Great White Fleet Circles the Globe

The Great White Fleet refers to a large force of American battleships that circumnavigated the globe between December 16, 1907 and February 22, 1909. Conceived by President Theodore Roosevelt, the fleets cruise was intended to demonstrate that the United States could project naval power anywhere in the world as well as to test the operational limits of the fleets ships. Beginning on the the East Coast, the fleet circled South America, and visited the West Coast before transiting the Pacific for port calls in New Zealand, Australia, Japan, China, and the Philippines. The fleet returned home via the Indian Ocean, Suez Canal, and the Mediterranean. A Rising Power In the years after its triumph in the Spanish-American War, the United States quickly grew in power and prestige on the world stage. A newly established imperial power with possessions that included Guam, the Philippines, and Puerto Rico, it was felt that the United States needed to substantially increase its naval power to retain its new global status. Led by the energy of President Theodore Roosevelt, the US Navy built eleven new battleships between 1904 and 1907. While this construction program greatly grew the fleet, the combat effectiveness of many of the ships was jeopardized in 1906 with the arrival of the all-big gun HMS Dreadnought. Despite this development, the expansion of naval strength was fortuitous as Japan, recently triumphant in the Russo-Japanese War after victories at Tsushima and Port Arthur, presented a growing threat in the Pacific. Concerns with Japan Relations with Japan were further stressed in 1906, by a series of laws which discriminated against Japanese immigrants in California. Touching off anti-American riots in Japan, these laws were ultimately repealed at Roosevelts insistence. While this aided in calming the situation, relations remained strained and Roosevelt became concerned about the US Navys lack of strength in the Pacific. To impress upon the Japanese that the United States could shift its main battle fleet to the Pacific with ease, he began devising a world cruise of the nations battleships. Roosevelt had effectively utilized naval demonstrations for political purposes in the past as earlier that year he had deployed eight battleships to the Mediterranean to make a statement during the Franco-German Algeciras Conference. Support at Home In addition to sending a message to the Japanese, Roosevelt wished to provide the American public with a clear understanding that the nation was prepared for a war at sea and sought to secure support for the construction of additional warships. From an operational standpoint, Roosevelt and naval leaders were eager to learn about the endurance of American battleships and how they would stand up during long voyages. Initially announcing that the fleet would be moving to the West Coast for training exercises, the battleships gathered at Hampton Roads in late 1907 to take part in the Jamestown Exposition. Preparations Planning for the proposed voyage required a full assessment of the US Navys facilities on the West Coast as well as across the Pacific. The former were of particular importance as it was expected the fleet would require a full refit and overhaul after steaming around South America (the Panama Canal was not yet open). Concerns immediately arose that the only navy yard capable of servicing the fleet was at Bremerton, WA as the main channel into San Franciscos Mare Island Navy Yard was too shallow for battleships. This necessitated the re-opening of a civilian yard on Hunters Point in San Francisco. The US Navy also found that arrangements were needed to ensure that the fleet could be refueled during the voyage. Lacking a global network of coaling stations, provisions were made to have colliers meet the fleet at prearranged locations to permit refueling. Difficulties soon arose in contracting sufficient American-flagged ships and awkwardly, especially given the point of the cruise, the majority of the colliers employed were of British registry. Around the World Sailing under command of Rear Admiral Robley Evans, the fleet consisted of the battleships USS Kearsarge, USS Alabama, USS Illinois, USS Rhode Island , USS Maine, USS Missouri, USS Ohio, USS Virginia, USS Georgia, USS New Jersey, USS Louisiana, USS Connecticut, USS Kentucky, USS Vermont, USS Kansas, and USS Minnesota. These were supported by a Torpedo Flotilla of seven destroyers and five fleet auxiliaries. Departing the Chesapeake on December 16, 1907, the fleet steamed past the presidential yacht Mayflower as they left Hampton Roads. Flying his flag from Connecticut, Evans announced that the fleet would be returning home via the Pacific and circumnavigating the globe. While it is unclear whether this information was leaked from the fleet or became public after the ships arrival on the West Coast, it was not met with universal approval. While some were concerned that the nations Atlantic naval defenses would be weakened by the fleets prolonged absence, others were concerned about the cost. Senator Eugene Hale, the chairman of the Senate Naval Appropriation Committee, threatened to cut the fleets funding. USS Wisconsin (BB-9) underway in heavy weather, during 1908-1909. US Naval History and Heritage Command To the Pacific Responding in typical fashion, Roosevelt replied that he already had the money and dared Congressional leaders to try and get it back. While the leaders wrangled in Washington, Evans and his fleet continued with their voyage. On December 23, 1907, they made their first port call at Trinidad before pressing on to Rio de Janeiro. En route, the men conducted the usual Crossing the Line ceremonies to initiate those sailors who had never crossed the Equator. Arriving in Rio on January 12, 1908, the port call proved eventful as Evans suffered an attack of gout and several sailors became involved in a bar fight. Departing Rio, Evans steered for the Straits of Magellan and the Pacific. Entering the straits, the ships made a brief call at Punta Arenas before transiting the dangerous passage without incident. Reaching Callao, Peru on February 20, the men enjoyed a nine-day celebration in honor of George Washingtons birthday. Moving on, the fleet paused for one month at Magdalena Bay, Baja California for gunnery practice. With this complete, Evans moved up the West Coast making stops at San Diego, Los Angeles, Santa Cruz, Santa Barbara, Monterey, and San Francisco. Ships of the Great White Fleet (center and left) and the Japanese Fleet (center and right) in Yokohama, Japan, 18-25 October 1908. US Naval History and Heritage Command Across the Pacific While in port at San Francisco, Evans health