Larsen and Toubro Case Study free essay sample

Organizational Development (OD) is a planned long term effort led and supported through the top management to improve an organization’s ability and to solve its own problems by continuously working together and on managing the culture using behavioural skills. Thus, there are some certain aspects worth discussing about which are- OD is a planned effort. It requires a lot of effort, patience, and faith and is time consuming. Secondly, OD usually uses outsiders. These ‘facilitators’ as they are called are process specialists and are involved in depth in this process. The pioneers of OD in India were Larsen and Toubro India (LT). OD at LT started by calling in 2 eminent professors- Dr Udai Pareek and Dr TV Rao to study the appraisal process at the company. The existing appraisal system had many faults and needed to be corrected. The difficult task started by the professors interviewing some bosses and subordinates from different departments (using Diagnosis or Action Research) and they got a very interesting feedback. We will write a custom essay sample on Larsen and Toubro Case Study or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Some of the aspects of the feedback were – juniors wanted to know how well they were doing on the job, but weren’t told; people wanted to know what the growth opportunities in the company were; the appraisal form was too lengthy; some bosses had too many subordinates to appraise, etc. After getting the feedback from the employees the professors gave a report to the top management about the actual problem. The appraisal system had to serve not just one but many purposes namely it should help people understand their strengths and weaknesses, their own progress on the job, how they can perform better, and how they could grow in the company. So the appraisal process had to address the issues of appraisal, potential, counselling, career development and training all in one! The top management after reviewing the report gave the go ahead and they did two main things which were the most important which were bifurcating the Personnel department into personnel department and HRD department. This bifurcation was the first sign of ‘structural’ change. Secondly, a team of 6 senior managers was formed which would be responsible for implementing the changes required. The story continues when the 6 task force and the professors decided that the appraisal process had to involve the line managers personally, the performance goals must be set jointly by boss and junior and the appraisals must also involve feedback and counselling to people. Thus, they prepared a Performance Appraisal Manual by involving the departmental heads and other senior managers to analyze what kind of objectives could be set and then added such guidelines in the manual. To address the issue of feedback and counselling, the team identified around 29 senior line managers and some senior staff with a flair for public speaking. These selected people were put through a workshop on how to be good ‘Givers’ and ‘Receivers’ of feedback and then later conducted the same workshop for other employees at HQ and regional offices. Thus, the first workshop was a ‘Train the trainer’ workshop which was cascaded to the other employees. After putting in so much of effort now the management at LT wanted to know whether the process was working for them or not. So again the professors interviewed some seniors and juniors about how the appraisals were going on. This time different views came into the picture – the goal setting was seen as time consuming, appraisal was becoming a numbers game, and was tending to become ritualistic. The HRD department was asked to conduct a survey (Participant Action Research). The survey also threw new light about the new appraisal process. The bosses now did involve their juniors in the goal setting and there was ‘healthy resolution’ of difficulties and there was a ‘high degree of trust’ between the seniors and juniors which led to ‘increased joint understanding about the job’. After receiving such a feedback, they again tried to simplify the appraisal form by adding the definitions of the attributes listed in the appraisal form. In addition, they held refresher courses in feedback skills for both ‘givers’ and ‘receivers’ of feedback. The facilitators felt that the appraisal system has stabilised when 80 to 85% of the appraisal forms were returned within six weeks of the target date. Also the HRD department started analyzing all the appraisal forms. The data from the analysis was used for listing high and low performers for a certain period; for finalising departmental developmental plans and for preparing the list of department wise employees and the training courses they needed. The above mentioned process took LT 8 years to complete and stabilise themselves. Thus, I can conclude that OD is a long term process which requires a lot of patience, support from the top management and a vision to a bright future.

Roe v Wade essays

Roe v Wade essays Roe vs. Wade: The Decision and its Impact on American Society The Court today is correct in holding that the right asserted by Jane Roe is embraced within the personal liberty protected by the Due Process Clause of the Fourteenth Amendment. It is evident that the Texas abortion statute infringes that right directly. Indeed, it is difficult to imagine a more complete abridgment of a constitutional freedom than that worked by the inflexible criminal statute now in force in Texas. The question then becomes whether the state interests advanced to justify this abridgment can survive the particularly careful scrutiny that the Fourteenth Amendment here requires. The asserted state interests are protection of the health and safety of the pregnant woman, and protection of the potential future human life within her. But such legislation is not before us, and I think the Court today has thoroughly demonstrated that these state interests cannot constitutionally support the broad abridgment of personal liberty worked by the existing Texas law. Accordingly , I join the Court's opinion holding that that law is invalid under the Due Process Clause of the Fourteenth Amendment (Craig and OBrien 17). On January twenty-second, 1973 Justice Harry Blackmun delivered the opinion of the Supreme Court regarding the Roe vs. Wade case. A pregnant single woman, Jane Roe, brought a class action lawsuit challenging the constitutionality of the Texas criminal abortion laws, which proscribed procuring or attempting an abortion except on medical advice for the purpose of saving the mother's life. Norma McCorvey, the real name of the plaintiff, was young and divorced at the time, searching for a solution to her unplanned pregnancy. No legitimate doctor in Texas would touch me, stated McCorvey. There I was pregnant, unmarried, unemployed, alone and stuck (Craig and OBrien 5). The plaint...

Learn how to write a conversation properly and get an A!

