Management Of Acute Coronary Syndrome

Management Of Acute Coronary Syndrome Acute coronary syndrome encompasses a collection of three acute processes related to myocardial ischemia. These include: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). Myocardial ischemia is caused by inadequate perfusion within the myocardial tissue due to oxygen demand exceeding oxygen supply. In a healthy person the amount of oxygen required by the myocardium (O2 demand) is determined by heart rate, myocardial contractility, myocardial wall stress, and afterload. As explained by Antman, et al (2012), oxygen supply to the myocardium requires a satisfactory level of oxygen-carrying capacity of the blood (determined by the inspired level of oxygen, pulmonary function, and hemoglobin concentration and function) and an adequate level of coronary blood flow. The coronary vessels have the ability to adjust their level of resistance to adapt to the increased oxygen demand required by the myocardium during certain times (such as during physical exertion). Ischemic heart disease is typically caused by atherosclerosis, which is a buildup of plaque inside the lumen of the coronary vessels. The emergence of atherosclerosis in the vessels does not occur overnight. Antman, et al. (2012) found that atherogenesis in humans typically occurs over a period of many years, usually many decades and that growth of atherosclerotic plaques probably does not occur in a smooth, linear fashion but discontinuously, with periods of relative quiescence punctuated by periods of rapid evolution. The process of atherosclerosis begins with an abundance of lipoproteins in the blood stream. These lipoproteins bind to the walls of vessels and are eventually deposited within the intima of the arteries. To counteract this process, phagocytes are sent into the vessel to attack these foreign particles (Antman et al., 2012). Once the phagocytes are within the intima, they mature into macrophages and become lipid-laden foam cells (Antman et al., 2012). As these plaques advance calcification occurs. This process is thought to be a key step in the formation of atherosclerotic plaques (Antman et al., 2012). Normally this narrowing of the vessel lumen does not cause chest pain or discomfort. Eventually, however, these plaques may rupture. At this point platelet activation occurs, which eventually leads to clot formation at the sight of the plaque. This clot, or thrombus, may break off and lodge in a coronary vessel. These two processes are a common pathogenic finding with acute coronary syndrome (Lincoff, Califf, Anderson, Weisman, Aguirre, Kleiman, Harrington Topol, 1997). A partial occlusion of the coronary vessels due to a ruptured plaque/platelet complex causes unstable angina or a NSTEMI. In this case, the oxygen demands of the heart cannot be met. A complete occlusion causes a STEMI (Anderson, Adams, Antman, Bridges, Califf, Casey Jr, Chavey II Wright, 2011), which eventually leads to myocardial cell death. Discussion/Analysis The emergency department providers are often the first line of defense in the management of patients with chest pain. The ability to quickly evaluate whether or not the cause of chest pain is potentially fatal is of great importance. Critical chest pain can be broken down in to non-cardiac and cardiac causes. Non-cardiac causes include: pneumothorax, pulmonary embolism, and Boerhaaves syndrome. Acute coronary syndrome is among several cardiac causes of emergent chest pain. An accurate diagnosis of the cause of chest pain requires several key components. These include: patient history (including risk factors), physical examination, diagnostics, and labs. History History is instrumental during the evaluation of a patient with chest pain. Ischemic chest pain is often described as a severe pressure or squeezing and is classically described as the feeling of an elephant sitting on my chest. Typically this pain is described as substernal chest pain which radiates to the neck, jaw, or down the left arm. Additional details regarding the onset of chest pain can also serve as important clues. For example, pain on exertion that resolves with rest suggests stable angina, whereas new onset chest pain or chest pain at rest suggests unstable angina. A good method to differentiate cardiac from non-cardiac chest pain is whether the pain improves after administration of nitroglycerin (NTG). If the pain is relieved by NTG it is considered to be likely due to cardiac causes. Additional details suggesting cardiac origin are shortness of breath, nausea +/- vomiting, diaphoresis, and the presence of syncopal/near-syncopal episodes. It is important to note that a patient with chest pain often have a silent or atypical presentation. This is especially true in elderly men (Woon Lim, 2003) and diabetics (Tabibiazar Edelman, 2003). A patient with an atypical presentation may present with shortness of breath but lack the classical symptom of angina pectoris which radiates to the jaw or left arm. Commonly these patients complain of a feeling of indigestion or epigastric discomfort. Thus it is very important to consider ACS in these patients. The presence of risk factors plays an important role in the evaluation of chest pain, especially in a patient with known disease. The landmark Framingham Heart Study showed that cardiac risk can be