Case Study On A Patient With Oesophagitis Nursing Essay

Case Study On A Patient With Oesophagitis Nursing Essay The patient was a female, age 89, with a BMI of 15.4 kg/m2 (underweight). Her presenting complaint was nausea and vomiting, bringing up coffee ground vomit, fatigue and loss of appetite since two days ago. Her past medical history included atrial fibrillation, paranoid psychosis and iron deficiency anaemia. She also had a cholestectomy done in year 2000. She was single and lived alone; she neither smoked nor drank. There was no relevant family history recorded for her case. On admission she was taking medication stated in Table 1 below. She was known to be allergic to ciprofloxacin. Table 1 Repeat medication taken on admission Drug Dose Digoxin 125 Â µg once daily Lisinopril 2.5 mg once in the morning Furosemide 40 mg once daily Clopidrogel 75 mg once daily Quetiapine fumarate 125 mg twice daily Tramadol hydrochloride 100 mg twice daily Codeine phosphate 60 mg one to be taken as required Paracetamol 500 mg four times daily Folic acid 5 mg once daily Ferrous fumarate 322 mg twice daily (Last prescription dated three months ago) Clinical data and diagnosis On admission, her temperature was 36.4Â °C, pulse was 83 beats per minute, and her blood pressure was 124/46 mmHg. Her Abbreviated Mental Test (AMT) score was 7 out of 10, indicating mild confusion. A full blood count, renal function test, liver function test, and an electrocardiogram (ECG) were carried out. Her liver function test came back normal. The ECG showed some ST depression, but the patient denied any chest discomfort. Her haemoglobin levels were low at 9 g/dl (11.5-16.5 g/dl), while platelets were low at 108109/l 150-400109/l). her plasma urea was elevated at 38.2 mmol/l (2.5-7.5 mmol/l), and her creatinine was 273 Â µmol/l (50-80 Â µmol/l for female). Her creatinine clearance was calculated to be 8.1 ml/min, which indicated severe renal impairment. The diagnosis was acute renal failure, and gastritis or peptic ulcer disease. Clinical progress On day 1, patient was dehydrated and had some upper abdominal discomfort (Dyspepsia). The plan was to stop tramadol, clopidogrel, lisinopril and furosemide, due to the coffee ground vomit and acute renal failure. Two units of RCC (Red cell concentrate) and IV fluids were given. A urinary catheter was used to monitor urine output. Patient was continued on ferrous fumarate and given gaviscon 10mls. Quetiapine fumarate was not given as it was not available. On day 3, patient was paranoid; as quetiapine fumarate was still not available, haloperidol 1 mg was given as an intramuscular injection according to the hospital guidelines. Her haemoglobin levels were back to normal (12 g/dl) and her creatinine clearance improved to 33.3 ml/min; measurements were taken again because the values were so different. The catheter was taken out, but she was to receive subcutaneous fluids hourly. Patient was passing black stools. She was given Peptac 10mls for abdominal discomfort and was scheduled for an endoscopy the next day. Quetiapine fumarate was given on day 4 and patient was taken off haloperidol. On day 6, the patients confusion was thought to be influenced by digoxin; levels were checked and found to be 1.1 Â µg/l (0.5-2.0 Â µg/l); however dose of digoxin was decreased to 62.5 Â µg. a rectum examination was conducted to make sure patient was not bleeding from the lower gastrointestinal tract. The gastroscopy report came back stating patient had grade D oesophagitis (Reflux oesophagitis), that is an extenxive mucosal breaks engaging at least 75% of oesophageal circumference. She was also found to have a large chronic duodenal ulcer, non-bleeding with visible vessels. The plan was to start the patient on IV proton-pump inhibitor (PPI, pantoprazole 8 mg/hr) for 72 hours, oral omeprazole 20 mg daily, and eradicate H. pylori if infection was present (CLO test). On day 9, the CLO test came back negative. Patient was taken off IV PPI and put onto oral PPI (Omeprazole 40 mg daily). A repeat endoscopy was scheduled for the week after. Disease Overview Prevalence Oesophagitis is the inflammation of the lining of the oesophagus, usually caused by irritation due to stomach acid reflux.1,2 It is included under the boarder term of gastro-oesophageal reflux disease (GORD), which also includes endoscopy-negative reflux disease.3 In the UK, there is a 28.7% prevalence of GORD, and the risk is found to increase with age, especially for those over 40 years of age. There is an estimated of over 50% of GORD patients between 45 and 60 years of age.4 About 25 to 40% of people with GORD are found to have oesophagitis on endoscopy.5 Pathophysiology, risk and diagnosis Acid reflux can occur because of incompetence of the lower oesophageal sphincter, a transient complete relaxation resulting from a failed swallow, that is, a swallow without the usual peristalsis wave (Found in 65% of patients). It can also be caused by a transient increase in intra-abdominal pressure (17% of patients), or a spontaneous free reflux due to the lower oesophageal sphincter having a low resting pressure (18% of patients).6 Possible risk factors for GORD are pregnancy, excess alcohol consumption, smoking and hiatus hernia. Obesity