6.2: Annuities and Sinking Funds
Learning Objectives
In this section, you will learn to:
- Find the future value of an annuity.
- Find the amount of payments to a sinking fund.
Ordinary Annuity
In the first two sections of this chapter, we examined problems where money was deposited in a lump sum in an account and left there for the entire period. Now, we will solve problems where timely payments are made in an account. When a sequence of payments of some fixed amount is made in an account at equal intervals, we call that an annuity . And this is the subject of this section.
To develop a formula to find the value of an annuity, we will need to recall the formula for the sum of a geometric series. A geometric series is of the form:
\[a + ax + ax^2 + ax^3+ \ldots + ax^n. \label{eq1} \]
In a geometric series, each subsequent term is obtained by multiplying the preceding term by a number, called the common ratio . A geometric series is completely determined by knowing its first term, the common ratio, and the number of terms.
The first term of the series in Equation \ref{eq1} is \(a\), the common ratio is \(x\), and the number of terms is \(n+1\). The following are some examples of geometric series.
\[3 + 6 + 12 + 24 + 48 \nonumber \]
This above series has first term \(a = 3\) and common ratio \(x = 2\)
\[2 + 6 + 18 + 54 + 162\nonumber \]
This above series has first term \(a = 2\) and common ratio \(x = 3\)
\[37 + 3.7 + 0.37 + 0.037 + 0.0037\nonumber \]
This above series has first term \(a = 35\) and common ratio \(x = 0.1\)
In your algebra class, you developed a formula for finding the sum of a geometric series. You probably used \(r\) as the symbol for the ratio, but we are using \(x\) because \(r\) is the symbol we have been using for the interest rate. The formula for the sum of the terms of a geometric series with first term \(a\), common ratio \(x\) and last term \(ax^{n}\) is:
\[\frac{a\left(x^{n+1}-1\right)}{x-1} \nonumber \]
We will use this formula to find the value of an annuity. Consider the following example.
Example \(\PageIndex{1}\)
If at the end of each month a deposit of $500 is made in an account that pays 8% compounded monthly, what will the final amount be after five years?
Solution
There are 60 deposits made in this account. The first payment stays in the account for 59 months, the second payment for 58 months, the third for 57 months, and so on.
- The first payment of $500 will accumulate to an amount of $500(1 + 0.08/12) 59 .
- The second payment of $500 will accumulate to an amount of $500(1 + 0.08/12) 58 .
- The third payment will accumulate to $500(1 + 0.08/12) 57 .
- The fourth payment will accumulate to $500(1 + 0.08/12) 56 .
And so on . . .
Finally the next to last (59 th ) payment will accumulate to \($500(1 + 0.08/12)^1\).
The last payment is taken out at the same time it is made and will not earn any interest.
To find the total amount in five years, we need to add the accumulated value of these sixty payments.
In other words, we must find the sum of the following series.
\[\$ 500(1+0.08 / 12)^{59}+\$ 500(1+0.08 / 12)^{58}+\$ 500(1+0.08 / 12)^{57}+\ldots+\$ 500 \nonumber \]
Written backward, we have
\[ \$500 +\$ 500(1+0.08 / 12)+\$ 500(1+0.08 / 12)^{2}+\ldots+\$ 500(1+0.08 / 12)^{59} \nonumber \]
This is a geometric series with \(a = $500\), \(r = (1 + 0.08/12\), and \(n = 59\). The sum is
\[\begin{align*} \text{sum} &= \dfrac{\$ 500\left[(1+0.08 / 12)^{60}-1\right]}{0.08 / 12} \\[4pt] &=\$ 500(73.47686) \\[4pt] &=\$ 36,738.43 \end{align*} \nonumber \]
When the payments are made at the end of each period rather than the beginning, we call it an ordinary annuity .
Future Value of an Ordinary Annuity
If a payment of PMT dollars is made in account m times a year at an interest \(r\), then the final amount \(FV\) after \(t\) years is
\[\mathbf{FV}=\frac{\mathbf{PMT}\left[(\mathbf{1}+\mathbf{r} / \mathbf{m})^{\mathbf{m} \mathbf{t}}-\mathbf{1}\right]}{\mathbf{r} / \mathbf{m}} \nonumber \]
The future value is also called the accumulated value
Tanya deposits $300 at the end of each quarter in her savings account. If the account earns 5.75% compounded quarterly, how much money will she have in 4 years?
Solution
The future value of this annuity can be found using the above formula.
\[\begin{align*} FV&=\frac{\$ 300\left[(1+.0575 / 4)^{16}-1\right]}{0.0575 / 4} \\[4pt] &=\$ 300(17.8463) \\[4pt] &=\$ 5353.89 \end{align*} \nonumber \]
If Tanya deposits $300 into a savings account earning 5.75% compounded quarterly for four years, then at the end of 4 years, she will have $5,353.89
Robert needs $5,000 in three years. How much should he deposit monthly in an account that pays 8% compounded monthly to achieve his goal?
Solution
If Robert saves PMT dollars per month, after three years, he will have
\[\dfrac{PMT\left[(1+.08 / 12)^{36}-1\right]}{0.08 / 12} \nonumber \]
But we'd like this amount to be $5,000. Therefore,
\[\begin{align*} \frac{\mathrm{PMT}\left[(1+.08 / 12)^{36}-1\right]}{.08 / 12} &=\$ 5000 \\[4pt] \mathrm{PMT}(40.5356) &=\$ 5000 \\[4pt] \mathrm{PMT} &=\frac{5000}{40.5356}\\[4pt] &=\$ 123.35 \end{align*} \nonumber \]
Robert needs to deposit $123.35 at the end of each month for three years into an account paying 8% compounded monthly to have $5,000 at the end of 5 years.
Sinking Fund
When a business deposits money at regular intervals into an account to save for a future purchase of equipment, the savings fund is referred to as a " sinking fund ." Calculating the sinking fund deposit uses the same method as the previous problem.
A business needs $450,000 in five years. How much should be deposited each quarter in a sinking fund that earns 9% compounded quarterly to have this amount in five years?
Solution
Again, suppose that \(PMT\) dollars are deposited each quarter in the sinking fund. After five years, the future value of the fund should be $450,000. This suggests the following relationship:
\[\begin{align*} \dfrac{\mathrm{PMT}\left[(1+ 0.09 / 4)^{20}-1\right]}{0.09 / 4} &=\$ 450,000 \\[4pt] \mathrm{PMT}(24.9115) &=450,000 \\[4pt]
\mathrm{PMT} &=\dfrac{450000}{24.9115} \\[4pt] &=\$ 18,063.93 \end{align*} \nonumber \]
The business needs to deposit $18,063.93 at the end of each quarter for five years into a sinking fund earning interest of 9% compounded quarterly to have $450,000 at the end of 5 years.
Annuity Due
If the payment is made at the beginning of each period rather than at the end, we call it an annuity due . The formula for the annuity due can be derived similarly. Reconsider Example 1, with the change that the deposits are made at the beginning of each month.
Example \(\PageIndex{5}\)
If at the beginning of each month, a deposit of $500 is made in an account that pays 8% compounded monthly, what will the final amount be after five years?
Solution
There are 60 deposits made in this account. The first payment stays in the account for 60 months, the second payment for 59 months, the third for 58 months, and so on.
- The first payment of $500 will accumulate to an amount of \($500(1 + 0.08/12)^{60}\).
- The second payment of $500 will accumulate to an amount of \($500(1 + .08/12)^{59}\).
- The third payment will accumulate to \($500(1 + 0.08/12)^{58}\).
And so on . . .
The last payment is in the account for a month and accumulates to \($500(1 + 0.08/12)\)
To find the total amount in five years, we need to find the sum of the series:
\[$500(1 + 0.08/12)^{60} + $500(1 + 0.08/12)^{59} + $500(1 + 0.08/12)^{58} + \ldots + $500(1 + 0.08/12) \nonumber \]
Written backward, we have
\[$500(1 + 0.08/12) + $500(1 + 0.08/12)^2 + \ldots + $500(1 + 0.08/12)^{60} \nonumber \]
If we add $500 to this series and later subtract that $500, the value will not change. We get
\[\textbf{\$500} + $500(1 + 0.08/12) + $500(1 + 0.08/12)^2 + \ldots + $500(1 + 0.08/12)^{60} - \textbf{\$500} \nonumber \]
Except for the last term, we have a geometric series with \(a\) = $500, \(r\) = (1 + .08/12), and \(n\) = 60. Therefore, the sum is
\[\begin{align*} \mathrm{A} &=\frac{\$ 500\left[(1+0.08 / 12)^{61}-1\right]}{0.08 / 12}-\$ 500 \\[4pt] &=\$ 500(74.9667)-\$ 500 \\[4pt] &=\$ 37483.35-\$ 500 \\[4pt] &=\$ 36983.35 \end{align*} \nonumber \]
So, in the case of an annuity due, to find the future value, we increase the number of periods \(n\) by one and subtract one payment.
\[\mathrm{FV}=\frac{\mathrm{PMT}\left[(1+\mathrm{r} / \mathrm{m})^{\mathrm{mt}+1}-1\right]}{\mathrm{r} / \mathrm{m}}-\mathrm{PMT} \nonumber \]
Summary
Finally, the author wishes that the students learn the concepts so they will not have to memorize every formula. It is for this reason formulas are kept at a minimum. But before we conclude this section, we will once again mention one single equation that will help us find the future value and the sinking fund payment.
If a payment of \(PMT\) dollars is made in an account \(m\) times a year at an interest \(r\), then the future value \(\mathrm{FV}\) after \(t\) years is
\[\mathbf{FV}=\frac{\mathbf{PMT}\left[(\mathbf{1}+\mathbf{r} / \mathbf{m})^{\mathbf{mt}}-\mathbf{1} \right]}{\mathbf{r} / \mathbf{m}} \nonumber \]
Note that the formula assumes that the payment period is the same as the compounding period. If these are not the same, then this formula does not apply.


1.4: Financial Statements
The goal of journalizing, posting to the ledgers, and preparing the trial balance is to gather the information necessary to produce the financial statements . The time period concept requires companies produce the financial statements on a regular basis over the same time interval, such as a month or year. Most of the amounts on these statements are copied directly from the trial balance, and then appropriate calculations and summary amounts are also displayed. The first of the four financial statements will be discussed here.
