Sepsis An Overview Health And Social Care Essay

Sepsis An Overview Health And Social Care Essay Sepsis is an infection of the bloodstream. The infection tends to spread quickly and often is difficult to recognize. One of our roles as a nurse is that of patient advocate, and as such we are closest to the patient, placing us in a key position to identify any subtle changes at their earliest onset and prevent the spread of severe infection. Knowledge of the signs and symptoms of SIRS, sepsis, and septic shock is key to early recognition. Early recognition allows for appropriate treatment to begin sooner, decreasing the likelihood of septic shock and life-threatening organ failure. Once sepsis is diagnosed, early and aggressive treatment can begin, which greatly reduces mortality rates associated with sepsis. sepà ¢Ã¢â€š ¬Ã‚ ¢sis (ˈsep-sÉâ„ ¢s) n. Sometimes called blood poisoning, sepsis is the bodys often deadly response to infection or injury (Merriam-Webster, 2011) Sepsis is a potentially life-threatening condition caused by the immune systems reaction to an infection; it is the leading cause of death in intensive care units (Mayo Clinic Staff, Mayo Clinic 2010). It is defined by the presence of 2 or more SIRS (systemic inflammatory response syndrome) criteria in the setting of a documented or presumed infection (Rivers, McIntyre, Morro, Rivers, 2005 pg 1054). Chemicals that are released into the blood to fight infection trigger widespread inflammation which explains why injury can occur to body tissues far from the original infection. The body may develop the inflammatory response to microbes in the blood, urine, lungs, skin and other tissues. Manifestations of the systemic inflammatory response syndrome (SIRS) include abnormalities in temperature, heart, respiratory rates and leukocyte counts. This is a severe sepsis that arises from a noninfectious cause. The condition may manifest into severe sepsis or septic shock. Severe sepsis is characterized by organ dysfunction, while septic shock results when blood pressure decreases and the patient becomes extremely hypotensive, even with the administration of fluid resuscitation (Lewis, Heitkemper, Dirksen, OBrien and Bucher (2007), pg 1778). The initial presentation of severe sepsis and septic shock is usually nonspecific.    Patients admitted with relatively benign infection can progress in a few hours to a more devastating form of the disease. The transition usually occurs during the first 24 hours of hospitalization (Lewis, et al 2007, pg 1779). Severe sepsis is associated with acute organ dysfunction as inflammation may result in organ damage (Mayo Clinic Staff, Mayo Clinic 2010). As severe sepsis progresses, it begins to affect organ function and eventually can lead to septic shock; a sometimes fatal drop in blood pressure. People who are most at risk of developing sepsis include the very young and the very old, individuals with compromised immune systems, very sick people in the hospital and those who have invasive devices, such as urinary catheters or breathing tubes (Mayo Clinic Staff, Mayo Clinic, 2010). Black people are more likely than are white people to get sepsis and black men face the highest risk (Mayo Clinic Staff, Mayo Clinic 2010). Severe sepsis is diagnosed if at least one of the following signs and symptoms, which indicate organ dysfunction, are noted; areas of mottled skin, significantly decreased urine output, abrupt change in mental status, decrease in platelet count, difficulty breathing and abnormal heart function (Lewis et al, 2007 pg 1779). To be diagnosed with septic shock, a patient must have the signs and symptoms of severe sepsis plus extremely low blood pressure (Mayo Clinic Staff, Mayo Clinic 2010). Sepsis is usually treated in the ICU with antibiotic therapy and intravenous fluids. These patients require preventative measures for deep vein thrombosis, stress ulcer and pressure ulcers. Hunter (2006) explains that the reason why sepsis is rarely given attention and popularized for public information and attention is because it is not a disease in itself, but a reaction of the body to a lowered immunological response. Sepsis is the leading cause of death in non-coronary intensive care units (ICUs) and the 10th leading cause of death in the United States overall (Slade, Tamber and Vincent, 2010, pg 2).   