Hydration management in acute stroke patients - Free Essay Example

Introduction Stroke is a global public health concern with many sufferers presenting with varying levels of confusion (Oh and Seo 2007). Management of hydration in acute stroke patients is not standardised and variations in practice can be very wide between different continents. The sheer number of possible comorbidities and the relative ease with which hydration can trigger concomitant problems can lead to increasing incidence and prevalence of long-term patient care resulting from inadequate hydration management. Optimum hydration assessment and management are key clinical activities; however, inadequate hydration controls by health professionals persist (Oh and Seo 2007). Research shows that to guide fluid management to desired levels, a regular assessment of the volume status has to be made Scope This literature review is based on works that are found on Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cumulative Index to Nursing and Allied Health literature (CINAHL), Cochrane, Department of Health (DoH), National Institute of Clinical Excellence (NICE), National Medical Council (NMC), World Health Organisation (WHO), Wiley Interscience and CKS databases that relate to hydration in stroke patients and nursing awareness of hydration in stroke patients. There is wide literature on different aspects of stroke and many authors have studied the effects of hydration in stroke patients. This review looks at literature that discusses management of hydration and/or the impacts of variations in hydration management on acute stroke patients outcomes like method of feeding, time- compliance in taking readings or measurements, legal issues and ethical issues. Relevance to clinical practice This literature review looks at relevant studies by experts that are found on credible databases. The purposes of the expert studies are reviewed and analysed to inform better understanding of current nursing practice in hydrating acute stroke patients. Several studies on hydration highlight specific difficulties relating to the assessment and management of hydration in acute stroke patients. There are differences between the management and the assessment of hydration in different hospitals and these complicate improving awareness of managing hydration for nurses in practice. If optimum hydration is directly linked to improved outcomes in acute stroke patients, research will be required to identify and overcome barriers to effective hydration management, including the development of specific tools (and knowledge base) to facilitate interventions that promote optimum hydration in seeking improved outcomes in acute stroke patients. Methods of search and documentation n on-line literature search of MEDLINE, CINAHL, COCHRANE, DOH, NICE, NMC, WHO and CKS from 1999 to May 2009 failed to identify enough relevant articles on hydration in stroke patients. Other sources were then reviewed for available literature on medical journals including the BMJ and American Family Physician. For the on-line computer-based literature searches, the following keywords were used: stroke, fluid balance, hydration, cerebrovascular accident (CVA), dehydration, stroke outcome, cerebrovascular disorders, medical management, artificial nutrition and hydration, dysphagia, dysphasia, pyrexia, acute brain infarction, enteral tube feeding, fluid and electrolyte balance, neurology, withholding treatment, pathophysiology and nurses and hydration Hydration and hydration management in acute stroke patients This literature review looks at one of the issues encountered globally in the treatment of acute stroke patients optimum hydration. It takes a particular look at the nursing awareness, measurement, assessment, methods of intervention and the legal issues associated with hydration in acute stroke patients. Stroke is a debilitating condition and can be caused by an ischaemic event or a subarachnoid/intracerebral bleeding. Stroke patients usually present in hospital with co-morbidities (Oh and Seo 2007). Variations exist in stroke fatalities across geographical regions even within the same continent. Studies by Bhalla et al (2003) across four European centres (London, Dijon, Erlangen and Warsaw) have shown significant variation (after adjusting for case mix) in stroke case fatality, in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity. There were also significant intervention differences between centres in intravenous fluid use, enteral feedin g, initiation of new antihypertensive therapy and insulin therapy, with the London centre having the lowest uptake of interventions. In another European BIOMED Programme, significant variations in case fatality for stroke between European centres (after adjustment for stroke severity) were observed, with the United Kingdom (UK) centres having the highest case fatality and the lowest levels of independence (Wolfe et al., 1999). There were lower intervention rates in the UK centre to correct abnormal physiological parameters in the acute phase which may reflect a difference in philosophy of acute medical supportive care compared with other European countries (Wolfe et al., 2001). Awareness of optimal hydration balance and assessment of the patients hydration condition (in the care of acute stroke patients) is a fundamental part of critical care nursing and optimising the hemodynamic situation can be seen as a team-effort. One of the important factors determining quality of the circula tion is the amount of circulating blood (Hoff et al 2008). Following a stroke, patients may have swallowing impairment and other changes of the gastro-intestinal (GI) tract that could affect nutritional and hydration status and that lead to aspiration pneumonia (Schaller et al 2006). Such changes affect the ability of the acute stroke patient to lead a normal nutritional life. Although the Schaller et al (2006) work did not show a direct link between hydration and other comorbidities, they agree that impaired hydrational status is associated with reduced functional improvement, increased complication rates, and prolonged hospital stays. Hydration and hydration status Hydration balance is a measure of the bodys ability to manage fluids and electrolytes. In order to identify the urgency