An Overview of Consent and Restraint

An Overview of Consent and Restraint Consent, Deliberate or implied affirmation; compliance with a course of  proposed action. Consent is essential in a number of circumstances. For example,  contracts and marriages are invalid unless both parties give their consent. Consent  must be given freely, without duress or deception, and with sufficient legal  competence to give it (see also INFORMED CONSENT). In criminal law, issues of consent  arise mainly in connection with offences involving violence and *dishonesty. For  public-policy reasons, a victims consent to conduct which foreseeably causes him  bodily harm is no defence to a charge involving an *assault, *wounding, or  *homicide; in other cases the defendant should be acquitted if the magistrates or  jury have a reasonable doubt not only as to whether the victim had consented but  also as to whether he thought the victim had consented. Restraint,  assault and  an intentional or reckless act that causes someone to be put in fear of  immediate physical harm. Actual physical contact is not necessary to constitute an  assault (for example, pointing a gun at someone is an assault), but the word is often  loosely used to include both threatening acts and physical violence (see BATTERY).   Words alone cannot constitute an assault. Assault is a form of *trespass to the  person and a crime as well as a tort: an ordinary (or common) assault, as described  above, is a *summary offence punishable by a *fine at level 5 on the standard scale  and/or up to six months imprisonment. Certain kinds of more serious assault are  known as aggravated assaults and carry stricter penalties. Examples of these are  assault with intent to resist lawful arrest (two years), assault occasioning *actual  bodily harm (five years), and assault with intent to rob (life imprisonment).   battery The intentional or reckless application of physical force to someone  without his consent. Battery is a form of *trespass to the person and is a *summary  offence (punishable with a *fine at level 5 on the standard scale and/or six months  imprisonment) as well as a tort, even if no actual harm results. If actual harm does  result, however, the *consent of the victim may not prevent the act from being  criminal, except when the injury is inflicted in the course of properly conducted  sports or games (e.g.rugby or boxing) or as a result of reasonable surgical  intervention. Duty of care, The legal obligation to take reasonable care to avoid causing damage. There is no liability in tort for *negligence unless the act or omission that causes  damage is a breach of a duty of care owed to the claimant. There is a duty to take  care in most situations in which one can reasonably foresee that ones actions may  cause physical damage to the person or property of others. The duty is owed to  those people likely to be affected by the conduct in question. Thus doctors have a  duty of care to their patients and users of the highway have a duty of care to all  other road users. But there is no general duty to prevent other persons causing  damage or to rescue persons or property in danger, liability for careless words is  more limited than liability for careless acts, and there is no general duty not to  cause economic loss or psychiatric illness. In these and some other situations, the  existence and scope of the duty of care depends on all the circumstances of the  relationship between the parties. Most duties of care are th e result of judicial  decisions, but some are contained in statutes, such as the Occupiers Liability Act  1957 Negligence and  Carelessness amounting to the culpable breach of a duty: failure  negligent misstatement 328 329 NHS Trust  to do something that a reasonable man (i.e. an average responsible citizen) would do, or doing something that a reasonable man would not do. In cases of professional negligence, involving someone with a special skill, that person is expected to show  the skill of an average member of his profession. Negligence may be an element in a  few crimes, e.g. *careless and inconsiderate driving, and various regulatory offences,  which are usually punished by fine. The main example of a serious crime that may  be committed by negligence is *manslaughter (in one of its forms). When negligence  is a basis of criminal liability, it is no defence to show that one was doing ones best  if ones conduct still falls below that of the reasonable man in the circumstances. See  also GROSS NEGLIGENCE. 2. A tort consisting of the breach of a *duty of care resultingà ‚  in damage to the claimant. Negligence in the sense of carelessness does not give rise  to civil liability unless the defendants failure to conform to the standards of the  reasonable man was a breach of a duty of care owed to the claimant, which has  caused damage to him. Negligence can be used to bring a civil action when there is  no contract under which proceedings can be brought. Normally it is easier to sue for  *breach of contract, but this is only possible when a contract exists. Generally, fewer  heads of damage can be claimed in negligence than in breach of contract, but the  rules limiting the time within which actions can be brought (see LIMITATION OF  ACTIONS) may be more advantageous for actions in tort for negligence than for  actions in contract. See also CONTRIBUTORY NEGLIGENCE; RES IPSA LOQUITUR.   vicarious liability   Legal liability imposed on one  person for torts or crimes committed by another (usually an employee but  vicarious performance 526 527 violent disorder  sometimes an *independent contractor or agent), although the person made  vicariously liable is not personally at fault. An employer is vicariously liable for  torts committed by his employees when he has authorized or ratified them or when  the tort was committed in the course of the employees work. Thus negligent  driving by someone employed as a driver is a tort committed in the course of his  employment, but if the driver were to assault a passing pedestrian for motives of  private revenge, the assault would not be connected with his job and his employer  would not be liable. The purpose of the doctrine of vicarious liability is to ensure  that an employer pays the costs of damage caused by his business operations. His  vicarious liability, however, is in addition to the liability of the employee, who   remains personally liable for his own torts. The person injured by the tort may sue  either or both of them, but will generally prefer to sue the employer.   Vicarious criminal liability may effectively be imposed by statute on an employer  for certain offences committed by an employee in relation to his employment. Thus  it has been held that an employer is guilty of selling unfit food under the Food Act  1984 when his employee does the physical act of selling (the employee is also guilty,  though in practice is rarely prosecuted). Likewise, an employer may be guilty of  supplying goods under a false trade description when it is his employee who  actually delivers them. For an offence that normally requires mens rea,an employer  will only be vicariously liable if the offence relates to licensing laws. For example, if  a licensee has delegated the entire management of his licensed premises to another  j:letson, and that j:letson has committed the offence with the nec~ssatymens YeQ, th~  licensee will be vicariously liable.   Vicarious liability for crimes may be imposed in certain other circumstances. The  registered owner of a vehicle, for example, is expressly made liable by statute for  fixed-penalty and excess parking charges, even if the fault for the offence was not  his. If the offence is a regulatory offence of *strict liability, the courts often also  impose vicarious liability if the offence is defined in the statute in a way that makes  this possible.   