Adjustment Disorder with Disturbance of Conduct Case Study

Adjustment Disorder with Disturbance of Conduct Case Study Identifying the Problem Bobby is 12-year-old boy. He was referred to counseling due to his recent onset of disruptive behaviors. Bobby’s parents recently divorced and currently he lives with his mother and a 1-year-old sister. During the last five minutes of the sixth session, he confessed that he hated his baby sister and he thought of killing and harming her. He reported that about a month ago, he made his sister sick by giving her a chocolate laxative. He also reported that he did not inform his mother about what he had done to his sister. His mother thought that his baby sister had a stomach virus. He stated that what he did was wrong. Bobby felt that his baby sister changed his life to the worse. He wants her to go away. He added that he did not want to hurt her today. Bobby’s parents has divorced recently which is a substantial change in his family life. There is no enough information or description about his disruptive behaviors except that they were severe enough to bring him to therap y. Additionally, he has homicidal ideation of killing his baby sister and violated her rights by giving her laxative which was luckily not life threatening. Bobby was diagnosed with Adjustment Disorder with Disturbance of Conduct. People including children develop this disorder due to a reaction of major stress. The intensity of this disorder depends on the child’s disposition, susceptibility, previous experiences and coping skills. Adjustment disorder lasts for six months. The symptoms may continue dependent on the stressor and its consequences. The divorce of his parents is unquestionably will have a long lasting effect on Bobby and his baby sister. Bobby has some of the feature of oppositional defiant disorder such as disobedience and opposition to authority figures; it does not include some of more severe behaviors such as violating the basic right of others or age appropriate social norms. When the behaviors meet both disorders’ symptoms, the conduct disorder take precedence and ODD is not diagnosed. I would schedule a same day session with Bobby and his parents to discuss the seriousness of the problem. I would explore all the concerns I have regarding the baby’s safety and depends on the outcome of that meeting, I will determine to call CPS. My responsibility as a therapist is to take each case seriously regardless whether Bobby is going to carry out his homicidal ideation toward his baby sister. Nevertheless, Bobby is having real feeling of hate toward his sister for a whole year. He is not getting used to having her in his life. During this meeting, I will learn from the parents regarding any recent changes in his health, and include his treating physician. In regards to the parents I would be cautious regarding their quality of care toward their children. I need to know whether there is a possibility of neglect and carelessness or that the parents, especially the mother, is suspecting any intention of Bobby to hurt his sister. They must be given the benefit of the doubt. Within that same vein of thinking, as a therapist, I must be cautious of accusing the parents of neglect due to the serious and could alter the parents’ life. Ethical Decision Making Model The author elected to employee the 7 step Kitchner Ethical Decision Making Model (1984) to apply to the aforementioned vignette. 1. Problem or dilemma: be aware of the different perspectives that may be used identify the problem. It is the duty of the therapist to take Bobby’s intension in homicidal ideation toward his baby sister seriously, while may not be serious about his homicidal ideations, it is important to ensure that baby sister is safe. It is important that this therapist ensure that Bobby’s feeling is not malicious. Sibling abuse can be physical, is the physical, emotional or sexual. It can vary from mild aggression such as shoving or severe such as using weapons or deliberately try to hurt their siblings (Frazier Hayes, 1994). Parents usually are not aware of the problem because either they are working outside the home or they assume that it is a sibling rivalry, which they conceive as normal (Strauss, Gelles, 1994). The difference between sibling abuse and sibling rivalry is that sibling may argue or call each other names but the main difference is that it become and abusive relationship when one child is always the victim and the other is always the aggressor. The result of sibl ing abuse is long lasting that may last to adulthood. Although Bobby’s sister is a baby and does not know what was going on, and that Bobby said that he did not want to kill her today, his anger may trigger this urge and think of killing her again. This therapist does not feel that the baby sister is safe without informing the parents and authority to prevent the next blow (Schneider, Ross, Graham, Zielinski, 2005). As a court mandated reporter it is my duty to report suspected child abuse within 24 hours. However, I have mixed feeling regarding this dilemma. Bobby is my client and by obeying the law, I am preaching the confidentiality and the trust that we built together through the last six sessions. Reporting this information may result in taking the baby out of the home. Would working with parents to ensure the baby’s safety be enough to resolve the issue? After all, the parents are divorced and Bobby may become angrier and more determined to hurt his baby sister. This family went through rough time, as is; however, having a mental disorder, being a teenager, I feel that he present an immediate danger to his sister. Bobby says that he is not thinking about killing her â€Å"today† is not guaranteed and the baby’s safety is in jeopardy. Thus, CPS should be contacted and conferred with in accordance to the APA code of Ethics: As Ethical Standard 5.02 states: Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work (2010). At times, the value of confidentiality will conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuseinformation that may be helpful or necessary to stop the abuse and protect the child. It is also important to schedule separate emergency sessions with the parents and their children to provided support and offer psychoeducation regarding the process. According to, the California Child Abuse and Neglect Reporting ACT (CANRA), located in California Penal Code Sections 11164 11174.3., states that mandated reporters should be knowledgeable of their duty to report. The law states that â€Å"when the victim is a child (a person under the age of 18) and the perpetrator is any person (including a child), the following types of abuse must be reported by all legally mandated reporters: Physical abuse (PC 11165.6) is defined as physical injury inflicted by other than accidental means on a child, or intentionally injuring a child.