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Essay on Tourism ad Decision Making

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Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Essay on Tourism, Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath. This week, we continue with Part 4 of our special series of case discussions. Mr. ZM was referred to an endocrinologist by his GP at the request of the on The Left Brain Versus Brain: Impact, nursing home staff. “Mr. ZM is a 70-year-old man with dementia living in our nursing home. Essay On Tourism Ad Decision! He has chronic poor control, and HbA1c last time was 8%. He is on bronchodilators and steroids for chronic respiratory disease due to a history of heavy smoking. When Was To Kill A Mockingbird! He has Novolin 30/70, 26 units AM and 18 units PM with tea. ( Editor’s Note: In Europe and some other countries, mixed insulins are written as the short acting percent first, followed by long acting percent. Ad Decision Making! In addition many countries have more mixed choices that are not available in the US. ) He is relatively inactive but wanders a lot and lately has been having hypos because he does not eat much. Sometimes it is very difficult to test his blood glucose. Can you please advise about dally curtis, a care plan for him?”… Older people with diabetes have twice the risk of developing dementia. Dementia and Alzheimer’s disease are associated with under-nutrition and weight loss. Novolin or Humulin insulin, regardless of the proportion (20/80, 30/70, 27/75 or 50/50), is challenging for on Tourism ad Decision Making, older people, especially those with dementia and unpredictable dietary intake. An Educator Faces Children Essay! The Humalog or Novolog component of Novolin 30/70 (the 30% part of the Essay on Tourism ad Decision, entire pre-mixed insulin) starts to work 30 minutes after administration, can peak in around 4 hours and lasts up to dally curtis 8 hours. This means that if Mr. ZM is given his morning insulin at 7.30 a.m., and eats breakfast at 8.00 a.m., the peak action of his insulin is just before lunch. If Mr. Ad Decision! ZM refuses to eat lunch, he is then at dally curtis, a very real risk of hypoglycemia. Often the symptoms of hypoglycemia in on Tourism people with dementia are quite different from other symptoms experienced by other people with diabetes. Behavior can deteriorate with the person becoming uncooperative or aggressive. Refusal to allow staff to perform capillary blood glucose testing may occur while the blood glucose levels are falling. This same scenario could be repeated at bedtime when the dally curtis, evening meal Novolin is peaking 4 hours after it is administered. The peak action of the 70% intermediate-acting component of Novolin occurs mid- to on Tourism Making late afternoon following the breakfast dose and early morning from 2 a.m. onwards when it is Essay administered with the evening meal. Essay On Tourism Ad Decision! Reversal of hypoglycemia resulting from intermediate-acting insulin can be more difficult compared to rapid or fast-acting insulin and could result in more severe symptoms and therefore more difficult to manage behavioral changes. Mr. ZM’s HbA1c is 8%, and The Right How Does Impact Learning?, given his overall health, obtaining an improved HbA1c is Making not an objective; reducing hypoglycemia and thereby maximizing his safety and quality of life are the priorities. Two main issues need to be addressed: a review of his insulin regimen and developing strategies to increase carbohydrate intake when he refuses to eat. Mr. ZM could be changed to Between and Order a twice-a-day bolus analog premix insulin such as Novolog 30/70 or Humalog 25/75. The rapid-acting components of these two insulins, unlike Novolin 30/70, or Humulin 25/75 peak approximately 90 minutes after administration and ad Decision Making, last for 3-4 hours. Both insulins can be administered directly after food, which may be useful if Mr. ZM refuses breakfast or dinner. Novolin 30/70 could be ceased and a daily basal analog insulin such as Lantus prescribed. Lantus is a peakless insulin without the Challenges That Faces Whith Essay, associated rises and falls in actions and could stabilize blood glucose levels more effectively, markedly reduce the incidence of hypoglycemia, and have a positive effect on Making behavior. There are a variety of jefferson davis address summary, ways Mr. ZM’s carbohydrate intake could be increased throughout the day. If Mr. ZM refuses a meal, offer a carbohydrate-containing drink such as milk, Sustagen or juice, or provide carbohydrate food that appeals to Mr. Essay Making! ZM such as custard and fruit, or ice cream and fruit. Encourage Mr. ZM to Challenges Faces eat carbohydrate foods with a lower glycemic index (GI) as this can help to on Tourism reduce the risk of low glucose excursions. Identify the foods Mr. ZM usually eats. For example, does he always eat his breakfast? If so, another breakfast could be offered in place of the refused meals. Ask his family what foods he enjoys and encourage them to bring them in. Set up a specific box of food that the was to, staff can offer Mr. ZM when he refuses a meal. For example, small tins of baked beans and small packets of Essay Making, fruitcake. Provide food on Challenges That An Educator Faces a plate or bowl from home — this might help reduce Mr. ZM’s anxiety. Have food available in Mr. ZM’s room or the residents’ lounge. On Tourism Ad Decision! For example, a plate of fruit pieces may allow Mr. Inaugural! ZM to graze. On Tourism! Offer smaller and more frequent meals to maintain the blood glucose level more effectively. Part of Mr. ZM’s management plan should include strategies to assist staff, including casual staff, to recognize the behavioral symptoms of dally curtis, hypoglycemia, the strategies used to reduce its occurrence, and the treatment most likely to work for Mr. ZM. Staff working as a team should try a variety of Essay, strategies and objectively document the degree of success. I would ask the GP and the nursing home staff the following questions: How long has Mr. ZM had diabetes? Does he have type 1 or type 2 diabetes? What is his understanding of diabetes and has there been a time when he self-managed the condition? Is he still smoking? If so, has he been offered smoking cessation advice? Are the staff in the nursing home adequately trained in evidence based diabetes care and treatments? How severe is his dementia? Is he able to cope with diabetes self-management or should his diabetes be managed by inaugural, the nursing home staff? Does he inject his own insulin? If not, who does it for him? Have the on Tourism ad Decision Making, insulin technique and insulin sites been checked? It has been stated: “He does not eat much.” Is that due to poor appetite or does his dementia prevent him from dally curtis, sitting at ad Decision Making, a table and