Differential Calculus: Maximum and Minimum Problem and Solution

An oil refinery is located on the north bank of a straight river that is 2 km wide. A pipeline is to be constructed from the refinery to storage tanks located on the south bank of the river 6 km east of the refinery. The cost of laying pipe is $200,000 per km over land to a point P on the north bank and $400,000 per km under the river to the tanks. To minimize the cost of the pipeline, how far from the refinery should P be located? (Round your answer to two decimal places. ) 1 year ago Report Abuse Colorado†¦ Best Answer – Chosen by VotersThis is a min-max calculus problem, where we want to minimize the cost function: We need a drawing of the situation: see https://docs. google. com/drawings/d/1PvkU†¦ where R is the refinery, O will be the x-axis origin, P is the point on the north bank, and x= distance from O to the storage tanks. [Note, we could have put R at the origin, but the algebra is a little simpler this way] The cost C(x) of the pipeline as a function of x is: C(x) = distance along north shore * pipeline cost over land + distance under the river * pipeline cost under land The distance along the north shore is 6-xThe distance (by Pythagorean theorem) under the water is sqrt( 2^2 + x^2) So, C(x) = (6-x)*200000 + sqrt(4 + x^2) * 400000 [You should graph this] To find the value of x where C(x) is minimized, we set dC/dx = 0, [Reminder – use the chain rule to differentiate the second term] Differentiating and simplifying, we get dC/dx = C'(x) = -200000 + 400000x/ sqrt(4+x^2) = 0 400000x / sqrt(4+x^2) = 200000 400000x/200000 = sqrt(4+x^2) Squaring both sides, we get 4x^2= 4 + x^2 x = sqrt(4/3) = 1. 15 So the distance from the refinery to point P is 6-x = 4. 85 km

“Explain the concept of homeostasis with reference to the control of heart rate, breathing rate, body temperature and blood glucose levels” Essay

Homeostasis is where the body keeps a constant internal environment. This involves all the metabolic processes taking place In the body as well as the blood, tissue fluid and all the contents in the body’s cells. There are a range of variables from heart rate to the blood glucose levels that the body will take into account. Negative feedback will occur when something changes from its normal in the body. The body then will come back with a response to cancel out the difference to bring it back to its normal. An example of this is if blood glucose level falls the body will then convert the glycogen in the body to glucose which will bring back the energy in the cells to its normal amount. This system requires receptors so that they are able to detect the change in your body. As well as receptors it also needs a control centre so that the information that has just been received can be processed to then give the correct response of what the body should do. Most of the control centres can be found in the brain. It will also need effectors so that after the change has happened and the body is back to normal it can reverse the change to keep the body at its original state. The brain and the central nervous system controls something called the homeostatic mechanisms. This is when they anticipate whether there may be a rise or a fall compared to that of the normal. An example of this is the feeling of being cold or tired this is a result of having not eaten for a sufficient period of time. This has then been sent as a message to the brain which your brain will then tell you to eat so that the energy you get from the nutrients in your food will counteract those feelings and make them disappear. As this is an anticipation from the central nervous system and the brain it is called feed forward as it hasn’t happened yet. Heart rate The heart is regulated by impulses produced by nerves acting on the sino-atrial node (S-A node). These nerves are called â€Å"sympathetic† and â€Å"parasympathetic† nerves. The sino-atrial node is found in the upper part of the right atrium it is made up of a cluster of excitable cells. Both the sympathetic and parasympathetic systems are two branches that come off the automatic nervous system which controls the heart. The parasympathetic nervous system- This is a calming system as it is active while the heart is resting. It causes the heart to beat slower than it would normally. The main nerve involved is the vagus nerve without it the heart rate would increase. The sympathetic nervous system- This occurs when the body is feeling stressed. As a result of it, it causes the heart to beat faster it also adds a boost to the hormone adrenaline which occurs during fear. The nerves involved in this system is called the cardiac nerves. The sino-atrial node releases nerve impulses that are sent across the atrial muscle fibres which causes them to contract. Cells that form the atrio-ventricular node (A-V node) catch those impulses which are then relayed to a band o conducting tissue. This tissue is made from large modified muscle cells that are called Purkinje fibres. So that the atria can complete their contractions and allow the atrio-ventricular valves to close there may be a delay for the transmission to come through. The valves of the hear are found on a fibrous figure-of-eight. It is centred between the atrial and the ventricular muscle masses. The first part of the conducting tissue will enable the excitatory impulses to be able to cross to the ventricles. It will then split into both sides of the ventricular septum where it will then spread out into their muscles. They pass extremely quickly which result in them contracting which forces the blood to travel around the body to the organs that need it. Breathing rate To control your breathing there is a respiratory control centre this again is located in the brain stem. This will observe the levels o carbon dioxide and oxygen in your blood. It also makes sure that your breathing stays at a steady rate which will maintain balance as well as homeostasis In the body. Most of the time you don’t have to think about your breathing at all or how you control it as your brain does it automatically for you. However in some cases in aerobic activity you control your breathing for example in Pilates when instructed through each stretch you get told when to inhale and exhale during the exercises. Saying that if the oxygen levels go down below a certain point your brain will override your control and make you breathe. During exercise or any physical activity that require more oxygen than normal. The oxygen in your blood will decrease while the carbon dioxide in the blood will increase. When the respiratory control centre in the brain realises that the levels aren’t normal as a result it will increase the heart rate and the breathing rate to counteract it. The brain will slow the heart rate and breathing rate once the exercise has stopped this will make sure that it maintains the homeostasis in the blood. While resting your breathing is at a steady rate. This means that there will be the right amount of oxygen in the blood on the inhale as a result the right amount of carbon dioxide will come out the blood in exhale. Body temperature Again the brain controls the body temperature. Specifically in the brain it is the hypothalamus processing centre that controls the exact temperature the body is. The brain will trigger changes to the effectors around the body for example to the sweat glands . If the body temperature is not maintained then it can either become too cold resulting in hypothermia or too hot resulting in heat stroke either can be fatal. On average your normal body temperature is 37 °C. Our body maintains this temperature by balancing the heat we generate compared to the heat we lose in everyday life. Saying that not our whole body is 37 °C for example are fingers and toes remain at a lower temperature as a result of the energy being lost from the blood while travelling to the tips. There are temperature receptors in our skin which once detects change in the external temperature will send a message to the hypothalamus in the brain. Again in the hypothalamus processing centre (brain) which will detect the changes in temperature of the blood. There are 2 ways in which the brain tells the body to keep its temperature at 37 °C. The first one is if someone is really cold then the hair on the skin if the hair is on ends then it will trap more warmth compared to if it is flat on the skin. The second one is if someone is really hot then the glands on their skin secrete sweat which increases the loss of heat when it evaporates, as a result it cools the body down, It slows back down when the body temperature returns to normal. During vasodilatation the warm blood will flow closer to the surface of the skin so that the heat will be able to transfer into the air. As a result of this the skin will become redder. During vasoconstriction which is where the blood vessels that supply war blood constrict, as a result this will reduce the blood flow in turn this will reduce the heat that can be lost. In this case their skin will look pale. Blood glucose This involves the kidneys keeping the water balance at the correct level of water in and out of the body. This will ensure that that the cells in our body work efficiently. The kidneys is where the blood gets filtered while passing through, these molecules are made up from water, glucose, salt and a waste product called urea. It then will reabsorb what the body needs which includes glucose salts and water back into the blood. It then travels around the body. The products that haven’t been fully absorbed are excreted from the body. It mainly consists of urea but there may be left over water glucose and salts that the body doesn’t need. In the brain the pituitary gland controls how much ADH is produced and released into the bloodstream which as you know travels to the kidneys to get filtered. Which in turn controls the concentration of urine. It also checks the concentration of blood plasma. When there isn’t enough water in the body the hypothalamus will detect it and send a message to the pituitary gland which will then release the ADH hormone, this will ensure that the urine is more concentrated resulting in less water, this will be maintained by the kidneys. As a result the water levels in the blood will return to normal. Cells make their energy from the glucose in the body this is why glucose levels need to be regulated tightly. As a result of this if there is too much glucose in the body may lead to diabetes 2, if too low it may lead to starvation of the body. In the body there are many reasons for the rise and fall of the glucose levels. For example digestion after a meal and the production of insulin by the liver these both lead to a rise in the glucose levels. An example of a fall in glucose levels is the transportation of the sugar into the cells as well as the loss of glucose through the urine. The regulation of the glucose levels relies on a variety of things from molecules to organs and cell types. Bibliography Edexcel Level 3 Health and Social Care Book http://www.ehow.com/how-does_5101742_describe-regulation-blood-glucose-levels.html