The incidence of severe sepsis in the United States is between 650,000 and 750,000 cases. Over 10 million cases of sepsis have been reported in the United States based on a 22-year period study of discharge data from 750 million hospitalizations Annually, approximately 750,000 people develop sepsis and more than 200,000 cases are fatal (Slade, et al 2010, pg 1). More than 70% of these patients have underlying co-morbidities and more than 60% of these cases occur in those aged 65 years and older (Slade, et al 2010, pg 1). When patients with human immunodeficiency virus are excluded, the incidence of sepsis in men and women is similar. A greater number of sepsis cases are caused by infection with gram-positive organisms than gram-negative organisms, and fungal infections now account for 6% of cases (Slade, et al 2010, pg 1). After adjusting for population size, the annualized incidence of sepsis is increasing by 8%. The incidence of severe sepsis is increasing greatest in older adults and the nonwhite population. The rise in the number of cases is believed to be caused by the increased use of invasive procedures and immunosuppressive drugs, chemotherapy, transplantation, and prosthetic implants and devices, as well as the increasing problem of antimicrobial resistance (Slade, et al 2010, pg 1). Despite advances in critical care management, sepsis has a mortality rate of 30 to 50 percent and is among the primary causes of death in intensive care units ((Brunn and Platt, 2006, 12: 10-6). It is believed that the increasing incidence of severe sepsis is due to the growing population among the elderly as a result of increasing longevity among people with chronic diseases and the high prevalence of sepsis developing among patients with acquired immune deficiency syndrome (Slade, et al 2010, pg 1). During an infection, the bodys defense system is activated to fight the attacking pathogens. These invading pathogens, especially bacteria, possess receptive lipopolysaccharide (LPS) coverings or release exotoxins and endotoxins that activate the T-cells and macrophages and trigger the Toll-like receptors (TLRs) to respond by releasing antibodies, eicosanoids and cytokines such as tumor necrosis factor (TNF) and interleukins. The antigens may also result in the production of lysozymes and proteases, cationic proteins and lactoferrin that can recognize and kill invading pathogens. Different microbes also induce various profiles of TNF and interleukin to be released. These molecules results in a heightened inflammatory response of the body and vascular dilation. The TLRs also affect a different cascade that involves coagulation pathways, which results in preventing the bleeding to occur at the area of infection. With too much molecular responses and signals, the recognition of the molecules sometimes fails and attacks even the bodys endothelial cells. These compounded immune and inflammatory actions result in the development of the symptoms of sepsis (Hunter, 2006 pg 668; Van Amersfoort, 2001 pg 400). Brunn and Platt (2006) believes that events leading to breakdown of the tissue such as injuries or infection, that naturally results in the activation of the immune system, is a major event that causes sepsis. During host infection, the release of tumor necrosis factor and interlekin-1 signals the dilation of the arteries and inflammation. These released cytokines also activate the coagulation pathway to prevent fibrinolysis but an increase in the concentration of these molecules may result in abnormalities in the hosts defense system (Gropper, 2004 pg 568). The common belief that sepsis is caused by endotoxins released by pathogens has fully been established but genomic advancements is shedding light on current insights that sepsis can also occur without endotoxin triggers, that is even without microbial infections (Gropper, 2004 pg 568). Diagnosing sepsis can be difficult because its signs and symptoms can be caused by other disorders. Doctors often order a battery of tests to try to pinpoint the underlying infection. Blood tests and additional laboratory tests on fluids such as urine and cerebrospinal fluid to check for bacteria and infections and wound secretions, if an open wound appears infected. In addition, imaging tests to visualize problems such as x-ray, computerized tomography (ct), ultrasound and magnetic resonance imaging (mri) to locate the source of an infection are also ordered. Early, aggressive recognition boosts a patients chances of surviving sepsis. Sepsis should be treated as a medical emergency. In other words, sepsis should be treated as quickly and efficiently as possible as soon as it has been identified. This means rapid administration of antibiotics and fluids. A 2006 study showed that the risk of death from sepsis increases by 7.6% with every hour that passes before treatment begins. (Mayo Clinic Staff, Mayo Clinic 2010). Early, aggressive treatment boosts the chances of surviving sepsis. People with severe sepsis require close monitoring and treatment in a hospital intensive care unit. Lifesaving measures may be needed to stabilize breathing and heart