is thought to be a risk factor, as well as certain foods like onions, citrus fruits and coffee. Drugs that are thought to relax the lower oesophageal sphincter like calcium channel blockers are thought to play a role in promoting GORD. There is however very limited evidence to support these claims.4,5 It is now thought that more than 50% of GORD risk is genetic, as it is found that a first degree relative of a person with GORD is four times more at risk of getting the disease.4 Diagnosis of GORD is based mainly on the patients symptoms, predominantly acid regurgitation or heartburn.7 An endoscopy is usually the main diagnostic procedure done to confirm GORD. Pharmacological treatments and mechanisms of action The main drug used for this disease is a proton-pump inhibitor (PPI). PPIs are one of the most prescribed drugs for the treatment of acid-peptic diseases, including GORD and peptic ulcer disease.8,9 They are substituted 2-pyridyl methysulfinyl benzimidazoles, with pKa around 4, and have a very short plasma half life of one to two hours. They are weak bases that are lipophilic, which allows them to cross the membranes of the parietal cells easily. Once inside the parietal cells, where the pH value is less than 4, they protonate into the activated tetracyclic sulphenamide form of the drug and accumulate inside the cells. Here they form covalent bonds with the cysteine residues in the hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) enzymes, forming disulphide bonds, inhibiting the acid secretion activity of the pump irreversibly. Due to the covalent bonds, their duration of action exceeds their plasma half life. To resume acid production, the parietal cells must then generate , or activate, new proton pumps.8,9 Examples of PPIs are omeprazole, lansoprazole, pantoprazole, and rabeprazole, the last of which has a pKa of 5, and is activated at a broader range of pH compared to the other three, leading to a higher acid-suppression activity. The common side-effects of PPIs are nausea, diarrhoea, abdominal pain and headache. Diarrhea seems to occur because of a change in the gut flora brought about by the PPI, and appears to be age-related.8 PPIs, especially omeprazole, are known to alter the activity of cytochrome P in the liver, an important consideration for patients taking drugs with narrow therapeutic windows like warfarin and phenytoin. They also cause a prominent gastric pH increase, and are able to inhibit or decrease the absorption of weak bases that require acid for absorption, like iron salts, griseofulvin, and vitamin B12.8 Other drugs that may be used in this case are H2 receptor antagonists, which inhibit the secretion of acid by stopping histamine from binding to the H2 receptors on the parietal cells; and prokinetic drugs, usual examples like cisapride, metoclopramide and domperidone, which work by increasing the pressure of the lower oesophageal sphincter, and accelerating gastric emptying.10 Evidence for treatment of the condition The National Institute for Health and Clinical Excellence (NICE) guidelines state that, for the management of oesophagitis on endoscopy, patients are to be given full dose PPI for one to two months. If there is a response to the treatment, low dose PPI is given, probably on an as required basis. If there is no response, the dose of PPI is doubled for another month, before switching to low dose PPI. If there is no response to the doubled dose of PPI, treatment is then switched to a histamine H2 receptor antagonist or a prokinetic.11 Klinkenberg-Knol EC et al1 compared the effects of omeprazole and ranitidine in a randomised, double-blind, endoscopically-controlled trial done on patients with reflux oesophagitis. Omeprazole was given at a dose of 60 mg daily while ranitidine was given at 150 mg twice daily. The symptoms were evaluated before starting the trial, and at the second, fourth and eighth week. Endoscopy was done at the start of the trial, and repeated during week 4, with another after 8 weeks if there was an absence of healing at week 4. For patients taking omeprazole, 19 out of 25 patients improved from Grade 2 or 3 (erosions or ulcerations) to Grade 0 or 1 (erythema and friability)12 after 4 weeks; while for patients taking ranitidine 7 out of 26 showed similar improvement (P = 0.002). At week 8, corresponding improvement was shown in 22 out of 25 for the omeprazole group, and 10 out of 26 for the ranitidine group (P = 0.001). Omeprazole showed a significantly higher healing rate, which was reflected in a better improvement of reflux symptoms as well. Patients receiving omeprazole experienced a more profound and faster relief of heartburn, which was the most common symptom complained by the patients (P = 0.0001). After 2 weeks, 92% (23 out of 25 patients) of patients receiving omeprazole reported that their reflux symptoms were either gone or had improved, while only 65 % (17 out of 26) of the ranitidine group reported the same (P = 0.01). This study however, only showed the superiority of omeprazole over ranitidine in the short term treatment of reflux oesophagitis. Further studies were needed to evaluate the effects of omeprazole in long term management and at a lower dose. Havelund T et al12 performed a double blind