Attitude and behavior towards internet shopping

Attitude and behavior towards internet shopping Studies on factors determining consumer attitude and behavior towards Internet shopping: Most of the studies conducted in the recent years in field of online shopping behavior and attitude have been focusing on the factors influencing the online shopping attitudes and behavior. But, different researchers have diverse opinions and focus, while studying the impact of these factors on the online consumer buying behavior and attitudes. For example, there is a segment of researchers who have tried to explain the consumer attitude and intentions for online shopping by taking theories like Theory of Reasoned Action, Technology acceptance model or Theory of Planned Behaviour as a basis and have tried to extend them further by adding more web specific factors to them(Cheung, Zhu, Kwong, Gloria, and Limayem, 2003), whereas there has been another segment who have derived relationships between various factors and customer satisfaction with reference to the Internet shopping experience in the form of dependent and independent variables. Further, there have been researchers who have f urther organized and compiled the previous researches done in this field so as to pave way for future researches. These researchers have also contributed in terms of designing structured frameworks for online consumer attitude, intention and buying behavior. Web experience The literature review done by Constantinides (2004) helps in identifying the web experience components and their role as the first step in shaping the online consumers behavior. He has added web experience as a controllable element in his model depicting factors that influence the online buying behavior. He has further explained web experience factor by classifying it in three sub-categories which are the building blocks of the web experience. These three sub-categories are Functionality factors (usability and Interactivity), Psychological factors (trust) and Content factors (aesthetics and Marketing Mix). The following figure as adopted from his article presents a brief description of the number of references in support of each of these factors: Source: Constantinides, E.(2004). Influencing the online consumers behavior: the web experience. Journal of Internet Research. Vol 14 No.2, pp. 114, figure 2. Literature review Li and Zhang (2002, p.508) have defined online buying behavior or Internet shopping/buying behavior as the process of purchasing products or services via the Internet; which according to Liang and Lai (2000), is similar to the traditional five steps process of consumer buying behavior (as cited by Li and Zhang, 2002). They have also defined online shopping attitude as the psychological state of the consumers in terms of Internet shopping (2002). Li and Zhang (2002) have analysed 35 empirical studies on online shopping attitudes and behavior conducted during the period of January 1998 to February 2002 and have finally identified 10 inter-related factors for which the reviewed studies have significant empirical evidences. These 10 factors have further been classified into five independent factors (viz. external environment, demographics, personal characteristics, vendor/service/product characteristics, and website quality) and five dependent factors (viz. attitude towards online shoppi ng, intention to shop online, decision making, online purchasing, and consumer satisfaction.) Another exhaustive literature review in this field has been by Cheung et al. (2003). They have examined a total of 351 articles in the area of online consumer behavior from 1994 to April 2002. They have attempted to link together the concepts of intention, adoption and continuance and form a base model- a Model of Intention, Adoption and Continuance (MIAC) for the development of an online consumer behavior framework. Further, the various factors as mentioned by various researchers in their study have been categorized under five major domain areas viz. individual/consumer characteristics, product/service characteristics, medium characteristics, and online merchant and intermediary characteristics. According to them, online purchase intention and adoption has been extensively studied and there are lots of empirical evidences available, but research on continuance or consumer online repurchase is in its infancy. The following figure describes the MIAC model as suggested by Cheung et al. Framework of online consumer behavior Source: Cheung, C.M.K., Zhu, L., Kwong, T., Chan, G.W.W. Limayem, M.(2003). Online Consumer Behavior: A Review and Agenda for Future Research. Proceedings of the 16th Bled eCommerce Conference, eTransformation. 194-218 A recent study conducted by Kuczmarski and James (April 2008) further contribute to the available body of literature by adding that consumers prefer online stores to actual stores due to potential reasons like convenience, cost and selection. Trust as a factor Studies also indicate that trust remains a crucial factor in e-commerce and in influencing the purchase decision of online shoppers. Consumers prefer to shop from trusted websites. Researches reveal that trust is a factor which also helps in forming long-term customer relationships (Dwyer, Schurr Oh, 1987; Gefen Straub, 2003; Kim, Xu Koh, 2004). Some researchers like Lee (2002), Liebermann and Stashevsky (2002), McKnight et al.(2002), Suh and Han(2002) and Liang and Lai(2002) have even argued that a new step has been added to the online buying process and that is the step of building trust or confidence (as cited by Constantinides, 2004). The available literature explains that trust facilitates e-commerce and online transactions, but at the same time the consumers lack of trust in online vendors continues to remain a hindrance in the growth of e-commerce. (Ba Pavlou, 2002; Gefen and Straub, 2003; Gefen, Karahanna Straub, 2003; Kim, Xu Koh, 2004; Lim, Sia, Lee Benbasat, 2006; P avlou Gefen, 2004). Gefen(2002) and Kim, Xu Koh (2004) have stated that a key challenge to e-commerce is that creating trust typically requires multiple interactions and superior service over a period of time(as cited by Lowry et al., 2008). Brand has also been established as one of the factors influencing the customer trust for a website (Bart, Shankar, Sultan Urban, 2005; Yoon, 2002). Ward and Lee(2000) conducted a research to examine whether consumers use brands as sources of information when shopping on Internet and they concluded that branding can facilitate consumers acceptance of e-commerce. Lowry, Vance, Moody, Beckman Read (2008) have studied the impact of branding alliances and web-site quality on the consumer trust of e-commerce websites. They explored the usage of branding alliances and website quality by the less familiar websites to enhance the consumer trust and suggested that branding and web-site quality can significantly increase the initial consumer trust in the e-commerce websites. Ballantine(2005) has studied the effects of interactivity and the amount of product information provided by an online shopping environment on consumer satisfaction. A web-based experiment was conducted where respondents were exposed to a simulated online retail store. Findings indicate that these two factors had a significant effect on the consumer satisfaction. Tangibility also remains an important factor in influencing the purchase process of Internet shoppers. Melian-Alzola and Padron-Robaina(2006) have analysed the role and importance of the tangible elements of purchase processes in business to consumer(B2C) e-commerce, and the impact on overall perceived quality and the customers attitudes. Their research concluded that that four attributes navigation, signposting, tools and explanation explain the tangible dimension in electronic commerce. They revealed that design was an important factor of overall perceived quality and the willingness to recommend the purchase experience to others. Security of transactions is another factor that remains as a matter of concern for e-commerce consumers. According to a study conducted by American Banker in 2007, one-third of Canadians refused to shop online due to fear of identity