1.9: Aldehydes and Ketones
- How to name aldehydes and ketones.
A carbonyl group consists of a carbon atom double-bonded to an oxygen atom, written as C=O . Aldehydes and ketones are two compounds which contain the carbonyl group.
Aldehydes and ketones are constitutional isomers . For example, the aldehyde and ketone below both have the molecular formula C 3 H 6 O.
The simplest aldehyde is methanal, commonly known as formaldehyde, and used as a preservative.
The name of this molecule is butanal.
1. What is the name of Molecule A?
2. This molecule is named 5-methylhexanal. Number the carbons.
3. Number the carbons. What is the name of Molecule B?
4. This molecule is named 3-ethyl-4-methylhexanal. Number the carbons.
5. Number the carbons. What is the name of Molecule C?
6. This molecule is named 3-pentenal. Number the carbons.
7. Number the carbons. What is the name of Molecule D?
8. A well-known ketone is 2-propanone, commonly known as acetone, and used as a nail polish remover.
This molecule is named 2-pentanone.
What is the name of Molecule E?
9. The name of this molecule is 5-ethyl-2-heptanone. Number the carbons.
10. Number the carbons. What is the name of Molecule F?
11. This molecule is named 6-chloro-4-ethyl-3-heptanone. Number the carbons.
12. Number the carbons. What is the name of Molecule G?
13. The name of this molecule is 3-bromocyclohexanone. Number the carbons.
14. Number the carbons. What is the name of Molecule H?
15. The name of this molecule is 4-hydroxy-2-butanone. Number the carbons.
16. Number the carbons. What is the name of Molecule I?
17. This molecule is named 5-chloro-4-oxohexanal. Number the carbons.
18. Number the carbons. What is the name of Molecule J?
19. What additions do we make to our existing naming rules to name aldehydes and ketones?
20. Write the steps that you use to name an aldehyde or ketone in order, as instructions for a student who doesn't know how to do it.
21. Draw any aldehyde or ketone and go through the steps in naming your molecule.


5.2: Basic Chronology and Periods of Roman History
According to Roman tradition, Rome was founded as a monarchy. However, it was not long-lived, and its history is overshadowed by myth and legend. Historians most often divided Roman history into two major periods, based on the type of government: the Republic (from 509 B.C. to 27 BCE) and the Empire (27 BCE- c. 476 CE). The basic difference between the two periods is quite simple. During the period of the Republic, Rome was ruled by a Republican government, which distributed power, in theory, among all Roman citizens. In practice, this was really an aristocratic oligarchy. By contrast, under the Empire, Rome was under one ruler, the Emperor.
This chapter proceeds chronologically, sub-dividing both the Republic and the Empire into early and late periods, while also devoting some attention to certain thematic topics that are key to understanding each period.


41.3.0: Chapter 1
Case Study
1.
b.
The client is well above the recommended 4 grams/day dose based on the manufacturer’s recommendation for acetaminophen. Taking the drug every 4 hours equates to taking the drug six times/day
( ). Taking more than 4 grams of acetaminophen in 24 hours can cause acute liver problems. Educating the client about the importance of safe dosing guidelines can prevent future problems.
( ). Taking more than 4 grams of acetaminophen in 24 hours can cause acute liver problems. Educating the client about the importance of safe dosing guidelines can prevent future problems.
2.
c.
Visits to health care providers may be reduced when clients self-medicate, following the directions that come with the medication, for minor ailments.
Review Questions
1.
d.
Acetaminophen is the generic form of the drug Tylenol, and they have the same active ingredients. Either formulation would be acceptable.
2.
b.
Both drugs belong under Schedule II and are highly addictive.
3.
b.
Ibuprofen is the generic name for Motrin; Motrin is the brand or trade name for ibuprofen. The chemical name for ibuprofen is 2-(4-isobutylphenyl) propanoic acid.
4.
a.
Generic drugs have the same active ingredients but may have different inactive ingredients.
5.
d.
Decreased GI motility causes increased transit time in the gut, which increases the time for absorption of the drug. Toxicity may result.
6.
c.
Toxicity is the greatest concern in this older client who is also underweight. Therefore, this client may require a lower dose of the drug.
7.
b.
IP collaboration has many advantages, including decreased hospitalization costs, improved client safety, and improved communication regarding team goals.
8.
a.
The FDA is the regulatory agency tasked with the responsibility of ensuring that all drugs are safe and effective for all individuals across the lifespan.
9.
b.
Phase II incorporates a relatively small number of volunteers with the disease the drug is designed to treat.
10.
b.
The first action by the nurse should be to assess the client’s medication history and whether or not the client is taking the medications as prescribed. All other actions will be performed, but the assessment should be completed first.


4: Proportional Relationships and Percentages Last updated Save as PDF Page ID 34997 Illustrative Mathematics OpenUp Resources 4.1: Proportional Relationships with Fractions 4.1.1: Lots of Flags 4.1.2: Ratios and Rates With Fractions 4.1.3: Revisiting Proportional Relationships 4.1.4: Half as Much Again 4.1.5: Say It with Decimals 4.2: Percent Increase and Decrease 4.2.1: Increasing and Decreasing 4.2.2: One Hundred Percent 4.2.3: Percent Increase and Decrease with Equations 4.2.4: More and Less than 1 Percent 4.3: Applying Percentages 4.3.1: Tax and Tip 4.3.2: Percentage Contexts 4.3.3: Finding the Percentage 4.3.4: Measurement Error 4.3.5: Percent Error 4.3.6: Error Intervals 4.4: Let's Put it to Work 4.4.1: Posing Percentage Problems


14.1: Introduction
Compared to other wealthy countries, the U.S. is unique in that it does not have a universal or government-sponsored healthcare system. Instead, the federal government (through Medicare and Medicaid) and a few large health insurance companies are the primary payers for healthcare. Health insurance is either provided by an employer, or purchased privately by individuals. The Affordable Care Act provided subsidies for low income individuals which did help increase coverage - but to date has never reached 100%. In 2023, the uninsured were at the lowest percentage yet - only 7.7% or around 25.3 million Americans still lacked health insurance coverage. In this chapter, we will cover the basics of the U.S. healthcare system: government funded programs, health insurance terms, and a few key issues facing U.S. healthcare.


4.1: Core Concepts
After completing this section, you will be able to
- Understand trademarks and their properties.
- Identify differences between trademarks and other intellectual property rights.
A trademark is an intellectual property right granted by a government to an individual, business, or legal entity that creates and uses a distinctive word, name, symbol, or device to distinguish its products or services from those from any other entity in the marketplace.
The original purpose of a trademark was to indicate the origin of goods and services. Trademarks thus protected the public by preventing mistakes, confusion, or deception by those who would “palm off” their goods as those of another. But it also served to protect the market and reputation (or goodwill) of the producers of goods. As modern markets evolved, trademarks also developed into guarantees of quality as well as potent marketing and advertising devices.
Trademarks as Branding
Consider, for example, the role that Nike’s “Swoosh” logo plays in its $106 billion shoe, equipment, and apparel business. In 1971, Nike founder Phil Knight paid graphic design student Carolyn Davidson a mere $35 to design the “Swoosh” logo for the fledgling new company. According to the Portland Oregonian newspaper, when Knight saw her design, he reportedly told her, “I don’t love it, but maybe it will grow on me.” Nike attorneys nonetheless registered the logo with the U.S. Patent and Trademark Office (USPTO) on June 18, 1971. i
Today, this one logo is estimated to be worth as much as $20 billion, and is recognized around the world as a symbol of Nike’s quality workmanship and design. Indeed, its vital role in protecting Nike’s market share and reputation explains why the company so strenuously protects its trademark rights from being infringed by counterfeiters. As for design student Carolyn Davidson, Phil Knight gave her Nike stock in 1983 that is today worth more than $850,000.
Trademarks vs. Other Intellectual Property Rights
Trademarks share with other intellectual property rights the power to encourage and reward creative enterprise. Trademarks also share with patent rights and copyrights the public policy goal of marshaling the benefits of creative endeavor—in this case, the distinctive branding of one’s products and services from those of others—to the public good. They do this by protecting the consumer from deception and encouraging sellers to provide quality products.
But trademarks are different from other intellectual property rights in three key respects. In the first place, the legal foundation for U.S. trademark law comes not from rights expressly enumerated in the Constitution, as is the case with patent rights and copyrights. Rather, it lies in the Commerce Clause of the Constitution, which gives Congress the authority to regulate interstate commerce and enact whatever necessary and proper legislation is required to do that.
Trademarks are also different from other intellectual property rights in that they are not limited in duration. Patents and copyright are granted only for limited periods of time because society benefits by putting an invention or literary work into the public domain once the inventor or artistic creator has recouped the costs of innovation and been rewarded for the pioneering endeavor. Trademarks, however, never hinder the sales of other products or services, so they are granted in perpetuity so long as they are not abandoned by the trademark owner.
Trademarks Mean Business
Finally, trademarks exist only in conjunction with commercial activity. An inventor may receive a patent for a new invention and never employ or “practice” that invention in a business or research endeavor. Similarly, an author can receive a copyright for an original literary or artistic work and yet never publish, display, or sell it. A trademark, however, cannot exist by itself, apart from commercial activity.
Thus a trademark cannot be obtained by mere adoption. It can only be acquired through commercial use or in anticipation thereof—i.e., through the sale of goods and services.
Footnotes
- i Allen Brettman, “ Creator of Nike’s Famed Swoosh Remembers Its Conception 40 Years Later ,” the Oregonian, June 15, 2011.


4.1: Examining Relationships
At the end of this section you should be able to answer the following questions:
- What is a statistical relationship?
