DVT Risk Assessment Tool for Nurses Using Modified Delphi

DVT Risk Assessment Tool for Nurses Using Modified Delphi Research article DEVELOPMENT OF PATIENT’S DVT RISK ASSESSMENT TOOL FOR NURSES USING MODIFIED DELPHI TECHNIQUE. Mr.Kapil Sharma1,Ms. Jaspreet Kaur Sodhi2, *Ms.Rupinder Kaur3 ABSTRACT Background Deep vein thrombosis (DVT) is a very serious, potentially fatal, and very preventable medical condition. It is important for all patients admitted to the hospital to be screened for the risk of developing a DVT. This could be easily accomplished by performing a risk factor assessment-screening tool on all patients. It is also important to educate the medical and nursing staff on the fact that all patients are at risk for developing DVT, not just surgical patients who are often believed to be at the highest risk of DVT. The implementation of the risk factor assessment could potentially save lives and reduce the hospital costs of treating and managing the complications of DVT and venous thromboembolic disease. The implementation of a risk factor assessment tool could potentially aid in the recognition and appropriate prophylaxis of those patients who are at extremely high risk for DVT. Without appropriate recognition of the risk for DVT, patients may be placed at risk for DVT and the p otentially fatal and/or debilitating complications associated with the development of DVT.1 Aim The aim of the study is to develop Patient’s DVT Risk Assessment Tool for Staff Nurses. Objectives To select and pool the items to develop Patient’s DVT Risk Assessment Tool for Staff Nurses. To obtain consensus of Panelists for the development of Patient’s DVT Risk Assessment Tool for Staff Nurses. To organize valid items in a structured format for the development of Patient’s DVT Risk Assessment Tool for Staff Nurses. Methods Using instrument development design for Patient’s DVT Risk Assessment Tool for Staff Nurses. 66 Items were generated from evidence and qualitative data. Face and content validity were established through experts by 3 modified Delphi round. Content validity was computed. The content validity index (CVI) was calculated for each item i.e CVI-i, content validity index for experts i.e CVI-e and general content validity index for the tool i.e CVI-total. Item level CVI (CVI-i) is calculated by number of experts agreeing on the value of relevance of each item (value between 3 and 4) divided by total number of experts, expert level CVI (CVI-e) is calculated by number of items scored between 3 and 4 by an expert divided by total number of items and general CVI (CVI-total) is calculated by sum of all experts individual CVI divided by number of experts. Based on expert panel, CVI-i lower than 0.6 were deleted, (CVI-e) is 0.8,and CVI-total) 0.89. Results Patient’s DVT Risk Assessment Tool for Staff Nurses had face and content validity. The content validity index was 0.89. Conclusion The study concluded that assessment of DVT risk is essential in hospitalized patients.The identification of DVT risk at its earliest stage can help to decrease the morbidity and mortality rate in hospitalized patients.The Patient’s DVT Risk Assessment Tool will be helpful to identify risk of DVT at its earliest stage so that preventive measures can be taken. Keywords Deep Vein Thrombosis,Patient’s DVT Risk Assessment Tool.Modified Delphi Technique,Content Validity Index INTRODUCTION â€Å"An ounce of prevention is cheap, the pound of cure costly† (A.Taylor, B.J. Whiting) In India, the incidence of deep vein thrombosis (DVT) is not well highlighted and literature survey shows scanty works in this field. Most of the literature available in India is from the orthopaedic departments, overall incidence of DVT in general population is largely unknown. Most of the DVTs are idiopathic and occur in less than 45 years age group. Irrespective of the etiology, LMWH and Warfarins are efficient, safety is well demonstrated, and domiciliary treatment is advisable with surveillance. Idiopathic DVTs require long term follow up to watch for recurrent thrombosis.2 Each year, deep vein thrombosis (DVT) occurs in 1 of every 1,000 Americans, hospitalizes nearly 600,000 for DVT-related complications, and kills up to 300,000. It is possibly the most common preventable cause of hospital deaths in the United States. Occupations