Marketing goals Essay

In order to set SMART (Specific, Measurable, Achievable, Realistic and Time bound) goals, it is highly important that there is a compatibility between the marketing and business goals. (Write Market). The broader marketing goal is to become a cost leader and gain a larger market share in the market of toy manufacturers (Locally) in 25-30 years since the company at present is at its infancy stage. Company’s focus at present unlike its competitors is to give customers â€Å"More for less† in terms of value. However, this long-term goal represents where the company wants to be in the future. The short-term goals include enhancing external positioning in the toy market by conducting ATL (Above the line marketing communication strategies like advertising, working on store ambiance and layout to make them more consumer friendly, etc) and BTL (Below the Line advertising like events, stalls, discounts, etc), maintaining and enhancing relationships with suppliers. Stakeholder engagement, Up-to-date Knowledge about market trends, customer needs and changes in customer needs are also important marketing goals. It is also important that the toys Unique Selling Proposition i. e. low price, environmental friendliness, distinct benefits of using ORIGIN, innovative uses, etc are clearly communicated.

Rise of Asia Essay Example | Topics and Well Written Essays - 500 words

Rise of Asia - Essay Example Unlike his neighbors, Japan opened its doors fully to mercantilism to all western countries. Countries such as China limited their trade with the western world which would cost them in the future. The Boxer Rebellion in 1899 (small planets communications) and the Opium War in 1840 (Chesneaus) resulted from China's resistance to foreign trade. Frank B. Tipton, author of "The Rise of Asia," mentioned that Japan and China shared the same social constructs and tradition that placed them in cultural crosswords in which they must decide which route the must take. Apparently, they both chose two different routes. (Tipton, pg. 92) Japanese embraced their culture industrial culture with open arms. The industrial movement posed new challenges for the government. These challenges insinuated that the government needed redesign their former policies and cultural traditions. For example, women before were viewed as peasants, artisans, samurais, and merchant women. But for the philosophical needs and recognition, the Japanese females undertook the sociological model of the "Japanese women." (Tipton, pg.130) They worked silk factories and cotton mills.

