Poverty in the USA Research Paper Example | Topics and Well Written Essays - 750 words - 1

Poverty in the USA - Research Paper Example For a person to get a satisfying job, he/she needs to have the quality education (Kotler, 12). Most students leave school due to diverse reasons such as early pregnancies or drugs; hence, cannot find a rewarding job. Monetary instability causes low quality or no education at all. Many youths desire to advance their education and acquire rewarding jobs. Unfortunately, their parents and guardians are unable to pay their fees; thus they have to abandon school to secure jobs and help their parents pay debts. Â  Therefore, they create a cycle that never ends, that is from uneducated parent to an uneducated child. American citizens’ faces poverty since they can not grant the manpower needed to ensure a boost in the country’s economy. Majority of the developing states globally lives in destitute scarcity. The wealthy states such as America are a source of refuge to the growing states. They are perceived as ‘lands of opportunities’. America is one such country, of ten referred to as the world’s superpower nation because of her stable economic. This makes it a niche for citizens of developing countries to scramble for employment possibility from its citizens and illegal immigrants. Since the immigrants can settle for any amount of money they are mostly offered jobs, unlike the Americans. The immigrants can work for the extra time, and do multiple jobs. For this reason, they further deny employment opportunities to the citizens who meanwhile, are fighting with the youths for menial jobs.

Examine consulting processes and techniques Assignment - 1

Examine consulting processes and techniques - Assignment Example Answering the above mentioned questions will help the management to step forward to the proper direction. Pilot project generally means a test or trial project which is undertaken prior to undertaking the main project. Thus, the failure of the pilot project provides the management a chance to make the necessary changes in the technique and in the processes of the project. In this regard, to respond to the above mentioned questions, there is a requirement of intense evaluation. The client had implemented SAP in his organizational operations related activities for the better integration and flexibility but instead of generating solutions to the identified problems, the client faced various issues. Firstly, the implementation failed because of the wrong approaches and investment of a lot of capital which had been largely wasted. Various consulting and managerial roles were not present in the client’s approach in the process of implement of the project successfully. These managerial and consulting roles include planning, organizing, staffing, directing, controlling, the leader, the liaison, the disseminator, the monitor, the entrepreneur, spokesperson and the disturbance handler. In this regard, various implementation strategies also were needed to be built such as location and pricing strategies (Wickham & Wickham, 2008). A consulting project aimed at creating specific outcome could be used to address and solve the problem in a much appropriate way. As the client wants to handle his departments such as financial performance management, supply chain management (SCM), manufacturing processes and sales thus job specific consulting project could be appropriate to provide attention in each single department. SAP ERP mainly delivers a comprehensive asset of business benefits that includes risk reduction, better financial management and corporate governance. As the firm was facing a problem related to the financial management

Propaganda Essay Example | Topics and Well Written Essays - 1000 words - 1

Propaganda - Essay Example The first image which represents the Nazi propaganda under the leadership of Hitler strongly suggests that the medium used by Hitler in his propaganda has been very effective. Hitler was able to successfully win the trust and support of its people in Germany. In fact, â€Å"even the youngest want to take Hitler’s picture†6. The second image is similar with the first image in the sense that Obama also managed to use effective medium in his propaganda. This explains why Obama won in the presidential election in the United States. â€Å"Time† is all about being able to disseminate the message across the target audiences at the right moment of time7. Hitler’s and Obama’s timing was both made at the right moment. For instance, to win the support of the majority of the Americans for his presidential campaign back in 2008, Obama’s propaganda is to create more jobs and make healthcare accessible to all8, 9. The timing of Obama’s propaganda was just right since majority of the people has been badly affected by the economic recession in the United States. ... Hitler was known for being a totalitarian12. Therefore, to win the people’s trust, he publicly announced that one of his goals is to gather the German people together so as to establish a national body strong enough to â€Å"resist destruction†13. All types of propaganda are based on either the â€Å"truth† of what most people assume to be the truth14. For example, Hitler said that â€Å"if the negative forces of destruction are to be overcome, the positive forces of preservation must be enhanced†15. Without the application of critical thinking, it is true that strengthening the positive forces is necessary to counteract the negative forces that will trigger destruction in a society. But, if one is to analyze Hitler’s statement carefully, people who are against his political agenda are considered as â€Å"the negative forces of destruction†16. Therefore, â€Å"positive forces of preservation† is actually referring to the need to remove all people who are against his political agenda17. Unfortunately, there is a hidden truth in all propagandas. Because of Hitler’s personal desire to manipulate and control the social order throughout the entire Germany, millions of people who were against his propaganda suffered and died18. On top of those who died in the battlefields, almost 6 million Jews and other less dominant races were murdered under his leadership19. Even though the political propaganda of Barak Obama was based on â€Å"a good cause†, it is clear that there is a personal interest behind the â€Å"observable truth† which is to create and offer more jobs for the local people20. It is true that each person has the right to receive health care services. However, if

