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Obesity Management in Adult Primary Care

 

Obesity Management in Adult Primary Care

Managing obesity in the primary care setting for patients who are over the age of 18 years requires a serious examination of the key risk factors which contribute to this problem and how it can contribute to multiple comorbidities and reduced quality of life. Primary care providers have a responsibility to be proactive in their efforts to support patients and to provide them with the best possible resources to improve their quality of life and wellbeing through targeted education and other interventions to minimize obesity risks as best as possible.  Primary care providers must share their knowledge and support for interventions which will have the best interests of each patient in mind and recognize motivation and other factors relative to obesity risk. The purpose of the paper is to implement a weight management program to promote weight loss and to reduce health risks in patients, including the development and administration of all available treatments to improve outcomes.

Background Information

Obesity is a serious public health epidemic among children and adults and can contribute to reduced quality of life and an increased cost of healthcare services and treatments for patients due to multiple comorbidities and other complications. Specifically, two-thirds of adults in the United States are considered overweight or obese and are often affected by type 2 diabetes, the emergence of cardiovascular disease, and a greater risk of developing some types of cancer; therefore, it is the responsibility of primary care providers to develop strategies that will be useful in treating patients with obesity and which stimulate weight loss in patients (Fitzpatrick et al., 2016). However, it is known that there are few proven interventions which are applied within healthcare organizations and which have a significant impact on reducing weight and improving quality of life in patients.

In accordance with the recommendations made by the Institute of Medicine (IOM) (2012), it is important to consider the following aims as part of a comprehensive strategy to reduce obesity: Increasing the amount of physical activity of each individual and making this process habitual so that it is part of the daily routine; facilitating easier choices regarding the consumption of healthier foods among adult population groups by reducing access to high sugar and high processed foods; and supporting an increased marketing push to promote increased physical activity and proper nutrition throughout the adult population. These steps are critical in addressing some of the most important health challenges within the adult population and in ensuring that all possible options are explored to promote exercise and physical activity and to improve health and quality of life among adult patients who are obese and have numerous health complications or other challenges which impact their long-term health prognoses.

Purpose Statement

The purpose of the project is to implement an evidence based weight management program in the primary care setting which is designed to emphasize physical activity and proper nutrition through enhanced behavioral modifications among patients who are overweight or obese; furthermore, this program is designed to reduce Body Mass Index (BMI), weight, and waist circumference among patients where no current program exists within the primary care practice setting, enabling nurses to provide critical education, guidance, and support to patients to meet their goals and objectives to stimulate weight loss and improved weight management.

Quality Improvement Model

The Quality Improvement Model chosen for this discussion is the Modified 5 As, which is defined as the following parameters to implement counseling among primary care providers for obese patients to stimulate an intervention to improve weight loss outcomes: Ask by using motivational interviewing to ask questions of patients to address their weight concerns; Assess each patient and the information that is available, such as BMI, along with psychosocial factors and root causes related to weight gain; Advise by improving the relationship between provider and patient through open dialogue and guidance in a professional yet sensitive manner; Agree to a treatment plan and allow the patient to clearly understand its specifics and how the plan will be executed; and Assist in carrying out the course of treatment and provide as much support as necessary to accomplish these goals in a timely manner (Vallis, Piccinini-Vallis, Sharma, & Freedhoff, 2013). This model is provided in the Appendix. Orem’s Theory of Self-Care is applicable to this model because it is often difficult for individuals to engage in self-care activities without a structured support system in place which is designed to improve the outcomes of the intervention and to ensure that patients receive the best possible support to accomplish the goals of the intervention (Eke, 2017). It is important to guide patients when an obesity-based intervention is in place because it is very difficult to overcome the challenges of completing the goals of each step of the intervention individually without a solid support system in place (Eke, 2017).

Synthesis/Overview of Evidence

For this discussion, the evidence that was obtained offers a variety of perspectives regarding the use of interventions to stimulate weight loss in overweight or obese adults. For instance, reducing the risk of cardiovascular disease is a primary objective of any intervention method and requires an examination of key guidelines and recommendations set forth to reduce these risks, such as those supported by the American Heart Association and the American College of Cardiology (Jensen et al., 2013). Lifestyle interventions are of critical importance to this process and require individuals to engage in specific behavioral modifications that will contribute to weight loss and improved quality of life (Brauer et al., 2015). Behavioral interventions are discussed at length throughout the literature and include the approval of interventions at the primary care level by the Centers for Medicare and Medicaid Services (CMS) (Wadden, Butryn, Hong, & Tsai, 2014). Furthermore, evidence addresses the use of motivational interviewing as part of a weight loss intervention to improve behavioral outcomes (Barnes & Ivezaj, 2015). However, although there is information regarding the use of behavioral approaches to weight loss, these practices as part of a larger framework to improve weight loss are not supported by policies that are fully integrated into the practice setting (Dietz et al., 2015).

Prior evidence in this area of study is often represented by a systematic review and meta-analysis technique, including interventions which are designed to lead to behavioral changes (Booth, Prevost, Wright, & Gulliford, 2014). Systematic reviews provide a summary of existing evidence through literature searches and determine if an existing intervention or policy is supported by credible evidence. Furthermore, systematic reviews such as the study by Texieira et al. (2014) considers the risk of relapse which is common when lifestyle interventions for obesity prevention are conducted. Therefore, it is necessary to consider this level of evidence as supportive of the risks associated with these interventions and how to best overcome the challenges that many patients and providers face when attempting to implement these interventions among different adult population groups (Texieira et al., 2014). These practices are essential to the discovery of new resources that may be applied to the practice setting that will have lasting benefits for patients and will contribute to effective outcomes over the long term for patients who face obesity and have specific healthcare complications due to this condition.

