By X. Osko. Western Governors University.

Coronary artery disease is usually becoming occluded after 10–15 years (and often after progressive and there are two roles for such interventions: much shorter periods) buy inderal 40mg arrhythmia diagnosis code. This antiplatelet/antithrombotic regime approximately halves the likelihood of myocardial infarction trusted inderal 80mg blood pressure by palpation, and is the most effective known treatment for improv- ing outcome in pre-infarction syndromes order inderal 40mg online blood pressure medication itchy scalp. If β-blockers are contraindi- cated, a long-acting Ca2 -antagonist is a useful alternative. Diltiazem is often used as it does not cause reflex tachycardia Consider nicorandil if above and is less negatively inotropic than verapamil. Moreover, there is a theoretical risk of severe bradycardia or of precipitation of heart failure if β-blockers lesions whose symptoms are not adequately controlled by are co-administered with these negatively chronotropic and medical therapy alone. Nicorandil is now often added as well, but again continued for at least one month following the procedure. However, at the present time, many hos- patients treated early with intravenous atenolol was 3. This small absolute benefit was cases, since prevention of death and other serious complica- not maintained (there were more deaths in the atenolol group tions is directly related to the speed with which opening of than in the control group at one year) and does not warrant the infarct-related artery can be achieved, antithrombotic/ routine use of β-blockers for this indication (as opposed to fibrinolytic treatment should be instituted. Aspirin and throm- their use in secondary prevention, five days or more after bolytic therapy both reduce infarct size and improve survival – acute infarction, which is discussed below). Early fears about toxicity of almost universally been positive in this context, showing bene- the combination proved unfounded, so they are used together. Recent evidence suggests that the increases with increasing ventricular dysfunction, whilst there additional use of clopidogrel in the early course of myocardial is little or no evidence of benefit in patients with normal left infarction improves outcome further, over and above the bene- ventricular ejection post-infarct. Cardiac rehabil- itation includes attention to secondary prevention, as well as to Treatable complications psychological factors. A supervised graded exercise programme These may occur early in the course of myocardial infarction, is often valuable. Neglect of these unglamorous aspects of man- and are best recognized and managed with the patient in a agement may cause prolonged and unnecessary unhappiness. Transfer from the admission room should therefore not be delayed by obtaining x-rays, as a portable film can be obtained on the unit if necessary. Drugs are used prophylacti- cally following recovery from myocardial infarction to pre- vent sudden death or recurrence of myocardial infarction. It is generally best used trials of β-adrenoceptor antagonists have also demonstrated as ‘acute’ prophylaxis, i. It is usually given sublingually, thereby discussed under Management of stable angina above, because ensuring rapid absorption and avoiding presystemic metab- of their clear prognostic benefit in this situation. In addition, olism (Chapter 5), but in patients with unstable angina it may numerous trials have now demonstrated that long-term use of be given as an intravenous infusion. In patients whose pattern of aldosterone antagonist eplerenone, continued long term (at pain is predominantly during the daytime, it is prescribed to least 18 months), prevents development/progression of heart be taken in the morning and at lunch-time, thereby ‘covering’ failure and improves mortality. Longer-acting controlled-release preparations Consideration of surgery/angioplasty are available for once daily use, and these usually provide Ideally all patients who are potentially operative candidates nitrate cover during most of the day, but leave a small ‘nitrate- would have angiography at some stage, even if they have not free’ window of a few hours, thereby again preventing the undergone early angiography/angioplasty as an in-patient. Adverse effects can be minimized by swallowing the tablet after strenuous activity is Psychological and social factors completed (a more genteel alternative to spitting it out! The evidence suggests that any benefit under physiological conditions by a constitutive enzyme in is very small (or non-existent) in patients with completely nor- vascular endothelial cells and is Furchgott’s ‘endothelium- mal ventricular function, but that with increasing ventricular derived relaxing factor’. Treatment should be for the resting vasodilator tone present in human resistance started with small doses with dose titration up to doses that arterioles under basal conditions. They are partic- Reduced venous return reduces ventricular filling and hence ularly useful in patients in whom beta-blockers are con- reduces ventricular diameter. This drugs do not appear to act synergistically in angina and reduces cardiac work and oxygen demand. Coronary blood should not be routinely co-administered as prophylaxis to flow (which occurs during diastole) improves due to the such patients. They may be particularly useful in the rare decreased left ventricular end-diastolic pressure. Short-acting dihydropyridines Reduced arterial tone reduces diastolic blood pressure and should be avoided because they cause reflex tachycardia. Nitrates relax some non-vascular or a controlled-release preparation of nifedipine) are often smooth muscles and therefore sometimes relieve the pain of used in this setting.

