Reducing Gender Inequality In Hiv Health And Social Care Essay

Globally, there has been a alteration in the tendency of infection among the sexes. Initially at the oncoming of the disease, the prevalence of the disease was higher among the males than the females due to the fact that the disease was concentrated among homophiles and drug users. However as the cuticular continues to turn there has been a progressive displacement to heterosexual transmittal with an addition in the figure of females being infected. The planetary pandemic of HIV/AIDS is now in its 3rd decennary, with adult females now at the epicenter of the pandemic, globally accounting for about 50 % of all HIV instances aged 15 and older, including about 60 % of all grownups populating with HIV/AIDS in Sub-Saharan Africa, and the figure of females populating with the disease in every part of the universe continue to increase. ( UNAIDS, 2009 ) The feminization of the pandemic is precipitated by biological and socio-cultural factors ; However although adult females are more vulnerable to the disease because of their biological makeup, there is grounds that gender norms play an built-in portion in act uponing an person ‘s exposure to the infection, entree to wellness attention services, sexual behavior and attitude, every bit good as entree to intervention and support when infected. ( WHO, 2003 ) The present tendency of the disease transmittal reveals that the epidermic is being aggravated by gender based exposures, stressing the importance of mainstreaming gender into HIV/AIDS programmes as an built-in effort to commanding farther spread of the disease. ( UNFPA, 2008 ) The Importance of Gender on the HIV/AIDS Pandemic: In most communities, gender determines how much information males and females are expected to hold approximately sexual affairs. Females are supposed to be nescient about sexual affairs as a mark of celibacy ; therefore doing them nescient about preventative schemes and doing it hard for them to be proactive in negociating safer sex. Different set of cultural norms apply to the males, they are frequently expected to hold more information and cognition about sexual affairs, be expericienced, and led as determination shapers in sexual issues. These make them vulnerable to being infected, prevents them from seeking information or acknowledging their limited information about sexual affairs. ( Carovano, 1992 ) . Social norms of virginity for single adult females besides increase her exposure ; it besides limits her information about sexual affairs to avoid being thought of as being sexually active. Puting her at a hazard of colza and sexual coercion. Research has besides shown that these immature misss practise other sexual behaviors such as anal sex, therefore increasing their hazard of undertaking the disease. ( Weiss et al.,2000 ) . Besides, because of the social norms of virginity accessing wellness installations for the intervention of sexually transmitted diseases is frequently stigmatising for both immature and big females. ( Weiss et al.,2000 ) . In many societies, maternity, merely like virginity is seen as being ideal, therefore utilizing preventives or barrier methods to guarantee safer sex is seen as a important quandary for adult females. ( Heise and Elias, 1995 ) . Research have shown that economic dependance of adult females increases their likeliness of interchanging sex for money, with no dialogue for safe sex, accompanied with their inability to go forth these dealingss even when they perceive them to be hazardous because of its fiscal additions. ( Heise and Elias,1995 ) . A reappraisal of literature done by Heise et Al ( 1999 ) showed it was more likely for persons who had been sexually abused to hold multiple sex spouses, engage in insecure sex and exchange sex for money or favor. Harmonizing to Societal norms, work forces are supposed to show their male power through force against adult females, lending both straight and indirectly to a adult female ‘s exposure to the disease. ( Heise and Elias, 1995 ) . A survey conducted in a voluntary HIV guidance and proving Centre in Tanzania by Maman et Al ( 2000 ) suggested that adult females who expericienced sexual force were at a hazard of HIV/AIDS. It was noticed that those who were HIV positive were 2.6 times more likely to hold expericienced sexual force in an confidant relationship. Social norms expect a adult male to hold several sexual spouses, for sufficient sexual release, herewith beliing the preventative message that emphasizes fidelity in relationships. ( Heise and Elias, 1995 ) . Social norms of maleness, which affirm males holding sexual laterality over females, as a characteristic of manhood, frequently lead to stigmatisation of work forces who have sex with work forces, thereby taking to secrecy of their sexual behavior, increasing the exposure of their sexual spouses, both males and females. ( UNAIDS, 1999 ) . Overall, the influence of social norms is frequently associated with addition in an person ‘s exposure of undertaking the disease. ( Courteney, 1998 ) Analysis of WHO ‘s Policy on Gender Mainstreaming in HIV/AIDS Programme: The guidelines on gender mainstreaming resulted from a WHO ‘s meeting held in Geneva in 2002 on incorporating Gender into HIV/AIDS. The demand to bring forth guidelines was emphasized as a agency to guaranting realisation of set ends. The present edition was developed by World Health Organization in concurrence with inputs from advisers peer reviewed by external referees, relevant proficient staff in the World Health Organization every bit good as research experience from old programmes that addressed the gender dimensions in HIV/AIDS and other wellness programmes. The intent of the guidelines is to increase consciousness of how gender inequalities affects a adult female ‘s ability to entree HIV/AIDS programmes and services, it besides offers practical ways on how to integrate gender into assorted types of HIV/AIDS programmes and services. Four specific countries were covered HIV proving and reding, Prevention of female parent to child transmittal ( PMTCT ) , HIV intervention and Home based attention for people populating with HIV/AIDS. The guidelines were formulated chiefly for programmes directors, wellness attention suppliers in the public and private sector involved in instituting, implementing or measuring HIIV/AIDS programmes. The guidelines are consistent and reinforced through assorted international understandings and declarations such as Beijing declaration and platform for action of the 1995 Fourth World conference on adult females ( FWCW ) and 1994 International conference on population and development. The United Nations General Assembly declarations of the committedness on HIV/AIDS besides emphasized the importance of turn toing gender equality as a agency to commanding the epidermic. This policy compliments old attempts done on incorporating gender into HIV/AIDS programmes with the purpose of bettering entree, informing and authorising clients, and besides taking to wellness equity and societal justness. However the guidelines focused chiefly on adult females.it did non offer equal chances to work forces, although the Beijing platform for action besides considered work forces ‘s concerns, guaranting that adult females and work forces benefit every bit from the ultimate end of accomplishing gender equality. The guidelines did non besides see the multi-sectoral attack ; it focused chiefly on the wellness sector attack to cut downing gender inequality. ( Beginning: World Health Organization ‘s guidelines on intergrating gender into HIV/AIDS Programmes within the wellness sector, 2007 ) Measuring the execution of this policy at the international and national degree. Following the 1995 United Nations conference on adult females, assorted developmental establishments, international organisations and states adopted the thought of gender mainstreaming. These International Organizations and development Institutions developed and endorsed gender mainstreaming Policies in HIV/AIDS ; nevertheless rating show restraints in execution, these policies have been slow in interpreting from policy into action. ( Moser, 2005 ) . This can be attributed to the fact that some development practicians in NGO ‘s continue to see gender issues as a distraction to the developmental issues they have to turn to, accordingly those involved in gender cyclosis are non in places to do determinations and alterations to these programmes. Since the Congress, gender mainstreaming in HIV/AIDS have been adopted and endorsed by assorted authoritiess, gender advocators in these states have successed in integrating gender issues into their national strategic programs for HIV/AIDS and HIV/AIDS programmes. The challenges in these states have been the execution of these policies and strategic programs at the territory degree. In a survey done in Botswana, it was observed that although gender had been incorporated into its national response to HIV/AIDS, with purposes to authorising the adult females, therefore cut downing the exposure of females in undertaking the disease, the intercessions focused on adult females, pretermiting the work forces, therefore gestating gender as a adult female ‘s issue. In Malawi, important efforts have been made, assorted programmes have been formed, and the National HIV/AIDS policy recognized that gender issues had to be considered, to guarantee effectual response to HIV/AIDS intercessions. However on rating it was noticed that bulk of the staffs in the NGO ‘s understood the construct in the European context, which was non applicable to their ain cultural norms and values, furthermore, the exposure of work forces was non considered sabotaging the proportion of drug users and homophiles in the population. The Zimbabwe ‘s national Aids Policy, showed committedness to gender inequality, acknowledging that adult females were more vulnerable, and prosecuting authorization of adult females as a agency to undertaking gender inequality, it besides developed schemes to guarantee the engagement of work forces in gender affairs. However rating showed that despite these schemes nidation of these policies at the grass-root degree have been impossible. ( Boom et al. , 2000 ) The national strategic program of South-Africa accepted adult females, and work forces who have sex with work forces, as portion of those who were vulnerable to the disease, and provided assorted intercessions to turn to gender related causes of exposure. It emphasized the difference in the prevalence of the disease in the age groups ( 20-29 ) , saying that adult females were more vulnerable due to social norms. Acknowledging that really small attending had been given to work forces who have sex with work forces, and drug users. It emphasized that the execution of these schemes were to suit both the demands of adult females and work forces. Evaluation nevertheless noted that commercial sex workers were discriminated and that gender force played an built-in portion in adult females ‘s exposure in South-Africa was non addressed therefore haltering the execution of these schemes. The Multi-sectoral HIV/AIDS strategic program of Switzerland recognized that harmful gender norms played a function in fuelling the cuticular, and that to guarantee long -term effects in schemes aimed at commanding the disease gender inequality had to be considered. This led to the National Emergency Response Council, developing schemes to steer the execution of these HIV/AIDS programmes. However it was noticed that gender was conceptualized as biological sex instead than gender, and its programmes were targeted at adult females, pretermiting work forces who had sex with work forces and other vulnerable groups such as drug users. On rating an addition in the incidence of mew infections was noticed among homophiles, showing that these groups played an of import function in commanding the disease. Discussion: Assorted International Organizations and Countries have integrated gender into their assorted policies, schemes and HIV/AIDS Programmes. The inquiry arising is why are these policies, schemes and plans non being implemented at the grass root degree? Decision: Gender norms influence an person ‘s exposure to undertaking the disease, therefore stressing the importance of Gender mainstreaming and adult females authorization in commanding the spread of the disease. Gender mainstreaming intercessions in assorted degree should acknowledge the functions work forces play in adult females ‘s expericiences, therefore gender related restraints of both males and females should be considered in HIV/AIDS Programmes. Training and support should be offered to HIV/AIDS programme directors and their staffs about gender issues to enable them implement policies turn toing gender inequality and HIV/AIDS.