theft. Web assurance services help in building up the trust and confidence of such consumers. In an experimental study undertaken by Mauldin and Arunachalam (2002), the impact of web assurance services and retailer disclosures on purchase intent was studied. They have defined web assurance as the measures taken to reduce information risks and increase online purchasing by improving the reliability of certain information on the website. Their findings indicate that web assurance. In this research they considered TRUSTe, WebTrust and VISA web assurance services for the study. Their findings indicate that there were no significant differences in intent to purchase among the three assurance providers. Mauldin and Arunachalam have also studied the impact of product and retailer familiarity on the buying behavior of online consumers in the above mentioned study and they suggest that web assurance is insignificant when product familiarity is higher, or in other words, where product familiarity is lower, intent to purchase is higher with web assurance. Retailer familiarity is not fou nd to be significant in any of the conditions. Further, their study also reveals that retailer disclosures are sufficient to impact buying intention of online consumers; the web assurance services studied in the above study did not provide any additional assurance beyond the retailer disclosures. They have further emphasized that comfort with the Internet, general intent to buy online, and website design played significant role in influencing purchase intention. Although security is a major concern of online buyers, their study indicates that information risk generally did not significantly influence purchase intention, which explains why web assurance is generally not significant in their study. Bruce, Katherine and Murphy (2008) have further explored the prior studies on web assurance models to provide detailed explanation on current reporting requirements, differences among web assurance services and perceptions of consumers regarding these services. The study concludes that consumers give importance to web assurance services, but younger consumers place greater value on these services rather than older consumers. Technology Acceptance Model as a basis for research on Literature review In an attempt to design a structured framework for the effects of different factors on consumer attitude towards Internet shopping and their intentions to shop online, Monsuwe, Dellaert and Ruyter (2004) have reviewed the various researches conducted in the field. They have used Technology Acceptance Model (TAM) as a base and suggested a framework based on previous research on consumer adoption of new technologies and services. The Technology Acceptance Model (Davis, 1989) has served as a basis for various researches conducted in the Information systems field. In order to support the selection of TAM as a basis for their research work, Monsuwe et.al, 2004 have cited Chen et al.(2002), Moon and Kim(2001) and Lederar et al.(2000) who suggest that although this model is specifically designed to understand the adoption of a new computer based technology in the job/workplace, it has also proven to be suitable as theoretical foundation for adoption of e-commerce as well. The Technology Ac ceptance Model (TAM) suggests the usefulness, ease of use and the later addition of enjoyment (Davis et al., 1992) as the determinants of consumers attitude towards adopting a new technology. This attitude, further, has a strong and positive effect on consumers intentions to actually use the new technology or system (Bobbitt and Dabholkar, 2001; Davis, 1993). While redefining the three constructs in context of online shopping Monsuwe et.al.(2004, p.107) have referred to usefulness as the consumers perceptions that using the Internet as a shopping medium enhances the outcome of their shopping experience. Similarly, they have redefined ease of use as the consumers perception that the process leading to online shopping will require minimum effort and will be easy. Further, according to them, the enjoyment construct refers to the fun and playfulness of the Internet shopping experience. While usefulness has a weak direct link to attitude, it shows a strong direct link towards intention t o shop online (Davis et al., 1989). It is also linked with ease of use to determine consumers attitude towards online shopping. Hence, ease of use has a direct as well as indirect effect on consumers intention to shop online. Using TAM as a basis for the study, the framework proposed by Monsuwe, Dellaert and Ruyter(2004) not only includes the functional/utilitarian and hedonic dimensions like ease of use, usefulness, and enjoyment which affect the consumers attitude and intention towards Internet shopping, but they have also included some of the exogenous factors recommended by various researchers in the framework such as consumer traits(Burke, 2002; Dhabolkar and Bagozzi, 2002; Brown et al., 2001; Eastin and LaRose, 2000), situational factors(Wolfinbarger and Gilly,2001; Avery, 1996), product characteristics(Grewal et al., 2002; Elliot and Fowell, 2000), previous online shopping experiences(Shim et al., 2001; Eastlick and Lotz, 1999) and trust in online shopping(Yoon, 2002; Lee and Turban, 2001) Monsuwe et.al. in their research, have mentioned about the various researches done in order to extend the TAM by suggesting additional factors. For example, Venkatesh (2000), who has proposed integrating factors like control, intrinsic motivation, and emotion into the existing Technology Acceptance Model which are considered to be strong determinants for ease of use construct of TAM. Dabholkar and Bagozzi (2002) have given an attitudinal model of technology based self-service by suggesting two exogenous factors like consumer traits and situational influences. Further, they have cited OCass and Fenech (2002) who have added seven key consumer characteristics namely opinion leadership, buying impulsiveness, satisfaction with websites, web shopping compatibility, shopping orientation, Internet self-efficacy, and web-security to the model. Further, they have substantiated their model by citing the classification given by Hirschman and Holbrook (1982) who have categorised Internet shoppers in two categories; one is of the problem solvers and other category is of those seeking for fun, fantasy, arousal, sensory stimulation, and enjoyment. Monsuwe et al. suggest that this classification also supports the basic three constructs of TAM which affect the consumers attitude towards Internet shopping as ease of use and usefulness reflect the utilitarian aspect and enjoyment is in sync with the hedonic aspect of the model. The above explanation given by Monsuwe et al. is similar to the categorization of the shopping orientations by Bellenger, Robertson and Greenberg(1977) as convenience versus recreational orientation (as cited by Kim, LaRose, 2004) Various researches have been conducted to identify the underlying dimensions for the basic constructs of the TAM model. These latent dimensions can be further used to understand how these constructs get influenced by various exogenous factors. For example, Mathwick et al. (2001) have added two interesting latent dimensions to the usefulness construct Consumer Return on Investment(CROI), and service excellence. Monsuwe, Dellaert and Ruyter (2004) have defined CROI as a perceived return on cognitive, behavioural or financial investment made by the consumer. Whereas, service excellence evaluates the delivered promises against the performance. If both these dimensions are satisfied, then consumers will judge the Internet shopping performance positively (Mathwick et al., 2002) which adds to the perceived usefulness. Zeithamal et al. (2002) have stated that site characteristics such as search functions, download speed and navigation also acts as a determinant in shaping ease of use constru ct of the TAM model. But, Monsuwe et al. (2004, p.109) have a different opinion regarding this dimension. They have stated that these site characteristics merely influence the ease of use of a particular web site or online store, and not the Internet as a shopping medium in