Decultralization and Education Essay Example | Topics and Well Written Essays - 750 words

Decultralization and Education - Essay Example Such group of students advocates for inclusion into the education system or may go a head to start their own system. The families that have been affected by the government schooling system have often sought alternative means in private institutions. Springs notes that Catholic schooling provided opportunities for the minorities who found public school unfriendly. This paper explores the work of spring in describing the education system of American society. Spring (57), has noted in his book that dominant culture in the United States of America has played a significant role in dictating education policies in United States of America. Dominant cultures or races in the United States have affected the education policies. Some student from minority groups finds it difficult to study in an environment that seems to segregate against them. Spring describes post racial society as one, which does to harbor any segregation or discriminatory traits. This seems not to be the case in America. Man y communities that live in America come from diverse backgrounds and cultures. The society should admit them the way they are and accept the presence of their children in schools without discrimination of any nature. The statement is contrary to what Spring points out in his book. He described the discrimination of the minority students in America public institutions. Post racial society contributes toward such for equality because of the inclination that many communities take towards advocating for common policies that would include members of diverse community. The blacks, whites and the Indians learn in the same institutions and would advocate for policies that give each of the communities an equal space in school. Native cultures of the American played a role in shaping the education system in 19th and 20th century. For examples, the Indians schools promoted the Indian cultures and were less friendly to the non-Indian students. Introduction of policies during the tenure of Presi dent Roosevelt provided an opportunity for creating a learning environment for students from diverse cultures. A senate sub committee of education noted the problems that student of minority cultures face in schools and came up with policies that aim at protecting them. Largely, the championing of the deculturalization by the rights activists has contributed in changing discrimination in schools. Entrenching of the non-discriminatory act has contributed towards stumping the retrogressive policies that promoted discrimination in schools. The democratic space that the society has provides a means of channeling critical issues for discussion. Incorporation of the government policies in education system of United States of America stumped out the dominant cultural policies that inhibited the democratic space in schools. The changes in the education system of United States have occurred due to respect to human rights as documented in the constitution. Legislation of the land provides an equal opportunity for people of diverse culture to pursue their interest without interference. Respect for human rights dictated the actions of people in the society. This legislation has promoted equality in public schools and has worked towards changing the treatment of the minority in schools. Teachers and students have shaped their reactions towards the minority or the less dominant groups in school based on this piece of legislations. Court cases against discrimination

The Value of Money Essay Example | Topics and Well Written Essays - 750 words

The Value of Money - Essay Example Compound interest is different from the simple interest on the grounds that it takes into account the accumulated interest that has to be paid over the years and the principle for compound interest assumes that interest should also be paid on the accumulated interest. Compounding can be done annually, semi-annually or quarterly depending upon the circumstances. Using compounding interest method, there are gigantic changes in the amount of interest that is received. The amount of interest gained, when comparing the gains from the compound interest method to the simple interest, magnifies to an enormous extent. When calculating future value transactions, the value increases by a greater extent. The concept of time value of money can be termed as the foundation of the field of finance. This concept talks about the increase in the value of money with the passage of time; Which means that the dollar that you hold in your hand right now, is worth more than it will be worth in the future, the reason being that you can conveniently invest it somewhere and earn additional money over that dollar. Another important concept that the time value of money put forward is, that the future value of the principal amount and the interest collected over a period of time can be summarized into a value today; just like you can calculate the value to which a certain amount of money today will convert into on a future date. Mortgage loans are Mortgage loans are an example of the proper application of the time value of money; reasons being the loans are given by deciding the series of future payments that are to be paid to the lender for a house that is bought. More interest is paid in the beginning because the procedure follows compounding interest method. In this case, with each payment, as the principle amount to be returned decreases, the interest that has to be paid on it decreases too. The terms that are being used to give off the loan are of immense importance; more terms mean more compounding of the loan, resulting in extra payment of interest. This law holds true for varying interest rates as well. As the terms are increased, consequently the interest rates increase too. There is a multiple effect on the payments of interest when both the factors increase. Bond Prices and Interest Rates At a glance, one would feel that there should be a direct relationship between the interest rates and bond prices. However, there exists a negative relationship between the two and this seems highly inappropriate. Bonds actually pay a certain amount of money over a period of time till the bond matures (Ken, 2008). To understand the inverse relationship between the two, let us consider the zero-coupon bonds which give no coupons but their value is determined by the difference in the value at the time of purchase to the time of maturity (Ken, 2008). As bonds provide a set interest over them, when the interest rates of the market increase from the set interest on the bond, the value of the bond has to be decreased to such an extent that the yield becomes equal to the market interest rate. For

Ethical Issue Essay Example | Topics and Well Written Essays - 1000 words

Ethical Issue - Essay Example astically, or placing heavy import duties on raw materials essential for a company to prosper, the public looks at ways to save themselves and their insecurities, and the way to do that is to elevate corruption, thereby, the government is being held responsible for this atrocity(Eiras, 2003). The author has also used some of her own secondary research in the form of comparative qualitative charts, a couple of which are as follows: Dr. Dragoljub Kavran and Dr. Sherman M. Wyman, spokespersons for the UNO have raised superb questions about the issue at hand. The authors state that corruption is above even the harshest levels in many developing and under developed economies; mostly, the authors blame the poor political and legal systems for these circumstances, the author also blames politicians who use their own laws for personal benefits rather than those of the populace. This issue has reached far out of hand and even some of the most developed economies such as the UAE and the US face diminutive levels of corruption. Within this 20 page whitepaper, the authors have raised the issue of ‘patience’, or in this particular situation: The wait-and-watch experimentation scenario. The authors believe the within such weak economic conditions, corruption may also be seen as a way to overcome several problems faced by the economies within under developed countries, but this is a commonly rejected principle and the fact still persists which looks at corruption as an evil element. (Kavran, et al., N.D.) Even though this article is inclusive of rich content about the public service organization Ethics resource center, this also includes the chief ethical issues about the corruption problem within Dubai. The chief ethical issue is ‘ignorance’, â€Å"If you are a deputy minister you dont it see as a problem to purchase from a dealer that could be your cousin† (Stier, 2007), this context from the authors article explains it all, the politicians must understand their