†. Additionally, child abuse must be reported if â€Å"â€Å"†¦has knowledge of or observes a child in his or her professional capacity, or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse or neglect†¦Ã¢â‚¬  (PC 11166[a]). â€Å"Reasonable suspicion† occurs when â€Å"it is objectively reasonable for a person to ente rtain such a suspicion based upon facts that could cause a reasonable person in a like position, drawing when appropriate on his or her training and experience, to suspect child abuse† (PC 11166[a][1]). 2. Identify the potential issues involved Consider: autonomy/beneficence/Nonmaleficence/justice. The first moral principle that applies to this situation is autonomy. In order for Bobby to grow, he needs to be able to make his own decisions and not rely on his therapist to make decisions for him. Corey, Corey and Callanan (2003) stated, â€Å"respect for autonomy entails acknowledging the right of another to choose and act in accordance with his or her wishes†¦Ã¢â‚¬  (p.16). If I report the homicidal ideation and possible physical abuse then I am not acting in accordance with Bobby and his family’s wishes and therefore I am not promoting autonomy. I feel very strongly about fostering independent relationships, which causes me to question which decision is best for Bobby. The very real issue of the therapist needing to break Bobby’s confidentiality and thus his autonomy is unfortunate but necessary. The different issues involved include Bobby homicidal ideation toward his baby sister and the real possibility that he could attempt to kill her. There is a possibility that Bobby is planning to kill his sister, if that the case, then something has to be done to protect the sister from him. Another issue include the possibility of Bobby having a more serious mental illness; his parents do not have to cope with that alone. It would be beneficent to help them through providing the right treatment, which involve therapy, training and medication if necessary to help build positive environment and deal with the disorder early in Bobby’s life. There is also the possibility that Bobby does not mean what he was saying, if this is the case, Bobby could suffer egregiously and emotionally and so are his parents. Furthermore, the therapist could lose Bobby as a client as a result of the unjust accusation and the subsequent mandated reporting of the claim. However, such a loss, while undesirable is acceptable as the therapist followed the proper code of conduct regarding mandated reporting and nonmalfecience. The therapist will on the same day schedule an individual session with Bobby and assess the client for homicidal ideation and then notify the proper authorities. Nonmaleficence can support either reporting the abuse or not reporting the abuse. In order to prevent physical harm to the baby, the therapist would have to report the abuse. On the other hand, if the therapist does not report the abuse Bobby, his sister may suffer and may be killed. What if Bobby’s actions of giving his sister harmful substance were a one-time action that will never happen again? Reporting may cause Bobby suffers harm that could have been avoided. The principle of beneficence can also support both courses of action. On one hand, if I report the abuse I am promoting the safety of the baby. On the other hand, if I do not report the abuse I am promoting Bobby’s best interests and ensuring that he will not be separated from his mother. Fidelity would support not reporting the abuse because it would require the therapist to break the trust of my client. She has a responsibility to her client and breaking Bobby’s trust would mean that the therapist honoring her responsibility as a professional. On the other hand, veracity would support reporting the abuse because the therapist was truthful from the start with the client when she provided him with informed consent. In the informed consent, the therapist explained that there were limits to confidentiality. There is an obvious conflict in the moral principles in this ethical dilemma. While some of the principle support reporting the abuse, others support not reporting the abuse. To raise even more conflict some of the principles can support both decisions. The therapist sees clear contradictions between fidelity and veracity, nonmaleficence and beneficence and autonomy and beneficence. Fidelity says not to break the trust of the client, while veracity says that she can because she outlined the limits in my informed consent. Just as nonmaleficence could support not reporting the abuse to avoid harm to Bobby’s emotional state, but beneficence would say that the therapist not promoting the baby’s physical well-being. Beneficence can also contradict with autonomy because if I promote the baby’s physical safety by reporting the abuse then I am not honoring the client Bobby’s wishes, which is not supporting his autonomy. 