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Barbara Bush heart failure

Barbara Bush heart failure


Barbara Bush served as the First Lady of the United States (US) between 1989 and 1993. She was the wife of George Bush, the 41st President of the US. Before her role as the first lady, she was the Second Lady between 1981 and 1989. Moreover, among her children are Jeb and George Bush, who served as governor of Florida and the 43rd President respectively. Regarding her medical history, in 1988, Barbara was diagnosed with Graves’ disease. The disease, also referred to as toxic diffuse goiter, is an autoimmune condition that affects the thyroid and is the leading cause of hyperthyroidism.

Years later, she was diagnosed with chronic obstructive pulmonary disease and congestive heart failure. Her caregivers expressed that her 25 years as a smoker may have played a key role as the cause of the two conditions. She quit the habit in 1968. Also, in 2008, she was hospitalized due to abdominal pain, and as a consequence, she underwent surgery on the small intestine. In 2009, she underwent surgery for aortic valve replacement, and she was treated for pneumonia in 2013. On April 15th of this year, their family spokesman released a statement on Barbara’s failing health and that she had chosen to stay at home for palliative care. She died on 17th April 2018 at the age of 92.

Heart failure refers to a pathophysiologic condition whereby the heart is unable to pump blood at a rate that meets the metabolic needs of tissues. The heart can only pump blood adequately to tissues by elevating the diastolic filling pressure. The condition results from an abnormality in cardiac function, which may or may not be detectable. Also noteworthy is the fact that heart failure can also occur when the cardiac function is near-normal but under conditions of increased demand (Morton et al., 2017). To preserve the heart’s pumping function, various compensatory mechanisms are initiated in the cardiovascular system. These mechanisms include increased cardiac filling pressure, blood volume, cardiac muscle mass and the heart rate. However, these mechanisms only serve to increase metabolic demands of the myocardium, which, over time leads to worsening of the condition (Jurgens et al., 2015). Most importantly, over time,there is remodeling of the myocytes and the myocardium which leads to their increase in mass and volume. The remodeling leads to increased oxygen demand, ischemia, and impaired contractility.

The clinical manifestations of heart failure include exertional dyspnea which refers to breathlessness after mild activity. In the early stages of heart failure, the breathlessness may appear to be normal since it occurs during strenuous activity. However, as the condition progresses, dyspnea manifests even with ordinary activity (Morton et al., 2017). Moreover, another manifestation is orthopnea, which is shortness of breath that happens when one lies flat and is only relieved when the head is propped up using pillows or when the individual changes posture to a sitting position. The patient may also present with jugular venous distension, pulmonary edema, and palpitations. The patient may also be frail with a feeling of heaviness in the limbs which is attributed to poor perfusion of the individual’s skeletal muscles. Other clinical manifestations include peripheral cyanosis, ascites, and peripheral edema as well as cerebral symptoms like confusion, nightmares, memory impairment and headaches.


Historically, Thomas Lewissimply described heart failure as a state where the heart fails to release its contents. He was also the first person to attribute smoking to myocardial infarction and heart failure after he suffered both due to his 70 cigarettes-a-day smoking habit. It was in 1950 that Paul Wood modified the definition to include failure of the heart to maintain sufficient circulation for the body’s needs. Later on, it was discovered that the manifestations were a bit different for various patients. Research revealed that heart failure might be predominantly right-sided or left-sided. The predominant signs of right-sided failure include congestive hepatomegaly, ascites, and anasarca (Jurgens et al., 2015). These were due to increased pressure on the rightside of the heart that is transmitted back into the portal venous circulation. This manifests as an increase in abdominal girth as well as pain in the right upper and epigastric quadrants due to fluid accumulation. In essence, distinguishing hepatic failure from right-sided heart failure is often difficult. On the other hand, left-sided heart failure is mainly characterized by dyspnea due to cardiogenic pulmonary edema.

Some of the physiological stressors that may aggravate heart failure include underlying conditions like structural abnormalities of the heart and some medications (Morton et al., 2017). Moreover, infections and anemia can also worsen the symptoms. In chronic heart failure, the reduction in cardiac output results in some physiological compensation mechanisms to maintain blood supply to the tissues.

The first mechanism is a reduction in arterial pressure. This is as a result of an increase in sympathetic activity due to the release of catecholamines in the blood. The result is vasoconstriction, which serves to restore the blood pressure. However, there is a concomitant increase in peripheral resistance, which increases the workload on the heart. The heart has to increase contractility leading to more metabolic demand from the myocardium. The increased sympathetic activity also stimulates the release of vasopressin that promotes fluid retention at the kidneys to increase the blood volume and, in turn, pressure. The second mechanism involves the release of renin, angiotensin, and aldosterone due to under-perfusion of the kidneys. As a result, there is salt and water retention leading to edema in the extremities. Under-perfusion of skeletal muscles leads to muscle atrophy, weakness and exercise intolerance. The third mechanism involves myocardial remodeling in the long term due to a chronic elevation in levels of circulating catecholamines, aldosterone, renin and angiotensin. There is hypertrophy in the myocardium to enable the heart to overcome the increased preload and pump blood to tissues (Jurgens et al., 2015). However, in the long run, the compensatory mechanisms worsen heart failure as the demands of the heart also increase as the compensatory mechanisms take effect.

Patient care technologies have made it easier to assess, diagnose and manage the condition in the early stages thus leading to a reduction in morbidity and mortality (Morton et al., 2017). In monitoring and management of heart failure, simple tools such as catheters as well as complex equipment such as the electrocardiogram, X-ray machine, angiography imaging equipment and pulse oximeters are used. Also, monitoring of metrics such as B-type natriuretic peptide levels has historically been an essential part of care.


The short-term goals of heart failure management involve relieving symptoms like shortness of breath, peripheral edema and decreased exercise tolerance. Moreover, another short-term goal is to improve functional capacity which is essential in improving the quality of life for the patient (Jurgens et al., 2015). On the other hand, long-term goals include reducing mortality as well as slowing or retarding the structural abnormalities attributable to heart failure.

