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By M. Tom. Stonehill College.

Client is no longer exhibiting any signs or symptoms of sub- stance intoxication or withdrawal cheap 20mg cialis soft amex. Client shows no evidence of physical injury obtained during substance intoxication or withdrawal buy generic cialis soft 20mg online. Possible Etiologies (“related to”) [Weak buy discount cialis soft 20 mg line, underdeveloped ego] [Underlying fears and anxieties] [Low self-esteem] [Fixation in early level of development] Defining Characteristics (“evidenced by”) [Denies substance abuse or dependence] [Denies that substance use creates problems in his or her life] [Continues to use substance purchase cialis soft toronto, knowing it contributes to impair- ment in functioning or exacerbation of physical symptoms] [Uses substance(s) in physically hazardous situations] [Use of rationalization and projection to explain maladaptive behaviors] Unable to admit impact of disease on life pattern Goals/Objectives Short-term Goal Client will divert attention away from external issues and focus on behavioral outcomes associated with substance use. Long-term Goal Client will verbalize acceptance of responsibility for own behavior and acknowledge association between substance use and personal problems. Ensure that he or she understands, “It is not you but your behavior that is unacceptable. Client may rationalize his or her behavior with Substance-Related Disorders ● 93 statements such as, “I’m not an alcoholic. Factual information presented in a matter-of-fact, nonjudgmental way explaining what behaviors constitute substance-related disorders may help client focus on his or her own behaviors as an illness that requires help. Identify recent maladaptive behaviors or situations that have occurred in client’s life, and discuss how use of substances may have been a contributing factor. The first step in decreas- ing use of denial is for client to see the relationship between substance use and personal problems. Confrontation interferes with client’s ability to use denial; a caring attitude preserves self- esteem and avoids putting client on the defensive. Do not accept the use of rationalization or projection as client attempts to make excuses for or blame his or her be- havior on other people or situations. Rationalization and projection prolong the stage of denial that problems exist in client’s life because of substance use. Peer pressure can be a strong factor as well as the association with individuals who are experiencing or who have experi- enced similar problems. Offer immediate positive recognition of client’s expres- sions of insight gained regarding illness and acceptance of responsibility for own behavior. Positive reinforcement en- hances self-esteem and encourages repetition of desirable behaviors. Client verbalizes understanding of the relationship between personal problems and the use of substances. Client verbalizes understanding of substance dependence and abuse as an illness requiring ongoing support and treatment. Possible Etiologies (“related to”) [Inadequate support systems] [Inadequate coping skills] [Underdeveloped ego] [Possible hereditary factor] [Dysfunctional family system] [Negative role modeling] [Personal vulnerability] Defining Characteristics (“evidenced by”) [Low self-esteem] [Chronic anxiety] [Chronic depression] Inability to meet role expectations [Alteration in societal participation] Inability to meet basic needs [Inappropriate use of defense mechanisms] Abuse of chemical agents [Low frustration tolerance] [Need for immediate gratification] [Manipulative behavior] Goals/Objectives Short-term Goal Client will express true feelings associated with use of substances as a method of coping with stress. Long-term Goal Client will be able to verbalize adaptive coping mechanisms to use, instead of substance abuse, in response to stress. Establish trusting relationship with client (be honest; keep appointments; be available to spend time). Be sure that client knows what is acceptable, what is not, and the consequenc- es for violating the limits set. Client is unable to Substance-Related Disorders ● 95 establish own limits, so limits must be set for him or her. Unless administration of consequences for violation of limits is consistent, manipulative behavior will not be eliminated. Verbalization of feelings in a nonthreaten- ing environment may help client come to terms with long- unresolved issues. Many clients lack knowledge regarding the deleterious effects of substance abuse on the body. Explore with client the options available to assist with stress- ful situations rather than resorting to substance abuse (e. Client may have persistently resorted to chemical abuse and thus may possess little or no knowledge of adaptive responses to stress. Provide positive reinforcement for evidence of gratifica- tion delayed appropriately. Positive reinforcement enhances self-esteem and encourages client to repeat acceptable behaviors. Provide positive feedback for independent decision-making and effective use of problem-solving skills. Client is able to verbalize adaptive coping strategies as alter- natives to substance use in response to stress. Client is able to verbalize the names of support people from whom he or she may seek help when the desire for substance use is intense. Long-term Goal Client will exhibit no signs or symptoms of malnutrition by dis- charge. For such a client, it is more appropriate to establish short-term goals, as realistic step objectives, to use in the evaluation of care given. In collaboration with dietitian, determine number of calories required to provide adequate nutrition and realistic (accord- ing to body structure and height) weight gain. This information is necessary to make an accurate nutri- tional assessment and maintain client safety. Determine client’s likes and dislikes and collaborate with di- etitian to provide favorite foods. Ensure that client receives small, frequent feedings, includ- ing a bedtime snack, rather than three larger meals. Administer vitamin and mineral supplements, as ordered by physician, to improve nutritional state. If appropriate, ask family members or significant others to bring in special foods that client particularly enjoys. Client may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness. Client’s vital signs, blood pressure, and laboratory serum studies are within normal limits. Long-term Goal By time of discharge, client will exhibit increased feelings of self-worth as evidenced by verbal expression of positive aspects about self, past accomplishments, and future prospects. Spend time with client to convey acceptance and contribute toward feelings of self-worth. Discuss past (real or perceived) failures, but minimize amount of attention devoted to them beyond client’s need to accept responsibility for them. Client must accept re- sponsibility for own behavior before change in behavior can occur. Minimizing attention to past failures may help to eliminate