Watergate Essay Example | Topics and Well Written Essays - 750 words

Watergate - Essay Example Finally, faced by a revolt from within his own party, he chose to step down. How did it come to this? The answer lay in the Watergate hotel complex and the break-in of the Democratic National Committee's headquarters there. The actions undertaken by Nixon and his lieutenants with regards to that event were unacceptable to Americans (Liebovich, 61). They belonged to a country like Romania or Guatemala. Americans had not died during the Revolutionary War against a tyrannical king only to have their president claim he was above the law. This paper will discuss the Watergate Scandal and the events leading to Nixon's resignation from the presidency. Following the discovery of the break-in to the Democratic National Committee's offices, both the courts and the media began to trace things up the chain of command. Reporters such as Woodward and Bernstein published stories linking some of Nixon's closest aides to the break-in. These men were then forced to resign. Congress began its own inves tigation, and Nixon also appointed Archibald Cox to be an independent investigator (Kutler, 330). The ties and connections between the burglars and Nixon were murky and complex. Every string that a reporter pulled ended up leading to another string or connection. So many people appeared to be either involved or trying to protect the president. During the hearings, one of the men who worked in the office of the president's counsel was asked if there was any sort of recording device in the Oval Office. It was revealed that Nixon had recorded all conversations (Kutler, 383). These tapes were subpoenaed but Nixon refused to release them, saying that they were covered by his executive privilege. This created a showdown. Most people felt that Nixon was refusing the release the tapes because they were incriminating. Nixon claimed that they had a great deal of privileged information on them. At this point, due to the many revelations, Nixon had lost the benefit of the doubt. Conversations o n the tapes showed that Nixon had discussed with John Dean the paying of blackmail money to the burglars (Liebovich, 60). Dean, the former White House counsel, later became a key witness against Nixon in the hearings. When the tapes were finally released, an 18 minute gap was discovered where portions of the tapes had been erased. This was thought by many to be a virtual admission of guilt, taking into consideration the massive mendacity that had to that point been supplied by the Nixon administration. Several more months passed. Nixon's men were indicted. Congress began to move towards a process of impeachment after more tapes revealed that Nixon knew more about the break-in than he had originally suggested. The result was that Nixon's position became untenable. He was extremely unpopular and his own party planned to vote against him. He decided to resign. A lot about this scandal is still unknown. One thing that it is easy to judge, however, is that this is an example of the maxim , the cover up is worse than the crime. The break-in was clearly illegal, but if Nixon had said at the beginning that this was bad and had turned the burglars in, it seems unlikely things would have ended up as they did. Instead, dozens of people became involved in illegal action—especially obstruction of justice—in trying to cover things up. Nixon thought he could fire special prosecutors at will. He relied on peoples' patriotism to protect himself. In the end, the American people had had enough of the spectacle he created. They were disgusted with him as their leader and he never recovered his reputation again. The coda of all of these events was surely the Frost/Nixon interviews of the late 1970s. These conversations, the first with Nixon since his

In-service teacher training Essay Example | Topics and Well Written Essays - 1250 words

In-service teacher training - Essay Example Such an analysis, based on four key texts, will re-assess the concept of information literacy in Angola, a developing African country. 1. Introduction Discussions over information literacy in the 21st century are very different from those in the 1980s. The report released on January 10, 1989 by the Presidential Committee on Information Literacy raised some important issues, namely â€Å"the Importance of Information Literacy to Individuals, Business, and Citizenship† and â€Å"Opportunities to Develop Information Literacy† [3]. In the same report, some characteristics of a new type of school were described: an â€Å"Information Age School† [3]. The recommendations from this document mirrored the optimism of such a committee, regarding the fundamental and revolutionary role of information literacy and the challenges this new reality presented to scholars, practitioners, and leaders. The question raised is how scholars, practitioners and leaders perceive the issue of information literacy in developed countries; whether in a national or a global framework. 2. Author’s Perspective Diane Zabel highlights the constraints of an attempt to integrate information literacy as a â€Å"mandated credit instruction† [4], based on the difficult current financial situation of many American students. In the article â€Å"Reaction to "Information Literacy and Higher Education" [4], this author is skeptical about the decision of integrating information literacy into the curriculum, especially involving librarians: It is naive to believe that it is easy to add a required course to the curriculum (†¦). The approval of new courses, majors, minors, and changes in the number of credits required for graduation is a rigorous process. Curricular changes must be justified, requiring the completion of a detailed proposal explaining how a change meets educational objectives and strengthens existing programs [4]. On the other hand, Lauer and Yodanis, i n the article â€Å"The International Social Survey Programme (ISSP) : A Tool for Teaching with an International Perspective† [2], explain the advantages scholars have in adopting a less Westernized perspective and developing a global view of the teaching and learning process. Although the three documents share the recognition that information literacy has brought changes to the process of teaching and learning, these authors do not have a consensual stance on the range of application of this new tool and how this reality can be optimized. Zabel raises several constraints in the inclusion of information literacy in the curriculum, whereas Lauer and Yodanis suggest the â€Å"enhancing of global literacy through teaching† [2]. In the 2009 message to students, the dean of the School of Advanced Studies at the University of Phoenix explained the meaning of the scholar - practitioner - leader model. Jeremy Moreland stated: Viewed operationally, the model represents a paradi gm for incorporating lifelong learning (scholarship), social and workplace contribution (practice), and the ability to exert positive influence (leadership) in our learners' academic, professional and personal lives. This means that important theory and research may support professionals in the effective implementation of their work. Consequently, more pragmatic and efficient ways of organizing, monitoring and evaluating public and private

