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By L. Vatras. The National Graduate School.
Fighting de-motivating thoughts The problem with finding and maintaining motivation to exercise lies in distorted 4mg amaryl free shipping diabetes test machine no blood, de-motivating thinking (see Chapters 5, 6, and 7 for more on distorted thinking). De-motivating thinking keeps you from taking action and puts you in a defeatist frame of mind, where you’re doomed to fail. The following example gives you an idea of how you can give de-motivating thoughts the one-two punch. She rushes off every morning to drop her kids at day care and tries to fit in her errands during a 45-minute lunch break. When her doctor suggests she begin exercising to improve her mood and health, Janine laughs and says, “You’ve got to be kidding; I don’t have an extra second in my day. Worksheet 10-5 shows what she comes up with, and Worksheet 10-6 has her reflections on the exercise. For example, rather than saying, “You’re the best person in the whole world,” consider narrowing it down and saying, “I love the way you play with the baby. For example, you may make a note in your calendar or put sticky notes in various places around the house. Get into the habit of handing out genuine compliments to everyone, not just your partner. Doing so will improve your popularity by making people notice you, and it may even get you a raise! Some people dismiss compliments by saying, “Oh, you don’t mean that,” or “That isn’t really true. People dismiss compliments not because they don’t want to hear them but because they have trouble accepting them. After you spend a couple of weeks increasing the compliments you give your partner, reflect on any changes in your relationship (see Worksheet 15-5). Self-Blame Reality Scramblers relationships, and effects of, 207–208 body signals. Hachette Livre’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. He considered a text in clinical pharmacology suitable for his undergraduate and postgradu- ate students to be an important part of the programme he developed in his department at Guy’s Hospital Medical School, London. In other words, he helped to change a ‘non-subject’ into one of the most important areas of study for medical students. He was also aware of the need for a high quality textbook in clinical pharmacology that could also be used by nurses, phar- macists, pharmacology science students and doctors preparing for higher qualifications. It is interesting to follow in all the editions of the book, for example, how the treatment of tumours has progressed. It was about the time of the first edition that Trounce set up the first oncology clinic at Guy’s Hospital in which he investigated the value of combined radiation and chemotherapy and drug cocktails in the treatment of lymphomas. John Trounce was pleased to see his textbook (and his subject) in the expert hands of Professor Ritter and his colleagues. Clinicians of all specialties pre- scribe drugs on a daily basis, and this is both one of the most useful but also one of the most dangerous activities of our professional lives. Understanding the principles of clinical pharma- cology is the basis of safe and effective therapeutic practice, which is why this subject forms an increasingly important part of the medical curriculum. This textbook is addressed primarily to medical students and junior doctors of all special- ties, but also to other professionals who increasingly prescribe medicines (including pharma- cists, nurses and some other allied professionals). Clinical pharmacology is a fast moving subject and the present edition has been completely revised and updated. It differs from the fourth edition in that it concentrates exclusively on aspects that students should know and understand, rather than including a lot of reference material.
A recent fashionable defense is that the presence of a metal stud through a hole pierced in the tongue invalidates the breath alcohol test because of the prohibition against foreign substances in the mouth and because of the poten- tial for the jewelery to retain alcohol and interfere with the breath test generic 1 mg amaryl with amex blood glucose watch. How- ever, experimental work has shown that the rates of elimination of mouth alcohol were no different in subjects with a tongue stud as opposed to controls and that for the purposes of breath alcohol testing, oral jewelery should be treated the same as metallic dental work and left in place without affecting the outcome of the breath test (46). Failure to Provide a Sample of Blood First, there must be a definite request to provide a sample of blood. Where the sample of blood is taken from is solely the choice of the forensic physician (or, in the United States, the emergency room physician). In Solesbury v Pugh (48), the defendant was found guilty of failing to supply a specimen as he would only allow a sample to be taken from his big toe, which the doctor was not prepared to do. In the United Kingdom, if the patient’s own doctor and forensic physi- cian are both present, the person can choose which