3. Review the relevant ethical guidelines. Is there one or should there be one? The client is an adolescent who has notified the therapist that he hated his baby sister and that he had homicidal ideation toward her. He gave her laxative and made her ill a month ago but he said he did not want to kill her today. In deference to section 11165.3 of the California Penal Code: â€Å"any mandated reporter who has knowledge of or who reasonably suspects that mental suffering has been inflicted upon the child or that his or her emotional well-being is endangered in any other way may report the known or suspected instance of child abuse or neglect to an agency† (2013). Since the therapist has an indication, that homicidal ideation could be occurring in the home, the therapist is mandated to report that information. In addition, the APA code of Ethics (2010) stipulates in section 5.02: Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work. At times, the value of confidentiality wil l conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuse.† Reporting the information to proper authorities will likely be helpful or necessary to stop the abuse and protect the child. In deference to the nineteen seventy-four Tarasoff case ruling, the mother should also be notified of possible danger. 4. Obtain consultation. Prior to reporting the therapist would seek consultation from fellow therapists, CPS and the APA to seek ethical and legal perspectives. In addition, she would refer to an ethical decision making model to assist in the decision process. Whether or not there is any indication on knowledge of the brother is abusing his sister and considering as just sibling rivalry. The therapist concern is that the boy is having enough time with the baby alone without any adult supervision to give her the laxative. Additionally, does the mother know that her son is cruel to his sister but she is afraid of revealing it for the fear that he may be taken away from her? 5. Consider possible and probable courses of action. Probable courses of action include: Emergency individual sessions with each family member will be scheduled within 24 hours of learning about the homicidal ideation. During the emergency session, the therapist would immediately assess Bobby and the respective family members. In addition, the therapist would assess Bobby’s cognition and remind him that he signed an informed consent form, which highlighted the exceptions to confidentiality. If it appears that the client intends to harm his sister the therapist while in session will call the clients treating physician and confer about the next course of action. If there is no time and the client is definitely going to hurt his sister, then separation and removing Bobby temporarily is appropriate. In addition, a mutually agreed upon plan between the therapist and Bobby needs to be in place to ensure that Bobby may refer to it whenever he feels the need to hurt his sister. As there has been a possibility of homicidal ideation by Bobby, child protective services (CPS) must be called within 24 hours. As mentioned previously, the mother according to the Tarasoff ruling should also be notified that there is a possible threat to her baby daughter and should be provided with the support they need to cope with the issue. Follow up sessions with the therapist should also be scheduled 6. Enumerate the consequences of various decisions The therapist could ignore what Bobby said, which could cause further harm to the baby sister. If Bobby decided to physically abuse his sister or gave her laxative or more potent substances then baby would have to continue to suffer from his actions. One of the consequences of reporting Bobby that should be considered is that Bobby may hate his sister even more and would carry out his ideation and actually kill her. On the other hand, if Bobby’s homicidal ideation is just an empty threats, Bobby could be affected emotionally and mentally to such an accusation. In addition, Bobby may refuse to come to therapy and not trust this therapist or any other therapists. Nevertheless, telling the therapist about his feeling toward his sister and wanting to kill her should be considered a â€Å"cry for help† and should be treated with respect. The question of protecting Bobby’s confidentiality arises due to his confession, however: according to the APA code of Ethics: As Ethical Standard 5.02 states, Psychologists have a primary obligation and take reasonable precautions to respect the confidentiality rights of those with whom they work. At times, the value of confidentiality will conflict with other important values. Such a conflict may arise when a psychologist receives information concerning child abuseinformation that may be helpful or necessary to stop the abuse and protect the child (2010). † In addition, if he were able to comprehend the information I would go over the informed consent form with Bobby, which highlighted the necessity of contacting proper authorities regarding the homicidal ideation. Breaking Bobby’s confidentiality could prove to cause him to react emotionally and his trust in the therapist could be broken. It could be very difficult to reclaim or develop trust in Bobby which cou ld hinder the therapeutic process, however if the therapist believes that abuse is occurring she has the law and the code of ethics on her side. 7. Decide what appears to be the best course of action After the therapist had conducted the emergency sessions and discussed the concern with Bobby, the therapist would review the issue(s) with her peers, refer to the APA ethical guidelines and consult with the APA attorneys and CPS, she would then likely call the proper authorities. If Bobby claims that, he was exaggerating and that he did not mean it literally. The therapist has to be cautious and ensure the safety of the baby and reassess Bobby to see whether the initial diagnosis is still appropriate. My initial response is to report this information immediately. â€Å"Failure to Report an abuse result in a misdemeanor punishable by up to six months in county jail and/or up to a $1000 fine (P.C. 11166[c]). He or she may also be found civilly liable for damages, especially if the child-victim or another child is further victimized because of the failure to report (Landeros vs. Flood (1976) 17C.3d399). Furthermore PC 11166.01[b] states that â€Å"any mandated reporter who willfully fails to report abuse or neglect, or any person who impedes or inhibits a report of abuse or neglect†¦ where that abuse or neglect results in death or great bodily injury, shall be punished by not more than one year in a county jail, by a fine of not more than five thousand dollars ($5,000), or by both that fine and imprisonment.