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Identify healthy middle-age adults and older likely to bring about the desired outcome? Compare their long- and short-range goals discount inderal 40mg with amex arrhythmia journal, life stressors generic inderal 80 mg with visa blood pressure ranges american heart association, physical ability cheap inderal 40mg amex heart attack risk factors, and emotional stability. Identify several health risks for older adults and preventive methods to promote health and safety. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Task roles Circle the letter that corresponds to the best answer for each question. In a helping relationship, the nurse would which both the sender and receiver of mes- most likely perform which of the following sages take turns participating. Encourage the patient to independently three or more people are involved in the explore goals that allow his/her human communication process. Set up a reciprocal relationship in which experience the communication process in patient and nurse are both helper and large groups. Establish communication that is continu- messages through verbal and nonverbal ous and reciprocal means, which occur simultaneously. In which of the following phases of the help- set in a specific time frame ing relationship is an agreement or contract 6. Therapeutic Touch uses his or her talents and interpersonal strengths to assist the group to accomplish 9. Effective groups possess members who elicit wonder if I’ll still feel like a woman. The group’s ability to function at a high express her concerns in more specific terms? In an effective group, power is used to “fix” participating in which of the following types immediate problems without considering of communication? An information giver or seeker is taking on Circle the letters that correspond to the best a maintenance role. Self-serving roles advance the needs of indi- vidual members at the group’s expense. Which of the following are levels of communi- describe how various factors influence cation that the nurse engages in during communication? Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. The nurse should never admit a lack correlated with the patient’s neurologic of knowledge to the patient to avoid under- competence and cognitive development. Culture influences a person’s worldview available opportunities to communicate and relationships with the surrounding information to patients in routine caregiv- environment, religion, time, and others. Which of the following are recommended derived from the patient’s occupation, help techniques to help improve listening skills? A nurse performing a patient interview environment with arms and legs crossed should sit as close to the patient as possible in a relaxed position. Always maintain eye contact with the regardless of the patient’s sense of “private patient in a face-to-face pose. Communication is influenced by the way gestures to indicate that you are paying people value themselves, one another, and attention to what the patient is saying. Which of the following are qualities of a help- even if this creates a lull in the conversation. The helping relationship is characterized by patient rather than interrupting the patient’s an equal sharing of information. The helping relationship is built on the patient’s needs, not on those of the helping person. When a doctor communicates with a nurse by likely help nurses improve their communications telephone to prescribe pain medication for a with patients and achieve a more effective patient, the telephone is considered to be the helping relationship?

The possibility of secondary exposure to health care and law enforce- ment providers exists with the use of chemical crowd-control agents cheap 80 mg inderal visa heart attack nursing diagnosis. Although published reports are few cheap 80 mg inderal with visa blood pressure printable chart, effects can be minimized with common sense prac- tices generic inderal 80mg mastercard arteriogram definition, such as decontamination before the patient is placed in a confined area (e. The use of protective personal equipment, such as gloves and careful washing of exposed areas, avoids cross-contamination. Law enforce- ment officers should be educated on the common clinical effects and the appro- priateness of seeking medical care. Medical care should never be withheld from those who request it or in those prisoners who have lingering effects. To limit injury or potential liability, many police forces regulate the use of chemical crowd-control agents by establishing Crowd-Control Agents 191 policies to guide their use. Words are used first, followed by more defensive actions (such as chemical agents), then batons, and finally firearms. Use of these agents is monitored, and formal reports are filed when they are used. These agents afford control of violent offenders with much less risk to life and limb than do firearms, explosives, and battering. Nervous system degeneration produced by the industrial solvent methyl n-butyl ketone. Neurobehavioral effects from acute exposures to methyl isobutyl ketone and methyl ethyl ketone. Capsicum and capsaicin—a review: case report of the use of hot peppers in child abuse. Quantitative analysis of capsaicinoids in fresh peppers, oleoresin capsicum and pepper spray products. Pepper-spray induced respiratory failure treated with extracorporeal membrane oxygenation. The effect of oleoresin capsicum “pepper” spray inhalation on respiratory function. Clinical effects of oleoresin capsicum (pepper spray) on the human cornea and conjunctiva. Effects of oleoresin capsicum pepper spray on human corneal morphology and sensitivity. Riot control agents: biomedical and health aspects of the use of chemicals in civilian disturbances. Acute pulmonary effects fromO-chlorobenzylidemalonitrile “tear gas”: a unique exposure outcome unmasked by strenuous exercise after a military training event. Tear gas—its toxicology and suggestions for management of its acute effects in man. Medical Issues of Restraint 195 Chapter 7 Medical Issues Relevant to Restraint Nicholas Page 1. Forensic phy- sicians’ involvement with these issues involves many of the core attributes needed in the practice of high-quality forensic medicine, includ- ing the need for good history taking from as many involved parties as is prac- tical to clearly establish events, and a precise examination recorded clearly and contemporaneously. Objectivity must be maintained in the light of dif- fering histories, and there is a need to keep abreast of developing restraint techniques that may bring new clinical problems. However, regardless of how careful police officers may be, there is the potential for serious injury requir- ing further medical intervention, and the real possibility of being a witness in a legal process, such as police disciplinary procedures. During restraint, any force used must be proportionate to the threat faced, lawful, and necessary. The restraint process is particularly challenging where the potential detainee has a mental health problem or is intoxicated. In addi- tion, the officer, in retrospect and under close scrutiny, must be able to dem- onstrate that his or her actions were entirely appropriate. It must be recognized From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M.

