Literature Review Acute Coronary Syndrome

The acute coronary syndrome is caused by a lack of adequate blood in the heart. In particular, the condition occurs when the coronary arteries are blocked, limiting their ability to supply oxygenated blood to the heart muscles. Unstable angina refers to the chest discomfort that is caused by the lack of enough blood flow. Unstable angina is more severe compared to stable angina but less severe than myocardial infarction. Unstable angina, also known as the angina pectoris is characterized by pain in the chest. When the left anterior descending artery is occluded, the walls of the left ventricle, the interventricular septum, and other parts are affected. When the right coronary artery is affected, the right atrium and left ventricle become ischemic. On the other hand, when the circumflex artery is occluded the left ventricle, atrium, fasciculus, and bundle branches become ischemic.

Literature Review Acute Coronary Syndrome

The etiology of this condition focuses on the formation of atherosclerotic plaques. The process starts with endothelial dysfunction. Endothelial dysfunction refers to a condition whereby the inner linings of the endothelium fail to function properly. Remember, the endothelium plays an important role in regulating blood clotting but this function is likely to be affected by several conditions including metabolic syndrome, hypertension, smoking and inactivity.  According to Balasubramaniam, Viswanathan, Marshall and Zaman (2012) endothelial dysfunction is characterized by an imbalance between vasodilating and vasoconstricting substances and an increase in leucocyte adhesion, hence leading to vascular reactivity. Ultimately, endothelial dysfunction leads to atherosclerosis. 

According to the American Heart Association, more than a million people are affected by this condition every year. In 2006 alone, more than 1.4 million patients were discharged with a primary or secondary diagnosis of acute coronary syndrome. Currently, more than 7 million people are living with this condition. Beside death, coronary heart disease can lead to premature, chronic disability to the affected patients. Following a discharge, patients suffering from acute coronary syndrome require re-hospitalization within the first six months. One in every five patients diagnosed with non-ST elevation myocardial infarction and ST-segment elevation, dies after hospitalizations. In total, acute coronary syndrome accounts for half of all mortality related to cardiovascular diseases. The cost of rehabilitating patients with acute coronary syndrome is enormous. The direct costs of treatment are estimated to be $75 billion while the indirect costs of treating patients with acute coronary syndrome are more than $142 billion.

A number of studies have been conducted to examine the threat of Acute Coronary Syndrome among the American population. One such study was conducted by Doyle, Simon, and Stenzel-Poore (2008) using a Behavioral Risk Factor Surveillance. Using self-reported data, the researchers found out that the Southern Eastern states are the ones that are heavily affected by the Acute Coronary Syndrome menace. The study analyzed the risk factors that are responsible for the high prevalence rates in the South Eastern states. One of the risk factor that was examined is the ethnic background and socioeconomic status. The southern eastern part is mainly occupied by minority communities including the blacks and the socioeconomic status of the occupants there is much lower compared to the rest of the nation. The high prevalence rate can also be explained by the lifestyle factors such smoking. The southeasterners also suffer from contributing diseases such as diabetes, coronary heart diseases and hypertension. Due to the high prevalence rates, death rates as a result of Acute Coronary Syndrome are also significantly higher, in the southeastern regions, compared to the other parts around the nation.

Acute Coronary Syndrome has affected other developed countries. In the UK, Acute Coronary Syndrome is a leading cause of disability, and a leading cause of death. Currently, there are around 1 million Acute Coronary Syndrome survivors while an estimated 150,000 people are diagnosed with Acute Coronary Syndrome every year. The majority of those affected by Acute Coronary Syndrome in the UK are the elderly and the leading risk factor is obesity. In England, Northern Ireland, Scotland and Wales, 25% of the whole population is considered obese. The levels of activity among the residents in these four countries are also very low and this explains why Acute Coronary Syndrome is responsible for a significant percentage of deaths that are reported in the country. Overall, £ 8 billion is spent in Acute Coronary Syndrome-related costs.

Developing countries have not also been spared either. In India the prevalence of Acute Coronary Syndrome has been on the rise and this occurrence has been attributed to an increase in the aged population. In Cuba, the crude mortality from Acute Coronary Syndrome is 84 per 100,000 population while in the neighboring countries it is the second leading cause of death (Bonita & Beaglehole, 2871). Just like in India, a significant percentage of the total population in Cuba is made up of elderly people. Incidences of Acute Coronary Syndrome in the developing countries are attributed to several factors. Firstly, low and medium income earning countries account for almost 80% of all chronic noncommunicable diseases that are reported in the world. At the same time, the local population in the developing countries continues to engage in lifestyle choices such as eating high-fat diets, smoking and living a sedentary lifestyle. As the residents continue to adopt the western lifestyle it is expected that the prevalence of Acute Coronary Syndrome will continue to rise. These statistics illustrate to us that Acute Coronary Syndrome is a serious condition which takes huge resources to rehabilitate patients. In addition, the disease has an adverse effect due to the loss in productivity. It is on this basis that it becomes important to evaluate the events surrounding the disease and how it can be prevented and managed.

Literature review

Acute cardiovascular syndrome is a form of cardiovascular disease and is a leading cause of death in the America. Death results when the atherosclerotic plaque breaks up hence stimulating platelet aggregation and thrombus formation. The thrombus formed then prevents myocardial perfusion.  Remember, the myocardial cells require oxygen to function properly but the formation of the thrombus restricts the supply of the oxygen hence increasing the myocardial demand for the oxygen. As a result, the ischemic tissues become necrotic leading to decreased renal perfusion. Ultimately, decreased renal perfusion stimulates the release of renin, angiotensin, aldeosterone, antidiuretic hormone hence increasing workload of myocardium.

