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Chronic Obstructive Pulmonary Disease Nursing Assessment Approach

DEVELOPING ADULT NURSING CARE With this essay, the names and setting will not be disclosed in order to protect confidentiality. The content within this essay is generalised across a patient group and does not relate to any specific patient, staff member or trust (NMC, 2018). The aim of this essay is to identify a patient group with a specific health need relating to a long-term condition they are living with. It will prioritise this health need with a specific focus on a holistic approach to nursing assessment, when assessing patients with Chronic Obstructive Pulmonary Disease, known as COPD. It will locate the point of the trajectory of the disease, as well as the care environment the assessment takes place with, and why these are important in relation to the relevance of the chosen assessment. COPD is one of the respiratory diseases which requires palliation of symptoms, is known to have four stages within its disease trajectory beginning with mild, moderate and progressing to moderately severe (Currie, 2017). The term ‘health trajectory’ describes changes in health over period of time, defending the stage a patient is at in their health trajectory allows for effective intervention and care planning ( Seamark et al, 2007).The patient group for purpose of that assignment are within the severe stage of their illness with long term limitation of function and well-being with intermittent serious episodes of COPD progression .Disease trajectory during the third stage of COPD patients experience exacerbation which can have a big impact on life quality (limitation) and often requiring hospital admission (Curie,2017). A study by Lunney et al (2002) introduce End of Life as its own phase, divided int four distinct trajectories varying in length and rate of decline in functionality. By Lunney et al (2002) trajectory has a four different End of Life Stages: terminal, frailty, sudden death and organ failure. The essay will introduce and describe the assessment tools used for individual health care needs and explore the need for holistic assessment based on the activities of daily living, using the Roper, Tierney, Logan model ‘Activities of Daily Living’ (ALD’s). ADL’s are what people take advantage of in everyday life, for example, bathing, dressing, work; (Roper et al, 2000). Twelve activities of daily living are used to measure a patient’s ability, they are: “maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying”. Performing ADL’s can help to gather as much information as possible, for example, does the patient live alone, is the patient is able to carry out basic tasks (washing, dressing, etc.). It helps to identify areas of risk, as well as highlight person own individual health, needs to support a patient’s journey. “Understanding the breadth of patients’ support needs is important for the delivery of person-cantered care, particularly in progressive long-term conditions such as chronic obstructive pulmonary disease (COPD). Existing reviews identify important aspects of managing life with COPD with which patients may need support”. COPD may continue to get worse despite treatment, eventually having a significant impact on their quality of life and leading to life limiting prognosis. Although COPD is a bracket name given to multiple lung conditions such as emphysema and chronic bronchitis the two conditions are very similar and often present with similar symptoms. (Ashelford et al, 2016). COPD has a wide spread effect on the body effecting weight loss, exercise intolerance and peripheral oedema, It is estimated around three million people in the United Kingdom (UK) are living with COPD, but the National Institute for health and care excellence reports only 900,000 of those have officially been diagnosed (NICE, 2010). The main focus within this essay will be on the need for nutrition for those with the long term condition of COPD as many patient with COPD are underweight and malnourished (Currie, 2017). The essay will introduce and describe the assessment tools used for individual need, and explore the use of that assessment as an integral part of an overlooking, holistic assessment of the needs of the chosen patient group, developed via the creation of an effective therapeutic nurse-patient relationship, as well as involvement of the families, carers, as well as multi-disciplinary team. This assignment will highlight the key clinical manifestations of an acute exacerbation in a COPD patient and will discuss the strategies for care management. Understanding a patient’s perception of their illness is an important first step to providing comprehensive, multifaceted care for patients with long term conditions. Being able to self-manage, not least because COPD is specific to the individual and can change on daily base, because of that educating a patient is key. Each long term condition comes with a set of challenges. This essay will focus on the group of the patients in a hospital environment which suffer from the chronic obstructive pulmonary disease (COPD) with a priority need for nutrition on the body and patient’s quality of life. Chronic obstructive pulmonary disease is a progressive lung disease characterised by airflow destruction and destruction of the lung parenchyma (GOLD, 2019). The Global Initiative for Chronic Obstructive Lung Disease (2019) states that COPD is a preventable and treatable disease. National Institute of Clinical Excellence (NICE, 2011) highlight “COPD is the fourth highest mortality rate being one of the costliest conditions treated within the NHS, with a total annual cost of over 800 million in direct healthcare costs. COPD is often characterised by persistent respiratory symptoms that effect the airflow limitations caused from long term chronic inflammation that damages the respiratory system by effecting tiny air sacs within your lungs, causing the peripheral airways to become narrower and thicker, which then results in restricted airflow, making it harder for COPD suffers to breathe and empty their lungs causing them to suffer breathing difficulties and breathlessness, often involving a long term chronic cough and increased mucus production” According to NICE, “around three million people in the UK are affected, two million of whom are undiagnosed. It causes 115,000 admissions to hospital every year. Most people find out they have COPD in their fifties or older, and it’s much more common in