The Use of Women Suicide Bombers Essay Example | Topics and Well Written Essays - 1500 words

The Use of Women Suicide Bombers - Essay Example This gift of life is to cherish not to be thrown away as Islam strictly forbids suicide and killing of innocent people. We must dedicate our lives to please Allah, and to also be kind and generous to our fellow human beings, rather than hurting a single soul, including ours. Human kind is created to revive and perpetuate life and preserve it in its best form. In one verse of the Koran Allah informs mankind, "And I (Allah) created not the jinn and mankind except that they should worship; Me (Alone)" (Surah Adh-Dhariyat Verse 56)  Ã‚  (Adedimeji, 2011). From this verse, it is evident that the purpose of our life is to worship God, and to live and let live. It is emphasized plenty of times in the Holy Koran, Ahadeeth (Traditions, teachings and Sayings of the Prophet Muhammad (Peace be upon him) and the Shariah (Islamic Law and Muslim way of living), that by transgressing the righteous path and the limits and boundaries set by God. Such kind of willful disobedience will only bring abou t displeasure and wrath of God.  These people will have to face the deadliest of punishments predestined for those who go astray and misled by the evil forces. These forces only believe in destruction, which is surely against the teachings and beliefs of Islam, which is a religion of Peace and Prosperity, not blood-shed and deadly war. There are a few very specific punishments expressed in the Koran against self-destruction. The Prophet Muhammad (SAW) also assigns suicide to the lower most levels of Hell. Allah says explicitly in the Koran, "And do not kill yourselves. Surely, Allah is Most Merciful to you" (Surah An-Nisa Verse 29) (Abdul-Rahman, 2009). In another verse of the Quraan, Allah says: "And do not throw yourselves into destruction" (Surah Al-Baqarah Verse 195) (Kotob, n.d.). The use of women for the purposes of self-sacrifice is new

RESEARCH CRITIQUE Paper Example | Topics and Well Written Essays - 1500 words

CRITIQUE - Research Paper Example oned in the article is not the lack of hourly rounding taking place; in fact it is that as the staff shortage has worsened over the years, the patient satisfaction had decreased which causes hindrance in the patient outcomes. The author identifies the significance of the problem as he mentions the detailed study about the change in the hourly rounding pattern in nursing and how it affects the patients and the whole system. The background information provided by the author supports the problem fully as he explains why the patient satisfaction rates fell, how they could be improved and what role does hourly rounding play. The purpose of the study is to work out the challenges faced by nurses every day and to improve the patient satisfactory level. The authors used previous researchers and their articles to support the current analysis and changing trends. The references that were used from the past 10 years were Meade and co-authors (2006), Krauss and co-authors (2005), Amador and Loera (2007) and Olive and co-authors (2006). The references used from the last 5 years are Culley (2008), Assi, Wilson, Bodino, Bognar and Lemenski (2008), Healy, Oliver, Milne, and Connelly (2008), Coussement and co-authors (2008) and Roszell, Jones and Lynn (2009). The authors suggest that future qualitative research should be done focusing on discharged patients’ perceptions about how nurses treated them during their hospitalization. The study is based on a theoretical framework discussing the many kinds of variables that need to be considered. The studies analyzed discuss the various views and methods used to implement the hourly rounding. The overall article shows a theoretical perspective of why the hourly rounding is needed, is significant, is effective, improves the patient satisfaction, and how it should be managed to ensure the future results are effective too. The research hypotheses are the use of hourly rounding in the nursing profession to improve the quality of services