Scope of practice (the legal and professional boundaries imposed upon you as a nurse)   Advocacy (the nurses role as an advocate for the client)   Documentation   Open disclosure   The Coroner   An officer of the Crown whose principal function is to investigate  deaths suspected of being violent or unnatural. He will do this either by ordering an  *autopsy or conducting an *inquest. The coroner also holds inquests on *treasure  trove. Coroners are appointed by the Crown from among barristers, solicitors, and  qualified medical practitioners of not less than five years standing.   Colour. The normal colour of urine is pale straw or light yellow.   It is mainly due to the pigment urochrome and partly to urobilin.   Womens urine is slightly lighter.   If the quantity of urine is increased or there is a diminution or dilution of urinary pigments, it becomes lighter and rendered very pale as in excessive drinking, nervousness, anaemia, chlorosis, diabetes, hysteria, epilepsy, poluria, in general debility and in chronic interstitial nephritis. The colour of the urine will depend on the degree of concentration; the more concentrated-the darker; the greater the quantity of water -the lighter.   Acid urine is slightly darker than alkaline urine. Urine becomes deeper in colour, like orange or dark yellow or brownish red generally known as high coloured or concentrated urine and is due to uroerythrin and urobilin produced by increased haemolysis, as in. fevers, after journeys, in hot days, in nervous excitability and after bodily exercises. N ormal urine on standing for a time will have a white or sometimes a bluish white scum on the surface due to contamination and putrefaction.   Urine glairy, whitish in colour indicates admixture with pus or leucorrhceal discharges. Urine coloured smoky, brown, reddish, brownish black or black indicates admixture with blood and denotes haemorrhage. Urine coloured greenish yellow or greenish brown indicates admixture with bile and denotes jaundice and other affections of the liver. Urine coloured milky indicates admixture with fat or pus and denotes chyluria or any purulent disease of the genitourinary tract.   Urine coloured blue indicates typhus fever, admixture with methylene blue or when there is excess of indigogens. Many drugs after absorption colour the urine, such as yellowish orange by santonin and chrysophanic acid; reddish or orange brown by senna and rhubarb; dark olive green or black by carbolic acid and other coaltar derivatives while antipyrin reddens the u rine. Odour.   When just voided urine is faintly aromatic but after a few minutes its characteristic odour is urinous.   The odour of urine is due to phenol.   It becomes pungent in concentrated urine, when urea is liberated in excess.   It becomes ammoniacal and putrescent and the reaction becomes alkaline after sometime when this excess of urea takes up water and is converted into ammonium carbonate.   It occurs quickly in urine from chronic cystitis or from suppurating diseases of kidney and bladder i.e., when urine is mixed with pus; blood or excessive phosphates.   The odour of urine in diabetes and in acetonuria is slightly sweetish.   The characteristic odour of garlic, sandal oil, cubebs, copaiba are given off when they are taken internally.   Turpentine gives an odour of violets. Appearance, physical character or transparency is the naked eye appearance of urine. Normal urine is always clear when voided but when allowed to stand for sometime it becomes slightly hazy or turbid due to suspended particles or from a slight cloud of mucus and epithelium. After sometime there may be sediments at the bottom due to gravity. If the urine is ammoniacal or decomposed a white turbidity forms due to sedimentation of phosphates or from bacterial activity. The turbidity or sediment is due mainly to the following suspended particles:- Urates. Uric Acid. Albumin. Phosphate. Mucus. Oxalate. Pus. Blood. Micro-organisms. To distinguish one from another, first of all fill three fourths of a test tube with urine and very gently heat the upper portion of the urine, holding the test tube by the bottom.   Now note whether the urine becomes clear or a cloudiness appears in the boiled portion, comparing with the lower unboiled portion of the test tube.   If the urine is turbid and clears up on heating then it contains Urates.   If the urine is clear and becomes cloudy with heat, before boiling point, then it is Albumen.   If the urine is clear and becomes cloudy at the boiling point, then it is Phosphate.   To distinguish between albumin and phosphate add 3 or 4 drops of acetic acid on the cloudy urine.   If the cloudiness disappears, then it is phosphate; but if the cloudiness remains or thickens, then it is albumin.   Lastly to distinguish between albumin and mucin add 2 drops of nitric acid, if the cloudiness disappears, then it is Mucin, but if the cloudi ness still persists, it is albumin. The turbidity of carbonates will clear up with effervescence on addition of nitric acid whereas heat and acid increases the turbidity due to albumin. To distinguish between phosphate and oxalate take some fresh urine and add ammonia, when there will be a precipitate. If on the addition of a few drops of acetic acid, the precipitates disappear, then it is phosphate, if it remains it is Oxalate. Failing the heat test take some urine in a test tube, preferably from the bottom and add a few drops of Liquor Potassae. Mix it thoroughly and if it clears up, then it is mucus; but if it becomes gelatinous or ropy, it is Pus. Next, if the deposit is coloured then take some urine in a test tube, preferably from the bottom and add a few drops of caustic potash and gently heat a little.   If it is dissolved, then it is Uric acid but if there is a precipitate, note the colour of the coagulum; if it is reddish brown or bottle green, it is Blood. If the urine is turbid and there is no change either by heat or by addition of caustic potash and heat, then the turbidity is due to Micro-organisms.   They generally clear up on the addition, of watery solution of ferric chloride and ammonium hydrate and then filter the urine.   Sometime the character, colour and reaction will roughly denote the element. Urates-They look like moss and are yellowish white or pink in colour.   Reaction is generally acid. They deposit when the urine becomes cold.   Uric Acid-It is crystalline and reddish brown in colour, resembling a shower of cayenne pepper grains. Reaction is moderately acid.   Phosphate-It forms a thin deposit and is white or yellowish white in colour.   Reaction may be slightly acid, alkaline or neutral.   Mucus-It is a cloudy or woolly looking white deposit. Reaction is slightly acid.   Oxalate-It is soft, shining and white in colour. Reaction is generally slightly acid. Pus- It looks like a ropy or creamy deposit, and is white in colour.   Reaction is slightly acid or  alkaline. Blood-It is clotted or thready and is red smoky or brownish in colour.   Reaction generally alkaline or may be slightly acid. Micro-organisms-The deposit is slightly hazy and white in colour.   