Post Implementation Review of Concur

Post Implementation Review of Concur 1. PURPOSE OF PROJECT CHARTER The purpose of the project charter is to setup the guidelines on which the entire project will go on. Project charter is basically to set the scope, budget, time and technology that will be used in the project after the discussion between client and team members. so, the post implementation review of concur will be done to assess whether extended destinations will meet, to decide how adequately the project will run and to learn lessons for the future, and to ensure that it will be beneficial for concur customers and users to get the conceivable advantage from the project.. Concur was developed by sniff and was further purchased by federation university and they use it for their staff which provides an estimate price for the travel expenses by getting feedbacks from the current users. when it regards to business travel and cost coordination it means everything. So with Concur our business travel and costs are coordinated by giving us a superior client encounter more precise information and wealthier answering to help us to settle on better choices and increment strategy control while sparing time and cash. There travel booking tools gives them arrangement worldwide travel content that is effortlessly open and constantly accessible from any place on the planet. Travelers have an expansive choice of travel decisions in light of corporate arrangement and individual traveler inclinations. Travelers can rapidly book local and global flights and reserve a spot for rental autos, hotels and trains. Once the trip is reserved travelers can oversee trip subtle ele ments like flight delay, cancellationÂÂ   and baggage claims.. Individual can do all these things in a single place. Concur also offer an web application to manage the trips. Concur make the record of all the bills like cab fare, air fare, hotel booking and food bills. There are several apps that are partnered with concur like Uber, Starbucks and they send their bill receipts directly to the Concur app which helps the user to take control of their expenses. 1. BUSINESS NEED IMPACT Concur system helps the people in making their travel easier by giving them the fair idea of the expenses before making a travel. Concur also helps in booking hotels, cabs, air tickets so that the traveler can travel without any worry and can make the arrangements on the spot. This helps business companies to grow while collaborating with Concur by increasing their customers. 2. STRATEGIC ALIGNMENT Project goals: Goal 1: Document the system impact and how it meets the objectives of the relevant stakeholder groups Goal 2: the major problem faced by concur team to deal with software .Its very complicated for the workers to work on this software. Goal 3: Identify the Concur glitches like after the completion of trip, some of the customers are getting e-mails to clear their dues which are already paid by customer. Goal 4: Update Concur with customer requirements like some customers recommend to stay in 3 star hotel rather than 5 star to save their money and some ask to use new technology updates. Goal 5: Address stakeholder and end-user needs 1. OBJECTIVES The objectives of the post implementation review of Concur are as follows: Better customer satisfaction in customer requirements, booking services, real time solution , real time updation in increased air fare and more options to select. Make required update in Concur solutions of problems that are faced by customers Data Analysation to get more correct expense estimate for the trip to be travelled in future. 2. HIGH-LEVEL REQUIREMENTS Req. # I Requirement Description 1 The project should match stakeholders requirements 2 The project should make Concur in control and reduce future risk 3 Identify the impact of Concur implemented 4 Based on the objective facts, judge the system shortfalls 5 Conduct user review and feedback of Concur system 6 Conduct further training and coaching of Concur system 1. TIMELINE Time Activity 08/03/2017 Project begins and weekly activity report start 15/03/2017 Meet with client 25/03/2017 Project charter approved 05/04/2017 Meet with client 07/05/2017 Project progress report approved 18/05/2017 Meet with client 27/05/2017 Team presentation 30/05/2017 Final project report approved 06/06/2017 Individual report 2. KEY MILESTONES Key Milestones Estimated Completion Timeframe Project team formed 28/02/2017-07/03/2017 End-user interview 08/03/2017-30/05/2017 Concur system research 08/03/2017-30/05/2017 Project charter approved 12/03/2017-26/03/2017 Project progress report 02/04/2017-07/05/2017 Team presentation 08/05/2017-27/05/2017 Final project report 08/05/2017-30/05/2017 Project released 30/05/2017-04/06/2017 1. ASSUMPTIONS Projects are actually judged against two parameters: How it is well defined? How well defined are methods to achieve it? Project should be divided in three structures Product breakdown structure Organization breakdown structure Work break down structure For good objectives it should meet following criteria. Outcome Oriented: Speaks to important changes in basic threat and opportunity figures that influence project goals. Measurable: Characterized in connection to some standard scale (numbers, rate, parts, or all/nothing states. Time Limited: Should be achievable within aÂÂ   given period. Specific: Clearly defined so that all people involved in the project have the same knowledge of what the terms in the objective mean . Practical: Appropriate or achievable within the context of the project and in light of the social and financial context. 