Hector Berliozs Contribution To The Symphony Music Essay

Hector Berliozs Contribution To The Symphony Music Essay The French composer Hector Berlioz (1803 1869) does not belong to any school. Because of his difference in style he has been criticized by critics, and his contemporaries about his works melodies and formal structures. Berliozs work could not be influenced by critics, because of the originality and vitality of his ideas as an orchestral innovator; it allowed expression that affected the fundamental elements of the symphony and the instrumental changes themselves. The misunderstanding between Berliozs work and his critics may be excused, because of the ideas he used in his works, he used it in an unusual extend that unified with literature themes. The themes determined the manner of each work so that there is no defined development from any period. From his early to late style he never repeated inventions, harmonic and melodic nor formal of his predecessors. (Alexander 1989: 143; Hicks 2001: 387; Slonimsky 2001: 314 315; Whittall 1987: 55.) BERLIOZS CONTRIBUTION TO THE DEVELOPMENT OF THE SYMPHONY Berlioz reconceived the symphony as a programmatic work and allowed it to be in an unconventional form to fit the program. Influenced by Beethovens Fifth and Sixth Symphonies, Berlioz shaped his Symphonies around a series of emotions that tell a story. Berlioz was not a pianist and was not influenced by thinking harmonically like a pianist, but was harmonically influenced by guitar playing that was overstated by those who criticized him. (Burkholder 2006: 639; Longyear 1988: 138.) In 1826 Berlioz entered the Paris Conservatoire; he composed Herminie in 1828 for the Prix de Rome and won the second prize, Berlioz used the idà ©e fixe (fixed idea, a medical expression of the new psychology that Berlioz made into a musical term) of Herminie in his first symphony, the Symphonie fantastique. (Downes 1978: 150; Hicks 2001: 386.) Berlioz was a twenty-six year old conservatorium student when he composed Symphonie fantastique. It was his love for the Irish actress Harrieth Smithson that inspired him to compose the Symphonie fantastique. He based the story on his own personal experiences with the actress. The Symphonie fantastique is much unrelated to the works contemporary with it or the past. It is seen as one of the biggest works that helped developing the symphony to new heights, it gave its listeners an experience to listen to, until Stravinsky composed Rite of the Spring. (Alexander 1989: 146; Burkholder 2006: 639; Downes 1978: 147; Einstein 1957: 163 164; Hicks 2001: 386 387; Slonimsky 2001: 315; Whittall 1987: 63.) The Symphonie fantastique is not operatic but is seen as a drama. Berlioz decided to integrate the music with a recurring melody known as the idà ©e fixe which he used in each movement to represent the image of the heros beloved to fit the mood and situation of each point of the symphony. After this work Berlioz and the rest of the Romantic Movement struggled to get along with the leitmotif. (Alexander 1989: 146; Burkholder 2006: 639; Einstein 1957: 134; Slonimsky 2001: 315.) Berlioz made sure that the people who listened to the Symphonie fantastique would understand the inspiration that inspired him to compose the Symphony, by giving it the subtitle Episode in the Life of an Artist and providing it with an autobiographical program, which is being read silently by the listener while the symphony plays. The Symphonie fantastique became a musical autobiography. There are no words sung or read aloud during the performance. The autobiographical document that was provided explained each movements expressions and moods. (Alexander 1989: 146; Burkholder 2006: 640; Slonimsky 2001: 315.) The Symphonie fantastique is divided into five movements: I. Dreams and Passions; II. A Ball; III. Scene in the fields; IV. March to Execution; V. Dream of a Sabbath Night. The first movement describes a musician that falls in love with a woman he sees for the first time, but his mind cannot stop thinking about her, causing the idea fixe to keep on recurring in the movements of the symphony. The first movement have a slow introduction followed by an allegro that has the same characteristics as a sonata form, but the development section is interrupted by an three-measure pause announcing the main theme in the dominant, which he keeps doing until tutti fortissimo appears in tonic. (Alexander 1989: 147; Burkholder 2006: 640; Downes 1978: 150 154; Slonimsky 2001: 315.) In the second movement the musician goes to a ball, but is troubled because he keeps on seeing images of his beloved in his head. Berlioz replaced the minuet with a waltz, describing the musician at a ball with the idà ©e fixe describing the images of the beloved recurring in his head. The third movement is a slow movement which takes place in a country, where he walks and then he hears in the distance two herdsmen piping to their flocks as his mind is distracted by thinking of his beloved. (Alexander 1989: 147; Burkholder 2006: 640; Downes 1978: 150 155.) In the fourth movement the musician is troubled by his rejected love and poisons himself with opium. But instead of the poison killing him he receives dreams that he killed his beloved and is condemned to death. In the end of the march the first four bars of the idà ©e fixe returns like a last memory of his beloved. (Alexander 1989: 147; Burkholder 2006: 640; Downes 1978: 150 155.) In the last movement he sees himself at a Sabbath where beasts and witches gather for his burial. The idà ©e fixe with two other themes are transformed, first alone then combined. The Dies irae is a chant sequence from one of the themes, which is part of the Mass for the Dead. (Alexander 1989: 147; Burkholder 2006: 640; Downes 1978: 150.) Berlioz hoped for an orchestra of over 200 for the premiere, but never had more than 130 players. The variety of orchestral colours was normally achieved with the list found in the printed score: 2 flutes, 2 oboes. 