The Development of West Torrens Council Area Essay

The Development of West Torrens Council Area - Essay Example The building height should have uniform scale with other developments. Fences and walls including street frontage are also part of the development plan. The site should provide sufficient space for vehicle access and parking. Visual privacy, private open space should be provided for each dwelling including acoustic privacy. The ground floor level of all the dwellings must be elevated above the design flood level to avoid the risk of the people and properties Areas affected within 100 metres by industrial noise and other impacts or residential developments located near the industrial boundaries should have a design to minimize potential negative visual and noise from the non residential activities. Outbuildings should not result in a significant loss of private open space. In the above mentioned development plan policies, the design of the proposed dwelling must conform to the design criteria. As we draft the designs of the dwelling areas, we must bear in mind the design criteria of the West Torrens residential zone policies. In doing so, the land developer, as well as the future dwellers are assured of healthy and problem free environment. The design proposal was made to conform with the development ... The 3 adjacent lots have identical areas of 383.70 sqm. And the 4th lot is 567.5 sqm. Lots 1, has a floor area of 129.76 sqm. While lot 2 has 131.49 sqm and lot 3 has 112.00 sqm. Lot 4 has the biggest floor area of 227.7 sqm. To conform with the West Torrens Council for Residential Zone Policy Area 40, the following are the conditions that will fit in the proposed residential dwellings for the site development plan. There are no significant trees in the area. There is no car parking restrictions in front of the houses because the roads are wide. There is no main streets like highways adjacent to the houses, only local primary and secondary streets. The adjacent houses are 3.00 meters in height. The three adjacent lots are facing the north side and the 4th adjacent lot is facing east. The houses facing north have a set back of 7.00 meters The house that faces the east side have a 5.00 meters set back The 3 adjacent lots are designed in such a way that they would have open spaces where a paved area is present and a soft landscape. Since there are no significant trees around the area, several trees are to be planted to give the area a healthy atmosphere. The front set backs of the 3 adjacent lots are 14 metere and they are bigger than the set back at the rear side. This is to give the would be dwellers to have a soft space for their relaxation and they can have a beautiful front landscaping and that it would be in line with the houses nearby. The paves area would be a future driveway or parking area. The paved area could even be considered a multipurpose area. In order to maintain the character of the house, a single storey dwelling would be perfect for the site character

Implement a program for juveniles Research Paper

Implement a program for juveniles - Research Paper Example Social dealings that guarantee smooth progressing of social relationships are now disintegrating. Lifestyles are changing and are becoming less predictable and more varied. Rapid population growth, inaccessibility of support services, unemployment amongst youth, overcrowding in poor neighborhoods, poverty and disintegrating families, etc. are some of the burdens the youth of today has to deal with. The young generation, irrespective of gender, country of residence or social origin is imperiled to risks, but on the other hand they are also presented with new opportunities; some of them beneficial while others may possibly be harmful. Quite frequently, young people commit numerous offences like; becoming drug addicts and using violence against peer. The youth indulge themselves into illegal activities due factors like; lack of adequate youth activities in underprivileged areas and increase in single-parent families or families with both parents working etc. This reduces the number of role models children have to look up to while growing up. (Youth Mentoring, 2003) This raises the need for youth mentoring programs to provide the youngster with role models and assist children to develop emotionally and socially. Such programs help children learn to comprehend their feelings and communicate them. Juvenile programs are designed to enable kids to relate to their own age group and also develop relationships with adults. There was a time when juveniles were thrown into jails and had to serve long prison terms and physical punishments just like adults. Though longs term sentences, corporal punishments and even death sentences are still practiced, but reformers who were concerned about harsh treatment of children urged the government to establish separate court system for the young criminals. The court here acts as a guardian or parent to help and protect children.

