## Cost Estimations for Proposed Solutions

Every company’s core objective is to maximize profits. This is usually achieved through improved productivity. Productivity in any workplace largely depends on the productivity of individual workers of the organization. Therefore it is vital to ensure that all the workers are in good conditions so as to harness the best out of them. One major problem that can arise from the workers and hamper productivity is the abuse of drugs, especially alcohol. There are various solutions that can be applied to by an organization to reduce the impact of alcoholism on the workers performance. However, these solutions also come with additional costs. These are the costs of implementing the solutions.

The AACE International published a number of key solutions to the methods of controlling problems that arise in the workplace (Hollmann, 2007). The following spreadsheet table summarizes everything about these methods: (see the attached spreadsheet)

However, all this methods might not be effective in every specific problem. Solving certain problems will require the application of a specific method. This depends on the suitability of the method to the problem. Each specific problem’s solution comes along with an additional cost. It is wise to choose a method that is cost effective since the main objective of companies is profit maximization.To ensure that the correct method is used, it is important to analyze all the possible advantages and disadvantages of the different methods so as to make a good decision. The following is a preview of all the methods of estimating the costs of solutions suggested by the AACE International:

1. Range estimation

This is a very good problem-solving method especially when it comes to profitability and cost analysis. This method ranks critical risks by combining the Monte Carlo techniques together with heuristics. This is then followed by the introduction of self-inflicted risks to cater for the narrow range of the Monte Carlo simulations.

Since range estimation is used to determine the probability and distribution of costs, it can therefore be used to determine the probability of the distribution of alcoholic employees in a company. Range estimation is highly applicable here bearing in mind that the privacy of employees is highly regarded. However, the problem associated with this method is that it does not give directions of how the critical items are estimated. It is also difficult to get the extreme items so as to calculate the range while applying this method.

1. Parametric estimation

Parametric estimation is used to estimate costs based on the available risk parameters. The method uses most tools available in Excel. It involves the analysis of the correlation existing between the growth of the costs and the systematic risk drivers. Parametric estimation is good especially when working to estimate the costs associated with risks at their early stages. However, it becomes difficult to make clear rating of a problem before presenting it in a parametric model (Hallmann& CEP, 2009). Sometimes it may require the judgment of people outside the organization who can give an impartial rate from the given heuristics.Therefore, the big problem associated with this method is that it is difficult to estimate the costs associated with its use.

1. The expected value/standard risk model of estimation

This method is highly recommended to managers because it helps in coming up with good managerial decisions. It works by estimating the total costs that every risk parameter comes with. Basically, this is summed up by the following expression:

Expected value   = Probability of the occurrence of the risk * Impact of occurring.

Therefore, in this case, it will greatly help in analyzing the profits achieved by a company when workers are alcohol-free and the losses that the company experiences when the number of alcoholic workers increases. It helps in assessing the correlation that exists between the risk of alcoholism and the costs that the company incurs. The problem with this method is that it is only suitable when specific risks are identified.

1. The hybrid method

The hybrid method is a mix of the parametric method and the expected values method. This method uses the outcome of the parametric method as the first risk in the expected value method. The projected specific values are then added into the value gotten from the expected value model. However, since this method entails a mix of the parametric and the expected value methods, errors are usually prone especially as a result of double counting.

After a clear analysis of all the above methods of solving cost associated with solving corporate risks, the standard risk model appears to be the most appropriate method of solving the problem of workers alcoholism. For this case, it is clear that the problem that we are dealing with is alcoholism and drug abuse. Therefore, the specific risk is known making the expected value model to be the most suitable solution.

Unlike the range estimation model which only presents a list of critical values and the range, the expected value model ranks the causes of risks according to their strength. This method links the root cause of the risk directly with its final outcome. Estimations are done using the work breakdown structure (WBS) and then their ranks are established.

