Common

Common

US Common #10 Envelope (105 x 241 mm)

US Common #10 Envelope (105 x 241 mm)

In 1917, a Finnish ophthalmologist named Lindberg first described pseudo exfoliation syndrome. This entity is characterized by flakes of granular material at the pupillary margin of the iris and throughout the inner surface of the anterior chamber. It is also associated with secondary openangle glaucoma, known as pseudo exfoliation glaucoma, which is the most common identifiable form of secondary open-angle glaucoma worldwide. Dvorak-Thebold suggested the term pseudo exfoliation to differentiate it from true exfoliation or lamellar delamination of the lens capsule found in glassblowers. True exfoliation syndrome is due to heat or infrared-related changes in the anterior lens capsule.

CHARACTERISTICS AND MOTIVATIONS OF TEACHERS IN ADULT CLASSES The Motives of the Teacher It is possible to pick out the main motive of those who give their time. The most prominent motive in undoubtedly that of service. Many of those who have had the benefit of good education and wide experience wish to take to opportunity of sharing these with their fellow men and women who have been less fortunate. In the great nation building projects that are underway in Africa, this motivation is very strong and will cause great sacrifices to be made in the general interests of the community. However it would be wrong to assume that this selfless attitude goes for all, and financial reward is another important motive. Many adult education schemes severely overlock this motive and, as a consequence, fail. It is very rare that people are prepared to work completely for nothing and, if they do, it will not be for very long. It is possible to idealize on how people ought to behave, but to base practical schemes of adult education on the conclusions of such thinking can lead to nothing but disastrous results. People do not like to be taken for granted and like to have some acknowleadgement of the efforts they make. Many make no bones of having no ‘service’ motivation and admit that what they do is entirely for financial gain. The prevailing customs in the society will condition the motives – where a spirit of mutual unrewarded help is common more will give that they have without thought of monetary gain. Where the prevailing spirit is to get what one can for oneself, then free services, except among the very dedicated, will be rare. However unfortunate it may be, many do give their help for financial gain and will not give it to any extent without it. It is thus unwise to overlook this fact. Another motive which causes people to give part-time help is that of gaining status. Most people have a wish to hold a place of the teacher is one of great importance. Where there is a desire to demonstrate to society the worth of an individual through teaching, this motive can be quite strong. Many people, having had educational opportunities themselves, enjoy teaching adult. It helps them – especially if they are not full-time teachers and they enjoy the opportunity of discussing their subjects in an informal class atmosphere. This motivation is especially true in formal and liberal adult education where many teachers do have an opportunity to teach their special subjects and thus keep them fresh. A strong interest in teaching is another reason why some people help in adult education classes. Many enjoy the personal satisfaction which they get from teaching a successful group of adult and are prepared to go on simply because they enjoy it. Some people who are in new places and meeting new people find the teaching of adult classes and entry into the local society. This especially applies to expatriate personal who wish to get to know and meet local people. Certainly adult education classes afford very good opportunities for this and it is an excellent way in which one can discuss with local people things which cannot easily be broached without some entry. A last reason is that some people teach simply to fill in time in an interesting and useful manner. This may not be the noblest of reasons but nevertheless some are indeed motivated by boredom into teaching. These then are the main reasons why people teach in part-times adult classes. There have been listed some seven reasons-there are many more. It is important to note that most people who participate do so for more than one reason and many of the motives are mixed together. One may teach partly out of a sense of service and still require some sort of recompense for services. A voluntary teacher may also wish to keep up with his subject and enjoy teaching at the same time. The motives are not mutually exclusive. The purpose of understanding the characteristics and motives of voluntary helpers working in the adult educational field is so that those who organize them can give them maximum support and encouragement and when thing go wrong will understand why they do, thus making correction that much easier. To those people who do help voluntarily, it is an extra duty which they carry out mostly after a heavy hard day’s work. They are tired. They often do not have time to do extensive preparation. They