What Are the Key Factors Which Lead to the Downfall of the Romanov Dynasty Essay Example for Free

What Are the Key Factors Which Lead to the Downfall of the Romanov Dynasty Essay 1917 saw the conclusion of the reign of the Romanov Dynasty, as well as the demise of Russia’s last monarch, Tsar Nicholas II. It is evident that the downfall of the Romanov Dynasty was directly linked to key factors such as the autocratic style of the Romanov dynasty and the nature of the social structure, as well as the evolving nation of Russia, as a result of industrialisation. The Romanov family was viewed by the people of Russia as leaders ‘sent from God’. However as the 20th century neared, this mystical admiration the public possessed for the royal family receded and was replaced by intellect. A growing sense of political and social awareness of the lower classes, as well as the introduction of democratic ideas from the West had sparked a change. The twentieth century saw the birth of new ideologies such as Leninism, Marxism, Liberalism and Socialism. These ideologies proposed new models of government techniques and questions the ruling of the Romanov Dynasty. Tsar Alexander II sensed the rising threat of terrorism threatening the Imperial family and more importantly the Dynasty’s autocratic rule. The responsibility of Russia was bestowed upon Nicholas II, son of Alexander II, based on the dynasty’s ritualistic practice of passing the throne to the Tsar’s eldest son or closest senior male relative. Nicholas II was reluctant to accept the responsibility of Russia, as well as its 126 subjects; however he acknowledged the burden of the crown as a spiritual experience destined by God. By the beginning of the 20th century, Russia had established itself as a vast empire, however in comparison to other countries; Russia was a ‘backward society’ with mostly undeveloped resources. At this time, Russia had established rigid class distinctions, with 88% of the population farming the countryside as serfs, whilst land and high government positions were owned by 5% of Russia’s population. In 1816, serfdom was abolished and peasants were free, however were required to pay compensation for land that they believed they already owned. Although agriculture remained the principle means of maintaining a livelihood for the lower class, peasants often struggled to live above starvation level, as they used inefficient farming techniques and had little land available to them. Those who struggled with agrarian lifestyles flocked to the cities, consequently causing a major increase in the urban population. As a result factory working conditions also suffered. Factory workers received low wages, at times only 25-30% of British workers, as well as long working hours, sometimes extending to 15 hour shifts. Workers were forced to endure these conditions, with little hope of assistance, as the Russian government had provided no means by which workers could express their grievances or dissatisfaction with their present conditions. The Tsar’s power was unlimited with no political party or constitution to inspect the Tsar’s ruling, as well as a secret police, known as the Ohkrana, which terrorised those threatening public order. ‘I shall uphold the principle of Autocracy as firmly and as undeviating as did my late father’ (Nicholas II, first proclamation, 29th January, 1895 source:Punch,9 February 1895 ) This proclamation illustrates Tsar Nicholas’s incentives to intimate his father Alexender II, by means of resisting modernisation and change, in the nation of Russia. Despite these obvious signs of corruption within the Tsar, the public, largely due to the coercive influence of the Russian Orthodox Church, continued to hold a mystical admiration for the Tsar and the royal family. However, while the myth of Tsar Nicholas or the public’s ‘little father’ retained some currency, the events of the years 1904 to 1905 disrupted this myth dramatically. In 1904, the government’s decision to go to war against Japan highlighted its weakness. The two countries had been competing for years over territory and influence in the Korean peninsula of Manchuria. Nicholas, along with most Russian’s believed that a brief encounter with Russia’s vast navy and army would be the solutions to their present conflicts with Japan. Nicholas was wrong. The war ended with the humiliation of Russian defeat, in August 1905. Confirmation of the Russian government and military weakness heightened discontent and fueled many reform movements. Meanwhile other incidences, such as the massacre or ‘Bloody Sunday’ on the 9th of January 1905, sparked political unrest in the capital of Russia. On this day a large crowd of people marched