- What is the difference between a positive and negative relationship?
- What does a Pearson correlation coefficient indicate?
When we discuss relationships or associations between variables, the terms “relationship” and “association” mean that two variables change, or vary, together. However, just because two variables change together does not mean that this change is statistically significant. Thus, there are two types of variation or relationships – significant and nonsignificant.
As a researcher, looking into the relationships between psychological constructs can tell me a great deal about how certain mental health concerns and behaviours effects individuals with respect to behavioural and emotional levels. For example, does a person with greater levels of social connection and support have greater feelings of well-being? Do people with greater levels of mindfulness have lower levels of perceived stress? These are questions that can be answered using correlational analyses.
So what is a statistical relationship? A statistical relationship is the association between two variables that is statistically significant. This significance is based on the level of a probability test, which is a p-value in the case of Pearson correlation coefficients. If one variable increases or decreases, an associated variable will also show an increase or decrease, and it is statistically significant if this variability can be attributed to more than chance. An example is calorie intake and weight, as more calories are consumed, weight will likely increase. This type of example shows a positive relationship between the variables which means that as one variable increases the other also increases (e.g., as height increases, weight usually increases). However, relationships can be either positive or negative. A negative relationship is present when one variable increases, the other decreases (e.g., as stress levels increase, health will likely decrease).
A Pearson correlation coefficient (represented as an r value statistically) is a very useful tool in psychological research. However, there are many other types of correlation coefficients, such as the Spearman rank-order correlation coefficient, which is a nonparametric measure of association between two variables.
A Pearson correlation draws on a “line of best fit” that will be imposed through the two variables in the data to establish the relationship between two variables. Using the linear model, the Pearson’s correlation coefficient (which is represented by an r) , represents the strength of the association. This means that the distance from the data points show the line of best fit and how strongly the two variables are related. Mathematically, the Pearson correlation is calculated from the central tendency statistic of the mean and the standard deviation for each of the variables. Have a look at the below illustration by clicking on the link labelled “Chapter Four – Line of Best Fit,” which displays a graph with the Line of Best Fit for the two variables mental distress and physical illness. The variables are in fact correlated with a significant Pearson correlation coefficient ( r = .472, p < .000).
PowerPoint: Line of Best Fit
Take a look at the following PowerPoint slides:
The Pearson correlation coefficient can range from +1 to -1, with positive values indicating that as one value increases (e.g., as height increases, weight increases) the other also increases, or negative values which show that as one value increases, the other decreases (e.g., as stress increases health decreases). The stronger the association between the two variables, the closer to 1 the value will be.
Coefficient, r
Strength of Association
Positive
Negative
Small
.1 to .3
-0.1 to -0.3
Medium
.3 to .5
-0.3 to -0.5
Large
.5 to 1.0
-0.5 to -1.0


32.1: The War on Terror
By the end of this section, you will be able to:
- Discuss how the United States responded to the terrorist attacks of September 11, 2001
- Explain why the United States went to war against Afghanistan and Iraq
- Describe the treatment of suspected terrorists by U.S. law enforcement agencies and the U.S. military
As a result of the narrow decision of the U.S. Supreme Court in Bush v. Gore , Republican George W. Bush was the declared the winner of the 2000 presidential election with a majority in the Electoral College of 271 votes to 266, although he received approximately 540,000 fewer popular votes nationally than his Democratic opponent, Bill Clinton’s vice president, Al Gore. Bush had campaigned with a promise of “compassionate conservatism” at home and nonintervention abroad. These platform planks were designed to appeal to those who felt that the Clinton administration’s initiatives in the Balkans and Africa had unnecessarily entangled the United States in the conflicts of foreign nations. Bush’s 2001 education reform act, dubbed No Child Left Behind, had strong bipartisan support and reflected his domestic interests. But before the president could sign the bill into law, the world changed when terrorists hijacked four American airliners to use them in the deadliest attack on the United States since the Japanese bombing of Pearl Harbor in December 1941. Bush’s domestic agenda quickly took a backseat, as the president swiftly changed course from nonintervention in foreign affairs to a “war on terror.”
9/11
Shortly after takeoff on the morning of September 11, 2001, teams of hijackers from the Islamist terrorist group al-Qaeda seized control of four American airliners. Two of the airplanes were flown into the twin towers of the World Trade Center in Lower Manhattan. Morning news programs that were filming the moments after the first impact, then assumed to be an accident, captured and aired live footage of the second plane, as it barreled into the other tower in a flash of fire and smoke. Less than two hours later, the heat from the crash and the explosion of jet fuel caused the upper floors of both buildings to collapse onto the lower floors, reducing both towers to smoldering rubble. The passengers and crew on both planes, as well as 2,606 people in the two buildings, all died, including 343 New York City firefighters who rushed in to save victims shortly before the towers collapsed.
The third hijacked plane was flown into the Pentagon building in northern Virginia, just outside Washington, DC, killing everyone on board and 125 people on the ground. The fourth plane, also heading towards Washington, crashed in a field near Shanksville, Pennsylvania, when passengers, aware of the other attacks, attempted to storm the cockpit and disarm the hijackers. Everyone on board was killed (Figure \(\PageIndex{2}\)).
That evening, President Bush promised the nation that those responsible for the attacks would be brought to justice. Three days later, Congress issued a joint resolution authorizing the president to use all means necessary against the individuals, organizations, or nations involved in the attacks. On September 20, in an address to a joint session of Congress, Bush declared war on terrorism, blamed al-Qaeda leader Osama bin Laden for the attacks, and demanded that the radical Islamic fundamentalists who ruled Afghanistan, the Taliban , turn bin Laden over or face attack by the United States. This speech encapsulated what became known as the Bush Doctrine , the belief that the United States has the right to protect itself from terrorist acts by engaging in pre-emptive wars or ousting hostile governments in favor of friendly, preferably democratic, regimes.
CLICK AND EXPLORE
Read the text of President Bush’s address to Congress declaring a “war on terror.”
World leaders and millions of their citizens expressed support for the United States and condemned the deadly attacks. Russian president Vladimir Putin characterized them as a bold challenge to humanity itself. German chancellor Gerhard Schroder said the events of that day were “not only attacks on the people in the United States, our friends in America, but also against the entire civilized world, against our own freedom, against our own values, values which we share with the American people.” Yasser Arafat, chairman of the Palestinian Liberation Organization and a veteran of several bloody struggles against Israel, was dumbfounded by the news and announced to reporters in Gaza, “We completely condemn this very dangerous attack, and I convey my condolences to the American people, to the American president and to the American administration.”
CLICK AND EXPLORE
In May 2014, a Museum dedicated to the memory of the victims was completed. Watch this video and learn more about the victims and how the country seeks to remember them.
GOING TO WAR IN AFGHANISTAN
When it became clear that the mastermind behind the attack was Osama bin Laden, a wealthy Saudi Arabian national who ran his terror network from Afghanistan, the full attention of the United States turned towards Central Asia and the Taliban. Bin Laden had deep roots in Afghanistan. Like many others from around the Islamic world, he had come to the country to oust the Soviet army, which invaded Afghanistan in 1979. Ironically, both bin Laden and the Taliban received material support from the United States at that time. By the late 1980s, the Soviets and the Americans had both left, although bin Laden, by that time the leader of his own terrorist organization, al-Qaeda, remained.
The Taliban refused to turn bin Laden over, and the United States began a bombing campaign in October, allying with the Afghan Northern Alliance, a coalition of tribal leaders opposed to the Taliban. U.S. air support was soon augmented by ground troops (Figure \(\PageIndex{3}\)). By November 2001, the Taliban had been ousted from power in Afghanistan’s capital of Kabul, but bin Laden and his followers had already escaped across the Afghan border to mountain sanctuaries in northern Pakistan.
IRAQ
At the same time that the U.S. military was taking control of Afghanistan, the Bush administration was looking to a new and larger war with the country of Iraq. Relations between the United States and Iraq had been strained ever since the Gulf War a decade earlier. Economic sanctions imposed on Iraq by the United Nations, and American attempts to foster internal revolts against President Saddam Hussein’s government, had further tainted the relationship. A faction within the Bush administration, sometimes labelled neoconservatives, believed Iraq’s recalcitrance in the face of overwhelming U.S. military superiority represented a dangerous symbol to terrorist groups around the world, recently emboldened by the dramatic success of the al-Qaeda attacks in the United States. Powerful members of this faction, including Vice President Dick Cheney and Secretary of Defense Donald Rumsfeld, believed the time to strike Iraq and solve this festering problem was right then, in the wake of 9/11. Others, like Secretary of State Colin Powell, a highly respected veteran of the Vietnam War and former chair of the Joint Chiefs of Staff, were more cautious about initiating combat.
The more militant side won, and the argument for war was gradually laid out for the American people. The immediate impetus to the invasion, it argued, was the fear that Hussein was stockpiling weapons of mass destruction ( WMDs ): nuclear, chemical, or biological weapons capable of wreaking great havoc. Hussein had in fact used WMDs against Iranian forces during his war with Iran in the 1980s, and against the Kurds in northern Iraq in 1988—a time when the United States actively supported the Iraqi dictator. Following the Gulf War, inspectors from the United Nations Special Commission and International Atomic Energy Agency had in fact located and destroyed stockpiles of Iraqi weapons. Those arguing for a new Iraqi invasion insisted, however, that weapons still existed. President Bush himself told the nation in October 2002 that the United States was “facing clear evidence of peril, we cannot wait for the final proof—the smoking gun—that could come in the form of a mushroom cloud.” The head of the United Nations Monitoring, Verification and Inspection Commission, Hanx Blix, dismissed these claims. Blix argued that while Saddam Hussein was not being entirely forthright, he did not appear to be in possession of WMDs. Despite Blix’s findings and his own earlier misgivings, Powell argued in 2003 before the United Nations General Assembly that Hussein had violated UN resolutions. Much of his evidence relied on secret information provided by an informant that was later proven to be false. On March 17, 2003, the United States cut off all relations with Iraq. Two days later, in a coalition with Great Britain, Australia, and Poland, the United States began “Operation Iraqi Freedom” with an invasion of Iraq.