The Adventure of the Sperm and Egg Essay Example for Free

The Adventure of the Sperm and Egg Essay Let me introduce myself, I am Penny the Egg and today I will embark on one of the most exciting times in my life span. This has been a long expedition and now that I have reached the infundibulum, this is the outer portion of a female fallopian tube. The name I was in the medical word is â€Å"Ova†, most people just call me egg but my name again is Penny. I have been in contact with a germ cell named Seymour. His medical name is sperm and he lives inside the male human body. Seymour and I have been dreaming about this adventure for our whole lives. I am hope everything goes as planned and Seymour and I get to meet. After we meet, we will become one to create another male or female embryo which will grow into a human baby. As the â€Å"Great Change† occurs, medically that would be puberty for a female; I was one of 2 million ova that once lived inside the female. After the great change there are around 400,000 of my sisters and I left. We all live inside the follicle; these are thin capsules inside the ovaries. Out of the 400,000 of us that survived the great change, only 400 or so of us will reach fulfillment and become a ripened ova (Nevid, Rathus Fichner-Rathus, 2011). When I have ripened to fulfillment I will leave the safety of the ovary where I spent my childhood, I have made my way to where I am now, the fallopian tube. This is where I will wait for Seymour to arrive. It takes me some time to travel down the fallopian tube, and during this time is when my female host will ovulate, and then two weeks later my host will menstruate unless Seymour and I create life. The length of my travel is around 4 inches, but I must travel different parts of the tube in order to be totally ready to meet Seymour. As I travel the fallopian tube, I will come a crossed various small groups who call themselves Cilia. The Cilia groups have miniature hair-like projections that help me along my travels’. I could not make it an inch a day without the help of the Cilia. I dream about Seymour and our meeting day and worry that my female host will not allow me to be discharged with her menstruation. I have now been in the fallopian tube for just over a day now and I pray that Seymour is skillful enough to make it in enough time to help me create life. If Seymour does not arrive within two day of my leaving the ovary, I will not be here to meet him and no life will be created (Nevid, Rathus Fichner-Rathus, 2011). I am the type of egg to worry all the time, I wonder if Seymour’s trip is going according to plan? I just hope Seymour is strong and fast enough to out swim his brother’s taking this adventure also. Hello everyone my name is Seymour the sperm, I ‘m sure by now you know Penny and I am sure she told you I have millions of brothers’. Honestly, I cannot wait to take that adventure because it is too crowded and very uncomfortable for me in here. I just hope I am strong enough and can survive the adventure, why worry? You ask, because many of us do not survive and it can be a very fatal because it is a false adventure, but I know that to keep life going I must swim as fast and hard as I can to meet my Penny. My Life began in a place in the male host body called the testicles. This is where I went through a 72 days process of spermatogenesis. In order for me to meet Penny inside her female host, I had to endure this process. I have been told that Penny only holds the X chromosome (female), and I contain a Y chromosome (male) and the X chromosome. Once Penny and I meet our sex chromosome will connect and I have one of the most important jobs at this point I will decide if Penny and I will create the life of a male or female, because I alone can make I male with the Y chromosome (Nevid, Rathus Fichner-Rathus, 2011). After my preparation for my adventure, I make my way to the epididymis while in this transition, I continue to mature. It will take a few more weeks for me to be able to move to the Vans Deferens tube of my male host. I will continue my adventure to meet my Penny by making my way into the seminal vesicle; this is where I get all my nourishment from seminal fluid rich in fructose. The nutrition I receive from the fructose in the seminal fluids is what will make me strong enough to out swim my brothers’ to meet Penny. I have discovered I look a lot like a tadpole. I have a tail that whips back and forth to move me forward. Before I matured to this â€Å"tadpole† stage my movements were conducted by the contractions in the epididymis, Vans, Deferens, and just like Penny, I also had help from groups of cilia (Nevid, Rathus Fichner-Rathus, 2011). As the prostate and Cowper’s are making secretions, I continue my adventure. The secretions the other organs are making are what my brothers’ and I will mix with in the ejaculation proses. Yes, I made it to the point I am ready to be ejected from the male’s penis darning sexual intercourse. Once this happens I can begin a whole other adventure to meet Penny in the fallopian tube of her female host. My male host has ejected me and my brothers from his body to Penny’s female host. I must move faster than I have ever moved before. Millions of my brother s are trying to get to my Penny also and will race through the cervical canal, onto the uterus, we will continue to battle to be the first one to successfully reach an ovum (Penny) waiting just outside the opening to the fallopian tube. I did it! I was the first one to reach the ovum and penetrate Penny’s hard outer lining. Even thou many of my brothers’ might find her, once I am inside the lining Penny will go through a chemical change that will insure we become an embryo. We will travel together down the rest of the fallopian tube so we can implant ourselves into the uterus until birth as a human .