doctor takes the sample. Similar rules apply in the United States, where statutes generally spell out that financial responsibility for such services rests with the driver and not the state. In the United Kingdom, if a blood sample is provided but the doc- tor spills the sample, then the law has been complied with on the basis that removal of the syringe from the vein by the doctor completes the provision of the specimen by the defendant (50). In the United Kingdom, a minimum of 2 mL of blood is required (the laboratory requires a minimum of 1 mL for analysis) for an adequate sample (51). If less than this is obtained, the sample should be discarded and another one attempted or the police officer advised that there is a medical reason why a sample of blood should not be provided and the urine option can then be selected. In the early 1980s, one police force purchased and used swabs containing alcohol with the result that numerous convictions were later overturned (52). Probably the most common defense for failure to provide a sample of blood is that of needle phobia. If this is alleged, a full medical history should be obtained and enquiry made of whether the person has had blood tests before, whether ears or other parts of the body have been pierced, or whether there have been foreign travel immunizations or any other medical or dental procedure undertaken in which an injection may have been administered. British appellate judges (53) have stated that “no fear short of phobia recognized by medical science to be as strong and as inhibiting as, for instance, claustrophobia can be allowed to excuse failure to provide a specimen for a laboratory test, and in most if not all cases where the fear of providing it is claimed to be invincible, the claim will have to be supported by medical evidence. Rix also gives some practical advice to police surgeons: be able to distinguish between repugnance and phobia, be able to distinguish between unwillingness and inability, document the history and examination with emphasis on the presence or absence of signs of anxiety, and ensure that the decision is based on firm medical evi- dence. Finally, record all this information, specifically note in the police record Traffic Medicine 369 whether a medical condition has been identified, and then verbally communi- cate this opinion to the police officers (55). Another common defense is that of consuming alcohol after the offense– the hip flask defense (56). It will be necessary for a scientist to prove that it was only the postdriving consumption that caused the analysis to reveal an alcohol level above the prescribed limit. Back calculations can only be approximate because they are based on average values, and although they are reasonable estimates for most people, they may occasionally fail to reflect accurately the situation of a particular individual, regardless of whether the calculation is for preincident or postincident drinking. Failure to Provide a Urine Sample If a woman is requested to provide a urine sample, it is important to have a female officer present because it has been held that because of the embarrassment that it could involve, the refusal to supply a sample of urine could be regarded as a reasonable excuse (58). However, any embarrassment at having to urinate in front of an officer of the same sex is not regarded as a reasonable excuse for not having supplied a specimen. Methadone and other opiates have an effect on the blad- der sphincter and can thus cause delayed bladder emptying; this effect could be considered a reasonable excuse for failing to provide a urine sample (59). In Sweden, Jones (56) reported the top 10 defense challenges for driving under the influence of alcohol (Table 2). This situation may be subject to some change, because medications, such as tolterodine (Detrusitol) and other muscarinic receptor antagonists, are being increasingly prescribed for treat- ment of patients with symptoms of an unstable bladder. This may explain why California has already dropped urine from its list of testing options. Postmortem Alcohol Measurements This topic has recently been reviewed in depth by Pounder and Jones (23). High postmortem alcohol concentrations do not imply that impairment 370 Wall and Karch Table 2 Top 10 Defense Challenges For Driving Under the Influence of Alcohol 1. Of 32 alcoholics presented at an emergency room for medical treatment, only 23 had apparent behavioral abnormalities, six were confused, and three were drowsy, even though the mean alcohol con- centration was 313 mg/100 mL (range 180–450 mg/100 mL) (60). Alcohol can be measured in numerous tissues, but the most accurate picture is usu- ally obtained when multiple sites are sampled (e. Because the eye is anatomically isolated, putrefaction is delayed, and there is little problem with postmortem redistribution, vitreous measurements can be used to confirm values obtained from whole blood and urine, to dis- tinguish postmortem alcohol production from antemortem ingestion, and to determine whether blood alcohol concentrations were rising or falling at the time of death.