generalà ¢Ã¢â€š ¬Ã‚ ¦ Online Shopping orientations Kim and LaRose (2004) have defined shopping orientation as a shoppers attitude toward shopping activity that may vary with the situation rather than an invariant personality trait of the shopper. They have cited the categorization given by Bellenger, Robertson and Greenberg (1977) which classifies shoppers on the basis of their shopping orientation into convenience versus recreation oriented. Kim and LaRose (2004) also posit that shoppers may possess multiple orientations depending upon the expected outcome of a shopping experience and may demonstrate a regulated/utilitarian or an unregulated/recreational shopping orientation depending upon the environmental stimuli. Their study also shows that these two shopping orientations are not mutually exclusive and interactive web features may draw shoppers with convenience orientation into unregulated buying. Li, Kuo and Rusell(2006) have also studied the impact of shopping orientations on online consumer behavior alongwith other factors like demographics, channel knowledge and perceived channel utilities. Primary data was collected by a research company using an online survey of 999 U.S. Internet users. They have classified Internet users as frequent, occasional and non-buyers. Findings indicated that frequent web buyers have a higher degree of perceived channel utility for the purpose of communication, distribution and accessibility. Similarly channel knowledge also has a positive effect on the Internet buying and it also has a reciprocal influence on the perceived channel utilities. Their study also indicates that frequent web buyers value convenience more than experience(touch and feel of the product) whereas those who are non-web buyers have a higher degree of experience orientation. Recreation and economy orientation are found to be similar for the three types of Internet buyers. Th e study of the demographic factors revealed that male are more frequent web buyers than women, better-educated consumers shop more frequently online and consumers with higher income are more likely to be in frequent web buyer category. Age was not significant as far as frequency of web buying was concerned. Note: Most of the researchers feel that the classical consumer behavioral theories used for can only act as a starting point for understanding the online consumer behavior. There is no structured framework for explaining the online consumer behavior; the studies are mostly fragmented. Researchers have suggested different factors and frameworks, but there is a lack of a cohesive theoretical base to the online consumer behavior. Ba, S.L., and Pavlou, P.A. Evidence of the effect of trust building technology in electronic markets: Price premiums and buyer behavior. MIS Quarterly, 26, 3 (2002), 243-268. Gefen, D., and Straub, D.W. Consumer trust in B2C e-commerce and the importance of social presence: experiments in e-products and e-services. Omega: The International Journal of Management Science, 32, 6 (2004), 407-424. Gefen, D.; Karahanna, E.; and Straub, D.W. Trust and TAM in online shopping: An integrated model. MIS Quarterly, 27, 1 (2003), 51-90. Kim, H.-W.; Xu, Y.; and Koh, J. A comparison of online trust building factors between potential customers and repeat customers. Journal of the AIS, 5, 10 (2004), 392-420. Lim, K.H.; Sia, C.L.; Lee, M.K.O.; and Benbasat, I. Do I trust you online, and if so, will I buy? An empirical study of two trust-building strategies. Journal of Management Information Systems, 23, 2 (Fall 2006), 233-266. Pavlou, P.A., and Fygenson, M. Understanding and predicting electronic commerce adoption: An extension of the theory of planned behavior. MIS Quarterly, 30, 1 (2006), 115-143. Dwyer, F.R.; Schurr, P.H.; and Oh, S. Developing buyer-seller relationships. Journal of Marketing, 51, 2 (1987), 11-27. Everard, A.P., and Galletta, D.F. How presentation flaws affect perceived site quality, trust, and intention to purchase from an online store. Journal of Management Information Systems, 22, 3 (Winter 2005-6), 56-95 Kuczmarski, James (2008, Apr). JOURNAL-IST: Freedom of Choice. Fast Company, Issue 124, 43-43, 1/2p Runyan, B., Smith, K.T., Smith, L. M.(2008, Mar). Implications of Web assurance services on e-commerce. Accounting Forum (Elsevier), Vol. 32 Issue 1, 46-61 Gefen, D. Customer loyalty in e-commerce. Journal of the AIS, 3, 1 (2002), 27-51. Bart, Y.; Shankar, V.; Sultan, F.; and Urban, G.L. Are the drivers and role of online trust the same for all Web sites and consumers? A large-scale exploratory empirical study. Journal of Marketing, 69, 4 (2005), 133-152. Yoon, S.-J. The antecedents and consequences of trust in online-purchase decisions. Journal of Interactive Marketing, 16, 2 (2002), 47-63. Lowry, P.B., Vance, A., Moody, G., Beckman, B. Read, A. (2008). Explaining and Predicting the Impact of Branding Alliances and Web Site Quality on Initial Consumer Trust of E-Commerce Web Sites. Journal of Management Information Systems / Spring 2008, Vol. 24, No. 4, pp. 199-224. American Banker(2007, 17 Dec), Vol. 172 Issue 241, p17-17, 1/9p Monsuwe, T.P., Dellaert, B.G.C. Ruyter, K.D.(2004). What drives consumers to shop online? A literature review. International Journal of Service Industry Management.Vol.15 No.1, pp.102-121 Ward,M.R. Lee, M. J.(2000). Internet shopping, consumer search and product branding. Journal of Product and Brand Management, Vol.9 No.1, pp.6-20 Ballantine, P.W.(2005). Effects of interactivity and product information on consumer satisfaction in an online retail setting. International Journal of Retail Distribution Management, Vol.33 No.1, pp.461-471 Melià ¡n-Alzola, L. Padrà ³n-Robaina, V. (2006). Tangibility as a quality factor in electronic commerce B2C. Managing Service Quality. Vol.16 No.3,pp.320-338 Li,N. Zhang, P.(2002). Consumer Online shopping attitudes and behaviour: An assessment of research. Proceedings of the Eighth Americas Conference on Information Systems. 508-517 Constantinides, E.(2004). Influencing the online consumers behavior: the web experience. Internet Research. Vol 14 No.2, pp. 111-126 Cheung, C.M.K., Zhu, L., Kwong, T., Chan, G.W.W. Limayem, M.(2003). Online Consumer Behavior: A Review and Agenda for Future Research. Proceedings of the 16th Bled eCommerce Conference, eTransformation. 194-218 Li, H., Kuo, C. Rusell, M.G.(2006, Jun). The Impact of Perceived Channel Utilities, Shopping Orientations, and Demographics on the Consumers Online Buying Behaviour. Journal of Computer-Mediated Communication. 5(2). Retrieved July, 1, 2009, from http://www3.interscience.wiley.com/cgi-bin/fulltext/120837782/HTMLSTART Mauldin, E. Arunachalam, V. (2002). An Experimental Examination of Alternative Forms of Web Assurance for Business-to-Consumer e-Commerce. Journal of Information Systems. 16. 33-54 Abstract: Customers in an Internet shopping environment actually play dual roles. One is the role as a customer in a shopping place, and the other is the role as a user of information technology. In both cases, the level of satisfaction is of great concern. In this vein, a way of measuring the satisfaction level that takes both roles into account is needed. However, in past research indexes for consumer satisfaction and indexes for user information satisfaction have been developed separately in the fields of marketing and management information systems. Because of this lack of interaction between the two streams of research, an index for electronic commerce consumers that has its base in the dual roles has not been developed and tested. In this research, an instrument for measuring electronic commerce consumer satisfaction was proposed and validated using a sample of over 400 customers. The relationship between the index and consumers purchasing intention was also examined. Title: Development of electronic commerce user-consumer satisfaction index (ECUSI) for Internet shopping Author(s): Namjae Cho, Sanghyuk Park Journal: Industrial Management Data Systems Year: 2001 Volume: 101 Issue: 8 Page: 400 406 ISSN: 0263-5577 DOI: 10.1108/EUM0000000006170 Publisher: MCB UP Ltd Abstract: Purpose The purpose of this study is to investigate the effects of consumers shopping orientation on