people who smoke. Breathing problems tend to get gradually worse over time, but there are many different medicines and therapies that can help people keep these under control for longer” (NICE, 2016). Symptoms include increased breathless, especially when people are active, a persistent cough with phlegm, frequent chest infections and wheezing. Breathing problems tend to get gradually worse over time, limiting everyday activities, although treatment can help to keep the condition under control. The patient may experience exacerbations when symptoms become more severe (NICE, 2018). Over the last few decades, the study of COPD has become one of the most rapidly developing fields in medicine (Lee, 2017). Exacerbation can often be caused by viruses and bacterial infection, patient with frequent exacerbation have an increased risk of decline in their lung function what and consequently impairs quality of their life, as well as putting a pressure on family, carers (Lung Institute,2017). Furthermore, evidences show that COPD gradually gets worse over time, however for many people treatment can be offered for better management of COPD, which improves quality of life and decrease limitation in their daily activities of life (British Lung Foundation, 2019). COPD has often been misdiagnosed as asthma due to similar symptoms, presentation, lack of knowledge, training and understanding around the disease its symptoms and causes study shows those who are undiagnosed or misdiagnosed often causes a delay in treatment at the earliest stage of disease trajectory. (Fromer,2011) In addition, looking at the effects of nutrition it’s also important to consider the effects of involving patients’ friends, family and care givers when assessing and planning future care. Some patients might find it difficult sharing their personal information to health care professionals in front of loved ones about their condition, due to sensitive information that might be exposed or harbouring guilt from either a history of smoking or not seeking treatment earlier (Fromer, 2011). When completing an assessment and planning care for patients it is important to consider and maintain patient confidentiality, valid consent must be gained from the patient before any information I shared outside of the nurse patient relationship. (MNC, 2018) NUTRITION The poor prognostic sight in COPD is the fact, that many patients with COPD are underweight. According to Currie (2017), malnutrition is associated with the severity of airflow obstruction. Good assessment, getting background information on a patient’s breathlessness, daily activities it’s important to maintain good nutrition status. Lack of information in assessment increasing patient’s risk to become malnourished rapidly due to lack of energy from poor nutrition. All those aspects will have an impact on skin condition as well down to poor mobility because of lack of energy. This factors at an early assessment will help improve a patient’s quality of life and help preventing from condition getting worsted (Former, 2011). In addition, looking at nutrition it also important to select an appropriate nutritional screening tool to be used during the assessment, for example the Malnutrition Universal Screening Tool, known as MUST (BAPEN, 2011). Other tool, less known is the Mini Assessment Tool, known as MNA, common in assessment in older adults (Nestle Nutrition Institute, 2009). It is very important to inform the patient about the reason for that procedure as well as obtain consent and using appropriate communication methods. The nurse, and other health professionals should be aware that effective nutritional assessment begins on first contact with the patient. It may be admission in hospital etc. Supporting patient’s nutritional requirements is a fundamental aspect of nursing care. During the initial nutritional assessment patient’s high and weight need to be obtain using calibrated weighing scale and a height measure; this information will enable the selected nutritional screening tool to be completed. If this is not possible, calculate the patient’s mid-upper arm circumference by measuring the ulna length an upper arm circumference with a tape measure, as described in the MUST (BAPEN,2011). It is important for nurses and carers to remember that patient s who are underweight or overweigh can be malnourished. However, malnutrition patients who are obese is more likely to be related to a diet deficient in essential nutrients, such as vitamins, and minerals, rather then protein energy undernutrition. Protein energy undernutrition develops when nutritional intake is not enough to meet demand; for example, when patients has a difficulty to access food. In this scenario, the condition can develop during acute or critical illness because of metabolic demand (Price,2008). The Council of Europe (2003) developed a resolution on food and nutritional care in hospitals, which identified ten characteristics of optimal nutritional care in hospital, including the requirement for screening for malnutrition on admission and weekly thereafter, and the development of a care plan which highlights the patient’s nutritional requirements and how to put them in live. The people which are at high risk of developing malnutrition extends beyond those with chronic, progressive conditions in this case its COPD. The risk of developing malnutrition can be quantified with the MUST tool (BAPEN 2011), which can indicate the necessity for referral to other part of multidisciplinary team, for example to dietitian, and address the implementation of an individualised needs and help create care plan. In addition, looking at the effects of nutrition it’s also important to consider the effects of involving patients’ friends, family and care givers when assessing and planning future care. Some patients might find it difficult sharing their personal information to health care professionals in front of loved ones about their condition, due to sensitive information that might be exposed from either a history of smoking or not seeking treatment earlier (Fromer,2011). Willis (2017) observed and noted that in an essential element of any assessment, nurse’s ability to identify the sings and symptoms of malnutrition will develop with increased interaction with the patient. The MUST (BAPEN, 2011) identifies unintentional weight loss as an indicator of risk; however, not all the issues that affecting or can affect a patient’s, person’s ability to maintain their nutritional health will be