The Difference Between Procedural and Substantive Law

Procedural law and substantive law are the two primary categories of law in the dual U.S. court system. These two types of law play different but essential roles in protecting the rights of individuals in the United States criminal justice system. Key Terms Procedural law is the set of rules by which courts in the United States decide the outcomes of all criminal, civil, and administrative cases.  Substantive law describes how people are expected to behave according to accepted social norms.  Procedural laws govern how court proceedings dealing with the enforcement of substantive laws are conducted.   Two Categories of Law Substantive law — literally the â€Å"substance† of the law — governs how people are expected to behave according to accepted social norms. The Ten Commandments, for example, is a set of substantive laws. Today, substantive law defines rights and responsibilities in all court proceedings. In criminal cases, substantive law governs how guilt or innocence is to be determined, and how crimes are charged and punished. Procedural laws govern how court proceedings that deal with the enforcement of substantive laws are conducted. Since the primary object of all court proceedings is to determine the truth according to the best available evidence, procedural laws of evidence govern the admissibility of evidence and the presentation and testimony of witnesses. For example, when judges sustain or overrule objections raised by lawyers, they do so according to procedural laws. Both procedural and substantive law may be altered over time by Supreme Court rulings and constitutional interpretations. Application of Criminal Procedural Law While each state has adopted its own set of procedural laws, usually called a â€Å"Code of Criminal Procedure,† the basic procedures followed in most jurisdictions include: All arrests must be based on probable cause;Prosecutors file charges that must clearly spell out what crimes the accused person allegedly committed;The accused person is arraigned before a judge and given the opportunity to enter a plea — a statement of guilt or innocence;The judge asks the accused whether they need a court-appointed attorney or will supply their own attorney;The judge will either grant or deny the accused bail or bond and set an amount to be paid;An official notice to appear in court is delivered to the accused;If the accused and prosecutors cannot reach a plea bargain agreement, trial dates are set;If the accused person is convicted at trial, the judge advises them of their rights to appeal;In the case of guilty verdicts, the trial moves to the sentencing phase. In most states, the same laws that define criminal offenses also set the maximum sentences that can be imposed, from fines to time in jail. However, the state and federal courts follow very different procedural laws for sentencing. Sentencing In State Courts The procedural laws of some states provide for a bifurcated or two-part trial system, in which sentencing is conducted in a separate trial held after a guilty verdict has been reached. The sentencing phase trial follows the same basic procedural laws as the guilt or innocence phase, with the same jury hearing evidence and determining sentences. The judge will advise the jury of the range of severity of sentences that may be imposed under state law. Sentencing In Federal Courts In the federal courts, judges themselves impose sentences based on a more narrow set of federal sentencing guidelines. In determining an appropriate sentence’ the judge, rather than a jury, will consider a report on the defendant’s criminal history prepared by a federal probation officer, as well as evidence presented during the trial. In the federal criminal courts, judges use a point system based on the defendant’s prior convictions, if any, in applying the federal sentencing guidelines. In addition, federal judges do not have the leeway to impose sentences more or less severe than those allowed under the federal sentencing guidelines. Sources of Procedural Laws Procedural law is established by each individual jurisdiction. Both the state and federal courts have created their own sets of procedures. In addition, county and municipal courts may have specific procedures that must that must be followed. These procedures typically include how cases are filed with the court, how parties involved are notified, and how official records of court proceedings are handled. In most jurisdictions, procedural laws are found in publications such as the â€Å"Rules of Civil Procedure,† and â€Å"Rules of Court.† The procedural laws of the federal courts can be found in the â€Å"Federal Rules of Civil Procedure.† Basic Elements of Substantive Criminal Law In comparison to procedural criminal law, substantive criminal law involves the â€Å"substance† of the charges filed against accused persons. Every charge is made up of elements, or the specific acts required to amount to the commission of a crime. Substantive law requires that prosecutors prove beyond all reasonable doubt that every element of crime took place as charged in order for the accused person to be convicted of that crime. For example, to secure a conviction for a charge of felony-level driving while intoxicated, prosecutors must prove the following substantive elements of the crime: The accused person was, in fact, the person operating the motor vehicle;The vehicle was being operated on a public roadway;The accused person was legally intoxicated while operating the vehicle; andThe accused person had prior convictions for driving while intoxicated. Other substantive state laws involved in the above example include: The maximum allowed percentage of alcohol in the accused person’s blood at the time of arrest; andThe number of prior convictions for driving while intoxicated. Because both procedural and substantive laws can vary by state and sometimes by county, persons charged with crimes should consult with a certified criminal law attorney practicing in their jurisdiction. Sources of Substantive Law In the United States, substantive law comes from the state legislatures and Common Law — law based on societal customs and enforced by the courts. Historically, Common Law made up set of statutes and case law that governed England and the American colonies prior to the American Revolution. During the 20th century, substantive laws changed and grew in number quickly as Congress and the state legislatures moved to unify and modernize many principles of Common Law. For example, since its enactment in 1952, the Uniform Commercial Code (UCC), governing commercial transactions has been fully or partially adopted by all U.S. states to replace the Common Law and differing state laws as the single authoritative source of substantive commercial law.