Nursing concerns in heart failure span a wide range of roles from initial patient assessment to monitoring and management. In the initial patient triage, the nurse practitioner is charged with eliciting the patient history, assessing the severity of the patient’s health status (Benhase et al., 2018). The nurse practitioner is normally trained to perform clinical assessment which helps them identify clinical manifestations of heart failure such as signs of congestion. The patient can then be referred for chest X-ray. Also, identifying the clinical stability of the patient during triage enables the nurse practitioner to promptly determine and transfer the patient to the appropriate level of care. This ensures the patient’s safety as well as effective therapy. The assessment may include objective determination of the severity of dyspnea by checking the respiratory rate, tolerance when lying down, oxygen saturation and use of the dyspnea severity scale. Additionally, the hemodynamic status, heart rhythm and cardiac output of the patient are essential. Also, s/he can check for jugular venous pressure, peripheral edema and pulmonary rales (Benhase et al., 2018). Laboratory blood tests, as well as the determination of anxiety levels using an objective assessment tool, is also part of the initial triage. Patient care technologies may include the electrocardiogram to assess heart function, ultrasound for echocardiography and angiography to determine underlying problems in blood vessels.


Nursing interventions may involve administering and monitoring treatment, patient education and assessment of changes in clinical status. With relation to activity intolerance, the nurse must check for vital signs prior and after activity. An electrocardiogram is invaluable in monitoring. The rationale is that during activity, orthostatic hypotension may occur due to compromised cardiac function. The nurse must also document the patient’s response to exercise and look out for symptoms such as tachycardia, dysrhythmias, and pallor (Benhase et al., 2018). The nurse should assist with self-care activities and range of motion exercises. As for edema, the nurse should monitor patient’s urine output and check for frequency and color of urine. Low output of concentrated urine may be a result of low renal perfusion. Devices such as catheters are useful in monitoring, but proper care is necessary to prevent urinary tract infections. S/he should also monitor fluid intake and establish schedules so that the patient can adhere to restrictions. The nurse could also auscultate for breath sounds and look out for adventitious sounds. The nurse will also administer medications as necessary. The mainstay for edema management is diuretic therapy with agents such as furosemide and spironolactone (Mebazaa et al., 2015). Potassium supplements may be added to the regimen in case there are significant potassium losses.

In case of decreased cardiac output, the nurse should monitor apical pulse, note heart sounds, palpate for peripheral pulses as well as monitor blood pressure. Medications may include vasodilators like nitrates, hydralazine, and prazosin. Vasodilators are essential components in heart failure treatment as they reduce ventricular workload through a reduction in circulating volume as well as systemic ventricular resistance. Also, angiotensin-converting enzyme inhibitors like enalapril and lisinopril; as well as angiotensin II receptor antagonists like irbesartan and valsartan aid in increasing cardiac output andreducing the blood and ventricular filling pressures (Mebazaa et al., 2015). Moreover, digoxin and inotropic agents like milrinone are effective in short-term cases unresponsive to other classes of drugs. Inotropic agents promote vasodilation and enhance myocardial contractility. Anticoagulants can be employed prophylactically to prevent blood clots. The nurse can also improve gas exchange by suction of secretions when necessary, elevating the position of the head and monitoring for cyanosis (Jurgens et al., 2015). Pulse oximetry may be used to identify reduced oxygenation.

Patient education is also important. Education on matters such as weight loss, monitoring of sodium intake to less than 2 grams per day and fluid restrictions to less than 2 liters daily may assist in the management of heart failure (Mebazaa et al., 2015). Also, modifying habits by ceasing smoking and alcohol consumption as well as exercising according to one’s capabilities are important.


Evaluation of the progress of improvement of symptoms and quality of life can be done through various ways. The nurse should consistently monitor the patient for any changes in signs and symptoms and inform the other members of the healthcare team on the progress. Additionally, s/he should identify any problems arising and offer recommendations based on the findings. The most important parameters for monitoring effectiveness of treatment include improvement of dyspnea, heart rhythm, cardiac output and the systolic and diastolic pressures (Benhase et al., 2018). It is important that the measurements for the parameters mentioned above are in line with the desired objectives that were determined after assessment of the patient. The blood pressure, heart rhythm and cardiac output are the parameters that bear the most weight when assessing the effectiveness of treatment.

The nurse can evaluate improvements in dyspnea by assessing the patient’s tolerance to different levels of activity. Moreover, to evaluate for fluid volume status of the patient, the nurse reviews the fluid intake and urine output and adjusts the consumption or medication to relieve edema accordingly. Additionally, the patient’s weight may be an indicator of the progress of treatment for ascites. Regarding long-term monitoring, monitoring of B-type natriuretic peptide level is essential. The nurse can also do home visits or admit the patient into a nursing care home (Mebazaa et al., 2015).



Nobel Prize 1995

Nobel Prize 1995


The Nobel Prize in the Physiology or Medicine category in 1995 involved threescientists, who identified, localized and classified a group of genes that were responsible for early development of the embryo of Drosophila melanogaster, the fruitfly. They determined that the group of genes influenced the body plan as well as segmentation of the body in the embryonic D. melanogaster. They preferred to use the fruitfly in their study due to its quick embryologic development.

Nüsslein-Volhard and Eric F. Wieschaus were working at the European Molecular Biology Laboratory in Heidelberg, Germany at the time they began their research in the late 1970s. They discovered that they had a common interest in researching on the embryonic development in D. melanogaster and the genes involved. On the other hand, Edward B. Lewis was doing independent research on the causes of mutations in the fruit fly. His focus was on the genes that cause the growth of an extra pair of wings which was the most common mutation. He began his research in the late 1970s and was working at the California Institute of Technology in Pasadena, California. He discovered that there is a group of genes that not only influenced the mutation that caused the duplication of wings but also created duplication of the body segments that supported the wings.

At the time Nüsslein-Volhard and Eric F. Wieschaus, very little was known concerning molecular and genetic mechanisms that influenced the development of multicellular organisms from a single cell into complex forms during the process of embryogenesis. There was no research on the influence of genetics on embryogenesis at the time. Most of what was known at the time on embryology and molecular biology was limited to the structure of the DNA after the helical structure was discovered in 1950. The alternative point of view came from the germ layer theory of development as proposed by Heinz Christian Pander and Karl Ernst von Baer.