continued to worsen and command of the fleet passed to Rear Admiral Charles Sperry. While the men were treated as royalty in San Francisco, some elements of the fleet traveled north to Washington, before the fleet reassembled on July 7. Before departing, Maine and Alabama were replaced by USS Nebraska and USS Wisconsin due to their high fuel consumption. In addition, the Torpedo Flotilla was detached. Steaming into the Pacific, Sperry took the fleet to Honolulu for a six-day stop before proceeding on to Auckland, New Zealand. Entering port on August 9, the men were regaled with parties and warmly received. Pushing on to Australia, the fleet made stops at Sydney and Melbourne and was met with great acclaim. Steaming north, Sperry reached Manila on October 2, however liberty was not granted due to a cholera epidemic. Departing for Japan eight days later, the fleet endured a severe typhoon off Formosa before reaching Yokohama on October 18. Due to the diplomatic situation, Sperry limited liberty to those sailors with exemplary records with the goal of preventing any incidents. Greeted with exceptional hospitality, Sperry and his officers were housed at the Emperors Palace and the famed Imperial Hotel. In port for a week, the men of the fleet were treated to constant parties and celebrations, including one hosted by famed Admiral Togo Heihachiro. During the visit, no incidents occurred and the goal of bolstering good will between the two nations was achieved. The Great White Fleet transits the Suez Canal, January 1909 Battleships of the fleet nearing Port Said, Egypt, circa 5-6 January 1909, as they approached the Mediterranean Sea during the final months of their cruise around the World. US Naval History and Heritage Command The Voyage Home Dividing his fleet in two, Sperry departed Yokohama on October 25, with half heading for a visit to Amoy, China and the other to the Philippines for gunnery practice. After a brief call in Amoy, the detached ships sailed for Manila where they rejoined the fleet for maneuvers. Preparing to head for home, the Great White Fleet departed Manila on December 1 and made a week-long stop at Colombo, Ceylon before reaching the Suez Canal on January 3, 1909. While coaling at Port Said, Sperry was alerted to a severe earthquake at Messina, Sicily. Dispatching Connecticut and Illinois to provide aid, the rest of the fleet divided to make calls around the Mediterranean. Regrouping on February 6, Sperry made final port call at Gibraltar before entering the Atlantic and setting a course for Hampton Roads. President Theodore Roosevelt addresses officers and crewmen on the after deck of USS Connecticut (BB-18), in Hampton Roads, VA, upon its return from the Atlantic Fleets cruise around the World, February 22, 1909. US Naval History and Heritage Command Legacy Reaching home on February 22, the fleet was met by Roosevelt aboard Mayflower and cheering crowds ashore. Lasting fourteen months, the cruise aided in the conclusion of the Root-Takahira Agreement between the United States and Japan and demonstrated that modern battleships were capable of long journeys without significant mechanical breakdowns. In addition, the voyage led to several changes in ship design including the elimination of guns near the waterline, the removal of old-style fighting tops, as well as improvements to ventilation systems and crew housing. Operationally, the voyage provided thorough sea training for both the officers and men and led to improvements in coal economy, formation steaming, and gunnery. As a final recommendation, Sperry suggested that the US Navy change the color of its ships from white to gray. While this had been advocated for some time, it was put into effect after the fleets return.

The Great Gatsby by F.Scott Fitzgerald - 768 Words

Everybody strives to earn it, those little green things in your wallet. Green is associated with good and happiness; above all, things of desire. Nevertheless, it doesn’t truly make you happy with your life and most importantly, yourself. In the fictitious novel, The Great Gatsby by F. Scott Fitzgerald, the characters who have money at their disposal are constantly looking for something else to fulfill their longing to have a meaningful life. Despite it’s problem-solving reputation, money isn’t what it’s chalked up to be, the characters with excessive money aren’t sincerely happy with their lives. Jay Gatsby, Tom Buchanan, Daisy Buchanan, and Jordan Baker and never satisfied with their m0ney. Fitzgerald’s characters never seem to connect their feeling of never being satisfied with their infinitesimal amount of happiness. Even though Jay Gatsby has a plethora of money, he still isn’t satisfied. He only wants Daisy to make himself actually blithe. The light at the end of Daisy’s dock is green; which represents things of desire that are potentially unattainable, Daisy is the only thing that will make Gatsby happy. â€Å"...I could have sworn he [Gatsby] was trembling. Involuntarily I glanced seaward- and distinguished nothing except a single green light, minute and far way, that might have been at the end of a dock.† (21) Gatsby’s mansion, private dock, boat, pool, and other gaudy items are all within his reach to set his focus on, but he chooses a small green light at the end ofShow MoreRelatedThe Great Gatsby by F.Scott Fitzgerald 1249 Words   |  5 PagesThe Great Gatsby-one of the most interesting books that describes American life and society in the 1920s.Novel was written by F. Scott Fitzgerald in 1925. Story primarily describes the young, mysterious millionaire Jay Gatsby and his passion for the beautiful Daisy Buchanan. Novel includes themes of idealism, resistance to change, social differences, American dream, Injustice, power, betrayal, Importance of money, careless, callousness. Scott Fitzgerald sets up his novel into separate social groupsRead MoreThe Great Gatsby by F.Scott Fitzgerald1280 Words   |  5 Pagesto showcase her innocence. When Nick meets Daisy in the beginning of the novel he notices her and Jordan Baker on the couch saying, â€Å"Daisy and Jordan lay upon an enormous couch, like silver idols weighing down their own white dresses†(122). While Gatsby does not represent purity because of his adulterous and illegal lifestyle, white represents purity because it is clean and unaltered. Daisy is again seen laying on the â€Å"enormous couch† waiting for something to occur. She acts like she cannot doRead More The Great Gatsby by F.Scott Fitzgerald. Essay1313 Words   |  6 PagesThe Great Gatsby by F.Scott Fit zgerald. F. Scott Fitzgerald aims to show that the myth of the American dream is fading away. The American values of brotherhood and peace have been eradicated and replaced