Research Proposal The Rise of China Example | Topics and Well Written Essays - 3500 words

The Rise of China - Research Proposal Example The secondary data collected from existing literature will be used throughout the study to supplement the primary data. The theory presented in the literature review will be obtained from existing literature on the topic of study. The researcher will use the literature review to critically and objectively analyse the data in establishing research gaps and coming up with possible areas of study. Simple random sampling, purposive and snow ball sampling will be used as the sampling techniques in the study. The researcher will also adhere to ethical considerations when carrying out the study. The limitations of the study such as financial constraints and time of the study are also considered in this proposal. Since the political and economic reforms of 1970, China has been experiencing an impressive rate of development characterised by rapid economic growth (Blanchard & Shleifer, 2001). This has resulted to the country’s increase in global economic and political influence in the past three decades. The Chinese government has invested heavily in third world countries in Africa, Latin America (Santiso et al 2004) and the Middle East in the spheres of manufacturing and construction. Critiques, however, view the country’s rapid export, investment and economic growth as a bubble because of the state driven nature of the economy which is heavily reliant on administrative methods in the management of financial and economic outcomes (ECLAC, 2005). Furthermore, the country is dependent on exports, has exposed banking institutions, environmental stress, unstable political climate and a fast aging population. Thus, if China was to be a pacesetter for the future of the globe, then ther e would be a great challenge as the practices of the country are incompatible with those of the West such as the rule of law, individualism, individual freedom, democracy, universal ethics and even coordination of economic activities through financial outcomes (Ikenberry, 2008). These

Executive Report to describe Operations Strategy at non-profit Org Case Study

Executive Report to describe Operations Strategy at non-profit Org - Case Study Example In the hospital’s financially self-sustaining framework defies the common belief that cheap care automatically means low-quality care. The facilities are designed to provide premium healthcare at hitherto impossible costs (Matalobos 2). Aravind drives costs down by operating an eye-care â€Å"factory† that is fast and efficient. Through this, the organization creates economies of scale through treating ridiculously high numbers of patients. The organization has adopted a standardized and engineered model for carrying our operations and maintaining low costs at all times. In the same way McDonald’s, Toyota and Ford concentrated on constantly enhancing and expanding their system models, so the organization gradually transformed to create the Aravind Eye Care System (Mehta and Shenoy 6. Vital components of this system include an international eye bank, a specialized factory for manufacturing lenses, and dedicated ophthalmic research facilities. Of special importance has been the hospital’s eye camp model, which transports the system to remote locations, providing advice, diagnosis, and admitting patients into the main hospitals which can treat them using high productivity models (Mehta and Shenoy 21). Doctors are positioned between two operating tables so that after they finish with one patient they practically turn to the next, who has already been prepared and is ready for surgery. The operations service strategy at Aravind could be compared to the just in time (JIT) model popularized by Japanese firms, with the only difference being that it involves humans instead of products. Aravind hospitals churn out thousands of treated patients a year via from its â€Å"conveyor belt† of surgeons and nurses (Matalobos 7). In essence, the organization has applied manufacturing principles to make its operations as fast and efficient as possible. The organization’s doctors also developed a new type of cataract surgery

Patient Abuse in Nursing Facilities Essay Example for Free

Patient Abuse in Nursing Facilities Essay Patient abuse in nursing facilities is becoming more prominent. Abuse is not only physical, but emotional, sexual, neglect and financial exploitations. The elderly are the most vulnerable and least likely to complain, so unfortunately they are the targets. Most families research in depth about the nursing facility that they will place their loved one, in hopes that abuse doesn’t occur. Although the research is done, families should still look for signs and symptoms of abuse since they are leaving their loved one in stranger’s hands. According to (Center), A recent investigation concluded that employment checks do not always provide adequate protection against elder mistreatment. For instance, the Centers for Medicare and Medicaid Services prohibit nursing homes from hiring persons with a prior history of committing abuse in a nursing home setting, but those who have been convicted of other forms of abuse like child abuse may still be hired. Some states require a criminal background check, while others do not. Even so, these checks usually do not uncover convictions in another state. Furthermore, in some states, non-caregiving staff such as maintenance workers and others without a direct patient care role do not undergo criminal checks even though they may have direct access to patients and patient areas. Understaffing is a common cause of nursing home abuse. When staff members become overworked, they may begin to lose their patience with the nursing home residents. In addition, understaffing leaves many workers unsupervised or untrained, which can lead to nursing home abuse. Still, physical abuse in nursing homes is illegal, and the owners of the assisted living facility can be held liable if a resident is subject to nursing home abuse or neglect. Sometimes, it is difficult to identify nursing home residents who have been physically abused. Very often, members of the nursing home staff will state that the residents injuries were the result of a fall rather than the actual causenursing home abuse. In addition, the staff member may bully the resident into agreeing with their story. Because detecting signs of physical nursing home abuse can be difficult, loved ones should pay careful attention when visiting the nursing home. Be aware of the common signs of physical nursing home abuse, including: unexplained bruising, cuts, sprains, fractures and broken bones and open wounds. In addition to physical signs, nursing home patients who have been physically abused may also show changes in their behavior. If the resident appears