They generally stick to the sides of the glass. COMPLICATIONS OF FRACTURES The majority of fractures heal without complications. If death occurs after a fracture, it is usually the result of damage to underlying organs and vascular structures or from complications of the fracture or immobility. Complications of fractures may be either direct or indirect. Direct complications include problems with bone infection, bone union, and avascular necrosis. Indirect complications are associated with blood vessel and nerve damage resulting in conditions such as compartment syndrome, venous thromboembolism, fat embolism, rhabdomyolysis (breakdown of skeletal muscle), and hypovolemic shock. Although most musculoskeletal injuries are not life threatening, open fractures, fractures accompanied by severe blood loss, and fractures that damage vital organs (e.g., lung, heart) are medical emergencies requiring immediate attention. Compartment Syndrome Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and/or tendons that run through that compartment. Compartment syndrome causes capillary perfusion to be reduced below a level necessary for tissue viability. Compartment syndrome usually involves the leg, but can also occur in the arm, shoulder, and buttock. Thirty-eight compartments are located in the upper and lower extremities. Two basic causes of compartment syndrome are (1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; and (2) increased compartment contents related to bleeding, inflammation, oedema, or IV infiltration. Oedema can create sufficient pressure to obstruct circulation and cause venous occlusion, which further increases oedema. Eventually arterial flow is compromised, resulting in ischemia to the extremity. As ischemia continues, muscle and nerve cells are destroyed over time, and fibrotic tissue replaces healthy tissue. Contracture, disability, and loss of function can occur. Delays in diagnosis and treatment cause irreversible muscle and nerve ischemia, resulting in a functionally useless or severely impaired extremity. Compartment syndrome is usually associated with trauma, fractures (especially the long bones), extensive soft tissue damage, and crush injury. Fractures of the distal humerus and proximal tibia are the most common fractures associated with compartment syndrome. Compartment injury can also occur after knee or leg surgery. Prolonged pressure on a muscle compartment may result when someone is trapped under a heavy object or a persons limb is trapped beneath the body because of an obtunded state such as drug or alcohol overdose. Clinical Manifestations. Compartment syndrome may occur initially from the bodys physiologic response to the injury, or it may be delayed for several days after the original insult or injury. Ischemia can occur within 4 to 8 hours after the onset of compartment syndrome. One or more of the following six Ps are characteristic of compartment syndrome: (1) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; (2) increasing pressure in the compartment; (3) paraesthesia (numbness and tingling); (4) pallor, coolness, and loss of normal colour of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. Collaborative Care. Prompt, accurate diagnosis of compartment syndrome is critical.17 Perform and document regular neurovascular assessments on all patients with fractures, especially those with an injury of the distal humerus or proximal tibia or soft tissue injuries in these areas. Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to muscles and nerves. Carefully assess the location, quality, and intensity of the pain (see Chapter 9). Evaluate the patients level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patients changing condition. Because of the possibility of muscle damage, assess urine output. Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules. This condition results in acute tubular necrosis and acute kidney injury.   Common signs are dark reddish brown urine and clinical manifestations associated with acute kidney injury (see Chapter 47). Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to remove or loosen the bandage and split the cast in half (bivalving). A reduction in traction weight may also decrease external circumferential pressures. Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary (Fig. 63-15). The fasciotomy site is left open for several days to ensure adequate soft tissue decompression. Infection resulting from delayed wound closure is a potential problem after a fasciotomy. In severe cases of compartment syndrome, an amputation may be required. DEFINITION Compartment syndrome is a condition that  occurs when elevated pressure within a limited  space compromises the circulation, with  increased risk of irreversible damage to its  contents and their function. Acute compartment  syndrome is a surgical emergency.   ICD-10CM CODES 958.90 Compartment syndrome unspecified   958.90 Compartment syndrome, not  otherwise specified T79.A0 Compartment syndrome,  unspecified, initial encounter   M79.A11 Nontraumatic compartment  syndrome of right upper extremity   M79.A12 Nontraumatic compartment  syndrome of left upper extremity   M79.A19 Nontraumatic compartment  syndrome of unspecified upper  extremity   M79.A21 Nontraumatic compartment  syndrome of right lower extremity   M79.A22 Nontraumatic compartment  syndrome of left lower extremity M79.A29 Nontraumatic compartment  syndrome of unspecified lower  extremity   M79.A9 Nontraumatic compartment  syndrome of other sites   T79.A19A Traumatic compartment syndrome  of unspecified upper extremity,  initial encounter   T79.A21A Traumatic compartment syndrome  of right lower extremity, initial  encounter   T79.A22A Traumatic compartment syndrome  of left lower extremity, initial  encounter   T79.A29A Traumatic compartment syndrome  of unspecified lower extremity,  initial encounter   EPIDEMIOLOGY   DEMOGRAPHICS   Occurs most commonly after acute trauma,  especially with long bone fractures, comprising  75% of cases.   It usually occurs in persons Incidence is higher in males.   It can occur in other parts, such as the foot,  thigh, gluteal region, and abdomen.   Supracondylar fractures in children can commonly  lead to compartment syndrome.   6% to 9% of open tibial fractures are complicated  by compartment syndrome.   It is seen in all races and ethnicities.   PATHOPHYSIOLOGY   Compartment syndrome occurs when the blood  flow is less than the tissue metabolic demands,  causing tissue injury. It occurs when the intracompartmental  pressure increases limiting  venous outflow with rising venous pressure,  resulting in compromise of the local circulation  and tissue hypoxia with decreased arteriovenous  pressure gradient. Venous congestion additionally  leads to tissue edema and interstitial pressure,  and the compartment pressure continues to  increase. Compartment pressure ranges between  10 and 30 mm Hg of diastolic pressure are able  to cause the condition.   Different conditions are known to cause compartment  syndrome:   Conditions that limit compartment volume, such  as when patients have fracture casts, when  sedated or comatose patients lie on a limb for  a prolonged period, or when patients have tight  dressings that are applied externally.   Conditions that cause increased compartment  content, such as bleeding in the compartment  from vascular injury or diathesis, fractures or  finger injuries, reperfusion after ischemic injury  such as embolectomy and arterial bypass  grafting, severe bruising of muscle, and thermal  or electrical burn injuries.   Other injuries, such as extravasation of intravenous  fluids, injection of recreational drugs,  and snake bites.   