Role of Leadership in Advanced Practice in Nursing

Contained herein is an analysis of role of leadership in advanced practice in learning. This is in understanding that lack of leadership in highly specialised nursing situation is mots likely to lead to ineffective provision of services to patients.According to Sofarelli (2005) advanced practice in nursing has the trend of incorporating individuals with deep understanding of all or specific areas of nursing practice. These individuals end up being relied upon in their respective stations to help deliver high quality healthcare services to patients.   These practitioners are further tasked with the responsibility of developing strategies to be applied in the future.However, their capacity to deliver is in most cases affected by lack of proper leadership skills. This analysis will therefore highlight three of the most common nursing leadership theories that could aid in helping professionals in advanced practice to effectively lead respective departments of institutions to better pos itions of meeting patient needs.Having professionals incorporate these theories in their day-to-day activities places them in positions of passing similar knowledge to followers, especially the new ones in nursing profession. In other words, the process of using leadership skills effectively ends up improving professionalism.The three nursing leadership to be discussed in this analysis includes: leader-follower, quantum, and transformational—each would be discussed independently. The theories are being included herein because of their proven effectiveness in achieving results. According to Porter (2007) the use of nursing theories reminds professionals about the best practices when carrying diverse activities. Individuals choose the theory to choose or even combine several approaches into hybrid leadership skills.In addition, professionals could embark on developing ways and means of having own leadership styles that do not fit with the theories discussed in this paper. The h ybrid system could be achieved intentionally by individuals or institutions; it could also be as a result of lack of proper knowledge of the theories. Results could, however, differ depending on the ability of using best practices in theory applications.Quantum leadership theory is mostly used in decision making processes and states that professionals need to look for own problem solving processes before seeking help from colleagues or seniors in respective work environment (Perra, 2001).In other words, the theory tends to initiate leadership in individual professionals, especially those in advanced practice. Fact that these individuals are usually tasked with the responsibility of leading others in various work situations means that they would have to solve problems in collaboration with the followers instead of running to respective superiors for help.Senior professionals in respective departments of institutions can therefore concentrate on other issues as nurses solve problems i ndependently. The senior management in healthcare institutions could, for instance, concentrate on more important issues such as strategy development and implementation (Kitson, 2001).ReferencesBrown, K. (2005). The Leader in Nursing.   Nursing Administration, 11(4), 91-115.Brown, M. (2003). Needs in nursing leadership to improve effectiveness. Nursing Management, 16(6), 101-108.Clifford, J. and Hastings, C (2000). Top trends predicted in nursing leadership. Nurse Management, 20(3), 16-24.Decker, M. (2004). Key to Quality Leadership. Nursing Administration, 22(3), 50-62.Smith, J.   (2003). Effective Leadership &   Management of Nursing. Upper Saddle River: Prentice Hall.Kerfoot, C. (2001). Nursing Leadership and theory. Journal of Nursing, 5(2), 64-70.Kitson, A., (2003). Leadership in nursing & how it influence health policy & nursing practice. Advanced Nursing 29, 700-723.Mohr, W. (2000). Fading in Nursing Leadership. Journal of Nursing Management, 40, 100-127.Perra, G. (2001 ). Future of Healthcare Leadership & Quantum Mechanics. Nursing Administration, 22(3), 16-22.Porter, G. (2007). New Roles in Quantum Leadership. Nursing Administration, 32(11), 30-43.Sofarelli, S. (2005). Consequences of Nurse Shortage in Medical Centers. Daily Bruin, 27(4), 14-26.