The Detrimental Effects of Anorexia on the Body and Mind

Ana’s Limelight Christy Greenleaf, assistant professor of kinesiology, health promotion and recreation at University of North Texas, stated, â€Å"Girls and women, in our society are socialized to value physical appearance and an ultra-thin beauty that rarely occurs naturally and to pursue that ultra-thin physique at any cost.† Anorexia is the third most common chronic illness among young women. Furthermore, one in every ten people with anorexia will die from a complication brought on by the disorder. Although Anorexia is a mental illness, it is most common in teenage females because it is incited by the media through the fashion industry and pro-anorexia websites. Anorexia is a mental illness that can be identified by its victims starving†¦show more content†¦Thus, there is a direct link to the rise of Anorexia and the media instills the importance of appearance into the culture and plants the idea in women’s minds that thin is essential. Through out time, the fashion industry has highlighted an ultra-thin physique and has come to play a huge role in the occurrence of Anorexia. In the 1960’s, models such as Twiggy were the first to be thin. However, many models remained natural looking. In the 1980’s Amazonian models were common and the 1990’s brought the heroin chic ito style. Today, models weigh twenty percent less than they did a few decades ago. In some places, models have been forced to have a BMI of eighteen, which is still low; however, many places continue to use overly skinny women in advertisements and fashion.Often, models have developed an eating disorder because it was seemingly essential to their career. Some models have even starved themselves to death. The Fashion Industry has had an undeniably great influence on Anorexia. Hollywood actresses are praised for their diets and workout regimen, advertisers promote diet products, and unnatural looking actresses. Christy Greenleaf is quo ted as saying, â€Å"Research demonstrates that poor body image and disordered eating attitudes are associated with internalizing the mediated bodies that dominate the fashion industry† (Schwarz). Thus, the industry is not only producing diet products but also women willing to go to any length to lose weight. Pro- Anorexia websitesShow MoreRelatedAnorexia Nervos A Psychological And Physical Causes And Consequences Of Anorexia930 Words   |  4 PagesEvery time you view your reflection in a mirror, the sight of your body horrifies you. You have become so brainwashed to believe that your body is unacceptable, that you have formed an obsession with being smaller. This is how people with eating disorders feel. According to the University of Maryland Medical Center (UMMC) (2016), about one-fifth of people with anorexia are related to at least one person with the disorder. Anorexia nervosa is an eating disorder with mainly adolescent victims. 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The people most often portrayed and effected by these messages are young women. Females can feel constant pressure to live up to these ideals which are most often unattainable. This pressure can cause detrimental physical and mental states. To fully understand thisRead MoreEssay on The Fear of Fat Criterion Within the DSM IV1626 Words   |  7 Pagesbeauty and â€Å"thinness†, conversations increasingly center on dieting and body dissatisfaction. The media advertises weight loss products in the form of pills, drinks, surgery, fitness equipment and support groups to mold individuals into the proposed ideal form. This evidence alone suggests a strong case for the possibility of a pathological fear of fat. Is this fear, however, the driving force behind all cases of anorexia nervosa and bulimia? According to the DSM IV, the fear of gaining weight

The Treatment Of Rheumatoid Arthritis Health And Social Care Essay Free Essays

In the current scenario, a 64-year-old female patient has suffered from Rheumatoid arthritis ( RA ) and she seemed to demo no betterment despite her current intervention for 6 months. RA is a chronic redness disease and harmonizing to the study of National Institute for Health and Clinical Excellence ( NICE February 2009 ) RA affects 10000 people each twelvemonth in the UK population. RA is characterised by swelling and painful articulations, usually symmetrical and frequently impacting diarthrodial articulations of custodies and pess [ Firestein GS. We will write a custom essay sample on The Treatment Of Rheumatoid Arthritis Health And Social Care Essay or any similar topic only for you Order Now , 2003 ] . Although RA normally attacks articulations, it can besides impact other variety meats such as