Vascular Sounds, Abdominal,

The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal authorities. To the best of our knowledge, these procedures reflect currently accepted practice. Nevertheless, they can’t be considered absolute and universal recommendations. For individual applications, all recommendations must be considered in light of the patient’s clinical condition and, before administration of new or infrequently used drugs, in light of the latest package-insert information. The authors and publisher isclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text.  © 2011 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanic al, photocopy, recording, or otherwise—without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher to instructors hose schools have adopted its accompanying textbook. Printed in China. For information, write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 323, Ambler, PA 19002-2756. Derived from American Gothic, 1930 by Grant Wood. All rights reserved by the estate of Nan Wood Graham/Licensed by VAGA, New York, NY. The publishers have made every effort to obtain permission from the copyright holders to use borrowed material. If any material requiring permission has been overlooked, the publishers will be pleased to make the necessary arrangements at the first opportunity. HAIV020410 Library of Congress Cataloging-in-Publication DataHealth assessment made incredibly visual!. —2nd ed. p. ; cm. —(Incredibly visual) Includes bibliographic al references and index. ISBN 978-1-60547-973-6 (alk. paper) 1. Physical diagnosis—Atlases. 2. Physical diagnosis—Handbooks, manuals, etc. I. Series: Incredibly visual. [DNLM: 1. Nursing Assessment—methods— Atlases. 2. Nursing Assessment—methods— Handbooks. 3. Physical Examination— methods—Atlases. 4. Physical Examination— methods—Handbooks. WY 49 H434 2011] RT48. H448 2011 616. 07'54—dc22 ISBN13 978-1-60547-973-6 ISBN10 1-60547-973-X (alk. paper) 2009049443 Staff Publisher Chris Burghardt Clinical Director Joan M. Robinson, RN, MSNProduct Manager Diane Labus Clinical Project Manager Beverly Ann Tscheschlog, RN, MS Editor Jaime Stockslager Buss, MSPH, ELS Copy Editor Karen Comerford Design Coordinator Joan Wendt Illustrator Bot Roda Associate Manufacturing Manager Beth J. Welsh Editorial Assistants Karen J. Kirk, Jeri O'Shea, Linda K. Ruhf Contents iii A work of art iv Contributors and consultants vi 1 Fund amentals 1 2 Skin, hair, and nails 11 3 Eyes and ears 27 4 Nose, mouth, throat, and neck 49 5 Respiratory system 67 6 Cardiovascular system 87 7 Breasts and axillae 113 8 Gastrointestinal system 127 9 Musculoskeletal system 147 10 Neurologic system 171 1 Genitourinary system 193 Selected references 239 Credits 240 Index 242 12 Pregnancy 213 iv Contributors and consultants I’m so excited to be here today! The gallery is opening its new exhibit, Health Assessment Made Incredibly Visual. best picture outside the norm take note I hear it’s a masterpiece that’s guaranteed to inspire top-notch assessment skills. It’s even more extraordinary than I expected. outside the norm take note v The vividly detailed illustrations and photographs of abnormal findings are definitely â€Å"Outside the norm. † And what chiaroscuro! And I’m certainly going to â€Å"Take note† of this piece. You an tell that it captures lifelike charts that illustrate the correct ways to document assessment findings. If this collection were a movie, it would have â€Å"Best picture† written all over it. The graphic depictions of best assessment practices that appear throughout are unique and innovative. All-in-all, I find this a visually stunning and exciting new work. It has certainly inspired me to master health assessment. best picture vi Contributors and consultants Nancy Berger, RN, MSN, BC, CNE Program Coordinator Middlesex County College Edison, N. J. Marsha L. Conroy, RN, BA, MSN, APN Nurse Educator Indiana Wesleyan University MarionChamberlain College of Nursing Columbus, Ohio Roseanne Hanlon Rafter, RN, MSN, GCNS, BC Director of Nursing Professional Practice Chestnut Hill Hospital Philadelphia, Pa. Dana Reeves, RN, MSN Assistant Professor University of Arkansas—Fort Smith Denise Stefancyk, RN, BSN, CCRC Clinical Specialist University of Massachusetts Medical Center Worcester Allison J. Terry, RN, PhD Director, Center for Nursi ng Alabama Board of Nursing Montgomery Leigh Ann Trujillo, RN, BSN Clinical Educator St. James Hospital and Health Centers Olympia Fields, Ill. Rita M. Wick, RN, BSN Simulation Coordinator Berkshire Health Systems Pittsfield, Mass.Sharon E. Wing, RN, PhD(C), CNL Associate Professor Cleveland (Ohio) State University Lisa Wolf, RN, MS, CMSRN Clinical Educator Mount Carmel West Columbus, Ohio Health history 2 Physical assessment 6 Documentation 9 Vision quest 10 Ready. Action! Health history Interviewing tips To make the most of your patient interview, create an environment in which the patient feels comfortable. Also, use the following techniques to ensure effective communication. Fundamentals  ¦ Provided by the patient, or â€Å"subject†  ¦ Verified only by the patient  ¦ Include statements such as â€Å"My head hurts† or â€Å"I have trouble sleeping† Subjective data Are observed  ¦ Are verifiable  ¦ Include findings such as a red, swollen arm in a pat ient with arm pain Objective data The success of your patient interview depends on effective communication.  Select a quiet, private setting.  Choose terms carefully and avoid using medical jargon.  Speak slowly and clearly.  Use effective communication techniques, such as silence, facilitation, confirmation, reflection, and clarification.  Use open-ended and closed-ended questions as appropriate.  Use appropriate body language.  Confirm patient statements to avoid misunderstanding.  Summarize and conclude with â€Å"Is there anything else?         2 Fundamentals All assessments involve collecting two kinds of data: objective and subjective. The health history gathers subjective data about the patient. Health history 3 Components of a complete health history Biographical data Name __________________________________________ Address ________________________________________ Date of birth ____________________________________ Advance directive explained:  Yes  No Livin g will on chart:  Yes  No Name and phone numbers of next of kin: NAME RELATIONSHIP PHONE # ________________________________________________ ________________________________________________Chief complaint History of present illness ________________________________________________ ________________________________________________ Current medications DRUG AND DOSE FREQUENCY LAST DOSE ________________________________________________ ________________________________________________ Medical history Allergies  Tape  Iodine  Latex  No known allergies  Drug: _________________________________________  Food: _________________________________________  Environmental: _________________________________  Blood reaction: _________________________________  Other: _________________________________________ Childhood illnessesDATE ________________________________________________ ________________________________________________ Previous hospitalizations (Illness, accident or injury, surgery, bl ood transfusion) DATE Health problems Yes No Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blood problem (anemia, sickle cell, clotting, bleeding). . . . Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . Eye problem (cataracts, glaucoma) . . . . . . . . . . . . Heart disease (heart failure, MI, valve disease) Hiatal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney problem . . . . . . . . . . . . . . . . . . . . . . . . . Liver problem . . . . . . . . . . . . . . . . . . . . . . . . . . . Lung problem (asthma, bronchitis, emphysema, pneumonia, TB, shortness of breath) . . . . . . . . . . . . Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thyroid problem . . . . . . . . . . . . . . . . . . . . . . . . . Ulcers (duodenal, peptic). . . . . . . . . . . . . . . . . . . . Psychological disorder . . . . . . . . . . . . . . . . . . . Obstetric history (females) Last menstrual period _____________________________ Gravida __________ Para ___________ Menopause Yes No Psychosocial history Coping strategies _________________________________________________ Feelings of safety ________________________________________________ Social history Smoker No Yes (# packs/day _____ # years ___ ) Alcohol No Yes (type ________ amount/day ___ ) Illicit drug use No Yes (type ____________ ) Religious and cultural observances ________________________________________________ Activities of daily living Diet and exercise regimen _________________________Elimination patterns _______________________________ Sleep patterns ____________________________________ Work and leisure activities _________________________ Use of safety measures (seat belt, bike helmet, sunscreen) ______________________ Health mainten ance history DATE Colonoscopy ____________________________________ Dental examination _______________________________ Eye examination _________________________________ Immunizations ___________________________________ Mammography __________________________________ Family medical history Health problem Yes No Who (parent, grandparent, sibling) Ask about the patient’s family edical history, including history of diabetes or heart disease. Ask about the patient’s feelings of safety to help identify physical, psychological, emotional, and sexual abuse issues. Arthritis . . . . . . . . . . . . Cancer . . . . . . . . . . . . . Diabetes mellitus . . . . . Heart disease (heart failure, MI, valve disease) . . Hypertension . . . . . . . . Stroke . . . . . . . . . . . . . Be sure to include prescription drugs, over-the-counter drugs, herbal preparations, and vitamins and supplements. 4 Fundamentals During the final part of the health history, ask about each body structure and syst em to make sure that important ymptoms weren’t missed. Start at the top of the head and work your way down to the toes. Head Psychological status Neck Endocrine system Breasts and axillae Gastrointestinal system Reproductive system General health Neurologic system Eyes, ears, and nose Mouth and throat Skin, hair, and nails Cardiovascular system Respiratory system Hematologic system Urinary system Musculoskeletal system Review of structures and systems Health history 5 Evaluating a symptom Perform a focused physical examination to quickly determine the severity of the patient’s condition. Take a thorough history. Note GI disorders that can lead to abdominal distention.Thoroughly examine the patient. Observe for abdominal asymmetry. Inspect the skin, auscultate for bowel sounds, percuss and palpate the abdomen, and measure abdominal girth. My stomach gets bloated. Your patient is vague in describing his chief complaint. Using your interviewing skills, you discover his pr oblem is related to abdominal distention. Now what? This flowchart will walk you through what to do next. Take a brief history. Intervene appropriately to stabilize the patient, and notify the doctor immediately. Review your findings to consider possible causes, such as cancer, bladder distention, cirrhosis, heart failure, and astric dilation. After the patient’s condition stabilizes, review your findings to consider possible causes, such as trauma, large-bowel obstruction, mesenteric artery occlusion, and peritonitis. Devise an appropriate care plan. Position the patient comfortably, administer ordered analgesics, and prepare the patient for diagnostic tests. Form a first impression. Does the patient’s condition alert you to an emergency? For example, does he say the bloating developed suddenly? Does he mention that other signs or symptoms occur with it, such as sweating and light-headedness? (Indicators of hypovolemia) Yes NoAsk the patient to identify the symptom th at’s bothering him. Do you have any other signs or symptoms? Evaluate your findings. Are emergency signs or symptoms present, such as abdominal rigidity and abnormal bowel sounds? Yes No 6 Fundamentals Physical assessment  ¦ Cotton balls  ¦ Gloves  ¦ Metric ruler (clear)  ¦ Near-vision and visual acuity charts  ¦ Ophthalmoscope  ¦ Otoscope  ¦ Penlight  ¦ Percussion hammer  ¦ Paper clip  ¦ Scale with height measurement  ¦ Skin calipers  ¦ Specula (nasal and vaginal)  ¦ Sphygmomanometer  ¦ Stethoscope  ¦ Tape measure (cloth or paper)  ¦ Thermometer  ¦ Tuning fork  ¦ Wooden tongue blade Assessment toolsAssemble the necessary tools for the physical assessment. Then perform a general survey to form your initial impression of the patient. Obtain baseline data, including height, weight, and vital signs. This information will direct the rest of your assessment. Measuring blood pressure  ¦ Position your patient with his upper arm at heart level an d his palm turned up.  ¦ Apply the cuff snugly, 1 (2. 5 cm) above the brachial pulse.  ¦ Position the manometer at your eye level.  ¦ Palpate the brachial or radial pulse with your fingertips while inflating the cuff.  ¦ Inflate the cuff to 30 mm Hg above the point where the pulse disappears. Place the bell of your stethoscope over the point where you felt the pulse, as shown in the photo. (Using the bell will help you better hear Korotkoff’s sounds, which indicate pulse. )  ¦ Release the valve slowly and note the point at which Korotkoff’s sounds reappear. The start of the pulse sound indicates the systolic pressure.  ¦ The sounds will become muffled and then disappear. The last Korotkoff’s sound you hear is the diastolic pressure. best picture Got your tools? Good. Let’s get to work! Tips for interpreting vital signs  ¦ Analyze vital signs at the same time. Two or more abnormal values may provide clues to the patient’s problem.For example, a rapid, thready pulse along with low blood pressure may signal shock.  ¦ If you obtain an abnormal value, take the vital sign again to make sure it’s accurate.  ¦ Remember that normal readings vary with the patient’s age. For example, temperature decreases with age, and respiratory rate can increase with age.  ¦ Remember that an abnormal value for one patient may be a normal value for another, which is why baseline values are so important. Physical assessment 7 Physical assessment techniques When you perform the physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation.Use these techniques in this sequence except when you perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. 1 Inspection Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Observe for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system. 2Palpation Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails hort and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. Types of palpation Light palpation  ¦ Use this technique to feel for surface abnormalities.  ¦ Depress the skin 1/2 to 3/4 (1. 5 to 2 cm) with your finger pads, using the lightest touch possible.  ¦ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Deep palpation  ¦ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.  ¦ Depress the skin 11/2 to 2 (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed. 8 Fundamentals 3Percussion Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient’s body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. 4Auscultation Auscultation involves listening for various breath, heart, and bowel sounds with a stethoscope. Types of percussion Direct percussion This technique reveals tenderness; it’s commonly used to assess an adult patient’s sinuses. Here’s how to do it:  ¦ Using one or two fingers, tap irectly on the body part.  ¦ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort. Indirect percussion This technique elicits sounds that give clues to the makeup of the underlying tissue. Here’s how to do it:  ¦ Press the distal part of the middle finger of your nondominant hand firmly on the body part.  ¦ Keep th e rest of your hand off the body surface.  ¦ Flex the wrist of your dominant hand.  ¦ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient’s skin.  ¦ Listen to the sounds produced. Getting ready Provide a quiet environment.  ¦ Make sure the area to be auscultated is exposed. ( Auscultating over a gown or bed linens can interfere with sounds. )  ¦ Warm the stethoscope head in your hand.  ¦ Close your eyes to help focus your attention. How to auscultate  ¦ Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient’s skin, enough to leave a slight ring on the skin afterward.  ¦ Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient’s skin, just enough to form a seal.Holding the bell too firmly causes th e skin to act as a diaphragm, obliterating low-pitched sounds.  ¦ Listen to and try to identify the characteristics of one sound at a time. Documentation 9 Documentation Get to know your stethoscope Your stethoscope should have snug-fitting ear tips, which you’ll position toward your nose. The stethoscope should also have tubing no longer than 15 (38. 1 cm) with an internal diameter not greater than 1/8 (0. 3 cm). It should have both a dia phragm and bell. The parts of a stethoscope are labeled below. Ear tips Binaurals (ear tubes) Tension bar Tubing Bell Stem Diaphragm Headset ChestpieceDocumenting initial assessment findings Here’s an example of how to record your findings on an initial assessment form. take note Name Age _______ Sex ______ Height ________ Weight ________ T ______ P ___ R ___ B/P (R) ____________ (L) _____________ Room _____________________ Admission time ____________ Admission date ____________ Doctor ____________________ Admitting diagnosis: __ _________________________ ___________________________ ___________________________ ___________________________ Patient’s stated reason for hospitalization ______________ ___________________________ ___________________________ Allergies ___________________ __________________________ ___________________________ Current medications ________ Name Dosage Last taken _______________________________ _______________________________ _______________________________ _______________________________ General survey _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Henry Gibson 55 M 163 cm 57 kg 37  C 76 14 150/90 sitting 148/88 sitting 328 0800 4 -28-10 Manzel Pneumonia â€Å"To get rid of the pneumonia† PenicillinCodeine None In no acute distress. Slender, alert, and well-groomed. Communicates well. Make s eye contact and expresses appropriate concern throughout exam. C. Smith, RN General information Identify the assessment technique being used in each illustration. Show and tell Unscramble the words at right to discover terms related to fundamentals of assess ment. Then use the circled letters from those words to answer the question posed. My word! Answers: Show and tell 1. Indirect percussion, 2. Deep palpation; My word! 1. Auscultation, 2. Subjective data, 3. Chief complaint, 4. Palpation; Question: Abdomen 10 1. 2. 1. tunicaastolu 2. ivateacub jest 3. place inchmotif 4. aplaintop Answer: Question: Assessment of which body part does not follow the usual sequence? Anatomy 12 Assessment 14 Skin abnormalities 16 Hair abnormalities 24 Nail abnormalities 25 Vision quest 26 Quiet on the set. The assessment is about to begin. Anatomy 12 Skin, hair, and nails SkinSkin, hair, nails The skin covers and protects the internal structures of the body. It consists of two distinct layers: the ep idermis and the dermis. Subcutaneous tissue lies beneath these layers. Epidermis  ¦ Outer layer  ¦ Made of squamous epithelial tissue Dermis  ¦ Thick, deeper layer  ¦ Consists of connective issue and an extracellular material (matrix), which contributes to the skin’s strength and pliability  ¦ Location of blood vessels, lymphatic vessels, nerves, hair follicles, and sweat and sebaceous glands Subcutaneous tissue  ¦ Beneath dermis and epidermis  ¦ Consists mostly of adipose and other connective tissues Stratum corneum Pore of sweat gland Free nerve ending Eccrine sweat gland Hair bulb Sensory nerve fibers Autonomic nerve fibers Artery Vein Anatomy 13 Hair Hair is formed from keratin produced by matrix cells in the dermal layer of the skin. Each hair lies in a hair follicle. Hair shaft Sebaceous gland Arrector pili muscleHair follicle Sensory nerve fibers Hair bulb  ¦ Contains melanocytes Hair papilla  ¦ Consists of a loop of capillaries  ¦ Provides nourishm ent to hair Nails Nails are formed when epidermal cells are converted into hard plates of keratin. Hyponychium Nail plate Lateral nail fold Lunula Eponychium Nail root Nail matrix Hair bulb Matrix cell  ¦ Produces hair Cuticle cells Inner root sheath Outer root sheath Capillary in hair papilla Melanocyte  ¦ Determines hair color What is the matrix? The area of the dermis on which the nail rests. 14 Skin, hair, and nails Assessment To assess the skin, hair, and nails, use inspection and palpation. SkinObserve the skin’s overall appearance. Then inspect and palpate the skin area by area, focusing on color, moisture, texture, turgor, and temperature. Examine the conjunctivae, palms, soles, buccal mucosa, and tongue. Look for dull, dark color. Examine the area for decreased color and palpate for tightness. Palpate the area for warmth. Examine the sclerae and hard palate in natural, not fluorescent, light if possible. Look for a yellow color. Examine the sclerae, conjunctivae, buccal mucosa, lips, tongue, nail beds, palms, and soles. Look for an ashen color. Examine areas of lighter pigmentation such as the abdomen. Look for tiny, purplish red ots. Palpate the area for skin texture changes. Cyanosis Edema Erythema Jaundice Pallor Petechiae Rashes Color Look for localized areas of bruising, cyanosis, pallor, and erythema. Check for uniformity of color and hypopigmented or hyperpigmented areas. Moisture Observe the skin’s moisture content. The skin should be relatively dry, with a minimal amount of perspiration. Be sure to wear gloves during your examination of the skin, hair, and nails. Detecting color variations in dark-skinned people Assessment 15 Texture and turgor Inspect and palpate the skin’s texture, noting its thickness and mobility. It should look smooth and be intact.To assess skin turgor in an infant, grasp a fold of loosely adherent abdominal skin between your thumb and forefinger and pull the skin taut. Then release the skin. Th e skin should quickly return to its normal position. If the skin remains tented, the infant has poor turgor. Temperature Palpate the skin bilaterally for temperature using the dorsal surface of your hands and fingers. The dorsal surface is the most sensitive to temperature changes. Warm skin suggests normal circulation; cool skin, a possible underlying disorder. Assessing skin turgor in an adult Gently squeeze the skin on the forearm or sternal rea between your thumb and forefinger, as shown. If the skin quickly returns to its original shape, the patient has normal turgor. If it returns to its original shape slowly over 30 seconds or maintains a tented position, as shown, the skin has poor turgor. best picture Normal skin variations You may see normal variations in the skin’s texture and pigmentation. Such variations may include nevi, or moles, and freckles (shown below). 16 Skin, hair, and nails Lesion configurations Discrete Individual lesions are separate and distinct. Gro uped Lesions are clustered together. Dermatomal Lesions form a line or an arch and follow dermatome. Confluent Lesions merge so that discrete lesions are not visible or palpable. Lesion shapes Discoid Round or oval Annular Circular with central clearing Target (bull’s eye) Annular with central internal activity Hair When assessing the hair, note the distribution, quantity, texture, and color. Hair should be evenly distributed. Nails Examine the nails for color, shape, thickness, consistency, and contour. Nail color is pink in light-skinned people and brown in dark-skinned people. The nail surface should be slightly curved or flat and the edges smooth and rounded. Lesions When evaluating a lesion, you’ll need to classify t as primary (new) or secondary (a change in a primary lesion). Then determine if it’s solid or fluid-filled and describe its characteristics, pattern, location, and distribution. Include a description of symmetry, borders, color, configuration, diameter, and drainage. Skin abnormalities I know you’ll have these assessment skills nailed in no time! Lesion distribution Generalized — Distributed all over the body Regionalized — Limited to one area of the body Localized — Sharply limited to a specific area Scattered — Dispersed either densely or widely Exposed areas — Limited to areas exposed to the air or sun Intertriginous — Limited to reas where skin comes in contact with itself Skin abnormalities 17 outside the norm Types of skin lesions Fissure A painful, cracklike lesion of the skin that extends at least into the dermis Cyst A closed sac in or under the skin that contains fluid or semisolid material Papule A solid, raised lesion that’s usually less than 1 cm in diameter Vesicle A small, fluid-filled blister that’s usually 1 cm or less in diameter Bulla A large, fluid-filled blister that’s usually 1 cm or more in diameter Ulcer A craterlike lesion of th e skin that usually extends at least into the dermis Macule A small, discolored spot or patch on the skinWheal A raised, reddish area that’s commonly itchy and lasts 24 hours or less Pustule A small, pus-filled lesion (called a follicular pustule if it contains a hair) Nodule A raised lesion detectable by touch that’s usually 1 cm or more in diameter Documenting a skin lesion take note At 0820, pt. c/o right shoulder blade pain, 4/10 on a 0-10 scale. A closed, purulent lesion noted in right upper scapular region of back, approx. 1. 5 cm x 1 cm, with 3 cm surrounding area of erythema. T 100. 2 F. Call placed to Dr. Tomlin’s service at 0830. Angela Kessler, RN 4/15/10 0845 18 Skin, hair, and nails Benign versus cancerous lesionsLesions may be benign, such as a benign nevus, or mole. However, changes in an existing growth on the skin or a new growth that ulcerates or doesn’t heal could indicate cancer or a precancerous lesion. Types of skin cancer outside t he norm  ¦ Abnormal changes in keratinocytes  ¦ Can become squamous cell carcinoma Precancerous actinic keratosis  ¦ Abnormal growth of melanocytes in a mole  ¦ Can become malignant melanoma Dysplastic nevus Note the differences between benign and cancerous lesions.  ¦ Symmetrical, round, or oval shape  ¦ Sharply defined borders  ¦ Uniform, usually tan or brown color  ¦ Less than 6 mm in diameter  ¦ Flat or raisedBenign nevus  ¦ Abnormal changes in keratinocytes  ¦ Can become squamous cell carcinoma  ¦ Abnormal growth of melanocytes in a mole  ¦ Can become malignant melanoma Skin abnormalities 19 More severe Less severe  ¦ Begins as a firm, red nodule or scaly, crusted, flat lesion  ¦ Can spread if not treated Squamous cell carcinoma  ¦ Most common skin cancer  ¦ Usually spreads only locally Basal cell carcinoma  ¦ Can arise on normal skin or from an existing mole  ¦ If not treated promptly, can spread to other areas of skin, lymph nodes, or int ernal organs Malignant melanoma If you suspect a lesion may be malignant melanoma, observe for these haracteristics. memory board ABCDEs of malignant melanoma A = Asymmetrical lesion B = Border irregular C = Color of lesion varies with shades of tan, brown, or black and, possibly, red, blue, or white D = Diameter greater than 6 mm E = Elevated or enlarging lesion 20 Skin, hair, and nails Common skin disorders outside the norm Contact dermatitis is an inflammatory disorder that results from contact with an irritant. Primary lesions include vesicles, large oozing bullae, and red macules that appear at localized areas of redness. These lesions may itch and burn. Contact dermatitis Psoriasis is a chronic disease of marked pidermal thickening. Plaques are symmetrical and generally appear as red bases topped with silvery scales. The lesions, which may connect with one another, occur most commonly on the scalp, elbows, and knees. Psoriasis Occurring as an allergic reaction, urticaria appea rs suddenly as pink, edematous papules or wheals (round elevations of the skin). Itching is intense. The lesions may become large and contain vesicles. Urticaria (hives) Skin abnormalities 21 Mites, which can be picked up from an infested person, burrow under the skin and cause scabies lesions. The lesions appear in a straight or zigzagging line about 3/8 (1 cm) ong with a black dot at the end. Commonly seen between the fingers, at the bend of the elbow and knee, and around the groin, abdomen, or perineal area, scabies lesions itch and may cause a rash. Scabies Herpes zoster appears as a group of vesicles or crusted lesions along a nerve root. The vesicles are usually unilateral and appear mostly on the trunk. These lesions cause pain but not a rash. Herpes zoster Tinea corporis is characterized by round, red, scaly lesions that are accompanied by intense itching. These lesions have slightly raised, red borders consisting of tiny vesicles. Individual rings may connect to form atche s with scalloped edges. They usually appear on exposed areas of the body. Tinea corporis (ringworm) Once I burrow under the skin, I settle down and make myself comfortable. 