Accounting-System in Switzerland essays

Accounting-System in Switzerland essays Brainstorming: Accounting of Switzerland 4 We have chosen the Switzerland for several reasons. First of all Swiss accounting is neither examined in our textbook nor is it one of our native countries. This was one of the requirements of the exercise. Then we thought that Switzerland is interesting because of its cultural background. There are four languages spoken in the Switzerland, which is enclosed by 5 neighbours (Germany, France, Italy, Liechtenstein, Austria). The Swiss adopted the language of Germany, France and Italy and that led us to the assumption that the Swiss accounting probably might be influenced by at least one or even more of its neighbours. Another reason choosing Switzerland was the well-known banking secrecy and the importance of privacy and secrecy in general. To get informations about Swiss accounting we looked at the articles in newspapers, books, magazines and the Internet. Interestingly it seemed that even the professionals wrangle with the challenges of switching the accounting system. Because Switzerland isnt a member of the European Union it was interesting to examine to which extent the EU policy in terms of accounting influences Swiss accounting. Brainstorming: Accounting of Switzerland Switzerland has only very few natural resources and a restricted surface area (~ 41 million km ², 60% of the surface is alpine area) (source: derweg.org/laender/schweiz/schweieinf.htm). Foreign trade is essential for its wealth. The total population of about 7,200,000 and - associated with that - a relatively small domestic market is another factor which forced Swiss manufacturers to look for cross border trade. They need foreign markets in order to make investment in research and development worthwhile. The constitution of Switzerland was published in 1848 and guarantees freedom of the press and settlement, religious and association liberty. Paragon for the swiss institution was the institut...

National Education Day Essay Example

National Education Day Essay Example National Education Day Essay National Education Day Essay A brief biography is given here Abul Kalam Azad Date of birth: 11 November 1888 Place of birth: Mecca, Ottoman Empire (now in Saudi Arabia) Date of death: 22 February 1958 Place of death: Delhi, India Movement: Indian independence movement Major organizations: Indian National Congress Maulana Abul Kalam Muhiyuddin Ahmed (11 November 1888 – 22 February 1958) was a Muslim scholar and a senior political leader of the Indian independence movement. He was one of the most prominent Muslim leaders to support Hindu-Muslim unity, opposing the partition of India on communal lines. Following India’s independence, he became the first Minister of Education in the Indian government. He is commonly remembered as Maulana Azad; he had adopted Azad (Free) as his pen name. As a young man, Azad composed poetry in Urdu as well as treatises on religion and philosophy. He rose to prominence through his work as a journalist, publishing works critical of the British Raj and espousing the causes of Indian nationalism. Azad became a leader of the Khilafat Movement during which he came into close contact with Indian leader Mahatma Gandhi. Azad became an enthusiastic supporter of Gandhi’s ideas of non-violent civil disobedience, and worked actively to organize the Non-cooperation movement in protest of the 1919 Rowlatt Acts. Azad committed himself to Gandhi’s ideals, including promoting Swadeshi (Indigenous) products and the cause of Swaraj (Self-rule) for India. He would become the youngest person to serve as the President of the Indian National Congress in 1923. As India’s Education Minister, Azad oversaw the establishment of a national education system with free primary education and modern institutions of higher education. He is also credited with the foundation of the University Grants Commission, an important institution to supervise and advance the higher education in the nation. Azad mastered several languages, including Urdu, Persian, Bengali, Arabic, and Hindi. He was also trained in the subjects of mathematics, philosophy, world history and science by reputed tutors hired by his family. An avid and determined student, Azad succeeded in completing the traditional course of study at the young age of sixteen, nine years ahead of his contemporaries. As Indias Education Minister, Azad oversaw the establishment of a national education system with free primary education and modern institutions of higher education. He is also credited with the foundation of the University Grants Commission (UGC), an important institution to supervise and advance higher education in the nation. The Ministry of Human Resource Development, had on September 11, 2008 announced, The Ministry has decided to commemorate the birthday of this great son of India by recalling his contribution to the cause of education in India. November 11 every year, from 2008 onwards, will be celebrated as the National Education Day, without declaring it a holiday. Maulana Abul Kalam Azad served as the Minister of Education in Pandit Jawaharlal Nehrus cabinet from 1947 to 1958. He died of a stroke on February 22, 1958. Maulana Azad had been appointed Indias first Minister for Education and served in the Constituent Assembly to draft Indias constitution. Azads persuasion was instrumental in obtaining the approval of Muslim representatives to end the communal electorates, and was a forceful advocate of enshrining the principle of secularism, religious freedom and equality for all Indians. He supported provisions for Muslim citizens to make avail of Muslim personal law in courts. [ As Indias first Minister of Education, he emphasized on educating the rural poor and girls. As Chairman of the Central Advisory Board of Education, he gave thrust to adult illiteracy, universal primary education, free and compulsory for all children up to the age of 14, girl’s education, and diversification of secondary education and vocational training. [17] Addressing the conference on All India Education on January 16, 1948, Maulana Azad emphasized,[17] â€Å"We must not for a moment forget, it is a birth right of every individual to receive at least the basic education without which he cannot fully discharge his duties as a citizen. He oversaw the setting up of the Central Institute of Education,Delhi which later became the Department of Education of the University of Delhi as â€Å"a research centre for solving new educational problems of the country†. [18] Under his leadership, the Ministry of Education established the first Indian Institute of Technology in 1951 and the University Grants Commission in 1953. ,[19][20] He also laid emphasis on the develo pment of the Indian Institute of Science, Bangalore and the Faculty of Technology of the Delhi University.

Recognizing Employee Contributions - Compensation & Benefits Essay

Recognizing Employee Contributions - Compensation & Benefits - Essay Example Every firm develops a specific structure of compensation and benefits. Incentive pay is an integral part of benefits being offered to employees. In this particular study views and opinions will be given to a new retail company so as to retain its talented base of employees. Team members tend to leave an organization when they are not satisfied with organizational environment or their compensation structure. It is major responsibility of HR manager to continuously modify compensation framework in order to deliver the best benefits to employees. Workforce can be motivated either through monetary rewards or non-monetary appreciation. This study outlines current scenario of a retail company that is into internet sales as well as has retail outlets. Employee survey in the firm has revealed that employees are not satisfied with compensation system and are leaving jobs. In this study different approaches would be highlighted that can help to retain employees and facilitate developing approp riate compensation system. Incentive pay is essential for retaining employees within the system. Pay can be defined as the first reward that is given to managers or employees. Incentives are additional benefits given to employees so as to motivate them for undertaking new challenges. Pay can be classified into three segments such as basic pay, pay for performance and merit pay. Basic pay occupies the main portion of compensation and is referred to as hourly wage or salary. Merit pay is totally based on predetermined criteria. On the other hand, pay for performance can be defined as incentive pay system. Rewards are given to distinguish between competencies possessed by team members and their respective contributions towards firm’s overall success. There are certain new pay techniques that can be adopted by the retail company so as to retain its employee base. Amongst all the techniques two mechanisms are most suitable in the given situation such as

Anti Death Penalty Research Paper Example | Topics and Well Written Essays - 2000 words

Anti Death Penalty - Research Paper Example All states in United States of America have been granted freedom to choose whether to apply death penalty or not. In 1999, ninety-eight people were executed and about three thousand five hundred and sixty-five prisoners were on the death row in 2000. Death penalty is perceived differently by different members of the society. To some, capital punishment provides ultimate solution to reduce or eradicate the vice while to others, it is brutal and a disgrace to a civilized society. To understand the magnitude of death penalty, it is important to know the views of both the opponents and proponents of death penalty as a punishment to capital offenders. First, supporters of death penalty argue that capital punishment is a sure way of eliminating worst criminals and making the society safe. This is because when capital offenders are removed from the face of the earth through a judicial process, they are stopped from committing further worst crimes. Worst criminals must be executed because they may commit the same worst crimes if released back to the society or escape from prisons walls. Furthermore, they may commit worst crimes in the prisons that host them. Therefore, terminating their existence through the judicial process is considered appropriate. Secondly, death penalty is considered retribution. The families and friends of victims of murder or rape may feel that justice has been delivered by executing the perpetrators that caused death or anguish to their loved ones. The perpetrators deserve death because it is a punishment proportional to committed offenses. Thirdly, death penalty acts as a strong deterrent to potentially wor st criminals. This is true especially where execution is carried regularly and immediately. In Britain and United States of America, the rate of worst crimes such as murders reduced significantly when the death penalty was in force and regularly

Close reading Essay Example | Topics and Well Written Essays - 1250 words - 1

Close reading - Essay Example On arrival at the hotel, we were welcomed by a smartly dressed lady in a white shirt and blue nicely fitting skirt. I later learnt was a headwaiter. She welcomed us in a professional manner and showed us to an unoccupied table close to the counter. The waiter gave us the menu to go through and as if to save time, she went through it mentioning the main dishes offered as I perused with little attention to what she was saying until I heard her mention the word Balut. I paused to look at her and she went on to underscore how favorite the food was among many patrons in the hotel. I asked the waiter to tell me more about ingredients and preparation of Balut. She explained that a duck’s egg prepared in the Filipino traditional style was the core component of the food. She said the egg is boiled and served when hot or warm and that it may not be as delicious if served when cold. My friend nodded in agreement and with a suggestive smile took the menu from my hands. I was curious and wanted to know more because I did not know anything unique in a duck’s egg apart from the fact that it is usually bigger than that of a chicken. The waiter informed me that other accompaniments depend on the tastes and preferences of the customer, for example ground pepper mixed with sour milk that is not fully fermented, lemon chips or garnish. Rice can also be served together with balut. What amazed me is the simplicity with which the waiter explained to me as if I was a member of the South Asian immigrant community who know balut. The waiter also informed me that apart from being a delicacy, balut has therapeutic value, which is the feature that is mostly sought after by immigrant South East Asians. According to Cherry and Morris, balut is known to strengthen the human immune system and was cholesterol free. I felt that I had come to the right place