Nursing Care Plan Assessment Health And Social Care Essay

Nursing Care Plan Assessment Health And Social Care Essay Gastroesophageal reflux is also referred to as GERD. It is caused by your esophagus becoming agitated by acidic substances coming from the stomach. It is a condition in which the stomach contents leak backwards from the stomach into the esophagus (referred to as reflux) which can cause inflammation and damage to the lining of the esophagus. This action can irritate the esophagus, causing heartburn as well as other symptoms. GERD is associated with failure of the lower esophageal sphincter to properly close. The outcome is reflux of acid into the unprotected lining of the esophagus which can be uncomfortable and painful to the patient. The pathophysiology of GERD indicates that the inner lining of the esophagus does not have the protection that is found in the stomach and therefore the acid could cause harm to the esophagus. The signs and symptoms a patient experiences are caused by the contact of unprotected lining of the tissue (esophageal) to acid. GERD is a chronic condition, once a patient has experienced the onset most likely they will deal with it the rest of their life. One major symptom experienced is acid reflux and heartburn,indigestion lasting up to two hours however; these two symptoms alone are not sole indicators of the diagnosis. GERD may also manifest as chest pain, tightness of the throat, difficulty swallowing, regurgitation, dysphagia, dry cough and a persistent cough. Other symptoms include feeling that food may be trapped behind breastbone, hiccups, regurgitation of food, and nausea after eating, and hoarseness in the voice. 3. Clinical manifestation from text: Gastroesophageal reflux occurs when food is passed from the pharynx into the esophagus (located behind the posterior trachea) by a peristalsis which is a propelling motion. The food is then carried from the esophagus to the stomach where acid production is created. What occurs next is that the esophagus produces bicarbonate and mucus that will from a protective barrier. This process creates a higher pH that the stomach. If the sphincter muscle does not close well, liquid, food and stomach acid can leak backward into the esophagus. The esophagus is divided into an upper and lower sphincter. The upper prevents air from entering during respirations and will open when food needs to pass. The lower sphincter opens while food is being passed to the stomach (i.e. LES). When the esophagus is in a healthy state, there are three mechanisms that keep acid out while swallowing. They include the following: Swallowed saliva which helps neutralize stomach acid. Next, sweeping muscles contractions w here the motion cleanses the lower esophagus stomach acid. Some main contributing factors that interfere with the LES working properly is obesity, pregnancy and asthma. Excess weight actually puts extra pressure on the diaphragm and stomach. In pregnancy the pressure on the stomach has a higher level of progesterone hormone which in turn relaxes the LES muscle as well as other muscle groups. It is unclear as to why asthma is a contributing factor to interference of the LES mechanisms but it is believed that coughing may lead to the pressure changes on the diaphragm. Some identified risk factors for reflux include hiatus hernia. This is a condition in which part of the stomach moves above the diaphragm (muscle separating the chest and abdominal cavities). Medications may cause or worsen GERD symptoms. They include the following medications: Anticholinergics, Beta-blockers (high blood pressure meds), Bronchodilators (asthma), Calcium channel blockers (BP medication), Dopamine-active d rug for Parkinsons disease, Progestin for abnormal menstrual bleeding, Sedatives used for insomnia or anxiety and finally Tricyclic antidepressants. . 4. Diagnostic Evaluation from text: 1. Review of History Obtain a detailed inquiry about the patients normal pattern of diet, and any other symptoms the patient may be experiencing. This is also a good time to question if they are taking any OTC medications. It is important to assess the duration of the problem. Next ask how long the patient has been experiencing reflux which will provide useful causative information. Determine what foods the patient is consuming, if they exercise, how much fluid intake daily, and most importantly if they are smoking -which inhibits saliva and may also increase acid production and weaken the LES. Certain exercise and bending may increase the abdominal pressure. Also wearing tight clothing (increase abdominal pressure) or lying flat after a meal may relax the muscles causing reflux. Ask about the patients diet and educate them on foods to avoid. For example, foods high in fat and greasy take longer to digest. Chocolate, peppermint, spearmint, weaken the LES. In addition, Carbonated and alcoholic beverages i ncrease the acidity in the stomach. Warn patient to consume smaller meal because large meals produce large acid levels. Other foods to avoid are citrus, onions and tomatoes. In general, all foods which contain a high acidic level may be irritating to the esophagus. Document any abnormal findings in patient record or MAR. Question the patients family history of disease and initial onset or exacerbation of episode. Finally, the evaluation should include the patients description of sensation of the symptoms. 2. Laboratory /Diagnostic Tests The most commonly used diagnostic tests include the following lab tests:-esophageal pH monitoring, esophageal manometry, the acid perfusion (Bernstein) test and the gastric analysis. A barium swallow and a Radionuclide scintigraphy may also be ordered by the MD. Specialty Lab tests CDSA 2.0 with parasitology, Detoxification Profile, Standard and Menopause Profile. Diagnostic tests use to diagnose GERD include: Barium swallow, Endoscopy, Esophageal motility studies, ambulatory pH monitoring and Esophageal manometry. 5. Therapeutic Management from text: Although GERD can be treated in several different ways most physicians will recommend antacids and changing the diet to a healthier one. Other methods of treatment include alternative medicines such as acupuncture and herbal tonics which promote proper function to the lower esophageal sphincter and acid production of the stomach. If recommended by a physician, surgery is an option for those with serious complication. The most common surgery is the Nissen Fundoplication. This surgery involves wrapping the fundus of the stomach around the lower esophagus and sutures the fundus to itself. Available therapies include a combination of the following types of medication: Benzodiazepines, Theophylline, and Narcotics containing codeine, Calcium channel blockers, Nitroglycerine, Anticholinergics, Potassium supplements, Iron supplements, NSAIDS, Fosamax, and Erythromycin. Patient Education: We want to educate the patient on how to prevent future flair ups. Because foods play an important role w e will educate the patient to avoid: chocolate, alcohol, caffeine, citrus fruits and vegetables, spicy or fatty foods, full fat dairy products, peppermint and spearmint Gastroesophageal Reflux Disease. PubMed. Retrieved February 2011, from www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001311/. Other preventative measures we can encourage pts to do is to avoid bending over after eating and avoid tight fitting waist bands on clothing. Also instruct pt not to lie down with a full stomach. It is extremely important to encourage them not to smoke and if they are