Learn how to write a conversation properly and get an A! Writing a Conversation: Main Tips to Follow If you ask language theoreticians what the main difference between spoken and written language is, they will probably say that there is none. However, it is obvious that both spoken and written language has a completely different influence on the audience so it can become a powerful instrument in rendering thoughts and ideas. When a conversation is held, the audience can obtain information directly and to interpret it without anyone’s corrections and word choice. However, when a written piece is given, the reader is not present, and understanding of the topic greatly depends on the choice of words. This means that if you want to insert a conversation into your story, you need to be familiar with all of the rules and demands in order to make such dialogues clear and understandable. Writing skills are not enough: you need to understand the physical and social background of people. In addition, it is important to know what a conversation is and how to render posture and gestures. A vivid dialogue shows how people agree or disagree, talk and express their thoughts. This means that you need to learn dialogue writing and formatting if you want to render a conversation and to make it an important part of your story. Knowing all of these peculiarities will surely help you to grab the attention of the reader. If you are ready to master this complex but yet effective writing tool, just go on reading, and we will provide you with all of the necessary details! What It Takes to Write a Great Conversation Before getting started and learning all of the tips on writing dialogue, let us determine what it is in order to use it effectively. So what is a conversation or a dialogue? It is an intentional discussion between people. Usually, it includes sharing opinions, ideas, fears, reactions and so on. Try not to use unnecessary details If you want to render interaction of people, it is important to give contextual clues.   It is very important because your readers are willing to listen or to watch the setting. When you are working on a conversation, you need to avoid fillers. For example, if you are describing a cell phone conversation, there is no need to add phrases like ‘I want to speak to Mrs. Smith’. Just go directly to the dialogue, like this: ‘Hello?’ [Her voice was low and insecure, almost in panic.] You may find it difficult to avoid fillers in situations when there is a need to introduce a new character. However, it is still a great chance to picture the character in vivid colors. For example: ‘Amanda was talking to Mrs. Johnson and a stranger. When I approached, the stranger gave me a cheerful smile’. ‘She was an attractive young woman with bright blue eyes. Her hair was curly, and the dress she wore was pure charm and innocence. It was a real pleasure standing in the rays of her light.’ Try not to omit the description of appearances, because they give a necessary background to characters and future plot of the story. Limit irrelevant dialogue tags Dialogue tags give readers information about who said what in the story. However, they are not always necessary. Instead of writing ‘John said’ you can provide information about gestures and posture at the end of the line. This will give your conversation additional motion, and the text will be more live and vivid.   Compare the following examples: ‘What are you reading?’ He asked. If based on the scene context it is obvious who is speaking, there is no need to include the dialogue tag. Try using gestures instead: ‘What are you reading?’†¦ He moved closer and looked over my shoulder. As you see, such gestures give your story additional details, and the reader can picture the situation more clearly without unnecessary repetitions. Most of the writers always use this simple but effective tool. Say no to fancy tags If for some reason you don’t want to use gestures or consider them out of place, you should still avoid fancy dialogue tags. Complex word combinations and phrases may distract the audience, so if you still need to mention the speaker, it is better to stick to a plain ‘he said’. Sequence of dialogue tags In case the above methods are not appealing, you can still try other options.   For example, to break the monotonous flow you can switch places of dialogue tags. Luckily, there are no rules that say you should start every line with ‘Matt said’. Try placing these tags in the middle of the conversation or at the end of your dialogue, and you will see how much brighter the story will be. Don’t forget to add conflict or disagreement If you want to make conversation an important part of your story, it is necessary to include conflict to it. In reality, when we are mad at someone, we can remain silent for weeks. However, in stories, it is necessary to render the tension through your dialogues. It is a way of transmitting emotions to your readers. Do you like reading stories, where characters get along so good that they don’t have a single disagreement? The only way to make your story exciting and appealing is to give the readers a chance to see a conflict, a collapse of different opinions and tension. In case you are not sure how to cope with such a task, you can always contact our professional writers. They will help you to come up with a catchy conflict and to build a plot around it! Mention goals, hopes, and fears of your characters It is not necessary to make your story characters happy, positive and honest all the time. Try adding shades to their personality, and you will see how the story will benefit.   The flow of the dialogue may require asking complex questions or avoiding answers. That is when you need to depict the weak sides of your characters, just as the police does during an interrogation. When you are working on dialogues, you need to understand your characters good enough: what motivates them, what are they afraid of, how will they benefit from the conversation and so on. How can their goals and desires influence the conversation and the whole course of the story? By building a connection between the conversation and goals of participants, you can create a deeper dialogue. This advice is crucial if you are working on a detective story or a mystery because sharing information becomes the main source of finding new clues and tips. Use subtext and gestures It is not a secret that subtext is a very important part of the story and is the key to understanding readers’ ideas and thoughts. It can answer the ‘why’ question, explaining what is hidden behind the words and phrases.   Adding subtext is a great way to make the context stronger and to explain elements that can’t be explained otherwise.   For example, ‘I was invited as a lecturer to Michigan University.’ She exclaimed. ‘Isn’t it where John, your former boyfriend is working?’ As we get from the context, he is not happy with the proposal and is quite suspicious whether she was invited by her ex-boyfriend. Obvious tension made the conversation more interesting, and a simple discussion of a job offer turned into jealousy and suspicions. Draw a picture of the tone and atmosphere We all love stories with an atmosphere, so adding colors and context is crucial for creating good and catchy dialogue. A context is a place, where the conversation unfolds. In addition, the context provides background information that leads to a certain dialogue. If you devote enough time adding context to the conversation, you will be able to avoid dialogue tags or adverbs. For example, ‘I saw her leaving with a stranger’. She cried. If you want to make the story more intriguing and catchy, you can add context to the story, describing what and where it is happening. Anna was missing for almost two days now. No one has seen her on campus, and she didn’t come back to her home town either. Hundreds of people were surveyed, and the police were losing hope of finding her alive and healthy. Around noon they received a phone call from Anna’s roommate. ‘I saw her leaving with a stranger’. She sobbed. Such details help readers to see the story behind and to explain the despair of police, family, and friends of a missing woman. Formatting a Dialogue It doesn’t matter what type of story you are writing: following rules of creating a dialogue is a must. To distinguish dialogues and conversations, you need to know common rules. First, all of the conversations should begin and end with quotation marks. Below are some of the additional rules you need to keep in mind when formatting a story. Breaking paragraphs to distinguish speakers Every dialogue involves at least two people, so the audience should have a clear understanding of who is speaking and when the next phrase begins. To reach this goal, you need to follow some visual rules: Every paragraph and every new speech should be indented; Even if it is an unfinished phrase, it should be on a separate line. Using quotation marks If you place a part of the text into quotation marks, it means that someone is speaking. It is also possible to use double quotation marks. For example, â€Å"Have you seen our English teacher today?† If several sentences make a single part of the dialogue, you can place them in a single quotation. For example, Mary exclaimed, â€Å"I was so worried about you! Why didn’t you tell me that you were leaving?† In case your character quotes someone’s statement, you can place the main dialogue in double quotation marks and use single ones around the words that are quoted; To mark speech, it is also possible to use angle brackets. Such an approach is often used by European and Asian writers. Punctuating dialogue tags Dialogue tags are a part of a conversation and are used to explain the reader who is speaking. That is why you need to know how to punctuate them properly: Separate the tag and the dialogue using a comma; If the tag is placed at the beginning of the sentence, you need to place a comma before the dialogue. If the tag is placed at the end, you need to put the full stop before the quotation mark is closed. For example, Anna said, â€Å"I would love to go with you.† Or â€Å"I would love to go with you.† Anna said; If you place the dialogue tag in the middle of the sentence, you need to put commas on both sides of the tag. For example, â€Å"Oh my God†, Mary exclaimed,† Where did you get it?†. Using question and exclamation marks You need to place both of them inside quotation marks. For example, â€Å"How did the meeting go?† or â€Å"I am so tired†. You shouldn’t separate your dialogue tag from the conversation if there is already an exclamation mark. Using dashes and ellipses When you want to show that the ending of the phrase is abrupt, you need to use dashes. Ellipses show that the thought is lost. Keep in mind that dashes are not hyphens. For example, where is b − â€Å"Anna began? If you want to show that the dialogue was interrupted, you can also use dashes. For example, â€Å"All I wanted was – â€Å"Don’t even start that!† In case you want to show that your character lacks words, you can use ellipses: â€Å"What I mean is†¦.† Breaking a dialogue into shorter lines If your character needs to make a long speech, it is better to break it into smaller paragraphs. This will make the text simpler to understand. To achieve such a result, you need to start the dialogue with opening quotation marks and then switch to the next paragraph. Place closing quotation marks at the end of the final paragraph. Conclusion Including dialogues to your story can make it engaging and vivid even though creating an interesting conversation is a real challenge. If you want to succeed, follow the tips above, master formatting and you will surely create an outstanding dialogue to spice up the story!

Otis-Lennon School Ability Test Essay Example | Topics and Well Written Essays - 750 words - 33

Otis-Lennon School Ability Test - Essay Example This paper illustrates that Roger has always managed to achieve an above average grade in Physical Education and Shop and even achieved a C grade in both subjects when he failed all other subjects in the first year of the 8th grade. In his second year of 8th grade, Roger achieved a B in both subjects which are quite an achievement considering he only barely passed all other subjects. Roger has demonstrated a progressive improvement in his Otis-Lennon School Ability Test (OLSAT) going from below average to average by the 9th grade. The OSLAT is very important for teachers because it informs of each student’s potential. On the Stanford Achievement Test (SAT), a test used to measure academic achievement and to predict the student’s performance in college, Roger scored an 8.3 in his last two sittings which demonstrates an improvement over the previous year where he scored a 7.5. What can be discerned from these achievements is that Roger has an innate ability to improve as he was able to successfully repeat the 8th grade and was able to improve on his SAT scores with each retake in successive years. His interests in sports and mechanical aptitude are reflected in his consistency in better than average achievement in physical education and shop in school and the fact that he achieved his highest score in Mechanical on the Differential Aptitude Test. In planning his sophomore program Roger is advised to focus on those subjects that he has a greater chance of succeeding in and using in the future. For example, Roger has always done well in physical education and shop. He might want to focus on those areas in his sophomore year as he appears to do well in those subjects. He is interested in sport and appears to have a natural ability in the shop. Since he demonstrates a greater ability in Mechanical and has an opportunity to pursue a career in mechanics having inherited his grandfather’s tools, Roger might want to take every opportunity available t o him to pursue this subject in his sophomore year as well.

Best Orientation Practices For Nurses Term Paper

Best Orientation Practices For Nurses - Term Paper Example In the nursing profession, one of the problems facing nurses involves the retention of nurses. A methodical investigation cited by Kiel (2012) indicates that approximately thirty percent of newly registered nurses abscond from the nursing profession before the end of the first year at the job. Additional investigations showed that a quarter of newly licensed or registered nurses leave their jobs before the end of two years at the job (Kiel, 2012). This has necessitated the need for the introduction of effective orientation programs geared towards equipping these newly licensed nurses with skills and competency to remain at the job. In other words, the main challenge faced by these nurses during orientation is transitioning from being a student to a nursing professional. An article by Brown and Pillar (2014) brings out the fact that health organizations are faced with difficulties relating to how to successfully orient nurses in a bid to help them be accustomed to the daily running of the organizations. According to Robitaille (2013), "An effective orientation process is crucial to help ensure an individual's competency to perform his or her role and familiarize the oriented with an organization's culture, policies, and procedures, and unit-level protocols" (p. C7). In some cases, nurse managers assume the newly employed nurses will orient themselves in the course of their duties. Additionally, some nurse managers fail to ensure orientation of new nurses due to the high costs involved in such orientations.

Compare Microsoft and VMWare for virtual computing Essay Example for Free

Compare Microsoft and VMWare for virtual computing Essay There are two types of firewalls, there is the in-bound firewall that protects against all things that come into your computer. Then there is the two-way firewall. With this firewall it protects both inbound and outbound threats. This type is used quite often these days. Many computer only have a one-way firewall, but many of them like Zone alarm are two way firewalls. Firewalls are used to block or accept information into your computer that is not a threat. It will either send it to where it needs to be or it will block it if the potential of the file is threatening to your device. A type of firewall is your basic McAfee, which works with Microsoft Corporation on your basic computer it is a program that is already installed into your device. It is a virus protector that works with your computers already installed firewall to keep out and potential harmful viruses or threats to your computer. You can do basic setting for the firewall or you can put it to your liking to make sure of no type of threats can enter your computer. With the security of a computer it can get very complicating. You have to make sure you are aware of what you are using and how it operates in your system. In today’s society there are a million anti-virus software programs. Many of them have free versions and some just have trail versions you can test drive before buying the full version. McAfee and Norton have trail versions you can sample before getting the full version. With Panda, AVG, and other anti-virus programs they have a free version and full upgraded version you can use. When it comes to viruses and the types that get put onto your computer there are many of them. For example: the Trojan Horse, it is put into your computer by saying it is good for file converting or cleaning a system out, when it is really putting bad programs into your computer along with spyware and other potentially harmful programs. Just like when you go into your email and you see an email with a suspicious name, you click it and it automatically downloads something into your computer and you computers starts to malfunction. When it does this it is because the files that were put on your computer are basically eating up you memory. It is extremely important to keep your computers malware and anti-virus programs up to date to prevent any type of program getting into your system. When you back up a system you have different types of backups you can use. For instances you have your full back up which is where you can back up all your information onto a DVD-R or DVD-RW, so you can recover your system at a later time is it crashes or is lost. You should also look at your back up disks periodically to make sure they are in good form if needed to be used. You also have your deferential back up is where you can select certain things to back up and incremental back up is where your computer sets up a certain time after you have put so much into your system to back it up for later use if needed. Checking back up disks are extremely important to check as well to make sure that they are able to be used on the future. Also it is really important to burn your files to a disk not on your hard drive in case they are lost or damaged. Five passwords that are good to use in the way of remembering and using are, â€Å"Bab1eg1r!†, â€Å"Crazy8ight$†, â€Å"GoP!a1†, or â€Å"Playf00!† They can be used to help protect your passwords by replacing a letter by a number and capitalizing some of the other letters that you choose to use, along with using symbols of some sort. Another way of using passwords is using movie titles and shorting them to remember for instance, the day I left your mother to make our love stronger could be shortened by using the first letters of each word like this, â€Å"Tdilymtmols.† Also I can count the ways I love you, â€Å"Icctwily.† Many times the world went around, â€Å"mttwwa†. Honey I shrunk the kids,†Histk†. I love the way you love me, â€Å"iltwylm.† Many of my passwords were very strong in the aspect of how I wrote them. Passwords are very important and they have a good use to them. To keep people out of your system and protect you information as well as identity you really need to choose wisely and carefully on what ones you use.