2. CONSTRAINTS Sometime the roles of team member changes if they cant handle the problem Less training or knowledge of team to understand the project. The analysis report given to client not accepted in case demand changes. Policies selected for accomplishing the goal not liked by the client. Project managers having difficulty to handle team and client because of less experience. 3. RISKS Unreal expenses documents submission by the current users. Change in government policies. Hike in airfares and other traveling aspects. A delay in one task deteriorates the quality of project. Time and budget management risk. Risk Category: Requirement Risk Requirement not fully known at project start Not deliver the expected results to the client Risk Category: Project Management Risk Priorities changes while working on project Sometime same resources required at same time Success criteria not well defined Risk Category: Product/Technology Risk Market competition with the similar softwares. Update in technology may result in budget risk. Technology selected to achieve project goal is poor. Including extra analysis method that are not required. Risk Category: Customer Risk Customer demand new requirements under the given time. Customer not accept the proposal Customer force to work different technology rather than previously used. Client not supportive. 1. ROLES AND RESPONSIBILITIES This section describes the key roles supporting the project. Person Role Responsibility Fiona Bryant (client) Client Provide information about concur to the team and share problem faced while working with concur. Surjeet singh (team member) Project manager Deliver the project to client expectations, Monitor and report to client on project progress, Advise client if project appears to be in danger of non delivery, control project scope and time, keep contact with team members for their working progress and difficulties, contact coordinator if client is unavailable; Work on plan and write project report of every part of the project with other team members, provide the report to client and supervisor. Taiwo Oseni (Supervisor) Coordinate project Give advice if client is unavailable, help the team to finish the project, help team members contact client if the team loose contact with client, balance the project requirement between team members and client, get project working process and project report from project manager and give advice. Harman (team member) Risk manager, researcher Control the project risk, support/provide responsive action for every times risk if happen; Work on plan and write project report of every part of the project with other team members, , discuss the project report detail with other team members; Amrit (team member) Documenter, Interviewer Work on plan and write project report of every part of the project with other team members, discuss the project report detail with other team members; discuss the client requirement with other team members and how to achieve the requirement; Interview end-user to get system feedback, check the coaching process and training materials Xinwen Hu (team member) Main documenter Execute issue management process when issues happen, Work on plan and write project report of every part of the project with other team members, discuss the project report detail with other team members, integrate all members report and provide it to project manager; Researching and help team members to get useful resources. 2. STAKEHOLDERS (INTERNAL AND EXTERNAL) Stakeholder Interest / stake Importance Fiona Bryant (Client) Make Concur able to use High Project manager Manage project , satisfy client ,fix meetings. Medium Team members Work on project, satisfy client Low Taiwo Oseni (Supervisor) Help team member finish the project Medium FedUni End-user Skilled to use Concur easily High The undersigned acknowledge they have reviewed the project charter and authorize and fund the post implementation review of Concur project. Changes to this project charter will be coordinated with and approved by the undersigned or their designated representatives. Signature: Date: Print Name: Title: Role: Signature: Date: Print Name: Title: Role: Signature: Date: Print Name: Title: Role:

Neurological Effects of Fos B Gene on Behavior of Mice Essay -- Biolog

The purpose of this study is to gain an understanding of the fos B gene and it's neurological effects on the behavior of mice through the analysis of "A Defect in Nurturing in Mice Lacking the Immediate Early Gene fos B" appearing in the July 26 issue of Cell. Through various chemical and behavioral tests it is found that fos B mothers demonstrate an inability to nurture their young. It was shown that the lack of expression of the fos B gene in certain areas of the brain was the probable cause of the lack of the nurturing response in the mutant mice. Background Immediate Early Genes (IEGs) When the central nervous system of an organism receives a stimulus, such as light, visual images, odors, etc., programs of gene expression are initiated. This expression of genes can start within minutes of receipt of the stimulus, and last for many hours in certain parts of the brain. The very first genes to be expressed are called the Immediate Early Genes. These genes can be transcribed almost immediately without the formation of new proteins. fos B: A Member of the fos Family The fos B gene belongs to a group of genes known as the fos