Since every worker is entitled to their privacy rights, it is difficult to determine the number of alcoholic workers in an organization. Therefore, the best way is to observe the behavioral changes of employees in the workplace. Early symptoms of alcoholism include desertion of duties, coming to work late, absenteeism and the general reduction of performance. Analysis of employees whose performance has significantly dropped after showing all these symptoms will then be taken to calculate their respective probabilities and impact of alcoholism on their performance in work.

Once the number of workers who are alcoholics is established, the Monte Carlo simulations are run to give the estimates of the costs associated with the solutions available. This should be done in a very honest manner. Much care should be taken to ensure that the link between specific risks being investigated is correctly determined.

The application of this method to estimate the cost of solutions to alcoholism can be divided into direct and indirect costs. Direct costs include:

Loss of workers

Workers will be ashamed of their actions and others might decide to quit their jobs. It is imperative to have this in mind when choosing ways of identifying alcoholic workers. Some might be using drugs because of some very pressing personal issues. Therefore, human resource managers are subjected to a dilemma dealing with alcoholic workers (Korman, 1994)

Further decrease in productivity

Workers might endure psychological trauma once they realize that the management is aware of their habits. They will be working under uncertainty and surety of their job security. This may affect their concentration and productivity.

Indirect effects are the effects that individual employees incur. These indirect effects do not usually impact greatly on the performance of the organization. A typical example is the loss of self-esteem by the workers once they feel guilty of their employer’s awareness of this bad behavior.

Works Cited

Hollmann, J. K. (2007). The Monte-Carlo challenge: A better approach. Proceedings of 2007 AACE International Transactions, 03-01.

Hollmann, J., & СЕР, Р. (2009). Recommended Practices for Risk Analysis and Cost Contingency Estimating. Association for the Advancement of Cost Engineering (AACE), Working Maual.

Korman, A. K. (1994). Human dilemmas in work organizations: Strategies for resolution. New York: Guilford.

## MARKETING PLAN: APPLE INC

Marketing Plan: Apple Inc

1. Executive Summary

Apple Inc. is among the world’s largest technology-oriented company based in America. The company deals with computer related products, and it focuses on designing, developing and selling of consumer electronics, computers, computer software, and other online services. Apple Inc. Headquarters are situated in Cupertino, California within the Silicon Valley. Apple is known for originality and standing out above its competitors.

Despite designing and creating a conglomerate of consumer and electronic goods, a few of those have been synonymous to Apple Inc. in the marketplace. For example, the Mac franchise of computers integrated with a Mac OS, the iPhone Smartphone brand, iPod, and the iPad are the products that have made an impact in the consumer market. To add to what we already know of Apple Inc., the company also gives its users the opportunity to enjoy their services online like the App Store, iTune Store and iCloud. Lastly, the multinational company “Apple Inc.” also designs and creates consumer software such as the iOS operating system, Safari web browser and the iLife productivity and creativity suites

1. Situation Analysis

Apple Incorporation has so far created an impact in the world in terms of professionalism and quality. The company has been operational since 1967 and from then Apple has done nothing but find pure luxury for its customers and everyone who gets involved with the enterprise. It is with no doubt the best company in technology and innovation.

• Market Summary

Apple Incorporation is well known and respected as the world leading innovative company. It is also given a reputation for having a good customer care service that is one of the reasons people always love their products (CNN MONEY 2012). However, for Apple to be what it is now, they must have a marketing team to get their products to the required destination and also educate the customers the benefits and advantages of having the products. Creating awareness of the clients is the fastest way to sell your products, and Apple is doing a good job in creating awareness to their customers.

Geographic Factors

Apple is an American international corporation with its headquarters situated in California. The company develops and sells consumer electronic goods. The company practices the method of distribution together with telecommunication services along with connected systems of entrepreneurship (LÜSTED, 2012). The company can be said to use a particular method in distributing their products all over the world, this is by using touch points to establish their distribution network i.e. Orange, T-Mobile, Vodaphone.

Demographic Factors

Apple is all about fun and different. Its products are mainly focused on younger generation. However, the old generation also has many things to get from Apple products. Since everyone needs to have a phone, Apple has to look for features that would both suit the old and young and not neglecting certain generation and by doing that they will stay competitive in the market.