Hydrogels for Wound Healing Applications

Hydrogels for Wound Healing Applications Abstract This chapter discusses about the hydrogels both natural and synthetic that can be used for wound healing applications. Also it discusses briefly about the various novel techniques that have been developed recently. Keywords: Hydrogels; Chitosan, Antimicrobial; Grafting; Blending; Wound dressing; Wound healing; Gene therapy, Stem cell therapy, Skin Engineering, pH and Thermosensitive polymers. 1 Introduction Healthcare is an essential aspect of human survival. So many biopolymers have generated interest in a number of biomedical applications. Wound management is one such area where management of cuts, ulcers, and sores needs dressings which help in promoting rapid wound healing in order to obtain both functional and cosmetic results. [45] There are different kinds of wound management products: staples or sutures, dressings or bandages, surgical sealants and adhesives, skin substitutes, and other biomaterials. [51] Human skin provides an effective barrier to microbial penetration and subsequent infection. However, once the wound has been developed in this barrier, the infection chances increases. In case of chronic wounds, the colonization and infection potential increases as the result of the presence of avascular eschar which provides an environment for the uninhibited growth of microorganisms. [89] The rate of infection is related to the type of wound, general wound care, and local health of the patient. [88, 90] For avoiding infection, good clinical practices are needed. The management of chronic wounds is a very costly practice and it also places an enormous drain on healthcare resources; studies have calculated the cost of wounds to the NHS to be about  £1bn a year. [166] So for lowering this cost such wound management products are needed that are more economical and effective. Out of all the above wound management products, here in this chapter we will discuss more about the wound dressings that will provide an optimal healing environment to the wound. A dressing is an adjunct used by a person for application to a wound in order to promote healing and/or prevent further harm. It is designed to be in direct contact with the wound, so it is different from the bandage in the manner that bandages are normally used to hold dressing in place. A wound is a break in the epithelial integrity of the skin and may be accompanied by disruption of the structure and function of underlying normal tissue. Wounds can be divided into four categories based on their appearance and stage of healing: Necrotic, sloughing, granulating and epithelializing wounds. [87] Wounds cause discomfort and are more prone to infection and other troublesome complications. [75] Some diseases like diabetes, ischaemia and conditions like malnourishment, ageing, local infection, local tissue damage due to burn leads to delay in wound healing. Infection is a major complication of burn injury and is responsible for 50-75% of hospital deaths. [76] Human skin has one of the greatest capacities to regenerate itself amongst all of the tissues in our body. It constantly replaces old cells with new cells, enabling it to repair itself when damaged. Wound healing is a complex-physiologic process, which consists of three overlapping phases: inflammatory, proliferative and remodeling phases. The normal healing response begins the moment the tissue is injured. As the blood components spill into the site of injury, the platelets come into contact with exposed collagen and other elements of the extracellular matrix. This contact triggers the platelets to release clotting factors as well as essential growth factors. During the inflammation process, neutrophils are the first leukocytes which come at the site of injury to rid it from bacterial contamination. Then, the monocytes and their conversion to macrophages initiate tissue repair by releasing a number of biologically active substances and growth factors that are necessary for the initi ation of tissue formation process. In the third process, fibroblasts proliferate and migrate into the wound space and started the deposition of the loose extracellular matrix. Endothelial cells grow into a wound simultaneously with fibroblasts and undergo angiogenesis. Finally, tissue remodeling takes place to reconstruct the basement membrane by the differentiation of keratinocytes as well as the formation of follicle cells. [43, 49, 50] A scar is an essential part of this natural healing process following any type of damage to the skin. This can occur after a surgical incision or the healing of a wound. As your body makes an effort to close an open wound and protect itself from infection, it replaces injured skin tissue with rapidly generated scar tissue. Scarring is slight when the damaged outer layer of skin is healed by rebuilt tissue. When we damage the thick layer of tissue beneath the skin, rebuilding is more complicated. Our bodies lay down collagen fibers (a protein which is naturally produced by the body) and this usually results in a highly obvious scar. A permanent reminder of the injury is left behind. So, a dressing that can induce scarless healing is needed. Historically, a dressing was usually a piece of material, sometimes cloth, but the use of cobwebs, dung, leaves and honey has also been described. However, modern dressings include gauzes, semipermeable films, low adherent dressings, gels, foams, hydrocolloids, alginates, hydrogels and polysaccharide pastes. Wound dressings are passive, active or interactive. Passive dressings simply provide cover while active or interactive dressings are capable of modifying the physiology of the wound environment. Interactive dressings include hydrocolloids, hydrogels, alginates, foam dressings and antimicrobial dressings. [17, 20, 85] Traditionally dry wound dressings are considered to be good for healing wounds i.e. the wound should be covered with gauze or left open. But it has been observed by Winter [191] that when wound is left open to air without any dressing, a scab i.e. a dry covering covers the wound and decreases the rate of epithelialization. On the other hand, if moist dressing is used in place of dry dressings scab will not form and rate of healing increases as moist dressings provide low oxygen tension which helps in wound healing, these dressings not only keep cells viable which enables them to release growth factors while maintaining contact between them and the healing tissues, but may also modulate or stimulate their proliferation, these dressings decrease the pain at rest, during ambulation and during dressing changes also moist environment allows rapid and efficient delivery of any added antimicrobial agent thus prevent the wound from infection. So, the dressings that create and maintain a mois t environment, however, are now considered to provide the optimal conditions for wound healing. 2 Requirements of an ideal wound care system These characteristics should be present in the ideal wound care system (a) it should be capable of maintaining a high humidity at the wound site, (b) it should be non-toxic, (c) non-allergenic, (d) it can be removed without causing trauma to the wound, (e) it should pe impermeable to bacteria, (f) Thermally insulating, (g) it should be soft to touch, (h) it should allow proper gaseous exchange, (i) it should be free from particulate and toxic product, (j) promote tissue reconstruction processes and (k) it should be cost effective. [20, 165, 177] Out of all the dressings hydrocolloids, alginates and hydrogels each one has its own advantages and limitations but hydrogels are best and have all the characteristics that are needed in an ideal wound dressing. All the above mentioned characteristics can be achieved in hydrogel wound dressings. 3 Hydrogels for Wound Healing Applications Hydrogels are natural or synthetic cross-linked polymers used in a variety of medical and biomedical applications. Hydrogels consist of a matrix of insoluble polymers with up to 96% water content enabling them to donate water molecules to the wound surface and to maintain a moist environment at the wound bed. They are used in the construction of contact lenses, drug-delivery vehicles, wound dressings and as physiological electrodes or sensors. [17] Examples of hydrogel include Aquaform, Intrasite, GranuGel, Nu-Gel, Purilon, Sterigel. These also have the ability to absorb a degree of wound exudate. They transmit moisture vapour and oxygen, but their bacterial and fluid permeability is dependent on the type of secondary dressing used. [20] Hydrogels swell or shrink in aqueous solutions due to the association, dissociation and binding of various ions to polymer chains. These systems may swell in water until an equilibrium state is reached and retain their original shape. The interactions responsible for water sorption by hydrogels include the process of hydration, which is connected to the presence of such chemical groups as -OH, -COOH, -CONH2, -CONH-, and -SO3H and the existence of capillary areas and differences in osmotic pressure. The forces that make hydrogel dissolution impossible are presence of covalent bonds between individual polymer chains, hydrophobic and electrostatic interactions. [46] These are hydrophilic polymer networks which may absorb from 10-20% (an arbitrary lower limit) up to thousands of times their dry weight in water. These may be chemically stable or they may degrade and dissolve. They are called ‘reversible, or ‘physical gels when the networks are held together by molecular entanglements, and/or secondary forces including ionic, H-bonding or hydrophobic forces. [13, 14, 15] Hydrogels are called ‘permanent or ‘chemicalgels when they are covalently-crosslinked networks as shown in 1. Hydrogels can be made by irradiation, freeze-thawing or chemical methods. Out of all the methods, irradiation is considered as a suitable tool for the formation of hydrogels as in this method there is easy control of processing, no need of adding initiators or cross-linkers which are harmful, and have the possibility of formation and sterilization in one step. But as everything has its own advantages and disadvantages this method also has a disadvantage which is hydrogels formed by this method have poor mechanical strength. Nowadays, Freeze thawing technique is generally used to prepare hydrogels having good strength, stability and no crosslinkers and initiators. But the main disadvantage is that the prepared hydrogels have opaque appearance and limited swelling and thermal stability. [120] In comparison to the traditional gauze therapy the application of a hydrogel seems to significantly stimulate wound healing. [11] Various natural and synthetic polymers having good biocompatibility are used to develop hydrogel wound dressing. These polymers include natural polymers such as alginate, chitosan, gelatin and collagen and synthetic polymers such as polyurethane, poly(ethylene glycol), polycaprolactone, poly vinyl pyrrolidone, poly(lactide-co-glycolide), polyacrylonitrile , poly(amino acid), etc. Table 1 below shows different hydrophilic polymers used to synthesize hydrogel matrices. Table 1 Hydrophilic polymers used to synthesize hydrogel matrices. [13] Hydrogels may be classified as homopolymer hydrogels, copolymer hydrogels, multipolymer hydrogels, and interpenetrating polymeric hydrogels. Homopolymer hydrogels are crosslinked networks of one type of hydrophilic monomer unit, whereas copolymer hydrogels are produced by the crosslinking of two comonomer units, one of which must be hydrophilic. Multipolymer hydrogels are produced by the crosslinking of more than three monomers. Finally, interpenetrating polymeric hydrogels are produced by the swelling of a first network in a monomer and the reaction of the latter to form a second intermeshing network structure. [46, 47] Also, it has been shown that the blending of a natural polymer with a synthetic polymer seems to be a good method for obtaining materials having required mechanical and thermal properties in comparison to pure components. It is also a simple method by which suitable shapes such as films, sponges and hydrogels can be obtained easily to realize a variety of biomedical devices. 