Nursing Cancer Patient Case Assignment Example | Topics and Well Written Essays - 2500 words

Nursing Cancer Patient Case - Assignment Example Osteoporosis is a chronic progressive metabolic disease of the bone characterized by low bone mass and micro-architectural deterioration of the tissue of the bones (Serota and Lane, 2006). It affects 16% of women and 7% of men above 50 years of age (Tenenhouse et al, qtd. in Targownik, Lix and Metge, 2008). The most dreaded complication of fall in this age group of people is hip fracture. Burt is 68 years old. Aging is a natural physiological process and there are many changes which occur in the various organs of the body. The common health problems frequently encountered in the elderly are altered response to medication, altered nutritional status, urinary incontinence, urine retention, fecal incontinence, pressure ulcers, mood disorders, dizziness, dementia and functional impairment, immobility and impaired gait (Nettina, 2006). Elderly people are more prone to falls and fractures, cognitive dysfunction, postural hypotension, electrolyte disorders, cardiac failure and polypharmacy. Burt needs to be given several medications because of his health condition. Pharmacokinetics of the aged is different and hence the effects of the drugs are more. The factors which contribute to altered pharmacokinetics are decrease in lean body mass and total body weight, increased percentage of body fat, decreased protein binding of drugs, increase in volume of distribution for lipophilic drugs that penetrate the central nervous system, decline in the metabolic capacity of the liver, decreased liver mass and hepatic blood flow, decreased renal blood flow and glomerular filtration rate. There may also be changes in the receptor numbers, affinity, and post receptor cellular effects. Along with these, there are also changes in the homeostatic mechanisms (Tregaskis and Stevenson, 1990). Dementia is a haunting problem amongst elderly who frequently get admitted to acute care settings for other health problems. Due to dementia, proper treatment is difficult to institute.

Microsoft Visio Case Tool Essay Example | Topics and Well Written Essays - 750 words

Microsoft Visio Case Tool - Essay Example Microsoft Visio’s interface is user-friendly by virtue of its numerous semblances to other Microsoft programs. As such, usual computer operators will find it easier to interact with and generate the finest drawing outcomes. For members of the team who are starters in this class of applications, the visual style is highly revealing, giving it greater intuitive qualities that anybody in the team can utilize to generate the best outcomes. Parker (2013) suggested that the ability of the program to automatically check the user’s diagrams and correct glaring mistakes on the projects is one of its iconic benefits that complement human skills and creativity to generate high-quality graphic deliverables for the software development team. Still, the Office utility enables users to insert hyperlinks to other more complex flowcharts that cannot be collated together in a single page. This feature improves the programs interactive nature with external sources of information. Wright and Roth (2013) added that by enabling the users to customize the way they route their primary ideas and include one’s own tasks made on Microsoft Visual Basic Express, each member of the software development teams will easily execute their tasks as spelt out in the work breakdown structure and compare notes on best they can carry out the process in a more seamless manner. Alternatives to the Office utility Gantt Chart is an alternative to MS Visio, considering that the both programs have comparable deliverables.

Tension between Analysis informing and analysis setting policy Essay

Tension between Analysis informing and analysis setting policy - Essay Example Every aspect of the issue has to be looked in to so that the policy becomes efficient and successful once implemented. While forming policy the practicability of the same should not be ignored otherwise setting up of the policy becomes invalid. However, once the policy is being formed and setting is under way, there can rose conflicts as to the people, budget, and time factors involved in the policy setting. Policy analysis helps in explaining, why are there so many differences in the way we organize productive activity. When a policy is about to be set the scope of the problem has to be evaluated well. Moreover, in analysis of setting policy an analyst must look in to more of practice and applying side rather than just projecting certain actions to achieve a goal. When analyzing a setting up of a policy, certain factors like cost effectiveness, people involved, time frame etc.,are also to be considered. If there is any discrepancy in the analyzing in forming policy it can very well reflect in the setting up process. According to Torjman(2005)â€Å"The actual formulation of policy involves the identification and analysis of a range of actions that respond to these concerns. Each possible solution is assessed against a number of factors such as probable effectiveness, potential cost, resources required for implementation, political context and community support†. Should analytical products be purely "informative? Analytical products are tools which are used for assessing the viability and utility of a policy in an organization. These products are used by organization while they formulate and set policies so as to give policy makers a wider spectrum of actions to choose from to achieving a specific goal. It is very essential for an analytical product to be purely informative as it allows the organizations to choose the right product suitable for them. In order to improve the policy forming and setting process utilization of analytical products is a key asp ect. They help in the appropriate evaluation and measuring of policies so as to give proper results. Analytical products are used primarily as a qualitative approach to evaluate the policy forming and setting. Process. Munger states that â€Å"Your evaluation of the major policy that was enacted to deal with the problem involves your assessment of how well that policy addressed the problem†. Analytical products set various bench marks to follow, so that the goal of the policies does not distract from the goal. It is very essential for the analytical products to be purely informative, so as to make the analysis process efficient. Decision and policy makers always make sure that the future policies and strategies have a solid ability to achieve the set goals. To obtain a quality analysis a very refined analytical product is required; otherwise the whole process of policy forming and setting becomes worthless. Most officials encourage the analytical products to be clearly inform ative to know what the product has to offer. The policy makers want their policies to be analyzed with a product which is transparent. They

PESTEL Analysis Indonesia Essay Example | Topics and Well Written Essays - 1250 words

PESTEL Analysis Indonesia - Essay Example 40% of these forests lies within protected areas (FAO 2010). Forest clearing within areas zoned for timber, logging, oil palm, and mining accounted for nearly 45 percent of deforestation in Indonesia between 2000 and 2010, (finds a new study that examined forest loss within industrial concessions). Analyzing the greenhouse gas emissions in the Indonesia, currently, paper plantations are the largest source of carbon emissions during the period, accounting for more than a third of total industrial emissions. Oil palm follows up with 28 %, logging with 22%. Nevertheless, the percentages vary from island to island. In Sumatra, fiber plantations amounted to nearly 60 percent of emissions, while the palm oil industry in Kalimantan accounted for about 40 percent. Logging concessions were the biggest source of industrial land use emissions in Papua, Sulawesi, and the Moluccas. In the future according to the study: Relative contributions of the logging, fiber, oil palm and mining industries t o forest loss in Indonesia, it is expected that forest concessions continue to grow, due to political treaties and economic investment in logging. In response to the general idea that the process of logging is illegal, corrupt in Indonesia, the new Minister of Environment and Forestry Siti Nurbaya Bakar imposed a moratorium (suspension) on the issuance of all new logging, by allowing issuances to be fair, accurate, clear and accountable. The moratorium is likely to last between four and six months.