negative ruminations and increase client’s sense of self-worth. Encourage participation in group activities from which cli- ent may receive positive feedback and support from peers. Help client identify areas he or she would like to change about self and assist with problem solving toward this effort. Low self-worth may interfere with client’s perception of own problem-solving ability. Ensure that client is not becoming increasingly dependent and that he or she is accepting responsibility for own behav- iors. Client must be able to function independently if he or she is to be successful within the less-structured community environment. Provide instruction in assertiveness techniques: the ability to recognize the difference among passive, assertive, and aggressive behaviors and the importance of respecting the human rights of others while protecting one’s own basic human rights. Self-esteem is enhanced by the ability to in- teract with others in an assertive manner. Teach effective communication techniques, such as the use of “I” messages and placing emphasis on ways to avoid mak- ing judgmental statements. Possible Etiologies (“related to”) Lack of interest in learning [Low self-esteem] [Denial of need for information] [Denial of risks involved with substance abuse] Unfamiliarity with information resources Defining Characteristics (“evidenced by”) [Abuse of substances] [Statement of lack of knowledge] [Statement of misconception] [Request for information] Verbalization of the problem Goals/Objectives Short-term Goal Client will be able to verbalize effects of [substance used] on the body following implementation of teaching plan. Long-term Goal Client will verbalize the importance of abstaining from use of [substance] to maintain optimal wellness. Baseline assessment of knowledge is required to develop appropriate teaching plan for client. Level of education and devel- opment are important considerations as to methodology selected. Measurable objectives provide criteria on which to base evaluation of the teaching experience. Implement teaching plan at a time that facilitates and in a place that is conducive to optimal learning (e. Retention is increased if introductory material pre- sented is easy to understand.

Psychological costs have also been reported after screening for coronary heart disease (Stoate 1989) 20mg cialis soft visa, breast cancer (Fallowfield et al generic 20 mg cialis soft mastercard. In addition generic 20 mg cialis soft visa, levels of depression have been found to be higher in those labelled as hypertensive (Bloom and Monterossa 1981) discount cialis soft 20 mg with visa. However, some research suggests that these psychological changes may only be maintained in the short term (Reelick et al. This decay in the psychological consequences has been particularly shown with the termination of pregnancy following the detection of foetal abnormalities (Black 1989). Although screening is aimed at detecting illness at an asymptomatic stage of development and subsequently delaying or averting its development, not all individuals identified as being ‘at risk’ receive treatment. In addition, not all of those identified as being ‘at risk’ will develop the illness. The literature concerning cervical cancer has debated the efficacy of treating those individuals identified by cervical screening as ‘at risk’ and has addressed the possible consequence of this treatment. This suggested that all women with more severe cytological abnormalities should be referred for colposcopy, whilst others with milder abnormalities should be monitored by repeat cervical smears. Shafi (1994) suggests that it is important to consider the psychological impact of referral and treatment and that this impact may be greater than the risk of serious disease. However, Soutter and Fletcher (1994) suggest that there is evidence of a progression from mild abnormalities to invasive cervical cancer and that these women should also be directly referred for a colposcopy. This suggestion has been further supported by the results of a prospective study of 902 women presenting with mild or moderate abnormalities for the first time (Flannelly et al. The results showed that following the diagnosis, the women experienced high levels of intrusive thoughts, avoidance and high levels of anger. However, the authors reported that there was no additional impact of treatment on their psychological state. Perhaps, the diagnosis following screening is the factor that creates distress and the subsequent treatment is regarded as a constructive and useful intervention. Marteau (1993) suggested that the existence of screening programmes may influence social beliefs about what is healthy and may change society’s attitude towards a screened condition. In a study by Marteau and Riordan (1992), health professionals were asked to rate their attitudes towards two hypothetical patients, one of whom had attended a screening pro- gramme and one who had not. The results showed that the health professionals held more negative attitudes towards the patient who had not attended. In a further study, community nurses were given descriptions of either a heart attack patient who had changed their health-related behaviour following a routine health check (healthy behaviour condi- tion) or a patient who had not (unhealthy behaviour condition) (Ogden and Knight 1995). The results indicated that the nurses rated the patient in the unhealthy behaviour condition as less likely to follow advice, more responsible for their condition and rated the heart attack as more preventable. In terms of the wider effects of screen- ing programmes, it is possible that the existence of such programmes encourages society to see illnesses as preventable and the responsibility of the individual, which may lead to victim blaming of those individuals who still develop these illnesses. This may be relevant to illnesses such as coronary heart disease, cervical cancer and breast cancer, which have established screening programmes. In the future, it may also be relevant to genetic disorders, which could have been eradicated by terminations. Screening in the form of secondary prevention involves the professional in both detection and intervention and places the responsibility for change with the doctor. The backlash against screening could, therefore, be analysed as a protest against professional power and paternalistic intervention. Recent emphasis on the psychological consequences of screening could be seen as ammunition for this movement, and the negative con- sequences of population surveillance as a useful tool to burst the ‘screening bubble’. Within this framework, the backlash is a statement of individualism and personal power. The backlash may reflect, however, a shift in medical perspective – a shift from ‘doctor help’ to ‘self-help’. In 1991, the British Government published the Health of the Nation document, which set targets for the reduction of preventable causes of mortality and morbidity (DoH 1991). This