Nüsslein-Volhard and Wieschaus began their research with the intention to find out how a segmented embryo developed from a newly fertilized egg. They chose the fruit fly due to its rapid development of nine days. Additionally, the fruit fly was easier to work with since it possesses only one set of genes that are involved in development;in comparison to human beings who have four sets. They first needed to identify and isolate the genes required for development. After this, they damaged the male flies’ DNA by “knocking out” one gene. The male fly was then used to breed generations of fruit flies without the specific gene that was knocked out. Through the method, they were able to isolate certain genes and their effects on the progeny. They performed their research on about 20,000 genes from the fruit fly. On the other hand, Lewis wanted to find out the reasons that cause duplication in wing development. He researched by mutating the embryos so that the resultant flies would have an extra pair of wings.

Their findings of Nüsslein-Volhard and Wieschaus included the fact that about 150 genes played an essential role in embryologic development. Moreover, out of the 150 genes, mutations in 15 of them would cause defects in the body segmentation. Through their findings, they were able to classify the genes. The first class of genes, the gap genes, influenced the body plan along the longitudinal axis from the head to the tail. Loss of these genes resulted in a reduced number of segments. The second class, pair-rule genes, had an influence on every second segment. Loss of this class of genes resulted in an embryo possessing only the odd-numbered body segments. The third class of genes, segment polarity genes, influenced the longitudinal polarity of each body segment.

Lewis found out that in flies that had an extra set of wings, the body segments bearing the wings were also duplicated. Additionally, he discovered that the duplication was caused by a family of genes referred to as bithorax-complex. These genes control the body segmentation along the head-tail axis. Moreover, the genes at the beginning of the complex influenced the development of an anterior segment while genes found towards the end influenced the development of posterior regions. These were the foundations of the colinearity principle. Furthermore, the genes in the complex overlapped, and if one was to knock out one gene, the genes next to it might influence the development of the region the affected gene was responsible for.

Figure 1. This image illustrates the defects from gene mutations. Adapted from

Figure 2. This image illustrates the colinearity principle. Adapted from



The impact of the discovery in medicine is that the genes that control the development of the embryo in D. melanogaster have their counterparts in more complex multicellular organisms like human beings. Therefore, the findings are relevant in applications that deal with the human genome as the counterpart genes also perform the same functions in embryonic development. The results are relevant in the study of the influence of genes on human birth defects. Moreover, the findings are relevant in the study of in vitro fertilization, the discovery of congenital birth defects and the effects of teratogenic substances during organogenesis. Furthermore, the research can help in the development of ways to treat individuals with a high propensity to have offspring with birth defects. The findings have been applied in the development of genetically-modified organisms that are more resistant to diseases and have higher yields such as chicken.

Rural and urban societies

Rural and urban societies

Rural and urban societies usually differ on different aspects. The rural and urban populations in developing societies and the United States of America (US) have some similarities in terms of population characteristics, economic activities and education. Urban populations usually differ from rural populations as a result of concentration of amenities and activities. For a long time, there has been a consistent migration from rural to urban areas as people go to search for better career prospects in the urban areas. This leads to a gap in distribution of wealth and resources between the rural and urban areas (Ogunnika, 2017). Consequently, political, economic and cultural activities are mainly concentrated in urban areas where most opportunities are. It is the role of governments to ensure equitable wealth distribution in both urban and rural areas


In terms of population and distribution, in both the US and developing societies, urban areas still have higher population numbers compared to rural areas. Moreover, the population distribution in urban areas is dense compared to scarce in the urban areas. The reasonsinclude the fact that many people relocate from the rural areas to urban areas in search of jobs, education and access to facilities which the rural areas may lack (Ogunnika, 2017). Urban areas present better opportunities for career and educational development due to the high number of active sectors of the economy in comparison to rural areas. However, in both the US and developing nations, the high population numbers in urban areas present issues like overcrowding, traffic jams and high crime rates (Strayer et al., 2013). Also, due to sparse settlements in the rural areas, their activity spaces are larger than those in urban settlements. Rural areas have more green areascompared to the extensive built-up areas in the urban areas.

Concerning economic activities, urban areas are highly industrialized hence there are many contributors to the economy. Urban areas have specialized industries like banking, information, and communication technology, and transport among many other sectors. Populations living in urban areas have attained higher levels of education and therefore prefer to seek jobs in areas where the opportunities for employment in the numerous companies and businesses exist. This means that the urban population is heterogeneous concerning the economic activities they engage in (Strayer et al., 2013). In contrast, most of the rural community engage in agriculture as the primary economic activity.

Moreover, other activities such as mining are also more prevalent in the rural areas. As a result, regarding economic activity, the rural populations are highly homogenous. Traditionally, economic growth from the rural areas has been slow, but the situation has been changing. In the recent past, some companies in the US have a preference for rural areas when setting up their factories and plants. These provide more employment opportunities and result in less rural-urban migration. The factories also offer the rural areas opportunity to expand through an increase in the number of businesses to serve the factory workers.

Urban populations also typically have higher incomes compared to counterparts in rural areas. Living standards in the urban areas is much higher than in the rural areas, thus the wages must be commensurate with living standards of the area one lives.In developing societies, most of the rural populations live in poverty (Ogunnika, 2017). Furthermore, a larger proportion of workers in urban areas are highly skilled compared to rural areas where the jobs require unskilled or semi-skilled personnel. As a result, urban populations have more disposable income, which leads to a lot of economic, political and cultural attention in these areas. Hence, social amenities such as schools and hospitals and infrastructure are well developed and maintained in the urban areas. The urban areas will therefore easily build an identity.

In contrast, rural populations normally have to travel for long distances to access some social amenities since they are not present within the rural centers. The net effect is that more business in the urban areas implies that their local authorities receive more revenue due to the high levels of productivity. In turn, urban areas will contribute more to the national economy compared to rural areas (Strayer et al., 2013). However, in recent times, as the rent and living standards continue to increase in the urban areas, more people are shifting to non-urban areas that are within commuting distances to urban areas commonly known as hinterlands. As a result, more businesses are moving into the hinterland to support the workers living in the areas. This may lead to development reaching the rural areas much faster.