22 Skin, hair, and nails Pressure ulcers Pressure ulcers are localized areas of skin breakdown that occur as a result of prolonged pressure. Necrotic tissue develops because the vascular supply to the area is diminished. Staging pressure ulcers You can use characteristics gained from your assessment to stage a pressure ulcer, as described here. Staging reflects the anatomic depth of exposed tissue. Keep in mind that if the wound contains necrotic issue, you won’t be able to determine the stage until you can see the wound base. outside the norm Suspected deep tissue injury  ¦ Maroon or purple intact skin or blood-filled blister  ¦ May be painful; mushy, firm, or boggy; and warmer or cooler than other tissue before discoloration occurs Stage I  ¦ Intact skin that doesn’t blanch  ¦ May differ i n color from surrounding area in people with darkly pigmented skin  ¦ Usually over a bony prominence  ¦ May be painful, firm or soft, and warmer or cooler than surrounding tissue Note: This stage shouldn’t be used to describe perineal dermatitis, maceration, tape burns, skin tears, or excoriation.Stage II  ¦ Superficial partial-thickness wound  ¦ Presents as a shallow, open ulcer without slough and with a red and pink wound bed Skin abnormalities 23 Stage III  ¦ Involves full-thickness wound with tissue loss and possibly visible subcutaneous tissue but no exposed muscle, tendon, or bone  ¦ May have slough but not enough to hide the depth of tissue loss  ¦ May be accompanied by undermining and tunneling Stage IV  ¦ Involves full-thickness skin loss, with exposed muscle, bone, and tendon  ¦ May be accompanied by eschar, slough, undermining, and tunneling Unstageable  ¦ Involves full-thickness tissue loss, with base of ulcer covered by slough nd yellow, tan, gray, green, or brown eschar  ¦ Can’t be staged until enough slough and eschar are removed to expose the wound base 24 Skin, hair, and nails Hair abnormalities Typically stemming from other problems, hair abnormalities can cause patients emotional distress. Among the most common hair abnormalities are alopecia and hirsutism. Alopecia occurs more commonly and extensively in men than in women. Diffuse hair loss, though commonly a normal part of aging, may occur as a result of pyrogenic infections, chemical trauma, ingestion of certain drugs, and endocrinopathy and other disorders. Tinea capitis, trauma, and ull-thickness burns can cause patchy hair loss. Alopecia Excessive hairiness in women, or hirsutism, can develop on the body and face, affecting the patient’s selfimage. Localized hirsutism may occur on pigmented nevi. Generalized hirsutism can result from certain drug therapy or from such endocrine problems as Cushing’s syndrome, polycystic ovary syndrome, a nd acromegaly. Hirsutism outside the norm Now â€Å"hair† this: Hair abnormalities may be caused by certain drugs or endocrine problems. Nail abnormalities 25 Nail abnormalities Although many nail abnormalities are harmless, some point to serious underlying problems.Nail abnormalities include clubbed fingers, splinter hemorrhages of the nail bed, and Muehrcke’s lines. outside the norm Splinter hemorrhages are reddish brown narrow streaks under the nails. They run in the same direction as nail growth and are caused by minor trauma. They can also occur in patients with bacterial endocarditis. Splinter hemorrhages Muehrcke's lines or leukonychia striata are longitudinal white lines that can indicate trauma but may also be associated with metabolic stress, which impairs the body from using protein. Muehrcke's lines Clubbed fingers can result from chronic tissue hypoxia. Normally, the angle between the ingernail and the point where the nail enters the skin is about 160 degr ees. Clubbing occurs when that angle increases to 180 degrees or more. Clubbed fingers Normal fingers Normal angle (160 degrees) Clubbed fingers Angle greater than 180 degrees Enlarged and curved nail Answers: Able to label 1. Epidermis, 2. Dermis, 3. Subcutaneous tissue, 4. Hair bulb, 5. Eccrine sweat gland; Rebus riddle The dorsal surface of the hand is most sensitive to temperature changes. 1. 2. 3. 4. 5. Identify the skin structures indicated on this illustration. Sound out each group of pictures and symbols to reveal terms that complete this assessment onsideration. Able to label? Rebus riddle 26 Anatomy 28 Assessment 31 Eye abnormalities 42 Ear abnormalities 46 Vision quest 48 Aye, aye, matey! I best be gettin’ along. They’re filming the eye and ear assessment down on Soundstage 3. 28 Eyes and ears Anatomy EyeEsye and ears The eyes are delicate sensory organs equipped with many extraocular and intraocular structures. Some structures are easily visible, whereas ot hers can only be viewed with special instruments, such as an ophthalmoscope. Extraocular structures The bony orbits protect the eyes from trauma. The eyelids (or pal pebrae), lashes, and lacrimal gland, punctum, canaliculi, and ac protect the eyes from injury, dust, and foreign bodies. Bony orbit Lacrimal gland  ¦ Pars orbitalis  ¦ Pars palpebralis Upper eyelid Lashes Lower eyelid Lacrimal punctum Lacrimal canaliculi Lacrimal sac Nasolacrimal duct Eye muscles Superior oblique muscle Superior rectus muscle Medial rectus muscle Lateral rectus muscle Inferior rectus muscle Inferior oblique muscle Anatomy 29 Intraocular structures The intraocular structures of the eye are directly involved in vision. The eye has three layers of tissue:  ¦ The outermost layer includes the transparent cornea and the sclera, which maintain the form and size of the eyeball. The middle layer includes the choroid, ciliary body, and iris. Pupil size is controlled by involuntary muscles in this region.  ¦ The innermost layer is the retina, which receives visual stimuli and sends them to the brain. Retinal structures: A closer view Superonasal arteriole and vein Optic disk Physiologic cup Arteriole Inferonasal arteriole and vein Vein Superotemporal arteriole and vein Fovea centralis Macular area Inferotemporal arteriole and vein Sclera Choroid Conjunctiva (bulbar) Ciliary body Cornea Lens Pupil Iris Anterior chamber (filled with aqueous humor) Posterior chamber (filled with aqueous humor) Schlemm’s canalVitreous humor Optic nerve Central retinal artery and vein Retina These structures are located in the posterior part of the eye, also called the fundus. They’re visible with an ophthalmoscope. 30 Eyes and ears Ear External ear The flexible external ear consists mainly of elastic cartilage. It contains the ear flap, also known as the auricle or pinna, and the auditory canal. This part of the ear collects and transmits sound to the middle ear. Middle ear The tympanic mem brane separates the external and middle ear. The center, or umbo, is attached to the tip of the long process of the malleus on the other side of the tympanic membrane.The eustachian tube connects the middle ear with the nasopharynx, equalizing air pressure on either side of the tympanic membrane. The middle ear conducts sound vibrations to the inner ear. Inner ear The inner ear consists of closed, fluid-filled spaces within the temporal bone. It contains the bony labyrinth, which includes three connected structures: the vestibule, the semicircular canals, and the cochlea. The inner ear receives vibrations from the middle ear that stimulate nerve impulses. These impulses travel to the brain, and the cerebral cortex interprets the sound. Auditory ossicles  ¦ Stapes (stirrup)  ¦ Incus (anvil) Malleus (hammer) Semicircular canals Vestibule Cochlea Cochlear nerve Eustachian tube Tympanic membrane (eardrum) Helix Anthelix Lobule of auricle External acoustic meatus Assessment 31 Assess ment Eyes Snellen charts The Snellen alphabet chart and the Snellen E chart are used to test distance vision and measure visual acuity. Snellen alphabet chart Snellen E chart Age differences 20 20 In adults and children age 6 and older, normal vision is measured as 20/20. 20 50 For children age 3 and younger, normal vision is 20/50. 20 40 For children age 4, normal vision is 20/40. 20 30 For children age 5, normal vision is 20/30.To measure distance vision: Have the patient sit or stand 20 (6. 1 m) from the chart. Cover his left eye with an opaque object. Ask him to read the letters on one line of the chart and then to move downward to increasingly smaller lines until he can no longer discern all of the letters. Have him repeat the test covering his right eye. Have him read the smallest line he can read with both eyes uncovered to test his binocular vision. If the patient wears corrective lenses, have him repeat the test wearing them. Record the vision with and without correction. Distance vision Recording results Visual acuity is recorded as a fraction.The top number (20) is the distance between the patient and the chart. The bottom number is the lowest line on which the patient correctly identified the majority of the letters. The larger the bottom number, the poorer the patient’s vision. The Snellen E chart is used for young children and adults who can’t read. 32 Eyes and ears Test peripheral vision using confrontation. Confrontation can help identify such abnormalities as homonymous hemianopsia and bitemporal hemianopsia. Here’s how to test confrontation:  ¦ Sit or stand directly across from the patient and have him focus his gaze on your eyes.  ¦ Place your hands on either ide of the patient’s head at the level of his ears so that they’re about 2 apart.  ¦ Tell the patient to focus his gaze on you as you gradually bring your wiggling fingers into his visual field.  ¦ Instruct the patient to tell you as soon as he can see your wiggling fingers; he should see them at the same time you do.  ¦ Repeat the procedure while holding your hands at the superior and inferior positions. Rosenbaum card The Rosenbaum card is used to evaluate near-vision. This small, handheld card has a series of numbers, E’s, X’s, and O’s in graduated sizes. Visual acuity is indicated on the right side of the hart in either distance equivalents or Jaeger equivalents. To measure near-vision: Cover one of the patient’s eyes with an opaque object. Hold the Rosenbaum card 14 (35. 6 cm) from the eyes. Have the patient read the line with the smallest letters he can distinguish. Repeat the test with the other eye. If the patient wears corrective lenses, have him repeat the test while wearing them. Record the visual accommodation with and without corrective lenses. Near-vision Confrontation Does your patient wear glasses or contacts? Remember to test his vision with and without his corrective lens es. Assessment 33 Each upper eyelid hould cover the top quarter of the iris so the eyes look alike. Look for redness, edema, inflammation, or lesions on the lids. Eyelids The corneas should be clear and without lesions and should appear convex. Examining the corneas Examine the corneas by shining a penlight first from both sides and then from straight ahead. Test corneal sensitivity by lightly touching the cornea with a wisp of cotton. The irises should appear flat and should be the same size, color, and shape. Irises Corneas Inspecting the eyes With the scalp line as the starting point, determine whether the eyes are in a normal position. They should be bout one-third of the way down the face and about one eye’s width apart from each other. Then assess the eyelids, corneas, conjunctivae, sclerae, irises, and pupils. 34 Eyes and ears Each pupil should be equal in size, round, and about one-fourth the size of the iris in normal room light. Testing the pupils Slightly darken th e room. Then test the pupils for direct response (reaction of the pupil you’re testing) and consensual response (reaction of the opposite pupil) by holding a penlight about 20 (51 cm) from the patient’s eyes, directing the light at the eye from the side. Next, test accommodation by placing your finger

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Social or Historical Events During the Time the Writers Wrote - Research Paper Example The study of historical context according to the subjected piece of literature allows the reader to have a better grasp of understanding of the story. Through this one must be able to associate the social and historical undertones found in the story to get a better comprehension of the ideas of the writer. ‘Huckleberry Finn’ by Mark Twain is a notable example of how a story can best be appreciated through the application of this critical analysis. Twain was able to capture as clearly had decades ago the imagination of his readers through the garish and offbeat boyish characters that he had managed to develop. Named Samuel Clemens in real life, the author made use of Mark Twain as a pseudonym and has been more popularly known by it since then. He was a known humorist of his time and has become a pressing subject through his works. His book ‘Huckleberry Finn’ has posted a dilemma where it had yielded conflicting views regarding the true intentions of the write r especially with his frequent use of the word nigger that drove some to the conclusion of its racist disposition. But more than this there have been a great number that support the notion that what this little affectionate book has done was to race awareness and to push on the social issue of racial discrimination prevalent during its time (Kirk, p.3, 2004). While it has often been criticized for being crude and lacking the artistic value that critics of his time sought, it has continued to provoke thinking more than so many other American novels.