family. The fos family has four members: c-fos, fos B, fra-1, and fra-2. The members of the fos family work in conjunction with a group called the Jun family. The protein that is produced as a result of fos gene expression can be dimerized with Jun prodeits utilizing a leucine zipper domain. This unit then binds to a certain region of DNA. The fos family of genes are expressed during a variety of adaptive neural responses. It has been found that fos related proteins are activated in areas of the nervous system that are needed for nurturing behavior. Creating a fos B lacking Population In or... ...e results of these tests point to a defect in a region of the brain that is specific for nuturing. So, areas of the brain were fos B was expressed were analyzed. It was seen that the fos B gene was expressed in the preoptic area of the hypothalamus and in the main and accessory olfactory bulbs, as well as the pyriform cortex. All of these areas have been shown, in previous studies, to be related to the nuturing response. As a result, the lack of expression of the fos B gene is directly related to the lack of nuturing behavior in mutants, probably due to a lack of gene expression in one, or more of these areas. Bibliography 1. Brown, J.R., Ye, H., Bronson, R. T., Dikkes, P., Greenberg, M. E. "A Defect in Nurturing in Mice Lacking the Immediate Early Gene fosB." Cell 86 (1996): 297 - 309. 2. Cohen, John. "Does Nature Drive Nurture?" Science 273 (1996): 577

Assess Critically Three Causes of World War One Essay

Assess Critically Three Causes of World War One BY 155 Assess critically three causes of the First World War The First World War began in Europe in 1914, after the assassination of Archduke Franz Ferdinand of Austria-Hungary. This trigger action caused the involvement of Germany, Russia, Serbia and Austria-Hungary. However, the war itself was caused by nationalism, alliances and Germanys fear of encirclement. Nationalism was the central cause of World War One because, due to the nationalism of the Slavs, the Balkan states became a powder keg. Austria-Hungary ade the Serbs fear annexation while the Slavs inside the country wanted a Pan- Slavic State. The assassination of the Archduke occurred due to the Serbs nationalism, to warn Austria-Hungary to stay away from Serbia. However, it had the completely opposite effect because Austria-Hungary now had a valid reason to give Serbia an Ultimatum that would allow them to attack the country. Austrians did not only do this because they wanted Serbia but also because they realised that the Slavic nationalism could cause another loss of their land as they had experienced in he Second Balkan War in 1913. There was also a significant number of Slave living inside the borders of Austria-Hungary who’s wish for a Pan-Slavic State could not be ignored and so they needed to be shown their limits. The nationalistic Slavs were a serious threat to Austria-Hungary and it was clear that this nationalism would result in a war. The alliances on the other hand, should not be left unspoken of due to the fact that they delocalized the war and caused distrust between countries. The Triple Entente (France, Russia, Britain) on one side and the Triple Alliance (Germany, Austria-Hungary, Italy) on the other made it impossible for Austria-Hungarys conflict with Serbia to stay local. An especially important aspect of the Triple Alliance was that it only lasted from 1882 until 1914, because at the start of World War One Italy switched sides and went to the Allied Powers. This only contributed to the growing distrust that the alliances caused amongst the European powers because each country feared to be attacked. However, the alliances would never have become relevant if the Slavs nationalism in Austria-Hungary hadn’t made a war inevitable hat soon made the alliances come into effect. Germany rushed to Austria-Hungarys aid and Russia came to help Serbia so soon most countries in Europe had to assist their allies. A last cause that is very significant is Germanys fear of encirclement and the other countries fear of Germany. Kaiser Wilhelm II feared encirclement by Russia and France for a very long time because, not only did France want revenge for the land losses in the Franco-Prussian War but they were also allied with Russia. This meant that Germany faced the serious risk of a two front war. Yet, what Germany didn’t now, was that the other European countries feared it Just as much or even more than it feared them. Germany had the biggest army and a lot of economic power during the time Just before the war. These fears helped cause the war because they state of war preparation. However, these fears were tightly connected to nationalism because if all these countries hadn’t been nationalistic and wanted territory and, in France’s case, revenge, the war would probably not have started out the way it did. Considering these three causes it is clear to see that nationalism was the main ause but the alliances and Germanys fear played a major role in the outbreak of World War One. Many historians such as Fritz Fischer believe that Germany was the only one to blame due to it’s apparently obvious wish for war, but it is clear that the nationalism in the Balkan states was the most significant cause. The alliances caused the war to be on a larger scale but this could ultimately only happen because of the trigger event in the Balkans. Though there are many plausible and arguable causes for World War One, nationalism is definitely the most important one.