their satisfaction level with the product search and purchase behavior using multi-channels. Design/methodology/approach A total of 181 students in a large US mid-western university provided usable responses to the survey. Exploratory factor analysis and multiple regression analyses were employed to examine the research questions. Findings The results showed that more than three quarters of the respondents shopped via the internet and catalogs, and about 95 percent shopped at non-local retailers. About 60 percent reported that they never shopped from TV shopping channels. Confident/fashion-conscious shopping orientation and catalog/internet shopping orientation were found to be key predictors of customer satisfaction level with information search via multi-channels. Both confident/fashion-conscious consumers and mall shopping-oriented shoppers were more satisfied with store-based retail channels for apparel purchases, whereas non-local store-oriented shoppers and catalog/internet-oriented shoppers were more satisfied with non-store-based retail channels for their apparel purchases. Research limitations/implications The sample of this study was biased by gender and age. For the apparel retail industry, this paper offers practical knowledge about the relationships between shopping orientation and consumer search and purchase behavior in a multi-channel retailing context. Originality/value No study has utilized the shopping orientation framework to explain consumer behavior in a multi-channel environment. This study provides understanding of consumer product information search behavior on four dimensions (price, promotion, style/trends, and merchandise availability) via multi-channels. Title: The effects of shopping orientations on consumers satisfaction with product search and purchases in a multi-channel environment Author(s): Hyun-Hwa Lee, Jihyun Kim Journal: Journal of Fashion Marketing and Management Year: 2008 Volume: 12 Issue: 2 Page: 193 216 ISSN: 1361-2026 DOI: 10.1108/13612020810874881 Publisher: Emerald Group Publishing Limited Article Information: Title: Attitude toward internet web sites, online information search, and channel choices for purchasing Author(s): Yoo-Kyoung Seock, Marjorie Norton Journal: Journal of Fashion Marketing and Management Year: 2007 Volume: 11 Issue: 4 Page: 571 586 ISSN: 1361-2026 DOI: 10.1108/13612020710824616 Publisher: Emerald Group Publishing Limited Document Access: Existing customers: Please login above. You do not have rights to view the article Purchase this document: Price payable: GBP  £13.00 plus handling charge of GBP  £1.50 and VAT where applicable. Purchase Request this document: Print or e-mail a document request to your librarian. Request Reprints permissions: Request Abstract: Purpose This study aims to examine the influence of attitudes toward particular clothing web sites, specifically favorite ones, on information search at those web sites and on the choice to purchase items from those web sites and from non-internet channels after finding the items at the web sites. Design/methodology/approach Using survey data from 414 US college students who had online shopping experience and favorite clothing web sites that they especially like to visit, hypothesized relationships among attitude toward internet web sites, online information search and channel choices for purchasing were tested using path analysis. Findings Results showed that participants attitudes toward their favorite clothing web sites had a direct, positive effect on their intentions to search for information at those web sites as well as intentions to purchase clothing items from those web sites after finding the items there. Additionally, operating through information-search intentions at the web sites, participants attitudes toward those web sites had an indirect, positive effect on their intentions to purchase clothing items from non-internet channels after finding the items at the web sites. Research limitations/implications Results cannot be generalized to the larger population of young consumers and to other consumer groups. Future research should include other population groups. Practical implications This research provides insights into how college students attitudes toward internet web sites affect their information search at the web sites and their channel choices for purchasing. Our results suggest potential benefits of multi-channel retailing for online clothing retailers targeting US college students and the importance of building effective web sites to elicit those consumers positive attitudes toward the web sites. Originality/value This study is the first to investigate young adult online shoppers attitude towards internet web sites and their information search and channel choices for purchasing. Keywords: Consumer behaviour, Information retrieval, Internet shopping, Purchasing, United States of America Article Type: Research paper Article URL: http://www.emeraldinsight.com/10.1108/13612020710824616 Article Information: Title: Do determinants of online shopping differ for personal shoppers and professional shoppers? Author(s): Amit Bhatnagar Journal: EuroMed Journal of Business Year: 2007 Volume: 2 Issue: 1 Page: 87 102 ISSN: 1450-2194 DOI: 10.1108/14502190710749974 Publisher: Emerald Group Publishing Limited Document Access: Existing customers: Please login above. You do not have rights to view the article Purchase this document: Price payable: GBP  £13.00 plus handling charge of GBP  £1.50 and VAT where applicable. Pu

Buffy the Vampire Slayer Essay -- Television TV Show Essays

Buffy the Vampire Slayer While the first seasons of Buffy are structured around an external threat seeking to corrupt the order of the world, later the source of the threat becomes increasingly internal, and the characters must embrace a side of themselves which is evil, irrational, or dangerous. When Giles kills an arguably innocent Ben, he does not suffer the moral ambiguity that Willow encounters when she kills a guilty Warren. Willow has to deal with an evil internal to her in a way Giles does not, and this apparent discrepancy is the result of a general evolution of the series, rather than a double standard. The murder of Ben is comparable to the murder of Warren, even though Ben is mostly innocent and Warren is mostly guilty. They are both human, and their deaths are necessary to stop further evil. Even though Ben cohabits the same body with the hell god Glory, he, as an independent being, is innocent of Glory's actions, as the Scoobies uniformly agree: "What about Ben? He can be killed, right? I mean, I know he's an innocent, but, you know, not, like 'Dawn' innocent. We could kill... a regular guy... (no we couldn't) God." Even the script directions ("no we couldn't") suggest that the way Xander delivers these lines should emphasize the moral impossibility of killing Ben as a way of stopping Glory. Being Glory is to Ben what being the Key is to Dawn: it could make him "other" but it cannot make him either good or bad on Glory's behalf. It is true that Ben is guilty of other things -- he summons the demon who kills (or merely finishes off) Glory's brain sucked victims; and, in "Listenin g to Fear," there is even a real chance that Joyce might get killed because of him (an event which Buffy prevents from happening). .. ...umans into vampires): "at some point someone has to draw the line, and that is always going to be me. You get down on me for cutting myself off, but in the end the slayer is always cut off" ("Selfless"). At the same time, she is the most ambiguous one, the one who is ready to cut all ties with family and friends and kill people she loves, if necessary (e.g., Angel). The requirement that she know exactly which side she must stay on (regardless of where those she loves are) gives her the responsibility to keep the other "other" at all costs -- even at the cost of becoming an "other" herself. This would be the moral equivalent of dying to save lives in "The Gift" -- in this case, crossing over to the dark side in order to prevent others from doing it. Paradoxically, she protects the line which separates good from evil by crossing it, by becoming more and more "other."