do not have time to seek out lecture material and books. They often need advice on the best way of teaching their subjects and student approach. If they are teaching a regular class, they will sometimes fail to turn up, sometimes they will be late, and sometimes they will forget. It is the task of the organisational body to minimize problems which may face the tutor. It is not always easy to get part-time tutors together to give them detailed help on teaching methods, so there must be simple notes prepared for them. Courses can be arranged if sufficient part-time tutors can be obtained. Tutors should be persuaded to prepare syllabi and reading lists, and maximum help should be given them by providing simple type syllabi and suggested books which they can use. Easy and efficient duplication facilities should be provided. Visual aids can be provided for them at their request. Administration, especially they which is expected of the tutors, should be simple and clear and prepared sufficiently early to allow the tutors to prepare adequately. There should be simple drill meeting-however, the need for tutors to attend regularly should be emphasized. Approach to tutor is important. They should be mad to feel they are carrying out an made for their services then the method and amound of payment should be clear and payment should made on time. Recruitment of voluntary teaching staff is important. In some circumstances it may be difficult. It will be that much easier if the organization has a good reputation and is known to provide good services of high repute. When a tutor is approached a great responsibility rests on the person doing the recruiting. He must make quite clear the obligations expected of the tutor, but at the same time not making these so heavy that any potential volunteer will frightened off. The part-time teaching staffs in adult education are most important, and they must be tread as such. Will careful and understandingly helpful treatment they make the success of any project. They must always be in the forefront of the mind of those actively organizing adult education. The teachers Whether we are thinking of formal, foundation or liberal adult education, the bulk of teaching is performed by part-time, non-professional teachers and tutors. In general, they come from three main groups-school teacher, civil servant and business and commercial people. School teacher always come into mind when there is talk of an adult education project. It is reckoned to be their job it is expexted of them. In Africa they generally the most educated part of the community and also the most numerous at the base of of the society. From necessity, then, they are immediately looked on as the source of help us education is their business. It assumed that they have a responsibility which not all teacher will willingly accept. Civil servants are another vocational group which reach to the base of the society. They are able to help, though having no educatioanal training, since administrative officers and similar cadres of people are often in in subjects which can be offered as teaching subjects. Business and commercial people especially in urban areas help a great deal. Housewives can be included in a special group. They are often able to help in the provision of foundation education and sometimes, where qualified, in the other types of adult education. There are two major characteristics which are common to all these-they are all busy people and they are all for the most part experience in the arts of adult education. Wheter they are school teachers or businessmen they all do a full day’s work before they begin any adult teaching. It often happens that the types of people who are prepared to help in adult education are also those members of society who do many other things other than their normal work. They therefore have great demands on their time. Similarly, by and large, they are experienced in adult education, never having been trained in the teachniques. Therefore, in the main it does not come easy to them and it is likely to be a strain to prepare material and face a class or group.

England

A. KONSEP DASAR PENYAKIT 1. Pengertian Peritonitis is an inflammation of the peritoneum (figure 4-12). It may be classified as localized or generalized and as primary or secondary. 2. Epidemiology Peritonitis is a serious inflammatory disorder; despite advances in supportive care and antibiotic therapy, the reported mortality is 18% to 60%. Mortality is especially high with peritonitis that occurs that after abdominal or pelvie surgely; factors associated with increased mortality rates include adfancing age and intraabdominal fecal contamination, such as occurs with perforation or anastomotic breakdown involving the colon. Primary peritonitis is a peritoneal infection caused by bloodborne organism or organism arising from the genital tract, as opposed to infection resulting from peritoneal contamination by gastrointestinal secretions. Primary peritonitis is relatively rare, especially in adults. One cause of primary peritonitis is cirrhosis with ascites; about 25% of these paticuts develop bacterial infection of the