influenced by diet, lifestyle, and familial risk factors (Oppenheimer, 2005). The more risk factors that a person carries, the greater their risk of developing ischemic heart disease. These risk factors are generally grouped into two categories: those that are modifiable and those that are not. Risk factors amendable are as follows: Tobacco smoke (American Heart Association, 2012) High blood cholesterol (AHA, 2012) High blood pressure (AHA, 2012) Physical inactivity (AHA, 2012) Obesity and overweight (AHA, 2012) Diabetes mellitus (AHA, 2012) Risk factors that cannot be changed include: Age- 82% of people who die of coronary heart disease are >65 (AHA, 2012) Male sex (AHA, 2012) Heredity- this includes both family history and race (AHA, 2012) Risk is higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans (AHA, 2012) Patients presenting with unstable angina or NSTEMI have variable levels of risk of cardiac death and ischemic cardiac events (Antman, Cohen, Bernink, McCabe, Horacek, Papuchis, Mautner Braunwald, 2000). The trial conducted by Antman et al. (2000) set out to develop a simple risk score that has broad applicability, is easily calculated at patient presentation, does not require a computer, and identifies patients with different responses to treatments for UA/NSTEMI. In doing so, the TIMI risk score was created. The scores are calculated using a score of 1 for each risk factor (7 total categories) assigned to a given patient. According to Antman, et al (2000) the score determines the patients risk of death, myocardial infarction, or severe ischemia. Antman, et al. (2000) found 7 prognostic variables that increase a patients risk. These are: Age 65 years or older At least 3 risk factors for coronary artery disease (male, dyslipidemia, smoking, hypertension, diabetes mellitus, obesity family history) Prior coronary stenosis of 50% or more ST-segment deviation on ECG at presentation At least 2 anginal events in prior 24 hours Use of aspirin in prior 7 days Elevated serum cardiac markers In TIMI 11B/ESSENCE, event rates increase significantly as the TIMI-score increases (Antman et al., 2000). A score of 0/1 showed a 4.7% event rate; 8.3% for 2; 13.2% for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7. This landmark pair of trials allows practitioners a quick assessment of a patients risk of suffering a serious cardiac event. Physical Exam Physical exam is also a key component in the evaluation of a patient with chest pain, as many clues can suggest acute coronary syndrome. Unstable vital signs can be an important hint that the patient has suffered an MI. A general examination may reveal a patient who is diaphoretic and/or using accessory respiratory muscles. The cardiovascular exam could reveal a new murmur, S3/S4 gallop, or JVD. Finally, during the pulmonary exam rales may be heard upon auscultation. Diagnostics Diagnostic testing is an essential part of the evaluation of a patient presenting with chest pain. Several important diagnostic tools were introduced to the emergency department in the latter half of the 20th century that greatly improved the diagnosis and care of acute coronary syndrome. Electrocardiogram The introduction of coronary care units in the 1960s allows physicians to utilize the electrocardiogram (ECG) to monitor potential fatal arrhythmias in patients with acute myocardial infarction (Julian, 1987). Shortly thereafter the portable electrocardiogram became commonplace within the emergency department to assist in diagnosing complications of acute coronary syndrome (Drew, et al, 2004). A patient presenting with myocardial ischemia will typically have symmetrically-inverted T waves in leads V2-V6 (Dubin, 2000). As the name suggests, a STEMI is an ST-segment elevation myocardial infarction, though ST-segment elevation can occur with Prinzmetals angina in absence of an infarction (Dubin, 2000). Additionally, the ECG allows us to evaluate necrosis of the heart in the form of the presence of Q-waves. Q-waves are the first downward deflection of the QRS complex (Dubin, 2000). As Dubin (2000) explains, a positive Q-wave MI must: Lack a preceding spike in the QRS complex Be at least 1 mm wide or Have an amplitude of 1/3 the QRS complex An additional benefit of the ECG is that it allows the practitioner to identify the location of an acute event. Each lead corresponds to a particular location of the heart. For example, leads II, III, and AvF are the inferior leads and reflect the inferior portion of the heart. Due to the relatively high specificity but low sensitivity of the 12 lead ECG in diagnosis of acute coronary syndrome, a group of researchers in Canada recently set out to enhance ischemia detection by conducted a trial which added a new criteria using a three vessel specific leads derived from the traditional 12 lead ECG (Horacek, Mirmoghisi, Warren, Wagner Wang, 2008). This trial showed a statistically significant improvement in the ability of the vessel specific lead protocol to detect ischemia (Horacek et al., 2008). Horacek et al. (2008) found the following sensitivity and specificity for conventional STEMI criteria versus that of the vessel specific leads (VSL): Vessel Sensitivity Specificity Left Anterior Descending 74% conventional, 91% VSL 97% conventional, 97% VSL Right Coronary Artery 60% conventional, 70% VSL 94% conventional, 94% VSL