A comparason of Finny in A Seperate Peace to Thomas Jefferson essays

A comparason of Finny in A Seperate Peace to Thomas Jefferson essays Comparison Paragraph of Thomas Jefferson to Finny in Separate Peace I dont care what people think, I am still going to wear a pink shirt. That was what finny thought in the book a Separate Peace. In this paragraph, Finny and Thomas Jefferson will be compared to each other in many different ways. There will be Self-respect, Honesty, and Skill. Thomas Jefferson also did not have a problem with what people thought about his clothes. One person saw this and said he wore ill-fitting, much worn clothes. Self-respect was a big thing to both Thomas Jefferson and to Finny. Thomas Jefferson was well educated. He became an architect and was heavily involved in politics. Like above, he did not care what he wore or what was said about him. Finny was always in good condition because he was involved in a lot of sports such as; hockey, football, baseball, and wrestling. When he broke his leg in the book, he kept good care of it by waiting for it to heal by having Gene train in his spot to get to the Olympics. Finny believed he could get better and be the same again even when he knew that he was not going to be able to play again. Honesty was important thing to Thomas Jefferson because he was very involved with the Declaration of Independence. He was so honest that some parts were so insulting to King Charles that it was written out in the rough drafts. He was honest about not wanting to get involved in politics but did so for the good of his country. Finny was a good friend because he said that you need to be honest and he was honest to everyone. He always spoke his mind even if it was not a good time to do so. At a meeting with the headmaster of Devon (the school where they were) Finny wore a tie as a belt and said, Im glad I put something on for a belt! He was telling what he thought. An honest characteristic. Skill to Thomas Jefferson was an important thing because he was a well-educ...

Quotes About the Importance of Words

Quotes About the Importance of Words Words can incite anger or invoke passion. They can bring people together or tear them apart. Words can uphold the truth or nurture a lie. We use words to encompass history, to describe the natural universe, and even to conjure realistic visions of things that exist only in fantasy. In fact, in some mythology, spoken words are thought to be so powerful that they can create worlds, creatures, and human beings. Here are some quotes about words from writers, poets, political figures, philosophers, and other notable minds. All our words are but crumbs that fall down from the feast of the mind.- Kahlil Gibran (from Sand and Foam) As we must account for every idle word, so must we account for every idle silence.- Benjamin Franklin Be careful of the words you say,Keep them short and sweet.You never know, from day to day,Which ones youll have to eat.- Anonymous A great many people think that polysyllables are a sign of intelligence.- Barbara Walters But words are things, and a small drop of ink,Falling like dew, upon a thought, producesThat which makes thousands, perhaps millions, think.- George Gordon, Lord Byron By words we learn thoughts, and by thoughts we learn life.- Jean Baptiste Girard Colors fade, temples crumble, empires fall, but wise words endure.- Edward Thorndike Duty is the sublimest word in our language. Do your duty in all things. You cannot do more. You should never wish to do less.- Robert E. Lee For me, words are a form of action, capable of influencing change. Their articulation represents a complete, lived experience.- Ingrid Bengis The good man brings good things out of the good stored up in his heart, and the evil man brings evil things out of the evil stored up in his heart. For out of the overflow of his heart his mouth speaks.- Luke 6:45 Good words are worth much, and cost little.- George Herbert However many holy words you read,However many you speak,What good will they do youIf you do not act on upon them?- Buddha I like good strong words that mean something.- Louisa May Alcott (from Little Women) If language is as inextricably tied up with consciousness as it seems to be, then the continuing diminishment of our inclination to use it to express in letters the times in which we live could mean that an element of human consciousness itself is on the verge of disappearing.- Anonymous If words are to enter mens minds and bear fruit, they must be the right words shaped cunningly to pass mens defenses and explode silently and effectually within their minds.- J. B. Phillips If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.