1.4.1 Income Statement
The net income from a business’s operations for a period of time is so important to business people and investors that one financial statement—the income statement—is dedicated to showing what that amount is and how it was determined.
The income statement is a report that lists and summarizes revenue, expense, and net income information for a period of time, usually a month or a year. It is based on the following equation: Revenue - Expenses = Net income (or Net loss). Revenue is shown first; a list of expenses follows, and their total is subtracted from revenue. If the difference is positive, there is a profit, or net income. If the difference is negative, there is a net loss that is typically presented in parentheses as a negative number.
The income statement answers a business’s most important question: How much profit is it making? It is limited to a specific period of time (month or year) from beginning to end. The income statement relies on the matching principle in that it only reports revenue and expenses in a specified window of time. It does not include any revenue or expenses from before or after that block of time.
FORMATTING TIPS
Complete heading: Company Name, Name of Financial Statement, Date
Two Columns of numbers—left one for listing items to be sub-totaled; right one for results
Dollar signs go at the top number of a list of numbers to be calculated
Category headings for revenue and expenses only if there is more than one item listed in the category
Expenses listed in order of highest to lowest dollar amounts, except for Miscellaneous Expense, which is always last
The word “Expense” on expense account names
Single underline just above the result of a calculation (two of these)
Dollar sign on final net income number
Double underline below the final net income result
You have just learned about the income statement—the accounts it displays and its format. We will hold off for now on the other three financial statements— the retained earnings statement, the balance sheet, and the statement of cash flows —and learn about those later.
1.4.2 The Accounting Cycle
Accounting is practiced under a guideline called the time period assumption, which allows the ongoing activities of a business to be divided up into periods of a year, quarter, month, or other increment of time. The precise time period covered is included in the headings of the income statement, the retained earnings statement, and the statement of cash flows.
Therefore, the accounting process is cyclical. A cycle is a period of time in which a series of accounting activities are performed. As was just stated, the typical accounting cycle is a year, a month, or perhaps a quarter. Once the current cycle is completed, the same recording and reporting activities are then repeated in the next period of time of equal length.
In accounting, journalizing and posting transactions to the ledgers are done every day in the cycle. Financial statements are typically prepared only on the last day of the cycle. Once the financial statements are complete, the process continues on into the next accounting period, where again the financial statements are the goal of the recordkeeping process.
1.4.3 Temporary Accounts
The accounts on the income statement are called temporary accounts. They are used to record operational transactions for a specific period of time. Once the income statement is prepared to report the temporary account balances at the end of the period, these account balances are set back to zero by transferring them to another account. When the next accounting period begins, the beginning balances of the temporary accounts are zero, for a fresh start.
1.4.4 Closing Entries
The financial statements are the goal of all that is done in the accounting cycle. However, there are some steps that need to be taken once those reports are completed to set up the ledgers for the next cycle. These steps involve closing entries.
Closing entries are special journal entries made at the end of the accounting period (month or year) after the financial statements are prepared but before the first transaction in the next month is recorded in the journal. The purpose of closing entries is to set the balances of income statement accounts back to zero so you can start fresh and begin accumulating new balances for the next month. This process ensures that the balances on the second month’s income statement do not include amounts from transactions in the first month.
Profit at the end of the accounting period is transferred into a new account called Retained Earnings when the revenue and expense accounts are closed out. The Retained Earnings account is only used for closing entries.
Closing entries transfer the balances from the revenue and expense accounts into Retained Earnings in preparation for the new month . Retained Earnings is an account where profit is “stored.” Think of the retained earnings balance as “accumulated profit,” or all the net income that the business has ever generated since it began operations.
Assume a business’s accounting period is a month. For the first month in which the business operates, the beginning retained earnings balance is zero since there were no previous periods and therefore no previous profits. At the end of the first month, the retained earnings balance equals the net income for the month.
After the first month, when closing entries for the current month are journalized and posted, the additional net income for the next month is added to any net income already in Retained Earnings from previous months. Since Revenue - Expenses = Net Income , moving revenue and expense balances into Retained Earnings is the same as moving the net income.
A track star is practicing running a lap at a time around the track. He has a timekeeper with a stopwatch timing each lap. The timekeeper clicks “Start” and the runner takes off. He crosses the finish line in 50 seconds, the time elapsed as shown on the stopwatch when “Stop” was clicked.
The runner rests, drinks, and decides to try again to see if he can do better. The timekeeper clicks “Start” and the runner takes off, running even faster. He crosses the finish line in 95 seconds, the time elapsed as shown on thestopwatch when “Stop” was clicked.
What is wrong with this picture? Was he so much slower? He did not have a poor sprint; he had a poor timekeeper! This person did not reset the stopwatch to zero for the second run, so the 50 seconds from the first run was includedwith the 45 seconds from the second run. The runner can subtract the 50 from the 95, but who wants to do math on the track? That is what the reset button is for, and it enables the results of both runs to be easily compared.
Similarly, income statements include revenue and expense amounts for a period of time—a month or a year. After one month is reported, the ledger balances of these accounts must be reset to zero so that the next month’s income statement does not include amounts from the previous month. This is done by closing out the revenue and expense ledger balances and resetting their balances to zero.
The Retained Earnings account is not closed out; instead, revenue and expense accounts are closed out into it. The effects are that the credit balance in Retained Earnings increases each month by the month’s net income amount, and the balances of Fees Earned and all the expense accounts become zero.
Closing entries are entered in the same journal that was used for the general entries during the month. The first closing entry is journalized right after the last general entry. Closing entries must be posted to the ledgers to impact the revenue, expense, and Retained Earnings account balances.
As an example, assume that on 6/30 Fees Earned has a credit ledger balance of $2,100 and Rent Expense (the only expense account) has a debit ledger balance of $500. Net income is therefore $1,600. The closing entry process would be as follows:
-
Zero out the Fees Earned account
(and any other revenue accounts, if there are others.)
Debit Fees Earned for its credit balance of $2,100 to close it out and bring its balance to zero.
Credit Retained Earnings for the same amount.
Date Account Debit Credit 6/30 Fees Earned 2,100 ▼ Fees Earned is a revenue account that is decreasing . Retained Earnings 2,100 ▲ Retained Earnings is an equity account that is increasing . -
Zero out the Rent Expense account
(and any other expense accounts, if there are others.)
Credit Rent Expense for its debit balance of $500 to close it out and bring the balance to zero.
Debit Retained Earnings for the same amount.
Date Account Debit Credit 6/30 Retained Earnings 500 ▼ Retained Earnings is an equity account that is decreasing . Rent Expense 500 ▼ Rent Expense is an expense account that is decreasing.
EXAMPLE
One month to the next WITHOUT closing entries on 6/30
The following journal shows five June transactions. (There would be more, but we will just use five for the example.) These are posted to the ledgers on the right. The running balance in Fees Earned as of 6/30 is a $2,100 credit. The running balances of Rent Expense and Wages Expense as of 6/30 are a $500 debit and a $300 debit, respectively. These three amounts would be reported on the income statement in arriving at a net income of $1,300 for June.
Then July begins and the journal also shows the first three July transactions. Once again Rent Expense on the first of the month is $500, the first Fees Earned transaction is $900, and Wages Expense is $300. Both amounts are posted to their respective ledgers, as is shown in the following example.
| Date | Account | Debit | Credit | |
| 6/1 | Rent Expense | x | 500 | |
| Cash | x | 500 | ||
| 6/5 | Cash | x | 600 | |
| Fees Earned | x | 600 | ||
| 6/8 | Wages Expense | x | 300 | |
| Cash | x | 300 | ||
| 6/20 | Cash | x | 700 | |
| Fees Earned | x | 700 | ||
| 6/29 | Cash | x | 800 | |
| Fees Earned | x | 800 | ||
| 6/29 | Cash | x | 800 | |
| Fees Earned | x | 800 | ||
| 7/1 | Rent Expense | x | 500 | |
| Cash | x | 500 | ||
| 7/2 | Cash | x | 900 | |
| Fees Earned | x | 900 | ||
| 7/7 | Wages Expense | x | 300 | |
| Cash | x | 300 | ||
LEDGERS (EXCEPT CASH)
| Date | Item | Debit | Credit | Debit | Credit |
| Date | Item | Debit | Credit | Debit | Credit |
| 6/5 | 600 | 600 | |||
| 6/20 | 700 | 1,300 | |||
| 6/29 | 800 | 2,100 | |||
| 7/2 | 900 | 3,000 | |||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/1 | 500 | 500 | |||
| 7/1 | 500 | 1,000 | |||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/8 | 300 | 300 | |||
| 7/1 | 300 | 600 | |||
Now there is an inconsistency. When the 7/1 Rent Expense debit is posted, the running balance becomes $1,000. According to procedure, that final balance would be copied to July’s income statement. That report would indicate that it cost the company $1,000 in rent during July, which is clearly not true. It only cost $500 for rent in July. The problem is that the $500 in June became a part of the July running total.
The same issue is true for Fees Earned. Only $900 was earned in July so far as of 7/2, but the running balance is showing $3,000. That is because the running total to date in July also includes the $2,100 that was earned in June.
The matching principle in accounting states that the revenue earned in a period must be reported in conjunction with the expenses incurred in that same period. The period we are now referring to is the month of July in this example. However, June’s revenues and expenses are still included in the balances in the ledgers. Closing entries on 6/30 here would have avoided this situation but were omitted, so the July balances erroneously contain amounts from June as well.
