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A nursing overview is given by Graver (1992) purchase super p-force 160 mg visa erectile dysfunction solutions, but most literature is inevitably medical or pharmacological super p-force 160 mg fast delivery erectile dysfunction caused by statins. Of medical texts cheap 160mg super p-force visa erectile dysfunction nervous, Hinds & Watson (1996) offers comprehensive application of drugs; Evans (1998) is a valuable recent addition to the nursing literature. Many articles discuss individual inotropes, or the specific effects of individual drugs. Manufacturers’ recommendations differ between systems, and so readers should adapt the material in this chapter to the systems used. Peritoneal dialysis and haemodialysis are briefly described, but nurses regularly using these therapies should resource specific texts on them. Plasmapheresis uses similar circuits to haemofiltration (usually used intermittently rather than continuously), and so most principles of haemofiltration apply to plasmapheresis. Haemofiltration considerably increases nursing workload; while caring for patients receiving haemofiltration can be rewarding, nurses should understand the potential complications. The terminology used to describe modes often varies between units (and in literature); ‘haemodialysis’ and ‘haemofiltration’ are interchanged and variously interpreted (Table 35. Material referring to ‘haemofiltration’ in this chapter also applies to variants (diafiltration, plasmapheresis) unless stated otherwise. Renal replacement therapies mimic normal renal function by placing semipermeable membranes between the patient’s blood and a collection Table 35. Filtration is the passage of fluid through this filter; dialysis is a similar movement of solutes. In the human kidney, both occur passively at the glomerular bed and actively as filtrate passes through renal tubules. While technically separate functions, in practice filtration necessarily contains solutes, while osmotic pressure of solutes on either side of the filter inevitably influences filtration. Peritoneal blood and dialysis fluid (infused through an abdominal catheter) achieves equilibrium of most solutes. Using fluids with large (glucose) molecules, excess body fluid is drawn by osmosis into dialysate, then removed by negative pressure (usually gravity). Peritoneal dialysis has many limitations, including: ■ limited dialysate volumes (abdominal distension causes pain, lung splinting and impairs major organ perfusion) ■ solute removal is limited by filtrate-to-plasma concentrations (toxin levels are reduced, not eliminated) ■ loss of albumin and other large molecules (the peritoneum is highly permeable) ■ peritonitis ■ contraindications (e. Haemodialysis (and haemodiafiltration) combines diffusion, ultrafiltration and convection; toxin removal is so efficient that a few (3–5) hours treatment once or twice each week enables people with chronic renal failure to live fairly normal lives. However complications of haemofiltration include ■ cardiovascular instability ■ disequilibrium syndrome ■ immunological deficiency ■ limited water and solute removal These complications can be especially problematic with critical illness. Hypotensive episodes are twice as likely with haemodialysis as with haemofiltration (Henderson 1987). However caused, disequilibrium syndrome rarely occurs, but when it does it can be distressing for both patients and others; neurological effects include confusion, aggression, nausea/vomiting, muscle twitching, lethargy, blurred vision and possible coning. Critical illness and sedation can mask many of these symptoms, but not the discomfort problems for patients. Removing intravascular fluid encourages replacement by extravascular fluid, but limited transfer occurs during the few hours of haemodialysis, whereas continuous treatments (e. It mimics human glomerular filtration, as plasma is forced under pressure through a semipermeable Haemofiltration 347 membrane (ultrafiltration), and solutes are drawn across the membrane by convection. Unlike the human kidney, haemofiltration (and haemodialysis) cannot selectively reabsorb. Ultrafiltrate volumes are large (although smaller than healthy human ultrafiltrate), so that large infusions are needed to mimic reabsorption. Driving pressure was therefore the differential between a patient’s arterial and venous blood pressures. Anticoagulation was added to prevent thrombus formation in extracorporeal circuits; replacement fluid was given to mimic tubular reabsorption. Manufacturers are rationalising terminology by renaming ‘arterial’ circuits ‘afferent’ and ‘venous’ circuits ‘efferent’; this follows human renal physiology, and is logical, and so although not (as yet) universal, it is used here. Compared with haemodialysis, haemofiltration: ■ enables filtration despite hypotension ■ improves cardiovascular stability ■ enables more gentle removal of solutes (less disequilibrium) ■ removes significantly larger fluid volumes High-speed haemofiltration for short periods may achieve better clearance than haemodialysis, but circuits are relatively costly and time-consuming to prime, and the use of intermittent filtration is almost exclusively confined to hospitals with on-site renal units (Amoroso et al. Haemodiafiltration Ultrafiltrate countercurrent was not used with early haemofilters, so solute clearance remained poor once ultrafiltrate concentrations in filters approached plasma levels. Most units now add countercurrent to haemofiltration, calling it simply ‘haemofiltration’ (literature describing haemofiltration may not always clarify whether it refers to systems with or without countercurrents). Intensive care nursing 348 Theoretically, countercurrent clearance is proportional to countercurrent volume, but exchanges above 2–3 litres per hour do not significantly increase clearance (Miller et al. Prediluting blood (before the filter) reduces viscosity, increasing filtrate volume, urea clearance and filter life (reducing need for anticoagulation) (Kaplan 1985a); but anecdotal reports suggest predilution both hastens coagulation and reduces filter life, perhaps due to activation of clotting