2 shows healing is faster with the hydrogel dressing than with the gauze dressing. Wound area covered by hydrogel decreases faster with increasing healing period. On the contrary, the wound covered by gauze dressing reduces by only half a percent even after 14 days. [192] 3.1 Natural Hydrogels Natural polymers, such as chitin, chitosan, alginate, collagen, elastin, genipin, gelatin, cellulose etc. have been used for dressing wounds because they play an important role in the healing process. [47] Chitosan is a partially deacetylated form of chitin. Chitin as BeschitinÃ’, Unitika, is also commercially available as dressing in Japan. [28] But as far as chitosan is concerned it is biocompatible, biodegradable, haemostatic, fungistatic [54] and non-toxic and can be successfully used as gels, films, fibres etc. This polymer also show antibacterial properties and possess good wound healing properties. [60, 61, 62] It has many applications as wound dressing, drug delivery device and as scaffold for tissue engineering. [63, 64] Some of the examples of wound dressings are given below which use chitosan as one of the biomaterial. Asymmetric chitosan membranes have been developed by using immersion-precipitation phase-inversion method. [123, 124, 125] These asymmetric chitosan membranes are homogeneous and have porous structure. This membrane was prepared by preheating casted chitosan solution in oven for different time periods for dry phase separation and then immersed in to coagulant tank for wet phase separation and were subsequently freeze-dried. The skin layer acts as the rate controlling barrier for the release of drug and the porous layer provide mechanical support to the skin layer. The water vapor transmission rate, gas permeability, PBS solution absorption, in-vitro degradation, cell culture, bacterial penetration and wound healing test of this dressing were carried out. These membranes are effective in controlling evaporative water loss, showed excellent oxygen permeability and also antibacterial in nature. These are also found to be an urgent hemostat. In another study, silver sulphadiazine was inc orporated as an antimicrobial agent to this asymmetric dressing. The release behaviour of both silver and sulphadiazine ions were studied and found to be significantly different from one another. Silver ions displayed a slow release behavior while sulphadiazine ions exhibited burst effect on first day of the drug release and then slowly tapered off. It is because of the interaction of silver with amino group of chitosan leading to its slow release throughout whereas, as the sulphadiazine ions were free to diffuse through the membrane to reach the wound site thus they showed a burst release. The membranes were further found effective against P. aerugniosa and S. aureus. In one of the papers, novel wound dressings were formed that composed of chitosan film and Minocycline Hydrochloride (MH) and commercial polyurethane film (Tegaderm) as a backing. It is also a useful formulation for the treatment of severe burn wounds. Water vapor and oxygen can permeate the Tegaderm film but water cannot. The tegaderm film support the polymer membrane. [126] In one of the studies, a silver nanocrystalline chitosan (SNC) wound dressing composed of nano-silver and chitosan was constructed by self-assembly and nanotechnology and used for treating deep partial-thickness wounds. In this, sterility and pyrogen testing were performed to ensure biosafety. These dressings promote wound healing and combat infection, and also decrease the risk of silver absorption in comparison with silver sulphadiazine (SSD) dressings. [127] There is also one more method of forming wound dressing composed of chitosan i.e. the formation of polyelectrolyte complex of gum kondagogu (GKG) and chitosan. This complex is formed by the electrostatic interaction between carboxyl group of gum and amine group of chitosan. This method is more advantageous as it avoids the use of organic solvents, chemical crosslinking agents and thus reduces the toxicity and undesirable side effects. In this, diclofenac sodium is used as model drug. The diclofenac loaded complex of gum kondagogu/ chitosan shows drug release which changes with change in pH. The drug release was higher at pH 6.8 as compared to pH 1.2, due to higher swelling of complex at higher pH. This holds a great potential as a natural polymer based delivery device for controlled delivery of drugs like diclofenac sodium for two reasons: (i) to reduce dosing frequency and (ii) lower the gastric toxicity. [152] Semi-interpenetrating polymer networks (SIPNs) composed of chitosan (CS) and poloxamer were prepared in order to improve the mechanical strength of CS. The WVTR was found to be 2508.2 ±65.7 gm−2 day−1, i.e. these can maintain a moist environment at wound site which enhance epithelial cell migration. Also, the in vitro assessment of SIPNs showed proper biodegradation and low cytotoxicity and in vivo is carried out on experimental full thickness wounds in a mouse model and found that the wounds covered with these were completely filled with new epithelium without any significant adverse reactions after 3 weeks. In one of the papers, a kind of surgical wound dressing, the chitosan-gelatin sponge wound dressing (CGSWD) having good antibacterial property is prepared. The in vitro test showed that the antibacterial effect of CGSWD on E. coli K88 is better than that of penicillin, and the effect on S. aureus is also better than that of cefradine. [137] One more wound dressing consists of two separate layers were prepared in which the upper layer is a swellable hydrogel material which can absorb exudates and also serve as mechanical and microbial barrier while lower layer is a chitosan acetate foam incorporated with the anti-microbial agent chlorherxidine gluconate. [183] The antimicrobial activity is checked by the Bauer-Kirby Disk Diffusion Test, inhibition zones can be clearly seen around the discs of chitosan acetate foams incorporated with chlorhexidine gluconate, in culture plates inoculated with either Gram-negative or positive bacteria showing that the dressing is antimicrobial in nature. Blending is a convenient and effective method to improve physical and mechanical properties of hydrogels. So modification of chitosan is done by blending with other polymers like cellulose. [178] In this, E. coli and S. aureus were used as the test bacteria to examine the antibacterial properties of chitosan, cellulose and chitosan/cellulose blends. The numbers of colony of these bacteria formed on the test membranes are shown in s 5 and 6. It was noted that the numbers of colony of all test bacteria formed on the chitosan/cellulose blend membranes were decreased with the increase of chitosan concentration. These blends are more effective against E. coli than that of S. aureus, as indicated by the lower colony unit. Thus these dressings are suitable to use as an antimicrobial wound dressing. Chitosan due to its structural properties has the ability to heal wounds without scar formation. [198] Since chitosan is composed of D-glucosamine, which is also the component present in the disaccharide subunits of hyaluronic acid, chitosan tries to structurally mimic hyaluronic acid and exerts similar effects. [197] It has been known that the fetal wound healing takes place without fibrosis or scar formation due to the presence of hyaluronic acid. [199] In one of the studies, Chitosan as a semi-permeable biological dressing maintains a moist environment and prevent the wound site from dehydration and contamination. In addition, digital colour separation analysis of donor site scars demonstrated an earlier return to normal skin colour at chitosan-treated areas as shown in 7. [196] Collagen is also a biopolymer that is used as a polymer for making wound dressing and drug delivery devices as it is biocompatible and biocompatibility of a material applied to wound tissue is a prerequisite for optimal wound environment and facilitation of the healing processes. A new collagen dressing with gentamycin or amikacin was prepared in one of the research work and these follow the basic requirement of antibacterial bandages. The dressing is composed of two collagen biomaterials—membrane and sponge—both possessing good tissue biocompatibility. These dressing released antibiotics slowly and show the antibacterial treatment in experimentally infected superficial wounds in mice. Thus, it can be used for the treatment of infected wounds in humans. [26] As discussed previously that both chitosan and collagen are excellent materials that can be used as wound dressing materials. So it has been seen that if both are used simultaneously then what will be the effect. It is found that the wound dressings composed of chitosan crosslinked collagen sponge (CCCS) enhance the diabetic wound healing. Collagen crosslinked with chitosan showed several advantages required for wound dressing, including the uniform and porous ultrastructure, less water imbibition, small interval porosity, and high resistance to collagenase digestion and slow release of FGF from CCCS/FGF. [138] Following moist healing concept, alginates which are able to absorb exudates from wound have become one of the most important materials for wound management. [52, 53, 54, 55, 56] In this particular field, the properties of alginate fibers are unparalleled in many respects. Alginate based products form a gel and effective in removing out of the wound on the contrary to traditional cotton and viscose fibres, which can entrap in the wound developing discomfort during dressing removal. [55] Also, the alginate fibres are non-toxic, non-carcinogenic, non-allergic, haemostatic, biocompatible, of reasonable strength, capable of being sterilized and easily processable. Sorbsanâ„ ¢ was first commercialized in 1981 and after that there were many dressings launched. The alginate fibers can be converted into wound dressings by using a number of textile processes. Because of its simplicity and also the high absorbency of the product, nonwoven is the main form of alginate wound dressings. [19] The antimicrobial action of alginate dressing can be seen as in 8 which shows the antimicrobial action of silver containing alginate fibers against E. Coli. There was 100% reduction in bacteria count within 5 hr after the fibers were placed in contact with solutions containing the bacteria. Sorbsan alginate fibers showed some antimicrobial activity while AquacelTM (made of carboxymethyl cellulose), does not show any antimicrobial effect. [18] Gelatin widely found in nature and is the major constituent of skin, bones, and connective tissue. Gelatin can easily be obtained by a controlled hydrolysis of the fibrous insoluble protein, collagen. [195] This is also used in number of biomedical applications like wound dressings. Hydrogel wound dressing from gelatin, oxidized alginate and borax were prepared and the composite matrix promotes wound healing because of alginate, has haemostatic effect of gelatin and is antiseptic because of borax. The water vapour transmission rate (WVTR) of the hydrogel was calculated and found to be 2686 ±124 g/m2/day indicating that this hydrogel can maintain a proper fluid balance at the wound site which helps in cell migration. 2 shows the loss of water vapour with time through the hydrogel when placed in a moisture rich environment. [119] Genipin has been used to crosslink chitosan membranes to control swelling ratio and mechanical properties. It increased its ultimate tensile strength but significantly reduced its strain-at-fracture and swelling ratio. It had significantly less cytotoxicity for human fibroblasts and slower degradation rate compared to the glutaraldehyde-crosslinked membrane. This genipin crosslinked chitosan membrane can be successfully used as a wound dressing. [132] Bacterial cellulose is a natural polymer consisting of microfibrils containing glucan chains bound together by hydrogen bonds. Bacterial cellulose with chitosan combines properties such as bioactivity, biocompatibility, and biodegradability of the two biopolymers and form an ideal material for dressing wounds. [66, 67] These are antibacterial and scar preventive in nature too. Since natural polymers have been considered limited in their applications for wound-dressing materials as their low mechanical properties and shortage of processing. So we move towards the synthetic polymers that can be used for wound healing applications. 