EXAMPLE
One month to the next WITH closing entries on 6/30
The following journal has similar transactions to the previous example PLUS it has the necessary closing entries in red for the three income statement accounts. It also shows how posting the closing entries impact the ledger account balances: revenue and expense balances are now zero on 6/30, and the Retained Earnings balance has increased from zero. Closing entries are shown in red in the following example. It is a good idea to enter the word “Closing” in the Item column in the ledgers to indicate that a closing entry has been posted.
| Date | Account | Debit | Credit | |
| 6/1 | Rent Expense | x | 500 | |
| Cash | x | 500 | ||
| 6/5 | Cash | x | 600 | |
| Fees Earned | x | 600 | ||
| 6/8 | Wages Expense | x | 300 | |
| Cash | x | 300 | ||
| 6/20 | Cash | x | 700 | |
| Fees Earned | x | 700 | ||
| 6/29 | Cash | x | 800 | |
| Fees Earned | x | 800 | ||
| 6/30 | Fees Earned | x | 2,100 | |
| Retained Earnings | x | 2,100 | ||
| 6/30 | Retained Earnings | x | 500 | |
| Rent Expense | x | 500 | ||
| 6/30 | Retained Earnings | x | 300 | |
| Wages Expense | x | 300 | ||
| 7/1 | Rent Expense | x | 500 | |
| Cash | x | 500 | ||
| 7/2 | Cash | x | 900 | |
| Fees Earned | x | 900 | ||
| 7/7 | Wages Expense | x | 300 | |
| Cash | x | 300 | ||
LEDGERS (EXCEPT CASH)
| Date | Item | Debit | Credit | Debit | Credit |
| 6/30 | Closing | 2,100 | 2,100 | ||
| 6/30 | Closing | 500 | 1,600 | ||
| 6/30 | Closing | 300 | 1,300 | ||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/5 | 600 | 600 | |||
| 6/20 | 700 | 1,300 | |||
| 6/29 | 800 | 2,100 | |||
| 6/30 | Closing | Closing | 0 | ||
| 7/2 | 900 | 900 | |||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/1 | 500 | 500 | |||
| 6/30 | Closing | 500 | 0 | ||
| 7/1 | 500 | 500 | |||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/8 | 300 | 300 | |||
| 6/30 | Closing | 300 | 0 | ||
| 7/1 | 300 | 300 | |||
Notice when the first July transactions are posted to the income statement accounts, the amounts are added to previous balances of zero. When the first July transaction is recorded in these accounts, it becomes the beginning balance for the new accounting period.
By doing this, the income statement for June reports only June transactions, and the income statement for July reports only July transactions. The income statements for the two months can then easily be compared.
The following table summarizes information about the accounts you know so far:
| ACCOUNT TYPE | ACCOUNTS | TO INCREASE | TO DECREASE | NORMAL BALANCE | FINANCIAL STATEMENT | CLOSE OUT? |
| Asset | Cash | debit | credit | debit | Balance Sheet | NO |
| Stockholders’ Equity | Retained Earnings | credit | debit | credit | Balance Sheet | NO |
| Revenue | Fees Earned | credit | debit | credit | Income Statement | YES |
| Expense |
Wages Expense
Rent Expense Utilities Expense Supplies Expense Insurance Expense Advertising Expense Maintenance Expense Miscellaneous Expense |
debit | credit | debit | Income Statement | YES |
1.4.5 Revenue Transactions on Account
EXAMPLE
6/1 Provide a service to a customer for $100 and receive cash.
| Date | Account | Debit | Credit | ||
| 6/1 | Cash | 100 | ▲ Cash is an asset account that is increasing . | ||
| Fees Earned | 100 | ▲ Fees Earned is a revenue account that is increasing . | |||
The 6/1 transaction is complete on that day. The company provided the service, and the customer paid cash in full for that service.
A second possibility involves the business sending a bill, or invoice, to the customer and typically giving the customer thirty days to pay. This is a revenue transaction on account .
The business records earnings and credits Fees Earned when it provides the service, regardless of when it receives the payment. When Fees Earned is credited because revenue is earned, there are now two possible debit accounts: Cash (paid on the spot), or Accounts Receivable (to be paid in the future).
Accounts Receivable is an asset account that keeps track of how much customers owe because a business sent invoices for goods or services to the customers rather than immediately receiving cash from them. This account is used as a substitute for a debit to Cash when a company provides services to customers and bills them on account rather than receiving cash right away.
When the customer pays the invoice and the business receives the cash payment, Cash is debited and Accounts Receivable is credited. The customer’s Accounts Receivable balance becomes zero now that they have paid in full.
The rules of debit and credit for Accounts Receivable are the same as they are for Cash since both are asset accounts.
| Debit ACCOUNTS RECEIVABLE when you invoice a customer | Accounts Receivable increases |
| Credit FEES EARNED when you provide a service to a customer | Fees Earned increases |
| Debit CASH when the customer pays the invoice | Cash increases |
| Credit ACCOUNTS RECEIVABLE when the customer pays | Accounts Receivable decreases |
The journal and the Accounts Receivable ledger below illustrate a revenue transaction on account for a business.
EXAMPLE
6/1 Provide a service to a customer for $200 on account and send the customer an invoice.
6/30 Receive payment on account from the customer for the service provided on 6/1.
| Date | Account | Debit | Credit | ||
| 6/1 | Accounts Receivable | x | 200 | ▲ Accounts Receivable is an asset account that is increasing . | |
| Fees Earned | x | 200 | ▲ Fees Earned is a revenue account that is increasing . | ||
| 6/30 | Cash | x | 200 | ▲ Cash is an asset account that is increasing . | |
| Accounts Receivable | x | 200 | ▼ Accounts Receivable is an asset account that is decreasing . | ||
| Accounts Receivable | |||||
| Date | Item | Debit | Credit | Debit | Credit |
| 6/1 | 200 | 200 | |||
| 6/30 | 200 | 0 |
In the 6/1 transaction, the company has received the product or service but has not paid for it yet. When the company does pay on 6/30, both parties in the 6/1 transaction have now received what they are due.
Stated another way, the company credited Accounts Payable when it received the product or service and later debited it when it paid the cash to the vendor. By 6/30, the two Accounts Payable entries negate one another (one credit and one debit to the same account for the same amount), resulting in a zero balance in that account on 6/30. If the Accounts Payable lines are crossed out in the journal since they wash out to zero, notice you are ultimately left with a debit to Supplies Expense and a credit to Cash. Both parties have received what they are due from the transaction by 6/30. The company received product or service and the vendor received cash.
The following table summarizes information about the accounts you know so far:
| ACCOUNT TYPE | ACCOUNTS | TO INCREASE | TO DECREASE | NORMAL BALANCE | FINANCIAL STATEMENT | CLOSE OUT? |
| Asset |
Cash
|
debit | credit | debit | Balance Sheet | NO |
| Liability | Accounts Payable | credit | debit | credit | Balance Sheet | NO |
| Stockholders’ Equity | Retained Earnings | credit | debit | credit | Balance Sheet | NO |
| Revenue | Fees Earned | credit | debit | credit | Income Statement | YES |
| Expense |
Wages Expense
Rent Expense Utilities Expense Supplies Expense Insurance Expense Advertising Expense Maintenance Expense Miscellaneous Expense |
debit | credit | debit | Income Statement | YES |
All accounts are reported on one of three financial statements. The balances of two of the five types of accounts—revenue and expenses—are reported on the income statement at the end of each accounting period. The summary number on the income statement is net income, which is revenue minus expenses.


6.3: READ - Mediation and the Conflict Resolution Process
Notes:
"It’s often the case that when two people or organizations try to resolve a dispute by determining who is right, they get stuck. That’s why so many disputes end up in court. There is a better way to resolve your dispute: mediation by hiring an expert mediator who focuses not on rights but on interests—the needs, desires, or concerns that underlie each side’s positions. If someone asks you why a dispute is important to you, your answer will reveal your interests."
Read the brief article below about mediation. As you grow in your business careers, you will likely experience conflicts of differing importance. Resolving conflict through mediation is one tool to get to resolution.


17.1C: Layers of the Heart Walls
The heart wall is comprised of three layers: the outer epicardium, the middle myocardium, and the inner endocardium.
- Distinguish between the epicardium, myocardium, and endocardium layers of the heart wall
Key Points
- The epicardium is a thin layer of connective tissue and fat serving as an additional layer of protection for the heart. It is considered a continuation of the serous pericardium.
- The myocardium is the muscle tissue of the heart, composed of cardiac muscle cells called cardiomyocytes that receive nervous stimulation from the sinoatrial (SA) and atrioventricular (AV nodes via the Purkinje fibers.
- Cardiomyocytes are shorter than skeletal myocytes, and contain fewer nuclei. Cardiac muscle is striated.
- The endocardium is composed of endothelial cells that provide a smooth, non-adherent surface for blood collection and pumping and may help regulate contractility.
- An infection or inflammation of the endocardium is called infective endocarditis.
Key Terms
- Purkinje fibers : A bundle of nerve fibers located under the endocardium, which supply nervous impulses to the mycardium’s cardiac muscle tissues.
- endocardium : A thin serous membrane that lines the interior of the heart and valves.
- cardiomyocyte : A cardiac muscle cell (or myocyte) in the heart, which makes up the cardiac muscle tissue.
The heart wall is comprised of three layers, the epicardium (outer), myocardium (middle), and endocardium (inner). These tissue layers are highly specialized and perform different functions. During ventricular contraction, the wave of depolarization from the SA and AV nodes moves from within the endocardial wall through the myocardial layer to the epicardial surface of the heart.
Epicardium
The Heart Wall : The wall of the heart is composed of three layers, the thin outer epicardium, the thick middle myocardium, and the very thin inner endocardium. The dark area on the heart wall is scarring from a previous myocardial infarction (heart attack).
The outer layer of the heart wall is the epicardium. The epicardium refers to both the outer layer of the heart and the inner layer of the serous visceral pericardium, which is attached to the outer wall of the heart. The epicardium is a thin layer of elastic connective tissue and fat that serves as an additional layer of protection from trauma or friction for the heart under the pericardium. This layer contains the coronary blood vessels, which oxygenate the tissues of the heart with a blood supply from the coronary arteries.
Myocardium
The middle layer of the heart wall is the myocardium—the muscle tissue of the heart and the thickest layer of the heart wall. It is composed of cardiac muscle cells, or cardiomyocytes. Cardiomyocytes are specialized muscle cells that contract like other muscle cells, but differ in shape. Compared to skeletal muscle cells, cardiac muscle cells are shorter and have fewer nuclei. Cardiac muscle tissue is also striated (forming protein bands) and contains tubules and gap junctions, unlike skeletal muscle tissue. Due to their continuous rhythmic contraction, cardiomyocytes require a dedicated blood supply to deliver oxygen and nutrients and remove waste products such as carbon dioxide from the cardiac muscle tissue. This blood supply is provided by the coronary arteries.
Endocardium
The inner layer of the heart wall is the endocardium, composed of endothelial cells that provide a smooth, elastic, non-adherent surface for blood collection and pumping. The endocardium may regulate metabolic waste removal from heart tissues and act as a barrier between the blood and the heart muscle, thus controlling the composition of the extracellular fluid in which the cardiomyocytes bathe. This in turn can affect the contractility of the heart.