factors; further research is needed both to identify mechanisms and to guide practice. Free-flow ultrafiltrate relies on gravity (height difference between the filter and collection bag) to create negative pressure, but most systems now control ultrafiltrate with volumetric pumps, so that the ultrafiltrate pump speed determines negative pressure. Filter membranes Cuprophane or cellulose, used for early filters (Kwan 1997), activate the immune complement system, releasing highly vasoactive substances (e. These cause: ■ hypotensive crises ■ neutropenia Haemofiltration 349 ■ thrombocytopenia ■ hypoxia (neutrophil sequestration in pulmonary circulation). Often containing more than 20,000 fine capillary 2 tubes, they have large surface areas (often 2 m (Ervine & Milroy 1997)), a small volume and, being cylindrical, they are also sturdy. Small capillary tube diameter (65 micrometres (Ervine & Milroy 1997)) usually necessitates anticoagulation to prevent thrombosis and obstruction. Ervine and Milroy (1997) suggest hollow fibre threshold is usually about 30 kDa, but various pore-size filters are available: most of the filters now used can double this threshold. Fibres are glued with polyurethane, making them less biocompatible than flat plate filters (Molnar & Shearer 1998). Although overall surface area is smaller than with hollow fibres, flat plates can clear small molecules more efficiently (Hinds & Watson 1996) and are less prone to clotting, and so require less anticoagulation. Most systems now measure transmembrane pressure directly, although some older systems may still rely on indirect indications (e. Transmembrane pressure is created by various factors, but rising pressure usually suggests significantly decreased filtration surface area from thrombus formation (efferent filters protect patients from emboli). While priming removes air emboli, its main purpose is the removal of glycerol and ethylene oxide used to protect filters during storage and transportation. These chemicals can cause convulsions, paralysis, renal failure and haemolysis (Martindale 1996), so that priming volumes should follow manufacturers’ recommendations and not be abandoned once circuits are filled with fluid. As with human nephrons, solute clearance is limited by ultrafiltrate concentrations, ending once equilibrium is reached. Pore sizes of human nephrons and artificial filters are normally large enough to clear anything potentially in blood apart from blood cells. Early filters allowed solutes of 30 kDa to pass—many are now more porous—but actual clearance varies with: ■ molecular size ■ It ultrafiltrate concentration ■ protein binding. Intensive care nursing 350 The use of lactate-based dialysate fluids can accentuate problems with acidosis; bicarbonate filtration (Hilton et al. Patients who are being haemofiltered are often ventilated, unconscious, monitored and receiving many drugs (often including large dose inotropes); their dependent state necessitates fundamental aspects of care (comfort, hygiene, pressure care), while family and friends of critically ill patients are often anxious, needing more time spent with them. Care may have to be prioritised to maintain safety; such workloads illustrate the dangers of assuming that one-to-one nurse-patient ratios are always safe.

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Avoidance of a death in police custody is a priority discount super p-force 160 mg free shipping erectile dysfunction 34 year old male, as is the assessment of fitness-to-be-detained generic super p-force 160 mg erectile dysfunction medicine in homeopathy, which must include information on a detainee’s general medical problems 160mg super p-force erectile dysfunction pump implant video, as well as the identification of high-risk individuals, i. Deaths in custody include rapid unexplained death occurring during restraint and/or during excited delirium. The recent introduction of chemical crowd-control agents means that health professionals also need to be aware of the effects of the common agents, as well as the appropriate treatments. However, in recent years there have been a number of well-publicized miscarriages of justice in which the conviction depended on admissions made during interviews that were subsequently shown to be untrue. Recently, a working medical definition of fitness-to-be-interviewed has been developed, and it is now essential that detainees be assessed to determine whether they are at risk to provide unreliable information. The increase in substance abuse means that detainees in police custody are often now seen exhibiting the complications of drug intoxication and withdrawal, medical conditions that need to be managed appropriately in the custodial environment. Furthermore, in the chapter on traffic medicine, not only are medical aspects of fitness-to-drive covered, but also provided is detailed information on the effects of alcohol and drugs on driving, as well as an assessment of impairment to drive. Once the eBook is installed on your com- puter, you cannot download, install, or e-mail it to another computer; it resides solely with the computer to which it is installed. Your web browser will open and you will be taken to the Humana Press eBook registra- tion page. If you need further assistance, contact Humana Press eBook Support by e-mail at [email protected] Forensic medicine is now commonly used to describe all aspects of forensic work rather than just forensic pathol- ogy, which is the branch of medicine that investigates death. Clinical forensic medicine refers to that branch of medicine that involves an interaction among law, judiciary, and police officials, generally involving living persons. The practitio- ners of clinical forensic medicine have been given many different names throughout the years, but the term forensic physician has become more widely accepted. In broad terms, a forensic pathologist generally does not deal with living individuals, and a forensic physician generally does not deal with the deceased. However, worldwide there are doctors who are involved in both the clinical and the pathological aspects of forensic medicine. There are many areas where both clinical