bosom, lung and eyes. The exact pathogenesis of the disease still remains to be discovered. However, autoimmunity activities are believed to be to play a major function in the development of the disease. The unnatural release of inflammatory factors such as interleukins ( IL ) and tissue mortification factor ( TNF ) by the peripheral inflammatory cells such as CD4+ T cells, B cells and macrophages are involved in the patterned advance of RA which leads to inflammatory reaction at the synovial fluid ( SF ) and synovial tissues ( ST ) that line the joint and resulted in joint devastation [ Agarwal et al. , 2005 ] . When the redness progresses into farther phase, portion of the synovial membrane which envelops the SF will develop into pannus which is an inflammatory tissues that farther assail the joint and gristle and may take to joint merger by let go ofing destructive enzymes suc h as collagenase. Harmonizing to Scots Intercollegiate Guidelines Network ( SIGN 48 ) guidelines, RA is normally diagnosed by recovering patient ‘s medical history and scrutiny on elevated degree of inflammatory markers such as non-specific erythrocyte deposit rate ( ESR ) , C-reactive protein ( CRP ) and a more specific arthritic factor, which is an auto-antibody nowadayss in 80 % of RA patients [ Firestein GS. , 2003 ] . The incidence of RA may non be seen every bit serious as other diseases such as cardiovascular diseases and malignant neoplastic disease which recorded a higher morbidity and mortality rate, but one time the disease progresses, it can give a great impact on patient ‘s day-to-day life. It accounts for 0.8 % of entire planetary Year Lived with Disability ( YLD ) , which is the 31st prima cause of YLD globally [ Symmons et al. , 2006 ] . As a chronic redness disease, RA causes lasting joint harm if it is non treated suitably every bit shortly as possible and a long-time medicine is required to decelerate down the patterned advance of the disease. The joint harm starts at the early phase of disease and worsens increasingly resulted in troubles in patients ‘ day-to-day work. A simple day-to-day undertaking such as opening a bottle or walking across the room can ensue in great hurting for RA patients. Some patients might even necessitate to discontinue or alter their current oc cupation due to sore articulations. Epidemiology survey showed that RA is associated with decreased life anticipation and increased mortality [ Anthony et al. , 2003 ] . As RA develops, the disease finally invades the bone around the joint and may take to osteoporosis due to inflammatory activities. Furthermore, RA intervention utilizing corticoid besides increases the hazard of osteoporosis due to depletion of Ca and increase loss of bone mass [ Kelman et al. , 2005 ] . Besides that, merely like other redness diseases, RA patients can confront anemic jobs where red blood cells production is inhibited during redness. After the importance of early intervention of DMARDs has been recognised, the old â€Å" intervention pyramid † used in RA which started off with diagnostic intervention utilizing anodynes such as NSAIDs has been reviewed. The â€Å" intervention pyramid † describes the usage of anodynes in the early phase of disease to alleviate hurting and merely starts DMARDs when the disease develops into more advanced phase where NSAIDs can no longer command the hurting and redness. However, several surveies have shown that protection of articulation from harm utilizing DMARDs should be started every bit shortly as possible to supply better patients ‘ forecast and continue patient functional ability [ Egmose et al. , 1995 ; van der Heide et al. , 1996 ] . Therefore both NICE and SIGN guidelines suggest the early usage of DMARDs to command and detain RA symptoms after diagnosing of RA is confirmed. There is no definite intervention for RA as patients may react otherwise to the assortment picks of RA pharmacological therapy. Normally RA patients would be started with the most normally used DMARDs and reviewed invariably for drugs effectiveness until symptoms are well-controlled by the DMARDs therapy. Further change in the intervention needs to be done if no satisfactory response is achieved. As in this instance survey, the female patient has failed to react to six-month intervention of sulfasalazine, which is one of the commonly used DMARDs in commanding RA. Thus an option should be sought every bit shortly as possible to forestall major joint devastation. Treatment Harmonizing to NICE guidelines 2009, it is stated that if RA patient does non react to the first DMARDs intervention, the dosage of the drug should be reviewed and focused to supply an effectual and suited dosage for the patient before