By B. Roy. University of California, Hastings College of Law.

Transpersonal Caring Theory and the caring Although Bernardo’s description of inpatient nurs- model “can be read generic 50 mg tenormin mastercard heart attack grill locations, taught cheap 100 mg tenormin amex blood pressure normal unit, learned about, studied, ing captures the composite and fragmented role researched and even practiced: however, to truly ‘get it,’ one has to personally experience it—interact and grow within the philosophy and intention of 1 See Watson,J. This section of Model® integrating theory, evidence and advanced caring-healing the chapter provides a look into Transpersonal therapeutics for transforming professional practice. Watson’s clinical caritas of deep respect for humanity and all life, of wonder processes are listed, as well as an abbreviated ver- and awe of life’s mystery, and the interconnected- sion of her guidelines for cultivating caring-healing ness from mind-body-spirit unity into cosmic throughout the day (Watson, 2002). Gadow (1995) describes written in Caring Theory language, expresses our nursing as a lived world of interdependency and intention to all and reminds us that caring is the shared knowledge, rather than as a service pro- core of our praxis. Caring praxis within this lived world is a Second, a shallow bowl of smooth, rounded praxis that offers “a combination of action and re- river stones is located in a prominent position at flection... A sign posted by the stones iden- and a relationship with the wider community” tify them as “Caring-Healing Touch Stones” invit- (Penny & Warelow, 1999, p. Caring praxis, ing one to select a stone as “every human being has therefore, is collaborative praxis. These stones serve as a reminder of our ca- in our endeavors to translate Caring Theory into pacity to love and heal. They reveal the nonlinear process and smooth cool surface, let its weight remind you of relational aspect of caring praxis. Share in the love openness to unknown possibilities, honor the and healing of all who have touched this stone be- unique contributions of self and other(s), and ac- fore you and pass on your love and healing to all knowledge growth and transformation as inherent who will hold this stone after you. These key elements support the Third, latched wicker blessing baskets have been evolution of praxis away from predetermined goals placed adjacent to the caring-healing touch stones. Through collaboration and cocreation, staff to offer names for a blessing by writing the we can build upon existing foundations to nurture person’s initials on a slip of paper and placing the evolution from what is to what can be. Every Monday through Friday, Our mission, to translate Caring Theory into the unit chaplain, holistic clinical nurse specialist praxis, has strong foundational support. Staff and families, our environment, and our caring tries not to enter patient rooms unless summoned. This book emphasizes that patients, the unit as evidence of our commitment to caring parents, and families are members of the health values. Depicting pictures of diverse families at the center, Sixth and most recently, the unit chaplain, child- the poster states our three initial goals for theory- life specialist, and social worker have organized a guided practice: (1) create caring-healing environ- ments, (2) optimize pain management through 2 Written by Terri Woodward. In order for these expressions to be deliberate Gathering,” offered every Thursday morning. It is actions of praxis, the centrality of caring as our core held in our healing room—a conference room value was clearly articulated. Caring Theory is the painted to resemble a cozy room with a beautiful flexible framework guiding our unit goals and unit outdoor view3 and redecorated with comfortable education and has been integrated into our im- armchairs, soft lighting, and plants. Goodies and plementation of an institutional customer service Gathering extends a safe retreat within the hospital initiative. Reflective of the to staff, these professionals provide snacks to feed broader institutional mission statement, each unit the body, a sacred space to nourish emotions, and is encouraged to develop a mission statement and their caring presence to nurture the spirit. Care as the core of praxis • Advocacy differs from the centrality of cure in the medical • Respect, research model. The unit on pain management has been expanded Large signs are currently being professionally to include use of caring-healing modalities. A new produced and will be hung at various locations on interactive session on the caritas processes has been our unit. The added that asks participants to reflect on how these largest, posted conspicuously at our threshold, processes are already evident in their praxis and to identifies our unit as the home of the Attending explore ways they can deepen caring praxis both in- Caring Team. In ad- Giving ourselves a name and making our caring dition to changes in phase classes, informal “clock intentions visible contribute to establishing an hours” are offered monthly. Clock hours are de- identity, yet may be perceived as peripheral activi- signed to respond to the immediate needs of the unit and encompass a diverse range of topics, from conflict resolution, debriefing after specific events, 3 Artwork created by and generously donated by artist Cynthia and professional development, to health treatment Telsey. Offered on the unit at varying hours Placing Caring Theory at the core of our praxis to accommodate all work shifts, clock hours pro- supports practicing caring-healing arts to promote vide a way for staff members to fulfill continuing wholeness, comfort, harmony, and inner healing. Building practice on awareness choose their attitude, work environments caring relationships has led to an increase in both improve for all. Previously, care conferences were called as caring, they become opportunities for authentic a way to disseminate information to families when human-to-human connectedness through I-Thou complicated issues arose or when communication relationships.