document no longer emphasized the process of secondary prevention – and therefore implicitly that of professional intervention – but illustrated a shift towards primary prevention, health promotion and ‘self-help’. During recent years there has been a shift towards self-help and health promotion, reflected by the preoccupation with diet, smoking, exercise and self-examination. Prevention and cure are no longer the result of professional intervention but come from the individual – patients are becoming their own doctors. Specific criteria have been developed to facilitate the screening process and research has been carried out to evaluate means to increase patient uptake of screening programmes. These have concerned the ethics of screening, its cost-effectiveness and its possible psychological consequences. Although screening programmes are still being developed and regarded as an important facet of health, there has been a recent shift from a system of ‘doctor help’ to ‘self-help’, which is reflected in the growing interest in health beliefs and health behaviour and the process of health promotion. However, it often does not challenge some of the biomedical approaches to ‘a successful outcome’. Perhaps promoting uptake implicitly accepts the biomedical belief that screening is beneficial. It is often assumed that changes in theoretical perspective reflect greater knowledge about how individuals work and an improved understanding of health and illness. Therefore, within this perspective, a shift in focus towards an examination of the potential negative consequences of screening can be understood as a better understanding of ways to promote health. However, perhaps the ‘backlash’ against screening also reflects a different (not necessarily better) way of seeing individuals – a shift from individuals who require expert help from professionals towards a belief that individuals should help themselves. This paper provides a comprehensive overview of the literature on screening and examines the contribution of psychological, service provision and demo- graphic factors. This comprehensive review examines the research to date on the impact of receiving either a positive or negative test result in terms of cognitive, emotional and behavioural outcomes. It then describes the concept of appraisal and Lazarus’s transactional model of stress which emphasizes psychology as central to eliciting a stress response. The chapter then describes the physiological model of stress and explores the impact of stress on changes in physiological factors such as arousal and cortisol production. Finally, it describes how stress has been measured both in the laboratory and in a more naturalistic setting and compares physiological and self- report measurement approaches. A layperson may define stress in terms of pressure, tension, unpleasant external forces or an emotional response. Contemporary definitions of stress regard the external environmental stress as a stressor (e. Researchers have also differentiated between stress that is harmful and damaging (distress) and stress that is positive and beneficial (eustress). In addition, researchers differentiate between acute stress such as an exam or having to give a public talk and chronic stress such as job stress and poverty. The most commonly used definition of stress was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of ‘person environment fit’. If a person is faced with a potentially difficult stressor such as an exam or having to give a public talk the degree of stress they experience is determined first by their appraisal of the event (‘is it stressful? A good person environment fit results in no or low stress and a poor fit results in higher stress. Cannon’s fight or flight model One of the earliest models of stress was developed by Cannon (1932). This was called the fight or flight model of stress, which suggested that external threats elicited the fight or flight response involving an increased activity rate and increased arousal. He suggested that these physiological changes enabled the individual to either escape from the source of stress or fight. Within Cannon’s model, stress was defined as a response to external stressors, which was predominantly seen as physiological. Cannon considered stress to be an adaptive response as it enabled the individual to manage a stressful event. However, he also recognized that prolonged stress could result in medical problems. The initial stage was called the ‘alarm’ stage, which described an increase in activity, and occurred immediately the individual was exposed to a stressful situation. The second stage was called ‘resistance’, which involved coping and attempts to reverse the effects of the alarm stage. They there- fore did not address the issue of individual variability and psychological factors were given only a minimal role.

Swindle and Moos (1992) argued that stressors in salient domains of life are more stressful than those in more peripheral domains order cialis soft australia. Overload: Multitasking seems to result in more stress than the chance to focus on fewer tasks at any one time discount cialis soft uk. Therefore a single stressor which adds to a background of other stressors will be appraised as more stressful than when the same stressor occurs in isolation – commonly known as the straw which broke the camel’s back order 20mg cialis soft fast delivery. Ambiguous events: If an event is clearly defined then the person can efficiently develop a coping strategy order discount cialis soft online. If however, the event is ambiguous and unclear then the person first has to spend time and energy considering what coping strategy is best. This is reflected in the work stress literature which illustrates that poor job control and role ambiguity in the workplace often result in a stress response. Uncontrollable events: If a stressor can be predicted and controlled then it is usually appraised as less stressful than a more random uncontrollable event. For example, experimental studies show that unpredictable loud bursts of noise are more stressful than predictable ones (Glass and Singer 1972). Self-control and stress Recently, theories of stress have emphasized forms of self-control as important in under- standing stress. This is illustrated in theories of self-efficacy, hardiness and feelings of mastery. In 1987, Lazarus and Folkman suggested that self-efficacy was a powerful factor for mediating the stress response. Self-efficacy refers to an individual’s feeling of confidence that they can perform a desired action. Research indicates that self-efficacy may have a role in mediating stress-induced immunosuppression and physiological changes such as blood pressure, heart rate and stress hormones (e. For example, the belief ‘I am confident that I can succeed in this exam’ may result in physiological changes that reduce the stress response. This shift towards emphasizing self-control is also illustrated by Kobasa’s concept of ‘hardiness’ (Kobasa et al. Hardiness