PICO Question

The following PICO question is considered for this discussion: Population: Adult patients who are 18 years and older. Intervention: A weight management program focuses on diet and exercise behavior modification.  Comparison: Currently, there is no intervention in the practice.  Outcomes: to reduce BMI /weight/waist /circumference and increased physical activity

In the development of the PICO question, the following key terms were search to identify relevant studies: primary care , obesity, weight loss and nutrition, weight loss and exercise, weight management, and behavioral modifications in weight loss.  A number of electronic databases have been selected due to their relevance for this subject. These databases are the Cochrane Collaboration, PubMed, CINAHL and Scopus.

The inclusion and exclusion criteria for this review of the literature was any study published in the last 5 years that followed an experimental, quantitative or qualitative design, which focused on the knowledge of diabetes self-management in the adult population and interventions to improve this knowledge. This date range was selected in order to ensure that the most up to date These key terms are important in addressing some of the most important challenges of the primary care setting and in recognizing the value of organized interventions with the intent to stimulate weight loss among obese adults.

Conclusion

Managing obesity among adults in the primary care setting is of critical importance because obesity is a serious public health issue with numerous consequences for patients. It is important to develop interventions which can have positive benefits for adult patients and to encourage the integration of motivational interviewing, counseling, and behavioral modifications to stimulate weight loss and reduce obesity in patients. When weight loss is achieved, patients will experience fewer complications and comorbidities and improve their quality of life. This is of critical importance in addressing how to improve weight loss outcomes in patients who are obese and for primary care organizations to introduce interventions that will have positive and lasting effects on patients. A proposed intervention involving adult patinets18 years and older will determine if weight loss can be achieved through improved dietary and physical activity among patients who are overweight or obese and who have multiple comorbidities.

References

Barnes, R. D., & Ivezaj, V. (2015). A systematic review of motivational interviewing for weight

loss among adults in primary care. Obesity reviews16(4), 304-318.

Booth, H. P., Prevost, T. A., Wright, A. J., & Gulliford, M. C. (2014). Effectiveness of

behavioral weight loss interventions delivered in a primary care setting: a systematic review and meta-analysis. Family practice31(6), 643-653.

Brauer, P., Gorber, S. C., Shaw, E., Singh, H., Bell, N., Shane, A. R., … & Canadian Task Force

on Preventive Health Care. (2015). Recommendations for prevention of weight gain and use of behavioral and pharmacologic interventions to manage overweight and obesity in adults in primary care. Canadian Medical Association Journal187(3), 184-195.

Canadian Task Force on Preventive Health Care (2004). Definitions of levels of evidence and

grades of recommendations of the Canadian Task Force on Preventive Health Care.

Dietz, W. H., Baur, L. A., Hall, K., Puhl, R. M., Taveras, E. M., Uauy, R., & Kopelman, P.

(2015). Management of obesity: improvement of health-care training and systems for prevention and care. The Lancet385(9986), 2521-2533.

Eke, P. (2017). Evaluating the Impact of an Evidence-Based Weight Reduction Program Among

the Obese at a Medical Facility in North Central United States.

Fitzpatrick, S. L., Wischenka, D., Appelhans, B. M., Pbert, L., Wang, M., Wilson, D. K., &

Pagoto, S. L. (2016). An evidence-based guide for obesity treatment in primary care. The

           American journal of medicine129(1), 115-e1.

Institute of Medicine (2012). Accelerating progress in obesity prevention: solving the weight of

the nation.

Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, K. A., … &

Loria, C. M. (2014). 2013 AHA/ACC/TOS guideline for the management of overweight

and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Journal of the American college of cardiology63(25 Part B), 2985-3023.

Teixeira, P. J., Carraça, E. V., Marques, M. M., Rutter, H., Oppert, J. M., De Bourdeaudhuij, I.,

… & Brug, J. (2015). Successful behavior changes in obesity interventions in adults: a systematic review of self-regulation mediators. BMC medicine13(1), 84.

Vallis, M., Piccinini-Vallis, H., Sharma, A.M., & Freedhoff, Y. (2013). Modified 5 As: minimal

Intervention for obesity counseling in primary care. Canadian Family Physician, 59: 27-31.

Wadden, T. A., Butryn, M. L., Hong, P. S., & Tsai, A. G. (2014). Behavioral treatment of

obesity in patients encountered in primary care settings: a systematic review. Jama312(17), 1779-1791.

 

Mental Health Capacity

 

Forensic Psychology Assessments

Mental Health Capacity Assessment

Daubert Scale

Angela A is a female client from Minnesota whose issue has been determined as an inability to parent her 14-year-old child. Based on the SA-45 test that has been used to objectively test the patient, it is unlikely that she can take care of a child in her current mental and physical state. To begin with, she exhibits issues related to an inability to instantly recognize her surroundings. This can be attributed to the fact that she is currently taking mood stabilizer pills, synonymous with tests that indicate she has a high risk of being schizophrenic (she has a score of 68 on the MMP1-2 scale). The MMP1-2 scale is effective in testing for various mental and physical issues that could lead to an inability for a person to conform to established practices of society. The method of analysis has a narrow margin of error as it entails questioning an individual in a way that can aid professionals’ assess their mental state (APA).