and pathological aspects of forensic medicine over- lap, and this is reflected in the history and development of the specialty as a whole and its current practice. The forensic physician must also present the information orally to a court or other tribunal or forum. This table illustrates the role of forensic physicians in the United Kingdom; roles vary according to geographic location. Police surgeon, forensic medical officer, and forensic medical examiner are examples of other names or titles used to describe those who practice in the clinical forensic medicine specialty, but such names refer more to the appointed role than to the work done. Table 1 illustrates the variety of functions a forensic physician may be asked to undertake. Some clinical forensic medical practitio- ners may perform only some of these roles, whereas others may play a more History and Development 3 extended role, depending on geographic location (in terms of country and state), local statute, and judicial systems. Forensic physicians must have a good knowl- edge of medical jurisprudence, which can be defined as the application of medi- cal science to the law within their own jurisdiction. The extent and range of the role of a forensic physician is variable; many may limit themselves to specific aspects of clinical forensic medicine, for example, sexual assault or child abuse. Currently, the role and scope of the specialty of clinical forensic medicine glo- bally are ill defined, unlike other well-established medical specialties, such as gastroenterology or cardiology. In many cases, doctors who are practicing clini- cal forensic medicine or medical jurisprudence may only take on these func- tions as subspecialties within their own general workload. Pediatricians, emergency medicine specialists, primary care physicians, psychiatrists, gyne- cologists, and genitourinary medicine specialists often have part-time roles as forensic physicians. The specific English terms forensic medicine and medical jurisprudence (also referred to as juridical medicine) date back to the early 19th century. In 1840, Thomas Stuart Traill (2), referring to the connection between medicine and legislation, stated that: “It is known in Germany, the country in which it took its rise, by the name of State Medicine, in Italy and France it is termed Legal Medicine; and with us [in the United Kingdom] it is usually denomi- nated Medical Jurisprudence or Forensic Medicine. There is much dispute regarding when medical expertise in the determination of legal issues was first used. Other historical examples of the link between medicine and the law can be found throughout the world. Amundsen and Ferngren (3) concluded that forensic medicine was used by Athenian courts and other public bodies and that the testimony of physi- cians in medical matters was given particular credence, although this use of physicians as expert witnesses was “loose and ill-defined” (4), as it was in the 4 Payne-James Roman courts. The interaction between medicine and the law in these periods is undoubted, but the specific role of forensic medicine, as interpreted by historical docu- ments, is open to dispute; the degree and extent of forensic medical input acknowledged rely on the historian undertaking the assessment. Traill (2) states that: “Medical Jurisprudence as a science cannot date farther back than the 16th century. However, the Constitutio Criminalis Carolina, the code of law published and proclaimed in 1553 in Germany by Emperor Charles V, is considered to have originated legal medicine as a specialty: expert medical testimony became a requirement rather than an option in cases of murder, wounding, poisoning, hanging, drown- ing, infanticide, and abortion (1). Medicolegal autopsies were well documented in parts of Italy and Germany five centuries before the use of such procedures by English coroners. Cassar (7), for example, describes the earliest recorded Mal- tese medicolegal report (1542): medical evidence established that the male partner was incapable of sexual intercourse, and this resulted in a marriage annulment. Beck (8) identifies Fortunatus Fidelis as the earliest writer on medi- cal jurisprudence, with his De Relationibus Medicorum being published in Palermo, Italy, in 1602. Subsequently, Paulus Zacchias wrote Quaestiones Medico-Legales, described by Beck as “his great work” between 1621 and 1635. Beck also refers to the Pandects of Valentini published in Germany in 1702, which he describes as “an extensive retrospect of the opinions and deci- sions of preceding writers on legal medicine. Late 18th Century Onward Beginning in the latter part of the 18th century, several books and trea- tises were published in English concerning forensic medicine and medical History and Development 5 jurisprudence. What is remarkable is that the issues addressed by many of the authors would not be out of place in a contemporary setting. It seems odd that many of these principles are restated today as though they are new. In 1783, William Hunter (9) published an essay entitled, On the Uncer- tainty of the Signs of Murder in the Case of Bastard Children; this may be the first true forensic medicine publication from England. John Gordon Smith writes in 1821 in the preface to his own book (10): “The earliest production in this country, professing to treat of Medical Jurisprudence generaliter, was an abstract from a foreign work, comprised in a very small space. Davis (11) refers to these and to Remarks on Medical Jurispru- dence by William Dease of Dublin, as well as the Treatise on Forensic Medi- cine or Medical Jurisprudence by O. Davis considers the latter two works of poor quality, stating that the: “First original and satis- factory work” was George Male’s Epitome of Juridical or Forensic Medicine, published in 1816 (second edition, 1821). Male was a physician at Birming- ham General Hospital and is often considered the father of English medical jurisprudence. John Gordon Smith (9) stated in The Principles of Forensic Medicine Systematically Arranged and Applied to British Practice (1821) that: “Forensic Medicine—Legal, Judiciary or Juridical Medicine—and Medical Jurisprudence are synonymous terms.