This tissue also covers the valves of the heart and is histologically continuous with the vascular endothelium of the major blood vessels entering and leaving the heart. The Purkinje fibers are located just beneath the endocardium and send nervous impulses from the SA and AV nodes outside of the heart into the myocardial tissues.
The endocardium can become infected, a serious inflammatory condition called infective endocarditis. This and other potential problems with the endocardium may damage the valves and impair the normal flow of blood through the heart.


28.3: Plotting
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Several modules are available in python for plotting. We will show here how to use the
pylab
module (which is equivalent to the
matplotlib
module). For example, we can easily plot the data in the two arrays from the previous section in order to plot the position versus time for the object:
python code \(\PageIndex{1}\)
Plotting two arrays
#import the pylab module import pylab as pl #define an array of values for the position of the object position = [0 ,1 ,4 ,9 ,16 ,25] #define an array of values for the corresponding times time = [0 ,1 ,2 ,3 ,4 ,5] #make the plot showing points and the line (.−) pl.plot(time, position, '.-') #add some labels: pl.xlabel("time") #label for x-axis pl.ylabel("position") #label for y-axis #show the plot pl.show()
Output
Exercise \(\PageIndex{1}\)
How would you modify the Python code above to show only the points, and not the line?
- Answer
-
We can use Python to plot any mathematical function that we like. It is important to realize that computers do not have a representation of a continuous function. Thus, if we would like to plot a continuous function, we first need to evaluate that function at many points, and then plot those points. The
numpy
module provides many useful features for working with arrays of numbers and applying functions directly to those arrays.
Suppose that we would like to plot the function \(f(x) = cos(x^{2})\) between \(x = −3\) and \(x = 5\). In order to do this in Python, we will first generate an array of many values of \(x\) between \(−3\) and \(5\) using the
numpy
package and the function
linspace(min,max,N)
which generates \(N\) linearly spaced points between
min
and
max
. We will then evaluate the function at all of those points to create a second array. Finally, we will plot the two arrays against each other:
python code \(\PageIndex{2}\)
Plotting a function of 1 variable
#import the pylab and numpy modules import pylab as pl import numpy as np #Use numpy to generate 1000 values of x between -3 and 5. #xvals is an array with 1000 values in it: xvals = np.linspace(-3,5,1000) #Now, evaluate the function for all of those values of x. #We use the numpy version of cos, since it allows us to take the cos #of all values in the array. #fvals will be an array with the 1000 corresponding cosines of the xvals squared fvals = np.cos(xvals**2) #make the plot showing only a line, and color it pl.plot(xvals, fvals, color='red') #show the plot pl.show()
Output


22.1: Magnets
Learning Objectives
By the end of this section, you will be able to:
- Describe the difference between the north and south poles of a magnet.
- Describe how magnetic poles interact with each other.
All magnets attract iron, such as that in a refrigerator door. However, magnets may attract or repel other magnets. Experimentation shows that all magnets have two poles. If freely suspended, one pole will point toward the north. The two poles are thus named the north magnetic pole and the south magnetic pole (or more properly, north-seeking and south-seeking poles, for the attractions in those directions).
UNIVERSAL CHARACTERISTICS OF MAGNETS AND MAGNET POLES
It is a universal characteristic of all magnets that like poles repel and unlike poles attract . (Note the similarity with electrostatics: unlike charges attract and like charges repel.)
Further experimentation shows that it is impossible to separate north and south poles in the manner that + and − charges can be separated.
MISCONCEPTION ALERT: EARTH'S GEOGRAPHIC NORTH POLE HIDES AN S
The Earth acts like a very large bar magnet with its south-seeking pole near the geographic North Pole. That is why the north pole of your compass is attracted toward the geographic north pole of the Earth—because the magnetic pole that is near the geographic North Pole is actually a south magnetic pole! Confusion arises because the geographic term “North Pole” has come to be used (incorrectly) for the magnetic pole that is near the North Pole. Thus, “North magnetic pole” is actually a misnomer—it should be called the South magnetic pole.
The fact that magnetic poles always occur in pairs of north and south is true from the very large scale—for example, sunspots always occur in pairs that are north and south magnetic poles—all the way down to the very small scale. Magnetic atoms have both a north pole and a south pole, as do many types of subatomic particles, such as electrons, protons, and neutrons.
MAKING CONNECTIONS: TAKE-HOME EXPERIMENT -- REFRIGERATOR MAGNETS
We know that like magnetic poles repel and unlike poles attract. See if you can show this for two refrigerator magnets. Will the magnets stick if you turn them over? Why do they stick to the door anyway? What can you say about the magnetic properties of the door next to the magnet? Do refrigerator magnets stick to metal or plastic spoons? Do they stick to all types of metal?
Summary
- Magnetism is a subject that includes the properties of magnets, the effect of the magnetic force on moving charges and currents, and the creation of magnetic fields by currents.
- There are two types of magnetic poles, called the north magnetic pole and south magnetic pole.
- North magnetic poles are those that are attracted toward the Earth’s geographic north pole.
- Like poles repel and unlike poles attract.
- Magnetic poles always occur in pairs of north and south—it is not possible to isolate north and south poles.
Glossary
- north magnetic pole
- the end or the side of a magnet that is attracted toward Earth’s geographic north pole
- south magnetic pole
- the end or the side of a magnet that is attracted toward Earth’s geographic south pole


2.19: Carbon - Hydrocarbons
- Discuss the role of hydrocarbons in biomacromolecules
Hydrocarbons
Hydrocarbons are organic molecules consisting entirely of carbon and hydrogen, such as methane (CH 4 ). Hydrocarbons are often used as fuels: the propane in a gas grill or the butane in a lighter. The many covalent bonds between the atoms in hydrocarbons store a great amount of energy, which is released when these molecules are burned (oxidized). Methane, an excellent fuel, is the simplest hydrocarbon molecule, with a central carbon atom bonded to four different hydrogen atoms. The geometry of the methane molecule, where the atoms reside in three dimensions, is determined by the shape of its electron orbitals. The carbon and the four hydrogen atoms form a shape known as a tetrahedron, with four triangular faces; for this reason, methane is described as having tetrahedral geometry.
As the backbone of the large molecules of living things, hydrocarbons may exist as linear carbon chains, carbon rings, or combinations of both. Furthermore, individual carbon-to-carbon bonds may be single, double, or triple covalent bonds; each type of bond affects the geometry of the molecule in a specific way. This three-dimensional shape or conformation of the large molecules of life (macromolecules) is critical to how they function.
Hydrocarbon Chains
Hydrocarbon chains are formed by successive bonds between carbon atoms and may be branched or unbranched. The overall geometry of the molecule is altered by the different geometries of single, double, and triple covalent bonds. The hydrocarbons ethane, ethene, and ethyne serve as examples of how different carbon-to-carbon bonds affect the geometry of the molecule. The names of all three molecules start with the prefix “eth-,” which is the prefix for two carbon hydrocarbons. The suffixes “-ane,” “-ene,” and “-yne” refer to the presence of single, double, or triple carbon-carbon bonds, respectively. Thus, propane, propene, and propyne follow the same pattern with three carbon molecules, butane, butene, and butyne for four carbon molecules, and so on. Double and triple bonds change the geometry of the molecule: single bonds allow rotation along the axis of the bond, whereas double bonds lead to a planar configuration and triple bonds to a linear one. These geometries have a significant impact on the shape a particular molecule can assume.
Hydrocarbon Rings
The hydrocarbons discussed so far have been aliphatic hydrocarbons, which consist of linear chains of carbon atoms. Another type of hydrocarbon, aromatic hydrocarbons, consists of closed rings of carbon atoms. Ring structures are found in hydrocarbons, sometimes with the presence of double bonds, which can be seen by comparing the structure of cyclohexane to benzene. The benzene ring is present in many biological molecules including some amino acids and most steroids, which includes cholesterol and the hormones estrogen and testosterone. The benzene ring is also found in the herbicide 2,4-D. Benzene is a natural component of crude oil and has been classified as a carcinogen. Some hydrocarbons have both aliphatic and aromatic portions; beta-carotene is an example of such a hydrocarbon.
Key Points
- Hydrocarbons are molecules that contain only carbon and hydrogen.
- Due to carbon’s unique bonding patterns, hydrocarbons can have single, double, or triple bonds between the carbon atoms.
- The names of hydrocarbons with single bonds end in “-ane,” those with double bonds end in “-ene,” and those with triple bonds end in “-yne”.
- The bonding of hydrocarbons allows them to form rings or chains.
Key Terms
- covalent bond : A type of chemical bond where two atoms are connected to each other by the sharing of two or more electrons.
- aliphatic : Of a class of organic compounds in which the carbon atoms are arranged in an open chain.
- aromatic : Having a closed ring of alternate single and double bonds with delocalized electrons.


10.2: Alkaloid Based Reactions
Conjugate Addition Reactions
Cinchona alkaloids are a large class of compounds extracted from the bark of homonym trees cultivated in equatorial climatic zones, between Bolivian and Venezuelan Andes, and Indonesia. In the extract of the bark are present more than 30 alkaloids (5-15% w/w). Four of them represent 50% of all the alkaloids such as quinine ( QN ), quinidine ( QD ), cinchonidine ( CD ) and cinchonine ( CN ) (Scheme \(\PageIndex{1}\)).
QN is the most well known alkaloid and used as the anti-malarial drug of choice for over 400 years until chloroquine discovered, while QD is used as an anti-arrhythmic agent. In chemistry, all these compounds ( QN , QD , CD and CN) are used as cheap chiral source. These molecules activate the nucleophile by enamine and carbanion formation, and electrophile via hydrogen bond.
These compounds are diastereomers having five stereogenic centers and the chiral quinuclidinyl nitrogen is the most important as it is responsible of the direct transfer of chirality during catalysis. Quinine vs quinidine and cinchonidine vs cinchonine have opposite absolute configuration this means that very often these pairs of diastereomers act as enantiomers at C-9 position. Furthermore, the C-9 OH group acts as Brønsted acid. So acid and base coexist in these molecules, and thus, it is possible to activate both the nucleophile and the electrophile simultaneously to use as bifunctional organocatalysts (Scheme \(\PageIndex{2}\)).
The catalytic asymmetric 1,4-addition of thiols to cyclic enones with modified cinchona alkaloid has been demonstrated (Scheme \(\PageIndex{3}\)). The Michael products can be isolated with high yield and enantioselectivity for a range of substances.