study on patients with Grade 1, 2 and 3 reflux oesophagitis. Patients were allocated randomly in this study to a treatment with omeprazole (40 mg once daily), and ranitidine (150 twice daily), for a period of 12 weeks. It was found that patients treated with omeprazole had a faster response to the treatment than those taking ranitidine (P < 0.0001). For the omeprazole group, healing rates were reported at 4, 8 and 12 weeks to be 90%, 100% and 100% respectively for those with Grade 1 reflux oesophagitis. For Grade 2 and 3, corresponding healing rates were 70%, 85% amd 91%. While for the ranitidine group, healing rates were 55%, 79% and 88% for Grade 1, and 26%, 44% and 54% for Grade 2 and 3. This pointed to a superiority of omeprazole at a lower dose (40 mg) over ranitidine. Sandmark S et al13 did a similar study, but with an omeprazole dose of 20 mg daily. Healing of oesophagitis was targeted in this study to be a complete healing of all ul cerative and erosive lesions in the oesophagus. At 4 weeks, healing rates were shown to be 67% in the patients taking omeprazole and 31% in those taking ranitidine (P < 0.0001). Corresponding healing rates were 85% (Omeprazole group) and 50% (Ranitidine group) after 8 weeks (P < 0.0001). This was also reflected in a more profound and faster- improvement in reflux symptoms in the patients taking omeprazole (51% by the end of the first week compared to 27% for patients taking ranitidine). Robinson M et al14 conducted a study to compare, in patients with erosive oesophagitis the efficacy and tolerability of omeprazole at a dose of 20 mg daily to ranitidine at a dose of 150 mg twice daily together with a prokinetic drug metoclopramide at a dose of 10 mg four times daily. It was found that healing rates for omeprazole were significantly greater than that for ranitidine in combination with metoclopramide. Omeprazole also provided a more profound relief for patients with reflux symptoms. More side effects and treatment-related withdrawals were found among the patients allocated the ranitidine-metoclopramide combination. Omeprazole was thus found to be more effective and better tolerated. Iskedjian M and Einarson TR conducted a meta-analysis15 of the three drugs cisapride, omeprazole and ranitidine for GORD treatment. At 12 weeks, 95% of patients were cured in the omeprazole group (40 mg daily), 81% in the ranitidine group (600 mg daily), and approximately 60% in the cisapr ide group (40 mg daily). In mild GORD, healing rate was 56% for cisapride versus 38% for ranitidine, while healing rates for cisapride and omeprazole showed no significant difference. In severe GORD, the healing rate for cisapride was only a half of that of omeprazole (43% versus 87%), while showing no significant difference when compared to that of ranitidine (50%). Thus it was concluded that omeprazole is favoured for treating severe GORD, while cisapride may be that of mild GORD. Vigneri S et al16 compared 5 maintenance therapies after an initial treatment of omeprazole 40 mg daily for 1 to 2 months, and healing was confirmed by endoscopy. Patients were then randomly assigned 12 months of treatment in the 5 following groups: cisapride (10 mg three times daily), ranitidine (150 mg three times daily), omeprazole (20 mg daily), ranitidine and cisapride, or omeprazole and cisapride. At 12 months 54% of the cisapride group, 49% of the ranitidine group, 80% of the omeprazole group, 66% of the ranitidine-cisapride group, and 89% of the omeprazole-cisapride group were found to be in remission at 12 months of maintenance therapy. Omeprazole showed a significantly better efficacy than cisapride (P = 0.02), and ranitidine (P = 0.003). Ranitidine-cisapride combination therapy was found to show a more profound improvement than ranitidine alone (P = 0.05). Omeprazole-cisapride combination therapy showed better efficacy than cisapride (P = 0.003), ranitidine (P < 0.001), an d also ranitidine and cisapride combination therapy (P = 0.03). Omeprazole as monotherapy or in combination with cisapride is found to be more effective for maintenance therapy of reflux oesophagitis, compared to ranitidine or cisapride alone. Omeprazole in combination with cisapride shows more efficacy than ranitidine and cisapride. The effects of newer PPIs lansoprazole (30 mg daily), rabeprazole (20 mg daily) and pantoprazole (40 mg daily) were compared with that of omeprazole (20 mg daily), ranitidine (300mg daily) and placebo in randomised clinical trials brought together by Caro JJ et al.17 The healing rate ratios noted for the newer PPIs as well as omeprazole were as follow: lansoprazole 1.62; rabeprazole 1.36; pantoprazole 1.60; and omeprazole 1.58. There was a greater decrease in the heartburn symptoms in patients taking PPIs than those taking ranitidine (P < 0.002), as well as in the healing of ulcers (P < 0.05), and relapse (P < 0,01). Compared to placebo, the PPIs obtained a much more profound relief of reflux symptoms (P < 0.01), healing of ulcers (P < 0.001) and relapse (P < 0.006). From this study, it was found that there is not much difference between the newer PPIs and omeprazole when it comes to relief of reflux symptoms, ulcer healing and rate of relapse, while all PPIs are better than ranitidi ne and