Greggs plc Essay

1.0 Executive Summary Greggs plc intend to expand their operations into international markets in order to satisfy their overriding objective: ‘to be Europe’s No. 1 Bakery’. Germany has been selected as the host country and justification for this decision has been discussed. Moreover, Greggs will enter the German Bakery market through the employment of a ‘Foreign Direct Investment’ method, more specifically a ‘Sales and Production Subsidiary’. This report outlines the blend of marketing mix components used to position the offering; the implementation method adopted to ensure effective product and service delivery; and the control mechanisms utilised to make sure that objectives are achieved. 2.0 Introduction Greggs is the currently the leading UK retailer in the bakery market having experienced high levels of growth in 2002. The company achieved revenues of  £422.6 million, an increase of 11.9% on the previous fiscal. Its operating profit also witnessed an increase of 11.8% to  £35.3 million in 2002. Their popularity has rapidly increased as consumers are seeking quick, convenient and indulgent foods to complement their fast-paced lifestyles . Greggs is actively expanding their operations and have over 1,200 retail outlets under the Greggs and Bakers Oven brands . They entered into the international arena in 2003 with the opening of two outlets in Belgium. This strategy was pursued in order to fulfil the company’s long-term objective of becoming a leader in the European market place. Further international expansion will therefore satisfy their current objectives and enhance their presence in the European bakery market. 2.1 Report Objectives To justify market choice To undertake internal and environmental analysis for the home and host country To identify the most appropriate foreign entry strategy To tailor a services marketing mix to requirements of the host market To suggest methods of implementation to allow successful market penetration To monitor the progress of this venture through the employment of control mechanisms 3.0 Mission statement â€Å"We intend to be Europe’s finest bakery-related retailer, achieving our ambitious growth targets by attaining world-class standards in everything we do. Our purpose is the growth and development of a thriving business for the benefit and enjoyment of employees, customers and shareholders alike. 3.1 Values Greggs is a customer-focused business, seeking to provide excellent products and services that deliver enjoyment and value-for-money. We are committed to people development, within a considerate culture that combines autonomy and accountability and maintains a strong focus on profitability. In all our activities, we aim to achieve excellence through continuous improvement†. 4.0 – Market Choice Cannon and Willis propose a method of â€Å"simple elimination † to identify a potential host market. This method of market choice ensures that the remaining country satisfies all main criteria highlighted by the  organisation. The diagram below shows a systematic approach to finding a suitable market for Gregg’s expansion. Industrial, economic and cultural factors will be integrated into the selection process as these are central to Greggs’ operations in addition to their main aim: ‘To be the no.1 bakery retailer in Europe.’ Parallel to their objectives, all non-EU countries will be excluded from the selection process. Greggs’ second priority is to enter markets which display fast growth in bakery markets. The countries with the highest levels of category growth are shown below: Figure A Country Cakes and Pastries Market – % Category Growth 1995 – 1999 Portugal 4.60% Germany 3.70% France 3.60% Spain 1.80% Denmark 1.80% Using this table, Greggs may eliminate Denmark and Spain from their market choice selection process. Psychological distance between the home and host country can also determine the success of international activities and thus have been incorporated into the process. The French have a wide selection of elaborate, exquisite and gourmet dishes. This contradicts the typical product proposition offered by Greggs. Although Greggs could consider a focused differentiation strategy targeting niche  markets, the abundance of specialist bakery retailers would suggestively make the French bakery market difficult to penetrate effectively and therefore exclude it from further scrutiny. Portuguese market trends highlight an increasing demand for â€Å"wholesome, family products â€Å". In contrast to the latter, Greggs offer an ‘on the move’ food proposition which is typically consumed individually rather than in a family environment. Suggestively the Portuguese are reluctant to embrace new food offerings as research illustrates a strong preference for traditional cuisine served in traditional restaurant settings . Moreover the market is dominated by both high street retailers such as Podaria Popular and industrial manufacturers thus implying high barriers to entry are high. Having adopted this process of elimination, Germany appears to be the prevailing market choice. Despite the high labour costs, long vacation time and slow economic growth , Germany’s overall economic performance is the 3rd largest in Europe and consequently presents itself as an attractive market choice for Greggs. â€Å"Products with a convenience character are continuing to prove popular in the German bakery market, ranging from ready to eat and impulse products to in store bakery products â€Å". Furthermore, â€Å"across the bakery market, international bakery specialties such as croissants, ciabattas and baguettes are rising in popularity, a reflection of higher consumer demand for more non-traditional or novel products â€Å". This market therefore presents itself as an ideal location for Greggs to expand their international operations. Greggs will pursue a ‘concentration’ technique with regard to country and customer target group. â€Å"A company may concentrate its efforts by entering countries that are highly similar in terms of market characteristics and infrastructure to the domestic market â€Å". This will enable Greggs to minimise risk and benefit from cultural fit. Moreover, as in the UK they will concentrate efforts on a focused target audience. 5.0 – Internal and Environmental Analysis 5.1 – Internal Analysis 5.1.1 Strengths Internal strengths need to be assessed to identify assets, capabilities and core competencies that are transferable to the host country. Greggs is a well recognised bakery retailing brand in the UK which aims to â€Å"create a single and cohesive Greggs brand nationwide â€Å". This is being executed using a coherent and consistent promotion of the company’s proposition and brand across the country. Greggs have sustained a strong cash flow which allows them to invest money in maintaining in their retail outlets, bakeries and brand. Key investments include significant funds spent on production facilities to support the growth of retail operations. Greggs actively seek to position their stores in prominent locations relative to distribution channels and customer access. Greggs stores are typically located in busy and heavily populated towns where their fast and convenient proposition is ideal. In response to the 6.4% increase in demand for takeaway foods , Greggs is adapting their servicescape to cater for these growing needs. 5.1.2 Corporate Culture Greggs operates in a risk taking corporate culture which allows them to be innovative and responsive to market changes. They believe in providing high customer service aiming to retain customers by inducing loyalty and trust. They place great emphasis on motivating and empowering employees as they believe that continued growth of the business is a reflection of the workforce . These competencies are transferable and of equal value to the  German marketplace. Greggs are actively expanding their operations internationally in order to spread risk, increase international brand awareness of their product portfolio and exploit fast growing new markets. 5.1.3 Value Chain Greggs UK have produced a ‘Value Chain Analysis’ which is â€Å"an analytical tool that describes all activities that make up the economic performance and capabilities of the firm .† This can be used by Greggs to exhibit core competences that can be exploited in the host market . 5.2 – Environmental Analysis The environmental analysis aims to identify the current situation of the German bakery market using relevant tools of analysis and international research methods. A PEST analysis has been used to identify influential factors for Greggs in Germany as discussed. 5.2.1 International Marketing Research â€Å"Marketing research refers to gathering, analysing and presenting information â€Å". It is the lack of knowledge on foreign markets that is one of the major barriers an international marketing manager must overcome . It is therefore imperative that Greggs formulate an effective market research strategy as the first step in overcoming this barrier. In this case, international marketing research was carried out for the purpose of reducing potential risk and providing us with a final systematic and objective approach for our proposition. Primary research has not been undertaken due to the limitations of this report. However, if Greggs were to implement this internationalisation  proposal, primary research would be an imperative tool when considering market choice. These could include qualitative methods such as interviews and observation. Secondary forms of research carried out have included Government reports, Internet sources and textbook literature, and further strengthened by journal articles. This variety of data collection methods helps to provide a rich analysis from numerous sources as a foundation for decision-making. From this research the following factors have been taken into consideration when considering Germany. 5.2.2 Social & Economic Environment Social factors, as outlined in the PEST analysis outline the increasing trend towards ‘on the go’ consumption. This reflects the busy lifestyle of the working population in Berlin hence the choice of location. The economic factor of high disposable income also provides an attractive reason for Germany as consumer spending is high. 5.2.3 Prospective Country Culture Greggs may use the Hofstede model to â€Å"identify persuasive fundamental differences of national cultures † and thereby assess their cultural fit. â€Å"According to Hofstede, the way people in different countries perceive and interpret their world varies along four dimensions: power distance, uncertainty avoidance, individualism and masculinity .† The German culture is a low context and explicit, perhaps ever more so than the British. Moreover, â€Å"the German national mentality is of a relatively high level of uncertainty avoidance. The Germans do not like a sense of insecurity which makes them feel uneasy in business. (Germans work with) hard facts, and sound arguments â€Å". There are therefore slight cultural differences that the UK management team will have to consider upon entering the German market. 5.2.4 Market Competition Competition in the German market is a key variable of Greggs’ success. Figure B- Competitor Analysis Germany cakes and pastries market share (% value) by company Manufacturer 2000 2001 Bahlsen 11.2 9.1 Lady Cake-Feine Kuchen 8.0 6.9 Dahli Kuchen 7.4 7.2 Grossbà ¤ckerei Wendeln 7.0 7.0 Dan Cake 3.2 3.4 Kuchenmeister 7.8 11.3 ABK 9.0 8.6 Private Label 15.1 16.5 Other 31.3 30.0 Total 100 100 It is therefore important to identify, analyse and monitor competitive movement. Figure B illustrates the potential competition in the German bakery market in accordance to market share 5.2.5 Geographical Climate Greggs’ sales are affected only by climatic extremes – very hot weather can depress demand for bakery products, and prolonged rain or snow can make people reluctant to go out and make their usual daily purchases . This pattern is mirrored in Germany and therefore fluctuations in sales must be accounted for. 5.2.6 The German Market The use of the Porters 5 Forces model has recognized the attractiveness of the German bakery market through the identification of barriers to entry and potential substitutes . 6.0 – International Marketing Objectives In light of the organisations resources and competencies, the following objectives have been established: 6.1 Short Term Objectives Utilise promotional mechanisms to encourage trial and to inspire customer loyalty to the brand By fulfilling this objective, Greggs will be working toward securing a loyal customer base thereby defending themselves, to a large extent, from competitors. Conduct quarterly pricing reviews to ensure that prices remain competitive with rivals By ensuring competitive prices, Greggs’ reinforce their commitment to offering ‘value for money’ as highlighted in their mission statement. To ensure all employees receive high standards of training that is reflected in high quality service to the consumer Greggs corporate strategy highlights the importance of a fun and supportive working environment. They promote themselves as being a â€Å"great place to work † and encourage personal development. This in turn reflects on their high quality service offered to the end consumer. 6.2 Long Term Objectives To continually monitor, anticipate and challenge competitor movements in the bakery market. This will allow Greggs to remain innovative and develop new and adapted recipes in response to market changes and consumer needs. To strengthen and build upon our place market to achieve 4% position by 2010. This will be achieved through â€Å"core growth and introduction of new outlets â€Å". It will enable Greggs to be a proficient player in the German Bakery market (see Figure B) To broaden the Greggs product portfolio by 5% year on year. This will permit Greggs to expand their operations, in line with their growth ideals, and additionally offer a larger product range to ever-evolving consumer needs. To launch a further 6 stores in Germany by 2010 thus expanding scope and influence. This will facilitate Greggs strive towards achieving their main aim: ‘To be Europe’s finest bakery-related retailer.’ Increase awareness of the Greggs brand in the German bakery market By attaining brand awareness, Greggs will able to insulate themselves, to an  extent, from the wrath of competition. The German bakery market is largely fragmented thus making it an attractive market for potential new entrants. 7.0 Foreign Market Entry Strategy â€Å"Firms deciding to enter a foreign market face a critical decision in choosing the best market entry mode to service the market. This decision is crucial because it can have an ongoing impact on a firm’s international business performance .† Root (1994) suggests three different rules ‘Naà ¯ve rules’, ‘Pragmatic rules’ and ‘Strategy rules’. However as a result of the increasingly heterogeneous nature of the international market, it is important that Greggs do not generalise their approach, but adapt each entry mode according to the host market. The mode selected in Belgium therefore, may not be entirely applicable to Germany. Based on this rationale, Greggs will be employing ‘Strategy rules’ which is when all entry modes are compared and evaluated before a choice is made . Moreover, according to Hollensen (2001) â€Å"some firms have discovered that an ill judged market entry selection in the initial stages in the firms internationalisation can threaten the firms future market entry and expansion activities â€Å", hence illustrating its importance to Greggs plc. Greggs will need to consider the main groups of entry mode influencers prior to choice in order to identify the most appropriate and profitable mode. 1) Internal Factors According to the Company’s Act (1985), firms with over  £5.75 million in turnover and over 250 employee are classified as large. Greggs more than qualifies this with a turnover of  £422.6 million and employment of 17600 people in 2003. This provides them with an adequate resource capability to open up a sales and production subsidiary in Germany. Moreover, in developing their theory of internationalization, Johanson and Vahlne 1977 assert that â€Å"uncertainty in international markets is reduced through actual operations in foreign markets (experiential knowledge) rather than through the acquisition of objective knowledge .† Greggs have already ventured into Antwerp and Leuven in Belgium hence increasing their experiential knowledge and expertise. Greggs produce is fresh and baked goods. In order to maintain this stance, the only feasible option would be to produce, as well as sell in the host country. Additionally, because Greggs will promote themselves as a British company, they will be communicating a clear differential and competitive advantage. 2) External Factors Both the UK and Germany are members of the European community thereby reducing their Socio-Cultural distance. This proximity between countries will therefore favour hierarchical modes of entry. Due to the proximity between countries perceived risk is reduced. Companies are therefore less reluctant to pursue more involving modes of entry. It has been stated that â€Å"the size of the host country is an important attraction to foreign direct investment † as large and growing markets will make management more likely to commit resources to the development of a wholly owned subsidiary . With a population in excess of 825 Million people in 2002 Germany is evidently a large and growing market making it an ideally suited to a FDI mode of entry. Moreover, the German bakery market is highly fragmented which reduces barriers to entry in the form of dominant competitors. All other variables being equal, the higher the intensity of competition, the more likely a firm is to select an export mode of entry. The German cakes and pastries market is made up of several small players each of which occupy small proportions of the marketplace . This presents itself as an ideal  proposition to Greggs who will be able to establish themselves without dominant opposition. 3) Desired Mode Characteristics The choice of mode of entry will also depend on the attitudes of the decision maker. Although it is difficult to determine how pro-risk or risk averse Greggs Managing Director Sir Mike Darrington is, one may assume from their hierarchical entrance into Belgium that a high risk, expansionist strategy has been adopted and will be pursued. The degree of control that management desire over operations will help establish which mode of entry to employ. Hierarchical modes allow high levels of control over operations ensuring that the latter are carried out to Greggs specification. All else being equal, the greater the resource investment, the lower the flexibility of the business. Consequently, if Greggs pursue a hierarchical mode of entry, they will have to consider their potential limited flexibility. The above suggests that Greggs’ would benefit from a hierarchical mode of entry as it satisfies all criteria for the latter. This is where the firm completely owns and controls the foreign entry mode. However, regardless of the apparent control over operations specified by this mode, the degree of control that head office can exert over the subsidiary depends on how many and which value chain functions can be transferred to the market. Having reviewed all alternatives, its was decided that a Sales and Production subsidiary will be introduced in Germany leaving the Research and Development and Marketing activities to be conducted at home in the UK. According to Hollensen (2001) , having selected this mode of entry, Greggs  will benefit from having full control over the whole operation. Moreover, Greggs has long term market potential in Germany and therefore the ownership of a sales and production subsidiary will enable Greggs to build a strong international presence over a long period of time. This method also eliminates the possibility that a national partner gets a ‘free ride’ and allows Greggs to gain market knowledge directly. A sales and production subsidiary will facilitate rapid entry to the German market allowing quick access to its distribution channels. Plus, no transportation costs will be incurred as raw materials will be purchased in the host country. In addition to those proposed by Hollensen, Greggs may benefit from being able to adapt the ingredients used to German tastes. They can additionally tailor the servicescape to German preferences. Greggs produce is non-durable and therefore it would be inappropriate to needs to be produced and sold quickly as it is predominantly sell fresh food. Retaining R&D and Marketing operations at home will reduce costs and risk. Having established themselves in the German market, Greggs may consider transferring these operations over in the future. Moreover, employing a hierarchical mode will enable Greggs to exploit new market opportunities as soon as they arrive with minimal delay. In line with the latter, Abell (1978) concept of a strategic window states that there are only limited periods during which the fit between the requirements of the market and capabilities of the firm are at an optimum . Investment should therefore be timed accordingly. Although, this method will require a great deal of investment in terms of time, money and commitment, research has shown that â€Å"the profit returns generated by foreign direct investment modes are usually greater than those generated by exporting â€Å". According to the Uppsala Internationalisation Model, companies begin their internationalisation process a) by moving into relatively close markets  first then more distant ones and b) companies entered new markets through exporting. Although at face value it appears that Greggs’ strategy contradicts the assumptions of model, it does however highlight the following exception: Firms that have larger resources can take larger steps with fewer consequences. Arguably Greggs fall under this category. This model also suggests that firms start by entering markets which are nearer in terms of psychic distance hence reducing uncertainty. Germany is considered relatively near and despite language barriers, the German culture is similar to that of the UK as highlighted in the ‘Environmental Analysis’ section of this report.