was described as reflecting (a) personal feelings of control; (b) a desire to accept challenges; and (c) commitment. It has been argued that the degree of hardiness influences an individual’s appraisal of potential stressors and the resulting stress response. Accordingly, a feeling of being in control may contribute to the process of primary appraisal. Karasek and Theorell (1990) defined the term ‘feelings of mastery’, which reflected an individual’s control over their stress response. In summary, most current stress researchers consider stress the result of a person environment fit and emphasize the role of primary appraisal (‘is the event stressful? This research has highlighted two main groups of physiological changes (see Figure 10. This results in the production of catecholamines (adrenalin and noradrenalin, also known as epinephrine and norepinephrine) which cause changes in factors such as blood pressure, heart rate, sweating and pupil dilation and is experienced as a feeling of arousal. Catecholamines also have an effect on a range of the bodies tissues and can lead to changes in immune function. This results in the production of increased levels of corticosteroids the most important of which is cortisol which results in more diffuse changes such as the management of carbo- hydrate stores and inflammation. These changes constitute the background effect of stress and cannot be detected by the individual. They are similar to the alarm, resistance and exhaustion stages of stress described by Seyle (1956). In addition, raised levels of the brain opiods beta endorphin and enkaphalin have been found following stress which are involved in immune-related problems. The physiological aspects of the stress response are linked to stress reactivity, stress recovery, the allostatic load and stress resistance. Stress reactivity Changes in physiology are known as ‘stress reactivity’ and vary enormously between people. For example, some individuals respond to stressful events with high levels of sweating, raised blood pressure and heart rate whilst others show only a minimal response. This, in part, is due to whether the stressor is appraised as stressful (primary appraisal) and how the individual appraises their own coping resources (secondary appraisal). However, research also shows that some people are simply more reactive to stress than others, regardless of appraisal. Two people may show similar psychological reactions to stress but different physiological reactions. In particular, there is some evidence for gender differences in stress reactivity with men responding more strenu- ously to stressors than women and women showing smaller increases in blood pressure during stressful tasks than men (Stoney et al. Stress reactivity is thought to be dispositional and may either be genetic or a result of prenatal or childhood experiences. However, there is great variability in the rate of recovery both between individuals as some people recover more quickly than others and within the same individual across the lifespan. Allostatic load: Stress recovery is linked with allostatic load which was described by McEwan and Stellar (1993). They argued that the body’s physiological systems constantly fluctuate as the individual responds and recovers from stress, a state of allostasis, and that as time progresses recovery is less and less complete and the body is left increasingly depleted. Stress resistance: To reflect the observation that not all individuals react to stressors in the same way, researchers developed the concept of stress resistance to empha- size how some people remain healthy even when stressors occur (e. Stress resistance includes adaptive coping strategies, certain personality characteristic and social support. Stress reactivity, stress recovery, allostatic load and stress resistance all influence an individual’s reaction to a stressor. Laboratory setting Many stress researchers use the acute stress paradigm to assess stress reactivity and the stress response. This involves taking people into the laboratory and asking them either to complete a stressful task such as an intelligence test, a mathematical task, giving a public talk or watching a horror film or exposing them to an unpleasant event such as a loud noise, white light or a puff of air in the eye. The acute stress paradigm has enabled researchers to study gender differences in stress reactivity, the interrelationship between acute and chronic stress, the role of personality in the stress response and the impact of exercise on mediating stress related changes (e. Naturalistic setting Some researchers study stress in a more naturalistic environment. Naturalistic research also examines the impact of ongoing stressors such as work-related stress, normal ‘daily hassles’, poverty or marriage conflicts. These types of studies have provided important information on how people react to both acute and chronic stress in their everyday lives. Costs and benefits of different settings Both laboratory and naturalistic settings have their costs and benefits: 1. The degree of stressor delivered in the laboratory setting can be controlled so that differences in stress response can be attributed to aspects of the individual rather than to the stressor itself. Researchers can artificially manipulate aspects of the stressor in the laboratory to examine corresponding changes in physiological and psychological measures. Laboratory researchers can artificially manipulate mediating variables such as control and the presence or absence of social support to assess their impact on the stress response. The laboratory is an artificial environment which may produce a stress response which does not reflect that triggered by a more natural environment. Naturalistic settings allow researchers to study real stress and how people really cope with it. However, there are many other uncontrolled variables which the researcher needs to measure in order to control for it in the analysis. Physiological measures Physiological measures are mostly used in the laboratory as they involve participants being attached to monitors or having fluid samples taken. However, some ambulatory machines have been developed which can be attached to people as they carry on with their normal activities. They can also take blood, urine or saliva samples to test for changes in catecholamine and cortisol production. Self-report measures Researchers use a range of self-report measures to assess both chronic and acute stress. Self- report measures have been used to describe the impact of environmental factors on stress whereby stress is seen as the outcome variable (i. They have also been used to explore the impact of stress on the individual’s health status whereby stress in seen as the input variable (i. Costs and benefits of different measures Physiological and self-report measures of stress are used in the main to complement each other. The former reflects a more physiological emphasis and the latter a more psycho- logical perspective.