function. (Mayo Clinic Staff, Mayo Clinic 2010). People with sepsis usually need to be in an intensive care unit (ICU). As soon as sepsis is suspected, broad spectrum intravenous antibiotic therapy is begun. The number of antibiotics may be decreased when blood tests reveal which particular bacteria are causing the infection. The source of the infection should be discovered, if possible. This could mean more testing. Infected intravenous lines or surgical drains should be removed, and any abscesses should be surgically drained. Oxygen, intravenous fluids, and medications that increase blood pressure may be needed. Dialysis may be necessary if there is kidney failure, and a breathing machine (mechanical ventilation) if there is respiratory failure (Mayo Clinic Staff, Mayo Clinic, 2010). While severe sepsis requires treatment in a critical care area, its recognition is often made outside of the Intensive Care Unit (ICU). With nurses being at the side of a patient from admission to discharge, this places them in an ideal position to be first to recognize sepsis. Thorough assessments are crucial and being able to recognize even the most minimal changes in a patient could be the difference between life and death. Once severe sepsis is confirmed, key aspects of nursing care are related to providing comprehensive treatment. Pain relief and sedation are important in promoting patients comfort. Meeting the needs of patients families is also an essential component of care. Research on the needs of patients families during critical illness supports provision of information as an important aspect of family care (Gropper et al, 2004 pg. 569). Teaching patients and their families is also essential to ensure that they understand various treatments and interventions provided in severe sepsis. Ultimately, prevention of sepsis may be the single most important measure for control (Mayo Clinic Staff, Mayo Clinic, 2010). Hand washing remains the most effective way to reduce the incidence of infection, especially the transmission of nosocomial infections in hospitalized patients (Mayo Clinic Staff, Mayo Clinic, 2010. Good hand hygiene can be achieved by using either a waterless, alcohol-based product or antibacterial soap and water with adequate rinsing. Using universal precautions, adhering to infection control practices, and instituting measures to prevent nosocomial infections can also help prevent sepsis (Lewis, et al 2007, pg 248). Nursing measures such as oral care, proper positioning, turning, and care of invasive catheters are important in decreasing the risk for infection in critically ill patients (Fourrier, Cau-Pottier, Boutigny, Roussel-Delvallez, Jourdain, Chopin, 2005 pg 1730). Newly released guidelines on the prevention of catheter-related infections stress the use of surveillance, cutaneous antisepsis during care of catheter sites, and catheter-site dressing regimens to minimize the risk of infection (Fourrier, 2005 pg. 1731). Other aspects of nursing care such as sending specimens for culture because of suspicious drainage or elevations in temperature, monitoring the characteristics of wounds and drainage material, and using astute clinical assessment to recognize patients at risk for sepsis can contribute to the early detection and treatment of infection to minimize the risk for sepsis. Critical care nurses are the healthcare providers most closely involved in the daily care of critically ill patients and so have the opportunity to identify patients at risk for and to look for signs and symptoms of severe sepsis (Kleinpell, Goyette, 2003 pg 120). In addition, critical care nurses are also the ones who continually monitor patients with severe sepsis to assess the effects of treatment and to detect adverse reactions to various therapeutic interventions. Use of an intensivist-led multidisciplinary team is designated as the best-practice model for the intensive care unit, and the value of team-led care has been shown (Kleinpell, et al 2003, pg 121). As key members of intensivist-led multidisciplinary teams, critical care nurses play an important role in the detection, monitoring, and treatment of sepsis and can affect outcomes in patients with severe sepsis (Kleinpell, et al 2003, pg 121). 