Factors Influencing Customer Loyalty Essay

The financial services and banking facilities industry has seen a growing intensity of competition within the market place over the last decade. A bank is a financial intermediary that accepts deposits and channels those deposits into lending activities, either directly or through capital markets. A bank connects customers with capital deficits to customers with capital surpluses. Banking is generally a highly regulated industry, and government restrictions on financial activities by banks have varied over time and location. Today, CIMB serves close to seven million customers in over 600 locations through over 36,000 staff. Nowadays, financial services and banking facilities has force to pass by intense competition by other bank that growth from inside also outside this country because of the regulation for financial institution to establish was deregulation by government, and causing the adding in growth of the bank in Malaysia. Thus, people also have various banks to choose and directly give the big impact to manager of bank to search the way to enhance the loyalty of current customer from switching to other bank. They are many strategies that have been attempted by managers of the banks to retain customers in order to increase customer loyalty. It is costly than to attract new customer compared to retain the current customers. Thus, many banks have introduced innovative products and services (Alam and Khokhar, 2006) in order to retain current customers. Another strategy is to understand the factors influencing customer loyalty. Figure 1: Graph profit of Agrobank Seri Iskandar branch in April 2009 until April 2010 1. 2. Background of the organization Agrobank is an institution which provides holistic financial services and banking facilities. It give their utmost priority to the needs of their customers by providing attractive products and services such as savings activities, banking services, loan facilities, insurance coverage and advisory services. Agrobank is a Government-linked-Company (GLC) under the Minister of Finance Incorporated (MFI). The bank’s financing of the agricultural sector is driven by a policy set forth by the Ministry of Agriculture and Agro-based Industries. Agrobank is a continuity of the former Bank Pertanian Malaysia which has 40 years of experience in agricultural banking and an excellent track record in shaping and developing successful entrepreneurs. With a wide network of branches throughout Malaysia, they are confident of providing the best services to all. The rebranding of Bank Pertanian Malaysia to Agro Bank was done on 8 April 2008. The move is taken as an initiative to make the bank more competitive by fostering a fresher outlook, and enable it to provide a broader range of services to the market and cater the whole segment of the agriculture industry. An external consultant was deployed to carry out the public relation (PR) and rebranding exercise for Agrobank, penetrate the market and create awareness among the public. The solutions include Agrobanking, Business Banking, and Personal Banking. 1. 3. 1 Agrobanking Loan facility / financing offered under Agrobanking are open to agropreneurs clients carry out primary agricultural activities such as fisheries, forestry, livestock and any other related agro-based industry. Financing utilizing fund from the government and related agencies which is offered at a very competitive and special rate to help stimulate economic growth. This includes; i. Fund for Food (3F loan) ii. Skim Kredit Pengeluaran Makanan (SKPM) iii. Skim Kredit Padi (SKP) iv. The researcher was interested in predicting what the factors influencing customer loyalty toward AgroBank Seri Iskandar. Variables such as satisfaction, switching cost, trust and commitment might all contribute towards customer loyalty. When using multiple regressions in psychology, researchers use the term â€Å"independent variables† to identify those variables that they think will influence some other â€Å"dependent variable†. Thus, in as an example above, satisfaction, switching cost, trust and commitment would emerge as significant predictor variables, which allow researcher to estimate the criterion variable. As have pointed out before, human behavior is inherently noisy and therefore it is not possible to produce totally accurate predictions, but multiple regressions allows researcher to identify a set of predictor variables which together provide a useful estimate of a participant’s likely score on a criterion variable. Multiple regression analysis is done to examine the simultaneous effect of several independent variables on dependent variables. Multiple regression analysis can be used in order to determine whether the independent variables explain a significant variation in the dependent variable which is whether a relationship exists.

The Reactions of Hoover and Roosevelt to the Great Depression Assignment

The Reactions of Hoover and Roosevelt to the Great Depression - Assignment Example The Smoot-Hawley Tariff Act (1930) however has been seen by historians and economists today though as something that actually made the problems associated with the Great Depression worse, not better. Those economists that believe that the economy can only benefit from lowering prices point to tariffs as a way of increasing prices rather than dropping them. Roosevelt, on the other hand, campaigned on a balanced budget and a promise not to intervene with the economy. However, once he was elected he went ahead and expanded some of Hoover’s programs and created some of his own. The minimum wage act and the Davis-Beacon Act (1931) meant a reduction is price flexibility which slowed the economy even further. The New Deal which was a program implemented under Roosevelt’s reign was actually two different deals. The first one which ran from 1933 – 1935 was aimed at inputting money at the top of the economy so that the people at the bottom benefitted from the trickle-down effect. The Agricultural Adjustment Act (1933) for example paid farmers to reduce their production. No one was actually able to explain why that would help children in the poverty end of the scale who were going without food or the countless numbers of tenants and sharecroppers who were evicted and left without a job but it did make the larger (wealthier) farmers happy. As far as helping alleviate the impact of the Depression however, it was a non-starter – consumer demand fell because of course there were fewer people with money to spend. The National Industry Recovery Act (1933) was instrumental in setting up a centralized planning scheme that would encourage businesses to set prices that would drive weaker and smaller businesses out of the marketplace completely. Again this might have benefitted larger businesses but the smaller ones were still forced to close and unemployment figures still continued to rise, meaning there was less money being spent in the economy.  

Module Review 3 Essay Example | Topics and Well Written Essays - 1500 words

Module Review 3 - Essay Example The control of integrated operation by the CPFR is performed through strategic planning, management of demand and supply, execution and analysis. In planning and strategy, the CPFR sets the goals of a firm, with distinctive outlines of the scope of the roles, responsibilities, procedures, and checkpoints. This Joint Business Plan spots the hindrances of effective demand and supply, and eliminates these obstacles through inventory policy changes, introduction of products, promotions, and opening or closing of branch stores (Sattar, 2012). The management of demand and supply focuses on sales forecasting and order forecasting. Sales forecasting projects the demand of consumers at a certain sales point. On the other hand, order forecasting determines the orders and deliveries depending on the sales forecast (Diederichs, 2009). The execution role of the CPFR in integrated operations constitutes the implementation of the firm’s forecast into the firm’s real demand and fulfillment of the orders through production, stocking of stores, delivery and shipping. In addition to execution, the CPFR analyses the planning of operations and calculates the returns of the business to determine the achievements of the strategic plans, or to expose the need for the development of more alternative strategies (Choi, Hui & Yu, 2013). Inventory is a critical visible asset for most firms, and determines the size of a firm’s purchasing power. The inventory levels are subject to focus by many company shareholders and executives. Despite this, the focus has reduces drastically, causing sever implications on the supply chain. The administration of inventory is necessary in the planning of inventory requirements and management of uncertainties that may occur in a business. The use of Pareto inventory practice enables the management to establish the amount of inventory on the low demand items that indicates the shortage of a product, the need for transitions or

Healthcare Workers. Workplace Violence Research Paper

Healthcare Workers. Workplace Violence - Research Paper Example Such perpetrators include customers, patients, inmates, and other groups of people who receive regular services from the business. Healthcare facilities such as nursing homes and psychiatric facilities have the highest number of customer violence (Lee et al, 2010). Workplace violence is also perpetrated by fellow workers where an employee threatens or assaults another employee or past employee. Violence can also be perpetrated by individuals without any relationship with the business but have personal relationships with the victims. This includes victims of domestic violence who are attacked or assaulted while at work. The victims of workplace violence are mostly employees in the business. The victims have the responsibility of conducting business activities or providing services (Lee et al, 2010). Nurses and care givers in a nursing home or hospital may be attacked by violent patients. Shop attendants become victims of violent crimes such as robbery. Police officers and prison warde ns are victims of violence from criminals and prisoners. Employees may be subjected to verbal abuses or unwanted touching from their supervisors (Lee et al, 2010). Harassment by senior employees is evident in workplaces such as warehouses. New employees or junior employees become victims of overworking, threats, and abuses from senior employees. Spouses may become victims of workplace violence when domestic violence extends to the workplace. An employee may be attacked or abused by the spouse in the workplace due to unresolved domestic issues (Lee et al, 2010). Risk factors include mental health disorders such as stress, anxiety, and drug intoxication are common among people who commit workplace violence. Employees, customers, or patients with mental disorders have the highest probability of becoming violent. The employees’ inability to deal with a crisis is another risk factor (Lee et al, 2010). Emergency situations in the workplace may increase the stress levels in an emplo yee who loses control of the crisis and may perpetrate verbal violence. The age, years of experience, gender, hours worked, and marital status predispose workers to violence. Women and new employees may experience verbal and physical violence from senior employees. Employees dealing with the public such as police officers are exposed to attacks. Workers handling money such as cashiers are usually victims of criminal violence during robberies (OSHA, 2009). Employees working at night, guarding valuables, working in high crime areas, or transporting passengers have a high probability of being attacked. Workplace violence affects all stakeholders in a business. It has been estimated that organizations lose $202 billion annually due to workplace violence (Bowlers et al, 2007). Employers are affected by the violence due to reduced workdays and low employee morale. Employers also have to restore stolen property, replace damaged property, legal expenses, and compensate victims. Employees ar e also affected by the violence due to high levels of stress, physical injuries, depression, and high healthcare expenses. The personal relationships between employees also change in cases of employee-employee violence (Snyder, Chen and Vacha-Haase, 2007). Demoralization of employees leads to reduced job efficiency. This affects the quality of services delivered to customers and clients. Violence involving customer or clients may lead

Wild justice Term Paper Example | Topics and Well Written Essays - 2000 words

Wild justice - Term Paper Example The then President, John Kennedy, appointed him the Justice of the Supreme Court on 1963 May. Goldberg considered capital punishment a bad public policy as it could never prevent criminal crimes. He asserted that death penalty levied mainly on specific groups of the society such as the poor, the politically powerless and to some extent, the innocent by misjudgments. Another issue that arose was the fact that most of those affected by the death penalty, were the blacks leading to a racial prejudice. He resolved to end capital punishment starting from the courts as a Supreme Court Justice. According to A Wild Justice (28), the Justice Arthur Goldberg dissected from a decision from the Supreme Court not to hear the death penalty appeal involving Frank Lee Rudolph verses a white woman from Alabama. Rudolph was a black man who had a death penalty for raping a white woman from Alabama. This issue clearly heightened, given the fact that it regarded racism. The then Chief Justice, Earl Warre n, feared taking on the issue as Justice Goldberg and his clerk Dershowitz had already written an extensive memorandum that detailed all the cases of racial discrimination in capital punishments. Goldberg knew it would become very necessary to get as much support as possible for his decent. While keeping a low profile, Goldberg used his clerk, Deshowtz to send his memo about his dissect to various organizations including the NAACP Legal Defense Fund (A Wild Justice, 30). The news about Goldberg’s dissection from the Supreme Court’s decision circulated to a suite of offices on the twentieth floor of 10 Columbus Circle in Midtown Manhattan in early November. This was a home to the most important law firm in America, and simply implied that the information was to be in the reach of public consumption. The New York Times wrote about his dissect immediately and praised him terming the move as raising â€Å"a potential far reaching idea† (A Wild Justice, 34). The Nati onal Association for the Advancement of the Colored People Legal Defense Fund was a very successful organization since its formation. It had several legal victories that clearly meant that the Goldberg’s dissect issue could get a serious back up. LDF was a supportive organization about issues that affected the social linings of American Citizens. Lawyers of LDF had won several cases in various social issues. In 1944, LDF lawyers won the Smith vs. Allwright case, in which a decision was made requiring Texas to allow the African Americans to vote in primary elections (A Wild Justice, 32). The support that LDF gave to these social classes was in conjunction with the core role of the organization, that is, to give equal rights to all Americans regardless of race or social status The role of LDF was also manifested in the Morgan verses Virginia case. This 1946 case involved desegregation of interstate buses and the LDF lawyers won. Most Africans had commonly been discriminated in terms of service in state offices. Several movements to avert these social issues had already sprung up and LDF played a major role in the support for this movements. LDF managed to secure victory in a case protecting the African Americans to serve on juries and allowed African Americans to be involved in real estate business and property ownership. The LDF’s lawyers also help in the more serious case involving Martin Luther King, Jr, in which charges of contempt followed his protest of Birmingham segregation. The arguments raised by the LDF’s lawyers enabled the Supreme Court to drop all the charges that stemmed from all the civil rights sit-ins. All of this success made people to believe the power of LDF to be limitless (A Wild Justice, 32). The issue of Goldberg dissection arrived at the LDF and they immediately

Behavioural Aspects of Marketing Essay Example | Topics and Well Written Essays - 2500 words