of interventions, nursing staff should characterize an individuals fluid and electrolyte imbalance as mild, moderate, or severe based on pertinent information including lab tests and other relevant criteria. It is important to recognize that the main electrolyte in extracellular fluid (ECF) is sodium and that of intracellular fluid (ICF) is potassium (Edwards, 2001). Toto (1998) pointed out that large increases or decreases in fluid volume can cause infarct, coma and confusion. This knowledge becomes significant in maintaining cerebral blood flow and in preventing secondary brain insult after an acute stroke. In a complication, respiratory or metabolic acidosis will promote the movement of potassium from the ICF and give rise to high serum potassium levels, which may affect cardiac function (Edwards, 2001). This phenomenon can be seen in many traumatic insults to th e brain. A basic knowledge of this physiology in addition to the homeostatic mechanisms for fluid and electrolyte balance is a vital foundation for nursing practice, and essential to the nurses role in hydration management. Cook et al (2005) highlighted the significance of fluids and hydration in the neuroscience patient and in Cook et al (2004) they highlighted that an understanding of the physiological mechanisms that surround stroke is important for nurses to monitor and treat such patients. Kelly et al (2004) in their study of dehydration and venous thromboembolism (VTE) after acute stroke believed dehydration after acute ischaemic stroke (AIS) is strongly independently associated with VTE, reinforcing the importance of maintaining adequate hydration in these patients. Their study of hydration over a 9-day period showed indication that dehydration was largely hospital acquired and that the association was causal. Although the possibility that VTE was already present at entry to hospital cannot be discounted, tests have shown that VTE is rarely present before the second day post stroke, and then it becomes increasingly prevalent over the next few days. This could be for one of many reasons including poor communication between patient and hospital staff, change of environment for the patient and the physiological impacts of stroke Hydration balance and nutritional/electrolyte balance The differences in how hydration is assessed in different hospitals have been subject of study for some time. The significance of fluid electrolyte homeostasis becomes very relevant in trauma and shock situations such as subarachnoid haemorrhage where an inflammatory response is triggered which causes a significant change in capillary membrane permeability in a short period of time. In such situations, water, electrolytes and albumin move into the interstitial space to permit the site of injury to receive the required factors (third space shift) (Edwards, 2001). A number of physiological mechanisms are required to maintain homeostasis of hydration status, all of which inform proactive nursing assessment, intervention and evaluation. Those with trauma to the nervous system are vulnerable to disruption to the homeostasis of fluid and electrolyte balance (Cook 2005). Older adults may have a poorer capacity to adapt to shifts in acute fluid balance, leading to the possibility of cardiac and renal functions being impaired and, as a result, a lower glomerular filtration rate (Sheppard, 2001). Managing the fluid balance of the stroke patient by intake and output measures needs to be exercised cautiously because even though the patients fluid volume may not have changed, his/her circulatory volume may be significantly lower in instances of major trauma (Edwards, 2001) Good hydration has been shown to reduce the risk of urolithiasis (category Ib evidence) (see Appendix 2), constipation, exercise asthma, hypertonic dehydration in the infant, and hyperglycemia in diabetic ketoacidosis (all category IIb evidence), and is associated with a reduction in urinary tract infections (UTIs), hypertension, fatal coronary heart disease, venous thromboembolism, and cerebral infarct Complications of measurement/control Naso-gastric v PEG, enteral v parentera Patient history taking on presenting in the hospital differs from hospital to hospital. History taking should include assessment of fluid intake and loss, baseline hydrational status, skin turgor, heart rate, blood pressure and urinary output. Normal fluid intake for the average adult is approximately 2-2.5 litres, obtained from food, fluids or metabolic by-products (Edwards, 2001). Methods of measurement are not standardised across hospital settings with Wise et al (2000) showing that faecal fluid losses are often neglected in daily fluid balance charts with the possibility of inaccurate hydration assessment. Fluid assessment must include estimating, as accurately as possible, the quantity of fluid taken in. It must take into consideration the entire processes by which water, potassium and sodium are obtained. Measurements are often mainly focused on the extremes of hydration (optimal hydration and extreme dehydration) and this should not be the case. Assessment of hydrational statu s and need is continuous and begins somewhere along a continuum of severe hypovolaemia/ dehydration to severe hypervolaemia/ overhydration. In looking at dehydration, not only extreme dehydration should be noted. Manz and Wentz (2005) highlight that there is increasing evidence mild dehydration may also account for many morbidities and play a role in various other morbidities. The way in which stroke is managed acutely, such as measures maintaining physiological homeostasis may also vary between different populations (Bhalla et al 2003). The physiological indicators of acute deficits in fluid balance may be masked in individuals where compensatory mechanisms are intact. A history of acute events, mainly from baseline documentation and history taking, may enable better identification of such imbalances (Sheppard, 2001). Fluid and electrolyte homeostasis is brought about by the interaction between the renal, pulmonary, neuroendocrine, integumentary and gastrointestinal systems (Edward s, 2001). According to (Cook 2005), fluid and electrolyte management is a fundamental aspect of the role of the neuroscience nurse. Artificial feeding and fluids are the options