identified using a screening tool. When risk is identified accurately can also relay on previous knowledge (if present) of the patient and information gained from the patient and information gained from the patient or their carer. Booker et al (2011) discussed the importance of undertaking an initial nursing assessment to identify the patient’s dietary history and changes in appetite, as well as thinking about individual lifestyle issues such as the patient’s ability to get shopping, the distance they have to travel, as well where they live, with whom they live or do they have any help and the most important the effect of limited budgets on nutrition (Wills, 2017). Wills (2017) highlighted that frailty in older people and social isolation must also be consider as they will affect nutritional intake. However, it is important to remember that frailty is not an inevitable consequence of ageing and a good assessment of nutritional risk can improve health outcomes since it enables the health care professionals to implement dietary interventions that can improve nutritional intake (Wallington,2016). As mentioned before, unintentional weight loss is associated with increased rates of mortality and morbidity; however, it is not always possible to identify a clear pathophysiological cause (Gaddey et al 2014). (Hodson and Blimires, 2015) Implies if a COPD patient had recently lost any weight or unintentionally gained, holistically assessing patients for muscle fatigue, oedema, hypersecretion and bronchoconstriction, Respiratory muscle fatigue can lead to hypoxaemia, hypercapnia and respiratory acidosis, Hypoxia and acidosis can lead to peripheral oedema.(Currie,2017) When screening with the MUST tool it may still show as a healthy weight, it wouldn’t show factors such as unexplained weight gain, shortness of breath, whether a person is able to still undertake their normal activities at their normal level of exertion, MUST also doesn’t identify factors such as age related changes in posture, ratio of body mass Index (BMI) and breathlessness. It is estimated between 10-45% of those with COPD within the community are at risk of malnutrition (Stratton et al, 2003). Malnutrition can often be identified by using the universal tool for measuring Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) flowchart (Stratton et al, 2003) .Whereas an assessment tool such as BORG, identifies a person’s ability to perform certain tasks and activities within their activities of daily living, while assessing their breathlessness level on exertion. Although this assessment tool is commonly used for those with COPD, it doesn’t identify if a person had lost or gained weight and become malnourished. By combing several tools together like the MUST and MNA (Nestle Nutrition Institute, 2009). When considering if a patient is malnourished following national guidance and pathways from National Institute Clinical Excellence (NICE, 2016) guidelines and Department of Health,(DOH, 2010) While on admission patients often have decreased mobility and reduction of their daily activities which can result in increased complications such as co-mobilities, decrease quality of life, while also influencing their emotional well-being and disease trajectory (Collins et al, 2010). When completing an assessment and planning care for patients it is important to consider and maintain patient confidentiality, valid consent must be gained from the patient before any information I shared outside of the nurse patient relationship. (MNC, 2018). Understanding patient’s perception of their illness is an important first step to providing comprehensive, multifaceted care for patients with long term conditions Overall, evidence supports the use of a screening tool when undertaking a nutritional assessment. However, Young et al (2013) also found little significant variation between nutritional screening tool, which shown that no single tool used, is more important to enable accurate assessment of patient’s nutritional status .Therefore, the continued use of the MUST (BAPEN, 2011) in the UK can be recommended, although the use of alternative such as the MNA ( Nestle Nutrition Institute, 2009), or BMI can also adequately identify nutritional risk. It is important to support adult patients with their nutritional requirements; it can be in hospital or community. The nurses should use a structured approach to assess the patient’s nutritional status. REFERENCES Ashelford S, Raynsford J, Taylor V. Pathophysiology and Pharmacology for Nursing Students. SAGE: London Blamires S, Hodson M (2015) Malnutrition in COPD: meeting patients’ nutritional needs. General Practice of Nursing Vol 1, pp1-3 Booker, C. Nicol, M. and Alexander M.F (2011). Alexander Nursing Practice. Fourth edition. Churchill Livingstone Elsevier, Edinburg. British Association for Parental and Enteral Nutrition (2011). Malnutrition Universal Screening Tool. Available at: https://www.bapen.org.uk/pdfs/must/must_full.pdf Downloaded 22st May, 2019. British Lung Foundation (2019). What is COPD? Available at: https://www.blf.org.uk/support-for-you/copd/what-is-copd. Accessed 16th May 2019. Collins PF, Elia M, Stratton RJ (2013) Nutritional support and functional capacity in chronic obstructive pulmonary disease: A systemic review and meta- analysis. Respirology 18(4): 616-29 Currie, G.P. (2017). ABC Of COPD. 3rd Edition. West Sussex: John Wiley
Heroin and Marijuana Abuse and Treatment Essay. The way of drug taking starts with a voluntary deed, a decision to try a drug, experience its effect, undergo its influence. Eventually this occupation may become dangerous, it may result in many dangerous consequences and unpleasant events, it threatens the consumer’s social, professional, family life, it leads to social withdrawal and severe health and mental issues of all kinds, some of this damage may turn out to be irreparable. The substance under a well known nickname “heroin” is prohibited in the majority of the world’s countries. Even though heroin is an illegal drug, it is included in several types of medications and it is also used for the replacement therapy for the drug addicts. Heroin is widely abused all over the world. The number of heroin users counts nine and a half million people. This number is, of course, not precise because not many people all over the world would openly and honestly confess that they are drug users. Heroin is a severely addictive drug, it makes a very fast effect on people’s health, a user turns into an addict very quickly. The addict’s