Balasubramaniam, Viswanathan, Marshall and Zaman (2012) evaluated the role of the endothelial cells in the atherosclerosis process. In the article Balasubramaniam, Viswanathan, Marshall and Zaman Balasubramaniam (2012) argues that endothelial dysfunction plays a pivotal role in the expression of atherosclerosis.  When the endothelium becomes impaired it fails to maintain vascular homeostasis. As a result, a number of abnormalities are experienced and they include loss of nitric oxide, over-production of vasoconstrictors, and reduction of the ability to control inflammation, thrombosis and cell growth.  The endothelium also plays the role of producing vasodilators such as nitric oxide, and prostacyclin while regulating the effect of vasoconstrictors such as endothelin-1 and angiotensin. The loss of vasodilators and over-production of vasoconstrictors affects the integrity of the arteries. One such vasoconstrictor is angiotensin. Angiotensin not only plays an important role in the loss of normal arterial compliance and patency, but it also mediates the plaque weakening process in a number of ways. Firstly, it leads to the up-regulation of the IL6 gene which is produced by the plaque microphages. Secondly, it leads to the up-regulation of the MMP genes which then lead to the degradation of the plaque fibrous cap. Thirdly, it leads to the activation of the nitrogen-activated protein kinase cascades and tyrosine kinases. Finally, it mediates the stimulation of neo-vascularisation.

In the article, Balasubramaniam, Viswanathan, Marshall and Zaman (2012) further look at the impact of the risk factors such as diabetes in the progression of atherosclerosis. In their view, diabetes mellitus is a strong predictor, and the studies that have been conducted indicate that patients suffering from diabetes have very a little opportunity of recovering from Acute Coronary Syndrome. Mortality rates for diabetes mellitus patients with acute myocardial infarction are also high. In this article, they also look at the role of endothelial NO synthase in the inflammation process. As a vasodilator, eNOS plays an important plays an important role in preventing leukocyte (Balasubramaniam, Viswanathan, Marshall & Zaman, 2012) adhesion while maintaining the antiflammatory state of the endothelium. However, the Acute Coronary Syndrome leads to the low production of eNOS and the endothelial cells are activated to produce vascular cell adhesion molecules such as the VCAM-1 and ICAM-1. These vascular cell-adhesion cells promote the adhesion of the leukocytes to the endothelial surface. 

In this article, Balasubramaniam, Viswanathan, Marshall and Zaman (2012) further argue that diabetes increases the platelet aggregation and adhesion process in several ways. Firstly, the condition leads to reduced platelet membrane fluidity. Secondly, the condition leads to increased production of thromboxane, hence increasing platelet sensitivity. Thirdly, it increases the expression of platelet adhesion molecules and the number of platelets. These two actors play an important role in the pro-coagulant activity. Fourthly, diabetes increases the expression of platelet surface receptors and generation thrombin. Fifthly, diabetes mellitus reduces the sensitivity of the platelets to the effects of the vasodilators. Sixthly, platelets of patients with diabetes mellitus are rich in cytokines and chemokines which contribute to inflammation of the endothelium. These findings are supported by Al Thani et. al. (2012) who concluded that diabetes is an independent predictor for presence of polyvascular diseases and Acute Coronary Syndrome.

Another study that was conducted by Zhong, Tang, Zeng, Wang, Yi, Meng, Mao, and Mao (2012) investigated the role of cholesterol content in atherosclerotic plaque progression. Zhong et al. (2012) used a sample of 136 participants. The researchers assessed the cholesterol content of erythrocyte membranes. It is well acknowledged that cholesterol plays an important role in plaque formation. The key feature of the plaque formation is the erythrocyte membrane. Erythrocyte membrane is a key source of cholesterol in plaques. Their findings are supported by Giannoglou,Koskinas, Tziakas,  Ziakas, Antoniadis, Tentes, and Parcharidis (2009) who found out that CEM in Acute Coronary Syndrome patients is significantly higher that in patients with stable angina pectoris. In the study, Zhong, Tang, Zeng, Wang, Yi, Meng, Mao, and Mao (2012 also (2012) investigated some of the factors that determine the size of the plaque in the artery. Obviously, the amount of the cholesterol determines the size of the lipid core. The researchers concluded that erythrocytes played a major role in plaque expansion by increasing the lipid content. In addition, they argued that cholesterol encouraged apoptosis of macrophages and formation of foam cells.

The role of the low-density lipoproteins as a cause of Acute Coronary Syndrome was investigated by Meisinger, Baumert, Khuseyinova, Loewel, and Koenig (2005). Very Low-density lipoproteins are secreted from the liver, and are then converted to low-density lipoproteins (LDLs).  LDLs may accumulate in the artery wall if their rate of removal is low (Meisinger, Baumert, Khuseyinova, Loewel, & Koenig, 2005). The LDLs stimulate the endothelial cells to express the monocyte chemotactic protein-1 (Meisinger, Baumert, Khuseyinova, Loewel, & Koenig, 2005). MCP-1 then attracts monocytes from the blood. In addition, LDLs encourages differentiation of monocytes into macrophages. Macrophages promote the formation lipid-cell foam cells, which are the hallmark of the atherosclerosis process. Following this narration it is rather apparent that low-density proteins mark the start of atherosclerosis process, and its subsequent progression.

Plaque rupture

According to Kumar and Cannon (2009) the molecules in the endothelium mediate the adhesion of leukocytes on the endothelial surface. The monocytes penetrate the endothelial wall, where they interact with oxidized LDL, transforming into foam cells. The foam cells produce cytokines and other substances that maintain atherosclerosis progression. The plaque usually has a thin fibrous cap which is destabilized by the inflammation cells such as the monocytes, macrophages and T-cells. In the article titled, Coronary events, Armin, Masataka, Renu and Valentin (2012) revisit how the plaque forms and how it later erupts. An atherosclerotic plaque normally has a large necrotic core but a small layer of the fibrous cap. The expansion of the atherosclerotic plaque is facilitated by the accumulation of free cholesterol, and macrophage infiltration. The fibrous cap only has a few smooth muscle tissues and is often inhabited by macrophages and T lymphocytes. Once the fibrous cap erupts, it exposes the thrombogenic materials to the blood stream.  Following the rupture of the plaque, thrombi are formed. It is the rupture of the fibrous cap that leads to the development of unstable angina and myocardial infarction.