a 2nd option of DMARDs is sought. In the current scenario, the patient had failed to react to six-month therapy of SLS, it is assumed that the dosage of SLS had been adjusted to the possible maximal bound but still demo no benefit in the patient. Thus, farther intervention would be focused on seeking for an alternate DMARDs. DMARDs are drugs from different categories that are grouped together due to their similarity in decelerating down the patterned advance of RA and understating joint devastation caused by RA besides commanding the symptoms. The normally used DMARDs include sulfasalazine ( SLS ) , amethopterin ( MTX ) , gold, Cuprimine, anti-malarial, azathioprine, leflunomide and cyclosporine. SLS and MTX are most preferable in clinical pattern due to their favourable toxicity profiles although intramuscular gold and Cuprimine had shown similar effectivity in handling RA [ Aletaha et al. , 2003 ; Felson et al. , 1990 ; Capell et al. , 1993 ] . MTX and SLS were considered to be safer at usage as it was shown that there was no important difference in the incidence of side-effects reported between high and low dose intervention of the drugs [ Aletaha et al. , 2003 ] . Since the patient has failed to react to SLS, MTX would normally be the following option in head. However, there is a pick to do whether t o utilize MTX in combination with SLS or replace SLS with MTX as monotherapy. DMARDs combination has been recommended in NICE guidelines for early RA intervention, but more clinical groundss need to be sought for the usage of combination in established RA, which is pictured in the current scenario as the patient has been suffered from RA for more than 6 months and immune to SLS therapy. Three surveies were found to compare the usage of MTX monotherapy and dual-therapy with SLS in patients unresponsive to SLS. Among the three, two were randomised controlled tests ( RCT ) while one was non-randomised experimental test [ Haagsma et al. , 1994 ; Capell et al. , 2007 ; Schipper et al. , 2009 ] The first RCT was carried out in 1994 which merely included a little figure of patients ( n=40 ) based on a single-observer method over 24 hebdomads while a longer continuance ( gt ; 18 months ) of double-blind placebo-controlled survey with a larger survey group ( n=165 ) was adopted in the 2nd RCT in 2007. Despite the difference in the survey features, both RCTs concluded that MTX-SLS double therapy had a greater efficaciousness in commanding symptoms over MTX monotherapy in SLS-resistant patients without important addition in toxicity. However, although the 2nd RCT had shown important clinical benefits for combination therapy compared to the usage of monotherapy, no important a dvantage was seen in radiological results or functional disablement. The 3rd survey was a recent test published in 2009 investigated 230 patients who were immune to SLS intervention utilizing the similar intervention magnitude as the old surveies to measure the drug efficaciousness. This test was carried out for more than 15 old ages and concluded that that both options provided similar consequence. The disagreement was believed to be caused by the deficiency of control group in the ulterior test which might lend to biased consequences and inconsistent usage of other drugs such as corticoids in different tests which might misdirect the reading of drug efficaciousness. Besides efficaciousness and toxicity, cost of intervention is the following of import factor to be considered in taking the right intervention for the patient. However, really few surveies were done comparing the cost-effectiveness of different DMARDs because RA is non every bit prevailing as other major diseases such as cardiovascular diseases and it does non normally result in immediate decease. The more recent cost-effectiveness analysis on DMARDs was done in Thailand from the social point of position where the costs included a direct cost and indirect cost [ Osiri et al. , 2007 ] . In order to enable numerical comparing, the cost-effectiveness of the therapies was measured utilizing the Incremental Cost-effectiveness Ratio ( ICER ) which is the entire cost in US dollar needed to accomplish one unit of ( HAQ ) Health Assessment Questionnaire, which comprised of 20 inquiries on patients ‘ self-report functional and disablement position. The ICER of each intervention was compa red against the anti-malarial monotherapy as anti-malarial was recognised as the cheapest and least efficacious DMARDs available. Comparing among the sum of 152 RA patients, it was found that MTX and SLS therapy recorded a three times lower ICER compared to MTX monotherapy, which explained that the double therapy was less dearly-won and more effectual