2 B-flat clarinets, 2 bassoons, 2 cornets, 2 trumpets, 2 tubas, 3 trombones, 4 horns, piccolo, E-flat clarinet, kettle drums, bass drum, bells, and the strings. (Downes 1978: 155.) Berliozs next important work was Harold en Italie, with a viola as a solo instrument and orchestra. This was his second symphony. The title was drawn and inspired by Lord Byrons poem; Childe Harold. Paganini commissioned it but refused to play it because of the viola part that does not have enough to play. (Burkholder 2006: 641; Downes 1978: 130; Slonimsky 2001: 315.) Harold en Italie is a picturesque symphony. It does not have a program, but it only has specific titles for each movement: I. Adagio Allegro Harold in the Mountains: Scenes of Sadness, of happiness, and of Joy. II. Allegretto. March of the Pilgrims Singing Their Evening Prayer. III. Allegro assai Allegretto. Serenade of an Abruzzi Mountaineer to His Mistress. IV. Allegro frenetic. Brigands Orgy; Memoirs of Past Scenes. (Alexander 1989: 152; Downes 1978: 132.) A reappearance theme in the viola reappears in every movement of the symphony and is combined contrapuntally to each movement. The first movement has an Melancholy opening section that anticipates the principal melody, which represents Harold. It is first presented in a minor key, then the viola takes over playing the melody twice, very soft the second time. The accompaniment is played by the harp. The live part of the movement has an idà ©e fixe symphonic-ally developed in fragments. (Burkholder 2006: 641; Downes 1978: 132.) In the second movement the strings play a melody, soft at first then it crescendos as if the pilgrims is approaching, the it fades away as the idà ©e fixe returns slightly transformed. The third movement after the fast introduction the serenade melody is related to the idà ©e fixe and played by the English horn. Berlioz added colour to this movement by imitating the pifferari. (Allexander 1989: 152; Downes 1978: 132.) The final movement recalls the themes of the first three movements almost like Beethovens ninth symphony, but does not end with a chorale. Between the episodes are rapid modulations, and the viola remains active, so that the work inverts the heroism of Beethovens symphonies. Throughout the first three movements a double idà ©e fixe accurse: in the first both where in the solo viola and melody, in the second and third instead of becoming the mood it is combined with the music. (Alexander 1989: 152; Burkholder 2006: 641; Downes 1978: 132.) The printed score has a piccolo, 2 flutes, 2 oboes, English horn, 2 clarinets, 4 bassoons, 4 horns, 2 cornets, 2 trumpets, 3 trombones, ophicleide or tuba, triangle, kettledrums, cymbals, harp. the solo viola part was conceived for Paganini. And the string section: 15 violins, 15 second violins, 10 violas, 12 cellos and 9 double basses. (Downes 1978: 132.) Berlioz conducted Harold en Italie near the end of 1838 in front of an audience. After the performance Paganini bowed on his knees and clamed Berlioz as the successor of Beethoven, the following day Paganini send Berlioz money, enabling Berlioz to reduce his journalistic commitments and devote himself to composition. By the end of 1839 he composed and performed Romà ©o et Juliette. (Alexander 1989: 153; Downes 1978: 141.) Romà ©o et Juliette is central to his achievements, it is also the first large-scale work that is based on a major work of art. His symphony played its part in the development of the musical language appropriate to the symphonic poem. It influenced Liszt and Wagner, who were at one of Berliozs performances. Berlioz called this symphony the dramatic symphony, he combined the orchestra, soloist and chorus into an concert drama. (Alexander 1989: 153; Burkholder 2006: 641; Downes 1978: 140 141.) CONCLUSION Hector Berlioz was criticized about his works, but because of his unique style he developed the symphony to a new standard that was beyond those of his contemporaries. Berlioz is seen as the father of the symphony, and was influenced by Beethovens Fifth and Sixth Symphonies. His harmonic influence was developed by guitar playing. (Alexander 1989: 143; Burkholder 2006: 639; Hicks 2001: 387; Longyear 1988: 138; Slonimsky 2001: 314 315; Whittall 1987: 55.) Berlioz invented the term idà ©e fixe and used it in his symphonies to showcase a recurring theme that keeps on returning reminding the listener of a previous event. This is an example that Berlioz was indeed an influence on Wagner when you go look at Wagners works such as his music dramas that contains leitmotivs that is a theme that recurs the whole time reminding the listener of something, like the ring leitmotive in The ring of the Nibelungs. (Burkholder 2006: 639 641, 693 694; Downes 1978: 150; Hicks 2001: 386.) The Symphonie fantastique is just not just an introduction to making a symphony into a narrative or autobiographical purpose, but also Berliozs skill to compose emotional content for communicational purposes. Berlioz unified the symphony by introducing the idà ©e fixe in all five his movements of the Symphonie fantastique and in the four movements of Harold en Italie, extending the ideas Beethoven had in his fifth, sixth and ninth symphonies. (Burkholder 2006: 641) Berlioz created a variety by changing his themes by using different instrumental colours that gave a character to each passage. Examples were muted strings, harps, English horns, offstage oboe, snare drum, cymbals, tubular bells, and by letting the violinists play on the wooden side of their bows. Berliozs creativeness is seen everywhere in his compositions. (Burkholder 2006: 641) Berliozs Symphonies made him the leader of the Romantic movement, all composers of program music would be indebted to Berlioz. He introduced the orchestra with new resources of harmony, colour, expression and form. His orchestration created a new era in which instrumental colour could be used as an expressive tool for composers. (Burkholder 2006: 641) SOURCES Alexander, L. Mc Culloch, D. 1989. Heritage of Music: The Romantic Era. New York: Oxford University press. Burkholder, J. P., Grout, D. J., Palisca, C. V. 2006. A History of Western Music. London: WW Norton. Downes, E. 1978. Everymans Guide to Orchestral Music. London: J. M . Dent and Sons. Einstein, A. 1957. Music In The Romatic Era. New York: Norton Company. Hicks, A. 2001. The New grove Dictionary of Music and Musicians, Vol 3. London: Macmillan. Longyear, R, M. 1988. Nineteenth-Century Romanticism in music. New Jersey: Prentice Hall. Slonimsky, N. 2001. Bakers Biographical Dictionary of Musicians. Volume 1. New York: Schirmer Books. Whittall, A. 1987. Romantic Music: A Concise History from Schubert to Sibelius. London: Thames and Hudson. Downes, E. 1978. Everymans Guide to Orchestral Music. London: J. M . Dent and Sons.