† What I understood from this lengthy definition is that if I had any suspicion that the baby was not safe that I should report (CANRA, 1980). Finally, if I did not report his homicidal ideation I would be sending a wrong message to Bobby and may think that is acceptable to have those feeling about his sister. As a therapist, I am dealing with the dilemma of fulfilling my legal duty to report and protect the baby sister rather than attempting to work with Bobby and doing what is in the best interest for his well being. Reference The Child Abuse and Neglect Reporting Act (CANRA), 1980.  www.leginfo.ca.gov/calaw.html

Mr. Darcy

Mr. Darcy  is an intelligent, tall, fine, handsome, wealthy and reserved gentleman, who often appears haughty or proud to strangers. Mr. Darcy has a strong moral fibre and a natural and somewhat embarrassed kindness. Mr. Darcy is the owner of the fictional estate of  Pemberley, he is described as the perfect landlord, a sensible and honourable manager of the estate. He has a great responsibility to keep the estate running – and the locals who depend on it for a livelihood are lucky to have such a good master.Mr. Darcy's inflated personal pride, snobbish indifference and arrogance causes him to consider  Elizabeth Bennet  as low-born and plain, â€Å"tolerable† and â€Å"not handsome enough to tempt him†. However, afterwards he becomes attracted to Elizabeth, and courts her clumsily while struggling against his continuing feelings of superiority. His arrogance and rudeness enhance his desirability, and they are reconsidered later as a sign of his repressed passion for Elizabeth. Pride and Prejudice Writing StyleSurprising Turns of Phrase, Sarcastic, Subtle, Pointed Austen is the total master of the slow, subtle burn. It's like poetry in motion – you just watch as sentence after sentence starts out nice and predictable and then – BAM! – right in the kisser. Let's watch and learn how a pro does it in this paragraph that introduces Sir William Lucas, Charlotte's dad: Sir William Lucas had been formerly in trade in Meryton, where he had made a tolerable fortune, and risen to the honour of knighthood by an address to the king during his mayoralty.The distinction had perhaps been felt too strongly. It had given him a disgust to his business, and to his residence in a small market town; and, in quitting them both, he had removed with his family to a house about a mile from Meryton, denominated from that period Lucas Lodge, where he could think with pleasure of his own importance, and, unshackled by business, occupy hims elf solely in being civil to all the world.For, though elated by his rank, it did not render him supercilious; on the contrary, he was all attention to everybody. By nature inoffensive, friendly, and obliging, his presentation at St. James's had made him courteous. (5. 1) First we go swimmingly along, as Sir William is shown to be a well-off guy who even gets to make a speech in front of the king. Then, though, check out the long third sentence, as the narrator asterfully goes from Sir William's point of view (he now finds actually working for a living â€Å"disgusting† and moves to a house in the country) to an outside perspective on Sir William's growing egotism (all he does now is â€Å"think with pleasure of his own importance†), and then, finally, rounds it off with an amazing judgment on the way climbing the social ladder creates a useless man out of an industrious one (Sir William is free from the â€Å"shackles† of his work and now just spends his time b eing â€Å"civil†).Funny – but we're not done yet. The problem isn't really just that Sir William himself has become totally purposeless ever since getting his knighthood and becoming too high class for his business. The narrator next expands the issue further, pointing to the culture at large, which is more than happy to go along with Sir William and his new attitude.Check out how, because he's all fancy and titled, in the eyes of his neighbors he gets a fancier adjective to describe his behavior (instead of simply â€Å"friendly† he's become â€Å"courteous,† which also carries the pun of â€Å"court† (as in royal court) inside it – the place where Sir William has picked up his new status). By the ‘two themes' I assume you mean pride as one theme and prejudice as the other? Because there are many, many more themes to the text than that: don't be led astray into thinking they're the only ones (or the most important; the novel's title is somewhat arbitrary).One of my personal favourite ways Austen plays with language in P&P is how, once married, Charlotte Lucas is often lumped into conversation as if she is property and little more than an animal (the quote that comes to mind is something about Lady Lucas enquiring of the ‘welfare and poultry of her eldest daughter' after the visit to Rosings — apologies I don't have to text to hand to find the exact quote). If you're looking for Irony, look carefully at practically anything Elizabeth says, particularly in conversations with her mother.Elizabeth says an awful lot in jest, where as her mother is very literal and very closed-minded. In fact, any exchange that involves Mrs Bennet tends to include some irony as she never realises she is being laughed at. Take a story's temperature by studying its tone. Is it hopeful? Cynical? Snarky? Playful? Ironic, arch, wry, full of witticisms and bon-mots, arm's length Reading this novel is kind of like having a conv ersation with someone who says snarky things in a deadpan voice while onstantly raising her eyebrow. You