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Both human and epistemology of Rogerian science and the as- beings and the environment are understood as sumptions embedded in quantitative research de- dynamic energy fields that cannot be reduced to signs; like Carboni (1995) and Butcher (1994) inderal 40 mg with mastercard prehypertension in young adults, she parts generic 40mg inderal mastercard heart attack jack johnny b bad. Pattern manifestations are indicators of change: may be more congruent with Rogers’ ontology and Pattern is the distinguishing characteristic of an epistemology 80 mg inderal fast delivery enrique heart attack. This chapter presents an inclusive view of Pattern manifestations are the source of infor- methodologies. Nevertheless, the researcher needs mation emerging from the human/environmen- to present an argument as to how the design of the tal mutual field process and are the only valid study and interpretations of results are congruent reflections of the energy field. Further- of concern in Rogerian inquiry is conceptualized more, nurses interested in engaging in Rogerian and understood as manifestations of human/ research are encouraged to use, test, and refine the environmental energy mutual process. Pandimensional awareness: Rogerian inquiry sistent with the ontology and epistemology of the recognizes the pandimensional nature of reality. Human instrument is used for pattern knowing and modification of the Criteria of Rogerian and appreciation: The researchers use themselves Inquiry developed by Butcher (1994) and the as the primary pattern-apprehending instru- Characteristics of Operational Rogerian Inquiry ment. The criteria may be ment sensitive to, and which has the ability to a useful guide in designing research investigations interpret and understand, pandimensional po- guided by the Science of Unitary Human Beings. A priori nursing science: All research flows from a appreciation is the process of apprehending in- theoretical perspective. Every step of the inquiry, formation or manifestations of patterning including the type of questions asked, the con- emerging from the human/environmental field ceptualization of phenomena of concern, choice mutual process. The process of pattern knowing of research design, selection of participants, se- and appreciation is the same in the research en- lection of instruments, and interpretation of deavor as described earlier in the Rogerian prac- findings is guided by the science of unitary tice methodology. It is important to note that because of the aware of dynamic unpredictability and contin- incongruency between ontology and episte- uous change and is open to the idea that pat- mology of Rogerian science with assumptions terns in the inquiry process may change in the in quantitative designs, Carboni (1995b) ar- course of the study that may not have been en- gues that the researcher must select qualitative visioned in advance. It is essential that the researcher docu- ods with Rogerian science and argue that the ment and report any design changes. Pattern synthesis: Rogerian science emphasizes hence, both qualitative and quantitative meth- synthesis rather than analysis. The separation of parts is not consistent ence is reflected in the nature of questions with Rogers’ notion of integrality and irre- asked and their theoretical conceptualization ducible wholes. However, qualitative designs, the whole emerging from the human/environ- particularly those that have been derived from mental mutual field process. Synthesis allows the postulates and principles of the science for creating and viewing a coherent whole. Shared description and shared understanding: the natural settings where the phenomenon of Mutual process is enhanced by including par- inquiry occurs naturally, because the human ticipants in the process of inquiry where possi- field is inseparable and in mutual process with ble. Any “manipulation” of participants in the study enhances shared “variables” is inconsistent with mutual process, awareness, understanding, and knowing par- unpredictability, and irreducibility. The researcher and the researcher-into are inte- are the best judges of the authenticity and va- gral: The principle of integrality implies that lidity of their own experiences, perceptions, the researcher is inseparable and in mutual and expressions. Participatory action designs process with the environment and the partici- and focus groups conceptualized within pants in the study. Each evolves during the re- Rogerian science may be ways to enhance mu- search process. The researcher’s values are also tual exploration, discovery, and knowing par- inseparable from the inquiry. Evolutionary interpretation: The researcher in- and environmental field are integral to each terprets all the findings within the perspective other. Purposive sampling: The researcher uses pur- the findings are understood and presented posive sampling to select participants who within the context of Rogers’ postulates of en- manifest the phenomenon of interest. Recogni- ergy fields, pandimensionality, openness, pat- tion of the integrality of all that is tells us that tern, and the principles of integrality, reso- information about the whole is available in in- nancy, and helicy. There is be explored is participatory action and cooperative strong support for the appropriateness of phenom- inquiry (Reason, 1994), because of their congru- enological methods in Rogerian science. Reeder ence with Rogers’ notions of knowing participation (1986) provided a convincing argument demon- in change, continuous mutual process, and inte- strating the congruence between Husserlian phe- grality. Cowling (1998) proposed that a case- nomenology and the Rogerian science of unitary oriented approach is useful in Rogerian research, human beings: because case inquiry allows the researcher to attend to the whole and strives to comprehend his or her [G]iven the congruency between Husserlian phenom- enology and the Rogerian conceptual system, a essence. Husserlian flows from the postulates, principles, and concepts phenomenology as a rigorous science provides just relevant to the conceptual system.