PHYSICAL FINDINGS CLINICAL   PRESENTATION Signs and symptoms are usually apparent but  can be unreliable and can lead to delayed  diagnosis. Acute compartment syndrome can  worsen within hours; therefore serial examination  is important in a patient with suspected  compartment syndrome. Patients with tense  painful limbs are considered to have acute  compartment syndrome; however, diagnosis  is confirmed with the assessment of elevated  compartment pressure. Clinical signs and  symptoms include the following:   Pain disproportional to injury (the earliest sign)   Constant deep pain and pain that is referred  to the compartment on passive stretching  of the muscles of the affected compartment   (Fig. E1C-84, A) Reduced sense of touch or sensation (hypesthesia) within the territory of the nerve passing the compartment (in acute anterior  compartment syndrome, the patient may  have hypesthesia in the territory of the first  webspace)   Tense and swollen compartment (Figs. E1C-  84, B and 1C-84, C)   Muscle weakness   Paresis (late finding) that suggests permanent  muscle damage   Capillary refill can be slow but normal.   Peripheral pulses that are normally palpable  even in severe conditions   Tingling and numbness in the affected limb.  Hypesthesia or paresthesia should be evaluated  with pinprick, light touch, and two-point  discrimination tests.   Difficulty moving the extremities.   DIAGNOSIS Diagnosis is based on clinical signs and  symptoms along with compartment pressure.   Compartment pressure testing may be unnecessary  if the diagnosis is clinically obvious.   DIFFERENTIAL DIAGNOSIS Muscle strains   Cellulitis Gangrene Peripheral vascular injury Necrotizing fasciitis Stress fractures Deep vein thrombosis and thrombophlebitis Tendinitis Muscle contusion Tarsal tunnel syndrome Posterior ankle syndrome Popliteal artery impingement Claudication Tumor Venous insufficiency LABORATORY TESTS Diagnosis is based on clinical findings and  the measurement of compartment pressures.   Laboratory values are not useful in the diagnosis  of compartment syndrome but are important  for other diagnoses or associated conditions.   CBC with differential for evaluation of infection   Creatine phosphokinase (CK) levels, which  can rise as muscle injury develops   Metabolic panel for the assessment of electrolytes  and renal function   Coagulation profile for bleeding diathesis   Urinalysis for rhabdomyolysis   Urine and serum myoglobin levels   Compartment Syndrome   A B FIGURE 1C-84 C: A, Severe calf swelling due to  anterior and posterior compartment syndromes  after ischemia-reperfusion. B, Appearance after  emergency fasciotomy. Note edematous muscle  and hematoma. (Courtesy Michael J. Allen, FRCS,  Leicester, UK. From Floege J et al: Comprehensive  clinical nephrology, ed 4, Philadelphia, 2010,  Saunders.) http://internalmedicinebook.com   Compartment Syndrome 307 Diseases and Disorders IMAGING STUDIES Direct intracompartmental pressure measurement  can be done by handheld manometer,  wick or slit catheter technique, and simple  needle manometer system. Compartment   syndrome is diagnosed when the difference  between diastolic blood pressure and compartment  pressure (Ά pressure) is à ¢Ã¢â‚¬ °Ã‚ ¤30 mm Hg.   Ultrasonography can be used to rule out deep  vein thrombosis, or Doppler ultrasonography  can be used to evaluate blood flow to the  extremity. Arteriography should be used to  evaluate the adequate blood flow through a  compartment. Near-infrared spectroscopy and technetium-  99m methoxyisobutylisonitrile scintigraphy  can also be used.   Radiography can be used on the affected  limb for fracture or foreign body evaluation.   TREATMENT   Treatment goal is to keep intracompartmental  pressure low and prevent tissue injury (Fig.  1C-84, D). NONPHARMACOLOGIC THERAPY Immediate relieving of all external pressure  on the affected compartment   Removal of casts, splints, and dressings   Placing limb at heart level to avoid decreased  or increased blood flow   ACUTE GENERAL Rx   Analgesics for pain Hyperbaric oxygen Hypotension can worsen tissue ischemia and  thus should be treated with IV isotonic saline. Fasciotomy of the affected compartment  is indicated if there has been >6 hr of  limb ischemia, or immediate decompression  should be performed when the compartment  pressure > 30 to 35 mm Hg.   Measurement of compartment pressure is  not necessary to perform fasciotomy if clinical  suspicion is high depending on history  and clinical examination.   When compartment pressures are trending  downward, it is often safe to delay emergent  fasciotomy, provided the Ά pressure is also  improving. CHRONIC Rx   Aftercare of fasciotomy wound: Wound is  inspected after 48 hours and dead tissue is  removed.   Wounds are left open, requiring later skin  grafting or delayed wound closure.   Opsite sheet and boot lace techniques are  also used for closing fasciotomy wounds.   Concomitant fractured bones should also be  stabilized with plating, external fixation, or  intramedullary nailing.   DISPOSITION With early diagnosis and treatment, the prognosis  is excellent for recovery of the muscles and  nerves inside the compartment. The following  conditions can be prevented:   Permanent nerve damage/paralysis   Muscle contracture Gangrene Amputation Muscle necrosis Fracture nonunion Rhabdomyolysis that leads to renal failure Compartment syndrome that can occur in  open fractures Permanent nerve injury, which can occur after  12 to 24 hr of compression; mortality rates in  patients who need fasciotomy is à ¢Ã¢â‚¬ °Ã‹â€ 15%. REFERRAL Patients with suspected compartment syndrome  should be referred promptly to orthopedic  and general surgery. PEARLS CONSIDERATIONS Universal precautions and aseptic measures are necessary for patients undergoing fasciotomy because the risk of local and systemic infection is high with the procedure. Invasive monitoring techniques should be undertaken with adequate analgesia so that patient immobility is ensured while the pressure is measured. Injection of local anaesthetics into the compartment can increase the pressure and pain and therefore should be avoided. Patients with fracture casts should be informed about the risks of swelling, and patients should also be encouraged to wear appropriate equipment while playing sports. A history of coagulation disorders and the use of anticoagulants should be mentioned in a patients medical history. Assault Assault has two different interpretations. 1. Traditionally called common assault and consisting of the making of an unlawful and intentional (or possibly only reckless) threat to inflict imminent force against the person where the victim was aware of the threat.   A distinction was previously maintained at common law between common assault and battery.   Increasing codification of criminal law has resulted in abandonment of this distinction and in Australia assault now commonly refers both to common assault and actual infliction of force.   Statutory provisions for the different states are numerous and terminology varies (e.g. offences of causing injury or threatening). 2. One of three ma

Ode on a Grecian Urn Essay