Use of Symbols in Yeatss Work, A Vision Essay -- Yeats Vision Essays

Use of Symbols in Yeats's Work, A Vision In his 1901 essay "Magic", Yeats writes, "I cannot now think symbols less than the greatest of all powers whether they are used consciously by the masters of magic, or half unconsciously by their successors, the poet, the musician and the artist" (p. 28). Later, in his introduction to A Vision, he explains, "I put the Tower and the Winding Stair together into evidence to show that my poetry has gained in self possession and power. I owe this change to an incredible experience" (Vision p.8). The experience he goes on to relate is the preliminary stage of the composition of the work itself. In A Vision, however, Yeats exhibits his poetic power as well, along with his knowledge of mysticism and affinity for symbology to illustrate the behavior of the forces of human consciousness and history. He ties these two cycles together into the overarching symbol of the work: the Great Wheel. This is a symbol that Yeats uses not only to explain the cycles of one individual's life, but al so through the same motions, to explain the cyclical movement of the centuries, and the conjunction of certain historical events. When asked about the factual reality of his cosmological descriptions, he replies that they are "purely symbolical ... [and] have helped me to hold in a single thought reality and justice" (Vision p.25). Though to a large extent obscure and complicated, these symbols are paramount to an understanding not only of the ideas contained in A Vision, also the thought process Yeats conveys in much of his poetry. The Great Wheel consists of and contains two opposing gyres, the primary and the antithetical, objectivity and subjectivity, which turn in opposite directions, the two... ...mary vein, men worshipping idols of far away deities, or return to its antithetical predecessor, in which man's idols seen as are actual living beings captured in myth. Eventually, he resigns himself to not knowing for certain what the future of mankind will be. He concludes "The particulars are the work of the thirteenth sphere, which is in every man and called by every man his freedom. Doubtless, for it can do all things and know all things, it knows what it will do with its own freedom, but it has kept the secret" (Vision p. 302). Works Cited: Adams, Hazard. The Book of Yeats's Vision. Ann Arbor: University of Michigan Press, 1995. Yeats, W.B. A Vision. New York: Macmillan, 1956. Yeats, W.B. The Poems. ed. Richard J. Finneran. New York: Macmillan, 1990. Yeats, W.B. "Magic". Essays and Introductions. New York: Macmillan, 1961. pp. 28-52.