in transportation, air travel, con ­fined spaces, and sedentary office positions pose risks for DVT. The risk of DVT increases with factors such as obesity, cancer, pregnancy, estrogen-containing medications, major surgery, and hospitalizations. , With an understanding of DVT, occupational health nurses are well positioned to promote DVT awareness and reduce the risk of complica ­tions for employees diagnosed with DVT.3 Deep vein thrombosis [DVT] is one of the most dreaded complications in post-operative patients as it is associated with considerable morbidity and mortality. Majority of patients with postoperative DVT are asymptomatic. The pulmonary embolism, which is seen in 10% of the cases with proximal DVT, may be fatal. Therefore it becomes imperative to prevent DVT rather than to diagnose and treat. Only one randomized trial has been reported from India to assess the effectiveness of low molecular weight heparin in preventing post-operative DVT.4 METHODOLOGY It is a methodological study to develop Patient’s DVT Risk Assessment Tool. The tool was validated by 10 multidisciplinary health care professionals. The study was conducted in 3 Modified Delphi rounds.The validity of tool was determined by content validity index (CVI). The data was collected via e-mail.The tool was developed under three phases and under each phase some steps were taken. PHASE 1- Preliminary preparation During this phase the investigator developed the preliminary Patient’s DVT Risk Assessment Tool for which the following steps were taken: Step-1: Review of Literature- An extensive review of literature was carried out from books, journals and through internet. Literature was searched which represent Patient’s DVT Risk Assessment Tool from all aspects. Various tool were searched. Literature related to tool construction and standardization was also reviewed. Step-2: Items selection and pooling- Different tools were analyzed and related items such as risk factors were selected from the content and items were pooled together. Step-3: Preparation of first draft- Selected items were seemed to represent Patient’s DVT Risk Assessment Tool to generate first draft of the tool. PHASE 2- Validation of first draft and subsequent drafts Step-1: Selection of panel- There were 10 experts in all Delphi rounds. The Delphi panel was consisted of multidisciplinary health care professionals (nurses, doctors, and administrator). The sample of the panelist were heterogeneous to ensure the entire spectrum of opinion to be determined. The written consent was taken from the selected experts to participate in the study. The first draft of tool was circulated among 10 experts from above stated field. Step-2: Delphi Rounds: The modified Delphi technique was used to validate the draft. (The Delphi is an interactive process designed to combine expert’s opinion into group consensus. According to this technique the response of each panelist remains anonymous that there are equal chances of each panelist to present the ideas unbiased by the identity of other panelist. There are subsequent Delphi rounds until a definitive level of consensus is recorded). All the panelist were requested to give their valuable suggestion pertaining to the content, accuracy of information, the item order i.e organization and sequence of the items and working of the items. The suggestions given by panelist was incorporated to generate the second draft of tool. Step-3: Modification: as per the experts opinion:The modification in the tool was made. PHASE 3- Assessing reliability and content validity of tool: Draft prepared after third Delphi round. Validity of Tool: It was done by expert’s opinion. The tool was circulated to 10 experts of various specialties . The experts were asked to rate the items in terms of relevance to the Patient’s DVT Risk Assessment Tool. A 4 point likert scale (1 not relevant, 2 somewhat relevant, 3 relevant, very relevant). The content validity index (CVI) was calculated for each item i.e CVI-i, content validity index for experts i.e CVI-e and general content validity index for the tool i.e CVI-total. Item level CVI (CVI-i) is calculated by number of experts agreeing on the value of relevance of each item (value between 3 and 4) divided by total number of experts, expert level CVI (CVI-e) is calculated by number of items