Other arguments supporting the invasion noted the ease with which the operation could be accomplished. In February 2002, some in the Department of Defense were suggesting the war would be “a cakewalk.” In November, referencing the short and successful Gulf War of 1990–1991, Secretary of Defense Rumsfeld told the American people it was absurd, as some were claiming, that the conflict would degenerate into a long, drawn-out quagmire. “Five days or five weeks or five months, but it certainly isn’t going to last any longer than that,” he insisted. “It won’t be a World War III.” And, just days before the start of combat operations in 2003, Vice President Cheney announced that U.S. forces would likely “be greeted as liberators,” and the war would be over in “weeks rather than months.”
Early in the conflict, these predictions seemed to be coming true. The march into Baghdad went fairly smoothly. Soon Americans back home were watching on television as U.S. soldiers and the Iraqi people worked together to topple statues of the deposed leader Hussein around the capital. The reality, however, was far more complex. While American deaths had been few, thousands of Iraqis had died, and the seeds of internal strife and resentment against the United States had been sown. The United States was not prepared for a long period of occupation; it was also not prepared for the inevitable problems of law and order, or for the violent sectarian conflicts that emerged. Thus, even though Bush proclaimed a U.S. victory in May 2003, on the deck of the USS Abraham Lincoln with the banner “Mission Accomplished” prominently displayed behind him, the celebration proved premature by more than seven years (Figure \(\PageIndex{4}\)).
MY STORY
Lt. General James Conway on the Invasion of Baghdad
Lt. General James Conway, who commanded the First Marine Expeditionary Force in Iraq, answers a reporter’s questions about civilian casualties during the 2003 invasion of Baghdad.
“As a civilian in those early days, one definitely had the sense that the high command had expected something to happen which didn’t. Was that a correct perception?”
—We were told by our intelligence folks that the enemy is carrying civilian clothes in their packs because, as soon as the shooting starts, they’re going put on their civilian clothes and they’re going go home. Well, they put on their civilian clothes, but not to go home. They put on civilian clothes to blend with the civilians and shoot back at us. . . .
“There’s been some criticism of the behavior of the Marines at the Diyala bridge [across the Tigris River into Baghdad] in terms of civilian casualties.”
—Well, after the Third Battalion, Fourth Marines crossed, the resistance was not all gone. . . . They had just fought to take a bridge. They were being counterattacked by enemy forces. Some of the civilian vehicles that wound up with the bullet holes in them contained enemy fighters in uniform with weapons, some of them did not. Again, we’re terribly sorry about the loss of any civilian life where civilians are killed in a battlefield setting.  [The civilian casualties happened because the Marines] felt threatened, [and] they were having a tough time distinguishing from an enemy that [is violating] the laws of land warfare by going to civilian clothes, putting his own people at risk. All of those things, I think, [had an] impact [on the behavior of the Marines], and in the end it’s very unfortunate that civilians died.
Who in your opinion bears primary responsibility for the deaths of Iraqi civilians?
DOMESTIC SECURITY
The attacks of September 11 awakened many to the reality that the end of the Cold War did not mean an end to foreign violent threats. Some Americans grew wary of alleged possible enemies in their midst and hate crimes against Muslim Americans—and those thought to be Muslims—surged in the aftermath. Fearing that terrorists might strike within the nation’s borders again, and aware of the chronic lack of cooperation among different federal law enforcement agencies, Bush created the Office of Homeland Security in October 2001. The next year, Congress passed the Homeland Security Act, creating the Department of Homeland Security, which centralized control over a number of different government functions in order to better control threats at home (Figure \(\PageIndex{5}\) ). The Bush administration also pushed the USA Patriot Act through Congress, which enabled law enforcement agencies to monitor citizens’ e-mails and phone conversations without a warrant.
The Bush administration was fiercely committed to rooting out threats to the United States wherever they originated, and in the weeks after September 11, the Central Intelligence Agency (CIA) scoured the globe, sweeping up thousands of young Muslim men. Because U.S. law prohibits the use of torture, the CIA transferred some of these prisoners to other nations—a practice known as rendition or extraordinary rendition—where the local authorities can use methods of interrogation not allowed in the United States.
While the CIA operates overseas, the Federal Bureau of Investigation (FBI) is the chief federal law enforcement agency within U.S. national borders. Its activities are limited by, among other things, the Fourth Amendment, which protects citizens against unreasonable searches and seizures. Beginning in 2002, however, the Bush administration implemented a wide-ranging program of warrantless domestic wiretapping, known as the Terrorist Surveillance Program, by the National Security Agency (NSA). The shaky constitutional basis for this program was ultimately revealed in August 2006, when a federal judge in Detroit ordered the program ended immediately.
The use of unconstitutional wire taps to prosecute the war on terrorism was only one way the new threat challenged authorities in the United States. Another problem was deciding what to do with foreign terrorists captured on the battlefields in Afghanistan and Iraq. In traditional conflicts, where both sides are uniformed combatants, the rules of engagement and the treatment of prisoners of war are clear. But in the new war on terror, extracting intelligence about upcoming attacks became a top priority that superseded human rights and constitutional concerns. For that purpose, the United States began transporting men suspected of being members of al-Qaeda to the U.S. naval base at Guantanamo Bay, Cuba, for questioning. The Bush administration labeled the detainees “unlawful combatants,” in an effort to avoid affording them the rights guaranteed to prisoners of war, such as protection from torture, by international treaties such as the Geneva Conventions. Furthermore, the Justice Department argued that the prisoners were unable to sue for their rights in U.S. courts on the grounds that the constitution did not apply to U.S. territories. It was only in 2006 that the Supreme Court ruled in Hamdan v. Rumsfeld that the military tribunals that tried Guantanamo prisoners violated both U.S. federal law and the Geneva Conventions.


Module 13 – End of Life Care
- Apply knowledge of the impact of pain on quality of life
- Demonstrate understanding of the need for sleep
- Develop understanding of the need for end-of-life care
- Demonstrate understanding of the stages of grief
People need care at the end of their life, often in the form of palliative care. Palliative care means care that is given to make a person as comfortable as possible as they live with an illness that will be the cause of their death. Hospice care is ordered when the person’s prognosis is less than six months. NAs who are assisting with end-of-life care should always use a compassionate, holistic, person-centered approach that keeps in mind the goal of comfort, rather than cure [1] .
Pain and Comfort
A person receiving palliative care or hospice care will likely experience pain and discomfort as part of their illness process. All the time, but particularly in the final stages of their life, residents have a right to comfort, rest, and sleep. Comfort, rest, and sleep are essential for a person’s overall wellbeing. Disruptions in a person’s comfort, rest, and sleep have a negative impact on a person’s holistic wellbeing (physical, emotional, spiritual).
A person is only comfortable when they are free from pain, anxiety, and emotional distress. A person is only comfortable if they are relaxed and at ease. NAs should always as a person what the NA can do to make them more comfortable. Rather than asking a yes-or-no question, asking “is there anything I can do to make you more comfortable” may allow a person more freedom to respond.
Pain looks different for everybody. NAs must never assume that somebody is free from pain, unless that person explicitly tells you they are free from pain. Sometimes a person in pain may need to be prompted more than once before they admit to being uncomfortable; NAs should get to know a person so they develop a sense of when the person is uncomfortable, and can ask follow-up questions when discussing their comfort.
GeriCare. (2021, March 2). What is pain? [Video]. Youtube. https://www.youtube.com/watch?v=att6sLZmKdU
Pain is a warning from the body that signals that some kind of damage is present. Though not technically a vital sign, it is sometimes considered the “fifth vital sign” because it provides caregivers with important information that may require a nursing response.
If a person says they are in pain, they are in pain. NAs must never second-guess a person’s testimony of pain. Refusing to believe somebody who says that they are in pain is an abusive behavior, and is not acceptable within a person-centered care framework.
Pain is a subjective experience, which means that everybody experiences and relates to pain differently. Some people may be comfortable expressing their pain and distress to others, while others may not want to express their pain and would rather grit their teeth through it. NAs should be attentive to a person’s pain signals when they are not comfortable expressing their pain openly.
- A person’s past experiences with pain, the idea of pain, and the idea of “resilience” or “weakness” can make a person less inclined to express their pain.
- Anxiety may prevent a person from expressing their pain if the person is not usually comfortable asking for help, or who believe that by voicing pain they are a burden on someone. NAs should go out of their way to assure anxious residents that they are there to help, that they are happy to provide care, and that NAs always prefer when a person in pain directly expresses that pain to them.
- Rest and sleep and pain are in a cyclical relationship. If a person is not rested and cannot sleep properly then they are more likely to experience pain, well, painfully. If a person experiences heightened pain levels, then they are less likely to rejuvenate through sleep and rest.
- One’s personal, familial, and cultural background plays a part in how they relate to pain. If somebody comes from a culture that discourages expressing one’s pain, or if they have internalized the belief that pain is something that ought to be suffered through rather than alleviated, they may be less likely to be honest about their pain levels with the care team.
Types of pain
Pain is felt differently by everyone, but there are different kinds of general pain that people can use to communicate the character and quality of their pain.