body starts to undergo a whole raw of harmful and extremely destructive influences that are irreversible. The recognized “short-term” effects of heroin abusing are nausea, rush, vomiting, depressed respiration. The typical “long-term” effects of such addiction are collapsed veins, abscesses, many infectious and very dangerous diseases such as AIDS/HIV and hepatitis C. (National Institute of Drug Abuse, par. 5). According to Frank Blanche, the image of a typical abuser of heroin changes with time (par. 7). Due to younger generations’ avoidance of drugs, the heroin users groups are getting older every decade. Besides, earlier there was a clear pattern of heroin abuse, showing that some years ago the main areas where the drug was distributed to were city centers. These days the drug dealers have a tendency to move to more suburban areas, this is why they young people living there are now under a risk of becoming potential heroin addicts. The author’s advice is that some effective measures should be developed and created in the areas that are included into the risk group because these areas are very likely to become major hubs for drug criminals in the future. Marijuana is another widely popular drug. This drug is being legally traded in at least twenty of the United States. Most of the typical abusers of marijuana are high school students, most of which are adolescent. O’Connor’s research shows that at least thirty six percent of senior school students from all over the Unites States have been involved into the drug consume (par. 6). The health of marijuana abusers undergoes many harmful influences. The short-term consequences of abusing marijuana are nausea, dizziness, vomiting, headache, loss of motor coordination, trouble with problem solving, increased heart rate (Marijuana Addiction Treatment, par. 5). Long-term consequences are more serious. For example, marijuana has been proved to influence a human brain development seriously, to be more precise, this drug produces a destructive effect on its user’s brain’s cognitive function and memory. This leads to a variety of learning disabilities the students of high schools across the United States tend to experience and struggle with. Besides, the people who often abuse marijuana become hyperactive and anxious; due to this the level of social violence increases in educational facilities. Some individuals regularly consuming marijuana tend to become locked up and live in social withdrawal. In general, the students, who often abuse marijuana, are not known for their achievement in studies, their learning performance can be characterized as negative. This drug is also medically used. Initially, marijuana was traded from the pharmacies. The trade of marijuana in recreational purposes was legalized not so long ago. As a medication cannabis can be helpful in treating various health and mental complications, among them are cardiopulmonary complications (Gupta, par. 34). Both of these drugs – heroin and marijuana – are in the same place in FDA drug schedule – they occupy the schedule one with high abuse liability and investigational use only (Drug Classification, par. 7). Treatment of any drug addiction is a complicated process because it is caused by a very complex illness (Drug facts, par. 2). When drug consuming becomes uncontrollable, turns into a habit, ruins a person’s health and social life, a series of measures have to be taken. The success in the process of drug addiction treatment is only possible when the patient is willing to co-operate and has a desire to recover and defeat the habit. Addiction to the drugs that belong to the category of opioids has been a global and very serious issue for the whole world for the last several decades. Drug abuse influences the way the human brain works and creates the compulsive craving for a certain chemical substance, the addict becomes obsessed with seeking for a dose. There is a series of medications especially developed to treat the opioid addiction. They are designed to work the same way as the drug does, the only difference is that these medications are safer than the addictive drug and do not tend to create an addiction in the user’s brain. The second approach to the treatment of the opioid addiction is behavioral treatment. These treatments work though the cognitive-behavioral therapy. The patient basically gets stimulated for avoiding the drug. In case of heroin abuse, the patient has to go through a detoxification program before starting the treatment. During the detoxification period, the patient is not allowed to use the drug, except for the small doses that can be given to the patient to minimize the withdrawal symptoms (What Are the Treatments for heroin Addiction? par. 4). The treatment of marijuana addiction is mostly done on the outpatient basis where the patients, are given medications to reduce the negative experience of the drug withdrawal. After the detoxification and the treatment programs are completed by the patient, a course of therapy is also offered. The therapy works to help the patient start a new life and stay clean forever. In conclusion, to my mind, even though marijuana is considered a lighter drug that is not as addictive, both of these drugs are equally bad. Both long and short-term effects of these drugs are negative and, in best case, will take a long time to cure. Abusing drugs to me feel like becoming a slave of a chemical substance that starts re-writing your brain and damages it severely. In the modern society there are people that are taking these drugs, as well as people, who are avoiding the drugs. Fortunately, anti-drug propaganda works well and drives many young people from the path of an addict. In general, due to multiple bad and lethal cases of addictions and overdoses, the society is aware of all the horrifying consequences drug abuse may cause. Works Cited Blanche, Frank. “An overview of heroin trends in New York City: Past, present and future”. The Mount Sinai Journal of medicine 67.5 (2000): 341-348. Print. Drug Classification. AddictionScience. 2009. Web. Drug Facts, National Institute on Drug Abuse. 2009. Web. Gupta, Sanjay. Gupta: ‘I am doubling down’ on medical marijuana. 2014. Web. Marijuana Addiction Treatment. Treatment Solutions. 2013. Web. National Institute on Drug Abuse. Heroin: Abuse and Addiction. Web. O’Connor, Anahad. “Increasing marijuana use in high school is reported”. The New York Times. 2013. Web. What Are the Treatments for heroin Addiction? About. 2013. Web. Heroin and Marijuana Abuse and Treatment Essay