Interview analysis

Mrs.A is unable to currently bear the responsibility of taking care of a young child as she suffers from issues such as low education ability and substance abuse. She has reportedly used heroin within the past year (last 90 days) and is currently on mood stabilizers. Therefore, she is also at risk of becoming dependent on these substances based on her history of drugs and addiction. While she seems well oriented with her surroundings, she showcases a form of oblivion where she is at times unaware of her actions (she has issues with getting to her appointment on time) (Chandler, 2008).

Collateral information analysis

Furthermore, her dependence on drugs also impedes her ability to take care of a child as she has low education. In this manner, she cannot afford to feed her habit while raising a child. Since she has vocational training, she is likely to be paid minimum wage, alleviating her ability to provide a well-structured home for her daughter. The medication that she is currently taking could also result in issues since it is impossible to realize the extent of her mood swings when such pills cannot be provided. In such a case, it is important to consider the fact that this issue puts the child at risk of harm, regardless of her parent’s upbringing (she did not witness domestic abuse or violence) (Crighton, 2015).

Recommendations

Mrs. A exhibits the traits associated with Gamma mothers, an issue that could lead to neglect for a child in such a parent’s care. Gamma mothers have issues relating to substance abuse as Angela possesses with Heroine. It would, therefore, be prudent to start her on a program to wean her off drugs before proceeding with recalibrating her mental disposition towards life. As a former inmate in the prison system, Angela could showcase instances of delirium. This can be seen in the moments where she is unable to understand her surroundings. Moreover, a strict regimen should be imposed as she is likely to dissociate from the established treatment plan. Gamma mothers are likely to be resistant to treatment offered, as such, physicians and other medical personnel involved in her care should be patient with her progress to ensure she does not deviate from the established design of treatment (Crighton, 2015).

Ethics

To begin with, verifiable means of testing for Angela’s illness have been used. MMP1-2 is a system used in Minnesota to assess the personality of an individual. In this case, the patient resides in the state and thus proper measures have been implemented in her treatment. While it would be helpful to include other methods of assessment to solidify this claim, the physicians responsible for her assessment have considered a due process to deem Angela incapable of raising a child. Furthermore, information used in the assessment has not been derived by force, rather, it has been shared voluntarily by the patient. In this case, the patient is to be treated based on the symptoms exhibited from a voluntary test (Scott, 2010).

Offender Risk Assessment

Johnny B is a male patient currently incarcerated and awaiting parole to determine his legibility to rejoin society. He is of Pakistani origin and has a young child named Albert. The child’s mother is Indian-American, the patient’s former lover and named Jamie. He is currently in prison because of exhibiting offer risk, where he has on several occasions been charged with domestic abuse. However, in 2003, he struck his 18-month-old baby and hurt his mother, resulting in his arrest and subsequent incarceration (Chandler, 2008).

Daubert scale

The Daubert scale has been successful in analyzing the relevance of Mr. B’s claim that he does not pose a risk to his family. Based on the Substance Abuse Subtle Screening Inventory (SASSI-3), the patient has an additive tendency as he has been caught in offenses, albeit minor, while in prison. These issues have arisen due to possession of tobacco, indicating a dependence on the substance. IORNS, a test used to measure the risk of offense has also been used in the assessment as people who have been in prison have a high chance of committing offenses and thus being jailed up again. SARA has also been used to assess the patient’s likelihood to resort to domestic violence in the future (Bartol & Bartol, 2012).

Interview analysis

Based on an analysis of the interview information, Mr. B seems to have used the time spent in prison to better his academic qualifications. This has the result of boosting self-confidence and alleviating issues such as domestic violence in most instances. Moreover, his admittance of the problem and intent to deviate from this tendency is also helpful as it provides a step in the right direction for his healing. Since his relationship with Jamie started at a young age, it is likely that the introduction of a baby in the scenario resulted in additional stress on the individual. Since he has attained significant knowledge during his time in prison, Mr. B. has a higher chance of finding employment than a large number of former inmates, further increasing his chances of thriving outside of prison (Cronin, 2018).

Collateral information

Mr. B has faced several stressful situations in his life. To begin with, he gets a young girl pregnant while in college and delves into drugs to cater for the family. In this way, he deems himself responsible for their well-being. At such a young age, an individual can be affected by stress if they take on a lot of responsibilities. Coupled with bad coping mechanisms such as the use of drugs as the patient has admitted to, this could have disastrous effects for the person and those around them (Jamie and Albert were victims of Johnny’s outburst). He does not showcase any form of prior mental illness that could have prompted violent behavior, nevertheless, he has abused Jamie twice before law enforcement intervened. Therefore, it could be possible that his current predisposition is not related entirely to Albert’s birth. However, it is important to consider his remorse and belief that the system has altered his manner of interaction with people since it is crucial in the determination of whether he is eligible to leave prison (Cronin, 2018).