Moreover, counter to popular belief, rural areas in the US have more entrepreneurial spirit compared to urban areas. Most start-ups begin in rural areas before they move to metropolitan areas after success. Most workers in rural areas are self-employed business proprietors. It is understandable since industries with salary jobs are scarce in the areas (Strayer et al., 2013). Also, the survival rate for start-ups in rural areas has consistently been higher than that of urban areas. This is despite the advantages that the urban areas enjoy in terms of denser networks of suppliers, workers and markets compared to rural areas. The higher survival rate for rural start-ups may be attributed to the more cautious business practices adopted by rural entrepreneurs. They have to be more cautious than their urban counterparts since they have fewer alternative options for employment. However, most start-ups in developing countries thrive in urban areas more than rural areas. In such societies, the higher purchasing power of urban populations is the key factor to success. Rural populations there have very low purchasing power and rely on subsistence farming for survival (Ogunnika, 2017). Urban entrepreneurs in both US and developing societies engage in risky ventures due to the cut-throat competition and availability of numerous businesses where they can seek employment in case the start-ups prove to be unsuccessful.

The role of governments in rural development is to support the local areas and make them more attractive to workers and businesses. Provision and maintenance of infrastructure are essential in ferrying people and goods to and from the rural areas. The increased accessibility thus opens up the areas to new opportunities. Also, amenities such as communication channels, schools, and hospitals are among key factors that attract people to any locality (Strayer et al., 2013). Availability of internet in the rural areas would attract entrepreneurs in areas such as information and communication technologies, whomainly prefer urban areas. Furthermore, supporting local entrepreneurs is essential through ways such as agricultural subsidies and marketing of the products for sale to other distant markets (Ogunnika, 2017). Moreover, supporting the local markets in rural areas is also helpful as most of the products in such markets are produced locally, in comparison to most products in urban areas where most products are imported.

The government can also encourage foreign investors to concentrate their operations in the rural areas where land and other factors of production may be cheaper. This will boost the local economies and employ the population. The government can also persuade urban consumers to buy locally-made products to support the businesses especially in this age of global trade where cheaper goods can be easily imported (Strayer et al., 2013). Through the above ways, rural development is attained faster. With relation to urban development, the role of the government is to provide and maintain infrastructure in terms of adequate housing and transport networks as these are the backbones of urban economies. The government should also take steps to encourage depopulation of urban areas by building amenities and housing in the hinterlands from where people working in urban areas can easily commute. The ever-increasing urban population puts a strain on the social amenities in urban areas.



Clinical Children and Adolescent Health

Clinical Children and Adolescent Health

At the beginning of my pediatric clinical rotation, I believed the dynamics of the pediatric section mainly differed from the adults’ section through my interaction with the patients. In my previous lectures, I already learned that it is important to make the patient feel comfortable with you as the caregiver. However, pediatric patients need more reassurance. I found that introducing myself while paying keen attention to my body language made me less intimidating in the eyes of children. One of my colleagues insisted that rapport was the key determinant to successful interaction with pediatric patients. Moreover, in the pediatric section, my definition of patient broadened, from one who is receiving direct health care, to include the patient’s family (Foster et al., 2016). The family members proved to be an invaluable resource to me as the caregiver as they would describe some situations better than the patient.

Furthermore, concerning drug administration, I learned that accuracy is vital in the pediatric section. It was not uncommon to find me with a calculator, keying in the patients’ weights to determine the exact amount of drug that a particular patient was to be administered. Additionally, I learned to pay attention to various body parameters such as the body mass index, weight and height. These affected the amount of drug or nutritional formula that a patient was to be given (Mahmood&Burckart, 2016). A new surprise for me was how pain control was essential for pediatrics. Before activities such as injections and insertion of intravenous lines, it was standard procedure for pediatric patients to be medicated using topical anesthetics like lidocaine/prilocaine cream (Hockenberry et al., 2016). In the same vein, I learned from my colleagues how to give detailed explanations to patients when they were about to undergo new or invasive procedures. I vividly remember a specialist describing the various steps of surgery and magnetic resonance imaging to each of the patients who were to undergo these activities.

After the rotation, I firmly believe that I have achieved the various course outcomes and that the experience will be valuable in my future practice. I enjoyed my time in the pediatricsas it offered me a different perspective of the profession. It was an eye-opener, and it will shape my decision on the area I choose to specialize in.



Response to a scenario; Anxiety

Response to a scenario: anxiety


Anxiety disorders refer to a category of mental disorders characterized by feelings of fear and anxiety. People suffering from anxiety disorders usually have a constant worry concerning a future event and it manifests as fear and nervousness when reacting to current events (Lissek&Grillon, 2015). More females than males suffer from anxiety disorders. Additionally, in their past, individuals with anxiety have been exposed to factors that predispose them to the disorder including poverty, genetic factors like family history of mental disorders and child abuse. Moreover, people with anxiety tend to have concomitant mental disorders including personality, substance abuse or depressive disorders(Lissek&Grillon, 2015). The causes of anxiety are varied in nature and may be categorized as selective mutism, panic disorder, social anxiety disorder, agoraphobia and generalized anxiety disorders.


The problem

Like most people suffering from other mental illnesses, individuals with anxiety disorders can often be misunderstood by the society. Mental illness is most of the time not as noticeable as physical illness, and thus most people may not recognize someone with mental illness. The misunderstanding stems from a lack of knowledge and experience concerning mental illness. Most people rely on stereotypes to make judgment on individuals with mental illness. This may manifest as stigma from other members of the society towards people with mental illness. Stigma has three components which are a stereotype, prejudice, and discrimination. Stereotype refers to a negative belief concerning a person or a group; in this case, people living with anxiety (Thornicroft et al., 2007). Such beliefs may include incompetence or character weakness. Additionally, prejudice refers to one’s agreement with the negative belief as well as the emotional reactions and attitudes due to those beliefs. For instance, one may believe that people with anxiety disorders are dangerous and have a fear of such people. Furthermore, discrimination refers to the behavioral response to the prejudice. Discrimination may manifest in many ways in both social and occupational lives of people with anxiety disorders.

The stigma against people suffering from anxiety disorders has severe implications on their lives as well as their friends, care providers, and families. Studies in Australia indicate that up to 40% of people suffering from mental illnesses have experienced stigma, with further reports showing that it is more prevalent for females than males (S. A. N. E., 2013). Also noteworthy is the fact that the caregivers of people living with anxiety disorders are also subject to stigma and discrimination from colleagues and the society. The principal effect of stigma is to exclude and deny rights to people living with anxiety through some reinforcing attitudes and behaviors which span various aspects of the society(Thornicroft et al., 2007). Stigmatization is perpetrated through social, political and economic structures that result in unequal opportunities for people living with anxiety. Stigma has dire negative consequences on the individual suffering from anxiety disorder. It prevents the individual from seeking help due to their condition as they are afraid of judgment and discrimination. Moreover, it affects their self-confidence and may lead to low self-esteem which can be a cause of other comorbid mental illnesses such as substance abuse or depression(S. A. N. E., 2013). Stigma also limits the social lives of people suffering from anxiety, leading to problems maintaining family relations and friendships.