Oppressed Caribbean Culture Essay Example for Free

Oppressed Caribbean Culture Essay Caribbean culture, in so far as it is conceded to exist, is at once the cause, occasion, and result of evolved and evolving paradoxes. The psychic inheritance of dynamic response to disparate elements interacting to find ideal, form, and purpose within set geographical boundaries over time could not have produced otherwise. The 1990s have witnessed no less of this, precisely because the decade serves to encapsulate contradictions in human development over the past half a millennium. The entire Caribbean, and indeed all of the modern Americas of which the Caribbean, like the United States, is only one part, are the creatures of the awesome process of cross-fertilization following on the encounters between the old civilizations of Europe, Africa, and Asia on foreign soil and they, in turn, with the old Amerindian civilizations developed on American soil long before Christopher Columbus set foot on it. It is a development that has helped to shape the history and modern condition of the world for some half a millennium and one that has resulted in distinctive culture-spheres in the Western hemisphere, each claiming its own inner logic and consistency. The Caribbean, at the core of which are a number of island nations, themselves in sub-regional groupings, is conscious of the dynamics of its development. For it rests firmly on the agonizing and challenging process actualized in simultaneous acts of negating and affirming, demolishing and constructing, rejecting and reshaping. Nowhere is this more evident that in the creative arts, themselves a strong index of a peoples cultural distinctiveness and identity. Admittedly, other indices of culture such as linguistic communication, which underpins the oral and indigenous scribal literatures of the region, religion, and kinship patterns, reveal the texture and internal diversity that are the result of cross-fertilization of differing elements. The result is an emerging lifestyle, worldview, and a nascent ontology and epistemology that all speak to Caribbean historical experience and existential reality, in some cases struggling to gain currency and legitimacy worldwide (and even among some of its own people) for being native-born and nativebred. For this is the original meaning of Creole. Whites born in the American colonies were regarded as creoles by their metropolitan cousins. And the Jamaican-born slaves were similarly differentiated from their salt-water Negro colleagues freshly brought in from West Africa. The term was soon to be hijacked by or attributed to the mulatto (half-caste) who defiantly claimed certified rootedness in the coloniesa status not as easily claimed by the person of African or European descent whose ancestry lay elsewhere, it was felt, other than in the Caribbean or the Americas. An understanding of the shared human thirst for freedom in terms of its cultural significance is critical. For the impulses that drive the Caribbean people (like people anywhere) to freedom within nation states, to the right to choose their own friends and political systems, and to independent paths to development are the same impulses that drive them to the creation of their own music, their own languages and literature, their own gods and religious belief-systems, their own kinship patterns, modes of socialization, and self-perceptions. All plans made for them from outside must take this fact into account, whatever may be the dictates of military and strategic interests or the statistical logic of tabulated growth rates and gross national products. The Caribbean people, faced as they are with the post-colonial imperative of shaping civil society and building nations, expect to be taken seriously in terms of their proven capacities to act creatively in coordinated social interaction over centuries in the Americas. They feel passionately that their history and experience are worthy of theory and explanation and expect others to understand and appreciate this fact. They are unique, paradoxically because they are like everybody else. The Caribbean has been engaged in freedom struggles and its inhabitants have been at the job of creating their own languages, and designing their own appropriate lifestyles for as long as and, in some cases, longer than most parts of what became the United States. Recognition of this and the according of the status due such achievement is a prized wish of all Caribbean peopleBlack, White, Mestizo, Indian (indigenous and transplanted), Chinese, and Lebanese. By general critical consent, the principal women writers in English to emerge, so far, from the Caribbean are the properly varied trio of Jamaica Kincaid (Elaine Potter Richardson) and Jean Rhys. I say properly varied because the immensely mixed political and social history of the Caribbean is reflected by and in its writers. Kincaid, the most experimental of the three, is seen by her admirers as a deliberate subverted of Dead White European Male modes of narrative. Yet any reader deeply immersed in Western literature will recognize that prose poetry, Kincaids medium, always has been one of the staples of literary fantasy or mythological romance, including much of what we call childrens literature. Centering almost always upon the mother-daughter relationship, Kincaid returns us inevitably to perspectives familiar from our experience of the fantasy narratives of childhood. Kincaid genuinely expresses her regard to Caribbean as those that have been creolized into indigenous form and purpose distinctively different from the original elements from which those expressions first sprang. With some of those original elements, especially those from a European source, themselves reinforcing their claims on the region, whether through politics, economic control, or cultural penetration, the Caribbean is becoming even more conscious not only of its own unique expressions but also of the dynamism and nature of the process underlying these expressions. These in turn constitute the basis for the claims made for a Caribbean identity. Jean Rhys, of Creole Dominican descent, is a formidable contrast to Marshall and seems to me the major figure to emerge thus far among Caribbean women writers. Though she lived mostly in Paris and England, the imagination of Rhys came fully alive in her novel of 1966, Wide Sargasso Sea, a remarkable retelling of Charlotte Brontes Jane Eyre from the perspective of Bertha Mason, Rochesters mad first wife. The terrifying predicament of the 19th-century Creole women of the West Indies, regarded as white niggers by colonialists and as European oppressors