New Born Athletes Essay -- College Athletes Professional MOney Fame Es

New Born Athletes There are many "cultures" people get caught up in today, and one of those is the desire for money and fame. Many people use those two words to define "success". So much emphasis is put on this that it sometimes becomes the only thing that motivates many of us today. We don't care what it takes to reach this. One place where this is very evident is in sports, especially basketball. In many instances, it has gotten to the point where children, or young adults are making the decision to forgo college, an education, to make money. These athletes are either leaving college early for a career in the NBA or they are going straight from high school to the NBA. Granted, this is what most of them love to do, it has been their lifelong dream, but that is not the reason they choose this route. They are listening to others who think it is the best choice for them, when many times it is not. When these decisions are made, it affects more than just the athlete. This movement affects the athlete, the athletes family, the NBA team, and for those who leave college early, it affects the team they leave. I am going to show you how each of these are affected. I am going to use some examples of successes and some failures in different types of situations. It has been my experience that people like to hear good news before bad news, so I will start by with an example of what society has labeled as a "success". Michael Jordan, the name almost speaks for itself, but I am going to use some of his circumstances to show one point of view. Michael is someone who decided to stay in college throughout his eligibility. It seems to have paid off in a big way; not to say he would not have made it if he had left early... ...ms we are continually moving even more in this direction. When are people going to realize that money can buy a lot of things, but happiness and true success are not within the realm of money. I also believe my example is timely because of any event of late, the NBA lockout. For one thing, it shows these players are not playing for the love of the game because if they were they would not be upset that they were only making millions of dollars. People who really enjoy what they are doing want enough money to get by on and have a few extras, enough to be "comfortable". The fact that these athletes are upset because they can't get paid more shows they have become far too dependent on money and what it can do. I know not everyone will agree with what I have said in this essay, but I think if you look deeply into what I have said, you will find most of it is true.