with ideas of immediate prosperity and wealth. Fitzgerald feels that the dream is no longer experienced and that the dream has been perverted with greed and malice. The Great Gatsby parallels the dreams of America with the dream of Jay Gatsby in order to show the fallacies that lie in bothRead MoreThe Great Gatsby by F.Scott Fitzgerald726 Words   |  3 PagesF. Scott Fitzgerald showcases characters illusions in the novel The Great Gatsby. Each of the characters gets wrapped up in the dream that they all wanted to live. The Great Gatsby is a novel about the American dream and the illusion is that one can be happy through wealth, power or fame. Gatsby, Myrtle, and George all had an illusion thinking they can live the american dream. Fitzgerald shows many illusions in the Great Gatsby. Throughout the novel Gatsby always wanted to be wealthy, thinking thatRead MoreThe Great Gatsby by F.Scott Fitzgerald559 Words   |  2 Pages Purity The Great Gatsby, a novel written in the 1920’s by F. Scott Fitzgerald, generates symbolism of characters through the use of simple diction to create a wild romance built on the past, deceit, mischief, and fraud of personality. Moreover, the setting and its different locations, signifies two distinct ways of life: East, old money, and West, new money. Although the locations are judged by material wealth, the people and their behavior are quite alike. Myrtle Wilson, Daisy Buchanan, purityRead MoreThe Great Gatsby by F.Scott Fitzgerald574 Words   |  2 PagesTake a look around you, and you will find a myriad of different colors in which you might not think much of, but in The Great Gatsby by F. Scott Fitzgerald colors represent different ideas. 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A character/narratorRead MoreThe Character of Daisy Buchanan in The Great Gatsby by F.Scott Fitzgerald928 Words   |  4 PagesThe Character of Daisy Buchanan in the novel - The Great Gatsby - by F.Scott Fitzgerald Daisy is The Great Gatsby’s most enigmatic, and perhaps most disappointing, character. Although Fitzgerald does much to make her a character worthy of Gatsby’s unlimited devotion, in the end she reveals herself for what she really is. Despite her beauty and charm, Daisy is merely a selfish, shallow, and in fact, hurtful, woman. Gatsby loves her (or at least the idea of her) with such vitality and determinationRead MoreFailure to Achieve the American Dream in The Great Gatsby by F.Scott Fitzgerald1020 Words   |  4 Pages Failure to Achieve the American Dream in The Great Gatsby The American dream is the idea that was presented through American literature. The Dreamer aspires to rise from rags to riches, while engrossing in such things as wealth, love on his way to the top and to West Egg. In 1920’s early settler’s rooted to the United States Declaration of Independence who demonstrates that â€Å"All men are equal†. The dream of a land that life can be better place that is richer and fuller for every man that givesRead MoreDepicting the Difference Between Reality and Illusion in ‘A Streetcar named Desire’ by Tennessee Williams and ‘The Great Gatsby’ by F.Scott Fitzgerald1740 Words   |  7 Pageswhich both texts portray individuals in the grip of dreams and illusions ‘A Streetcar named Desire’ by Tennessee Williams and ‘The Great Gatsby’ by F.Scott Fitzgerald both depict the conflict between reality and illusion centring on the desire to achieve the ‘American dream,’ which causes many characters in the texts to become engulfed in dreams and fantasy. Gatsby and Blanche are the protagonists of the texts not only due to their central role in the plots, but also that they are characters who

Child Development Stages Free Essays

Unit 201 Child and young person development Outcome 3: Understand the potential effects of transitions on children and young people 3. 1 Identify the transitions experienced by most children and young people 3. 3 Describe with examples how transitions may affect children and young people’s behaviour and development Under each heading, explain how each aspect may impact on a child’s behaviour development, giving examples. We will write a custom essay sample on Child Development Stages or any similar topic only for you Order Now  ·Puberty: Growth spurts, early bloomers, late bloomers, jealousy from late bloomers, personal odour, self conscious of body changing. Males, become taller and stronger, body changes , body odour may develop and he may need to start using deodorant. They become moody at times and parents need to try and understand this to help there adolescent cope with changes. The most important factors in the adolescence through puberty is peers, family and school. Any disturbance in these 3 factors can be a heavy burden on this growing child. This could lead to depression, drugs, criminal acts and more.  ·Starting school- From pre – school to primary (Reception class). Child could feel nervous and feeling insecure. May start primary with no friends from pre-school. New faces, new friendships. Learning to dress themselves for P. E, more independence needed. How may this affect the child’s behaviour and development? Starting school -( cont from above) If child J slips through the cracks, is not offered reassurance by his teacher or by parents, he will continue to feel left out. He will then become withdrawn and isolate himself from everyone and everything. He will fall back in class and because he has isolated himself from peers, he might start to feel that he is on his own. He will then start to enjoy his own company. He will not have any social skills and will not move beyond this point. If child J starts school and this kind of behaviour is picked up early he is offered reassurance from his parents, teacher and all that are a positive role in his life things could be very different. The more positive the parents are, the more the child will be. He will thrive in school and be able to communicate well with the teacher and peers.  ·Moving class or school – Moving from reception class to year one. Children start to follow the national curriculum and are often taught more formally. It can effect a child who is used to learning through play, suddenly they have to work in a formal way for longer periods. More learning , less free time. Change of teacher, teaching assistant ( have a supply teacher). Affects learning, self esteem, not wanting to go to school. Eg. ) We moved to England when my son was 4 years old. On arrival he attended primary school A, he did reception class and year one at this school. By the time he got to year 2, I felt the teacher was very laid back and I was not happy with her method of teaching. I then moved him out of school A in the middle of year 2 and moved him to school B. It was a different area. He had to then start all over again, new school, start to make a whole new circle of friends. In school B this is where the bullying started. He kept it very quiet and it was not till I was approached by one of the mothers at the school, she informed me that my son was being bullied. I thought I was doing the best for my son by moving him into a new school because all I wanted was for him to thrive. Moving school was not a good choice, instead of thriving, he was unhappy, it affected his self esteem and he became withdrawn. I should have considered my sons happiness. This is better Kamilla, you have used a good example.  ·Starting Secondary School – There are differences in the curriculum and the way subjects are taught. Some children may find that there close friends have transferred into different schools, so they must develop new friendships. Although transitions can be difficult, moving on can also be a positive and exciting experience eg) Biggest to smallest, timetables, many schools feed friendships, change of classes, change of subjects, start to carry bags, finding there way around the school. Eg. ) The quiet shy male /female student may fall into the clutches of the group of peers. To avoid being bullied or to try and fit in with the â€Å" In kids† he/ she will go to the ends of the earth to avoid being made fun of. In some schools there is initiation. Some children lose their confidence right at the start of secondary school. . 2 Identify transitions that only some children and young people may experience e. g bereavement 3. 3 Describe with examples how transitions may affect children and young people’s behaviour and development Under each heading, explain how each aspect may impact on a child’s behaviour development, giving examples.  ·Bereavement – Following a death of a parent or someone close to a child can be traumatic. If child was living with one parent this may mean a change in carer and perhaps a move into residential or foster care. Loss of parent is devastating . Keep an eye on change of behaviour . Grief goes through several changes Eg) Anger, denial, withdrawn and crying all the time. It may affect memory, concentration and learning. This challenge lasts for months and can last for two or more years. It can affect children in different ways. Eg. ) There are children who continue to do well in school following the death of a loved one. These children go unnoticed. They my use the tasks of school work or sports to block out painful feelings or thoughts, or they may feel a need to excel because of a feeling that the parent is watching them and will want to show the deceased parent how much they care in this way. This type of response to loss can result in stress – related health problems later on in life, as well as potential physical and emotional difficulties from unresolved grief. How to Help Maintain routines in school Be realistic about expectations for academic achievement Allow make-up opportunities Remember that some children continue to have academic difficulties up to 2 years following a death, and sometimes beyond Make exceptions for sports participation†¦ sports can help with the healing process Refer to the school counselor Communicate with the parents Respect the child’s need to grieve Avoid telling the child to â€Å"Move on† or â€Å"Get over it†. Create an emotionally safe classroom Learn about children’s grief Recognize that intense grief can come at developmental stages, years after a death occurs Be patient Affirm the person, regardless of academic performance  ·new baby – The older children experience change, Younger children often find changes tin family life because of the new arrival, particularly difficult to cope with. Eg) My son was was an only child till he was 10years old. We always did everything thing together, I over smothered him and therefore he was not an independent child. Once his sister was born, he became mature over night and became more independent. I feel this was a positive change in his life. His little sister looks up to him. Think also about a child that feels left out, how may that affect their behaviour and development The first child may experience a range of emotions, from excitement to jealousy or even resentment. Younger toddlers are unable to verbalize their feelings, and their behaviours may regress after the new child is born. They might suck their thumb or drink a bottle, forget their recent potty training skills and communicate baby talk in an effort to get your attention. Older toddlers and kids might express their feelings by testing your patience, misbehaving, throwing tantrums, or refusing to eat. These problems are usually short lived and a little preparation can help and older child adjust to the idea of welcoming a new sibling.  ·moving house – A family may move house either into a poorer environment where there may be high incidences of crime or into a better area where they are more open spaces. A child that moves into a new area will leave behind friends and extended families. How will this affect their behaviour and development A new house, new environment, new area can affect a child in many different ways. A new surrounding depending, can affect a child by making them feel unsettled. Unfamiliar faces, unfamiliar scents, unfamiliar bedrooms can set a child back. The breakdown of connections with peers, discontinuation of group activities, distress and worries related to a new environment are potentially psychologically distressing events for young children. Frequent exposure to these events can be stressful and confusing and may affect their psychosocial wellbeing, thus increasing their intention toward ending their life if they are unable to cope.  ·parent divorce separation – Both familiar routines and lifestyles will change. Children will become more independent when there is only one parent. Sometimes they think it is there fault. Some children become withdrawn from everyone. Some children rebel, school work may suffer. Do you have any examples Eg) Child Z was 13years old when his parents got separated. His body was going through major changes hormonally. Once his parents separated he became a different child. He automatically became the man of the house. He rebelled against his mother, had no respect, came home when he pleased, his school work suffered. He disrespected everyone around and was very easily influenced. He got into trouble with the law due to peer pressure. When you put all this kind of behaviour, this child was seeking attention. His grandparents intervened, sat him down and had a one to one with him. He informed them that he felt that his parents had split up because of him, he felt that he couldn’t bare to see his mum in tears all the time. He also mentioned that there was no stability in the house and it was very unsettling for him, hence his behaviour.  ·Fostered/ looked after children – If fostered because parents can’t cope eg) because of drug abuse, alcohol abuse. Foster children are normally placed miles away from where they grew up. Issues of distance. Foster kids are normally moved around due to behaviour or reasons out of their control. Some children experience feelings being unsettled. Some children are already damaged before they are even fostered eg) Due to unsettled background. They make take several behaviours with them, insecure , difficult to make friends – lack of trust. Good Well done Kamilla. You have expanded your answers, but occasionally didn’t really say what affect the transition had on behaviour and development. I will chat to you about this on Tuesday morning. See you then Could you leave the comments on your answers please – it shows I am doing my job. Thank you. E assessed 16th October, 2011 How to cite Child Development Stages, Papers

Complete Heart Block Case Study free essay sample

It is an empirical inquiry that investigates a phenomenon within a real life context. It provides a systemic way of looking at events, collecting data, analysis information and reporting the result. It tends to be selective, focusing on one or two issues that are fundamental to understanding the system being examined. Cardiac cases are under typical category of case studies where symptoms are described, probable causes are suggested, treatment is recommended and prognosis is recorded till the hospital stay of the case. So it is the complete study of the case and about the diseased condition from which the case is suffered. Objectives of case study 1. To collect data related to the etiology and predisposing factors causing diseases. 2. To identify the manifestations of medical/surgical conditions from the underlying patho physiological changes. 3. To correlate the principles of physical, biological and behavioral sciences in application of nursing process in care of the patients with specific conditions regarding Medical/Surgical treatment. We will write a custom essay sample on Complete Heart Block Case Study or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page 4. To conduct health educations for individuals and groups. 5. To provide comprehensive nursing care according to the need of the patient. 6. To assist individual in different diagnostic investigations. . Controls the infection by applying recommended Infective prevention measures. HISTORY TAKING Demographic Data Name: Nutan Govinda Joshi Age: 82 years. Sex: Male Marital Status: Married. Religion: Hindu. Education: Literate (Bachelor in Pharmacology) Occupation: Retired Address: Jhamsikhel Ward:CCU Bed no: 10 Hospital No. :51974 Diagnosis: Complete heart block with hypertension with type 2 DM Date of admission: 2069/09/02 Date of discharge: 2069/09/11 Unit:1 ‘A’ Dr. Murari Dungana and Dr. Pranita Dhakal. Chief complaints At the time of admission: * Generalized weakness since 3pm * Altered sensorium since 5pm At the time of assessment: * Pain at pacemaker implanted site History of Present illness: According to the patient, he was in his usual state of health then he suddenly developed generalized body weakness since today 3pm associated with two episodes of vomiting. Patient also gave history of altered sensorium for few minutes. ECG done at Kathmandu Hospital show Complete Heart Block at rate of 42 bpm for which he received 4ml of atropine and isoprenaline was started. Patient referred here for TPI. No history of loss of consciousness, SOB, palpitation, chest pain, burning micturation, constipation and passage of loose stool. History of past illness: * Known case of Hypertension and type 2 DM and under medication. Personal History: No history of any drugs or food allergy. He is non-vegetarian and he used smoke in past about 2-3 sticks/day since 16 years and he left smoking 35 years back. He is non-alcoholic. Bowel : Has not passed stool since 2 days Appetite: Normal Sleep : Decreased Urine : Normal Socio-economic status: * Income source: Pharmacy and Son * Road and electricity facilities : Present * Drinking water : boiled water * Excreta disposal: Toilet * Health facilities : Nearby hospital: Kathmandu Hospital * Waste disposal : Manure 9yrs Family tree67 yrs 83 yrs 78 yrs 80 yrs 76 yrs 80 years 82 yrs 5 Male: Female: Patient: Marriage 49 yrs 42 yrs 55 yrs 62 yrs 37 yrs 61 yrs 58yrs 56 yrs 60yrs His father had history hypertension. Died at 67 yrs age due to some cardiac problems. Mother had suffered from hemiparalysis for about 6 years and later died at 79 yrs. PHYSICAL EXAMINATION: On date:2069/09/03 Hi s general condition is weak. He is well oriented to time, place and person. General appearance: Looks ill. Level of consciousness: Conscious. Cleanliness: Maintained. Gait : Balanced Weight : 50 kg. VITALS: * Temperature: 98 F Pulse: 88 beats per min * Respiration: 20/min * Blood Pressure: 90/70 mmHg * PILCCOD: nil HEAD TO TOE EXAMINATION: * Head and face Hair: whitish and short with no dandruff present No any scars and injuries. Face : wrinkled face and looks tiered. * Eyes Pupil: React to light Vision: Decreased. Opacity of lens: Transparent. Blurred vision: Not present Anemia: Not present Jaundice: Not present * Ears Normal shape and size, and No any discharge. Condition of mastoid area: No any sign of Inflammation External ear canal: Normal * Nose Normal shape and size, and no any bleeding. Nasal deviation absent. * Mouth, Throat and Neck Lips: Pink, no cracks Gums: Normal Tonsils: Not enlarged. Palate: Normal Uvula: Normal. Thyroid: Not enlarged and palpable. * Chest and Lung Inspection Shape : Normal Movement of chest: Moving equal during respiration Palpation : Non tender Percussion : Resonant sound felt on Percussion. Auscultation Breath sound: Normal Vesicular Breathing Sound Bilateral Equal Air Entry No wheezing or crept. Respiration: Normal 20/minute. * Cardiovascular System Chest pain: complains of pain at incision site on movement Pulse : 88/minute Blood pressure: 110/70 mm of Hg Incision on left side of the chest made for Permanent Pacemaker implantation. Auscultation Heart sound: Normal (lub and dup) Murmur: absent. * Gastro-intestinal system Bowel habit: has not passed stool since 3 days Vomiting: Absent Loss of appetite: Absent Palpation Liver: Not palpable. Spleen: Not palpable. Kidney: Not palpable. Any abnormal masses: No. Auscultation for bowel sound: 3-4 times per minute. Tenderness : Absent * Genito Urinary System No any abdominal pain present Pain on micturation: No Blood in urine: No Color of urine: Light