Leucocyte by-products cause most damage generic amaryl 4mg amex blood glucose test results, and so possible treatments (needing further evaluation) include (Neoptolemos 1992): Pancreatitis 367 ■ antioxidants ■ tumour necrosis factor antagonists ■ leukotriene antagonists ■ plasminogen activation factor antagonists Lexipafant appears promising, but antioxidant therapy remains untested (Johnson 1998) and trials of antibodies for tumour necrosis factor-alpha have proved detrimental, so that this treatment is not now recommended. The current treatment is largely support systems, with pain control being a particularly important nursing role. Further reading Pathophysiology is well described by Reece-Smith (1997), although Johnson’s (1998) article draws on more recent material. Krumberger (1995), Gunning (1997), Santamaria (1997)) usually provide useful overviews. Prior to this Gita was attending a large family wedding where she experienced worsening of left-sided epigastric pain. She had experienced this pain intermittently over two days The pain radiated towards her back and was accompanied by nausea and Intensive care nursing 368 vomiting. Other abnormal results from admission assessment included: Vital signs Blood serum Temperature 38. Consider the type, route and amount of nutritional support suitable for her increased metabolic demands, impaired digestion and carbohydrate metabolism, control of blood sugars. What advice and information can you give to Gita to enhance her short-term recovery and longer-term health? Consider: infection risks, metabolic disturbances from pancreatic insult, advice on diet/medications/activities, etc. Impaired voluntary nervous function may be frustrating for patients, but autonomic nervous system dysfunction may prove life-threatening. The problems are similar in all three conditions: muscle weakness (including respiratory), underlying hypotension and bradycardia with potentially excessive inappropriate episodes of hypertension and tachycardia. Nursing patients with these conditions can be labour intensive and stressful; they need care and support with many activities of living, while minimising complications significantly improves recovery and survival. Management of all three conditions centres on ■ attempts to remove underlying causes ■ prevention of complications ■ system support. While there is some research evidence, practice varies between units; some approaches described below are anecdotal rather than evidence-based. While the literature is consistent on incidence, it is inconsistent about possible gender, age, racial and seasonal prevalence. Immune system dysfunction results in T-lymphocyte migration to peripheral nerves causing inflammation oedema (Ross 1993) and myelin destruction (Desforges 1992), creating lesions (especially in spinal nerves and near dorsal root ganglia) (Waldock 1995) and the progressive destruction of the nodes of Ranvier. This, in turn, causes ascending motor and sensory paralysis, resulting in diffuse muscle weakness. Prolonged artificial ventilation is often needed, and many units favour early tracheostomy. Steroids, once used widely, are not recommended in Desforges’ (1992) literature review. Circulating mediators may be removed through plasma exchange (Fulgham & Wijdicks 1997), plasmapheresis (Hund et al. If basement membrane remains intact, recovery begins once Schwann cells’ mitosis remyelinates damaged nerves (usually 2–4 weeks (Skowronski 1997)). Death is usually caused by respiratory or cardiac arrest (McMahon-Parkes & Cornock 1997), so that the prevention of complications improves survival. Muscle weakness and autonomic dysfunction can cause: ■ pain from nerve dysfunction, exacerbated by touch (Coakley 1997) and anxiety, which is usually worse in the evening (Mirski et al. Neurological pathologies 371 ■ hyper salivation and loss of gag reflex from autonomic dysfunction necessitate oral suction to prevent aspiration. Prophylactic beta blockers can control hypertension (Hinds & Watson 1996), although Fulgham and Wijdicks (1997) recommend caution with vasoactive drugs. Routine atropine (Hinds & Watson 1996) or sequential pacing may prevent bradycardias. Two per cent of deaths are caused by pulmonary emboli (Coakley 1997); cerebral and myocardial infarction may also occur. Thrombosis risk can be reduced by • frequent changes of position • prophylactic subcutaneous heparin (Winer 1994) • thromboembolytic stockings (Winer 1994) • early and aggressive rehabilitation, including active and passive exercises ■ limb weakness, ascending from distal to proximal muscles, affecting hands, feet or both. Passive exercises may prevent contractures (Winer 1994) and promote venous return.