A lot of research has focused on how the plaque ruptures. One likely cause is the accumulation of T-lamphocytes and microphages-derived foam cells which secrete cytokines and proteolytic enzymes leading to the depletion of smooth muscle cells. The apoptosis of smooth muscle cells is promoted by the mast cells which are abundant in the plaque. The reduction of the smooth muscle cells impairs the repair process. Remember, smooth muscle cells produce the cap-stabilizing collagen and so a significant reduction of the cells is likely to have deleterious effects. Plaque rupture is also facilitated by the blood flow-induced shear stress. It is assumed that as the plaque grows, the tensile stress on the plaque shoulders increases hence leading to fissuring and subsequent rupturing. Armin, Masataka, Renu and Valentin (2012) found out that areas of low shear stress had advanced plaques than areas with high stress. Armin, Masataka, Renu and Valentin (2012) further notes that not all plaque ruptures lead to coronary events.

Armin, Masataka, Renu and Valentin (2012) examined the atherosclerotic process and the effect it has on the size of the artery. During the initial stage, the size of the artery is usually normal. In the second stage, as the plaque formation progresses, the artery remodels itself to avoid lumen encroachment. In the third stage, the plaque ruptures and hemorrhages leading to formation of intramural thrombi. Armin, Masataka, Renu and Valentin (2012 notes that mostly the plaque heals and continues to grow. Alternatively, the thrombogenic materials may be embolized distally leading to coronary arterial insufficiency or asymptomatic micro-infarctions. In the fourth stage, if the right conditions exist, the rupture of the plaque leads to the occlusion of the affected arteries.

In the article, Armin and his colleagues also looked at the interplay of factors that contribute to acute coronary event risk (2012). One factor is plaque burden which is determined by the blood viscosity, platelet function, stress and smoking (Armin, Masataka, Renu & Valentin, 2012). The other coronary plaque characteristic is lumen encroachment which depends on shear stress, circadian variation, obesity, catecholamine surge and pollution (Armin, Masataka, Renu & Valentin, 2012). Other coronary plaque characteristics include lesion locations, plaque composition, plaque biology, plaque configuration, endothelial dysfunction and plaque remodeling (Armin, Masataka, Renu & Valentin, 2012).

On their part, David and Valentin (1999) looked at the activities surrounding the atheromatous plaques. The formation of plaques according to David and Valentin (1999) can be traced to the early lesions. Early lesions then grow bigger as the extracellular lipid and cholesterol content increase and fibrous cap grow thin. This development according to David and Valentin (1999) occurs in 5 phases. During phase 1 the development of lesion types I-III occurs while in the phase 2, lesion types IV and Va develops (David & Valentin, 1999). Plaque disruption starts from phase 3, eventually leading to the growth of more complicated plaques. The acute coronary syndrome occurs in phase IV, when plaques are more complicated (David &Valentin, 1999). However, plaques may fail to rupture and occlude the affected arteries. Such plaques characterize the last stage of the plaque development.

Clinical sequellae and symptoms

The eruption of the fibrous cap exposes the content of the plaque to the blood elements. In addition, an alteration of the blood flow is experienced around the ruptured plaque and the blood flow supporting myocardial distal is reduced (David &Valentin, 1999). Vasoconstriction at the site of the ruptured plaque makes coronary events to become much more severe. (David &Valentin, 1999) If the ruptured plaque does not significantly disrupt the flow of the blood, only an asymptomatic progression of the lesion is experienced (David &Valentin, 1999). On the other hand, if the rupture leads to complete vessel occlusion, acute myocardial infarction results (David &Valentin, 1999). The common symptoms of Acute Coronary Syndrome include chest pain, arrhythmia, shortness of breath, fatigue, weakness, heart palpitations, nausea, numbness, confusion, slurred speech, vertigo and headache.


Detection of atherosclerosis is one of the main objectives of the diagnostic tools. One such advancement is the use of plasma markers. One of the markers that have been used widely is the C-reactive protein and the lipoprotein associated phospholipase A2. Such markers are used to predict coronary events. Using peripheral blood has become popular due to the low cost that is associated with this process. An alternative method that is used in diagnosing coronary patients is the non-invasive imaging. Some of the imaging tools that can be used for identifying vulnerable carotid plaques include: ultrasound, MRI, nuclear imaging and X-Ray multi-detector. A CT angiogram and a nuclear scan could also be used to check the site of rupture and identify whether the arteries are constricted or blocked. Other diagnostic tests include an electrocardiogram, blood tests, chest X-ray, and coronary angiogram.


Reperfusion therapy

In the article titled, Acute coronary syndromes: diagnosis and management, Cannon and Kumar (2009) looks at the interventions for the acute coronary syndrome. Reperfusion therapy has been found to improve patient outcomes. The efficacy of reperfusion therapy in acute coronary syndrome was tested in a study that was conducted by Desai (2008). The 80 participants in this study were all Acute Coronary Syndrome patients. The two researchers also compared the efficacy of the percutaneous balloon angioplasty and systematic thrombolysis. The two interventions were found to increase systolic and left ventricle functions.

Antithrombotic therapy

According to Kumar and Cannon (2009) the aim of this intervention is to maintain the patency of the infarct-related artery. Antithrombotic therapies are augmented by anti-platelet strategies such as aspirin and glycoprotein IIb/IIIa antagonists. Antianginal therapy could also be used and use of nitrates to reverse the vasospasm, reduce the coronary blood flow at the site of rupture and the myocardial oxygen demand.