Left Circumflex Artery 36% conventional, 71% VSL 100% conventional, 100% VSL Totals Set 60% conventional, 76% VSL 96% conventional, 96% VSL Based on these results, Horacek et al. (2008) concluded that using vessel specific leads can identify acute ischemia better than existing STEMI criteria. While a STEMI criteria using vessel specific leads has yet to become a mainstay within the standard emergency room protocol, this study provides exciting new improvements in the detection and management of patients with ACS. Serum Biomarkers The use of biochemical markers to detect cardiac cell death significantly evolved in the 1980s and 1990s. Initially, nonspecific markers such as aspartate transaminase and total creatinine kinase were used to detect myocardial necrosis (Lewandrowski, Chen Januzzi, 2002). During the mid-1990s the more cardiac specific enzymes CK-MB became the gold standard for detection of myocardial injury (Lewandrowski et al., 2002). CK-MB, which commonly rises 4-9 hours after the onset of angina, was not without its shortcomings. CK-MB may be falsely elevated due to several different causes, including recent strenuous exercise or skeletal muscle damage, or renal failure (Vivekanandan Swaminathan, 2010). In the late 1990s a more predictable biomarker, troponin I, was introduced for more accurate detection of acute coronary syndrome (Heeschen, Goldmann, Moeller Hamm, 1998). According to Heeschen et al. (1998), Troponin I can be evaluated at the bedside in the emergency room and has a higher diagno stic sensitivity for the detection of acute myocardial infarction (60% vs 48%) when compared to CK-MB. The reason for this improvement in accuracy is that troponin I is not found in skeletal muscle tissue or renal failure (Heeschen et al., 1998). As Heeschen et al. (1998) demonstrated in a head to head study that cTnI test systems produced no positive results in patients with end-stage renal failure and acute or chronic skeletal muscle injury, whereas 30% and 71% of the patients, respectively, had increased CK-MB mass concentrations. One disadvantage of troponin I, however, is that it has a lower sensitivity for the detection of acute myocardial infarction compared to that of CK-MB (Heeschen et al., 1998). This is due to an increased level of cTnI in patients with unstable angina (Heeschen et al., 1998). For this reason, a typical workup for a patient with chest pain in the emergency room includes both cTnI and CK-MB assays, which are drawn at presentation and every 3-6 hours therea fter (Ross, Bever, Uddin Hockman, 2000). Imaging A common component of a chest pain protocol is a chest x-ray. This is normally either a standard AP/lateral series or a portable chest x-ray if the patient is unable to get out of bed. The chest x-ray is useful to eliminate other possible causes of chest pain, such as an aortic aneurism or a pneumothorax. Contrast-enhanced computed tomographic angiography, or CTA, has become an integral part of the management of acute coronary syndrome due to its high sensitivity and specificity (Hoffman, Truong, Schoenfeld, Chou, Woodard, Nagurney, Pope Udelson, 2012). According to the ROMICAT-I study performed by Hoffman et al., (2012), CTA is an effective way to rule out myocardial infarction or ischemia as well as major cardiovascular events over the next 2 years from presentation. The data presented in ROMICAT-I showed that patients undergoing CTA decreased their hospital stay by 7.6 hours compared to standard therapy (Hoffman et al., 2012). Additionally, 50% of CTA patients were discharged from the hospital within 8.6 hours of presentation versus only 10% of patients undergoing standard therapy (Hoffman et al., 2012). Finally, the mean time to diagnosis was significantly decreased with the CT group versus the standard group (Hoffman et al., 2012). Overall, CTA was shown to reduce time spent in the hospital and time to diagnosis when compared to standard therapy for acute coronary syndrome. This is important to note considering the importance of quick coronary reperfusion of STEMI patients (Trost Lange, 2011). An additional observation was that these benefits were achieved without an increase in the cost of care (Hoffman et al., 2012). There was no overall difference between the groups in incidence of myocardial infarction 30 days after initial presentation (Hoffman et al., 2012). It is important to note that a patient undergoing a CTA is exposed to increased radiation. Additionally, patients undergoing CTA were more likely to undergo invasive coronary procedures when compared to standard evaluation. Based on this data, a question arises as to whether every patient presenting with possible acute coronary syndrome should undergo a CTA. The population studied in ROMICAT-I consisted of low to intermediate risk patients. Overall, CTA was shown to decrease the time to diagnosis and hospital stay for patients with possible ACS. In contrast, CTA increases a patients exposure to radiation and increases the likelihood that these patients will undergo an increase in invasive coronary procedures. These factors should all be considered when evaluating a patient presenting with chest pain. Treatment Pharmacologic Aspirin: Early aggressive aspirin (ASA) therapy (162-325mg followed by 81-162mg daily) is currently recommended for all patients with acute coronary syndrome, unless