In the case of a double-barreled weapon order tenormin 100 mg overnight delivery hypertension jnc 7 guidelines, the circular abraded imprint of the nonfiring muzzle may be clearly seen adjacent to the contact wound generic tenormin 100 mg otc heart attack remix dj samuel. The wound margins and the tissues within the base of the wound are usually blackened by smoke and may show signs of burning owing to the effect of flame. Because the gases from the discharge are forced into the wound, there may be subsid- iary lacerations at the wound margin, giving it a stellate-like shape. This is seen particularly where the muzzle contact against the skin is tight and the skin is closely applied to underlying bone, such as in the scalp. Carbon mon- oxide contained within the gases may cause the surrounding skin and soft Injury Assessment 145 revolver, which tends to have a low muzzle velocity of 150 m/s, is a short- barreled weapon with its ammunition held in a metal drum, which rotates each time the trigger is released. In the self-loading pistol, often called “semi-automatic” or erroneously “automatic,” the ammunition is held in a metal clip-type maga- zine under the breach. Each time the trigger is pulled, the bullet in the breach is fired, the spent cartridge case is ejected from the weapon, and a spring mecha- nism pushes up the next live bullet into the breach ready to be fired. The rifle is a long-barreled shoulder weapon capable of firing bullets with velocities up to 1500 m/s. Most military rifles are “automatic,” allowing the weapon to continue to fire while the trigger is depressed until the magazine is empty; thus, they are capable of discharging multiple rounds within seconds. Shotgun Wounds When a shotgun is discharged, the lead shot emerges from the muzzle as a solid mass and then progressively diverges in a cone shape as the distance from the weapon increases. The pellets are often accompanied by particles of unburned powder, flame, smoke, gases, wads, and cards, which may all affect the appearance of the entrance wound and are dependent on the range of fire. Both the estimated range and the site of the wound are crucial factors in deter- mining whether the wound could have been self-inflicted. If the wound has been sustained through clothing, then important resi- dues may be found on the clothing if it is submitted for forensic examination. It is absolutely essential that the advice of the forensic science team and crime scene investigator is sought when retrieving such evidence. When clothing is being cut off in the hospital, staff should avoid cutting through any apparent holes. The entrance wound is usually a fairly neat circular hole, the margins of which may be bruised or abraded resulting from impact with the muzzle. In the case of a double-barreled weapon, the circular abraded imprint of the nonfiring muzzle may be clearly seen adjacent to the contact wound. The wound margins and the tissues within the base of the wound are usually blackened by smoke and may show signs of burning owing to the effect of flame. Because the gases from the discharge are forced into the wound, there may be subsid- iary lacerations at the wound margin, giving it a stellate-like shape. This is seen particularly where the muzzle contact against the skin is tight and the skin is closely applied to underlying bone, such as in the scalp. Carbon mon- oxide contained within the gases may cause the surrounding skin and soft 146 Payne-James et al. Con- tact wounds to the head are particularly severe, usually with bursting ruptures of the scalp and face, multiple explosive fractures of the skull, and extrusion or partial extrusion of the underlying brain. Most contact wounds of the head are suicidal in nature, with the temple, mouth, and underchin being the sites of election. In these types of wounds, which are usually rapidly fatal, fragments of scalp, skull, and brain tissue may be dispersed over a wide area. At close, noncontact range with the muzzle up to about 15 cm (6 in) from the skin, the entrance wound is still usually a single circular or oval hole with possible burning and blackening of its margins from flame, smoke, and unburned powder. Blackening resulting from smoke is rarely seen beyond approx 20 cm; tattooing from powder usually only extends to approx 1 m. Up to approx 1 m they are still traveling as a compact mass, but between approx 1–3 m, the pellets start to scatter and cause variable numbers of individual satellite punc- ture wounds surrounding a larger central hole. At ranges greater than 8–10 m, there is no large central hole, only multiple small puncture wounds, giving the skin a peppered appearance. Exit wounds are unusual with shotgun injuries because the shot is usu- ally dispersed in the tissues. However, the pellets may penetrate the neck or a limb and, in close-range wounds to the head, the whole cranium may be dis- rupted. Rifled Weapon Wounds Intact bullets penetrating the skin orthogonally, that is, nose-on, usually cause neat round holes approx 3–10 mm in diameter. Close examination reveals that the wound margin is usually fairly smooth and regular and bordered by an even zone of creamy pink or pinkish red abrasion.