- Acute pain is sudden onset pain due to tissue damage resulting from injury, disease, trauma, or surgery. Acute pain lasts less than 6 months and diminishes as the damaged tissue heals.
- Chronic pain is pain that lasts longer than 6 months and persists after any tissue damage has healed. Chronic illnesses such as arthritis may be at the root of chronic pain.
- Radiating pain is pain felt in one part of the body that is caused by a problem in another part of the body. Examples may be developing a headache because of a toothache, or pain in the left arm and jaw during a heart attack.
When asking about pain, NAs can use a 1 – 10 scale to ask the person to rate their pain, in addition to asking questions about how the pain feels; is it a burning sensation, a stabbing sensation, does it feel like a shock? etcetera. Always follow facility protocol and the care plan when it comes to how to ask patients about their pain levels and quality.
Image by Robert Weis, CC BY-SA 4.0
Reporting and recording pain
NAs must carefully report and record when residents relay information about their pain. When recording communications about pain, NAs should write down the exact words that the person uses to describe their pain. The specific language the person uses can give nurses and doctors important clues into the pain’s underlying cause [2] .
These are some basic pieces of information NAs should make sure to record:
- Location of the pain (placement in the body)
- When the pain began, how long it lasted or is lasting
- The intensity of the pain over time, including any changes in the intensity of the pain throughout its duration
- Any other descriptive features the person can offer, including any observations they have about positions, activities, or conditions that alleviate the pain or make it worse.
Sometimes a person will not be able to communicate their pain levels, or will display pain signals without admitting to being in pain. If a person is unable to or won’t communicate their pain, NAs will need to observe them for other signs and symptoms of pain. If a resident displays or expresses any of the following symptoms of pain, NAs should report it to the nurse promptly and record it in the person’s chart [3] .
- Changes in appetite
- Dizziness, lightheadedness, and vertigo
- Nausea and/or vomiting
- Numbness and/or tingling
- Increases in pulse, respirations, and blood pressure
- Pale skin
- Difficulty sleeping
- Sweating
- Crying and/or gasping, grunting, and sighing
- Tightening of the facial muscles, including squeezing the eyes closed, grinding teeth, clenching the jaw, grimacing or frowning
- Changes in behavior such as increased restlessness, agitation, or distraction
NAs and pain management
So what is the NA’s role with regard to pain management during end-of-life care? NAs should focus on providing excellent basic care and making the person as comfortable as possible, including by being a calming and positive presence for them during moments of pain.
- Regular repositioning is an important aspect of pain management. Always follow the care plan and respond promptly to the resident’s preferences.
- Keep the person’s bed linens neat and wrinkle free. This goes hand in hand with repositioning as a strategy to prevent pressure injuries and ulcers. The last thing somebody needs during end-of-life care is to develop yet another source of physical discomfort.
- Assist with the person’s elimination needs promptly. Pain increases a person’s chance of incontinence, and having an unmet need to eliminate adds yet another source of discomfort.
- Apply cold and heat therapies as directed by the nurse, doctor, and by the care plan.
NAs can be a comforting presence to a person in pain by telling stories, conversing, and providing distraction and relaxation through guided imagery techniques. Recorded guided meditations or calming video and music compilations can also help relax a person. Ask a person what their favorite movie or music is, and see if you can play it as a pleasant means of distraction. The most important thing is to be attentive, responsive, and do one’s best to anticipate ways the person can be distracted from their discomfort.
Other factors impacting comfort
Comfort is different for everybody, and different people will all feel most comfortable in slightly different conditions. NAs should be aware of some factors that relate to comfort so they can best meet the person’s comfort preferences. Some factors that affect comfort are:
- Activity level – immobility comes with serious complication; if it is in the person’s care plan, NAs should encourage activity and exercise. Regular activity promotes physical comfort and high-quality rest.
- Room temperature – older adults are more susceptible to cold. OBRA requires that nursing home facilities be kept between 71- and 81-degrees Fahrenheit. If a person still experiences chill at 81 degrees, NAs can offer blankets.
- Ventilation and airflow – rooms with stale and stuffy air are unpleasant to be in. NAs can improve the airflow in a room by opening the person’s door, or opening a window depending on the outdoor air quality.
- Noise level – some people are bother by noise and prefer quiet. NAs can close the person’s door, and request that anybody having audible conversations in the hallway move to a common area instead. If the person would prefer noise to silence, NAs can play some of the resident’s favorite music.
- Odors – odors can be unpleasant and induce discomfort. NAs can reduce odors by providing attentive perineal, skin, and bathing care. NAs should not smoke on the job, but if they must they should make sure to thoroughly wash their hands, and be conscious of odors’ tendency to stick to clothing. Breath odors can be controlled by regular teeth brushing, mints, and gum.
- Lighting – lighting should be comfortable and safe. If a person finds harsh overhead lighting uncomfortable, NAs can see about options for softer and ambient lighting. If the person has difficulty seeing, adequate lighting will be an important safety consideration.
Sleep and Rest
Sleep is a basic need; without sleep, a person cannot function physically, cognitively, emotionally, or socially. Sleep is a state of unconsciousness that allows the mind and body to rest, restore its energy, and process information from the day. During sleep voluntary muscle activity is reduced and the metabolism is lowered. All of the person’s vital signs are lower than when the person is awake.
Sleep allows for restoration and healing. Adequate sleep promotes physical healing and tissue repair. It also helps a person to lower their stress levels and anxiety, and gain emotional clarity.
The Economist. (2019, January 30). What happens when we sleep? [Video]. Youtube. https://www.youtube.com/watch?v=eTgNgGO_bLs
Sleep can sometimes be elusive, or difficult to achieve, especially when somebody is in a new and unfamiliar environment; their regular routines and rhythms will be disrupted and thrown out of balance, which may result in poor and dysregulated sleep [4] .
- Make sure that all rooms have sufficient pillows and blankets.
- Make oneself available for conversation as the resident goes to sleep; trying to sleep in an unfamiliar environment can be difficult, and some people may appreciate a friendly presence.
- Make sure the lighting, noise, ventilation, and odor needs are met. Try to maintain quiet when a resident is sleeping, whether at night or as an afternoon nap.
- Remember that people who are ill will need more sleep than usual.
- A person’s nutrition and exercise can impact their sleep. If a resident is having difficulty sleeping and consumes caffeine regularly throughout the day, NAs can recommend that they lower or eliminate caffeine intake. Regular activity and exercise increases tiredness and can make it easier for a person to fall asleep.
Mental health problems such as anxiety and depression can negatively impact a person’s sleep. If a resident reports feelings of anxiety and depression, tell a nurse so they can develop strategies to address the resident’s mental wellbeing. Mental health professionals are available for persons with ongoing mental health concerns.
Sleep disorders
Sleep disorders can influence a person’s ability to sleep. Sleep disorders can be caused by a variety of factors including illnesses (physical and mental), medication, problems with the environment such as noise and lighting, and embodied distractions such as pain or the need to urinate [5] .
Image by Videoplasty.com, CC BY-SA 4.0
Insomnia is a chronic condition where the person cannot fall asleep or cannot stay asleep through the night. Some people may require medication to manage their insomnia, while others may be able to mitigate it through lifestyle changes.
Sleep deprivation is a condition where the amount or quality of sleep is seriously decreased. Many different factors can cause sleep deprivation; the best way to address sleep deprivation is to diagnose the underlying cause and work from there. Minimizing caffeine and increasing activity levels is often a first step.
Sleepwalking occurs when a person remains asleep but gets up and performs activities that they normally would only perform while awake. The sleepwalker is usually unaware and will have no memory of the event. If NAs encounter somebody sleepwalking they should gently guide them back to bed. People can become startled when woken from a sleepwalking episode; NAs should always interact gently with a person sleepwalking.
Caring for residents with disordered sleep
NAs can care for people in ways that allow them to get as much rest as they can.
- Care should be planned for uninterrupted rest; do not waken somebody to provide care unless it is necessary.
- Flexible bed times and waking times allow residents to be on their own schedule and sleep in the way best suited to their body’s rhythm.
- A warm bath or shower before going to bed can relax a person and soothe their muscles. A backrub can also help a person physically relax.
- Follow regular bedtime routines, offer the use of the bathroom, and make sure residents with incontinence are clean and dry.
- Provide a comfortable temperature, in addition to cozy and loose-fitting pajamas, and plenty of soft linens.
- Make sure the person feels safe. Sometimes this is accomplished by creating a pleasant sleeping environment, other times a person may need some conversation, music, or a guided meditation to mentally prepare for sleep.
- Pay attention to the resident’s routines, body language, and stated preferences. NAs should ask residents what makes them most comfortable, and remember their answer.
End-of-Life Care
Terminal illness
A terminal illness is a disease or injury for which there is no reasonable expectation of recovery [6] . Many illnesses and diseases have no cure, and are known to eventually be the cause of death. Similarly, after some injuries the body is not able to function, and recovery is not expected. Examples include serious damage to the brain and internal organs. When a disease or injury is reasonably expected to end in death, it is deemed terminal.
Doctors cannot truly predict when a terminal illness will end a person’s life. They may be able to make educated guesses, but so many different and sometimes inexplicable factors go into how a person responds to terminal illness that a precise prediction is ultimately impossible.
ElouiseFord, CC BY-SA 4.0
The care outcome for a person with a terminal illness will be strongly influenced by a person’s will to live and their experience of hope. A person with a terminal illness will likely prolong their life by engaging in activities they enjoy, remaining active in their community and social circle, and bringing an awareness of the value of their life into their daily reality.
At the same time, the nursing staff should be realistic about the person’s impending death. Language should not be softened because of a desire to make things easier on a person, since this can have the opposite impact; shying away from the terms “death” and “dying” is infantilizing and may prevent the person from reckoning with their circumstance.