scored between 3 and 4 by an expert divided by total number of items and general CVI (CVI-total) is calculated by sum of all experts individual CVI divided by number of experts. Based on expert panel, CVI-i lower than 0.6 were deleted, (CVI-e) is 0.8, and CVI-total) 0.89. Instrument development: The content validity assessment process described by Waltz and Bausell (1981) and Lynn (1986) was used. 66 items were generated and were carefully investigated for clarity, grammar, and construction. A likert scale was chosen as scale type. Each item was rated on 4 point likert scale (1 not relevant, 2 somewhat relevant, 3 relevant, very relevant) with significant agreement (10 experts rating item a 4 or 3) needed for it to be retained. The experts were asked also to evaluate the set of items to determine if any content area was missing. REFERENCES 1.Race TK, Collier PE. The hidden risk of deep vein thrombosis the need for risk factor assessment: case reviews. Critical Care Nursing Quarterly [serial on the Internet]. 2007, July;30(3): 245-254. 2. L Chinglensana, Santhosh Rudrappa, K Anupama, T Gojendra, Kala K Singh, Sudhir T Chandra. Clinical profile and management of deep vein thrombosis of lower limb. Journal Of Medical Society.2013;27(1):10-14 3. Emanuele, P,. Deep Vein Thrombosis, AAOHN Journal 2008; 56(9):389-392. 4.Anandan Murugesan, Dina N. Srivastava,Uma K. Ballehaninna, Sunil Chumber,Anita Dhar,Mahesh C. Misra,Rajinder Parshad, V. Seenu, Anurag Srivastava,and Narmada P. Gupta. Detection and Prevention of Post-Operative Deep Vein Thrombosis [DVT] Using Nadroparin Among Patients Undergoing Major Abdominal Operations in India; a Randomised Controlled Trial. Indian J Surg. 2010 August; 72(4): 312–317

Nicotine Addiction :: Research Analysis

Nicotine addiction Cigarette addiction is responsible for over four million deaths every year. The question most people ask is why don’t people just put down their cigarettes? Well, the answer to that often asked question is nicotine. Nicotine is a neurotransmitter that targets certain receptors in the brain. It is a chemical messenger that induces feelings of pleasure. When someone takes a hit off of a cigarette, they ingest the harmful chemicals that can cause cancer and other serious health threats. They only inhale these chemicals to get one thing and one thing only, nicotine. Curing addiction becomes harder and harder with each puff of a cigarette one takes. When nicotine is consumed, it communicates with the brain and is absorbed into receptor molecules, Doctors for years have undergone hundreds of experimental studies on the human brain to help understand just how these chemicals neurologically affect the brain, and which sectors of the brain are affected. This goal has not yet been accomplished due to the large amounts of receptor cells in the brain. In a study performed at the California Institute of Technology performed by Andrew Tapper, Professor Allan Collins from the University of Colorado, Several colleagues, and Henry A. Lester, the Caltech University Bren Professor of Biology revealed that nicotine affects a small subunit of the brain called alpha four. This subunit of the brain increases levels of pleasure, response, sensitization, and increases tolerance of multiple doses of the drug nicotine. Many people do not know what nicotine does inside the brain. Here’s how it works when the nicotine reacts with the cells in the brain. It creates nerve impulse that jump chemically across a gap between two different nerve cells. This action is called a synapse. The neurotransmitter acetylcholine is used in this process and is used to affect specified receptors in the brain targeting post-synaptic nerve cells. After this process, the feel good brain messenger, dopamine, is released. This chemical is released into the brain creating an extreme high. The acetylcholine is then supposed to diminish the dopamine after completing its task. The drug disguises itself as acetylcholine causing the process of dopamine release to last for minutes rather than milliseconds. In several lab studies performed on mice in the 1990’s, results concluded that nicotine also affects the subunits of the brain labeled beta two. Knowing how this drug affects many different subunits shows just how complicated it is to find a cure for addiction to this drug.