John Locke Second Treatise on Government vs. Voltaire Candide Term Paper

John Locke Second Treatise on Government vs. Voltaire Candide - Term Paper Example Locke attempted to explain the reasons King James II was overthrown justifiably and why he was ascended by William III. He as well wanted to define the legal role of the civil government. He defined the role of the civil government as the political power and a right of law making which includes penalties of death and fewer penalties for regulating property as well as preserving them and employing forces of executing these laws, in defense of common wealth against foreign injury. This is all for the good of the public . On the other hand, Voltaire Candide is about Candide who grows in the province of Westphalia in Germany. He is made to believe that he lives in a world that is of the best quality . This belief starts to change when he started experiencing horrors of poverty, war, the hypocrisy that the church had and maliciousness of man. According to Locke, the government was in existence, among many other things, in order to promote the good of the public as well as to protect the property, liberty and life of its people. This is what is considered to being the main point of having a government and these are the purposes for its existence (Locke 12). For the above reasons, the people who run or govern are supposed to be voted in by the entire society. It is the right of the society to hold powers of instating another government when it is necessary. Locke believes that people are free by nature. This is the belief that founded his philosophy about the government. This is also supported by Voltaire Candide. He says that the government is supposed to be in existence in order to support the society and provide them with all they need. But according to Candide, this does not happen since the people having authority were corrupt and usually abused their powers. The society’s rights and freedom were not granted and they faced a lot of hardships. There are certain literary artifacts that were used in making the different points they had. Locke argues that in case the society is dissolved, it is also likely that the government will as well dissolve. He said that it is very impossible to have the frame of any house subsist and the materials that make it are jumbled into heaps that are confused by an earthquake4. The agreement of individuals to work as a single body is what makes up a society. If the agreement brakes and the different individuals make the decision to separate, then the community will end up breaking. When the government does not have its society, the government will as well dissolve. But in case a government dissolves and the society remains as one, the people shall still have the power to reform the government as they would like. On the other hand, Voltaire Candide uses wealth in explaining his points of view. Wealth leads to greed and causes war. The need to possess wealth enco uraged robbery and abuse of power. In his work, wealth is depicted as transient. Even though it may be beneficial, it is not ultimately fulfilling5. There are different practices of their time that these writers mock or criticize. Locke criticizes the act of slavery. He says that men has a natural liberty of being free and not have any power that is superior on earth. Man is not supposed to be under any legislative authority or will of man but is supposed to have the law of nature to rule him. He also says that no man should control the right to own property. This is because God gave life to all men in common and gave them reason to use it to their advantage and convenience. Every person has the right of owning property wherever they would like to. Just like Locke, Voltaire Candide criticizes slavery in a great way. The abuse of power leads to slavery since the leaders use their power

Drexler's World Famous Bar-B-Que Article Example | Topics and Well Written Essays - 1000 words

Drexler's World Famous Bar-B-Que - Article Example The ability to utilize windows of opportunity is a vital factor of success. This paper gives a discussion on factors that enhances Drexler’s existence and its impact on the neighboring population. What role do values play in how Drexler's Bar-B-Que interacts with its neighbors and customers? Values are essential in the advancement of any organization and, they are of particular interest to Drexler. The business has specific values for both the business and the surrounding population. The business also has value for family membership and participation. This indicates that Drexler values family ties among its different stakeholders. The different values that Drexler have on its business play vital roles that determine interactions between the business and its environment. The effects or benefits of Drexler’s value have a cumulative effect that has helped to sustain the bar-b-que business at a competitive edge. Firstly, the business has values for its heritage. Its heritag e included unique recipes and value for conservative taste for their products. These values have enabled the business to retain its originality despite the numerous transformations that it has gone through. In addition to the maintenance of originality, the value for heritage enabled Drexler to be identified among its competitors. The value also promoted a sense of uniqueness that made customers to identify themselves with the business. This value ensured that the memory of the business and its bar-b-que remained in customers’ minds despite the numerous times that the business closed down. This value promoted customers service or the value of customers to the business. Unlike other competing businesses, Drexler had value for its customers. Value for its customers is demonstrated through the impeccable services offered to customers who visit the restaurant. In addition to the quality services, customers to the business were treated with high degree of respect and appreciation. Value for customer enabled Drexler to attract and retain dedicated and loyal customers. The ability to attract large number of loyal customer has enabled the business to rise to success. Customer value also enabled Drexler to have continuous and lucrative business in a highly competitive food industry. Drexler value for customers created and maintained a warm relationship between the business and its customers. This guaranteed the business a constant supply of customer despite the various options for bar-b-que. This factor was of particular interest during the numerous occasions that the business had to re-open after a close down. The ability to maintain customers was promoted by the fact that the business had high value for quality products. Drexler invested in producing quality bar-b-que through their highly researched secret recipes. The recipes that were used in the restaurant had been tested and tried throughout the entire duration that the business was in operation. Offering high quality products remained as the sole secrete of the business’ success. The business’ success was also heavily determined by its interaction with the immediate external environment. Drexler maintained a good relationship with its neighborhood that enabled it to create and maintain a competitive business. Unlike other businesses, Drexler also had value for its competitors. This enabled the business managers to learn useful skills from their competitors and methods they could use in order to remain in

Unemployment and Skills Essay Example for Free

Unemployment and Skills Essay Obtaining a degree from institute of higher education in local or overseas has become necessary in order to get a good job with nice salary. However, a quite alarming issue is a high unemployment rate among graduate in this country. Many factors have been identified as being the causes for the increase in the unemployment rate among university graduates. Having straight â€Å"A’s† is no longer enough to secure a job or to give one a competitive edge in career advancement. These are the issues on unemployment among Malaysian graduates. Lack of social and communication skill in addition to a poor command of language and low level of confidence. Many graduates had achieved excellent academic results but could not secure employment without the relevant skills required in the labour market. 2. The lack of experience and skills are the causes leading to the unemployment of graduate’s. In Malaysia, the private sector today is not interested in recruiting local graduates because they lack several important skills, such as the capacity to communicate well in English, a lack of ICT proficiency, and a lack of interpersonal skills. 3. Another issue that contributes to unemployment is inability to solve problem efficiently. This is tied to skills without skills, you have nothing to apply to solve a problem efficiently. This can be linked to the simple example of partial fractions. If you have the skills, you can dissect a fraction into its partial fraction quickly. Without, and you spend time dividing, which takes more time than a person with skills would have took. 4. Then the graduates themselves demand too much. The idea of a degree is contorted to such that a degree means good jobs, and that graduates deserve the jobs. Little do these group understand that while a person with degree in Engineering with First Class Honours may have the luxury of demanding a job (or they would be headhunted even before they start looking for a job), those who possess Pass with Merit arent in that same bunch, and that sad to say, their degree is indeed of a lower quality than the First Class. This is made even worse with those who have these degrees, in addition to having little skills, start blaming companies for not hiring them. . The mismatch between qualification acquired and current job market demand also cause the unemployment among graduates. Colleges and higher learning institutions should make sure that their syllabuses were relevant to the present industrial needs. It was therefore very important for learning institutions to conduct some research on the actual needs of the various industries to prevent students from taking up irrelevant courses which in the end would lead to unemployment among graduates. In conclusion the increasing unemployment rate among the graduates in Malaysia is a worrying trend. For many years, the issue cropped up again and again, made the news headlines, and even hit the parliament. The days have passed when a degree scroll can become your automatic passport to employment. Higher education is no longer a symbol of career success. This may sound painful for graduates but let’s face it. It is reality, no matter how harsh it may appear. According to Dacre Pool ; Sewell, 2007 â€Å"employability is having of skills, knowledge, understanding and personal attribute that make a person more likely to choose and secure occupations in which they can be satisfied and successful† and Yorke, 2006 â€Å"A set of achievements of skills, understanding and personal attributes, that will make graduates more likely to gain employment and be successful in their chosen occupations which benefits themselves, the workforce, the community and the economy†. Malaysia is a world class education system appears to have produced unemployable graduates with 90% of them are bumiputera. In 2010, about 30,000 graduates could not find a job six month after they graduate. There are several ways to Improve Graduate employability; 1. Use of democratic instructional strategies (Singh;Singh,2008) such as role playing, simulations, problem solving exercises and case studies methods of promoting discussions among students and minimum the lectures class. By involve all the students in the class, it will make the class becomes lively. 2. To develop graduate skills and expertise such as in ICT proficiency are by working as temporary contract, doing an internship and other work experience. Both unpaid work experience and paid internship it’s a way to improve the important skills for the workplace and a stop-gap to avoid holes in jobseeker’ CVs whilst they are searching for permanent employment. 3. The implementation of the assessment of soft skills in public universities, such as in UPM there is a program for final year student called as finishing school that is compulsory to attend to before they graduate. These programs are providing a presentation in classes, encouraging problem-based learning and others. 4. Find out the most popular interview questions. There are some interview questions that will be used in most interviews. Use the internet to research common interview questions, and then develop clear, structured and intellectual answers. Next, practise the answers in front of a mirror, a friend or a family member to become confident in your answers. 5. Graduates must be ready. They have to find out which skills are currently required by employers. By reading up-to-date literature on what businesses are looking for in a person’s skill set, they can stay ahead of the game. The more information graduates gain, the easier they will satisfy the employers. 6. Graduates must expose themselves by pay a visit to a career centre. Career centres are designed to offer advice and direction for those who are seeking to gain employability skills. Once enrolled, you can begin a course which is specific to the skill you require. In conclusion as an intellectual graduate, they must fully prepare mentally and physically towards the unforeseen future. Graduates have to be more creative about how they build their prospects after university. They must endeavour to develop their skills and make contacts wherever possible, and remain focused on exactly what will make them more employable for their chosen market. Job prospects are perhaps not as bleak as the world would have graduates think, but they must be prepared to rise to the challenge and prove themselves well-equipped for the world of work.

