Abdominal Aortic Aneurysm (AAA) Post Surgery Care

Abdominal Aortic Aneurysm (AAA) Post Surgery Care Introduction Nursing care of the patient following major surgery is a complex task, involving holistic management of patient wellbeing in the light of several challenges to health and homeostatic stability. This essay sets out to discuss the care of one such patient, following surgery to repair an abdominal aortic aneurysm. In order to address the issue and provide the highest possible standards of individualised care, nurses need a considerable knowledge base, gleaned from training, from ongoing updating, from the available evidence, and from their experience as professionals in their field. This essay will also set out to explore how nursing knowledge is applied to practice, always keeping the patient as the focus of care, with reference to the underlying physiology which relates to the patient’s condition. Nursing skills are also based on knowledge and experience, both the experience of the nurse themselves and the experience of those who have taught them, who work with them and who collaborate in the provision of care. While this essay focuses on the nurse’s role in relation to the case and the client, it is important to remember that nursing care does not take place within a vacuum, and reference will be made to those with whom the nurse must interact and engage as part of this role. The care of a patient following surgical abdominal aortic aneurysm repair follows the principles of general postoperative surgical care, along with specific interventions, monitoring and support that are a consequence of the condition and the nature of the surgery. The holistic management of this case must also take into account the psycho-social and emotional factors which may affect the case, given the life-threatening nature of the condition and the potential complications of the surgery. The Case David Grainger is a 65 year old man, who is retired and who tries to keep himself fit by playing golf. He had a history of recurrent pain underneath his rib cage for some month, and had been treating himself for indigestion with limited success. His friends became worried about him and his condition when he appeared to be losing weight, and so eventually David plucked up the courage to visit his GP. He was referred to the local hospital for tests, which eventually led to a diagnosis of abominal aortic aneurysm. David was later admitted to the surgical ward for surgery to repair the aneurysm. On return to the ward David had a blood transfusion running and a wound drain (Redivac) from the abdomen close to the surgical incision site. He had an indwelling Foley catheter with an hourly urine bag, which was changed to free drainage after 12 hours of adequate urine output, and a PCA (patient controlled analgesia) device in situ. He has a mepore dressing to the abdominal wound site. David has two IVI sites, one in each hand. The blood transfusion was running via the left hand, and normal saline (0.9%) was running in the other, along with the PCA, on a three-way tap. The day following surgery David’s temperature is recorded at 39.6c with an elevated pulse of 90bpm. He repeatedly complains of feeling cold. Discussion with the senior sister and the SHO suggests that David is experiencing a potential pyrexia. Abdominal Aortic Aneurysm. Abdominal Aortic Aneurysm (AAA) is a fairly common condition (the 14th leading cause of death in the US (Birkmeyer and Upchurch, 2007). It is a life-threatening condition (Isselbacher et al, 2005). The greatest risk of an AAA is the risk of rupture, which has a significant mortality rate attached to it (Birkmeyer and Upchurch, 2007). It is defined as an abnormal localised arterial dilation or ballooning that is greater than one and half times the artery’s normal circumference, and must involve all three layers of the vessel wall (Irwin, 2007). Abdominal aortic aneurysms are those which are located below the diaphragmatic border, and account for 75% of aortic aneurysms (Irwin, 2007). Men are four to five times more likely to develop the condition, and risk factors include smoking, hypertension and dyslipidemia, cellular changes in the tunica media associated with diseases such as Marfan syndrome, inflammation, and blunt trauma (Irwin, 2007). There is also a family history facto r, with increased risk amongst primary relatives of someone with AAA (Irwin, 2007). Another risk factor is atherosceloris, although someone without this condition can develop an aneurysm (Irwin, 2007). Repair is either through open surgical repair, through a large midline incision (Irwin, 2007). The procedure is major surgery, and the aorta is cross-clamped to allow the insertion of a synthetic graft which is attached to proximally and distally to health aortic tissue (Irwin, 2007). Another procedure is endovascular repair using a percutaneous vascular stent (Irwin, 2007; Beese-Bjustrom, 2004). In this procedure, a woven polyester tube covered by a stent is placed