lord of the rings :: essays research papers

The Fellowship of the Rings   Ã‚  Ã‚  Ã‚  Ã‚  I read The Fellowship of the Rings for my book report. It is the first book to the Lord of the Rings, written by J.R.R. Tolkien. The settings in this book changed many times from the hills of the Shire where the hobbits live, to the deep darkness of the mines of Moria. The book takes place in a place called Middle Earth, which is described by Tolkien as a mysterious place full of good and evil. The way Tolkien described each place is amazing and it is as if u were looking at a picture and copping it down into your head. The Shire, a peaceful place, full of little people, known as hobbits. The hobbits are friendly folk who don’t pay attention to the outside world. They live in little holes dug in the sides of hills. The hobbits have large gardens of, pipe weed, corn, and their favorite, potatoes. The hobbits are used to their everyday life, and are very content with the lack of adventure. Most do not travel farther then Bree. Bree is a small town mixed with big and little people, (men and hobbits) who live together through the hard time that trouble the old town. The Forest of Lothorien is where the elves live in peace, hidden for the evil not far off. The forest is very magical and full of beautiful trees. The trees were described to have silver bark and rich golden leaves. These were the homes of the elves that had built platforms in the center of the trees, like tree houses. In Lothorien the weather is always as if it were a warm spring day even in the dead of winter. Lothorien is unaffected by time, as if the days just repeat them selves but the people go on with their lives. The lady of the land, Galadriel, has another magical ring that the dark lord is seeking. The magic ring kept the forest protected and healthy along with everyone that lived there. Darkness, silence, emptiness describes the Mines of Moria. The mines cut through the Misty Mountains, and connect the fields of Rohan to the forest of Lothorien. The mines were abandon by the dwarfs in a war with the orcs, who worked for a wizard who wanted the same ring that the dark lord wanted. The are many passages that were crafted bye the dwarves to mines and lookouts but only one way out.

Diet Analysis Project Essay

1. How does your daily caloric intake stack up compared to what is recommended? Unfortunately, after completing my diet analysis, I found out that my daily caloric intake is 1,5 times higher than it is recommended. According to the USDA website my caloric intake should be 1880 per day, by in reality it is 2972 (about 3000 per day). Now I understand why I started to gain weight, even though I don’t eat much or often. 2. What nutrients do you consume the most? Does this pattern reflect a healthy diet? Compare your results to dietary recommendations provided on the website. After reviewing my nutrient intakes, I discovered that I consume too much carbohydrates, cholesterol and sodium. While acceptable range of carbohydrates is 130, I consume about 300 per day. Similarly, instead of recommended

Written Critique of Drug Therapy in Nursing Practice

According to Wayne K. Anderson, Dean, State University of New York, School of Pharmacy, â€Å"statistically, if you take six different drugs, you have an 80% chance of at least one drug-drug interaction. † The drug regimen of Mrs. Brown includes six drugs that may interact with each other if not administered and monitored carefully. This is the reason why healthcare providers should be aware of the possible adverse affects that may happen related to her drug regimen. Necessary precautions should be observed to get the full benefits of the needed drugs and minimize possible drug-drug interactions. Nursing Management Mrs. Brown has a history of seizure, therefore, necessary measures should be provided to ensure the patient's safety. It is also known that seizure is one of the many side effects of the drug metronidazole (Drugs. com, 2010). To prevent injury to patient, the nurse should provide comfort and safety measures if the CNS effect occurs such as siderails, and assistance with ambulation if dizziness and weakness are present† (Karch, 2006, p. 170). Since Mrs. Brown has numerous risk factors and health conditions, the nurse should â€Å"monitor for drug-drug interactions to arrange to adjust dosages appropriately† (Karch, 2006, p. 47). The drug regimen of Mrs. Brown may present several adverse effects that should be observed, the nurse â€Å"monitor adverse effects and provide appropriate supportive care as needed to help patient cope with these effects† (Karch, 2006, p. 347). To achieve therapeutic effects, it is also important that the nurse is aware how to â€Å"administer the drug as prescribed in appropriate relationship to meals† (Karch, 2006, p. 572). The nurse should provide supportive management to the drug regimen so she should â€Å"monitor the patient's clinical status closely especially during the initial stages of treatment† (Karch, 2006, p. 34). This includes daily monitoring of serum lithium and phenytoin levels, blood glucose, prothrombin time (PT) and hepatic functioning. It is essen tial to promote compliance to the patient. The nurse should â€Å"provide thorough patient teaching, including drug name and prescribed dosage, as well as measures for avoidance of adverse effects, warning signs that may indicate possible problems and the need for monitoring and evaluation to enhance patient knowledge about drug therapy† (Karch, 2006, p. 347). Some of the teaching points that should be included are any sign of blood loss ( petechiae,bleeding gums, bruises, dark colored stools, dark colored urine) to evaluate the effectiveness of warfarin and symptoms of phenytoin toxicity, including drowsiness, visual disturbances, change in mental status, nausea, or ataxia. Indications and Actions The indications and actions of Mrs. Brown's regimen is presented to help verify the purpose of the drugs and their effects on the overall condition of the patient. Metronidazole (Flagyl, MetroGel, Noritate) Metronidazole is used for the treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease, H. pylori infection causing peptic ulcers, bacterial vaginosis, and anaerobic infections and perioperative prophylaxis in colorectal surgery† (Kee & Hayes, 2006, p. 470). In this case, it is also used to treat abscesses in the pelvis caused by susceptible anaerobic bacteria. It is classified as â€Å"an antiprotozoal agent that acts to inhibit DNA synthesis in