contraindicated (Kirk, Kontos Diercks, 2011). Plavix (Clopidogrel): According to the CURE trial Clopidogrel has been shown to provide a 20% reduction in cardiovascular death, MI, or stroke for NSTEMI patients with positive biomarkers or ischemic ECG changes (Kirk et al., 2011). It is important to note that the significant anti-platelet benefits of Clopidogrel administration should also be weighed against the increased risk of bleeding events if the patient may be a candidate for coronary artery bypass surgery. Antianginal Agents: Nitroglycerin (NTG): NTG is commonly administered by EMS respondents but can also be ordered once the patient arrives in the emergency department, typically sublingually or in the form of Nitropaste. Nitroglycerin dilates the coronary arteries, which reduces myocardial oxygen demand (Trost Lange, 2011). For this reason, it is important to evaluate the patients baseline blood pressure. If SBP is less than 100, caution should be used. Morphine: Intravenous morphine may be given in the event that chest pain is not relieved by NTG administration. Morphine reduces ventricular preload, thereby decreasing myocardial O2 demand (Trost Lange, 2011). Beta-Andrenergic Blockers: Beta-blockers decrease demand on the heart by decreasing heart rate, blood pressure, and myocardial contractility (Trost Lange, 2011). In a patient presenting with ACS, IV Lopressor is typically the agent of choice. These are especially effective agents in patients with elevated blood pressure or tachycardia. It is important to evaluate relevant contraindications to beta-blocker therapy, such as: HR Calcium-Channel Blockers: Diltiazem and Verapamil improve cardiac O2 supply by vasodilation of the coronary vessels, reduce O2 demand by reducing afterload, and reduce heart rate and contractility (Trost Lange, 2011). Calcium-channel blockers are 2nd line treatments for ACS and are typically reserved for patients who are unable to take a beta-blocker (Trost Lange, 2011). Contraindications include: sick sinus syndrome, 2Â ° or 3Â ° AV heart block, hypotension, acute MI with pulmonary congestion, atrial fibrillation or flutter with accessory bypass tract, and ventricular tachycardia, severe left ventricular dysfunction, and cardiogenic shock (Epocrates, 2012). Antithrombotic therapy: Antithrombotic therapy is recommended in a patient with suspected ACS, unless contraindicated (Trost Lange, 2011). Unfractionated heparin is easy to administer (IV) and is rapidly reversible with protamine in the event of bleeding. (Trost Lange, 2011). As with any antithrombotic, there is a risk of bleeding so these patients require close monitoring. Low molecular weight heparin is more predictable, has a lower incidence of thrombocytopenia, and does not require monitoring (Trost Lange, 2011). LMWH is the preferred agent for a more conservative, ischemia-guided strategy to prevent in hospital death or myocardial infarction (Trost Lange, 2011). Bivalirudin is an antithrombotic agent that does not cause thrombocytopenia (Trost Lange, 2011). It has been shown to be equally as effective as unfractionated heparin or LMWH but with a significantly lower rate of bleeding (Trost Lange, 2011). Oxygen administration should be administered for patients who are short of breath, showing signs of shock, or O2 saturation Next Step for NSTEMI or Unstable Angina Patients If a patient is considered to be high risk, such as a patient is at risk of future ischemia or infarction, an early invasive strategy is recommended (Trost Lange, 2011). For these patients, cardiac catheterization should be performed within 24-48 hours of admission (Trost Lange, 2011). In a low risk patient, a more conservative treatment is typically recommended. For these patients, catheterization is only recommended if recurrent or provocable ischemia occurs (Trost Lange, 2011). TIMI scores are a valuable tool to assess the patients risk and to guide the practitioner on the appropriate next step. Next Step for STEMI Patients Prompt coronary reperfusion is paramount in patients presenting with STEMI (Trost Lange, 2011). A door-to-balloon time of less than 90 minutes is considered to be the goal (Trost Lange, 2011). If the patient presents to a facility without a percutaneous coronary intervention facility the patient should be either: Treated with fibrinolytic therapy if not contraindicated (Trost Lange, 2011) Or Transferred to a nearby PCI facility (Trost Lange, 2011). Conclusion Acute coronary syndrome is spectrum of diseases typically caused by atherosclerotic disease. Emergency department practitioners must be able to rapidly diagnose and manage ACS patients in order to potentially preserve precious heart muscle. While treatments for ACS have improved dramatically over the past 30 years, several recent innovations have brought upon exciting new possibilities for the care of these patients. These include new vessel specific ECG leads, cardiac specific biomarkers, and the use of computed-tomographic angiography to assess patients with possible ACS. One component of the management algorithm that has not changed is the need for a strong history and physical examination to aid in diagnosis. Urgency in obtaining diagnosis cannot be stressed enough, and patients presenting with STEMI should be rapidly sent for PCI or transferred to a facility with PCI capabilities.