ascitic fluid, usually with Escherichia coli. The infection is thought to be caused by the increased permeability of the bowel wall that results from portal hypertension; the increased permeability permits bacterial migration into the abdominal cavity. Additional causative factors include genitourinary infections that spread to involve the peritoneum, such as gonococcal salpihgitis and chlamydia trachomatis infection. A nonbacterial, granulomatous peritonitis can also occur, usually in response to such irritants as gauze fragments, dusting powders used on surgical gloves, and suture material. Secondary peritonitis is a peritoneal inflammation resulting from contamination by gastrointestinal secretion. Common causes include the following: • Acute infections and perforation involving intraabdominal organs (e.g.,pancreatitis, appendicitis with rupture, perforated peptic ulcer, biverticulitis with perforation). • Blunt or penetrating trauma to intraabdominal organs resulting in perforation and spillage of secretion (e.g., gunshot wounds or stab wounds involving small bowel or colon). • Obstructive disorders of the bowel resulting in transudation of bacteria trough the dilated ischemic bowel wall and potentially resulting in perforation and spillage of intestinal contents if the obstruction is not corrected (e.g., volvulus or strangulated hernia). • Ischemic disorders afecting the bowel, with transudation of bacteria through the ischemic bowel wall followed by frank necrosis, perforation, and spilage or intestinal contents (e.g., mesenteric infarction). • Postoperative peritonitis resulting from breakdown of anastomoses (e.g., colon resection with end-to-end anastomosis). Postoperative peritonitis is fairly common and potentially fatal. It is more likely to occur when there is intraoperative spillage or when intestinal anastomoses are constructed under tension or when intestinal anastomoses are constructed under tension or with inadequate blood supplay current recommendation are that compromised anastomoses be exteriorized, (e.g., by constructing a temporary, double-barreled colostomy rather than a primary colunic anastomosis in a patient at risk). Peritonitis is sometimes deseribed as aseptic or septic; aseptic peritonitis refers to peritoneal inflamation caused by contamination with noninfected secretions, such as paneretic fluid. However, bacterial invasion of any exudate eventually occurs, and the peritonitis becomes septic, or infected. The organisms commonly involved in peritonitis include the mixed flora of the intestinal tract and adjacent organs; gram-negative aerobes and anaerobs are the predominant organisms. Specific organisms commonly involved are E. Coli, sterptococcus faecalis, pseudomonas aeruginosa, staphylococci, klebsiella sp., proteus sp., bacteroides fragilis, and clostridium sp. 3. Etiologi 4. Pathophysiology Bacterial proliferation withinthe abdominal cavity produces classie results; the peritoneal membrane becomes hyperemic and edematous, and large volumes of exudate are produced. The inflammatory exudate are produced. The infection, because it contains fibrin as well as leukocytes; the fibrin causes loops of bowel and segments of omentum to stick together, which helps to localize the inflammatory process, and the leukocytes begin phagocytosis of bacteria. However, the exudate may also contribute to the spread of infection, because it tends to disseminate throughout the abdominal cavity unless effective localization occurs early in the inflammatory process. Spread of the infection may also occur along the peritoneal membrane itself and by way of the lymphatics. The bacteria may also invade the blood stream, causing septicemia; about 30% of patients with peritonitis have positive blood cultures, and studies have shown that bacteria are present in the blood stream within 12 minutes after injetion into the peritoneal cavity. If the peritonitis is localized, the fluid losses into the abdominal cavity are limited and phatologies changes in the peritoneum and surrounding tissues remain localized, large volumes of fluid may be lost into the abdominal cavity, and the inflammatory changes . . . . . involvethe entire peritoneum and surrounding tissue. Ileus is an in variable result of peritonitis. Although the exact cause is not known, it probably results from peristaltic inhibition by a combination of factors such as gaseous distention, fluid-electrolyte disturbances (e.g., hypokalemia), and sympathetic stimuli. The outcome of the infections process varies, the depending on the cause and severity of the infection, the body’s resistance, and the effectiveness of treatment. Optimally, the causative factors are corrected, the infection is controlled, and the inflammatory exudate reabsorbed with no residual pathologic condition in the abdomen. If ischemic tissue is involved, adhesions tro be produced, because new vessels sprout in response ischemia, and the vascular ingrowth, the fibrinous exudate to fibrous adhesions. (if there is no vascular ingrowth , the fibrinous exudate usually is completely absorbed). Incomplete control of the infection and incomplete absorption of the inflammatory