susceptible protozoa, leading it to unable to reproduce and subsequent cell death† (Karch, 2006,p. 169). Paracetamol (Acetaminophen) Acetaminophen is indicated for the treatment of pain and fever associated with a variety of conditions, including influenza; for the prophylaxis of children receiving diptheria-pertussis-tetanus (DPT) immunizations; and for the relief of musculoskeletal pain associated with arthritis† (Karch, 2006, p. 241). Paracetamol was prescribed for the presence of pain in the client's perineal area. Metformin (Glucophage) â€Å"Metformin is a biguanide compound used for the management of type 2 diabetes† (Kee & Hayes, 2006, p. 787). In this case, the patient was known to have diabetes. This medication could be considered as a new mechanism for the management of her type 2 diabetes. This oral diabetic agent â€Å"acts by decreasing hepatic production of glucose from stored glycogen† (Kee & Hayes, 2006, p. 787). It is said to diminish the increase in serum glucose after meals and lessen the degree of postprandial hyperglycemia. Phenytoin (Dilatin) â€Å"Phenytoin is the protoype hydantoin used in the treatment of tonic-clonic seizures and status epilepticus, as well as in the prevention and treatment of seizures after neurosurgery† (Karch, 2006, p. 342). Since the patient has a history of seizure disorder, this medication was prescribed for maintenance. It acts as â€Å"an anticonvulsant drug that works by suppressing sodium influx through the drug binding to the sodium channel when it is inactivated, thus prolonging the channel inactivation and thereby preventing neuron firing† (Kee & Hayes, 2006, p. 341). Warfarin ( Coumadin) â€Å"Warfarin (Coumadin) is an anticoagulant drug in oral form that is used to maintain a state of anticoagulation in situations in which the patient is susceptible to potentially dangerous clot formation† (Karch, 2006, p. 38). The patient was given this medication since she has a history of atrial fibrillation that makes her susceptible to thrombus and embolus formation. The drug Warfarin inhibits the formation of thrombus and embolus formation by decreasing certain clotting factors. â€Å"Warfarin causes a decrease in the production of vitamin K-dependent clotting factors (II [prothrombin], V II, IX and X) in the liver† (Karch, 2006, p. 740). Lithum Carbonate â€Å"Lithium is used as a mood stabilizers which is used to treat bipolar affective disorder† (Key & Hayes, 2006, p. 399). Mrs. Brown has a bipolar mood disorder so this drug was prescribed to control her periods of mania and depression. It is said to function in several ways, â€Å"it alters sodium transport in nerve and musle cells; inhibits the release of norepinephrine and dopamine, but not serotonin, from stimulated neurons; increases the intraneuronal stores of norepinephrine and dopamine slightly; and decreases intraneuronalcontent of second messengers† (Karch, 2006, p. 330). Common Drug Interactions Drug to Drug Interactions Metronidazole (Flagyl, MetroGel, Noritate) This drug is known to produce interactions with phenytoin, oral coagulants and lithium. â€Å"Coadministration with a nitromidazole may increase the serum concentration of phenytoin† (Drugs. com, 2010). It is known to induce microsomal liver enzyme activity such as phenytoin that may accelerate the elimination of metronidazole resulting in reduced plasma; impaired clearance of phenytoin has been reported† (DailyMed, 2009). In this case, pharmacologic responses and serum phenytoin should be checked frequently whenever metronidazole is being administered to the patient. The drug dosage should be adjusted as necessary. Another thing to do is to educate the patient the signs and symptoms of phenytoin toxicity for immediate physician notification. â€Å"Metronidazole has been reported to potentiate the anticoagulant effect of warfarin and other oral coumarin anticoagulants, resulting in a prolongation of prothrombin time† (DailyMed, 2009). Mrs. Brown should be advised to report any signs of bleeding to her physician. INR should be checked frequently for adjustments in warfarin dosage, specifically after starting or discontinuing metronidazole. And lastly, lithium is said to produce interactions when administered with metronidazole. â€Å"Concurrent use of metronidazole with lithium may provoke lithium toxicity due to reduced renal clearance† (Rxlist, 2010). Since Mrs. Brown has a bipolar mood disorder, lithium is a long drug regimen. The serum lithium and creatinine levels should be monitored after the initiation of metronidazole. Phenytoin (Dilantin) Besides the impaired clearance of phenytoin with the use of metronidazole, there are other drug interactions that can happen in reference to Mrs. Brown's drug regimen. It is said that Phenytoin can increase the effects of anticoagulants. â€Å"The hydantoins displace the anticoagulants and aspirin, causing more free drug and increasing their activity† (Kee & Hayes, 2006, p. 342). Still, it is important to check on the prothrombin time (PT), phenytoin level and prothrombin time of the patient during the administration of both drugs. â€Å"Signs of an active bleed include coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea-colored urine (hematuria), and black, tarry stools (hemoccult positive)†. Brown should be observed and notified to the physician. It is also said that the use of phenytoin can lead to â€Å"increased hepatotoxicity with acetaminophen† (Karch, 2007, p. 952). Lithium interacting with Phenytoin â€Å"may either increase or decrease the effectiveness of lithium or increase or decrease the effectiveness of the drug† (Raber, 2010). Phenytoin level and lithium serum level should be checked frequently to monitor the effectiveness of these drugs. Warfarin (Coumadin). Aside from the drug interactions of warfarin to both Metronidazole and Phenytoin, there is an existing interaction between Metformin and Warfarin. It is said that Metformin â€Å"oral hypoglycemic drugs for diabetes can displace warfarin or dicumarol from the protein-bound site, causing more free-circulating anticoagulant† (Kee & Hayes, 2006, p. 663). Due to this possible interaction, it is important to monitor the blood glucose level and prothrombin time (PT). The patient should be informed of the signs and symptoms of hypoglycemia and bleeding so that she could report it to the health care team immediately. Warfarin also interacts with paracetamol (acetaminophen); it said that â€Å"some investigators advise that the hypothrombinemic response to warfarin can increase when