A Rose for Emily Summary

Faulkner beautifully illustrates the morbid parallelism between Emily’s father and the house that imprisoned her. Both were controlled and manipulated by the very being that would eventually destroy them. Faulkner strategically places the home of the Grierson’s, on what was once consider a prestigious street in the crumbling, overcrowded town of Jefferson. Here, both monuments of the past are forced to maintain a dignified facade of sanity among an ever-changing society. There are two interpretations to be made in understanding the motive and meaning behind Emily murdering Homer Barron, in â€Å"A Rose for Emily†. The first motive deals with the personal revenge Emily seeks towards her father, the second being towards the town of Jefferson who scrutinized her and critically analyzed everything she did. The death of Emily’s father set in motion a diabolically evil scheme to seek the ultimate revenge on the patriarchal society of Jefferson, which controlled and ultimately claimed her sanity. Her revenge began with her father whom she hated for denying her the privilege of having a normal and successful woman’s life. Emily’s hatred began to fester within the depths of her soul as a young child, dominated by a father who concluded that no male figure was good enough to inherit the status of courting or marrying a Grierson. Emily became emotionally tormented by the very thought of being a spinster and having no other male figure to love, besides her controlling father. The growing resentment continued as she became older and perspective suitor’s appeared at the front door, ultimately to be chased away with a horsewhip. Although the violence is apparently outward-the upraised horsewhip against the would be suitor- the real object of it is the woman-daughter, forced into the background and dominated by the phallic figure of the spraddled father whose back is turned on her and who prevents her from getting out at the same time that he prevents them, suitors, from getting in. † (560). Emily was a caged animal, imprisoned by her controlling father, in a circus whose master manipulate s all of the animals’ movements, emotions, and physical appearance by a carefully illustrated system of rewards and punishments. Emily’s’ rewards, according to her father, was that she be portrayed to the towns people as â€Å"a slender figure in white† too pure for the stains of any human being to corrupt what he, the father, masterfully created. Emily’s punishment was that she would eventually be revered as an untouchable figure who’s every action or movement would be analyzed by the town of Jefferson. It wasn’t until that fateful day, the death of her father, when Emily was finally able to outwardly express her revenge upon the very first male who suppressed her emotionally and physically, by not giving him the proper burial a Grierson deserved. Instead, she was able to experience, first hand, the feeling of triumph over watching her so-called beloved father rot before her very eyes, the sweet revenge of a twisted character. Emily cleverly denied to the town’s people that her father died in order to secretly express her future intention of revenge towards the town of Jefferson by not letting them, the residents, immediately dispose of his decrypted and decaying body. â€Å"She told them that her father was not dead. She did that for three days, with the minister calling on her, and the doctors, trying to persuade her to let them dispose of the body. Just as they were about to resort to law and force, she broke down, and they buried her father quickly. †(27). â€Å"Because she is Miss Emily Grierson, the town invests her with that communal significance which makes her the object of their obsession and subject of their incessant scrutiny†¦ the town is able to impose a particular code of behavior and to see her in failure to live up to that code an excuse for interfering in her life. (560). The result of the towns interfering adds fuel to her fire to seek the revenge for interfering in her life and being so critical of every movement that she makes. The most significant diabolically evil plan Emily sought was the revenge on the patriarchy society of Jefferson, which no one would be able to comprehend the magnitude of the murder of Homer Barron. After the death of her father, the townsme n felt pity for her and claimed that leaving her the decrypted; decaying housing structure was a way of knocking her off the pedestal and becoming more humanized. The patriarchal society outwardly expressed their need to watch over and care for the lonely spinster who they concluded incapable of providing for her financially. Colonel Satoris, the eldest patriarch of Jefferson, fabricated a story to justify why the town remitted her taxes, claiming that it was from a financial loan her father provided for the town many years ago. The motive for the murder of Homer Barron was for Emily, on her deathbed, to gain the last laugh at a town that scrutinized and critiqued her yet never came to understand why she acted and lived as she did. Another motive for the murder of Homer Barron was to prove to the patriarchal society of Jefferson that even though she, Emily, could not â€Å"persuade him to marry her† (535). Due to his perversions, she may still succeed in controlling Homer if her were dead. No one would be able to take that secret love she had for Homer away even though he would never reciprocate it the same way because of his alternative lifestyle. Homo Homer was an embarrassment to Emily, because for the first time ever she was free love someone, and he turned out to love young men more than women. This humanizes Emily even more and in turn it helps explode the decades of manipulation and control she receives at the hands of her father. She had a perfect plan; no one in the town of Jefferson would ever believe that Emily, being a real lady â€Å"to forget noblesse oblige—without calling it noblesse oblige† (535). â€Å"Emily is exempted from general indictment because she is a real lady-that is, eccentric, slightly crazy, obsolete, a â€Å"stubborn and coquettish decay†, absurd but indulged; â€Å"dear, inescapable, impervious, tranquil, and perverse†; indeed, anything and everything but human. (561). Who would believe she would have murdered someone in order to have their love. â€Å"A Rose for Emily† is taken from a morbidly crepitated point of view where an author obviously is hiding many deep dark secrets within his past without bluntly coming out and exposing it to the rest of society. Faulkner disguises his own tragedies from his past t hrough the story to give himself a sense of personal release from his own personal bondage. â€Å"A Rose for Emily† is utilized as a clever way for William Faulkner to disguise his own slide from sanity.