by blacks, is presented by Rhys with unforgettable poignancy and force. Shrewdly exploiting the modernist formal originalities of her mentor, Ford Maddox Ford, Rhys achieved a near masterpiece in Wide Sargasso Sea. Allusive, parodistic, and intensely wrought, the novel remains the most successful prose fiction in English to emerge from the Caribbean matrix. In Wide Sargasso Sea, the starting point is this placelessness. Although Rhyss novel starts with Antoinettes childhood in Coulibri, its boundaries lie outside the novel in another womans text. In Jane Eyre we have the madwoman Bertha locked up in the attic of Thornfield Hall. The significant title Wide Sargasso Sea refers to the dangers of the sea voyage. Rochester first crosses the Atlantic alone to a place which threatens to destroy him, then once more, bringing his new wife to England. Both Rochester and Antoinette are transformed through this passage. Rochester gives Antoinette a new name, Bertha, and in England she finally is locked up as mad. Rhys finds her own place in Jane Eyre, a prisoner of anothers desire. She sets out to describe that place and, in doing that, she redefines it as her own. In her challenge to Jane Eyre, Rhys draws on the collective experience of black people as sought out, uprooted, and transported across the Middle Passage and finally locked up and brutally exploited for economic gain. She uses this experience and the black forms of resistance as modes through which the madwoman in Jane Eyre is recreated. In the film version Wide Sargasso Sea develops stereotypes of Black West Indians that strongly mirror Bogles discussion of classic film depictions of African Americans. The inner stereotype in the film is that of the tragic mulatto which, the film hints, describes Angelique, the evidently White child who has been raised by Blacks. Although Angelique insists on her Whiteness, a menacing dark skinned stranger claims at diverse points in the film to be her brother through her fathers relationship with a slave. The viewer is left to consider whether the widowed plantation owner seen at the beginning of the film is actually Angeliques mother. While it does not answer this question directly, it obviously shows through Angeliques actions that her culture is far more African than European. These suspicions, actions, and Angeliques reliance on the ex-slave Christophine ultimately destroy her marriage and drive her insane. Christophine, herself, fulfills the mammy role since the film portrays her as a constant presence who fiercely guards Angelique from all dangers. In the West Indian context, though, she is given a twist, as she is not only guardian angel but also a practitioner of the magical art of obeah. This portrayal a staple of films dealing with the West Indies is never completely developed. Nevertheless, the film permits us to witness its potency, as Angelique, despairing of keeping her husbands love, calls on Christophine to develop a magical potion to bind his affections to hers. One opponent for those affections is Emily, a young Black servant who might well be characterized as a female Black buck a sexual predator who seduces a married White man into interracial unfaithfulness. Finally, there is Nelson, the long-suffering head of the household who intimately approximates Bogles Tom. In the film, insults of various sorts that are directed towards him result only in silence and a determination to remain a faithful servant. Though, in Dominican novelist Jean Rhys Wide Sargasso Sea (1966), the islands riotous vegetation and dramatic landscape are depicted with an ominous intensity that prompts the protagonists English husband to equate it with evil. Lally, the narrator of another Dominican classic, Phyllis Shand Allfrey The Orchid House ( 1953), faced with the menacing power the islands nature exerts over Stella and Andrew, ruefully concludes that the island offered nothing but beauty and disease. Rhyss protagonists, most evidently Antoinette in Wide Sargasso Sea, share a view of England as deadening, grey and emotionally destructive. England is a place of hypocrites, and the English have a bloody, bloody sense of humour. With a West Indian accent, she goes on, and stupid, lord, lord (Wide Sargasso Sea: 134). But it remains Rhyss place, the source of those English books which provided an early contribution to her construction of herself as writer. The idea of definitive national origin and affiliation is a source of anxiety for Rhyss protagonists. For Rhys herself nationality was complicated by her exile and her race: also England did not value her Caribbean origins. For Rhyss women, as perhaps for herself, England is also a place where human emotions, especially those associated with sexuality, are outlawed or repressed; she described sex in a letter of 1949 as a strange Anglo-Saxon word (Abalos, David T. 1998, 66). Hemond Brown comments that Rhyss attitude to England remained remarkably consistent over her whole writing career: For those fifty-odd years, England meant to her everything she despised (Bandon, Alexandra. 1995). But despite this, she surely demonstrated in her characterisation of working-class English chorus girls and call girls and Rochester (perhaps informed by her important attachments to Lancelot Grey, Hugh Smith, Leslie Tilden Smith and Max Hamer, all upper- or middle-class Englishmen), that the poor Englishwoman and even the colonizing, socially secure Englishman have their own areas of serious emotional damage. She may have blown off steam sometimes, but in her fiction she took pains to be fair to the country which had both given her sustained literary identity and denied her dignity. In the Caribbean, complex racial narratives are the most powerful signifiers, although class increasingly reverberates now. In England, in Rhyss lifetime, it was the class narrative which primarily constructed identity, though Rhys clearly writes the importance of race as a formative self-construction from her Dominican childhood. She sometimes sees race and class as equally important even in England, as in the case of Selina, who carries Rhyss own outlaw status during an important period of her life. In the two explicitly Caribbean novels, Voyage in the Dark and Wide Sargasso Sea, race is evidently a major source of identity. Jean Rhys had long described the cultural dialectic of his regions historical experience and contemporary reality in the following way: But the tribe in bondage learned to fortify itself by cunning assimilation of the religion of the Old World. What seemed to be surrender was redemption. What seemed the loss of tradition was its renewal. What seemed the death of