inside the aneurismal section of the abdominal aorta, which keeps normal blood flow away from the aneurysm, greatly reducing the risk of dissection and rupture (Bese-Bjustrom, 2004). In this case David underwent open surgery. Assessment Assessment of the patient’s condition is the first stage in nursing care planning and management, forming the basis of nursing decision making (Watson-Miller, 2005). A summary of assessment activities carried out for David can be found in Table 1. Table 1. Nursing Assessment of David on Day 1 Post-Op. Action Rationale Monitor Blood Pressure, Pulse, Pulse Oximetry Respirations Vital observations indicate changes in underlying condition. Low blood pressure with high pulse, for example, would be suggested of haemorrhage. After aneurysm repair, an elevated BP can stress the graft site and cause graft failure (Irwin, 2007). This also increases myocardial oxygen demand, and an imbalance between oxygen supply and demand may lead to myocardial ischaemia and lead to MI (Irwin, 2007). Respiratory rate must be monitored post-anaesthetic, and observation of respirations allows the nurse to prepare for preventive measures to reduce the risk of atelectasis or DVT. Four hourly observations are usual from 24 hours postoperatively (Zeitz, 2005). Monitor Temperature Usually carried out four hourly, to detect potential sings of pyrexia, or reaction to blood transfusion (Jones and Pegram, 2006) or medications. Another complication could be malignant hyperthermia, although this is rare and unlikely to develop this late postoperatively (Neacsu, 2006). Intravenous Monitoring and Fluid balance Monitor site for patency and condition; monitor fluid intake and rate; record fluid balance. IVI pump checked at this time. Urinary output via catheter also recorded. PCA/Pain Pump check should usually be every hour if a controlled drug is used in the PCA, and recorded on the appropriate chart. Pain levels assessed (Manias, 2003). Wound Dressing observed for signs of exudates; wound observed for signs of healing/infection/dehiscence. Wound drain Site observed for signs of infection; drain bottle check for amount and type of exudates; fluid balance recorded. Other monitoring specific to AAA repair. Fluid and electrolyte balance; neurological status; full blood count (elevated white count indicates infection) (Beese-Bjustrom, 2004) Assessment during the first 24 hours is usually aimed at establishing physiological equilibrium, managing pain, preventing complications and supporting the patient towards self-care (Watson-Miller, 2005). These are standard post-operative observations, but the care of the person having undergone abdominal aortic aneurysm repair may be somewhat more specific. Some of these areas will be dealt with in more detail below, considering the evidence base and the nature of nursing knowledge applied to the problem. The nursing knowledge applied in the assessment process derives from acquired knowledge (that gleaned during training, and study), and experiential knowledge, from previous experiences of applying theoretical knowledge to practice. If the nurse has previously cared for patients with this condition, she will apply that experience to this case. If not, the application of clinical, theoretical and other knowledge (such as colleagues’ experience) to the scenario, alongside thoro ugh understanding of physiological principles, should result in effective and appropriate care. The evidence base must also be utilised. Pyrexia Having identified a potential problem in relation to temperature regulation, it is important to plan for ongoing monitoring, identification of the cause of increased temperature, treatment of the cause and relief of symptoms. The cause of the temperature is most likely to an infection. Nosocomial infection is a concern after surgery, especially when the patient has an incision involving any aspect of the vascular system (Irwin, 2007). In order to prevent wound infection, David will be prescribed IV antibiotics, which will then be changed to oral antibiotics at the appropriate time (Irwin, 2007). Symptomatic relief of the pyrexia can be achieved by fan therapy and the administration of paracetamol, which can be given PR if David remains nil by mouth. However, the nurse would ensure this was prescribed and not contraindicated due to any interactions with David’s other medications. David’s increased temperature may also be due to the development of ischaemic colitis (a com plication of abdominal aortic aneurysm repair) and so white cell counts should be checked, as a raised count may be indicative of this (Beese-Bjustrom, 2004). The pyrexia may be in response to the blood transfusion (Jones and Pegram, 2006), although we would expect this to have developed earlier in the treatment. At this point, David’s pyrexia indicated a potential problem, and may not require paracetamol or fan therapy. Instead, prevention of the development of infection, and reassurance that his feeling of being cold may be due to