of course, placebo in terms of treatment for erosive oesophagitis. Kahrilas PJ et al18 compared esomeprazole and omeprazole efficacies in reflux oesophagitis patients. It was found that more patients (P < 0.05) on esomeprazole 40 mg and esmoprazole 20 mg were healed after 8 weeks of treatment compared to omeprazole (94.1% and 89.9% compared to 86.9%). Adverse effects were common in both treatments. Esomeprazole was found to have a greater efficacy compared to omeprazole in reflux oesophagitis and both have a similar tolerability profile. Rohss K et al19 showed that esomeprazole at 40 mg daily had better acid control than omeprazole 40 mg daily. Since maintenance of intragastric pH > 4 is important for the effective management of GORD, the mean percentage of a 24 hour period with intragastric pH > 4 was taken as an indication of the efficacy of the treatments. Measurements were taken on day 1 and day 5, and on both days esomeprazole showed a greater mean percentage (P < 0.001) at 48.6% and 68.4% versus 40.6% and 62.0% for omeprazole. Wahlqvist P et al20 compared,from the perspective of the National Health Service (NHS),the cost effectiveness of the actue treatment of esomeprazole (40 mg daily) with omeprazole (20 mg daily) in reflux oesophagitis patients.It was estimated that, taking into consideration of the healing probabilities over 8 weeks, treatment with esomeprazole saves up toa total of 1290 pounds compared to treatment with omeprazole. Esomeprazole was found to provide a greater effectiveness at a lower cost. This is reflected in another study conducted by Plumb JM and Edwards SJ,21 which found that esomeprazole is cost effective in comparison to all other PPIs for the treatment of reflux oesophagitis. Conclusion The treatment given to this patient was appropriate in terms of the algorithms stated in the NICE guidelines; she was started on a full dose PPI after eosophagitis was confirmed on the endoscopy. As stated above, PPIs are proven to have superior effects in comparison with histamine H2 receptor antagonists and prokinetic drugs, both providing relief of reflux symptoms but not healing the oesophagitis itself.10 Among all the PPIs currently available, esomeprazole, the S-isomer of omeprazole, has been found to show more improvement than all other PPIs. Current studies have shown that the treatment of reflux oesophagitis with esomeprazole is more cost effective than treatments using any other PPI, providing a greater healing rate at a lower cost. Thus it might be in the interest of the NHS to treat this patient with esomeprazole than omeprazole. (2271 words)

Pathogens :: essays research papers fc

Emerging Waterborne Pathogens In today’s food preparation world waterborne pathogens are becoming a real threat. Why? Simply because in today’s culture people are quick to blame the food industry for most cases of disintary or other ill effects caused by bacteria. In this paper several things will be discussed. To understand what I’m trying to say, you must understand a few key terms. First lets define waterborne pathogen. A waterborne pathogen is a micro-organism whose ability to cause disease has recently been identified. Now that you know what a waterborne pathogen is lets name a few. 1. Bacteria in the form of, Arcobacter Butzleri Helicobacter Pylori And E. Coli 2. Viruses Rotaviruses and Adenoviruses Type 40 and 41 3. Protozoa Acanthamoeba. Each of these possible pathogens has been identified but according to the WRc’s â€Å"Final Report to the Department of the Environment on Waterborne Pathogens,† it is still possible that several unidentifie d pathogens may be at large and dangerous. In order to understand how these pathogens work, and how to destroy them we must understand several of the parts that make them up. Some of these parts are: Morphology Biochemical Characteristics Detection Methods Cultural characteristics Health Effects Routes of Transmission Occurrence in Water Sources Sources of Exposure and Susceptibility to removal or inactivation by conventional water treatment processes. Each of these parts is used in today’s world to identify and destroy existing, and new pathogens. What happens if someone ingests a pathogen before it is identified? Well that is one reason that the Department of the Environment is so concerned. Due to current environmental status new pathogens are appearing semi-daily, and consequently overwhelming those who are working to stop them. One major example of this is Legionella. Legionella is unique in the fact that 42 strains have been identified, and yet only one is within our ab ility to control. So obviously there is a major shortage of knowledge on pathogens, and how to control them. According to the WRC’s report to the Department of the Enviroment â€Å"The threat which is posed by an organism to contaminate water supplies and cause outbreaks always exists,† and furthermore they state that â€Å"The threat which is posed by an organism, in terms of its occurrence and distribution in water sources and the ability to remove it is often poorly understood and or completely unknown.† Does this alarm anyone else? Just the thought that our government admits that there are diseases out there that we have no ability to control is alarming.