A Game of Thrones Chapter Forty-four

Sansa He wouldn't send Ser Loras,† Sansa told Jeyne Poole that night as they shared a cold supper by lamplight. â€Å"I think it was because of his leg.† Lord Eddard had taken his supper in his bedchamber with Alyn, Harwin, and Vayon Poole, the better to rest his broken leg, and Septa Mordane had complained of sore feet after standing in the gallery all day. Arya was supposed to join them, but she was late coming back from her dancing lesson. â€Å"His leg?† Jeyne said uncertainly. She was a pretty, dark-haired girl of Sansa's own age. â€Å"Did Ser Loras hurt his leg?† â€Å"Not his leg,† Sansa said, nibbling delicately at a chicken leg. â€Å"Father's leg, silly. It hurts him ever so much, it makes him cross. Otherwise I'm certain he would have sent Ser Loras.† Her father's decision still bewildered her. When the Knight of Flowers had spoken up, she'd been sure she was about to see one of Old Nan's stories come to life. Ser Gregor was the monster and Ser Loras the true hero who would slay him. He even looked a true hero, so slim and beautiful, with golden roses around his slender waist and his rich brown hair tumbling down into his eyes. And then Father had refused him! It had upset her more than she could tell. She had said as much to Septa Mordane as they descended the stairs from the gallery, but the septa had only told her it was not her place to question her lord father's decisions. That was when Lord Baelish had said, â€Å"Oh, I don't know, Septa. Some of her lord father's decisions could do with a bit of questioning. The young lady is as wise as she is lovely.† He made a sweeping bow to Sansa, so deep she was not quite sure if she was being complimented or mocked. Septa Mordane had been very upset to realize that Lord Baelish had overheard them. â€Å"The girl was just talking, my lord,† she'd said. â€Å"Foolish chatter. She meant nothing by the comment.† Lord Baelish stroked his little pointed beard and said, â€Å"Nothing? Tell me, child, why would you have sent Ser Loras?† Sansa had no choice but to explain about heroes and monsters. The king's councillor smiled. â€Å"Well, those are not the reasons I'd have given, but . . . † He had touched her cheek, his thumb lightly tracing the line of a cheekbone. â€Å"Life is not a song, sweetling. You may learn that one day to your sorrow.† Sansa did not feel like telling all that to Jeyne, however; it made her uneasy just to think back on it. â€Å"Ser Ilyn's the King's Justice, not Ser Loras,† Jcyne said. â€Å"Lord Eddard should have sent him.† Sansa shuddered. Every time she looked at Ser Ilyn Payne, she shivered. He made her feel as though something dead were slithering over her naked skin. â€Å"Ser Ilyn's almost like a second monster. I'm glad Father didn't pick him.† â€Å"Lord Beric is as much a hero as Ser Loras. He's ever so brave and gallant.† â€Å"I suppose,† Sansa said doubtfully. Beric Dondarrion was handsome enough, but he was awfully old, almost twenty-two; the Knight of Flowers would have been much better. Of course, Jeyne had been in love with Lord Beric ever since she had first glimpsed him in the lists. Sansa thought she was being silly; Jeyne was only a steward's daughter, after all, and no matter how much she mooned after him, Lord Beric would never look at someone so far beneath him, even if she hadn't been half his age. It would have been unkind to say so, however, so Sansa took a sip of milk and changed the subject. â€Å"I had a dream that Joffrey would be the one to take the white hart,† she said. It had been more of a wish, actually, but it sounded better to call it a dream. Everyone knew that dreams were prophetic. White harts were supposed to be very rare and magical, and in her heart she knew her gallant prince was worthier than his drunken father. â€Å"A dream? Truly? Did Prince Joffrey just go up to it and touch it with his bare hand and do it no harm?† â€Å"No,† Sansa said. â€Å"He shot it with a golden arrow and brought it back for me.† In the songs, the knights never killed magical beasts, they just went up to them and touched them and did them no harm, but she knew Joffrey liked hunting, especially the killing part. Only animals, though. Sansa was certain her prince had no part in murdering Jory and those other poor men; that had been his wicked uncle, the Kingslayer. She knew her father was still angry about that, but it wasn't fair to blame Joff. That would be like blaming her for something that Arya had done. â€Å"I saw your sister this afternoon,† Jeyne blurted out, as if she'd been reading Sansa's thoughts. â€Å"She was walking through the stables on her hands. Why would she do a thing like that?