The Medieval Era and the Renaissance period are two of the most well-known time periods of European history. Despite being intertwined in history, the Medieval and Renaissance periods contain vast differences in European culture from one another. These eras are usually either seen as great educational and societal strides made in history, or as periods that simply stunted Europe from reaching its full potential sooner. The Europeans were looking for a system that would work for their growing and changing nation. The combination of the Medieval Era and Renaissance period culminated in a Continent that was educated, experienced, and prepared for the future of the modern ages. There are three major sections in the timeline encompassing the history of Europe. These time periods are referred to as Antiquity, the Medieval era, and the Renaissance period. The Medieval era began in the dying years of Antiquity and preceded the Renaissance period. The Medieval era, which is often called the Middle Ages, is further divided into these three subcategories: the Early, High, and Late Middle Ages. This entire time period lasted from the late fifth century to the middle of the fifteenth century. The Early Middle Ages took place from about A.D. 470 to 1000, the High from 1000 to 1300, and the Late began in 1300 and lasted for approximately the next 150 years (K., Nimisha). The changes that accompanied the Renaissance period began to sprout in the early fourteenth century in Italy and started to catch on throughout the entire continent in 1350. The Renaissance period is most widely believed to have ended around 1620 (Alchin, L.). In the beginning of the Middle Ages, the remnants of the Roman Empire held on to governmental control in the eastern European civilizations, but were lost in the west. Prior to the start of the Medieval Era, great military progress was made in the eastern half of Europe; this was in large part due to the military campaign of Constantine the Great in the early fourth century. As the eastern half of the continent was progressively gaining strength and unity, the western half began a slow and steady decline. In the fourth and fifth centuries, the Western Roman Empire was repeatedly assaulted by barbarian forces and other warrior tribes which surrounded the weakening nation. These invasive forces caused great divides throughout the land of Western Europe; as tribes would conquer certain areas, they would assume rule over the Europeans. These tribes brought new government and economic policies and drastically affected the Western European culture. At the end of the fifth century, Romulus Augustulus, the last emperor of Western Europe, was dethroned and the civilized Western Roman Empire came to an end. The Eastern Roman Empire remained strong and continued to claim the western territory as its own, but had scarce control of the occurrences in the land. Under the new barbaric rule, the west departed from its traditional Latin language system and into derivation of Latin used by the controlling tribes. The Medieval Age was a simple time period; this was in large part due to the great influence and involvement of the church on nearly every aspect of society. The religion of Europe in the Middle Ages was completely controlled by the Catholic Church. The religious hierarchy sought to have their entire continent unified in the Catholic religion. As a result, religious leaders began to be integrated into the government and received great power throughout Europe. The more power these religious officials were given, the more likely it appeared that a unified Catholic Europe might not be an unreachable goal. The fusion of church and government began primarily in Eastern Europe as the western half was controlled by non-Christian tribes. Eventually in the Middle Ages, the Christian religion gained influence on the western societies as well. At first, the two religious powered governments were able to coexist, but in time small differences between the two cultures caused religious controversy as well. The difference in language- the east using Greek and the west using Latin- as well as rising theological and doctrinal differences soon divided the one unified religion into two separate churches: the Eastern Orthodox Church and the Western Roman Catholic Church. The split was so dreadful that both of the churches actually excommunicated one another. Western Europe also saw an influx of monasteries and monks in the Early Middle Ages. In a society which largely disregarded writing, reading, and many educational facets, the monk worked to keep the literature and learning of an area alive. Monks would write literature, religious as well as secular, and were often willing to teach people in surrounding areas how to read and write. Because monks were some of the only Medieval authors, literature was produced in small quantities and often reserved for only the wealthy and powerful (Langley, Andrew pg. 38-39). Medieval life was dominated by what is known as feudalism. Feudalism was a class system which divided the population of Europe into three major classes. The first and least respected of these classes was the peasantry; the majority of Europe fell into this class. Peasants usually lived on manors, plots of land owned by nobility. The nobles in charge of the manors would bring in peasants for the labor and upkeep of the land. These peasants were treated more like slaves than employees and were often forced to pay rent or provide foods for their noble masters. The second level of the feudal system was that of the clergymen. The clergy was the class that communicated with God. Clergymen were either monks living in isolated monasteries or parish priests living among the people. The third and most powerful of the three classes was the nobility. The nobility was comprised of any kind of knight and his family. The nobles held great power in the Middle Ages, largely due to their economic and governmental immunities, such as exemptions from taxation. The nobles were in control of the manors and reaped all of the rewards provided by their peasant workers. Later in the Middle Ages, nobles also gained control of castles, which were often used as another means of escaping governmental policy (Brocard, Philippe pg. 10-21). The Medieval Era was a time period riddled with disease; this was caused by a widespread lack of sanitation throughout Europe which went unnoticed until it was too late. In the late Middle Ages the Black Death struck