5 Priority Nursing Diagnosis Diagnosis #1: Deficient fluid volume related to vasodilatation of peripheral vessels leaking of capillaries. Intervention #1: Watch for early signs of hypovolemia, including restlessness, weakness, muscle cramps, headaches, inability to concentrate and postural hypotension. . Rationale #1: Late signs include oliguria, abdominal or chest pain, cyanosis, cold clammy skin, and confusion (Kasper et al, 2005). : Intervention #2: Monitor for the existence of factors causing deficient fluid volume (e.g., vomiting, diarrhea, difficulty maintaining oral intake, fever, uncontrolled type 2 diabetes, diuretic therapy). Rationale #2: Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss (Metheny, 2000). Intervention #3: Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh the client on the same scale with the same type of clothing at same time of day, preferably before breakfast. Rationale #3: Body weight changes reflect changes in body fluid volume (Kasper et al, 2005). Weight loss of 2.2 pounds is equal to fluid loss of 1 liter (Linton Maebius, 2003). Diagnosis #2: Imbalanced nutrition less than body requirements related to anorexia generalized weakness. Intervention #1: Monitor for signs of malnutrition, including brittle hair that is easily plucked, bruise, dry skin, pale skin and conjunctiva, muscle wasting, smooth red tongue, cheilosis, flaky paint rash over lower extremities and disorientation (Kasper, 2005). Rationale #1: Untreated malnutrition can result in death (Kasper, 2005). Intervention #2: Recognize that severe protein calorie malnutrition can result in septicemia from impairment of the immune system or organ failure including heart failure, liver failure, respiratory dysfunction, especially in the critically ill client. Rationale #2: Untreated malnutrition can result in death (Kasper, 2005) Intervention #3: Note laboratory test results as available: serum albumin, prealbumin, serum total protein, serum ferritin, transferring, hemoglobin, hematocrit, and electrolytes. Rationale #3: A serum albumin level of less than 3.5 g/100 milliliters is considered and indicator of risk of poor nutritional status (DiMaria-Ghalli Amella, 2005). Prealbumin level was reliable in evaluating the existence of malnutrition (Devoto et al, 2006). Diagnosis #3: Ineffective tissue perfusion related to decreased systemic vascular resistance. Intervention #1: If the client has a period of syncope or other signs of a possible transient ischemic attack, assist the client to a resting position, perform a neurological assessment and report to the physician. Rationale #1: Syncope may be caused by dysrhythmias, hypotension caused by decreased tone or volume, cerebrovascular disease, or anxiety. Unexplained recurrent syncope, especially if associated with structural heart disease, is associated with a high risk of death (Kasper et al, 2005). Intervention#2: If the client experiences dizziness because of postural hypotension when getting up, teach methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several time while seated, rising slowly, sitting down immediately if feeling dizzy and trying to have someone present when standing. Rationale #2: Postural hypotension can be detected in up to 30% of elderly clients. These methods can help prevent falls (Tinetti, 2003). Intervention #3: If symptoms of a new cerebrovascular accident occur (e.g., slurred speech, change in vision, hemiparesis, hemiplegia, or dysphasia), notify a physician immediately. Rationale #3: New onset of these neurological symptoms can signify a stroke. If the stroke is caused by a thrombus and the client receives thrombolytic treatment within 3 hours, effects can often be reversed and function improved, although there is an increased risk of intracranial hemorrhage (Wardlaw, et al, 2003) Diagnosis #4: Ineffective thermoregulation related to infectious process, septic shock. Intervention #1: Monitor temperature every 1 to 4 hours or use continuous temperature monitoring as appropriate. Rationale #1: Normal adult temperature is usually identified as 98.6 degrees F (37 degrees C) but in actuality the normal temperature fluctuates throughout the day. In the early morning it may be as low as 96.4 degrees F (35.8 degrees C) and in the late afternoon or evening as high as 99.1 degrees F (37.3 degrees C). (Bickely Szilagyj, 2007). Disease injury and pharmacological agents may impair regulation of body temperature (Kasper et al, 2005). Intervention #2: Measure the temperature orally or rectally. Avoid using the axillary or tympanic site. Rationale #2: Oral temperature measurement provides a more accurate temperature than tympanic measurement (Fisk Arcona, 2001; Giuliano et al, 2000). Axillary temperatures are often inaccurate. The oral temperature is usually accurate even in an intubated clients (Fallis, 2000). The SolaTherm and DataTherm devices correlated strongly with core body temperatures obtained from a pulmonary artery catheter (Smith, 2004). A study performed in Turkey found that axillary and tympanic temperatures were less accurate than oral temperatures (Devrim, 2007). Intervention #3: Take vital signs every 1 to 4 hours, noting changes associated with hypothermia; first, increased blood pressure, pulse and