- Nelson Mandela If you would be pungent, be brief; for it is with words as with sunbeams- the more they are condensed, the deeper they burn.- Robert Southey In a sense, words are encyclopedias of ignorance because they freeze perceptions at one moment in history and then insist we continue to use these frozen perceptions when we should be doing better.- Edward de Bono It has not been for nothing that the word has remained mans principal toy and tool: without the meanings and values it sustains, all mans other tools would be worthless.- Lewis Mumford It seems to me that those songs that have been any good, I have nothing much to do with the writing of them. The words have just crawled down my sleeve and come out on the page.- Joan Baez Its always a bit of a struggle to get the words right, whether were a Hemingway or a few fathoms below his level.- Rene J. Cappon Kind words are a creative force, a power that concurs in the building up of all that is good, and energy that showers blessings upon the world.- Lawrence G. Lovasik The most valuable of all talents is that of never using two words when one will do.- Thomas Jefferson My task which I am trying to achieve is by the power of the written word, to make you hear, to make you feel- it is, before all, to make you see. That- and no more, and it is everything.- Joseph Conrad Often when I write I am trying to make words do the work of line and color. I have the painters sensitivity to light. Much ... of my writing is verbal painting.- Elizabeth Bowen One of the hardest things in life is having words in your heart that you cant utter.- James Earl Jones Our words should be purrs instead of hisses.- Kathrine Palmer Peterson Poetry is a deal of joy and pain and wonder, with a dash of the dictionary.- Kahlil Gibran The real art of conversation is not only to say the right thing at the right place but to leave unsaid the wrong thing at the tempting moment.- Dorothy Nevill The six most important words: I admit I made a mistake.The five most important words: You did a good job.The four most important words: What is your opinion?The three most important words: If you please.The two most important words: Thank you.The one least important word: I.- Anonymous So difficult it is to show the various meanings and imperfections of words when we have nothing else but words to do it with.- John Locke The teachings of elegant sayings should be collected when one can. For the supreme gift of words of wisdom, any price will be paid.- Siddha Nagarjuna To me, the greatest pleasure of writing is not what its about, but the music the words make.- Truman Capote Words are the model, words are the tools, words are the boards, words are the nails.- Richard Rhodes Watch your thoughts, they become your wordsWatch your words, they become your actionsWatch your actions, they become your habitsWatch your habits, they become your characterWatch your character, it becomes your destiny.- Anonymous When I read great literature, great drama, speeches, or sermons, I feel that the human mind has not achieved anything greater than the ability to share feelings and thoughts through language.- James Earl Jones A word is deadWhen it is said,Some say.I say it justBegins to liveThat day.- Emily Dickinson (A Word is Dead) Words are chameleons, which reflect the color of their environment.- Learned Hand Words are not as satisfactory as we should like them to be, but, like our neighbors, we have got to live with them and must make the best and not the worst of them.- Samuel Butler Words are potent weapons for all causes, good or bad.- Manly Hall Words are the most powerful thing in the universe... Words are containers. They contain faith, or fear, and they produce after their kind.- Charles Capps Words do two major things: They provide food for the mind and create light for understanding and awareness.- Jim Rohn Words, like nature, half reveal and half conceal the soul within.- Alfred, Lord Tennyson Words may show a mans wit, but actions his meaning.- Benjamin Franklin Words- so innocent and powerless as they are, as standing in a dictionary, how potent for good and evil they become, in the hands of one who knows how to combine them!- Nathaniel Hawthorne A writer lives in awe of words for they can be cruel or kind, and they can change their meanings right in front of you. They pick up flavors and odors like butter in a refrigerator.- Anonymous You see these dictators on their pedestals, surrounded by the bayonets of their soldiers and the truncheons of their police. Yet in their hearts there is unspoken- unspeakable!- fear. They are afraid of words and thoughts! Words spoken abroad, thoughts stirring at home, all the more powerful because they are forbidden. These terrify them. A little mouse- a little tiny mouse!- of thought appears in the room, and even the mightiest potentates are thrown into panic.- Winston Churchill