In the poem â€Å"Ode on a Grecian Urn,† Keats took inspiration from a visit to a museum exhibiting artifacts, one of which is an urn with figures on its surface. The urn depicts scenes taken from ancient Greek life. Intrigued by the Urn’s beauty and the figures depicted on its sides, Keats was moved to write a poem expressing wonder, admiration, questions and criticisms. Without knowing who these figures are, what they are meant to reflect and to what purpose were they made for, the poet revels in the mystery they represent. The Ode’s first stanza is filled with wonder and questions; the last stanza has none. Being a piece of art, the urn can speak to its viewers in whatever way it chooses to communicate. In the first stanza of the poem, the writer addresses an ancient urn and reflects on its beauty and what story it can tell. He calls the urn a â€Å"historian† possessing secret knowledge. The writer looks at one group of pictures that seem to be of men pursuing women. He wonders if it was a pursuit among lovers, a struggle between sexes, or a playful episode among the young on a beautiful day. In the next stanza, the poet focuses on another figure on the vase. This time, it portrays a man with his lover, both lying beneath a tree while he plays his pipe. The writer declares that the pipe’s silent music is sweeter than a mortal’s music because the former lives through time. While the man and woman cannot kiss because they are frozen in time, they should not despair because their beauty and youth will forever remain. In one stanza, the poet is able to present two contrasting realities. One is that of unfilled longing through eternity, while the other speaks of unfading glory. The ode’s third stanza reflects the poet’s general feeling of happiness for the things he observed about the couple described in the previous stanza, as well as the trees surrounding them. The poet is glad for the trees’ leaves, which will forever be green and remain attached to the branches. The poet is also happy that the man with the pipe will have his songs forever new. He is also happy that the lovers’ love will last until eternity. Here, the poet laments that mortal love is just the passing of passion. By the time it passes, which it eventually will, there is nothing left. In the fourth stanza of the Ode, the poet turns to examine another picture. This time, it represents villagers leading a young cow, which seems to be a sacrificial offering. He imagines where they have come from and where they are headed for. The poet visualizes empty streets because the citizens have all left to witness the sacrifice. And the streets will forever remain empty for those who have left the town are frozen on their way to the sacrificial place. For the fifth and final stanza, the poet goes back to addressing the urn. He tells the ornamental vase that while it lives and remain forever, the poet’s generation would have long passed. He ends it with the famous quote that equates beauty with truth. By doing this, the author seems to criticize and admire the urn at the same time. While the poet thinks the urn beautiful, he thinks that that is the only thing it will ever possess. This is the same manner of admiration and criticisms that the poet has vested on the characters found on the urn.

Did Weight Loss Fail Us. . Do You Think That The Way That

Did Weight Loss Fail Us? Do you think that the way that people have tried to achieve weight loss over the years has been successful? In the article, The Emperor s Tailors: The Failure of the Medical Weight Loss and its Causal Role in the Obesity of America, J.S. Puterbaugh talks about how we have been going about weight loss hasn’t been working and it ties in with the obesity problem in America. He starts the opening statement of the article by saying that there are three things that are usually suggested people should do as a means of losing weight, those being: taking responsibility for yourself, going by a groups specific diet, and doing certain exercise routines. Then he says that more than 60% of the population now is considered†¦show more content†¦It really seems like he is trying to warn people about these method. It seems this way, because he starts the article by talking about how big of an issue being overweight is. This is a problem that lots of people look into all of the time. T hen he gets into talking about what people do or say when they are introduced to all of the different solutions. With his research he has found many things that a lot of people might not have heard of when talking about this issue. He states that, 60% of the population is overweight or obese,(J.S. Puterbaugh 558). This would really get the attention of the reader, because not a lot of people realize how big of an issue this is. Then he gets into the history of the issue of weight loss. He said that this has been an issue since the time of the old physician Hippocrates. To continue his research into the history of the subject, he found that up until the 20th century obesity was controlled by a requirement of high physical activity and lower amounts of access to foods. Puterbaugh continues talking about all of the different approaches that have been taken over the course of history and shows that no matter what we have done the issue with obesity is still becoming a bigger issue today. He also includes a lot of statistics to back him up. He talks about how people are doing less now in terms of exercise than they did in the past. He foundShow MoreRelated Biotrim: True Weight Loss or Scam? Essay1428 Words   |  6 PagesBiotrim: True Weight Loss or Scam? In todays society, everybody wants a quick fix to all of their cosmetic problems. Whether we want better faces, better bodies, whatever, we want it now and we surely do not want to work for results. Due to this incredible demand for immediate self-improvement, the weight loss market has turned into a multi-billion dollar industry preying on people who are uniformed about weight loss and the bodys capabilities. Many products and programs such as Jenny CraigRead MoreQuick Weight Loss Diet Plan Essay1583 Words   |  7 PagesFast Quick Weight Loss Diet Plans Intro Why Some People Fail to Lose Weight FAQ s How Much Will You Lose Conscious Eating Leads to Weight Loss Success The Basic Diet Plan Alternative Plan One Alternative Plan Two Alternative Plan Three Alternative Plan Four Alternative Plan Five Intro We live in a land of too much food. Every where that you look food is trying to entice us to just take one little bite. It is a fact of life that food is the long haired siren that is beckoning us to the shoreRead MoreAnalysis Of The Article Water And Weight Loss Goals By Susan Moss1238 Words   |  5 PagesWater and Weight Loss Goals By Susan Moss | Submitted On June 14, 2012 Recommend Article Article Comments Print Article Share this article on Facebook Share this article on Twitter Share this article on Google+ Share this article on Linkedin Share this article on StumbleUpon Share this article on Delicious Share this article on Digg Share this article on Reddit Share this article on Pinterest Our bodies need water to perform well. Most of us do not drink enough water each day, thus we likelyRead MoreWhy Relationships Fail1220 Words   |  5 PagesSome people think that heartbreak is the worst feeling in the world. Many relationships have gone wrong, leaving more questions than answers. Why does it sometimes feel like a broken heart hurts worse than a broken bone? Do feelings really have that much of an impact on a person’s day-to-day life? There are a number of reasons why a relationship fails. Jealousy, attachment, detachment, selfishness, time, trust, communication, honesty, and acceptance are just a few reasons. Do opposites reallyRead MoreWhy Relationships Fail1217 Words   |  5 PagesSome people think that heartbreak is the worst feeling in the world. Many relationships have gone wrong, leaving more questions than answers. Why does it sometimes feel like a broken heart hurts worse than a broken bone? Do feelings really have that much of an impact on a person’s day-to-day life? There are a number of reasons why a relationship fails. Jealousy, attachment, detachment, selfishness, time, trust, communication, honesty, and acceptance are just a few reasons. Do opposites reallyRead MoreThe Problem Of Extreme Plastic Surgery1019 Words   |  5 Pageswith their appearance. Some people spend money to look good, but they do not stop there. They will continue to get surgery and the result will not be pretty. Most people do surgery because some are not satisfied with