Later, tandem Michael-aldol reactions have been developed for the preparation of medicinally important chiral thiochromanes (Scheme \(\PageIndex{4}\)). This new one-pot process proceeds with 1 mol % of the cinchona alkaloid derived thiourea catalyst L2 , which synergistically activates both the Michael donor and acceptor.
Similarly, the conjugate addition has been reported with catalyst L3 for a direct, stereocontrolled construction of adjacent carbon- or heteroatom-substituted quaternary and tertiary stereocenters from readily available starting β -ketoester (Scheme \(\PageIndex{5}\)).
Chiral oxacyclic structures such as tetrahydrofuran rings are commonly found in many bioactive compounds. Cinchona-alkaloid-thiourea L4 catalyzes the cycloetherification of ε-hydroxy-α,β-unsaturated ketones with excellent enantioselectivity, even with low catalyst loadings at room temperature. The probable activation intermediate might go through TS-1.
The catalyst L4 can also catalyze the domino aza-Michael–Michael reactions of anilines with nitroolefin enoates to afford chiral 4-aminobenzopyrans bearing two consecutive stereogenic centers and one quaternary stereocenter (Scheme \(\PageIndex{7}\)). The products can be isolated with high yield and enantioselectivity.
Chiral amine L5 has been used to activate α,β -unsaturated enones with nitro alkenes toward a well-defined enamine-iminium activation mode in presence of 2-fluorobenzoic acid as an additive. The reaction affords the Diels–Alder adduct bearing three or four stereogenic centers with high enantioselectivity (Scheme \(\PageIndex{8}\)). The extension of this process to other Michael acceptors such as N -benzyl maleimide leads to the formation of cyclohexanones with up to >99% ee
The synthesis of trifluoromethyl-substituted 2-isoxazolines can be accomplished by a domino Michael–cyclization–dehydration reaction of hydroxylamine (NH 2 OH) with a range of (E)- trifluoromethylated enone derivatives in the presence of N -3,5-bis(trifluoromethyl benzyl) quinidinium bromide L6 as a chiral phase transfer catalyst (Scheme \(\PageIndex{9}\)).
Aldol Reaction
The cross-aldol reaction between enolizable aldehydes and α -ketophosphonates can be achieved using 9-amino-9-deoxy- epi -quinine L7 (Scheme 10). The reaction works especially well with acetaldehyde, which is a tough substrate for organocatalyzed cross-aldol reaction.
10.2.3 Henry Reaction
Henry reaction is a classical carbon-carbon bond forming reaction in organic synthesis. Aryl aldehydes react with nitromethane in the presence of 6'-thioureasubstituted cinchona alkaloid L8 with high enantioselectivity (Scheme \(\PageIndex{11}\)). Hydrogen-bond donor at the C6′ of L8 has been found to induce preferential formation of one enantiomer.
The 6'-OH cinchona alkaloid L-9 is an excellent catalyst for the reaction of α- ketoesters with nitromethane (Scheme \(\PageIndex{12}\)). The highly enantioenriched products from the Henry reaction could be elaborated to aziridines, β- lactams and α -alkylcysteines. This reaction is operationally simple and affords high enantioselectivity as well as good to excellent yield for a broad range of α-ketoesters .
Bifunctional cinchona alkaloid-thiourea L10 can catalyze efficiently the aza-Henry reaction of cyclic trifluoromethyl ketimines with nitromethanes (Scheme \(\PageIndex{13}\)). The title reaction can provide biologically interesting chiral trifluoromethyl dihydroquinazolinone frameworks with high yield and enantioselectivity.
Hydroxyalkylation Reaction
The readily available cinchonidine (CD) and cinchonine (CN) can be used for the catalysis of the hydroxyalkylation of heteroaromatics. For example, the hydroxyalkylation of indoles with ethyl-3,3,3-trifluropyruvate occurs to afford corresponding 3-substituted products in high yields and ee values (Scheme \(\PageIndex{14}\)) .


8.7: Colligative Properties and Entropy
All four solution effects ( Reduced Vapor Pressure , Freezing Point depression , Boiling Point Elevation , Osmotic pressure ) result from “dilution” of the solvent by the added solute. Because of this commonality they are referred to as colligative properties (Lat. co ligare , connected to.) The key role of the solvent concentration is obscured by the greatly-simplified expressions used to calculate the magnitude of these effects, in which only the solute concentration appears. The details of how to carry out these calculations and the many important applications of colligative properties are covered elsewhere. Our purpose here is to offer a more complete explanation of why these phenomena occur.
Basically, these all result from the effect of dilution of the solvent on its entropy, and thus in the increase in the density of energy states of the system in the solution compared to that in the pure liquid. Equilibrium between two phases (liquid-gas for boiling and solid-liquid for freezing) occurs when the energy states in each phase can be populated at equal densities. The temperatures at which this occurs are depicted by the shading.
- Dilution of the solvent adds new energy states to the liquid, but does not affect the vapor phase . This raises the temperature required to make equal numbers of microstates accessible in the two phases.
- Dilution of the solvent adds new energy states to the liquid, but does not affect the solid phase . This reduces the temperature required to make equal numbers of states accessible in the two phases.
Effects of pressure on the entropy: Osmotic Pressure
When a liquid is subjected to hydrostatic pressure— for example, by an inert, non-dissolving gas that occupies the vapor space above the surface, the vapor pressure of the liquid is raised. The pressure acts to compress the liquid very slightly, effectively narrowing the potential energy well in which the individual molecules reside and thus increasing their tendency to escape from the liquid phase. (Because liquids are not very compressible, the effect is quite small; a 100-atm applied pressure will raise the vapor pressure of water at 25°C by only about 2 torr.) In terms of the entropy, we can say that the applied pressure reduces the dimensions of the "box" within which the principal translational motions of the molecules are confined within the liquid, thus reducing the density of energy states in the liquid phase.
Applying hydrostatic pressure to a liquid increases the spacing of its microstates, so that the number of energetically accessible states in the gas, although unchanged, is relatively greater— thus increasing the tendency of molecules to escape into the vapor phase. In terms of free energy, the higher pressure raises the free energy of the liquid, but does not affect that of the gas phase.
This phenomenon can explain osmotic pressure . Osmotic pressure, students must be reminded, is not what drives osmosis, but is rather the hydrostatic pressure that must be applied to the more concentrated solution (more dilute solvent) in order to stop osmotic flow of solvent into the solution. The effect of this pressure \(\Pi\) is to slightly increase the spacing of solvent energy states on the high-pressure (dilute-solvent) side of the membrane to match that of the pure solvent, restoring osmotic equilibrium.
Osmotic pressure does not drive osmosis, but is rather the hydrostatic pressure that must be applied to the more concentrated solution (more dilute solvent) in order to stop osmotic flow of solvent into the solution.


5.10: Chapter Review - Practice Exercises
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Practice Exercises
19 .
Design an invoice for the sales of screen panels using a Microsoft template. The client wants 25 LEDs with 64” screens, 99 LCDs with 55” screens, and 15 QLEDs with 75” screens. Use the following information:
Client: Doe’s Electronics
Client Address: 123 Doe Street, Doe City, Virginia, 12345
Use today’s date to date the invoice. Search for the unit price of these TVs on the internet.
Client: Doe’s Electronics
Client Address: 123 Doe Street, Doe City, Virginia, 12345
Use today’s date to date the invoice. Search for the unit price of these TVs on the internet.
20 .
At this point in your life, you might have a résumé of your own. Let’s look at it critically and revise it. Choose a template as described in the chapter, then copy and paste your information into the résumé you are updating for yourself.
21 .
Write a business memo for your department at WorldCorp using one of the Microsoft memo templates. The memo should announce to WorldCorp employees that there is a new set of company brand guidelines, and that all employees at WorldCorp need to upgrade their logos and design in their letterheads, envelopes, and business cards.
22 .
Use mail merge to create envelopes using the names/addresses we used in the example in the chapter. Use a fictional WorldCorp address found on the main document as the return address.
23 .
WorldCorp is sending a letter to its clients thanking them for their participation in a survey. Write the “thank you form letter” for the main document from scratch, or use one of these templates. Adjust the merge fields as needed to include the company name. Add five company names, street addresses, city, state, and zip code by creating a new list as outlined in the chapter. These five names and addresses can be made up, or you can use the data in the downloadable
List Names worksheet
. Perform the mail merge of the “thank you form letter,” and use the Edit Individual Documents command for the final mail merge.
24 .
Design a new form for your WorldCorp coworkers. You are holding training sessions on the new company-wide computer system, and you need to know when your coworkers can come. Attendance is mandatory, but the coworkers can choose their own time slot and date. Make a form with the necessary information (name, position, department, time, date).
25 .
Create a form that could be used when contacting a new business client for cell phone/tablets for employees. You will want to gather enough information about their needs to provide them an accurate quote for monthly costs. Information that you will collect could be decision maker’s contact information, number of employees, estimated usage of phones/data, how many phones/tablets might be needed, and other related information. Be creative in selecting the correct question type for the correct form controls.
26 .
Go to the Extensions menu in Docs. Find a free add-on for business cards. Install the add-on and create business cards using your own information.
27 .
Find an invoice template from the Google user-generated templates and create a generic invoice. Find an image, such as your college logo, to add to the invoice.
28 .
Use Forms to create a party invitation from scratch. You want to collect names and see how many people plan on attending a party you are hosting. You might consider what type of party you are planning (e.g., a graduation party) and other relevant information in order to generate appropriate questions. Consider adding questions about food allergies or preferences when creating the invitation.
29 .
Find a template for a customer feedback survey. Modify the template with a different theme and font style. Change a couple of the questions to different question types and reorder the questions.
30 .
Write a sample business memo to your WorldCorp coworkers, describing the upcoming market trends report. Create the memo in Docs. Using the Publish to web option, publish the document to the web using the two methods: link and embed.
31 .
Create a Doc detailing a plan for completing an assignment for one of your classes. You could create the plan based on when the assignment is due and include items such as the date on which you will begin work on it, what you will need to complete the task, and other related items. Share the Doc with a friend using the skills in the section. Change the permissions so that the friend can add comments and edit the Doc.