Each nurse must individually decide whether (and cialis soft 20 mg amex, if so order cialis soft master card, how) they should perform tasks; following guidelines order cheap cialis soft on-line, although normally reliable effective 20mg cialis soft, is no defence from individual professional accountability (Tingle 1997b). In civil law, the standards of care expected from qualified nurses are those of the ordinary skilled nurse (‘Bolam test’ (Brazier 1992)). Failure to meet professional standards may also cause removal from the professional register. If each person is accountable for their own actions, then patients’ best interests are served by professional collaboration rather than power conflicts. Whatever terminology, educational structures and requirements are established, continuous professional development will remain integral to individual professional accountability. Single-use items should be clearly identified by manufacturers (de Jong 1996); if disposable equipment is recycled, manufacturers’ liability may be transferred to the recycler (e. Small savings through recycling disposable equipment may incur greater costs from healthcare litigation. They have unfortunately encouraged defensive nursing, but do highlight deficiencies in services provided, afford a conduit for public accountability, and may diffuse concerns that would otherwise end in litigation. Most complaints result from failures of communication; Intensive care nursing 428 ironically, it is those least ill who often complain the most, so encouraging diversion of time away from those with the greatest need. Nurses have a professional duty to prioritise care (acts and omissions) so that actions can be justified. Traditionally, preregistration training was assumed to prepare nurses for possible lifelong practice. Such stasis in nursing became increasingly inappropriate to modern, dynamic society: ‘certification has tended to freeze and narrow the profession, has tied it to the past, has discouraged innovation’ (Rogers 1980:247). The 1977 circular establishing ‘extended roles’ (DoH 1977; now withdrawn), enabled doctors to delegate tasks to nurses provided ■ delegation was recognised by employers ■ appropriate training was given ■ competence was assessed and certified. The 1977 criteria eventually proved cumbersome and restrictive, hindering the progress of intensive care and the delivery of patient care; nurses became increasingly competent to perform tasks which they were not allowed to carry out because they did not have appropriate pieces of paper (e. Often those allowed to perform these tasks (junior doctors) did not have the knowledge to do so, and learned under verbal instruction from nurses who did know how the task should be done, but were not allowed to do it. Such restrictive practices might leave cardiac output studies unmeasured (and so inotropes unaltered) between the doctor’s last round at night and first round in the morning (possibly an eight-hour gap). Until 1992 nurses were expected to perform up to, but not beyond, their level of (formal) training. Both emphasise that each nurse must maintain their own knowledge, skill and competence, acknowledging any limitations. The human and financial costs of professional malpractice can be high for each nurse, employer and patient. Further reading Dimond (1995) remains the key text on the legal aspects of nursing, although Brazier’s (1992) book on medicine and the law is also useful. Identify to whom you are accountable and the main areas of accountability in your practice. Examine the extent of nurse accountability in this situation (re The Scope of Professional Practice, a nurse’s knowledge of drug administration, awareness of adverse effects, appropriateness of drug, etc. How often are intravenous administration sets for blood transfusions used with more than one unit of blood and/or non-blood products (e. Justify this practice with reference to physiology, patient safety, manufacturer’s information, hospital or unit policy, established practices in your area. Chapter 46 Stress management Fundamental knowledge ‘Fight or flight’ response—see Chapter 3 Introduction Stress is a widely used word, but concepts of stress are often poorly defined. Physiological and psychological effects of stress on patients were discussed in Chapter 3. Stress management, at all levels, is therefore fundamental to both good nursing and good health. Although a popular topic, much literature on stress remains anecdotal, cathartic or dubious. Human responses to stress change little between generations, and so the literature dates less quickly than with most topics in this book; however, contexts of practice do change so that older literature should be placed within the context of changes in nursing practice. Stress: a problem Nurses experiencing distress work less efficiently, and are less able to support others; unresolved distress usually escalates. The Office of Population Census Surveys for 1979– 1990 identified an average yearly suicide rate of 29 female nurses every year; this rate increased to 50 per year between 1990 and 1992 (Seymour 1995b). While not all suicides necessarily result from work-related pressures, nurses need to look after themselves as well as others, and need staff support systems. Psychological aspects of stress are less precise as stress is an individual subjective response, so that while stressors may be common, what one person finds stressful another person may enjoy (e. Eustress (eu=good) is stress that stimulates people to function more efficiently and enjoy life; ‘distress’ is a familiar concept. Because responses to stressors are individual, what is eustressful and distressful will vary between people; excessive exposure to eu-stimuli can become distressful. If relatives perceive nurse-stress, their loss of confidence may accentuate their own stress levels (although Ramos’s (1992) American study of general nurses suggested emotional involvement with patients provided potential support). Developing technical skills can obscure the human focus central to nursing (see Chapter 1); however nurses choose to develop their knowledge, they should ensure that they maintain and develop the interpersonal/human skills they already possess. Stimulus-based model Following the behaviourist philosophy (see Chapter 2), stressful stimuli would cause a response of stress. Therefore, reducing environmental stressors should reduce stress (Lloyd-Jones 1994). However, this approach fails to recognise the individuality of people and their stress responses (Lloyd-Jones 1994. Intensive care nursing 434 Response-based model This model focuses on internal responses: fear (stimulus) causes cate-cholamine-induced hypertension (response). Selye’s General Adaptive Syndrome (1976) has three stages: ■ alarm reaction ■ resistance ■ exhaustion. Transactional model This theory largely combines the previous two: stress results from dynamic interaction between both stressors and individuals. Neuman’s (1995) model of nursing develops this theory, suggesting that each person has variable lines of resistance to stressors. Therefore stress response has three aspects: ■ source of stress ■ mediators of stress ■ manifestations of stress (Lloyd-Jones 1994). Coping mechanisms Exposure to stress initiates various coping mechanisms (responses). The fight and flight response is a simple physiological response, but there are more complex cognitive responses. When something causes distress we can try and change either the stressor or ourselves. These coping mechanisms may be positive or negative/palliative, so that attempts to escape reality (changing ourselves) with drugs (e. However, taking antidepressants (again, changing ourselves) can be a positive coping mechanism, the problem (depression) being internal. Palliative coping mechanisms include: ■ denial Stress management 435 ■ smoking ■ excessive drinking ■ excessive overeating. Positive coping mechanisms attempt to change stressors, which may require finding out further information about them, just as preoperative information can reduce postoperative pain (Hayward 1975). Permitting and enabling people to express and release their stress may be more beneficial than trying to offer advice (cf. Recognising stress Recognising distress in others is often relatively easy, but recognising signs of stress in ourselves can be harder. The stressors may be common to all, but their responses (types of stress) differ from person to person; in order to recognise stress, therefore, we must recognise how each stressor affects each person by trying to understand experiences from their viewpoint (i. Unrecognised distress can progress, causing multiple problems, such as staff conflict, absenteeism, low morale, inefficient/poor work and (eventually) burn-out (Stechmiller & Yarandi 1993). Problems usually prove increasingly difficult to resolve, possibly causing potentially valuable staff to leave the unit and even, perhaps, nursing. Tyler and Ellison’s (1994) recommendation that nurses should attend stress management study days could be extended to other self-awareness courses, such as time management. Enabling staff to recognise their own (and others’) stress can help to limit crises. Burn-out, ultimate failure of coping mechanisms, causes: ■ decreased energy ■ decreased self-esteem ■ output exceeding input ■ a sense of hopelessness and helplessness ■ the inability to perceive alternative ways of functioning ■ cynicism ■ negativism ■ feelings of self-depletion (Farrington 1997) Intensive care nursing 436 When burn-out is reached, work becomes hard, unrewarding and of poor quality.