withdrawn, fearful, nervous or depressed, they may be suffering from physical nursing home abuse. The most common type of physical abuse is battery, which can include forcing the resident into restraints for no valid reason. Other forms of physical abuse in nursing homes include: overmedication, use of excessive restraints, chemical or physical, for no reason, burning, pushing, shoving, force feeding, hitting the resident with the hand or an object, pulling the residents hair and mishandling the resident when transporting them from beds, bathrooms etc ( (Morgan). According to (Emotional Abuse in Nursing Homes), Emotional abuse in nursing homes is not as overt as other forms of abuse. Regardless, the effects that emotional abuse in nursing homes can result in are damaging to the happiness, health, and other areas of that resident’s life. Not knowing what signs to look for can allow emotional abuse in nursing homes to continue. Often times, a resident thinks that telling someone about abuse suffered, including emotional abuse in nursing homes, will make them a burden to the family or they feel afraid of enduring an increased amount of abuse. If emotional abuse in nursing homes is occurring the family members should immediately notify the facility. The facility should amend the situation at once but if the emotional abuse in nursing homes persists, the family should take further action. The chances of the emotional abuse in nursing homes occurring to just one resident are very slim so other residents are probably suffering as well. Emotional abuse in nursing homes can include humiliation, harassment, threat of punishment, deprivation, and intimidation, as well as other behaviors. One of the most pervasive forms of nursing home abuse today is that of neglect. Nursing home neglect is too frequently overlooked and results all too often in a decline in general health and eventually the death of those elderly people entrusted to nursing home care facilities. The problem can occur anywhere and can take many shapes. What makes this particularly sinister is that it can be overlooked or ignored for so long. Even upon repeated visits to a nursing home, the signs of nursing home neglect can remain hidden. In order to understand the scope of the problem, it is important to know the different types of nursing home neglect and nursing home abuse. The most obvious, most egregious, and the first that comes to mind for many people is physical neglect. Unfortunately common in nursing homes today, neglect takes many forms, however, all of which are disturbing in their own right. Any of the following forms of neglect warrant contacting a nursing home abuse lawyer to bring justice to the victim of neglect, as well as make conditions safer for other residents (Center). According to (Financial Exploitation of Nursing Home Residents), Financial exploitation of the elderly occurs when an individual takes or uses the money or property of a senior for any wrongful use, or with the intent to defraud the elder. Senior citizens who live in nursing homes or other long-term care facilities can be victims of financial abuse by their direct caregivers or by the administrators of the nursing homes. Financial exploitation is defined as the wrongful use of an individual’s finances or property for another’s advantage. This can occur when residents personal or financial resources are taken from them without their consent, either because the residents were incapacitated and unable to give consent or because they were subjected to threats, intimidation, manipulation, and deception. Examples of financial exploitation include cashing an elderly person’s checks without authorization, forging a senior’s signature, stealing an older person’s money or possessions, or deceiving an older person into signing any contract, will, or other document. According to (Nursing Home Abuse), It is critical for every resident to understand their nursing home patient rights in order to successfully acclimate to the very different living environment of a skilled nursing facility. Patients and their families should become well versed in the policies and procedures inherent to life in the facility and must know exactly what they can and should expect when it comes to care and safety. In the US, the federal government and each state government have written legislation which guarantees each nursing home resident specific and general rights while under professional care. Most foreign counties have similar laws enacted to protect elders from abuse and neglect in nursing facilities, as well. When your loved one is placed in a nursing home, it is required that they are given a written bill of patient’s rights. It is recommended that the family and loved one go over this bill of rights in detail so they are familiar with the rights of their loved one. Most often, nursing home patients cannot defend themselves, due to several different reasons: physical health, mental health, social isolation or dependency issues. Unless someone comes forward for these patients, they won’t get help and no one is penalized for their actions. Many do not know how to report nursing home abuse, so they remain silent and struggle with their disturbing knowledge of the abuse or neglect. Once the repost is filed, the organization that is responsible, will investigate thoroughly and will hold the person/persons responsible for their actions. If you are a family member and suspect any minor abuse or neglect, it is always wise to report the activity to the nursing home administrator directly. Tell them that you have evidence of the abuse and that you intend to take this matter as far as it will go. Do not back down. If the infraction is minor and resulted in no real damage, then you may consider allowing them to discipline the staff member internally. Just be sure to watch out for any retribution which may come back to your loved one if the staff member is not fired. If the infraction is more serious or you do not feel completely confident that the matter will be settled in the best interest of your loved one, then take the concern one step further. Immediately call police and report the incident. Additionally, contact adult protective services, your ombudsman, your local nursing home regulatory agency and Medicare, if applicable. You might also consider consulting with a nursing home abuse attorney and filing a civil lawsuit (Nursing Home Abuse). Although abuse in nursing facilities is becoming more prominent, there are several things that family members can do to protect their loved one from being a victim from this horrible crime. The elderly are very vulnerable, but they do not deserve the abuse that the under paid, aggravated staff member may give them. If someone suspects abuse in a nursing facility, they should report it immediately. If not, this makes you just as guilty.