Behavioural Aspects of Marketing - Essay Example Even in the remote, unheard of societies, all people remain consumers with diverse interests and gullibility to get influenced in their decisions. Placing the consumers in the market place and psychologically dissecting their behaviour could be a cross-subject study of psychology, marketing and advertisement results. When we take consumers individually, it is necessary to take the perception and the factors influencing it. Learning and the resultant memory that motivates further action with changed or unchanged values that cause involvement and attitudes are very important. It is necessary to remember that this research region is very young, influx and energetic. It also is being 'constantly cross-fertilised' by external perspectives belonging to various disciplines. It is interesting to know the everyday activities of people. In one of the most influential works in the field, Solomon et al have impressively provided a comprehensive and contemporary detail of the currently prevalent consumer behaviour. The arguments are lively and practical while portraying the strategic marketing issues, diverse European values etc. They also provide a peek into the multi-dimensional European lifestyle, buying habits, marketing behaviour, their relationship with the global market and the behavioural fluctuations. They wrote in the preface: "The field of consumer behaviour is, to us, the study of how the world is influenced by the action of marketers. We're fortunate enough to be teachers and researchers whose work allows us to study consumers". This consumer behavioural insight has to be applied to our Whole Foods Market. USUAL BEHAVIOUR OF CONSUMERS The advertisements are so persuasive today that it is impossible not to listen or get influenced. Marketing opportunities, to a large extent are connected with the cultural dimensions that influence the behaviour issues and concepts. This does not mean that cultural compulsions do not change at all. We have seen that even in the rigidly religious countries, where almost everything is a taboo, consumer behaviour changes, but changes with ultimate slowness. Consumers are eager to new experiences, especially in the food region, with the recent food and nutrition knowledge. Solomon et al have drawn a multi-dimensional portrait of European consumers within which they have shown the European modern family structure and how it has influenced the household decision making. They have shown the traditional influence of the culture which still holds its own in addition to the influence and compulsions of income and the social class and how they command the consumer behaviour and individual decisions. Basic model of consumer decision making might follow the traditional path of problem recognition, search for the information, evaluation of alternatives, decision of choice, evaluation after the purchase and all these are adequately influenced or dictated by the values, lifestyle, cultural and cross-cultural differences. Habit forming products, non-habit forming products that are not purchased regularly fall into two different categories and are not influenced by the same decision making process. Then comes the power of

Should firms price discriminate Essay Example | Topics and Well Written Essays - 1500 words

Should firms price discriminate - Essay Example Therefore, PD can be defined as the situation in which price charged to a customer can be based partly on the value of the good to the customer, rather than just on the cost of producing the good itself (Paul, 1987). As a result, allowing a firm to capture all or most of the consumer surplus, increasing overall profit of the firm. Although this definition is different, it highlights an importance of utility and consumer surplus theorems allowing us to analyze how firms might use their monopoly power. In other words, how PD could be applied, so maximum profit can be gained in different monopoly markets. First of all in order to discuss the usefulness of PD as a profit maximizing tool, we should identify the conditions that firm must meet in order to price discriminate. According to Fritz Machlup, (Fritz, 1955)there are three main prerequisites, firstly, a firm has to have the monopoly power in order to set the price. For example, if a firm is a price taker and its operates in perfectly competitive market it cannot price discriminate as demand curve is perfectly elastic, therefore there is no consumer surplus to capture, whereas if a firm is a monopoly it has a downward sloping demand curve therefore, there are some consumers who are willing to pay more than the uniform price. Secondly, for different groups of consumers it is necessary to have different price elasticity. For example, assume that all consumer groups have the same price elasticity then ceteris paribus; monopoly firm does not have an incentive to apply PD as the profit will be the same as a firm would have applied sing le price strategy. The third criteria, is that a firm must be able to prevent an arbitrage, in other words preventing resale of its products. For instance, why do Apple restricts on the number of IPhones that can be purchased, it is not because Apple products are exclusive, the reason is to prevent an arbitrage. Some people might buy IPhones in the US and sell them in the

In general Essay Example | Topics and Well Written Essays - 500 words

In general - Essay Example In the original work, an author tends to own the writing by mentioning his name in it. The writer is responsible for the authenticity of information and is liable for consequences in case, the information is invalid. On the other hand, a plagiarized work lacks ownership. A reader can not believe that the writer had faith in the information he/she has included while plagiarizing in the paper. Originality in writing shows the author’s individualistic contribution in widening and deepening the sea of knowledge, whereas an individual who plagiarizes creates whirlpools in this sea. The most fundamental difference between originality and plagiarism is that the former gives birth to knowledge whereas the latter is a literary theft. Moreover, originality is clear whereas plagiarism often gets too blurred a concept to be put into black and white (â€Å"Types of Plagiarism†). For example, many times, the same old ideas have to be repeated in a new paper. If the language is suffic iently changed so as to remove the originality but the meaning is kept unchanged, would it not be a theft of idea? Different people have different answers to this question. Difference between description and analysis: Description is a straight mention of facts about a thing, matter, incident or anything.

FUNDAMENTALS OF FINANCE Essay Example | Topics and Well Written Essays - 2000 words

FUNDAMENTALS OF FINANCE - Essay Example So, going by the NPV rule projects B and C are the ones that SKATE plc should consider investing in. However, since project C is expected to generate much greater present value for the firm, it is the one that should be invested in if the firm is under the obligation to choose only one from the given set of three alternatives. The IRR rule says invest in a project only if the IRR is greater than the required rate of return. So in the given situation we have to calculate the IRRs for the three projects and compare those to the given required rate of return, 15%. So we find that the IRR to be lesser than the required rate of return in case of project A and greater for project B and C implying that only these latter two should be considered for investment. And the fact that the IRR is so high in case of project C implies that it is the project that should be chosen if only one has to be chosen. So we find similar results and suggestions for both the NPV and the IRR criteria. The discounted payback rule is another criterion for investment projects. Essentially this measure discounts the future cash flows obtainable from a certain project to calculate the time the project takes to payback the initial investment and hence the name. If for instance, X is the amount that needs to be initially invested, this rule solves for that value of T which satisfies the equation Where Ct represents the cash flow at time t and r is the discount rate representing the time value of money. If the value of T is lower than some predetermined time period, the project should be accepted according to this rule. So, with the cut off period being one year, project B should be accepted according to the discounted payback rule as the project generates cash flows the discounted values of which are greater than the initial investment in the first period itself. Similarly, for project C, we get C1/ (1.15) = 78.2609 > 50 = C0 implying that this project also pays back he invested

Changes in Faith and the Coming of Age Essay Example for Free

Changes in Faith and the Coming of Age Essay In â€Å"Bless Me Ultima† by Rudolfo Anaya, Ultima represents the benevolent guide for Toni, in â€Å"Night† by Elie Wiesel, God serves as Elie’s benevolent guide. Both of these guides serve to help Toni and Elie decide where they stand in terms of their faith and religion and come to age in the process. In â€Å"Bless Me Ultima† Toni starts out firmly believing in God as taught so vehemently by his own mother, Elie also starts out by having faith, even more so than Toni as is shown by his admiration, even adoration of Moshe the Beathe and when he says â€Å" Why did I pray?-Why did I live? Why did I breathe?†. Both Toni and Elie believe what they have been taught too believe but Elie believes even more whole-heartedly than Toni which is why his seperation from God is much more brutal and sudden than Toni’s own seperation. Both boys are on the brink of being thrown into turnmoil and hardships that their fragile minds, bodies and beliefs are not ready for. When Ultima first comes to live with Toni and his family, Toni is intimidated by her precense but quickly warms up to her and in the process begins to witness and experience a side of spiritualism he never knew existed. Elie’s faith does not change but rather begins to dissipate throughout the novel due to his experiences as does Toni’s faith in God.Ultima serves as Toni’s protector, guide, and nurturer as does the figure and belief in God for Elie. The death of Lupito plants the seed of doubt in God in Toni’s mind as does the death of the pipel in Elie’s mind. None of these events succeed in shattering their faiths but it suceeds in managing to make them question their faith. With Narcisso and Florence’s death comes the further loss of faith in God for Toni and the further witnessing of pain, death, and cruelty makes Elie alternate between belief and disbelief in his once precious God. Both Toni and Elie are let down by their own God’s silence. Toni says â€Å" There was nothing, only silence† when he is in the confessional waiting for a reply from God and Elie says â€Å"Why should I sanctify His name? The Almighty, the  eternal and terrible Master of the Universe chose to be silent, what was there to thank him for?† when everybody else is praying to God. The constant days and nights full of terror, fear, torture, and the desolation that came with the death of his father finally broke Elie and his faith in God if even for a moment. Elie says â€Å"Never shall I forget those moments that murdered my God and my soul and turned my dreams to ashes.† The same happens to Toni due to the deaths he has been witness to and especially the death of Ultima. In the book Toni says â€Å" Everything I believed in was destroyed. A painful, wrenching in my heart made me cry aloud, â€Å"My God, my God, why have you forsaken me?†. The difference between Toni and Elie was that Toni’s benevolent guide who was Ultima gave him the ability to regain faith even if it was not towards God himself. Elie’s benevolent guide was God himself so when his faith was shattered he had no other place to direct his faith towards. At the end of the novel Toni manages to hold on to a form of faith prompted by others that could not have been managed without the influence of Ultima and Eli begins to regain faith in God himself even through his ordeals due to the unwavering faith he had in God in the beginning. Both characters learn that only through experiences and hardships can innocence be lost and maturity be gained as shown when Toni says â€Å"The tragic consequences of life can be overcome by strenght that resides in the human heart.†, and when Elie says â€Å" There are victories of the soul and spirit, sometimes even if you lose, you win.† Ultima and God, the symbolic benevolent spirits of both of these characters helped them decide what they believe in in the form of faith and come of age through this process.

Radiation Protection for Angiography Procedure.