3.2 Synthetic Hydrogels Synthetic polymers are also being used successfully in biomedical applications as one of the materials because of their wide range of mechanical properties, suitability for easily forming into a variety of different shapes, and low production costs. In an ideal dressing both the characteristics i.e. antimicrobial ability and moist healing environment should be present, so in order to prevent the wound from dehydration and bacterial penetration a new dressing composed of polyurethane is designed in such a way that the upper layer of the dressing is microporous (pore size Polyvinyl pyrrolidone (PVP) is one of the most widely used synthetic polymers in medicine because of its solubility in water and its extremely low cytotoxicity. Hydrogels prepared by radiation crosslinking of an aqueous solution of polyvinyl pyrrolidone (PVP) have been used as wound dressing. [21] These are biocompatible, reduces pain, easily replacable, permeable to oxygen, maintain moist environment at the wound site. Polyvinyl alcohol (PVA) is a well-known polymer because it is biocompatible and have required mechanical properties and polyethylene oxide (PEO) is a hydrophilic semicrystalline polyether which is biocompatible, non toxic, non polar, non antigenic and non immunogenic and is highly desirable in most biomedical applications requiring contact with physiological fluids. A hydrogel composed of PEO for wound dressing is prepared and PVA is added to give toughness to the hydrogel by electron beam irradiation and found that these hydrogels showed satisfactory properties for wound dressing that has been evaluated by creating wound on the back of the marmots. [157] The hydrogel gives a wet environment to wounds which causes faster healing compared with the gauze dressing with a dry environment. The weight of the hydrogel increases quickly at the earlier stages, up to 4 days, due to absorption of effusion produced from the wound as shown in Table 2. After that, the production of effusion from the wound ceases and the weight of the hydrogel decreases due to evaporation of the water in the hydrogel. This means that the healing of wound proceeds smoothly with time. The hydrogel can be peeled off easily from the wound at the time of removal. Table 2 Absorption of effusion from wound of dressing during healing. [157] The toughness of PEO hydrogel is improved by the addition of PVA and tensile strength is measured and found that as shown in 10 and 11, the tensile strength and elongation decrease with increasing dose because of the increase of crosslinking. Various synthetic polymers as discussed above are used for wound dressing applications. But the major problem with these materials is their biocompatibility characteristics are often unsatisfactory and their interaction with living tissues is a major problem. So a combination of both natural and synthetic polymers is the better option to make a hydrogel having biocompatibility and desired mechanical strength. 3.3 Blended hydrogels Since both the natural and synthetic polymers have their own advantages and disadvantages so a combination of natural and synthetic polymers can endow the optimal properties necessary for wound repair. [47] The combination of natural and synthetic polymers is used in the biomedical, bioengineering and biotechnology field nowadays because of their great potential. A blended hydrogel composed of polyvinyl alcohol/polyvinyl pyrrolidone and charcoal were prepared by single ‘‘freezing and thawing or two-step ‘‘freezing and thawing and ÃŽ ³-ray irradiation and applied as wound dressing. It is found that the absorption of S. aureus and P. aeruginosa by charcoal/PVA/PVP hydrogels was larger than those by PVA/PVP hydrogels, this is due to the absorption and attachment capability of bacteria by charcoal, this can be shown in 12 given below. [22] The most classical way of fabricating a CS based wound dressing has been to design an asymmetric composite structure. In this method, the Cotton fabric was coated with chitosan (CS) and polyethylene glycol (PEG) followed by freeze-drying. The outer dense layer helps in preventing the microbial passage across the dressing and provides a rate controlling barrier for water vapor permeation, while the inner porous layer provides a high surface area for the exudates absorption. For the absorption of wound exudates porosity is the prime requirement in a dressing. It has been found that these dressings have the porosity 54-70% and the pore size was in the range of 75-120 µm. [45] The increase in the PEG content in the blend composition led to an enhanced destabilization of pores, leading to an increase in the pore size with elongated morphology. There seems to be phase separation between the two components which is an important factor for the observed behavior of the porous structure. Cot ton fabric has been used as the support layer for the CS-PEG layer and leads to very thin and light weight structures. The structure of the dressing has been designed in such a way that it leads to the high porosity of the bulk structure. The thickness of CS coating plays an important role in the development of the porosity on the surface. The influence of the CS thickness on the surface morphology is presented in 13 given below. PEG addition to CS makes significant alteration in the surface morphology of this CS-PEG/cotton membrane (freeze-dried), henceforth known as CPC membrane. There is a distinct trend in the loss of inherent elongated porous structure in membranes and formation of the partially collapsed porosity takes place due to the PEG addition. This suggests that a very limited interaction between CS and PEG exists which is reflected in the observed surface morphology. It has been observed that higher the amount of PEG, the higher is the pore destabilization leading to larger pores. This is evident from the morphology of the CPC membrane at 50% PEG-20 content as shown in 14.45 On the above matrix, the addition of PVP and drug followed by coating on the cotton fabric and freeze drying of the coated matrix is also done. It has been found that the drug Hydrogels for Wound Healing Applications Hydrogels for Wound Healing Applications Abstract This chapter discusses about the hydrogels both natural and synthetic that can be used for wound healing applications. Also it discusses briefly about the various novel techniques that have been developed recently. Keywords: Hydrogels; Chitosan, Antimicrobial; Grafting; Blending; Wound dressing; Wound healing; Gene therapy, Stem cell therapy, Skin Engineering, pH and Thermosensitive polymers. 1 Introduction Healthcare is an essential aspect of human survival. So many biopolymers have generated interest in a number of biomedical applications. Wound management is one such area where management of cuts, ulcers, and sores needs dressings which help in promoting rapid wound healing in order to obtain both functional and cosmetic results. [45] There are different kinds of wound management products: staples or sutures, dressings or bandages, surgical sealants and adhesives, skin substitutes, and other biomaterials. [51] Human skin provides an effective barrier to microbial penetration and subsequent infection. However, once the wound has been developed in this barrier, the infection chances increases. In case of chronic wounds, the colonization and infection potential increases as the result of the presence of avascular eschar which provides an environment for the uninhibited growth of microorganisms. [89] The rate of infection is related to the type of wound, general wound care, and local health of the patient. [88, 90] For avoiding infection, good clinical practices are needed. The management of chronic wounds is a very costly practice and it also places an enormous drain on healthcare resources; studies have calculated the cost of wounds to the NHS to be about  £1bn a year. [166] So for lowering this cost such wound management products are needed that are more economical and effective. Out of all the above wound management products, here in this chapter we will discuss more about the wound dressings that will provide an optimal healing environment to the wound. A dressing is an adjunct used by a person for application to a wound in order to promote healing and/or prevent further harm. It is designed to be in direct contact with the wound, so it is different from the bandage in the manner that bandages are normally used to hold dressing in place. A wound is a break in the epithelial integrity of the skin and may be accompanied by disruption of the structure and function of underlying normal tissue. Wounds can be divided into four categories based on their appearance and stage of healing: Necrotic, sloughing, granulating and epithelializing wounds. [87] Wounds cause discomfort and are more prone to infection and other troublesome complications. [75] Some diseases like diabetes, ischaemia and conditions like malnourishment, ageing, local infection, local tissue damage due to burn leads to delay in wound healing. Infection is a major complication of burn injury and is responsible for 50-75% of hospital deaths. [76] Human skin has one of the greatest capacities to regenerate itself amongst all of the tissues in our body. It constantly replaces old cells with new cells, enabling it to repair itself when damaged. Wound healing is a complex-physiologic process, which consists of three overlapping phases: inflammatory, proliferative and remodeling phases. The normal healing response begins the moment the tissue is injured. As the blood components spill into the site of injury, the platelets come into contact with exposed collagen and other elements of the extracellular matrix. This contact triggers the platelets to release clotting factors as well as essential growth factors. During the inflammation process, neutrophils are the first leukocytes which come at the site of injury to rid it from bacterial contamination. Then, the monocytes and their conversion to macrophages initiate tissue repair by releasing a number of biologically active substances and growth factors that are necessary for the initi ation of tissue formation process. In the third process, fibroblasts proliferate and migrate into the wound space and started the deposition of the loose extracellular matrix. Endothelial cells grow into a wound simultaneously with fibroblasts and undergo angiogenesis. Finally, tissue remodeling takes place to reconstruct the basement membrane by the differentiation of keratinocytes as well as the formation of follicle cells. [43, 49, 50] A scar is an essential part of this natural healing process following any type of damage to the skin. This can occur after a surgical incision or the healing of a wound. As your body makes an effort to close an open wound and protect itself from infection, it replaces injured skin tissue with rapidly generated scar tissue. Scarring is slight when the damaged outer layer of skin is healed by rebuilt tissue. When we damage the thick layer of tissue beneath the skin, rebuilding is more complicated. Our bodies lay down collagen fibers (a protein which is naturally produced by the body) and this usually results in a highly obvious scar. A permanent reminder of the injury is left behind. So, a dressing that can induce scarless healing is needed. Historically, a dressing was usually a piece of material, sometimes cloth, but the use of cobwebs, dung, leaves and honey has also been described. However, modern dressings include gauzes, semipermeable films, low adherent dressings, gels, foams, hydrocolloids, alginates, hydrogels and polysaccharide pastes. Wound dressings are passive, active or interactive. Passive dressings simply provide cover while active or interactive dressings are capable of modifying the physiology of the wound environment. Interactive dressings include hydrocolloids, hydrogels, alginates, foam dressings and antimicrobial dressings. [17, 20, 85] Traditionally dry wound dressings are considered to be good for healing wounds i.e. the wound should be covered with gauze or left open. But it has been observed by Winter [191] that when wound is left open to air without any dressing, a scab i.e. a dry covering covers the wound and decreases the rate of epithelialization. On the other hand, if moist dressing is used in place of dry dressings scab will not form and rate of healing increases as moist dressings provide low oxygen tension which helps in wound healing, these dressings not only keep cells viable which enables them to release growth factors while maintaining contact between them and the healing tissues, but may also modulate or stimulate their proliferation, these dressings decrease the pain at rest, during ambulation and during dressing changes also moist environment allows rapid and efficient delivery of any added antimicrobial agent thus prevent the wound from infection. So, the dressings that create and maintain a mois t environment, however, are now considered to provide the optimal conditions for wound healing. 