what the look. They want to change the outside so they could have looks and confident they need. In the present, more and more people are getting plastic surgery do then those back then. It is a trend most people do to fit in. One of the five C’s is community. In almost every communityRead MoreBenefits And Benefits Of Insurance Policies2333 Words   |  10 Pagesarray of sickness to the extent of minor and major operations needed. That is why before considering any surgery such as weight loss; try to look back at the papers that were signed during the acquisition of the insurance policy. This will help one in deciding whether to go into a surgical procedure or not. The first thing that must be taken into consideration during a weight loss surgery is the cost of the whole process. Since this kind of surgery is considered to be a valid surgical interventionRead MoreSpirit Catches You And You Fall Down Reader S Guide2026 Words   |  5 Pagesï » ¿Ã¢â‚¬Å"The Spirit Catches You and You Fall Down† Reader’s Guide Directions: Read the captioned book. Then answer the questions contained in this study guide. Post your completed document to the appropriate assignment box on the course website. 1. What do you think of traditional Hmong birth practices (pp. 3-5)? Compare them to the techniques used when Lia was born (p. 7). How do Hmong and American birth practices differ? I think the Hmong traditional give birth practice is very unsafe and dirty.Read MoreWomen In The United States Generally Have One Very Specific3147 Words   |  13 Pagesvery specific shared obsession: losing weight. They are constantly bombarded with claims of effective weight loss- secrets of the stars, fool-proof fad diets, etc. How many women try these diets? Probably hundreds of thousands, and how many lose weight from them? Maybe a few- the ones that end up gaining all of it back plus forty pounds. Something has to be wrong. This cannot be some strange coincidence, and it isn t. The way in which we think about our weight, our bodies, and the attention we putRead MoreEssay on Wanting to be Beautiful1310 Words   |  6 PagesBeautiful How do women’s magazines influence how women think, look, and feel? What is so special about these magazines to get some women to center their lives around them? Personally, I didn’t really understand why any women would listen to anything a magazine says until I opened one up. While I was waiting in line at a department store, I picked up and flipped through a Cosmopolitan magazine, and found a story that caught my attention. The story was about the loss of a father, and for that

Observe and Interview - 1458 Words

Assignment 02: Exploring language diversity where you live Compiled by Hannelie Millar – student 49498843 Instructions: Task 1: Observe your community †¢ Go out into the community where you live for one or two afternoons or evenings. For an example, we put a photo from the Bree taxi rank in Johannesburg. †¢ Observe what you see around you. o Who is talking with whom? o What language are they using? o Why do they use one language or another? †¢ Why do you think people are acting the way they do? Try to come up with some reasons, just by observing what is happening around you. Task 2: Interview one of the members who you have observed †¢ Now choose one of the people who are around you and ask their permission to do a short interview †¢ Ask them†¦show more content†¦My first inclination as to the reason for common gym terminology being said in English, even though the rest of the sentence was in Afrikaans, is laziness. Although I grew up in an Afrikaans home, I am now living with English being my first language, since my Scottish husband cannot speak Afrikaans well. I avoid mixing my language when I speak in Afrikaans, since it is such a beautiful language to me. I would expect that other Afrikaans speaking people should make the same effort. As for the Zulu speakers using the English terminology, I would suspect that this happens quite simply because there is no corresponding Zulu word for some of the terminology. I don’t believe during the era that the Zulu language was born, dumbbells and push-ups were something this group was exposed to, so why would there be a need to give it a name in their language? Why do they act the way they do? There were two types of behaviours that stood out to me, and for which I could identify the opposite behaviour in other people. 1. The black middle aged members were very loud in their expressions. Although they were communicating to each other in Zulu, in what seemed like encouragement to lift the heavy weights, or to lift it one more time before finishing a set, their demeanour was boisterous, noisy and energetic, a common trait of their culture. In the opposite sense, I noticed an elderly white man, who seemed to be a little annoyed with the noise that the Zulu menShow MoreRelatedA Presentation Of The Rationale For The Qualitative Case Study Approach1659 Words   |  7 Pagesstudy. I will begin with a presentation of the rationale for the qualitative case study approach. Next, I will present the participant selection criteria, the design of the study, and the methods of the data collection which will include the two interviews (first and follow-up), classroom observation, videotaping the participant during instruction, and docum ent data collection. I will also discuss the strategies I will be using to enhance the trustworthiness of the study. At the end of this chapterRead MoreA Situational Analysis of Shared Leadership in a Self-Managing Team1154 Words   |  5 Pageson an agreed upon site, often just gathering around the back of a truck for their meeting. I will attend these three mornings a week for four weeks, and will stay on to observe their work for approximately 20 hours during the four week period. My primary focus will be on their interaction in meetings, although I will also observe (and perhaps enquires about) interactions during their other work. [Describe the context of the proposed research, making it clear how this context will allow you to accomplishRead MoreStrengths And Weaknesses Essay899 Words   |  4 Pagesmethods are observation, interviews and questionnaires. â€Å"Observational research (or field research) is a type of correlational (i.e., non-experimental) research in which a researcher observes ongoing behavior† (ATLAS.ti, 2017). A key strength of observations is that you can observe what people actually do or say, rather than what they say they do. People are not always willing to write their true views on a questionnaire or tell a stranger what they really think at interview. Observations access toRead MoreReserch Proposal Example1307 Words   |  6 Pageson an agreed upon site, often just gathering around the back of a truck for their meeting. I will attend these three mornings a week for four weeks, and will stay on to observe their work for approximately 20 hours during the four week period. My primary focus will be on their interaction in meetings, although I will also observe (and perhaps enquires about) interactions during their other work. [Describe the context of the proposed research, making it clear how this context will allow you to accomplishRead MorePrimary Research Comes Directly from the Customers682 Words   |  3 PagesPrimary Research By Primary research we mean, getting information directly from the customers. There are several ways we can get information directly from customers. We can interview customers. We can survey customers. We can observe customers actions and behaviors. All of these methods have their pros and cons. Interviewing Customers We need to identify target customers. Then we need to focus on purpose of interviewing customers. We may want to extend relationship with customers. We may want toRead MoreThe Impact Of Diversity Training On A Group Dynamics Experiment1018 Words   |  5 Pagesthis particular research study is observations. The role of complete participant is one of the best ways to get a â€Å"true† feeling for a working diverse group. The researcher would observe two groups- one where he/she would take over leadership and another where he/she would simply participate.  