Europe with a devastating force. The Black Death likely began in Asia and traveled to Europe through fleas that lived on rats, which were the primary carriers, which came through trade routes and on ships that sailed throughout European waters. The most common symptoms of the Black Death were the appearance of swollen boils in the groin and armpits. Most victims with these symptoms would die within seven days of infection. There were worse effects of the disease, such as respiratory failure that would cause the infected person to have extreme breathing difficulties and cough up blood from their lungs. Most people with these symptoms would die within two days of infection. The Black Death along with most other diseases of the Middle Ages was largely incurable due to the lack of antibiotics and basic medicines. The Black Death is estimated to have killed close to half of Europe’s total population. (Medieval-life-and-times.info) Women living in the Middle Ages saw relative equality and were often necessities in society. Women were given the chance to become part of churches in positions such as nuns or Abbesses, which were in charge of monasteries. These opportunities provided women with the ability to learn how to read and write, and elevated their value far beyond marriage and child-bearing. Women were also provided with a fairly large selection of job opportunities. Women in the Middle Ages usually worked with their husband in his business, but other jobs such as midwifing and beer brewing were occupations primarily held by women. Prostitution also became fairly common in urban areas of Europe. Marriages were often arranged based on economic reasons and divorce did not exist in society. In Medieval society, it was often seen as a man’s job to attract and please a woman into marriage (Historysage.com). The art in the Middle Ages was extremely driven by religion. Most paintings were depictions of saints or some sort of religious affairs. Painters used a one dimensional style and added little emotion in their works. The use of gold to illuminate figures in paintings or to outline books became very popular in the Middle Ages. Gothic and Byzantine style was the driving style in Medieval architecture. One of the most well-known examples of the Byzantine style of architecture is the Hagia Sophia, a cathedral constructed by Emperor Justinian in the sixth century. This massive church was built in Constantinople and remained the largest building of its kind for centuries to come. The Hagia Sophia is characterized by large granite columns, illustrious marble pillars and constructs, beautiful religious mosaics, and most notably its massive dome. The original dome was too heavy for the poorly made walls of the cathedral and eventually collapsed. A new larger dome was placed on improved walls in the late sixth century by Isidore the Younger (Historysage.com). One of the best examples of Gothic architecture is the Notre Dame Cathedral in Paris, France. This church is characterized by large arched supports known as flying buttresses. The Building had two towers and one spire which was 300 feet tall. The thin walls of the Gothic style became hazardous and the architects had to add in further means of exterior support. This was one of the first buildings to include support statues made in the likeness of gargoyles and chimeras. The interior was furnished with grand organs and large bells (K., Nimisha). In the same manner as Medieval art, Medieval literature had great focus on the incorporation of religion. The primary source of literary works in the Middle Ages was educated monks from European monasteries. These monks would hand-copy literature; most monks wrote in Latin but some used Greek as well. Due to the lack of production and the educated tone of the works, literary works of the Middle Ages were reserved for wealthy nobility; the peasantry simply passed stories down through the generations by word of mouth. Medieval literature placed great emphasis on the combination of reality and fantasy. Most stories included human characters with personalities or traits resembling those of a distinct god or saint. Codes of honor and romance took great precedence in literature of the Middle Ages. Geoffrey Chaucer who lived in the fourteenth century is often considered to be one of the best and most influential writers of the Medieval Era. In his most famous work, The Canterbury Tales, he critiqued the social class system that had overtaken Europe in the Middle Ages. He did not elevate any one class over another in his story and showed that corruption and sin was present in all classes, even the clergy and nobility (K., Nimisha). The Renaissance period first began in the fourteenth century in Northern Italy and made its way throughout the rest of Europe in the fifteenth century. The Italians desired a culture that emulated that of the ancient Greeks and Romans. They longed for a society that was educated and innovative. The Italians had seen the Middle Ages as a relatively dull period and the new ideals that began to rise gave new hope for a changing nation. The Italians called this new era that was beginning in their country “rinascita”, which translates to “rebirth” (K., Nimisha). These new ideals can be accredited to a few great Italian minds, such as the painter Giotto and the writer and humanist Francesco Petrarch. Petrarch was one of the first humanists and vernacular writers of the Renaissance period. He criticized the zeitgeists of the Medieval Era and pushed for the ancient ways of Greece and Rome to be the new ideals of all of Europe. Petrarch believed that God desired for mankind to use its talents and abilities to serve and honor God. Additionally, he strongly believed in active study of ancient literature, as the ancient times were filled with eras of enlightenment. Donald R. Kelley said this about Petrarch’s beliefs and his legacy: “To Petrarch and his followers, nothing that was human (and little that was divine) was foreign. Curiosity, nostalgia, and an attitude of tolerance would lead to a deeper understanding of the past and a willingness to extend such understanding beyond the boundaries of Christendom. What resulted was a transformation not only of knowledge but also of values and assumptions about the human condition.” (Thompson, Stephen, ed. Pg. 14-16). Petrarch’s views and beliefs caught on with many Italians and in time with many people throughout all of Europe; however, this man died before the end of the fourteenth century and never got