2 Requirements of an ideal wound care system These characteristics should be present in the ideal wound care system (a) it should be capable of maintaining a high humidity at the wound site, (b) it should be non-toxic, (c) non-allergenic, (d) it can be removed without causing trauma to the wound, (e) it should pe impermeable to bacteria, (f) Thermally insulating, (g) it should be soft to touch, (h) it should allow proper gaseous exchange, (i) it should be free from particulate and toxic product, (j) promote tissue reconstruction processes and (k) it should be cost effective. [20, 165, 177] Out of all the dressings hydrocolloids, alginates and hydrogels each one has its own advantages and limitations but hydrogels are best and have all the characteristics that are needed in an ideal wound dressing. All the above mentioned characteristics can be achieved in hydrogel wound dressings. 3 Hydrogels for Wound Healing Applications Hydrogels are natural or synthetic cross-linked polymers used in a variety of medical and biomedical applications. Hydrogels consist of a matrix of insoluble polymers with up to 96% water content enabling them to donate water molecules to the wound surface and to maintain a moist environment at the wound bed. They are used in the construction of contact lenses, drug-delivery vehicles, wound dressings and as physiological electrodes or sensors. [17] Examples of hydrogel include Aquaform, Intrasite, GranuGel, Nu-Gel, Purilon, Sterigel. These also have the ability to absorb a degree of wound exudate. They transmit moisture vapour and oxygen, but their bacterial and fluid permeability is dependent on the type of secondary dressing used. [20] Hydrogels swell or shrink in aqueous solutions due to the association, dissociation and binding of various ions to polymer chains. These systems may swell in water until an equilibrium state is reached and retain their original shape. The interactions responsible for water sorption by hydrogels include the process of hydration, which is connected to the presence of such chemical groups as -OH, -COOH, -CONH2, -CONH-, and -SO3H and the existence of capillary areas and differences in osmotic pressure. The forces that make hydrogel dissolution impossible are presence of covalent bonds between individual polymer chains, hydrophobic and electrostatic interactions. [46] These are hydrophilic polymer networks which may absorb from 10-20% (an arbitrary lower limit) up to thousands of times their dry weight in water. These may be chemically stable or they may degrade and dissolve. They are called ‘reversible, or ‘physical gels when the networks are held together by molecular entanglements, and/or secondary forces including ionic, H-bonding or hydrophobic forces. [13, 14, 15] Hydrogels are called ‘permanent or ‘chemicalgels when they are covalently-crosslinked networks as shown in 1. Hydrogels can be made by irradiation, freeze-thawing or chemical methods. Out of all the methods, irradiation is considered as a suitable tool for the formation of hydrogels as in this method there is easy control of processing, no need of adding initiators or cross-linkers which are harmful, and have the possibility of formation and sterilization in one step. But as everything has its own advantages and disadvantages this method also has a disadvantage which is hydrogels formed by this method have poor mechanical strength. Nowadays, Freeze thawing technique is generally used to prepare hydrogels having good strength, stability and no crosslinkers and initiators. But the main disadvantage is that the prepared hydrogels have opaque appearance and limited swelling and thermal stability. [120] In comparison to the traditional gauze therapy the application of a hydrogel seems to significantly stimulate wound healing. [11] Various natural and synthetic polymers having good biocompatibility are used to develop hydrogel wound dressing. These polymers include natural polymers such as alginate, chitosan, gelatin and collagen and synthetic polymers such as polyurethane, poly(ethylene glycol), polycaprolactone, poly vinyl pyrrolidone, poly(lactide-co-glycolide), polyacrylonitrile , poly(amino acid), etc. Table 1 below shows different hydrophilic polymers used to synthesize hydrogel matrices. Table 1 Hydrophilic polymers used to synthesize hydrogel matrices. [13] Hydrogels may be classified as homopolymer hydrogels, copolymer hydrogels, multipolymer hydrogels, and interpenetrating polymeric hydrogels. Homopolymer hydrogels are crosslinked networks of one type of hydrophilic monomer unit, whereas copolymer hydrogels are produced by the crosslinking of two comonomer units, one of which must be hydrophilic. Multipolymer hydrogels are produced by the crosslinking of more than three monomers. Finally, interpenetrating polymeric hydrogels are produced by the swelling of a first network in a monomer and the reaction of the latter to form a second intermeshing network structure. [46, 47] Also, it has been shown that the blending of a natural polymer with a synthetic polymer seems to be a good method for obtaining materials having required mechanical and thermal properties in comparison to pure components. It is also a simple method by which suitable shapes such as films, sponges and hydrogels can be obtained easily to realize a variety of biomedical devices. 2 shows healing is faster with the hydrogel dressing than with the gauze dressing. Wound area covered by hydrogel decreases faster with increasing healing period. On the contrary, the wound covered by gauze dressing reduces by only half a percent even after 14 days. [192] 3.1 Natural Hydrogels Natural polymers, such as chitin, chitosan, alginate, collagen, elastin, genipin, gelatin, cellulose etc. have been used for dressing wounds because they play an important role in the healing process. [47] Chitosan is a partially deacetylated form of chitin. Chitin as BeschitinÃ’, Unitika, is also commercially available as dressing in Japan. [28] But as far as chitosan is concerned it is biocompatible, biodegradable, haemostatic, fungistatic [54] and non-toxic and can be successfully used as gels, films, fibres etc. This polymer also show antibacterial properties and possess good wound healing properties. [60, 61, 62] It has many applications as wound dressing, drug delivery device and as scaffold for tissue engineering. [63, 64] Some of the examples of wound dressings are given below which use chitosan as one of the biomaterial. Asymmetric chitosan membranes have been developed by using immersion-precipitation phase-inversion method. [123, 124, 125] These asymmetric chitosan membranes are homogeneous and have porous structure. This membrane was prepared by preheating casted chitosan solution in oven for different time periods for dry phase separation and then immersed in to coagulant tank for wet phase separation and were subsequently freeze-dried. The skin layer acts as the rate controlling barrier for the release of drug and the porous layer provide mechanical support to the skin layer. The water vapor transmission rate, gas permeability, PBS solution absorption, in-vitro degradation, cell culture, bacterial penetration and wound healing test of this dressing were carried out. These membranes are effective in controlling evaporative water loss, showed excellent oxygen permeability and also antibacterial in nature. These are also found to be an urgent hemostat. In another study, silver sulphadiazine was inc orporated as an antimicrobial agent to this asymmetric dressing. The release behaviour of both silver and sulphadiazine ions were studied and found to be significantly different from one another. Silver ions displayed a slow release behavior while sulphadiazine ions exhibited burst effect on first day of the drug release and then slowly tapered off. It is because of the interaction of silver with amino group of chitosan leading to its slow release throughout whereas, as the sulphadiazine ions were free to diffuse through the membrane to reach the wound site thus they showed a burst release. The membranes were further found effective against P. aerugniosa and S. aureus. In one of the papers, novel wound dressings were formed that composed of chitosan film and Minocycline Hydrochloride (MH) and commercial polyurethane film (Tegaderm) as a backing. It is also a useful formulation for the treatment of severe burn wounds. Water vapor and oxygen can permeate the Tegaderm film but water cannot. The tegaderm film support the polymer membrane. [126] In one of the studies, a silver nanocrystalline chitosan (SNC) wound dressing composed of nano-silver and chitosan was constructed by self-assembly and nanotechnology and used for treating deep partial-thickness wounds. In this, sterility and pyrogen testing were performed to ensure biosafety. These dressings promote wound healing and combat infection, and also decrease the risk of silver absorption in comparison with silver sulphadiazine (SSD) dressings. [127] There is also one more method of forming wound dressing composed of chitosan i.e. the formation of polyelectrolyte complex of gum kondagogu (GKG) and chitosan. This complex is formed by the electrostatic interaction between carboxyl group of gum and amine group of chitosan. This method is more advantageous as it avoids the use of organic solvents, chemical crosslinking agents and thus reduces the toxicity and undesirable side effects. In this, diclofenac sodium is used as model drug. The diclofenac loaded complex of gum kondagogu/ chitosan shows drug release which changes with change in pH. The drug release was higher at pH 6.8 as compared to pH 1.2, due to higher swelling of complex at higher pH. This holds a great potential as a natural polymer based delivery device for controlled delivery of drugs like diclofenac sodium for two reasons: (i) to reduce dosing frequency and (ii) lower the gastric toxicity. [152] Semi-interpenetrating polymer networks (SIPNs) composed of chitosan (CS) and poloxamer were prepared in order to improve the mechanical strength of CS. The WVTR was found to be 2508.2 ±65.7 gm−2 day−1, i.e. these can maintain a moist environment at wound site which enhance epithelial cell migration. Also, the in vitro assessment of SIPNs showed proper biodegradation and low cytotoxicity and in vivo is carried out on experimental full thickness wounds in a mouse model and found that the wounds covered with these were completely filled with new epithelium without any significant adverse reactions after 3 weeks. In one of the papers, a kind of surgical wound dressing, the chitosan-gelatin sponge wound dressing (CGSWD) having good antibacterial property is prepared. The in vitro test showed that the antibacterial effect of CGSWD on E. coli K88 is better than that of penicillin, and the effect on S. aureus is also better than that of cefradine. [137] One more wound dressing consists of two separate layers were prepared in which the upper layer is a swellable hydrogel material which can absorb exudates and also serve as mechanical and microbial barrier while lower layer is a chitosan acetate foam incorporated with the anti-microbial agent chlorherxidine gluconate. [183] The antimicrobial activity is checked by the Bauer-Kirby Disk Diffusion Test, inhibition zones can be clearly seen around the discs of chitosan acetate foams incorporated with chlorhexidine gluconate, in culture plates inoculated with either Gram-negative or positive bacteria showing that the dressing is antimicrobial in nature. Blending is a convenient and effective method to improve physical and mechanical properties of