How Infidelity Affects the Marriage and Family? Essay

A liaison, sexual or in any aspect, outside of a marital relationship is an immoral effort and excuse to improve something. Others may say that not all people, who are having or had an extra-marital affair, are regarded as bad and despiteful. These people are generally and oftentimes are in pain, bewildered and lonesome. However, for those who were betrayed, these reasons do not justify nor make one’s infidelity acceptable. One’s involvement to other than his or her partner has a lasting painful and devastating effect not only on the marriage of a couple but more on their children. Fidelity among the parents is the most treasured component of a marriage. It can be regarded as a strong foundation of the entire family. When infidelity sets in, the strong union of the couple is shattered, leaving traces of dishonesty, guilt, and anger. Aside from the betrayed spouse, the children who are not involved in the problem between the couple that caused the break-up are the ones who suffer from the effects more. Infidelity is caused by complicated and different reasons. Extra-marital affairs can happen in both happy and disturbed marriages. Regardless of the cause, what the family evidently needs to be overcome is the manners in which infidelity severely affects the couple’s marriage and the family in general. Characteristics of Infidelity According to Marriage and Family Encyclopedia, infidelity is characterized by a â€Å"breach of trust† which is a reflection of one’s adulterous and cheating of ethical and emotional responsibilities to his or her spouse. Infidelity normally and oftentimes connotes a person’s intimate or sexual relationship to another individual other than his or her partner (Treas). Aside from an immoral sexual relationship, infidelity also comes in other forms. For instance, despite the lack of physical contact, women generally consider a deep emotional liaison as another form of a treacherous extramarital relation (Treas). These characteristics present infidelity as any emotion or conduct that go against or not in accordance with what one expects from his or her spouse and what makes the relationship exclusive (Treas). Infidelity is a worldwide issue, with some countries going beyond their boundaries to address its causes and effects. Aside from the ways in which infidelity affects the marriage and the family, its related topic such as an open marriage that is practiced in liberal countries also has an impact to the overall understanding of such unfaithful relationship. The books of Blumstein and Schwartz, as well as that of Greeley, states that the practice of open marriage in the United States which allows and opens an opportunity for a married person to commit extramarital sex is the only exclusion. Although the two books report that some Americans apparently tolerate open marriage, majority of American couples still regard sexual fidelity as an ultimately significant aspect of their marriage and the one which hold their family together (Blumstein & Schwartz; Greeley). This high consideration to fidelity is supported by an article which states that almost one hundred percent of American couples look for â€Å"sexual exclusivity† from their partners (Treas & Giesen 48). The Effects of Discovered Infidelity An article written by Shirley Glass which appeared on the American Association for Marriage and Family Therapy site states that it is usual for the couple, either the one who committed infidelity or the one who was betrayed, to be depressed. Glass further stated that such feeling of demoralization includes suicide tendencies and anxiety. She added that an intense perception of loss follows the discovery of infidelity. According to Glass, the responses of the cheated partner correspond to the indications of â€Å"post-traumatic stress† experienced by the victims of harmful or even fatal situations. At the onset of the disclosure of the unfaithful relationship, the usual effects are â€Å"loss of innocence and shattered assumptions. † Included in such premises are the obsessive contemplation of the details of the infidelity, nonstop observation of other aggravating symptoms of cheating, recurring and invasive images of the betrayal, and an increased biological arousal due to a sexual effort to win back the partner (Glass). Those who have exerted much trust and the least suspecting are the most badly affected and hurt. The philandering partner, on the other hand, is worried that his or her infidelity will result in a lasting punishment and further suffering. This is because the dreams he or she associated with the extramarital relationship were wasted (Glass). Ways in Which Infidelity Affects The Marriage Infidelity affects not only the marriage but the divorce proceedings that happen afterwards (Treas). Prior to the passing of â€Å"no-fault divorce laws in the 1970s,† a cheating spouse is expected not to be granted with custody rights over his or her children, endure disadvantages in the separation of conjugal properties as well as in payments of support (Treas). In eliminating adultery as grounds for divorce, the â€Å"no-fault laws† likewise remove extra-marital sex as a vindication for preferring one’s welfare over the other partner (Treas). Aside from affecting the marriage, infidelity or other related laws in the United States would forbid a philandering spouse from casting a vote, engaging in alcohol-related works, exercising law, legally adopting a child and living with the previous partner (Treas). It was unfortunate that adultery laws are almost never implemented, despite the fact that a lot of states have silently revoked such outdated legislative acts (Treas). Unrepealed laws then only function mostly for symbolic intentions, representing the state’s adherence for traditional ethical and family living (Treas). Laumann, and his colleagues, on the other hand, stated that the issue of how sexual infidelity impacts the marriage necessitates further