Also discount 160 mg super p-force free shipping erectile dysfunction medicine names, because of lack of regulation and standardization order super p-force overnight delivery erectile dysfunction with age, ingredients may be adulter- ated order 160 mg super p-force mastercard goal of erectile dysfunction treatment. There is a greater likelihood of unwanted side effects with combined herbal preparations. Table 23-1 lists information about common herbal remedies, with possible implications for psychiatric/mental health nursing. Toxic in large doses, Extracts from the causing dizziness, nausea, roots are thought to headaches, stiffness, and have action similar trembling. Cascara sagrada Relief of constipation Generally recognized (Rhamnus as safe; sold as purshiana) over-the-counter drug in the U. Echinacea Stimulates the immune Considered safe in reason- (Echinacea system; may have able doses. Fennel Used to ease stomach- Generally recognized as (Foeniculum aches and to aid safe when consumed in vulgare or digestion. Foeniculum a tea or in extracts officinale) to stimulate the appetites of people with anorexia (1-2 tsp. Effective ence the adverse effect in either the fresh of temporary mouth leaf or freeze-dried ulcers. Hops Used in cases of ner- Generally recognized as (Humulus vousness, mild anxi- safe when consumed in lupulus) ety, and insomnia. Kava-Kava Used to reduce anxiety Scaly skin rash may occur (Piper while promoting when taken at high methylsticum) mental acuity. Peppermint Used as a tea to relieve Considered to be safe when (Mentha upset stomachs and consumed in designated piperita) headaches and as a therapeutic dosages. Oil of pep- permint is also used for inflammation of the mouth, pharynx, and bronchus. Psyllium Psyllium seeds are a Approved as an (Plantago popular bulk laxative over-the-counter ovata) commonly used for drug in the U. Scullcap Used as a sedative for Considered safe in reason- (Scutellaria mild anxiety and able amounts. John’s Wort Used in the treatment Generally recognized as (Hypericum of mild to moderate safe when taken at recom- perforatum) depression. Taking doses higher to make a tea, or than recommended may capsules are avail- result in severe headache, able in a variety of nausea, morning grog- dosages. Acupressure and Acupuncture Acupressure and acupuncture are healing techniques based on the ancient philosophies of traditional Chinese medicine dating back to 3000 b. The main concept behind Chinese medicine is that healing energy (qi) flows through the body along specific pathways called meridians. It is believed that these meridians of qi connect various parts of the body in a way similar to the way in which lines on a road map link various locations. There- fore, it is possible to treat a part of the body distant to another because they are linked by a meridian. Trivieri and Anderson (2002) have stated, “The proper flow of qi along energy channels (meridians) within the body is crucial to a person’s health and vitality. This pressure is thought to dissolve any obstructions in the flow of healing energy and to restore the body to a healthier functioning. In acupuncture, hair-thin, sterile, disposable, stainless-steel needles are inserted into acupoints to dissolve the obstructions along the meridians. The needles may be left in place for a specified length of time, they may be rotated, or a mild electric current may be applied. Complementary Therapies ● 377 The Western medical philosophy regarding acupressure and acupuncture is that they stimulate the body’s own painkilling chemicals—the morphine-like substances known as endorphins. Recent studies suggest that acupuncture may aid in the treatment of cocaine dependence and chronic daily headaches (Avants et al. Acupuncture is gaining wide acceptance is the United States by both patients and physicians. This treatment can be admin- istered at the same time other techniques are being used, such as conventional Western techniques, although it is essential that all health-care providers have knowledge of all treatments being received. Acupuncture should be administered by a physician or an acupuncturist who is licensed by the state in which the service is provided. Typical training for licensed acupuncturists, doctors of oriental medicine, and acupuncture physicians is a 3- or 4-year program of 2500 to 3500 hours. Diet and Nutrition The value of nutrition in the healing process has long been un- derrated. Lutz and Przytulski (2006) stated: Today many diseases are linked to lifestyle behaviors such as smok- ing, lack of adequate physical activity, and poor nutritional habits. Healthcare providers emphasize the relationship between lifestyle and the risk of disease. Many people, at least in industrial- ized countries, are increasingly managing their health problems and making personal commitments to lead healthier lives. Individuals select the foods they eat based on a number of fac- tors, not the least of which is enjoyment. Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intakes of fat, cholesterol, added sug- ars, salt, and alcohol. Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the guidelines in Table 23-2. Table 23-3 provides a summary of informa- tion about essential vitamins and minerals. Maintain body weight in a healthy range; balance calories from foods and beverages with calories expended. To prevent gradual weight gain over time, make small de- creases in food and beverage calories and increase physi- cal activity. Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. To reduce the risk of chronic disease in adulthood, en- gage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood, engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. To sustain weight loss in adulthood, participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Achieve physical fitness by including cardiovascular con- ditioning, stretching exercises for flexibility, and resis- tance exercises or calisthenics for muscle strength and endurance. To help meet calcium needs, non-dairy calcium-containing alterna- tives may be selected by individuals with lactose intoler- ance or those who choose to avoid all milk products (e. Keep total fat intake between 20% and 35% of calo- ries, with most fats coming from sources of polyunsatu- rated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils. Consume less than 10% of calories from saturated fatty acids and less than 300 mg/day of cholesterol, and keep trans–fatty acid consumption as low as possible. Carbohydrate intake should comprise 45% to 64% of total calories, with the majority coming from fiber-rich foods. Important sources of nutrients from carbohydrates include fruits, vegetables, whole grains, and milk. Individuals who choose to drink al- coholic beverages should do so sensibly and in moderation— defined as the consumption of up to one drink per day for women and up to two drinks per day for men.