know what we mean? Austen is just so clearly amused by her characters and their nonsense and also totally committed to discretely pointing out their foibles. It's not that she hates them or is disinterested or anything, but her narrator definitely keeps a distance and functions as an observer who is always elbowing the reader to look at the next funny thing. Check out this description of the aftermath of Mr. Collins proposing to Charlotte: In as short a time as Mr.Collins's long speeches would allow, everything was settled between them to the satisfaction of both; and as they entered the house he earnestly entreated her to name the day that was to make him the happiest of men; and though such a solicitation must be waived for the present, the lady felt no inclination to trifle with his happiness. The stupidity with which he was favoured by nature must guard his courtship from any charm that could make a woman wish for its continuance; and Miss Lucas, who accepted him solely from the pure and disinterested desire of an establishment, cared not how soon that establishment were gained. 22. 2) Both Charlotte and Mr. Collins are clearly mocked here, although, obviously, Mr. Collins is a much easier and bigger target. Look at the different ways the mockery works, though. First, we've got the overhead view, meaning the narrator takes in the scene and shows us the ridiculous in all its glory: it's funny to try to picture just how not â€Å"short† Mr. Collins's â€Å"long speech† would be. There's also that great joke in the idea that the proposal is â€Å"settled to the satisfaction of both† (because the satisfaction is kind of pragmatic since Charlotte is Mr.Collins's third choice and he is her choice only because he's got a job and a house and it beats living at mom and dad's). Next, we get to laugh at Mr. Collins more from Charlotte's point of view. Even though they aren't in quotes, the words about his â€Å"stupidity† and the lack of â€Å"charm† in his â€Å"courtship† are clearly her thoughts as he goes on and on in his pompous way. Finally, we circle back around to the narrator mocking the characters again, as we check out how Charlotte is going to deal with the fact that she can see how lame Mr. Collins is. Answer: she's going to wait as long as possible to actually get married. ) What’s Up With the Title? You know what's funny about this title? Well, you know how nowadays, the book jackets for novels written by the same author are usually really similar – same font, same general layout, and so on? (Think about those endless  John Grisham novels. ) That's because publishers are going for an if-you-liked-that-you'll-also-love-this approach. Pride and Prejudice  is basically the result of the same kind of thing, turn of the 19th century-style.Originally, the novel was going to be calledFirst Impressions, but after Austen hit the big time with the blockbuster sales of  Sense and Sensibility, her publisher asked if they could try for a little branding magic by sticking to the same title formula: noun-and-noun. This is all well and good, and sure enough, this new novel went over like gangbusters. Does anything change, though, about how we might see the novel when we go from the first title to the second? Well, with  First Impressions, readers are right off the bat being shown things from the characters' point of view.After all, it's Darcy and Elizabeth that are going be to be making and having these impressions, and, this title suggests, we're going to experience these impressions right alongside them. Also, think about what first impressions are all about – people interacting with each other. A novel called  First Impressions  puts the idea of people meeting with and reacting to other people front and center. The focus is on manners, behavio r, and outward appearance. Not to mention, oftentimes first impression are wrong. On the other hand,  Pride and Prejudice  turns the thing around 180 degrees.With a title like that, we're no longer looking at things through the characters' eyes. Instead, the title sounds like someone is being called names – and it's up to the reader to try to figure out who is who. The reader isn't buddy-buddy with the characters any more, but is instead totally supposed to be all judgy and superior from the get-go. With  Pride and Prejudice  as the title, our novel BFFs aren't Darcy or Elizabeth at all. Instead, our main pal is the narrator, who knows ahead of time that someone's full of pride and someone else is probably full of prejudice.Also, we've now moved into some deep psychological territory here. Feeling prideful and being prejudicial are things we do in the privacy of our thoughts, not things we wear on our sleeve. A novel named in this way makes readers immediately get rea dy for being all up in the characters thoughts, seeing how they make decisions and what their value systems are all about. Which title do you prefer? Why? ————————————————- Style Pride and Prejudice, like most of Jane Austen's works, employs the narrative technique of  free indirect speech.This has been defined as â€Å"the free representation of a character's speech, by which one means, not words actually spoken by a character, but the words that typify the character's thoughts, or the way the character would think or speak, if she thought or spoke†. [8]  By using narrative that adopts the tone and vocabulary of a particular character (in this case, that of Elizabeth), Austen invites the reader to follow events from Elizabeth's viewpoint, sharing her prejudices and misapprehensions. The learning curve, while undergone by both protagonists, is disclosed to us so lely through Elizabeth's point of view and her free indirect speech is essential  Ã¢â‚¬ ¦ for it is through it that we remain caught, if not stuck, within Elizabeth's misprisions. â€Å". [8] Clear, Witty, Sarcastic In this dialogue-driven novel, wit and sarcasm predominate the text. Pride and Prejudice is often an exercise in reading between the lines, as Austen’s characters must almost always