Enteral and Parenteral Nutrition Essays

Enteral and Parenteral Nutrition Essays Enteral and Parenteral Nutrition Essay Enteral and Parenteral Nutrition Essay Which critically ill patients should receive TPN? Prof R D Griffiths in conjunction with Fresenius-Kabi Why are these guidelines required? In the critical care setting, nutritional support influences the outcome for critically ill patients. This guideline seeks to outline the important role of parenteral nutrition in the critically ill patient. Enteral and parenteral nutrition The enteral route for nutrition delivery is preferred where it can be safely delivered in the absence of gastrointestinal intolerance. For a small proportion of patients enteral feeding is not possible but in addition for a larger proportion of patients research consistently shows that enteral nutrition does not always cover the total nutritional needs of intensive care unit patients. There has been a reluctance to use parenteral nutrition (PN) or to supplement enteral (EN) or oral nutrition with parenteral nutrition (PN) for the perceived risk that to do so increases the infection and mortality risk. Systematic review evidence acquired from studies in the critically ill shows that while there may be an increased risk of infection there is no added mortality risk [ 1 ]. Parenteral nutrition has changed considerably over the last forty years and many of the complications were a feature of historical PN practice associated with its inappropriate use, unbalanced formulations and liberal overfeeding. Even the risk of infection may be more related to the underlying patient disease and indication for PN rather than modern PN formulations and delivery in ICU. Malnourishment It has been estimated that around 40% of all patients in hospital are undernourished and this is associated with further complications. Acute critically ill patients lose on average approximately 5-10% of skeletal muscle mass per week during their ICU stay [ 3 ]. Complications such as septicaemia in these patients are to a large extent caused by malnutrition and impaired immunological function [ 2 ]. Complications versus choice of nutrition route When correctly applied, the complications of PN are less likely to result in death compared with those of EN. Recent studies conclude that PN compared with early EN is risk-neutral overall [ 3 ]. It is reassuring that in critically ill patients, when used with EN in the ICU as a supplement, PN has been confirmed to be risk-neutral or may even offer benefits. However from current data it is not possible to justify the extra cost of supplemental PN when started concurrently with EN at the start of an ICU admission [ 1 ] but more importantly there are no studies where it has been started in the more appropriate situation after EN has been shown to fail in already malnourished ICU patients. It has been demonstrated that nutritional goals were reached in 22% of ICU patients fed via EN compared with 75% with PN [ 2 ]. It must be remembered that under nutrition is a debt that must eventually be repaid and this is also worse if it is compounded! The ACCEPT study showed that survival from intensive care was improved when an evidence based guideline for nutrition was followed and more nutrition delivered more consistently. This was achieved by earlier introduction and more complete enteral nutrition delivery without any decline in the use of PN alone or in supplementation. Using the guidelines These guidelines have been developed using a step-by-step approach as follows: Step 1ASSESSMENTDoes the patient require nutritional support? Step 2ADMINISTRATIONWhich route(s) should be used? Step 3ACHIEVEMENT (REVIEW)Are nutrition goals being met? Step 1 Nutritional Risk Screening (adapted from NRS 2002 ESPEN) Does this patient require nutritional support? Initial screening of patients is recommended in these guidelines but it is assumed that ALL patients fulfill the criteria for requiring a final screening assessment which follows. The adaptation assumes an affirmative answer to the question â€Å"Is the patient severely ill? (e. g. in intensive care) Impaired nutritional statusSeverity of disease (increase in requirements) Score 0Normal nutritional statusScore 0Normal nutritional requirements Score 1 Wt loss 5% in 3 months or foodScore 1Hip fracture. Chronic patients in (Mild)intake below 50-75% of normal particular acute complications of requirements in preceding weekcirrhosis, COPD. Chronic diabetes haemodialysis, oncology. Score 2Wt loss 5% in 2 months or BMIScore 2Major abdominal surgery, stroke, (Moderate)18. -20. 