compared to the monotherapy ( US $ 625 versus US $ 2061 per one unit of HAQ mark ) . However, this survey was non specifically directed to SLS-resistant patients. Therefore, merely a comparative comparing can be made on the cost for the current scenario. The following option of intervention for the current patient is the usage of three-base hit therapy which uses MTX, SLS and an anti-malarial. It was shown in a biennial, prospective randomised test on 180 patients that the ternary therapy had given a better curative efficaciousness over the dual- ( MTX and SLS or MTX and anti-malarial ) and MTX monotherapy irrespective of the drugs given in the early RA intervention [ Calguneri et al. , 1999 ] . Again, the incidence of inauspicious effects did non increase significantly with the addition in figure of drugs. The enhanced benefit by adding an anti-malarial agent to MTX intervention had further strengthened the grounds shown antecedently by a long-run followup survey on patients who were treated with ternary therapy. It was shown in the old survey that patients who had failed to react to at least one DMARD and treated with ternary therapy had shown continued betterment with minimum toxicity after 3 old ages compared to MTX monotherapy a nd SLS-hydroxychloroquine therapy [ O’Dell et al. , 1999 ] . Addition of anti-malarial agent to MTX had been shown to execute better than MTX-SLS combination, which proposed an implicit in interactive activity of anti-malarial and MTX when they are used together likely due to heighten MTX bioavailability by anti-malarial [ O’Dell et al. , 2002 ; Carmichael et al. , 2002 ] . In footings of the intervention cost, based on the same cost-effectiveness survey mentioned above, ternary therapy recorded a lower ICER ( US $ 1222 per one unit of HAQ mark ) than MTX monotherapy, but about twice every bit high as the ICER of MTX-SLS therapy. Other than utilizing the traditional DMARDs, the freshly developed biological anti-rheumatic drugs are besides being studied for SLS immune patients. Since RA involves a great trade of cytokines activities, specific cytokines blockers have been investigated to stamp down or modify the redness procedure. The most normally used biological agents include infliximab, etanercept and adalimumab which target the tissue mortification factor, TNF-I ± , which is one of the chief cytokines released by macrophage that farther induces the release of other cytokines which are responsible for the redness. NICE guidelines emphasized that TNF-I ± inhibitors can merely be used when the patient has failed to react to intervention of at least two DMARDs including amethopterin. However, Combe et Al. had tried a different attack where Enbrel has been used and investigated in patients specifically having SLS intervention but still have ailment of active RA without affecting MTX [ Combe et al. , 2006 ] . It was found that etanercept monotherapy or in combination with SLS had given better betterment in American College of Rheumatology ( ACR ) standards compared to patients treated with SLS entirely. There was no important difference in the efficaciousness in the etanercept monotherapy and combination group. However, there was a significantly higher incidence rate of side-effects such as concern, sickness and astheny in the combination group while a higher hazard of infections and injection side reactions were recorded in patients with etanercept entirely. Besides that, as a biological drug, TNF-I ± inhibitors can non get away the fact of doing serious inauspicious effects such as malignance, demyelination and increased susceptibleness to infections like TB [ Nahar et al. , 2003 ] . However when the ratio of efficaciousness over toxicity is concerned, a meta-analysis showed that TNF inhibitors have a higher ratio than gold and sulfasalazine [ Ravindran et al. , 2008 ] . Again, whe n cost is concerned, etanercept intervention, as expected is much expensive compared to DMARDs, where the cost was shown to be more than twice higher than the most expensive DMARD available, cyclosporin [ Jobanputra et al. , 2002 ] . TREATMENT RECOMMENDATION Comparing the four options available, MTX monotherapy, MTX-SLS dual-therapy, ternary therapy and etanercept therapy, MTX-SLS dual-therapy seems to be the best intervention for the current patient as it is supported by groundss for its lower cost with comparable efficaciousness in SLS immune patients. It might non be the most effectual intervention compared to treble therapy, but it is ever advisable to understate the figure of drugs used in a patient to forestall unneeded inauspicious effects or drug interactions. However, there is still possibility that the patient may still be