smokers educate them on smoking cessation. If a patient is overweight, encourage an exercise regimen designed and individualized specifically for the pt. Weight loss and eating smaller meals in key to their diet change. Also have patient refrain from eating 3 hours after bedtime and stay upright position two hours after each meal. Inform the patient that the head of the bed must be raised approximately 6 inches. It is important to let pt know about OTC and presription options. Some medications available are Proton pump inhibitors which are the most potent acid inhibitors. Prilosec, Prevacid, Zantac, Tigamet and Protonix Common Nursing Diagnosis and Interventions: Altered Nutrition: less than body requirements R/T vomiting: Educate patient on importance of eating healthy and increasing caloric intake as necessary. Nausea R/T gastric irritation food AEB vomiting after meals: Dietary changes to decrease frequency of nausea Risk for Aspiration: Assist in correcting factors that can lead to aspiration Deficit Fluid Volume: Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. Assess V/S respirations, (temp pulse may be elevated). Note change in functional behavior (i.e. confusion, falling, lethargy, dizziness). PRIORTIZED FHP ASSESSMENT: Activity/Exercise Subjective: My energy level is very low recently and I dont exercise very often. Patient reports that she only exercise she gets lately is, while I am working on my hobbies, not much walking mostly standing, Patient denies any chest pain but does experience a shortness of breath upon exertion. Patient admits that she lives a very sedentary lifestyle. Patient states she is totally independent with activities of daily living ADLs and has no difficulty performing usual ADLs. Patient states her leisure activities include: taking photos and enjoying my art work of painting. Patient does not use any assisted devices for walking and does not exercise daily. Objective: 1.Patient has no VTE risk factors and can ambulate fully and independently with daily ADLs. No fall risk identified and pt reports she does not do any physical activity such as exercising while at home. Diet: Patient is on NPO for stress test ordered today. Abdomen is soft, non distended, and non tender, bowel sounds are present in all four quadrants. Patient activity order is full ambulation, full weight bearing and activity. Impairments include decreased mobility and experiences SOB on excretion. Energy level is described good but easily fatigued with high level of exertion 2. Hygiene: fully independent-sponge washed independently. Respiratory data indicates no SOB while speaking, patient able to carry long conversations without difficulty. MD ordered continuous O2 via nasal cannula; no fall precautions were ordered. Upon auscultation of lung sounds anterior and posterior were auscultated, on auscultation lung sounds clear bilaterally. Chest is non tender to the touch. R espiratory: No cough, no dyspnea noted (O2 2liters). Alert and oriented. Assessment Cardio Vascular: Regular rate rhythm, no chest pain, no palpations, pt denies SOB at resting; Chest: Lungs Clear bilaterally; Cardiac auscultation indicates regular rhythm, no murmurs, P 68. BP 154/84. RR 18, O2 SAT 94% on O2 2 liter via nasal cannula, T 97.1 (orally). Radial pulse is palpable on both sides, strong and equal bilaterally. Abdomen: bowel sounds present, soft, non distended, non tender upon palpation. Pt denies any pain in abdomen. ROM (active/passive) assessment revealed no signs of pain (0/0 pain scale) on when force applied during passive range of motion. Muscle strength RUE 5/5 and LUE 5/5 RLE 5/5 and LLE 5/5. Although no weakness noted in upper and lower extremities, patient states that stressing her muscles for a long period of time increases her fatigue. CSM: Color pink and even, full sensation and patient able to wiggle toes without difficulty. TEMP: warm to the touch. A Capillary refill test done on UE indicates normal blood return (less than 3 second return). Medications ordered: Acetaminophen 650 mg PO every 4 hours, Aspirin enteric coated 81 mg PO daily, Atorvastatin PO 10 QHS, Maalox-Alumina, Magnesia, S PRN PO every 6 hours, Pantoprazole 40mg PO twice daily, Metoprolol Tartate PO 25 mg twice daily, Ibuprofen PO 400mg ever 6 hours and Bactrim DS PO 1 tab twice daily. Nursing Diagnosis: Impaired physical mobility related to SOB with intense activity and inability to move purposefully within the environment. Outcome: Pt will verbalize understanding of importance of exercise activity to increase abdominal muscle strength to strengthen muscle groups and increase breathing ability. Cognition/Perceptual Subjective: Patient states, I was awoken by chest pain that went to the back of my jawà ¢Ã¢â€š ¬Ã‚ ¦I had very spicy food for dinner and thought it was heartburn or my GERD acting up Patient recalls why she was admitted to hospital, I got up and thought it would be best for my husband to bring me to the ER. At first I thought it was the usual reflux pain but it ended up getting a lot worse. Objective: Patient alert and oriented x3, speech is clear with no slur or stutter. Pt has no difficulty expressing ideas and feelings clearly and concisely. Patient is well oriented to place and time is and shows no signs of confusion or disorientation. Pt appears comfortable and verbalizes she does not currently have any level of pain. Patient PMH: Esophageal ulcers, High Cholesterol, high blood pressure, Fibromyalgia, Ulcers in esophagus,? MRSA in left leg when pt had cellulites in the past. Nursing Diagnosis: Sedentary lifestyle related to shortness of breath during activities AEB pt weight gain. Outcome: Patient will have full understanding of importance of increase activity and importance of low fat diet. Nutrition Metabolic Subjective: Patient Diet: on NPO due to scheduled Stress Test. Patient states that prior to patient being hospitalized she was totally dependent with feeding herself and states, I usually only eat lunch and dinner and usually skip breakfast. I love food so I pretty much eat anything. Patient reports burning in esophagus and can feel acid coming up in the past and take OTC drugs to control if necessary. Objective: Pt on NPO diet, no deficits noted, patient over weight (wt 211.6 lbs). Patient complains of not eating the right foods daily. Encouraged patient to increase fluids to 2,000 mLs everyday and choose beverages low in calorie (i.e. diet soda and water). Assessment of integumentary skin: no rashes, no lesions or broken skin or erythemia noted one bruise on left lower extremity. No fever, no chills, no sore throat. Gastro: the pt has history of GERD and esophageal ulcers. Genitourinary: no hematuria, no dysuria, no frequency, no urgency. Encourage a well balanced diet, and adequate fluid intake to promote peristalsis. Edema test done to ankles (no trace or pitting edema noted =normal). Nursing Diagnosis: Risk for deficient fluid volume related to inefficient H2O intake as evidenced by complaints of dry mouth and pt verbal cues. Outcome: Patient will increase fluid intake to 2,000 mLs to increase hydration prior to discharge. Coping and Stress Subjective: I want to get better and know that I need to work on my diet and make changes in my lifestyle. Patient states that she only slept a total of 5 hours. Objective: Pt denies and feeling of depression and is happy in home life with husband. Patients EMR indicated that her behavior was cooperative. Patient verbally expressed appreciation and gratitude when educating her on some relaxation techniques (i.e. deep meditative