Dr. Gregory House Essay

Dr. Gregory House is the main character in the House television series. He is currently working as the Head of Diagnostic Medicine with a double specialty in infectious disease and nephrology at Princeton-Plainsboro Teaching Hospital. He is portrayed as narcissistic, sarcastic, and appears to dislike most people. He prefers superficial relationships with others, sometimes using prostitutes to satisfy his sexual needs. Descriptive Information: Gregory is a 52 year old Caucasian male. He prefers to be called House, as he views being called Greg as too personal. Dr.  House has a permanent disability in his leg. Dead muscle tissue had to be removed and left a divot in the skin. He is also very sensitive about the appearance of his thigh, being badly scarred from multiple operations. He is very reluctant to talk about this disability and is easily offended if it is brought up. House has been in constant pain since the surgery and has become addicted to painkillers. He does not acknowledge his using as a drug problem; he reports it is a pain problem. He states that it does not interfere with his ability to work. At the present time he has been to npatient treatment for detoxification, however still struggles with his addiction. House is above average in his intelligence, having been accepted to John-Hopkins University for his pre-med studies. It is his disregard for ethics and protocol that has caused him problems. He lost an opportunity for an internship at the Mayo Clinic when he was caught cheating and expelled. His inability to work well with others has been a source of employment issues for him in the past. House’s father was a Marine pilot, and he spent most of his childhood moving to different countries. As a result he isolated, and concentrated on a variety of interests. He is fluent in several languages, and plays the piano and guitar. At the age of 12, discovering the timing of his conception did not correlate with a time his father was around, he confronted his parents on the paternity. It was revealed to him that his mother had an affair with the family minister. House feels this was the turning point in his relationship with his father, John. He feels he was mistreated by John for this reason. John was cold and controlling, showing House limited affection. House was rebellious and was often punished harshly both physically and emotionally. House and his mother had a loving relationship, however in his desire to avoid his father he does not have her in his life. Presenting Problems: House’s presenting problems at this time are: his addiction to painkillers, his fear of intimacy, and anti-social traits. He also displays a problem with impulse control. Dr. House states his main reason for using Vicodin was for pain management, however he has admitted to recreational drug use in his past. His dependence has caused him professional problems, getting him into trouble on several occasions. His addiction has also caused him problems with Lisa, the woman he has feelings for. Dr. Lisa Cuddy and House have had an ongoing attraction spanning 25 years. They were beginning to form a relationship when she had a scare with cancer. When House couldn’t face losing her, he turned again to the Vicodin. Lisa ended their relationship when she realized his inability to cope without the use of drugs. Dr. House has been afraid to experience any real closeness to others in his life. He has issues of trust due to his mother’s dishonesty and his father’s distance and hostility towards him. This is the primary source of his fear of intimacy and cynicism. He hides his fears with a narcissistic attitude, and pushes people away instead of exposing any vulnerability. House can be extremely defensive, and it is likely he uses his personality in a deliberate attempt to alienate anyone who tries to get close to him. He is conflicted when facing his feelings for Lisa, while trying to hold onto his belief he is entirely self-sufficient. House has acted on numerous occasions without regard to his health and safety. He also takes his behaviors to the extreme. When Dr. Cuddy starts dating after their reak-up, he reacts by driving his car through her front window. He states his reason as simply â€Å"returning her hairbrush. † He uses himself as a test subject for drugs and medical tests, sometimes just to satisfy his curiosity. He has taken experimental drugs in hopes of restoring his leg muscle, which eventually led to tumors. House has also injected himself with questionable blood received by an ill patient to see if a blood transfusion caused their symptoms. Model: I believe that person-centered therapy would be the model best suited for House. I would also incorporate some cognitive-behavioral techniques. House would not respond well to any theory that is confrontational, he needs to feel in control. I also recognize that although his past plays a big part in why he has relationship issues, he does not seem to want to revisit these occurrences. I believe very little time should be spent on the subject of his parents specifically, with more time spent on how he’s dealing with relationships now. House would be a difficult client to build a therapeutic relationship with; however I do feel it could be done over a period where he felt he was in a safe and non-judgmental environment. He is intelligent and lives to figure out the â€Å"pieces† in difficult medical diagnoses. House may have a little trouble in using this in regards to his own mental health, since he is so enveloped in denial, but he does have the capacity to do so. The person-centered model works