People suffering from anxiety experience stigma in different ways. First, the community may treat people with anxiety from the perspective of the various myths about the disease. Due to a lack of knowledge or ignorance, members of the community may sideline the individual with anxiety; hence, they may feel left out and unable to enjoy the company of others and a sense of belonging. In the residential areas, people with anxiety disorders may be given the cold shoulder or even be mistreated by other tenants(Thornicroft et al., 2007). Landlords, accommodation workers, and agents were also found to be more likely to describe their rooms as unavailable if they encountered a potential tenant with anxiety disorders. Schools are also a source of stigma for people living with anxiety. Students with anxiety report that friends and colleagues ridicule them about their symptoms. Moreover, parents and teachers also show stigma towards students with anxiety disorders.

Additionally, stigma may come from the health professionals charged with providing care and counseling to the individuals with anxiety. Most of the anxiety patients usually put their trust in their health care providers as they are expected to understand the conditions better than the average person. However, some healthcareproviders exhibit stigma against their patients. About 44% of people suffering from anxiety reported that they received different treatment from their healthcare providers after they discovered the history of mental illness on the patients(S. A. N. E., 2013). In the workplace, the attitudes toward mental illness and anxiety disorders seem more positive as employers aim to provide equal opportunities to people living with mental illness or people close to them.

Additionally, about 74% of employers described their experience working with people with anxiety as positive(S. A. N. E., 2013). On the other hand, caregivers of people living with anxiety disorders report stigma from colleagues as they are viewed as irrelevant or problematic. They feel they are poorly supported and are not afforded the respect they deserve at their places of work(MHCA, 2012). Moreover, most mental healthcare professionals and clinicians do not recognize the roles and expertise of the caregivers and hence do not include them in treatment planning exercises. Therefore, most of the caregivers resort to social isolation as they feel they are not understood.


Advice to individuals with anxiety disorders

Individuals with anxiety should speak out and seek to educate people around them about their mental disorder and their experiences. This would help to reduce stigmatization from the society as most of it arises from a lack of knowledge or ignorance. Additionally, people living with anxiety disorders should seek help from healthcare professionals and carers who will provide counseling and treatment services which improve the quality of life for the patient (Archer et al., 2012). This is vital since anxiety is a manageable condition. Moreover, individuals with anxiety should join groups comprising other people with anxiety disorders, and as a result, they can have a channel through which they can voice their opinions and raise awareness with the public on anxiety and stigmatization. This ensures that their rights and needs are observed and respected by other people.


Advice to caregivers

Caregivers should take regular breaks from work to avoid burn out. Carers can seek help from facilities with respite services that can provide care to persons with an anxiety disorder, hence, allowing the carer to have time for other aspects of their life(MHCA, 2012). Taking care of individuals with anxiety can be a taxing job and can have significant implications for the mental and physical health of the caregiver. About 70% of caregivers have reported that in the recent past their health has deteriorated as a result of their work(MHCA, 2012). Affected caregivers can seek help from CarerCounselling programs that provide psychological and emotional support. Caregivers also need to further their knowledge and training on anxiety so that they can actively participate in the planning of care for people with anxiety disorders. As a result, their input and presence may be taken into consideration by mental health professionals as well as clinicians when making decisions.



Consumer Lifestyle Project

Consumer lifestyle project

I interviewed Matt, a technologically savvy and health conscious man in his early thirties. Matt works for a technology start-up as a programmer. In addition, he is a member of a fitness group that meets five days every week. The group’s collective aim is to improve the fitness and wellbeing of every member as they engage in different physical activities. In his spare time he enjoys reading up on the latest trends in technology, playing video games and watching movies.

One crescive norm in Matt’s lifestyle is that he cannot eat “junk” food for two consecutive days or for more than thrice a week. Matt and his fitness group subscribe to the thought that ‘garbage-in-garbage-out.” Therefore he is very particular on what he feeds on as it affects his fitness and health status. He buys and consumes foods considered healthy such as unprocessed slow carbohydrate diets and fruits. In turn, he avoids carbonated soft drinks, fast foods and foods containing processed sugars. However, he “cheats” with relation to his diet by eating junk food once or twice a week.

One of his enacted norms is the fact that he must perform exercise five days a week. Matt is aware that his daily job as a programmer involves sitting in front of a computer for extended periods thus he spends his workday living a sedentary lifestyle. To counteract the effects of the sedentary lifestyle on his health and physical fitness, he has to spend at least one hour after work form Monday through to Friday engaging in physical exercise. He has been performing this for more than two years.

The social event of the year for Matt is known as “Fit, Wit and Fun.” The event happens during the first week of June annually. Participants engage in fitness competitions such as strongman and endurance competitions as well as trivia games that test the knowledge of the participants in the area of fitness. Winners in the different competitions are rewarded with fitness gear, gym memberships and supplements. In addition, after the competitions, there is an after-party where people socialize and get to meet the featured dignified guest of the night, who is normally a successful fitness model.

Additionally, one other key event in Matt’s lifestyle is the International Consumer Electronics Show (CES). This is an annual event where major tech companies get to showcase new electronic gadgets such as smartphones, robots and televisions as well as the latest technological innovations. Matt attends the annual CES events religiously in orderto keep abreast with novel ideas as it is invaluable information in his programming job. He also gets to interact and share ideas with other stakeholders in the technology industry.

His main gift-giving event is during the Black Friday. During this time, he can get access to and purchase some of the latest gadgets at a much cheaper price. Consequently, he takes advantage by making lots of purchases during Black Friday and offers most of them as gifts to his family members and friends. He mainly gifts gaming consoles, video games, smartphones, speakers and televisions. He usually saves part of his income specifically for Black Friday purchases.

The hot trend currently in Matt’s lifestyle involves using a fitness tracking device to track and monitor the main fitness-associatedmetrics such as calorie consumption, distance covered when walking and running, sleeping patterns and his heart rate. Incorporating fitness tracking into one’s lifestyle makes it much easier to exercise especially with relation to managing the diet to maintain the appropriate weight and energy levels as well as improving sleep patterns (de Zambotti et. al., 2015). He has since purchased an Apple Watch series 3 which is a wearable smart watchwith sensors that works in conjunction with a mobile phone application to keeptrack of his lifestyle.