Coronary surgery and angioplasty

It is apparent that administration of anti-platelet and anti-thrombotic drugs improves the chances of survival to the patients. These drugs are often used before percutaneous coronary or surgery revascularization is performed. The coronary surgery is performed to bypass the affected portion of the coronary artery. The grafted artery goes around the area with the plaque, a process that creates a new path for oxygen-rich blood. The efficacy of coronary artery bypass surgery is supported by a study that was conducted Kumar and Cannon (2009). All the participants in this study had ST-segment elevation myocardial infarction. The result of the study indicates that high-risk patients who undergo surgery intervention have very high chances of survival. An alternative to the bypass surgery is the percutaneous coronary surgery otherwise known as coronary angioplasty or balloon angioplasty. The process entails using a catheter with a balloon at the tip. Once in place, the balloon inflated to compress the plaque against the artery wall. This process targets unstable plaques which have thin fibrous caps, lipid full macrophages, and deficient smooth muscle cells. During balloon angioplasty, a stent is used to maintain the patency of the occluded arteries.


Al Thani, H., El-Menyar, A., Alhabib, K., Al-Motarreb, A., Hersi, A., Alfaleh, H., Asaad, N., Saif, S.A., Almahmeed, W., Sulaiman, K., Amin, H., Alsheikh-A., Alnemer, K. & Suwaidi, J. (2012). Polyvascular disease in patients presenting with acute coronary syndrome: its predictors and outcomes. Scientific World Journal, 2012, 284851

Armin, A., Masataka, N., Renu, V., & Valentin, F. (2012). Acute coronary events. Circulation, 10(1), 1147-1156

Balasubramaniam K, Viswanathan G, Marshall S, & Zaman A. (2012). Increased Atherothrombotic Burden in Patients with Diabetes Mellitus and Acute Coronary Syndrome: A Review of Antiplatelet Therapy. Cardiology Research and Practice, 2012, 1-18

Bonita, R., & Beaglehole, R. (2007). ACUTE CORONARY SYNDROME prevention in poor countries: Time for action. Stroke, 38(11), 2871–2

David, E. G. & Valentin, F. (1999). Pathophysiology and clinical significance of atherosclerotic plaque rupture Cardiovascular Research, 41(2), 323-333

Desai, N.D. (2008). Pitfalls assessing the role of drug-eluting stents in multivessel coronary disease. Annals of Thoracic Surgery, 85 (1), 25–7.

Doyle, K. P., Simon, R. P., & Stenzel-Poore, M. P. (2008).  Mechanisms of ischemic brain damage. Neuropharmacology, 55, 310.

Giannoglou, G., Koskinas, K., Tziakas, D.,  Ziakas, G., Antoniadis, A., Tentes, I., & Parcharidis, G. (2009). Total Cholesterol Content of Erythrocyte Membranes and Coronary Atherosclerosis: An Intravascular Ultrasound Pilot Study. Angiology,  60(6), 676

Kumar, M.D. & Cannon, C. (2009). Acute coronary syndromes: Diagnosis and Management. Mayo Clinic Proceedings, 84(10), 917-938

Meisinger, C., Baumert, J., Khuseyinova, N., Loewel, H. & Koenig, H. (2005). Plasma oxidized low-density lipoprotein, a strong predictor for acute coronary heart disease events in apparently healthy, middle-aged men from the general population. Circulation, 2; 112(5):651-7.

Zhong, Y., Tang, H., Zeng, Q., Wang, X., Yi, G., Meng, K., Mao, Y., & Mao, X. (2012). Total cholesterol content of erythrocyte membrane is associated with the severity of coronary artery disease and the therapeutic effect of rosuvastatin. Upsala Journal of Medical Sciences, 117(4): 390–398

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Acute Stress Disorder

For the Psychology Database assignment, research the topic adjacent to your name, discuss the four (4) questions in your research paper and do not exceed two typed double pages in APA style.
1. What is the cause of the syndrome?
2. Discuss the cure and your plan to share with the world.
3. What are the signs and symptoms of this syndrome?
4. What are your thoughts from researching the topic?

The book we use is exploring psychology eleventh edition by David g. Myers & C.Nathan DeWall


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Determine a specific employment law that may affect the hiring and selection process at the acute hospital in your community. Provide support for your rationale.

Imagine that you have applied for the position of Manager of Human Resources at an acute care hospital in your community. The hospital is planning to expand its services to meet the needs of a growing community. As part of the application screening process, you have been asked to write a document that outlines the steps you would take, as the manager of HR, to improve the effectiveness of HRM in this organization.

Write a three to four (3-4) page paper in which you:

  1. Analyze two (2) current trends in health care that are affecting human resources management that may likely impact your hiring decision as HR manager. Provide support for your analysis.
  2. Suggest a significant opportunity for HR to become more of a strategic partner within an organization. Justify your response.
  3. Recommend a model of human resources management that would be the most appropriate for this organization in question. Provide support for your recommendation.
  4. Recommend a strategy that HR could implement in order to develop more effective relationships between Human Resources and the organization’s managers and senior executives, indicating how each strategy will achieve the desired goal.
  5. Determine a specific employment law that may affect the hiring and selection process at the acute hospital in your community. Provide support for your rationale.
  6. Use at least three (3) quality academic resources in this assignment. Note:Wikipedia and other Websites do not qualify as academic resources.


Your assignment must follow these formatting requirements:

  • Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA or school-specific format. Check with your professor for any additional instructions.
  • Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.