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Encour- age independence and give positive reinforcement for inde- pendent behaviors buy super p-force 160 mg cheap erectile dysfunction treatment diabetes. Sudden and complete elimination of all avenues for dependency would create intense anxiety on the part of the client super p-force 160mg mastercard impotence urinary. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors buy super p-force from india erectile dysfunction treatment with viagra. Client may be unaware of the relationship between emotional problems and compulsive behaviors. Provide structured schedule of activities for the client, includ- ing adequate time for completion of rituals. Gradually begin to limit the amount of time allotted for ritualistic behavior as client becomes more involved in unit activities. Anxiety is minimized when client is able to replace ritualistic behaviors with more adaptive ones. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. Encourage recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Client is able to verbalize signs and symptoms of increasing anxiety and intervene to maintain anxiety at manageable level. Client demonstrates ability to interrupt obsessive thoughts and refrain from ritualistic behaviors in response to stressful situations. Possible Etiologies (“related to”) Lifestyle of helplessness [Fear of disapproval from others] [Unmet dependency needs] [Lack of positive feedback] [Consistent negative feedback] Defining Characteristics (“evidenced by”) Verbal expressions of having no control (e. Long-term Goal Client will be able to effectively problem-solve ways to take con- trol of his or her life situation by discharge, thereby decreasing feelings of powerlessness. Allow client to take as much responsibility as possible for own self-care practices. Respect client’s right to make those decisions independently, and refrain from attempting to influence him or her toward those that may seem more logical. Unrealistic goals set the client up for failure and reinforce feelings of powerlessness. Client’s emotional condition interferes with his or her ability to solve problems. Assistance is required to perceive the benefits and consequences of available alternatives accurately. Help client identify areas of life situation that are not with- in his or her ability to control. Encourage verbalization of feelings related to this inability in an effort to deal with unresolved issues and accept what cannot be changed. Encourage par- ticipation in these activities, and provide positive reinforce- ment for participation, as well as for achievement. Client verbalizes choices made in a plan to maintain control over his or her life situation. Client verbalizes honest feelings about life situations over which he or she has no control. Client is able to verbalize system for problem-solving as required for adequate role performance. Possible Etiologies (“related to”) [Panic level of anxiety] [Past experiences of difficulty in interactions with others] [Need to engage in ritualistic behavior in order to keep anxiety under control] [Repressed fears] Defining Characteristics (“evidenced by”) [Stays alone in room] Uncommunicative Withdrawn No eye contact Developmentally [or culturally] inappropriate behaviors Preoccupation with own thoughts; repetitive, meaningless actions Expression of feelings of rejection or of aloneness imposed by others Experiences feelings of differences from others Insecurity in public Goals/Objectives Short-term Goal Client will willingly attend therapy activities accompanied by trusted support person within 1 week. Long-term Goal Client will voluntarily spend time with other clients and staff members in group activities by time of discharge from treatment. Be with the client to offer support during group activities that may be frightening or difficult for him or her. The pres- ence of a trusted individual provides emotional security for the client. Short-term use of antianxiety medications, such as diaze- pam, chlordiazepoxide, or alprazolam, helps to reduce level of anxiety in most individuals, thereby facilitating interactions with others. Discuss with client the signs of increasing anxiety and techniques for interrupting the response (e. Maladaptive behaviors, such as withdrawal and sus- piciousness, are manifested during times of increased anxiety. Give recognition and positive reinforcement for client’s volun- tary interactions with others. Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors. When anxiety is high, client may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions. Client may be unable to tolerate large amounts of food at mealtimes and may therefore require additional nourishment at other times during the day to receive adequate nutrition. Assist client to bathroom on hourly or bihourly schedule, as need is determined, until he or she is able to fulfill this need without assistance. Client maintains optimal level of personal hygiene by bathing daily and carrying out essential toileting procedures without assistance. They are classified as mental disorders because patho- physiological processes are not demonstrable or understandable by existing laboratory procedures, and there is either evidence or strong presumption that psychological factors are the major cause of the symptoms. It is now well documented that a large proportion of clients in general medical outpatient clinics and private medical offices do not have organic disease requiring medical treatment. It is likely that many of these clients have somatoform disorders, but they do not perceive themselves as having a psychiatric problem and thus do not seek treat- ment from psychiatrists. Symptoms can represent virtu- ally any organ system but commonly are expressed as neuro- logical, gastrointestinal, psychosexual, or cardiopulmonary dis- orders. Onset of the disorder is usually in adolescence or early adulthood and is more common in women than in men. The disorder usually runs a fluctuating course, with periods of re- mission and exacerbation. This diagnosis is made when psychological factors have been judged to have a major role in the onset, severity, ex- acerbation, or maintenance of the pain, even when the physical examination reveals pathology that is associated with the pain. Hypochondriasis Hypochondriasis is an unrealistic preoccupation with the fear of having a serious illness. Occasionally medical disease may be pres- ent, but in the hypochondriacal individual, the symptoms are grossly disproportionate to the degree of pathology. Individu- als with hypochondriasis often have a long history of “doctor shopping” and are convinced that they are not receiving the proper care. Conversion Disorder Conversion disorder is a loss of or change in body function re- sulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism.

Generally behaviours linked to reproduction were seen as normal and those such as masturbation and homosexuality as abnormal buy cheap super p-force impotence herbs. This is illustrated by the Victorian concern with sexual morality generic 160 mg super p-force with mastercard erectile dysfunction neurological causes, movements proclaiming sexual puritanism and attempts to control prostitution buy super p-force 160mg without a prescription erectile dysfunction homeopathic. Sex was seen as a biological drive that needed to be expressed but which should be expressed within the limitations of its function, reproduction. Sex as biological, for pleasure From the beginning of the twentieth century, there was a shift in perspective. Although sex was still seen as biological, the emphasis was now on sexual behaviour rather than on outcome (reproduction). It resulted in a burgeoning literature on sex therapy and manuals on how to develop a good sex life. This emphasis is illustrated by the classic survey carried out by Kinsey in the 1940s and 1950s, the research programmes developed by Masters and Johnson in the 1960s and the Hite reports on sexuality in the 1970s and 1980s. The Kinsey Report Kinsey interviewed and analysed data from 12,000 white Americans and his attempts to challenge some of the contemporary concerns with deviance were credited with causing ‘a wave of sexual hysteria’ (e. He developed his analysis of sexual behaviour within models of biological reductionism and argued that sex was natural and therefore healthy. Kinsey argued that the sexual drive was a biological force and the expression of this drive to attain pleasure was not only acceptable but desirable. He challenged some of the contemporary concerns with premarital sex and argued that as animals do not get married, there could be no difference between marital and premarital sex. He emphasized similarities between the sexual behaviour of men and women and argued that if scientific study could promote healthy sex lives then this could improve the quality of marriages and reduce the divorce rates. His research suggested that a variety of sexual outlets were acceptable and emphasized the role of sexual pleasure involving both sexual intercourse and masturbation for men and women. Masters and Johnson used a variety of experimental laboratory techniques to examine over 10,000 male and female orgasms in 694 white middle-class heterosexuals (e. They recorded bodily contractions, secretions, pulse rates and tissue colour changes and described the sexual response cycle in terms of the following phases: (1) excitement; (2) plateau; (3) orgasm; and (4) reso- lution. They emphasized similarities between men and women (although it has been argued that their data suggests more difference than they acknowledged; Segal 1994) and emphasized that stable marriages depended on satisfactory sex. According to Masters and Johnson, sexual pleasure could be improved by education and sex therapy and again their research suggested that masturbation was an essential component of sexuality – sex was for pleasure, not for reproduction. The Hite Reports Shere Hite (1976, 1981, 1987) published the results from her 20 years of research in her reports on female and male sexuality. Her research also illustrates the shift from the outcome of sex to sex as an activity. Hite’s main claim is that ‘most women (70 per cent) do not orgasm as a result of intercourse’ but she suggests that they can learn to increase clitoral stimulation during intercourse to improve their sexual enjoyment. She describes her data in terms of women’s dislike of penetrative sex (‘Perhaps it could be said that many women might be rather indifferent to intercourse if it were not for feelings towards a particular man’) and discusses sex within the context of pleasure, not reproduction. Segal (1994) has criticized Hite’s interpretation of the data and argues that the women in Hite’s studies appear to enjoy penetration (with or without orgasm). Although this is in contradiction to Hite’s own conclusion, the emphasis is still on sex as an activity. In summary From the start of the twentieth century, therefore, sex was no longer described as a biological means to an end (reproduction) but as an activity in itself. Discussions of ‘good sex’, orgasms and sexual pleasure emphasized sex as action, however, even as an activity sex remained