towards the Winter Palace, in St Petersburg, presenting a petition to the Tsar. The petition demanded a series of measures that would improve the position of those being exploited by their factory owners. â€Å"Don’t refuse to help your people, lead them out of the grave of disfranchisement, poverty and ignorance Tear down the wall between you and your people, and let them rule the country with you Look without anger at our requests, they are not intended for an evil but for a good cause, for both of us† (Petition of the Workers and Residents of St Petersburg for Submission to Nicholas II) This extract displays the continuing confidence in the Tsar and assurance that he will overcome his evil advisors and attend to the struggling lower classes. However this confidence in the Tsar was completely destroyed by the following event. Under command, troops, who were guarding the palace, opened fire on the crowd, killing 100 protestors and wounding almost 300. Although it is still unknown who directed the final orders, Nicholas’s absence from the protest, eroded the iconic image of the Tsar and the myth upon which the Tsarist system was sustained. Hostility towards the blood bath was generated from the lower proletarian classes and reverberated upwards throughout the empire. As a result nine months of strikes, peasant revolts and mutinies among the army and navy, followed. Workers began to form councils, known as soviets, where worker’s representatives would voice their grievances and political protest campaigns were fashioned. Under immense pressure from these disturbances, the Tsar was forced to make compromises to the demands of the people in order to preserve the support of the public. On the 17th of October, the Tsar introduced the October Manifesto. This granted the people of Russia the freedom of conscience, speech, meeting and association. The manifesto also promised the introduction of a Duma, or parliament, elected by universal suffrage. The design of the Duma was to provide the people of Russia with the power to create and approve laws. The intentional exclusion of the word ‘constitution’ ensured that the Tsar autocratic power remained unscathed. The Duma was the Tsar’s puppet; he could dismiss and announce the duma, personally choose and dismiss ministers and declare new laws unaided, at any time. The first two Duma’s lasted only a few months before they were later dissolved, by the Tsar. The third Duma survived as a result of an alteration in the electing process of representatives. Subsequently the Duma became dominated by land-owners and businessmen who were more conservative and ‘trustworthy’ elements to the Tsar. This alteration destroyed the sole purpose of Duma as it hindered all classes from expressing their opinions. Although evidence of reform in the government was present, the manifesto did not address current problems affecting the lower classes such as poverty, low wages and poor working and living conditions. The grievances of the lower classes remained unheard and the gap between the Tsar and his subjects widened. For these reasons recently legalised parties such as the Social Democrats and Socialists revolutionaries had a willing audience. By the end of July 1914, the revolutionary discontent echoed the events of 1905 revolution. When World War II commenced early August 1914, Russia was in no state for battle. Although intensified emotions of patriotism temporarily calmed civil disputes, the hardships of the war brutally hit the home front. Russia’s undeveloped economy struggled to sustain the war efforts and keep up with increased demands. By late 1914, dreams of a short successful battle were doubtful. In addition to previous hardships, concerns of high causality rates, inadequate medical care and shortages of resources, such as food, weaponry and ammunition were affecting the Russian front. In Mid 1915, Nicholas II, with the aim of improving Russia’s current stance in the war, accepted the position as Commander-in-Chief of the Russian forces. Nicholas II had few military skills and was surrounded by ministers who had been chosen by himself, therefore were also sufficiently inexperienced. Meanwhile, German-born Tsarina Alexandra was temporarily responsible for the home front whilst her husband was away. The Tsarina was greatly influenced by Grigori Rasputin, a Russian mystic who was praised by Alexandra for his fanatical abilities to help her haemophilic son, Alexi, the heir to the throne. Tsarina had little political ability and looked towards Rasputin for advice. Due to the nepotism within the royal family, Rasputin was able to quickly posses doctrinal powers and become a influential member of the Russian court. The