Women Opting Out Of Work

Women Opting Out Of Work Opting out is a term most commonly understood to describe the decision of married women to voluntarily quit professional careers and remain out of the labor force for a relatively extended period of time during which they are engaged in family care giving, primarily motherhood, to the exclusion of paid employment. Women use a variety of strategies to reconcile work and family responsibilities, including time out of the labor force, opting out, by virtue of the attention given it by the media, has assumed special prominence and a distinct identity. The novelty of opting out is that the women said to be returning home to re-create the traditional family form of male breadwinners are, unlike the stay-at-home mothers of the 1950s, seasoned professionals with considerable career success who are making their decisions in an historical context that affords them a wider range of options than were available to earlier generations of women, even privileged women. Employment, when anticipated a t all after marriage, was regarded as short-term and secondary. In the 1970s, educated women made a break with the past and began, in significant numbers, to combine sustained employment with motherhood. Opting out is the ability to exercise this option which is typically open only to women with a male partner whose earnings can offset the loss of their own. (Stone, 2007a) Some women have resorted to opting out of work because they are not satisfied with their careers. They are not choosing to quit but rather are unable to continue, pushed out by the conditions of their jobs rather than pulled home by their children. Highly educated, elite professional women get tired of the demands of work, do not like the effects on their family lives, and opt out of the fast professional tracks of law, business, and journalism to take care of their children. Some of these women are full-time mothers; others work part-time, typically at less demanding jobs. Not all elite professional women are opting out by any means. How much of womens decision to stay home is a choice, and how much is the result of inflexible and hostile workplaces. Suffice it to say here that the ideology of intensive mothering, combined with the rising demands of workplaces and lack of public support for childrens welfare (e.g., healthcare, daycare, maternity and paternity leave) create severe di fficulties for many mothers, privileged and otherwise. (Belkin, 2003, October 26.) Their children are pure, innocent and helpless and need a selfless nurturer who will shelter them from the corrosive outside world, either by providing care herself or ensuring that alternative (although inevitably second-best) care is provided. The mother/child bond is uniquely tight, and lasting, and essential to a childs healthy psychological development and only a mother (not a father, other family member, or paid caretaker) can provide this care. Mothers are responsible for nurturing, listening, responding, explaining, negotiating, distracting, and searching for appropriate alternative care, practices which are so labor-intensive, so time-consuming, so energy-absorbing because mothers understand themselves as largely responsible for the way their children turn out. Children seem happier, more rested and childlike. They get along better with siblings, and are quite creative in their uses of free t ime. (Hays, 1996, p. 120) Professionals who had quit their jobs and were stay-at-home mothers -opted out, as conventionally understood -which found that the large majority of these women were highly conflicted about their decision, Further challenging the prevailing explanation that their decision was primarily about motherhood. (Stone, 2007a) Because of the high cost of living, life becomes expensive thus making women to look for work to support the demands of their families. Middle-class women cant afford to quit their jobs without scaling back considerably. The families of working class parents are believed to flourish with large amounts of unscheduled time, and adult intervention in their activities is not considered a worthwhile use of anyones time. Poor and working-class parents use fewer words with their children, and although children prove quite capable of expressing opinions, adults do not actively cultivate this ability, nor do they cultivate the questioning of authorities and negotiation. Finally, discipline is a matter of rules and sometimes physical force, not reason. As a result, poor and working-class children find themselves disadvantaged vis a vis their middle-class peers, and privilege is passed down. Mothers who work full-time, for instance, often defend this choice as better for the child in the long-r un. Also importantly, mothers are held responsible by others for their childrens well-being, which means that choosing not to adopt tenets of this ideology requires a defense which is often made in terms of the ideology itself. The accomplishment of natural growth does not, however, mesh as neatly with the procedures and expectations of schools and the workplace as does concerted cultivation, which encourages children to engage in many time management and linguistic practices that institutions expect and reward. (Lareau, 2003) Women do not quit their careers because of a preference to stay home with their children. Some professions might be more or less conducive to womens persistence suggests that there are lessons to be learned from certain fields that might be usefully applied to others, especially the corporate sector. Although virtually all of the women in the sample were happy to have more time to spend with their children, most still identified with their professions and int ended to return to work at some point in the future, although their plans are uncertain. Having a job, especially a fulfilling professional career, is more interesting than housework and child-rearing. Men dont want housewives, Some men fantasize about having a woman running their home and doing not much more, sure. But nowadays, a lot of men prefer to marry more independent women, and would find the idea of supporting a wife intimidating. Women with children are found to have lower full-time, year-round labor force participation rates overall than male graduates or women without children, but those with advanced degrees showed a strong commitment to their careers by returning to work after only brief absences following childbirth (Stone, 2007a) I would agree with Ann Crittenden the Author of The Price of Motherhood: Why the Most Important Job in the World is still the Least Valued. This is because she portrays women as the good mother, the wise mother . . . is more important to the community than even the ablest man; her career is more worthy of honor and is more useful to the community than the career of any man, no matter how successful. A mothers work is not just invisible; it can become a handicap. Raising children may be the most important job in the world, but you cant put it on a rà ©sumà ©. The idea that time spent with ones child is time wasted is embedded in traditional economic thinking. People who are not formally employed may create human capital, but they themselves are said to suffer a deterioration of the stuff, as if they were so many pieces of equipment left out to rust. Inflexible workplaces guarantee that many women will have to cut back on, if not quit, their employment once they have children. The re sult is a loss of income that produces a bigger wage gap between mothers and childless women than the wage gap between young men and women. The very definition of a mother is selfless service to another. We dont owe Mother for her gifts; she owes us. And in return for her bounty, Mother receives no lack of veneration. Crittenden proves homemakers are essential to the economic and political success of our country and its inhabitants. She also emphasizes the contributions of the large number of educated women who have chosen to stay home and raise children.(Crittenden, February 2001) Opting out is a luxury unavailable to most women and only applicable to those with high earnings/savings or wealthy partners; professional women with the option to opt out might take it because they are not given flexible options to stay in their professional jobs and parent; women in all job sectors are more affected by the recession, especially in jobs like finance where a male-dominated environment might lead to high-ranking women being axed because of the perception they arent tough enough; women with the ability to pretend they werent forced out of their jobs might do so by claiming they chose not to work to stay home and parentsuch women are not included in unemployment numbers or given the attendant benefits of unemployment; and the new frontier might be the flexibility stigma. The only way to get rid of the flexibility stigma is to embrace a culture where professional men and women each take off work in equal measure to care for children or attend to household tasks. Then, we might in a world where there is a parent stigma but at least it wont be borne solely by women. (Leonhard, 2010, August.) Conclusion. Because it does not conform to the standard conception of a profession, motherhood might seem to have no place in this issue. A woman requires no special expertise, no knowledge, skill or educational degree to become a mother. Furthermore, the work she does as a mother is unpaid, sometimes even unrecognized as work. These two features of motherood its accessibility to any fertile girl or woman, and the fact that society provides no financial compensation to mothers for their hard workare often lamented, though towards very different political ends. In fact, motherhood might be considered the very opposite of a profession: a status dependent upon biological, cultural and social factors, not educational ones, and involving labor done without pay or recognized steps to advancement. (article)

the bear :: essays research papers fc

Composition II Research Paper Rough Draft title   Ã‚  Ã‚  Ã‚  Ã‚  In â€Å"The Bear† by William Faulkner, there are several different personalities and attitudes that come into play at various times in the story. The story is told from the perspective of Isaac McCaslin, the boy of the story and one of the main characters as well, and many critics feel that this was â€Å"probably a projection of Faulkner’s own youthful self†(Monarch Notes 5). Isaac was of the aristocratic class of people who were a part of the South, and who also played a significant part of the stories that Faulkner wrote. Another class of people that were a consistent part of Faulkner’s short stories were the poor-whites such as the Snopes family in â€Å"Barn Burning.† Abner Snopes is a man who seems to blame everyone but himself for his problems. Being a Civil War veteren from the Confederate point of view, he was bitter about the War and the way that the Southerners were treated, though it appears that he brought his parti cular condition upon himself. During the War, the only loyalty was to himself and he remained that way Another class of people that are a significant part of Faulkner short stories are the non-whites which include the Negro, the Indian, and any mixture of the different races found in the South. Abner Snopes gave no regard or respect to the â€Å"nigger†(155), who was the de Spain servant and door man, when the Snopeses came to announce their arrival for the sharecropper job, but muttered â€Å"get out of my way, nigger.† Sam Waters gained more kindness and respect than that, though he was still a mixed blood in a wealthy, white world. He was Works Cited Faulkner, William. â€Å"The Bear.† Big Woods New York: Random House, 1955. 11-97. Faulkner, William. â€Å"Barn Burning.† Short Story Masterpieces Ed. Robert Penn Warren and Albert Erskine. New York: Dell, 1954. 148-68. â€Å"Works of William Faulkner: Introduction and Bibliographical Scetch(sic).