Psychographics

Apple targets all age set of people, however, some of their products are specifically made for the young generation who care about style and what is trending in the market. This therefore keeps Apple on the edge when it comes to innovation in order to keep up with the pace of other competitors.

Market Needs

For Apple to stay on top of its competitors, they must know exactly what the people need. Therefore, they have to assign marketers to go out, get ideas from people, and with that have a clue on the next upgrade to add in their product.

• Competitive prices: Apple is so far the most expensive electronic production in the world. Despite the high prices of their product, they still have millions of consumers all over the world. As far as Apple is concerned, people do not care about the price all what they care about is the quality of the product delivered to them.
• Type: Apple has a variety of products and services that they bring to their consumers. For example for the people who love using iPhones they are given a variety of different Apple phones for them to choose from while purchasing, however, this the purchase on the phones and products differ in prices depending on the upgrades installed.
• Quality: For those people who think that prices of a product matter, Apple is a company that will prove them wrong. For years now, the products created by Apple have been extremely expensive as compared to other competitors. Instead of consumers going for the other products, they end up going for Apple. The reason as to why people love Apple is that they create quality products, which can be trusted by customers.

Market Trend

Apple has so far confirmed a new release on the IPhone, which is said to be launched on 10 September 2015(CNN MONEY, 2013).  Reports also say that there might be a new iPad coming out soon. Nevertheless, Google’s Android is coming off the chats with a tremendous rate and so far, nothing Apple has done has been able to change the trend. The iPhones rating at the smartphone market peaked at 25% in the year 2011; this was according to a survey done by Gartner research firm. However, this share dropped rapidly to 21% the next year and again to 14% the next year.

With that fall, Android is left leading the market with 80% share of the market (CNN MONEY, 2013). The iPad is also said to be losing its grip on the market at an alarming rate. Data compiled from tech consultancy IDC shows the iPad rated at 76% of the market when it was introduced back in 2010, however this rating dropped to 35% in the last quarter. Moreover, as Apples products went down Androids tablet almost tripled their share from 24% to 65%. One of the main problems that can be causing these misfortunes for Apple is that it has not released any new smartphone or tablet for about a year now, while on the other side its rivals get to release new gadgets more frequently.

Market Growth

Apple and iPad were legendary when they were released, however rival competitors are now close to beating apple. The biggest question on everyone’s mind is if Apple is going to release a new product that is different from its competitors. The problem is that Apple is having problems is starting a new market where its rivals are dominating. In addition, competitors like Microsoft and Google have already come up with compelling connections between the devices and services and those combinations are driving consumers away from Apple. The smartphone demand is rising in china but Apple remains no. 7 on the chats according to Canalys research firm. Therefore, for Apple so stay on the market it has announced a new cheap iPhone 5C.

Competition

Apple is facing an extraordinary competition on all sides. Companies like Nokia, Samsung, and Sony are working tirelessly to take Apple out. Most of Apples competitors use Android and Windows which is much cheaper that iOS and therefore giving the competitors and advantage over iPhone. In most parts of the world, Android has already dominated over the iPhone since they are innovative and have a variety of cheap quality products to bring to their customers.

2.2. Product Offering

Apple offers its customers with a variety of gadgets they can use for communication and entertainment. The most known and common product from Apple is iPhone. This is the mobile franchise offered by Apple, moreover, there are a few designs released even though Apple plans to look into innovation this coming fall. There is the iPad and the Tablet, which can also be used as a form of entertainment or communication.