research. However, experts on marriage counseling have attested that sexual infidelity definitely rocks a couple’s marriage (Laumann, et al. ). In their book, Laumann and his associates also identified another manner, aside from divorce, in which infidelity affects the marriage. This is the existence of domestic violence which was also already identified as an effect of sexual enviousness (Laumann, et al. ). Lawson corroborated the above destabilizing theory or effect of infidelity to marriage. According to Lawson, infidelity contradicts the couple’s intimacy, weakens the perceptions of shared â€Å"ownership† between a husband and wife, and cuts short commonality that exists when one’s spouse is the only one giving a treasured intimate or â€Å"sexual service. † Sexual infidelity also deviates â€Å"time, energy, and money† outside of the marital union. This is evident when a betraying partner allots or spends more of his or her quality time, physical energy, and cash with a person other than the legal partner. Lawson also said that women’s extramarital relationships are likely inclined to result into divorce or new marriage. This is because of women’s nature of involving of too much emotion into a relationship (Lawson). Ways in Which Infidelity Affects The Children Aside from the emotional and psychological trauma, the infidelity of the parents creates confusion among children, similar to the effects experienced by the betrayed parent that the children feel. An online article by Dianna J. Gould-Saltman stated that in the event the extramarital relationship eventually resulted into the separation of a couple, it becomes an issue if the presence of the new partner will be considered in limiting custody or visitation right over the children. Confusion among the children is evident when the new partner of their father or mother starts to live in the house and the new couple can eventually and freely exercise their sexual activities even when the children are around. This scenario causes children to ask if sex outside of marriage is alright. However, it was stressed that the law states that â€Å"the court must make custody orders consistent with the best interests of the children. † The said article added that unless there is opposing evidence, it is expected that the children of the separated couple still require constant contact with both the father and the mother regardless of whoever committed the infidelity (Gould-Saltman). Infidelity Affects Both the Marriage of the Couple and their Children The same Gould-Saltman article identified three combined issues resulting from infidelity that affect both the marriage of the couple and their children. First is misappropriation which is manifested when the philandering partner takes away or deviates the money supposedly intended for the needs of his or her family. A married person is obligated to manage his or her marital assets, such as the monthly employment income, for the purpose of addressing the needs and promoting the welfare of his or her family. Gould-Saltman said that â€Å"spending community money on a girlfriend or boyfriend, especially expensive gifts, paying for rent or mortgage, or vacations can be deemed a misappropriation. † In view of this the betrayed spouse and the children are authorized to refund â€Å"one half of the funds spent, possibly with interest, from the date of the misappropriation† (Gould-Saltman). Misappropriation, however, is different to another effect which is â€Å"supported spouse. † In the latter, the spouse who was left behind in favor of a new partner will be burdened with proof in getting support from his or her spouse. This takes place when the spouse already â€Å"cohabits† with his or her new partner who now receives the financial support. In doing so, the child support may also somehow be affected because the income is now shared with the new partner. However, this situation can be resolved through legal arrangements. The last effect, which is the possibility of acquiring sexually transmitted disease, is solely experienced by the betrayed spouse. With this impact, the offended spouse, who was transmitted with the disease resulting from the philandering of his or her spouse, is considered a battered spouse and entitled for monetary damages (Gould-Saltman). Conclusion Infidelity is a sensitive issue which does not only affect the legal union of a couple but also leaves the entire family devastated. It is perceived as a one-sided option wherein only the betraying spouse benefits while the offended spouse and their children suffer. The ways in which infidelity affects the spouse and the children cause them to endure suffering in terms of emotional, psychological, and financial aspects which are unfairly happening to them. Such unfaithful conduct unjustly favors the philandering spouse and steps on the rights and protecting the feelings of the betrayed spouse and children. This is because while the philandering spouse is enjoying his or her sexual trysts with the new partner, a husband or wife and the children are left tormented with the pains of infidelity. Works Cited Blumstein, Philip and Pepper Schwartz. American Couples: Money, Work, Sex. New York: Morrow, 1983. Glass, Shirley P. â€Å"AAMFT Consumer Update: Infidelity. † American Association for Marriage and Family Therapy. 2002. 14 April 2008 . Greeley, Andrew M. Faithful Attraction: Discovering Intimacy, Love, and Fidelity in American Marriage. New York: TOR Books, 1991. Gould-Saltman, Diana J. Adultery: Does It Make Any Difference? Divorce Wizards. 1998. 14 April 2008 . Treas, Judith. â€Å"Infidelity-What Are The Consequences? † Marriage and Family Encyclopedia. 14 April 2008 . Laumann, Edward. O, et al. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press, 1994. Lawson, Annette. Adultery: The Analysis of Love and Betrayal. New York: Basic Books, 1988. Treas, Judith and Deirdre Giesen. â€Å"Sexual Infidelity Among Married and Cohabiting Americans. † Journal of Marriage and the Family 62 (2000):48–60.