Radiation Protection for Angiography Procedure. Fluoroscopic procedure produces the greatest patient radiation exposure rate in diagnostic radiology. Therefore the radiation protection in fluoroscopy is very important. Several feature and techniques in fluoroscopy are designed for protection to the patient during fluoroscopic procedure. a) Protection to Patient * A dead-man switch is a device (switch) constructed so that a circuit closing contact can only be maintained by continuous pressure on the switch by the operator. Therefore, when the machine is turned on by any means, whether by the push button at the control panel, or by the foot pedal, this switch must be held in for the machine to remain on. * The on-time of the fluoroscopic tube must be controlled by a timing device, and must end alarm when the exposure exceeds 5 minutes. An audible signal must alert the user to the completion of the preset on time. This signal will remain on until the timing device is reset. * The X-ray tube used for fluoroscopic must not produce X-rays unless a barrier is in position to intercept the entire cross-section of the useful beam. The fluoroscopic imaging assembly must be provided with shielding sufficient that the scatter radiation from the useful beam is minimized. * Protective barriers of at least 0.25 mm lead equivalency must be used to attenuate scatter radiation above the tabletop. This shielding does not replace the lead garments worn by personnel. Scattered radiation under the table must be attenuated by at least 0.25 mm lead equivalency shielding. * Additionally, most c-arm fluoroscopes have a warning beeper or light that activate when the beam is on, some have both. Never inactivate any warning devices, and keep ones foot off the foot pedal whenever possible. * Methods of limiting radiation exposure include: o making certain that the fluoroscopy unit is functioning properly through routine maintenance, o limiting fluoroscopic exposure time, o reducing fields of exposure through collimation, o keeping the X-ray source under the table by avoiding cross-table lateral visualization when possible, and o bringing the image intensifier down close to the patient b) Protection to personnel There are therefore three basic ways to minimize dose: * Reduce time of exposure * Use the inverse square law-doubling your distance away quarter your exposure * Use shielding by barrier These basics known as Cardinal Principle which is important to achieved ALARA. i) Time Radiation dose is directly proportional to the time, those by doubling the radiation time the dose is doubled and by having the radiation time the doses halved. Many factors impact the on time of a fluoroscopic procedure. The exposure time is related to radiation exposure and exposure rate (exposure per unit time) as follows: Exposure time = Exposure/Exposure rate Exposure = Exposure rate x time The algebraic expressions simply imply that if the exposure time is kept short, then the resulting dose to the individual is small. Method of reducing exposure time include meticulous advanced planning of the procedure, judicious use of contrast enhancement, appropriate positioning of the patient, orientation of the fluoroscope unit prior to beginning the procedure. ii) Distance The second radiation protection action relates to the distance between the source of radiation and the exposed individual. The exposure to the individual decreases inversely as the square of the distance. This is known as the inverse square law, which is stated mathematically as: where I is the intensity of radiation and d is the distance between the radiation source and the exposed individual. For example, when the distance is doubled the exposure is reduced by a factor of four. In mobile radiography, where there is no fixed protective control booth, the technologist should remain at least 2 m from the patient, the x-ray tube, and the primary beam during the exposure. In this respect, the ICRP (1982), as well as the NCRP (1989a), recommended that the length of the exposure cord on mobile radiographic units be at least 2 m long. Another important consideration with respect to distance relates to the source-to-image receptor distance (SID). The appropriate SIDs for various examinations must always be maintained because an incorrect SID could mean a second exposure to the patient. Long SID results in less divergent beam and thus decreases the concentration of photons in the patients. Short SID results in the reverse action and increases the patient dose. Hence the longest possible SID should be employed in examinations. However, if a greater than standard SID is used then greater intensity of radiation would be required to produce the same film density. Therefore it is recommended that only standard SIDs should be used. iii) Shielding Shielding procedure the most utilitarian results in the reduction of staff dose as there are times when the procedure list simply must function in close proximity, even directly cines fluoroscopy. In these circumstances there simply is no substitute for the best modern flexible lead gloves, lead glasses, lightweight lead apron and lead lined thyroid shield available. Appropriate shielding is mandatory for the safe use of ionizing radiation for medical imaging. Other method of shielding includes beam collimation, protective drapes and panels. Shielding of occupational workers can be achieved by following methods: * Personnel should remain in the radiation environment only when necessary (step behind the control booth, or leave the room when practical) * The distance between the personnel and the patient should be maximized when practical as the intensity of radiation decreases as the square of distance (inverse square law). * Shielding apparel should be used as and when necessary which comprise of lead aprons, eye glasses with side shields, hand gloves and thyroid shields. Lead aprons are shielding apparel recommended for use by radiation workers. These are classified as a secondary barrier to the effects of ionizing radiation. These aprons protect an individual only from secondary (scattered) radiation, not the primary beam. The thickness of lead in the protective apparel determines the protection it provides. It is known that 0.25 mm lead thickness attenuates 66% of the beam at 75kVp and 1mm attenuates 99% of the beam at same kVp. It is recommended that for general purpose radiography the minimum thickness of lead equivalent in the protective apparel should be 0.5mm. It is recommended that women radiation workers should wear a customized lead apron that reaches below mid thigh level and wraps completely around the pelvis. This would eliminate an accidental exposure to a concept us. Other protective apparel included eye glasses with side shields, thyroid shields and hand gloves. The minimum protective lead equivalents in hand gloves and thyroid shields should be 0.5mm. Lead lined glass and thyroid shield likewise reduce 90% of the exposure to the eyes and thyroid respectively. Lead lined gloves reduce radiation exposure to the hands; however they are no substitute for strict observation of appropriate fluoroscopic hygiene. Gloves should be considered as an effective means of reducing scatter radiation only. 2. State five clinical indications for the patient undergo the angiography procedure. 3. Explain the patient care management before, during and after the procedure Before a procedure: * Patients undergoing an angiogram are advised to stop eating and drinking eight hours prior to the procedure. * They must remove all jewelry before the procedure and change into a hospital gown. * If the arterial puncture is to be made in the armpit or groin area, shaving may be required. * A sedative may be administered to relax the patient for the procedure. * An IV line will also be inserted into a vein in the patients arm before the procedure begins in case medication or blood products are required during the angiogram. * Be aware of and follow all Local Rules and protocols * Prior to the angiography procedure, patients will be briefed on the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form. * Ensure that all exposures are justified and there is informed consent * Check patient identity * Position patient comfortably flat, with arm above head where possible * Ensure all members of staff in room are wearing suitable. For operations this should be lead glasses, thyroid collar and wrap-around lead apron * Check all staff are wearing radiation monitors correctly * Use all available lead shielding appropriately sited * Position table before screening * Keep tube current as low as possible and kVp as high as possible for cardiac studies, 60 – 90 kV is appropriate * Keep x ray tube at maximum and image intensifier / receptor at minimum distance from patient * Check all staff are as far away as possible in their role * Use dose reduction programmers when possible * Perform acquisitions on full inspiration where possible * Collimate closely to area of interest * Prolonged procedures: reduce dose to the irradiated skin eg. Change beam angulations * Minimize fluoroscopy time, high dose rate time and no of acquisitions * Remember software features, such as replay fluoro to minimize dose * Dont over use geometric magnification * Remove grid for small patients or when image intensifier / detector cannot be placed close to patient * Check and record screening time and DAP at the end of the case and review against the DRL. During the procedure: * The radiologic technologist will position you on the exam table. A radiologist a physician who specializes in the diagnostic interpretation of medical images will administer a local anesthetic and then make a small nick in your skin so that a thin catheter can be inserted into an artery or vein. The catheter is a flexible, hollow tube about the size of a strand of spaghetti. It usually is inserted into an artery in your groin, although in some cases your arm or another site will be selected for the catheter. * The radiologist will ease the catheter into the artery or vein and gently guide it to the area under investigation. The radiologist will be able to watch the movement of the catheter on a fluoroscope, which is an x-ray unit combined with a television monitor. * When the catheter reaches the area under study, the contrast agent will be injected through the catheter. By watching the fluoroscope screen, the radiologist will be able to see the outline of your blood vessels and identify any blockages or other irregularities. * Angiography procedures can range in time from less than an hour to three hours or more. It is important that you relax and remain as still as possible during the examination. The radiologic technologist and radiologist will stay in the room with you throughout the procedure. If you experience any difficulty, let them know. * Angiography also can be performed using magnetic resonance instead of x-rays to produce images of the blood vessels; this procedure is known as magnetic resonance angiography (MRA) or magnetic resonance venography (MRV). After the procedure: * Because life-threatening internal bleeding is a possible complication of an arterial puncture, an overnight stay in the hospital is sometimes recommended following an angiography procedure, particularly with cerebral and coronary angiograms. * If the procedure is performed on an outpatient basis, the patient is typically kept under close observation for a period of at six to 12 hours before being released. * If the arterial puncture was performed in the femoral artery, the patient will be instructed to keep his leg straight and relatively immobile during the observation period. * The patients blood pressure and vital signs will be monitored and the puncture site observed closely. Pain medication may be prescribed if the patient is experiencing discomfort from the puncture, and a cold pack is applied to the site to reduce swelling. It is normal for the puncture site to be sore and bruised for several weeks. * The patient may also develop a hematoma, a hard mass created by the blood vessels broken during the procedure. Hematomas should be watched carefully, as they may indicate continued bleeding of the arterial puncture site. * Angiography patients are also advised to enjoy two to three days of rest and relaxation after the procedure in order to avoid placing any undue stress on the arterial puncture. Patients who experience continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure should seek medical attention immediately. * Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure. 4. Identify the type of contrast medium, the dose and delivering technique in angiography procedure. * Reducing radiation doses to the patient also generally reduces doses to the medical personnel. Â · Angiography procedure is using fluoroscopy imaging technique which is a real-time imaging technique. 5. List down the catheters and guide wires inclusive of size, shape and the hole type that are used in angiography procedures. The use of lead gloves during procedures is unusual as they are cumbersome and difficult to work in. The automatic brightness control will increase the exposure to go through two layers and one only protects the hand, so if they are going to be used a programme that sets the radiation factors rather than allowing adjustment may be appropriate. In practice, with careful collimation and attenuation to detail it should not necessary for the operators hand to be in the primary beam and only close to it for short periods. While doing catheterization, radiologist should do it behind the lead glass viewer which consists of lead equivalent glass of 0.25mm thickness. Geometric consideration is one of the important things in angiography because source of exposure to personnel is mainly from scattered radiation from the patient. So, it is important to minimize the amount of scattered radiation to personnel. This can be achieved by geometric consideration involving the x-ray tube, patient and image intensifier. The image intensifier should be as close as possible to patient to minimize the amount of scattered radiation hitting personnel. Because in angiography room is sterile for all things, personnel such as radiologist, nurses, radiographer or student should wear shoes which are prepared only. Make sure that film badges always outside personnel body to measure the dose receive to the personnel. The most important thing to remember is that all individuals should be fully trained and learned to be responsible for radiation safety. Involvement of a radiation expert is essential and is particularly useful in equipment specification, assessment and quality assurance, but also in the formulation of Local Rules. Technique Reduces Physician Radiation Exposure During Angiography Current technique requires that physicians performing radiation procedures wear lead gowns. The new technique involves use of a body length floor mounted lead plastic panel to protect to physicians as they monitor patients angiograms and control exam table movement. An extension bar allows the physician to remain safely behind the shield and still retain table control for panning. In the