Sepsis and Barbara

This portfolio will provide evidence of my experience in an acute care setting. I will provide an appendix giving a brief summary of a patient I cared for whilst undertaking a placement in an acute setting. This portfolio of evidence will be based on a patient diagnosed with sepsis secondary to her chest infection. I will discuss extensively the aetiology, pathophysiology and clinical features of a patient presenting with sepsis treated in an acute care setting.I will explore the role of the different healthcare professionals that were involved in the care of the patient describing how they contributed to her holistic care. I will incorporate evidence base supporting the approach used by the doctors, nurses and microbiologists in the diagnosing and caring for the patient. I will equally evaluate practice using findings from contemporary research policy and practice on the care of the adult with acute care needs.I will also discuss the value of our practice in accordance with professi onal, ethical and legal frameworks that ensure the privacy of the patient’s interest and well-being. Finally, I will conclude by summarising this portfolio of evidence in relation to acute care practices and focus on identifying my future learning needs in developing myself personally and my professional practice. It is indicated by Latto (2011) that a meeting between The American College of Chest Physicians and the Society of Critical Care Medicine in 1991 brought about the use of systemic inflammatory response syndrome (SIRS) to define sepsis.SIRS being manifestation of two or more of certain medical signs including, a temperature of less than 36 degrees Celsius or greater than 38 degrees Celsius, a heart rate of over 90 beats per minute, respiratory rate of over 20 breaths per minute and white blood cells count of greater than 12000 or less than 4000. Further on to recognise sepsis, a patient has to have at least two signs of SIRS as well as a documented infection. Sepsis, as defined by Matot and Sprung, (2001) â€Å"is the systemic inflammatory response to infection. In addition to this definition, Herwald and Egesten (2011) indicate that sepsis could also be defined as the existence of bacteria or other micro-organisms in the blood, hypotension or shock. Rello, Diaz and Rodriguez (2009) emphasise that there is a difference between sepsis and systemic inflammatory response syndrome (SIRS) as sepsis is systemic inflammatory response to  infection  while systemic inflammatory response syndrome is a tool used to simplify the diagnosis of sepsis.Sepsis occurs as a result of the body fighting infection that has spread though the body via the blood stream as defined by Sepsis Alliance UK (2012). Barbara presented with low blood pressure, a high temperature, tachycardia and an increased respiratory rate. Patients who present with sepsis can progress to severe sepsis which is defined by Marini and Wheeler (2010) as â€Å"a syndrome caused by infection and defined by the presence of vital sign abnormalities and new organ system failure caused by the ensuing inflammation and coagulation. Associated with severe sepsis, there are three integrated responses as explained by Kleinpell, R. (2003) which are; activation of inflammation, activation of coagulation, and impairment of fibrinolysis. As the body detects infection, its natural response is inflammation. â€Å"Inflammation is a response of a tissue to injury, often injury caused by invading pathogens. It is characterized by increased blood flow to the tissue causing increased temperature, redness, swelling, and pain. † Kleinpell (2003).Ball (2011) in describing the process of inflammation in the body explains that inflammation occurs due to the white blood cells releasing pro-inflammatory mediators called cytokines these are proteins, peptides, or glycoproteins which include tumour necrosis factor alpha, interleukin-1 and interleukin-6, the white blood cells also releases a platelet-activating factor which is a lipid mediator that is well-known for its ability to cause platelet formation. The work of these mediators is to repair damages caused and prevent further damages from occurring.Normally, the body’s response in order to prevent damage by the release of these pro-inflammatory mediators is to release anti-inflammatory mediators which are interleukin-4 and interleukin-10 these are also cytokines which are a type of protein. In severe sepsis, there are excessive pro-inflammatory mediators which are not regulated by the anti-inflammatory mediators which results in overwhelming inflammatory reactions causing impaired tissue function and organ damage. Due to the pro-inflammatory mediators being released and unregulated by anti-inflammatory mediators, coagulation is promoted which is the clotting of blood.This happens in the capillaries which obstructs the flow of blood into the tissues causing hypoxia which then leads to the dysfunction of orga ns. Hypoxia is defined by Wiebe and Machulla (1999)  as â€Å"reduction of oxygen supply to tissue below physiological levels. † The activation of coagulation then causes fibrinolysis to be activated. Fibrinolysis is the process of breaking down of blood clots as defined by Leslie, Johnson, and, Goodwin (2011). This happens because the levels of plasminogen rapidly reduce.Plasminogen is a protein that when activated by enzymes transforms into plasmin which promotes dissolving of blood clots. Though the plasminogen levels fall rapidly, the antiplasmin levels remain normal which causes an end result of a decrement in the fibronolytic response. â€Å"The imbalance between inflammation, coagulation, and fibrinolysis that occurs in severe sepsis results in systemic inflammation, widespread coagulopathy, and microvascular thrombosis, conditions that can lead to multiple organ dysfunction†Ã‚  Kleinpell (2003)   Severe sepsis if not properly treated can then lead to septic shock.Septic shock is defined as sepsis with hypotension which is unresponsive to fluid resuscitation as well as abnormal perfusion that may include lactic acidosis, oliguria or alteration in mental status, Sepsis Alliance UK. (2012). In relation to the care that Barbara received whilst being treated for sepsis, there were different health care professionals involved throughout her stay in the hospital. An inter-professional team worked together to ensure that she was given holistic care taking into consideration the social aspect of her life, her spiritual values, her emotional and mental state of mind and full physical care.On recording Barbara’s clinical observations, we passed on our results to the doctors as Barbara was scoring a mews of seven. Guidelines on the Modified Early Warning Signs chart advices that if a patients’ scores a MEWS of four or more, the patient must be referred for urgent medical review, NHS Outer North East London Community Services (2011) The doctors immediately ordered for blood cultures to be taken. The blood cultures were used to investigate the reason why Barbara had an increased temperature as an increased temperature is a sign of infection as described by Hegner, Acello and Caldwell (2009).The blood tests and cultures taken were also to test for the serum lactate level, white blood cell count, tests to check how the liver and kidneys were functioning. The doctors then prescribed fluids to help in increasing Barbara's blood pressure. Working collaboratively to enhance the care that Barbara received, the microbiologists were involved in the diagnosis and care she received through the involvement by the doctors requesting for blood samples to be taken and investigating the reason why Barbara had an elevated temperature.By collecting a sputum sample from Barbara, the microbiologists were also involved in looking for the medication sensitive to the bacteria causing Barbara’s chest infection. The microbiologis ts also took blood for arterial blood gases test. They were very efficient in delivering the results of the blood tests showing that Barbara had an increased white blood cell count. Her serum lactate levels were 3. 