Generation Ecstasy :: essays research papers

For my book report I read Generation Ecstasy. There was so much information in the book about the rave scene and "ecstasy", I didn't know where to begin. It's been ten years since the English seized on Detroit techno, Chicago house, and New York garage as the seeds of what's generally agreed-over there, at least-to be the most significant music since punk, and they're celebrating with a slew of historical studies. Simon Reynolds attempts to bridge the gap with "Generation Ecstasy," an exhaustive compendium of almost every rave-associated sound and idea, both half-baked and momentous, that traces the digital Diaspora back and forth across Europe and America. Using the multiple perspectives of music critic, enthusiastic participant, and sociological outsider to trace the development of dance music's "rhythmic phsycadelic," Reynolds, finds two predominant, contrasting strains: the search for gnosis, or spiritual revelation, and the desire to get completely out of it at the weekend. Setting these timeless traits in the context of the up-to-the-minute technology that made rave emblematic of its era-the fragmentary, fast-forward aesthetic, the flexible production and distribution network, the avoidance of personality and narrative in favor of sensation-he comes up with a portrait of hi-tech millennium that resonates well beyond its subculture confines. There are those who might find a book to analyze music that often aims for the effect of a sledgehammer to the head a mite pretentious. Yet the radicalism of dance music lies precisely in its "meaninglessness," which, paradoxically, requires intellectualization in order to get at its significance. This problem is particularly acute for Reynolds, who wants to both valorize everything about techno that makes it resistant to rock-crit "literary" analysis, and also explain exactly why it really did mean something, man. His central tool for resolving this contradiction is the idea of the "drug-tech interface": the reciprocal relationship between Ecstasy (and other less central intoxicants) and machine music that resulted in a feedback loop between sounds geared to enhance the rush, and rushes that inspired producers to take sound into new spaces. The drug-tech interface gives "Generation Ecstasy" a narrative backbone that applies again and again, ac ross continents and cultures from Texas, where Ecstasy culture first reared its head in the mid-'80s, to Scotland, Holland, and Germany. The story starts with the initial, utopic discovery of Ecstasy and its boundary-lowering qualities, and ends, with varying degrees of speed, with the descent into polydrug abuse and depression.

Stroke Care Management and Pressure Ulcer Assessment Tool

Student Number: 21127187 Module: Assessment and Therapeutic Care Management Module Code: AN 602 Assignment Title: A Case study: Stroke Care Management and Pressure Ulcer Assessment Tool Word Count: 3296 Date Submitted: 11th January, 2012 This academic work aims to present a clinical case study of a patient who is diagnosed of cerebrovascular accident (CVA), also called â€Å"stroke†, achieve a deeper understanding of debilitating post-stroke complications using an assessment guide and nursing interventions to the nursing diagnosis of impaired skin integrity.This essay aims to incorporate the utilisation of a pressure ulcer grading assessment tool to establish baseline assessment data and facilitate ongoing wound care management in relation to pressure ulcers (PrUs) as one of long term problems encountered in the care of a stroke patient. A holistic assessment of the patient will be required, identifying activities of daily living to enable the nurse to devise a plan involving the therapeutic team in line with identified nursing diagnoses.Due to limitation on word count, the essay will focus more on the present health status in relation to areas pertinent to PrUs management during the rehabilitation process. For the purpose of this academic work, the patient will be protected by the Nursing and Midwifery Council (NMC) Code of Conduct (2008) by use of a pseudonym, ‘Mr. X’. Mr. X, is an 87 year-old elderly obese patient, with long-term diagnosis of Hypertension (HPN) and Non-Insulin Dependent Diabetes Mellitus (DM), on maintenance medications, who was recently diagnosed of Cerebrovascular Accident (CVA).Mr. X was transferred to a nursing home after the acute hospitalisation for long-term care. Brunner (2008) defines CVA, Ischemic Stroke, or â€Å"Brain Attack† as sudden loss of neurologic functioning resulting from blood flow disruption in cerebral blood vessels. Stroke has two main types, Ischaemic and Hemmorhaegic: the former is caused by an infarct of blood clot in brain artery and accounts for 80 % of all stroke cases; while the latter is caused by bleeding into the brain tissues accounting to 20 % of stroke occurrences (Feigin et al, 2003).Stroke is the third leading cause of death and is a major cause of adult neurological disability which affects approximately 130,000 people a year in the UK (National Audit Office, 2005). Mr. X was diagnosed of having left middle cerebral artery (MCA) infarct 7 months ago resulting to neurological deficits on the contralateral side of the body. The extent of deficits following stroke depends upon the affected cerebral artery and subsequent areas of brain tissue compromised of blood supply by the damaged vessel (Porth, 2007). Upon assessment, Mr.X has right side hemiplegia, contralateral sensory impairment, dysphasia, bowel and bladder incontinence, and an existing Category I PrUs on both heels. The hemiplegia is explained by Brunner (2008) that because motor neurons decussat e, a disturbance of motor control on one side of the body may reflect damage to the motor neurons on the opposite side of the brain. Williams et al (2010) states that following a MCA infarct, there is alteration of the brain’s ability to process and interpret sensory data which results in Mr. X’s sensory impairment.Porth (2007) defines aphasia as a general term with varying degrees of inability to comprehend, integrate, and express language. Porth (2007) further states that a stroke on the MCA territory is the most common aphasia-producing stroke. It is then imperative to understand the pathology of