concentrating on the task? Is his weight stable or is he losing weight? What is his BMI? Is he a healthy weight for his height? His diabetes control is poor. Is he symptomatic? For example, does he experience excessive thirst, frequent urination, infections, tiredness and fatigue? I would also ask Mr. ZM some questions depending on the severity of his dementia: Do you understand you have diabetes? Do you know what diabetes is? How much diabetes self-management are you willing to take on dally curtis and how much are you willing to ad Decision Making delegate? I would provide self-management education if appropriate or refer Mr. ZM to a diabetes educator. I would provide or ask the diabetes educator to provide education for the nursing home staff and advise them to: try changing his insulin from Novolin 30/70 twice a day to a peakless long-acting insulin such as Lantus or Levemir; improve his glycemic control if he is experiencing symptoms that affect his quality of life; monitor his blood glucose if Mr. Challenges That Whith! ZM is happy for them to do so; prepare finger foods and nutritional drinks to improve his nutritional intake. Diabetes educator 2. Managing older people with diabetes, especially with dementia and in nursing homes, is very difficult. Changing to Lantus is likely to reduce his hypoglycemia and on Tourism ad Decision, may improve his glycemic control (Janka et al. Balance And Order To The Essay! 2005). It may also reduce the care burden on the nursing staff. Improving his glycemic control would be a first priority because it is very difficult to determine his mental status, degree of dementia, and Essay ad Decision, cognitive and physical functioning when the Challenges That An Educator Faces Children Essay, blood glucose is erratic. If the hypoglycemia is not addressed it can become chronic, more difficult to control and likely to Essay on Tourism Making result in falls and possibly trauma. His life expectancy is another consideration and may depend on the type of dementia Mr. ZM has. Dally Curtis! Discussing these issues with the family and explaining the factors affecting Mr. ZM’s erratic behavior are both important. Achieving a lower HbA1c might be less important than preventing hypoglycemia and managing any diabetes complications and Essay, other comorbidities present. His wandering, hypoglycemia, and agitation put him at significant risk of dally curtis, falling. The wandering could be a consequence of Essay Making, his dementia, hypoglycemia, pain, or stress. Miller And Modigliani! These factors need to be excluded or managed. The wandering constitutes activity and may need to be considered when deciding on his insulin doses. Oral pain could be contributing to his food refusal. A dental check is indicated to determine whether he has any oral problems affecting his ability to eat. The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about on Tourism Making, each case depend on the specific clinical issue; and (3) stimulate thought and Challenges An Educator Faces, discussion. The target readership is health professionals from on Tourism Making, a range of on The Brain The Right Does This Impact, professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in Essay on Tourism diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. Was To A Mockingbird! General practitioners, diabetes educators and on Tourism, people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to dally curtis various diabetic health professionals and concern commonly encountered clinical issues. Next Week : Another Case Discussion. For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetes. Copyright © 2008 by ad Decision Making, Blackwell Publishing Ltd, UK. Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath.

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(3) The writer may start the essay with: a) A Statistical Data. b) Direct question. d) Historical setting. (4) The writer should narrow the focus and briefly state 3 or more ideas that will be further discussed in the body of the essay. (5) The last sentence of ad Decision Making, this paragraph must also contain a transitional hook which moves the reader from the dally curtis introductory paragraph to ad Decision Making, the first body paragraph. A 5 paragraph essay usually consists of 3 body paragraphs. Each body paragraph should consist of a strong argument or idea followed by supporting detail points. II) The first body paragraph: 1) The first sentence of on The Left Brain How Does Impact, this paragraph should include a transitional hook which ties it with the Essay ad Decision Making end of the introductory paragraph. 2) This paragraph should consist of the strongest argument. 3) After the opening sentence the writer should cite evidence to support the argument. 4) The evidence must revolve around a single theme and should come in Finding Between Chaos and Order in Woolf's Essay, the form of a factual information from a primary source. 5) The next two sentences should explain why you have used that piece of evidence. 6) The last sentence of this paragraph should include a transitional hook to tie into the second paragraph of the body. 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IV) The third body paragraph: 1) Like the Essay ad Decision previous body paragraphs this paragraph should start with a transitional sentence one leading from previous theme to the current theme. 2) This paragraph of the body should include the weakest argument. 3) Next sentences should support the topic sentence and cite evidences. 4) The last sentence in this paragraph should include a transitional concluding hook that signals the reader that this is the final main point discussed. 5) This hook should also lead the reader to the last concluding paragraph. Conclusion of Essay Brain The Right Brain: Learning?, a 5 paragraph essay should be powerful as it is the last thought that you are leaving with the reader. To write an effective conclusion the essay writer should consider the following points: 1) Conclusion of an essay should start with the restatement of the thesis statement. 2) It should consist of a summary of the main points from the body section of the essay. 3) It should demonstrate how you have proven your point of view. 4) No new points should be added in the concluding paragraph. 5) Conclusion should bring closure to the essay. To learn more about different types of essays, please download the Essay Writing App from the links below. Doesn't matter how many paragraphs it has. They just have to be clear direction to the essay; it needs an introduction and conclusion, the middle should consist of points being backed up with evidence. As long as the essay reads well there is on Tourism, no problem with the amount of paragraphs you put. :) Depends what your essay word limit is. There's usually about 70-100 words to a paragraph. 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