on the premises that the client is the expert, and I believe it is one he would respond to best given his personality type. Treatment Goals: House’s primary issue is addiction, and a lack of having a recovery plan. He has been trying to deal with this on his own terms, and has had relapses. His untreated condition contributes to his anti-social personality, interferes with his relationships, and causes issues at work. I feel his other presenting problems can never be fully addressed until he can gain control over his addictive behaviors. Until he comes to terms with his addiction, he will remain isolated and continue to be self-destructive. Dr. House needs to address his difficulty with any type of relationship. It is apparent at times that he does have the capacity and this facet of him is not part of a personality disorder. He displays a need for people despite his not wanting to. He shows jealousy when Lisa dates others and does has a close friendship with Dr. James Wilson from the hospital. Dr. Wilson provides House with consultation about cases, and often personal issues. James is one of the few who can away with calling House out on behaviors. They sometimes have real moments on a deeper level, and at times they can let go and share laughs. House has displayed many instances of problematic impulse-control. He has experimented with Methadone, self-induced insulin shock, and tried deep brain stimulation with an electrical prod. The electrical current caused him seizures, brain leeding, and ultimately led to him being in a coma. He often shows no regard for his well-being. Once in an agitated state, he dove from a balcony into a pool. These behaviors horrify others around him. Techniques: The person-centered therapy is flexible enough to be adapted to most personalities. I feel a technique building a person profile would help House to address his addiction issues and in building a plan. This would begin with listing his attributes and strengths. Learning what is likable and worthy about himself, instead of focusing on negatives, will present to him a view of himself in wish he wants to be seen. Next he should verbalize what is important to him. Having clear, concrete thinking on what he wants in his life can help when addressing what his drug use will take away from him, and how it is a barrier in achieving his desired outcome. Finally House should look at what has been working and what is not working as support in his life. This includes relationships, both ones that may be unhealthy and those he needs to build. Recovery is greatly impacted by support systems. These can include relationships on a personal level, and outside support groups. House needs to consider what should be changed, what should stay the same, and what makes sense as far as being realistic. Rational emotive behavioral therapy (REBT) could be beneficial to House in dealing with his fear of intimacy. The basic hypothesis is that people are not disturbed by events, but by the views in which they take on them. Therapy would dispute his irrational beliefs and engage him in activities that can counter them. Showing House the faulty belief system he imposes on everyone he meets, he can begin to work on seeing how his actions are self-sabotaging. If he can really grasp how his beliefs are blocking him, he can find ways to change and control them. It will help him to communicate more effectively with others. I believe social skill groups could help House with his impulse-control. Group therapies help with accountability of the behavior, and provide for feedback. This therapy is a powerful venue for growth and change. Participants receive tremendous understanding, support, and encouragement from others facing similar issues. House could also gain different perspectives, ideas, and viewpoints on those issues. I feel a variance outside of one-on-one would be beneficial for House. As narcissistic as he can be, I think too much attention to solely his issues at once would force him to become more defensive and less open to treatment. Assessment: House’s treatment goals will take some time to be actualized. Addiction is rooted not only in behaviors, but also his biology. He will need to have some strong support built in along with coping skills. Given the fact relationships with others need to exist for the support to be effective, these treatment goals are dependent on one another. His treatment with addiction will not show promise until a minimum of a year without use has been met, and regular involvement in a self-help group has been established. I do not expect House to develop newer relationships at this time; however I will gauge his success in fostering his existing ones. His changes should include learning how to express his feelings maturely, and learning to give of himself without the use of sarcasm to hide when it feels uncomfortable. There is also a strong correlation between addiction and impulse-control, by identifying coping skills for urges, House could utilize some of these with his behaviors. In addition, low self-esteem can be part of the problem in engaging in such dangerous and high risk activities. House needs to address both his physical condition that causes him embarrassment, and his abandonment issues with his family. I feel as time goes on, and he gives recovery and relationships with others a chance, he will begin to see himself as a person worth caring for. Once he begins to feel that he is valuable and deserving of love from others, he should be able to accept this within himself. It is my hope through those changes his disregard for his safety will dissipate.