use polite language to mask their true intentions. The greatest exception is, of course, when Elizabeth chews Darcy out after his proposal. ) We’ll offer two examples up for you. Mr. Bennet’s response to his wife after she subjects him to a play-by-play of Mr. Bingley’s actions at the ball: â€Å"If he had had any compassion for me,† cried her husband impatiently, â€Å"he would not have danced half so much! For God's sake, say no more of his partners. O that he had sprained his ankle in the first place! † Mr. Bennet clearly doesn’t mean the se things. What he’s really saying is that he wishes his wife would spare him the details.The following snippet of conversation between  Lady Catherine  and Elizabeth takes place at the end of a long interrogation from Lady Catherine. â€Å"‘Upon my word,’ said her ladyship, ‘you give your opinion very decidedly for so young a person. Pray, what is your age? ’ ‘With three younger sisters grown up,’ replied Elizabeth, smiling, ‘your ladyship can hardly expect me to own it. ’ Lady Catherine seemed quite astonished at not receiving a direct answer; and Elizabeth suspected herself to be the first creature who had ever dared to trifle with so much dignified impertinence. See what we mean? Elizabeth dodges Lady Catherine’s question, but does so in the politest way possible. We call it†¦polite resistance, and it requires a great deal of quick thinking. STYLE Jane Austen's graceful, economical narrative style was un ique in her time. It was an era in literature given to flowery wordiness and emotional excess. Readers of the day could take their choice among collections of sermons to improve their minds, tales of sin and punishment to improve their morals, and horror stories to stimulate their circulation.Pride and Prejudice is told in a readable prose without a single superfluous word, and it frequently breaks into dialogue so lively and so revealing of characters that entire scenes have been lifted bodily from the novel and reproduced in dramatized versions for stage and screen. In some passages the author enters into the mind of one or another of her characters, most often into her heroine Elizabeth's, and there she reveals her character's capacity for humor and self-criticism. Austen's style is so deceptively lucid that we can hardly believe she submitted her writing to so much polishing and revision. | POINT OF VIEW Pride and Prejudice is mostly written from the objective view of an externa l observer. However, from time to time the novel departs from this objective storytelling approach to explore the thoughts and feelings of a character-either Darcy as he slips little by little into love with Elizabeth, or Elizabeth as she considers her own behavior and the behavior of others. Whatever the approach whether through Elizabeth's mind or through the voice of a narrator, the point of view is always and unmistakably Jane Austen's.It is always her sharply critical eye, youthful though it was when she wrote the novel, that observes and subtly comments on her society's follies and foibles, making us laugh but also making us aware. When we finish her book we know very well the defects she saw in the people of her world, but we also know how much she enjoyed her life among them, faults and all. FORM AND STRUCTURE Like her writing style, the structure of Jane Austen's novel is deceptively simple. She appears to be telling a straightforward story, character by character and happe ning by happening, exactly as it occurred in chronological sequence.We can in fact read the novel that way. But on closer look we find that Pride and Prejudice is not merely a record of events. Instead, it is an interweaving of plot and subplots, an intricate pattern with various threads. The main plot follows the far from smooth course of the romance between Elizabeth and Darcy and the conflict of his pride and her prejudice. Their feelings, born of first impressions, are not the only obstacles between them. Three subplots complicate their relationship. The first is Bingley's attraction to Jane Bennet and Darcy's intervention to save his friend from what he sees as an undesirable marriage.The second is Wickham's involvement with the Darcy family, and his ability to charm Elizabeth and deepen her prejudice against Darcy. The third is Charlotte Lucas' marriage to Mr. Collins, which throws Elizabeth and Darcy together and sharpens their differences. Elizabeth ends up rejecting Darcy i n what we come to see as the first dramatic climax of the story. The Wickham subplot brings on the second dramatic climax: his elopement with Lydia and the scandal and probable ruin of the entire Bennet family. Austen maintains an air of suspense to the very end. She also keeps her three subplots alive with a novelist's juggling skill.In the end, all three subplots contribute to the resolution of the principal plot, and the hero and heroine come together in happiness at last Writing Style: In Pride and Prejudice there is very little focus on natural surroundings such as trees, bushes, flowers, or descriptions of the weather. Rarely does Austen describe character’s psychological states, instead this aspect of the characters is revealed through dialogue. The unnaturally flowery language in Pride and Prejudice may be seen by modern audiences as â€Å"cold† or â€Å"sterile,† but it is this use of language that helps to develop the characters and themes.Exaggeration and hyperboles (in a melodramatic form) are also common writing styles of Austen. In terms of style conventions, the usage of â€Å"Miss† and â€Å"Mr. † in Pride and Prejudice makes it at times unclear which character is talking, and therefore at times very confusing to follow the story. The frequent dialogue between characters also makes it difficult to distinguish which character is speaking. A number of plot points are also advanced in Pride and Prejudice through the writing of letters between essential characters, which tend to be some sort of monologue regarding a possible theme or conflict in the story.