faith was its rebirth. Caribbean existential reality is here portrayed as a creature of paradox. Surface appearances may well be masks for their opposites. What one sees is not likely to be what one gets. Other similar manuscript was in Goodbye Mother by Reinaldo Arenas, the grief inundated daughters Ofelia, Otilia, Odilia and Onelia kill themselves in front of their dead mum just for their cadavers to occasion a series of triumphant choruses from the legion of rats and maggots who feast on the putrefactory banquet. Neither of these authors, nor the evenly talented Rene Depestre and the former Dominican President Juan Bosch, is Anglophonic. Its usually believed that the most excellent Caribbean literature in English consists of chronological polemics On the other hand Cristina Garcia novel â€Å"Dreaming In Cuban† tells the stories of the women of a Cuban family, scattered by revolution but still connected through a shared past. The narrative is polyphony of several voices who, in turn, describe their world from their viewpoint. Characters include Lourdes, an anti-Castro exile who runs a chain of Yankee Doodle Bakeries, and Felicia, whose perceptions connect and blur the lines between insanity and santeria. Pillar, Lourdess daughter and an aspiring punk artist, is determined to return to Cuba to reconnect with her grandmother and make her present life meaningful. She laments that history does not tell the important stories and longs to recover Cuba for herself: [T]heres only imagination where our history should be (138). In the title of Dreaming in Cuban, Dreaming includes all the diverse dreams of Garcias female protagonists about the nature of being Cuban, what it is to be Cuban, to dream, not in American, but in Cuban. This necessitates Garcias taking into account all the conflicting elements of contemporary Cuban-ness for Cuban and Cuban American women. Amazingly, she never invalidates or disputes the diverse and conflicting perspectives of these different dreamers. She succeeds by giving readers a complexity of experience beyond binaries, where many diverse and conflicting perspectives circle around one another endlessly. These differences are constructed by differences in the various ideologies that the characters embrace communism, capitalism, traditional gender relations, voodoo, and feminismand also by differences in their experiences due to varying historical locations in time and place.

Importance of Choice in the Strategy Formulation

Importance of Choice in the Strategy Formulation In recent years, international hospitality industry, like any other industry, has been affected by the effects of globalization, the information technology revolution, and the consumer demand. Hence, the targets in tourism have suffered considerable alterations and forced hospitality managers to re- examine their decision-making plans. Hospitality is difficult to manage and assess as long as it deals with a new awareness and addresses to new demands. Its level can be given through the customer feedback. For tourism to be considered an industry it must have a production process and a generic product mutually and inseparably related. The purpose of this chapter is to focus attention upon the theoretic aspects regarding the strategic choices in this field, the way they are elaborated, implemented, used, and put into practice. To be more precise, the chapter looks at the strategic choices used be Romania and Bulgaria on the sea side tourism. 2.2. STRATEGIC CHOICE 2.2.1. IMPORTANCE OF CHOICE IN THE STRATEGY FORMULATION PROCESS Ranking the elements in a strategy formulation process, strategic choice comes third. When there are no choices, there can be little value in considering strategy at all. To be better understood, a definition of strategy is necessary to mention. According to Michael Baker, Marketing strategy is a process that can allow an organization to concentrate its resources on the optimal opportunities with the goals of increasing sales and achieving a sustainable competitive advantage.(See Baker, MICHAEL, The Strategic Marketing Plan Audit, 2008, ISBN,p.3 ). According to the above definition, any strategy must have a pre established plan which establishes goals, identifies alternatives, and makes use of intuition and experience. In other words, it includes basic activities on a long term, as well as objectives. In general, small companies are limited by their resources, whereas large ones find it difficult to change quickly. Even when managers seem free to make strategic choices, the results may depend in the same measure on chance and opportunity, as on the managers deliberate choices. It is proven fact that events, and especially unexpected events, can play a major part in determining results. Any process of choice could be divided into four steps: Identifying options Evaluating the options against preference criteria Selecting the best option Taking action In practice, it may be difficult to identify all possible actions at the same time. Sometimes, unexpected events create new opportunities, destroy the foreseen ones, or alter the balance of advantage between opportunities. For these reasons, good strategic choices have to be challenging enough and achievable. And here comes analysis, judgment and skills, elements which make the difference in defining strategies. 2.2.2 STRUCTURE OF STRATEGIC CHOICE The Figure 1.1 shows how the three logical elements of strategy formulation process interact. The shaded background is a reminder of the importance of context in determining the aspects to be solved by strategic choice. Figure 1.2 expands the detail so that to illustrate the significance of the overlaps. The common ground between any two circles is of some interest, but it is only where all three circles overlap that viable options exist. Thus, the chosen strategy is a viable option because it is here where intent and assessment fully meet. Of interest are also the areas where any two circles overlap. So, the criteria for choice derive from intent and assessment. In practice, the process for choosing a strategy may be structured like in Figure 1.3. It starts by identifying available options. Any chosen strategy will have to answer the questions what , how , why , who , and when in order to provide answers to each of these questions. There are likely to be different kinds of options. Figure 1.3 shows three types: products/ services / markets, resources/ capabilities, and methods of progress. They are typical but not necessarily exhaustive. 