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The health visitor is concerned about an eight-month-old girl who is failing to grow generic tenormin 50mg free shipping blood pressure ranges child. On further enquiry discount tenormin 50 mg mastercard arrhythmia 27 years old, the mother tells you that she has been This route provides access to the central nervous system for applying clobetasone, which she had been prescribed her- self for eczema, to the baby’s napkin area. The mother stops using the clobetasone this route should never be used without adequate training. It is prescribed for its top-ical effect, but can penetrate disability is such that extra care must be taken in checking that skin, especially of an infant. Examples of drugs used appropriate for an adult would readily cover a large frac- in this way include methotrexate and local anaesthetics (e. Microspheres for controlled release drug deliv- Therapeutic Drug Carrier Systems 2003; 20: 153–2. The pharmacological activity of many drugs is reduced or Hepatocyte endoplasmic reticulum is particularly important, abolished by enzymatic processes, and drug metabolism is one but the cytosol and mitochondria are also involved. These metabolic delayed effects of the long-lasting metabolite as it accumulates reactions include oxidation, reduction and hydrolysis. Monoamine oxidase is found in liver, kidney, intestine and nervous tissue, and its substrates include catecholamines Glycine and glutamine are the amino acids chiefly involved in conjugation reactions in humans. Hepatocellular damage depletes the intracellular pool of these amino acids, thus restricting this pathway. Acetylating – Hydrolysis – Glucuronidation – Sulphation activity resides in the cytosol and occurs in leucocytes, gastro- – Mercaptopuric intestinal epithelium and the liver (in reticulo-endothelial rather acid formation than parenchymal cells). Some patients inherit a deficiency of glu- with thiol donors such as N-acetyl cysteine or methionine to curonide formation that presents clinically as a non- increase the endogenous supply of reduced glutathione. Drugs that are normally conju- gated via this pathway aggravate jaundice in such patients. This occurs with drugs such as Naphthalene and some sulphonamides also form conjugates paracetamol and morphine. It is present in bronchoconstrictor mediators in anaphylaxis and in asthma the cytosol, and catalyses the transfer of a methyl group to (see Chapters 12 and 33). Phenylethanolamine N-methyltransferase is also important in catecholamine metabolism. It is induced by which enzyme activity is enhanced, usually because of increased corticosteroids, and its high activity in the adrenal medulla enzyme synthesis (or, less often, reduced enzyme degrada- reflects the anatomical arrangement of the blood supply to the tion). The increase in enzyme synthesis is often caused by medulla which comes from the adrenal cortex and conse- xenobiotics binding to nuclear receptors (e. Under physiological conditions, sulphotrans- hexachloride), herbicides, polycyclic aromatic hydrocarbons, ferases generate heparin and chondroitin sulphate. In addition, dyes, food preservatives, nicotine, ethanol and hyperforin in they produce ethereal sulphates from several oestrogens, St John’s wort. Apractical consequence of enzyme induction is androgens, from 3-hydroxycoumarin (a phase I metabolite of that, when two or more drugs are given simultaneously, then warfarin) and paracetamol. There are a number of sulphotrans- if one drug is an inducing agent it can accelerate the metabo- ferases in the hepatocyte, with different specificities. The availability of glutathione is critical ↓ Effect of target in determining the clinical outcome. Patients who have drug ingested large amounts of paracetamol are therefore treated Figure 5. Aconsiderably smaller fraction of the absorbed dose goes of some enzymes may be increased and that of others reduced. It is important in drug elim- If a drug is subject to a high hepatic clearance (i. Neonates fail to form glu- extracted from the portal blood and metabolized before it curonide conjugates because of immaturity of hepatic uridyl reaches the systemic circulation. This, in combination with glucuronyl transferases with clinically important conse- intestinal mucosal metabolism, is known as presystemic or quences, e. The route of administration and presystemic metabolism markedly influence the pattern of drug metabolism.