mass reposed of the inflamed organ, adjacent loops of bowel and segments of inflamed mesentery or omentum. The mass frequently is walled aff from the rest of the abdominal cavity by dense adhesions. The mass eventually may resolve or may progress to formation of an abscess that requires drainage. Occasionally numerous inflammatory masses form, resulting in several abscesses and a chronic septic state that frequently is fatal. The clinical manifestations also depend on the extent and severity of the underlying inflammation. Abdominal pain is the most consistent symptom; it may be gradual or abruptin onset and may range from a dull ache to intense, unremitting pain. The pain may be generalized or localized to the area of the abdomen overlying the inflammation. Abdominal palpation elicits rigidity and complaints of tenderness in the areas of peritoneal inflammation. Nausea and vomiting commonly occur as a result of peritoneal irritation and ilcus. Abdominal distention may be mild or severe; it results from the combined effects of ileus, gaseous distention of the bowel, and accumulation of inflammatory exudate within the abdominal cavity. Evidence of circulatory collapse may be seen in patients with septicemia or severe fluid losses (i.e, hypotension, tachycardia, oliguria, dry mucous membranes, and diminished skin turgor). The temperature is commonly elevated, although it may drop to subnormal if the patient’s immune system is overwhelmed by fulminant peritonotis. 5. Complications Septicemia, formation of intraabdominal abscesses, circulatory collapse (shock and death). 6. Diagnostic studies and findings Diagnostic test findings White blood cell count (WBC) Hematocrit (het) Serum electrolytes Arterial blood gases (ABGs) Urinalysis Chest x-ray X-ray (flat plate and upright) of abdomen Computed tomography (CT) scan of abdomen Arteriography Peritoneal aspiration with culture and sensitivity Usually elevated May be elevated as a result of fluid loss and hemoconcentration Abnormalities may be seen as a result of fluid losses from vomiting (e.g., altered levels of potassium, sodium and chloride) May show reduced levels of bicarbonate and carbon dioxide (metabolic acidosis with respiratory compensation) May be done to rule out pyelonephritis May be done to rule out pulmonary sources of pain and distention (e.g., pneumonia or pleurisy) May show air fluid levels if obstruction is present; may show dilated loops of bowel (gaseous distention consistent with ileus); may shoe free air if bowel has perforated May show abscess formation May be done to rule out mesenteric infarction May show cloudy peritoneal fluid; culture may reveal bacterial or fungal organisms B. ASUHAN KEPERAWATAN 1. Pengkajian keperawatan Assessment Observations Pain May describe sudden or gradual onset of pain; may describe pain as generalized or may be able to lacalize pain; may describe pain as dull and aching or as severe and unrelenting; respirations may be shallow, and patient may complain of pain on deep inspiration; may keep knees bent; may exhibit guarding when abdomen is approached Abdominal examination May exhibit guarding and muscle rigidity; may complain of localized or generalized tenderness may be present; palpation in unaffected quadrants may cause pain in affected quadrant; bowel sounds may be hyperactive with tinkling, rushing sounds or may be diminished or absent; distention is present; tympanitic sound heard on percussio Vital signs Temperature may be elevated, normal or subnormal; hypotension, tachycardia, and tachypnea may be present GI function May complain of anorexia, nausea and vomiting; may report inability to pass gas or stool Fluid-electrolyte balanco May exhibit signs of fluid volume deficit and electrolyte imbalance; orthostatic hypotension, tachycardia, oliguria, dry mucous membranos, diminishod skin turgor, weakness, confusion 2. Diagnosa keperawatan Nursing diagnosa Subjective findings Objective findings Pain related to peritoneal inflammation Complains of generalized or localized abdominal pain; may describe pain as dull and aching or intense; complains of pain with deep breathing Shallow respirations; abdominal guarding; keeps knees bent; facial expressions reflect pain; palpation elicits rigidity and complaints of tenderness; rebound tenderness may be present Fluid volume deficit related to vomiting and third spacing Complains of anorexia and nausea; reports vomiting; complains of dry mouth thirst; may complain of dizziness and weakness Vomiting; dry mucous membranes; diminished skin turgor; tachycardia; orthostatic hypotension; oliguria; concentrated urine; lethargy; confusion Altered renal, cerebral, cardiopulmonary, gastrointestinal and peripheral tissue perfusion related to septicemia and shock Reports feeling short of breath and anxious; may report increasing pain Hypotension; tachycardia; tachypnea; diaphoresis; oliguria; fever; increasing abdominal distention and tenderness Altered nutrition; less than body requirements related to anorexia, nausea and vomiting Reports nausea and vomiting Actual weight is below 90% of usual weight; reduced oral intake of nutrients; vomiting 3. Rencana tindakan/intervensi