroxysmal atrial tachycardia, digitalis preparation is used to slow the heart rate, and an antidysrhythmic such as quinidine is used to correct the dysrhythmia. (Brunner, Suddarth 1988). TYPE II DIABETES MELLITUS: In diabetes, insulin is not secreted in proportion to blood glucose levels because of several possible factors: deficiency in the production of insulin by the beta cells, insensitivity of the insulin secretory mechanism of the beta cells, delayed or insufficient release of insulin, or excessive inactivation by chemical inhibitors or â€Å"binders† in the circulation. In some non-insulin dependent persons with diabetes, however, insulin secretion is increased, resulting in higher , circulating insulin levels. Although excess insulin is present, it is not utilized because of an inadequate number of insulin receptors present on cells. This mechanism has been observed in obese patients. With weight loss, the number of insulin receptors on the cells increases, thereby allowing glucose to enter the cell. This may result in return of a normal glucose tolerance. (Burner/ Suddarth, 1988 )HYPOTHYROIDISM : Hypothyroidism is a condition in which there is a slow progression of thyroid hypofunction, followed by symptoms indicating thyroid failure. More than 95% of patients with hypothyroidism have primary dysfunction of the thyroid gland itself. When the thyroid dysfunction is due to failure of the pituitary gland, it is known as sec ondary hypothyroidism; when failure of the hypothalamus is the underlying cause, the term tertiary hypothyroidism is used. When thyroid deficiency is present at birth, the condition is known as cretinism. In such instances, the mother may also suffer from thyroid deficiency. (Brunner/ Suddarth, 1988) TREATMENTS AND PROCEDURESPatients activity orders are as tolerated with wheel chair transport. Pt needs partial assist with ADLs. He is continent of B B with assistanceNeeds to be turned in bed Q 2 hr, elevate heels in bed . Pt has a special mattress. Encourage I.S. Q 1 hr w/a. IV flush q shift peripheral line. PICC line flush. Chest tube to water seal to 20cm, with cont. suction 55-60 wall green. DO NOT DISCONTINUE SUCTION. Chest tube dressing change no deviations from present form. Accurate IO’s . VS. Q shift and prn. with lung sounds assessment. Skin assessment q 2 hr with wound assessment at the same time(abrasion on the back ) and finger ulceration. FSGs q 6 hr with Sliding scale coverage. Weight every week on Monday. SUMMARY OF CARE GIVER NOTES:All times are approximate07:30 Received report on G.B. from night shift. 08:00 Spoke with G.B. before breakfast was delivered. Vital signs taken and noted. Insured patency of chest drainage tubes and amount of fluid from last shift. Noted time and initialed on collecting container. 09:00 09:00 medications given and noted09:30 Assisted G.B. with ADL’s. Pt stated that he wasn’t very hungry. Pt. Ate only 25% of solid food. Noted intake of 250ml. Urine output after breakfast 225ml. Pt. Performed own bed bath and oral care. Lotion applied to Pt. Pt. Helped into bedside commode. Curtains drawn for privacy. 10:30 Dressing change on tube insertion site as ordered. Skin assessment done and lung sounds checked. Check position of G.B. He had re-positioned himself for comfort10:45 X-Ray of G.B. performed in room. G.B. dressed and assisted into wheel chair. 11:00 Reported pt status to Team Leader. 11:00 Documented morning activities in appropriate charts, i.e. Nsg Notes, treatment book and V/S charts. 11:15 Returned to room to interview G.B. . Pt was cheerful but stated that he was feeling tired and wanted to be helped back into bed. 11:45 Noted I O 12:00 G. B. In bed resting comfortably. Reported pt status to team leader and report off floor to post-conference. DIAGNOSTIC VALUES OUT OF NORMAL RANGE CLINICAL IMPLICATIONSBUN 32H 10-26 A. Increased BUN levels (azotemia) 1. The most common cause of increased BUN level is inadequate excretion due to kidney disease or urinary obstruction, frequently- : occurring in cases of prostate enlargement. (A) An increased BUN of 50 to 150 mg / 100 ml indicates serious impairment of renal function. (Fishbach p. 312)Creatinine .5H 0.7-1.4 A disorder of kidney function reduces excretion of creatinine, resulting in increased levels of blood creatinine. The test is used to diagnose impaired renal function. It is a more specific and sensitive indicator of kidney disease than BUN, although in chronic renal disease, BUN correlates more accurately with symptoms of uremia than does the blood creatinine.( (Fishbach p. 312)WBC 10.4H 5-10 A. Leukocytosis (white blood cell count above l0000 / gl) 1. Leukocytosis is usually due to an increase of only one type of White cell and is given the name of the type of cell that shows white cell and is given the name of the type of cell that shows the main increase. .In increase in circulating leukocytes is rarely due to a proportional increase in leukocytes of all types. When it occurs it is usually to hemoconcentration. Leukocytosis occurs in acute infections in which the degree of increase of white cells depends on, 1. The severity of the infection, 2. The patient’s resistance, 3. The patient’s age.(Fishbach p. 25.)RBC 2.96L 4.2-5.6 Decreased RBC Values . Anemia, a condition in which there is a reduction in the number of circulating RBCs, in the amount of hemoglobin, and/or in the volume of packed cell(hematocrit).