Phase 5 Individual Project 5 Coursework Example | Topics and Well Written Essays - 1250 words

Phase 5 Individual Project 5 - Coursework Example The global spread is due to its superior quality brand that meets consumers’ tastes and preferences and high reputation in customer service delivery a critical factor that its competitors lack. Currently, the firm is the fourth largest retailers in world. Profitability being one of the main objectives that guarantee sustainability and growth of an organization, Home Depot is trading at a profit. This is  showed  by an  increase in the Net sales from $78.8Billion in the year 2013 to $83.2Billion in 2014. The net earnings scaled up from $4.5Billion in 2012 to $5.4Billion in 2013 and finally to $6.3Billion in 2014. Additionally, the store count also improved from 2256 in 2012 to 2263 in 2013 to 2269 in 2014. This result indeed shows that the firm will continue operating at a profit for unforeseen future pursuant to the basis of a going concern (The home depot, 2015). For the purposes of financing its internal activities and investments, the firm preferred long-term debt because of the tax shield that is tied up in the debt. The total amount of debt that is spent by the enterprise is $16.869Billion. The huge sum loan was due to the decrease in its assets by $572Million, decrease in shareholders equity by $572Million, an increase in accounts payable by approximately $10Million all from February 2014 to February 2015. However, this is not  an issue  to shareholders as Home Depot’s statement of cash flows clearly indicates that the cash and cash equivalents have been increasing. This is evidenced by an increase in cash from operation from 6975 in 2013 to 7628 in 2014 and 8242 in 2015. The cash from investing activities increased from 1432 to 1507 and 1271 from the year 2013 to 2015 respectively. The cash from financing activities scaled up from 50354 in 2013, to 6652 in 2014 and 7071 in 2015. This stipulates that the cash and cash equival ents have been increasing substantially and, therefore,

Cloud-based efficiency gains within e-Business strategies Essay

Cloud-based efficiency gains within e-Business strategies - Essay Example E- Business is a process in which the business transactions are made via networks of telecommunication especially the internet. The invention and innovation in the ICT sector led to the development of cloud computing. Cloud computing is the process of using remote server networks on internet to process, manage and store e- business data (Geoffrion and Krishnan, 2003: 1445). This technological process is an option for the use of a personal computer or a local server. Cloud computing has gained popularity within the business sectors over the past years because there has been a need to reduce the energy costs. The cloud computing is also more of environment friendly technology. It is efficient in relation to energy consumption during computation, communication and storage of data. Studies show that cloud computing is more energy efficient compared to in- house information centers. Its efficiency can be categorized into: economies of scale, aggregation and diversity, flexibility and effe ctiveness. It was found that businesses can improve their efficiency by spreading the costs. The costs are spread over a server that is larger, thus allowing efficiency improvements. There has been increased usage of information and communication technologies (ICT) due to technological improvement. The use of ICT has been preferred in the businesses due to its efficiency and effectiveness. The technological dynamics has made efficiency of the ICT to be more energy efficient. There has been increased usage of ICT in businesses due to its ease of use and reliability. Since businesses aim to see that the profit is maximized, there has been a need for cost- effectiveness in ICT (Kyriazoglou, 2012: 213). The environmental concerns, efficiency and effectiveness have seen that cloud computing gets preferred in the business sector. This is because cloud computing has improved the efficient utilization of information

The study of organizational behavior Essay Example for Free

The study of organizational behavior Essay The study of organizational behavior is concerned with: A) psychosocial, interpersonal, and organizational structure B) interpersonal, group dynamics in organizations, and work design C) psychosocial, interpersonal, and work design D) psychosocial, interpersonal, and group dynamics in organizations Points Earned: Correct Answer(s): D 2. The beliefs and assumptions about people, work, and the organization best reflects the: A) social surface B) formal organization C) informal organization D) overt part of an organization Points Earned: Correct Answer(s): C 3. The task of an organization is reflected in its: A) mission, purpose or goal B) human resources C) input materials D) structure Points Earned: 1. 0/1. 0 Correct Answer(s): A 4. The science of human behavior and individual differences is: A) psychology B) sociology C) engineering D) anthropology 5. EXTRA CREDIT: What was your preferred learning style as indicated by the VARK Questionnaire? Also list one way you want to take in intormation according to your style. For the extra point you had to name your VARK learning style AND one way to take in information (according to VARK) Points Earned: 0. /0. 0 6. The internal or external perspectives offer: A) conflicting explanations for human behavior B) complementary explanations for human behavior C) alternative explanations for human behavior D) similar explanations for human behavior 7. The specific setting within which organizational behavior is enacted would be called the: A) external environment B) situation C) organizational context D) group Points Earned: 0. 0/1. 0 8. Culture and the study of learned behavior comprise the domain of: A) management B) psychology C) sociology 9 . All of the following are internal behavioral processes except: A) Judging B) perceiving C) leading D) cognition The four main driving forces creating and shaping changes at work include: A) globalization, demography, diversity, ethics B) globalization, technology, diversity, employee attitudes C) globalization, diversity, ethics, and technology D) globalization, technology, religiosity, ethics 11. The description of an organization as clockworks, in which human behavior is logical and rational, would come from which level within the organization? A) organizational level B) internal level C) group or department level D) individual level The work of Hofstede is important because his studies revealed that more differences n work-related attitudes can be explained by: A) culture B) age C) gender D) profession The major difference between prejudice and discrimination is: A) prejudice refers to behavior and discrimination refers to an attitude B) discrimination has been shown to have more of an impact on productivity than prejudice C) prejudice has been shown to have more of an impact on productivity than discrimination D) prejudice refers to an attitude and discrimination refers to behavior Points Earned: 0. 0/1. According to your text, African-Americans and Hispanic-Americans are likely to be at disadvantage within organizations because: A) available Jobs in the tuture will require less skill than in the past B) they are under-represented in declining occupations C) the proportion of African-Americans and Hispanic-Americans who are qualified for higher level Jobs are often higher than the proportion of qualified whites and Asian- Americans D) they tend to live in a small number of large cities that are facing severe economic difficulties Points Earned: 0. 0/1. 0 Globalization implies all of the following except: A) a borderless world B) competition between workers from other countries C) an organizations nationality is held strongly in consciousness D) the world is free from national boundaries Which of the following was NOT recommended as a technique for increasing the sensitivity of differences between people from various cultures? A) describing one anothers culture B) cultural sensitivity training C) cross-cultural task forces or teams D) role analysis technique (RAT) Which statement best captures the spirit of managing diversity? A) It is a painful examination of hidden assumptions that employees hold. B) It is assimilating women and minorities into a dominant male culture. C) It is complying with affirmative action. D) It is being a good corporate citizen. Which of the following statements/statistics about women in the workforce is incorrect? A) There has been little increase in the number of women CEOs.