raised temperature, may suffice. Blood Pressure Management and Fluid Balance. Keeping David’s blood pressure within the normal range is critical to maintain end organ perfusion, and so both hypertension and hypotension must be prevented in this case (Irwin, 007). In order to prevent hypertension and the complications described above, David may be given IV beta blockers, and will be monitored for any cardiovascular changes such as chest discomfort, ST-T wave changes, or dysrhythmias (Irwin, 2007). Given his stability 24 hours post-operatively, he may be moved from ITU to a high dependency or standard surgical ward, where telemetry may then be stopped. Monitoring mean arterial pressure and maintaining a reading of at least 70 mmHg can ensure proper perfusion of major organs, and this can be supported by careful infusion of intravenous fluids as described above (Irwin, 2007). In relation to fluid balance (and continuing organ functioning) a urine output of around 50ml/hour would indicate adequate glomerular filtration rate and renal perfusion (Irwin, 2007). Any deviations from these ‘ideals’ would be recorded and reported promptly to the appropriate members of the multi-disciplinary team (Irwin, 2007). Pain Management While David’s pain is being managed effectively with the Patient Controlled Analgesia (PCA) device, the use of a PCA is not a long-term means of pain management. Therefore, the planning stage of management of David’s care for the nurse looking after him should involved a collaborative plan for pain management. This may be in collaboration with the medical team, the anaesthetist, and David himself. A range of medications are available for David to use once he has reached a stage of being able to manage without the PCA, but it is also important that his pain be properly managed during the postoperative period, because good pain management will help David to mobilise properly and reduce the other postoperative risks, such as those of DVT, PE (Irwin, 2007) and pressure sore development. Another area to address is the prevention of atelectasis. Regardless of the type of surgical procedure, as many as 90% of patients who have a general anaesthetic develop some degree of atlectasis in the postoperative period ( Irwin, 2007; Pruitt, 2006). Pneumonia is another risk (Irwin, 2007). As well as the risks from having an anaesthetic anyway, David is at increased risk because he is more likely to demonstrate postoperative hypoventilation, because pain from abdominal surgery can prevent him from deep breathing and coughing which helps prevent atelectasis (Pruitt, 2006). David can be taught to splint the surgical site with a pillow or roll of blanket, and then carry out these breathing exercises – incentive spirometry, coughing and deep breathing – to help keep his lungs clear (Irwin, 2007). Adopting a good upright position also helps to increase lung capacity and encourage deeper breaths (Pruitt, 2006), and so good pain management is also important in supporting D avid to do this (Irwin, 2007). Adequate pain control is also essential to graft patency, because uncontrolled pain causes the release or epinephrine, noreinephrine, and other hormones that active the fight or flight response (Bryant et al, 2002). The consequent vasoconstriction can decrease blood flow through the graft and can increase risk of thrombus formation (Bryant et al, 2002). Alongside a drug therapy plan for pain management, it might also be appropriate to consider nondrug pain management as well (Tracy et al, 2006). Opioids used to manage postoperative pain can cause respiratory depression (Irwin, 2007). Some of the other advantages of nondrug pain management techniques is that they are readily available, inexpensive, and not associated with side effects, but the biggest advantage in this case is that they promote self-care and enhance personal control for one’s own health (Tracy et al, 2006). For David’s case, promoting self-care may have a number of beneficial effects on him holistically, given that he has recently experienced the diagnosis and treatment of a life-threatening condition (Manias, 2003). There is some evidence to suggest that tailored education and support in such therapies can benefit patient outcomes (Tracy et al, 2006), but this would require that the nurse is knowledgeable about the techniques, and that all members of t he multidisciplinary team are equally invested and have been prompted to include nondrug pain management in the care plan (Tracy et al, 2006). Prevention of Problems Associated with Aneurysm Repair. There are a number of potential complications of surgical abdominal aortic aneurysm repair, which are in addition to the usual postoperative risks. These include graft rupture, haemorrhage, and graft occlusion (Irwin, 2007). This is another reason for close monitoring of David’s haemodynamic status, because a drop in blood pressure or urine output, associated with increased heart rate and perhaps a change in mental status may indicated shock