affected areas of the brain to anticipate presence of motor, sensory, and speech deficits where the nurses and entire therapeutic team can intervene. For the purpose of data gathering and assessment, Gordon’s Functional Health Pattern (1987) is utilised as a framework of this essay.The model presents 11 functional health patterns categorized systematically for data c ollection and analysis, and is used as a guide in the development of a comprehensive nursing data base ( Gordon, 2000). The nurses can identify functional patterns as the clients’ strengths and dysfunctional patterns as the nursing diagnoses, which assist the nurse in developing the care plan (Gordon, 1994, 200). The assessment guide is particularly chosen because it gives the nurse a full opportunity to examine not only the physical aspect f human functioning but includes physiological and psychological disturbances experienced by the patient. Nursing diagnoses can then be derived from the wide-range of assessment data collected. The Gordon’s assessment tool is thereby used a framework for ensuring that all aspects of an individual’s patient’s life are considered. However, this essay will only focus on the following health patterns: Cognitive – Perceptual, Nutritional-Metabolic, Activity and Exercise where nursing problems were identified and ther eby require therapeutic care management.The Agency for Healthcare Policy and Research Guideline for Post-Stroke Rehabilitation (AHCPR, 2005) recommends that initial assessment of stroke patients should include a complete history and physical assessment with emphasis on medical co-morbidities, level of consciousness, skin assessment and risk of PrUs, mobility, and bowel and bladder function. Moreover, the following areas of assessment contribute to the development of PrUs: impaired sensory perception or cognition, decreased tissue perfusion, nutrition and hydration status, friction and shear forces, skin moisture, mobility, and continence status (Brunner, 2008; Porth 2007).The specific areas mentioned above will be of greater emphasis due to its contribution to PrU management in post-stroke Mr. X. Based upon history taking, Mr. X has been living with Hypertension (HPN) and DM for 12 years and has been insulin dependent for 5 months now after the occurrence of stroke. Past medical his tory must be taken into essential consideration especially in chronic conditions to ascertain levels of compliance to medical interventions, perception towards illness, and impact on patient’s lives (Crumbie, 2006).Establishment of rapport and consequently gaining trust from the patient thereby enables the nurse to create a good baseline history assessment and attain patient’s cooperation through the entire rehabilitation process. The nursing process first step is assessment which involves collecting data to help identify actual and potential health problems and patient needs. In order to develop appropriate nursing diagnoses, accurate assessments should be made to guarantee allocation of appropriate resources in the planning stage to achieve expected outcomes. Potter and Perry, 2008). It could be suggested that nurses in this stage of nursing process should employ opportunities for holistic assessments and use critical thinking in determining focus areas to be include d in the database. The cephalo-caudal principle of assessment is incorporated as a guide for presenting the health patterns, which sets the Cognitive – Perceptual pattern as the first to be approached highlighting assessments on cognition, perception, sensory, pain, and language.Williams et al (2010) states that post-stroke damage to the brain can result to cognitive and sensory impairment which often includes a decrease in thinking, effective decision-making, memory, and perception. Mr. X’s assessment of this health pattern reveals communication difficulty between patient and healthcare team. If communication problems arise, nurses conduct referrals to the Speech and Language Therapy (SLT) who diagnoses presence of aphasia. However, the type of aphasia has not been established yet since Mr.X has been reportedly uncooperative to therapies. It could be suggested however, that basing on research, the Frenchay Aphasia Screening test (Enderby et al, 1987) can be utilised b y the SLT to administer a quick language measure. Another recommendation is the participation of nurses in an interview (Inpatient Functional Communication Interview, McCooey et al, 2004) by the SLT to describe how Mr. X communicate at bedside to help the SLT diagnose communication problems, if any.The limitation on data gathering and assessment process can be compromised at this stage because of problems on communication between the nurse and the patient. It could be suggested that a referral to a speech pathologist can be made to evaluate the patient’s speech, language and ability to understand by testing verbal expression, writing ability, reading, and understanding of verbal expression (Barker, 2002). A nursing diagnosis identified is Impaired verbal communication related to effects of dysphasia.It may be suggested that nurses should provide patients with aphasia a constant way of communicating, through hand gesture, tone of voice, facial expressions and verify responses with family members when warranted ( Holland et al, 2003). It may also be necessary to talk slow, clear, in simple terms and render the patient ample time to understand the information given (Barker, 2002). Family members of aphasic stroke survivors may also experience difficulty in various roles of care giving since the patient cannot communicate effectively (Christensen and Anderson, 1989; Draper and Brocklehurst, 2007).Therefore, it is also necessary to include the family, caregivers, and the nurses at bedside during therapies to maximise nursing care (Intercollegiate Stroke Working Party, 2008). Mr. X’s perception of pain is assessed periodically at varying times of a day to ensure pain relief. Mr. X cannot verbalise pain, but most of the time shows facial grimaces while pointing to right shoulder and hand where pain are felt. Brunner (2008) says that as many as 70 % of stroke patients suffer severe shoulder pain that prevents patients to perform balance and perform self- care activities.Mr. X upon physical assessment has painful