The Migration and Assimilation of Mexican Americans Essay Example for Free

The Migration and Assimilation of Mexican Americans Essay The migration of Mexican Americans has been a long journey. The road in which most have taken is one of sacrifice and hard-work. A road paved with the dreams and hopes, faith, determination, and the forbearance to achieve all that this land has to offer. The subject to be discussed is how Mexican Americans have migrated and how they were assimilated into â€Å"American† society. The history of Mexican Americans migration dates back to the twentieth century, which are closely associated to the growth of the railroads and irrigated agriculture. Economic conditions in Mexico caused hundreds of thousands of Mexicans to make new beginnings in the United States in the years from 1917 to the outbreak of the Great Depression in 1929 (Compean, n. d. ). Because of the expansion of sugar beets in Idaho, many Mexican migrant workers were recruited to the basin of the Columbia River. An increase in the demand for labor was seen when recruiters for the railroad companies and agriculture started to move out to the southwestern states and the borders cities in northern Mexico because many Mexicans voluntarily enrolled to find employment and a better life in the United States (Compean, n.d. ). On the other hand, many traveled to the areas of Oregon, Idaho, and Washington on their own because they received word about work opportunities. However, The Great Depression drastically slowed Mexican migration to those regions, but it did not fully come to a halt. Agriculture started to increase in volume because of World War II coming into place and so the demand for labor also increased. Recruiters, again, went in search for Mexicans and Mexican Americans to work the fields. Thousands from the regions of northern Mexico and the Southwest responded to this call to engage in hard and unceasingly hard work in the fields and orchards. At this time the federal government also joined in this struggle by coming to an agreement with Mexico to import Mexican contract workers, who became known as braceros, to harvest crops in the Pacific Northwest and other regions of the country (Compean, n. d. ). Many criticized the Bracero program indicating that it was an indentured alien program and a system of cross-border labor exploitation. Many Mexicans and Mexican Americans were not all eligible for the Bracero Program. Only healthy, landless, and surplus male agricultural workers from regions not experiencing a shortage in labor were allowed to be part of the Bracero Program contract (Hernandez, 2009). In the post-World War II years that the agricultural work opportunities continued to increase and attract Mexicans and Mexican Americans to such states as Oregon, Idaho, and Washington. An increase in the Mexican American migrant â€Å"settling out† of the migrant stream to search for year-round employment and to establish roots close to where they worked was becoming more predominated. Many plants were erected providing more employment and education was also provided for their children. It could be clearly seen that an assimilation process was occurring because Mexican Americans were able to establish communities. As a subordinate group, they have taken on many similarities or characteristics of the dominant group. Religion-based celebrations and customs also encouraged ethnic fellowship and the continuity of Mexican culture among Mexican American communities in the Pacific Northwest. Many of the assimilated features among the Mexican American people were that of volunteer, cultural, and political associations, which has played an important role in the building Mexican American communities in the Columbia River Basin (Compean, n. d. ). Before 1970, a small amount of inhabitants with poor levels of education and discrimination prohibited many from any purposeful political participation in the community where they reside. Mexican Americans will continue striving to shape politics and in the Columbia River Basin as they become citizens. As second-generation descendants; Mexican Americans will continue to obtain education to have the opportunity for voting, erecting businesses, and to contribute important factors to the cultural life of the region. The Mexican American subordinate group has had a great deal an impact not just in the past but well into the present regarding the agricultural department here in the United States. Hernandez (2009) stated, â€Å"By the turn of the twenty-first century, over one hundred years of Mexican and Latino immigration had forged a large Hispanic population in the United States, which signified a fundamental shift in U. S. demographics and carried a significant impact upon American society and culture. However, the century of mass migration from Mexico and, more recently from Central America, was dictated by developments that spanned far beyond the borders of the United States. Uneven capitalist development and U. S. foreign policy framed the story of Latino immigration to the United States,† (pp. 28). References Compean, M. (n. d. ). Mexican Americans in the Columbia basin. Retrieved from http://archive. vancouver. wsu. edu/crbeha/ma/ma. htm Hernandez, Kelly Lytle. OAH Magazine of History, Oct2009, Vol. 23 Issue 4, p25-29, 5p Schaefer, R. T. (2006). Understanding Race and Ethnicity (10th ed. ). : Prentice-Hall.