yellow. (Straw) Patient was on indwelling catheter No any signs of UTI seen (fever, lower abdomen pain, foul smelling urine, frequency in urination etc) * Musculoskeletal system Normal body posture. No any deformity * Nervous System Convulsion: No. Level of conscious: Conscious. Gait balance: Well balanced. Orientation : Oriented to time, place and person. Speech problem : No. Problem of rest and sleep : not present. Findings of physical examination * Looks ill. * Has not passed stool since 3-4 days * On the left side of his chest there was a surgical incision done for the permanent pacemaker implantation. Patient complains of pain on movement. * Patient on indwelling urinary catheter. ANATOMY AND PHYSIOLOGY OF CONDUCTIVITY OF HEART: The SA node is situated at the junction of the superior venacava and RA. It comprises specialized atrial cells that depolarize at rate influenced by the automatic nervous system and by circulating catecholamine. During normal (sinus) rhythm, this depolarization wave propagates through both atria via sheets of atrial myocytes. The annulus fibrosus forms a conduction barrier between atria and ventricles, and the only pathway through it is AV node. This is midline structure extending from right side of inter atrial septum, penetrating the annulus fibrosus anteriorly. The AV node conducts relatively slowly, producing a necessary time delay between atrial and ventricular contraction. The His-Purkinje system is comprised of the bundle of His extending from AV node into interventricular septum, the right and left bundle branches passing along the ventricular septum and into the respective ventricles, the anterior and posterior fascicles of left bundle branch, and the smaller Purkinje fibers that ramify through ventricular myocardium. The tissues of His-Purkinje system conduct very rapidly and allow near simultaneous depolarization of entire ventricular myocardium. The heart rate is determined by the myocardial cells with the fastest inherent firing rate, under normal circumstances, the SA node has highest inherent rate (60-100impulses per minute), the AV node has second highest inherent rate (40-60 impulses per minute, and the ventricular pacemaker sites have the lowest inherent rate (30-40 impulses per minute). If SA node malfunctions, AV node generally takes over the pacemaker function of the heart at its inherently lower rate. If both the SA node and AV node fail in their pacemaker function, the pacemaker site in ventricle will fire its inherent rate at 30-40 impulses per minute. DESCRIPTION OF DISEASE – COMPLETE HEART BLOCK * It is the medical condition in which the impulse generated in the SA node in the atrium does not propagate to the ventricles. * When AV conduction fails completely, the atria and ventricles beat independently. Ventricular activity is maintained by an escape rhythm arising in the AV node or bundle of His (narrow QRS complexes) or distal purkinje tissues (broad QRS complexes). Distal escape rhythms tend to be slower and less reliable. Complete heart block produces a slow (25-50/min), regular pulse that, except in the case of congenital complete heart block, does not vary with exercise. There is usually compensatory increase in stroke volume with a large volume pulse and systolic flow murmurs. * Rate: atrial rate is measured independently of the ventricular rate, usually normal b ut the ventricular rate is usually very slow. * Rhythm: each independent rhythm will be regular, but they will bear no relationship to each other * P wave: present but no consistent relationship with the QRS * PR interval: not really measurable QRS complex: depends on the escape mechanism (ie, AV nodal will have normal QRS, ventricular will be wide and the rate will be slower) * T wave: normally conducted Aetiology of complete heart block * Congenital * Acquired * Idiopathic fibrosis * Myocardial infarction/ischemia * Inflammation * Acute (e. g. aortic root abscess in infective endocarditis) * Chronic (e. g. sarcoidosis, chagas disease) * Trauma (e. g. cardiac surgery) * Drugs (e. g. digoxin, Beta blockers) Clinical features In book | In my patient | Bradycardia | Present (43 beats per minute) | Hypotension | Present (90/70 mm of Hg)| Hemodynamic instability | Present (semi-conscious, dizziness, altered body sensorium)| Fatigue | Present | Shortness of breath | Present | Exercising may be difficult | Present | Test and diagnosis In book | In my patient | Remarks | ECG | Done | Heart rate= 43bpm, Complete heart block| Complete blood count | Done | WBC elevated | Echo | Done | Mild MR and mild TR| Electrolytes | Done | Electrolyte imbalances present. Sodium level decreased. And others; urea, creatinine, RBS elevated. | Cardiac enzymes| Not done| | Chest x ray | Done | Normal | Types: 1) Temporary pacemaker 2) Permanent pacemaker Temporary pacemaker This is an artificial device used to stimulate or pace the heart for short term treatment. The pulse generator containing the circuit and batteries is located outside the body and the pacemaker lead is fixed in right ventricle Purpose: * To initiate and maintain the heart rate when the natural pacemaker of heart is unable to do so. * To prevent circulatory failure * To slow rapid arrythmia not responding to drugs or cardioversion Indication: * Complete heart block * Symptomatic sick sinus syndrome Anterior or inferior wall infarction with second or high AV block * Tri fascicular block * Post cardiac surgery * Prior to permanent pacemaker generator change Complications: * Infection and phlebitis * Cardiac temponade * Pulmonary embolism/pneumothorax * Battery failure * Lead dislodgement * Diaphragmatic stimulation * Venous thrombosis Medical and nursing management (TPI) Before: patient preparation * Explain the pr ocedure and type of pacemaker to the patient. * Obtain written consent from the patient and patient party * Clean and shave the area (both groin) Check the vital signs * Mental support * Maintain the room temperature at 24 to 26 deg centigrade * Check serology: HIV, HbsAg, HCV and others * Start an IV line with 5% dextrose solution or normal saline solution * Prepare isoprenaline drip * Check battery in pulse generator * Prepare the emergency cart, the defibrilator and ECG monitor * Set up all the equipment for insertion of pacemaker * The nurse should know about the pacemaker generator including the power switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial, and their proper setting. During the procedure * Assist the doctor and scrub nurse during procedure step by step * Scrub hands thoroughly and put on sterile gloves aseptically * Assist during the insertion of temporary pacemaker lead * Observe vital signs and observe ECG monitor carefully