for a patient who has an advanced, life-threatening illness and is dying. The patient, family members and doctor can talk about these options and the benefits and risks (Ackermann 2000). Hydration and electrolyte status are crucial mediators to the extent of the neuro-hormonal response to trauma. Edwards (1998, 2001) highlighted that homeostasis is maintained by a constant movement of water, sodium and potassium between intra- and extracellular compartments. While the movement of water and electrolytes between the cellular compartments is highly significant, it is important to recognize that in acute and chronic illness intracellular fluid (ICF) is reduced and extracellular fluid (ECF) increased almost to the extreme (Edwards, 2001). This is highly relevant for cerebral metabolism, because transport of oxyge n, glucose, proteins and other products for cellular metabolismà ¢Ã¢â€š ¬Ã¢â‚¬ and their by-productsà ¢Ã¢â€š ¬Ã¢â‚¬ may be severely impaired. Stroke may affect ones level of alertness, perception of thirst, ability to access liquids, and ability to swallow them when offered. Stroke victims with such impairments may be at increased risk for diuretic-induced dehydration (Churchill et al 2004). Managing hydration balance is of crucial importance and the mechanisms for the adequate monitoring and controls need to be in place. Nursing management questions in the assessment of hydration in acute stroke patients should include whether use of intravenous fluids during the first week of stroke was recorded. Questions should also include whether the patient was fed orally, by nasogastric tube, through percutaneous gastrostomy tube, by intravenous methods or not at all? The fact that these questions can be raised enforces the need for adequate documentation and recording of acute stroke pa tient records. Bhalla et al (2002) says that the use of artificial ventilatory support with intubation or nasal intermittent positive pressure ventilation should be documented as well as the use of supplemental oxygen given through nasal catheters or masks. Enteral tube feeding is a vital means of feeding and balancing hydration levels in patients with stroke. There are no set standards for hospitals in the UK and hospitals have recorded much variation between them in the timing of the start of enteral tube feeding and whether a nasogastric or percutaneous endoscopic gastrostomy (PEG) tube is used (Ebrahim and Redfern 1999). Some clinicians delay tube feeding for 2 weeks or more, and although early nutrition is unlikely to be harmful, whether any nutritional benefits offset the difficulties and complications of initiating and maintaining early enteral tube feeding is unclear. If the timing or route of enteral tube feeding does affect outcome, the present variation in practice means that large numbers of patients are being denied best treatment. Whether enteral tube feeding via PEG rather than nastrogastric tube or early initiation of enteral tube feeding improve outcomes was tested in the FOOD trials and no evidence of significant benefit from PEG rather than nasogastric tube feeding was found. Neither was any hazard from early tube feeding found (The FOOD collaboration 2003). The explanation for any difference between PEG and nasogastric groups is not clear, but one factor might be the effect of a long-term PEG tube on dependency since more patients in the PEG group were still receiving such tube feeding than in the nasogastric group at follow-up (The FOOD collaboration 2003). The survivors in the PEG group were also more likely to be living in institutions and had lower quality of life. Another intriguing finding was the excess of pressure sores in the PEG group, raising the possibility that those with such tubes might move less or be nursed differently. Wea knesses in this test results include insufficient statistical power to exclude more modest differences between groups; no information about the proportion of eligible patients enrolled in each centre; our use of an informal (although reliable and highly predictive) assessment of nutritional status; absence of precise monitoring of patients daily intake of nutrients (rather than fluids); absence of on-site source data verification or collection of information on changing nutritional status (e.g. in-hospital weights); possible bias due to masking of secondary outcome measures. Although compliance was not 100%, this fact results from the inevitable difficulties of adhering to rigid schedules when patients conditions change. Difficulties with nasogastric feeding in stroke patients (who are often confused and uncooperative) have led to increasing use of PEG tubes at an early stage. Enthusiasm for this method has been encouraged by the results of a trial that reported much lower case fata lity rates in patients fed via PEG (13%) rather than nasogastric tube (57%) (The FOOD trial collaboration 2003). Due to significant alterations in fluid balance after enteral tube-feeding in patients, close attention to the recording of fluid balance such as intake/output measurements, body weights and simple bedside assessments is needed to detect fluid imbalances and other serious complications at an early stage (Oh and Seo 2007). One explanation for the varying and inconsistent readings in fluid hydration between enteral and PEG might b Stroke patients and the impacts of stroke on life Difficulty with swallowing is a common problem in acute stroke patients, and can lead to aspiration pneumonia, dehydration, and exacerbation of any existing malnutrition (Finestone and Greene-Finestone 2003). In Oh and Seo (2007) the authors set out to examine the fluid and electrolyte complications after enteral tube feeding in acute brain infarction patients. The background is that inconsistencies in the results of the water and electrolyte complications associated with enteral tube feeding are partly because of uncontrolled disease-related variables. The implication is that these variables were not adequately managed. Stroke patients very often present with dysphagia and this is very commonly dehydration associated with undernutrition (The Food Trial 2005). Up to half of stroke patients in hospital have dysphagia, which precludes safe oral nutrition for the first few days and can persist for long periods (Mann et