These numbers are expected to rise substantially over the next few decades due to our aging population order cialis soft 20mg free shipping. Alzheimer’s is not a normal part of aging purchase 20mg cialis soft with visa, but it is more common in people as they age generic cialis soft 20mg free shipping. In a healthy brain cheap 20mg cialis soft with amex, there are billions of neurons (nerve cells) that generate elec- trical and chemical signals, which help us think, remember, and feel. In those with Alzheimer’s the neurons begin to die, affecting the normal signalling in the brain. A key feature of this disease is the development of plaques and tangles in the brain. It is thought that a genetic defect in these proteins may be involved in the development of the disease. Tangles refer to a twisting of internal support structures of the brain, which causes damage and death of the neurons. Research has shown that Alzheimer’s disease involves oxidative and inflamma- tory processes, although it is not known whether these processes are a cause or effect of the disease or both. The ultimate result, however, is disruption of neuronal cell functioning and signalling, leading to neuronal cell death, which impairs memory and other mental abilities. There also are lower levels of some neurotransmitters, chemicals in the brain that carry messages back and forth between nerve cells. Although there’s no cure for Alzheimer’s disease, a number of medical advances in recent years and the use of natural supplements can delay the progression of the disease and improve symptoms and quality of life. He described the two hallmark features of the disease—plaques (tiny dense deposits scattered throughout the brain) and tangles (structures of the brain that are twisted)—which interfere with normal brain processes and cause death of brain cells. As the disease A progresses, there is a decline in language skills and the ability to perform tasks. The average length of time from diagnosis of Alzheimer’s to death is about eight years, but some people live beyond 10 years. There are no drugs that can reverse the disease, but there are a few that can help improve cognitive function and slow the cognitive decline associated with Al- zheimer’s, such as Aricept, Reminyl, and Exelon. These drugs improve the levels of neurotransmitters (chemical messengers such as serotonin and acetylcholine) in the brain and can delay the onset of Alzheimer’s in those with mild cognitive impair- ment. Not everyone responds positively to these drugs; some people have to stop because of side effects such as nausea, vomiting, and diarrhea. Two studies have found a lower risk of Alzheimer’s disease with a higher food intake of vitamin E. Boost your intake by eating pumpkin seeds, black-eyed peas, wheat germ, tofu, and seafood. Foods to avoid: • Aluminum has been associated with an increased risk, although the evidence is not conclu- sive. However, it may be wise to avoid aluminum food additives, which are found in some baked goods, processed foods, and beverages. Avoid fast foods, deep-fried foods, and baked goods and margarine containing hydrogenated oils; minimize saturated fat (red meat and high-fat dairy). Being obese and its consequences of high blood pressure and cholesterol are risk factors for Alzheimer’s. According to one study, regular exercises (walking 15 minutes three times per week) reduced the risk of Alzheimer’s and dementia by 40 percent in individuals over age 65. The theory is the more you use your brain, the more synapses you create, which provide a greater reserve as you age. A Bacopa monnieri: An herb that has been shown to enhance several aspects of mental function. It increases availability of acetylcholine in the brain, which improves memory and cognition. Ginkgo biloba: An herb that improves memory and cognitive function and slows the progression of Alzheimer’s. Dosage: 120–240 mg daily, standardized to 6 percent terpene lactones and 24 percent flavone glycosides. Phosphatidylserine: A nutrient that is related to lecithin, which is naturally occurring in the brain. Several studies involv- ing more than 1,000 people suggest that phosphatidylserine is an effective treatment for Alzheimer’s disease and other forms of dementia. It improves both behaviour and mental function and reduces symptoms of depression. Vitamin B1 is involved in nerve transmission and may be deficient in those with Alzheimer’s. Regular consumption of fish reduces Alzheimer’s risk and is important for brain function. Vitamin E: A potent antioxidant that protects the brain from damage due to oxidative stress and inflammation. Higher blood levels of vitamin E are associated with better brain function in older adults and some research has shown that supplements can lower the risk of Alzheimer’s. Consider supplements of acetyl-L-carnitine, bacopa, ginkgo, phosphatidylserine, and fish oils. Anemia impairs the ability of blood to transfer oxygen to the tissues throughout the A body. Either the body produces too few healthy red blood cells, loses too many, or destroys them faster than they can be replaced. The body needs iron to produce hemoglobin, the oxygen-carrying component of red blood cells. This form of anemia can result from poor diet (inadequate iron), blood loss (menstruation, surgery, or hemorrhoids), malabsorption diseases such as celiac, or increased iron needs during pregnancy. In addition to iron, the body needs folate and vitamin B12 to produce healthy red blood cells. It is more common among the elderly and those with intestinal disorders, which impair B12 absorption. Bariatric surgery, gastric ulcers, stomach tumours, and excessive alcohol consump- tion are other known risk factors for the development of pernicious anemia. Certain chronic diseases such as cancer, Crohn’s disease, kidney failure, rheuma- toid arthritis, and other inflammatory disorders can impair red blood cell production, which results in anemia. Aplastic anemia is a rare, life-threatening disease caused by a decrease in the bone marrow’s ability to produce blood cells. This may result from chemotherapy, radiation, exposure to environmental toxins, pregnancy, and lupus. Hemolytic anemia is a condition in which the red blood cells are destroyed faster than they can be produced in the bone marrow. This may result from autoimmune disease and use of certain medications, such as antibiotics. Sickle