Summer Internships And Their Benefits

Summer Internships And Their Benefits Summer Internship is an integral part of the two year full-time Post Graduate Management Course. It can help a student to gain exposure of the industry and apply the knowledge gained in the first year of MBA to the practical scenarios. The internship provides an opportunity to gain the relevant knowledge and skills required in the field as well as add an important element to the resume. Gaining relevant experience through internships, co ops, service learning, or externships and making professional contacts. There are two best things students can do to prepare themselves for getting a job in their field of specialization after college. The main objective has been to find out factors contributing towards improving the quality of Summer Internship Project. It has been observed over the past that not much importance has been given to the projects by students, faculty as well as the industry. Research studies have been done over the same issue and we have considered all these relevant studies to form the basis for our literature review. LITERATURE REVIEW Many have touted college student summer business internships as highly beneficial experiences that facilitate transitioning into the real world of business. Indeed, a recent survey revealed that 92% of business schools had some type of internship experience (Coco, 2000). To justify the high participation rate among business schools, educational professions recognize that internships seem to offer many benefits: (a) internships may help students to find jobs, (b) internships may be stepping stones that can be directly translated into full-time jobs, (c) internships may create satisfying experiences that motivate students to continue along a career path (e.g., Business Internships, 1994; Clark, 2003; Divine, Linrud, Miller, Wilson, 2007), and (d) internships may create realistic expectations about the world of work and help clarify students career intentions. The fundamental question, however, is do these internships actually make a difference? The purpose of this literature review is to analyze the research findings regarding the perception towards summer internships and how beneficial they actually are. FINDINGS ON PERCEPTION TOWARDS SUMMER INTERNSHIPS AND THEIR BENEFITS Enhanced Employability One of the primary benefits of internships for students is that students with internship experience supposedly have an advantage in the job market, which can translate into their being hired more readily for subsequent jobs. Several studies show evidence of this. Knouse, Tanner, and Harris (1999) found that students who had chosen to complete internships were offered jobs more quickly than those who had not opted for internships. The authors raised the question, however, about whether such job offers were due to the internship experience on students resumes or due to students with internships being better students (having higher grade point averages [GPAs]) than students without internships; that is, interning students might be more motivated and more effective in finding jobs faster. At least one study (Taylor, 1988) found that the first explanation seemed to be the important factor. Recruiters rated students whose resumes showed evidence of internship experience higher than they ra ted students who did not have such experience. This advantage of quicker hiring and overall better employability was also found by other researchers (Callanan Benzing, 2004; Gault, Redington, Schlager, 2000; Taylor, 1988). Although internships were linked to career-oriented employment, Callanan and Benzing did not find that internships improved confidence that students would fit well into the job. An interesting corollary benefit of internships is that even if interns were not immediately hired, companies tended to keep them in the employment pool longer than they kept applicants without internships (Roever, 2000). Gault et al. (2000) also found that interns could command higher salaries and experienced higher job satisfaction in their subsequent jobs. Taylor (1988) showed that interns who had greater autonomy in their internships had better employment opportunities. Moreover, Molseed, Alsup, and Voyles (2003) found that employers rated problem-solving experiences as perhaps the key skill set in internships that enhances employability. Additional research has indicated that internships and projects can make students more marketable by helping them develop desired skills, such as critical thinking and written and oral communication, and providing them with the practical experience that many employers seek from new graduates (Maskooki, Rama, Raghunandan, 1998; Perry, 1989; Raymond, McNabb, Matthaei, 1993). Specifically, Raymond et al. showed that the ability of students to apply the knowledge gained in the classroom and to solve problems is essential to employers and is most effectively learned through internships. Additionally, the study found that internships exposed students to ethical issues and global dimensions sometimes not gained through class work. Realistic Expectations of Interns Another supposed perception of internships is learning to create a set of realistic expectations for work in the business world. Interestingly, Hall, Stiles, Kuzma, and Elliott (1996) found that employers were more concerned than students were about creating realistic expectations. Students seemed to focus more on compensation for their internships and parlaying their internships into full-time jobs after graduation. Research by Hall et al. (1996) showed that students and employers differed on many internship expectations, such as appropriate dress, turning internships into permanent jobs, and corollary efforts (e.g., outside reading, oral presentations of experience, and types of grading). Frederickson (2000) found that interns who had accurate perceptions of the organizational culture had more success in their internships. Satisfaction With the Internship Experience Many believe that the essence of successful internship experiences is whether students were satisfied with their internships (Clark, 2003). Results are mixed. Beard and Morton (1999) and Cho (2006) found a high level of satisfaction among students, whereas Perlmutter and Fletcher (1996) noted a high failure rate associated with dissatisfaction. Rothman (2007) found several factors that related to satisfaction with internship experiences: clear tasks, challenging assignments, ongoing feedback, exposure to different parts of the business, and respectful treatment. In addition, Narayanan, Olk, and Fukami (2006) showed that internships were more satisfying when students had a voice in project selection. Moreover, Cook, Parker, and Pettijohn (2004) showed a relatively stable trend of satisfaction with internships over a 10-year period. On the other hand, Bass (2002) found higher job satisfaction among women, especially when internship experiences were congruent with the job. Internship Prerequisites as Predictors of Internship Success Many internship programs require completion of a certain level of course work and attainment of a minimum GPA (Clark, 2003). Interestingly, Beard and Morton (1999) found that prior course work and GPA were less important predictors than were students attitudes toward internships and interning with approved sites. Moreover, Braswell and Cobia (2000) found that career self-efficacy (belief about successful career performance) before internships was the best predictor of an increase in career self-efficacy after internships. From the employers viewpoint, focused selection for internships may be more effective than open-ended offers. For example, Pan American Airways first develops intern projects and ascertains the skill mix needed to complete the projects and only then contacts schools and begins evaluating students, through resumes and interviews, who match the desired skill mix (Solomon, 1985). Mentoring the Intern Several studies have shown that internship experiences were more valuable if the interns were mentored at the work site (Callanan Benzing, 2004, Snyder, 1999). Particularly in international internships, mentors can produce better socialization into the organization, higher levels of learning, and larger numbers of job offers (Feldman, Folks, Turnley, 1999). Indicator of final placements Summer placements indicate how well the final placements will be to a great extent, not only for the second year batch, but for the first year batch also. As an example, the quality and extent of summer placements for the batch of 2010-2012 will become an indicator of the final placements of both the batches of 2009-2011 as well as 2010-2012. The main factor that must be seen here is to convert as many summer internships into PPOs Pre-Placement Offers, as possible. Niraj Arora, placement coordinator of the Institute of Management, Nirma University, Ahmedabad says, Our prime concern is to set the quality standard for the students during the summer internship so that they are converted into PPOs. If the institute is able to secure a decent number of PPOs for a batch, the process of final placements becomes easier, because you have so many fewer students to place that year. It is also a pointer to B-schools to know sectors are likely to generate more jobs in the immediate future. If a company shows an interest in recruiting a larger number of summer interns than usual, we try and build a steady relationship with that company. A higher number of interns usually mean larger upcoming fulltime openings, new projects or products, says Sapna Pokli, Director of IILM Institute for Higher Education, New Delhi. (5 reasons why summer placements are important to b-schools and you by Vasundhara Vyas on 12 November 2010 in summer placements, Summer placements 2010-12) Feedback from the industry Many institutes are setting up advisory boards for their curriculum comprising people from enterprises in order to make the courses germane to the industry needs. The feedback from the corporate where a student completes his/her summer internships is often used an as input for curriculum advancements. Even, the feedback of the company also adds to the students grades and academic assessment.(5 reasons why summer placements are important to b-schools and you by Vasundhara Vyas on 12 November 2010 in summer placements, Summer placements 2010-12) IMPROVEMENTS TO INCREASE EFFECTIVENESS OF INTERNSHIPS The research findings have indicated that internships seem to have several effective benefits overall. Internships apparently do make a difference. Nevertheless, internships can be improved in several ways. * Active student participation in the process. One important variable is active student participation in the process, whether in the form of an active voice in setting up the intern project (Narayanan et al., 2006) or as freedom in carrying out the project (Taylor, 1988). * Active employer participation in the process. The more effective internships seemed to be those in which the employer first defined the project and skill mix needed and then tried to match student skills with project requirements (Narayanan et al., 2006). * Clear expectations. Students who had well-defined programs with clear tasks seemed to perform better than those who participated in open-ended programs with less-defined objectives (Rothman, 2007). * Change prerequisites to reflect the predictors more closely related to intern success. * Clear expectations. Students who had well-defined programs with clear tasks seemed to perform better than those who participated in open-ended programs with less-defined objectives (Rothman, 2007). * Change prerequisites to reflect the predictors more closely related to intern success. The traditional emphasis on completion of a certain number of courses and attainment of a minimum GPA seems less effective at predicting intern success than evaluation of positive attitude about the project and appropriate skill mix to do well on the internship (Beard Morton, 1999). Beard and Morton used an 18-item scale to measure positive attitude and skill mix (e.g., relevant college courses, proactive volunteering, internship treated as real job, attitude toward learning and work, quality of internship supervision, and adapting internship toward interns interests). Measures of career self-efficacy (e.g., confidence that intern will perform well) could also be relevant (Braswell Cobia, 2000). * Build mentoring into the internship program Students who have mentors in their internship programs tend to have better experiences (Callanan Benzing, 2004: Feldman et al., 1999: Snyder, 1999). Mentors can help students navigate the organization and learn valuable skills for their career aspirations. * Keeping a journal. Writing about problem solving and other experiences in internships can provide insights and understanding about careers and organizations (Clark, 2003). Moreover, keeping a journal can reveal how expectations change over the duration of the internship. Keeping a journal is also a technique for developing the insight process (Burke Miller, 1999) and for providing further information about the experience (Alm, 1996). CONCLUSION Our review of the research on the perception of internships shows that the internship is a beneficial activity overall. Employability seems to be enhanced, and interns generally experience both work-related and organizational learning. We found, however, that the internship experience can be improved. We recommend that both students and employers become more actively involved in the process; prerequisites and expectations be made clear; and hands-on activities, such as mentoring and journaling, be included.