The Awakening Quotes and Analysis - Free Essay Example

Sample details Pages: 6 Words: 1765 Downloads: 9 Date added: 2019/10/30 Category Literature Essay Level High school Tags: The Awakening Essay Did you like this example? Quotes, passages, or sentences go on the left side with a page number. #1 You are burnt beyond recognition, he added, looking at his wife as one looks at a valuable piece of personal property which has suffered some damage. (pg. 48, paragraph 2.)     Ã‚  Ã‚  Your responses to those quotes go on the right side. (100 word minimum) Don’t waste time! Our writers will create an original "The Awakening Quotes and Analysis" essay for you Create order The first sign of the bubbling conflict is that her husband doesnt treat her as a true individual. He seems to be distant from Edna as a spouse. Là ©once now sees his wife as a possession that can easily affect his reputation and place in society. He is a business man who is frequently away from his family, which can strip a relationship of its passion and contentment. Tension easily intensifies when a loved one isnt present to show expected affection. He has become so distant from Edna that not only is their excitement drained, but his image of her is not influenced by his feelings for her. Instead, it is distorted by comparisons to other women and materialism.   Quotes, passages, or sentences go on the left side with a page number. #2 They were women who idolized their children, worshiped their husbands, and esteemed it a holy privilege to efface themselves as individuals and grow wings as ministering angels. (pg. 19, paragraph 1.) Your responses to those quotes go on the right side. (100 word minimum) Edna is not the ideal mother. She does not show the affection that most mothers in New Orleans show their children. Her children do not necessarily go to her for comfort. However, her sons seem to be stronger from this. Instead of crying after a fall while playing, they will fix themselves up and continue to have fun. Although her sons dont seem to be particularly bothered, Là ©once is. He desperately wishes that Edna could be more like Alcà ©e. Alcà ©e is considered one of the most perfect women in their town. Shes very caring of her children. She listens to her husbands opinion. Shes extremely charming and talented. While Edna and Alcà ©e are close, Edna may distance herself to avoid comparison. Quotes, passages, or sentences go on the left side with a page number. #3 At a very early period she had apprehended instinctively the dual lifethat outward existence which conforms, the inward life which questions. (pg. 35, paragraph 1.) Your responses to those quotes go on the right side. (100 word minimum) While Edna tries to appeal to societys standards, she often feels unhappy and suffocated. She is not mentally for her current role as a mother and wife. For so long, she has been strolling along and settling for the circumstances. She hasnt been living and her passion lays dormant within. However, as she slowly becomes an individual, she is no longer conforming. In fact, she begins to neglect her old, humdrum life. As she strives for independence, she begins questioning her current situations set up. Quotes, passages, or sentences go on the left side with a page number. #4 Add to this the violent opposition of her father and her sister Margaret to her marriage with a Catholic, and we need seek no further for the motives which led her to accept Monsieur Pontellier. for her husband. (pg. 46, paragraph 2) Your responses to those quotes go on the right side. (100 word minimum) As most young people do, Edna accepts Là ©once as her husband, seeing that it upset her father. The second that someone, especially an authority figure, opposes an idea, the urge to rebel ignites. Theres something exhilarating about going against basic morals or commands. It allows one to feel completely free and a bit euphoric. This same feeling could have influenced her to open a physical affair with Alcà ©e. He satisfies her animalistic urges. It is later explained that he enjoys pursuing married women. The feeling is dangerous and risky, but its enough to make the consequences worth it. The rebellious urge helps eradicate the bore of standards. Quotes, passages, or sentences go on the left side with a page number. #5 several persons informed her simultaneously that Robert was going to Mexico. She laid her spoon down and looked about her bewildered. He had been with her, reading to her all the morning, and had never even mentioned such a place as Mexico. (pg. 104, paragraph 2) Your responses to those quotes go on the right side. (100 word minimum) Robert and Edna have gotten more intimate and their relationship has become complicated. There is no doubt that their feelings for one another causes tension between them. However, they cannot act on impulse. Infidelity is very shameful, and it will not only ruin their reputations, but Là ©onces as well. Roberts sudden departure crushes Edna. Robert seems to know this as he is noticeably uneasy and quiet. That night, he strains himself to be distant as he leaves her. As Edna was blatantly honest about how she felt, he started to truly explain his reason for leaving. He abruptly stops, which shows that he is not fond