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Helping parents deal with childrens acute disciplinary


We have all heard of a child who “had frequent tantrums in which he cursed at his mother, kicked her and threw things at her. As a result, his mother would hit him and cursed him in return, thus making the event in symmetrical bout. The mother felt that as long as he kept attacking her, she was compelled to hit him back, otherwise he would feel that he had won” (Alon & Omer, 2006, p.86). We know that the child has a violent and self-destructive behavior problem and the mother is not giving-in, but unsure if hitting her child was the proper way to deal with the situation. According to Waldman (2000) Children who have behavior problems create stress within the home. Resolving these problems smoothes the parent-child relationships, helps the child’s emotional, social and educational development, and often improves the parents’ marital relationship (“Introduction,” p16). Omer and London-Sapir (2003) characterized children with violent and self-destructive behavior by lack of boundaries, uncontainable outbursts, and an ever growing readiness to go to extremes. Most of these children are deeply averse to being supervised or guided by their parents or by other responsible adults. When a confrontation arises, they usually convey the message: “Leave me alone!” or “I am the boss!” (p.1). Parents should be able to deal with this situation by “overcoming serious inhibitions to be able to perform the steps” (Omer & London-Sapir, 2003, p56). And these “inhibitions can be overcome with information and support” (Omer & London-Sapir, 2003, p.173).


Escalation and Non-Violent Resistance

There are two kinds of escalation between parents and children with acute disciplinary problems: (a) complementary escalation, in which parental giving-in leads to a progressive increase in the child’s demands, and (b) reciprocal escalation, in which hostility begets hostility. Extant programs for helping parents deal with children with such problems focus mainly on one kind of escalation to the neglect of the other. The systematic use of Gandhi’s principle of `nonviolent resistance` allows for a parental attitude that counters both kinds of escalation. An intervention is described, which allows parents to put this principle into practice (Omer, 2001, “Abstract”).
Hostility escalation between parents and children is common but what’s uncommon is the fact that one can resort to a less damaging kinds of escalation known as reciprocal (hostility increases hostility) and complementary (giving-in increases demands) escalation (Bateson, 1972). They are characterized by “the parent gives in to the Childs’ demands, the child increases the demands, the parent gives in again, and so forth” (Omer, 2001, p.40). Patterson coercion theory presented that “parental giving in not only increases the child’s demands (complementary escalation), but also the chances the either the parent or the child will display higher levels of hostility (reciprocal escalation) in the next bout” (Omer, 2001, 40:53-66).

The New Approach: Non-Violent Resistance

Nonviolent Resistant is the new approach in dealing with destructive behavior in children by increasing more of the parent’s presence and make them feel they have somewhere to go to in times of helplessness, boost their confidence and give them the authority over the young people. Conforming to the social care settings, nonviolent resistance promotes the preservation of the families and keeps the children from going into care by avoiding the weakening of the family structure and avoids having the need for a costly residential or a secure accommodation. Additionally, nonviolent resistance is a therapeutic means that is known to lessen conduct problems and various anxiety and control-related difficulties in the family. Where education is concerned, nonviolent resistance can be used to ameliorate the behavior of the young people by reducing its destructive and violent attitude within the school community (Partnership Projects, 2006).

The Intervention

The nonviolent resistance approach is a brief treatment but an intensive one lasting up to around three months. Parents get to have one to two supportive phone calls and home visits every week besides the weekly sessions of therapy. To maintain continuity, people in support groups such as the telephone supporters maintain regular interaction with the therapists.

Haim Omer’s team at the University of Tel Aviv has formulated a systematic approach in helping families with children having disciplinary problems. The team’s intervention model described is based on a number of research projects at the Department of Psychology by M.A. students for their M.A. theses. More than a hundred families, whose children had acute disciplinary problems were interviewed and underwent a process of parental counseling in different studies (Omer, 2001). Children’s participation is not necessary in the therapy, giving the parents the time to address the disciplinary problems they face. Parents can have the total freedom to focus on self-empowerment to be able to counter the behavioral problem of the young people. This process gives the parents the sense of being in control of the situation (Partnership Projects, 2006). Non-Violent Resistance deal with family interaction in particular methods such as Developing parental ‘disobedience’, De-Escalation, Taking direct, non-violent action and Making reconciliation gestures. Direct and non-violent actions in the family are presented by Campaigns, Sit-ins and Tailing.


Pertaining to when should nonviolent resistance be adopted and when does it fail, the author explained that non-violent resistance is not a strategy or procedures, but a state of how one incorporates all the principles (Omer, 2001). Acts of non violent resistance are complicated and entail careful preparation, investigation and therapeutic reflection. “By showing deferred, carefully planned and strategic responses to violent acts, parents no longer react ‘on the hoof’, are calmer, can create optimal conditions under which to act, and gain maximum support from outside helpers” (Partnership Projects, 2006). Parents must do something about the situations properly and in place when handling behavioral approaches. But contrary to behavioral approaches, nonviolent resistance targets the parents and not the destructive children and extends support by helping them overcome their feelings of helplessness by resisting control according to context.  Basically, what these strategies do is they take the parent’s ability to act decisively at a given moment in time into consideration, as well as the supportive network around the family (Partnership Projects, 2006). Additionally, families often become socially isolated due to the children’s violent behavior, and the need to develop a support network counterbalances this isolation. In this way, nonviolent resistance is a community-based therapeutic approach for parents, helping families reconnect and develop their interpersonal resources (Partnership Projects, 2006).

According to Omer (2001), children with acute discipline problems, include children of all ages who display violent and antisocial behavior or defiant and oppositional patterns, both on clinical i.e. DSM-IV conduct disorders and defiant-oppositional disorders, and subclinical levels. Passive resistance is often used interchangeably with nonviolent resistance. It was a misnomer to Ghandi because the method of nonviolence entails a more active step and does not involve practicing of violence which is the very opposite of what it was named as (Iyer, 1991 as cited in Omer, 2001).