The researcher would observe a group as the role of observer similar to a group dynamics experiment explained by authors Bennis and Sheppard (1956). However, the researcher would not take on the role of the trainerRead MoreDescriptive Research Article1530 Words   |  7 Pageslaboratory experiments. In contrast to laboratory experiences, descriptive research is valuable because it allows for the human element of research. Four of the most common ways to collect information for descriptive research include surveys, interviews, observations, and portfolios. These may be used singly or in various combinations depending on the research question to be addressed. Used in the simplest way, surveys may be used to reveal summary statistics by showing responses to all possibleRead MoreArticle Review1507 Words   |  7 Pageslaboratory experiments. In contrast to laboratory experiences, descriptive research is valuable because it allows for the human element of research. Four of the most common ways to collect information for descriptive research include surveys, interviews, observations, and portfolios. These may be used singly or in various combinations depending on the research question to be addressed. Used in the simplest way, surveys may be used to reveal summary statistics by showing responses to allRead MoreThe Reading By Atkinson Provides Information On Using Life Stories827 Words   |  4 Pagesend. The last part of the reading explained guidelines that will prepare or get one ready to do an interview. The guidelines includes finding out who you want to interview and learn more about. The last step is encouraging the individual to share their story by being a good listener and asking open ended questions. The reading by Silverman discussed in-depth information about open-ended interviews. There are several problems the interviewer must resolve when doing open-ended questions such as decidingRead MoreMy Study of Child Poverty in My Own Community Essay681 Words   |  3 Pageshomeless children. I would observe different kids that I find for a week. I would take notes on how they survive. I would observe where do they eat, where how they sleep. I would also observe thei r interaction around other people. After I observed them for a week. I would pick 4 children to Interview. I would pick two girls and two boys. I would interview an African American girl that is in poverty that lives with her family that is close to the age of 16. I would also interview another girl that is

Interpretations of Slavery Essay - 3734 Words

Interpretations of Slavery INTRODUCTION Slavery is known to have existed as early as the 18th century B.C. during the Shang Dynasty of China. Slavery was widely practiced in many other countries, including, Korea, India, Greece, Mexico and Africa. (Britannica 288-89). When most people consider slavery, however, they think of Western slavery in North America because it is well documented and it was such a horrible institution. Even though there is no one definition of slavery, the people who study it (historians, anthropologists and sociologists) agree that certain characteristics are present in all forms of slavery. Slaves were property and objects, not subjects of the law. Slaves had few rights, always fewer than their owners. Slave†¦show more content†¦Terry was one, among a number of slaves, who was encouraged by their masters to compose and publish literature, as long as it was written in the accepted format and on accepted topics. These early slave-poets did not write on the abolition of slavery, or show any anger toward their white masters. After the Revolutionary War, people became more vocal about wanting slavery to end. In the 1830s and 1840s, there were large numbers of slave narratives written and printed. These narratives described how bad slavery was as well as the authors personal experiences and tragedies. Three very influential slave narratives were written by Gustavas Vassa, Frederick Douglass and Harriet Jacobs. Vassa wrote in an earlier period so his writing was not openly hostile toward slavery. Instead, he carefully called for an end to slavery by comparing African slavery to Western slavery. Frederick Douglass wrote his narrative in 1845 and attempted to make clear that the slavery issue was a test of American Democracy. He wanted people to question the fact that not everyone had equal opportunity and freedom. Finally, Harriet Jacobs, wrote from a feminist perspective. She brought up the struggles and problems that were unique for black women in their fight for freedom. These three writers are still important and influential because they all had personal experiences with slavery and worked hard to get their message across for an end to slavery.Show MoreRelatedSlavery And Freedom : An Interpretation Of The Old South989 Words   |  4 PagesIn James Oakes book, Slavery and Freedom: An Interpretation of the Old South, talks about the relationships between slaves and master liberal capitalism in southern United States during the nineteenth century. Slaves was a name given to blacks because of their color and their freedom once taking away. Freedom and unfreedom are experienced most by human relationship between men and women. The relationship which they produce was to survive and live on to reproduce. Therefore work and society was largelyRead MoreSlavery And Freedom : An Interpretation Of The Old South1870 Words   |  8 PagesOakes, James. Slavery and Freedom: An Interpretation of the Old South. (New York: Knopf, 1990) In James Oakes book Slavery and Freedom: An Interpretation of the Od South, the author talks about slavery during the nineteenth century and the infinite question of â€Å"what was slavery?† (xi). Oakes starts off his book making a questionable reference of what is freedom and how a person without it is a slave. It also talks about how was the relationship between master and slave, differencesRead MoreSlavery And Freedom : An Interpretation Of The Old South867 Words   |  4 PagesJames Oakes book, Slavery and Freedom: An Interpretation of the Old South, is a reflection of slavery and freedom that was closely associated with the ordinary life in the South. The book also hits on points of liberal capitalism that the slave-owner s had. This book goes into immense detail on liberal capitalism as well as the lack of freedom that the slaves had in the Deep South. ...And this could only mean that southern slavery was defined as the denial of the assumptions of liberal capitalismR ead MoreWilliam Patton, An Abolitionist And Reverend937 Words   |  4 Pagesreverend, had a two-fold argument against the idea of Christianity supporting slavery which he laid out in his 1846 book â€Å"Slavery, the Bible, Infidelity†. His first argument, was that God could never support because, in simple terms, â€Å"God is just, and that slaveholding is unjust† (Patton, 6). Supporting this idea, Patton quotes Thomas Jefferson in saying in response of proslavery rhetoric, that â€Å"If your interpretation of the Bible be correct,it cannot be the word of God—for it gives him a characterRead MoreThe Compromise Of 1850, The Fugitive Slave Act, And The Dred Scott Case1423 Words   |  6 Pageshad been based upon, began to diminish and after the Mexican-American War, the nation began to face a large split in opinions mainly when regarding slavery. By the 1850’s the largely different interpretation of the Constitution caused such tension between citizens (northerners vs. southerners; those who were for slavery vs. those who opposed slavery), that the constitution could be described as an instrument of destruction that would lead to one of the darkest periods in this country’s history. TheRead MoreThe Slavery Of The South1561 Words   |  7 Pages was highly dependent upon the institution of slavery. It was still primarily an agricultural society that needed as many laborers as possible in order for the plantation owners to make ends meet. According to historian Douglas Harper, â€Å"In 1793 came the cotton gin, which brought a 50-fold increase in the average daily output of short-staple cotton, promoted the rapid expansion of a ‘cotton kingdom’ across the Deep South, and made large-scale slavery profitable.