respirations; then decreased values as hypothermia progresses. Rationale #3: Mild hypothermia activates the sympathetic nervous system, which can increase the levels of vital signs; as hypothermia progresses, the heart becomes suppress, with decreased cardiac output and lowering of vital sign readings (Ruffolo, 2002; Kaper et al, 2005). Diagnosis #5: Risk for impaired skin integrity related to desquamation caused by disseminated intravascular coagulation. Intervention #1: Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or lesions. Determine whether the client is experiencing loss of sensation or pain. Rationale #1: Systemic inspection can identify impending problems early (Ayello Braden, 2002; Krasner, Rodeheaver Sibbald, 2001). Intervention #2: Identify clients at risk for impaired skin integrity as a result of immobility, chronological age, malnutrition, incontinence, compromised perfusion, immunocompromised status or chronic medical conditions such as diabetes mellitus, spinal cord injury or renal failure. Rationale #2: These client populations are known to be at high risk for impaired skin integrity (Maklebust Sieggreen, 2001: Stotts Wipke-Tevis, 2001). Targeting variables (such as age and Braden Scale Risk Category) can focus assessment on particular risk factors (e.g., pressure) and help guide the plan of prevention and care (Young et al, 2002). Intervention #3: Monitor the clients skin care practices, noting type of soap or other cleansing agents used, temperature of water and frequency of skin cleansing. Rationale #3: Individualize plan according to the clients skin condition, needs, and preference (Baranoski, 2000). As a nursing student with a strong interest in working with trauma patients, I am intrigued by the fact that as to why some trauma patients are more susceptible to contracting sepsis than others. Therefore my suggestion for future research would be to determine if there is an underlying factor that we, as healthcare professionals are overlooking. Apparently, I am not alone in my thinking and in performing additional reading on sepsis I was pleasantly surprised to learn that an investigation into this matter is underway. Hinley (2010), a staff writer for Medical News Today, reports how an emergency room nurses curiosity about why some trauma patients develop sepsis while others dont has led to an expanded career as a researcher studying the same, burning question. Dr. Beth NeSmith, assistant professor of physiological and technological nursing in the Medical College of Georgia School of Nursing received a three-year, $281,000 National Institutes of Health grant in September, 2010 to examine risk factors for sepsis and organ failure following trauma. Based on her own research, Dr. NeSmith concluded that trauma kills more than 13 million Americans annually and sepsis is the leading cause of in-hospital trauma deaths, yet little data existed to explain differences in population vulnerability to these deadly outcomes. NeSmith believes lifetime chronic stress may be the culprit and a simple test on hair may identify those at risk. Her theory is that a person who grows up with chronic stress, such as socio- economic stress or abuse, will have a different response to trauma in terms of their inflammation profile, NeSmith said. Inflammation is a normal body response to trauma, but if it gets out of hand its dangerous. The only care for it is supportive until if the body gets better. (Hinley, P., Medical News Today, 2010) As the trauma clinical nurse specialist at MCG Health System from 1997-2003, NeSmith was intrigued by the limited treatment options available for sepsis. Her grant will allow her to test the theory that people with existing chronic stress respond differently physiologically to trauma than non-stressed individuals. NeSmith spends three days a week in the lab working with basic science research techniques. Nurses play a critical role in improving outcomes for patients with sepsis. To save the lives of those with sepsis, all nurses, no matter where they work, must develop their skills for recognizing sepsis early and initiating appropriate therapy. With nurses dedicated to understanding and stopping this deadly disorder, the goal of reducing mortality will be realized.  Ã‚  

Participation – Citizenship Coursework