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Vitamin B12 deficiency is common in patients who are strict vegetari- ans and in patients who have malaborption syndromes (cancer generic tenormin 100 mg fast delivery hypertensive retinopathy, celiac disease) order tenormin 100 mg with amex heart attack jaw pain right side, gastrectomy, Crohn’s disease, and liver and kidney diseases. Vitamins and the Nursing Process The nurse must assess the patient for signs and symptoms of vitamin deficiency before beginning vitamin therapy because vitamin therapy could result in a toxic effect if the patient does not have a vitamin deficiency. If so, then the nurse should educate the patient on the importance of maintaining a balanced diet. In many cases, the nurse may reach one of the following diagnoses: • Altered nutrition; less than body requirements • Lack of knowledge related to proper nutrition • Lack of knowledge related to vitamin use Based on these diagnoses, the nurse should develop a plan for having the patient eat a well-balanced diet and to take vitamin supplements as prescribed. The plan should also take into consideration the following interventions: • Administer vitamins with food to promote absorption. Teaching the patient is an important intervention because this gives the patient the knowledge to implement preemptive actions that lower the risk of vitamin deficiency in the future. It is important that the patient understands that vitamin supplements are not necessary if he or she is healthy and eats properly. Hyper- vitaminosis A causes nausea, vomiting, headache, loss of hair, and cracked lips. The nurse should evaluate the patient for proper dietary intake and determine if vitamin therapy is having a therapeutic effect. Minerals Minerals are inorganic compounds that are required by the body for metabolism and to form bones and teeth. Minerals are extracted from ingested food such as meats, eggs, vegetables, and fruits. Iron Iron (ferrous sulfate, gluconate, or fumarate) is used for the regeneration of hemoglobin. The patient requires 5 to 20 mg of iron each day from eating liver, lean meats, egg yolks, dried beans, green vegetables (such as spinach), and fruit. Iron Dose Adult 50 mg/day Infant and child dose of iron, ages 6 months to 2 years old is 1. Life threatening: cardiovascular collapse, metabolic acidosis Contraindications Avoid a megadose in the first trimester because it might cause birth defects. Iron is absorbed in the intestine where it enters plasma as heme or is stored as ferritin in the liver, spleen, and bone marrow. Food, the antibiotic tetracycline, and antacids decrease absorption up to 50% of iron. Toxicity can develop with as few as 10 tablets of ferrous sulfate (3g) taken at one time—and can be fatal within 12 to 48 hours. Copper is also a component in the produc- tion of the neurotransmitters norepinephrine and dopamine. Foods rich in copper are shellfish (crabs and oysters), liver, nuts, seeds (sunflower, sesame), legumes, and cocoa. A prolonged copper deficiency can result in anemia and cause changes in the skin and blood including a decrease in the white blood count, intolerance to glucose, decrease in skin and hair pigmen- tation, and mental retardation if the patient is young. High levels of copper in serum can be an indication of Wilson’s disease, which is an inborn error of metabolism that allows for large amounts of copper to accumulate in the liver, brain, cornea, or kidney. Zinc also inhibits tetra- cycline (antibiotic) absorption and therefore should not be taken with antibi- otics. Chromium Chromium is acquired from meats, whole-grain cereals, and brewer’s yeast and plays a role in controlling non-insulin-dependent diabetes by normalizing blood glucose thereby increasing the effects of the body’s insulin on cells. Chromium 50 to 200 µg/d is considered within the normal range for children older than 6 years old and adults. Selenium Selenium is a trace mineral that is a cofactor for antioxidant enzymes that pro- tect protein and nucleic acids from damage caused by oxidation. Contraindications Although contraindicated for diabetic patients blood sugar levels should be monitored closely. However, such a dose might cause weakness, loss of hair, dermatitis, nausea, diarrhea, and abdominal pain. Selenium Dose 40 to 75 µg (high doses for males and lower dose for females) Maintenance 40 to 75 µg (high doses for males and lower dose for females) Pregnancy category A Deficiency conditions Heart disease Side effects Causes a garlic-like odor from the skin and breath in large doses. Each day we need to eat a balanced diet that supplies us with the sufficient amount of vita- mins and minerals to remain healthy. Water-soluble vitamins are used immediately and then excreted from the body in urine.

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