Case Analysis of Mdd, Gad, and Substance Use

Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Nicole Gapp University of Minnesota School of Nursing Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Major Depressive Disorder (MDD) is a mood disorder with symptoms that greatly affect the life of the individual. MDD could in fact be called a public health crisis, as it is projected that it will soon overtake heart diseases as the major worldwide health concern (Boyd, 2008).Diagnostic criteria for MDD are depressed mood or loss of interest or pleasure in nearly all activities, present for at least 2 weeks. Findings and behaviors associated with MDD are disruption of sleep, suicidal ideation, feelings of worthlessness and hopelessness, and fatigue and loss of energy. MDD is also associated with a high impairment in occupational, social, and physical functioning, causing as much disability and distress as chronic medical disorde rs (United States Department of Health and Human Services, 1999).MDD has been shown to be associated with increased medical illnesses. MDD can make everyday living a challenge, as research shows that depressive symptoms are associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning (Yen, Rebok, Gallo, Jones, & Tennstedt, 2011). It is important for MDD to be identified and treated early on, as MDD that is not treated appropriately results in recurrent depressive episodes, with each successive episode increasing in severity.As MDD is highly associated with suicidal ideation and suicide, it is imperative that MDD be treated to ensure patient safety. Risk factors for MDD are a prior episode of depression, lack of social support, lack of coping abilities, medical comorbidity, substance use, and presence of life and environmental stressors. In addition, major depression may follow adverse or traumatic life events, especially those that involve the loss of an important human relationship or role in life. Social isolation, deprivation, and financial deprivation are also risk factors (APA, 2002).Genetics play a role in the development of MDD, and deficiency or dysregulation of neurotransmitters are also thought to play a part in its etiology. Psychological theories of MDD hypothesize that an early lack of love and warmth may be involved with the development of depressive symptoms, while developmental and family theorists have proposed that parental loss, emotionally inadequate parenting styles, or maladaptive patterns in family interaction may contribute to the etiology of MDD.Women are twice as likely as men to be diagnosed with MDD, though it is believed that the incidence in men is under-diagnosed. Prevalence rates are unrelated to race (Boyd, 2008). Nursing responses to MDD should involve interventions to treat symptoms within the biologic domain, such as changes in appetite, weight, sleep, or energy, as well as symptoms within the psychological domain, such as changes in mood and affect, thought content, suicidal behavior, and cognition and memory. Many types of interventions are used to treat the varied effects and symptoms of MDD.Pharmacologic interventions, such as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine oxidase inhibitors, and other classes of antidepressants may be used to decrease or manage depressive symptoms. Medication should be continued for at least six months to a year after complete remission of depressive symptoms. Lifestyle patterns, such as good sleep hygiene, activity and exercise, and adequate intake of well-balanced meals should also be encouraged, as these patterns help the client move toward a healthy daily routine that supports remission or recovery.Psychotherapy, such as cognitive therapy, behavior therapy, and interpersonal therapy, has been shown to be effective in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for patients with severe or recurrent MDD as a strategy to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an effective treatment for MDD, especially severe MDD that has not responded to medications. Major depression frequently occurs in conjunction with ther psychiatric disorders, such as anxiety or substance use disorders, which can also affect antidepressant responsiveness. In such cases, the co-occurring mental health problem should be treated in addition to major depression (President and Fellows of Harvard College, 2011). The patient described in this case analysis has comorbid diagnoses of generalized anxiety disorder and substance abuse. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive worry and anxiety with an insidious onset.The anxiety of GAD persists for at least six months, with excessive anxiety and worry occurring for more days than not, and for some individuals, persisting daily. Risk factors for GAD are thought to be unresolved conflicts, cognitive misinterpretations, and multiple stressful life events (Boyd, 2008)). Few studies have examined the genetic basis of GAD, but it is thought to be moderately heritable. In clinical settings, the incidence of GAD is equally distributed in women and men. However, in wider studies GAD is twice as common in women.In no studies has the prevalence of GAD been related to race (Boyd, 2008). Patients with GAD often have associated depressive symptoms, and MDD is a common comorbid disorder. For this reason, there has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the course of MDD. However, research shows that many patients with GAD do not present with a distinct MDD symptom profile. This does not support the hypothesis that co-morbidity between MDD and GAD is artificially inflated because of the similar symptom criteria required by th e current diagnostic system.Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria state that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic disorder, or pervasive developmental disorder. For example, a patient who experiences persistent excessive anxiety but has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid anxiety disorder may make MDD harder to resolve or manage.One particular study comparing individuals with MDD and individuals with MDD and a comorbid anxiety disorder showed that after adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been suffering from depression for a longer period, were more likely to experience a r ecurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was also characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and previous suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). Patients with GAD are often highly somatic, with many complaints of physical symptoms. One study concluded that painful physical symptoms in patients with GAD are twice as prevalent as in the control group, which consisted of individuals with neither GAD nor MDD. The presence of comorbid MDD was associated with a significantly higher prevalence of painful physical symptoms. Painful physical symptoms were significantly associated with functioning and health status impairment both in GAD alone and in GAD and comorbid MDD compared with controls (Romera, Fernandez, Perez, Montejo, Caballero, F. Caballero, L. , Arbesu & Gilaberte, 2010). In addition, those with GAD also often experience poor sleep habits, irritability, and poor concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on edge and experience clinically significant distress or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on work functioning, although smaller than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, van Dyck & Penninx, 2010).Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet pills, amphetamines, ginseng, and ma huang, which have all been shown to be anxiety-producing substances (Boyd, 2008). In addition, good sleep hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The nurse should teach the patient breathing control and progressive muscle relaxation as calming techniques, help the patient identify other positive coping strategies, and educate the patient on time management.Pharmacological int erventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reducing anxiety. Roughly 75% of those with GAD have at least one additional current or lifetime psychiatric diagnosis, with MDD being one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use alcohol, anxiolytics or barbiturates to relieve anxiety, and this may lead to abuse and dependency. Such is the case of the patient described in the case analysis, who also has a substance-related disorder.The DSM-IV-TR defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in failure to fulfill major role obligations at work or home, recurrent use in situations that are physically hazardous, recurrent substance related legal problems, or continued use despite feeling persist ent or recurrent effects of the substance. To constitute substance abuse, three or more of these manifestations must be present within a 12-month period.In general, men consume more alcohol and abuse drugs more than women, though women are more likely to abuse prescription medication. Substance abuse and dependency are not correlated so much with gender as with an early age of initiation of substance use (Boyd, 2008). Comorbid mental disorders occur often with substance dependence and abuse. For some, comorbid mental disorders are byproducts of long-term substance abuse. Other people have mental conditions that predispose them to substance abuse, with substance abuse becoming a comorbid problem as they use drugs and/or alcohol to self-medicate existing mental illnesses.There is a well-documented association between depression and alcohol abuse and dependence which cannot be explained solely by the random overlapping of these two conditions. A systematic review of 35 studies estimate d the prevalence of current alcohol problems in depressed patients to be 16%, as compared to 7% in the general population. The three most commonly described causal hypotheses for this comorbidity are as follows: 1) an independent depressive episode (e. g. he self-medication theory), 2) alcohol induced depressive symptoms and 3) the existence of shared biological and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavy drinking occasions were found to be 2. 6 times as likely to be classified as being depressed as men who drank heavily less than four times in the previous 28  days (Levola, Holopainen & Aalto, 2011). Specific substances that have been abused by the patient who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription drugs oxycodone and Valium.At the time of admission, the patient was no longer regularly using drugs or alcohol, but his history of substance abuse, including overdose, is extensive. Thus, although the patient is already withdrawn from drugs and alcohol, his long-term substance use has significant physical and mental consequences. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as reduced concentration and attention, and impaired judgment and memory. In particular, this patient engages in periodic binge drinking, drinking up to 15 drinks in one evening.This alcohol use would result in several days of intoxication, which were interspersed with periods of sobriety. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired motor function and coordination difficulties, emotional lability, stupor, disorientation, and in extreme cases, even coma, respiratory failure, or death. Long-term abuse of alcohol can adversely affect all body systems, and research has shown a conne ction between alcohol dependence and increased risk for diabetes mellitus, gastrointestinal problems, hypertension, liver disease, and stroke (Smith & Book, 2010).Cocaine users typically report that cocaine enhances their feelings of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and agitation are all symptoms or cocaine withdrawal. Withdrawal causes intense depression, craving, and drug seeking behavior that may last for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this patient abused. Patients who abuse benzodiazepines often feel hyperactive or anxious after using them.Often, patients who abuse these drugs combine them with alcohol, putting the patient at risk of coma or death. Symptoms during benzodiazepine withdrawal include anxiety rebound, such as tension, agitation, tremulousness and insomnia, as well as symptoms of autonomic rebound, sensory excitement, motor excitati on, and cognitive excitation, such as nightmares and hallucinations (Boyd, 2008). Opiates are powerful drugs that can quickly trigger addiction when used improperly. Heroin is an opiate that was abused by this patient.Heroin is the most abused and most rapidly acting of all opiates. It can be injected intravenously, and such was the method of delivery for this patient. Heroin produces profound degrees of tolerance and physical dependence. Withdrawal from opiates should be tapered, and if abruptly withdrawn from someone dependent on them, severe physical symptoms may occur, along with nervousness, restlessness and irritability (Boyd, 2008). In addition to heroin use, the patient attempted to commit suicide by overdosing on oxycodone, a prescription opiate.Overcoming substance abuse and preventing relapse can be especially difficult as denial is common in substance abusing patients. Denial is defined as the patient’s inability to accept his loss of control over substance use, o r to accept the consequences associated with the substance use (Boyd, 2008). Because many patients find it difficult or impossible to believe they have a serious problem with drugs and alcohol, many do not seek treatment, or stop treatment prematurely. Motivation is a key predictor of whether individuals will change their substance abuse behavior.Several effective modalities are used effectively to treat addiction, such as 12-step programs, social skills groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques will be more or less helpful. History of Present Illness The patient is a 58-year-old Caucasian male who was participating in a partial hospitalization program (PHP) at Hennepin County Medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his last discharge from the HCMC psychiatric inpatient unit in early March.The patient was coope rative with treatment and medication compliant. He was put on a 72-hour hold after becoming angry and hostile during the PHP group and threatening to hang himself that evening when he got home from PHP. He eventually committed himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be clean, casually dressed, and of normal weight. He is alert and oriented. His attention, cognition, and abstract reasoning are intact, and his thought content is appropriate and organized.In conversation, he is pleasant and cooperative, exhibiting a stable mood and a slightly blunted affect. The patient will talk to staff members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a normal gait but moves quite slowly. In addition it appears that his thought processes are slowed, as he is slow to respond during conversation and seems to have difficulty finding the words to express what he wants to say. The patient appears to have intact recall, short-term, and long-term memory.He appears to be an adequate historian though he exhibits poor judgment due to his depressive and anxious symptoms, as evidenced by his extensive history of drug and alcohol abuse and dependency. The patient has psychiatric diagnoses of severe and recurrent major depressive disorder, generalized anxiety disorder, and polysubstance abuse. The patient has been suffering from MDD with chronic suicidal ideation since age 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at approximately the same time.His extensive history of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a teenager led to a DWI charge. He has participated in mental health outpatient treatment and has undergone chemical dependency treatment numerous times. He completed high school without apparent difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the record. He does not have a history of violent or sexual crime. He has a history of five suicide attempts. He began smoking as a teenager and currently smokes one pack of cigarettes per day.In 1983, the patient married and remained so until his wife died 25 years later, in 2008. He had no children. According to the patient, he was happily married, and he called his relationship with his wife â€Å"the best thing that has ever and will ever happen to me. † While he was married, he got completely clean from drugs and alcohol, remaining drug free and sober for 12 years. Though he struggled with episodes of depression and suicidal ideation, he was able to manage his symptoms with medication and mental health outpatient treatment. Most of my problems faded into the background,† said the patient. During