to see the completion of the intellectual nation that he had envisioned (Thompson, Stephen, ed. Pg. 14-16). Religion in the Renaissance was largely affected by the rise of humanistic views also. Many of the great religious leaders of that time, such as Martin Luther, John Calvin, and Erasmus, started to realize that their beliefs did not match those of the Catholic Church. This is, of course, what led Martin Luther to nail his Ninety-five Theses to the church door in 1517. He believed the Catholic Church and the power of the pope was a corrupted system that needed to be corrected. As a result, this act sparked the reformation and led to the rise of protestant churches within Europe (Historysage.com). The rise of humanism in the Renaissance also affected the Europeans views of life. A typical Renaissance man was expected to be well-rounded in many areas, whereas a Medieval man was often only trained in one specific area. Men were often trained in the arts and sciences. The Renaissance was a period in which women’s right began to diminish. Sexual double standards began to arise in Europe at the end of the Middle Ages and only increased over the next few centuries. Some women were still educated and were able to receive minor roles in business and society, but were always considered to be inferior to men. It was also the expectation of the times that women make themselves appealing to the men; it was their duty to look good for men when they were asked to do so. Furthermore, marriages in the Renaissance period were based more on love and romance than economic standings as they were in the Medieval Era. Prostitution began to occur more frequently around Europe. Due to the diminished views of woman and the large prostitution rates, rape was not seen as a serious crime in the Renaissance period (Historysage.com). Renaissance art was an ever evolving field; many new discoveries and ideas regarding art were proposed during this period. Renaissance artists placed increased emphasis on secular themed artwork and art involving the human body (Langley, Andrew pg. 44). The artists of this period were some of the first to use perspective in their paintings, as well as brighter colors and natural sources of light and shadowing. The Renaissance also saw some of the first oil paintings. Renaissance architecture was largely based off of classical forms of art, such as those of the ancient Greeks and Romans. Some of the most famous artists of all time came out of the Renaissance period; Leonardo, Donatello, Raphael, Michelangelo, and Leonardo da Vinci are just a few of the greatest artists of the era. Michelangelo’s David is an excellent example of the use of perspective, two dimensional effects, and the knowledge of human anatomy that were so common in Renaissance art (K., Nimisha). Literature in the Renaissance period made great progress in availability and context. Renaissance literature placed greater emphasis on the adventurer of a story as opposed to the adventure itself. The humanist aspects were evident in literature as the feelings and emotions of characters were of utmost importance in the stories. The invention of the printing press by Johann Gutenberg in 1440 eliminated the need for all works of literature to be hand-copied. This, of course, allowed for more works of literature to be spread throughout Europe which were in turn sold at lower prices and available to far more people. As James E. Burke said, “The coming of the printing press must have seemed as if it would turn the world upside down in the way it spread and, above all, democratized knowledge. Provided you could pay and read, what was on the shelves in the new bookshops was yours for the taking. The speed with which printing presses and their operators fanned out across Europe is extraordinary. From the single Mainz press of 1457, it took only twenty-three years to establish presses in 110 towns: 50 in Italy, 30 in Germany, 9 in France, 8 in Spain, 8 in Holland, 4 in England, and so on.” (quotationsbook.com) The printing Press was able to further unify Europe around the philosophy of the importance of knowledge and education (Eawrap.wordpress.com). The Medieval Era and Renaissance period shared some similarities, but are primarily seen for their vast differences. First off, religion was one of the most important factors to the Europeans in both of these time periods. In the Medieval Ages religion was fought for in the Inquisition and the Crusades; in the Renaissance religion was spread through more peaceful means in the Reformation. Additionally, different art styles and literary techniques between the two periods were clearly evident, as well as the higher availability of literature to people of all social and economic classes in the Renaissance. Moreover, Renaissance literature also covered a large variety of topics such as politics, art, short-stories, and more; whereas Medieval literature was almost completely about religion. Finally, the Renaissance also introduced the ownership of African slaves, while very few blacks even lived in Europe in the Middle Ages (Historysage.com). The Middle Ages and the Renaissance changed Europe forever. From the changes in religious powers and doctrines to the improved lifestyle and education of the population, Europe made great strides in building itself into the powerful nation that is has become in more modern times. These time periods brought their fair share of destruction and devastation, such as the Black Death, the Crusades, and barbaric invasions; however, the ever-strengthening continent was able to recover and regrow into a better place. In conclusion, The Middle Ages and the Renaissance period were vastly different times but resulted in a Europe that would become one of the strongest nations in the world.
java object oriented programming Momento patterns.

When the user hits the space-bar, the state of the game is stored.When the user types an ‘r’ character, the last-saved state of the game is restored.Furthermore, you must achieve this using a faithful implementation of the https://www.oodesign.com/memento-pattern.htmlfinlay it should also have a momento.md that describes how your solution maps to the standard momento pattern. For our purposes, the above linked description or the Gang of Four description count as standard momento patterns.also explain why a momento pattern is not a good solution for general save states in this situation. I.e. if we wanted to save game state between games, momento would not be a good choice – why not?