4mmols/l. An increased white blood cell count along with an elevated temperature proved to the doctors that Barbara had an infection.The doctors commenced Barbara on the sepsis six bundle. The sepsis six bundle is a guideline within the Surviving Sepsis Campaign which gives information on what should be done in the first 6hrs that sepsis is diagnosed in a patient in order to aid safe recovery. The nurses ensured that from the moment Barbara was admitted, it was a duty to monitor her clinical observations. With the use of the Modified Early Warning Signs (MEWS) chart, we recorded her observations which enabled us to monitor changes in her blood pressure, respiratory rate, temperature, heart rate and oxygen saturation.This was also a way for us to assess her consciousness l evel checking to see if she was alert, responsive to voice alone, responsive to pain alone or unconscious. This enabled us to check for signs of improvement in her health or for deterioration. Our duty as nurses was to provide 24hr care to Barbara. With a blood pressure of 85/42 mmHg we ensured that Barbara got enough fluids as were prescribed by the doctors. These fluids were given intravenously to increase Barbara’s blood pressure.In a patient with sepsis, due to vasodilation as an inflammatory response to the infection, arterial circulation is ineffective therefore; intravenous fluids are required as advised by Institute for Healthcare Improvement (2011) Apart from receiving care from the nurses, we referred Barbara to the occupational therapist. The role of an occupational therapist as defined by Institute For Career Research, (2007) is to help in the development, recovery and maintaining of daily living and work skills of people with conditions that are disabling mentall y, physically, emotionally and developmentally.Institute For Career Research (2007). They ensured that on returning home, patients will have everything needed to make them comfortable. If need be, they will get their houses modified with a stair lift, a ramp or any additional equipment needed for them to make living at home easier. In relation to Barbara, the occupational therapist focused on her personal care, they assessed how easy or difficult it was for her to wash and dress herself and if she could manage cooking her food in the kitchen.This enhanced collaborative working as this enabled the nurses to be aware of what steps needed to be taken to provide optimum care to Barbara. We were informed by the occupational therapist that she would need all care in the area of her personal hygiene and assistance in most areas of her activities of daily living. With the information derived from the occupational therapist, we were able to refer Barbara to the social services to ensure that when she was fit for discharge, extra measures were taken to provide her with care in her own home.Barbara also received care from the physiotherapist. The role of the physiotherapist is to work as part of the multidisciplinary team to assess the patient and then provide treatment. Treatment would include exercise, movement, hydrotherapy, electrotherapy, massages and manipulation. A physiotherapist is also involved in providing health education this is elaborated by NHS Scotland (2002). In relation to Barbara, after we had referred her to the physiotherapy, they ensured that she received physiotherapy for her chest which was a series of claps on her chest, back and under her arms.This was very helpful to Barbara as due to her chest infection, she had a lot of mucus in her breathing passages and with treatment from the physiotherapist; she managed to cough it up. This positively enhanced the care that Barbara received as through collaborative working, the physiotherapist encouraged the loosening of mucus from her breathing passages which enabled us as nurses to acquire a sputum sample to send to the microbiologist to test for what antibiotics were suitable to treat Barbara’s chest infection.In addition to having lung cancer, Barbara also had liver and bone metastasis. With her consent, we involved the Macmillan nurses in her care. They focused on the social, emotional and practical impact cancer had on Barbara. They also gave her information on different support groups which were accessible to her and meetings where she could share her experience and listen to others experiences. Involved in the care of Barbara was the church priest.As Barbara was too ill to attend the hospital Sunday services as were her wishes, we invited a priest who could give her communion, emotional and spiritual support through her stay in the hospital. Barbara had a reduced appetite so we commenced her on a food diary in which we recorded everything that Barbara ate and how much of it she ate. After three days of commencing Barbara on the food diary, we showed it to the dietician. Barbara was quite ill and did not have the strength to take part in most of her activities of daily living including feeding herself.The dietician came to the ward to review Barbara and then prescribed ensure drinks and little cups of procal shots. These are nutrient supplements which provide protein, fat and carbohydrate in the body. All healthcare professionals worked together to enhance the quality of care that Barbara received although because Barbara had been diagnosed with sepsis, the decision of the dietician to provide Barbara with medication to boost her nutrition arguably caused deterioration in Barbara’s health.Studies show that when treating a patient with sepsis, permissive underfeeding is required to ensure that recovery is enhanced as encouraging a lot of dietary intake would cause lipogenesis which would result to excess production of carbon dioxide and res piratory overload, hyperglycaemia and over usage of energy which would lead to stress for the patient. Vincent, Carlet and Opal (2002).In supporting the doctors’ decision to prescribe intravenous fluids for fluid resuscitation on Barbara, Evidence has shown from the Surviving Sepsis Campaign (2011) under the sepsis resuscitation bundle that patients who are suspected of being in septic shock should be commenced on fluid resuscitation immediately. Guidelines on the Surviving Sepsis Campaign states that, â€Å"In the event of hypotension and/or lactate ;gt; 4mmols/L (36 mg/dL) deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). † As explained by Winters and Glatter (2009), serum lactate levels are used to identify patients who have sepsis.They explain that an elevated serum lactate level