this time, he and his wife bought a condo, and the patient was employed as a janitor and handyman, working at the Minneapolis-Saint Paul airport. He remained at this job for over a decade and was promoted to the position of supervisor. He had, as he said â€Å"everything I ever wanted. † In 2007, his wife became very ill and eventually died in 2008 after complications from a surgery intended to prolong her life. The patient reports that as his wife got sicker, he became increasingly depressed.Unlike in the previous 12 years, medication and outpatient treatment did not seem to manage his symptoms. In addition, he started experiencing extreme and persistent anxiety, feeling â€Å"like I was always one second away from a panic attack. † He was diagnosed with generalized anxiety disorder and was prescribed benzodiazepines to manage this condition. As his wife got sicker, he slowly began to self medicate with alcohol and admitted to â€Å"popping an extra pill† occasionally to decrease his anxiety.When his wife died, the patient became so depressed and anxious that he was unable to concentrate at work. He had to give up his job as a supervisor, and said, â€Å"I couldn’t even manage myself, how was I supposed to handle anyone else. † As his depression and anxiety got worse, he turned increasingly to alcohol and drugs. He reported binge drinking, consuming up to 20 drinks in one evening. He would remain intoxicated for several days, and would switch to using drugs as the alcohol cleared his system. He reported being either drunk, high, or both almost every day.Although he used cocaine and heroine, which were the drugs he used as a teenager, he also became dependent on prescription benzodiazepines to manage his increasingly severe anxiety. The increase in anxiety may be explained by his cocaine use, which, though it reduces anxiety while high, causes increased anxiety with long term use. Additionally, though proper use of benzodiazepines decreases anxiety, benzodiazepine abuse or dependency results in increased anxiety levels. When his request for more prescription benzodiazepines was denie d due to drug seeking behavior, he gained possession of Valium illegally and continued abusing them.He was arrested for illegal Valium possession in 2009, and received two DWIs between 2008 and 2011. His medical record notes that he has a history of antisocial behavior, though it does not expand on this statement beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol addiction, he lost his condo and all of his savings and was living at the Salvation Army homeless shelter by June 2008. His depression grew in severity as the major life losses piled up and his substance dependency problem worsened.In 2008, he lost consciousness due to heroin intoxication. In August of that year, the patient overdosed on oxycodone, intending to kill himself. He was brought to HCMC, and for the past several years has experienced being in and out of the psychiatric inpatient. In 2010, he moved from the homeless shelter to Alte rnative Homes in Minneapolis. Following his latest psychiatric hospitalization in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be returning o Alternative Homes and participating again in the PHP program. A common finding associated with a diagnosis of either MDD, GAD, or substance abuse is the presence of sleep disturbances. Such is the case with the patient described. These sleep disturbances may present themselves as difficulty falling asleep, trouble maintaining sleep, or waking up too early (National Insititute of Health, 2005). This patient currently experiences insomnia, getting only 3-4 hours of sleep per night. Reportedly, this insomnia has been a chronic issue.The insomnia the patient experience sets him up for a negative cycle. Because of his depression and anxiety, it is difficult for the patient to sleep. This lack of sleep, in turn, exacerbates his anxiety and depressive symptoms. As his symptoms p rogress in severity, he turns to substances to self medicate. The use of substances results in a worsening of his insomnia. Thus, finding a way for the patient to get adequate sleep is important. He has tried a variety of medications to promote sleep, but none have been effective.He can no longer be prescribed many of the medications for insomnia because of his history of abuse and overdose using prescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient might also consider participating in a sleep study, as this may reveal additional factors that prevent him from getting the sleep he needs. In addition to his mental illnesses, the patient also has significant medical problems. He has been diagnosed with hypertension, hepatitis C, diabetes mellitus, osteoarthritis of the left shoulder, and acid reflux.Research shows that diabetes mellitus, gastrointestinal problems, hypertension, liver disease are correlated wi th substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patient’s hepatitis C is a direct consequence from his use of street drugs. Interestingly, multiple studies have revealed that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and mortality among diabetic patients (Moffitt et al. 2010). Also, as previously discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patient’s osteoarthritis pain could well be exacerbated by the presence of these psychiatric conditions. Thus, it is possible that with improved management of his psychiatric conditions, his medical problems may improve as well. Family and Social History The patient’s social and family history is somewhat lacking. The patient was adopted at a young age.He has three non-biological brothers and he reports that he is estranged from all of them, and is not willing to contact them until he has â€Å"my life back together. † In addition, both of his adoptive parents are dead. The patient was not keen on discussing his adoptive family or his childhood and adolescence, but stated that this adoptive family â€Å"were good people, and tried hard to give me everything I needed. † He denies any history of physical, emotional, or sexual abuse. According to the social history, there is no history of mental illness in his adoptive family.This does not mean that environmental or social factors play no role in the etiology of his mental illness, but that these factors may be less obvious. Information on the patient’s biological mother and family history is unavailable. The patient was given up for adoption at birth, and remained a ward of the state, living in various foster homes, until he was adopted at age 3. As the patient wa s given up for adoption and adopted at such a young age, he has he has no recollection of his biological family or his time in the foster care system.Any instances of abuse, neglect, or trauma in his early years are thus unknown. Because there is no available family history, it is impossible to know if any of the patient’s first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of information is unfortunate, as it is impossible to conjecture whether, or to what degree, the patient’s mental disorders have a basis in genetics or in disturbed fetal development.Because MDD, GAD, and substance abuse have all been shown to have a moderate to high degree, of heritability, it is very plausible that mood, anxiety, or substance related disorders were present in his biological family. The patient seems to have very limited social support, as he is estranged from his adoptive siblings and has no commu nication with his biological family. The patient also has a history of limited social interactions and close friendships. He reports that he has felt disconnected from others for as long as he remembers, and that he had few close friendships throughout his childhood, adolescence, and adulthood.In addition, the patient reports that most of the relationships that he would call the closest have been with people who have substance abuse problems, as he spent â€Å"years and years running with the wrong crowd. † The basis of most of these relationships was a shared interest in drug and alcohol use, and he does not think that these friends would be of any support to him in pursuing and maintaining recovery. During the time that he was sober, he states that his wife was â€Å"the only friend I really needed† and as a result, he did not form many close friendships with his peers.He states that he currently has no supportive relationships. Furthermore, he has little desire to f orm such relationships. Application of Developmental Theories Viewing the patient and his family and social history through the lens of attachment theory provides a possible framework for viewing the patient’s development of mental illnesses. Attachment theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the importance of stable and secure relationships of all infants, especially those in foster care (Bruskas, 2010).This theoretical approach reasons that infants and children have a need to belong and to experience secure relationships with a small number of consistent â€Å"preferred† primary caregivers in order to successfully develop into normal healthy adults who can actively and emotionally participate in social life (Boyd, 2008). In particular, a child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathy–an inabilityto show affection or concern for others. Research, such as the Adverse Childhood Experiences Study, correlates untreated childhood adversity with an increased risk toward poor developmental health and other major diseases seen later in life such as cardiac disease, depression, and even premature death (Felitti & Anda, 2010).Studies reveal that infants in foster care are among the most vulnerable because of their complex and immense brain development, and the importance of attaining developmental milestones. The onset of brain development begins soon after conception and will continue to mature well into adulthood, but the most abundant and dramatic time of growth is during the first few years of life, specifically within the first three years. The primary and most important developmental milestone for any infant is to establish a relationship, especially one with a primary caregiver.This period presents sensitive â€Å"windows of opportunity† for the development of particular parts of brain structure and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The majority of children entering foster care are infants, and the impact of not addressing mental health needs of preverbal children can have deleterious effects (National Research Council Committee on Integrating the Science of Early Childhood Development, 2000).Although an infant may not be able to articulate losses because of their preverbal age, they nonetheless experience grief and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of unresolved losses have a much more devastati ng affect in infancy than adulthood because of the potentially permanent psychological impact on the developing brain of an infant or child (Bruskas, 2010).Infants and children in foster care who are not afforded supportive primary caregivers to help them develop an internal ability to regulate their own will continue to use whatever coping methods they can. Under stress-provoking adversities such as abuse, neglect, and relationship disruptions, children’s coping strategies to manage such circumstances may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).The relationships infants and children develop while in foster care are crucial; relationships characterized by trust and commitment help an infant or child become more resilient toward the challenges and obstacles that all humans face in life; conversely, a lack of such relationships in life can result in long-term dysfunction socially and physica lly. Attachments and â€Å"templates† of the world are significantly developed by the time a child reaches a year old (Bruskas, 2010).Efforts to address behavioral problems later in life may prove to be more difficult and costly as brain structure becomes permanent and behavior becomes more difficult to change. Due to the patient’s experience of foster care as an infant and toddler, it is likely that he was unable to form a secure attachment with a primary caregiver. Although this disruption in attachment is not the sole contributor to his problems with depression, anxiety, and substance abuse, it is very possible that the chaotic structure of his early years play a large role in the development of these conditions.Applying the concepts of Erikson’s model of psychosocial development allow for a greater understanding of the patient’s current state. Because of the disruption of relationships early in life, the patient may not ever have resolved the developm ental conflict of basic trust vs. mistrust, which is often resolved in infancy. This may be one reason behind his feeling of disconnectedness from others. According to Erikson, this inability to resolve this developmental conflict results in a decreased sense of drive and hope. It is also likely that the patient was able to resolve the developmental conflict of autonomy vs. hame and doubt, which is often resolved in toddlerhood (Boyd, 2008). This may explain the patient’s reliance on his wife as the sole supportive relationship in his life, as well as his fast descent into previous behaviors after his wife’s death. As the patient was never able to develop a sense of autonomy, it seems that he became extremely emotionally dependent on his wife. Because of this relationship, he was able to progress at his job and maintain his recovery. However, with the death of his wife, he was brought back to the conflict of autonomy vs. shame and doubt.Really, it was through the prese nce of his wife that he was able to take initiative, be industrious, and have an intimate relationship, all of which are successful outcomes of developmental conflicts. The marriage provided him with hope, purpose, a sense of devotion and fidelity, as well as affiliation and love. In short, it seems that his wife was his mental and emotional anchor. The recurrence of symptoms of his mental disorders after the loss of the anchor of his life threw him back into the early developmental conflicts that he was unable to resolve due to his unstable childhood.According to Erikson, in order for the patient to move forward from his regressed state he must tackle and resolve the conflicts of trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role diffusion, and intimacy vs. , isolation to reach the adulthood stage of generativity vs. stagnation. Ultimately, with the resolution of all these conflict, the patient will reach a mature sta te in which he is able to attain ego integrity instead of falling into despair. Patient Prognosis and Treatment RecommendationsIt is important to remember that the patient was seeking help and trying to recover prior to his most recent hospitalization. He was enrolled in and regularly attending the partial hospitalization program. In addition, he was no longer abusing drugs or alcohol. PHP staff report that he had been medication compliant, cooperative, and was motivated to change. The patient’s recent hospitalization was precipitated by a change in drug dose and type. He reported that it was only after the medication change that the suicidal ideation intensified.Thus, an important goal for this patient is to find the drug types and dosages that will successfully manage his depression and anxiety. However, because the patient has such an extensive history of addiction, primary care providers are hesitant to prescribe large dosages of often highly addictive medications. This h esitation is especially understandable given the patients past abuse of prescription drugs, including an overdose with the intent to commit suicide. However, the types and dosages of the drugs he is currently receiving are not enough to manage his symptoms.The severity of the patient’s depression and anxiety necessitates the use of powerful antidepressants and anxiolytics, but his past substance abuse and dependency make the prescription of these drugs a last resort. Appropriate pharmacotherapy is also complicated by the fact that this patient has tried various classes and types of drugs to manage his symptoms, but no drug therapy has been effective enough to prevent the periodic recurrences of major episodes of depression and anxiety.To manage his depression, the patient has tried typical and atypical antipsychotics, anticonvulsants, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressan ts, such as Serotonin Norepinephrine Reuptake inhibitors, Norepinephrine Dopamine Reuptake Inhibitors, Alpha-2 Antagonists, and Serotonin-2 Antagonist/Reuptake Inhibitors. Although the apparent failure of all these drugs to manage his depression might cause one to