† â€Å"I'm sure I don't know why Arya does anything.† Sansa hated stables, smelly places full of manure and flies. Even when she went riding, she liked the boy to saddle the horse and bring it to her in the yard. â€Å"Do you want to hear about the court or not?† â€Å"I do,† Jeyne said. â€Å"There was a black brother,† Sansa said, â€Å"begging men for the Wall, only he was kind of old and smelly.† She hadn't liked that at all. She had always imagined the Night's Watch to be men like Uncle Benjen. In the songs, they were called the black knights of the Wall. But this man had been crookbacked and hideous, and he looked as though he might have lice. If this was what the Night's Watch was truly like, she felt sorry for her bastard half brother, Jon. â€Å"Father asked if there were any knights in the hall who would do honor to their houses by taking the black, but no one came forward, so he gave this Yoren his pick of the king's dungeons and sent him on his way. And later these two brothers came before him, freeriders from the Dornish Marches, and pledged their swords to the service of the king. Father accepted their oaths . . . â€Å" Jeyne yawned. â€Å"Are there any lemon cakes?† Sansa did not like being interrupted, but she had to admit, lemon cakes sounded more interesting than most of what had gone on in the throne room. â€Å"Let's see,† she said. The kitchen yielded no lemon cakes, but they did find half of a cold strawberry pie, and that was almost as good. They ate it on the tower steps, giggling and gossiping and sharing secrets, and Sansa went to bed that night feeling almost as wicked as Arya. The next morning she woke before first light and crept sleepily to her window to watch Lord Beric form up his men. They rode out as dawn was breaking over the city, with three banners going before them; the crowned stag of the king flew from the high staff, the direwolf of Stark and Lord Beric's own forked lightning standard from shorter poles. It was all so exciting, a song come to life; the clatter of swords, the flicker of torchlight, banners dancing in the wind, horses snorting and whinnying, the golden glow of sunrise slanting through the bars of the portcullis as it jerked upward. The Winterfell men looked especially fine in their silvery mail and long grey cloaks. Alyn carried the Stark banner. When she saw him rein in beside Lord Beric to exchange words, it made Sansa feel ever so proud. Alyn was handsomer than Jory had been; he was going to be a knight one day. The Tower of the Hand seemed so empty after they left that Sansa was even pleased to see Arya when she went down to break her fast. â€Å"Where is everyone?† her sister wanted to know as she ripped the skin from a blood orange. â€Å"Did Father send them to hunt down Jaime Lannister?† Sansa sighed. â€Å"They rode with Lord Beric, to behead Ser Gregor Clegane.† She turned to Septa Mordane, who was eating porridge with a wooden spoon. â€Å"Septa, will Lord Beric spike Ser Gregor's head on his own gate or bring it back here for the king?† She and Jeyne Poole had been arguing over that last night. The septa was horror-struck. â€Å"A lady does not discuss such things over her porridge. Where are your courtesies, Sansa? I swear, of late you've been near as bad as your sister.† â€Å"What did Gregor do?† Arya asked. â€Å"He burned down a holdfast and murdered a lot of people, women and children too.† Arya screwed up her face in a scowl. â€Å"Jaime Lannister murdered Jory and Heward and Wyl, and the Hound murdered Mycah. Somebody should have beheaded them.† â€Å"It's not the same,† Sansa said. â€Å"The Hound is Joffrey's sworn shield. Your butcher's boy attacked the prince.† â€Å"Liar,† Arya said. Her hand clenched the blood orange so hard that red juice oozed between her fingers. â€Å"Go ahead, call me all the names you want,† Sansa said airily. â€Å"You won't dare when I'm married to Joffrey. You'll have to bow to me and call me Your Grace.