Recommendations

The prison system has indicated that Johnny’s issues relating to his interactions with people are due to stress. As such, it is important to ensure that he does not pose a risk to Jamie and his son. Before his incarceration, he believed he was his family’s head and thus had to provide sustenance for them. As they have been able to get along without his aid, he can see that he does not need to put a lot of stress on himself, issues that could lead to violent outbursts. However, Mr. B’s interaction with his child and Albert’s mother should be limited at the time of his release and monitored to ensure he does not pose a danger to either of them. It is prudent that Mr. B attends a mandatory anger management class and joins a support group for individuals dealing with these issues. The class is to help him gain new methods to cope with stressful situations rather than resulting to violence. A support group, on the other hand, is to aid the patient as they adjust to society since prison can take a huge toll on an individual. To prevent relapse, support systems are necessary as they prevent individuals from deviating from set plans (APA).

Ethics

The assessment has been presented in an impartial manner. Mr. B has been judged in a manner that reflects the results exhibited by assessment tools used. While one may take a side on the issue, it is important to remain impartial as one’s credibility is reliant on one’s ability to remain impartial when making decisions regarding a client’s status. Though the tests administered do not indicate Mr. B as a threat to himself or others, being biased could lead to wrongful conclusions. The decisions arrived at in the assessment are, however, impartial, exposing weaknesses in the patient’s recovery where seen and indicating the positive aspects in the same light. Impartial treatment of patients helps one remain objective as they develop measures to deal with a situation (Cronin, 2018).

Substance Abuse Potential

Daubert Scale

Jeannie C is a female patient from Minnesota with substance abuse issues that have led to other problems spawning in her life. She is divorced with four children and minimal sources of money, necessitating an assessment of the patient’s ability to sustain herself and her children. Moreover, it is important to ascertain the safety of Jeannie’s children in their current living environment.

Investigators conducted the assessment using the Symptom Assessment-45 test. Furthermore, there is a use of the SASSI-3 test while SARA and MMP1-2 have also been employed to comply with relevant laws. Of this nature, the assessment has yielded a lot of information regarding the nature of Jeannie while allowing an individual to develop a recommendation that protects all parties involved. Based on tests administered, the patient exhibits signs of depression and anxiety. Nevertheless, she is well in tune with her surroundings and indicates a high level of understanding. She does not appear to have any difficulty answering questions asked. Therefore, the tests administered are likely to elicit correct results and thus allow for proper treatment to be administered to Jeannie (Chandler, 2008).

Interview Analysis

Jeannie has in the past been involved in domestic abuse cases, she assaulted her husband, indicating violent tendencies. She has also admitted to occasionally fighting with her current spouse though the arguments are less heated. Nevertheless, this poses a chance for stress to be incurred by both Jeannie and the children in case the relationship status deteriorates. Jeannie’s ability to stay off drugs and alcohol use indicates a will to alleviate destructive factors from her life. She has attended mandatory drug offender meetings due to a court order. However, as her demeanor indicates, she is likely to continue abstaining from methamphetamines in the future. Jeannie’s depression and anxiety issues could have resulted from her experience with the ex-husband. She claims that there are incidences of rape within their marriage, an indicator that she was traumatized by the experiences (Chandler, 2008).

Collateral Information

Jeannie does not exhibit any evidence of homicidal tendencies and thus does not pose a danger to her children and spouse. Nevertheless, she has been in an abusive relationship prior to her current relationship where she is engaged. She is quick to rush into relationships, an aspect that could confuse the children. In this way, children living in such a household are at risk of being neglected as their principle guardian showcases a minimal interest in the children’s welfare when making decisions such as choice of spouse. She has admitted to occasional fights which could potentially affect the children as they are at risk of being exposed to domestic violence to the point where they develop issues of their own which manifest well into adulthood (Davies, 2017).

Recommendations

The patient is a Beta mother and thus is at risk of neglectful actions towards her children. She is also lax about relationships as she is currently engaged after being married before. Therefore, she does not take into account the children’s thoughts when making huge decisions such as being married. In this way, the children could be confused and left in the hands of strangers (she is willing to introduce a new father figure in their lives in a fast manner and thus is not apprehensive of the role models she allows to meet her children). It is important to motivate Jeannie to study more and thus improve her position at work. She may be feeling inadequate in terms of career exploits since her work does not require her skill-set obtained in education. Therefore, it would be prudent to ask the patient to consider joining an academic institution as it affords her the opportunity to advance her skills and thus gain better revenues to sustain her family (Davies, 2017).

Ethics

Jeannie has provided information regarding her health status in a voluntary manner. Well-established tests that are considered viable under Minnesota jurisdiction have been used to come up with an effective analysis of Jeannie. Based on recommendations drawn from the assessment, there is a high chance that the patient could be aided in her integration in society. While she is not incarcerated, Jeannie does not have stable relationships as evidenced by arguments posed within the household. She has been responsible for these fights and thus could be deemed a bad influence towards her children. Nevertheless, it is important to consider each party’s take on an issue before making a conclusion. In this instance, Jeannie cannot be wholly accountable for the damage in her first relationship. She has even stated that there were instances of rape by the ex-husband. Such information is, however, confidential and will remain in this state unless dictated otherwise by the law.

Trauma Symptoms among Children

Daubert Scale

Little Alberta is a six-year-old female client that suffered a major incident a year prior to the assessment.  She was involved in a car accident a year before foster care placed her with the Brady family. However, since her inception, she has showcased a lot of signs that indicate some form of abuse as having taken place such as withdrawal and confusion.