suspect that he is exhibiting purely drug seeking behaviors, the depressive symptoms he xperiences impair and affect him so severely that a denial of the reality of these symptoms would be unsafe and unethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patient’s anxiety is more easily managed than his depression, and benzodiazepines have proven effective. However, his past abuse of benzodiazepines make his primary care providers reluctant to give them to him, and they have prescribed non-benzodiazepines, such as Buspar and Zolpidem, instead.Unfortunately, these medications have not been effective in controlling the pati ent’s anxiety. As a result, the patient has been asking repeatedly for benzodiazepines, while promising that he will use them responsibly. Ultimately, for the patient to achieve effective maintenance of his comorbid mental disorders, he must be able to take medications as prescribed. Due to his history of substance abuse and his still unstable depression and anxiety, it is unlikely that the patient will be able to take his medications as prescribed.It is recommended that a staff member have control of his drugs while he is attending the PHP, and that once discharged, a home health nurse be sent to administer his medication. This would reduce the potential for abuse. In addition, the use of coping mechanisms besides substance abuse may help the patient adhere to the prescribed drug regimen, as well as decrease his depression and anxiety. Coping skills the patient has identified as helpful are watching television and spending some quiet time alone.However, interaction with othe rs should also be encouraged, as too much time spent alone will only reinforce depressive symptoms of isolation. An increase in the quantity and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively correlated with depressive symptoms and anxiety levels. The patient’s prognosis is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had maintained a long period of sobriety prior to this, during which he was happy, productive, and high functioning.The patient’s ability to achieve remission from his mental illnesses during his marriage to his wife shows that investing in a supportive relationship is an important and powerful coping skill for this patient. Thus, if the patient is able to form and maintain new supportive relationships, his chance of recovery will improve substantially. It is also important to remember that he was doing very w ell until his wife died. According to the Holmes and Rahe Index, the death of a spouse is the number one most stressful event that occurs in the life of an individual (Perry & Potter, 2009).It is not an exaggeration to say that with his wife’s death, life as he knew it ended. Many people experience periods of long and severe depression following the death of a loved one. For this patient, his descent into depression, combined with the resurgence of his anxiety sent his life into a complete tailspin. Under the severe stress of not only his wife’s death but also his inability to keep working, he returned to his former coping mechanisms of drug and alcohol abuse.These habits detracted him from working through the grief of his wife’s death, and furthermore caused him to lose his house and his savings, thus increasing his depression and anxiety, thus perpetuating the substance abuse. Now that the patient has withdrawn from drugs and alcohol and is in a safe environme nt, he can continue his grief work. As a result, his depression may begin to subside, and he may be able to get closer to his previous level of functioning. DSM-IV-TR Axis I: Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse Axis II: Cluster B traitsAxis III: Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, Acid Reflux, Bilateral hearing loss Axis IV: Chronic mental illnesses, chronic medical conditions, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V: 35 (current), 75 (potential) Patient Goals: †¢ I want to find medications that will help my depression and anxiety †¢ I want to keep from abusing my medications †¢ I want my grief over my wife’s death to get better †¢ I want to take one day at a time †¢ I want to feel less alone †¢ I want to get better sleepNursing Goal: Patient will be safe during hos pital stay. Interventions: †¢ Assess for suicidal ideation every shift. †¢ Perform rounds every 15 minutes to ensure patient safety. †¢ Ensure that the patient has no access to potentially harmful objects and/or substances. †¢ Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. Nursing Goal: Patient will seek help in dealing with grief-associated problems. Interventions: †¢ Develop a trusting relationship with the client by using empathetic therapeutic communication (Eakes, Burke & Hainsworth, 1998). Educate the client that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever (Matthews & Marwit, 2004). †¢ Identify available community resources, including grief counselors and community or Web-based bereavement groups. †¢ Focus on enhanci ng coping skills to alleviate life problems and distressing symptoms such as anxiety and depression. Nursing Goal: Patient will practice social and communication skills needed to interact with others. Interventions: †¢ Discuss causes of perceived or actual isolation. Assess the patient’s ability and/or inability to meet physical, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated. †¢ Use active listening skills to establish trust one on one and then gradually introduce the patient to others. †¢ Provide positive reinforcement when the patient seeks out others. †¢ Encourage the client to be involved in meaningful social relationships and support personal attributes (Gulick, 2001). Nursing Goal: Patient will use effective coping strategies instead of abusing drugs and alcohol.Interventions: †¢ Assist the client to set realistic goals and identify personal skills and knowledge. †¢ Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals. †¢ Offer instruction regarding alternative coping strategies (Christie & Moore, 2005). †¢ Encourage use of spiritual resources as desired. Nursing Goal: Patient will identify actions that can be taken to improve quality of sleep.Interventions: †¢ Obtain a sleep-wake history, including history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. †¢ Encourage the patient to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. †¢ Encourage the patient to use soothing music to facilitate sleep (Lai & Good, 2005). †¢ Teach the patient sleep hygiene guidelines for improving sleep habits (ie. go to bed only when sleepy, avoid afternoon an d evening naps, use the bed only for sleeping, get up at the same time every morning). Use relaxation techniques to decrease anxiety before going to sleep. †¢ Refer to a sleep center if interventions are ineffective. Analysis of Interaction Before interacting with the patient, I read the patient’s medical record and notes. I paid particular attention to ways the patient said he learned best, which for my patient was one on one conversation. Prior to approaching the client, I asked myself if I had any beliefs, biases, or limitations that would affect my interaction with the patient or prevent the formation of a therapeutic relationship.In order to set the tone of a professional therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I made some small talk with him about such topics as sports and the patient’s hobbies in order to show interest in the patient and develop rapport. During this conversation, t he patient grew more visibly at ease. His face became less taut, his answers became longer and less forced, and he moved from an erect posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he wanted to use. Such a speech pattern is characteristic of depression, one of the patient’s psychiatric diagnoses. This first conversation was punctuated with the start of morning group. After morning group, I gave the patient some space, as I did not want him to feel overwhelmed or threatened by my questions. About a half hour later, I asked the patient if we could continue the conversation we were having that morning, and he agreed without hesitation. In this second interaction, I began with a few open-ended questions about how group had been.I then started asking the patient some more questions about his readmission into the hospital and precipitating events. I asked open-ended question, and often responded to h is answers by asking further open-ended questions. For example, after asking the patient if he was having suicidal thoughts, he responded that he did not want to hurt himself right now. I replied with the open-ended question, â€Å"So are you feeling safe? † using reflection to redirect the idea back to the patient and allow him to explore whether or not he felt safe.I focused on actively listening to the patient, following the patient’s lead and sometimes asking clarifying questions. Because of the patient’s slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed at his own pace. As the patient told me more about recent events in his life, including the death of his wife, the loss of his job and his descent into substance abuse, he began to look away more and more. This decrease in eye contact might be the result of the patient feeling ashamed, embarrassed, or guilty about his feelings and behaviors.In order to mai ntain connection with the patient and assure him of my nonjudgmental view of his situation, I used empathy and restatement, saying, â€Å"It sounds as though you have had a very difficult past couple of years. † Upon saying this, the patient looked up, maintained eye contact, and agreed. He then began to expand on his current feeling of hopelessness, saying, â€Å"I wonder if life is worth living, and sometimes I just want to go to sleep and not wake up. † As he explored and expanded on his feelings I alternated between using silence and validating what he said.The silence allowed him to express intense feelings without interruption, while statements of restatement and interpretation, such as â€Å" It sounds like you have been feeling pretty hopeless,† demonstrated empathy and a nonjudgmental attitude toward what the client was feeling. At one point, the patient put his head in his hands, saying â€Å"I had so much going for me, and after my wife died, everyth ing went to pot. † I felt that in this moment, what the client needed was neither a cheery reassurance that things would get better, nor dispensation of advice, but rather a person to understand and acknowledge his current misery.I replied that sometimes life gets you down, and sometimes when it rains it pours, and it’s ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat silently with him for 2-3 minutes, as I felt it was important for him to feel, sit with, and process these emotions for a short period of time. During these periods of silence, I continued to lean forward slightly, as I had done throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.Because I had acknowledged the patient’s hardships and thereby connected with him, I felt that I was in a good position to explore with him goals he had for the future, and ideas th at could help him reach these goals. I made sure to approach this topic not by giving advice or suggestions, but by asking him open-ended questions about what things made him feel less sad or anxious and what things he wanted to work on during his stay. These open ended questions elicited the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didn’t seem to work.He also stated that he knew he needed to â€Å"continue grieving my wife, because the drugs and alcohol kept me from doing that. † I thought that this realization of substance abuse as inhibitory to his grief process was very insightful, and told him so. He made a small smiling expression and responded that he wanted to â€Å"get back on the straight and narrow† and take his medications â€Å"the way I’m supposed to—no more, no less. † The patient’s elucidation of his goals and his insight into help ful and hindering coping devices was a very positive outcome of this therapeutic conversation.The patient seemed less burdened after the opportunity to talk about his recent losses in life, and more hopeful after verbalizing his goals and ways to meet them. References Ackley, B. J. & Ladwig, G. B. (2008). Nursing Diagnosis Handbook (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. American Psychological Association. (2002). Boyd, M. A. (2008). Psychiatric nursing: contemporary practice (4th ed. ). New York: Lippincott Williams & Wilkins. Bruskas, D. (2010). Developmental health of infants and children subsequent to foster care.Journal of Child and Adolescent Psychiatric Nursing, 23(4), 231-241. doi:http://dx. doi. org/10. 1111/j. 1744-6171. 2010. 00249. x Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211-218. Cohn, A. M. , Epstein, E. E. , McCrady, B. S. , Jensen, N. , HunterReel, D. , Green, K. E. , & Drapki n, M. L. (2011). Pretreatment clinical and risk correlates of substance use disorder patients with primary depression. Journal of Studies on Alcohol and Drugs, 72(1), 151-157. Eakes, G. G. , Burke, M. L. & Hainsworth, M. A. 1998). Middle-range theory of chronic sorrow. Image Journal Nursing Scholar, 30, 179. Felitti, V. J. & Anda, R. F. (2010). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. Cambridge University Press. Gulick, E. (2001). Emotional distress and activities of daily living functioning in persons with multiple sclerosis. Nursing Resolutions, 50(3), 147-154. Lai, H. L. & Good, M. (2005). Music improves sleep quality in older adults. Journal of Advanced Nursing, 49(3), 234-244.Lawrence, A. E. , Liverant, G. I. , Rosellini, A. J. , & Brown, T. A. (2009). Generalized anxiety disorder within the course of major depressive disorder: Examining the utility of theDSM-IV hierarchy rule. Depression and Anxiety, 26(10), 909-916. Levola, J. , Holopainen, A. , & Aalto, M. (2011). Depression and heavy drinking occasions: A cross-sectional general population study. Addictive Behaviors, 36(4), 375-380. doi:http://dx. doi. org/10. 1016/j. addbeh. 2010. 12. 015 Matthews, L. & Marwit, S. (2004). Complicated grief and the trend toward cognitive-behavioral therapy.Death Studies, 28, 849-863. Moffitt, T. E. , Caspi, A. , Harrington, H. , Milne, B. , Melchior, M. , Goldberg, D. , & Poulton, R. (2010). Generalized anxiety disorder and depression: Childhood risk factors in a birth cohort followed to age 32 years. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V (pp. 217-239). Washington, DC, US: American Psychiatric Association; US. National Institute of Health. (2005). National Research Council Committee on Integrating the Science of Early Childhood Development. (2000). Perry, A. G. , Potter, P.A. (2009). Fundamentals of Nursing (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. Plaisier, I. , Beekman, A. T. F. , de Graaf, R. , Smit, J. H. , van Dyck, R. , & Penninx, B. W. J. H. (2010). Work functioning in persons with depressive and anxiety disorders: The role of specific psychopathological characteristics. Journal of Affective Disorders, 125(1-3), 198-206. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 01. 072 President and Fellows of Harvard College. (2011). Harvard Mental Health Letter. Harvard Health Publications. Retrieved from http://www. health. harvard. du Romera, I. , FernandezPerez, S. , Montejo, A. L. , Caballero, F. , Caballero, L. , Arbesu, J. A. , . . . Gilaberte, I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127(1-3), 160-168. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 05. 009 Seo, H. , Jung, Y. , Kim, T. , Kim, J. , Lee, M. , Kim, J. , . . . Jun, T. (2011). Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression.Journal of Nervous and Mental Disease, 199(1), 42-48. doi:http://dx. doi. org/10. 1097/NMD. 0b013e3182043b60 Smith, J. P. , & Book, S. W. (2010). Comorbidity of generalized anxiety disorder and alcohol use disorders among individuals seeking outpatient substance abuse treatment. Addictive Behaviors, 35(1), 42-45. doi:http://dx. doi. org/10. 1016/j. addbeh. 2009. 07. 002 Sunderland, M. , Mewton, L. , Slade, T. , & Baillie, A. J. (2010). Investigating differential symptom profiles in major depressive episode with and without generalized anxiety disorder: True co-morbidity or symptom similarity?Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 40(7), 1113-1123. doi:http://dx. doi. org/10. 1017/S0033291709991590 United States Department of Health and Human Services. (1999). Yen, Y. , Rebok, G. W. , Gallo, J. J. , Jones, R. N. , & Tennstedt, S. L. (2011). Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. The American Journal of Geriatric Psychiatry, 19(2), 142-150. doi:http://dx. doi. org/10. 1097/JGP. 0b013e3181e89894 Case