7.2: Learning Management - The Two Cultures
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There are two main thrusts in formal learning: academic education, and corporate training (including government and the non-profit sector). In educational institutions, the learning model uses courses of fairly long duration (weeks to months) for the long-term educational benefit of the learner. In corporate training, the model is usually short courses (hours to days) for immediate updates, with specific focus on job functions and objectives. Some corporations try to emphasize the importance of their training services by calling them “universities” such as McDonald’s University and General Motors University. As part of their long-term development plans, many businesses also provide support for their employees to attend educational institutions for longer courses and degree programs. For centuries, both systems have relied upon classroom-based, instructor-led facilitation in which a live teacher leads the process.
Distance learning by correspondence has been with us now for many decades. When e-learning became a reality over 10 years ago (first on CD-ROM and then over the Internet), it extended the opportunities for distance learning, and new options and models became possible. The education and corporate training models have evolved separately and somewhat differently.
In the online education environment, it is generally assumed that an instructor leads the course, is available by chat (synchronous), via email and discussion groups (asynchronous), and sometimes via virtual classrooms. In the corporate online learning environment, there is a high degree of dependence on self-directed learning often using courses that have been purchased off-the-shelf from third-party vendors. Only occasionally is an instructor present. As a result, the communication/collaboration tools for email, chat, and group activity are well developed in education LMSs while they are less so in corporate LMSs.
Education LMSs are primarily for the delivery of instructor designed online learning and include course content creation (or course authoring) capability as well as some tools to manage the content. While corporate LMSs provide features to help manage classroom instruction, the e-learning is often assumed to be primarily asynchronous, self-directed courses. Many of these courses are purchased from off-the-shelf courseware vendors. As a result, corporate LMSs do not typically include course authoring or content management features. The larger corporate vendors do often offer suites of tools that do include these capabilities.
In most educational institutions, computer systems for registration already exist, so the features for this in education LMSs are limited while many corporate LMSs offer full capabilities for managing classroom learning from registration to assessment as well as e-learning. It is highly desirable that in an educational institution, the LMS can send data to and from the registration system, and in corporate training the LMS can communicate with the human resources information system.
The focus of both education and corporate LMSs often tends to be more on the administration and technical requirements of the organization rather than on the dynamic facilitation of learning. Some instructors and designers are frustrated by the constraints (both technical and learning) of using these systems and would prefer more dynamic learning support systems such as student weblogs and learning wikis. (See Chapters 25 and 26 for further discussion of these tools). Some of the open-source systems, especially when combined with social learning tools, are more student-centred than the commercial ones.
Online and classroom learning each offer different advantages for different learners. Many people argue that classroom learning is better. Some believe that the classroom offers interactivity—a dynamic exchange of information, questions and opinions between students and instructor and among students. Unfortunately interactivity in a classroom often involves a minority of students who choose to participate, and for others it may not be interactive at all. We have been conditioned since the age of five to believe that learning only happens in a classroom. The reality is that we are continuously learning in all situations. One benefit of the classroom is the social structure and support of schedule, deadlines, the physical presence of the instructor, and other learners. Self-directed online courses offer the obvious advantages of time flexibility—they can be done almost anywhere and at anytime at the convenience of the learner, and they can be repeated several times if necessary. Well-designed online courses can be more effectively interactive than many classrooms in that they require active learning on the part of each student in responding to questions, doing an activity, getting feedback—there is no back of the classroom in an online course—and give them the added flexibility of the freedom from time and place constraints.
Tip
There are at least 100 LMSs available for business and at least 50 available for education. Many of the latter are open-source. Although they offer different features, it is best not to ignore the LMSs from the other sector.
Features of Education Learning Management Systems
The original educational learning management system was probably PLATO, which was developed in the early 1960s. In the late 1970s there were initiatives like the Open University in the UK Cyclops system and CICERO project, Pathlore’s Phoenix software, and Canada’s Telidon project. Wikipedia has an extensive listing of initiatives in its article, History of Virtual Learning Environments.
In formal education LMSs were first used to support distance education programs by providing an alternative delivery system. They are also now used as platforms to provide online resources to supplement regular course material and to provide courses for students who require additional flexibility in their schedules, allowing them to take courses during semesters when they are not physically present or are not attending on full time basis. This also benefits students who are disabled or ill and unable to attend regular classes.
Education LMSs primarily support e-learning initiatives only. Systems for regular classroom support are already in place.
The model for an LMS designed for education is that an instructor creates a course using web-based tools to upload the necessary materials for the students, and sets up collaborative tools such as:
- text chat
- bulletin board presentation tools (e.g., a whiteboard for collaborative drawing and sketching)
- group web page publishing
Students access the course materials on the Web, do both individual and collaborative assignments, and submit them to the instructor. Most education LMSs offer the following features:
Tools for instructors:
- course development tools—a web platform for uploading resources (text, multimedia materials, simulation programs, etc.), including calendar, course announcements, glossary, and indexing tools
- course syllabus development tools with the ability to structure learning units
- quiz/survey development tool for creating tests, course evaluation, etc.
- grade book
- administrative tools to track student activity both as individuals and in groups
Tools for students:
- password protected accounts for access to course materials
- course content bookmarking and annotation
- personal web page publishing
- accounts for access to the collaborative tools (email, discussion groups, collaborative web page publishing)
- access to grades and progress reports
- group work areas for collaborative web page publishing
- self-assessment tools
Administrative tools:
- management of student and instructor accounts and websites
- monitoring and reporting activity
- e-commerce tools for sale of courses
- communication and survey tools
Some may also offer, maybe at extra cost, some of the following features:
- learning object management (course content management for reusability)
- e-portfolios
- file and workflow management
- streaming audio and video
- access to electronic libraries
Blackboard now offers an e-commerce module, and Moodle integrates with PayPal to allow for customers to pay online.
Although LMSs often claim a learner-centred approach involving active collaboration between the instructor and students, both as individuals and in groups, there are some social networking tools such as wikis and weblogs (blogs) that most of these systems do not (as of this writing) support. There are numerous initiatives underway to develop add-on tools and to integrate social learning tools with open-source platforms.
In most cases it is assumed that the teacher provides the content, but some system vendors are now selling content as “e-Packs” or “cartridges” that can be uploaded by teachers. It is also possible to purchase course materials from other institutions. Using courses from other sources, however, may be challenging if they are not compatible with your LMS, consistent with the instructor’s approach, or accessible by students with disabilities. This may improve with the development and application of operating and accessibility standards.
Commercial systems
The most widely adopted commercial systems are WebCT and Blackboard. Web CT was originally developed by Murray Goldberg at the University of British Columbia, beginning in 1995. In 1999 the company was purchased by Universal Learning Technology of Boston, and became WebCT, Inc. Blackboard was originally developed at Cornell University. The company was founded in 1997 by Matthew Pittinsky and is based in Washington, DC. WebCT and Blackboard currently control about 80 percent of the LMS market in higher education (Sausner, 2005, p. 9). Blackboard purchased WebCT in 2005, making them the dominant force in the market. The WebCT products are currently being merged and re-branded as Blackboard products.
The most widely adopted commercial systems are WebCT and Blackboard. Web CT was originally developed by Murray Goldberg at the University of British Columbia, beginning in 1995. In 1999 the company was purchased by Universal Learning Technology of Boston, and became WebCT, Inc. Blackboard was originally developed at Cornell University. The company was founded in 1997 by Matthew Pittinsky and is based in Washington, DC. WebCT and Blackboard currently control about 80 percent of the LMS market in higher education (Sausner, 2005, p. 9). Blackboard purchased WebCT in 2005, making them the dominant force in the market. The WebCT products are currently being merged and re-branded as Blackboard products. Office (USPTO) ordered re-examination of the patent. On February 1, 2007, Blackboard announced its patent pledge, which is a promise by the company to never assert its issued or pending course management system software patents against open-source software or homegrown course management systems.
It is hard to say what the effect of this will be on current and potential WebCT and Blackboard customers. Some will want to go with the market leader regardless, others will stay with what they have, and many may move to open-source solutions. Cornell University, the birthplace of Blackboard, is reconsidering whether Blackboard is the most appropriate software for Cornell professors and students.
Some other education oriented systems offered by commercial vendors:
- Desire2Learn
- College
- Jenzabar
- Odyssey Learning Nautikos
- WBT Systems Top Class (now appears to be targeting the corporate sector)
- ANGEL
- Centrinity First Class (now a division of Open Text)
- Geometrix Training Partner (primarily a corporate LMS but often used by educational institutions for distance learning programs with a business orientation).
Notes:
- IBM/Lotus Learning Space no longer seems to be a viable contender in the education market. It is now called Workplace Collaborative Learning, and appears to be targeted to the business market.
- Prometheus has been purchased by Blackboard and no longer seems to be supported.
Tip
If you currently are using a commercial education LMS, you may find costs escalating, and a continual demand for upgrades. For these and other reasons, many educational institutions are considering opensource systems as an alternative.
Open-source systems
Open-source software is computer software whose source code is available free “under a copyright license … that permits users to study, change, and improve the software, and to redistribute it in modified or unmodified form.” ( http://en.Wikipedia.org/wiki/Open-source_ software, February 2007). Open-source LMSs are gaining ground in the education market as a reaction to increasing costs for the commercial systems, and because of the greater flexibility and more student-centred learning approaches in the open-source systems. Some instructors, particularly those with technical expertise, will prefer these systems because of fewer constraints, a greater sense of control, and and generally better communication tools. Other instructors won’t like them because they prefer more rule-based systems with full administrative features.
There are numerous open-source systems available. Some of the better known ones are:
- Moodle
- ATutor
- Sakai
- Bodington
- Claroline
- Magnolia
Although the software is free, open-source solutions are not without their costs. They need continuous support and maintenance, which require either a strong and supportive internal IT group, very dedicated instructors, or a contract with outside vendors who will do it for you. Open-source software is maintained by an active community of users who are constantly upgrading the code. These code changes can affect the operability of courses unexpectedly, and require more local maintenance. The “hidden” costs of the time of the IT people and the instructors may or may not outweigh the cost of a licence for a commercial system.
There are useful discussions of open-source systems at http://www.funnymonkey.com , http://openacademic.org/ and in Chapters 8 and 12 of this book.
Other aspects of LMSs
Some educational institutions have built their own LMS, and have not chosen to market them. Although it is possible for anyone to do the same, it is an expensive process, and it may be vulnerable if one person is the primary developer. Some of the open-source systems have been built by an institution or a group of institutions, and then shared. ATutor was developed at the University of Toronto. The Sakai initiative is a collective effort by 65 academic partners.