1. Marketing Strategy

Due to the high competition Apple is facing, it has decided to expand and modify its distribution abilities by positioning its own retail stores in major cities all over the world in a market of high quality shopping centers. Apple provides qualified retail floor staff to pick sellers stores, the company has also joined strategic forces with other companies in order to brand and market Apple products and services for example it branded with HP who are now selling branded form of iPod and pre-loading iTunes into a consumer personal computer and laptop. The company also increased accessibility of iPod through a number of sellers that are at the moment not carrying Apples operating system, and therefore increasing the accessibility of online store. There are only a few researches done about Apples strategy such as marketing (KURTZ, D, 2011).  All the companies successful retain stores offer their clients a direct experience of Apples branded products. The consumers experience an once in a life time customer care experience

• Mission

Apples mission is to be more acquainted to their customers wants, and also expand their working environment to more cities in the world. They also plan to introduce new products that will help them keep up with the rapid growing market. With previous success, Apple is planning to keep up with the trend and keep up the image they have created for themselves in the world of technology. The company will mainly focus on Asian countries and Africa and for that, they will have to produce low cost product that can be affordable in the locations.

• Marketing Objectives

In order for a company to have an effective target on its market, it should come up with a specific, achievable, measurable, realistic and time specific market objective. And for a company like Apple to have more market shares in technology it should focus on quality, trend, sleek, bulkiness, price, durability of its products and also its availability to consumers. Below are a few of the market objectives Apple has archived.

• The company has so far dominated other phone and electronic operating system machining it unique from all other products.
• The company has also given people the ability to access their services online all over the world and get to talk to their agents any time.
• Besides focusing on youths alone Apple has been able to give all people exactly what they want in terms of technology current products.
• Target Markets

China has the largest population in the world, and therefore Apples main aim is to assure that they have secured all their customers in china. People in china live being on current affairs in terms of technology and Apple know it has to up its game in order to secure china. However, besides china the company is looking for a way to introduce offices in all major cities all over the world and with that all their customers will have an opportunity to enjoy first hand customer care system offered by Apple (THE TIMES OF INDIA, 2012).

• Positioning

Apple has always managed to emerge on top of other companies in terms of innovation. However due to the current technology the company has been shifted from the top by operating systems like android which so far has the highest number of user according to the (CNN MONEY 2013). However, apple remains to be the preferred technology in some parts and after the announcement of releasing new products; they have a high chance of taking the top position again.

• Marketing Mix

3.1. Price

Apple Incorporation business analysis contains competition, cost, discounts and geographical area. The marketing plan for Apple Inc. should include cost considerations. Price being a broad field it involves completion, cost, discount, markup and geographical area. A company might have a perfect idea and marketing strategy, however if the business has the wrong prices for its products then customers will not want anything to do with the products (Gillooley & Varley, 2001).

3.2. Promotion

Apple is always aggressive in terms of marketing their products due to the high competition of electronics in the market. Promotion, as the name suggest, is not as important as marketing. Advertising is mainly used to show the company where the target market for their product is located and any other procedure the company should take on getting out the right product (KURTZ, 2011). When Apple launched iPhone, the company began with 4TV to which it could be used as a means of entertainment and share information about the device and by focusing on new ideas on how to advertise the present 4TV advertisements in 2010 July.

1. FINANCIALS

In regarding of the finances relating to Apple Incorporation activities, the following graph will provide an in depth understanding analyses, expenses, sales and expenses forecast and show how these activities connect to the market strategy.

4.1 Sales Forecast

Just like marketing strategies the company also focuses on providing and improving its services. This involves focused marketing procedures such as introducing a website for the company for it to operate as the main source of information for the company (DEPAMPHILIS, 2013).  .

Conclusion

After an observation on the above analysis, it is evident to say that Apple is one of the most competitive companies in the world.  Apple Inc. is company based in America and it specializes in technology and online services.  The company got a double revenue turnover three years in a raw with an average growth rate of above 700%.  In the 80s and 90s Apple had the highest success rates in both manufacture and distributing of their products to the consumers (Kurtz 2011).  Even though the company faces a number of strong competitors, Apple has some strength that always keep it in the market.  The company has an established and experienced team of marketers and advertising team.  The fact that Apple sells its products at a higher price is the greatest weakness that the company faces as compared to its competitors in the market such as Samsung.

References

CNN MONEY (2013).  What is eating Apple?  The analysts weigh in.

DEPAMPHILIS, D. (2013).  Mergers, acquisitions, and other restructuring activities: an   integrated approach to process, tools, cases, and solutions.