predominantly biological. Kinsey regarded sex as a drive that was natural and healthy, Masters and Johnson developed means to measure and improve the sexual experience by examining physiological changes and Hite explained pleasure with descriptions of physical stimulation. Sex as a risk to health Recently, there has been an additional shift in the literature on sex. Although research still emphasizes sex as an activity, this activity has been viewed as increasingly risky and dangerous. However, studying sexual behaviour is not straightforward from a psychological perspective as it presents a problem for psychologists – a problem of interaction. Sex as interaction Social psychologists have spent decades emphasizing the context within which behaviour occurs. This is reflected in the extensive literature on areas such as con- formity to majority and minority influence, group behaviour and decision making, and obedience to authority. Such a perspective emphasizes that an individual’s behaviour occurs as an interaction both with other individuals and with the broader social context. In addition, psychological methodologies such as questionnaires and interviews involve an individual’s experience (e. I felt happy because she made me feel relaxed), only their own individual experiences are accessed using the psychological tools available. Sex is intrinsically an interaction between individuals, yet many areas of psychology traditionally study individuals on their own. Furthermore, the recent emphasis on sex as a risk to health and resulting attempts to examine indi- viduals’ competence at protecting themselves from danger, may have resulted in a more individualistic model of behaviour. This problem of interaction is exacerbated by the psychological methodologies available (unless the researcher simply observes two people having sex! They also raise the question of how much can and should psychologists be concerned with the context of individual behaviour? Sex as a risk and pregnancy avoidance A focus on sex for pleasure and an emphasis on sex as a risk has resulted in a literature on contraception use and pregnancy avoidance. Psychologists have developed models in order to describe and predict this behaviour. Researchers have used several different classifications of contraception in an attempt to predict contraceptive use. In addition, different measures of actual behaviour have been used when predicting contraception use: s at first ever intercourse; s at most recent intercourse; s at last serious intercourse; s at last casual intercourse. This produced a wealth of data about factors such as age of first intercourse, homosexuality, attitudes to sexual behaviours and contraception use. These results suggest that the younger someone is when they first have sex (either male or female), the less likely they are to use contraception. The results from this survey also show what kinds of contraception people use at first intercourse. The different measures of contraception use have implications for interpreting findings on contraception. Developmental models are more descriptive, whereas decision-making models examine the predictors and precursors to this behaviour. Developmental models Developmental models emphasize contraception use as involving a series of stages. Therefore, they describe the transition through the different stages but do not attempt to analyse the cognitions that may promote this transition.

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These authors suggest that • Relations between structure and function of the the next step in the evaluation process is critical re- theory purchase super p-force american express erectile dysfunction pump ratings, including clarity generic super p-force 160mg fast delivery erectile dysfunction news, consistency discount super p-force 160mg erectile dysfunction grand rapids mi, and sim- flection about whether and how the nursing theory plicity works. Questions are posed to guide this reflection: • Diagram of theory to further understand the theory by creating a visual representation • Is the theory clearly stated? Questions for analysis in this frame- work flow from the structural hierarchy of nursing knowledge proposed by Fawcett and defined in Chapter 1. The questions for evaluation guide ex- amination of theory content and use for practical Nursing theory, knowledge development purposes. Following is a summary of the Fawcett through research, and nursing practice are (2000) framework. In order to en- For theory analysis, consideration is given to: hance both nursing practice and nursing the- ory, it is incumbent upon the practicing nurse • scope of the theory to study theory, just as it is upon the theorist • metaparadigm concepts and propositions in- to study the practice of nursing. Considering cluded in the theory a commitment to study nursing theory raises • values and beliefs reflected in the theory many questions from nurses about to un- • relation of the theory to a conceptual model and dertake this important work. This chapter to related disciplines presented some of the questions worth con- • concepts and propositions of the theory sidering before undertaking extensive study For theory evaluation, consideration is given to: and deciding on a theory to guide practice. Analysis and evaluation of nursing theory • significance of the theory and relations with are the main ways of studying nursing structure of knowledge theory. Literature presents a number of dif- • consistency and clarity of concepts, expressed in ferent guides to analyzing and evaluating congruent, concise language theory. Aesthetic Meleis (1997) states that the structural and knowing grounded in an explicit conception of nursing. Fundamental patterns of knowing in nurs- are assumptions, concepts, and propositions of the ing. Integrated knowledge de- nurse-client interactions, environment, and nurs- velopment in nursing (6th ed. The structure of nursing knowledge: Analysis care through self-awareness and reflection (pp. Parker Study of Theory for