unresponsive to the dual-therapy as there is no definite warrant on the action of the therapy on every RA patient and the possibility of developing immune to MTX. Thus, the National Clinical Guidelines recommends monthly reappraisal of CRP ( C-Reactive Protein ) , an inflammatory marker and other cardinal constituents of disease activity such as DAS 28 ( Disease Activity Score based on 28 articulations ) unti l the disease is controlled by the given intervention to a degree antecedently discussed and agreed by the patients. If there is still no satisfactory respond, farther change in the therapy needs to be done such as sing the ternary therapy or etanercept therapy. Besides giving the slow-acting disease modifying drugs, SIGN 48 guidelines suggest the usage of intra-articular injection of corticoids to give rapid diagnostic alleviation before the oncoming of the new DMARDs therapy. Oral corticoids are non preferred to be used as a long-run intervention as it can do serious inauspicious consequence on bone mass and GI systems and it merely shows benefit in the early intervention of active RA [ Saag et al. , 1995 ; Kirwan et al. , 1995 ] If injection is non possible, so low dosage of unwritten corticoid is used in a shortest continuance possible [ Laan et al. , 1995 ] . For the diagnostic hurting control on top of DMARDs, mentioning to SIGN 48 guidelines, whenever possible, simple anodynes such as paracetamol are preferred over NSAIDs due to set up side-effects peculiarly GI annoyance. If simple anodynes are non powerful plenty to alleviate the hurting, a low dose NSAIDs such as isobutylphenyl propionic acid or more selective Cyclooxygenase ( Cox-2 ) inhibitors such as etoricoxib can be prescribed for the shortest continuance possible. When NSAIDs or Cox-2 inhibitors have to be used, coincident usage of GI protective medicine such as proton-pump inhibitors should be considered for aged and patients with history of GI ulcerations. Both NICE and SIGN guidelines recommend that dosage of NSAIDs should be reviewed and reduced once patients show equal response to DMARDs. In drumhead, the patient should be continued with SLS, at the same clip, added with MTX as the combined DMARDs therapy. In add-on, intra-articular or short-course unwritten corticoid should be commenced as a â€Å" span therapy † before the oncoming of action of the new DMARDs therapy. For diagnostic control, if paracetamol is non equal to relief hurting, NSAIDs such as diclofenac together with a proton pump inhibitor such as Prilosec can be used unless it is contraindicated in the patient, so a Cox-2 inhibitor such as etoricoxib should be used. Besides that, patient would be put on a monthly monitoring to reexamine the effectivity of the new therapy. 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Myocardial Infarction Symptoms and Treatment-MyAssignmenthelp.com

Question: Discuss about the Myocardial Infarction : Symptoms and Treatments. Answer: Introduction: Smoking and alcohol consumption are the most causes of myocardial infarction. Mr. Savea was associated with smoking and alcohol consumption. Older age, family history, genetic factors, hypertension, obesity, diabetes mellitus, high cholesterol and low density lipoprotein levels are the risk factors associated with myocardial infarction. Myocardial infarction can also be developed due lack of physical activity, lack of exercise and mental stress. Smoking, obesity, lack of exercise and stress are responsible for occurrence of myocardial infarction in 36 %, 20 %, 12 % and 3 % people respectively. Mr. Savea is older person and associated with obesity, hypertension and high level of cholesterol. Hence, these factors are responsible for occurrence of myocardial infarction in Mr. Savea. Chest pain can occur in people with angina. Reduced supply of blood to heart muscles is responsible for the occurrence of chest pain in angina. This angina can be developed due to myocardial infraction. Syst emic embolism can be developed due to Mitral valve stenosis and systemic embolism can leads to myocardial infraction. Mr. Savea is associated with both angina and Mitral valve stenosis (Mehta et al., 2014; Cardoz et al. 2015). Worldwide 15.9 million populations are suffering through myocardial infraction and approximately 1 million people in US are suffering through myocardial infraction. Myocardial infraction treatment is expensive and it ranked fifth position in expensive treatment and approximately 10 % patients end into the death due to myocardial infraction. These risk factors for myocardial infraction are same in all parts of the world. Upto 5 cigarettes consumption per day can lead to myocardial infraction in 40 % people. Mr. Savea was affected