consequent to blood loss (Irwin, 2007). It is also important to carefully and frequently assess the abdomen, for pain, distension or increasing girth (Irwin, 2007). Graft occlusion may manifest as coronary ischaemia, MI, cerebral ischaemia or stroke, ischaemic colitis or even spinal cord ischaemia resulting in paralysis (Irwin, 2007). Similarly, occlusion of an abdominal graft can also compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, which might lead to limb loss (Irwin, 2 007). Therefore it might be prudent to calculcate ankle/brachial index regularly to evaluate lower extremity perfusion (Irwin, 2007). Nursing Issues In an empirical study of nursing in patients undergoing procedures for abdominal aortic aneurysm repair, Kozon et al (1998) found that patients who undergo the traditional open procedure require more intensive nursing care of lengthier duration, to move them along the illness-wellness spectrum towards self-care and independence. Kozon et al (1998) demonstrate a tailor made model based on the nursing process, which allows nurses to predict the postoperative course for individual patients. They also consider the psychological aspects of care, discussing the state of fear of patients, which is either externally visible to the nursing staff or is expressed by the patients themselves (Kozon et al, 1998). This is important in ensuring the holistic management of David’s care. However, Kozon et al (1998) also recommend further nursing research on this area to fully optimise nursing and enable the recognition of the nursing needs of the individual patient. This says much about the natu re of nursing knowledge and the evidence base on this topic, which remains very much focused on the physical and medical aspects of care. Kozon et al (1998) developed a protocol to apply to such cases, but in terms of evidence, larger scale studies are needed to validate this. The high risks of both the procedure and the repair are highlighted in the literature (Bryant et al, 2002), and so a thorough understanding of these is vital in order to underpin nursing practice and ensure rapid and appropriate prioritisation of care needs, recognition of deviations from the norm and prompt, appropriate referral and treatment. Another issue which the evidence base throws up is the documentation and monitoring of pain management. In a descriptive, retrospective audit of nursing records, Idvall and Ehrenberg (2002) found that there are many shortcomings in content and comprehensiveness of nurses’ monitoring and recording of patients’ pain. This is of particular importance in relation to postoperative care of those patients having undergoing surgical repair of abdominal aortic aneurysm, given that pain can indicate a number of complications of the procedure. Conclusion As can be seen, the care of the patient having an AAA repair is a complex undertaking, requiring a thorough knowledge base on the part of the nurse, and the skills necessary to recognise complications, deviations from clinical parameters, and effects of treatments in order to promptly and appropriately treat and refer the patient (Warbinek and Wyness, 1994). In David’s case, he has presented with a potential complication of his surgery, but the complex nature of his condition could mean that his potential pyrexia is due to a number of causes. Understanding the underlying physiology of his condition is vital in ensuring all his care needs are met and that he is kept in the optimal state of health to promote rapid recovery. This involves an holistic approach, with attention paid to his pain management and psychological state as well as his considerable medical and physical needs. The evidence base for care is suggestive of the existence of some useful nursing evidence on which t o base care, but also suggests the need for more concrete and comprehensive research to underpin practice. Nursing assessment and intervention can be crucial to the survival of patients with this condition (Myer, 1995). Thus nursing knowledge must draw upon their own and other’s knowledge and experience, and the knowledge and understanding of the patient, and their reported symptoms and feelings, in order to provide the highest standard of care and promote David’s optimal wellbeing and return to health. References Beese-Bjustrom, S. (2004) Aortic Aneurysms and dissections. Nursing 34 (2) 36-42. Birkmeyer, J.D. and Upchurch, G.R. (2007) Evidence –Based Screening and management of Abdominal Aortic Aneurysm. Annals of Internal Medicine 146 (10) 749-751. Bryant, C., Ray, C. and Wren, T.L. (2002) Abdominal Aortic Aneurysm Repair: a Look at the first 24 Hours. Journal of PeriAnaesthesia Nursing 17 (3) 164-169. Idvall, E. and Ehrenberg, A. (2002) Nursing documentation of postoperative pain management. Journal of Clinical Nursing.11 734-742. Irwin, G.H. (2007) How to protect a patient with aortic aneurysm. Nursing 37 (2) 36-43. Isselbacher, E.M. (2005) Thoracic and Abdominal Aortic Aneurysms. Circulation111 816-828. Jones, A. and Pegram, A. (2006) Management of pyrexia during blood transfusion. British Journal of Nursing. 