Figure1. This image illustrates aFitbit smart watch. Adapted from   

One cooled trend for him is going to the theatre to watch movies. Matt is a big movie enthusiast but has since reduced the frequency with which he attends the theatre. He states that he is at a point in his life where he can afford some of the best televisions and movie players and he already possesses these in his home theatre room. As a result, he sees no need to leave his house for movies as he can comfortably stream the movies at home through services like Netflix and Amazon and get picture and sound quality that rivals those of the traditional theatres (“Fullstream ahead? The brave new world of cinemagoing,”2016).In the recent years, there has been a decline in the number of consumers who go to the traditional movie theatres as they have become old and redundantcompared to the various streaming services.

Figure2. This image illustrates people streaming a movie from home using Netflix. Adapted from   

A future trend for Matt will be converting his home into a smart home. Essentially, Matt intends to replace various gadgets in his home with smart devices that are connected through a local network which facilitates their interoperability. A smart home is automated whereby one can control the lighting, entertainment systems, electric appliances, climate and security aspects such as controlling access points and alarm systems of the home (“The future of the smart home,” 2017). The smart devices can be controlled through a smartphone or tablet, or currently, through voice activated devices such as Google Home and Amazon Alexa that recognize the user’s instructions from his/her words.

Figure3. This image illustrates a smart home network. Adapted from 



Sexual Harassment Training Plan

Sexual harassment training plan


The training will be done annually for all employees from the managers and supervisors to the subordinates. In addition, repeat trainings will be performed for new hires. They will also be furnished with the organization’s sexual harassment policy which they will read and sign off as part of the orientation process(Bond, 2014). The employees will be expected to gain an understanding on what constitutes prohibited behavior and sexual harassment, the distinction between a hostile work environment and quid pro quo harassment, their roles on the issue and how to report and who to report to when sexual harassment happens(Nickerson et al., 2014). Also, the managers and supervisors are expected to understand the legal and ethical implications of harassment in their organization, how to act on such cases and how to solve them. Moreover, the management and other employees are expected to commit themselves to preventing and condemning sexual harassment as well as fostering a positive working environment for all.


The training is to be performed through a face-to-face interactive workshop between. The interactive session ensures that not only do employees learn about sexual harassment but also get to ask questions and seek clarifications from the trainer (Bond, 2014). Additionally, employees are able to participate in the open forumwhich is meant to further reinforce their understanding on the issue. The sessions will be performed over a period of one week so that employees in different locations or performing different shifts also get the chance to undergo the training. The core elements of the training will comprise: what constitutes sexual harassment, who can perpetrate and experience harassment, the legal aspect governing liability as well as mechanisms for reporting and intervention. Moreover, the parties charged with carrying out investigations after allegations of sexual harassment will also be trained. The management will be made to understand that they are charged with prevention and taking corrective action againstemployees found guilty of sexual harassment.


The managementand supervisors will be provided with the company policy first before the other employees as they bear the responsibility to prevent and take action against offenders(Bond, 2014). Thereafter, all employees will be provided with the company policy handbook on sexual harassment which they should read in advance before the actual training. The training will be led by a professional trainer in form of interactive classes. The training will mainly focus on the aspect of knowledge concerning the issue. In addition, there will be by-stander training, whereby the employees will be guided on what actions to take when they witness behaviors that constitute harassment (Nickerson et al., 2014). Through gaining a deeper understanding on the issue, the employees are expected to change their behavior towards preventing occurrence of sexual harassment. There will be an open forum where employees will ask questions and seek clarifications on matters that they do not understand. The trainer as well as other employees will answer such questions.


The trainer will use the open forum to gauge the level understanding of the employees. The trainer will ask the trainees to synthesize the salient points they heard through questions such as “can a volunteer briefly summarize what we covered during this session?” (Buchanan et. al., 2014)Additionally, the trainer will ask a few questions about what s/he covered. The trainer will then seek commitment from the management and supervisors that they will prevent harassment and that disciplinary action against sexual harassment will be applied to everyone equally with no exception (Cheung et al., 2017). The employees will also commit to prevent and report any cases of harassment without fear. The investigators must commit to carry out fair and thorough investigations as well as assure confidentiality in harassment cases. The management must also assure the trainer and employees of swift and appropriate action when investigations indicate that harassment occurs.

Claudia Rankine’s Citizen

Claudia Rankine’s Citizen

Citizen: An American Lyric is a book by Claudia Rankine. She is an influential author, poet, editor and essaysit
and has written among others, Don’t Let Me Be Lonely: An American Lyric and The End of the Aphabet. Her books and essays

center or racism, social inequalities and freedom of rights. In 2014, Citizen: An American Lyric won a national award. It is widely proclaimed
to be one of the best works of the Jamaican-born author. She even the MacArthur ‘genius grant’ worth $625,000 because
of the book.
Lyric is derived from the greek word lyricus which means originiating from or related to a lyre. The latter term, on the
other hand, refers to an ancient musical instrument used by the Greeks. A lyric is, therefore, a poem that can be sung
with the accompaniment of a musical instrument. It is also defined as a type of poem that expresses the feelings of the
subject. The difference between it and a narrative poem is that the latter is used to tell a story while the former
expresses emotions. The Oxford English Dictionary, defines Lyric as “(of poetry) expressing the writer’s emotions, usually
briefly and in stanzas or recognized forms”. Another definition is ” of or pertaining to the lyre, meant to be sung;
pertaining to or characteristic of song. Now used as the name for short poems (whether or not intended to be sung),
usually divided into stanzas or strophes, and directly expressing the poet’s own thoughts and sentiments.” In this essay, Claudia Rankine’s book is analysed to determine whether or not
it constitutes a lyric, having been aptly named so.
In the book Citizen, Rankine expresses her thoughts and feelings from the beginning of the book. She starts by saying,
“When you are alone and too tired even to turn on any of your devices, you let yourself linger in a past stacked among
your pillows”. The introductory statement introduces the reader to subsequent paragraphs that emphasize more on emotion
rather than a narration.