breathing). Nursing Diagnosis: Readiness for enhanced Outcome: Pt to demonstrate relaxation techniques prior to discharge. Health Perception/ Health Management Subjective: I try to take care of all my health needs but I dont always feel good about my food choices. I know that if I dont start watching my weight, I am going to get diabetes. Patient indicated that he regularly follows up with his PCP and dentist and all medical appointments as necessary. Objective: Pt is alert and oriented, has overall good hygiene and likes to be well groomed. She shows ability to perform activities of daily living (ADLs) independently and was very cooperative, allowing me to take V/S and examine her feet which soft, pink and adequately maintained. Patient demonstrates full independence with hygiene activities such as bathing; dressing and toileting require no assistance. General foot appearance of patient is good, with her nails trimmed, hair is maintained. Patient wanted to wash her hair which indicates a healthy perception of hygiene and was appreciative when given a shampoo cap to use. Admission Labs: HGB:13.2 g/dL, HCT: 41.1%, WBC: 13.7 (elevated), RBC: 4.87, MCH: 27.0, MCV 84.4, MXHX 32.0, RDW 14.0, Plt count 211, MPV 7.5l , Neutrophils 70, Lymphocytes 26, Atypical Lymphs 14, Monocytes 1L, Eosinophils 3, Absolute neutrophil 4.5, Lymphocytes 8.3 (high), Monocytes 0.4, Eosinophils 0.2, Basophils 0.2, Platelet estimate adequate. Admission V/S BP 143/74, (T)97.8 orally, (P)69, R:19, SaO2 (96% on RA). Nursing Diagnosis: Readiness for enhanced therapeutic regimen Outcome: Patient will maintain responsibility for planning and achieving self care goals Self Perception/Self Concept Subjective: I am aware when I need medical attention and will get medical treatment and see my doctor when necessary. Patient expressed that she always follows up with her healthcare needs and does not ignore signs and symptoms of being ill. Objective: Pt exhibits positive self esteem and currently has no worries in life except the possibility of developing diabetes because of her weight gain. When I questioned her about her knowledge of the disease she stated that she knew it was a disease that occurred when people were overweight and ate junk food. She indicates a strong determination when discussing the willingness to change her eating habits and developing a healthier lifestyle (i.e. walking more and being more active). She shows some indications of embarrassment for letting herself gain weight over the years. Nursing Diagnosis: Readiness for enhanced self care. Outcome: Patient will maintain responsibility for planning and achieving self care goals Elimination Subjective: I had a bowel movement this morning. Objective: Bowel habits: soft, formed. Medium, brown BM x1 every day. Bladder habits: voids x3 -5 times a day. Patient denies any burning, pain, urgency, or dribbling during urination. Patient also states that she does not usually have issues with having bowel movement. Prior to hospital admission patient denies taking any laxatives. Patient is able to independently toilet self. No abdominal distention noted upon palpation. Bowel Sound: present in all 4 quadrants. Nursing Diagnosis: Risk for constipation Outcome: Patient will have a regular BM once daily Roles/Relationships Subjective: I have a wonderful husband and one son. Patients participation in group social activities has been relatively healthy most of her life. I love my artwork and previously had a shop which has been closed for several years nowà ¢Ã¢â€š ¬Ã‚ ¦I thought was time to retire. Objective: Patient lives with husband and son frequently visits and she speaks very highly of them both. Patient appears to be overall in good spirits and satisfied with home life. Patient did not have any visitors but received phone calls from family members. Pt also made phone call on two occasions to check up on husband during my interview. Nursing Diagnosis: Risk of caregiver role strain. Outcome: Pt will be able to provide clues to potential stressors and possible supportive interventions before discharge. Sleep Rest Subjective: Pt complains of sleep deprivation last night, I just couldnt fall asleep, probably because Im not in my own bed. I think I only slept a total of 4 hours. Objective: Patient complains that she sometimes does not sleep at night and her MAR indicates poor sleep habits. Pt could benefit with sleep aid to help her sleep through the night. Pt complains of pain and discomfort while trying to sleep (Fibromyalgiaà ¢Ã¢â€š ¬Ã‚ ¦skin sometimes hurts). Patient describes sleep pattern at home usually only needing six hours of sleep daily. Patient denies taking any sleep aide medications while at home. Nursing Diagnosis: Risk of sleep deprivation related to bilateral lower extremity pain. Outcome: Patient to practice healthy sleep patterns while in hospital within 1 day. Value Belief Subjective: I go to church, but not as often as I use to especially in the cold Objective: Pt declined discussing spirituality and value system. Sexuality Subjective: I dont see how these questions relate to my health. Objective: Pt declined to discuss this topic with me during the interview. Nursing Care Plan Nursing Diagnosis: Sedentary lifestyle R/T lack of training for accomplishment of physical exercise AEB by patient verbal cues and demonstrating physical deconditioning. Goal: Patient will verbally understand the importance of regular exercise to general well being by discharge. INTERVENTIONS SCIENTIFIC RATIONALE 1. Abdomen inspection, auscultation, percussion, palpation and measurement of abdominal girth. 1. Will provide objective data on the patients bowel elimination status. (Craven 1126) 2. Encourage daily exercise regimen 2. Will provide education on importance of maintaining a healthy lifestyle. 3. Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. 3.Will assist in peristalsis and segmentation of stool Patients, (Craven 1122) 4. Encourage increased activity and patient to exercise or increase daily activity. 4. Ambulation and/or abdominal exercises strengthen abdominal muscles help facilitate defecation and will help increase peristalsis. (http://www.mayoclinic.com/health) 5. Position bed in lowest position, with side rails up 5. Low position of bed minimizes distance to the floor so if client falls, side rails maintain patient safety (Craven, 675) 6. Place client call light within reach and explain the call system as assess the ability to use it. 6. A call light allows the patient to call for help if needed (Craven, 675). 7. Promote normal bowel health Assess usual pattern of elimination; compare with present pattern. Include size, frequency, color, and quality. 7. Normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is normal for each individual. (Craven, p. 1117) 8. Encourage a regular time for elimination. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the persons usual schedule, any regular time is fine. 8. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the persons usual schedule, any time, as long as it is regular, is fine. (Craven, 1117) 9. Assess orthostatic hypotension before taking the client OOB to chair, if any signs of dizziness or lightheadedness. 9. Rationale: allows nurse to be aware of orthostatic hypotension upon standing which may result in a fall. (Craven, 457) 10. Place patient call light with reach, and explain the system and assess the ability to use it 10. Promotes safety and decreases stress for patient allows pt to call for help If needs assistance to toilet after given stool softener or enema. (Craven 675)