15(5) 257. Kozon, V., Fortner, N. and Holzenbein, T. (1998) An empirical study of nursing in patients undergoing two different procedures for abdominal aortic aneurysm repair. Journal of Vascular Nursing. 16 (1) (1-5). Manias, E. (2003) Pain and anxiety management in the postoperative gastro-surgical setting. Journal of Advanced Nursing 41 (6) 585-594. Myer, S.A. (1995) Case studies: what a difference a nurse makes. Advanced Practice in Acute and Critical Care. 6(4) 576-87. Neacsu, A. (2006) Malignant hyperthermia. Nursing Standard 20 (28) 51-57. Pruitt, B. (2006) Help your patient combat postoperative atelectasis. Nursing 2006 36 (5) 31-34. Tracy, S., Dufault, M., Kogut, S. et al (2006) Translating Best Practices in Nondrug Postoperative Pain Management. Nursing Research 55 (2S) S57-S67). Warbinek, E. and Wyness, M.A. (1994) Caring for patients with complications after elective abdominal aortic aneurysm surgery: a case study. Journal of Vascular Nursing. 12(3): 73-9. Watson-Miller, S. (2005) Assessing the postoperative patient: Philosophy, knowledge and theory. International Journal of Nursing Practice. 11 46-51. Zeitz, K. (2005) Nursing observations during the first 24 hours after a surgical procedure: what do we do? Journal of Clinical Nursing 14 334-343.

A Time To Kill Essay -- essays research papers

A Review and Commentary On:A Time to Kill By John GrishamA Time to Kill written by John Grisham is a book that presents the high racial tensions in Canton Mississippi in the early 1990’s. The book opens with two young men, James Lewis Willard and Billy Ray Cobb, joy riding in their brand new yellow pick up truck decked out with Confederate flags. They speed though black neighborhoods throwing full beer bottles at people and houses, until they come across ten-year-old Tonya Hailey walking home from the grocery store. The men pull over, trap her, rape her repeatedly, beat her, hang her, throw her off a bridge and leave her for dead. Her siblings find Tonya later that day, barely alive, her father, Carl Lee Hailey., and the black community are outraged. Tonya’s missing shoe is found in the back of the yellow pick up truck and both men are arrested for rape and attempted murder. Carl Lee confronts his lawyer, Jake Brigance , about similar cases where the white criminals wer e let off or given light sentences for similar charges, which enrages Carl Lee further. Carl Lee asks if Jake will stand by him in a jam, Jake promises he will. The next morning Carl Lee shoots the two men on the way to their arraignment, both men die and a cop is shot and loses his leg. Carl Lee is immediately arrested for the murder of the two men, as promised Jake stands by his side. Carl Lee confesses to the murders and admits he never had anything against the two men until they messed with his baby, he feels sorry for the men’s families, but not for what he has done. Jake and Carl Lee begin to discuss every aspect of the case immediately, they decide that Carl Lee with plea not guilty by reason of insanity. The District Attorney, Rufus Buckley, begins to discuss the importance of keeping the case in this county in order to have a better chance of an all white jury, Jake files a change of venue for the opposite reason. Meanwhile, members of the Cobb and Willard family see k out the Ku-Klux-Klan to get even with Carl Lee and Jake, they begin a Klan chapter in their county, which immediately begins to terrorize Jake and his family. The NAACP comes to Canton and offers Carl Lee a more experienced lawyer, the NAACP believes â€Å"Carl Lee’s acquittal for the killing of two white men will do more for the black people of Mississippi than any event since we integrated the schools. His conviction woul... ...ts the entire plot rolling. Finally, the entire courtroom chapters, from opening statements to the acquittal of Carl Lee, are truly important. Through out the scenes in the courtroom, the truth about racism in Canton and America is revealed. Carl Lee and Jake prove to the jury that Carl Lee being black, Tonya being black, and Cobb and Willard being white are the central issues in the case. The jury then finds the strength to pass judgment that was not based on race. Although A Time to Kill is based on a fictional story, it still presents many interesting and realistic scenarios. It is easy to imagine that the events in the book actually did happen or could happen in American today. The series of events that unfold easily invoke strong emotions in the reader, no matter where that reader stands as far as racial beliefs. The book represents a wide range of views on the situation, from the Ku Klux Klan, Jake, Carl Lee, the NAACP, Buckley, the Judge, the jury, Dept. Luny, and the gene ral population of Canton. The book presents everything from the extreme events to everyday actions. A Time To Kill is an outstanding book that deals with important issues and shows many simple realities.