How Is Parish Activities Important - 865 Words

Parish activities are important because for a person to truly be a part of a church he or she has to be involved in that church. This is not limited to attending mass, being involved in a parish means helping with other activities that the church puts on like the youth activities, service projects, fish dinners, and chicken dinners. I whole heartily enjoy volunteering at all of the activities the church puts on. These activities are a nice way to give back to the church, and to get to know members of the church that I may not see on Sundays at church. Volunteering is important because it shows others that you care about them pr the group that a person is helping. Any chance I have to volunteer, I take that opportunity and do the best I†¦show more content†¦I truly enjoy this volunteerism because I get to set-up for an event then watch everyone enjoy the event which brings a smile to my face. Also, in college through football I have had opportunities to serve including being one of only 5 who went around and picked up cans for a can drive, and an all day service project cleaning a local summer camp for the children who would be attending this summer. Although volunteering may not solely be done through the church it is a great way to show faith. One of my favorite bible verses is James 2:14-18 which states that faith without works is dead to put it simply. This verse is one of the reasons that I hold volunteering deep in my heart. Catholicism is a very important to me for a few reasons. First, faith through works is one reason why being a Catholic is important to me because I believe that we are put on this earth to help others as much as we can. So if someone has not volunteered then that person has lost part of what being a true Catholic means. Another reason being Catholic is important to me is the tradition. This tradition was set a long time ago and will hardly change. Although some aspects like wording has changed, the foundation of the mass itself has been the same for many generations. Also, the tradition of every single object in the church and everything father does during the mass. These core Catholic traditions go back a long way and have only changedShow MoreRelatedFaith Based Nurse : Review Healthy People 2020885 Words   |  4 PagesReview Healthy People 2020. Identify objectives that are amenable to parish nurse intervention. Describe how faith communities can contribute to the accomplishment of these national health objectives and accomplish the goal of improving the health of the public. How can nurses working in the community form partnerships with parish nurses and faith communities? How would such partnerships be beneficial? Health and healing are important factors in faith communities. 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Later released prospectus indicated that the Archdiocese paid over $10 million directly from its own assets to settle claims of sexual abuse, and these payments were not part of financialRead MoreWhat Are Generally Accepted Accounting Principles?1448 Words   |  6 PagesArchdiocese of New Orleans from 2001 to 2009. In 2008, the archdiocese announced that it had lost more than $100 million as a result of Hurricane Katrina — because insurance failed to cover all its property losses. Those losses had no bearing on the parish a closure, the church says. Not all the faithful are convinced. Later released prospectus indicated that the Archdiocese paid over $10 million directly from its own assets to settle claims of sexual abuse, and these payments were not part of financialRead MoreOffi ce Administration1449 Words   |  6 Pages An investigation of the effectiveness of the auditing procedures used in the accounting office at the Portland Parish Council. Name Page Acknowledgement 1 Title 2 Aims 3 Functions 4 Letter of Correspondence 5 Methodology 6 Questions Asked 7 Schedule of Activities 8 Regulations and Policies 9 Report 10-11 Office Equipment 12 Interview questions 14 Business Form 15 Bibliography 16 Read MoreCanine Assisted Therapy And Mental Health1539 Words   |  7 Pagesdecreased levels of activity, social functioning and social problem-solving strategies compared to non-institutionalised patients. The participant group comprised of seven patients working with a psychiatrist, a social worker, a dog and its handler. C.A.T took place over nine months. This was done at weekly intervals at the same time for 50 minutes. Assessment was made using the Independent Living Skill Survey (ILSS). Kovà ¡cs et al. (2004) found that although for normal everyday activities the patients demonstratedRead MoreTaking a Look at Vatican II1244 Words   |  5 Pagesrelations with other Christian churches and with non-Christian religions, the churches relationship to the modern world, and the Catholic understanding of revelation . These contributions came in the forms of legislation and texts. Perhaps the most important text of Vatican II was The Dogmatic Constitution on the Church or Lumen Ge ntium. In Latin, Lumen Gentium can be translated as â€Å"light of nations†. Pope Paul VI, who continued the work of Pope John when he passed away, declared Lunem Gentium to beRead MoreThe Religious Education ( Re ) Grades 1-8 Policy Document765 Words   |  4 Pagesâ€Å"spiritual growth of each person† (p. 4). It highlights how the â€Å"soil of the believer† (p. 4) is identified as essential for the connections of the student and family culture. The connection is the power needed to encourage the students’ experiences, values and beliefs in their journey of their faith. This section guides the missionary activity for non-believers, initial catechetical activity for those partaking in the Gospel and pastoral activity for those more enrich within mature faith community.Read MoreI Was A Single Mom Raising Two Young Children1691 Words   |  7 Pagespoverty line. My hope was this new career path would lift us up and set us on a new path to financial stability . A path where I would not have to worry about where our next meal was coming from. Those within the grip of difficult times may not know how they will feed their children. Feeding the hungry, especially children, is the purpose of my organization, The Saint Philomena Breakfast Kitchen, Inc. Prior to forming a board of directors or applying for tax exempt status I must first determine

The Philosophy Of Knowing And Learning - 2646 Words