(Fishbach p. 41)HGB 10.L 13.1-17.2 AnemiaHCT 29.3L 39-50 decreased hematocrit values are an indicator of anemia. In hematocrit of 30 or less means the patient is moderately to severely anemic. ALBUMIN 3.1l 3.9-5 decreased albumin levels severe hypoalbuminemia is often associated with edema and decreased transport function such as hypocalcemia. Decreased albumin levels are caused by many different conditions i.e. Nephrosis (Fishbach p. 363)LY# 1.2L 1.8-2.6 AnemiaMCH 34H 26-34 An increase of the MCH is associated with macrocytic anemia. MCV 99.2H 87 -103 Note VA values differ from Fishbach. F the MCV is greater than 103 mm3, the red cell 5 are macrocy tic. PLT 433H 150-350 Abnormally increased numbers of platelets (thrombocythemial thrombocytosis) occur in iron-deficiency and posthemorrhagic anemia acute infections and many other diseases. In 50% of those patients who exhibit an unexpected increase in plate- lets, a malignancy will be found. This malignancy is usually disseminated, advanced, or inoperable. MPV 6.3L 8 -10L This test is done in the investigation of various hematologic disorders such as thrombocytopenic purpura, and study of alcoholics under treatment. Na+ 135 135-148 Hyponatremia usually reflects a relative excess of body water rather than a low total body sodium. K 4.6 2.7-4.5 Hyperphosphatemia (increased phosphorus levels) The most common causes of elevated blood phosphate levels are in association with kidney dysfunction and uremia. This is because phosphate is so closely regulated by the kidneys. Renal insufficiency and severe nephritis (accompanied by elevated- : BUN and creatine) Albumin 3.1 3.8-5.0 albumin is a protein that is formed in the liver and that helps to maintain normal distribution of water in the body (colloidal osmotic pressure). It also helps in the transport of blood constituents such as ions, pigments, bilirubin, hormones, fatty acids, enzymes, and certain drugs. Decreased albumin levelsDecreased albumin levels are caused by many different conditions- inadequate iron intake, Severe liver diseases Malabsorption, Starvation, excessive administration of IV glucose in water RADIOLOGYF/Y empyema status no change since 9/3/96. F/U bilateral sever pulmonary emphysema interstitial fibrosis. CBC shows high levels of WBC’s and bends indicative of ongoing infection. Chemistry shows elevated liver enzymes. UA and CS are negative. Blood cultures are also negative. Sputum CS and Gram Stain show WBC* 25, Eph.*10 and presence of Alpha streptococcus neisseria. NATO EssaySelf-Expression Reflection, reminiscence, self-actualizing pursuits within physical capabilities. BW p 898 Neat, clean, well groomed; articulate; Affective response consistent with norms. Articulate; expresses self well. Concerned about his future at home. â€Å"Who will help me take care of my tubes at home?† Client expresses accep-tance of stage in life but not physical limitations. Skin Tissue Integrity Skin more fragile less elastic, less SC fat, blood vessels more fragile; Increases risk of skin tears. Vascular insufficiency increases risk of decubitus ulcer BW p 974 Warm, pale, good turgor. Reddened area on coccyx Understands import. of being turned in bed, moving extremities, ingesting adequate fluids food. Good personal hygiene. Client demonstrates a little anxiety about the possibility of developing a decubitis ulcer. Client verbalizes anxiety about possibility of skin tissue breakdownNutrition Body maintenance and repair, type and quality of food, calories must be rich in nutrients. Lowered calorie requirements due to lower BMR BW p 1082 Cachexia secondary to malnutrition, poor intake. TPN q 12 hrs, supplements Client understands his need to increase the food intake for adequate nutrition healing. Client does not like hospital food but tries to eat as much as possible. He also dislikes his supplements. Client wants to gain weight stating, †I try to eat more than I want.†Fluid Balance Decreased renal concentra-tion fx. Increased loss amounts of water salt, muting of thirst response, decreased intake. BW p1558 Good skin turgor, no edema IO’s q shift Client understands the need for adequate fluid intake. No emotional relationship seen with regard to fluid balance. Understands importance of adequate fluid intake in health maintenance. Elimination Loss of muscle tone in bladder bowel changes elimination patterns, that vary with diet, lifestyle, medications. BW p 1136 Continent of bowel bladder. Uses toilet with assistance. Bowel sounds present X4. Urine clear yellow Client recognizes the need for regular bowel schedule. Non-verbalized discomfort with having to go to the bathroom while in bed. Client verbalizes no concerns. Oxygenation Some loss of lung elasticity; pO2 decreased, especially if smoked. BW p 1227 Resp. rate 18-24/min. lung sounds slightly diminished Understands the need for O2 and reason for SOB. Does not like the idea of needing O2 inhalers to control SOB. Client admits to periods of SOB, and pain with coughing. Sleep-RestPatterns/Pain Incr. Time to get to sleep, incr.# times awaken, decrease total sleep time. Daytime naps may compensate. BW p 1321 Client naps several times during day, sleep-rest poor at night. Being turned q2hrs and pain from chest tube wakes up. Verbalized that being turned q 2 hrs interrupted his sleep causes