for arrythmias and other complications * The pacemaker lead can be inserted through the femoral, sub clavian or internal jugular vein and fixed into the right ventricular apex. The lead and generator should be connected and fixed properly to avoid pacing failure. * Record the pacing parameters After the procedure * Observe the patient and check vital signs. Continue ECG monitor for arrythmias, pacing function for at least 24 hours * Watch for the symptoms of nausea, palpitation, rigor and pain for next 3-4 hours. Asses the pacing parameters, battery, wire connection and take a 12 lead ECG. * Confirm inserted position of wire, rate and output. * Use elastoplast to immobilize hands and legs of the pacemaker implant site. Then allow gradual mobilization after 48 hours with sterile dressings. * Assist the technician to take chest X ray Cover the dial of pacemaker to prevent accidental disconnection * Record and report about the patient’s condition. Permanent pacemaker * An artificial device used to stimulate the heart for long term treatment. The pulse generator is permanently implanted in the body. It is most commonly used in patient with complete heart block. Purpose: * To initiate and maintain the heart rate when natural pacemaker of the heart is unable to do so * To prevent circulatory failure Indication: * Complete heart block * Symptomatic sick sinus syndrome * Tri fascicular block * Symptomatic Mobitz II AV block Complications: As in temporary pacemaker In addition: Pneumothorax/ hemothorax Pacemaker pocket infection Pacemaker syndrome APPLICATION OF NURSING THEORY VIRGINIA HENDERSON’S INDEPENDENT THEORY OF NURSING According to Henderson, â€Å"The unique function of nurse is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to peaceful death) that he/she would perform unaided if he/she had the necessary strength, will or knowledge and to do so in such a way as to help him/her gain independence as rapidly as possible. †-1996. Since my client was admitted in the CCU with the diagnosis â€Å"Complete Heart Block with known case of hypertension and type2 DM’, there were various changes and problems which were diagnosed on the basis of Henderson’s Unique Function of Nurses. Henderson conceptualized the nurse role as assisting sick or well and gain independence in meeting 14 fundamental needs. Essential Components| Findings in my patient| Breathe normally. | Shortness of breathing and wheezing present (pneumothorax) present. Oxygen at 4lt/min through facemask. | Eat and drink adequately| Appetite was normal. | Move and maintain desirable posture. | Assisted to move and maintain desire posture with support. | Eliminate body wastes| On indwelling urinary catheter later removed and self voiding. No bowel since 3-4 days, passed stool on enema. | Sleep and rest. | Rest and sleep normal, but some difficulty and discomfort due to pain on left chest tube site. | Select suitable clothes-dress and undress. | Able to select suitable clothes-dress and undress. | Maintain body temperature within normal range by adjusting clothing and modifying the environment| Able to maintain body temperature within normal range. Keep the body clean and well groomed and protect the integument. | Patient’s body was clean and well groomed. | Avoid dangers in the environment and avoid injuring others. | Able to avoid dangers. | Communicate with others in expressing emotions, needs, fears or opinions. | Was expressive and cheerful. | Worship according to one’s faith. | Patient worships according to her belie f. | Work in such a way that there is a sense of accomplishment. | he works with a sense of accomplishment. | Play or participate in various forms of recreation. he participates in various forms of recreational activities. | Learning, discovering or satisfying the curiosity that leads to normal development of health using available health facilities. | Try to use available health facilities. | ASSESSMENT Patient was assessed from the 2nd day of admission until day of discharge and continuous nursing care was provided as per the need identified according to Henderson’s Independent theory. FINDINGS Patient problems were: * Restricted left hand movement S/P PPI. * Patient on indwelling urinary catheter. Patient has not passed stool since 3-4 days. * Ineffective breathing pattern; Pneumothorax (left side) PRIORIOTIZED NURSING DIAGNOSIS * Acute pain and discomfort related to chest tube insertion and pleural effusion. * Ineffective breathing pattern related to pain at left sided pl eural effusion. * Activity intolerance related to status post Permanent pacemaker implantation with restriction of left hand movement * Constipation related to impaired physical mobility and change in daily routines. * Risk for infection (UTI) related to indwelling urinary catheter. Risk for infection related to surgical incision for pacemaker implantation. Date| Day| C/O| Vital signs| O/E| S/E| I/O| Plan| 09/02| DOA with diagnosis of Complete heart block with known case of type 2 diabetes mellitus amp; hypertension. S/P Temporary pacemaker implantation at 9:00 pm. | Generalized weakness since 5-6 hoursAltered sensorium since 3-4 hours. | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| Urine nil. Informed to Dr. so Inj. lasix 20 mg stat at 7am . | Monitor vital signs 2 hourly. Watch for arrythmias. Patient to be kept in NPO from 6am tomorrow. Plan for PPI tomorrow. Insulin on sliding scale. | | | | 970F| 62 bpm| 18/min| 90| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 9/03| Ist DOA ;CHB with TPI, K/C/O T2DM amp; HTN. Day of PPI. Received from cath S/P PPI at 12:15pm | Cough | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| 1600/ 3600ml -ve balance 2000ml| Administer Nebulization 8 hourly. Syp. Grillinctus, Inj. levoflox, Inj. Monocef added. Tab Glycomet SR stopped. Oxygen through face maskFoleys continue. | | | 97. 80F| 64 bpm| 20/min| 110| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 09/04| 2nd DOA:CHB with PPI, K/C/O T2DM amp; HTN. | Shortness of Breathing Pleural effusion done : C/O pain at chest tube site | 97. 