keperawatan Diagnosa keperawatan Tujuan (goal, objective, outcomes) Intervensi keperawatan Rasional Pain related to peritoneal inflammation Monitor patient for increasing pain and for response to pain control measures. Administer analgesics (e.g., morphine) as ordered and needed. Help patient assume a position of comfort (e.g., knees flexed). Increasing pain indicates worsening of the inflammation; assessment of response to pain control measures permits modification of care plan as needed. Narcotic analgesics are indicated to relieve severe pain. Positioning with knees flexed reduces traction on peritoneum and thus reduces pain . Fluid volume deficit related to vomiting and third spacing Monitor patient for intake and output and for signs of hypovolemia; dry mucous membranes, oliguria, orthostatic hypotension, diminished skin turgor, tachycardia. Administer antiemetics as ordered and needed. Keep patient NPO and place N/G tube as ordered (or assist with placement); irrigate tube as needed to maintain patency. Administer IV fluids as ordered. Prompt recognition of fluid deficits permits early intervention. Antiemetics reduce vomoting, thus reducing fluid losses. Decompression of stomach and proximal bowel reduces vomiting and permits accurate measurement of fluid losses. IV fluids are administered to maintain plasma volume, which is essential for maintaining tissue perfusion. Altered renal, cerebral, cardiopulmonary, gastrointestinal and peripheral tissue perfusion related to septicemia and shock Monitor patient for increasing pain and tenderness and for signs and symptoms of septicemia and shock; fever, tachycardia, hypotension, diaphoresis and shortness of breath. Help with placement of swan-Ganz or CVP line as ordered; monitor hemodynamic parameters, and report abnormal findings promptly. Administer antibiotics as ordered. Carry out continuous peritoneal lavage as ordered. Administer oxygen by nasal cannula as ordered to patient with signs of hypoxia (e.g., shortness of breath, tachycardia). Notify physician of worsening clinical status, and prepare patient for surgery. Increasing pain and tenderness indicate worsening intraabdominal infection; fever, tachycardia, hypotension, diaphoresis, and shortness of breath indicate sepsis and shock; hypotension coupled with tachycardia and dropping temperature is a grave prognostic sign, where as rising temperature coupled with slowly dropping pulse rate indicates localization of the infection. Accurate hemodynamic monitoring permits prompt intervention. Antibiotics eliminate bacteria and help control infection, thus reducing the potential for bacterial invasion of the bloodstream and septic shock. Continuous peritoneal lavage helps rid the abdominal cavity of bacteria and bacterial debris, thus helping to control the infection. Administration of oxigen increases the oxigen delivered to tissues. Emergency laparotomy may be required to correct underlying pathologic condition or to drain abscesses. Altered nutrition; less than body requirements related to anorexia, nausea and vomiting Collaborate with physician and nutritional support team to provide TPN until patient can resume oral nutrient intake. Nutritional support is needed to maintain positive nitrogen balance, which helps prevent complications and maintain immune system function. 4. Tindakan keperawatan Tindakan keperawatan dilakukan dengan mengacu pada rencana tindakan/intervensi keperawatan yang telah ditetapkan/dibuat 5. Evaluasi keperawatan Patient outcome Data indicating that outcome is reached Patient has no abdominal pain or tenderness. Patient states that abdominal pain and tenderness have resolved; he requires no analgesics; abdominal palpation elicits no guarding, rigidity, or tenderness. Patient maintains a normal fluid electrolyte balance. Patient states that nausea has resolved; he tolerates oral food and fluids without vomiting; intake and output are balanced; there are no signs or symptoms of fluid volume deficit (e.g., oliguria, dry mucous membranes, diminished skin turgor, weakness, confusion); B/P and pulse are within normal limits. Patient has adequate perfusion of renal, cerebral, cardiopulmonary, gastrointestinal, and peripheral tissues. Abdomen is soft, nondistended, and nontender; temperature, pulse, B/P, and respiratory rate arewithin normal limits; patient has no shortness of breath andis alert and oriented. Patient has attained and maintains usual weight and ingests adequate nutrients dally. Patients’s weight is 90% or more of usual weight; he ingests oral food and fluids in adequate amounts without vomiting. 6. Patient teaching 1) Explain the rationale and specifies of the care plan; provide time for the patient and family to ask questions and discuss their concerns about the disease and the treatment plan. 2) If surgery is required, explain the planned procedure, as well as preoperative and postoperative care procedures. 3) If the patient is discharged with open wounds or drain sites, teach him and family members appropriate home care procedures. 4) If the patient is discharged with medications, explain their purpose, dosage, and any potential adverse reactions.