al 1999). Although a 50% prevalence can be considered to be high, th e nutritional/fluid status of a stroke patient can rapidly deteriorate in hospital. The difficulty in feeding stroke patients with dysphagia coupled with the discomfort associated with stroke can exacerbate undernutrition and/or dehydration. Studies show that undernutrition shortly after admission is independently associated with increased case fatality and poor functional status at 6 months (The FOOD trial collaboration 2003). The current financial burden of efficiency savings and reduced budgets in the NHS hospitals results in reduced staff numbers so that patients can not be attended to on a one-on-one basis so that ensuring appropriate hydration levels is done by periodic but regular monitoring of charts. An option for the future in this area may be to involve the patients family members in hydration monitoring and provide them with appropriate training if evidence can show that being around loved ones improves outcomes and early warnings. In acute stroke, artificial nutrition t hrough an enteral route is needed because of dysphagia and since oral feeding is unsafe in some dysphagic patients, enteral nutrition is often administered as nasogastric or percutaneous endoscopic gastrostomy (PEG) tube feeding (Finestone and Greene-Finestone 2003). Naso-gastric tube feeding (a prevalent enteral method) has been reported to improve clinical outcomes more than the parenteral route in brain-injured patients (Rhoney et al 2002). Oh and Seo (2007) in their study used 85 subjects, but their work was limited by the fact that it was performed retrospectively and some of the subjects records were incomplete. Also, because the patients in the study were from one hospital it is not conclusively known whether the results can be generalised to the whole population./p Legal and other aspects Japanese physicians attitudes towards artificial nutrition and hydration (ANH) as a life-sustaining treatment (LST) were examined to find out if they withhold or withdraw the LST when treating older adults with stroke-caused profound impairment with no hope for recovery. The study findings show that the informants held different views towards LST because most doctors considered ANH to be indispensable and ANH is automatically provided to patients (Aita and Kai 2006). With the advancement of medical technology, decisions to withhold or withdraw LST are among the most difficult to make for health professionals (British Medical Association 2001). Physicians caring for stroke patients often encounter comatose or semi-comatose patients with severe stroke for whom it is difficult to determine whether or not to continue care (Asplund and Britton, 1989). By administering LST, some patients in this patients group, whose bodily functions other than brain function could remain stable, could pot entially survive for months or years without achieving awareness or being able to interact with others (Aita et al 2008). Certain Japanese physicians have criticized the current efforts regarding life prolonging as Aita et al (2008) states: Prolonging the process of dying like this constitutes the violation of dignity and human rights. The life-prolongation only serves hospital operators who want to make profits by keeping hospital beds occupied. They also said this practice impacted the carers and that some nurses also feel emptiness toward the manipulative life-prolongation when taking care of these elderly patients. In the West, some countries have worked out nation-wide guidelines related to withholding or withdrawing LST that say stroke-caused profound impairment with no hope for recovery is a potential reason to withhold or withdraw LST (British Medical Association, 2001). Ackermann (2000) believes withholding and withdrawing therapy challenge family physicians to be excellent communicators with patients and families and recommends that family physicians should continue to be strong advocates for dying patients. Sprung et al (2003) highlighted differences between withholding and withdrawing therapy showing that withdrawal of therapy is followed by a nearer and more rapid death than withholding therapy, and that physicians and nurses were more inclined towards withholding rather than withdrawing therapy. Food and water are considered symbols of caring (Ackermann, 2000), therefore, it may be natural for physicians to give a special status to ANH as food and water. Whether to withdraw ANH from a patient in persistent vegetative state has also drawn substantial media attention in the U.S. (Casarett et al., 2005; Ganzini, 2006). The findings of the study also suggest that the physicians double standard is partly based on their subjective judgment whether the treatment is ordinary or extraordinary. However, the standard of ordinary/extraordinary care has long been criticized as too vague to guide decision-makers in the U.S. (Beauchamp and Childress, 2001). It is believed the current legal framework has also inappropriately led some physicians to simply continue care regardless of the patients conditions, thus resulting in putting an unnecessary burden on patients. The physicians subjective interpretation of the current legal framework may lead to decisions not to initiate mechanical ventilation in some older adults for fear of facing a situation in which physicians cannot withdraw it at a later stage Conclusion Hypovolemia and hypervolemia occurred frequently after acute stroke but were often not recognized as such by nurses. The nurses predictions of current volume status do not seem sufficiently reliable to serve as a basis for therapeutic decisions. More advanced techniques for bedside assessment of volume status may be indicated for optimizing volume status in patients with acute stroke (Hoff et al 2004). Whereas studies have looked at the optimal method of improving hydration, whether correcting dehydration in stroke improves outcome is not very clear. Given the complexity of the cell death cascade following brain ischemia, novel approaches and combination therapy are inevitable for victims of stroke (Fisher and Brott 2003). The review indicates that standards vary from country to country in the legal framework for withdrawing and withholding hydration and nutrition during end stage care.