influence Rasputin had on the royal family as well as the scandalous relationship assumed to be between Alexandra and Rasputin discredited the Tsarist government. These scandals affected the way the public viewed the royal family and supported the idea that the royal family was easily dominated by religious mystics. By late 1916, discontent within Russia had reached crisis point. The duma and the majority of Russia’s upper class no longer supported the Tsar. The Tsar had lost his authority in the eyes of the public. By 25th of January 1917, St Petersburg, the capital of Russia, was at a standstill. Numerous factories were shut, shops closed, public transport ceased to run and radical political leadership seemed to be using all possible means of protest. Unlike 1905, troops did not restrain the strikes; some even rebelled and joined the workers. Tsarist authority had vanished. On the 2nd of March 1917, Nicholas II abdicated and within a few hours, the Grand Duke, Nicholas II’s brother, refused the responsibility of the throne. This was the definitive end to the Romanov Dynasty. In conclusion, although the Tsar’s character had great effect on the downfall of the Romanov Dynasty, it was ultimately the fault of Romanov dynasty’s ineffective style of government. As Russia became more industrialised, larger, and far more complicated, the inadequacies of autocratic Tsarist rule became increasingly apparent. Ritualistic beliefs such as the nepotistic process by which successive monarchs were selected, was unsuitable in an ever evolving world desperate for change and development. The Romanov Dynasty’s Autocratic approach to leadership had been successful for the previous three centuries, however as the twentieth century approached, the need for social and political reform advanced with it. For this reason, Nicholas II, was a victim of a time warp, where despite his best efforts to maintain authority of the autocratic crown, was forced to abandon inherited methods of leadership. He was trapped in a modernising world with outdated beliefs and traditions. Nevertheless, to a minor extent Tsar Nicholas was responsible for his own demise as he was aware of the changes occurring within the nation, however he didn’t not administer the needs and wants of his subjects.

Anaesthetic care

Anaesthetic care In the following text I the author will provide an account of the anaesthetic care given to a paediatric patient in my care during a surgical procedure to repair her cleft palate. I will discuss the rationale behind the chosen anaesthetic technique and will analyse why the method was identified as the most suitable backing the findings up with related literature. The text will explore the care given to the patient and the preparation needed to ensure a safe procedure starting from the pre-assessment visit right to the anaesthetic room looking at the roles of some of the multi disciplinary team members involved in the childs care. An episode of care for any individual patient is a complex series of interactions that make up the process of care. The recipient of this anaesthetic care is an 8-month-old female, who, as patient confidentiality forbids the use of her real name (NMC 2002a) shall be known as Eve. Eve was born at 41 weeks gestation, during a routine prenatal scan at 23 weeks gestation an abnormality of her facial structure was noted, her parents were informed of this and counselling and advice was offered. The extent of the abnormality was not seen until Eve was born. She was born with a unilateral cleft lip and palate, which is were there is a single cleft of the lip, and the hard, and soft palate are also divided (Shprintzen and Bardach 1995) but was otherwise fit and well. In accordance to Watson et al 2001 clefts of the lip and palate may be isolated deformities or may be a part of a syndrome. Eve has not been diagnosed with a syndrome there for this is an isolated deformity. Watson (2001) suggests that non-syndromic clefts are multi-factorial in origin and could occur due to gene involvement, various environmental factors or embryo development in relation the mothers life choices during pregnancy i.e. excessive alcohol, drug abuse etc. Eve had previously undergone the first stage of the surgery, which was a repair to her cleft lip. This is done between the ages of two and four months within our trust. This is mainly due to cosmetic reasons but also to encourage oral feeding and sucking and to encourage the tissues to grow at the same rate as the childs facial structure (Watson Et al, 2001). Eve was admitted to hospital the day prior to her surgery. Eves mother had requested this rather than attending pre-admission clinic as she had problems with