Malaysian Airline vs Airasia: An Analysis

Malaysian Airline vs Airasia: An Analysis Introduction 1.1.1 The first air service route is conducted between Penang and Singapore during the colonial of British and this led to the incorporation of Malaysia Airways Limited (MAL) in year 1937 by the British government. With the emergence of Malaysia in year 1963, the airline changed its name to Malaysian-Singapore Airlines then to Malaysia Airline Limited in year 1973 and eventually to Malaysia Airlines in year 1987. 1.1.2 AirAsia was set up in 1993 and started up its business on 18 November 1996. The founder of Airasia was a government-owned conglomerate DRB-Hicom. Airasia has incurred a lot of debt and liability at that time and former Time Warner executive Tony Fernandess company Tune Air Sdn Bhd decided to purchase Airasia based on market share price at time of RM1 on 2 December 2001. Mission and objectives Malaysia Airlines vision is to become An Airline of Excellence. Its mission is to become a consistently profitable growth airline through the strategy of business transformation plan and its objective is to flying to win customers and convert the airlines IT operations to deliver fantastic internal customer experience. The mission of Airasia is to form ASEAN brand of Airline Company that is widely known around the globe and to arrive at the lowest cost so that everyone can afford to fly with AirAsia. It also aims to keep its company on track with the latest industry developments and to incorporate excellence practices into their operations that will benefit their customers. The brands or products manufactured Malaysia Airlines Domestic benefits, international benefits, annual benefit travel insurance Malaysia Airlines management team has offer three product plan options: Basic Plan, Value Plan and Premier Plan for domestic traveler, overseas traveler, and frequent traveler. Frequent flyer program Malaysia Airlines has two frequent flyer programs: Grads for Students (Grads) and Enrich. Grads is a frequent flyer program with benefits designed for students whereas Enrich is specifically designed for frequent travelers especially businessman will enable them to gain privileges of obtaining discount or free flights when travelling around the world. Airasia 1.3.2.1 AirAsia Insure Travel Protection is exclusively designed to protect and insure the respective traveler during the duration of flying with Airasia. It comprises In-Flight Plan and Comprehensive Plan. In-Flight Plan was insurance program specifically designed for one-way journey passenger. However, Comprehensive Plan was devised for two-way journey passenger. Types of products Malaysia Airlines offered products such as travel insurance, air cargo services, international and domestic flight services, classes of cabin seats, MAS magazines, MAS souvenirs and value fare packages like Get-the-Deal, and Balik Kampung. Airasia is offering products such as Airasia courier services, Airasia souvenirs, Airasia credit card, Airasia self-produced magazines and Airasia cargo delivery service. Logo and tag-lines The appearance of the corporate logo is designed to be moon kite, with a sheared swept-back look. The word MALAYSIA is italicised to lean parallel with the logo to emphasize on speed as well as direction. The letters MAS bear red clippings in the font style to symbolize the initials of the statutory name of the airline, Malaysian Airline System (MAS). The introduction of blue to the original red to the moon kite logo has national meaning. Moreover, the red and blue divide equally in the middle has a sense of equilibrium. Moreover, the tag-line emphasizes that MH is more than just an airline code; in fact MH is Malaysian Hospitality. Airasia logo is Airasia in italicized form with the characters shaded by red color background whereas its tag-line is Now Everyone can fly. The red color logo is a strong message to the world about environmental problem. Current business development Type of business Topic Sentence: Both Airasia and Malaysia Airlines engaged in trading and services industry. Supporting detail 1: Malaysia Airline is a Malaysia-based company service whereas Airasia is a Thai-based company that engaged in air transportation and their related services. Supporting detail 2: They engaged in operation such as cargo and courier service, goods retailing as well as passenger carrier. Strategies Topic Sentences: In order to be competitive in the industry, Airasia has practised cost leadership strategies whilst Malaysia Airlines(MAS) involved in business transformation plan. Supporting detail 1: Airasia tend to focus on short route to a certain destination in order2 to reduce operating cost. Supporting detail 2: Business transformation program is competitive strategy used by MAS to fight over the big threat such as intense competition, rising cost of fuel in airline industry 2.3 Investor relations Topic Sentences: Airasia and Malaysia Airlines are public listed company traded on the main board of Kuala Lumpur Stock Exchange. Supporting detail 1: The stock of Airasia and Malaysia Airlines are ordinary shares offered to be transacted in primary market and secondary market. Supporting detail 2: Airasia recorded revenue of RM941 million year over year with a 26% growth while Malaysia Airline incurred an operating loss of RM 286 million in the second quarter of year 2010. Public relations Topic Sentence: Airasia launched AirasiaMegastore, an online shopping gateway for consumers while Malaysia Airlines established PINTAR visit mainly for students Supporting detail 1: Airasia Mega Store open 24 hours every day and it offers a wide variety of branded product at discounted price Supporting detail 2: MAS provide students with academic tour to Malaysia Airlines and tourist spot in Kuala Lumpur and Putrajaya because they are concerned about the academic progress of students in Malaysia. 3.0 Marketing strategies. 3.1They market their product by using different strategies in order to gain competitive advantage in the markets. 3.1.1 They use market segmentation strategy to split out the market they want to serve. For example, Air Asia segments the market with different income groups and serves the low income group. However, MAS serve the high income group initially, but because of the emerging of Air Asia, it also moves into serving the low income group of customers. 