Knowing and learning can be interpreted in many different ways, but my philosophy of knowing and learning is based on my understanding through the personal experience in the tutoring situation. As a Tutor for students who were 9 years old, majority of the time was spent reading to develop their English. An aspect that impacted the students’ learning progress tremendously was the tutor’s responsibility to understand the student’s capability, needs and interest to support their learning progress. When tutoring the students, there were some theories that were appropriate to aid the students’ in reading and influenced the tutor’s techniques employed to support the students’ learning. The philosophers that influenced my tutoring techniques were Etienne Wenger, Jerome Bruner, Albert Bandura, Ivan Pavlov, Burrhus Frederic Skinner, Jean Lave, Wolfgang Kohler and Lev Vygotsky. Wenger’s social theory believed that adding meaning and interest int o an activity encourages learning (Lave Wenger,1991). The Gestalt Approach influenced Kohler’s idea where the student would need to know the basic elements before being able to learn and acquire more knowledge (Phillips Soltis, 2009). To build up new ideas from the initial basic elements, Scaffolding by Bruner and Modelling by Bandura were the two learning strategies utilized to support the student’s learning (Nalliah Idris, 2014). The student is made aware that the new acquired skill or knowledge taught by Scaffolding and ModellingShow MoreRelatedCurriculum Development618 Words   |  3 PagesAs an emerging educator the education philosophy embraced will have great impact on the teaching and learning process, beliefs about students, beliefs about knowledge concepts as well as the belief about what is worth knowing. This is so, as each of us perception or the construct of our education philosophy differs as the source may be stemming from differing schools of thoug ht. According to Wiles Bondi, major philosophies of life and education have traditionally been defined by three criteria;Read MoreComponents Of An Educational Philosophy1038 Words   |  5 Pagesperson’s philosophy is defined as, â€Å"A theory or attitude held by a person that acts as a guiding principle for behavior.† If a person’s philosophy shapes his or her actions, then it is vital for any professional to have a good philosophy in their profession, so their actions follow suit. Therefore, it is important for an educator to have a solid philosophy of education so that his or her teaching is effective and right before God. Six important components of an educational philosophy are metaphysicsRead MorePhilosophy : The Liberalistic Philosophy Of Education807 Words   |  4 Pages Philosophy of Education 2 Perspective: The Liberalistic Philosophy of Education The empowerment of individuals within a community appeared to be nonexistent in Greek philosopher Plato s, Allegory of the Cave. Preferentially, it was simply not within the range of one s knowledge, experience, or understanding; strange; therefore, unfamiliar. Greek philosopher Plato, an astute student of Socrates, his focal point - an advocateRead MoreThree Propositions That The National Board For Professional Teacher Standards1364 Words   |  6 Pageshas listed, which are Proposition 1: Teachers are Committed to Students and Their Learning, Proposition 2: Teachers Know the Subjects They Teach and How to Teach Those Subjects to Students, Proposition 3: Teachers are Responsible for Managing and Monitoring Student Learning, Proposition 4: Teachers Think Systematically about Their Practice and Learn from Experience, and Proposition 5: Teachers are Members of Learning Communities. The five propositions are similar to the code of ethics that are setRead MoreTeaching Educa tion For Students Of All Ages, Genders, Ethnicities, And Differences987 Words   |  4 Pagesstrategies to connect with students of all ages, genders, ethnicities, and differences in learning. Educational philosophies are the foundation of education and how it influences students learning in classrooms. All teachers have their own belief on how education should be taught, I will express my thoughts to how I will provide education to my students. The purpose of education, three to four educational philosophies I plan to use, and why teaching matters to me, and how I will teach my classroom. Read MoreThe Knowledge Argument By Jackson1134 Words   |  5 Pagesis seemingly sufficient to understand color (Philosophy 101 slides, The Knowledge Argument). Jackson’s basic argument is as following. â€Å"Before her release from the black and white room, Mary has all the physical information concerning human color vision. Mary learns something new about color when she leaves the room. So, there is some information about human color vision which Mary doesn’t know. So, not all information is physical information† (Philosophy 101 slides, The Knowledge Argument). BecauseRead MoreJean Piaget And Lev Vygotsky And Vygotsky s Views On Teaching Philosophy And The Children Of The Future Essay1119 Words   |  5 Pagesperiod I observed that every teacher has a different learning and teaching philosophy, therefore I would like to describe my own teaching and learning philosophy and by whom I was influenced. In my discussion I will elaborate on the philosopher: John Dewey with his philosophy: â€Å"Progressivism† and other philosophers: Jean Piaget and Lev Vygotsky with their philosophy: â€Å"Constructivism†. I am also going to elaborate on my ideas on teaching, learning and the children of the future in my class togetherRead MoreEssay about My Philosophy of Education1364 Words   |  6 PagesMy Philosophy of Education Generally when you compare twins you find that they are different in many ways. Even if they are identical and they look exactly alike they usually have different personalities. Normally they are extreme opposites; one takes up the more dominant outgoing personality while the other is shy and more of a follower. Ever since my sister and I were little I have taken on the more dominant role. From the time of playing school when I was little I have alwaysRead MoreNature Of Philosophy : The Nature Of Philosophy1333 Words   |  6 PagesThe Nature of Philosophy Philosophy is a subject that chases wisdom by trying to answer the questions we have regarding our life, what we know, and what we choose to do. One aspect of philosophy stands out too because it refers to the knowledge and what we do with the information we receive from our experience on a day to day basis and how we process this information. The nature of philosophy surrounds the techniques we use, how we react to new knowledge, the answers to questions we have all askedRead MoreMy Reflection On My Philosophy933 Words   |  4 PagesMy teaching philosophy is a reflection of my passion for providing all students with the tools necessary to not only succeed in school but also out in the real world. My passion is a reflection of my experiences as a student and now as a future secondary mathematics educator. From my experiences, I have been able to determine that my teaching philosophy entails three tenets. Students should be ready for the world, no two learners are the same and a gre at teacher can inspire a student to do the impossible