These are the values nurses hold that lead partners (husbands or male mates) in the first year them to practice in a caring manner generic 2 mg amaryl with amex diabetes symptoms type 15. All intervention materials have scribes the conditions (nurse, patient, and organi- been developed based on the Miscarriage Model zational factors) that enhance or diminish the and the Caring Theory. Nursing as informed caring for the well- long way to go to make a case for the educa- being of others. What’s known about caring in nursing importance of nurses practicing in a caring science: A literary meta-analysis. The effects of caring, measurement, ing in terms of time, money, and personal en- and time on miscarriage impact and women’s well-being in ergy expended. Research-based practice with women under the framework of caring in order to tie who miscarry. The unborn one: The human (nurses and clients), to the cultural contexts experience of miscarriage (Doctoral dissertation, University of Colorado Health Sciences Center, 1983). Miscarriage: A new under- and communities experience when living standing of the mother’s experience. Her current research, McMaster University in Hamilton, Canada, and which uses both qualitative and quantitative re- a doctorate from the University of Utah in search methods, relates to the study of the complex Transcultural Nursing. She retired as a colonel in nurse-patient relational caring process and its im- 1999 after 30 years of service with the U. Revolutionary approaches to scientific theory de- velopment, such as the quantum theory, the science of wholeness, holographic and chaos theories, and Introducing the Theory fractals or the idea of self-similarity within the sci- ences of complexity (Bassingthwaighte, Liebovitch, This chapter will present a discussion of contempo- & West, 1994; Battista, 1982; Briggs & Peat, 1984; rary nursing culture, share theoretical views related Davidson & Ray, 1991; Harmon, 1998; Peat, 2003; to the author’s developmental theoretical vision of Ray, 1998; Wheatley, 1999; Wilbur, 1982) illuminate nursing, and discuss the Theory of Bureaucratic the nature and creativity of science itself. After revisiting the ception of the multiple interconnectedness and re- theory in the contemporary age, the author will lational reality of all things, the interdependence of elucidate bureaucratic caring theory as a holo- all human phenomena, and the discovery of order graphic theory to further the vision of nursing and in a chaotic world demonstrate the pioneering organizations as relational, integrated, and com- story of twentieth-century science and how the in- plex. Theory is the intellectual life of nursing sightful idea of relationality (a powerful nursing (Levine, 1995). Van Manen (1982) refers position that nurses do need nursing theory to to theory as “wakefulness of mind” or the pure stimulate thinking and critique as they function in viewing of truth. Truth in the Greek sense is not the the complex world of nursing science, research, ed- property of consensus among theorists but the dis- ucation, and practice. Theories, as the integration closure of the essential nature or the good of things. The Theory assumptions of nursing as serving the good, the locus of the discipline centers on caring for others, The Theory of Bureaucratic Caring illu- caring in the human health experience (Newman, minated in this chapter is a theory with 1992; Newman, Sime, & Corcoran-Perry, 1991). A a practical purpose that emerged from theory of nursing actually must direct or enlighten the worldviews of health professionals the good. Grounded or middle-range theories, how- the significance of spiritual and ethical caring in re- ever, focus on particular aspects of nursing practice lation to the structural dimensions of complex or- and are commonly generated from nursing prac- ganizational cultures, such as political, economic, tice. As such, some intellectuals view middle-range technological, and legal, bureaucratic caring theory theories as more relevant and useful to nursing invites us to view how a new model may facilitate than the application of grand theories (Cody, understanding of how nursing can be practiced in 1996). Confidence in major health-care institutions and The practice of nursing occurs in organizations their leaders fell so low as to put the legitimacy of that are generally bureaucratic or systematic in na- executives at risk. Although there has been much discussion ment to employees, investment in the worker, fair- about the end of bureaucracy to better cope with ness in pay, and the need to provide good benefits twenty-first-century innovation and worklife were in jeopardy. Health-care systems fell victim to (Pinchot & Pinchot, 1994), bureaucracy remains a the corporatization of the human enterprise. Informal organization or the 2001), currently is being evaluated in terms of is- integration of codes of conduct encompassing sues of patient safety (Page, 2004). Nursing educa- commitment, identity, character, coherence, and a tion is highlighted as a bridge to quality (Long, sense of community was considered essential to the 2003). Since the Institute of Medicine report (Page, successful functioning or the administering of 2004), a resurgence of interest is taking place in the power and authority in the formal organization. What distin- work (Cuilla, 2000; Ray, Turkel, & Marino, 2002) is guishes organizations as culture from other para- replacing the language of downsizing, restructur- digms, such as organizations as machines, brains, ing, mergers, and acquisitions. Cuilla (2000) stated or other images (Morgan, 1997), is its foundation that “[t]he most meaningful jobs are those in which in anthropology or the study of how people act in people directly help others or create products that communities or formalized structures and the sig- make life better for people” (p. Although the nificance or meaning of work life (Ciulla, 2000; traditional work of nurses is defined as directly Louis, 1985). Organizational cultures, therefore, are helping others, contemporary nurses’ work is also viewed as social constructions, symbolically defined by and in the organizational context— formed and reproduced through interaction legal, ethical, economics, technological, and politi- (Smircich, 1985). Urging nurses, physicians, and administrators organizational mission and policy statements. A to find cohesion among organizational phenomena nation’s prevailing tenets and expectations about and body, mind, and spirit integration for the sake the nature of work, leisure, and employment of the patient calls for the reinvention of work (Fox, are pivotal to the work life of people; hence, there is 1994).