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Dear Brother Nuryana, Thanks for your prompt response and i hope all was well with you and your family over the Weekend.It was nice speaking with you few minutes ago. I call you my Brother because i have now taken and accepted you like a Brother,Partner and Family.I hope you take me the same way.Be rest assured once again that this project is completely REAL and TRUE.This project will be 100% successful as long as you are sincerely committed to the success of the project while we both work like team to attain our common goal for success at the end of the day. You must note that with your utmot co-operation and committment we can get this lofty project concluded within 14 banking working days. I have attached a copy of statement of account on the fund still in the name of the late depositor which was released early last 2 years by the bank during its monthly audit exercise.This is a proof of the existence of the fund.Please note that this is strictly for your perusal and personal record.Do keep it safe and confidential. We are partners in these deal and we must be open and free with each other so that we can attain success at the end of the day.Trust is most needed in this partnership and i will like to assure you 100% that on my honor you have my TRUST and HONESTY.i hope to have all the same from you completely. All your information's as requested have been received including your Identification copy as requested.Now your information's will be filed at the bank on Monday Morning next week in your Beneficiary application file by Miss Ann Phillips.After that is done then the next stage is that i will have to make proper changes of the Beneficiary Status into your own name at the Bank.We will need the assistance of the staffs working at the Bank Central Database Department of the bank to make the changes.They will be aware of what we both will be doing and i know for sure that they will be demanding some administrative fees from us because they will not be a part of sharing the fund once i am able to secure the Approval and release of the fund in your name. Miss Ann Phillips will meet the bank officials working at the banks central database system where she will have to negotiate on the administrative fees to be given to the bank officials so that they can effect the changes on the Account Status Beneficiary Name directly from the banks central database system on the account and input your own full provided information's as the new owner of the account with balance of $85MUSD.You know the Late Depositor never stated any Next of Kin/Beneficiary to the deposited fund in the account.Miss Ann Phillips will now be at the bank on Wednesday 18/04/12 to meet with the bank officials to discuss and know how much the staffs will be demanding as administrative fees and if it is within my reach then i will give it to them to enable them make all the changes into your own name accordingly. Why i am doing this is because if this fund is unclaimed it will be reverted back to the banks treasury as an unclaimed fund and it will now be shared among the banks top executives without anyone's knowledge which is not right.We cant allow that to happen rather it will be better that we both have the fund and share it equally while we now give some percentage to the needy.This is what i feel. When the changes are done by the bank officials i will now contract a banking Attorney who will be procuring all the relevant documents like the Affidavit of Proof and Letter of Administration from her Majesty Court of England and Wales in your favor.This is very important so that it will be legally proofed that you are the full Legal Beneficiary/Next of Kin of the fund. Those documents are really the main thing that will back up our claims for the fund to be Approved and released to you because with those documents, the law of England and Wales must have accepted you as the Full Legal Beneficiary of the fund. Once the Legal procurements is concluded the attorney will now file a memo of application to the bank on your behalf for the immediate Approval and release of the fund in your favor.The Executives of the Bank will sit and vote in order to issue and an approval of the fund in your name. At this time i already have two of the banks Top executives on our side that will help influence the vote for approval in your favour at the board meeting but we will also issue some kickbacks to the 2 of them which is so high but i believe with the help of God i will be able to settle the Executives without much problems or delays. I am waiting to hear from you. You can call me anytime on my direct line so that we can talk more. 44 703 5940 734 Your Brother and Partner, Tim Tookey

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