Rankine’s Citizens is a unique because it contains elements of a lyric, yet it is not a typicl one. It conforms to a number
of conventions, including the fact that it expresses emotion and is not narrated. The book highlights the author’s
opinions and thoughts about racism. Whereas it cannot be sung, it is divided into a structurally coherent piece. A rhythm
becomes clear if read aloud. It is one of the characteristics that make it a lyric. Citizen is divided into clusters.
It expresses Rankine’s own thoughts. She attempts to get the reader to reason and feel the same way she does be describing
incidences that they can relate with. Although this aspect gives it the outlook of expressing the sentiments of a group of
people rather than one person, it actually focuses on an individual sharing experiences that may be similar to those of
the reader.
In some parts of the text, it leans more on a narrative than a lyric. For instance, while using her unique way of
expression, Rankine states, “When you arrive in your driveway and turn off the car, you remain behind the wheel another
ten minutes.” She continues, “You fear the night is being locked in and coded on a cellular level and want time to function
as a power wash. Sitting there staring at the closed garage door you are reminded that a friend once told you there exists
the medical term-John Henryism- for people exposed to stresses stemming from racism. They achieve themselves to death trying
to dodge the buildup of erasure.” The excerpt bears little semblance to a poem, and it borders on a narrative. However,
since this is a stanza on its own and the content is not a story but rather an imaginary situation, it should not qualify
as a narrative.
A narrative is defined as a story. It can also be described as an account of related events. The stanzas in Citizen are
connected as they hint at experineces of racism. However, each stanza is unique and is based on a diffeerent setting.
This disqualifies it as a story, and can, therefore not be classified as a narrative.
She constantly addresses ‘you’ in the poem, alluding to the reader. One line reads, “You are in the dark, in the car
watching the black-tarred street being swallowed by speed; he tells you his dean is making him hire a person of color
when there are so many great writers out there.” It is intended to be a singular referral and not a plural
term as she relates her personal experiences or thoughts to that of an individual in the same circumstance.
The “You” is used in singular form and refers to an I rather than Is. Rankine (the author) relates her experiences (whether
imginary or real) with those of an individual, not a group.

The police have constantly been associated with institutionalized racism. Activits and the public have been vocal in

What it takes to become a professional Japanese chef

What it takes to become a professional Japanese chef

To become a professional Japanese chef (shokunin), one needs a deep understanding of the Japanese culture coupled with excellent culinary skills. According to Wells, the Japanese culture is broad in that it consists of several permutations of keyelements. Such elements include the language, the seasons of the year and to some extent how to relate to people of different ages. The most importantaspectsof learningare the language and how the tastes and preferences of the people change with seasons. Excellent language skills are neededtoread and interpret characters from menus, which may not use the typical Japanese alphabets. Moreover, efficient communication between the chef and his colleagues as well as clients is essential for a smooth workflow in the kitchen and the eatery area of the restaurant. For the Japanese, each season is characterizedby its food and a particular way of presentation of the food to the customers in a restaurant. Therefore, it is imperative for a prospective chef to learn these concepts in their quest to become a shokunin. The second set of skills that a potentialshokunin must have is the actual culinary skills. These involve understanding how to operate in the kitchen. Activities such as maintaining kitchen cleanliness, inspection of food, handling and preparation of food, the types of food and the different tastes that need to be in the food are some of the basics that the shokunin should be competent in1. In addition, having years of hands-on experience in different sections of the kitchen is essential.




The training of a professional Japanese chef has three critical stages. These comprise learning and understanding of the language, attending culinary school and finally attending apprenticeship in one of the restaurants. David Wells, being an American who was not proficient in the Japaneselanguage had to start his journey by learning the language. The language was significant in that it was the medium used to teach the lectures as well as communicate with tutors, other students,and colleagues at work. Additionally, the menus were inscribed using Japanese and sometimes Chinese characters or even symbols that had no relation to the languages, such as the one used to signify the clan that first grew tubers to represent sweet potatoes. After mastery of the necessaryJapanese language skills, Wells enrolled into a culinary school.

The culinary school marks an essential step in training for a Japanese chef. This is the stage where the students get to learn on the operations in the kitchen. The course in the culinary school is a two-year program. The topics taught in the first year involve cleanliness and basicJapanese culinary skills1. The mode of teaching is two-part, lectures and actual cooking. As part of the addresses, the students are expected to internalize concepts such as cleaning before one starts cooking, cleaning while cooking and cleaning the workstation after cooking. Consequently, the students learn about prevention of contagious diseases and the public health factors. After this, the curriculum involves learning Japanese, Western and Chinese cuisines. The lectures in the first year further delve into hygiene, nutrition,and economics while the practical part of the studies involved the actual cooking2. During the practical lessons, the teacher prepares the menu of the day while the students watch. The students were then grouped in teams of five people, where they were to work together to make a similar menu to the teacher’s in the most precise manner.

The students also had to pass some individual tests that involved assessment of their technical abilities, speed, cleanliness,and presentation3. One of the mainindividual tests involved assessing the students’ ability to handle three basic Japanese knives. The first test required handling of the usuba, a thin-bladed, long and wide vegetable knife employed in cutting a piece of carrot and long white radish. The second knife was the deba that has a triangular blade for fish-filleting. The third knife was the yanagiba, a shashimi knife for slicing tuna blocks. Additionally, the learners had to acquaint themselves with the workflow in the kitchen and the importance of using the right hand for knife operations, especially for left-handed students like Wells.


The second year in culinary school was characterized mostly by cooking. The students had to choose one cuisine to specialize in from the three they learned in the first year. The main concepts involved learning about the four seasons and their associated ingredients and visual presentation1. According to Wells, each season had its own identity. For instance, in the spring as the fish changes its shade to a darker pink hue, the presentation of the food involved placing flowers from blossoming cherry trees that signified the transition of the shade of the fish. In summer, food was presented in porcelain dishware that was lighter in the shade. Additionally, during the winter, cooking pots were placed on burners on guests’ tables.