transportation to the hospital. This highlights good communication (Department of Health, 2003) between the nursing staff and Eves mother, which is of benefit to both the child and the familys needs (Clayton, 2000). The Department of Health (1989) states that the welfare of the child is paramount, however Smith and Daughtrey (2000) believe that it is also important to ensure that parental needs are also met. Wong (1999), states that good family centred care is considerate of all family members needs and not only the needs of the child. The initial assessment of Eve involved her primary nurse, Eve and her mother Joanne. The cleft palate pathway was used as assessment aid and highlighted any needs that Eve and her family had. The anaesthetist (Dr A) then examined Eve and was able to explain the procedure to Eves mother. This meeting with Dr A provided Eves mother with both verbal and written information therefore equipping the family with knowledge and support (Summerton, 1998). During Dr As visit she was able to assess Eves physical and mental condition ensuring that it would be safe to administer a general anaesthetic. During this assessment Dr A was able to request that routine blood samples were taken including cross match in case Eve should need a blood transfusion due to high blood loss during the procedure. She was able to read the operation notes from Eves previous visit making notes of the ET tube size used, the analgesia given, there amounts and if they had the given effects on Eves pain relief and do an assessment of Eves airway. Dr A was aware that Eve would have a difficult airway due to her cleft palate and the fact that her mother reports of her snoring whilst asleep, however she is also aware that assessment of this can be difficult due to Eve being uncooperative or asleep and that most tests used in adult practice including the mallampati scoring system are not validated for use in the paediatric population and are not really useful in the y ounger child (Sumner and Hatch, 1999). She was able to discuss the proposed anaesthetic and pain relief techniques and pre warn eves mother about the monitoring that she may see being used on eve in both the anaesthetic and recovery rooms. Dr A also discussed the use of premeditation such as madazalam with Joanne, it was decided that Eve would not have this as rendering her semi or fully unconscious with a respiratory depressant drug can become hazardous due to Eves cleft palate as her tongue may fall backwards and obstruct her already compromised airway (Sasada, M and Smith, S.2003). All information obtained during the pre assessment by Dr A should and was relayed to the operation department practioner (ODP) who was working alongside her during the case, ensuring that all equipment needed was readily available as and when needed. As Morton (1997) states the motto â€Å"Be Prepared† is a very important principle in anaesthesia. If things were to go wrong during the anaesthesia, intervention must be immediate to avoid harm to the patient; therefore preparation and the checking of equipment and drugs are vital. At the start of each case careful attention to detail is required when setting up the work area. The anaesthetic machine both in the anaesthetic room and in side theatre must be checked in accordance with The Association of Anaesthetists guidelines (Appendix 1) and the manufactures guidelines, and all equipment required must be gathered. There seems to be no set guidelines stating the exact equipment needed so the anaesthetist and the ODP must work together and decide for themselves what they need. â€Å"The success of a paediatric procedure depends not only on the skill and knowledge of the anaesthetist, but also on the possession and utilisation of the proper equipment† (Bell.1991.pg81) Bell (1991) offers the Pre-Anaesthesia Checklist: SCOMLADI that may help towards the selection of equipment: SCOMLADI is a mnemonic for Suction Circuit Oxygen Monitors Laryngoscope handle and blades Airway oral, nasal, ETT, +/- LMA Drugs: Intravenous drips (Bell, 1991.) In Eves case the pieces of equipment that were made available were: Suction, this can be a vital piece of equipment during anaesthesia. This is due to the fact that it can remove gubbings that may cause airway obstruction quickly ensuring the safety of the unconscious patient, although great care must be taken when using suction on an oral wound to ensure no further damage or trauma to the repaired area (Stoddart and Lauder, 2004) Circuit, the Jackson Rees modification of the Ayres t-piece is the main choice as it was designing for paediatric use and it is said to decrease the resistance to breathing by eliminating valves and decreases the amount