Nursing Practice A Guide for Study of Nursing Theory for Use in Practice Study of Theory for Nursing Administration Summary References Nurses, individually and in groups, are affected Theories and practices from related disciplines by rapid and dramatic change throughout health are brought to nursing to use for nursing purposes. Nurses practice in increas- The scope of nursing practice is continually being ingly diverse settings and often develop organized nursing practices through which accessible health The scope of nursing practice is continu- care to communities can be provided. Community ally being expanded to include additional members may be active participants in selecting, knowledge and skills from related designing, and evaluating the nursing they receive. This guide was tice in hospitals, an increasing number of nurses developed for use by practicing nurses and students practice elsewhere in the community, taking the in undergraduate and graduate nursing education venue of their practice closer to those served by programs. The guide may be used to to provide nursing often realize that they share the study most of the nursing theories developed at all same values and beliefs about nursing. It has been used to create surveys of nursing nursing theories can clarify the purposes of nursing theories. An early motivation for developing this and facilitate building a cohesive practice to meet guide was the work by the Nursing Development these purposes. This chapter offers guides for continuing study 1 How is nursing conceptualized in the of nursing theory for use in nursing practice. Because many nurses are creating new practice or- ganizations and settings, a guide for study of nurs- Is the focus of nursing stated? The first guide is a set of • What does the nurse think about when con- questions for consideration in study and selection sidering nursing? The second • What are illustrations of use of the theory to guide is an outline of factors to consider when guide practice? Responses to questions offered and points sum- • What do nurses do when they are practicing marized in the guides may be found in nursing lit- nursing? Subsequent chapters of this • Is the richness and complexity of nursing book offer such sources. Four main questions have been developed and re- • What is the range of nursing situations in fined to facilitate study of nursing theories for use which the theory is useful? What major resources are authoritative • How can interactions of the nurse and the sources on the theory? What are major theoretical influences on this • Is the theory used to guide programs of nurs- theory? What were major external influences on devel- • Has nursing research led to further theory opment of the theory? What are projected influences of the theory on 3 Who are authoritative sources for infor- nursing’s future? Who are nursing authorities who speak about, • In what ways has nursing as a professional write about, and use the theory? Nurses in group practice may seek to use a nursing theory that will not only guide their practice, but also pro- vide visions for the organization and administra- This chapter has presented a guide designed tion of their practice. A shared understanding of for nurses to study nursing theory for use in the focus of nursing can facilitate goal-setting and practice. The guide is intended to accompany achievement as well as day-to-day communication more general formats of analysis and evalua- among nurses in practice and administration. This guide provides Allison and McLaughlin-Renpenning (1999) de- additional evaluative components for nurses scribe the need for a vision of nursing shared by all who are focusing on nursing practice. These questions are in- strate that a theory of nursing can guide practice as tended to further guide the study of nursing well as the organization and administration. The following questions are derived from components of a nursing administration model References (Allison & McLaughlin-Renpenning, 1999). Nursing questions are intended to guide descriptions of the administration in the 21st century: A self-care theory approach. New • How can the range of nursing situations be de- York: National League for Nursing. A nursing administration perspective on use • What nursing and related technologies are re- of Orem’s self-care nursing theory. Parker Introduction Why Evaluate Resources for Nursing Inquiry and Research Theory as a Guiding Framework for Evaluation How Do You Know What You Know? And if one begins, can the information that is often “here today and Never in human history have such vast quantities of gone tomorrow” be relied upon as accurate and information been so easily available. How can the information be evalu- brief space of a few decades, the acquisition, stor- ated? Given the complexity of data now available, age, and retrieval of information has been trans- can nursing theory resources even be evaluated formed from the realm of a labor-intensive manual across various types of media? Will the process be process to that of a digital, multidimensional vir- congruent with the theory and the values of the re- tual medium. The guide for evaluation of theory Nursing exists on the cusp of continual change, resources presented within this chapter moves to- with interfacing technological revolutions taking ward a realistic appraisal by the researcher of the place in nursing education, practice, and research. The rapid advance and integration of technology has not only affected practice (Sparks, 1999), but has also affected ways in which nurses investigate, eval- Theory as a Guiding Framework uate, think, and speak about practice (Turley, 1996). The framework for practice also becomes nursing knowledge is enhanced by the quality of a framework for education, research, and adminis- the resources used. A call for books, journals, and media recordings, emphasis nursing is also a call for transforming knowledge rests upon evaluation of the author and contents of and information; therefore, the response from each resource.