acetaminophen is taken in a dosage of more than 2 g per day for longer than one week† (Ament, Bertolino & Liszewski, 2000). Since Mrs. Brown has a prescription of 1000mg to be taken four times a day, her dosage is more than 2g per day. â€Å"If acetaminophen therapy is needed, the dosage should be as low as possible, and the drug should be taken for only a short period. In addition, the INR should be monitored closely† (Ament et al. 2000). Metformin (Glucophage) Meformin has moderate drug interaction with the drug Phenytoin. It is said to diminish the efficacy of oral diabetic agents and insulin. â€Å"These drugs may interfere with blood glucose control because they can cause hyperglycemia, glucose intolerance, new-onset diabetes mellitus, and/or exacerbation of preexisting diabetes† (Drugs. com, 2010). There should be close monitoring of Mrs. Brown's blood glucose level in order to observe hypoglycemia in the patient. Lithium (Eskalith) Lithium has drug interactions with Metronidazole and Phenytoin. It is also established that lithium may diminish the therapeutic effects of insulin and oral anti-diabetic agents. â€Å"In one study, 10 psychiatric patients treated with lithium carbonate for 2 weeks demonstrated elevated blood glucose levels and impaired glucose tolerance tests. There have also been isolated case reports of hyperglycemia, impaired glucose tolerance, or diabetes mellitus in patients on lithium, although a causal relationship has not been established† (Drugs. com, 2010). The blood glucose level should be checked frequently after starting or discontinuing lithium therapy. Drug to Food, Drug to Herbal, Drug to OTC drugs Interactions Metronidazole Metronidazole has a significant interaction with ethanol. â€Å"Use of alcohol or products containing alcohol during nitroimidazole therapy may result in a disulfiram-like reaction in some patients† (Drugs. com, 2010). Necessary precautions should be made in relation to use of ethanol and ethanol-containing products. Mrs. Brown should be instructed not to take alcohol beverages and alcohol-containing products. It is said that â€Å"alcohol beverages should not be consumed for at least a day after completion of metronidazole therapy† (Drugs. om). Metronidazole has an interaction to the herb milk thistle. â€Å"Milk thistle has been reported to protect the liver from harm caused by some prescription drugs. While milk thistle has not yet been studied directly for protecting people against the known potentially liver-damaging actions of metronidazole, it is often used for this purpose† (Morazz oni & Bombardelli, 1995). Phenytoin Phenytoin has moderate interaction with alcohol and food. The effects of alcohol on the therapeutic level of Phenytoin depend on the duration of its consumption. â€Å"Acute consumption of alcohol may increase plasma phenytoin levels. Chronic consumption of alcohol may decrease plasma phenytoin levels† (Drugs. com, 2010). Phenytoin (oral drug) could be given with or without food in a consistent manner. Give with food if patient complains of GI upset ( Karch, 2007). The bioavailability of Phenytoin is said â€Å"to decrease to subtherapeutic levels when the suspension is given concomitantly with enteral feedings† (Drugs. com, 2010). Antacids containing calcium may decrease the blood level of phenytoin while aspirin (more than 1500 mg/dl) may increase the blood level of phenytoin (Epilepsy. om, 2010). Phenytoin also will lower the blood levels of other types of medication like acetaminophen (Epilepsy. com, 2010). Warfarin Patients taking Warfarin should not take Vitamin K-rich foods like â€Å"liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and other green leafy vegetables† (Drugs. com). There are also particular medicines that should not be taken for they m ay cause serious bleeding problems in the stomach and intestines and alterations in blood clotting. These particular medicines are as follows: â€Å"acetaminophen (Tylenol), aspirin, and NSAIDs including celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Motrin, Advil), indomethacin, naproxen (Aleve, Naprosyn),and others† (Drugs. com, 2010). It is also said that the patient should â€Å"avoid eating cranberries, drinking cranberry juice, or taking cranberry herbal products† (Drugs. com, 2010). Warfarin can interact with the following herbal products: â€Å"garlics, gingko biloba, ginseng or St. John's wort†. (Drugs. com, 2010). Metformin Drugs that can raise the blood sugar affecting the use of Metformin include medicines to treat colds and allergies while drugs that lower blood sugar include some nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and sulfa drugs (Bactrim)† (Drugs. com, 2010). Alcohol should also not be taken concomitantly with this drug. â€Å"Alcohol lowers blood sugar and may increase the risk of lactic acidosis while taking this drug† (Drugs. com, 2010). There could be increased risk for hypoglycemia if the drug is taken with â€Å"juniper berries, ginseng, garlic, dandelion root and celery† (Karch, 2007, p. 58). Lithium Patients taking lithium carbonate should â€Å"avoid drinking large amounts of coffee, tea, or cola, which can cause dehydration through increased urination† (Drugs. com, 2010). Besides having interactions with other drugs in the patient's regimen, lithium also interacts with over-the-counter drugs. â€Å"If Eskalith is taken with certain other drugs, the effects of either could be increased, decreased, or altered such as nonsteroidal anti-inflammatory drugs† (Drugs. com, 2010). â€Å"Patients being treated with lithium should be encouraged not to use the herbal therapy psyllium. If combined with lithium, the absorption of the lithium may be blocked and the patient will not receive therapeutic level† (Karch, 2006, p. 333) Possible Adverse Reactions and Nursing Interventions Metronidazole â€Å"Convulsive seizures have been reported in patient treatment with metronidazole† (DailyMed, 2009). Necessary seizure precautions should be implemented. Mrs. Brown has a history of seizure; this is why the healthcare team should take necessary adjustments to the dosage of metronidazole. Aside from this major adverse reaction, the patient can develop â€Å"unpleasant metalic taste, nausea, vomiting and diarrhea† (Karch, 2007, p. 86). Nursing care for strange metallic taste should be â€Å"frequent mouth care, sucking sugarless candies†, and for nausea, vomiting and diarrhea, the patient should be advised to â€Å"eat frequent small meals† (Karch, 2007, p. 786). In the case of Mrs. Brown, complains of discomfort in her