of dead space in the circuit. Oxygen, this is readily available on the anaesthetic machine. The oxygen is delivered to the machine via a pipeline from the hospital stores. There must also be a full cylinder on the machine for use in case of a malfunction of the pipeline supply. This must be checked during the machine check. Monitors and monitoring aids. Some of the important aids are: Pulse oximeter, this gives a continuous reading of the oxygen saturation in the blood via a fingertip sensor. Although extremely reliable the probes may not pick up a good trace if the patient is cold of has a poor peripheral perfusion. ECG, This provides us with the information of the heart rate and rhythm. This is a valuable aid in detecting bradycardia and arrhythmias in paediatric patients. Blood pressure (bp), the most common way to measure Bp is by using a cuff this is known as non-invasive. Parameters are set on the monitoring console to enable the cuff to inflate and record the patients blood pressure at regular intervals. Arterial Bp can be measured via a cannula placed in an artery, which attaches to a transducer, this is known as invasive monitoring and can give continuous readings. In Eves case a cuff was used in accordance to Dr As wishes. Capnography This is attached to the breathing circuit and analyses the gas mixture. The monitor displays the concentration of oxygen, nitrous oxide, carbon dioxide and volatile agents. This information is useful for assessing the adequacy in ventilation and the depth of anaesthesia. The presence of carbon dioxide on the reading confirms that the ET tube is in the right place (Morton, 1997). Temperature Infants lose heat very quickly and there ability to maintain their own temperature is blocked by the anaesthetic (Kumar, 1998). A naso/oesophageal probe is placed in Eves nostril instead of her mouth, as that is where the surgery is taking place. There is other methods of monitoring available such as blood gases, central venous pressure, neuro muscular transmission etc but in Eves case these would only be used if Dr A requested them. Laryngoscope and blade, the different choices of blades are due to the variation in the anatomy found in small infants and children, this is due to the fact that a childs larynx lies higher and more interiorly in the neck and there epiglottis is longer and thinner than adults (Watson, 2001). The use of different size and shape blades is down to the anaesthetists personal choice Dr A prefers to use a lateral approach with a straight blade such as a Magill (Morton.1997). Dr A also likes to have a piece of rolled up gauze filling the cleft to ensure that the blade does not get caught in the deep cleft. The difficult intubations trolley is also essential this is because there is a large selection of different blades, handles, bougies and airways such as cut/uncut endotracheal tubes, guidell airways, laryngeal masks and face masks which are all available on hand. Airways, A selection of pre-formed south facing, uncut and reinforced endotracheal tubes. The size of which can be calculated by using a formula (age / 4 + 4.5 = estimated tube size) or by the childs weight (Morton, 1997). Eve should take a 4.0mm tube but it was noted on her last anaesthetic sheet that a 3.5mm tube was used with a gauze pack insitu due to her different anatomy. Drugs, There are many different types of anaesthetic drugs available such as Volatile induction agents (Gas), Intravenous induction agents, muscle relaxants, reversal agents, anti emetics, local anaesthesia and analgesics. All of which have the own pros and cons for using them. Dr A has chosen to use the volatile agent Sevoflurane in order to initially anaesthetise Eve this is due to the fact that Eves Venous access is poor due to her being a â€Å"podgy† baby. Sevoflurane is the least pungent and irritant of the volatiles and rivals many of the other inhalation induction agents for children. Eve was induced with oxygen, nitrous oxide and 8% sevoflurane, her airway was difficult to maintain due to her tongue being large in relation to her oral cavity which is normal in infants (Wong, 1999) therefore a size 1 guedel airway was used in order to keep the tongue from causing an obstruction. Anaesthesia was maintained with oxygen, nitrous oxide and isoflurane another of the volatil e agents also used within paediatrics with the feeling that this is mainly due to the low cost. Eve also had an infusion of the opioid remi-fentinal. Intra-Venous (IV), IV access was gained when an adequate depth of anaesthesia was reached and endoteacheal intubation was achieved. In total four IV lines were inserted, one to administer IV drugs such as anti emetics, anti biotics and IV