‘Macbeth’ English Coursework Essay

1. The scene opens with Lady Macbeth speaking in soliloquy; as a director I would tell the actress to look agitated, maybe wringing her hands and pacing the stage, quite near the back of the stage so it looks as if she is almost trying to hide. In the first soliloquy she seems less powerful compared to when she is with Macbeth. Lady Macbeth begins to imagine noises that represent bad omens, for example, ‘the owl shriek’d’. She probably didn’t hear that noise but an owl shrieking is a symbol of evil and she knows she is doing wrong. She then begins to go over the plans as if she is reassuring herself of what to do and wondering what is going on and how the plan is doing. Lady Macbeth obviously wasn’t that confident because she even says that she needed an alcoholic drink to calm her and make her brave again. Then when Macbeth enters, still in soliloquy, she panics that Macbeth hasn’t committed the murder, that they woke up and caught him and she expresses her doubts very obviously as shown in this quotation, ‘I am afraid’ this shows how she lacks confidence and proves that she wasn’t ‘bold’. Then when Macbeth and Lady Macbeth begin to talk to each other they are both very nervous and jumpy but slowly Lady Macbeth begins to regain control again and she can then comfort and sooth Macbeth who is very shocked and seems almost hysterical. Then Macbeth’s concerns worry Lady Macbeth but she still remains in control because she starts to command and order Macbeth around. For example, ‘give me the daggers’, ‘get on your nightgown’; Lady Macbeth regained her calm and Macbeth has become worried. Lady Macbeth gets worked up because of Macbeth’s doubting and worrying and she is almost shouting in rage at him when she says ‘infirm of purpose’ and as a director I would definitely say to be bossy and very angry towards Macbeth. She then begins to insult him which shames him as he is supposed to be a brave warrior when she calls him a ‘child’ so she has definitely regained her control and is ‘bold’ at the end of the scene. 2. In lines 16-31 Shakespeare creates lots of tension and anxiety by showing Lady Macbeth who is supposed to be very brave and someone who would rather ‘bash her baby’s brains out’ than show cowardice being nervous and jumpy. Lady Macbeth says that she couldn’t do it herself and doubts that Macbeth has the willpower to do it as well. Following this there is a very jumpy quick exchange between them in lines 22-30. The punctuation in this section is very short like full stops exclamation marks it is very quick answering, they almost finish off each others sentences. This would make the audience think whether they were going to get away with it? Would they be found out? Could they cover it up? Lie about it? So this creates a lot of anxiety as the audience want to know what is going to happen to them. 3. Macbeth is in a state of shock when he returns from Duncan’s Chamber. He hears sounds which frighten him so he appears very shocked and upset when he enters the scene. He is concerned that they will be found out and in that era the punishment would have been death for high treason. When he talks to Lady Macbeth they have a very quick and nervous exchange. During this exchange he begins to realise the seriousness of what he has just done and Macbeth then begins to feel guilty. He doesn’t seem to be able to focus on one thing at a time but the two dominant things he talks about is that he won’t be able to get spiritual forgiveness and he won’t be able to sleep. He then starts to talk about two lodgers praying and the fact that when they said ‘Amen’ he couldn’t because he had gone against God and broken the Divine Right of Kings. The Divine Right of Kings is an ancient belief system that was the eldest son of the king or queen would become the next ruler of the country. Macbeth had killed the king and taken his place so broken this spiritual belief. So Macbeth knows that he has disobeyed God and cannot get forgiveness. This