hydrogels. So modification of chitosan is done by blending with other polymers like cellulose. [178] In this, E. coli and S. aureus were used as the test bacteria to examine the antibacterial properties of chitosan, cellulose and chitosan/cellulose blends. The numbers of colony of these bacteria formed on the test membranes are shown in s 5 and 6. It was noted that the numbers of colony of all test bacteria formed on the chitosan/cellulose blend membranes were decreased with the increase of chitosan concentration. These blends are more effective against E. coli than that of S. aureus, as indicated by the lower colony unit. Thus these dressings are suitable to use as an antimicrobial wound dressing. Chitosan due to its structural properties has the ability to heal wounds without scar formation. [198] Since chitosan is composed of D-glucosamine, which is also the component present in the disaccharide subunits of hyaluronic acid, chitosan tries to structurally mimic hyaluronic acid and exerts similar effects. [197] It has been known that the fetal wound healing takes place without fibrosis or scar formation due to the presence of hyaluronic acid. [199] In one of the studies, Chitosan as a semi-permeable biological dressing maintains a moist environment and prevent the wound site from dehydration and contamination. In addition, digital colour separation analysis of donor site scars demonstrated an earlier return to normal skin colour at chitosan-treated areas as shown in 7. [196] Collagen is also a biopolymer that is used as a polymer for making wound dressing and drug delivery devices as it is biocompatible and biocompatibility of a material applied to wound tissue is a prerequisite for optimal wound environment and facilitation of the healing processes. A new collagen dressing with gentamycin or amikacin was prepared in one of the research work and these follow the basic requirement of antibacterial bandages. The dressing is composed of two collagen biomaterials—membrane and sponge—both possessing good tissue biocompatibility. These dressing released antibiotics slowly and show the antibacterial treatment in experimentally infected superficial wounds in mice. Thus, it can be used for the treatment of infected wounds in humans. [26] As discussed previously that both chitosan and collagen are excellent materials that can be used as wound dressing materials. So it has been seen that if both are used simultaneously then what will be the effect. It is found that the wound dressings composed of chitosan crosslinked collagen sponge (CCCS) enhance the diabetic wound healing. Collagen crosslinked with chitosan showed several advantages required for wound dressing, including the uniform and porous ultrastructure, less water imbibition, small interval porosity, and high resistance to collagenase digestion and slow release of FGF from CCCS/FGF. [138] Following moist healing concept, alginates which are able to absorb exudates from wound have become one of the most important materials for wound management. [52, 53, 54, 55, 56] In this particular field, the properties of alginate fibers are unparalleled in many respects. Alginate based products form a gel and effective in removing out of the wound on the contrary to traditional cotton and viscose fibres, which can entrap in the wound developing discomfort during dressing removal. [55] Also, the alginate fibres are non-toxic, non-carcinogenic, non-allergic, haemostatic, biocompatible, of reasonable strength, capable of being sterilized and easily processable. Sorbsanâ„ ¢ was first commercialized in 1981 and after that there were many dressings launched. The alginate fibers can be converted into wound dressings by using a number of textile processes. Because of its simplicity and also the high absorbency of the product, nonwoven is the main form of alginate wound dressings. [19] The antimicrobial action of alginate dressing can be seen as in 8 which shows the antimicrobial action of silver containing alginate fibers against E. Coli. There was 100% reduction in bacteria count within 5 hr after the fibers were placed in contact with solutions containing the bacteria. Sorbsan alginate fibers showed some antimicrobial activity while AquacelTM (made of carboxymethyl cellulose), does not show any antimicrobial effect. [18] Gelatin widely found in nature and is the major constituent of skin, bones, and connective tissue. Gelatin can easily be obtained by a controlled hydrolysis of the fibrous insoluble protein, collagen. [195] This is also used in number of biomedical applications like wound dressings. Hydrogel wound dressing from gelatin, oxidized alginate and borax were prepared and the composite matrix promotes wound healing because of alginate, has haemostatic effect of gelatin and is antiseptic because of borax. The water vapour transmission rate (WVTR) of the hydrogel was calculated and found to be 2686 ±124 g/m2/day indicating that this hydrogel can maintain a proper fluid balance at the wound site which helps in cell migration. 2 shows the loss of water vapour with time through the hydrogel when placed in a moisture rich environment. [119] Genipin has been used to crosslink chitosan membranes to control swelling ratio and mechanical properties. It increased its ultimate tensile strength but significantly reduced its strain-at-fracture and swelling ratio. It had significantly less cytotoxicity for human fibroblasts and slower degradation rate compared to the glutaraldehyde-crosslinked membrane. This genipin crosslinked chitosan membrane can be successfully used as a wound dressing. [132] Bacterial cellulose is a natural polymer consisting of microfibrils containing glucan chains bound together by hydrogen bonds. Bacterial cellulose with chitosan combines properties such as bioactivity, biocompatibility, and biodegradability of the two biopolymers and form an ideal material for dressing wounds. [66, 67] These are antibacterial and scar preventive in nature too. Since natural polymers have been considered limited in their applications for wound-dressing materials as their low mechanical properties and shortage of processing. So we move towards the synthetic polymers that can be used for wound healing applications. 3.2 Synthetic Hydrogels Synthetic polymers are also being used successfully in biomedical applications as one of the materials because of their wide range of mechanical properties, suitability for easily forming into a variety of different shapes, and low production costs. In an ideal dressing both the characteristics i.e. antimicrobial ability and moist healing environment should be present, so in order to prevent the wound from dehydration and bacterial penetration a new dressing composed of polyurethane is designed in such a way that the upper layer of the dressing is microporous (pore size Polyvinyl pyrrolidone (PVP) is one of the most widely used synthetic polymers in medicine because of its solubility in water and its extremely low cytotoxicity. Hydrogels prepared by radiation crosslinking of an aqueous solution of polyvinyl pyrrolidone (PVP) have been used as wound dressing. [21] These are biocompatible, reduces pain, easily replacable, permeable to oxygen, maintain moist environment at the wound site. Polyvinyl alcohol (PVA) is a well-known polymer because it is biocompatible and have required mechanical properties and polyethylene oxide (PEO) is a hydrophilic semicrystalline polyether which is biocompatible, non toxic, non polar, non antigenic and non immunogenic and is highly desirable in most biomedical applications requiring contact with physiological fluids. A hydrogel composed of PEO for wound dressing is prepared and PVA is added to give toughness to the hydrogel by electron beam irradiation and found that these hydrogels showed satisfactory properties for wound dressing that has been evaluated by creating wound on the back of the marmots. [157] The hydrogel gives a wet environment to wounds which causes faster healing compared with the gauze dressing with a dry environment. The weight of the hydrogel increases quickly at the earlier stages, up to 4 days, due to absorption of effusion produced from the wound as shown in Table 2. After that, the production of effusion from the wound ceases and the weight of the hydrogel decreases due to evaporation of the water in the hydrogel. This means that the healing of wound proceeds smoothly with time. The hydrogel can be peeled off easily from the wound at the time of removal. Table 2 Absorption of effusion from wound of dressing during healing. [157] The toughness of PEO hydrogel is improved by the addition of PVA and tensile strength is measured and found that as shown in 10 and 11, the tensile strength and elongation decrease with increasing dose because of the increase of crosslinking. Various synthetic polymers as discussed above are used for wound dressing applications. But the major problem with these materials is their biocompatibility characteristics are often unsatisfactory and their interaction with living tissues is a major problem. So a combination of both natural and synthetic polymers is the better option to make a hydrogel having biocompatibility and desired mechanical strength. 3.3 Blended hydrogels Since both the natural and synthetic polymers have their own advantages and disadvantages so a combination of natural and synthetic polymers can endow the optimal properties necessary for wound repair. [47] The combination of natural and synthetic polymers is used in the biomedical, bioengineering and biotechnology field nowadays because of their great potential. A blended hydrogel composed of polyvinyl alcohol/polyvinyl pyrrolidone and charcoal were prepared by single ‘‘freezing and thawing or two-step ‘‘freezing and thawing and ÃŽ ³-ray irradiation and applied as wound dressing. It is found that the absorption of S. aureus and P. aeruginosa by charcoal/PVA/PVP hydrogels was larger than those by PVA/PVP hydrogels, this is due to the absorption and attachment capability of bacteria by charcoal, this can be shown in 12 given below. [22] The most classical way of fabricating a CS based wound dressing has been to design an asymmetric composite structure. In this method, the Cotton fabric was coated with chitosan (CS) and polyethylene glycol (PEG) followed by freeze-drying. The outer dense layer helps in preventing the microbial passage across the dressing and provides a rate controlling barrier for water vapor permeation, while the inner porous layer provides a high surface area for the exudates absorption. For the absorption of wound exudates porosity is the prime requirement in a dressing. It has been found that these dressings have the porosity 54-70% and the pore size was in the range of 75-120 µm. [45] The increase in the PEG content in the blend composition led to an enhanced destabilization of pores, leading to an increase in the pore size with elongated morphology. There seems to be phase separation between the two components which is an important factor for the observed behavior of the porous structure. Cot ton fabric has been used as the support layer for the CS-PEG layer and leads to very thin and light weight structures. The structure of the dressing has been designed in such a way that it leads to the high porosity of the bulk structure. The thickness of CS coating plays an important role in the development of the porosity on the surface. The influence of the CS thickness on the surface morphology is presented in 13 given below. PEG addition to CS makes significant alteration in the surface morphology of this CS-PEG/cotton membrane (freeze-dried), henceforth known as CPC membrane. There is a distinct trend in the loss of inherent elongated porous structure in membranes and formation of the partially collapsed porosity takes place due to the PEG addition. This suggests that a very limited interaction between CS and PEG exists which is reflected in the observed surface morphology. It has been observed that higher the amount of PEG, the higher is the pore destabilization leading to larger pores. This is evident from the morphology of the CPC membrane at 50% PEG-20 content as shown in 14.45 On the above matrix, the addition of PVP and drug followed by coating on the cotton fabric and freeze drying of the coated matrix is also done. It has been found that the drug