5 + impaired general condition orsevere pneumonia, haematologic food intake 25-60% of normal requirement malignancy. in preceding week. Score 3Wt loss 15% in 3 months or BMI Score 3Head injury, Bone marrow transplant (Severe)18. 5 + impaired general condition orIntensive Care Patients (APACHE 10) food intake 0-25% of normal requirement in preceding week SCORE+ SCORE= TOTAL SCORE AGE ADJUSTMENT (IF PATIENT ? 70 YRS ADD 1 TO TOTAL SCORE)= TAAS SCORE INTERPRETATION SCORE ? 3The patient is nutritionally at risk and a nutritional plan should be initiated. SCORE 3Weekly re-screening of the patient. If the patient is scheduled for a major operation a preventative nutrition plan should be considered to avoid associated risk status. Step 2Administration route(s) Nutritional support does influence the outcome of critically ill patients and evidence suggests that the consistent achievement of nutritional goals is important and this should if feasible be through the enteral route [ 7 ]. Evidence suggests that for most patients this is just as effectively and safely delivered through a naso-gastric tube compared to tubes sited after the stomach [ 1 ]. It must be recognized that problems do occur with all forms of enteral delivery and that delivery is more often attained by the parenteral route3 and this is apparent in critically ill patients where enteral nutrition is inappropriate, contraindicated or has failed. Parenteral nutrition should be used when the GI tract is not functional or cannot be accessed or when the patient’s nutrient needs are greater than those which can be met through the GI tract. However it should not be commenced in the non-malnourished as a supplement until approaches to enteral delivery have been optimized [ 1 ]. Assess the integrity and function of the bowel using the following prompts: IF THE ANSWER IS â€Å"NO† TO EITHER QUESTION – TIME TO CONSIDER PN Is the digestive tract functioning? Is the patient well nourished and recovery of gut function expected within 3 days? IF THE ANSWER IS â€Å"YES† TO EITHER QUESTION – TIME TO CONSIDER PN While using an enteral feeding protocol does the presence of excess gastric aspirates (e. g. persistently 150mls after measures to improve gastric emptying) lead to reduced enteral intake. Does the nutrition equirements of the disease or injury exceed that which can be delivered safely via the enteral route? Some patients with an intact GI tract do not tolerate enteral feeds or do not receive sufficient intake enterally or orally to meet their energy and protein requirements. The reasons for poor gastric emptying should be considered. Simple measures such as turning to the right side or reducing opiate intake may be tried along w ith short trials of either Metoclopramide or Erythromycin if other causes have been excluded. However gastrointestinal intolerance is an important and worrying sign and is associated with increased pneumonia and risk of death independently of illness severity . The supine posture is also associated with increased risk of aspiration pneumonia and if patients cannot be nursed in the semi-erect position parenteral nutrition may be a safer option whether it is used as a supplement or as the sole source of nutrition in these patients [ 6 ]. Choice of feed and amounts In the critical care setting estimation or measurement of precise requirements is fraught with error. A target of 25 kcal/kg/day for the first week is acceptable. Protein intake is the central component as this cannot be stored metabolically. Most evidence supports 1. 5 gm/kg/day as a reasonable target. Requirements change during an illness and generally increase in the second week and when patients become more active. Simple methods using patient size bands based upon accessible measures of body size (height or weight) should be used to calculate target amounts. More sophisticated individual patient calculations have not been shown to be any more accurate. Polymeric complete enteral feeds should be used for most patients and infused continuously. Evidence for the use of specific formulations is lacking, except that the immunonutrition cocktails that contain extra arginine should NOT be given [ 1 ] outside of the peri-operative setting where evidence exists. An all-in-one complete balanced parenteral formulation should be used and evidence based recommendations suggests where practical these should contain glutamine [ 1 ]. They should be delivered continuously through a dedicated lumen that should not be used for any other access. Some of the energy should come from lipid sources but there is paucity of evidence to suggest any particular lipid formulations although this may change as more advanced formulations come on the market. Caution should be applied when other lipid containing infusions are also in use (e. g. propofol). Lipid infusion is safe at rates up to 1. 