is shown in lines 37-44. In these lines a very strong metaphor is used to show just how guilty he feels. The metaphor is: ‘Hangman’s hands’. This is comparing his hand to those of someone who kills frequently so this means that Macbeth’s guilt is so strong that it feels as though he has killed more than one person. The second dominant topic is that Macbeth sleep has the power to heal and nurture people who are troubled and weary but he has lost the right to sleep and will never sleep again. Lines 47-52 use a lot of good personification which further shows the guilt that Macbeth is feeling. He refers back to the witches in this extract:’ Glamis hath murder’d sleep, and therefore Cawdor Shall sleep no more; Macbeth shall sleep no more.’ this suggests that the witches are on his mind and how their prophecies have driven him to treachery. He then begins to question why he is jumpy; why his guilt and regret is so great; why he can’t go back in the room or even look at his hands. 4. The scene starts off with Macbeth in control because Lady Macbeth couldn’t commit the murder but after Macbeth did he couldn’t re-enter the room and face what he had done. Their relationship is very interesting because they have a large reliance on each other. Lady Macbeth needs Macbeth to commit the murder and Macbeth needs Lady Macbeth to drive him and push him so he has courage to commit the crime. Macbeth looses all his control in the relationship after he commits the murder because he is so haunted and shocked by what he has done and he then needs Lady Macbeth to calm him and make him feel at ease. You can find this change between lines 20-79. Lady Macbeth is in complete control at the end because she begins to call Macbeth names to make him feel ashamed of his cowardice and uses very commanding vocabulary to make him hide what they know and she is in some ways scared in case he can’t pretend that he doesn’t know anything. 5. The main themes of the play are nearly all mentioned in this scene. To me the most significant theme is that this story is about a man who potentially could have been great, powerful and strong but has been corrupted by darkness, witches and greed. Witchcraft is the theme that got them to this stage and is what really drives Macbeth to commit the murder. The witches’ prophecy drives him to killing anybody who got in his way especially Macduff’s family in Act IV Scene 2. Macbeth is constantly referring back to the witches and seems to have complete trust in them. An example showing that they are on his mind is in Act II Scene 2 when he is distraught about the murder in lines 55-57. Lady Macbeth also refers to witchcraft when she hears bad omens like the ‘owls’ scream’ so witchcraft and darkness is a main concern and theme of this particular scene. The theme of deception is carried on throughout this scene; at a more physical level than the deception of the witches with their contradicting language. In this scene, Act II Scene 2, Macbeth and Lady Macbeth are putting the blame of the murder on the King’s guards and appearing to be unaware of the situation. Bloodshed and guilt is another key issue especially with phrases like ‘Hangman’s hands’ and they very graphic visual image in lines 76-79. This theme is referred to throughout the rest of the play and eventually until Lady Macbeth’s death. The guilt is so strong that it causes her to take her own life and the guilt rules Macbeth into decisions and causes a lack of sleep which is another key theme. His lack of sleep is because he has ruined his own equilibrium. Macbeth knows that he has disrupted the Divine Right of Kings so therefore upset God. So Macbeth finds that he is unable to pray and has lost the right to sleep which is ‘nature’s healer’ which is a theme which continues right from the murder to the end of the play. He becomes mentally disturbed. The final topic in this scene is the power shifting in the relationship between Macbeth and Lady Macbeth. They both rely on each other to be strong.