† Because of this, the slave becameRead MoreThe Beginning Of The Civil War1289 Words   |  6 PagesJuan Moreno U.S. History 102 Mr. Anderson Period 6 February 4, 2015 Blight Revised At the beginning of the Civil War the reasoning was nothing but clear. It can’t be ignored that the Civil War was in fact about slavery and that slavery was an issue â€Å"resolved† by the Civil War. Yes the war was initially about race and how the country â€Å"needed† to free slaves, David W. Blight states it, â€Å"The emancipationist vision, embodied in African Americans’ complex remembrance of their own freedom, their politicsRead MoreHistorical Contridictions in Slavery1494 Words   |  6 PagesThe history of American Slavery has been recounted by many scholars, taking into account different perspectives. During the 1850’s an abolitionist movement began, gaining momentum to pass anti-slavery legislation. Slave owners concerned about the growing movement, decided to take the matter into their own hands and fight for their property rights. Now as historians look back and analyse slavery, many different ideologies are constituted. While the dep iction of philosophy in history is a way to analyzingRead MoreThe Writing Of The Constitution And The 1850s901 Words   |  4 PagesUnited States landscape increased, division was created between the North and South, and the diminishing effectiveness of national unity promoted by the constitution became evident by the 1850s. The topic and the view of the constitution concerning slavery and other key points caused the people of the States to become more polarized in their views and grow apart. The constitution’s lack of representation caused sectional distaste and tension resulting in the failure of the union. During the mid-centuryRead MoreThe Slavery Of The Bible1371 Words   |  6 PagesBible is left largely to personal interpretation, so the way people conducted themselves was varied person to person. As slavery was a hotly contested subject in the nation, people yearned to prove that their beliefs were in line with scripture, and that they were divinely sanctioned to behave how they did. Both pro and anti slavery sentiment were largely fueled by interpretation of scripture, as the Bible does provide substance for both sides of the argument. Pro slavery advocates pointed to the fact

Customer Types Free Essays

Customer Types Tanya Myers HTT 200 March 22nd, 2013 Karen Stevens Customer Types According to the AHLA website the typical lodging customer in 2011 stayed 40 % for business and 60 % for leisure. The typical lodging customer in a business room is a male, age 35 to 54 years old. The typical lodging customer is employed in a professional or managerial position with an average annual income of $119,388. We will write a custom essay sample on Customer Types or any similar topic only for you Order Now They usually stay by themselves, make reservations ahead of time and pay $129. 00 per night for the room. 0% of the business travelers spend one night, 22% spend 2 nights and 38% spend 3 or more nights in a hotel. The typical lodging customer in a leisure room is usually 2 adults ages 35 to 54, with an average annual income of $89,736. They usually are auto travelers and also make their reservation ahead of time; they pay $109. 00 per night for the room. 47% of the leisure travelers spend 1 night, 27 % spend 2 nights and 26% spend 3 or more nights in a hotel (The American Hotel and Lodging Association, 2013). 3 different lodging types would be Executive Conference Centers, Health Spa’s and Resorts. I feel that business travelers would stay the most in the Executive Conference Centers; this is because they offer both small meeting rooms and classrooms. Meals and recreation facility use are often included in the room rate this would be very convenient for a business traveler to have everything they need handy under one roof. The traveler looking for relaxation, stress management, or to pamper themselves would love to visit a health spa. The health spa often includes mineral baths, fitness facilities and massage therapists. The baby boomers are usually the one’s that love to go to this type of lodging. When I picture a resort I think of destination type lodging such as Mexico, Hawaii and the Caribbean. The type of traveler that would go to these would be one looking for tons of amenities, including lots of food with fine dining. Some cities are desirable for year round resort visitation such as Orlando and Las Vegas. I think that any type of lodging depends on the person and what suits them, they have to make sure they amenities are good before they travel and that they prepare ahead of time. Sources The American Hotel and Lodging Association. (2013). Retrieved from ahla: http://www. ahla. com How to cite Customer Types, Essay examples

Difficulties in Learning English Language free essay sample

Learning different languages sounds a little tough. English is one of theses difficult languages. In some countries, learning English is very difficult because they start learning it in a late ages. Actually, learning English is difficult because of its various vocabularies, complicated grammar, and its hard accent. English language has a lot of words. These words are not easy to remember for most of English learners. Most English words have different parts of speech like adjective, verb, and adverts. This division of English words make them not easy to remember. In some cases, it is tough not only for the foreigner students, but also for the native speaker students. Moreover, some English word have the same meanings and sometimes we can use them in different situations. As a result, English words are not easy for many students. We will write a custom essay sample on Difficulties in Learning English Language or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page One obvious difficult thing in learning English is grammar. English grammar has many rules that could be tough for many students. For instance, the past perfect, the past perfect continuous, and the past perfect participles. Many students are confused when they speak or write especially if they try to speak fluently, Thus, the grammar is considered one of the most difficult issues in learning English. The accent of the English language in some countries makes English a little bit tough to understand. Moreover, the American accent is not easy especially for the foreigners who are not familiar with it. Thus, the accent is not easy in understanding English. To sum up, learning English has many difficulties. These are involved with its various words, different grammar, and the accents. These problems face many foreigner students who want to learn this language.