pain relief etc. another for the IV infusion of Remi fentinal pain relief. Another for the maintenance fluids and the last on as a spare of to use if blood products are needed. Fluid therapy is important in both adults and children due to the fact that they have been nil by mouth for many hours before there procedure in accordance to hospital guidelines. IV fluids are given as maintenance to preserve hydration, to compensate fluid/electrolyte defects as a result of fasting and also to replace ongoing loss due to evaporation and surgical bleeding (Wong, 1999). As well as the preparation of the anaesthetic room the ODP must also ensure that all equipment needed inside theatre and during the procedure is available such as an operating table that is in good working order, a cleft palate mattress to ensure the correct positioning of Eve, a warming blanket to ensure temperature maintenance and a jelly mat to protect from pressure area sores (Kumar, 1998). It is also the ODPs responsibility along with Dr A to ensure that Eve is transferred in to theatre and on the to operating table safely, that all monitoring equipment is transferred to the inside machines and that all IV therapy equipment is connected before the surgeon preps and drapes the patient as this helps towards maintaining the sterile field around the patient. Throughout the surgery it is seen as best practice for the ODP to remain within close proximity to the patient and anaesthetist in case there is a problem (Kumar, 1998), one such problem noted in Eves case was that when the surgeon inserted the gag needed to keep Eves mouth open he unintentionally moved the position of the ET tube causing a drop in her O2 saturations. Dr A listened to Eves chest with a stethoscope whilst hand ventilating her, this enable her to reposition the ET tube back in to the correct position. Once back in the right place more tape was applied, and the tube was fastened in more securely. If Dr A was unable to just reposition the tube she would have had to remove the tube and reintubate Eve, this means that she would have needed a new Et tube the laryngoscope and blade, maybe a face mask in order to pre oxygenate before re intubation. This is the main reason why all intubation equipment used in the anaesthetic room must follow with the patient into theatre. Whilst in theatre a mechanical ventilator is use in order to ventilate Eve. The Newfield 200 is the vent used within this trust it works by intermittently occluding the expiratory limb of the t-piece and is able to compensate for any leaks around the tube. The ventilator can be adjusted in accordance to Dr As request meeting Eves needs by changing the pressures and times needed. Ventilation was once carried out purely by squeezing the bag by hand; leaving the anaesthetist with just one hand to do other important things such as administer medication or record information, meaning that the Newfield 200 is the preferred method of ventilation in recent times (Sumner and Hatch, 1999). Following the procedure Dr A stopped the infusion of Remi Fentinal and turned off the volatile gas this was to help with the waking up procedure and the safe extubation of Eve. Dr A also ensured that the pack inserted at the beginning was removed safely without causing trauma. Extubation should take place when the patient is fully conscious with there protective reflexes fully intact (Sumner and Hatch, 1999), this is even more important in Eves case due to the nature of her surgery as there could be excessive bleeding or oedema due to the trauma of the oral surgery causing more obstruction to her airway. Although suction should be available during extubation it is noted that large suction catheters such as a yanker should not be used and suction kept to a minimum this is to lower the risk of airway obstruction caused by trauma or by disruption of the surgical repair site. Eves was extubated safely and was transferred to the recovery room with out the need of ICU or HDU intervention. There she was given o2 and monitored by trained recovery staff until they were satisfied that she was able to maintain her own airway and o2 saturations, there was no or minimal blood loss from the wound site and she was pain free. Dr A had prescribed Eve with analgesics to be given back on the ward if needed, this was to ensure that she had a pain free recovery preventing her from getting upset and crying which can encourage the healing process of the wound and maintaining her patient airway. The process of Eves anaesthetic ran a smooth cause. She remained safe throughout the procedure. Great care and planning by both Dr A and the ODP ensured that all events that may have occurred were well prepared for.