2.2.3 OPTIONS FOR MARKETS AND PRODUCTS / SERVICES The tourism industry is a constellation of businesses, agencies, and non-profit organizations which work together to create products. Thus, the type of option relates to which products or services to offer in which markets. The diagram in Figure 1.4 structures a certain decision, as it was suggested for the first time by Igor Ansoff .The axes of the diagram represent the product, market needs, and market geography. The last is defined by four cells. The possible choices about products and markets can be represented as movements within or away from these cells. One set of choices is possible within the existing product / market set. Do nothing choice means continuing the present strategy. This strategy compares any proposed change with the do nothing option as a baseline. This option, however, is not often viable for the long term as competitors will be likely to gradually take the market by improving their product, processes, relationships. Withdraw choice is leaving the market by closing down or selling out .This may seem a negative option but necessary to focus available resources into areas of greater strength. It mainly occurs in declining markets. Consolidate choice refers to attempting to hold market share in existing markets. This is a defensive option which involves cutting costs and prices. It mostly occurs in mature markets or ones beginning to decline. Market Penetration choice means increasing market share within the same market. This is a more aggressive option and involves investing in product improvement, advertising, or channel development. Other possible options are Product Development that is developing and acquiring new products and Market Development, an option which addresses to new market needs. Diversification is another type of option having to do with new products. It may be of two kinds: related and unrelated. Related diversification, in its turn, divides into: backward, forward, and horizontal integration. Any management choice has to focus on the relative attractiveness of available options. Whether the present position is bad enough, even risky alternatives are preferable to doing nothing. 2.2.4 OPTIONS IN METHODS OF IMPLEMENTATION Options are likely to occur in methods of implementation as well. There are four main methods to make companies grow their capabilities: internal development, acquisition, contractual arrangements, and strategic alliances. Internal development is the most obvious approach to growth. It involves developing the necessary skills among the existing staff and acquiring the necessary production capacity. This method has one disadvantage: it takes time for the competitors to move faster, otherwise opportunities may be lost. Acquisition is a very common implementation option, used by such countries as the UK and USA. Take overs and mergers are dominant for this method of implementation. The disadvantage for mergers is that they can cause operational and psychological disorder which distracts the people. Competitors can use this turmoil in their benefit as they are free to concentrate on customers rather than on internal changes. Many acquisitions may be beneficial at the right price, but may also destroy shareholder value at a too high price. Contract arrangements, regardless of their type, have in common the need for a written contract which binds two or more parties into a clear agreement as to who will do what and pay what. When disputes happen they can be handled in courts by agreed arbitration procedures, or by not renewing the present contract at the expiry. The contract arrangements come in different forms: Consortia are groups of companies that form a joint entity for a specific purpose. When this purpose is achieved, the consortium breaks up and the separate partners may find themselves competing in different consortia for a new project. Franchising is common in retailing. The franchisee pays the franchiser a fee for services and royalties. The franchisee is halfway between an employee and an independent entrepreneur. His risk is limited by the previous success of the brand name and the support and advice given by the franchiser. Licensing allows a small inventive company to license its product to be manufactured and marketed by others. This can determine quick growth by avoiding the need to build manufacturing or distribution capability. Agents imply doing business in foreign countries or specialized markets where the volume of business is too low to justify a permanent presence. The agent must be familiar with local requirements and calls for additional support from the principal when opportunities arise. There are conflicts among agents which include conflicts of interest. Strategic alliances and partnerships have come into fashion over the last decade .When there are contracts between the parties, there is a wider intention to cooperate at a strategic level in order to share information and to work together in a way that goes beyond a clear contractual arrangement. It is considered that for a rapidly changing world, strategic alliances are the only way to achieve speed of response and global spread. 2.2.5. GROUPING OPTIONS INTO STRATEGIC OPTIONS Possible options about product / markets, resources / capabilities, and the method of implementation must be combined into a smaller number of strategic options. This may be an up or down process. The bottom -up approach implies linking what might be done in detail into strategies. The top- down approach means testing general ideas of future direction against detailed options. 2.2.6. GENERAL TESTS OF STRATEGIC OPTIONS The tests, important otherwise, cannot be totally objective. Each strategic option has to pass two tests as shown in Figures 1.2 and 1.3 .These tests must be: Aligned in that it conforms to the strategic intent. This test answers the question: Does this option take us where we want to? Feasible in that the capabilities and resources needed to get success can be made available. The test answers the following question: Will it work? Acceptance is a third test, related to the two mentioned above, asking the question: Will this option be acceptable? Acceptable means to win the approval of two groups: those who will have to approve it and those who will have to implement it. Any strategic option has to pass all these three tests. In the case when more than one strategic option passes these tests, they have to be compared with each other to find the best solution, at that particular moment. It is also important to take into account such situations as risks. 