The Foolproof Technology Cause and Effect Essay Topics Strategy

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<h1>Essay Topics For Current Issues - Tips To Help You Choose The Right Essay Topic For Current Students</h1><p>Students might be thinking about what paper subjects for current issues could be valuable in school and graduate school. With the quantity of current points understudies are required to cover, there is a decent possibility that their selection of subjects will represent the moment of truth their scholastic career.</p><p></p><p>The most basic inquiries are what ought to be the subject of current themes for current understudies? The appropriate response is that everything relies upon the sort of understudy. It likewise relies upon whether the understudies have earlier composing experience and additionally on the off chance that they were doled out a specific exposition theme for a paper assignment.</p><p></p><p>When understudies are given a particular subject for an article, they have to consider how to use thi s task in a significant manner. Most understudies compose the paper dependent on the teacher's solicitation. They would be exceptionally amped up for composing a task where they realize they can hope to get passing marks. The issue emerges when they come to school and understand that they won't have the option to compose the task and really complete it.</p><p></p><p>Many understudies, even the individuals who have composing experience, think that its hard to finish assignments and get passing marks. Frequently, they are not provided any direction or guidance as far as what to do regarding paper points for current issues. They don't figure out how to approach composing expositions appropriately. Understudies are not furnished with legitimate, complete assets that can enable them to choose what to expound on and when to compose it.</p><p></p><p>If understudies come to school without expecting to expound on current subjects for current is sues, at that point they are going to need to discover where to start. There are a lot of online assets that are intended to assist understudies with finishing assignments on the Internet. These assets are explicitly intended to assist understudies with getting some answers concerning current subjects for current understudies. A portion of these assets are notable. Others are not too known, however they are available.</p><p></p><p>Students who need to investigate the a wide range of sorts of articles accessible can utilize paper assets that can furnish them with the capacity to look over the a wide range of sorts of papers that can be utilized for current subjects for current understudies. An understudy might need to utilize an asset that will give them a thought of what different understudies are expounding on, just as what they will expound on. They might need to utilize an asset that gives data about current issues and furthermore gives data on the best wa y to compose a paper. One famous paper subject for current understudies is the ongoing downturn. Understudies can discover a case of an exposition subject for ebb and flow understudies via looking for the term in Google.</p><p></p><p>After understudies comprehend the various sorts of articles that are accessible, they can choose which one best meets their requirements and what they will expound on. When they have chosen what subjects they need to expound on, they can peruse through the numerous choices to locate the best paper theme for current understudies. When they can pick the subject they need to expound on, they will have the option to realize what scholars for different fields are expounding on and this will assist them with making their own one of a kind essay.</p>

IELTS Essay Topics With Answers PDF - Why You Should Use It

<h1>IELTS Essay Topics With Answers PDF - Why You Should Use It</h1><p>IELTS Essay Topics With Answers PDF is the new and simple approach to get ready for your IELTS assessment. Utilizing indistinguishable customary strategies from those utilized before, however in a progressively adaptable organization, it will empower you to plan for your assessment at all conceivable time.</p><p></p><p>IELTS appraisal focuses have since quite a while ago utilized numerous techniques for testing, for example, the composed part of the test and the genuine handy areas, where a scope of abilities and information are inspected. The schedule that was utilized by past assessments was to a great extent dependent on recently tried tests, which implied that a lot of the information that had been picked up before the IELTS test was placed being used. Along these lines, a lot of data was found out toward the finish of the prospectus and an enormous number of individua ls couldn't hold any of this information.</p><p></p><p>A parcel of research has been done in the course of the most recent couple of years into how to all the more likely get ready for the test, with the goal that understudies can concentrate on the commonsense parts of the test. The improvement of IELTS Essay Topics With Answers PDF was one of the means that were taken to tackle this issue. It centers around giving an understudy a practical evaluation of the present information level that they have to accomplish. This will empower the understudy to concentrate on stepping through examinations such that they can be sure of passing them, as opposed to concentrating on subtleties that might be insignificant to the test.</p><p></p><p>In a customary strategy for planning for a test, the understudy would invest a great deal of energy in assessing and retaining the material that would be tried. This could likewise mean investing a great deal of energy understanding course readings and different assets. This methodology didn't enable the understudy to realize what the test is in reality about, which is the reason such a significant number of individuals bombed the IELTS exam.</p><p></p><p>Another issue with the customary technique for arrangement is that it doesn't consider the way that the IELTS test is intended to test information as opposed to general aptitudes. This implies an understudy should concentrate on responding to inquiries regarding themes that are applicable to the test, rather than focusing on retaining realities about a specific subject. The outcomes were frequently that the understudy concentrated on subtleties that might not have been applicable to the test and would not hold a great part of the information.