The Factors affecting dividend payout policy

The Factors affecting dividend payout policy INTRODUCTION Dividend policy in the firm has been the major matter for recognizing how managers set dividend ratio and change dividend given to stockholders. The existing literature on dividend payout ratios provides firms with no generally accepted prescription for the level of dividend payment that will maximize share value. Black (1976) in his study concluded with this question is that what the corporation should do about dividend policy. It has been argued that dividend policy has no cause on either the price of a firms share or its cost of capital. Thus, extensive studies were done to find out various factors affecting dividend payout ratio of a firm. The setting of corporate dividend policy remains a troublesome issue and involves ocean deep judgment by decision makers. The behavior of dividend policy is the most debatable issue in the corporate finance literature and still keeps its prominent place both in developed and emerging markets. Many researchers try to uncover the issue regarding the dividend behavior or dynamics and determinants of dividend policy but still dont have an acceptable explanation for the observed dividend behavior of firms (Black, et.al (1976), Allen and Michaely, 2003 and Brealey and Myers 2005). One of the well known explanations of dividend behavior is the smoothing of firms dividends vice versa earnings and growth. Linter (1956) found that firms in the United States adjust their dividends smoothly to maintain a target long run payout ratio. Numerous studies appeared after this work and facts suggested that the dividend policy of the companies varies from country to country due to various institutions and capital market differences. The study examined the relationship between determinants of dividend payout ratios from the context of a developing country like Pakistan. The primary objective of this thesis is to find out whether numerous factors influence the dividend payout ratio of Sugar Sector in Pakistan. The purpose of this study is to investigate the dynamics and determinants of dividend policy of sugar firms in Pakistan. After that it explored how Pakistani firms set their dynamic dividend policies in a different institutional environment than that of developed markets. This study examined whether Pakistani firms follow stable dividend policies as in developed markets or they are going to retain their earnings. The paper also identified the areas of firm level factors that influence the degree of dividend smoothing. This paper indicated that importance of institutional features towards the dynamic of dividend policy and also critical out the advantages of examining the dividend policy in different institutional environments. The outcomes of the thesis provided meaningful and handy information in the role of institutional factors which creates dividend policy at firms level. More than a few studies become visible after this work and evidence suggest that the dividend policy of the c ompanies varies from country to country due to various institutions and capital market differences. The Pakistans capital market and the economy have several important features for examining the dynamics of dividend policy. Firstly Pakistan is moving towards the development and improving the economy position in the world since the 1980. Pakistan capital markets are much better than before. Many studies conclude that firms are likely to pay constant dividend during the high growth period and it is interesting to find that how dynamic dividend policy is determined in growing economy like Pakistan. In fact, in Pakistan the many major investors are still disagreed with dividends and consider stock prices positive reception as the major part of stock returns therefore, it is assumed that investor attitude towards dividends is expected to have an impact on the way in which firms set their dividend policy in Pakistan. Sugar Industry in Pakistan The sugar industry plays an important role in the economy of the Pakistan. It is the second largest industry after textiles. The Pakistan sugar industry is the second largest agro based industry consists of 78 sugar mills with per year crushing capacity of over 6.1 million tones. Sugarcane farming and sugar manufacturing contribute significantly to the national exchequer in the form of various taxes and levies. Sugar manufacturing and its by-products have contributed appreciably towards the foreign exchange resources through import substitution. The Sugar industry employs over 75000 people, including management experts, technologists, engineers, and financial experts, skilled, semiskilled and unskilled workers. It contributes around 4 billion rupees only under the head of excise duty and other levies to the Government are also paramount significance. In the year 2008-09 sugarcane production is estimated at 51.5 MMT, a decrease of 19 percent over the previous year due to both a decline in area harvested and yield. Milling policies and practices, coupled with attractive prices for alternative/competing crops (rice, cotton and sunflower) and insufficient irrigation supplies are major factors limiting crop expansion in the country. In the year 2009-10 sugarcane production is estimate at 53.6 MMT, an increase of 4 percent over the previous year due to an expected increase in area and yield. A shortage of cane supply during the current crushing season led to an increase in cane prices. This situation benefitted growers who received prices higher than the indicative prices announced by the Government. This development is expected to contribute to an increase in sugarcane area and productivity in the ensuing year. Moreover, last years higher production of rice and sunflower led to lower prices received by farmers, thereby encouraging the switch back to sugarcane. Purpose of the Study In Pakistan there were few firms which paid dividend to stockholders constantly. For this explore, the listed sugar firms of Karachi Stock Exchange (KSE) were not able to pay their dividends and which factors are influencing or determining the dividend policy in Pakistan. In this thesis it examined the number of firms various factors and their function in dividends policy. The liquidity of the stock market, is the profitable firms are paying dividends in Pakistan, is the firms with greater investment opportunities pay less dividends in Pakistan, is the dividends and debts are substitutes and the degree of leverage is negatively associated with dividends payments and finally examined the firms with greater cash flows pay lesser dividend in Pakistan. Research Objective Objective of thesis has to find out the relationship between dividend policy and operating cash flow, EBIT, Sales and Debt to Equity Ratio. It is very important for investors to examine the factors of dividend policy that whether they have been impact on the sugar sector of Pakistan or not. Hypotheses Development H1: There is association between CFO and dividend payout ratio. H2: There is association between Debt to Equity and dividend payout ratio. H3: There is association between Revenue and dividend payout ratio. H4: There is association between EBIT and dividend payout ratio Thesis Structure: This thesis is composed of five chapters. The first part of a thesis is introduction (Chapter I).Then after it evaluates and discusses the literature review in (Chapter II), in this chapter it examined the dividend payout policy of Pakistan and the main factors that influenced on it, theories, models put forward by many well-known authors is examined various studies. In (chapter III), it explained research methods and sample in detail. (In chapter IV),examined the dividend payout policy and the main indicators that affect the dividend payout policy of listed firms on the Karachi Stock Exechange 100 over the period 2003-2008 and present the interpretation of results. Finally in Chapter V, we present and discuss the main contributions and conclusion, implication and recommendation of this thesis. CHAPTER-2 LITERATURE REVIEW Naceur (2006) found that the high profitable firms with more stable earnings can manage the larger cash flows and because of this they pay larger dividends. Moreover, the firms with fast growth distribute the larger dividends so as attract to investors. The ownership concentration does not have any impact on dividend payments. In Indian case Reddy (2006) showed that the dividends paying firms are more profitable, large in size, and growing. The corporate tax or tax preference theory does not appear to hold true in Indian context. Amidu and Abor (2006) found dividend payout policy decision of listed firms in Ghana Stock Exchange is influenced by profitability, cash flow position, and growth scenario and investment opportunities of the firms. Lease (2000) the firms should follow a life cycle and imitate managements assessment of the importance of market imperfection and factors including taxes to equity holders, agency cost asymmetric information, floating cost and transaction costs. Linter (1956) studied and developed a compact mathematical model based on survey of 28 well established industrial U.S. firms which is well thought-out to be a finance classic. According to him the dividend payment pattern of a firm is influenced by the current year earnings and previous year dividends. Linters (1956) study of dividend policy found that a firms bottom line net income is the key determinant of dividend changes, which in his sample are largely dividend increases since he primarily surveys healthy firms. If one can extrapolate this finding to dividend decreases, it implies that low bottom line earnings drive dividend reductions. Jensen (1986) argued that debt is an effective substitute mechanism for dividends in this respect. By issuing debt instead of equity, managers give bondholders the right to take the firm into bankruptcy court if managers do not maintain their promise to make the interest and principal payments. This substitutability between debt and dividends as alternative mechanisms for reducing the agency costs of FCF implies that firms that use low debt ratios will tend to follow a policy of high- dividend payout. Alli (1993) the liquidity or cash flows position is also an important determinant of dividend payouts. A poor liquidity position means less generous dividends due to shortage of cash. It reveals that dividend payments depend more on cash flows, which reflect the companys ability to pay dividends, than on current earnings, which are less heavily influenced by accounting practices. They claim current earnings do no really reflect the firms ability to pay dividends. Farzad Farsio and Amanda Geary (1983) in their research the relationship between Dividends and Earnings say that dividends have no explanatory power to forecast future earnings. They presented four cases for possible effects of earnings on future dividends and show that there should be no significant relationship between dividends and future earnings in the long run. The contribution of this study is that it provides financial managers and investors with evidence that it would be a mistake to base investment decisions on inferences about dividend/earnings relationships that rely on some certain short-term periods. John and Kalay (1982) Debt agreement to minimize dividend payments are necessary to prevent bondholder wealth transfers to shareholders. An additional way dividend payout ratio affects agency costs is the reduction of agency cost through increased monitoring by capital market. Analysis shows the positive association among profitability and dividend payout ratio, corporate tax and cash flows. The study also suggests that when the liquidity of companies increases the companies disburse more dividends. The companies with dynamic profitability find out hard to disburse dividends. Last but not least, conclusion of the study shows that cash flow, profitability, growth and investment opportunities influence the dividend payout policy. Amidu and Abor (2006) conducted and they have taken the Payout Ratio as dependent variable and defined as dividend per share divided by earning per share. The included the explanatory variable profitability(profit), risk(risk), cash flows (cash), corporate tax(tax), institutional holdings(INSH), Sales Growth and Market to Book value(MTBV). By using the Panel data which involves the pooling of observations on a cross sectional of unit over several time periods and provides the results that are simply not measurable in pure cross-sections or exact time series studies. Because the panel time series is different from a regular time series or cross section regression equation and each variable use the double subscript in the data. Jensen (1986) concluded that funds remaining after financing all positive net present value projects cause conflicts of interest between managers and shareholders. Dividends and debt interest payment decrease the free Dividend payout ratios in Ghana cash flow available to managers to invest in marginal net present value projects and manager perquisite consumption. Crutchley and Hansen (1989) examined the hypothesis that financial leverage, dividends and managerial ownership are jointly determined by firms attempts to minimize the total agency costs of debt and equity. Chaplinsky and Niehaus (1992) examine whether managerial ownership share and financial leverage common determinants. In addition to the agency costs of debt and equity, they also assess whether these decisions are governed by the tax advantage of debt, the costs of issuing securities and the demand for risk sharing by insiders. Avazian (2006) conducted the study on United Stated listed firms at NYE and find that decision to smooth dividends depend at the part of public market access as proxies by the rating of bonds. In their study dividend payment is the optimal for firms raising debts in the public Unknown bond markets but not for firms in the private informed bank markets. In this logic the dividend decision is related to information asymmetric between the managers and the creditors of the firms. Pruitt and Gitman (1991) found that risk (year-to-year variability of earnings) also important factor firms dividend payout ratio. A company that has constant earnings is often able to forecast approximately what its future earnings will be. Company is therefore more likely to pay out a higher percentage of its earnings than a firm with unpredictable earnings. The liquidity or cash flow from operation is an important factor of dividend payouts policy. A less liquidity position means less generous dividend due to shortage of cash. He exposed that dividend payments depend more on cash flows, which reflect the companys ability to pay dividends, than on current earnings, which are less heavily influenced by accounting practices. They claim current earnings do not really reflect the firms ability to pay dividends. (Alli, 1993) Green (1993) questioned the irrelevance argument and investigated the relationship between the dividends and investment and financing decisions. Their study showed that dividend payout ratio is not totally decided after a firms investment and financing decisions have been made. Dividend decision is taken along investment and financing decisions. Higgins (1981) indicated a shortest link between growths and financing needs, speedily growing firms have external financing needs because working capital needs usually exceed the cash flows from new sales. Daniel (2007) conducted the study that they found that firms are more likely to manage their earnings upward when their earnings would otherwise fall down of expected dividend levels. The earning management behavior significantly