cell anemia is an inherited form of anemia caused by a defective form of he- moglobin that causes the red blood cells to become an abnormal (sickle) shape. Untreated pernicious anemia can lead to nerve damage and decreased mental function, as vitamin B12 is important not only for healthy red blood cells but also for optimal nerve and brain function. A Some inherited anemias, such as sickle cell anemia, can be serious and lead to life-threat- ening complications. Pernicious anemia is treated with injections of vitamin B12, and folate defi- ciency is treated with folate supplements. Aplastic anemia is very serious and may require blood transfusion or bone marrow transplant. Hemolytic anemia is managed with medications that suppress the immune system so that it stops attacking the red blood cells. Sickle cell anemia is treated with oxygen, intravenous fluids, and some- times blood transfusions. Do not self-diagnose or begin taking iron supplements unless advised by your doctor. The following informa- tion is provided for anemia due to iron, folate, or vitamin B12 deficiency. Dietary Recommendations Foods to include: • Iron-rich foods such as organic beef (calf liver), beans, lentils, fortified cereals, figs, eggs, blackstrap molasses, brewer’s yeast, nuts, and seeds 103 • Folate-rich foods such as dark green citrus, legumes, and fortified cereals • Dark-green leafy vegetables (except spinach) are good sources of iron and folate • B12 is found in meat and dairy products, fish, and eggs • Foods rich in vitamin C, such as citrus, peppers, and berries, improve iron absorption A Foods to avoid: • Star fruit, rhubarb, spinach, chard, beets, chives, parsley, and chocolate are high in oxalic acid, which inhibits iron absorption • Coffee reduces iron absorption (more than 3 cups per day) • Tea contains tannins, which inhibit iron absorption Lifestyle Suggestions • Have regular medical checkups and report any changes to your doctor. Top Recommended Supplements Folate: Supplements are required by those deficient and women trying to get pregnant. Iron supplements: Should be taken only if you have deficiency anemia as excess iron can be dangerous.

The sequence and age range of the developmental changes associated with puberty can vary widely cialis soft 20mg low cost. Al- though most children begin puberty between the ages of 10 and 12 cheap cialis soft uk, it can start at any age from 8 to 16 discount cialis soft online amex. The most obvious determining factor is gender; on average cialis soft 20 mg sale, puberty arrives earlier for girls than boys. Compared to an overall age range of nine to 18 for menarche, the age difference for sisters averages only 13 months and for identical , less than three months. Body weight is a factor as well: puberty often begins earlier in heavier children of both sexes and later in thinner ones. The onset of menstruation, in particular, appears to be relat- ed to amounts of body fat. Girls with little body fat, es- pecially athletes, often start menstruating at a later- than-average age. Over the past 100 years, puberty has tended to begin increasingly early in both sexes (a phe- nomenon called the ). Herman-Giddens of University of North Carolina at Chapel Hill School of Public Health provided evidence that the average age of menarche was declining. Instead of occurring between the ages of 12 and 14, as is typical in the late 1990s, girls’ first menstrual periods commonly appeared be- tween the ages of 15 and 17 in the 19th century. Puber- ty in boys usually didn’t begin until the ages of 15 or 16 (in the late 18th and early 19th centuries, boy sopra- nos in their mid-to-late teens still sang in church least a year after menarche young women’s fertility lev- choirs). Explanations for this pattern have ranged from els are very low, and they are prone to spontaneous evolution to better health, especially as a consequence abortions if they do conceive. In boys, as in girls, the first outward sign of sexual An important aspect of puberty is the development maturation is often light-colored pubic hair around the of. The testes and scrotum bodies during this period, either because they feel they begin to grow, and the scrotum darkens, thickens, and are maturing too early or too late, or because they fail becomes pendulous. About a year after the testes begin to match the stereotyped ideals of attractiveness for to increase in size, the penis lengthens and widens, tak- their sex (i. Girls who mature early have a hard increases, and ejaculations—the male counterpart to time initially because they feel self-conscious and iso- menarche in girls—begin, occurring through nocturnal lated, but they adjust well and even gain in status once emission, masturbation, or sexual intercourse. Some research even sug- from one to three years until ejaculations contain enough gests that girls who mature early may ultimately be sperm for a boy to be really fertile. Those who are already tall and athletic grows and the vocal cords lengthen, his voice drops in junior high school feel better about themselves than (roughly an octave in pitch) and changes in quality. Researchers have though girls’ voices also become lower, the change is linked late physical maturation in boys to the develop- victim’s home. Rape is one of the most underreported crimes in the United States, due to the victim’s fear of With the rise of Nazi Germany, Rank, a Jew, emi- embarrassment, humiliation, or retaliation by the rapist. Teaching at the Penn- Estimates of the percentage of rapes reported to authori- sylvania School of Social Work, he adopted the nickname ties range from 10 to 50 percent. Because of the difficul- “Huck,” after his favorite American book, ty of obtaining a conviction, about two percent of all. Rank and his wife separated in rapists are convicted, and most serve approximately half 1934. A survey conducted in 1987 found that 57 percent of women who have been raped develop post-traumatic Rank has never received full credit for his contribu- disorder. These women may lose their appetite, tions to psychoanalysis and psychotherapy, primarily be- become easily startled, and suffer from headaches, cause of the attacks by Freudians. Many women have difficul- horred the Nazis, in 1939 the psychologist ty maintaining a normal life following a rape, and may labeled Rank’s “will therapy” a Nazi-style phi- repress