There is a very small chance that the results elicited in the tests administered to Little Alberta are false. This is because they have been continually tested across many states in the U.S.A. when compared to others. In this manner, the TSCYC scale employed to measure Little Alberta’s personality for signs of mental and physical distress could aid in developing accurate recommendations. Moreover, the investigation employs the use of CAPI in analyzing the potential of patents to affect child behavior through an analysis of their attributes. The tests used in this analysis are, therefore, both viable and reliable, in terms of their application in Little Alberta’s case (Chandler, 2008).

Interview Information

Little Alberta is under the care of the Brady family, a strict Christian home that does not tolerate disobedience. They, therefore, expect the child to behave as an adult, ignoring the fact that they should help her deal with the parents’ deaths. As such, she seems to have formed some form of delusion as she has not been addressed regarding the matter. In this way, she continues to live in the past, where she claims that the accident that killed her parents affected her head. There are no indications that she was hurt in this manner, prompting an investigation into the reason for her behavior. Moreover, as children, it is irresponsible for parents or guardians to neglect to provide for them. Alberta is neglected once her foster parents lose their positions at work (Goldstein, 2007).

Collateral Information

Alberta is punished whenever her foster parents consider her behavior to be unacceptable. As staunch believers, the individuals conduct themselves in a way that cannot be deemed acceptable in modern society. They have admitted to spanking Little Alberta whenever she throws a tantrum or talks back to them in a rude manner. In this way, the child could retract from associating with others as her expression of emotions could indicate a deeper issue within her psyche. Traditionally, Little Alberta was a jovial child whose intellectual capacity and level of understanding soared. Recently, her concentration level and the manner in which she conducts herself indicate stress and should thus be eliminated before causing more harm (Heilbrun, Grisso & Goldstein, 2008).

Recommendations

The Brady family is not a good fit for Little Alberta. To begin with, they have adopted a less than perfect method for dealing with issues within the house. Spanking the child cannot be considered an appropriate method to deal with indiscipline, especially for a small child. As a Beta couple, the Bradys have been unable to cope with the loss of income and thus pose a danger for Alberta’s upbringing. Mr. Brady has been charged with domestic abuse in the past, in this way, lack of employment could lead him to take out his anger and frustrations on Alberta. This issue has also led to the child being neglected as indicated by her dwindling score on cognitive function. It is, therefore, prudent to remove Alberta from the current situation and place her in a family with stability. In her current situation, Alberta is likely to grow up with severe mental issues as her parents do not provide her with mental stimulation but rather ignore her as they focus on monetary problems facing them (Heilbrun, Grisso & Goldstein, 2008).

Ethics

Alberta’s well-being is the paramount interest when conducting the assessment. Therefore, regardless of the feelings of the Brady family, the final decision to be made regarding Alberta’s placement should ensure she grows up without any form of deficiency developing. Currently, the Brady family has shown that it cannot refrain from physical punishment when a child under their care makes a mistake. As such, it would not be ethical to send Alberta back to the family. They have demonstrated an inability to look after the child where she has been seen at night watching adult videos. To prevent further degradation of Little Alberta’s potentials, it would be prudent to alleviate her from a neglectful scenario in favor of a situation where she is looked after. This is especially in light of the current predicament where the guardian faces the challenge of making the child come to terms with the reality of her parents dying (Heilbrun, Grisso & Goldstein, 2008).

Child Abuse potential

Daubert Scale

Sue Z is a female patient whose issues related to child abuse. She exhibits several worrying traits such as an affinity to violence and thus requires professional analysis to ascertain the level of risk she poses to those affected by her actions.

Firstly, the SA-45, MMP1-2, SARA and CAPI tests have been instrumental in developing a narrative that explains the individual’s tendency to commit a crime or any other wrongful act. The tests have been used in a myriad of cases and thus illustrate a positive inclination towards proper measurement methods for testing individual viability. Through the SARA test, the patient’s violence traits towards the spouse are monitored while CAPI assesses the likelihood of a child to be harmed by the guardian in question. MMP1-2 is a test reserved for Minnesota patients and illustrates various personal issues that could be developed from certain situations such as physical abuse. Tests used in this manner do not possess a high error rate and are reliable. They can also be checked for validity and viability through scientific testing methods (Chandler, 2008).

Interview Information

Ms. Z illustrates a desire to refrain from violent tendencies as evidenced by her active participation in the programs prescribed for her. Nevertheless, she has been denied freedom to have any other child as she cannot raise her current one. As such, the court has mandated her to abstain from starting a family and instead focus on improving her life. In this way, Ms. Z is attending GED classes though as a requirement by law. This could help her gain better employment since her current education capacity is low. Ms. Z has been in police custody following an assault charge imposed on her after she shot an individual, part of a gang she thought were ‘trying to rape’ her (Chandler, 2008).

Collateral Information

Sue Z has experienced rejection all her life since her mother’s family refused to accept her as part of their own. In this way, she shares the negative trait with her mother’s family where she does not concern herself with the child’s life. As a juvenile, the patient does not have a lot of education skills. It is earlier stated that the government has currently forced her to attend GED classes. In this way, she could gain better employment upon integration in the society. Sue Z also uses marijuana as she claims to have taken some within the past seven days. Here, the emphasis lies on her tendency to lie (she initially denies using any form of drug abuse) where she has not accepted that she has a problem but instead focuses on portraying false information (Cronch, Viljoen & Hansen, 2006).