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Chapter 16 Ethics Introduction The value of ethics for healthcare has been increasingly recognised: critical care often adds greater focus and poignancy to ethical dilemmas 40mg inderal sale blood pressure kit target. Ethics raises questions rather than provides answers; dilemmas have more than one solution buy inderal 80 mg otc hypertension education materials. Each person has values; some are formed or shared with peer groups order inderal 80 mg online blood pressure 200 over 100, others are individual. Different values may cause conflict (for example, the care versus cure debate of Chapter 1). Active questioning enables evaluation of beliefs underpinning practice, helping nurses to understand others’ perspectives, but solutions necessarily remain individual. Increasing public expectations (and litigation) of healthcare, and changes within nursing (increased autonomy, responsibility and accountability) are reflected by greater emphasis on ethics in nursing education. A high public and media profile makes intensive care nursing a much-scrutinized area. This chapter provides a basis both for practice and for the remainder of this book; professional development can usefully be extended through discussion with colleagues and further study. This chapter describes the four main ethical principles identified by Beauchamp and Childress (1994): ■ autonomy ■ non-maleficence ■ beneficence ■ justice and the three main ethical theories identified by Rumbold (1993): ■ duty-based ■ goal-based ■ rights-based Other authors may give different arrangements, wording or additional theories and principles. Ethical principles provide a framework with which to work through dilemmas, identifying what is harmful, what is good and what is just. Decisions may differ between individuals because individual morals (values and beliefs) influence decision-making Intensive care nursing 138 processes. Ethical theories identify different sets of beliefs; understanding our own and others’ sets of beliefs (values) helps towards the understanding of differences. Some examples presented in this chapter include legal and professional perspectives; unlike ethics, these expectations can be enforced, and so nurses should consider their individual professional (and legal) accountability. Ethics are guides to decision-making, and decisions are influenced by sources such as ■ religion ■ law ■ society (and social values) ■ peers ■ individual values If growth from novice to expert entails moving from following rules to initiation (Benner 1984), understanding sources of ‘intuitive’ decisions can substantiate accountable evidence-based practice. The literal translation of both is ‘norm’ (Greek ethos, Latin mores), but they have different connotations. Many staff are uncomfortable with applying economics to healthcare, but while decisions should never be made solely on economic grounds, finance cannot be ignored where resources remain finite. Intensive care nursing relies on technology to support and monitor physiological function. Breathing and heartbeat can be replaced by technology (causing redefinition of death as absence of brainstem function), but intervention may prolong dying rather than prolong life: Rachels (1986) draws a distinction between living and the physical process of being alive. Technology may be used inappropriately; no treatment, intervention or observation should become ‘routine’. This much-used term is value-laden: what one person considers acceptable quality, another may not (e. Values vary between the extremes of preserving life at all costs, and always letting ‘nature’ take its course. Ethical principles Autonomy Beauchamp and Childress (1994) suggest that each ethical principle is part of a continuum. Autonomy, the first principle, is usually interpreted as ‘self-rule’—that is, making an informed free choice. Consent by relatives for mentally competent adults has no legal validity (Brazier 1992; Dimond 1995; Braithwaite 1996). Parents or guardians have the right to consent to treatment for children under 18 (Dimond 1995), but the 1989 Children’s Act and civil law precedent of ‘Gillick competence’ emphasise rights of children to make their own informed decisions provided they have achieved sufficient maturity to fully understand what is proposed (Brazier 1992). So one relatively young child may (legally) make more profound decisions than an older child. If in doubt, nurses should seek help to clarify the rights and duties of all concerned (most hospitals have legal advisors). The law assumes that healthcare staff will act in patients’ best interests (Brazier 1992). Actions in patients’ best interests may be condoned, but nonconsensual touch (including Intensive care nursing 140 any nursing/medical intervention without valid consent) is technically assault.

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