After graduation from culinary school, the graduate must take part in a two-year apprenticeship in a kaiseki restaurant. This is where the prospective professional chef gets to work in a real-world setting and gain experience in the field2. The apprenticeship comprises working in various departments of the restaurant tounderstand how the departments work autonomously but towards achieving a common aim. The normal working conditions involve twelve-hour workday with a two-hour break for six days a week3. The apprentices work under the guide of senior chefs. They may be stationed as assistants to the hors d’oeuvres chef, in the storehouse or several other sections in the kitchen. In addition, the apprentices may choose to participate in other activities like accompanying the restaurant owner to the fish market in Tsukiji. The apprenticeship also offers foreign learners the chance to hone in on their language skills by deepening their grasp of the Japanese cuisine terminologies and symbols. For Wells, after completion of the apprenticeship, he moved back to New York where he worked in a Japanese restaurant after which he got the chance to further his studies in the prestigious Tsuji School of Cooking. After the six months training there, he worked as a personal chef for a private client and ventured further into ceramic artistry to customize the visual presentation of his food.

The training and subsequent working experience that Wells went through differ slightly from that of young chefs in Jiro Dreams of Sushi in that after culinary school, the young chefs attend apprenticeships for more than two years and work under senior chefs.Jiro’s first son exemplifies the mode of training, where he chose to work in his father’s sushi restaurant under his father’s guide as preparation to take over the leadership of the restaurant in the future.



Becoming a kaiseki chef

I believe a person from my region can become a kaiseki chef,but it is not an easy feat. Learning and pursuing a profession as a kaiseki chef has been made easy by globalization that has popularized the Japanese meal, sushi, in different parts of the globe1. The wide acceptance of sushi has further led to spreading and understanding of Japanese cuisines and culture exemplified by the establishment of restaurants that specialize in the cuisine. However, pursuing the Japanese chef profession is not an easy task and requires someone with special attributes2. Thisis exemplified by Wells’ case, where his admission to the culinary school was stalled for a whole year as the school administration did not believe that a foreigner would be patient and diligent enough to learn and understand the Japanese cuisine. However, Wells proved that through hard work, determination and focusing on the main goal, it is possible to study and work towards becoming a professional Japanese chef. Some of the barriers that may hinder a foreigner from becoming a kaiseki chef include language barrier. The Japanese language has complex elements and especially in the presentation of menus in restaurants where symbols that have no relation to the alphabets may be used1. This may prove to be a difficulty for people who do not speak Japanese as the first language. In addition, the Japanese cuisine is highly dependent on the seasons. A professional chef must learn all the necessary ingredients and visual presentation techniques for the different seasons. This may be a challenge to some peopleas some meals have up to eighty-five ingredients and since they are only preparedfor not more than three months each year, the chef must remember how to prepare a meal after almost nine months of not preparing it.

Analyzing the steps in a scientific research process

Analyzing the steps in a scientific research process


The research process refers to a plan or method to carry out a study with the aim of answering a particular question(s) about a phenomenon. The research process involves various steps that are termed as cyclic. In healthcare, following the steps in the process is essential to obtain credible, objective and replicable results. The steps include selecting the problem and formulating the research question, formulating the hypothesis, designing the experiment and data collection, analyzing the data and interpreting the findings.


Problem selection and formulating the question

In this step, the researcher makes observations and defines the topic of interest which s/he wishes to research on. After this, the researcher has to perform a thorough review of available literature on the topic which may comprise reviewing books as well as academic journals. The researcher may also seek assistance from colleagues, faculty, and supervisors for opinions on topics to research.Through the review, the researcher can obtain invaluable information that guides them on what has been answered on and the areas that are yet to be researched with relation to the topic (Neutens&Rubinson, 2014). The researcher is then able to formulate a question that he seeks to answer through his/her research project. The question may be as simple as “What is the role of nurses in patient advise and counseling?” the question acts as a compass for the researcher by offering the direction which the researcher should pursue. It defines to him/herthe next courses of his/her actions.

Formulating the hypothesis

A hypothesis is a concise and clear statement that is an educated or an informed guess as to what the answer to the research question might be. To formulate a proper hypothesis, the researcher must define all the variables pertaining to the research as the hypothesis defines the relationship between the variables. The hypothesis may be a precise cause-and-effect clause about the various variables or a generalized statement on the variables. A good hypothesis should be testable, falsifiable, show a clear relationship between the research variables and offer a logical explanation for the predicted outcome (Neutens&Rubinson, 2014). The research findings will aim to prove or disprove the hypothesis.

Designing the experiment and data collection

The experiment is a crucial part of the research as it defines the process through which the data is going to be collected. The design of the experiment must be appropriate for the research question at hand as it will determine the quality and quantity of data that is collected. Designing the experiment involves defining the methods of data collection, the target population;the sample size and how samples will be obtained (Neutens&Rubinson, 2014). Besides, it involves determining the dates and times for the experiments to be carried out, defining and testing the instruments to be used for data collection and defining any controls that will be used. Moreover, the researcher also defines the best methods to use for analysis of data after collection. The methods of analysis depend on the type of experiment and the type of data collected about the research question

After designing the experiment, the researcher has to go to the field and collect all the relevant data according to the sample size desired. The researcher must stick to the plans defined during the design of the experiment. Moreover, s/he must take measures to ensure that the data collected should be authentic, accurate and free from bias. Additionally, s/he must adhere to all the ethical standards that are relevant to the type of research s/he is conducting.


Analyzing the data

In this stage, the researcher converts the raw data obtained into meaningful information that is in line with the objectives of the research. The data is broken down and evaluated thoroughly and transformed into a form that the end users can understand (Neutens&Rubinson, 2014). The researcher must adhere to the plans and analytical methods that were defined during experiment design. The plans must define what information the data should reveal to confirm the hypothesis. Analysis can be done through the use of statistical tools which may be either inferential or descriptive. Inferential statistics consists of carrying out tests of significance that can either prove or disprove the hypothesis. On the other hand, descriptive statistics will describe the data collected through measures such as means, data distribution and standard deviation.

Interpreting the findings

After analysis, the information obtained is used to draw conclusions and make decisions. In scientific research, the findings are evaluated against the hypothesis as well as conclusions obtained from experiments by previous researchers if they exist. The researcher explains his findings in detail and how they relate to the real world. If the findings confirm the hypothesis to be true, then the researcher has succeeded in answering his research question. If the results disprove his hypothesis, the researcher may continue with the inquiry and forms another hypothesis and tests it.

The researcher then publishes his findings and shares it with other scientists so that they can verify the findings and to be used as reference material that will assist in future research endeavors.  It is important to note that this is not the final stage in research as it generates valuable data that will be applied by another researcher who will incorporate the data into the first step of his research process (Neutens&Rubinson, 2014). Hence, the scientific research process is termed as cyclic.