The Review

The target audience for this article extends beyond parents to educators. This article may interest a broad audience because it is not based from any particular psychological perspective, no need for an in-dept knowledge of Psychology and proposes a positive and actual solution to handling disciplinary problems among the children and youths. The article begins by describing the nonviolent resistance principles and how they can be used to parenting practice. Omer Haim completely included relevant information in the article with detailed description of particular methods such as sit-ins, refusing orders etc., and procedures on its applications. The methods are made to raise parental presence, collapse the destructive cycle of escalations and aid the parents employ a wider support network. The detailed procedure include scripted words designed to see that the center is on the behavior, not the child and that both the child and parents with the child in question gather to seek a solution to the subject matter. Reconciliation gestures are the central ingredient. The procedures also include advice concerning the child’s anticipated adverse reactions and the ways to handle them. This part is followed by a series of descriptions of Omer Haim’s practice including the theories on psychological reasoning and the debate on the effectiveness of the strategy taken in use. The most interesting finding in the article is how the author illustrates the examples of the subject matter. The examples present how nonviolent resistance can be used even in situations where both parents have a conflict or do not agree. They also illustrate how the techniques used cover a range of individual beliefs and thoughts concerning psychology. Omer Haim points out that pathological explanations tend to make parents and teachers helpless and create an idea that the problem can’t be solved. Additionally, developmental aspects are regarded and it is distinguished that temperamental configurations are more thought-provoking to parents than others. Finally, there is a part in the article that focuses on the application on nonviolent resistance in covering more challenging situations like the violence against siblings, association with pathology such as obsessive compulsive disorder and the violence in schools. Both the teachers and parents are encouraged to connect with each other, communicate and become unified in fighting the behavioral problem instead of putting the blame on each other.


The modern parenting of today suggests a move toward permissiveness that creates a more relaxed parenting method that can sometimes cause a weakening of the family structure. These changes brought about disempowering of parents and teachers especially when dealing with behavioral problems of the children both at home and in schools. The article presents an approach in handling violent and self-destructive children. Starting out with an analysis of Gandhi’s non violent resistance approach that covers family settings, Haim Omer introduces violence escalation model methods between parents and children with disciplinary problems including the means to overcome escalation. The approach to non-violent resistance contains a step-by-step procedure manual for the parents. The subjects include dealing violence against siblings, dealing with children who take control of the house, building alliances between parents and teachers, community uses of the approach. The primary goal of the techniques is to break the cycles of escalation that stem from educators and parents who are either too lax or strict in treating the behavioral problems of the children.

The article written by Haim Omer is very informative and complete with all the pertinent and relevant information on helping parents and teachers deal with children’s acute disciplinary problems without escalation. As discussed above, the procedures were in step-by-step details and easily understood by many without any understanding of Psychology issue.


Alon, N. & Omer, H. (2005). Psychology of demonization. Mahwah, NJ: Lawrence Erlbaum Associates.

Omer, H, & London-Sapir, S. (2003). Non-violent resistance a new approach to violent and self-destructive children. New York: Cambridge University Press.

Omer, H. (2001). Helping parents deal with children’s acute disciplinary problems without escalation: The principle of nonviolent resistance. Family Process 40(1), 53-65.

Partnership Projects. (2006). Training, education and consultancy in social care, CAMHS and psychology. Retrieved April 11, 2009, from

Waldman, L. (2000). Who’s raising whom a parent’s guide to effective child discipline. Annapolis, MD: Wellness Institute.


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A Client in the Acute Inpatient Facility

A Client in the Acute Inpatient Facility.

Case Study: A Client in the Acute Inpatient facility

The client under consideration is called John. Various reasons rally behind the need for the admission of John in the acute inpatient facility. The primary reason for the admission is due to the deterioration of his health condition as portrayed by various symptoms. The journey to the current situation of John has been long from the time he was a teenager. John has been admitted to the acute inpatient facility as it seems impossible to remain outside. This is because the inpatient facility will offer better support in terms of medication as well as counseling. The form of medication offered to John is mixed up as his condition touches on physical as well as mental health. The fact that John suffers both mentally and physically makes his condition critical (White et al, 2017). It is, therefore, dangerous to have John staying in the outside world as he poses a threat to his life as well as that of others. For instance, John can be observed as a person who has turned out to be quite tempered and thus could result in attacks against the people he interacts with. The diseases that John battles touch on his mental, physical as well as the psychosocial stability aspects (Hyde et al, 2015). To make the matters worse, history traces that John has become an addict to the abuse of drugs and considers taking them rather than enjoying in any other forms. This is, therefore, a complicated situation that cannot be in any case attended from home. John requires the assistance of the psychiatrist due to the mental challenges (Klee et al, 2016). On the other hand, he requires a medical doctor to cater for the deteriorating physical health of the client. John also requires the attendance of a counselor to have back the social life as that led by a normal person.
Assessment of John’s Physical, mental as well as psycho-social health
Assessment of the physical health

John’s physical health is in question. This is due to the various aspects that he has portrayed in the recently. First, John has lost the ability to walk upright as he used to in the past. This means that he must be suffering from a disease that affects the walking system. In close examination, it is discovered that the inability to walk well and use his legs as well as hands results from the various injuries that he acquired in the various occurrences (Beasley et al, 2016). For instance, John’s life before getting admitted was full of violence cases, in some getting a beating and in some beating other people (Elbogen & Graziano 2016). John got serious bruises on many occasions but unfortunately did not make the efforts of getting medical attention. For this reason, the injuries became a problem to the proper functioning of the body.

Also, John is not able to eat properly as the men of his age do. This is an indication that he has lost appetite for food. Thus, the food system must be having some complications thus leading to the loss of appetite (Bucher et al, 2016). For a long time, John never took even the common medication such as deworming. It is probable that the problems have accumulated and led to the loss of appetite. Due to the low food and water intake, John has illustrated the signs of slimming at a very fast rate (Habib et al, 2015). This means that there are needful substances that lack in the body of the client.