2.2.7. THEORETICAL FRAMEWORKS FOR ASSISTING STRATEGIC CHOICE There have been several attempts to provide theoretical frameworks for making strategic choices .One highly influential, was the concept of Generic Strategies, devised in 1985 by Porter. He mentioned that the most important choices dealing with any business are the scope of the markets. It is about how to serve and how to compete in the chosen markets. The scope can be broad- tackling the whole market , or narrow tackling one particular part of the market. Companies achieve competitive advantage either by having the lowest product cost or by having products which are different in ways valued by customers. The axes of Figure 1.5 are the scope of the chosen market and chosen basis of competition. The four quadrants in the same figure suggest four possible strategies. When the scope is narrow, the distinction between cost and differentiation becomes unimportant so Porter mentions only three generic strategies : coast leadership, differentiation, focus. While differentiation implies a difference in the perception of the product by clients, focus implies a difference in target market. According to Porter, the weakest strategy is b being stuck in the middle . Managers were enthusiastic about generic strategies when first published. Gradually, the reality showed a distinction between differentiation and cost. Few companies afford to ignore cost however different their product may be. On the other side, there are very few companies to admit that their product is the same as all the others. Porters Generic Strategy Model has been extended into the Strategy Clock (Figure 1.6) The important addition is the hybrid strategy, an optional balance between price and the added value perceived by the customer. The offerings may often fall into three categories. There are cheap offerings for those customers to whom the price is the most important aspect. At the other end are the luxury offerings with high quality and appeal to those customers who want the best and most differentiated. In the middle, are the good valued offerings which compromise between the other two and offer a good trade off between price and value. 2.3 STRATEGIC CHOICES USED BY ROMANIA AND BULGARIA When discussing this issue, it is important to focus upon the targets in tourism, targets that have changed in accordance with the new demands. Among these targets, here are some: Increasing visitor satisfaction Increasing the amount visitor spend for services Delivering the best prices Reducing seasonality Involving the local authorities to create community In terms of hotel industry, Romania has inherited a great tourist accommodation capacity from the communist period. Since the 1960s Romania had developed many accommodation facilities, mainly on the sea- side coast of the Black Sea. The low ranked hotels from this area are convenient for a mass tourism demand. After the 1990s the main tourism indicators have pointed out two distinctive periods on the Romanian market. These are characterized by severe government instability and lack of policies and strategies regarding the tourism industry. During 1990 2000 there was a slow intensity of the privatization process, only 55, 3 % of the accommodation facilities were private owned. After 2001 , Romanian tourism industry has followed and increasing trend due to an accelerated privatization , 92 % of the accommodation facilities have been transformed from state owned to private owned .Lots of investments have occurred in modernizing the accommodation structures and increasing the volume of the green field investments. Elaborating and applying strategies in Romanian tourism companies is a complex process, alive, and in continuing expansion. Meanwhile, Bulgaria has come in with a dynamic and harsh competition .This has determined the need to change this industry by elaborating new strategies which focus on perspective , positioning , plan , and pattern. The differentiation strategy, suggested by Porter, is the strategy that the Romanian hotels are following. The Romanian hotel market considers that differentiation can be the result of a strong marketing campaign meant to strengthen the unique characteristics of the product / services within the mentality of the customers. The hotels in Romanian market are pursuing a focus differentiation strategy. They are producing products and services for the high price market segments. Another strategy used by Romania is the training strategy. Within the service sector, it is of great importance to exist an interaction client employee. The customers satisfaction is given by the behavior of the employees. The hybrid strategy is pursued by those hotels which envision a decrease f the distribution costs and those that renounce to the unprofitable clients. These hotels attempt to sustain their strategy by the use of the Internet and E- commerce. The tourism industry in Bulgaria plays an important part in the countrys economy. Accession to the UE has had a great impact on its market, as the seaside summer resorts on the Black Sea Coast are the main attraction. One of the strategies used by Bulgarian hoteliers is to base their prices on the products perceived value .Value based pricing means that the marketer cannot design a product and a marketing program and then fix the price. Price is a worth value to consider .The company uses the non- prices variables to build in the buyers minds a perceived value by setting prices to match the perceived value. ( Kotler , 2003 ).To simplify, hoteliers are aware that consumers must feel as if they get a good deal for their money. Perceived value is the key of any good pricing strategy. Bulgarians also use the differentiating strategy. Their purpose is to offer unique products and services so as to obtain a price premium. In other words, by implementing differentiated services or personalized services , a company can build its customer loyalty when substitute products or services are not available in the market. In this way, they charge their customers a higher price than their rivals based on the cost of the delivery system and service quality. The coast- leadership strategy has made the Bulgarian hospitality a name. Researchers in the fields of marketing and strategic management have suggested numerous approaches to help firms achieve cost leadership. Some of these are using mass production techniques, achieving economies of scale, adopting a new technology, achieving mass -distribution, reducing input costs , achieving resource, and improving access to raw materials. 2.4 SUMMARY Strategic choice is the third logical element of the strategy process, playing a central role. The process of choice is deciding between different options. There are likely to be possible options about a product and services and about market segments defined by both customer need and geography. Indicators between what is possible and what is required may follow from the results of a strategic assessment. The various options may inter-relate so it is necessary to identify a small number of strategic options made up of appropriately related options. Strategic options have to be aligned, acceptable, and feasible. If here is more than one strategic option, that meets these tests, they need to be compared both logically and politically in order to take a final decision.