Everybody dies. Death is a reality that brings meaning to the living of a life. Rather than ruminating on the fear and anxiety of death, NAs should consider how they can talk about death in a way that treats it as a natural, necessary stage of the life process.
Attitudes towards death
People have many different attitudes about death. Some of these attitudes are personal, while others relate to someone’s cultural and religious background. Some people believe in a paradise-like afterlife, others believe in reincarnation, and other believe that nothing much happens at all. Death rites, prayer and scripture readings, and funeral services are common in various religious and cultural practices.
NAs should ask if the person they are caring for would be comfortable sharing some of their attitudes and beliefs about death, and simply listen to them. It may give someone comfort to remind themselves of a framework for understanding their own death in the greater scheme of things [7] .
Many people strengthen their religious convictions, or seek out new ones, when they are made aware of the immanence of their death. This sort of spiritual grasping may be based on a genuine sense of spiritual awakening, a response to fear and anxiety, or both.
Adults may fear or resent their death. They may fear experiencing pain and suffering upon death, dying fearful and alone, and having their privacy and dignity invaded as they are dying. They may fear being separated from their loved ones, or leaving their dependents and community without them. Perhaps they were not ready to die, and still had plans, hopes, dreams or ambitions. These are difficult things to make peace with; if a person is able to use their spirituality and religion to make peace with the fact of their death, this should be encouraged.
Religious attitudes towards death
A person’s religious beliefs and cultural background will impact how they relate to their death, and the approaches to care that will be most helpful with the person’s spiritual outlook in mind. Someone who believes that their soul is headed for an eternity of either paradise or torture may be comforted by the idea leaving the earthly plane, or concerned and anxious for the fate of their soul. A person’s spiritual ideas about death may be a source of comfort, a source of anxiety, or both as they are dying.
Someone who believes in an afterlife with Heaven and Hell will likely want different spiritual care and communication than somebody who believes in reincarnation. When someone is reincarnated their essence or their constitutive elements returns to the total cycle of life and they are reborn, either as a human, animal, a celestial entity, or something else. They may want to reflect on their life and the aspects of it to which they assign high spiritual importance to consider their cyclical journey towards Nirvana.
In all cases, NAs will listen to residents’ thoughts and feelings about their death, and tell the nurse if they request any spiritual or religious services. All residents have a right to meeting their spiritual needs.
Meeting a person’s spiritual needs as they are dying is associated with better psychological and physiological outcomes. In other words, by fully meeting a terminally ill person’s spiritual needs, the healthcare team can help them live longer and ease the discomfort and emotional turmoil of their passing [8] .
Spiritual Needs
A dying person has psychological, social, and spiritual needs. NAs will have to address the full scope of a person’s needs in order to relieve their suffering as they are dying. A steady listening ear and comforting touch can be important to someone who feels scared and alone in these moments. Some people may request to see a spiritual leader or take part in religious practices; NAs should tell a nurse immediately if a person wants to see a religious official or to have religious rites performed.
- A dying person’s religious objects may become especially important to them as the they are dying. NAs must handle such objects with respect, and encourage the resident to find comfort in their religious practices if it is appropriate.
- NAs should provide a person with privacy when they want to pray or meditate, unless the person requests that they remain.
- A dying person may feel the need to take a confessional approach with whoever will listen. NAs must never judge anybody for the things they are told; a dying person deserves peace and dignity, even if they want to confess sources of guilt and other things they want to get off of their chest before passing. This information must be kept private and may only be shared with the person’s nurse. NAs should avoid discussing their own spiritual and religious beliefs with the dying person.
- NAs should spend quality time with dying residents. They may be tempted to avoid dying people, especially if they are uncomfortable with death themselves. A dying person deserves opportunities for human connection, and may carry anxiety about the possibility of dying alone.
- Never respond to a resident’s fear of death with clichés or personal stock-phrases. It is always best to acknowledge a resident’s fear and anxiety and attentively listen, and then inform the nurse. The person may benefit from the skilled care of a mental health professional or social worker.
Providing End-of-Life Care
End-of-life care is the care and support given to somebody and their family during the time surrounding their death. End-of-life care may range anywhere from a single day to multiple months. A person’s death may come on suddenly, or be a gradual and drawn-out process. Healthcare teams see and interact with death regularly – a person’s attitudes, feelings, and associations with death will impact the end-of-life care they provide.
Most people die either in a hospital or a long-term care facility, and hospice care is becoming a more widely used option [9] . A person in hospice care will likely be aware that they are dying. Such awareness means that they will have a unique set of psychological and spiritual needs. The healthcare team should provide every service available to make the person as holistically comfortable and secure as possible.
In order to provide good care to someone who is dying, NAs will need to bring an awareness of the dying process into their communications to approach the person with caring, kindness, and respect. They will also need to bring an understanding of their own feelings about death and dying into their care to remain positive, un-phased, and authentic in their interactions with the dying person.
A person’s emotional and spiritual experiences and beliefs regarding death can increase their suffering [10] . Perhaps they feel that they are leaving things unattended to, or have not gathered closure on important questions; the experience of dying can be disempowering and leave someone feeling out of control.
Being able to participate in the decision-making process about one’s own end-of-life care can help make someone feel more agential in their dying process. It also gives them an opportunity to prepare themselves for death. If somebody is unable to make their own decisions about end-of-life care, it may prevent them from reckoning frankly and honestly with their own death. Reckoning honestly with death is an important part of maintaining relationships and finding a sense of closure.
TEDx Talks. (2018, August 14). Making end of life care matter | Deb Wilkes | TEDxSouthampton [Video].
Hospice care is one form of palliative care, though palliative care is broader than hospice care. The goal of palliative care is symptom and pain management; while palliative care is given to people who have a terminal illness, it does not necessarily mean that somebody’s death is immanent. Someone with congestive heart failure may live decades after diagnosis with the right kind of palliative care. Palliative care uses a person-centered approach to keep someone’s holistic quality of life as high as possible while living with an incurable condition.
GeriCare. (2021, February). What you need to know about palliative care [Video]. Youtube. https://www.youtube.com/watch?v=KZ9ZXS4C3No
Supporting the person’s family is an important dimension of palliative care. Palliative care encourages residents to continue doing the things they enjoy, seeing the people they love, and generally leading a full life. Palliative care emphasizes symptom management, emotional wellbeing, and spiritual services and care.
Hospice care is palliative in the sense that it aims to make a person as comfortable and pain-free as possible; the goal is to facilitate a dignified death. Hospice also provides services to the person’s family and the healthcare team after the person’s death in the form of emotional care and support groups. Hospice care may be provided in a nursing facility or as home healthcare.
Stages of Grief
In her book On Death and Dying (1969), Dr. Elisabeth Kübler-Ross came up with the Five Stages of Grief model [12] . She breaks down the grief process of a dying person, or somebody coping the dying of a loved one, into five general stages: Denial, Anger, Bargaining, Depression, and Acceptance.
A dying person may not move through these stages linearly, they may not even start with denial. A person can also occupy more than one stage at a time, or shift back and forth between different stages depending on the day. It is not guaranteed that each dying person will experience all five stages. The stages apply both to the person who is dying, and to others in their life who have to reckon with the impending death of a loved one.
- Stage 1, Denial: The person experiences a refusal to recognize that they are dying. Denial can manifest in a refusal to make arrangements for one’s death, an insistence that the tests gave a false result, or an unwillingness to discuss one’s feelings about their health and death.
- Stage 2, Anger: Once somebody recognizes that they are dying, they may respond to this realization with anger ang rage. Their anger may be directed at their family, friends, the healthcare team, god, themselves, or at everything at once. NAs should always meet the anger of a dying person with compassion and empathy, and remember not to take their anger personally. Becoming angry is a normal part of reckoning with one’s death.
- Stage 3, Bargaining: After admitting to themselves that they really are dying, the person may try to strike a deal with the universe, god or God, or some other higher power. Such bargaining usually involves a promise to live differently in exchange for elongated life, perhaps to see their children grow up or another event after which the person believes they will have achieved some closure.
- Stage 4, Depression: Depression is a condition where a person becomes too sad and mournful to function normally. Perhaps they question the meaningfulness of their remaining time, withdraw from the people around them, and cannot bring themselves to perform simple tasks or care for their own wellbeing. The care team must be kind, patient, and understanding with people who are experiencing this kind of depression.
- Stage 5, Acceptance: Some people will come to accept their own death before it happens. This allows them to make final arrangements and say goodbye. People at this stage may seem detached from the world, or they may seem extra present. However a person responds to accepting their death, the care team should be available to listen, talk with, and assist the person with anything they’d like to do before dying.
These stages are descriptive, rather than prescriptive. In other words, nobody should try to move a dying person through the stages of grief. Instead, the stages provide a framework for thinking about and interpreting how somebody is responding to their death. The care team’s role is to listen and make the person as comfortable as possible, without trying to get the person to think or feel in a different way.
LevelUpRN. (2021, July 28). Stages and Types of Grief, Types of Comfort Care – Fundamentals of Nursing [Video]. Youtube. https://www.youtube.com/watch?v=9nRHY3oIIeU
Comfort
A central goal of caring for a dying person is to keep them physically comfortable. Residents have a Right to attentive and compassionate care at the time surrounding their death. As a person is dying all of their bodily systems will begin to slow down; their vitals will lower, they may lose control over their stomach and elimination, and they may become confused, disoriented, or appear vacant. They may become unable to express discomfort or ask for their needs to be met. NAs should remain attentive to the person’s needs even as they move closer toward death. Residents have a right to comfort and attentive care [13] .