</p><p></p><p>The improvement of IELTS Essay Topics With Answers PDF was created in light of this information. It takes the IELTS prospectus and make s it increasingly engaged around perusing, composing and talking instead of general information. It incorporates explicit answer clarifications that are pertinent to the inquiries that the understudy will be posed. This implies an understudy will have the option to recollect what they have realized without depending on memorization.</p><p></p><p>This will guarantee that the understudy can address the inquiries and appropriately clarify the appropriate responses and effectively compose the paper. Since the entire prospectus is based around the IELTS appraisal focus, the understudy can concentrate on what the test is about and center around all regions of the test as opposed to simply the composed area. This implies an understudy will have the option to take in what's in store from the test and get ready for it at all measure of time possible.</p><p></p><p>If you need to be set up for the IELTS test, at that point utilizing IELTS Essay T opics With Answers PDF is a decent method to do as such. It consolidates the conventional techniques for concentrate with an emphasis on down to earth abilities and planning for the exam.</p>

Grossman Land of Hope Essay Writing

<h1>Grossman Land of Hope Essay Writing</h1><p>Are you one of the understudies that is battling with a huge grossman Land of Hope exposition and might want to know how you can get an evaluation lower? Grossman Land of Hope exposition is troublesome on account of the exacting directions of the article requires. You have to ensure you completely comprehend the exposition and afterward attempt to follow its directions.</p><p></p><p>In request to assist you with your Grossman Land of Hope article, here are a few proposals. Initially, make sense of what is the subject of the article. Here are a couple of thoughts you can use.</p><p></p><p>There are numerous decisions in the subjects that can be utilized to expound on the significant occasions throughout your life. Be innovative. You will find that once you get your subjects made sense of you will have a simpler time.</p><p></p><p>If you don't have an y thoughts for your Grossman Land of Hope exposition, consider one that is identified with the theme that you need to cover. For instance, on the off chance that you are expounding on somebody you love, you can utilize the individual's preferred topic for the exposition. This can truly be a compelling method to compose the essay.</p><p></p><p>Of course, when you have your topic and related topic made sense of, you should compose the article. You can do this at your own pace. Be that as it may, in the event that you have just invested a great deal of energy in this sort of paper, you should know whether you are prepared to move onto the following level.</p><p></p><p>The most straightforward approach to complete your exposition is to compose it utilizing a product program. There are a wide range of projects accessible to assist you with figuring out how to compose an article. These projects are composed by specialists who have long perio ds of involvement with this field.</p><p></p><p>When you are prepared to compose your article, make certain to think about this alternative. You can likewise compose the exposition yourself. When you get your subject made sense of, begin composing the paper and you will see your evaluations go up.</p>

Types of College Paper Writing Services

<h1>Types of College Paper Writing Services</h1><p>When you need assistance with your school paper composing, look no farther than the web for administrations that can support you. There are several destinations that offer school paper composing administrations and many are free.</p><p></p><p>College-paper composing specialist organizations may offer a few types of assistance that can assist you with making an exceptionally compelling paper. Some may offer organizing administrations. Others may offer editing administrations. Still others will give specialized help to guarantee that the paper is accurate.</p><p></p><p>Many school paper composing administrations likewise offer PC projects to enable your understudies to utilize PCs to learn. Through these projects, they can type the paper themselves without being reliant on you for help. Such PC helped classes can assist your understudies with learning by doing and to fig ure out how to chip away at their own.</p><p></p><p>Besides organizing, altering, and helping understudies use PCs for paper composing, school paper composing specialist organizations may likewise offer online administrations that can accelerate the way toward conveying papers, inquire about papers, and different sorts of papers. The online assistance may offer preparing administrations, information section administrations, and documenting services.</p><p></p><p>With the utilization of the Internet, your understudies can acquire their own PC and it's anything but difficult to monitor their desk work. For instance, in the event that you have a great deal of papers that need documenting, it will be a lot simpler to screen the advancement of those papers online.</p><p></p><p>Some of the administrations that can be given by these administrations include: If your paper is excessively protracted, your specialist organ ization can convey the paper legitimately to the library. They can likewise deal with the paper during class hours and on a standard basis.</p><p></p><p>If you would prefer not to sit around idly having an incredible length paper made, your specialist co-op can make short papers for your understudies. They can likewise give them tips on the most proficient method to sort out their considerations with the goal that they can be utilized in the correct way.</p><p></p><p>With the assistance of these school paper composing administrations, you can without much of a stretch make an incredible paper that will set an extraordinary model for your understudies. Understudies who turn in these papers will be progressively persuaded to go to class. Regardless of whether they need assistance with a test or due date or some other task, these administrations will make it simpler for them to finish the assignment.</p>

Ronald Reagan’s A Time For Choosing Speech Essay - 1784 Words