† She shrieked as Arya flung the orange across the table. It caught her in the middle of the forehead with a wet squish and plopped down into her lap. â€Å"You have juice on your face, Your Grace,† Arya said. It was running down her nose and stinging her eyes. Sansa wiped it away with a napkin. When she saw what the fruit in her lap had done to her beautiful ivory silk dress, she shrieked again. â€Å"You're horrible,† she screamed at her sister. â€Å"They should have killed you instead of Lady!† Septa Mordane came lurching to her feet. â€Å"Your lord father will hear of this! Go to your chambers, at once. At once!† â€Å"Me too?† Tears welled in Sansa's eyes. â€Å"That's not fair.† â€Å"The matter is not subject to discussion. Go!† Sansa stalked away with her head up. She was to be a queen, and queens did not cry. At least not where people could see. When she reached her bedchamber, she barred the door and took off her dress. The blood orange had left a blotchy red stain on the silk. â€Å"I hate her!† she screamed. She balled up the dress and flung it into the cold hearth, on top of the ashes of last night's fire. When she saw that the stain had bled through onto her underskirt, she began to sob despite herself. She ripped off the rest of her clothes wildly, threw herself into bed, and cried herself back to sleep. It was midday when Septa Mordane knocked upon her door. â€Å"Sansa. Your lord father will see you now.† Sansa sat up. â€Å"Lady,† she whispered. For a moment it was as if the direwolf was there in the room, looking at her with those golden eyes, sad and knowing. She had been dreaming, she realized. Lady was with her, and they were running together, and . . . and . . . trying to remember was like trying to catch the rain with her fingers. The dream faded, and Lady was dead again. â€Å"Sansa.† The rap came again, sharply. â€Å"Do you hear me?† â€Å"Yes, Septa,† she called out. â€Å"Might I have a moment to dress, please?† Her eyes were red from crying, but she did her best to make herself beautiful. Lord Eddard was bent over a huge leather-bound book when Septa Mordane marched her into the solar, his plaster-wrapped leg stiff beneath the table. â€Å"Come here, Sansa,† he said, not unkindly, when the septa had gone for her sister. â€Å"Sit beside me.† He closed the book. Septa Mordane returned with Arya squirming in her grasp. Sansa had put on a lovely pale green damask gown and a look of remorse, but her sister was still wearing the ratty leathers and roughspun she'd worn at breakfast. â€Å"Here is the other one,† the septa announced. â€Å"My thanks, Septa Mordane. I would talk to my daughters alone, if you would be so kind.† The septa bowed and left. â€Å"Arya started it,† Sansa said quickly, anxious to have the first word. â€Å"She called me a liar and threw an orange at me and spoiled my dress, the ivory silk, the one Queen Cersei gave me when I was betrothed to Prince Joffrey. She hates that I'm going to marry the prince. She tries to spoil everything, Father, she can't stand for anything to be beautiful or nice or splendid.† â€Å"Enough, Sansa.† Lord Eddard's voice was sharp with impatience. Arya raised her eyes. â€Å"I'm sorry, Father. I was wrong and I beg my sweet sister's forgiveness.† Sansa was so startled that for a moment she was speechless. Finally she found her voice. â€Å"What about my dress?† â€Å"Maybe . . . I could wash it,† Arya said doubtfully. â€Å"Washing won't do any good,† Sansa said. â€Å"Not if you scrubbed all day and all night. The silk is ruined.† â€Å"Then I'll . . . make you a new one,† Arya said. Sansa threw back her head in disdain. â€Å"You? You couldn't sew a dress fit to clean the pigsties.† Their father sighed. â€Å"I did not call you here to talk of dresses. I'm sending you both back to Winterfell.† For the second time Sansa found herself too stunned for words. She felt her eyes grow moist again. â€Å"You can't,† Arya said. â€Å"Please, Father,† Sansa managed at last. â€Å"Please don't.† Eddard Stark favored his daughters with a tired smile. â€Å"At last we've found something you agree on.† â€Å"I didn't do anything wrong,† Sansa pleaded with him. â€Å"I don't want to go back.