Case Study on Calculous Cholecystitis Essay

I.Introduction A. Concepts in nutrition, medical nutrition therapy, and organ systems concerned Nutrition is the study of food in relation to health. The Food and Nutrition Council of the American Medical Association defined nutrition as the â€Å"science of food, the nutrients and other substances therein, their action, interaction and balance in relation to health and disease, and the processes by which the organism ingests, digests, absorbs, transports, utilizes and excrete food substances.† Nutrition is also concerned with the physiologic needs of the body in terms of specific nutrients, the means of supplying these nutrients through adequate diets, and the effects of failure to meet nutrient needs. In this similar viewpoint, nutrition is also concerned with the social, economic, cultural, and psychological implications of food and eating. Nutrition follows the four basics concepts, namely: 1.) Adequate nutrition is essential for health. 2.) Food items are classified according to content in terms of majority of nutrients, broadly classified as carbohydrates, proteins, fats, minerals, vitamins and water and are needed daily in the diet of humans. 3.) An adequate diet is the foundation of good nutrition, and it should consist of a wide variety of natural foods. 4.) Nutrients should be provided preformed in food, whereas a few may be synthesized within the body. 5.) Nutrients are interrelated and there should be metabolic balance in the body. 6.) The body constituents are in a dynamic state of equilibrium. 7.) Human requirements for certain nutrients are known quantitatively within certain limits. 8.) The effects of nutritional inadequacy are more than physical; behavioral patterns and mental performance are also compromised, and; 10.) Proper education, technical expertise in addition to the use of all resources available in the practice of nutrition will help upgrade the nutritional status of people. (Lagua, Claudio and Ruiz, 2004) Race has been a predisposing factor in developing gallstones. Westerners usually develop cholesterol stones, while Asians tend to have pigment or mixed stones. There has been an increasing prevalence of calculous cholecystitis in the Philippines. Whatever the type, size or origin of these stones, they can present with a variety of signs and symptoms. Stones develop in a sluggish, diseased gallbladder. Formation of stones may be due to infection, stagnation of the bile or changes in the chemical composition of the bile, overeating or poor eating habits. Obesity is highly associated with prevalence of gallstones. Prevalence increases with age, history of diabetes mellitus and elevated serum triglycerides ( Lagua, Claudio, 2011) The gallbladder may contain one large stone or many small ones. Infection accompanied by formation of gallstones is referred as calculous cholecystitis. Often times, people with gallstones must have their gallbladder removed through a process called cholecystectomy. Transition diets are given accordingly after surgery and if the patient advances to an oral diet post-surgery, intake of fat is allowed as tolerated. As an accessory organ, the gallbladder is fairly easy to live without. Once it is removed, bile travels from the liver directly into the small intestine. B. IMPORTANCE/ SIGNIFICANCE OF THE STUDY Disorder of the accessory organs present a significant impact on the absorption and nutritional status of an individual. Failure to give immediate treatment could bring about complications which are more difficult to manage. These complications may or may not possibly lead to death of an individual. This study was conducted to enable the students to practice his/ her skills on Diet Therapy I. It may help the students to understand better the disease condition, the actions and interactions of food and medications to the body and the rationale for the diet prescription for the case patient. Moreover, it would help the students, as well as the readers to draft a nutritional care plan for patients with calculous cholecystitis upon acquiring information about the disease through data collection. C. Objectives (General and Specific) The study generally aims to analyze, assess and give proper recommendations to a patient diagnosed with calculous cholecystitis. This study was also conducted to allow students to apply the knowledge gained in the lecture and laboratory class of Diet Therapy I. The study specifically aims to: 1) Gather all the necessary information from the patient’s medical records and the interview 2) Assess the patient’s nutritional status and disease condition base from the information obtained 3) Know the causes, signs and symptoms of the disease condition and its complications 4) Determine and relate the factors and causality for the formation of the patient’s disease 5) Interpret and relate the findings to the patient’s disease condition 6) Formulate a nutritional care plan for the patient 7) Provide a diet prescription appropriate for the condition of the patient 8) Provide short and long term intervention for the patient and other recommendation that could help the prevent disease condition of the patient. D. Limitations of the Study The case study is only limited to the disease condition of the patient with calculous cholecystitis and its possible complications if not given immediate intervention. Due to time constraints, the attending physician and nurse were not interviewed for further understanding of the disease. There was also no diet prescription written on the patient’s medical chart, thus, the hospital’s cycle menu was used as a basis for some computations and analysis. II. Methodology Students of Diet Therapy I were grouped into pairs and were asked to get a patient for the case study. Approved letters provided by instructors of Diet Therapy II, requesting for a case patient with infections, burns, surgery, allergies and diseases of the gastro-intestinal tract were personally submitted to different hospitals in Laguna. Laguna Provincial Hospital in Sta. Cruz Laguna accommodated the request, with the approval of the medical director and assistance of the attending physician, nurse and head nutritionist-dietitian. In the nurses’ station, the necessary information was gathered on the selected case patient and the medical records were copied as data for the study. An interview with the case patient followed afterwards. The patient, together with her aunt, was interviewed to collect necessary data such as personal information, nutritional and dietary history and the 24hr. food recall. Before the said interview, a questionnaire