adversely due to myocardial infraction because it was difficult for him to attend his job due to myocardial infraction. Myocardial infraction adversely affected Mr. Savea both socially and psychologically. Being a myocardial infraction patient, Mr. Savea couldt participate in social activities and couldt meet friends. Hence, he might feel socially isolated due to myocardial infraction. Psychological effects like depression and low moral can exist in Mr. Savea. More amount of money need to be spend on the treatment of myocardial infraction and he could not attend his job. Hence, there would be considerable financial impact on Mr Saveas family. Mr. Saveas family might be under stressful condition due to diseased condition (Valensi et al., 2011). Myocardial infraction is predominantly associated with chest pain. Insufficient blood supply to myocardial cells is mainly responsible for the occurrence of chest pain. Imbalanced blood supply and demand to the myocardiaum are also responsible for chest pain. Chest pain in myocardial infarction can lasts upto 20 minutes. Chest pain in myocardial infarction radiate to shoulder and right arm (Malik et al., 2013). Patients with myocardial infraction are also associated with shortness of breath. Shortness of breath impairment in myocardial infration reflects effect of cardiovascular impairment on functioning of respiratory system. As a result of heart damage, cardiac output from the left ventricle can be reduced. This leads to the left ventricular failure and as a result pulmonary edema. Pulmonary edema adversely affects breathing pattern by affecting amount of exhaled and inhaled air. Reduced inhalation of air can lead to reduced oxygen saturation. Reduced oxygen saturation leads to compensatory mechanism of increased breathing rate to supply more amount of oxygen. Increased breathing rate leads to shortened breath in patients with myocardial infraction (Botker et al., 2016). Insufficient supply of blood to the brain tissues can lead to the occurrence of loss of consciousness. Reduced supply of blood supply results in less amount of oxygen to the brain tissues which leads to the death of brain tissues, consequently brain dysfunction and loss of consciousness (Lu et al., 2015; Sandler et al., 2011). Increased firing of the sympathetic nervous system occurs in the patients with myocardial infraction. Fight or fligt response occurs mainly due to the activation of the sympathetic nervous system. Sweat glands get stimulated and consequently sweating occurs due to activation of sympathetic nervous system. Chest pain is responsible for the increased hormone secretion. These hormonal changes can produce bradycardia and hypertension in patients with myocardial infraction. Bradycardia and hypertension are responsible for increased sweating (Gokhroo et al., 2016). Less supply of oxygen to tissues results in the metabolic activity in the cells and reduced ATP generation. This reduced ATP levels can lead to fatigue development in patients with myocardial infraction. Mainly two types of drugs can be used in the management of myocardial infraction like angiotensin converting enzyme inhibitors (ACE inhibitors) and beta-blocker. Conversion of angiotensin I (AI) to angiotensin II (AII) can be blocked by ACE inhibitors. ACE is the significant component of the reninangiotensin system. Within 24 hours of evidence of myocardial infraction, ACE inhibitors should be administered. ST elevation MI (STEMI) patients are more beneficial with ACE inhibitors as compared to the non-ST elevation MI (NSTEMI). ACE inhibitors are helpful in reducing arteriolar resistance, increasing venous capacity, reducing cardiac volume and capacity and reducing resistance in blood vessels. Blood vessels dilatation, decreased blood pressure and reduced demand of blood by the heart can occur due to inhibition of ACE enzyme. ACE inhibitors also produce its action through activation of parasympathetic nervous system. ACE inhibitors reduce vasoconstriction effects of noreoinephrine by reducing plasma levels of norepinephrine. Zofenopril, perindopril, trandolapril, captopril, enalapril, lisinopril, and ramipril are the commonly used ACE inhibitors. Cough, hyperkalemia, headache, reduced blood pressure, dizziness, fatigue, nausea, and renal impairment are the common side effects of ACE inhibitors. Duration of survival of myocardial infarction patients can be improved by administering ACE inhibitors (Bangalore et al., 2017; Lubarsky and Coplan, 2007) Beta blockers produce its effects by acting as competitive antagonist of endogenous catecholamines epinephrine and norepinephrine receptors on adrenergic beta receptors. These drugs are specifically administered in case of