On the eyesight assessment, it is also discovered that John’s eyesight capability has reduced with time. According to John, the inability to see effectively began after getting too much into alcoholism and other forms of drugs. It is, therefore, possible that the abuse of the drugs poses a threat to John regarding being able to see clearly. An attempt to give medical spectacles to John bore no fruits in the past as he later broke them after engaging in a quarrel with a family member (Gandhi et al, 2017). The effects to look for an alternative have been futile as John threatened any person coming to his rescue.

John also suffers from the breathing complications from time to time. Therefore, he has to make use of the breathing aids from time to time to prevent the possibility of suffocating. Before getting admitted, the situation was worse as John would faint anytime he had the breathing complications (Cai et al, 2018). However, being admitted has made things better as the breathing aids are always available and reliable. From John’s confession, he had been smoking tobacco for a long time (Faye et al, 2016). This could, therefore, be one of the main reasons that he suffers from the breathing problems, due to the possible destruction of the lungs and the entire breathing system (Bartels et al, 2018). The admission provides a chance for John to be rehabilitated from such behaviors to save the breathing systems. The admission also offers a good chance for John to be able to regain the lost health aspects.
Mental illness

Various aspects indicate that John suffers from the mental disorder. There are various medical disorders that John has been diagnosed with and thus complicating his heath further. First, John is diagnosed with the mood disorder. In this case, he has been diagnosed with the disorder of having his moods change abruptly, at times without any cause (Ture et al, 2017). He has also been diagnosed with the Schizophrenia disorder. In this case, it is indicated that he suffers from the ability to think clearly, resulting in the unclear behavior as well. Under this diagnosis, it is included that he has the inability to have clear feelings and gets lost of what he feels (Sakhvidi et al, 2015). This has led to lots of confusion all along. John also sufferers from the Drug-related disorder in which case he has also been diagnosed with. The drugs that John has taken in his life and especially the hard drugs have major impacts on the minds and affect his ability to behave clearly. The client also suffers from the anxiety disorder, in which case he gets anxious for small matters or even for nothing. It has therefore been considered fit to diagnose him for the same problem. John has also been diagnosed with dementia, which represents the loss of memory (Gühne et al, 2015). Signs have been conspicuous that he suffers from loss of memory due to the ease of forgetting small matters after a short period (Zarea et al, 2017). John also suffers from the impulse control disorder. This is because he is not able to control his tempers whenever he gets slightly angry (McKee et al, 2018). As part of his health complications, this has taken the health position to the worse side. John suffers critically from the personality disorder. This is because he doesn’t have the ability to determine the right and the wrong thing as accepted in the society (Sande et al, 2017). For this reason, he has engaged in assault cases in the past and never thought of being remorseful as he considered it the right thing to do.
Psychosocial health

In this case, John seems to suffer as well. He is unable to determine if he is healthy or not. The admission comes after being forced to seek medical attention in the hospital. This is an indication that he does not have the ability to determine if he is sick or healthy on his own (Bunyan et al, 2017). He is not able to determine what history provides for regarding a person being healthy and sick. He, therefore, suffers from the psychological inability to think effectively and make the right conclusion regarding his personal health.
Vulnerabilities and strengths

John is vulnerable to himself. This is because he may be tempted harm himself, to an extent of thinking of taking away his life (Russell et al, 2016). On the other hand, he is also a threat to the rest of the people. This is because he can easily attack those around him whenever he gets angry. He poses a risk to the family members and the rest of the people due to his violent character (Wells 2017). Also, John is vulnerable to addition. In this case, John is already an addict and has been doing drugs for a long time. For this reason, staying away from the inpatient facility would render him back into doing the drugs, thus deteriorating his health the more.

John’s strength is mainly exhibited physically. This is seen in his ability to fight off people with aggressiveness. In many cases, John illustrates lots of strength when he gets angry. However, the side3 of strengths is quite limited due to the poor health conditions.

It is clearly evident that John is seriously suffering and requires being in an inpatient acute admission facility. Various symptoms illustrate that he is unhealthy physically, mentally as well as psychosocial wise. For instance, the frequent loss of memory, abrupt changes of moods, hot tempers, and other aspects indicate that he suffers mentally. On the other hand, the slim body, poor walking style, loss of food appetite as well as the poor eyesight illustrates the unhealthy physical condition. Considering that John is unable to determine that he is sick until the time he is forced into the hospital, this indicates that he is psychosocially unhealthy. The combination of all the above factors makes John’s condition critical. It is therefore paramount that he remains in the acute inpatient facility for as long as he gets better.

Bartels-Velthuis, A. A., Visser, E., Arends, J., Pijnenborg, G. H., Wunderink, L., Jörg, F., … & Bruggeman, R. (2018). Towards a comprehensive routine outcome monitoring program for people with psychotic disorders: The Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS). Schizophrenia research.

Beasley, J. B., Klein, A., & Weigle, K. (2016). Diagnostic, Treatment and Service Considerations to Address Challenging Behavior: A Model Program for Integrated Service Delivery. In Health care for people with intellectual and developmental disabilities across the lifespan (pp. 1629-1644). Springer, Cham.

Bucher, C. O., Dubuc, N., von Gunten, A., & Morin, D. (2016). Measuring change in clinical profiles between hospital admission and discharge and predicting living arrangements at discharge for aged patients presenting behavioral and psychological symptoms of dementia. Archives of gerontology and geriatrics, 65, 161-167.

Bunyan, M., Crowley, J., Cashen, A., & Mutti, M. F. (2017). A look at inpatients’ experience of mental health rehabilitation wards. Mental Health Practice (2014+), 20(6), 17.

Cai, S., Lin, H., Hu, X., Cai, Y. X., Chen, K., & Cai, W. Z. (2018). High fatigue and its associations with health and work related factors among female medical personnel at 54 hospitals in Zhuhai, China. Psychology, health & medicine, 23(3), 304-316.