Recommendation

Sue Z is a Gamma mother based on her upbringing and other factors such as the inclination to crime and education level. She has limited education capacity and could, therefore, not support a child while dealing with addictions on her previous salary. In this way, the best approach to take would be to ensure that the patient is weaned from drug addiction. Her use of marijuana a day prior to her assessment indicates stress. She may be using drugs to cope with normal situations, a fact that could spell disaster as it would lead to dependence on drugs for normal mood. Therefore, eradication of drugs is the first step of healing for Ms. Z. she should also be enrolled in a support group to help her build a sense of belonging. This would also help her alleviate drug cravings as these result in neglect and abuse of her young child. It would also be prudent to allow her monitored access to her child. In this way, she could form a better bond than the one between her and the mother (Petrila, 2010).

Ethics

The investigator ensured that they presented the patient with a question regarding their mental stability and health prior to questioning. In this manner, there is proof that the individual was in her right mind when conducting the assessment. Sue Z has also been tested using modern measures of assessing risk typologies since it would be erroneous to use methods that are deemed dated to analyze current patient characteristics.

Violence risk assessment

Daubert scale

Mr. Doug X is a patient from Minnesota with severe violent tendencies. These issues pertain to violence against women, an act that has led to his incarceration. He is currently seeking release by the parole board as he claims to have changed his erroneous ways.

The MMP1-2 has been used to conform to the state’s laws while SASSI-3 has also been used since he has in the past used drugs. IORNS and SARA are also being use in the patient’s assessment, leading to better conclusions. This is because the methods of measure employed have a low error rate and exhibit minimal variance from the mean. That is because they are accurate and thus tend to be reliable in their application to determine the mental and psychological state of a person.

Interview information

Mr. X has been in prison due to committing violent acts against his wife, Susanne. While in prison, he is often cited for continuing with this destructive behavior, further adding to his anger issues. This lack of adequate management skills has in the past led to the patient being involved in two cases (2011 and 2012) of aggravated assault. His delusional tendencies have made him force Susanne to take drugs before having sexual intercourse. In this scenario, it is clear that he does not consider his acts as negative but rather reinforces his ill-gotten belief in being superior to others (Robbé, Vogel & Douglas, 2013).

Collateral information

The manner in which Mr. X is portrayed showcases deep psychological issues. He is in denial, a fact that leads to the patient trying to justify their actions while ignoring actual adverse effects of their actions. He also believes himself to be superior to others, a delusion that is reinforced by his tendency to daydream and have visions that are not synonymous with normal thinking. Therefore, while he claims to have reformed, he has continued to exhibit violent tendencies in prison. This form of denial has led to one questioning the manner in which the prison system has helped Mr. X in his recovery since denial leads to false belief while the truth does not change (Robbé, Vogel & Douglas, 2013).

Recommendations

Mr. X does not showcase any form of remorse for his previous actions. He has a high likelihood of returning to prison as indicated by a score of 77% in a risk of re-offense test. Moreover, he does not seem to have changed any of his actions, exhibiting violent outbursts whenever he is unable to control his temper. As such, it is unlikely that releasing Mr. X will be advantageous to Susanne since he could continue to harm her as in the past. Therefore, Mr. X requires mandatory supervision if the parole board should release him. Nevertheless, it would be prudent for Mr. X to attend anger management groups and psychology sessions to alleviate delusions that he has allowed to fester in his mind. Releasing the patient would, however, require a lot of supervision while placing Susanne’s life at risk and thus it would be better to hold the patient until such a time when his violent tendencies have been dealt with (Bartol & Bartol, 2012).

Ethics

Firstly, the assessment conducted used the MMP1-2 scale, thus conforming to the state in which patients are located. The use of other measures of mental and psychological wellness could have been erroneous as states differ in terms of laws and regulations applied to assess patient inclination to mental and psychological disorders. Moreover, the patient’s best interest is focused on in the assessment and recommendations arrived at. This is because the focus should be patient-centered to elicit positive results.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

APA. (n.d.). Specialty Guidelines for Forensic Psychology.

Bartol, C. R., & Bartol, A. M. (2012). Current perspectives in forensic psychology and criminal          behavior. Thousand Oaks, Calif: SAGE.

Crighton, D. A. (2015). Forensic psychology. Wiley-Blackwell.

Cronch, L. E., Viljoen, J. L., & Hansen, D. J. (2006). Forensic interviewing in child sexual abuse    cases: Current techniques and future directions. Aggression and Violent Behavior, 11(3),          195-207.

Cronin, C. (2018). Ethics in Forensic Psychology.

Davies, G. M. (2017). Forensic Psychology: Crime, Justice, Law, Interventions. Wiley & Sons,           Incorporated, John.

Goldstein, A. M. (2007). Forensic psychology: Emerging topics and expanding roles. Hoboken,        N.J: John Wiley & Sons.

Heilbrun, K., Grisso, T., & Goldstein, A. M. (2008). Toward Best Practices in Forensic Mental             Health Assessment. Foundations of Forensic Mental Health Assessment, 143-156.

Petrila, J. (2010). Forensic Psychologists, Roles and Activities of. The Corsini Encyclopedia of          Psychology.

Scott, A. J. (2010). Forensic psychology.

 

“Bach System”-Alexander Bach

 

Clemens von Metternich

Crimean War

“Bach System”-Alexander Bach

Decembrist Revolt

 

Part II.  Essay Questions (50 points)  Write and insightful and historically accurate response to one of the following essay questions. Please limit your response to your own words and analysis. (Choose ONE)

  1. Assess the roles of liberalism and conservatism during the Revolutions of 1830s and 1848. Why did the majority of these Revolutions fail? What were the implications for the future?