Chemistry Lab Report on standardization of acid and bases Essay

Purpose: To prepare standardize solution of sodium hydroxide and to determine the concentration of unknown sulfuric acid solution. Data and Calculations: This experiment is divided into two parts (Part A and Part B). In the first part of experiment, the standardize solution of sodium hydroxide is prepared by titrating it with base Potassium hydrogen phthalate (KHP). The indicator Phenolphthalein is used to determine that whether titration is complete or not. PART A: Standardization of a Sodium Hydroxide solution NaOH Sample Code = O Trial 1 Mass of KHP transferred = 0.42 g Volume of Distilled water = 25 mL Volume of NaOH used = 22.50 mL Molar mass of KHP = 204.22 g/mol No. of moles of KHP = Mass of KHP used / Molar mass = 0.42 g / 204.22 g/mol = 0.0021 moles Concentration of NaOH = No. of moles / Volume = [0.0021 mol / {(22.50 + 25) / 1000} L] * 100 = 4.4 M Trial 2 Mass of KHP transferred = 0.4139 g Volume of Distilled water = 25 mL Volume of NaOH used = 22.80 mL Molar mass of KHP = 204.22 g/mol No. of moles of KHP = Mass of KHP used / Molar mass = 0.4139 g / 204.22 g/mol = 0.0020267 moles Concentration of NaOH = No. of moles / Volume = [0.0020267 mol / {(22.80 + 25) / 1000} L] * 100 = 4.24 M Trial 3 Mass of KHP transferred = 0.4239 g Volume of Distilled water = 25 mL Volume of NaOH used = 23.10 mL Molar mass of KHP = 204.22 g/mol No. of moles of KHP = Mass of KHP used / Molar mass = 0.4239 g / 204.22 g/mol = 0.0020757 moles Concentratio n of NaOH = No. of moles / Volume = [0.0020757 mol / {(23.10 + 25) / 1000} L] * 100 = 4.32 M Trial 4 Mass of KHP transferred = 0.4311 g Volume of Distilled water = 25 mL Volume of NaOH used = 22.60 mL Molar mass of KHP = 204.22 g/mol No. of moles of KHP = Mass of KHP used / Molar mass = 0.4311 g / 204.22 g/mol = 0.0021109 moles Concentration of NaOH = No. of moles / Volume = [0.0021109 mol / {(22.60 + 25) / 1000} L] * 100 = 4.43 M Table: Trail 1 Mass weighing bottle + KHP (g) Mass empty weighing bottle (g) Mass of KHP transferred (g) Initial volume of burette, Vi (mL) Final Volume of burette, Vf(mL) Volume of NaOH used (mL) Trial 2 Trial 3 Trial 4 11.561 11.6217 11.6113 11.6329 11.1461 11.2078 11.1874 11.2018 0.4200 0.4139 0.4239 0.4311 4.30 6.30 10.1 33.20 26.80 29.10 33.20 55.80 22.50 22.80 23.10 22.60 Concentration of NaOH (moles/L) 4.4 4.24 4.32 Average concentration of NaOH = [4.4 M + 4.24 M + 4.32 M + 4.43 M] / 4 = 4.35 M 1. % Difference between Trial 1 and Trail 2 = [4.24 M / 4.4 M] * 100 % = 96.3 % Difference = (100 – 96.3) % = 3.7 % 2. % Difference between Trial 2 and Trail 3 = [4.24 M / 4.32 M] * 100 % = 98.1 % Difference = (100 – 98.1) % = 1.9 % 3. % Difference between Trial 3 and Trail 4 = [4.32 M / 4.43 M] * 100 % = 97.5 % Difference = (100 – 97.5) % = 2.5 % 4.43 Observations: KHP is white color crystals and has definite shape. NaOH is clear and transparent solution with no color. In the first trial, after adding 90 drops of NaOH solution there was repeatedly appearance and disappearance of light pink color. When the whole solution of KHP and water get titrated then, the color of solution becomes light pink and it stays permanently. The same color changes happen with the next three trials. Concentration of NaOH was almost similar for every trials. PART B: Concentration of Sulfuric Acid solution H2SO4 Sample Code = 34 Trial 1: Volume diluted acid = 25 mL Volume of NaOH used = 14.39 mL H2SO4 (aq) + 2NaOH (aq) 2H2O (l) + 2Na2SO4 (aq) Average concentration of NaOH = 4.35 M No. of moles of NaOH = (Average concentration of NaOH) * (Volume of NaOH used) = 4.35 M * (14.39 / 1000) L = 0.0626 moles No. of moles of H2SO4 = 0.0626 mol / 2 = 0.0313 moles Concentration of H2SO4 = No. of moles / (volume of diluted acid / 1000) = 0.0313 mol / (25 / 1000) L = 1.2 M Trial 2: Volume diluted acid = 25 mL Volume of NaOH used = 13.51 mL H2SO4 (aq) + 2NaOH (aq) 2H2O (l) + 2Na2SO4 (aq) Average concentration of NaOH = 4.35 M No. of moles of NaOH = (Average concentration of NaOH) * (Volume of NaOH used) = 4.35 M * (13.51 / 1000) L = 0.0588 moles No. of moles of H2SO4 = 0.0588 mol / 2 = 0.0294 moles Concentration of H2SO4 = No. of moles / (volume of diluted acid / 1000) = 0.0294 mol / (25 / 1000) L = 1.2 M Trial 3: Volume diluted acid = 25 mL Volume of NaOH used = 14.10 mL H2SO4 (aq) + 2NaOH (aq) 2H2O (l) + 2Na2SO4 (aq) Av erage concentration of NaOH = 4.35 M No. of moles of NaOH = (Average concentration of NaOH) * (Volume of NaOH used) = 4.35 M * (14.10 / 1000) L = 0.0613 moles No. of moles of H2SO4 = 0.0613 mol / 2 = 0.0307 moles Concentration of H2SO4 = No. of moles / (volume of diluted acid / 1000) = 0.0307 mol / (25 / 1000) L = 1.2 M Trial 4: Volume diluted acid = 25 mL Volume of NaOH used = 14.20 mL H2SO4 (aq) + 2NaOH (aq) 2H2O (l) + 2Na2SO4 (aq) Average concentration of NaOH = 4.35 M No. of moles of NaOH = (Average concentration of NaOH) * (Volume of NaOH used) = 4.35 M * (14.20 / 1000) L = 0.0618 moles No. of moles of H2SO4 = 0.0618 mol / 2 = 0.0309 moles Concentration of H2SO4 = No. of moles /  (volume of diluted acid / 1000) = 0.0309 mol / (25 / 1000) L = 1.2 M % Difference between Trail 1 and Trail 2 = [1.2 M / 1.2 M] * 100 % = 100 % Difference = (100 – 100) % =0% % Difference between Trail 1 and Trail 2 = [1.2 M / 1.2 M] * 100 % = 100 % Difference = (100 – 100) % =0% % Diff erence between Trail 1 and Trail 2 = [1.2 M / 1.2 M] * 100 % = 100 % Difference = (100 – 100) % =0% % Difference between Trail 1 and Trail 2 = [1.2 M / 1.2 M] * 100 % = 100 % Difference = (100 – 100) % =0% Table 2: Trail 1 Volume diluted acid titrated (mL) Initial Volume of burette, Vi (mL) Final Volume of burette, Vf (mL) Volume NaOH used (mL) Concentration Of Sulfuric Acid Trail 2 Trial 3 Trial 4 25 25 25 25 2.41 17.20 8.50 22.60 16.94 30.71 22.60 36.80 14.39 13.51 14.10 14.20 1.2 M 1.2 M 1.2 M 1.2 M Observations: The H2SO4 is colorless and transparent liquid. The NaOH solution is colorless, odorless and transparent liquid. While doing the first trail, there were continuous appearance and disappearance of light pink color. After adding 10 mL of NaOH solution the pink color starts appearing. At certain volume the light pink color appeared, indicating that titration is done. The indictor phenolphthalein has no color and there was no specific odor of reagent. Discussion: Average concentration of NaOH solution was 4.35 M. There are many sources of error in this experiment as we got some percentage differences in the two different trials. For the Trial 1 and Trial 2, the percentage difference is 3.7 % which is significant difference to be noted. This percentage difference could occur due to many reasons such as not measuring the KHP properly as we got 0.42 g for first trial and 0.4139 g for second trial of KHP for performing titration but it is more than required value as per literature value is concerned (0.40 g). The almost same percentagedifference occurs for next two trials (1.9 % and 2.5 %). The KHP is always 99.9 % pure, so the titration should give perfect results (Lab Manual). The other possible errors was due to the disturbance on the shelf by other students where analytical balance is placed in balance room, as it cause variability in the values in weight of KHP. In Part B of experiment, the average concentration of sulfuric was found to be 1.2 M and there was 100 % titration of both reagent (NaOH and H2SO4). This 100 % results comes due to significant figures, if significant figures would not be concerned then there would be error of 1.0 % to 2.0 % in every two trials. There was identical difference of volume of NaOH used to titrate the acid for each  trial due to some possible errors. The possible errors in this Part of experiment were same as for Part A, as the process is followed in the same way. The most significant error could occur by not shaking the flask properly while adding sodium hydroxide solution and not recognizing the pink color on the instant it appears and adding the NaOH solution vigorously into the sulfuric acid. Questions: The 10 mL volumetric pipette is rinse 2 or 5 times to make sure there is no bubble inside because air bubble can cause error in the measurement of concentration because the actual volume of unknown will be less. The accuracy and precision for both sets of experiment was almost same as there were percentage difference of concentrations lies only in 2 % to 4 %. The endpoints of titration for each set of trails in both cases (Part A and Part B) were almost same but there is little difference in volume of NaOH used which cause errors in accuracy and precision of experiment. Using the analytical balance is really careful job as it is most accurate weighing machine with accuracy of 0.0004 g (Lab Manual) and we need to be prà ©cised using the balance but some few disturbance can cause big error such as disturbance other students on the shelf it is placed on and not reading the balance properly and taking measurements fastly. Using Volumetric glassware is other method to be more accurate in experiment but there are some possible random error while reading the values such as not reading the lower meniscus of liquid cause error and not removing the air bubble from the burette and using the beaker in place graduated cylinder in case of volume as graduated cylinder is more accurate as compared to beaker (0.02 g) (Lab Manual). Sources of Experimental Error include: The Analytical balance could give wrong reading because of the disturbance due to other students on the shelf it is placed on. Also, taking the reading rapidly and not considering the reading when balance display gets steady. The possible error can occur using wrong glassware like using beaker instead of graduated cylinder. The error could occur while taking reading through graduated cylinder and not considering the lower meniscus of liquid. The air bubble in burette can cause error in the true value of NaOH used. Few drops of liquid remain in burette and volumetric pipette which causes the error. Not shaking the flask properly while adding the NaOH solution. Adding the NaOH solution vigorously into the flask. Not recognizing the pink color instantly as it appears.  Adding the more drops of indicator as needed (2 or 3 drops). The biggest error occur due to leaking of NaOH solution form burette, we lost 4 drops during every one trial and it cause the significant error in reading the volume of NaOH used. There is water left after washing the glass wares which can cause the error. This lab could be improved by improving the method of drying the graduated cylinder and beaker before filling it with the NaOH solution. The glassware could be dried by small amount of acetone. Any acetone could be removed by evaporation. Finally, the experimenter should remove the clinging droplets to the neck of burette and volumetric pipette by using Kim Wipe. Conclusion: After careful consideration of all the results and all the possible concentration, it is concluded that the average concentration of NaOH (sample code O) was 4.35 M and average concentration of H2SO4 (sample code 34) was 1.2 M.