study, researchers recorded radiation exposure to various parts of a physicians body during 25 coronary angiography procedures and compared those results with radiation exposure during angiography on 25 patients using conventional radiation protection. A lead apron, thyroid shield, eyeglasses and facemask were used in both techniques, but a ceiling mounted shield was used in the conventional technique. The researchers placed radiation badges outside and inside the facemask; outside and inside the thyroid shield; on the right and left arm; outside and inside the lead apron; and on the right and left leg. The new equipment resulted in a 90 percent reduction in radiation exposure to the physicians head, arms, and legs. Exposure of the thyroid and torso was minimal with both techniques. Enhanced physician radiation protection during coronary angiography is readily achievable with this new technique, said Martin Magram, M.D., of the University of Maryland Medical Center in Baltimore, Md. Dr. Magram presented the study results on May 3 at the American Roentgen Ray Society Annual Meeting in Vancouver, British Columbia. Dr. Magram pointed out that by freeing physicians from the need to wear lead gowns, the new technique could preserve their ability to benefit patients. It may extend by years their ability to apply the skills they have developed over long careers of serving patients, noted Dr. Magram. New methods of radiation protection must parallel the development of new radiation techniques, added Dr. Magram. The key is to limit medical workers radiation exposure with effective and easy-to-use techniques, and the use of this extension bar and lead plastic shield may be such a technique. Definition Angiography is the x-ray study of the blood vessels. An angiogram uses a radiopaque substance, or dye, to make the blood vessels visible under x ray. Arteriography is a type of angiography that involves the study of the arteries. Purpose Angiography is used to detect abnormalities or blockages in the blood vessels (called occlusions) throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumors; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to hemorrhage), tumor, blood clot, or arteriovenous malformations (abnormals tangles of arteries and veins) in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate map of the heart prior to open-heart surgery, or of the brain prior to neurosurgery. Precautions Patients with kidney disease or injury may suffer further kidney damage from the contrast mediums used for angiography. Patients who have blood clotting problems, have a known allergy to contrast mediums, or are allergic to iodine, a component of some contrast mediums, may also not be suitable candidates for an angiography procedure. Because x rays carry risks of ionizing radiation exposure to the fetus, pregnant women are also advised to avoid this procedure. Description Angiography is usually performed at a hospital by a trained radiologist and assisting technician or nurse. It takes place in an x-ray or fluoroscopy suite, and for most types of angiograms, the patients vital signs will be monitored throughout the procedure. Angiography requires the injection of a contrast dye that makes the blood vessels visible to x ray. The dye is injected through a procedure known as arterial puncture. The puncture is usually made in the groin area, armpit, inside elbow, or neck. The site is cleaned with an antiseptic agent and injected with a local anesthetic. First, a small incision is made in the skin to help the needle pass. A needle containing an inner wire called a stylet is inserted through the skin into the artery. When the radiologist has punctured the artery with the needle, the stylet is removed and replaced with another long wire called a guide wire. It is normal for blood to spout out of the needle before the guide wire is inserted. The guide wire is fed through the outer needle into the artery and to the area that requires angiographic study. A fluoroscopic screen that displays a view of the patients vascular system is used to pilot the wire to the correct location. Once it is in position, the needle is removed and a catheter is slid over the length of the guide wire until it to reaches the area of study. The guide wire is removed and the catheter is left in place in preparation for the injection of the contrast medium, or dye. Depending on the type of angiography procedure being performed, the contrast medium is either injected by hand with a syringe or is mechanically injected with an automatic injector connected to the catheter. An automatic injector is used frequently because it is able to propel a large volume of dye very quickly to the angiogram site. The patient is warned that the injection will start, and instructed to remain very still. The injection causes some mild to moderate discomfort. Possible side effects or reactions include headache, dizziness, irregular heartbeat, nausea, warmth, burning sensation, and chest pain, but they usually last only momentarily. To view the area of study from different angles or perspectives, the patient may be asked to change positions several times, and subsequent dye injections may be administered. During any injection, the patient or the camera may move. Throughout the dye injection procedure, x-ray pictures and/or fluoroscopic pictures (or moving x rays) will be taken. Because of the high pressure of arterial blood flow, the dye will dissipate through the patients system quickly, so pictures must be taken in rapid succession. An automatic film changer is used because the manual changing of x-ray plates can eat up valuable time. Once the x rays are complete, the catheter is slowly and carefully removed from the patient. Pressure is applied to the site with a sandbag or other weight for 10-20 minutes in order for clotting to take place and the arterial puncture to reseal itself. A pressure bandage is then applied. Most angiograms follow the general procedures outlined above, but vary slightly depending on the area of the vascular system being studied. A variety of common angiography procedures are outlined below: Cerebral angiography Cerebral angiography is used to detect aneurysms, blood clots, and other vascular irregularities in the brain. The catheter is inserted into the femoral or carotid artery and the injected contrast medium travels through the blood vessels on the brain. Patients frequently experience headache, warmth, or a burning sensation in the head or neck during the injection portion of the procedure. A cerebral angiogram takes two to four hours to complete. Coronary angiography Coronary angiography is administered by a cardiologist with training in radiology or, occasionally, by a radiologist. The arterial puncture is typically given in the femoral artery, and the cardiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries. The catheter may also be placed in the left ventricle to examine the mitral and aortic valves of the heart. If the cardiologist requires a view of the right ventricle of the heart or of the tricuspid or pulmonic valves, the catheter will be inserted through a large vein and guided into the right ventricle. The catheter also serves the purpose of monitoring blood pressures in these different locations inside the heart. The angiogram procedure takes several hours, depending on the complexity of the procedure. Pulmonary angiography Pulmonary, or lung, angiography is performed to evaluate blood circulation to the lungs. It is also considered the most accurate diagnostic test for detecting a pulmonary embolism. The procedure differs from cerebral and coronary angiograms in that the guide wire and catheter are inserted into a vein instead of an artery, and are guided up through the chambers of the heart and into the pulmonary artery. Throughout the procedure, the patients vital signs are monitored to ensure that the catheter doesnt cause arrhythmias, or irregular heartbeats. The contrast medium is then injected into the pulmonary artery where it circulates through the lung capillaries. The test typically takes up to 90 minutes. Kidney angiography Patients with chronic renal disease or injury can suffer further damage to their kidneys from the contrast medium used in a kidney angiogram, yet they often require the test to evaluate kidney function. These patients should be well-hydrated with a intravenous saline drip before the procedure, and may benefit from available medications (e.g., dopamine) that help to protect the kidney from further injury due to contrast agents. During a kidney angiogram, the guide wire and catheter are inserted into the femoral artery in the groin area and advanced through the abdominal aorta, the main artery in the abdomen, and into the renal arteries. The procedure will take approximately one hour. Fluorescein angiography Fluorescein angiography is used to diagnose retinal problems and circulatory disorders. It is typically conducted as an outpatient procedure. The patients pupils are dilated with eye drops and he rests his chin and forehead against a bracing apparatus to keep it still. Sodium fluorescein dye is then injected with a syringe into a vein in the patients arm. The dye will travel through the patients body and into the blood vessels of the eye. The procedure does not require x rays. Instead, a rapid series of close-up photographs of the patients eyes are taken, one set immediately after the dye is injected, and a second set approximately 20 minutes later once the dye has moved through the patients vascular system. The entire procedure takes up to one hour. Celiac and mesenteric angiography Celiac and mesenteric angiography involves x-ray exploration of the celiac and mesenteric arteries, arterial branches of the abdominal aorta that supply blood to the abdomen and digestive system. The test is commonly used to detect aneurysm, thrombosis, and signs of ischemia in the celiac and mesenteric arteries, and to locate the source of gastrointestinal bleeding. It is also used in the diagnosis of a number of conditions, including portal hypertension, and cirrhosis. The procedure can take up to three hours, depending on the number of blood vessels studied. Splenoportography A splenoportograph is a variation of an angiogram that involves the injection of contrast medium directly into the spleen to view the splenic and portal veins. It is used to diagnose blockages in the splenic vein and portal vein thrombosis and to assess the strength and location of the vascular system prior to liver transplantation. Most angiography procedures are typically paid for by major medical insurance. Patients should check with their individual insurance plans to determine their coverage. Aftercare Risks Because angiography involves puncturing an artery, internal bleeding or hemorrhage are possible complications of the test. As with any invasive procedure, infection of the puncture site or bloodstream is also a risk, but this is rare. A stroke or heart attack may be triggered by an angiogram if blood clots or plaque on the inside of the arterial wall are dislodged by the catheter and form a blockage in the blood vessels or artery. The heart may also become irritated by the movement of the catheter through its chambers during pulmonary and coronary angiography procedures, and arrhythmias may develop. Patients who develop an allergic reaction to the contrast medium used in angiography may experience a variety of symptoms, including swelling, difficulty breathing, heart failure, or a sudden drop in blood pressure. If the patient is aware of the allergy before the test is administered, certain medications can be administered at that time to counteract the reaction. Angiography involves minor exposure to radiation through the x rays and fluoroscopic guidance used in the procedure. Unless the patient is pregnant, or multiple radiological or fluoroscopic studies are required, the small dose of radiation incurred during a single procedure poses little risk. However, multiple studies requiring fluoroscopic exposure that are conducted in a short time period have been known to cause skin necrosis in some individuals. This risk can be minimized by careful monitoring and documentation of cumulative radiation doses administered to these patients. Normal results The results of an angiogram or arteriogram depend on the artery or organ system being examined. Generally, test results should display a normal and unimpeded flow of blood through the vascular system. Fluorescein angiography should result in no leakage of fluorescein dye through the retinal blood vessels. Abnormal results Abnormal results of an angiography may display a restricted blood vessel or arterial blood flow (ischemia) or an irregular placement or location of blood vessels. The results of an angiography vary widely by the type of procedure performed, and should be interpreted and explained to the patient by a trained radiologist. Arteriosclerosis A chronic condition characterized by thickening and hardening of the arteries and the build-up of plaque on the arterial walls. Arteriosclerosis can slow or impair blood circulation. Carotid artery An artery located in the neck. Catheter A long, thin, flexible tube used in angiography to inject contrast material into the arteries. Cirrhosis A condition characterized by the destruction of healthy liver tissue. A cirrhotic liver is scarred and cannot break down the proteins in the bloodstream. Cirrhosis is associated with portal hypertension. Embolism A blood clot, air bubble, or clot of foreign material that travels and blocks the flow of blood in an artery. When blood supply to a tissue or organ is blocked by an embolism, infarction, or death of the tissue the artery feeds, occurs. Without immediate and appropriate treatment, an embolism can be fatal. Femoral artery An artery located in the groin area that is the most frequently accessed site for arterial puncture in angiography. Fluorescein dye An orange dye used to illuminate the blood vessels of the retina in fluorescein angiography. Fluoroscopic screen A fluorescent screen which displays moving x-rays of the body. Fluoroscopy allows the radiologist to visualize the guide wire and catheter he is moving through the patients artery. Guide wire A wire that is inserted into an artery to guides a catheter to a certain location in the body. Iscehmia A lack of normal blood supply to a organ or body part because of blockages or constriction of the blood vessels. Necrosis Cellular or tissue death; skin necrosis may be caused by multiple, consecutive doses of radiation from fluoroscopic or x-ray procedures. Plaque Fatty material that is deposited on the inside of the arterial wall. Portal hypertension A condition caused by cirrhosis of the liver. It is characterized by impaired or reversed blood flow from the portal vein to the liver, an enlarged spleen, and dilated veins in the esophagus and stomach. Portal vein thrombosis The development of a blood clot in the vein that brings blood into the liver. Untreated portal vein thrombosis causes portal hypertension. For Your Information Books * Baum, Stanley, and Michael J. Pentecost, eds. Abrams Angiography. 