 

 

 

 

 

  1. German unification was accomplished in three short wars. How did Prussia succeed and what impact did it have on the future of Europe?

Competition and Strategy in Asia/Pacific

Prepare an MBA-level Project Report on the following:
Critically examine a global industry in a country in the Asia-Pacific region. What are some of the interesting companies in the industry (provided in attachments), and what strategies are they pursuing?
Choose TWO firms (already provided in attachments – Cochlear v/s Nurotron), one of which should be classified as a challenger or latecomer in the industry, and one should be classified as a leading global incumbent. Compare the differences in resource building and strategy between the two organisations using appropriate course frameworks, models and concepts.

Be sure to: (1) analyse how the global challenger firm fashioned its strategies in relation to the resources available, the competitive dynamics of the industry and its country context, and, (2) consider/discuss some of the key CAGE factors and institutional voids that the leading global incumbent firm likely had to navigate when entering the marketplace in the Asia Pacific.

The assignment should include the following:
– A business report structure
– Executive summary
– A brief introduction, description of the challenger and incumbent firms, overview of the industry, and the rationale for the choice of firms (an expanded section can be in an appendix)
– Discussion of your analysis (the analysis itself can be mostly contained in appendices
– use VRIN/VRIO, Porter 5 Forces, Porter Diamond, Porter Generic Model Strategy, Institutional Voids, 7 Struggle Framework)
– Conclusions/findings, together with any lessons learned that can be applied into the future for maintaining the firm’s competitiveness considering the changing external environment and existing and potential strategic threats
– Appendices
– Ability to apply unit knowledge (i.e., theories, models, frameworks, concepts, etc.) to analyse the Challenger and the Incumbent firm dynamics selected within a global industry in an emerging economy.
– Clearly written and argued, and well supported with integrated, synthesised evidence from the literature and research sources with full acknowledgment of sources consulted, references used etc. included in the reference list.
– Ability to logically choose, arrange and present the materials and make sense of them for the audience/reader.
– Written presentation to an acceptable postgraduate standard.

Assignments that are excessively descriptive or make excessive use of point-form, will not achieve a high grade.
In your report, be sure to focus on the “how” and “why”, as this is more analytical and interpretative, rather than descriptive (i.e., do not just describe the firms… you must apply the concepts, models and theories to help make sense of, explain, what has happened and is likely to happen.)

ethical philosophy

We’ve looked at several different ethical theories. Re-read the selections beginning from the 1st week of class and then answer the following using ideas from the readings and discussions to help support your answer:

The Hijacked Plane

You are now on a plane containing 150 people currently flying over barren desert. Hijackers take over, killing the pilot and co-pilot and sealing themselves in the cockpit. There is no way for you to open the door, but you could damage the ventilation system causing poisonous fumes to fill the cockpit. If you do this, the hijackers will die, but no one will be able to enter the cockpit and fly the plane; it will crash in the desert killing everyone on board. If you do nothing, the hijackers might land the plane safely – or they might crash it into a civilian target killing even more people. Time is quickly running out and you need to make a choice right now. What should you do? Why is your solution the best possible choice?

Directions: Select, define, and explain how at least one ethical philosophy might best resolve this dilemma; you can use more than one philosopher/theory if you prefer. You can use any of the ideas discussed in the readings; for example, from Ch. 1 there is Aristotle, Kant, Mill, and Rawls. You might also use ideas from the philosophers and writers in other chapters as part of your answer as well. Remember some of the main underlying principles of ethics discussed throughout this semester, e.g., to not to make a situation worse; do no harm; exhibit good conduct. Write clearly and concisely. Use proper sentence structure, grammar, etc. This exam is testing your level of comprehension of the theory or theories selected and their application (synthesis) to this dilemma. Be sure your answer is complete and accurate; for instance: writing only 5 sentences would not be considered a thorough response. Your answer should be at least 2-3 complete paragraphs.

CASE STUDY

CASE STUDY INSTRUCTIONS
Select a scenario below and discuss how you would proceed if working with this client.
Scenario #1
Mario is an illegal alien from Mexico. He has lived in the U.S. for five years and worked various construction jobs in the South. Mario’s family stayed behind in Mexico so he struggles with loneliness and has a poor social network except for an outreach ministry at a local Catholic Church.
Mario was pulled over and charged with a DUI. He was sent to your agency for mandatory counseling in addition to attending a drug treatment support group like Alcoholics Anonymous. You are assigned Mario’s case.
Scenario #2
Janet just completed her fourth divorce. She is in her early 30s. Her personal life is in chaos. She has children by three of her former husbands. Janet has struggled with addiction issues over the years including alcohol and drugs. She came from a very difficult family where her parents were alcoholics and often fought with each other. Janet was sexually abused by her uncle on more than one occasion when he lived with the family during her early teen years. Janet’s problems with drugs and alcohol began as a teenager.
Scenario #3
Roger is an obese 40-year old man and suffers from other health issues like diabetes and high blood pressure. Roger reports that he lives alone and has very few friends. Roger is single and would like to be married. However, he is afraid that women will reject his advances due to his weight. To further complicate the issue, he reports struggling with homosexual thoughts and feelings. Roger sought your help because he recently contemplated suicide.