impacts the likelihood of dividend cut. The firms made discretionally accruals because reported earnings to exceed the expected dividend levels are significantly less likely to cut dividends than those firms whose reported earnings fall down of expected level of dividends. They conclude that managers treat expected dividend levels as a vital earning threshold. Higgins (1972) and McCabe (1979) et.al the leverage (Lev) also influenced the dividend behavior of the firm, if the level of the leverage is high that mean the firm is high risky in the cash flows. The negative effect of leverage on dividends payments is documented in the literature, finds that the firms with higher leverage pay lower dividends in order to evade the cost of raising external capital of the firm. Lintner (1956) founded that past dividends of the companies and current earnings are the key determinants of current dividends and managers prefer to maintain stable dividends and make cyclic adjustments toward a target payout ratio. Arditti (1976) carried out research in order to evaluated dividend policy with respect to taxes and uncertainty. The purpose of this paper has been to tackle the distressing dilemma of the zero dividend solution by clearly incorporating MMs original proposal that dividends have an information aspect that is of potential worth to investors. The analysis of ambiguity they have offered is only one of many possible hypotheses which can account for the experimental fact that companies naturally do not take on intense dividend policies. Arnott and Asness (2003) suggested that a higher payout ratio results in low future growth, based their study on America stock market it founded that higher aggregate dividend payout ratios were associated with higher future earnings growth. Modigliani and Miller (1985) carried out research to evaluate dividend Policy under asymmetric information. The Standard finance model of the firms dividend/investment/financing decisions gives manager more appropriate information regarding the firms current earnings. The purpose of research is to replace the assumption built by Miller and Modigliani that the outside investors and inside managers have the same information about companies profit and future income with the assumption that inside managers know more than outside investors about the actual situation of firms current earnings. James A. Gentry (1990) informed about free cash flow analysis, showed that the financial position of a company depends upon its ability to generate net operating cash flows that are sufficient to cover up a hierarchy of cash outflows. The profiles generated from a large sample of companies show that relative cash flow components vary across company size and across industry groups. The researcher hopes that these profiles will serve as benchmarks for comparing cash flow components and encourage financial analysts to use cash flow analysis. Miller and Modigliani et.al (1961) suggest that in perfect markets, dividend do not affect firms value. Shareholders are not concerned to receiving their cash flows as dividend or in shape of capital gain, as for as firms doesnt change the investment policies. In this type of situation firms dividend payout ratio effect their residual free cash flows and the result is when the free cash flow is positive firms decide to pay dividend and if negative firms decide to issue shares. They also conclude that change in dividend may be conveying the information to the market about firms future earnings. Gordon and Walter (1963) present the bird in the hand theory which says that investors always prefer cash in hand rather than a future promise of capital gain due to minimizing risk. Jensen and Meckling (1976) the agency theory is based on the conflict between managers and shareholder and the percentage of equity controlled by insider ownership should influence the dividend policy. Easterbrook (1984) gives further explanation regarding agency cost problem and says that there are two forms of agency costs; one is the cost monitoring and other is cost of risk aversion on the part of directors or managers. The firm size (SIZE) defined as natural logarithm of total assets is expected to have a positive effect on dividend payouts as large more diversified firm are likely to have very low chance of bankruptcy and can sustain higher level of debt. In investigating the determinants of dividend policy of Tunisian stock Exchange, found that the high profitable firms with more stable earnings can manage the larger cash flows and because of this they pay larger dividends. (Naceur, 2006) Baker (2007) reports that Canadian dividend paying firms are significantly larger and more profitable, having greater cash flows, ownership structure and some growth opportunities. The liquidity or cash flows position is also an important determinant of dividend payouts. A poor liquidity position means less generous dividends due to shortage of cash. Alli et.al (1993) reveal that dividend payments depend more on cash flows, which reflect the companys ability to pay dividends, than on current earnings, which are less heavily influenced by accounting practices. They claim current earnings do no really reflect the firms ability to pay dividends. Megginson and Eije (2006) examined that the dividend paying tendency of fifteen European firms decline dramatically over this period 1989 to 2003. The increase in the retained earnings to total equity doesnt increase the payout ratio, but company age does. The empirical study of Canadian dividend-paying firms found that they try to maintain stable dividends per share, are reluctant to decrease the payout level, and smoothly adjust the level of payout based on level of expected future earnings. (Adjaoud, 1986) Easterbrook (1984) argues that increasing dividends raises the probability that additional capital will have to be raised externally on a periodic basis and consequently, the firm will be subject to constant monitoring by experts and outside suppliers in the capital market. Green (1993) questioned the irrelevance argument and investigated the relationship between the dividends and investment and financing decisions. Their study showed that dividend payout levels are not totally decided after a firms investment and financing decisions have been made. Dividend decision is taken along investment and financing decisions. Partington (1983) revealed that firms use of target payout ratios, firms motives for paying dividends and level to which dividends are determined are independent of investment policy. Lipson (1998) conducted study to examine the factors that derives dividend initiations and earnings surprises, look at the performance of newly firms that started dividends with those that did not. Earnings increases following the dividend initiation and earnings revelations for initiation firms are more constructive than for those non initiating firms. In an economy that charges taxes on investment income, dividends are obviously a disadvantageous means of transferring wealth to shareholders. To validate dividend costs, two clarifications are typically given: dividends are used to solve agency problems inside the firm, or dividends are used to communicate information to the market. H. Kent Baker, Gail E. Farrelly (1983) in their study A Survey of Management Views on Dividend Policy say that the major determinants of dividend payments today appear strikingly similar to Linters behavioral model developed during the mid-1950. In particular, respondents were highly concerned with dividend continuity. Second, the respondents seem to believe that dividend policy affects share value, as evidenced by the importance attached to dividend policy in maintaining or increasing stock price. Although the survey does not uncover the exact reasons for their belief in dividend relevance, it does provide evidence that the respondents are generally aware of signaling and clientele effects. Finally, the opinions of the respondents from the utilities differ markedly from those of the other two industries. Smith and Watts (1992) examined the relationship among executive compensation, corporate financing and dividend policy. They concluded that a firms dividend policy is affected by its other corporate policy choices. Jensen et.al, Solberg and Zorn (1992) linked the interaction between financial policies (dividend payout and leverage) and insiders ownership to informational asymmetries between insiders and external investors. They found that corporate financial decisions and insider ownership are interdependent. Lintner (1956) suggested that the firms have long run target dividend payout ratios and place their attention more on dividend changes than on absolute dividend levels. He also finds that dividend changes follow shifts in long-run sustainable earnings and managers are hesitant to make dividend changes that may later need to be reversed. Managers also try to stabilize dividends and avoid dividend cuts. Linter developed a partial adjustment model to describe the dividend decision process that explained 85 percent of year-to-year dividend changes. Gordon (1959) argued that an increase in the dividend payout raise stock price (value) and lowers the cost of equity, but practical support for this position is weak. Bemstein (1996) maintain that dividend policy makes no difference because it has no effect on either stock prices or the cost of equity. According to Gordon (1959) a higher payout ratio will reduce the required rate of return (cost of capital), and hence increase the value of the firm. Miller and Rock (1985) dividends contain this private information and therefore can be used as a sign device to influence share price. An announcement of dividend increase is taken as good news and accordingly the share price reacts favorably, and vice versa. Only good-quality firms can send signals to the market through dividends and poor-quality firms cannot mimic these because of the dissipative signaling costs. According to Easterbrook (1984) the agency costs thesis predicts that dividend payments can reduce the problems associated with information asymmetry. Dividends may also serve as a mechanism to reduce cash flow under management control, and thus help to mitigate the agency problems. Reducing funds under management discretion may result in forcing them into the capital markets more frequently, thus putting them under the scrutiny of capital suppliers. The tax-preference theory posits that low dividend payout ratios lower the required rate of return and increase the market v aluation of a firms stocks. Because of the relative tax disadvantage of dividends compared to capital gains investors require a higher before-tax risk adjusted return on stocks with higher dividend yields. Higgins et.al indicated that a direct connection between growth and financing needs: growing firms have outside financing requirements because working capital needs normally go beyond the incremental cash flows from new sales. It showed those payouts ratios are negatively related to firms need top fund finance growth opportunities. (Higgins, 1972) De Angelo (2004) conducted a study on dividend policy, agency cost and earned equity. The study told that why companies pay dividends? If they didnt have their assets and capital structure, would ultimately become unsustainable as the earnings of successful firms surpass their investment opportunities. They found that dividend payments prevented major agency problems since the retention of the earnings would have given the managers command over an additional $1.6 trillion without access to better investment opportunities and without any monitoring. This sense suggests that firms with high retained earnings are especially likely to pay dividends. In this view, firms pay high dividend when earned equity to total equity is high, and decline when this ratio declines and when this ratio is zero or near to zero, meaning that firms dont have the earned equity. They finally found that the highly significant association between the decision to pay dividends and the ratio of earned equity to t otal equity controlling for size of the firm, profitability, growth, leverage, cash balance. CHAPTER-3 RESEARCH METHODS As a various factors available in literature review have been identified that they affect the dividend policy decisions of the companies. It includes some important variables in order to achieve at some positive conclusions. Multiple linear regressions model has been developed to conduct the research, which contain of dependent variable and independent variables. Dependent variable in this study has dividend payout that is defined as the percentage of earnings disbursed as dividends. While the independent variables include of profit (EBIT), sales, debt equity ratio and cash flow from operation. These four variables are used as predictors in order to conclude that how much each of the variables affects the dividend payout of sugar firms listed on the Karachi Stock Exchange over the period of eight years (2001-2008). Model: DP = ÃŽÂ ± + ÃŽÂ ²1 EBIT + ÃŽÂ ²2 sales + ÃŽÂ ²3 CFO + ÃŽÂ ²4 DER+ ÃŽÂ µ DP is the annual dividend paid by firms during the period, while ÃŽÂ ± is Alpha constant in the model. Whereas ÃŽÂ ² (beta) shows the times of the variable in the model and ÃŽÂ µ represents the error term. Variables include in the model are Earning before interest and tax, Sales per year, Cash flow from operation and Debt equity ratio. Dependent Variable: Dividend payout ratio: The dividend policy is the one of the very important issue of corporate finance. It developed the dividend model which becomes very famous and known as Linter Partial Adjustment Model. According to the Linter each firms i has target dividend payout ratio. By using the target payout ratio linter calculated the target dividend at time (Dit*) as percentage of net earnings of the firms i at the time t (Eit), i.e Dit*= ri. Eit. John Linter (1956) In this study we used dividend payout ratio as dependent variable. It is calculated by percentage of net earnings of the firms paid at the end of period. The set of determinants of dividend payout ratio consist of following variables. CFO (cash flow), Sales, EBIT (earning) and Debt to Equity Ratio (leverage). Independent Variable: There are four independent variables are used in this thesis to find out their impact on the dependent variable as dividend payout. Operating Cash Flow: The liquidity or cash flows position is also an important determinant of dividend payouts. A poor liquidity position means less giving dividends due to shortage of cash. Alli (1993) reveal that dividend payments depend more on cash flows, which reflect the companys ability to pay dividends, than on current earnings, which are less heavily influenced by accounting practices. They claim current earnings do no really reflect the firms ability to pay dividends. The market liquidity is defined as annual value of stock traded divided by the stock market capitalization. Market liquidity is one of very important factor that can influence the decision or behavior of the dividend policy. Belanes (2007) there is a negative relationship between the market liquidity and dividend yield in Tunisian Stock exchange (TSE). OCF= EBIT +Depreciation-Taxes H1: There is positive impact of CFO on dividend payout ratio. Debt to Equity Ratio (leverage): The leverage has been used as proxy of Debt to equity ratio and variable in this study. Because debt to equity is very important variable for the determinants of dividend policy,if the level of the leverage is high its mean the firm is more risky in the cash flows. The effect of negative leverage on dividends payments is already documented .Higgins (1972) and McCabe (1979) suggested that long term debt had