was formulated to systematically and completely obtain all the essential information for a better further analysis. Questions include the 24-hour food recall of the patient food intake (prior to admission and during confinement), personal data, signs and symptoms experienced, patient’s tolerance and acceptance to the food given in the hospital, and some other information that would be beneficial to the study. After data gathering, the case was analyzed and a case study was then formulated. This was done through evaluation of the disease condition of the patient and correlating the symptoms experienced by the patient with the clinical manifestation of the disease. The dietary and the medical intervention given to the patient were also analyzed. This included correlating the principle and rationale of the diet with the patients’ actual illness. The possible nutrient-drug interaction that can happen due to the prescribed medication to the patient was also analyzed. The result of the laboratory and biochemical findings of the patient was also interpreted. After this, the diet of the patient PTA and DC were analyzed quantitatively and qualitatively. The diet was evaluated quantitatively by computing the CPF of the patient’s food intake and computing the adequacy of that diet. Qualitative evaluation, on the other hand, was used using RDA. After analyzing the recommendations given to the patient, short-term and long-term diet plan was prepared for the patient. In computing the desirable body weight (DBW), the Tanhausser’s Method. The WHO standards for body mass index served as the basis in determining whether the client’s nutritional status. Method I was used to determine the patient’s total energy requirement (TER) for long term intervention and the carbohydrates-protein-fat distribution was distributed using the non-protein calorie method. III. Theoretical Considerations A. Disease Condition Calculous cholecystitis or cholecystolithiasis, is caused by the precipitation of the substances contained in the bile, mainly cholesterol and bilirubin with accompanying inflammation. The bile is consisted of bile salts, cholesterol, bilirubin, lecithin, fatty acids, electrolytes and water usually found in the plasma. The cholesterol formed in the bile has no function; it is only a by-product of bile salt formation and the presence is only linked in the excretion of bile. Cholesterol is normally insoluble in water and this is where lecithin and bile salts combine with it to form micelles. Inside the gallbladder, water and electrolytes are absorbed in the liver bile, causing it to be more concentrated. Lecithin and bile salts are not absorbed in the gallbladder, their concentrations increases alongside cholesterol’s. This is the mechanism of maintaining the solubility of cholesterol. B. Definitions and Classifications Cholecystitis – inflammation of the gallbladder. There has been an association of cholecystitis with cholelithiasis. There is almost always a close association with complete or partial obstruction of the stones formed inside the gallbladder. Cholelithiasis – gallstones that precipitated from bile, cholesterol or bilirubin due to impaired gallbladder function or excessive production of by-products from fat digestion. C. Etiology Gallstone formation is due to bile salt, pigments and cholesterol salt accumulation. The stones rub off on the walls of the gallbladder, causing pain and inflammation in the subsequent internal structures. There is also a link between elevated or abnormal estrogen levels with gallstone formation. D. Incidence/ Prevalence There is a 10% incidence of adults getting gallstones. Approximately, there are twice as many women who develop this disease and it increases with age: after 60 years old, there is a 10-15% prevalence in men while a 20-40% prevalence in women was noted. E. Pathology Gallstones obstruct bile flow and causes reflux and subsequent inflammation in the gallbladder. The inflammation is caused by chemical irritation from the concentrated bile, along with the swelling of the mucosal area and ischemia from venous congestion and stasis. Bacterial infections may be a complication and this could account for the infection and could reach the adjacent gallbladder through the circulation. Staphylococci and enterococci are the most common pathogens. Perforation of the gallbladder could lead to gangrene. F. Clinical Manifestations and Underlying Mechanisms Pain is evident in early cholecystolithiasis. There is similarity in the pain experienced with biliary colic and is usually felt after a fatty meal. Pain is experienced in the right upper quadrant and there is spasm in the right, subcostal region. There is elevation in total serum bilirubin, amino transferase and alkaline phosphatase. G. Prognosis After cholecystectomy, patients can return to work in a span of 1-6 weeks. IV. The Patient A. Personal Data The patient is Chastine Salazar, 28 years old, female admitted on January 3, 2013 at Laguna Provincial Hospital in Sta Cruz, Laguna. Her physician is Dr. Flores. B. Socio-Economic History The patient works as a registrar in the Head Office of AMA in Quezon City, Philippines. Due to her sedentary lifestyle, she and her husband jogs for 2 hours every weekend. Her middle-class income allows her to select food items of higher market value, thus chocolate is always present after every meal. The patient does not smoke nor drink but based on the interview, it was found out that she uses laxatives due to constipation problems. C. Present illness and chief complaint Patient has cholecystolithiasis with cholecystectomy as the surgical procedure of which 8 marble-sized gallstones were removed. Pain and vomiting was experienced by the patient and was immediately rushed to the hospital on January 3, 2013. D. Past Illnesses and surgery, allergies, hospitalization There were no family history of predisposing risk factors to cholecystolithiasis but it was found out from the interview that the patient has allergic reaction to sea foods and patient has allergic rhinitis of which she has treated before with steroids. E. Physical State of Health Patient has allergy to sea foods and has allergic rhinitis. Patient also has constipation of which she self-medicates with laxatives. G. Nutritional and Dietary History It was observed from the 24-hr food recall that the patient has frequent consumption of chocolates and carbonated beverages. There was also a high intake of fatty and fried food and dishes every day. Snacking patterns are also noted as the patient tends to overeat every 3 hours.

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