ASSIGNMENT INSTRUCTIONS
Select a scenario and explain how you would proceed in counseling this client. The following items can serve as sections in the paper. Be sure to identify each section in the paper as a heading.
1. Personal Information
Discuss the information you want to obtain from the client in the first session. Why do you want this information? Would one of the taxonomy models such as the one offered by Hays or Maslow be appropriate? Be clear in identifying this information such as Family Background or Relationship Background and explain why you would want to know this information.
2. Personal Biases and Limitations
Every counselor needs to consider personal biases and limitations carefully. If the topic is a hot-button or you lack sufficient knowledge to be effective with the client then you would need to refer. Identify possible problems in working with the client. Be clear in explaining why these issues could detract from counseling.

3. Goals
What goals would you like to achieve with the client? Why do you believe that these goals are important? What would you do if the client refused to accept a goal that you believe would be helpful? If you were allowed only one goal, what would that goal be? Why do you believe this would be the most beneficial goal?
4. Theoretical Approach
Discuss the theoretical approach or model that you believe will be most effective for the client. Why will this model be the best model to use?
5. Therapeutic Techniques
What counseling techniques would be appropriate (e.g., genograms, journaling)? How many sessions would you schedule? Would you encourage the client to seek other areas of psycho-educational assistance or resources?
6. Measurement of Progress and Success
How do you plan to measure success? Why is this form of measurement the best method to use with this client?
7. Conclusion
The conclusion should provide a brief summary of your closing thoughts or concerns about the future progress of the client.

PAPER REQUIREMENTS
The body of the paper must be 3–5 pages.
The paper must include a minimum of 3 peer-reviewed or scholarly sources published within the past 5 years. The information borrowed from the resources should offer support for your comments. Use the course materials and peer-reviewed journals easily accessed through Liberty University’s online library. If you have questions about the online library, contact the online librarian.
Information borrowed from other resources must be cited APA style in the body of the paper in addition to listing the source citations alphabetically on the reference page.
The assignment must include a title page and an abstract page in addition to a References page that are current APA format compliant. Follow current APA formatting throughout the paper.
If you need assistance with current APA format, contact the Online Writing Center or Tutor.com. Liberty University offers a link to Tutor.com through the Liberty University Online website. Sign in with your Liberty username and password.

Global Harmonization System

The Global Harmonization System of Classification and Labeling of Chemical Substances (GHS) has been adopted by the Occupational Safety and Health Administration (OSHA) and the Department of Transportation (DOT).

What is the GHS?
Why was the GHS developed?
Describe the GHS classification system?
What is the format for the GHS Safety Data Sheet (SDS)?
In your opinion, what are the benefits and drawbacks of this system?

Your response must be at least 75 words in length.

Question 2
A recent industrial facility released lead into the surrounding soil. Soil sampling results indicated the area impacted with lead above action levels is 30 feet by 55 feet. The depth of the lead contamination plume is three feet below ground surface. The land owner wanted to clean this site for future development. Using your textbook, answer the questions below to help you prepare a cost estimate for this portion of the project. Your solutions and any assumptions to justify your estimate must be shown.

What is the chemical symbol of lead, and what group/family does it belong to?
Solve for the minimum volume of soil that will be excavated in cubic yards?
If each dump truck can transport 18 cubic yards, determine how many dump trucks loads will be transported? For calculation purposes, add a 15% “fluff factor” (add to the volume that will be transported).
If the bulk density of soil is 1350 kg/m3 (84.3 lb/ft3), solve for the weight of the soil that will be transported to a disposal site in kilograms.

Your total response to parts a-d must be at least 75 words in length.

Infectious disease prevention and management

Infectious disease prevention and management in specialised settings.

This assignment centres around infectious disease prevention and management planning for the 2018
Commonwealth Games.

Scenario: You are the public health advisor responsible for establishing the processes to manage
potential risks associated with the conduct of the Commonwealth Games at the Gold Coast in 2018. Thisevent saw a substantial influx of local and international athletes, support staff, spectators and tourists.
This expansion of the population between 4-15 April will place added stress on local community
infrastructure, thus posing potential public health risks, particularly in relation to infectious disease. You
will apply your knowledge and understanding of disease prevention and management principles to
address the following (approximate distributions of word count):

 Description of the Gold Coast environment relevant to infectious disease (400 words)

 Outline of infrastructure related to infection control and management (400 words)

 Outline major infectious diseases of concern and their relevant etiology and epidemiology (600
words)

 Describe infectious disease health services capacity and identify critical control points (400
words)

 Describe the role of transport access in affecting risk of infectious disease transmission (200
words)

Microeconomic Theory

Compose a 1050- to 1400-word essay in which you:
Identify a microeconomic theory of interest to you.
Describe the properties and characteristics of the theory.
Illustrate how the theory is used in actions and interactions of individual actors in the economy.
Demonstrate the effect the theory has or may have on your actions as a consumer.
Identify strategies in this theory that could help you in your professional career.
Cite a minimum of five scholarly resources.
Format your paper according to APA standards.

management

Question #1:

When should a manager rely on natural consequences or use sanctions and penalties in addressing employee behavior?

Question #2:

What type of confidentiality threats or important for managers to safeguard against in terms of information systems in human services organizations and why?

Question #3:

Why is it common for employees to be resistant to change when a new manager takes over leadership?

Question #4:

What are the most common sources of stress for managers and why?