is a method of forewarning of an increased mortality in patients with sepsis or septic shock. This proves that ordering for blood tests to check the serum lact ate level of Barbara was a positive step in treating Barbara by identifying the diagnosis of Barbara’s condition. Current evidence from the Surviving Sepsis Campaign (2011) indicates that analysing serum lactate levels in septic patients is not conclusive as â€Å"a number of studies have suggested that elevated lactate levels may result from cellular metabolic failure in sepsis rather than from global hypo perfusion.Elevated lactate levels can also result from decreased clearance by the liver. Although blood lactate concentration may lack precision as a measure of tissue metabolic status, elevated levels in sepsis support aggressive resuscitation. † This gives reason to why the doctors ordered for blood tests to be taken so as to measure Barbara’s serum lactate level. Through continuous input of intravenous fluids, Barbara’s blood pressure increased to 99/55 and remained stable and she was now scoring a MEWS of 3 as her respiratory rate was still elevate d at 24 breaths per minute and a heart rate of 105 beats per minute.Barbara’s temperature was still a little bit elevated at 37. 4? C but not scoring on the MEWS chart. The MEWS chart played a very important role in helping us evaluate Barbara’s health status. Although different studies show that there are pros and cons of using the MEWS system to evaluate patients’ health status. Studies show that the modified early warning scoring systems in the accident and emergency department or an acute care setting can help healthcare professionals identify patients that are at risk of deterioration.Though, concerns have been raised questioning the sensitivity of this system as a risk assessment tool in comparison with the early modified warning score (EWS). Griffiths and Kidney (2011), in their survey assessing the use of MEWS in the UK’s acute care departments found out that over 90% of respondents in the survey supported the use of the Early Warning Score in hel ping identify deterioration or improvement in patients who are admitted to the acute care departments to the use of the Modified Early Warning Score.This is evidence that supports the practice of nurses in monitoring Barbara’s condition through the use of modified early warning score. On the other hand, another study shows that many issues arose in implementing the MEWS chart in recording patients’ observation. The problems encountered with the MEWS chart include complaints of font size, size of the boxes provided to write in and due to this, some staff members have been reluctant to engage with the process making it difficult to monitor deterioration in acutely ill patients.NICE (2011) I think that the MEWS chart was very effective in helping us monitor Barbara’s condition because we were able to use the information recorded on it as a means of communication with other healthcare professionals involved in her care. In caring for Barbara, we ensured that her con fidentiality was optimised. This is a professional requirement for every nurse by the Nursing and Midwifery Council (2008). Through the use of a model called ‘Situation – Background – Assessment – Recommendation’ (SBAR), we ensured that communication between all health care professionals were detailed and solely on a need to know basis.This model did not only protect the confidentiality of Barbara, it also encouraged assessment skills helping to provide all information to health care professionals in a manner that makes it difficult to omit any information. In communication with other bodies involved in Barbara’s care, SBAR stood as a guideline in divulging information. Stating the situation Barbara was in, giving background information only in relation to her present condition, providing results of assessments carried that would relate to their function in the care of Barbara and finally getting the recommendation from the other body.This wa y, disclosure of information is kept to a minimum. Confidentiality is a key concept in protecting people that are vulnerable. Apart from being an ethical requirement, confidentiality also is a legal requirement. The legal principle of confidentiality lies within the Data Protection Act (1998), which simplified by Mind (2005) states that â€Å"Confidence is breached by the unauthorised use or disclosure of confidential information. † This act emphasises the principles that define confidentiality one of which includes sensitive personal data.This has to do with matters relating to a persons’ ethnicity, religious and political beliefs, physical and mental health, sexual orientation as well as criminal offences. In relation to Barbara, whenever we received a phone call from people claiming to be family members, in order to protect Barbara’s confidentiality, we never disclosed results of tests or doctors’ orders. We always gained consent from Barbara before gi ving information out to other parties involved in her care.Timing when caring for critically ill patients is a valuable commodity which makes it important to be able to identify when a patient is in need of urgent medical attention. In the course of looking after Barbara through her admission in the hospital, I realised that prioritising care was the main issue surrounding her treatment. Observing my mentor who was in charge of Barbara’s care as well as nine other patients, using the ABC technique she was able to prioritise the care that Barbara received.Ensuring that she had open Airways, Breathing with addition of oxygen therapy, Circulation through constant monitoring of her blood pressure. Prioritising of care is a skill that is essential in a care setting because if it was decided that all patients would be cared for in respect of their bed position on the ward, that would have had a negative impact on Barbara because she would not have received the urgent attention that she needed which could lead to a tragedy.Through prioritising care, my mentor was able to organise herself in caring for the other patients she was in charge of placing Barbara on the top of her list because she was in constant need of urgent care as when it was time for her intravenous fluids to be commenced because she had organised her time accurately she was able to meet up with demands placed by Barbara’s condition as well as demands of her duty to the other patients.In conclusion, this portfolio of evidence has defined the different stages of sepsis. It has explored the causes, pathophysiology and clinical manifestations. Fluid resuscitation was highlighted as the most important step to take in recognising a patient with sepsis. I described the different roles of the healthcare professionals in relation to the care that Barbara received.Using information from the surviving sepsis campaign, I explained the guidelines used in the treatment of sepsis and related it to the steps taken by the doctor to treat Barbara. I identified the key strength of my mentor in working under pressure by prioritising care. This is an area that I will need to develop myself in the course of attending placement in the future. I will research on techniques of prioritising patient care and research on the process of triage in relation to a care setting.