4th ed. Radiation Protection for Angiography Procedure. Radiation Protection for Angiography Procedure. Fluoroscopic procedure produces the greatest patient radiation exposure rate in diagnostic radiology. Therefore the radiation protection in fluoroscopy is very important. Several feature and techniques in fluoroscopy are designed for protection to the patient during fluoroscopic procedure. a) Protection to Patient * A dead-man switch is a device (switch) constructed so that a circuit closing contact can only be maintained by continuous pressure on the switch by the operator. Therefore, when the machine is turned on by any means, whether by the push button at the control panel, or by the foot pedal, this switch must be held in for the machine to remain on. * The on-time of the fluoroscopic tube must be controlled by a timing device, and must end alarm when the exposure exceeds 5 minutes. An audible signal must alert the user to the completion of the preset on time. This signal will remain on until the timing device is reset. * The X-ray tube used for fluoroscopic must not produce X-rays unless a barrier is in position to intercept the entire cross-section of the useful beam. The fluoroscopic imaging assembly must be provided with shielding sufficient that the scatter radiation from the useful beam is minimized. * Protective barriers of at least 0.25 mm lead equivalency must be used to attenuate scatter radiation above the tabletop. This shielding does not replace the lead garments worn by personnel. Scattered radiation under the table must be attenuated by at least 0.25 mm lead equivalency shielding. * Additionally, most c-arm fluoroscopes have a warning beeper or light that activate when the beam is on, some have both. Never inactivate any warning devices, and keep ones foot off the foot pedal whenever possible. * Methods of limiting radiation exposure include: o making certain that the fluoroscopy unit is functioning properly through routine maintenance, o limiting fluoroscopic exposure time, o reducing fields of exposure through collimation, o keeping the X-ray source under the table by avoiding cross-table lateral visualization when possible, and o bringing the image intensifier down close to the patient b) Protection to personnel There are therefore three basic ways to minimize dose: * Reduce time of exposure * Use the inverse square law-doubling your distance away quarter your exposure * Use shielding by barrier These basics known as Cardinal Principle which is important to achieved ALARA. i) Time Radiation dose is directly proportional to the time, those by doubling the radiation time the dose is doubled and by having the radiation time the doses halved. Many factors impact the on time of a fluoroscopic procedure. The exposure time is related to radiation exposure and exposure rate (exposure per unit time) as follows: Exposure time = Exposure/Exposure rate Exposure = Exposure rate x time The algebraic expressions simply imply that if the exposure time is kept short, then the resulting dose to the individual is small. Method of reducing exposure time include meticulous advanced planning of the procedure, judicious use of contrast enhancement, appropriate positioning of the patient, orientation of the fluoroscope unit prior to beginning the procedure. ii) Distance The second radiation protection action relates to the distance between the source of radiation and the exposed individual. The exposure to the individual decreases inversely as the square of the distance. This is known as the inverse square law, which is stated mathematically as: where I is the intensity of radiation and d is the distance between the radiation source and the exposed individual. For example, when the distance is doubled the exposure is reduced by a factor of four. In mobile radiography, where there is no fixed protective control booth, the technologist should remain at least 2 m from the patient, the x-ray tube, and the primary beam during the exposure. In this respect, the ICRP (1982), as well as the NCRP (1989a), recommended that the length of the exposure cord on mobile radiographic units be at least 2 m long. Another important consideration with respect to distance relates to the source-to-image receptor distance (SID). The appropriate SIDs for various examinations must always be maintained because an incorrect SID could mean a second exposure to the patient. Long SID results in less divergent beam and thus decreases the concentration of photons in the patients. Short SID results in the reverse action and increases the patient dose. Hence the longest possible SID should be employed in examinations. However, if a greater than standard SID is used then greater intensity of radiation would be required to produce the same film density. Therefore it is recommended that only standard SIDs should be used. iii) Shielding Shielding procedure the most utilitarian results in the reduction of staff dose as there are times when the procedure list simply must function in close proximity, even directly cines fluoroscopy. In these circumstances there simply is no substitute for the best modern flexible lead gloves, lead glasses, lightweight lead apron and lead lined thyroid shield available. Appropriate shielding is mandatory for the safe use of ionizing radiation for medical imaging. Other method of shielding includes beam collimation, protective drapes and panels. Shielding of occupational workers can be achieved by following methods: * Personnel should remain in the radiation environment only when necessary (step behind the control booth, or leave the room when practical) * The distance between the personnel and the patient should be maximized when practical as the intensity of radiation decreases as the square of distance (inverse square law). * Shielding apparel should be used as and when necessary which comprise of lead aprons, eye glasses with side shields, hand gloves and thyroid shields. Lead aprons are shielding apparel recommended for use by radiation workers. These are classified as a secondary barrier to the effects of ionizing radiation. These aprons protect an individual only from secondary (scattered) radiation, not the primary beam. The thickness of lead in the protective apparel determines the protection it provides. It is known that 0.25 mm lead thickness attenuates 66% of the beam at 75kVp and 1mm attenuates 99% of the beam at same kVp. It is recommended that for general purpose radiography the minimum thickness of lead equivalent in the protective apparel should be 0.5mm. It is recommended that women radiation workers should wear a customized lead apron that reaches below mid thigh level and wraps completely around the pelvis. This would eliminate an accidental exposure to a concept us. Other protective apparel included eye glasses with side shields, thyroid shields and hand gloves. The minimum protective lead equivalents in hand gloves and thyroid shields should be 0.5mm. Lead lined glass and thyroid shield likewise reduce 90% of the exposure to the eyes and thyroid respectively. Lead lined gloves reduce radiation exposure to the hands; however they are no substitute for strict observation of appropriate fluoroscopic hygiene. Gloves should be considered as an effective means of reducing scatter radiation only. 2. State five clinical indications for the patient undergo the angiography procedure. 3. Explain the patient care management before, during and after the procedure Before a procedure: * Patients undergoing an angiogram are advised to stop eating and drinking eight hours prior to the procedure. * They must remove all jewelry before the procedure and change into a hospital gown. * If the arterial puncture is to be made in the armpit or groin area, shaving may be required. * A sedative may be administered to relax the patient for the procedure. * An IV line will also be inserted into a vein in the patients arm before the procedure begins in case medication or blood products are required during the angiogram. * Be aware of and follow all Local Rules and protocols * Prior to the angiography procedure, patients will be briefed on the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form. * Ensure that all exposures are justified and there is informed consent * Check patient identity * Position patient comfortably flat, with arm above head where possible * Ensure all members of staff in room are wearing suitable. For operations this should be lead glasses, thyroid collar and wrap-around lead apron * Check all staff are wearing radiation monitors correctly * Use all available lead shielding appropriately sited * Position table before screening * Keep tube current as low as possible and kVp as high as possible for cardiac studies, 60 – 90 kV is appropriate * Keep x ray tube at maximum and image intensifier / receptor at minimum distance from patient * Check all staff are as far away as possible in their role * Use dose reduction programmers when possible * Perform acquisitions on full inspiration where possible * Collimate closely to area of interest * Prolonged procedures: reduce dose to the irradiated skin eg. Change beam angulations * Minimize fluoroscopy time, high dose rate time and no of acquisitions * Remember software features, such as replay fluoro to minimize dose * Dont over use geometric magnification * Remove grid for small patients or when image intensifier / detector cannot be placed close to patient * Check and record screening time and DAP at the end of the case and review against the DRL. During the procedure: * The radiologic technologist will position you on the exam table. A radiologist a physician who specializes in the diagnostic interpretation of medical images will administer a local anesthetic and then make a small nick in your skin so that a thin catheter can be inserted into an artery or vein. The catheter is a flexible, hollow tube about the size of a strand of spaghetti. It usually is inserted into an artery in your groin, although in some cases your arm or another site will be selected for the catheter. * The radiologist will ease the catheter into the artery or vein and gently guide it to the area under investigation. The radiologist will be able to watch the movement of the catheter on a fluoroscope, which is an x-ray unit combined with a television monitor. * When the catheter reaches the area under study, the contrast agent will be injected through the catheter. By watching the fluoroscope screen, the radiologist will be able to see the outline of your blood vessels and identify any blockages or other irregularities. * Angiography procedures can range in time from less than an hour to three hours or more. It is important that you relax and remain as still as possible during the examination. The radiologic technologist and radiologist will stay in the room with you throughout the procedure. If you experience any difficulty, let them know. * Angiography also can be performed using magnetic resonance instead of x-rays to produce images of the blood vessels; this procedure is known as magnetic resonance angiography (MRA) or magnetic resonance venography (MRV). After the procedure: * Because life-threatening internal bleeding is a possible complication of an arterial puncture, an overnight stay in the hospital is sometimes recommended following an angiography procedure, particularly with cerebral and coronary angiograms. * If the procedure is performed on an outpatient basis, the patient is typically kept under close observation for a period of at six to 12 hours before being released. * If the arterial puncture was performed in the femoral artery, the patient will be instructed to keep his leg straight and relatively immobile during the observation period. * The patients blood pressure and vital signs will be monitored and the puncture site observed closely. Pain medication may be prescribed if the patient is experiencing discomfort from the puncture, and a cold pack is applied to the site to reduce swelling. It is normal for the puncture site to be sore and bruised for several weeks. * The patient may also develop a hematoma, a hard mass created by the blood vessels broken during the procedure. Hematomas should be watched carefully, as they may indicate continued bleeding of the arterial puncture site. * Angiography patients are also advised to enjoy two to three days of rest and relaxation after the procedure in order to avoid placing any undue stress on the arterial puncture. Patients who experience continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure should seek medical attention immediately. * Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure. 4. Identify the type of contrast medium, the dose and delivering technique in angiography procedure. * Reducing radiation doses to the patient also generally reduces doses to the medical personnel. Â · Angiography procedure is using fluoroscopy imaging technique which is a real-time imaging technique. 