second attack of myocardial infraction. Existing beta blocker drugs are acting on all the beta adrenergic receptors and also acting on individual beta adrenergic receptors like 1, 2 and 3 receptors. These beta blockers can be administered as adjuvant therapies for ACE inhibitors and diuretics in patients with myocardial infraction. Most commonly used beta blockers are bisoprolol, carvedilol and sustained-release metoprolol (Bangalore et al., 2014). Beta blockers also produce its effects by decreasing secretion of rennin by acting on rennin-angiotensin system. Beta blockers gives relief from ischemic chest pain by reducing oxygen demand by heart, reducing heart rate, reducing blood pressure and reducing contractibility of blood vessels. Beta blockers increases ventr icular fibrillation threshold and reduces ventricular fibrillation. Beta blockers also reduce infract size and prevent development of infraction (Kezerashvili et al., 2012). Pain management: Nurse should assess characteristics of pain in Mr. Savea by verbalizing him and collecting non-verbal cues for him. Nurse should evaluate intensity of pain in him on scale of 0 10 and compare it with the previous episodes of pain in him. Nurse should instruct Mr. Savea to report pain in timely manner and he should report pain in terms of duration and intensity. Pain can be relieved in Mr. Savea by providing calm and relaxed environment. For this purpose he should be taught with deep breathing which is a relaxation technique. His attention also should be distracted form pain. Antianginals like nitroglycerin, beta blockers like propranolol and analgesis like morphine should be administered in him to relieve him from pain (Ignatavicius and Workman, 2015). For the assessment of cardiac output, nurse should record blood pressure in Mr. Savea. This blood pressure should be assessed by asking him to sit and stand. Along with blood pressure heart rate and respiratory rate also should be assessed. Mr. Savea should perform different activities while recording heart rate and blood pressure. In between these activities, suitable rest should be provided to him. Caffeinated and carbonated drinks should be avoided in him. Cardiac output, ECG, chest X-ray and laboratory tests like cardiac enzymes, ABG (arterial blood gas) and electrolytes should be assessed in Mr. Savea. Antidysrhythmic medications should be administered in Mr. Savea and pacemaker should be used (deWit and Kumagai, 2014). Impairment in tissue perfusion is associated with conditions like anxiety, lethargy and confusion in Mr. Savea. Nurse should monitor for these conditions in Mr. Savea. Tissue perfusion also can be monitored by monitoring food consumption and urine output. Assessm ent of erythema and edema should be performed in Mr. Savea. Tests for ABGs, BUN, prothrombin time, creatinine, and electrolytes should be performed in Mr. Savea. Anticoagulant and antacid drugs should be administered in Mr. Savea. Reperfusion therapy also should be performed in Mr. Savea (Anderson and Taylor, 2014). 2000 mL/24 hr fluid balance should be maintained in Mr. Savea. This fluid balance should be in the range of cardiovascular tolerance. Reduced cardiac output should be recorded and fluid balance should be balanced. Antidiuretic drugs should be administered in Mr. Savea along with the administration of low sodium and liquid administration (Ignatavicius and Workman, 2015). Activity intolerance: Nurse should advise him to increase activity level in stepwise manner. These activities include getting up form bed and ambulation in sitting position. Nurse should monitor all the activities of Mr. Savea and assess intolerance in his activities to provide required nursing intervention (deWit and Kumagai, 2014). Nurse should monitor Mr. Saveas behavior for abandonment and rejection from tests and medication consumption. Anxiety behavior should be noted in the form of verbal and non-verbal from. For the management of anxiety, nurse should inform him about detailed procedure to be carried out and information about the medications. Nurse should give him confidence for improvement in his condition. Nurse should take him in confidence and provide comfortable environment for his anxiety management (Ignatavicius and Workman, 2015). References: Anderson, L., and Taylor, R.S. (2014). Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews. The Cochrane database of systematic reviews, 12, doi:10.1002/14651858.CD011273. Bangalore, S., Makani, H., Radford, M., Thakur, K., et al., (2014). Clinical outcomes with -blockers for myocardial infarction: a meta-analysis of randomized trials. The American Journal of Medicine. 127(10), 93953. 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