5 gm/kg/day, and glucose should be given at 3-4 gm/kg/day. Use simple standardized regimens for most patients. Within ICU acute electrolyte management (e. g. potassium and phosphate) is more readily managed by separate infusions if safe systems exist. Patients on renal support will have increased nutritional losses so maintain on full feeding. Important when using either EN or PN Nutrition should be commenced at reduced rates especially in the malnourished until metabolic tolerance established. Increase to full target over a 3 day period and monitor for re-feeding syndrome. It is possible to overfeed with PN but unless glucose intake exceeds 4-5 gm/kg/day hyperglycaemia indicates peripheral insulin resistance and the need for additional insulin and not reduction in feed volume. Step 3 Are nutrition goals being achieved? Set targets and check nutrition intake daily and act upon the findings. It is recommended that calorie (and nitrogen) intake is calculated daily in addition to the fluid balance. Has the patient received the amount of nutrition prescribed over previous days? Nutritional support, once instigated, should be monitored to confirm the safety of treatment. The following guide illustrates the type of monitoring required. The tests required will depend upon duration and method of feeding. The frequency of testing will vary depending on the illness severity. Fluid balance and calorie intake and if possible weight. Urea and electrolytes daily (watch K+ as feeds may have only a modest K+ content) Blood glucose monitored frequently and preferably as part of a tight glycaemic control. Phosphate (This should be monitored closely especially when starting feeds in the malnourished) Plasma lipid clearance or triglycerides Full blood count Liver function tests, Calcium Magnesium Calculation or measurement of nitrogen balance is not reliable in the routine setting. Nutrition support algorithm summary ASSESS Is nutritional support required? 40% of patients admitted to hospital are undernourished REASSESS Supplemental PN? ADMINISTER Which route? Is enteral feeding practical and safe? If not consider PN ACHIEVE and REVIEW Are you satisfying the nutrient needs of the patient? N Y WEANING STRATEGY If on EN can oral intake be started? If on PN can EN be started?

Case Analysis - Management Essay Example | Topics and Well Written Essays - 500 words

Case Analysis - Management - Essay Example The strengths and weaknesses of NASCAR go hand-in-hand, as often overlap each other. The biggest weakness is trying to make everyone happy. While Brian France wants to do one thing, his sponsors and other people in power, such as those at Nextel and ISC, want something completely different. The larger argument is that NASCAR is now being treated as though it were a source of entertainment, something that Brian claims is true. However, he is treating it as such for the sakes of the audience and fans. The external environment of NASCAR involves sponsors, fans, Nextel, and ISC. These are the groups and individual people that have the power to make things happen, as well as the power to stop other things from taking place. They are the ones to supply the money and the tracks. The fans play a large role, considering there would be no NASCAR if there were not people to watch and cheer the racers on. Brian France is the person whom the responsibilities of NASCAR were passed down to, after his father, Bill Jr., gave them up himself. All of the decisions to be made are now in the hands of Brian, as well as his sponsors and the company that is attached to NASCAR, ISC. There is much controversy between Brian and the others that are helping him out; constant debates are arising in regards to what there next steps should be concerning spreading NASCAR. Brian sees expanding the locations of races and the companies that broadcast them as benefiting the audience and fans, while his company believes he is in it for his own publicity, as well as for personal monetary benefits. As the costs go up to maintain the racing tracks, as well as the team, equipment, and other goods to keep the races running, Brian must convince his sponsors and companies to keep spending. To do this, Brian must convince them of his intentions, and prove to them that it is not for personal gain. Another thing that needs to be considered is that there are other tracks already available; it is