3.1.2 In order to serve the market they have targeted, they positioned themselves differently to gain a different brand image in the mind of customers. Air Asia is using price or quality positioning strategy. On the other hand, MAS tend to use product class positioning at first, but it changes to a mix positioning strategy of price or quality and product class. 3.2 They compete with their competitors with 4P strategies which are commonly applied in marketing. 3.2.1 They use different price strategies that reflect their positioning strategy and price objective to compete in the market. Air Asia is using everyday low price strategy and trying to compete in Blue Ocean. However, MAS use prestige pricing strategy at first, after then which it change to mixed pricing strategies included meeting competitors pricing. 3.2.2 They use different product strategies, so that they can provide different kind of services to compete. Air Asia provides non-frills services in order to keep the cost as low as possible. While MAS provides excellent and luxury services at first, after which it also come out with low price product to compete with its competitors. 3.2.3 They use different promotion strategies to fight against their competitors promotion strategies. Both come out with a variety of special promotions to attract customers. For example, MAS come out RM 1 for ticket to compete with free seat of Air Asia and sometime the fare of MAS is even lower than Air Asia. 3.3 Advertising methods have played an important role to attract the attention and perform the function of informing, persuading and reminding the customers. 3.3.1 They are involved in different advertising channel like television, newspaper, MATTA fair, sponsorship, internet, radio and even performing social corporate responsibility to grab the public attention. 4.0 Conclusion 4.1 The unpredictable changing environment and fierce competition are challenging their company stability. 4.1.1 The increase of fuel price globally has challenged their ability to control the operating cost. Both companies performance was also seriously affected. 4.1.2The management of resources has to be managed effectively and efficiently to remain agile in the market. Air Asia has to control the punctuality index and customer services which were resulted from the behavior of over save cost. In contrast, MAS has to control its behavior of being uneconomical. 4.2 Recently, both of them have developed so well to proceed to their vision, mission and objective. 4.2.1 They have made a lot of improvement on customer services standard to please their beloved customer. Air Asia has adopted complex information system such as state-of-the-art booking system to process various booking. At the same time, MAS has also invested few hundred millions on passenger service system to shorten and provide faster services. 4.2.2 They have expanded their service world-wide in order to provide more choices to customer. Air Asia has joined VietJet airline from Vietnam, and Jestar airline from Australia to expand their routes. However, it also involves in other business, like hotel sector, online purchase and so on. MAS also expand their routes to more area, and involve in online shopping. 4.2.3 They have performed corporate social responsibility to contribute to the society. Air Asia has supported MERCY Malaysias relief mission in Padang, Indonesia whereas MAS has put effort to reduce the carbon dioxide emission to promote a greener environment. 4.3 They are continuing their effort to achieve their vision and promise to do better! 4.3.1 Both companies do not reveal any specify future plan about 2011. But by referring to previous ongoing plans, we tend to know fairly how and where these two companies will move in their future plan. MAS will continue their steps of business transformation plans 2 in this case, such as maintaining 5 stars quality of services and low cost, attracting more customers, building up the network and capacity through service providing. In the future, Air Asia will provide more low cost journey and increase the regularity of fly. It will also continuously keep the cost as low as possible and enable more people to fly! Prepared by: Betty Yong Siew Ning (0902327) Wong Chin Hong (0902068)

Mathematics Technology Lesson Plan :: essays research papers

NTeQ Lesson Plan Project Title: Developing Time Management Unit Topic: Statistics and Data Collection Grade Level: High School (9th-12th) Overview: Students all over the world seem to battle with time management. Many students are involved in extra-curricular activities, or they work while they attend school. Therefore, they not only have the burden of the everyday school assignments, they have several responsibilities outside of school itself. This project will allow students to communicate with students from other tellecollaborating classrooms to discuss the issue of expectations versus time and create a project on their data. This project will provide the opportunity to research topics on how our lifestyles affect our health. Another important aspect of this project is to propose ideas for why we are so constricted by time and if our time constraints have changed over the years. The project will take three weeks to complete and it will address content in mathematics, health, history, and language arts. The students will be responsible for developing their own questions in the survey they will conduct. The surveys will need to be word processed. They will survey a variety of people asking fellow students how much time they spend various activities each day. The students will then classify the information into categories they feel are important. These categories can be discussed with the tellecollaborating classrooms for further input. Once they have collected sufficient data they will present the information on a spreadsheet through a program like Microsoft Excel. After analyzing the data the students will research the information they found through resources such as the library and/or Internet. Once the students have gained sufficient knowledge from their research they will need to develop a paper/presentation on the effects of time constraints and how it has changed through out the years. They can begin by organizing their ideas using concept map software. In displaying the data t he student will have the opportunity to develop a PowerPoint presentation. Objectives: Students will be able to: †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Collect data and present ideas that support the data. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Present the data in the form of a spreadsheet. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Analyze data to support and draw conclusions. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Classify information. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Identify ways to collect information. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Express data and interpretation of data in a presentation. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Expand their understanding of mathematics in real world settings. †¢Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Understand and interpret graphs and charts. Benchmarks/Standards: Patterns, Relationships and Functions (Strand I, Standard I, and Benchmark II) Analyze, interpret and translate among representations of patterns including tables, charts, graphs, matrices and vectors. Patterns, Relationships and Functions

Diabetes Mellitus Study Guide

DIABETES MELLITUS * Chronic multisystem dz , abnormal insulin production / impaired utilization * Disorder of glucose metabolism related to absent/ insuff insulin supply or poor utilization of inslin that’s available * 7th leading cause of death * leading cause of blindness, ESRD, lower limb amputation * contributing factor for heart dz/ stroke risk 2-4 x higher than without DM * INSULIN – hormone produced by cells in islets of Langerhans of pancreas.Normal – continously into bloodstream ( basal rate), or increased w/ meals (bolus) * Normal glucose range 70-120 mg/dL, average insulin secreted daily 40-50 U 0. 6 U/kg * Glucagon, epinephrine, GH, cortisol oppose effects of insulin counterregulatory hormones they blood glucose lebels, stimulate glucose production by liver, movement of glucose into cells. Insulin released from cells – as precursor / proinsulin thru liver enzymes form insulin & C-peptide ( C-peptide in serum & urine indicator of cell function) * in plasma insulin after meal storage of glucose as glycogen in liver/ muscle, inhibits gluconeogenesis, fat deposition, protein synthesis * Nl overnight fasting release of stored g;ucose from liver, protein from muscle, fat from adipose tissue * Skeletal muscle & adipose tissue receptors for insulin insulin-dependent tissues Type I Diabetes Juvenile onset, insulin-dependent, s/s abrupt but dz process present for several yrs, 5-10%, absent or minimal insulin production, virus/toxins, under 40, 40% before 20 yr * s/s thirst( polydipsia), polyuria, polyphagia ( hunger), fatigue, wt loss, Kussmaul respirations * immune mediated dz; T-cells attack & destroy cells * genetic predisposition & exposure to virus * Idiopathic diabetes – not atoimmune, strongly inherited, in small # pt w/ type I DM , African/Asian * Predisposition HLAs human leukocyte ntigens when exposed to viral infection cells destroyed * Long preclinical period, s/s develop when pancreas can no longer produce suffi cient insulin to maintain nl glucose levels * Req. insulin from outside source exogenous insulin eg. injection * No insulin diabetic ketoacidosis (DKA) life threatening, results in metabolic acidosis * â€Å"honeymoon period† – newely diagnosed pts, tx initiated pt experience remissions req little insulin because cells produce suff amount of insulin lasts 3-12 mths then req permanent insulin Prediabetes * risk for developing diabetes glucose levels high but not high enough for diabetes diagnosis * impaired fasting glucose IGF 100-125 mg/dL * 2 hr oral glucose tolerance test OGTT 140-199 mg/dL * HgB A1C – 5. 7%-6. 4% risk for diabetes * Increased risk for developing DM type II – if no preventive measures develop DM in 10 yrs * Long term damage to body heart, blood vessels occur in prediabetes * Usually no symptoms * Maintain healthy weight, exercise regularly, healthy diet risk of developing diabetes Type II Diabetes * Adult onset, non-insulin dependent, 9 0% * > 35, overweight, tendency to run n families * African Am, Asian, Hispanics, Amerian Indians Some insulin is produced but either insufficient for body needs / poorly utilized * Gradual onset, many yrs undetected hyperglycemia, 500-1000mg/dL * Early usu. asymptomatic; high risk pt screen annually * Fatigue, recurrent inf, vaginal yeast inf, candida inf, prolonged wound healing, visual changes * Risk factor obesity ( abdominal/ visceral ) * 4 major metabolic abnormalities * insulin resistance > tissue no response to insulin / unresp receptors – receptors are located on skeletal muscles, fat & liver * ability of pancreas to produce insulin – fatigued from compensatory prod of insulin, ell mass lost * inappropriate glucose by liver – too much glucose for body needs – type II * altered prod. of hormones & cytokines by adipose tissue ( adipokines) role in glucose & fat metabolism – type II. Two adipokines ( adiponectin & leptin ) affect insulin sens itivity altered mechanism in type I & I * Metabolic syndrome > risk for type II & cardio dz, cluster of abnormalities, insulin resistance, insulin levels, triglycerides, HDLs, LDLs, HTN * Risk factors for metabolic syndrome central obesity, sedentary lifestyle, urbanization, westernization Gestational Diabetes During pregnancy, 7% of pregnancies * High risk – severe obesity, prior hx of gestational DM, glycosuria, polycystic ovary syndrome, family hx of DM II screened at 1st prenatal visit * Average risk OGTT at 24-28 wks of gestation * Higher risk of cesarean delivery, perinatal death, neonatal complications * Will have nl glucose levels within 6 wks postpartum but risk of DM II in 5-10 yrs * Nutritional therapy – 1st line , if doesn’t work insulin therapy Other specific types of diabetes * Due to other medical condition or treatment causes abn blood glucose levels * Damage , injury, destruction of cell function Cushing’s, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, TPN * Meds > corticosteroid (prednisone), thiazides, phenytoin(Dilantin), antipsychotics – clozapine * Tx underlying condition, stop meds Diagnostic studies * A1C > 6. 