GILLOOLEY, D. & VARLEY, V. (2001). Retail product management, buying andmerchandising. Routledge, London.

KURTZ, D. (2011).  Contemporary marketing. Australia, Southwestern Cengage Learning.

LÜSTED, M. A. (2012). Apple: the company and its visionary founder, Steve Jobs. Minneapolis,   MN, ABDO Pub.

THE FINANCIAL TIMES (2012).  A little less Samsung in Apple sourcing.

THE TIMES OF INDIA (2012).Apple once again crowned world’s most innovative company.

APPENDIXES

 Strengths Weakness Opportunities Threats Customer loyalty Incompatibility with famous apps High demand of iPhone 5 Rapid change in technology Mobile innovations Decrease market share iTV launch tax increase Revenue: \$567 million Patent in fragment law suit Smartphone and tablet market growth Rising pay levels of employees Cash flow from operations: \$77million Apple maps defect acquisitions Unstable dollar fluctuations dividends Declining fan base Strong growth of mobile market Price competition from Samsung

## Acute upper gastrointestinal (GI) bleeding

A Case Presentation Of An Acute Gastrointestinal (GI) Bleed Due To The Use Of Nonsteroidal Anti-Inflammatory Drugs(NSAIDS).

Acute upper gastrointestinal (GI) bleeding is one of the most common medical emergencies and most cases require urgent medical assessment. Half of all the cases are due to peptic ulcer.After emergency hospital admission, the main goal is to support the circulation of the shocked patient rather than to identify the source of bleeding. It is vital that all nurses are fully aware of the signs, symptoms, and management of acute upper GI bleeding (Smith, 2004, p. 40).

Pathophysiology of acute upper GI bleeding

Acute GI bleed as a result of excessive NSAIDs use is mostly due to inflammation of the gastric mucosa resulting in gastritis and the formation of peptic ulcers and in some cases duodenal ulcers.The pathophysiology of an acute GIbleed as a result of NSAID use is as follows; NSAIDs and some other drugs such as aspirinare known to inhibit the biosynthesis of prostaglandins. Due to this inhibitionthere is a decrease in sub-mucosal blood flow, suppression of secretion of mucus and bicarbonate, and gastric acid secretion is enhanced. This results in decreased pH and increased acidity in the stomach or duodenum resulting in mucosal irritation and/or inflammation.In majority of the cases,acid hypersecretion of the gastric acid, by itself, is not the primary reason to cause ulcers. In most of the patients with peptic ulcers, factors in addition to gastric acid need to be present to cause an ulcer. Additionally, NSAIDs can have a direct effect on the mucosa that can result in mucosal irritation (Lehne,2012,p. 986). Our female patient had a significant history of high dose NSAIDs use to alleviate severe dental painthat contributed to the patient’s admitting diagnosis of gastritis and possible peptic ulcer secondary to the usage of NSAIDS.

The risk factors contributing to diagnosesin our patient were vomiting of large quantities of dark brown liquid followed by dark brown liquid diarrhea after a month long use of high dose of NSAIDS.Furthermore, the patient’s admission physical assessment suggested that she was pale(anemic/shock),blood pressure(BP) was102/55(In young, athletic and or pregnant females the systolic blood pressure could be normal), she was tachycardic (pulse>110bpm). JVP was not mentioned in the case history.The respiratory rate was 26-28 breaths/min suggesting she was hyperventilating.SaO2 values (96%) suggested normal oxygen saturation in her blood.

The clinical signs and symptoms of pathology that warranted close monitoring in our patient washypovolemia and recurrence of bleeding. For that purpose patient was given IV fluids, her BP, CVP and urine output was closely monitored. Hemoglobin(Hb) had to be >10g/dl for that purpose transfusion was given. AdditionallyProton pump inhibitors (PPIs) omeprazole 40mg IV was started.Fluid replacement was monitored as dictated by BP, CVP,and urine output. Initially hourly then the frequency is decreased to 4hrly if patient is haemodynamically stable(Longmore, 2007, p.244).The patient did not require high flow oxygen as her SaO2 values(96%) were well within normal limits. Furthermore,table.1 displays additional management for hypovolemic shock and upper GI bleeding to manage and stabilize the patient.