5. List down the catheters and guide wires inclusive of size, shape and the hole type that are used in angiography procedures. The use of lead gloves during procedures is unusual as they are cumbersome and difficult to work in. The automatic brightness control will increase the exposure to go through two layers and one only protects the hand, so if they are going to be used a programme that sets the radiation factors rather than allowing adjustment may be appropriate. In practice, with careful collimation and attenuation to detail it should not necessary for the operators hand to be in the primary beam and only close to it for short periods. While doing catheterization, radiologist should do it behind the lead glass viewer which consists of lead equivalent glass of 0.25mm thickness. Geometric consideration is one of the important things in angiography because source of exposure to personnel is mainly from scattered radiation from the patient. So, it is important to minimize the amount of scattered radiation to personnel. This can be achieved by geometric consideration involving the x-ray tube, patient and image intensifier. The image intensifier should be as close as possible to patient to minimize the amount of scattered radiation hitting personnel. Because in angiography room is sterile for all things, personnel such as radiologist, nurses, radiographer or student should wear shoes which are prepared only. Make sure that film badges always outside personnel body to measure the dose receive to the personnel. The most important thing to remember is that all individuals should be fully trained and learned to be responsible for radiation safety. Involvement of a radiation expert is essential and is particularly useful in equipment specification, assessment and quality assurance, but also in the formulation of Local Rules. Technique Reduces Physician Radiation Exposure During Angiography Current technique requires that physicians performing radiation procedures wear lead gowns. The new technique involves use of a body length floor mounted lead plastic panel to protect to physicians as they monitor patients angiograms and control exam table movement. An extension bar allows the physician to remain safely behind the shield and still retain table control for panning. In the study, researchers recorded radiation exposure to various parts of a physicians body during 25 coronary angiography procedures and compared those results with radiation exposure during angiography on 25 patients using conventional radiation protection. A lead apron, thyroid shield, eyeglasses and facemask were used in both techniques, but a ceiling mounted shield was used in the conventional technique. The researchers placed radiation badges outside and inside the facemask; outside and inside the thyroid shield; on the right and left arm; outside and inside the lead apron; and on the right and left leg. The new equipment resulted in a 90 percent reduction in radiation exposure to the physicians head, arms, and legs. Exposure of the thyroid and torso was minimal with both techniques. Enhanced physician radiation protection during coronary angiography is readily achievable with this new technique, said Martin Magram, M.D., of the University of Maryland Medical Center in Baltimore, Md. Dr. Magram presented the study results on May 3 at the American Roentgen Ray Society Annual Meeting in Vancouver, British Columbia. Dr. Magram pointed out that by freeing physicians from the need to wear lead gowns, the new technique could preserve their ability to benefit patients. It may extend by years their ability to apply the skills they have developed over long careers of serving patients, noted Dr. Magram. New methods of radiation protection must parallel the development of new radiation techniques, added Dr. Magram. The key is to limit medical workers radiation exposure with effective and easy-to-use techniques, and the use of this extension bar and lead plastic shield may be such a technique. Definition Angiography is the x-ray study of the blood vessels. An angiogram uses a radiopaque substance, or dye, to make the blood vessels visible under x ray. Arteriography is a type of angiography that involves the study of the arteries. Purpose Angiography is used to detect abnormalities or blockages in the blood vessels (called occlusions) throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumors; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to hemorrhage), tumor, blood clot, or arteriovenous malformations (abnormals tangles of arteries and veins) in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate map of the heart prior to open-heart surgery, or of the brain prior to neurosurgery. Precautions Patients with kidney disease or injury may suffer further kidney damage from the contrast mediums used for angiography. Patients who have blood clotting problems, have a known allergy to contrast mediums, or are allergic to iodine, a component of some contrast mediums, may also not be suitable candidates for an angiography procedure. Because x rays carry risks of ionizing radiation exposure to the fetus, pregnant women are also advised to avoid this procedure. Description Angiography is usually performed at a hospital by a trained radiologist and assisting technician or nurse. It takes place in an x-ray or fluoroscopy suite, and for most types of angiograms, the patients vital signs will be monitored throughout the procedure. Angiography requires the injection of a contrast dye that makes the blood vessels visible to x ray. The dye is injected through a procedure known as arterial puncture. The puncture is usually made in the groin area, armpit, inside elbow, or neck. The site is cleaned with an antiseptic agent and injected with a local anesthetic. First, a small incision is made in the skin to help the needle pass. A needle containing an inner wire called a stylet is inserted through the skin into the artery. When the radiologist has punctured the artery with the needle, the stylet is removed and replaced with another long wire called a guide wire. It is normal for blood to spout out of the needle before the guide wire is inserted. The guide wire is fed through the outer needle into the artery and to the area that requires angiographic study. A fluoroscopic screen that displays a view of the patients vascular system is used to pilot the wire to the correct location. Once it is in position, the needle is removed and a catheter is slid over the length of the guide wire until it to reaches the area of study. The guide wire is removed and the catheter is left in place in preparation for the injection of the contrast medium, or dye. Depending on the type of angiography procedure being performed, the contrast medium is either injected by hand with a syringe or is mechanically injected with an automatic injector connected to the catheter. An automatic injector is used frequently because it is able to propel a large volume of dye very quickly to the angiogram site. The patient is warned that the injection will start, and instructed to remain very still. The injection causes some mild to moderate discomfort. Possible side effects or reactions include headache, dizziness, irregular heartbeat, nausea, warmth, burning sensation, and chest pain, but they usually last only momentarily. To view the area of study from different angles or perspectives, the patient may be asked to change positions several times, and subsequent dye injections may be administered. During any injection, the patient or the camera may move. Throughout the dye injection procedure, x-ray pictures and/or fluoroscopic pictures (or moving x rays) will be taken. Because of the high pressure of arterial blood flow, the dye will dissipate through the patients system quickly, so pictures must be taken in rapid succession. An automatic film changer is used because the manual changing of x-ray plates can eat up valuable time. Once the x rays are complete, the catheter is slowly and carefully removed from the patient. Pressure is applied to the site with a sandbag or other weight for 10-20 minutes in order for clotting to take place and the arterial puncture to reseal itself. A pressure bandage is then applied. Most angiograms follow the general procedures outlined above, but vary slightly depending on the area of the vascular system being studied. A variety of common angiography procedures are outlined below: Cerebral angiography Cerebral angiography is used to detect aneurysms, blood clots, and other vascular irregularities in the brain. The catheter is inserted into the femoral or carotid artery and the injected contrast medium travels through the blood vessels on the brain. Patients frequently experience headache, warmth, or a burning sensation in the head or neck during the injection portion of the procedure. A cerebral angiogram takes two to four hours to complete. Coronary angiography Coronary angiography is administered by a cardiologist with training in radiology or, occasionally, by a radiologist. The arterial puncture is typically given in the femoral artery, and the cardiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries. The catheter may also be placed in the left ventricle to examine the mitral and aortic valves of the heart. If the cardiologist requires a view of the right ventricle of the heart or of the tricuspid or pulmonic valves, the catheter will be inserted through a large vein and guided into the right ventricle. The catheter also serves the purpose of monitoring blood pressures in these different locations inside the heart. The angiogram procedure takes several hours, depending on the complexity of the procedure. Pulmonary angiography Pulmonary, or lung, angiography is performed to evaluate blood circulation to the lungs. It is also considered the most accurate diagnostic test for detecting a pulmonary embolism. The procedure differs from cerebral and coronary angiograms in that the guide wire and catheter are inserted into a vein instead of an artery, and are guided up through the chambers of the heart and into the pulmonary artery. Throughout the procedure, the patients vital signs are monitored to ensure that the catheter doesnt cause arrhythmias, or irregular heartbeats. The contrast medium is then injected into the pulmonary artery where it circulates through the lung capillaries. The test typically takes up to 90 minutes. Kidney angiography Patients with chronic renal disease or injury can suffer further damage to their kidneys from the contrast medium used in a kidney angiogram, yet they often require the test to evaluate kidney function. These patients should be well-hydrated with a intravenous saline drip before the procedure, and may benefit from available medications (e.g., dopamine) that help to protect the kidney from further injury due to contrast agents. During a kidney angiogram, the guide wire and catheter are inserted into the femoral artery in the groin area and advanced through the abdominal aorta, the main artery in the abdomen, and into the renal arteries. The procedure will take approximately one hour. Fluorescein angiography Fluorescein angiography is used to diagnose retinal problems and circulatory disorders. It is typically conducted as an outpatient procedure. The patients pupils are dilated with eye drops and he rests his chin and forehead against a bracing apparatus to keep it still. Sodium fluorescein dye is then injected with a syringe into a vein in the patients arm. The dye will travel through the patients body and into the blood vessels of the eye. The procedure does not require x rays. Instead, a rapid series of close-up photographs of the patients eyes are taken, one set immediately after the dye is injected, and a second set approximately 20 minutes later once the dye has moved through the patients vascular system. The entire procedure takes up to one hour. Celiac and mesenteric angiography Celiac and mesenteric angiography involves x-ray exploration of the celiac and mesenteric arteries, arterial branches of the abdominal aorta that supply blood to the abdomen and digestive system. The test is commonly used to detect aneurysm, thrombosis, and signs of ischemia in the celiac and mesenteric arteries, and to locate the source of gastrointestinal bleeding. It is also used in the diagnosis of a number of conditions, including portal hypertension, and cirrhosis. The procedure can take up to three hours, depending on the number of blood vessels studied. Splenoportography A splenoportograph is a variation of an angiogram that involves the injection of contrast medium directly into the spleen to view the splenic and portal veins. It is used to diagnose blockages in the splenic vein and portal vein thrombosis and to assess the strength and location of the vascular system prior to liver transplantation. Most angiography procedures are typically paid for by major medical insurance. Patients should check with their individual insurance plans to determine their coverage. Aftercare Risks Because angiography involves puncturing an artery, internal bleeding or hemorrhage are possible complications of the test. As with any invasive procedure, infection of the puncture site or bloodstream is also a risk, but this is rare. A stroke or heart attack may be triggered by an angiogram if blood clots or plaque on the inside of the arterial wall are dislodged by the catheter and form a blockage in the blood vessels or artery. The heart may also become irritated by the movement of the catheter through its chambers during pulmonary and coronary angiography procedures, and arrhythmias may develop. Patients who develop an allergic reaction to the contrast medium used in angiography may experience a variety of symptoms, including swelling, difficulty breathing, heart failure, or a sudden drop in blood pressure. If the patient is aware of the allergy before the test is administered, certain medications can be administered at that time to counteract the reaction. Angiography involves minor exposure to radiation through the x rays and fluoroscopic guidance used in the procedure. Unless the patient is pregnant, or multiple radiological or fluoroscopic studies are required, the small dose of radiation incurred during a single procedure poses little risk. However, multiple studies requiring fluoroscopic exposure that are conducted in a short time period have been known to cause skin necrosis in some individuals. This risk can be minimized by careful monitoring and documentation of cumulative radiation doses administered to these patients. Normal results The results of an angiogram or arteriogram depend on the artery or organ system being examined. Generally, test results should display a normal and unimpeded flow of blood through the vascular system. Fluorescein angiography should result in no leakage of fluorescein dye through the retinal blood vessels. Abnormal results Abnormal results of an angiography may display a restricted blood vessel or arterial blood flow (ischemia) or an irregular placement or location of blood vessels. The results of an angiography vary widely by the type of procedure performed, and should be interpreted and explained to the patient by a trained radiologist. Arteriosclerosis A chronic condition characterized by thickening and hardening of the arteries and the build-up of plaque on the arterial walls. Arteriosclerosis can slow or impair blood circulation. Carotid artery An artery located in the neck. Catheter A long, thin, flexible tube used in angiography to inject contrast material into the arteries. Cirrhosis A condition characterized by the destruction of healthy liver tissue. A cirrhotic liver is scarred and cannot break down the proteins in the bloodstream. Cirrhosis is associated with portal hypertension. Embolism A blood clot, air bubble, or clot of foreign material that travels and blocks the flow of blood in an artery. When blood supply to a tissue or organ is blocked by an embolism, infarction, or death of the tissue the artery feeds, occurs. Without immediate and appropriate treatment, an embolism can be fatal. Femoral artery An artery located in the groin area that is the most frequently accessed site for arterial puncture in angiography. Fluorescein dye An orange dye used to illuminate the blood vessels of the retina in fluorescein angiography. Fluoroscopic screen A fluorescent screen which displays moving x-rays of the body. Fluoroscopy allows the radiologist to visualize the guide wire and catheter he is moving through the patients artery. Guide wire A wire that is inserted into an artery to guides a catheter to a certain location in the body. Iscehmia A lack of normal blood supply to a organ or body part because of blockages or constriction of the blood vessels. Necrosis Cellular or tissue death; skin necrosis may be caused by multiple, consecutive doses of radiation from fluoroscopic or x-ray procedures. Plaque Fatty material that is deposited on the inside of the arterial wall. Portal hypertension A condition caused by cirrhosis of the liver. It is characterized by impaired or reversed blood flow from the portal vein to the liver, an enlarged spleen, and dilated veins in the esophagus and stomach. Portal vein thrombosis The development of a blood clot in the vein that brings blood into the liver. Untreated portal vein thrombosis causes portal hypertension. For Your Information Books * Baum, Stanley, and Michael J. Pentecost, eds. Abrams Angiography. 4th ed.