Millions of viewers tuned into the National Broadcasting Company television network for a special broadcast on the 27th of October. Viewers were anticipating Ronald Reagan’s â€Å"A Time for Choosing† speech. Reagan was acknowledged for his acting in motion pictures and television episodes since 1937, and was now being seen in an unfamiliar role. Reagan emerged in support of the Republican nominee Barry Goldwater. Barry Morris Goldwater was a businessman and five-term United States Senator from Arizona and the Republican Partys nominee for president in the 1964 election. â€Å"A Time for Choosing† was effective, because he gave personal examples to capture the audiences’ attention, and gave humor to a tough subject. The United States†¦show more content†¦For the audience he gives them examples of how government interference hurts Americans and also allusions to past times such as the revolution and how the founding fathers did not want a big gove rnment. He shares that he has â€Å"an uncomfortable feeling that this prosperity isn’t something on which we base our hopes the future.† Reagan’s ability to connect with his audience was rare and unlike many of his colleagues. Whether the topics he spoke on were always relevant to that of the listener, it did not always matter. Reagan had gained strong speaking skills while previously working in the acting industry thus enabling him to better connect with his audience. Reagan believes that the country is headed in the wrong direction and that America has several challenges at home and abroad. America’s government was in an economic crisis during the time this speech was given. He knew the citizens needed to hear something strong and powerful that promised change for a better way of life. â€Å"A Time for Choosing† was deliberative and not only informed and inspired the audience but it also provided America with a lighthearted source of entertainment. The style changes at the end of the speech and establishes an optimistic anticipation for the future. Reagan constructs the case for Goldwater and states in his closing sentence â€Å"We will keep in mind and remember that Barry Goldwater has faith in us. He has faithShow MoreRelatedAnalysis Of A Time For Choosing By Ronald Reagan1327 Words    |  6 PagesRonald Reagan Declaring for President in 1964 Just over two years before Ronald Reagan competed in his first statewide or national office, the former actor gave a speech in support of a doomed presidential candidate, Senator Barry Goldwater. This speech had little effect on 1964 presidential election. 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His family settled in Dixon, Illinois in 1920. After graduating from Dixon High School in 1928, Reagan attended Eureka (Illinois) College where he majored in economics and sociology. In 1937, Reagan was â€Å"discovered† by an agent for Warner B rothers and offered a seven-year contract as an actor. He movedRead MoreRonald Reagan, The Great Communicator Of The United States Of America Essay2033 Words   |  9 PagesRonald Wilson Reagan, the great communicator of the United States of America began his legacy of embodying the conservative movement during one of the most famous speeches in American history. Before Ronald Reagan became the fortieth president of the United States, he began his switch from acting and movies to government and politics. Early in Reagan’s career he saw himself as a democrat, with Theodore Roosevelt as his hero. This would change thru his acting and professional career as Ronald Reagan

Marketing Portfolio Removable Online Security Device

Question: Discuss about the Marketing Portfoliofor Removable Online Security Device. Answer: Product Description Q key removable online security device is a product founded and co-founded by Christopher Maus and Brandon Maus respectively. Christopher Maus, as a security expert, has previously architected products that help the individuals to take control. The product has been assembled by a varied global team of experts in technologies and security. These experts are exceptionally talented in aspects of engineering, design and business development. Q key was introduced in the market to help people control their web privacy and security. It is simple, virtually anywhere, smart and secure, opening a new experience on the internet. Q key is termed as simple as it provides a uniform and rich online experience anywhere and at any time. For it to work, it simply requires the owner to insert it in a computer, enter a password, normally shop, open the digital wallet and choose a card and finally tapping the Q key to pay. Q key is practically anywhere as it is compatible with most existing websites. It contains a single access login that logs one instantly into web accounts that are protected by passwords. Furthermore, it is portable, as it can easily fit into a pocket. This product is termed as smart as it abolishes the need for one to dredge up all login access and passwords required for the web accounts that are secured. Q key is secure as it uses a smart chip like the one used in military evaluation encryption, physical touch sensor s and new payment cards to ensure security on online payments. Current Market Conditions Current market conditions for a particular product describes the characteristics of the market it is going to be released to, or introduced. These conditions may include the competitiveness level, the rate at which the market grows and number competitors already in the market (Feng et al., 2017) Currently, the market is crowded by different cloud systems like Yahoo, JP Morgan Chase, eBay, and others. These systems support online shopping, allows people to store personal information online by providing accounts that are secured with passwords. The one thing common with these online systems is that they store such information in the cloud, which acts like someone elses computer. This makes them susceptible to breaches and hacking (Smith et al., 2010). For example, Yahoo has got about 500 million accounts that have been hacked, JP Morgan Chase with 83 million while eBay records approximately 145million hacked accounts. This has led to the need for change of condition and output in the market, leading to a positive gradual change over the years. An example of such change is the introduction of Q key into the market. However, there is growing competition from the online systems as they use technology to better their services. Such healthy competition also encourages the improvement of the Q key product, which aims to implement its idea of providing a simple, secure and smart internet experience needed as technology continues to grow. The consumers also need an assurance of their accounts being safe from hacking and breaches. With the information being stored online, such guarantee is not provided, making them feel violated and uncomfortable. Q key offers a simple solution of posing to keep personal data away from the online cloud, thus away from hackers and into our pockets, offering us a total control of the data. SWOT Analysis for the product SWOT analysis evaluates the Strengths, Weaknesses, Opportunities and Threats of the product. This helps in specifying the objectives of the project as well as identifying favorable and unfavorable factors that are available in