80F| 72 bpm| 24/min| 90| Ill | Nil | RS: wheezing present | 1770/ 1360 ml + ve balance | Chest X-Ray. Pneumothorax present so left pleural drainage done. Post c hest X-ray. Continue O2 at 4 lt/min. Blood for WBC,DC, RFT tomorrow. Tab codomol SOS added. Inj, Lantus added today. | | | | | | 60| | | CVS: S1 S2 and no murmur| | | | | | | | | | | | PA: soft, non-tender and no organomegaly, BS 3 to 5 times per 10 mins. | | | 09/05| 3rd DOA:CHB with PPI, K/C/O T2DM amp; HTN| Not passed stool since 4 days. Severe pain at left pleural drainage site. | T| P| R| BP| GC| PILCyCOD| RS: wheezing present | 1400/1500ml-ve balance100ml| Nasal cannula at 3lt/min. Dressing at PPI site. Chest X-Ray done and Seen by Dr, left pleural drain to be clamped on from tomorrow 6am. Perform chest X-Ray while clamping. Sliding scale insulin stopped and regular started,blood sugar testing tomorrow. | | | 960F 0F 0F 0F. 80F| 80 bpm| 20/min| 100| Ill| Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non tender and no organomagaly, BS=3-5/10m| | | 09/06| 4th DOA:CHB with PPI, K/C/O T2DM amp; HTN| None | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added so und| 1600/ 1400 ml | Drain tube clamped. Chest X-ray at 9 am FBS, pre dinner, post dinner to be done daily by glucometer. Inj, mixtard dose increased. Plan to transfer out to Single cabin,Drain tube out at 3:15 pm and no any chief complain. O2 at 3lt/min continue. Chest X-ray after tube out. Foleys out. | | | | 980F| 74 bpm| 20/min| 110| Satisfactory | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 80| | | PA: soft, non-tender and no organomeagaly, BS+| | | MEDICATION USED IN MY PATIENT: 2069/09/02 * Inj. Cefazolin 1gm IV 8 hourly TDS * Tab. Glymet SR 500mg PO BD * Inj. humolog 50 S/C 10U morning: HOLD * Inj, levomor 14U S/C evening: HOLD * Tab. Omnitan 50mg PO BD * Inj. insulin sliding scale * 150-200 : 2U, 200-250: 4U, 250-300: 6U, 300-350: 10U, 350-400: 12U, 400 or more then 400: 2069/09/03 * Tab. Augmentin 625mg PO BD Inj Monocef 2gm IV OD * Inj. levoflox 500mg IV OD * Syp Ascril 2tsf PO TDS 2069/09/04 * Syp. Cremaffin 2069/09/05 * Inj. Mixtard 30:70 (12U S/C in morning and 6U S/C in evening : both ? hour before meal) * Tab. Tramadol 50mg PO BD * Inj. Pethidine 25mg IV stat and SOS * Inj Phenargan 25mg IV stat and SOS. * Herbolax 3 cap with warm water HS * Note: NO NSAID: allergy history HEALTH TEACHING TO PATIENT AND FAMILY DURING STAY P atient education about disease condition: The patient and the family were given all the information regarding the disease condition. He and his family members were taught about the possible causes and contributing factors according to book and in comparison with his life to make them know about it. So that they will all be aware of it and follow the necessary consideration. Nutrition: Patient was encouraged to take adequate amount of fluid and fiber diet to prevent from constipation. Patient was encouraged to take low salt diet, decrease intake of fatty diet, decrease cholesterol intake for healthy heart as per antihypertensive medicines suggest. She was advised to avoid red meat and replaced it by chicken or fish that has low fat with high protein. Paient was advised for diabetic diet and regular use of insulin as advised by Doctor. Personal hygiene: Personal hygiene is an important factor for the health recovery of the patient. It brings the sense of self well being and promotes self-esteem. Besides this maintaining oral hygiene promotes appetite and prevents weight loss, vomiting. Daily dressing once a day basis was given to promote wound healing and prevent infection. Medication: Medication is important for restoration of clients health. So, it should be continued as doctor advised. I explained him about the importance of complete dose of antibiotic to be taken to eradicate infection that degrades her disease condition. I also encouraged him to continue the use of antihypertensive medication and antidiabetic medication as per doctor’s advice. I also said about the possible adverse effects of the drug. Daily habit changes: I explained her disease condition and important daily activities to be changed like taking proper rest until she recovers and avoidance of sexual activities for 6 to 8 weeks. She was advised to change her dietary habit into low salt diet, low fatty diet as per hypertensive patient should take. Possible complication: Patient was made aware of possible complication like hemorrhage, retention of urine, bladder injury, rectal injury, vault cellulitis, pelvic abscess, thrombophlebitis, pulmonary embolism, vault prolapse etc were explained resulting from complication of vaginal hysterectomy and Pelvic floor repair. And patient was encouraged to come for F/U immediately with any of the symptoms of underlying complications. Discharge Teaching At the time of discharge, teaching was basically given to the patient and patient’s party. Following things were included in the teaching at the time of discharge. Treatment at Discharge: CONCLUSION Nutan Govinda Joshi, 60 years old female from Kavre was admitted in bed no. 222 in Gynae Ward of Kathmandu Medical College at 11:30 pm on 2068/12/12 and discharged at 3:00 pm on 2068/12/16 with the diagnosis of â€Å"2nd degree Utero-Vaginal Prolapse with cystocele† and â€Å"Vaginal hysterectomy with pelvic floor repair† was done on 2068/12/13. The patient was under my close observation from the 2nd day of admission till the day she was discharged. During her hospital stay, I tried my level best to provide her a quality nursing care based on her needs with the application of Virginia Henderson’s independent theory and I also tried to give suggestion to her and her family members on the management of her disease condition. Though I had very short duration to provide her care, I kept my maximum efforts and help her in any ways that I could. I provided teaching to her, her husband and her mother in laws her present disease condition and treatment she has undergone through. It was very exciting case and I felt very happy to have company with the patient along with her family members so that I could teach and convince them about the care needed. She and her family members were very co-operative and supportive. Even then, it was very educational to study this case. It helped to learn in better way and even helps to practice as well as enhanced my skills to some extent. Bibliography * Burner and Suddharth’s, â€Å"Text book of Medical Surgical Nursing† Volume:2; 12th edition Wolters Kluwer(India) Pvt. Ltd, New Delhi,. * Chaurasia, B. D. (2009). Human Anatomy volume 2 (4th edition). CBS Publishers amp; Distributors Pvt. Ltd. New Delhi, India. * Kozier and Erb’s â€Å"fundamental of Nursing†; 8th edition; Pearson Education, published by Dorling Kindersley (India) Pvt. Ltd. ; 528-43. Lippincot,Manual of Nursing Practice , 9th edition, churchill livinstone * Mosby’s â€Å"Comprehensive Review of Nursing for NCLEX- RN examination† ;19th edition; Elsevier publication; 535-36 * Mosby’s â€Å"Nursing drug reference†; 22nd edition 2009 Elsevier publication;22-23,129-30,1143-44,685-89. * Smeltzer, S. C amp; Bare; 2008. Textbook of Medical-Surgical Nursing, 11thedition. Lippincott Williams amp; Wilkin s. Philadelphia. * Retrieved on 2069/09/10 http://en. wikipedia. org/wiki/Artificial_cardiac_pacemaker#Considerations http://www. nhlbi. nih. gov/health/health-topics/topics/hb/