Is Macbeth a hero or a murderous tyrant? Discuss Essay

Macbeth, the Thane of Cawdor was a murderous tyrant without question. Macbeth was originally considered to be a ‘hero’ at an early stage in the play however; the people of his Kingdom soon saw another side of him which turned him into a ‘butcher’. It is clear that through all of Macbeth’s schemes of becoming king, such as killing King Duncan and then his friend Banquo, he was a bloodthirsty and ruthless man. This malicious and tyrannical behaviour was not evident in Macbeth’s character early in the scenes, but became obvious as the play progressed and more and more people died because of him in an attempt to keep a secret. Killing Duncan for his position of King was the secret that Macbeth tried desperately to hide. He and Lady Macbeth thought that the crime they had committed would easily be erased with the simple washing of hands to remove the blood. The criminal pair went to the extent of framing other people for their crime so that they would not be even considered as the culprits. Dressing in their nightgowns before they went back to bed and ridding their bloody clothes was also an attempt to draw no suspicious attention to themselves. However, the traumatic incident that Macbeth experienced when killing an innocent, good man was something that would haunt him for many nights to come. Macbeth became paranoid after the awful deed and confided in Lady Macbeth saying that Methought I heard a voice cry†¦ â€Å"Sleep no more!’ to all the house†¦ Macbeth shall sleep no more’. As well as being haunted by his dreams at night, Macbeth had suspicions of Banquo’s knowledge of the murder and so, had to put an end to it. Macbeth, through his greed, murdered Duncan for power and the throne, and then, through the aid of henchmen, he killed Banquo also. To Macbeth, murder appeared to be the only sure way of keeping his secret that he was convinced Banquo would reveal. Our fears in Banquo stick deep, and in his royalty of nature reigns that which would be fear’d: ’tis much he dares. Macbeth was scared that his and lady Macbeth’s crime may come undone and so, once again, took to murdering the innocent. As well as Banquo, Macbeth instructed the henchmen to make Banquo’s son Fleance, embrace the fate of that dark hour. That is, kill Fleance also to stop him from revealing his fathers murderers, and therefore link it back to the King. This murderous intent from Macbeth was due to not only fear but also jealousy. Macbeth would not have royal descendants unlike Banquo according to the witches. So, by murdering Banquo, he thought he would succeed in concealing King Duncan’s death once and for all. By murdering Fleance, he would also prevent the line of Banquo continuing and becoming kings themselves. These actions of Macbeth were the beginning of the stage where he became desensitised to cold-blooded murder and therefore, as it did not affect him anymore, he became a ruthless and murderous tyrant showing no mercy. Macbeth had already been responsible for two deaths (as Fleance escaped the attack) and was in no hurry to cease until his position of king was not threatened. His murderous ways had paid off to a degree and now, because of his confrontation with the three apparitions in the woods, he felt invincible as they said. None of woman born shall harm Macbeth†¦never vanquished be until Great Birnam Wood to Dunsinane Hill shall come against him. It was after this discovery of his newly charmed life, that Macbeth truly turned into the ‘butcher’ that some had expected, and others had not. Originally known as brave Macbeth, over the series of murders and problems he had faced with seeing ghosts of Banquo, his fair, noble and valiant exuberance was lost and in its place, a malicious, merciless and murderous tyrant was born. Tyrant was the name given to Macbeth and he lived up to his title (through the use of henchmen again) when he massacred Macduff’s castle inhabitants. Macbeth was told to â€Å"beware Macduff† and when Macduff defiantly refused doing something and fled to England, Macbeth was immediately angered, determined to get his own back. The castle of Macduff I will surprise†¦give to the edge of the sword, his wife, his babes, and all unfortunate souls that trace him in his line. Murderers seized Macduff’s castle and everyone living there was brutally slain under orders of the King. Even though all slaughtered were unknowing and innocent to matters regarding Macbeth, because of this desire to hurt Macduff, the emotional trauma would be the real weapon against him. Because of Macbeth’s murderous and tyrannical ways, being affected by death became an unheard of reaction and this was particularly evident when, just prior to battle, he was notified of his wife, Lady Macbeth, committing suicide. Macbeth barely cared about this and was focused more on the war rather than his wife’s tragic death. An explanation of this indifferent response is based upon himself becoming a murderous tyrant, desensitised to the unnecessary execution of many innocent lives. Therefore, his wife’s death held no importance, in fact more of a nuisance as â€Å"She should have died hereafter; there would have been a time for such a word.† Macbeth had no understanding anymore about his actions. Macbeth was a murderous tyrant. The barbaric and ruthless actions that he went through with were unnecessary and were carried out for the tyrant’s personal power gain and stability in the throne. A tyrant cannot be a hero just as a hero cannot be a tyrant. The change from hero to tyrant in Macbeth’s self is clearly evident and cannot be mistaken for anything but murderous. Not grieving his wife’s death, organising for his friends murder and murdering a good and noble king is evidence to prove that Macbeth was desensitised to killing. Macbeth killed everyone that attempted to stand in his fate’s way and regardless of innocence; they were brutally murdered. These actions clearly prove that Macbeth was an abominably murderous tyrant.

How Modern Medical Technology is Easing Out Standard Physical Examination Essay

In today’s time-constrained society, medical practitioners are noticeably turning to modern technology to pinpoint health problems of patients. Most new-generation doctors who rely a great deal on sophisticated machines in ascertaining medical issues faced by their patients illustrate a startling reality: the standard physical examination stands to be eased out. While science has made possible quicker, more convenient, and non-invasive ways of spotting and treating health disorders, being overly dependent on technology has its drawbacks. The problem with technology arises when doctors rush to order tests without first performing a thorough physical exam†¦ Doctors may be overly reliant on tests because they have confidence in the results; however, tests aren’t always accurate† (Max, 2009, par. 6). A seemingly better approach that redounds to patient benefit is the combination of modern technology with age-old practices that worked, notably a thorough physical examination — done prior to tests or possible confinement and as part of the doctor’s hospital rounds. There are several factors contributing to the demise or exclusion of the standard physical examination in modern medical practice. For one, there is the shortage of medical personnel in certain localities. Harried doctors and nurses end up employing measures to maximize time. â€Å"Time constraints also discourage performing a complete physical during routine office visits. The managed care system pushes doctors to see patients as briefly as possible† (Obel, 2003, par. 6). The fact is that the physical examination â€Å"can be a valuable guide in deciding which tests to order and letting specialists know where to concentrate their efforts† (Obel, 2003, par. 7). Hence, the standard physical examination can greatly aid doctors in ruling out certain health issues, thereby saving time and money on unnecessary tests. However, new-generation doctors overlook these, believing that using sophisticated equipment is more effective in reaching an accurate medical analysis than conventional routine practices. Indeed, a professional diagnosis relying first and foremost on the standard physical examination appears to have been displaced by modern devices. The downside is the loss of human contact that most patients may still prefer. â€Å"There is an intangible benefit to the contact afforded by the physical exam†¦(it) can go a long way in establishing and building a good doctor-patient relationship† (Max, 2009, par. 11), something which most patients – from the very young to the elderly – yearn for. The emotional bonding between the healthcare giver and the patient is obliterated with less time allocated to examine patients. As seasoned medical practitioners decry the demise of the physical examination, which â€Å"can be therapeutic in itself† (Obel, 2003, par. 35), concerned medical institutions have instigated efforts to train and retrain medical interns on the vast range of medical approaches – including the routine physical examination. The increasingly important role of nurses, who can assume the vital task of resuscitating the fading practice of conducting a thorough physical examination and promoting human interaction, cannot be underestimated. Well-trained nurses who realize the value of human interaction can play significant role in fostering enhanced patient care and faster recovery. The upsurge in electronic technology users is another phenomenon affecting the demise of face-to-face interaction with physicians and the traditional physical examination. With many doctors nowadays dispensing medical advice online by relying purely on patient history and description of symptoms, thereby eliminating the need for a comprehensive physical examination, it becomes clear that modern trends are taking the place of traditional medical approaches. The inescapable fact is that medical practitioners cannot always totally rely on modern technology alone to ascertain patient needs. Even in modern times, there is a need to go back to basics, ingrain patient-oriented skills among the emerging crop of doctors, and revive conventional medical approaches like the physical examination.