A risk assessment score (Rockall score) had been established for patients with acute GI bleeding. A series of independent risk factors is scored and the total score predicts clinical outcome.

Laboratory and test values

Table.2Lab assessments

 Laboratory Tests Value Reference Range Adults Hematocrit (%) 19.4 37.0-47.0 Hemoglobin (g/dl) 7.2 12.0-15.0 White blood count (x 103/µL) 9.8 4.8-10.8 Blood urea nitrogen (BUN) mg/ml 27 8-21 Platelet (x 103 / µL) 223 150-400

The lab values in table.2suggest that our patient’s hematocrit, hemoglobin and BUN values were out of range. This is a classic case of upper GI bleed,however, the other labs includingprothrombin time, international normalized ratio, creatinine, sodium, potassium, phosphorus, magnesium, calcium, total protein, albumin, were all within normal ranges.The low hemoglobinvalue suggests decreased tissue perfusion and oxygen-carrying capability, which can affect every organ system in the body(Praskash& Zuckerman, 2003, p.330).That is why acute upper GI bleeding calls for vigilant nursing assessment and intervention.The lab values that would need close monitoring in this patient will be FBC, U&E,LFT,and blood clotting. Any changes would require adjustment in management plans.A patient who is bleeding slowly may have a very low haematocrit, yet have no change in vital signs (Hines, 2000, p. 20).

The elevated BUN level and normal creatinine level in this patient suggested an upper GI bleeding source.Hypovolemia due to acute blood loss causes a rise in BUN; however other factors such as digestion of blood proteins in the small intestine, the absorption of nitrogenous waste products, and dehydration can also lead to rise in BUN levels(Avunduk, 2008,p.85).

The Coombs’ test is used to detect antibodies that act against the surface ofan individual red blood cells. The presence of these antibodies indicates a condition known as hemolyticanemia, in which the blood does not contain enough red blood cells because they are destroyed prematurely.There are two types of Coombs’ tests: direct and indirect. The direct Coombs’ test, also known as the direct antiglobulin test, is the test usually used to identify hemolyticanemia(“Coombs’ test,” 2009,n.p.).

This autoimmune hemolyticanemia could be the reason our patient had a complicated delivery with hemorrhage that same pregnancy requiring hysterectomy and multiple transfusions in the past.

Medication Management.Acetaminophen, ibuprofen, and,vicoprofen belong to a group of drugs known as NSAIDs.As previously mentioned NSAIDS act by inhibiting the biosynthesis of prostaglandins.In doing so they can decrease submucosal blood flow, suppress secretion of mucus and bicarbonate, and promote secretion of gastric acid. Additionally, NSAIDs can irritate the mucosa directly. NSAID-induced ulcers are most likely with long-term, high-dose therapy(Lehne, 2012, p. 986).

Prophylaxis.For patients with risk factors for ulcer development (e.g., age over 60, history of ulcers, high-dose NSAID therapy), prophylactic therapy is indicated. Histamine2 receptor blockers and proton pump inhibitors are preferred. If possible, the offending NSAID should be discontinued, so as to accelerate healing. According to the author if the NSAID cannot be discontinued, a proton pump inhibitor is the best choice to promote healing(Lehne, 2012, p. 987).

Mechanism of action.Omeprazole is a prodrug that undergoes conversion to its active form within parietal cells of the stomach. The active form then causes irreversible inhibition of H1,K 1-ATPase (proton pump), the enzyme that generates gastric acid.Because it blocks the final common pathway of gastric acid production, omeprazole can inhibit basal and stimulated acid release. Partial recovery occurs 3 to 5 days after stopping treatment. Full recovery may take weeks(Lehne, 2012, p. 992).