Elbogen, E. B., & Graziano, R. (2016). Assessing Acute Risk of Violence in Military Veterans. The Oxford Handbook of Behavioral Emergencies and Crises, 185.

Faye, A. D., Gawande, S., Tadke, R., Kirpekar, V., & Bhave, S. (2016). Focusing on Psychiatric aspects of cancer: A need of the day?. Panacea Journal of Medical Sciences, 6(3), 117-124.

Gandhi, S., Thomas, L., & Desai, G. (2017). Effect of VAPE about mother and infant health on knowledge among primary caregivers of patients with postpartum psychiatric illness:-A pre-experimental study. Asian journal of psychiatry, 28, 21-25.

Gühne, U., Weinmann, S., Arnold, K., Becker, T., & Riedel-Heller, S. G. (2015). S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations. European archives of psychiatry and clinical neuroscience, 265(3), 173-188.

Habib, N., Dawood, S., Kingdon, D., & Naeem, F. (2015). Preliminary evaluation of culturally adapted CBT for psychosis (CA-CBTp): findings from developing culturally-sensitive CBT project (DCCP). Behavioural and cognitive psychotherapy, 43(2), 200-208.

Hyde, B., Bowles, W., & Pawar, M. (2015). ‘We’re Still in There’—Consumer Voices on Mental Health Inpatient Care: Social Work Research Highlighting Lessons for Recovery Practice. British Journal of Social Work, 45(suppl_1), i62-i78.

Klee, A., Adams, L., Beesley, N., Fisk, D., Hunt, M. G., Kalacznik, M., … & Harkness, L. (2016). CLINICAL COMPETENCE IN OUTREACH AND FOR SPECIAL POPULATIONS. The Yale Textbook of Public Psychiatry, 197.

McKee, K., Glass, S., Adams, C., Stephen, C. D., King, F., Parlman, K., … & Kontos, N. (2018). The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective. Psychosomatics.

Russell, H. F., Richardson, E. J., Bombardier, C. H., Dixon, T. M., Huston, T. A., Rose, J., … & Ullrich, P. M. (2016). Professional standards of practice for psychologists, social workers, and counselors in SCI rehabilitation. The journal of spinal cord medicine, 39(2), 127-145.

Sakhvidi, M. N., Bafrooi, N. M., Pak, S., Jafari, L., & Ahmadi, N. (2015). Comparison of Temperament and character pattern in patients with type 2 diabetes and acute myocardial infarction and healthy individuals.

Sande, R., Noorthoorn, E., Nijman, H., Wierdsma, A., Staak, C., Hellendoorn, E., & Mulder, N. (2017). Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning. International journal of mental health nursing, 26(5), 423-436.

Ture, M., Angst, F., Aeschlimann, A., Renner, C., Schnyder, U., Zerkiebel, N., … & Walt, H. (2017). Short-term effectiveness of inpatient cancer rehabilitation: A longitudinal controlled cohort study. Journal of Cancer, 8(10), 1717.

Wells, P. (2017). SO BODY AND SOUL DO MATTER, BUT…. Treating Body and Soul: A Clinicians’ Guide to Supporting the Physical, Mental and Spiritual Needs of Their Patients, 193.

White, N., Leurent, B., Lord, K., Scott, S., Jones, L., & Sampson, E. L. (2017). The management of behavioural and psychological symptoms of dementia in the acute general medical hospital: a longitudinal cohort study. International journal of geriatric psychiatry, 32(3), 297-305.

Zarea, K., Fereidooni-Moghadam, M., Baraz, S., & Tahery, N. (2017). Challenges Encountered by Nurses Working in Acute Psychiatric Wards: A Qualitative Study in Iran. Issues in mental health nursing, 1-7.

A Client in the Acute Inpatient Facility

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In an acute care hospital with not more than 30 beds will patient?s satisfaction increase with improved nursing level of communication?

In an acute care hospital with not more than 30 beds will patient?s satisfaction increase with improved nursing level of communication?.

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You are to create a Design for Change proposal inclusive of your PICO and evidence appraisal information from your Capstone Project Milestone #1. Your plan is to convince your management team of a nursing problem you have uncovered and you feel is significant enough to change the way something is currently practiced. In the event you are not currently working as a nurse, please use a hypothetical clinical situation you experienced in nursing school, or nursing education issue you identified in your nursing program.
1. Create a proposal for your Design for Change Capstone Project. Open the template in Doc Sharing. You will include the information from Milestone #1, your PICO question, and evidence appraisal, as you compose this proposal. Your plan is to convince your management team of a nursing problem you have uncovered and you feel is significant enough to change the way something is currently practiced.
2. The format for this proposal will be a paper following the Publication manual of APA 6th edition.
3. The paper is to be four- to six-pages excluding the Title page and Reference page.
4. As you organize your information and evidence, include the following topics.
a. Introduction: Write an introduction but do not use ?Introduction? as a heading in accordance with the rules put forth in the Publication manual of the American Psychological Association (2010, p. 63). Introduce the reader to the plan with evidence-based problem identification and solution.
b. Change Plan: Write an overview using the Johns Hopkins Nursing EBP Model and Guidelines (2012)
i. Practice Question
ii. Evidence
iii. Translation
c. Summary
5. Citations and References must be included to support the information within each topic area. Refer to the APA manual, Chapter 7, for examples of proper reference format. In-text citations are to be noted for all information contained in your paper that is not your original idea or thought. Ask yourself, ?How do I know this?? and then cite the source. Scholarly sources are expected, which means using peer-reviewed journals and credible websites.
6. Tables and Figures may be added as appropriate to the project. They should be embedded within the body of the paper (see your APA manual for how to format and cite). Creating tables and figures offers visual aids to the reader and enhances understanding of your literature review and design for change.

In an acute care hospital with not more than 30 beds will patient?s satisfaction increase with improved nursing level of communication?

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