shoulder, swelling and stiffness on right hand, defined by Brunner (2008) as shoulder-hand syndrome which causes a frozen shoulder and subcutaneous tissue atrophy, and is always painful. However, according to Edwards & Charlton (2002), it cannot be a cause of pain if managed correctly with appropriate limb support. In this regard, pain assessments should always be subjective and be backed up with objective data gathered. Nursing diagnosis identified is Chronic pain related to immobility secondary to disease process (Heath, 2008).Mr. X has been prescribed with pain relief, Piroxicam gel onto pain areas three times a day and Tramadol tab daily. Piroxicam Gel is a non-steroidal anti-inflammatory drug that inhibits the enzyme prostaglandin thereby reducing pain and swelling whereas Tramadol is an Opiod analgesic (British National Formulary, 2010). Moreover, Mr. X has been receiving Amitryptiline HCl to help in the management of post-stroke pain but it causes cognitive problems and sedation (Brunner, 2008) thereby requiring safety nursing measures.However, non-pharmacological nursing interventions should be employed first hand before medical interventions. Brunner (2008) suggests elevation of the hand and arm to prevent edema. National stroke guidelines recommend any patient whose range of motion at a joint is reduced should undergo passive stretching of all affected joints on a daily basis, and furthermore, taught to carers (Carter & Edwards, 2002) provided that pain relief is achieved at all times.Referrals to physical therapy or occupational therapy are suggested to evaluate physical debilitations relating to functional mobility to promote pre-morbid independence and subsequently enhance quality of life (Barker, 2011). The second health pattern to be presented is Nutritional – Metabolic. Stroke can present a wide range of deficits which can affect ability to eat and predispose a post-stroke patien t from malnutrition (Williams et al. , 2010).It is supported by Shelton and Reding (2001) who integrates associated weakness and sensory loss on arm and face more than the leg in patients who has had occlusion of the MCA. Barker (2002) states that nearly one third of stroke survivors have dysphagia and chewing difficulties which prompts nurses strategies to liaise aspiration risk with SLT and nutritionist or dietitian. Special diet and caloric calculations may also be needed for Mr. X due to daily insulin management, not to mention daily blood glucose monitoring.Waterlow (1985) emphasizes that those with eating difficulties are likely to eat less, thereby slowly predisposing to poor nutritional intake, so efforts should be directed at creating good balanced diet, is well-presented, and if possible, assistive devices are provided such as adapted cutlery for ease in eating, plate guards, non-slip pads and beakers for drinking. Monitoring of nutritional deterioration of post stroke pat ients is essential during rehabilitation phase thereby giving attention to nutritional intake, weight, gastrointestinal function, and general health condition (NICE, 2005).Weekly weighing has been advocated and utilization of nutritional screening tools that are validated and reliable are recommended by NICE (2005). Review of systems provides skin assessment in nutritional metabolic health pattern which revealed presence of pressure ulcer on heels. The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) (2009, p7) defines, ‘ A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence , as a result of pressure, or pressure in combination with shear’.Waterlow (1996) emphasizes that excessive weight increases pressure on a bony area thinly covered by tissue such as the sacrum, heels, and trochanters. Pressure ulcers (PrUs) on the heel is a very common site of PrUs, ranking second fro m the sacrum (Bennett & Lee,1985; Hunter et al, 1985; Wong & Stotts, 2003) and is often painful (Black, 2005). Krueger (2006) in her study, stated that 25% of heel PrUs are related to diabetic neuropathy and peripheral arterial occlusive disease.PrU classification systems describe how severe the tissue damage is through progressive numbers or categories (Dealey, 2009). Given that all professionals utilize same system, logic dictates that all PrUs will be objectively assessed, however, Ousey (2005) debates that many grading systems available are rather subjective in nature giving professionals varying assessment interpretations. Grading systems assists healthcare professionals identify the severity of PrUs and serve as a baseline for care plans. However, careful clinical judgement by the nurse s essential in ensuring that the classification systems are used only as a guide, professional skills in assessment are needed to ascertain objective assessment data. In conclusion, grading sys tems serve as valuable tools to determine pressure sore severity in clinical practice, audit, and research ( Beeckman, 2007). Moreover, consistency in the use of classification system will enable the professionals to define progress of healing, allow evaluation of goals of treatment, and revise plans as deemed necessary.Based on the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) (2009) Pressure Ulcer Classification System, Mr. X has a Category I PrU and is defined as an area of intact skin with non-blanchable redness of a localized area, usually on a bony prominence, which may present as painful, warm, and edematous. The NPUAP and EPUAP classification system was designed to provide commonality in the definition and grading / categorization / staging of pressure ulcer, which is applicable in international settings.It has four categories, Category I to IV, each defining level of skin injury and adding physiologic descriptions, which i s recommended by NICE (2005). Terms such as unclassified or unstageable and deep tissue injury (DTI) which are classified as category IV is discussed separately in the new guideline (NPUAP and EPUAP, 2009). Ousley (2005) stated that Surrey system of classifying PrUs is the simplest tool available, presenting same four levels in plain terms, however, warns professionals of its relative subjectivity due to its simplicity.The EPUAP (2007) grading system is almost similar to NPUAP (2007), describing four grades, each is described in detail. However, according