Dilutional Hyponatremia During Intrauterine Adhesion

Dilutional Hyponatremia During Intrauterine Adhesion Severe dilutional hyponatremia in a patient during hysteroscopic of intrauterine  adhesion : A case report YE Yuzhu, LIN Lina Abstract Hysteroscopy is a minimally invasive procedure for the patients of intrauterin adhesion, but may result in potentially disastrous complication labeled transurethral resection of the prostate (TURP) syndrome. Excessive absorption of large scale of distension media under high inflow pressure by openings of venous channels in endometrium, the large volume of transfusion fluid that is beyond the modulation ability of body may produce the most dangerous situation of severe hyponatremia, hypervolemia and hypoosmolality. The consequence of hysteroscopy is mainly determined by the type of distension medium, irrigation pressure,condition of endometrium, preoperative catheterization, type of electrode system and duration of the surgery. A case of hysteroscopic resection of intrauterine adhesion in which severely symptomatic hyponatremia and hypervolemia happended with epidural anesthesia is presented. Key words: Hysteroscopy, hyponatremia, distension medium, infusion pressure, TURP (transurethral resection of the prostate ) syndrome. Introduction Hysteroscopy technique in the detection and treatment of intrauterine diseases plays an dominant role because of its unique feature of minimal invasion and remains the â€Å"gold standard† mean for the diagnosis of uterine disease, but may result in potentially disastrous complication known as TURP syndrome or hyponatremia and hypervolemia. A hysteroscopy precdure requires an intrauterin installation inserting into the uterine cavity accompanied by a suitable type of distention medium including dextrose 5% in water (D5W), 2.7% sorbitol, 0.54% mannitol and saline for the visualization of intrauterine situation. The most common fluid used clinically is D5W for its distinct features of low-viscosity, electrolyte-free, safety and lower cost. TURP syndrome appears when large scale of distension media (D5W) is overly absorbed including the following clinical signs: dyspnea, headache, nausea and vomiting, coma, and even can progress to cerebaral and pulmonary edema. Signs and syndrom es are nonspecific when the conditon is in its early stages and, as a result, it’s easy to be ignored. Vigilance and communication of the whole medical team is extremely required to avoid state of illness aggravating. Early management must be rendered as soon as possible for the critically ill patients by anesthetists. We report a case of a 36-year-old woman who developed TURP syndrome during hysteroscopic of intrauterine adhesion herein. 2. Case Report A 36-year-old, weight 62 kg , no medication or coexisting diseases, ASA physical status II , underwent hysteroscopy treatment because of her reiterative intrauterin adhesion during epidural anesthesia. Past surgical history revealed four times of previous hysteroscopies within the year, both of which were aimed to remedy for her secondary infertility but failed in acquiring satisfactory therapeutic efficacy. There were no positive fingds on the preoperative physical examination and normal values in laborarory results included blood routine test and plasmic electrolytes, and the concerntrations of sodium ion, potassium ion and blood glucose level were 139 mmol/L, 3.47 mmol/L and 4.0 mmol/L, respectively. A 12-lead electrocardiogram showed sinus rhythm. Upon arrival to surgical operating room, 500 ml lactated Ringers solution was dripped intravenously as maintenance fluid after standard monitors were placed. The heart rate was 76 beats per minute, respiratory rate was 18 breathes per minute and the oxygen saturation was 99%. Contiuous epidural anesthesia was performed successfully with 0.5% lidocaine and 0.375% ropivacaine 15ml totally within 15 minutes. Then the patient was placed in lithotomy position and no catheterization was offered because of the short operation period we had anticipated preoperatively although she expressed her micturition desire. The surgery initially proceeded unevenfully with very steady state of hemodynamics. 8,000 mL D5W as the irrigation fluid was delivered throught the hysteroscope by gravity pressure (60cm above the patient), and the irrigation pressure for uterine cavity distending was 150 mmHg. Monopolar electrode system was selected for endometrium resection, and controled the watts of electroresec tion and electrocoagulation within 40 60 watts and 60 80 watts, respectively. Simultaneous ultrasonographic monitoring was used to identify the sickness of uterus wall and uterine cavity size. A total of 1,000 mL of lactated Ringers solution was infused during the 70 minutes of surgery, with a total blood loss of 20 mL. Twenty minutes before the termination of surgery , the patient complainted of difficulty in breathing with simultaneous polypnea, shiver, and sensations of vertigo and nausea. Oxygen saturation dropped from 98% to 90% and recoverd soon after mask oxygen inhalation. Thereupon tramadol 50 mg was administered intravenously, and excellent effect obtained. Approximately 300 mL output of urine when the bladder was squeezed incautiously by ultrasound probe and the patient vomited once just the procedure completed. The patient appeared haziness of spirit-mind but responded appropriately to verbal stimulate. A dorsalis pedis artery blood sample was obtained from the patient , and electrolytes were reported using a blood-gas analyzing device. Results as follows: PH 7.31; Na+, 115 mmol/L; K+, 3.0mmol/L; ionized Ca2+, 0.93 mmol/L; Glucose, 27.8 mmol/L; HCO3—, 18.6 mmol/L. Based on the symptoms mentioned above, TURP syndrome was suspected. An indwelling urinary catheter was inserted immediately and 1,800 mL urine output was collected totlly at twice. A mixture of 50ml 10% saline and 100ml 0.9% saline was dripped to raise sodium concentration, meanwhile metoclopramide 10 mg was used for anti-nausea. But there were no diuretic and insulin used in case of aggravating of hypokalemia. Oxygen saturation maintained in 92% after oxygen mask was removed and with a progressive rise. Vital signs on permission to PACU were as follows: blood pressure, 126/79 mmHg; heart rate, 79 beats per minute; breathing rate, 20 breaths per minute; and oxygen saturation, 96%. The patient was transported to postanesthesia care unit (PACU) for continued treatments and review of blood gas analysis. On our arrival into PACU, arterial blood gas (ABG) analysis was performed when the venous transfusion of the hypertonic saline solution ended, revealing PH 7.36; Na+, 127 mmol/L; K+, 3.0mmol/L; ionized Ca2+, 1.0 mmol/L; glucose, 22.9 mmol/L; HCO3—, 21.5 mmol/L; BE, -3.6 mmol/L. The patient still had low sodium and potassium level from ABG, a mixture of 100ml 10% saline and 100ml 0.9% saline containing potassium chloride 0.5 g was supplemented in low-speed intravenously. Nurse anesthetist was asked to record vital signs every 15 minutes. 