5 % ; greater convenience, no fasting req, less day to day alterations during stress/ illness * FPG >126 – no caloric intake for 8 hrs prior testing ; confirmed by repeated testing another day; if has s/s and FPG>126 further testing OGTT not req * 2 hr OGTT >200, glucose load 75g accuracy depends on pt preparation, and factors that influence results.False negative > impaired GI absorption, falsely elevated> severe restrictions of carbs, acute illness, meds corticosteroids, contraceptives, bed rest * IFG impaired fasting glucose & IGT > prediabetes, 100-125 mg/dL, IGT 2 hr > 140-199 * Glycosylated HgB – HgB A1C > amount of glucose attached to HgB molecules over lifespan ( RBC 90-120 days ) DM pts should check it regularly, done to monitor success of tx / make chang es to tx < 6. % – risk of retinopathy, nephropathy, neuropathy dz affecting RBCs – can affect A1C results Treatment * Goals > s/s, promote well being, prevent acute complications, prevent/ delay onset/ progression; met when pt maintain glucose level as near to nl, daily decisions about food intake, blood glucose testing meds, exercise * Rapid acting insulin – lispro (Humalog), aspart (NovoLog) – onset 0-15 min, peak 60-90 min, dur. -4 hrs , clear, give 15 min before meals ; bolus * Short acting – Regular (Humulin R, Novolin R) onste ? -1 hr, peak 2-3hr, dur 3-6 hrs, injected 30-45 min before meals; bolus * Intermediate acting – NPH, basal insulin, onset 2-4hrs, peak 4-10hrs can result in hypoglycemia, dur. 10-16 hrs, can be mixed w/ short & rapid, cloudy, must be agitated before adm. Long acting – glargine (Lantus), detemir ( Levemir) addition to mealtime insulin, type I, to control glucose between meals & overnight, without it risk of developing DKA, no peak – risk of hypoglycemia , not diluted or mixed, clear; onset 1-2 hrs, dur. 24hrs +, basal * Combination > pt don’t want 2 separate injections, 2 type of insulin mixed together, not same control of glucose levels as with basal-bolus; ahort/rapid mixed w/ ntermediate provide both mealtime & basal coverage * Storage > vials room temperature 4 wks, heat & freezing alter insulin, between 32-86 F; avoid direct exp to sunlight, extra insulin in fridge/ traveling-thermos, Prefilled syringes – sight impaired, manual dexterity; syringes w/ c;udy solution in vertical position needle up to avoid clumping of suspension, rolled gently, warm before injection. * Injection > abdomen fastest absorption arm, thigh, buttock, rotate within 1 particular site; never into site that’s about to be exercised (heat = absorption & onset), vial 1ml=100U, SQ 90 degrees * Needles ? 5/16 inch (short – children, thin adults); gauges 28,29,30,31 – hi gher gauge = smaller diameter = more comfortable injection * Recapping done only by person using syringe, never recap syringe used by pt; alcohol swabs in health care facility before inj to HAI, at home soap & water * Insulin pump – continuous subq insulin infusion 24 hr/d basal rate , loaded w/ rapid acting insulin via plastic tubing to catheter in subq tissue.At meal time – bolus . (+) tight glucose control, similar to nl physiologic pattern, nl lifestyle, more flexibility (-) infection at site, risk of DKA, cost Problems w/ insulin therapy * Hypoglycemia * Allergic rxn – itching, erythema, burning around inj. site, may improve w/ low dose antihistamine ; rxns to Zinc, protamine, latex , rubber stoppers on vials * Lipodystrophy – atrophy of subq tissue if same inj site used Somogyi effect – rebound effect, overdose of insulin induces undetected hypoglycemia in hrs of sleep, produces glucose decline in response to too much insulin s/s headaches, n ight sweats, nightmares ; if in morning glucose – adcised to check glucose levels at 2-4am if hypoglycemia present at that time.If it is insulin dosage in affecting morning blood glucose is reduced TX : less insulin * Dawn phenomenon – hyperglycemia on awakening in the morning due to release counterregulatory hormones in predawn hrs ( possibly GH/cortisol) adolescence/ young; TX: adjustment in timing of insulin adm. or in insulin. Predawn fasting glucose levels insulin production from pancreas , s. ff > wt gain, hypoglycemia * Meglitinides repaglinide(Prandin) insulin prod, less likely cause hypoglycemia because more rapidly absorbed/eliminated, cause wt gain, take 30 min before meal, not if skipped * Biguanides – Metformin > glucose lowering, first choice DM II/prediabetes, obese & â€Å"starch blockers† slow down carbs absorption, taken with â€Å"first bite†, effectiveness> check 2 hr postprandial glucose levels * Thiazolidinediones – Ava ndia > â€Å"insulin sensitizers†, for pts w/ insulin resistance, don’t insulin Production, not cause hypoglycemia; risk of MI, stroke , not for pt w/ HF * DPP4 inhibitor – Januvia > new class, slow inactivation of incretin hormones; DDP4 inh are glucose dependent = risk of hypoglycemia, no wt gain * Incretin mimetics – exenatide (Byetta) > stimulate incretin horm which are in DM II, stim. of insulin, Suppress glucagon, satiety = caloric intake, slows gastric emptying; prefilled pen * Amylin analog > Amylin hormone secreted by cells, co secreted w/ insulin Pramlintide (Symlin) is Synthetic , type I & II when glucose level not achieved w/ insulin at mealtimes , subq thigh or abdomen NOT arm , not mixed w/ insulin – cause severe hypoglycemia ! * blockers — masks s/s of hypoglycemia, prolong hypoglycemic effects of insulin * Thiazide / loop diuretic — hyperglycemia, K Nutrition Type I > meal planning, exercise, developed w/ pt’s e ating habits & activity pattern in mind, day to day consistency in timing & amount of food eaten * Type II > wt loss = improved insulin resistance, total fats & simple sugars = calorie & carbs intake; Spacing meals , wt loss 5-7% = glycemic control, regular exercise * Carbohydrates > sugar, starches, fiber whole grains, fruits, veggies, low fat milk included min 130g/d * Glycemic index GI > describe blood glucose levels 2 hrs after carb meal , GI of 100 = 50g glucose * Fiber intake 14g/1000 kcal * Fats 7% of total calories , < 200mg/d cholesterol & trans fats * Protein same for diabetes / normal renal function / gen. population, high proein diet not recommended * Alcohol > inhibits gluconeogenesis ( breakdown of glycogenglucose) by liver; severe hypoglycemia in pt on insulin / oral hypoglycemic dx.Moderate alcohol consumption < 2 drinks men, track carbs w/ each meal & daily, set limit for max amount ( depends on age, wt, activity level) usu. 45-60g /meal ; also My Pyramid & plate me thod ( ? nonstarchy veggies, ? starch, ? protein, nonfat milk & fruit * Exercise > 150 min/wk moderate intensity aerobic; DM II resistance