- Frequent oral hygiene
- Carefully clean the person’s nose so it is free from crusts and drainage
- Regular skin care, bathing, and repositioning to promote cleanliness and prevent pressure ulcers
- Changing the bed linens and the resident’s clothing as needed
- Careful perineal care, especially after elimination
- Good body alignment in bed to promote comfort and easy rest
- Attentive pain management. NAs should report to the nurse if the resident appears to be in pain or discomfort.
A dying person may have personal objects with them, such as sentimental mementos, pictures of their family and friends, flowers, or religious objects. Such items should be positioned where the resident can always see them; carefully hand the objects to the person if they seem like they want to hold or touch them, and put them back when the person is finished.
Approaching death
A person’s comfort needs will change as they approach the moment of their death. Their bodily systems will lose function, and they may become uncomfortable as their body loses the ability to keep itself alive [14] .
Respiration
- Dyspnea is common as a person is dying. Being placed in semi-Fowler’s position can alleviate some pressure on their chest and make breathing easier. Additional oxygen can also be useful.
- The person may begin breathing with a wet sounding rattle called Cheyne-Stokes respiration; this occurs because mucus collects in the airway. A side-lying position, suctioning by the nurse, and mucus-reducing drugs can may be used to ease breathing.
- Air circulation is an important aspect of comfort. If a person is having trouble breathing, opening a window for fresh air or turning on a fan for increased circulation will help them breathe more easily.
Vision, hearing, speech
As a person approaches death, their vision, hearing, and speech systems will gradually fail.
- A person’s eyes stop working as they approach death. The person’s room at this moment should be well-lit but not bright; a dying person tends to turn towards sources of light.
- As a person progresses along their dying process, NAs must remember to verbalize their presence and their activities. Even if the person cannot respond, they are likely still hearing. Maintaining verbal communication with the person as they die is an important aspect of person-centered care, and may bring them comfort knowing that somebody is there with them.
- When speaking with the person, it is good to maintain a normal voice. NAs should not shout or whisper, but should instead engage with the person compassionately and under the assumption that the person can hear the NA and appreciates their presence and communication. NAs can use these moments to reassure the dying person and explain the care they are administering.
- A person will find it increasingly difficult to speak as they approach death. NAs should try not to put the person in a position of needing to provide long answers to questions, since this may be hard and exhausting if it is possible. NAs should do their best to anticipate the person’s needs; rather than asking “would you like your eyes cleaned,” NAs can notice when a resident’s eyes are gunky and can simply say “it looks like your eyes are uncomfortable, I am going to gently clean them for you with a warm cloth.” Similar approaches can be used for oral care, and for offering the person a bedpan.
It is necessary to maintain communication with the person, even if they are incapable of speaking or communicating. Since they can likely still hear, they may be calmed by knowing that care is being provided, or simply by the sound of another person’s voice. Something as simple as talking about one’s day or telling a story can help bring a dying person a moment of peace and distraction. What is one thing you could do or talk about to provide a dying person with a moment of comfort and connection? Write for 5 minutes, and share your response with a friend or classmate.
Nutrition and elimination
Nausea, vomiting, are common at the end of life. While nausea and vomiting can be mitigated using medications, loss of appetite is difficult to manage. NAs should never force somebody to eat or drink, as this will only make them more uncomfortable and emotionally distressed.
If a person is refusing to eat, alert the nurse promptly.
Some people may become too fatigued to eat and will require assistance, while others may simply refuse. Offering the person’s favorite foods in small, regular meals can stimulate appetite.
Urinary and fecal incontinence are common as a person is dying. So are constipation and urinary retention; NAs should report to the nurse if the person is showing symptoms for edema and constipation.
NAs will provide attentive catheter care according to the care plan.
The person may receive enemas to help ease their bowel movements.
The person and the family should have full control over how the person’s room is arranged. This helps the person and their family feel autonomous and in-control as they experience the end of life. Equipment that is unpleasant to look at such as suction machines, drainage containers, ventilators, and other devices should be removed or positioned out of sight of the resident. Personal items should be placed in view to help the person feel safe, peaceful, and at-home.
The family
A person’s family also goes through the stages of grief as their loved one is dying. This can be an extremely difficult time for family members and friends of the dying person.
NAs must provide close, attentive care to the person while also giving them and their family space to grieve and be together. NAs should be available, friendly, and courteous without imposing themselves on the family’s grieving process.
Some family members may want to participate in caring for the dying person. NAs should help family members care for the dying person, as long as it has been OK’d by the nurse.
Relationships with residents
NAs may develop close relationships with residents who are dying. Even if the NA feels especially close to the person, they should refrain from spending much time with the person while their family is present and instead focus on spending time with the person when they are not being visited by family and friends.
Be careful not to choose favorites among residents. Relationships are encouraged, because they genuinely improve a dying person’s quality of life. However, NAs should also remember that their care responsibilities extend to all patients they are assigned to, and that everybody deserves friendly companionship at the end of their life.
Legal and ethical concerns
There are certain legal and ethical issues at play when a person is dying or when they have already died [15] .
Advanced directives
One important legal concept NAs must be familiar with is that of advanced directives. Advanced directives are instructions that the terminally ill person decides upon in advance should they die or become incapable of making or communicating their decisions (if they fall into a coma, for example).
Power of attorney, also called durable power of attorney or a health care proxy, is one form of advanced directive in which the dying person names another person as the arbiter of their medical care should they become incapable of making their own decisions. Power of attorney in this context only applies to what sort of care someone will or won’t receive; it does not entail anything about control over their finances or assets.
A living will is a document that details what sort of care the person does or does not want while they are still alive. A living will may instruct doctors not to use measures that prolong a person’s dying process, or to remove measures that prolong a dying process.
The healthcare team must always respect the wishes of a dying person, regardless of whether they accord with their own religious, spiritual, or personal beliefs.
A Do Not Resuscitate (DNR) or “no code” order is put in place when the dying person decides that they do not want CPR performed on them when they go into cardiac arrest. When their heart stops beating, they want that to be their death; they do not want a healthcare team member to try to save them in that moment. Honoring DNR orders is an important part of respecting patient autonomy and empowering someone with agency over their own dying process.
The healthcare team needs to respect the wishes and autonomy of the dying person. It is critical that doctors and nurses take the time to fully explain the implications of advanced directives, and to follow up with the person to make sure they understand exactly what their choices are. Doctors and nurses are responsible for giving the person a realistic picture of what end-of-life treatment is and is not capable of doing.
Rights
A person who is dying still has basic quality of life rights that must be upheld for all residents. People who are dying may find themselves dehumanized or objectified because of their proximity to death.
NAs must always respect the rights of people who are dying, and advocate on their behalf if they notice these rights being devalued or violated.
- The right to privacy before and after death. A person always has the right to ask someone to leave the room, including healthcare staff and visitors. A person also has a right to visit with others privately.
- A person should not be unnecessarily exposed to provide care, even after the person has died. Health team members must treat a person’s body with respect and dignity before and after the person has died.
- A person always has a right to freedom from abuse, mistreatment, and neglect. They also have a right to freedom from physical and chemical restraints, unless they become and active danger to themselves or others.
- Residents have a right to a safe and home-like setting. They should be encouraged to arrange the room in the way that makes them most comfortable, and to decorate the room with personal possessions that bring them comfort.
- The right to make choices extends to the right to refuse care; at a certain point, a person and their family may make the decision to refuse any further medical treatment. NAs and the rest of the healthcare team must respect this choice, even though it amounts to the person choosing to die.
A dying person is less able to advocate for themselves, and is thus vulnerable to abuse and neglect. Make sure that all patients receive compassionate and attentive care.
Nearing death
The healthcare team, and the person themselves, may be able to tell when a person’s death is approaching. In the weeks leading to someone’s death, they may experience some or all of the following symptoms:
- Restlessness, agitation, and anxiety
- Depression
- Loss of appetite
- Nausea
- Dyspnea, shortness of breath, and pauses in breathing
- Drowsiness and persistent fatigue
- Confusion and disorientation
- Problems with elimination
- Swelling of the extremities and other areas
- Healing problems
- Changes in vital signs
- Diminished senses
The healthcare team may be able to tell when someone is about to die, or has just died. If NAs notice any of these signs they should alert the nurse immediately.
- Loss of movement, muscle tone, and sensation
- Abdominal swelling, vomiting, and involuntary emptying of the bowels and bladder
- The person’s measured body temperature rises, they feel cool to the touch with pallor, and have heavy perspiration
- The pulse becomes fast, weak, and irregular. Blood pressure will fall quickly.
- Slow or rapid respirations that give a “rattle” due to mucus in the airway
- A person’s pain decreases, and they may lose consciousness.
- When a person dies, they will have no pulse, no respirations, and no blood pressure. Their pupils will be dilated and fixed.
Postmortem
Postmortem care, or caring for the body of a person who has died, begins immediately after the doctor formally pronounces somebody as dead. A person’s family and friends may want to spend time with the body after their loved one has passed, either to process their own grief or two perform any religious or spiritual rites that they and the person deem necessary. NAs should be patient, kind, and present for family members grieving with a dead body.
Lecturio Nursing. (2022, October 19). How to Provide Postmortem Care After a Patient Death | Lecturio Nursing Clinical Skills [Video]. Youtube. https://www.youtube.com/watch?v=vtraSJQ6fsE
NAs provide postmortem care by turning off any machinery still hooked up to the person, and gently closing the eyes and mouth. Remember to provide for privacy, and to treat the body with gentleness and respect at all times.