In the summer, my class decided to run a charity stall to raise money for our house charity, The British Heart Foundation. I knew someone that recently underwent a triple heart bypass and thought that raising money for such a cause that could help to extend peoples life was an excellent idea. The temperature at school was becoming unbearable so I suggested that a great way to earn money selling something that people need would be to run an ice-cream stall outside the picnic area where the majority of the school eat their lunch. Everyone agreed that it was a good idea but we came across the problem of finding a price that we could agree on. So we decided to do some market research and some members of my class organised a questionnaire in which students at our school were asked questions about their favourite flavours or how much they would be willing to pay for one ice cream. We discovered that most people enjoyed strawberry, vanilla and mint chocolate chip ice cream and that they would pay around 50p for one ice cream with extra toppings. Everyone in my class had a role in participation, whether it was finding a place to store 30 tubs of ice cream or organising security so that people didn't try to get ice cream without paying. We all had to bring in one litre tub each and we stored them in the freezer. Buying ice cream wasn't a problem for most, however I personally found it hard to find mint chocolate chip ice cream and ended up buying plain mint ice cream instead. Also in the hot weather, some people's generators had given in and their freezers had broken, so I offered to store some extra tubs in my freezer for those who didn't have room. My main role was organising what stuff we needed and who was supplying it. I brought in scoopers and cool bags to place the ice cream in when we were selling it so that it didn't melt. Melting ice cream didn't become a problem as the dinner ladies kindly offered to place a fridge outside the canteen with an extension lead to keep it running so that we could store some ice cream in the fridge outside. I also had another role in being a â€Å"scooper† and making the ice creams for people to buy, at the same time I had to keep an eye on people trying to skip the queue. I enjoyed being a scooper and in my opinion it was one of the better roles of the task, we even brought in music to motivate the scoopers and entertain people waiting in the queue. The disadvantage of being a scooper would probably be that after scooping for 1hr and 10 minutes my hand felt numb and I couldn't move it. However the customers seemed to love it, probably because it was such a sweaty day and they needed something to cool them off, even the head teacher came down to buy some ice creams. People who bought ice creams from our stall then told their friends, a lot of people bought more than one! There was some quarrelling when the people who were supposed to be running the stall didn't show up or their friends kept taking free scoops or abusing our â€Å"extra topping service† by pilling the toppings on. Although after they did this they did drop their ice cream on the floor, which serves them right. And they weren't the only ones, because people kept dropping them on the floor it encouraged wasps, and we also lost profit, as we had to give them a new one. When the end of lunch drew near, I helped to count the money made in the day, this made me feel very responsible and trusted with so much money. There was also a lot of cleaning up to do, as well as putting back the tables, cleaning the cool bags and counting our profit. We made approximately à ¯Ã‚ ¿Ã‚ ½150 pounds on the first day and because it was successful we were approached to do it again the next day. The second time around we knew where we went wrong last time and how to make our stall more efficient. This time I helped to re-decorate the stalls, make signs to place around the school and put leaflets in the registers to remind people to bring their money to school for a second time. We also read out a notice in assembly. This time a lot more people came to buy stuff because the weather was warmer, and those who forgot their money yesterday brought it this time. At the end of the day we raised a further à ¯Ã‚ ¿Ã‚ ½172 pounds, and astonishing amount of money for one lunchtime. The school was very pleased and we got a lot of credit for our charity work. On the third day we decided instead of selling the leftovers to give everyone one each and we invited another form to join us. It was nice for me because it was actually my last day at that school. Afterwards we presented the canteen staff with flowers to thank them for giving us freezer space. Our head teacher called it â€Å"a huge success† and many people wished there had been something like it when we had the hottest day in 20 years. Overall it was a good two days and we didn't come across too many problems other than minor disagreements about staff rotas on the scooping table and we made a lot of money. They said that it is likely they will do it again next year, if I was still there I would defiantly suggest it, then next time we could sell something else like balloons or badges at the same time.