training 3 x wk, most adults should 30 min moderate intensity activity 5 x most days * Exercise > insulin resistance, blood glucose, wt loss which insulin resistance ( may need less meds), triglycerides, LDL, HDL, BP, circulation * Start slowly w/ progression. Insulin, sulfonylureas, meglitinides >risk of hypoglycemia with increase physical activity esp if exercise at peak of dx or no food intake.Effect may last 48 hrs post exercise Exercise 1 hr after meal, have 10-15g carb snack every 30 min. during exercise (prevent hypoglycemia). Before exercise glucose immediate info about glucose levels – can make adjustments diet, activity, meds * Recomm. for all insulin-treated pts * Multiple insulin injections – 3 or more x day, done before meals, before & after exercise esp in type I, whenever hypoglycemia suspected, when ill (stress), 2 h rs after start of meal – if effective Pancreas transplantation * For pt w/ ESRD, plan to have kidney transplant * Pancreas transplanted following kidney transplant, pancreas alone –rare * Pancreas alone only if hx of severe metabolic complications, emotional roblems w/ exogenous insulin, failure of insulin-based management * Improve quality of life, no exogenous insulin need, no dietary restrictions * Only partially able to reverse renal & neurologic complications * Need lifelong immunosuppression to prevent rejection * Pancreatic islet cell transplantation in experimental stage, islets from deceased pancreas via catheter into abdomen portal vein Nursing management * Pt active participant in management of diabetes regimen * Few/no episodes of acute hyper/hypoglycemic episodes, maintain glucose level near nl * Prevent/ delay chronic complications * Adjust lifestyle to accommodate DM regimen w/ min. stress Nursing assessment Past hx mumps, rubella, viral inf, recent trau ma, stress, pregnancy, infant>9lbs, Cushing, acromegaly, family hx of DM * Meds > compliance w/ insulin, OA; corticosteroids, phenytoin, diuretics * Eyes > sunken eyeballs, vitreal hemorrhages, cataract * Skin > dry, warm, inelastic, pigmented lesions on legs, ulcers(feet), loss of hair on toes * Respiratory > Kussmaul – rapid, deep * Cardio > hypotension, weak rapid pulse * GI > dry mouth, vomiting, fruity breath * Neuro > altered reflexes, restlessness, confusion, coma * MS > muscle wasting * Also electrolyte abnormalities, fasting glucose level >126, tolerance test> 200, leukocytosis, BUN, creatinine, triglycerides, cholesterol, LDL, HDL, A1C 45yrs without risk factors for diabetes Acute intervention * Hypoglycemia, DKA, HHS – hypersmolar hyperglycemic syndrome * Stress f acute illness/ surgery > counterregulatory hormones > hyperglycemia ( even minor upper resp infection or flu can cause this) * Continue regular diet, noncaloric fluids (broth, water, diet gelatin, decaffeinated), take OA/insulin as prescribed, monitor glucose Q4H * Acutely ill DM I , glucose>240 test urine for ketones Q3-4H , medium/large report to MD * Ill > eat than normal > continue OA meds/ insulin as prescribed + carbohydrate containing fluids (soup, juices, decaffeinated) * Unable to keep fluids/ food down MD * Don’t stop insulin when ill counterregulatory mechanisms will glucose level * Food intake important body needs extra energy to deal w/ stress Extra insulin may be needed to meet this demand, prevent DKA in DM I * Intraoperative > IV fluids & insulin before, during, after sx when there’s no oral intake In DM II w/ OA – explain it’s temporary measure, doesn’t mean worsening of DM * If contrast medium (w/iodine) > Metformin discontinued 1-2 days before sx, resumed 48 hrs after sx risk of acute renal failure.Resume after kidney function nl ( creatinine checked & is nl) * Insulin adm > teach proper administration, adjustments, side e ffects, assess response to insulin tx, if new to insulin assess ability to manage tx safely, cognitive status, ability to recognize/ tx hypoglycemia, if cognitive skill another responsible person must be assigned; diff to self inject/ afraid of needles * Follow ups > inspect injection sites ( lipodystrophy ) * Short term memory deficit > OA or short acting OA cuz doesn’t cause hypoglycemia * OA w/ diet & activity, not take extra pill when overeating * Diligent skin care & dental > aily brushing/ flossing, inform dentist about DM * Foot care !!! scrapes, burns treated promptly & monitored > nonirritating antiseptic ointment > dry sterile pad> not start to heal in 24 hrs or infection > MD * Regular eye exams * Travel – sedentary > walk Q2H to prevent DVT & prevent glucose , carry snacks, extra insulin COMPLICATIONS Diabetic Ketoacidosis DKA * Diabetic coma Profound deficiency of insulin > hyperglycemia, ketosis, acidosis, dehydration * Most likely in DM I pts, but someti mes in DM II ( severe illness/ stress) * Causes > illness, infection, undiagnosed DM I, inadeq insulin dosage, poor self management, neglect * Insulin – glucose cant be properly used for energy fat broken for fuel ketones (by product) serious when excessive in blood alter pH, cause metabolic acidosis ketonuria (in urine) & electrolyes depleted; impaired protein synthesis, nitrogen lost from tissues * Untreated depletion of Na, K, Cl, Mg, phosphate hypovolemiarenal failure/ retention of ketones & glucose shockcoma (result of dehydration, lytes & acidosis)death * s/s > dehydration, poor turgor, dry mm, HR, orthostatic hypotension, Kussmaul , abdominal pain, sunken eyeballs, acetone fruity odor, early s/s > lethargy,weakness * blood glucose >250, arterial blood pH IV access begin fluid/ electrolyte replacement NaCL 0. 45% or 0. 9% to restore urine output 30-60 ml/hr & BP * glucose level approach 250 5% dextrose added * Incorrect fluid repl > sudden Na & cerebral edema * Obtain K level before insulin started – insulin > further K * Insulin withheld until fluid resuscitation & K>3. 5 * Too rapid IV fluids & rapid lowering of glucose cerebral edema Hypersmolar hyperglycemic syndrome HHS * Life threatening, able to produce insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, ECF depletion * Less common than DKA * Often > 60, in DM II Causes > UTI, pneumonia, sepsis, acute illness, new DM II * Asymptomatic in early stages > so glucose can rise very high >600mg/dL * The higher glucose > in serum osm > neurologic manifestations somnolence, coma, seizures, hemiparesis, aphasia * Resemble CVA (stroke) determine glucose level for correct dx * Ketones absent in urine * Tx similar to DKA * First IV 0. 