Course development: Course development tools (also called course-authoring tools) are an integral part of most education LMSs. Some instructors also like to use some of their own tools such as web authoring/HTML editors (e.g., Dreamweaver, FrontPage, GoLive), word processing (e.g., Microsoft Word) and presentation tools (e.g., Flash, PowerPoint). The LMS should be capable of working with such tools.
Virtual classrooms/web conferencing: Virtual classrooms (also known as web conferencing tools) add audio, video, and graphics to synchronous classes over the Internet. Such tools are not usually included as part of an LMS but are available separately.
Learning content management systems (LCMS) provide a means of storing developed courseware in learning repositories (databases) as learning objects where it can be retrieved and used by others. Most education LMSs have at least some learning content management capabilities.
Most LMSs are primarily administrative tools, and it is up to the instructors and designers developing the courses to address the issues of the learning model, but many of the LMSs lack the tools to support more student-centred learning. The integration of social learning tools such as wikis and blogs with an LMS can help create a more dynamic learning environment.
Social learning is closely related to social networking and social computing and is the essence of what is being called Web 2.0. It is the use of wikis, blogs, podcasting, etc., by individuals and groups to create content instead of simply being the recipients. Web 1.0 was about downloading; Web 2.0 is about uploading.
Web 2.0 is defined not only by technologies (blogs, wikis, podcasts, vodcasts, RSS feeds, and Google Maps are a few examples), but also by the social networking that it enables. Web 2.0 tools can scaffold learning environments for enhanced communication among students as well as between students and the instructor. Creating learning opportunities that harness the power of Web 2.0 technologies for collaborative learning, distributed knowledge sharing, and the creation of media-rich learning objects can further the scope of what students can learn by fostering a constructivist environment, and putting learning in the control of the students. Both students and instructors are embracing these tools at a phenomenal rate. Examples are Wikipedia and YouTube. LMSs will need to catch up.
Initiatives to include social learning into LMS include:
- Learning objects is a commercial product, and targets users of large-scale course management platforms.
- Elgg elgg.net/ (February 2007)—open-source
- Drupal http://drupal.org/ (February 2007)—opensource
- MediaWiki http://www.mediawiki.org/ (February 2007) —open-source
It is interesting to note that the University of Phoenix, one of the largest e-learning organizations in the world with nearly 200,000 students online simply uses Outlook Express newsgroups for its courses, along with other tools it has developed internally. Other early online universities like Pepperdine University use newsgroups extensively as well.
Tip
Adult and continuing education departments tend to follow more of a business model. If you are seeking an LMS for this application and need registration and payment features, consider some of the more reasonably priced business LMSs (see below).


19.4: Nursing Management of Elimination
By the end of this section, you will be able to:
- Describe nursing considerations for functional elimination
- Explain nursing management of peritoneal dialysis
- Identify nursing management of hemodialysis
This chapter looks at many diseases that can affect fluid and electrolyte balance. It is important for the nurse to remember that the elimination of excess fluids and electrolytes includes both the body’s ability to filter and collect excess fluid and electrolytes, and the to remove the collection from the body. This section discusses bladder assessment, functional elimination, and peritoneal dialysis and hemodialysis.
Nursing Considerations for Alterations in Functional Fluid and Electrolyte Elimination
When a person thinks about urinary elimination, often what comes to mind is the need to urinate, badly and at the most inconvenient times. However, urinary elimination is actually a complex and multisystem process. The structures of the kidneys must remain healthy for blood to be filtered and urine created. The ureters must be patent and able to assist urine to get to the bladder. The bladder must have a healthy connection to the spinal cord and brain to sense the presence of urine and be able to contract forcefully enough to get urine out. Unfortunately, difficulties can arise from any of these parts that contribute to urinary elimination.
Assessing Bladder Function
The creation and elimination of urine alone do not guarantee normal or adequate fluid and electrolyte balance. The patient may be able to void light-yellow urine but still have a FVE or deficit and an electrolyte imbalance. The nurse must consider a full fluid and electrolyte assessment to determine if the patient is meeting the demands for homeostasis . However, one aspect of fluid and solute waste elimination is bladder function.
If the patient’s fluid and regulatory systems, discussed throughout this section, result in the formation of urine, then adequate bladder function is necessary to eliminate urine. If a patient is consuming or receiving adequate intake but is not eliminating urine, the nurse should perform a bladder assessment to determine if urine is present in the bladder.
The patient should be comfortably lying supine, and privacy ensured. Beginning with light palpation, the nurse will assess the lower abdomen. The bladder is below the umbilicus in the lower abdomen and is not palpable when empty. Using deeper palpation, the nurse should attempt to feel the base of the bladder. If the bladder is palpable, the nurse should continue to palpate, outlining the bladder. A bladder that is mildly full will be slightly firm and nontender, below the umbilicus. A bladder that is full may be firm and may extend above the umbilicus.
A more objective method to assess for the presence of urine in the bladder is to use a bladder scanner. To perform a bladder scan, place the scanner head about 1 inch above the symphysis pubis, pointing slightly down toward the expected bladder location. The screen will display an ultrasound image of the bladder. The bladder should be centered on the screen—often within a crosshair image. Once the nurse has the correct position, the scanner will scan the bladder and indicate a volume of urine within the bladder. Often, nurses will perform multiple scans to guarantee an accurate reading.
A straight catheter is used for intermittent catheterization of urine. The catheter is inserted to allow for the flow of urine and then is immediately removed, so a balloon is not required at the insertion tip. Intermittent catheterization is used for the temporary relief of urinary retention. It may be performed once, such as after surgery when a patient is experiencing urinary retention due to the effects of anesthesia, or several times a day to manage chronic urinary retention. Some patients may also independently perform self-catheterization at home to manage chronic urinary retention caused by various medical conditions. In some situations, a straight catheter is also used to obtain a sterile urine specimen for culture when a patient is unable to void into a sterile specimen cup. According to the CDC, intermittent catheterization is preferred to indwelling urethral catheters whenever feasible because of decreased risk of developing a urinary tract infection (UTI).
At times, the patient may be making urine and able to eliminate some urine, but not fully empty their bladder. If this is suspected, the provider may request a post-void residual (PVR) assessment. The nurse should ask the patient to fully empty their bladder, and then, using either a bladder scanner or straight catheterization, assess how much urine is left in the bladder. This amount is reported to the provider and/or documented. A PVR of less than 50 mL is expected if the bladder is adequately emptying. In older adult patients, that volume may increase to 100 mL and still be considered adequate emptying. A PVR of greater than 200 mL is considered abnormal, and a value of 400 mL or greater is considered a high amount of urinary retention (Ballstaedt & Woodbury, 2023). The provider should be notified of anything outside the normal range.
Incontinence
Urinary output can be difficult for the nurse to measure, and urinary elimination can be difficult for the patient to manage during urinary incontinence (UI) . Urinary incontinence is a loss of urine from the bladder that is unplanned or uncontrolled. Urinary incontinence can range from an occasional small leak of urine to full bladder emptying.
There are several types of UI. To assist in determining what type the patient experiences, the nurse should ask the patient about urinary frequency, urinary urgency, and urinary leaking. Urinary frequency can indicate a type of UI called overflow incontinence . In overflow incontinence, the bladder does not fully empty during trips to the toilet, and incontinence occurs because the bladder is too full or overflowing. In this case, pharmacological treatment is directed toward medications that increase bladder contraction, which are cholinergic drugs, such as bethanechol (e.g., Urecholine). Urinary urgency may result in urge incontinence . Urge incontinence, often termed overactive bladder, results in the feeling of the need to urinate and urine leaking even when the bladder is not full. Typically, drugs that are anticholinergic, such as oxybutynin (Ditropan) are used to treat urge incontinence. Another type of urinary incontinence, stress incontinence , is the result of a weak urethral sphincter, weak pelvic floor muscles, or both, that allow urine to escape during times of increased intra-abdominal pressure, such as may occur with laughing, coughing, jumping, and so forth. Stress incontinence treatments often focus on increasing pelvic floor muscle strength. Kegel exercises are one example. Often, UI is a combination of two or more types and is called mixed incontinence .
Lastly, functional urinary incontinence may be the most difficult type of UI to manage. In functional UI, the bladder and support structures are functioning properly but other illness or disability prevents the patient from being able to access the toilet. Examples include patients experiencing dementia for whom acknowledging and communicating the need to urinate are challenging, or patients who require assistance to the toilet as a result of residual physical deficits from a cerebral vascular accident, falls, or other debilitations.
Most UI is treatable. Unfortunately, there is a misconception that UI is a normal part of aging and often is not addressed. Fifty percent of residents in long-term care facilities experience UI (McDaniel et al., 2020). Urinary incontinence is associated with a decreased quality of life and decreased interpersonal interaction due to embarrassment, frustration, depression, and loss of self-esteem. Additionally, UI is associated with a higher risk for skin integrity alterations, falls, and UTIs. It is estimated that medical cost associated with UI exceeds $5 billion (McDaniel et al., 2020).
Indwelling Urinary Catheter Management
An indwelling urinary catheter (IUC) is a urinary catheter that stays in the bladder for a time. The term “Foley catheter” is used interchangeably, although “Foley” is the brand name of a type of IUC invented by a man named Frederic Foley in 1929 (UroToday, n.d.). An IUC has two proximal lumens and an inflatable balloon on the distal end. The balloon volume can vary, but is generally 10 mL to 30 mL. The IUC is inserted through the urethra into the bladder. The balloon is inflated inside the bladder by injecting sterile water into one of the proximal lumens. The other proximal lumen terminates with a hole on the end of the catheter and drains urine into a collecting bag (Figure 19.13). In IUCs that have three proximal lumens, the third is for bladder irrigation. These are called “three-way IUCs.”
See the competency checklists for Applying an External Urinary Sheath (Condom Catheter), Catheterizing the Female Urinary Bladder, and Catheterizing the Male Urinary Bladder. You can find the checklists on the Student resources tab of your book page on openstax.org.
A catheter-associated urinary tract infection (CAUTI) is a common, life-threatening complication caused by IUCs. The development of a CAUTI is associated with patients’ increased length of stay in the hospital, resulting in additional hospital costs and a higher risk of death. It is estimated that up to 69 percent of CAUTI cases are preventable, meaning that up to 380,000 infections and 9,000 patient deaths per year related to CAUTI can be prevented with appropriate nursing measures (CDC, 2015).