of professing his love for another mans wife. Quotes, passages, or sentences go on the left side with a page number. #6 Does he write to you? Never a line. Does he send you a message? Never a word. It is because he loves you, poor fool, and is trying to forget you, since you are not free to listen to him or to belong to him. (pg. 209, paragraph 5.) Your responses to those quotes go on the right side. (100-word minimum) Though Robert promised Edna he would write her, he never does. Edna frequently visits Mademoiselle Reisz, who allows Edna to read the letters she receives. When Edna hears that Robert is coming back from Mexico, she searches for his reason, hoping its for her. Reisz explains to Edna that Robert is trying to diminish his love for her. He believes it is impossible for him to pursue her while she belongs to Là ©once. Robert, like most people in society at the time, view women as the property of their husbands (if they are married). Since he cannot let this go, he feels he must force himself to stop loving Edna.   Quotes, passages, or sentences go on the left side with a page number. #7 Im jealous of your thoughts tonight. Theyre making you a little kinder than usual; but some way I feel as if they were wandering, as if they were not here with me. (pg. 217, paragraph 6.) Your responses to those quotes go on the right side. (100-word minimum) Alcà ©e, Ednas physical affair, is a man who is very flirtatious and pursues married women. However, Edna does not fit his desperate, lonely, housewife stereotype. Her urge to be independent allows her to stay free. When Edna hears of Roberts soon arrival, she is elated and its quite noticeable. Its the happiest she has been in a while. Alcà ©e suspects that he is not the reason for this sudden burst of joy. He expects her to be infatuated with him, as many other women in the past. Instead, he is seemingly becoming the desperate one in this affair.   Quotes, passages, or sentences go on the left side with a page number. #8 You have tried to do too much in the past few days. The dinner was the last straw; you might have dispensed with it. (pg. 241, paragraph 4.) Your responses to those quotes go on the right side. (100 word minimum) At her dinner, celebrating her move, she snaps at one of the guests that sings. She has been wearing herself out with the move and the adjustment to the lifestyle she is trying to have. Many say that artists tend to be very lonely. Edna is increasingly isolating herself from her friends and family, so she can go through these awakenings. She does not desire to become anyones possession, including Roberts. As of right now, it seems that he is never going to pursue her. This means that Edna truly will be alone. Edna is struggling with these feelings along with the events happening outside. She is mentally and physically exhausted. Quotes, passages, or sentences go on the left side with a page number. #9 So he had come back because the Mexicans were not congenial; because business was as profitable here as there; because of any reason, and not because he cared to be near her. (pg. 255, paragraph 3.)  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Your responses to those quotes go on the right side. (100-word minimum) When Robert explains why he has returned from Mexico, Edna is hurt. He did not come back for her. If business was more profitable there, he would have never returned. He would continue to ignore his promise to write her. It must pain her deeply that she didnt influence his return. He could have very well stayed in Mexico. While Edna was so deeply missing Robert, his response gives her the impression that she hasnt crossed his mind. She had hoped that Robert felt the same as she did. But Robert is still not willing to deal with his confliction. Quotes, passages, or sentences go on the left side with a page number. #10 You have been a very, very foolish boy, wasting your time dreaming of impossible things when you speak of Mr. Pontellier setting me free! I am no longer one of Mr. Pontelliers possessions to dispose of or not. I give myself where I choose. If he were to say, Here, Robert, take her and be happy; she is yours, I should laugh at you both. (pg. 282, paragraph 3.) Your responses to those quotes go on the right side. (100 word minimum) Robert has this societal view of wives being property to their husbands. Edna despises this perspective, one of the many factors driving her need for independence. She has become exhausted trying liberate herself and she will not be possessed by another. She is now in control of her feelings and actions. Even though Edna loves Robert, she will not allow herself to be owned by him. The idea of Là ©once passing her to Robert is highly degrading. She is appalled that he could even stomach it, let alone allow it to conflict his love for her. However, Robert is still torn inside. He leaves, and Edna is left alone. Though being independent could grow lonely, its much better. To have an awakening cause so much distress and change only to return to the same lifestyle is truly a waste. For page and paragraph references:   Chopin, Kate. The Awakening. Internet Archive, Chicago, New York, H. S. Stone Company, 1 Jan. 1899, https://archive.org/details/awakeningthe00choprich