† She loved Mng's Landing; the pagaentry of the court, the high lords and ladies in their velvets and silks and gemstones, the great city with all its people. The tournament had been the most magical time of her whole life, and there was so much she had not seen yet, harvest feasts and masked balls and mummer shows. She could not bear the thought of losing it all. â€Å"Send Arya away, she started it, Father, I swear it. I'll be good, you'll see, just let me stay and I promise to be as fine and noble and courteous as the queen.† Father's mouth twitched strangely. â€Å"Sansa, I'm not sending you away for fighting, though the gods know I'm sick of you two squabbling. I want you back in Winterfell for your own safety. Three of my men were cut down like dogs not a league from where we sit, and what does Robert do? He goes hunting.† Arya was chewing at her lip in that disgusting way she had. â€Å"Can we take Syrio back with us?† â€Å"Who cares about your stupid dancing master?† Sansa flared. â€Å"Father, I only just now remembered, I can't go away, I'm to marry Prince Joffrey.† She tried to smile bravely for him. â€Å"I love him, Father, I truly truly do, I love him as much as Queen Naerys loved Prince Aemon the Dragonknight, as much as Jonquil loved Ser Florian. I want to be his queen and have his babies.† â€Å"Sweet one,† her father said gently, â€Å"listen to me. When you're old enough, I will make you a match with a high lord who's worthy of you, someone brave and gentle and strong. This match with Joffrey was a terrible mistake. That boy is no Prince Aemon, you must believe me.† â€Å"He is!† Sansa insisted. â€Å"I don't want someone brave and gentle, I want him. We'll be ever so happy, just like in the songs, you'll see. I'll give him a son with golden hair, and one day he'll be the king of all the realm, the greatest king that ever was, as brave as the wolf and as proud as the lion.† Arya made a face. â€Å"Not if Joffrey's his father,† she said. â€Å"He's a liar and a craven and anyhow he's a stag, not a lion.† Sansa felt tears in her eyes. â€Å"He is not! He's not the least bit like that old drunken king,† she screamed at her sister, forgetting herself in her grief. Father looked at her strangely. â€Å"Gods,† he swore softly, â€Å"out of the mouth of babes . . . † He shouted for Septa Mordane. To the girls he said, â€Å"I am looking for a fast trading galley to take you home. These days, the sea is safer than the kingsroad. You will sail as soon as I can find a proper ship, with Septa Mordane and a complement of guards . . . and yes, with Syrio Forel, if he agrees to enter my service. But say nothing of this. It's better if no one knows of our plans. We'll talk again tomorrow.† Sansa cried as Septa Mordane marched them down the steps. They were going to take it all away; the tournaments and the court and her prince, everything, they were going to send her back to the bleak grey walls of Winterfell and lock her up forever. Her life was over before it had begun. â€Å"Stop that weeping, child,† Septa Mordane said sternly. â€Å"I am certain your lord father knows what is best for you.† â€Å"It won't be so bad, Sansa,† Arya said. â€Å"We're going to sail on a galley. It will be an adventure, and then we'll be with Bran and Robb again, and Old Nan and Hodor and the rest.† She touched her on the arm. â€Å"Hodor!† Sansa yelled. â€Å"You ought to marry Hodor, you're just like him, stupid and hairy and ugly!† She wrenched away from her sister's hand, stormed into her bedchamber, and barred the door behind her.

Economics Outline Essay - 951 Words

Health Care Economic Issues Outline Abdel, Susan Erin, Irma September19, 2011 I. Introduction Providing health care service for uninsured and underinsured individuals in the United States is an ongoing concern. A report released by the U.S. Census Bureau reveals the number of uninsured Americans under age 65 rose from 45.7 million in 2008 to 50.0 million in 2009 and an estimated 25 million American’s were reported to be underinsured in 2007 (Gould, 2010). Uninsured are individuals not covered by any type of health insurance. Underinsured are individuals who have health coverage that does not adequately protect them from additional costs of care. From an economic perspective, the weight of this concern falls heavily on the leaders†¦show more content†¦Recommended Improvement Strategies a) Key Players 1) Federal Regulators: Federal legislators are responsible to providing health reform initiatives, as well as policy proposals involving health system reform. 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