Side effects of omeprazole.Headache,diarrhea, nausea, vomiting,Pneumonia(alteration of upper GI flora (owing to reduced gastric acidity) and impairment of white blood cell function), fractures in long-term therapy, especially in high doses, rebound Acid hypersecretion,hypomagnesaemia with long-term use, Clostridium difficile Infection and gastric cancer.The prescribeddose of 40 mg IV bid is within the normal range for acute GI bleed prophylaxis for this patient since this patient is not been given a bolus dose.There is no evidence that high-dose I.V. PPI therapy is beneficial in patients with GI bleeding from an ulcer that has a low risk of rebleeding (i.e., a clean-based ulcer on endoscopy). In these patients, oral PPI therapy can be instituted after the patient has recovered from the endoscopy. (Lauritsen,1985; McFarland, 1990; Marks, 1991).Sertraline (Zoloft) blocks reuptake of 5-HT, relieve symptoms of major depression,causes  CNS stimulation rather than sedation, andhave minimal effects on seizure threshold and the electrocardiogram (ECG).

Mechansim of action.Sertraline is slowly absorbed following oral administration. Food increases the extent of absorption. In the blood, the drug is highly bound (99%) to plasma proteins. Sertraline undergoes extensive hepatic metabolism followed by elimination in the urine and faeces. The plasma half-life is approximately 1 day(Lehne, 2012, p. 362).

Side effects of sertraline.Headache, tremor, insomnia, agitation, nervousness, nausea diarrhea, weight gain and sexual dysfunction are some of this drugs side effect. Treatment may also increase the risk of suicide. Because of the risk of serotonin syndrome, sertraline must not be combined with MAOIs and other serotonergic drugs.mg/mL). To initially treat depression, the adult daily dosage is 50 mg, administered in the morning or evening. After 4 to 8 weeks, the dosage may be increased by 50-mg increments to a maximum of 200 mg/day. When discontinuing the drug, dosage should be reduced gradually. However it can be taken with vitamins(Lehne, 2012, p. 362).Our patient would need drug counselling and her anxiety and drug related queries should be addressed such that she should not be discouraged to take NSAIDS in the near future, however she should be advised not to take high quantities or dosage of NSAIDs as it could lead to recurrence of ulcers.

Nursing Interventions in support of plan of care

In our case the patient hadpositive direct Coomb’s test for warm autoantibodies and the hospital was preparing 2 units of leukoreduced packed red cells for transfusion.Leukoreduced red Blood cell units contain leukocytes in a specifically reduced amount. In the United States, Blood processing centers use filtration to make leukoreduced red Blood cell units. Indications are for patients who have experienced two or more non-haemolytic febrile transfusion reactions. They are usually effective in preventing non-haemolytic febrile transfusion reactions for most patients and prevention of CMV transmission or HLA alloimmunization (“Leukoreduced red blood cells,” 2013,n.p.). If there is a transfusion reaction blood samples from the person getting the transfusion and from the donor are tested to find thecause and transfusion can be stopped.Mild symptoms such as back pain,bloody urine, chills, fainting, fever and flushing of the skin may be treated with Acetaminophen, and fluids given through a vein (intravenous) and other medicines to treat or prevent kidney failure and shock(“Transfusion reaction,”2015, n.p.). Additionally the patient is vigilantly monitored and evaluated constantly as mentioned in table 3.

Table.3.Montioring and Evaluation of patient while undergoing blood transfusion (“Blood transfusion therapy,”2015, n.p.)

 The patient maintains normal breathing pattern. The patient demonstrates adequate cardiac output. The patient reports minimal or no discomfort. The patient maintains good fluid balance. The patient remains normothermic. The patient remains free of infection. The patient maintains good skin integrity, with no lesions or pruritus. The patient maintains or returns to normal electrolyte and blood chemistry values.

Once all these measures are undertaken and the patient is stable while she undergoes endoscopy a good prognosis can be anticipated.