buy custom Developing an Implementation Plan essay

buy custom Developing an Implementation Plan essay According to Laux and Herbert (2006), ventilator-associated pneumonia, an infection of the airway, is the most common infection acquired from hospitals among mechanically ventilated patients. It has been known to develop more than 48 hours after mechanical ventilation initiation. 6 to 52 of 100 patients requiring mechanical ventilation develop ventilator-associated pneumonia. Around 1 to 3 percent of mechanically ventilated patients are at risk of developing ventilator-associated pneumonia daily (Stonecypher, 2010). The aspect of ventilator-associated pneumonia that troubles health care professionals is the high associated mortality. Al-Tawfiq and Abed (2010) mentioned that 46 percent of patients requiring mechanical ventilation who developed ventilator-associated pneumonia die, while hospital mortality of patients without ventilator-associated pneumonia is only 32 percent. According to Cutler and Davis (2005), ventilator-associated pneumonia patients are more likely to add an estima ted amount of $40,000 to their hospital charges against a typical hospitalization expense. This is due to the fact that these patients are required to undergo prolonged intensive care and services. In this case, health care professionals organized a procedure focusing on identifying ventilator-associated pneumonia at an early stage. In addition to this, they also adapted consistency in the application of evidence-based practices. These measures are performed for the reduction of ventilator-associated pneumonia incidence. Problem Description In the authors medical facility, mechanically ventilated patients who have developed ventilator-associated pneumonia have experienced an increase in hospital mortality and morbidity, higher hospitalization charges, and longer hospitalization. According to their data review, the number of patients with ventilator-associated pneumonia reached 8 percent from August 2, 2010 to January 29, 2011. The review also revealed that health care professionals failed to place much emphasis on oral care, although they have a bundle program for ventilator-associated pneumonia to prevent its immediate development. Good oral care still proved its importance in the prevention of ventilator-associated pneumonia based on significant number of evidence-based researches. According to Cutler and Davis (2005), most patients requiring hospitalization have pathogens in their respiratory tract, unlike normal healthy adults. When the respiratory condition of these patients worsens, the respiratory pathogens are more likely to micro aspirate into the respiratory tract. In this case, the patients risk of respiratory pathogenic micro aspiration can be intervened through proper oral care. This process is crucial in the prevention of ventilator-associated pneumonia development. The importance of proper oral hygiene maintenance is fundamental in the prevention and reduction of ventilator-associated pneumonia. However, this is traditionally the most neglected process. Health care professionals tend to consider it a lower priority intervention compared to other complex interventions. Proper oral care and hygienic procedures for mechanically ventilated patients have long been a cause of major concern to health care professionals. At the authors facility, for example, there are inconsistencies in the performance of systematic oral assessment during the patients stay in the Intensive Care Unit and also during the admission of these patients. Although most nurses and health care professionals are aware that proper oral hygiene is significant in the prevention of ventilator-associated pneumonia, they still tend to neglect to put it in practice in a consistent manner. As a result, ventilator-associated pneumonia has risen from 0 to 8 percent within a period of six months. Proposed Solution Usually, other health care professionals and nurses are challenged with changes to the current practices. But researches proved that the nursing profession has to change and improve their attitude towards oral hygiene measures. It has been recognized already that good oral hygiene is essential in the prevention of ventilator-associated pneumonia in mechanically assisted patients. However, nurses are usually less aware of this importance. Observational visual audits and electronic chart reviews alike distinguished the insufficiency of nurses and health care professionals in ensuring standardized oral hygiene for mechanically intubated patients. In this case, a standardized oral care protocol has to be developed to enhance nurses and other health care professionals compliance with the implementation of oral care. In response to this, health care professionals should formulate and encourage strict enforcement of systematic oral care protocol for the patients requiring mechanical ventil ation. With this, the compliance of nurses in implementing oral care will increase. Approval The proposed solution will be discussed with the unit manager, director, and staff. After the discussion, the Institutional Review Board (IRB) will review the standardized oral protocol for approval. The IRB board assures that the propoed solution is not involved in any unethical modalities and protects the patients right. The IRB reviews all requests for approval on the 15th of every month, and notifications regarding the approval come within the week of the review. Upon the approval from the Institutional Review Board of the proposed solution, health care professionals will develop a standardized oral care protocol. Then, it will be implemented for three months as an admission protocol for all patients requiring mechanical ventilation. Rationale for the Selection Usually, proper oral hygiene procedures for patients requiring mechanical ventilation are rarely, if at all, prioritized by nurses and other health care professionals. In the authors facility, for example, there are currently no consistent oral care method, frequency, and guidelines for nurses to follow in performing oral care. Evidence from Literature The risk of ventilator-associated pneumonia in patients requiring mechanical ventilation can be decreased with the implementation of comprehensive oral care. The protocol is an evidence-based solution to the said problem. Cason, Saunders, and Broom (2007) found out through research that more than half of all the hospitals do not have strict oral care protocol for patients requiring mechanical ventilation. In such a case, these hospitals very seldom perform the assessment of oral cavity (Cason et al., 2007). Several studies linked ventilator-associated pneumonia to dental plaque and colonization of microbes in the oropharynx. To decrease dental plaque colonization, tooth brushing plays a major role. However, even if current evidence shows that it has beneficial effects, the intervention is seldom used in most Intensive Care Units (Halm Armola, 2009). According to the study of Cason, Saunders, and Broom (2007), oral care procedures were very seldom performed, and moreover, the import ant part of the procedure was not done properly, if no standardized oral care protocol exists. Garcia, Jendresky, Colbert, Bailey, Zaman, and Majumder (2009) showed in their study that an increase in the nurses compliance of oral care protocol has a positive effect in prevention of ventilator-associated pneumonia among mechanically ventilated patients. Different studies indicated that hospitals with comprehensive protocols are more consistent in performing oral care (Cason et al., 2007). For example, tooth brushing was proved to decrease microorganisms; however, this is not performed as a part of the oral care routine in critically ill patients. In this case, a multidisciplinary approach is required for the improvement of quality oral care in Intensive Care Units. Education, sufficient time, prioritizing and positive attitude towards oral care have a direct effect on the quality of the oral care provided for the patients. Therefore, it is important to educate nurses to reinforce proper oral care, give them enough time to perform the procedures, and help them unlearn the usually perceived unpleasantness of oral care (Furr et al. 2004). Resources The personnel required for the implementation of the proposed solution are the staff nurses and respiratory therapists. The materials needed are pamphlets, posters, and power point presentations. The assessment tools necessary for comprehension and feedback before and after implementation are surveys and questionnaires. Computers are also needed for presentations and communications, and some space for presentation should be provided as well. Funds must be made available for the initiation, supervision, and evaluation of changes of the staff, the cost of education, the production of educational and other materials, gathering and analyzing data, and other expenses including refreshments. Implementation Process and Logistics When nurses follow a strict oral care protocol, they are more likely to improve the initiation of oral care and, what is more importantly, prevent the occurrence of ventilator-associated pneumonia. For this to be possible, a measurable goal is needed for the improvement of implementation of the proposed solution. To have it implemented in a timely manner, the organization and the solution itself should have a clear and solid intention. Moreover, the objective should be measurable and time-specific. It should also consider a specific population involved. For its success, a mutual agreement between the upper management and the staff is necessary. Both the personnel and the resources must be distributed properly for the accomplishment of the task. The solution is successful if it includes a careful development, testing, necessary modifications, re-testing, and careful implementation of the process. The program will, therefore, be included as part of the admission requirements and proce sses for patients requiring mechanical intervention. The process includes the following procedures: Assessment of the oral cavity upon admittance and every 12 hours tthereafter. Administration of oral care every 4 hours to all patients requiring mechanical ventilation. The procedures will be repeated as needed on an 8-12-4 program with or without 0.12% chlorexidine. Prior to repositioning and every 2 hours assessment of all mechanically ventilated patients for the identification of necessary removal of oral secretions. Suction tooth brushing with antiseptic oral rinse for 1-2 minutes every 12 hours. Cleaning the teeth and tongue using suction swab between brushing or as needed. Application of mouth moisturizer every 2 hours and as needed. Provision of deep orophhyrangeal suction as needed to remove secretions in intubated patients. Once the Institutional Review Board approved the proposed solution, it would be introduced and presented at scheduled meetings for the education department, nursing administration, nurses assigned in infection control, Intensive Care Unit director, and respiratory director. During the presentation, the cost, mortality, and morbidity rates of ventilator-associated pneumonia would be pointed out. Upon the approval of the respiratory care director and nursing administration, the solution will be presented during weekly meetings to the Intensive Care Unit respiratory therapists and nurses. The ancillary staff will also be informed during monthly staff meeting. The procedures prior to implementation include: Selection of personnel and venue. All Intensive Care Unit respiratory therapists and nurses are part of the team. Approval acquisition from the chief nursing officer for the funds used for printing, power point presentations, pamphlets, and refreshments with minimal costs involved. The created budget will be presented for approval to the chief nursing officer. Assessment and evaluation of the present oral care status. Collaboration with the respiratory department for the commencement of the preparation and implementation procedures. Organization of the educational program through power point presentations and handouts. Every part of the proposal should be taught to the Intensive Care Unit staff, and the respiratory therapy department. Feedback should be enhanced. Arrangement of simulation terminals for demonstration and training of the involved personnel. Introduction of the oral care procedures to the key stakeholders. Identification of a process owner for operation of the procedure after implementation and onwards to preserve long-term integrity. Strategies for a Good Outcome Periodic oral care should be discussed during daily patient rounds to enhance awareness and positive attitude toward the procedures. Oral care applications should be recorded after every administration for further documentation, study, and modification. It can be used as a solid tool for further measurements and checking procedures. Nurses should be offered comment and suggestion sheets, and questionnaires. This will aid them in the continuation and development of oral care. Moreover, nurses will also develop a sense of ownership to the oral care procedures. A discussion of the oral care processes, necessities, and modifications in strategy should be conducted with the involved nursing staff and the education department. Staff meetings should also be conducted monthly to share modifications and other information. Possible Barriers Because the nursing staff is accustomed to the current procedures, changes are often difficult to accept. However, concern over the proposed solution can be relieved by providing enough information about the deficiencies of the current procedures. Moreover, if possible benefits of the proposed process are discussed thoroughly, hopefulness may be developed in them. The initial implementation procedure may be difficult at first, but if necessary measures are taken, the implementation will run smoothly. One aspect that can impede the change is poor communication. The failure to communicate freely may prevent the personnel from following through with the implementation of the change. All hospital personnel, including the stakeholders, should cooperate in the implementation of the proposed change to encourage continuity of the newly-adopted solution. Contention should not be encouraged either. All possible barriers that will prevent the application of the procedures should be settled and resolved prior to implementation. If these measures are followed, the possibility of a successful outcome increases. Oral care hygiene process is crucial to ventilator-associated pneumonia patients, and therefore immediate action is required. The initial implementation may be difficult and demanding and may cost money and time, but the effect on the patient will be rewarding. The additional time that nurses will spend on oral care proceedings will actually cut the time they need to provide care for the patient in the long run. The amount of time that the patients will spend in the hospital will be reduced. Moreover, the overall expense of the hospital itself will be reduced. In this given situation, most of the patients, if not all, will find cure, and therefore their lives will be saved. Buy custom Developing an Implementation Plan essay