16:15~18:05, the patient got her vital signs stablized gradually and oxygen staturation could maintain over 95%. Review of her blood gas analysis showed: PH 7.36; Na+, 137 mmol/L; K+, 3.4mmol/L; ionized Ca2+, 1.0 mmol/L; glucose, 7.2 mmol/L; HCO3—, 23.2 mmol/L; BE, -3.6 mmol/L. The patient recieved 500 ml lactated Ringers solution totally in PACU, with a total urine output of 850 mL(data from PACU anesthetic chart), and sent back to the ordinary ward without any complaints and Alderete scores 10. 2. Discussion Hysteroscopy has gained widely used in diagnostic and therapeutic in gynecologic surgery for many special advantages, but is not devoid of risks especially when hysteroscopy is applied to resection of extensively endometrial lesion. Excessive absorption of irrigation fluid during hysteroscopic surgery from uterine cavity is the main cause of TURP syndrome or water intoxication, of which reported incidence is 0.2% [1]. The TURP syndrome mainly has clinical symptoms in cardiovascular system, respiratory system and nervous system including elevation of blood pressure, bradycardia, dyspnea, pulmonary edema, cerebral hemia and even death. The severity of consequence is associated with multiple factors, analysis of this case were as follows. The patient’s uterine cavity has low compliance and severe adhesion, so an intrauterine pressure (IUP) of 150 mmHg is required to obtain excellent visual conditions of bilateral tubal orifices. 8,000 mL D5W as the irrigation fluid is delivered i nto uterine for uterine distension in 70 minutes operation time. Based on clinical research, the absorptivity of distension media by body is within the range of 10 30 ml/min only when the irrigation pressure is less than 100 mmHg [2]. Therefore, we estimated 700 2,100 mL D5W is absorbed into circulatory system approximately, along with an infusion of 1,000 mL lactated Ringers solution. As a result, 1,700 3,100 mL is administered into blood intravenously at least, and even more. Hyperglycemia caused by excessive absorption of D5W produces hyperglycemic hyperosmolar status and then makes intracellular fluid transfers to outside the cell, which bings about exacerbating of hyponatremia status. The patient received high frequency hysteroscopy procedure in the short term leads to large-scale and severe damage of endometrium, allowing the distension fluid entering into blood circulation more easily, which contributes to hypervolemia in a more faster pace. As one of essential factors, ex cessive irrigation pressure plays a crucial role in distension fuild over absorption in the condition that endometrial venous sinus are widely open in hysteroscopic electric resection. In our case, we have to raise the pressure to 150 mmHg for a clear surgical vision of uterine cavity, therefore, rendering excellent chance for fluid entering into body. No catheterization was performed preoperatively, thus a large amount of fluid accumulates in bladder and circulation system. To sum up, in this case, fluid overload, hyperglycemic hyperosmolar status, high intrauterine pressure, disruption of endometrial vessles and lack of preoperative catheterization lead to a significant increasement of circulating volume and a sharply reduce of plasma colloid osmotic pressure. Extracellular free water in brain are transported from the outside to the inside of the cell, which results in cerebral edema and causes intracranial hypertension. A serious of neurological syndromes develop including dizzin ess, headache, nausea, vomiting, and haziness of spirit-mind. Likewise, as a consequence of irrigation fluid overload and dilution of the plasma protein concentration, pulmonary hydrostatic pressure elevated, leading to the accurrence of acute pulmonary edema and pulmonary interstitial edema. The ventilation/perfusion imbalance occurs, and then manifests in dyspnea, hypoxemia and a sustained downward trend of oxygen saturation, etc. Timely recognition and urgent corresponding treatment measures should be taken in the early course of water intoxication to prevent the condition deteriorated. In a general way, for every liter of hypotonic fluid absorbed, the serum sodium concentration will decrease by 10 mmol/L(10 mEq/L) [3]. 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¸Ã…  Ãƒ ¤Ã‚ ¸Ã¢â€š ¬Ãƒ ¦- ¦Ãƒ ¥Ã‚ Ã¢â‚¬ËœÃƒ §Ã… ½Ã‚ °Ãƒ ¦Ã‚ °Ã‚ ´Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¦Ã‚ ¯Ã¢â‚¬â„¢Ãƒ ¥Ã‚ ¿Ã¢â‚¬ ¦Ãƒ ©Ã‚ ¡Ã‚ »Ãƒ ¥Ã‚ Ã…   à ¦- ¶Ãƒ ¥Ã‚ ¤Ã¢â‚¬Å¾Ãƒ §Ã‚ Ã¢â‚¬  Ãƒ ¯Ã‚ ¼Ã…’à ©Ã‹Å" ²Ãƒ ¦Ã‚ ­Ã‚ ¢Ãƒ ¦Ã‚ Ã‚ ¶Ãƒ ¥Ã…’-à ¨Ã¢â€š ¬Ã…’à ¥Ã‚ Ã‚ ±Ãƒ ¥Ã‚ Ã…  Ãƒ §-†¦Ãƒ ¤Ã‚ ºÃ‚ ºÃƒ §Ã¢â‚¬ Ã… ¸Ãƒ ¥Ã¢â‚¬ËœÃ‚ ½Ãƒ £Ã¢â€š ¬Ã¢â‚¬Å¡ Reference [1] Jansen FW, Verdevoogd CB, Ulzen KV, et al. Complications of hysteroscopy: aprospective multicenter study [J], Obstet Gynecol, 2000, 96 (2): 266 270. [2] Rhymer JS, Bell TS, Perry KC, et al. Hyponatremia following transurethral resection of the postate [J].Br Jurol, 1985, 57(4): 450à ¯Ã‚ ¼Ã‚ 452. [3] Prost AM, Liberman RF, Harlow BL, Ginsburg ES. Complication of hysteroscopic surgery: predincting patients at risk. Obster Gynccol. 2000; 96:517-520 [4] Cooper JM Brady RM. Intraoperative and early post-operative complications of operative hysteroscopy. Obstetric and Gynecology Clinics of North America 2000; 27: 347-365 [5]Romer T. Benefit of GnRH analogene treatment for hysteroscopic surgery in patients with bleeding disorders [J].Gynecol.Obstet Invest,2003,50:112-120. [6]Murdoch JA. Tong JG. Anesthesia for hysteroscopy. Anesthesiol Clin North Am. 2001;19:125-140 [ J ].à ¤Ã‚ ¸Ã‚ ­Ãƒ ¥Ã¢â‚¬ ºÃ‚ ½Ãƒ ¥Ã‚ ¾Ã‚ ®Ãƒ ¥Ã‹â€ Ã¢â‚¬ ºÃƒ ¥Ã‚ ¤-à §Ã‚ §Ã¢â‚¬ËœÃƒ ¦Ã‚ Ã¢â‚¬Å¡Ãƒ ¥Ã‚ ¿-,2009,9(12):1097-109 à ¨Ã¢â‚¬Å¾Ã‚ ±Ãƒ ©Ã‚ «Ã¢â‚¬Å"à ©Ã… ¾Ã‹Å"à ¯Ã‚ ¼Ã… ¡Witz CA, Silverberg KM, Burns WN, Schenken RS, Olive DL. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993;60:745-56.