NAs should position the body so it is properly aligned before rigor mortis sets in; rigor mortis is a stiffening of the body’s muscles that sets in 2 -4 hours after death. Once the body is properly positioned, NAs can gently sponge-bathe the body with the designated soap or cleansing agent. Drainage pads should be placed under the body’s head, buttocks, and anywhere else necessary to prevent leaking or mess.
NAs must practice Standard Precautions throughout the handling of a dead body.
The body should have a clean gown before being covered up to the neck with a sheet. Once the body is in good condition, visitors can enter and be with the body.
Once the visitors leave the body can be covered with a shroud, carefully transferred to a stretcher, and prepared for moving to a funeral home, morgue, or another location that prepares corpses for processing.
NAs should follow facility policy on cleaning the room and removing the person’s personal belongings after the body has been transferred.
Grieving
It is normal for staff members to grieve, especially if they were close with resident who passed. NAs should make sure to talk with friends and loved ones about their grief, and to do activities that allow them to emotionally and spiritually recharge.
If it seems like it would be helpful, NAs can share their grief with the person’s family, highlighting the positive experiences that the NA and the resident had together in the last stage of the resident’s life. The family may find comfort in knowing their loved one was cared for by somebody who saw their value and connected with them [16] .
Key Takeaways
- Pain has a heavy impact on a person’s overall quality of life. Towards the end of life, pain presents an obstacle to a resident’s comfort, sleep, and wellbeing. Check in with residents about their pain levels, and communicate with the nurse about the frequency and quality of the residents’ pain. Provide a comforting presence and atmosphere whenever possible.
- Sleep is essential for comfort at the end of life. Make sure that residents have good opportunities for rest by providing a comfortable atmosphere, helping them with sleep conducive activities and nutrition, and scheduling care tasks around a resident’s uninterrupted sleep.
- End-of-life care is an important part of helping somebody die comfortably and with dignity. End-of-life care always involves a holistic approach, and tends to a person’s physical need for comfort, as well as their psychological, social, and spiritual needs as they approach death.
- The stages of grief are denial, anger, bargaining, depression, and acceptance. A person may not go through all of these stages in the grieving process, and will probably not go through them in a linear order. Understanding each stage of grief can help the care team work with a terminally ill person and their family to provide dignity and autonomy throughout their dying process.
Comprehension Questions
1) When is a person comfortable? Select the best answer.
a. When they are having their psychosocial needs fulfilled.
b. When they are resting well, and free from pain.
c. When they are free from pain and emotional distress, and the temperature is between 71- and 81-degrees Fahrenheit
d. When they are free from pain and emotional distress, have the full scope of their needs met, and have agency over their sensory environment
2) If a resident tells you that they are in pain, how should you respond?
a. Immediately tell the nurse that the resident needs pain medication
b. Ask questions about the pain to learn more about what might be causing it and how it can be treated; report the pain and what you learn about it to the nurse
c. Ask follow-up questions to make sure that the person is really in pain
d. Record that the person is in pain and ask if they need anything else
3) What are some details NAs should include in their observations about a person’s pain? Select all that apply.
a. Non-verbal behaviors like crying, gasping, or tightening facial muscles
b. What you think should be done about the pain
c. The location, duration, and intensity of the pain
d. Whether you think the pain is as bad as claimed
e. Any positions or activities that might have caused or worsened the pain
4) Beginning with hygiene care, what are some things NAs can do to help residents wind down in the evening and have a comfortable and restful sleep? Try to write about a paragraph with 5 – 6 details of the care provided.
5) Respond to the following sentences with T (true) or F (false).
____ Doctors can exactly predict when a person will die once they are diagnosed with a terminal illness.
____ A person’s attitude towards death will be influenced by their cultural, religious, and personal background. Nobody relates to death in exactly the same way.
____ People tend to have a more comfortable and dignified dying process when somebody else makes their practical decisions for them. This is to give them privacy and the space to introspect about their death.
____ Palliative care and hospice care are the same thing.
____ The number of people who use hospice services is increasing.
6) Please list the five stages of grief, and write a short description of each.
7) You are providing care for a dying resident named Ms. Haley. Even though she had been told she had weeks to live, Ms. Haley had been in good spirits until this morning. After breakfast, she yelled at you and blamed you for her illness. Rather than react, you try to comfort her, because you know that Ms. Haley is undergoing the grief process. Which stage of grief is Ms. Haley displaying?
a. Denial
b. Bargaining
c. Anger
d. Depression
8) As a person dies, their sensory systems will diminish and fail. Please describe two ways that NAs should communicate with a resident at this stage of their dying process.
9) Respond to the following sentences with T (true) or F (false).
____ A “DNR” order means that a dying patient does not want a defibrillator used; staff should use CPR instead.
____ Residents, or their power of attorney on their behalf, have the right to refuse care.
____ Residents who are dying are often the most shielded from abuse and negligence because they often have visitors.
____ As a person is about to die, their measurable body temperature falls and they become warm to the touch.
____ A person has a right to dignity and respect even after death. This matters for how their body is treated and handled.
10) What are some things NAs should do when providing postmortem care? Select all that apply.
a. Position the body in alignment and place any incontinence pads under the buttocks and had before bathing the body.
b. Allow the body to remain in the clothes the person was wearing when they died.
c. Immediately tell the nurse so any religious rites can be performed.
d. Have the family come in right away so they know what has happened.
11) Consider your own relationship to death and grief. How has your life experience shaped your relationship to death? How do you hope you will be able to relate to your own death when it eventually arrives? What is your experience or understanding of grief? What do you think it means to grief healthily, either for your own death or that of a loved one?
12) You have been able to form a friendship with a dying resident named Mr. Emma. Recently, Mr. Emma has started saying “I’m so scared of dying” every afternoon. What stage(s) of grief do you think Mr. Emma is experiencing? How could you converse with Mr. Emma in a way that provides comfort and allows him the space to work through some of his feelings? What questions might you use to start this conversation?
References
- National Institute on Aging. (2021, May 14). Palliative Care. National Institute on Aging; National Institutes on Health. https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care ↵
- Nursing Assistant, Chapter 6 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License . ↵
- For information on the use of nonverbal pain scales, check out this video: https://www.youtube.com/watch?v=4uNnLd_oWf8 . While the video focuses on juvenile patients, it is a useful introduction to utilizing non-verbal pain scales for people across the lifespan. ↵
- Centers for Disease Control. Tips for Better Sleep (2022). https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html#:~:text=Go%20to%20bed%20at%20the,smart%20phones%2C%20from%20the%20bedroom ↵
- Centers for Disease Control. Key Sleep Disorders (2022). https://www.cdc.gov/sleep/about_sleep/key_disorders.html ↵
- Sorrentino, S. A., & Remmert, L. N. (2019). Mosby's essentials for nursing assistants (6th ed.), Chapter 37. Elsevier. ↵
- Check out this resource for more information on different cultural and religious attitudes toward death: https://courses.lumenlearning.com/suny-nursing-care-at-the-end-of-life/chapter/diversity-in-dying-death-across-cultures/ ↵
- Heering, Helle, and Stephanie Gunder. “Spiritual Needs of Hospitalized Patients.” CINAHL Nursing Guide, edited by Diane Pravikoff, Dec. 2018. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=T700608. ↵
- QuickStats: Percentage of Deaths, by Place of Death — National Vital Statistics System, United States, 2000–2018. MMWR Morb Mortal Wkly Rep 2020;69:611. DOI: dx.doi.org/10.15585/mmwr.mm6919a4external icon. ↵
- Schub, Tanja, and Penny March. “End-of-Life Care and Decision Making.” CINAHL Nursing Guide, edited by Diane Pravikoff, Aug. 2017. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=T700310 ↵
- Dugan, D. (2020). Nursing assisting: A foundation in caregiving (5th ed.), Chapter 27. Hartman. ↵
- Kübler-Ross, E. (1969). On death and dying. New York, The Macmillan Company. ↵
- Family Comfort Hospice and Palliative Care. (2019, May 27). The Vital Role of the CNA in Hospice and Palliative Care. https://familycomforthospice.org/the-vital-role-of-the-cna-in-hospice-and-palliative-care/#:~:text=The%20Certified%20Nursing%20Assistant%20(CNA,palliative%20care%20team%2C%20is%20crucial . ↵
- Dugan, D. (2020). Nursing assisting: A foundation in caregiving (5th ed.), Chapter 27. Hartman. ↵
- Sorrentino, S. A., & Remmert, L. N. (2019). Mosby's essentials for nursing assistants (6th ed.), Chapter 37. Elsevier. ↵
- Check out this video for more information on caring for dying people and their families: https://www.youtube.com/watch?v=qaGVst-r50U ↵


1.4.3: Intercultural Communication
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As mentioned in the Communication and Culture section intercultural communication generally describes communication efforts between different cultural groups or subgroups. Differences between those groups, even if they speak the same language, can create problems and make understanding each other much harder. As globalization has brought the whole world closer together, business between different cultures happens on a daily basis. To make things run smoothly, intercultural communication skills are crucial.
Intercultural communication research mainly focuses on national comparisons and is hooked in the background of management and organizational theories. One pioneering model is the one Geert Hofstede derived in worldwide studies of different nations along certain characteristics.
Hofstede refers to culture as “the collective programming of the mind distinguishing the members of one group or category of people from others” (Hofstede, 2013). Comparing values, behaviors and organization for different nations Hofstede developed five dimensions to classify cultural principles. Each dimension builds up between two poles who describe the idealized extremes of it.
Hofstedes original dimensions included power distance (PDI), individualism vs. collectivism (IDV), masculinity vs. femininity (MAS) and Uncertainty avoidance (UAI) (Hofstede, 2001). A fifth definition, the one of long-term vs. short-term orientation or in other words pragmatic vs. normative, was added by Micheal Bonds research in 1991, followed by the definition of indulgence vs. restraint by Michael Minkov (Hofstede 2013). In each dimension the lowest possible score is 0 and the highest is 100.