to a study done by Beeckman (2007), the EPUAP system of classification has a low inter-rater reliability because of complex details in the definition, leading to a low commonality of professionals identifying the categories of PrUs, jeopardising audit of prevalence rates and affectivity of wound management.The Torrance grading system involves five stages, each stage described simply and is easy to use, however it was not widely uti lised because of its number of categories (Ousey, 2005), which may impose confusion against four categories, rather than achieving consensus. Healey (1995) in her study, revealed that Surrey, Torrance, and Stirling systems do not have a high level of reliability. Similarly, the Stirling Pressure Sore Severity scale (SPSSS) tool is argued by Healey (1995) to have the lowest reliability rate because of its most complex subscales under each category.There are four stages starting from 0 where there is no evidence of pressure ulcer, then each category has subsections, describing the level of skin injury, wound bed, and presence of infection parameters (Ousley, 2005). However, Waterlow (1996) in her work on pressure sore prevention established the use of SPSSS as the standard classification system to be implemented because she argues that specialists and researchers need to define pressure ulcers in greater depth whereas the other systems’ relative simplicity is regarded as weakne ss in lieu of its use on clinical audit.In this regard, the NPUAP and EPUAP guideline is considered useful because it provides evidence-based assessment as it is proven to be an effective and reliable tool in every healthcare setting. This will enable the healthcare team to improve the care required for pressure ulcer due to a common baseline assessment of the ulcer, thereby requiring a specified care management depending on its stage. Nurses can then devise a care plan based on ulcer grading, identify appropriate treatment, allocate care resources, implement the plan, and do continual evaluation of the care plan with its goal directed at wound healing.However, to achieve this level of patient assessment and care, every nurse should possess the necessary knowledge and skills which can be achieved through continuing education and trainings in pressure risk assessment and PrUs management, an interdisciplinary collaboration ( NICE, 2005). Nursing diagnosis identified is Impaired skin i ntegrity related to immobility and decreased sensory perception secondary to disease process (Heath, 2009). Nursing management employed were repositioning Mr.X every 2 hours avoiding positioning on pressure area (EPUAP and NPUAP, 2009) and taking weight off the mattress by placing a pillow or a folded blanket under entire length of the leg and not under the Achilles tendon to protect the knee as well (Waterlow, 1996; NPUAP and EPUAP, 2009, Langermo et al, 2008). There are marketed devices for heel protection but needs constant care giver assessment since these devices are found to not keep the heels off the bed better than pillows do (Tymec et al, 1997).Relieving the pressure off the heels is often all that is needed to recover the tissues in category I Heel PrUs (Langemo et al, 2008) and if offloaded continuously hastens recovery time (Black, 2005). Periods of frustration and depression are sporadically experienced by 40 % of stroke patients throughout the recovery process or as a new phase in the trajectory of a chronic illness and is often underdiagnosed (Barker, 2002).Ideally, a psychiatrist or a clinical psychologist diagnoses depression, but according to Intercollegiate stroke Working Party (2008) a healthcare professional with mental health training can diagnose using a clinical interview. It can also be suggested to use brief screening tools to identify patients at risk of depression such as the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) or the Geriatric Depression Scale GDS ( Yesavage et al, 1982) which are validated tools to assess mood in stroke populations (Williams et al, 2010). Amitryptiline HCl, a Tricyclic antidepressant (BNF, 2010) is prescribed for Mr.X, and is taken daily. Duncan (2005) sets the prevention of stroke recurrence as the highest priorities in stroke rehabilitation and is therefore the responsibility of the nurse to understand stroke risk factors and apply contemporary evidence based lifestyle changes after pr oper training (Lawrence et al, 2011). Barker (2002) reports that stroke survivors have 30% probability of recurring stroke within a year and 50% can suffer fatal strokes in 5 years. It could then be suggested that a Stroke Risk Screening Tool (Barker, 2002) be utilised to decrease risk of death and evaluate risk factors of Mr.X such as HPN which is managed at present with antihypertensives, DM managed with Insulin injections, Hypercholesterolemia managed with Antilipidemics, advancing age, obesity, and diet. Therefore, an important aspect of nursing care is health education whereby nurses promote lifestyle change and supportive behavioral approach towards long-term health modification. In conclusion, nurses’ role in the care of post-stroke patient is multi-faceted, one that requires interprofessional linkage and deep understanding of contemporary evidence based interventions to address issues.DH (2007) further suggests that post stroke patients and their carers should receive support from varying range of services made available locally. Most importantly, though nursing interventions are standardized as guidelines, it could be suggested that it may not be all applicable in every patient interaction and care should be individualized as needed (Landers & McCarthy, 2007). Therefore, it is of prime importance for nurses to understand that healthcare decisions are based from patient’s individual choices derived from rational decision-making and the objective and rofessional advice of every member of the therapeutic team. Reference List Agency for Health Care Policy and Research. (1992) Pressure ulcers in adults: prediction and prevention. Clinical practice guideline no. 3. AHCPR, Public Health Service, US Department of Health and Human Services. Rockville, MD: US Department of Health and Human Services. Barker, E. (2002) Neuroscience nursing: a spectrum of care. 2nd ed. Missouri. Mosby. Beeckman, D. , and Schoonhoven, L. (2007). EPUAP classification s ystem for pressure ulcers: european reliability study. Journal of Advance Nursing. 