Appearance vs Reality Essay - 453 Words

Appearance vs Reality One normally disguises in order to be someone else, whether this be in a costume during Halloween, or as a character in a play or movie. Shakespeare uses the idea of disguise in his ‘Taming of the Shrew’ The minor theme of the play is appearance vs reality. Throughout the drama, things are never really as they seem. Katherine appears to be a real shrew, but it is all a cover-up for the hurt she feels. Bianca appears to be a self-sacrificing angel, but she is really a spoiled young lady who can quickly revert to shrewish behavior. Baptista appears to the outside world as a wonderful father; in truth, he pampers Bianca, totally spoiling her, and treats Katherine badly, depriving†¦show more content†¦The play is also filled with people in disguise, appearing to be something they are not. Lucentio disguises himself as Cambio, the tutor, so he can get to know Bianca. Hortensio also disguises himself as Licio, another tutor to Bianca. Tranio disguises himself as Lucentio in order to present his master as a suitor for Bianca. The Pedant pretends to be Vincentio, the father of Lucentio. Through these appearances, the plot becomes complicated and often humorous, but Shakespeare masterfully reveals the true identity of all characters in the fourth act of the play. Some see Katherinas nature as revealed rather than changed- she was always brilliant and admirable, but her qualities were hidden under her shrewishness. Bianca, on the other hand, reveals willfulness and deceit under her mildness. Tranio reveals qualities that make him more effective than Lucentio. Is he really more of a master than a servant? Most of the plays humour comes from the way in which characters create false realities by disguising themselves as other people, a device first introduced in the induction. Initially this is accomplished by having Christopher Sly believe he is someone he is not and then by having the main play performed for him. 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In William Shakespeare’s tragedy, Macbeth, the theme of appearance versus reality is seen frequentlyRead MoreAPPEARANCE vs. REALITY IN THE PRINCE AND HAMLET1614 Words   |  7 Pages3. Reality and appearances, or if you prefer, being and acting, are important themes for both Machiavelli and Shakespeare. Why? How do their perspectives on this subject agree or differ? APPEARANCE vs. REALITY IN THE PRINCE AND HAMLET One of the most fundamental questions in philosophy is the appearance vs. reality. We find ourselves asking the question of what is genuinely real, and what is viewed merely as just an appearance, and not real? It becomes difficult when we assume there is

The Endangered Species Act By Pete Mccloskey - 1767 Words

I was inspired to get involved in politics in the 1970s by my local Congressman, Pete McCloskey, a leading environmental advocate, co-founder of the first Earth Day, and one of the original authors of the Endangered Species Act. As a lifelong hiker and nature lover, two of my early heroes were John Muir, the founder of the Sierra Club, and Rachel Carson, a leading conservationist of her time. Today, I enjoy hiking through Catoctin Mountain Park, biking along the C and O Canal, and I am committed to preserving the wildlife and natural resources of the 8th District and Maryland. Among my top priorities as your Representative in Congress will be protecting nature and addressing climate disruption by supporting a transition to a clean energy†¦show more content†¦I will also support regulatory measures and incentives to conserve energy in buildings, homes, cars and other transportation, as well as funding for mass transit. Fracking / Fossil Fuels The shale revolution has provided a new source of natural gas and energy independence for the United States, but it must be carefully regulated to keep our nation’s water supply safe and clean. That’s why I am a firm supporter of the Clean Water Act and Safe Drinking Water Act. In Congress, I will diligently work to end the â€Å"Halliburton Loophole,† which has dangerously exempted fracking from necessary federal environmental regulation, and I will advance efforts to create stronger regulations by the EPA to ensure that hydraulic fracturing is practiced in a safe and environmentally conscious manner. I also oppose the Keystone Pipeline and support ending costly fossil fuel subsidies, which totaled over $18.5 billion in the United States in 2013.2 This is a waste of taxpayer money, as the top five oil companies earned $93 billion in profit in the same year.3 In Congress, I will fight to end Republican expansion of oil subsidies and instead focus on incentivizing the production of clean energy that will eliminate our dependence on coal and oil companies. Conservation I was raised in a family that practiced â€Å"reduce, reuse, recycle,† and brought that