References:

1. Avunduck, C. (2008). Manual of Gastroenterology: Diagnosis and Therapy (4thed). (Lippincott Manual Series (Formerly known as the Spiral Manual Series)).
3. Coombs’ test. (2009).Medline Plus. US National Library of Medicine and National Institutes of Health. Retrieved from: http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003344.htm
4. Delle F-G, Annibale B, Franceschi M, Quatrini M, Cassetta MR, Torsoli A.(1992). Omeprazole versus famotidine in the short-term treatment of duodenal ulcer disease. Aliment PharmacolTher, 6:469-78.
5. Hines, S. E. (2000). Current management of upper GI tract bleeding. Patient Care, 30(2), 20.
6. Hotz J, Kleinert R, Grymbowski T, Hennig U, Schwarz JA.(1992). Lansoprazole versus famotidine: efficacy and tolerance in the acute management of duodenal ulceration. Aliment PharmacolTher, 6:87-95.
7. Lauritsen K, Rune SJ, Bytzer P, Kelbaek H, Jensen KG, Rask M-J,et al.(1985). Effect of omeprazole and cimetidine on duodenal ulcer. A double-blind comparative trial. N Engl J Med, 312:958-61.
8. Lehne, R.A. (2012). Pharmacology for Nursing Care (8th ed.). St.Louis, MO. Elsevier.
10. Longmore, J. M. (2007). Oxford handbook of clinical medicine. Oxford: Oxford University Press.
11. Marks IN, Danilewitz MD, Garisch JA. (1991). Omeprazole 20 mg qd and ranitidine 150 mg bid in the treatment of benign gastric ulcer. Italian Cooperative Group on Omeprazole. Hepatogastroenterology, 38:400-3.
12. McFarland RJ, Bateson MC, Green JR, O’Donoghue DP, Dronfield MW, Keeling PW,et al. (1990). Omeprazole provides quicker symptom relief and duodenal ulcer healing than ranitidine. Gastroenterology, 98:278-83.
13. Praskash, C., & Zuckerman G. R. (2003). Acute small bowel bleeding: A distinct entity with significantly different economic implications compared with GI bleeding from other locations. GastrointEndosc, 58(3), 330.
14. Smith, G.D. (2004).The management of upper gastrointestinal bleeding. Nursing Times,100: 26, 40-43.

## Statement of Cash flows

The Statement of Cash Flows is also called a cash flow statement, it is a financial statement showing changes in income and balance sheet accounts  as this affects cash equivalents and cash and breaks the analysis down to investing, operating and financial activities. The cash flow statement captures and determines both the accompanying changes in the balance sheet and current operating results. It is vital in determining the short-term viability of a company most especially the ability to pay bills.

Reasons why companies prepare a statement of cash flows:

Profitability reasons

To know the Company Positions in terms of financial strength

To determine the durability of the Company

To know The assets and liabilities of the Company

Profitability reasons:  The reason why company prepare the statement of cash flows is to determine and know its profit, the organization or company need to know how much it makes every year, either a company makes profit or loss

Company Positions: The Company can determine its liquidity position to determine its position

Durability of the company: Statement of cash flows helps to determine the long-term solvency of a company as this determines how long a company will last or will it fold up at a future date.

The Assets and Liabilities of the Company: The Statement of Cash flows can be used to know a company or organization assets such as land and building, equipment, freehold premises, plant and machinery and many more and also used to know the company or organizations outstanding debts

The statement of cash flows is separated in to three sections namely:

1. Cash flows from operating activities
2. Cash flows from investing activities
3. Cash flows from financing activities

1. Cash flows from operating activities: This section deals with how much cash the company generates from its main business as opposed to peripheral activities such as borrowing or investing. It deals with how company or business is producing cash that will ultimately benefit shareholders.
2. Cash flows from investing activities: It shows the amount of cash companies or organizations spend or expended on investments. Investments is classified into monetary investments such as purchase or sales of money market funds or capital expenditures, that is money spent or expended on items or goods such as new equipment or anything else needed to keep the organization or company running smoothly.
3. Cash flows from financing activities: This has to do with transactions with the company’s or organization debtors or owners. For example, cash proceeds from dividends paid to investors would be found in this section.