achieving the objectives (Xing Gao, 2015). Strengths Strengths include the advantageous features and unique features Q key has over other products in the market. In this case, Q key plays a role in ensuring online accounts are completely under the owners' control, thus decreasing cases of hacked accounts. This product aims to create strengths in its profitability, and by doing so, the cost of production is effectively managed (Phadermrod et al., 2016). The strengths of Q key comes from the need of satisfying a need of a specific targeted audience by using unique selling benefits. Weaknesses Weaknesses in product launching signals that the product needs to overcome certain competitions in the market in order to gain consumers (Phadermrod et al., 2016). For example, in order for Q key to gain market share, more capital is needed in marketing. The product may also be sold at a loss for a short time so as to introduce it to the market. Since customer brand loyalty is hard to break, Q keys position will further be weakened even if it is better than other relatable products. This can be a weakness it might be experiencing as a new product in the market. Opportunities New products contain built-in Opportunities when they are the first to launch a certain idea (Phadermrod et al., 2016). This allows Q key to be able to sell at a higher price for a short time if too much competition is not an issue. The product also gets an opportunity of taking advantage of the medias interest in advertising and showcasing new products. Threats Threats experienced by Q key may be as a result of the reactions its competitors have when it enters the market. It is therefore recommended for the launchers to have backup pricing, distribution channels, and promotion plans when the competitors start changing their playing fields (Phadermrod et al., 2016). This helps them respond to the competitors reactions. Nature and Scope of Marketing and the Marketing Concept Marketing refers to the act of creating, communicating and delivering a product or service to customers by an organizational (Hair Lucas, 2014). This is done to benefit both the stakeholder and the organization. The nature of marketing is described by the fact that it is an economic function, a series of networking business activities, a legal process allowing transfers of ownership, a social process and a managerial function (Barnes, 2016). The scope of marketing studies consumers' needs and wants, the behaviors of the user, the policies used in pricing, promotion, distribution, control of the market and customer satisfaction (Hanssens Pauwels, 2016). The marketing concept involves identifying what the customers want or need, establish whether such wants can be satisfied if the wants are still on demand and finally coming up with ways to keep the consumers satisfied. This is done by an organization focusing on the consumers' needs, aligning its functions used to focus on such need s and eventually realizing profits over the long term by fruitfully satisfying the needs of the customer (Morris Rahtz, 2015). Marketing Research Techniques and their Importance to Marketing Decision Making The marketing research techniques are divided into the primary and secondary researches. Secondary researches involve studying existing data suitable for a particular research need. The main research methods involve conducting surveys especially if data is to be measured quantitatively, use of effective focus groups especially for exploratory qualitative researches, conducting interviews, use of observation technique and use of experiments especially in scientific testing (Andaleeb Hasan, 2016). Research of the present market for a particular product helps organizations in making decisions regarding the product. A good research may suggest alternative options for products entering a new market. An organization may come up with ways of distributing a product using research outcomes, the promotion techniques, and pricing. External factors affecting the product may also be established and the target market for a particular product identified (Babin Zikmund, 2015). Marketing Mix and Extended Marketing Mix A business' marketing mix refers to a combination of different elements it uses to enable it to meet the consumers' expectations and needs (Khan, 2014). Each element used in the marketing mix is related to each other. The marketing mix consisted of four elements traditionally, but in recent years, new elements have been added to form the extended marketing mix. The four elements that previously constituted the marketing mix were; price, place, promotion and product. They worked together in order to achieve marketing intents. Three more elements were added recently, as mentioned, to form the extended marketing mix (Movchan Karpenko, 2014). The added elements include; process, physical environment, and people. The seven elements work closely together to ensure marketing is effective. References Andaleeb, S. S., Hasan, K. (2016). Marketing Research. InStrategic Marketing Management in Asia: Case Studies and Lessons across Industries(pp. 111-160). Emerald Group Publishing Limited. Babin, B. J., Zikmund, W. G. (2015). Essentials of marketing research. Nelson Education. Barnes, S. (2016). Understanding Virtual Reality in Marketing: Nature, Implications, and Potential. Feng, H., Neil A. M., and Lopo L. R. (2017). Firm capabilities and growth: the moderating role of market conditions. Journal of the Academy of Marketing Science45.1 (pp. 76-92). Hair Jr, J. F., Lucas, B. (2014). Marketing Research. McGraw-Hill Education Australia. Hanssens, D. M., Pauwels, K. H. (2016). Demonstrating the value of marketing.Journal of Marketing,80(6), 173-190. Khan, M. T. (2014). The concept of marketing mix and its elements (a conceptual review paper). International journal of information, business, and management, 6(2), 95. Morris, M. M., Rahtz, D. R. (2015). Integrating the Concept of Marketing: The Environment Organization Marketing Interface. InProceedings of the 1983 Academy of Marketing Science (AMS) Annual Conference(pp. 598-598). Springer International Publishing. Movchan, Y., Karpenko, N. (2014). Marketing Theories- The Marketing Mix From 4 PS TO 7 PS. Phadermrod, B., Crower, R. M., Wills, G. B. (2016). Importance-performance analysis based SWOT analysis. International Journal of Information Management. Smith, K. T., Smith, M., Smith, J. L. (2010). Case studies of cybercrime and its impact on marketing activity and shareholder value. Xing, B., Gao, W. J. (2015). A SWOT Analysis of Intelligent Products Enabled Complex Adaptive Logistics Systems. InEncyclopedia of Information Science and Technology, Third Edition(pp. 4970-4979). IGI Global.