java object oriented programming Momento patterns

The Cultural Myths Of America

A cultural myth is a traditional story that has a meaning attached to it. These myths have an effect in they way people lead their lives and even how they interact with each other. It is notable that myths have a role to play be it personally, or to the wider society. In as much as one may believe or doubt such myths, they still continue to exist in different ways, and are shaping destinies of many. Myths can be full of truth or falsehood and depend on the interpretation a person may prefer. Many societies and races in the world have diverse myths which may encourage or discourage certain patterns of behavior. Rituals and customs are explained in myths and their merits or demerits laid down for everyone to discern. The Greek mythology (Detienne, 18) is most notable especially in the way they exhort ancestors to be like gods. Myths came before science and this makes it impossible to discredit them. Long time ago, people depended on myths to explain the mysteries of creation and they accepted them with a lot of zeal. Many other questions were answered including the origin of man and his eventual destiny after death. Evil is also brought under the scrutiny of myths and they expound its cause and reason for its existence. The rise of modern civilization can too be traced in myths ranging from agriculture to industry to settled life in cities. The modern world has continued to embrace myths in one way or another. Modern technology has given rise to much development in mass media which in turn has enabled many myths from different parts of the world to be collected together for study. Books have been printed and availed to anybody with interest to read and either agree or disagree with the subject. From an individual to a community, some cultural myths seem worthy in the sense that they encourage or uplift the spirit (Wessels, 92). Others may not necessarily be so and may seem unrealistic especially if they are prejudicial or implying immorality. Happily Ever After; the American society as any other society has not been left behind in embracing myths. Many of them believe that happiness can be sought and achieved despite the hardship one may go through. Happiness is attributed to material possessions whereby those who do not have ample material wealth are considered unhappy. The ideology of possessions can be traced through ancient myths some of which are still followed today. Hard work is associated to prosperity and lack of it therefore leads to a lowly life. Studies have shown that happiness is not related to material or money possessions (Veenhoven, 5). The old notion which led many people to acquire as much as they could has been proven false. Traditionalists believed that it is out of what you possess that gives you the feeling of happiness. People then would strive so much in order to have money so that they may live the rest of their lives happily. In did not matter the means or the extent to which this was sought as long as one could proudly claim he had money. Americans forgot that happiness is never permanent and mostly is derived from being comfortable with what one has, however little. Obsession with possessions created greed in American people which can never be satisfied. Someone even came up with a term “National Happiness”, a system that oversaw people overlook other important issues in order to acquire happiness. Ironically, this myth has wrought greed, selfishness and immorality in the Americans (Alesina

Hello, I attached the guidelines to do the assignment. The assignment has several sections that you have to complete

online dissertation writing Hello, I attached the guidelines to do the assignment. The assignment has several sections that you have to complete separately according their guidelines. The paper that you write for one section should not mix up with a paper you write for another section. Please follow the guidelines. The guidelines tell you everything. I started the assignment on a disease called Cystic Fibrosis and I attached what I started in word document below along with the assignment guidelines. If you want to pick another topic, other than Cystic Fibrosis, you can do so. If you want to stick with Cystic Fibrosis, you can continue doing what I already starting.

TUTA The Do Not Resuscitate Order Medical Practitioners & Terminal Illnesses Essay

TUTA The Do Not Resuscitate Order Medical Practitioners & Terminal Illnesses Essay.

This is a 1-2-page written reflection that does not need to adhere to APA.This week’s course materials (Module 6) focus on end-of-life decisions as well as facing death and living with life-threatening illness.You are a hospice social worker in Texas who has been working with a family for several months that includes a married couple in their 50s, their 25-year-old daughter, and her 6-year-old son. The husband’s 85-year-old father has been living with them for the past year. His wife died 7 years ago, and he had been living alone in a small town in another state. He has outlived the majority of his friends and neighbors. The family home was sold, and he moved in with his son, daughter-in-law, granddaughter, and great grandson on the advice of his physician since he had been struggling with depression and loneliness. He has heart disease and a pacemaker. He has been steadily declining, losing weight, not eating, not exercising, and does not want to have the battery in his pacemaker replaced. He has a DNR and is prepared for the end of his life. The couple is frightened, worried, and exhausted from caretaking.You are meeting with the family to discuss the decision to not replace the pacemaker battery as well as what to expect moving forward. Discuss how you would approach this meeting, the focus of the discussion, and how you would communicate.Reflect on this scenario and describe your personal thoughts and reactions.
TUTA The Do Not Resuscitate Order Medical Practitioners & Terminal Illnesses Essay

Stayer University External CSS Document JavaScript Project

Stayer University External CSS Document JavaScript Project.

After weeks of intense work, your client is excited to view the final webpage. Instructions Remember to include: A consistent design and color scheme. An external CSS document to control these aspects. CSS applied to a single page. Use of inline styles. A consistent navigation between parts of your site. A minimum of 5–8 pages. At least three external hyperlinks. An e-mail link with the subject filled in. A form (it does not have to connect to a database, because that is beyond the scope of this class). Properly placed images on at least three pages. The use of alert message on one page. JavaScript that adds value to your page. This could be mouse-over events for navigation, a photo gallery, form field validation, performing a calculation in a form (such as adding tax or shipping), et cetera. JavaScript additions. The preparation of the desktop and mobile versions of your site. Requirements Now that you have begun to write your pages in HTML, please add the following to a comment in theof your work: Name, date, week #, class with section, and campus # (for example, CIS373001VA016)
Stayer University External CSS Document JavaScript Project

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