Nurses can save lives, prevent harm, and lower healthcare costs by following key interventions (American Nurse’s Association, n.d.):
- Ensure the patient meets CDC-approved indications before inserting an IUC. If the patient does not meet the approved indications, contact the provider and advocate for an alternative method to facilitate elimination.
-
According to the CDC, appropriate indications for inserting an IUC include the following:
- end-of-life care
- healing of open sacral and perineal wounds in patients with UI
- hourly monitoring of urinary output in critically ill patients
- perioperative use for selected surgeries
- prolonged immobilization
- urinary retention or bladder outlet obstruction
-
Inappropriate reasons for inserting an IUC include the following:
- prolonged postoperative care without appropriate indications
- substitution of nursing care for a patient or resident with incontinence
- to obtaining a urine culture when a patient can voluntarily void
- After an IUC is inserted, assess the patient daily to determine if the patient still meets the CDC criteria for an indwelling catheter and document the findings. If the patient no longer meets the approved criteria, follow agency policy for removal.
- When an IUC is in place, prevent CAUTI by following the maintenance steps outlined by the CDC.
- Continually monitor for signs of a CAUTI and report concerns to the healthcare provider.
- Signs and symptoms of a CAUTI to urgently report to the healthcare provider include fever greater than 100.4°F (38°C); change in mental status, such as confusion or lethargy; chills; malodorous urine; and suprapubic or flank pain. Flank pain can be assessed by assisting the patient to a sitting or side-lying position and percussing the costovertebral areas.
Urinary tract infections have a typical presentation in adolescents and adults. Urinary frequency, urgency, and burning are all common manifestations of UTIs. However, in older-adult populations, UTIs often present atypically with a change in personality or level of interaction, confusion or delirium, new incontinence, sleepiness, diminished appetite, and/or frequent falls (Dutta et al., 2022).
Providing Education
At times, a patient may need to be at home with an IUC. The nurse should provide education focused on preventing CAUTI and maximizing patient quality of life. The nurse will teach the patient how and when to clean the catheter. At least twice daily and after any bowel movement, using soap and water and a clean washcloth, the patient should gently wipe from the urinary meatus toward the collecting bag. The patient may shower and clean the catheter in the shower in the same manner. If the patient desires to be out in public, a leg bag can be used under the patient’s clothing to conceal the urine-collecting bag (Figure 19.14). The patient should be taught to wash their hands before manipulating collecting bags. The patient should clean the bag connector with soap and water and allow it to dry whenever changing bags. When not in use, the bags should be washed in soap and water and allowed to dry thoroughly.
Dialysis
For some patients, the body is unable to adequately filter water, electrolytes, and waste products. In this case, the patient will require an external method to adequately clean the blood. These patients must undergo dialysis , a procedure to remove waste products and excess fluids from the blood when the kidneys are unable to do so. There are two types of dialysis: peritoneal dialysis (PD) and hemodialysis (HD). Both types of dialysis rely on water osmosis and solute diffusion between the blood and another compartment.
Nursing Management of Peritoneal Dialysis
In peritoneal dialysis , the peritoneal cavity is used as the other compartment. The peritoneal cavity is lined with tiny capillaries perfusing with blood. Dialysate, a fluid created in a pharmacy with a prescribed fluid, electrolyte, and other solute composition is instilled into the peritoneal cavity and dwells around the abdominal organs, exchanging fluids, electrolytes, and other solutes with the capillaries (Figure 19.15). When the exchange has had adequate time, the dialysate along with any additional fluid and solute is removed.
For a patient to receive PD, a peritoneal cavity access site is established in the patient’s abdomen. A nephrologist will determine the correct dialysate concentration based on the patient’s kidney function and laboratory data and prescribe the frequency and length of time the dialysate should dwell inside the patient’s abdomen. One significant advantage of PD is a patient’s ability to perform it at home. The nurse is an important source of education and support.
Assessment of the Access Site
The peritoneal catheter is placed percutaneously by a surgeon using a laparoscopic technique. The catheter is a flexible silicone tube with several holes inside and a closable external port. A cuff is present on the outside of the patient’s abdomen to prevent the catheter from migrating too far into the abdomen and to allow the catheter to be secured to the abdomen. In some cases, a cuff is also present under the skin surface. The nurse will assess and instruct the patient to monitor the insertion site for signs and symptoms of infection. Skin flora is the most likely cause of catheter insertion site infection, so the site should be cleansed with soap and water or another approved antiseptic and covered with a sterile dressing when not being used. Additionally, the site should be monitored for leakage around the catheter during use. Too much leakage can decrease the effectiveness of dialysis. The patient should report any concern to their nephrologist.
Monitoring for Complications
The nurse will instruct the patient to closely monitor how much dialysate is instilled and how much effluent (dialysate plus all waste) is returned. The patient’s nephrologist will provide an acceptable quantity of effluent, but the amount of effluent is always greater than the amount of dialysate. If all dialysate is not returned, the patient may need to reposition. In some cases, the peritoneal catheter may be clogged or dislodged. In such situations, the patient should seek urgent medical care. In addition to the amount of effluent, the nurse will educate the patient to note the color and clarity of the effluent.
Nursing Management of Hemodialysis
The decision regarding the type of dialysis will be made by the patient in conjunction with the provider considering multiple factors, including the degree of kidney disease, the patient’s lifestyle goals, and the patient’s confidence in their ability and desire to perform PD. If HD is the best choice for a patient, the nurse’s role is focused on educating the patient about how to care for their HD access and how best to maintain fluid and electrolyte levels in between HD visits. Unlike PD, HD uses an external filter as the second compartment and blood is filtered outside of the body. Hemodialysis is usually delivered in a hospital or outpatient HD clinic setting. The patient is a more passive recipient in HD.
Scenario: The nurse is caring for a patient recently diagnosed with chronic kidney disease and who is now requiring dialysis. The patient’s adult son and documented representative asks the nurse if she thinks the patient would be better off having PD or HD. The nephrologist has provided education about both options and has asked the patient and family to make a decision.
Patient’s son: You’ve been working with mom for several days now. What do you think? Should she try peritoneal dialysis or just go straight to hemodialysis?
Nurse: Well, do you think she will be able to manage peritoneal dialysis on her own or will she need one of her children to help her with it?
Patient’s son: I think we’d need to be there. She was already having trouble remembering her medications before she came to the hospital.
Nurse: It is plausible for your or your brother to sister to be there several times a day or find someone who can be there?
Patient’s son: It sound like too much. Mother’s going to hate having people in and out of her house all the time and she hates depending on her “babies.”
Nurse: That sounds like a good reason to go with hemodialysis. If she likes her independence, you can coordinate a ride to get her to the dialysis clinic, but she won’t have to rely on her children as much. It sounds like a good option; however, your mom is the one who will ultimately make the decision.
Assessment of the Access Site
Hemodialysis access can take two different forms. A large-bore central venous catheter, often referred to as a Vascath, is a short-term HD access catheter. There is a significant risk of infection with Vascaths due to their size, location, and the frequency with which they are accessed. In most cases, nurses specially trained in HD care for HD catheters. However, the nurse caring for the patient will still assess the catheter insertion site for signs and symptoms of infection and monitor the patient for fever and/or white blood cell count elevation, Additionally, the nurse should assess the catheter dressing and ensure it is clean, dry, and intact. If there is drainage present or the dressing is not occlusive, the nurse should change the dressing using sterile procedure for central-line dressing changes.
A variation of the Vascath is the tunneled catheter. The tunneled catheter, commonly called a permacath, is also a large-bore central catheter, but the insertion site differs. The tunneled catheter is inserted several inches away from where it enters the vein. The catheter is inserted and then “tunneled” underneath the skin of the abdomen and/or chest wall before it enters the vein. In this way, skin flora and other organisms are not directly in line with the venous system and there is a lower risk of infection (Figure 19.16).
Definition : Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Knowledge : Recognize contributions of other individuals and groups in helping the patient and family achieve health goals.
Skill : Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. The nurse will:
- Provide a full report to the HD nurse who will be caring for the patient while the patient is in dialysis.
- Include any information about patient preferences, pain control, meals, and snacks that will allow for the best experience for the patient.
Attitude : Appreciate the risks associated with handoffs among providers and across transitions in care.
A more permanent HD access is a surgical procedure that connects an artery and a vein, usually in the patient’s upper arm. If the connection is made by opening and sewing together an artery and a vein, the result is called an arteriovenous (AV) fistula. If the connection is made using a graft, either from a blood vessel from the patient or a synthetic graft, the result is called an AV graft. In either case, a surgical procedure is performed, and the nurse will assess the patient for postsurgical complications and for incision healing. Additionally, due to the high blood flow through the fistula or graft, the nurse will assess for a thrill by gently palpating the fistula or graft site. A positive thrill feels like a vibration. The nurse will auscultate using a stethoscope and listen for a bruit over the fistula or graft site. A bruit sounds like a strong arterial whooshing. The patient should also be taught to also feel for a thrill. The presence of a thrill indicates blood is flowing through the fistula or graft. If the thrill and bruit are not present, the nurse and/or the patient should contact the nephrologist and the HD unit or clinic.
The nurse should teach the patient to avoid wearing any tight clothing or shirt sleeves near the HD access site. Patients should avoid carrying purses or grocery bags hanging from the affected arm. Patients should also be aware that no blood pressure cuffs or tourniquets should be used on that arm. In the hospital setting, the nurse should follow hospital protocol to notify other staff and ensure no blood pressure, IVFs, or blood draws occur on the affected side.
Monitoring for Complications
Several HD complications are related to the access site. Infection, sepsis, and air embolism are possible with HD catheters. Fistulas and grafts can occlude and leave the patient without HD access. Other complications are related to the rapid change in a patient’s fluid volume status and electrolyte levels. Hemodialysis is usually performed about three times each week. Prior to HD, patients may experience FVE, hypervolemia , hypertension, and altered electrolyte and acid-base balances. Immediately after HD, patients can experience hypovolemia and hypotension, and although electrolyte and acid-base balance is restored, the rapid change can cause nausea, vomiting, headache, and muscle cramping. Most patients report feeling fatigued after dialysis . The nurse will assess for manifestations of these alterations and focus on providing the patient rest.