60 (6), 682-691. Bennett L, & Lee, BY. 1985) Pressure vs. shear in pressure sore causation:Chronic ulcers of the skin. New York. McGraw Hill. Black, J. (2005) Treating heel pressure ulcers. Nursing. 35:68. British national formulary. (2010) British national formulary:March 2010. London. BMJ group. BNF. org Carter, P. & Edwards, S. (2002) General principles of treatment. Neurological Physiotherapy: A problem solving approach. 2nd ed. Edinburgh. Churchill Livingstone. Christensen, JM. and Anderson, JD. (1989) Spouse adjustment to stroke:aphasic vs. non-aphasic partners. Journal of Communication Disorder. 22 (4), 225-231. Crumbie, A. 2007) Assessment and management of the patient with chronic health problems : Watson;s clinical nursing and related sciences. 7th ed. Edinburgh. Dealey, C. (2009) Skin care and pressure ulcers. Advances in Skin and Wound Care. 22 (9), 421-428. Department of health (2007) The national stroke strategy for England. Department of health. [online]. Available from:http://www. stroke. org. uk/campaigns/stroke_policy/the_national_stroke. html [14 November, 2011] Draper, P. and Brocklehurst, H. (2007) The impact of stroke on the well-being of the patient’s spouse: an exploratory study. Journal of Clinical Nursing. 6 (2), 264-271. Duncan, P. , Zorowitz, R. , Bates, B. , Choi, J. , Glasberg,J. , Graham, G. , Katz, R. , Lamberty,K. , and Reker,D. (2005) Management of adult stroke rehabilitation care:a clinical practice guideline [online]. American heart association. Available from: http://stroke. ahajournals. org/content/36/9/e100. full. [Accessed 12 October 2011]. Edwards, S. & Charlton, PT. (2002) Splinting and the use of orthoses in the management of patients with neurological disorders. Neurological Physiotherapy: A problem solving approach. 2nd ed. Edinburgh. Churchill Livingstone. Enderby, P. , Wood, V. , and Wade, D. 1987) Frenchay Aphasia Screening Test. NFER-Nelson. Windsor. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. , (2009) Pressure ulcer prevention: quick reference guide [online]. Available from: www. eupap. org [Accessed 20 November 2011]. Feigin, V. , Lawes, C. , Benett, D. , Anderson, C. (2003) Stroke Epidemiology: a review of population-based studies of incidence, prevalence, and case fatality in the late 20th century. The Lancet Neurology. 2 (1) 45-53. Gordon, M. (1994). Nursing diagnosis: Process and application. 3rd ed. St. Louis: Mosby. Gordon, M. (2000). Manual of nursing diagnosis: 1995-1996.St. Louis: Mosby. Healey, F. (1995) The reliability and utility of pressure sore grading. Journal of Tissue Viability, 5 (40), 111-114. Heath, H. (2002) Potter and perry’s foundation in nursing theory and practice. London. Elsevier science limited. Heather, H. (2009) North American nursing diagnosis association international nursing diagnoses. Oxford. Wiley-blackwell. Holland, K. , Jenkins, J. , Solomon, J. and Whittam, S. (2003) Applying the roper logan Tierney model in practice. London. Elsevier limited. Hunter, SM. , Langemo, DK. , and Olson, B. (1995) The effectiveness of skin care protocols for pressure ulcers.Journal of Rehabilitation Nursing. 20 (2), 50-55. Intercollegiate Stroke Working Party. (2008) National clinical guideline for stroke. 3rd edition. London. Royal college of physicians. Kelly, J. (1994) The aetiology of pressure sores. Journal of tissue and viability. 4(3), 77 Krueger RA. (2006) Pressure relieving support surfaces: a randomized evaluation. Poster presented at the 9th European Pressure Ulcer Advisory Panel Conference. Berlin, Germany. Landers, M. and Mc Carthy, G. (2007) Person-centred nursing practice with older people in Ireland. Nursing Science Quarterly. 20 (1), 78-84. Langemo, D. , Thompson, P. Hunter, S. , Hnason, D. , Anderson, J. (2008) Heel pressure ulcers:stand guard. Advances in Skin and Wound Care. 21 (6), 282-292. Lawr ence, M. , Fraser, H. , Woods, C. , and McCall, J. (2011) Secondary prevention of stroke and transient ischemic attack. Nursing Standard. 26 (9), 41-46. Maklebust, J and Magnan, MA (1994) Risk factors associated with having a pressure ulcer: a secondary data analysis. Advances in Skin and Wound Care. 7 (27), 31-34. Maklebust, J and Magnan, MA (2005) Preventing heel pressure ulcers in immobilized patients. Advances in Skin and Wound Care. 18 (1), 22 McCooey, R. , Worrall, L. , Toffoko,D. Code, C. , and Hickson, L. (2004) Inpatient functional communication interview. Singular publishing. National audit office (2005). Reducing brain damage – faster access to better stroke care. The stationary office. London. National institute for health and clinical excellence (2005) CG29 Pressure ulcer development:quick management guide [online]. Available from: http://publications. nice. org. uk/pressure-ulcers-cg29/guidance [Accessed 26 October 2011]. National pressure ulcer advisory panel ( NPUAP). (2007). Pressure Ulcer Definition and Stages. NPUAP. Available from: www. npuap. org [Accessed: 16th December 2011).Nursing and Midwifery Council. (2008). The code Standards of conduct, performance and ethics for nurses and midwives. London. Nursing and midwifery council. Ousey, K. (2005) Pressure area care. Oxford. Blackwell. Porth,C. (2007) Essentials of pathophysiology:concepts of altered mental states. 2nd ed. London. Lippincott Williams & wilkins. Shelton, FN. and Reading, MJ. (2001) Effect of lesion location on upper limb motor recovery after stroke. Stroke. 32 (1), 107-112. Smeltzer,S. , Bare, B. , Hinkle, J. , and Cheezer, K. (2008) Brunner & suddarth’s textbook of medical-surgical nursing. 11th ed. London.Lippincott williams & wilkins. Tymec AC, Pieper B, Vollman K. (1997) A comparison of two pressure-relieving devices on the prevention of heel pressure ulcers. Advances in Skin and Wound Care. 10(1), 39-44. Waterlow, J. (1996) Pressure sore prevention manual. Taunton, Somerset Williams, J. , Perry,L. and Watkins, C. (2010) Acute stroke nursing. Chichester. Wiley-blackwell. Wong, VK. , Stotts, NA. (2003) Physiology and prevention of heel ulcers: the state of science. Journal of Wound Ostomy and Continence Nursing. 30 ( ), 191-198. Yesavage, JA. , Brink, TL. , Rose, TL. , Lum, O. , Huang, V. (1982) Development