the experience for an extended period before losophy. Over the past 20 years 1970s when it was resurrected by the psychologists feminist organizations have fought successfully to and , among others, and by writ- change public attitudes toward rape as well as treatment ers such as Anaïs Nin. Efforts have been made to increase the , with writings by Rank and his followers, was sensitivity of police and hospital personnel to rape vic- published biannually from 1966 until 1983. Today, women work, ,was finally published in police officers routinely investigate rape cases. Most states require physical evi- dence of recent sexual intercourse in which the victim most undergo a medical examination within 24 hours of the assault. In recent years, increased attention has been focused on “date” or “acquaintance” rape, a widespread phenom- ena that is particularly insidious because women who are victimized in this way are more likely to blame them- selves and are less likely to seek help or prosecute their Rape is essentially an act of and dominance. A 1987 study of acquaintance rape at 32 col- Although an estimated 15 to 40 percent of American lege campuses sponsored by magazine found that women are victims of rape or attempted rape, men are one in four women surveyed were victims of rape or at- raped as well. Women are more likely to be raped by tempted rape, that most rape victims knew their attack- someone they know; between 50 and 70 percent of all ers, and over half the assaults were date rapes. Only 27 rapes occur within the context of a romantic relationship, percent of the women identified themselves as rape vic- and more than half the time the assault takes place in the tims, and five percent reported the rapes to police. Of the Sigmund Freud mental health psychoanalysis character traits A projective personality assessment based on the subject’s reactions to a series of ten inkblot pictures. A group therapy approach in which clients act out their problems to gain new insights and achieve emotional catharsis. A powerful and destructive phenomenon wherein a person or group of people are blamed for what- ever is wrong. Too much or too little arousal can produce effect long-lasting behavioral changes. Thus, usefulness of encounter groups is limited to psychologi- appropriate degrees of sensory deprivation may actually cally healthy individuals, as the intense and honest na- have a therapeutic effect when arousal levels are too high. Sensory deprivation experiments of the 1950s have shown that human beings need environmental stimula- tion to function normally. In a classic early experiment, Separation anxiety emerges according to a develop- college students lay on a cot in a small, empty cubicle mental timetable during the second half year in human nearly 24 hours a day, leaving only to eat and use the infants. They wore translucent goggles that let in light maturation, rather than the onset of problem behaviors. The continuous hum kibbutzim, and Guatemalan Indians display quite similar of an air conditioner and U-shaped pillows placed patterns in their response to maternal separation, which around their heads blocked out auditory stimulation. They became disori- that the one-year-old is alerted by the absence of ented and had difficulty concentrating, and their perfor- the parent and tries to understand that discrete event. If it mance on problem-solving tests progressively deteriorat- fails, is created and the child cries. Although Cultural practices have an impact on separation anx- they were paid a generous sum for each day they partici- iety. Infants who remain in constant contact with their pated in the experiment, most subjects refused to contin- mothers may show an earlier onset of separation anxiety, ue past the second or third day. After they left the isola- and possibly more intense and longer periods of reactivi- tion chamber, the perceptions of many were temporarily ty. For example, Japanese infants who are tested in distorted, and their brain-wave patterns, which had ’s Strange Situation show more intense slowed down during the experiment, took several hours reactions to the separation, presumably as a result of cul- to return to. The intensity of the discomfort tural norms prescribing constant contact between mother these volunteers experienced helps explain why solitary and infant for the first several years of life. City of Hope National Medical the normal school experience by impeding the develop- Center. Systems that address personality as a combi- about 40% of children with Tourette syndrome often nation of qualities or dimensions are called trait theories. One was the distinction be- Tourette syndrome whose symptoms interfere with their tween personal dispositions, which are peculiar to a sin- ability to learn in a regular classroom gle individual, and common traits, which can be used for should become familiar with their children’s rights to an describing and comparing different people. While person- individualized education program under Public Law 94- al dispositions reflect the individual personality more ac- 142, the 1975 federal law aimed at insuring an adequate curately, one needs to use common traits to make any education for children with special needs. Allport also claimed that about seven central traits dominated each individual personality (he described Baton Rouge Tourette’s Support Group. Allport was the cardinal trait—a quality so intense that it [Juvenile] governs virtually all of a person’s activities (Mother personal management styles in many American corpo- rations have been linked to the increase in workplace violence, nearly one-fourth of which end in the perpe- trator’s suicide. One type of violence that has received increased at- The high incidence of violence in the United tention in recent years is domestic violence, a crime for States is of great concern to citizens, lawmakers, and which statistics are difficult to compile because it is so law enforcement agencies alike. Between 1960 and heavily underreported—only about one in 270 incidents 1991, violent crime in the U. Estimates of the and over 600,000 Americans are victimized by hand- percentage of women who have been physically abused gun crimes annually. Violent acts committed by juve- by a spouse or partner range from 20 percent to as high niles are of particular concern: the number of Ameri- as 50 percent.