The following questions give a better understanding of the six dimensions which have been researched to a broad extent in the last couple of years:
Power distance:
- How flat are hierarchies?
- How does a culture deal with inequalities?
- Is societal influence concentrated in the hands of a few or distributed throughout the population?
- How authoritarian is a country’s organization?
- Are communication efforts interactive?
United States Score: 40
This score indicates a culture with flat hierarchies and a very low power distance. "Both managers and employees expect to be consulted and information is shared frequently. At the same time, communication is informal, direct and participative to a degree." (Hofstede, 2021)
Individualistic vs. Collectivist culture:
- Does the interest of the group or the individual matter the most?
- Are people only looking after themselves and their immediate family?
- How well are individuals integrated and networked?
United States Score: 91
With the rather high score of 91 the United States can be described as a rather individualistic culture with people looking after themselves and their immediate families first.
Masculinity vs. Femininity:
- Which values are aimed for?
- How strong is a society following material values and success in comparison to the quality of life, interpersonal relationships and the concern for the weak?
United States Score: 62
A score of 62 signals masculinity rather then femininity. The score of the US on Masculinity is high at 62, and this can be seen in the typical American behavioral patterns. This can be explained by the the combination of a high Masculinity drive together with the most Individualist drive in the world. In other words, Americans, so to speak, all show their Masculine drive individually. (Hofstede, 2021)
Uncertainty avoidance vs. taking risks:
- Do members of a society feel threatened by unknown situations?
- Are there attempts to control the future or do people just let it happen?
- How high is the willingness to try something new or different?
United States Score: 46
With a score of 46, the United States can be described as a pragmatic society that deals with uncertainties in a relaxed and flexible fashion. There is a fair degree of acceptance for new ideas, innovative products and a willingness to try something new or different, whether it pertains to technology, business practices or food.
Long-term vs. short-term orientation (Pragmatic vs. normative):
- How are individuals subordinating themselves for longer term purposes?
- How are the tendencies towards short-term spending and long-term savings, perseverance and quick results?
United States Score: 26
The United States is shown to be a normative country with a normative way of thinking. Motivation to save for the future is rather low, therefore the focus on quick results is high.
Indulgence vs. Constraint:
- How freely are hedonist drives as gratification towards enjoying life and having fun tolerated and allowed?
- Is the gratification of needs restricted by strong social norms?
United States Score: 68
A rather high score of 68 pictures the United States’s society indulgent. With it people tend to possess a positive attitude and a tendency towards optimism. Leisure time is regarded as important, also the ability to spend money as one likes and and to follow desires and needs to enjoy life and have fun.
As you can see in the questions above Hofstede’s model is all about comparison. National cultures and their distinct attitudes, behaviors and norms can be seen as specific through boundaries and differences in comparison to others. Although Hofstede’s model is widely accepted in organizational communication and management theory critics argue that most research is not integrated with findings from research that is not concentrating on purely economic and organizational values (Kirkman et al, 2006).
While values change with the developments of society globalization and convergence tendencies of new technologies and communication structures lead to a broader integrated international consumer culture and national values. General tendencies towards a culture of networked individualism are researched and referred to in literature (Castells 1996; Wellman 2002). Still Hofstede’s dimensions seem to be quite stable and remain over time. Changes in technology affect a lot of countries at the same time or with only a small delay and therefore make their relative position amongst the other nations rather stable as every nation shifts in the same direction.
Discussion
- What can you say about your nation’s culture?
- How would you classify it in terms of Hofstede’s model?
- How do you evaluate the United States’s scores? Do you agree?
- Have a look online to compare your estimation with your country’s scores!
- Compare with other countries you know.
Alternative links
Hofstede youtube channel “Hofstede insight”: www.youtube.com/user/HOFSTEDE.../5/PVbkjobD8ao
Hofstede homepage and score results for the United States :
References
Castells, M. (1996). The rise of the network society. Malden: Blackwell.
Hofstede, G. H. (2001). Culture’s consequences: Comparing values, behaviors, institutions and organizations across nations. Thousand Oaks: Sage.
Hofstede, G. H. (2013). National Culture. Retrieved from: geert-hofstede.com/national-culture.html
Jandt, F. E. (2012). An introduction to intercultural communication: Identities in a global community. Thousand Oaks: Sage.
Wellman, B. (2002). Little Boxes, Glocalization and Networked Individualism. In Tanabe, M.; van den Besselaar, P.; Ishida, T. (eds.). Digital Cities II. Computational and Sociological Approaches. Berlin: Springer. pp. 10-25.


12: Tracheostomy Care and Suctioning
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- 12.1: Tracheostomy Care and Suctioning Introduction
- Tracheostomy suctioning uses a sterile catheter that is inserted through a tracheostomy tube into a patient’s trachea. A tracheostomy tube is a tube that is inserted through a surgical opening in the neck to the trachea to create an artificial airway. Tracheostomies require routine care to prevent infection and obstruction, as well as frequent suctioning to maintain a patent airway. Tracheostomy care and suctioning are performed collaboratively by nurses and respiratory therapists.
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- 12.2: Basic Concepts Related to Suctioning
- It is important for the nurse to have an understanding of the underlying structures of the respiratory system before performing suctioning to ensure that care is given to protect sensitive tissues and that airways are appropriately assessed during the suctioning procedure.
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- 12.5: Checklist for Tracheostomy Suctioning and Sample Documentation
- Tracheostomy suctioning may be performed with open or closed technique. Open suctioning requires disconnection of the patient from the oxygen source, whereas closed suctioning uses an inline suctioning catheter that does not require disconnection.
Thumbnail: Tracheostomy tubes. (CC BY 3.0; Klaus D. Peter via Wikimedia Commons )


9.5.6: Marine (Humid) West Coast Climate
The marine or humid west coast climate is exactly what its name describes. This climate is found on the west coast of midlatitude continents and is very humid through most of the year. Its geographic location places it in the path of westerly winds from the ocean that bring cloudy skies, much precipitation, and mild temperatures. The distribution of the climate is greatly influenced by the orientation of mountain systems in North America and Europe.
Geographical Distribution
The marine west coast climate is found along a relatively narrow strip of coastal Oregon, Washington, British Columbia, and southern Alaska in North America. It is likewise found along coastal Chile in South America. The marine west coast climate extends further inland into northwest Europe than in North America due to the orientation of mountains. This climate is also found on the southeast coast of Australia and New Zealand.
Controlling Factors
The most important control over the climate characteristics of the marine west coast is its west coast location in the midlatitudes. Here maritime polar air masses are constantly coming ashore bringing mild temperatures and high humidity. In some cases like northern Europe, warm ocean currents moderate the temperature of the site.
As noted above, the orientation of mountains has a large effect on the geographic distribution of the climate. In North and South America, mountains tend to be north-south oriented, whereas in Europe they tend to run more west to east. The north-south orientation acts as barrier to oceanic air masses in the Westerlies forcing them to rise and cool producing cloudy, rainy conditions along the coast. In Europe, the oceanic air masses can penetrate further inland, moderating the climate of a much larger region.
A significant difference in the climate situations at Vancouver and London (below), both Marine West Coast climates, arises from location, local topography, and ocean current influence. The dry summer in Vancouver is due in part to subsiding, subtropical high pressure lying to the south. Precipitation is nearly double that of London due to local orographic uplift of air. Milder winter temperatures in London arise from the moderating influence of the North Atlantic Drift.
Distinguishing Characteristics
Temperature
The marine west coast is noted for its mild summers and winters and, as a result, a small annual temperature range. Its location on the west coast of a continent in the midlatitudes places the climate in the path of the Westerlies. In this situation, the climate receives a constant influx of oceanic air throughout the year. The mild temperatures are a direct result of the moderating influence of ocean bodies on air temperatures. The is especially true for those situations where a warm ocean current borders the continent, like the North Atlantic Drift's effect on northwestern Europe. Temperature ranges increase as one moves away from the coast.
Precipitation
Not only is the marine west coast noted for its mild temperatures but also for its heavy cloud cover and high humidity through much of the year. This is especially true for the marine west coast climate of North America where orographic uplift is an important climate control. Maritime polar air masses forced to rise up the windward, western slope create significant cloud cover and precipitation. The marine west coast climate is dominated by cyclonic activity embedded in the Westerlies. Frequent cyclonic storms bring prolonged periods of rain, drizzle and fog to these west coast locations. In some locations it is not uncommon to receive as much as 2540 mm (100 in) of precipitation in a year, an amount that rivals the rainy tropics.


9.3.1: Measuring Long Distances Over Uneven Terrain
Lesson
Let's measure long distances over uneven terrain.
Exercise \(\PageIndex{1}\): How Far Is It?
How do people measure distances in different situations? What tools do they use? Come up with at least three different methods and situations where those methods are used.
Exercise \(\PageIndex{2}\): Planning a 5K Course
The school is considering holding a 5K fundraising walk on the school grounds. Your class is supposed to design the course for the walk.
- What will you need to do to design the course for the walk?
- Come up with a method to measure the course. Pause here so your teacher can review your plan.
Exercise \(\PageIndex{3}\): Comparing Methods
Let’s see how close different measuring methods are to each other. Your teacher will show you a path to measure.
- Use your method to measure the length of the path at least two times.
- Decide what distance you will report to the class.
- Compare your results with those of two other groups. Express the differences between the measurements in terms of percentages.
- Discuss the advantages and disadvantages of each group’s method.