buttocks, pain in per ineal area and offensive odor could mean that she developed cadidiasis as â€Å"known or previously unrecognized candidiasis may present more prominent symptoms during therapy with metronidazole† (DailyMed, 2009). Treatment with candidicidal agent should be instituted to the patient. Other adverse effect can be â€Å"disulfiram-like interaction with alcohol† (Karch, 2007, p. 786). The patient should be always reminded of precautions on ingesting alcohol and alcohol-containing products. Phenytoin â€Å"Nausea,vomiting, diarrhea, constipation and gingival hyperplasia† (Karch, 2009, p. 951) could be present in patients taking Phenytoin. The nurse should â€Å"arrange instruction in proper hygiene technique for long-term patients to prevent development of gum hyperplasia†, â€Å"take drug with food, eat frequent small meals† (Karch, 2007, p. 953). Among the other common adverse effects are â€Å"dizziness ,drowsiness, confusion and headache†. The patient should be advised to â€Å"avoid performing tasks requiring alertness and visual acuity† (Karch, 2007, p. 953). Warfarin The common adverse effects of Warfarin are â€Å"nausea, vomiting, abdominal cramping, diarrhea and hemorrhage† (Karch, 2007,p. 1216). Nurse should advise the patient to â€Å"avoid any situations in which she could be easily injured. † Necessary care should be provided to avoid bleeding in the patient like â€Å"not giving any IM injections† (Karch, 2007, p. 1217). The patient should also be asked to â€Å"report unusual bleeding (from brushing teeth, excessive bruising), black or bloody stools, cloudy or dark urine† (Karch, 2007, p. 1218). Metformin The most significant possible adverse effects of this drug are â€Å"hypoglycemia and lactic acidosis† (Karch, 2007, p. 758). The nurse should â€Å"monitor blood for glucose and ketones† or â€Å"should ask the client any sign of hypo- or hyperglycemic reactions† (Karch, 2007, p. 758). There could also be â€Å"signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat† (Drugs. om, 2010). In this case, it is necessary to â€Å"stop the medication and report to the physician† (Drugs. com, 2010). Lithium The common side effects of Lithium involves CNS manifestions such as â€Å"lethargy, slurred speech, muscle weakness and fine hand tremor; GI manifestions such as nausea, vomiting , diarrhea, thirst; GU effect is polyuria† (Karch, 2007, p. 704). It is important to instruct the client to â€Å"report any signs of toxicity such as diarrhea, vomiting, tremor, drowsiness, muscle weakness† (Karch, 2007, p. 705). The patient should also be prohibited or â€Å"avoid driving or performing tasks requiring alertness† and should be instructed to â€Å"eat frequent small meals† (Karch, 2007, p. 705). Health Education Metronidazole It is impotant to instruct the client to â€Å"not drink alcohol (beverages or preparations containing alcohol, cough syrups)† (Karch, 2007, p. 786). The nurse should also mention to the client that she may experience â€Å"urine with darker color , dry mouth with strange metallic taste, nausea, vomiting and diarrhea† (Karch, 2007, p. 786). Intervention to relieve these side effects should be taught like â€Å"frequent mouth care, sucking sugarless candies for dry mouth; eating frequent small meals for nausea, vomiting and diarrhea† (Karch, 2007, p. 786). Phenytoin Patients taking Phenytoin should be advised to â€Å"take this drug exactly as prescribed with food to reduce GI upset or without food — but maintain the consistency† (Karch, 2007, p. 953). Mrs. Brown should be advised to â€Å"not discontinue this drug abruptly or change dosage, except on advice of health care provider† (Karch, 2007,p. 953). Since Mrs. Brown has diabetes, it should be advised that she should â€Å"monitor blood or urine sugar regularly, and report any abnormality to health care provider† (Karch, 2007, p. 953). She should be advised that she should â€Å"maintain good oral hygiene to prevent gum disease and arrange frequent dental checkups† (Karch, 2007, p. 953). Warfarin It should be advised to the patient to â€Å"not start or stop taking any medication without consulting her health care provider† (Karch, 2007, p. 1217). She should â€Å"carry or wear a medical ID tag to alert emergency medical personnel about the drug† (Karch, 2007, p. 218). She should be instructed to â€Å"avoid situations that may cause injury and have periodic blood tests to check on drug action† (Karch, 2007, p. 1218). Lastly, the patient should be instructed to â€Å"report unusual bleeding, black or bloody stools and cloudy or dark urine† (Karch, 2007, p. 1218). Metformin Some of the instructions t hat should be given to the patient are â€Å"not to discontinue the medication without consulting health care provider and avoid using alcohol while taking the drug† (Karch, 2007, p. 758). She should also be advised to â€Å"monitor blood for glucose and ketones and report any hypo-or hyperglycemia reactions† (Karch, 2007, p. 758). Lithium Health teaching about this drug should include the following: â€Å"take the drug exactly as prescribed, after meals or with food or milk; eat a normal diet with normal salt intake and maintain adequate fluid intake and arrange for frequent checkups including blood tests† (Karch, 2007, p. 705). Mrs. Brown has numerous risk factors and health conditions that may produce drug interactions that may worsen her health. It is known that Metronidazole can produce seizures as its side effect. Considering this, safety precautions should be made since she has a history of seizure. This drug can also impair the clearance of the drug Phenytoin in her system and potentiate the anticoagulant effects of Warfarin. These things should be monitored by the healthcare team for them to make necessary adjustments. Phenytoin can also increase the anticoagulant effect of Warfarin and may either increase or decrease the efficacy of lithium. Necessary drug dosage adjustments should be made to minimize these interactions. Daily blood glucose monitoring should be done and symptoms of hypo- or hyperglycemia should be reported. This is necessary because Warfarin can increase the effects of oral diabetic agents such as Metformin. However, Phenytoin and Lithium can diminish the efficacy of this drug. Thus, it is really important to monitor the client's clinical status and the possible adverse effects of the drug regimen. It is also important to â€Å"offer support and encouragement to help the patient cope with the drug regimen† (Karch, 2006, p. 334).

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