45% or 0. 9% NS, regular insulin given after fluid replacement * Glucose fall to 250 – add glucose 5% dextrose * Hypokalemia not as significant as in DKA * HHs require greater fluid replacement * Assess VS, I&O, turgor, l abs, cardiac / renal monitoring related to hydration & electrolyte levels, mental status, serum osm Hypoglycemia Low blood glucose glucagon & epinephrine > defense against hypoglycemia * s/s of epinephrine > shaking, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor * brain req constant supply of glucose > when > affect mental functioning > LOC, diff speaking, visual disturbances, confusion, coma, death * Hypoglycemis unawareness > no warning signs until glucose reach critical point > incoherent, combative, LOC > often elderly w/ beta blocker meds * When very high glucose level falls too rapidly, too vigorous management of hyperglycemia * Mismatch in timing of food intake & peak of isulin/ OA * Can be quickly reversed Check glucose levels, if contain fat that glucose absorption; check glucose in 15 min * Still 70 eat regular meal/snack low peanut butter, bread, cheese, crackers, check glucose in 45 min * No significant imptovement after 2-3 doses of 15g carb MD * Pt no t alert to swallow 1mg glucagon IM in deltoid muscle ( nausea, vomiting rebound hypoglycemia) * Hospital setting > 20-50ml of 50% dextrose IV push * CHRONIC COMPLICATIONS OF DM Angiopathy * end organ dz from damage to blood vessels (angiopathy) 2nd to chronic hyperglycemia * leading cause of diabetes-related deaths, 68% deaths due to cardio, 16% strokes * causes: accumul.Of glucose metabolism by products (sorbitol) damage to nerve cells, abnormal glucose molecules in basement membrane of small blood vessels (eye,kidney), derangement in RBCs – oxygenation to tissues * DM I > keep blood glucose levels near to normal – retinopathy & nephropathy (complications of microvascular complications) Macrovascular complications * Dz of large, medium size blood vessels , earlier onset in pt w/ diabetes * W > 4-6x risk of cardiovascular dz, M > 2-3 x * risk factors > obesity, smoking, HTN, fat intake & sedentary lifestyle * Smoking injurious to pt w/DM, risk for blood vessel dz, CV d z, stroke, lower extremity amputations * Maintain BP control – prevention of CV / renal dz Microvascular complication * Thickening of vessel membranes in capillaries/ arterioles in response to chronic hyperglycemia * Are specific to diabetes Eyes ( retinopathy ), kidneys ( nephropathy ), skin (dermopathy ) * Some changes present w/DM II at time of dx, but s/s not appear until 10-20 yrs after onset of DM * Diabetic retinopathy – microvascular damage to retina, most common cause of blindness 20-74 yrs old. Nonproliferative> most common, partial occlusion of small blood vesselin retina microaneurysms, Proloferative> most severe, involves retina & vitreous neovasculization ( form new blood vessels to compensate) if macula involved vision is lost * DM II > dilated eye exam at time of diagnosis & annually, DM I within 5 yrs after DM onset * Laser photocoagulation * Virectomy * Glaucoma Nephropathy – microvascular complication, damage to small blood vessels that supply glomeruli / kidney.Leading cause of ESRD in US; same risk for DM I & II > HTN, smoking, genetic predisposition, chronic hyperglycemia * Screen for nephropathy annually w/ measurement albumin / creatinine ratio * If micro/macroalbuminuria > ACE inh ( lisinopril ) or angiotensin II rec antagonist ( Cozaar ) tx HTN & delay progression of nephropathy * Aggressive BP management & tight glucose control Neuropathy Sensory neuropathy (PNS)– loss of protective sensation in lower extremities amputations * Hyperglycemia > sorbitol & fructose accumulate in nerves damage * Distal symmetric polyneuropathy > hand/ feet bilaterally * Loss of sensation – to touch/ temperature * Pain > burning, cramping, crushing, tearing , at night * Paresthesias > tingling , burning, itching * At times skin too sensitive (hyperesthesia) * Foot injury & ulcerations without having pain TX : blood glucose control, topical creams capsaicin ( Zostrix ) 3-4 X/d pain in 2-3 wks, selective serotonin, norepin ephrine reuptake inh ( Cymbalta ), pregabali ( Lyrica ), gabapentin Autonomic neuropathy – can affect all body systems & lead to hypoglycemic unawareness, bowel incontinence, diarrhea, urinary retention Complications : * Delayed gastric emptying ( gastroparesis ) anorexia, n/v, reflux, fullness, can trigger hypoglycemia by delaying food absorption * Cardiovascular abnormalities , postural hypotension assess change from lying, sitting, standing, painless MI, resting tachycardia HR * Risk for falls * Sexual dysfunction > ED in diabetic men > 1st s/s of autonomic failure * Neurogenic bladder > urinary retention, diff. voiding, weak stream empty bladder Q3H in sitting position, Crede maneuver ( massage lower abdomen) * Cholinergic agonists > benthanechol Feet & lower extremities Risk for foot ulcerations & lower extremity amputations * Sensory neuropathy > major rosk for amputations due to loss of protective sensations LOPS * Unaware of foot injury, improper footwear, stepping on objects w/ bare feet * Screening using microfilament > insensitivity to 10g Semmes-Weinstein > risk for ulcers * Proper footwear, avoid injuries, diligent skin care, inspect feet daily * PAD risk for amputations due to blood flow to lower extremities * PAD s/s > intermittent claudication, pain at rest, cold feet, loss of hair, cap refill, dependent rubor ( redness when extr in dependent position ) * DX : ankle brachial index ABI & angiography * Casting to redistribute weight on plantar surface * Wound control > debridement, dressings, vacuum, skin grafting etc. Charcot’s foot > ankle & foot changes joint deformity need fitted footwear * Acanthosis nigricans – dark, coarse, thickened skin in flexures & neck * Necrobiosis lipoidica diabeticorum – DM I, red-yellow lesions w/ atrophic skin , shiny & transparent revealing blood vessels under the surface – young women * Granuloma annulare – DM I, autoimmune, partial rings of papules, dorsal surface of h ands/ feet Infection Candida albicans, boils, furuncles, bladder infections (glycosuria) antibiotics Gerentologic * reduction in cells, insulin sensitivity, altered carbohydrate metabolism * 20 % > 65 YO * # of conditions treated w/ meds that impair insulin action (