Theme of Alienation in Frosts Poem - 1933 Words

Man: His Solitariness Robert Frost has written on almost every subject, but alienation and isolation, both emotional and physical, are the major themes of his poetry. His, ‘book of people’, North of Boston, is full of solitaries who are lonely and isolated for one reason or the other. Frost is a great poet of boundaries and barriers which divide men from men and come in the way of communication, and so result in lack of understanding and friction. Man is not only isolated from other man, but Frost pictures him as also alone and solitary in an impersonal and unfeeling environment. Separateness from the Stars This concern with barriers, barriers which result in alienation and loneliness, is a predominant theme in Frost’s poetry. There†¦show more content†¦In the end they are in love, or about to fall in love, and have made a pact to return and rebuild the old homeplace.† Alone and helpless as he is, man must wage a constant war against his physical environment which is inimical to human existence. The Otherness of Nature Thirdly, Man’s physical existence itself is a barrier which divides man from the soul or spirit of nature. While Wordsworth denied the very existence of barriers between man and nature, for Frost a wide gulf separates man and nature, spirit and matter. In a number of poems he stresses the ‘othernes’s and indifference of Nature, and shows that it is futile to expect any sympathy from the spirit of soul which moves or governs the world. Individual man and the forces of nature are two different principles, and the boundaries which separate them must be respected. These boundaries are insisted upon. In Two Look at Two, the man and the woman do feel that there is an affinity between themselves and the buck and the doe that stare back at them. But such moments are rare. They are ‘a favour’, and even here there is the man-made fence of, ‘barbed wire binding’, which separates, â€Å"human nature from deer nature†. I n Most of It man is shown in all his terrifying loneliness by the behaviour of the buck: But after a time allowed for it to swim, Instead of proving human when it neared And someone else additional to him, As a great buck—itShow MoreRelatedRobert Frost Alienation Essay845 Words   |  4 PagesFrost poems, such as Birches, Stopping by Woods on a Snowy Evening, Mending Wall, and many others all display alienation. Robert Frost loved writing poem about nature and urban areas as well. In most of these poems Robert Frost portrays alienation, this could be, because he himself experienced alienation. Alienation means to feel like youre lonely, it is not literally being alone. You can be in a crowded of hundreds of people and still feel alone, or left out. We all experience Alienation at someRead MoreThe Poetry of Robert Frost Essay754 Words   |  4 Pagesone of America’s greatest poets. Each poem begins with a straightforward description of a place or situation and then gently moves towards commentary and reflection on human life. There are life lessons to be learned in every poem which appeal to the reader both intellectually and emotionally. Frost deals with various aspect s of human life throughout his poetry, such as; childhood, relationships, death, decision making, depression etc. Frost expresses these themes and emotions in a very personal wayRead MoreRobert Frost had a fascination towards loneliness and isolation and thus expressed these ideas in1400 Words   |  6 Pagesand isolation and thus expressed these ideas in his poems through metaphors. The majority of the characters in Frost’s poems are isolated in one way or another. In some poems, such as â€Å"Acquainted with the Night† and â€Å"Mending Wall,† the speakers are lonely and isolated from their societies. On other occasions, Frost suggests that isolation can be avoided by interaction with other members of society, for example in â€Å"The Tuft of Flowers,† where the poem changes from a speaker all alone, to realizing thatRead MorePoem Analysis of Fire and Ice by Robert Frost and The Day They Came For Our House by Don Mattera1916 Words   |  8 Pagesthe d estructive nature of power, the poems are both concerned with Mortality of Age. The ideal readers of these poems are people old enough to understand how harsh and cruel this world can be. Furthermore, people who can appreciate the sense of grief portrayed in these poems, as both poets investigate deeply the potentially devastating capability of humans to destroy themselves and others. Fire and Ice, written by Robert Frost, is a carefully constructed poem, which carries a straightforward messageRead MoreEssay about Isolation and Nature in the Works of Robert Frost3175 Words   |  13 PagesIsolation and Nature in the Works of Robert Frost During the height of Robert Frost’s popularity, he was a well-loved poet who’s natural- and simple-seeming verse drew people - academics, artists, ordinary people both male and female - together into lecture halls and at poetry readings across the country.1 An eloquent, witty, and, above all else, honest public speaker, Frost’s readings imbued his poetry with a charismatic resonance beyond that of the words on paper, and it is of littleRead More Death of a Modernist Salesman Essay3513 Words   |  15 Pagesno longer be found.   They could not find any meaning or order in the old ways.   Despair was a common reaction for them.   The dilemma they ran into was what to do with this knowledge.   Poet Robert Frost phrased their question best in his poem â€Å"The Oven Bird.†Ã‚   Frost’s narrator and the bird about which he is speaking both are wondering â€Å"what to make of a diminished thing† (Baym 1103).   The modernist writers attempted to mirror this despair and tried to superimpose meaning on it or find meaning in it