The eNotes Blog The Point of Life Was to Press On Remembering TomClancy

The Point of Life Was to Press On Remembering TomClancy Fans of espionage and military science novels have lost one of that genres most popular authors. Tom Clancy has died at age 66.   The cause of death has not yet been released. Here are some facts about Clancy that you may not know: Worked as an insurance salesman after attending Loyola College. Tried, but failed, to purchase the Minnesota Vikings. Divorced after thirty years following revelations of an affair with a New York Assistant D.A. Second wife is the niece of General Colin Powell. Although he loved the military, poor eyesight prevented him from enlisting. In 1984, President Ronald Reagan boosted sales of Clancys first novel,  The Hunt for Red October, by praising it at a press conference. Its a really good yarn, Reagan said. Founded the gaming company Red Storm Entertainment in 1996 and sold it for a reported $45 million Was the  co-owns the Baltimore Orioles Tom Clancy was one of the best-selling authors of the last thirty years.   In addition to  The Hunt for Red October,  his other popular works included  Patriot Games  (1988),  Clear and Present Danger (1989), and  The Sum of All Fears (1991).

How to Make Changes to Your MCAT Registration

How to Make Changes to Your MCAT Registration When you choose an MCAT test date, pay the registration fees, and complete your MCAT registration, you never figure that you may have to make a change. However, when it comes to your MCAT registration, you can certainly make changes if life doesnt work out according to your carefully made plans. Read on for ways to change your test center, change your test date or time, or cancel your MCAT registration. Change Your MCAT Test Center, Test Time or Test Date Shifting your test center or registering for a different test date or time isnt really all that difficult, providing there is space at the new center where youd like to test and availability on the dates youve provided. And there are benefits to changing multiple things at once if you need to change your test center and test date, for instance. If you change them separately, youll be charged a rescheduling fee twice. Change them together and youll only be charged once. There are a few caveats, though: You must make a change prior to the Silver Zone registration deadline for the exam for which youre currently registered.You cant change your test date before registration has opened for the new exam date as no special permissions or privileges are granted in registration order to previously registered testers.Rescheduling into an exam date that is within the Bronze Zone will cost you an additional $50. This fee is the difference between the initial Silver Zone registration fee ($275) and the initial Bronze Zone registration fee ($325). Cancel Your MCAT Registration Lets say youre called away on military duty. Or, heaven forbid, theres a death in your immediate family. Or, youve decided that you dont want to take the MCAT on your registered date and youre not sure when (or if!) youd like to register again. What can you do? If theres no emergency- youd just like to cancel for your own personal reasons- then here are the details: You must cancel before the end of the Gold Zone registration deadline in order to receive a partial refund- $135 for standard testers and $50 for FAP recipients.If you cancel after the Gold Zone registration deadline, you will not receive a refund at all! So youd better make sure youd really like to cancel.If you decide to register for a new test date in the same calendar year in which youve canceled, then youll have to pay the entire registration fee again, along with a rescheduling fee, which is nonrefundable. If youve experienced a crisis like being hospitalized or having a death in the family OR youre called away on military duty or to help medically in a catastrophic event, then you can receive a maximum of $135 no matter when the cancellation occurs. If youre a FAP recipient, youll receive a $50 cancellation reimbursement. Youll need to contact the MCAT Resource Center either by phone (202) 828-0690 or by email at mcataamc.org for instructions regarding canceling during a crisis. Please note that youll be required to provide either military papers explaining the dates of your deployment and length of service, a funeral program or death certificate, or medical documentation explaining the duration of your hospital stay. Make an MCAT Registration Change Here If youve decided you need to change your MCAT registration for any reason, you can log into the MCAT Scheduling and Registration System to make the necessary adjustments to your testing experience.