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Acceptable/Not Acceptable Does the information cover nursing research purchase 500 mg cyklokapron with mastercard, administration order cyklokapron 500 mg fast delivery, and education? Are you able to The Web site/resource is easy to use and well or- contact the webmaster from an onsite address? Yes/No Are you informed when you are seamlessly transferred to an- The Web site/resource is satisfying to visit cheap 500mg cyklokapron amex. Are there fees or membership required to access the infor- Yes/No mation you need? This nursing theory resource will ground my inquiry as a credible, authoritative, and accurate source of information. Yes/No Reservations: ____________________________________________________________________________________ questions may not apply to all Web sites and may be • How comprehensive do you intend your analy- modified by the purpose of the Web site. Following are key reflective preparations that will When you have answered as many questions as help focus your activities: you are able to, synthesize your findings. White paper: Criteria for assessing the accuracy, credibility, currency, and trust- quality of health information on the Internet (working draft). Nursing decision making and the science of the Bartlett Publishers and National League for Nursing. The Nightingales Florence Nightingale transformed a “calling from were on an extended European tour, begun in 1818 God” and an intense spirituality into a new social shortly after their marriage. A reflection on this statement A legacy of humanism, liberal thinking, and love appears in a well-known quote from Notes on of speculative thought was bequeathed to Nursing (1859/1992): “Nature [i. His views on the educa- tion of God] alone cures … what nursing has to tion of women were far ahead of his time. Florence and her sis- Although Nightingale never defined human care or ter studied music; grammar; composition; modern caring in Notes on Nursing, there is no doubt that languages; Ancient Greek and Latin; constitutional her life in nursing exemplified and personified an history and Roman, Italian, German, and Turkish ethos of caring. It is model is yet to truly come of age in nursing or the Parthenope, the older sister, who clutches her fa- health care system. Justice- making is understood as a manifestation of com- passion and caring,“for it is our actions that brings about justice” (p. This chapter reiterates Nightingale’s life from the years 1820 to 1860, delineating the formative influences on her thinking and providing historical context for her ideas about nursing as we recall them today. Part of what follows is a well-known tale; yet it remains a tale that is irresistible, casting an age-old spell on the reader, like the flickering shadow of Nightingale and her famous lamp in the dark and dreary halls of the Barrack Hospital, Scutari, on the outskirts of Constantinople, circa 1854 to 1856. Early Life and Education A profession, a trade, a necessary occupation, some- thing to fill and employ all my faculties, I have always felt essential to me, I have always longed for, con- sciouslyornot.... Nightingales and both daughters made an extended —Florence Nightingale, private note, 1850, cited tour of France, Italy, and Switzerland between the in Woodham-Smith (1983, p. From there, Nightingale vis- By all accounts, Nightingale was an intense and ited Germany, making her first acquaintance with serious child, always concerned with the poor and Kaiserswerth, a Protestant religious community the ill, mature far beyond her years. A few months that contained the Institution for the Training of before her seventeenth birthday, Nightingale Deaconesses, with a hospital school, penitentiary, recorded in a personal note dated February 7, 1837, and orphanage. What that Fleidner, and his young wife had established this service was to be was unknown at that point in community in 1836, in part to provide training for time. This was to be the first of four such experi- women deaconesses (Protestant “nuns”) who ences that Nightingale documented. Nightingale was to return there in The fundamental nature of her religious convic- 1851 against much family opposition to stay from tions made her service to God, through service to July through October, participating in a period of “nurses training” (Cook, Vol. What the make it without”(Nightingale, private note, cited in Kaiserswerth training lacked in expertise it made Woodham-Smith, 1983). It would take 16 long and torturous years, from Florence wrote, “The world here fills my life with 1837 to 1853, for Nightingale to actualize her call- interest and strengthens me in body and mind” ing to the role of nurse. Nightingale took two trips to Paris she turned down proposals of marriage, potentially, in 1853, hospital training again was the goal, this in her mother’s view, “brilliant matches,” such as time with the sisters of St. In August 1853, she accepted her need to serve God and to demonstrate her caring first “official” nursing post as superintendent of an through meaningful activity proved stronger. She “Establishment for Gentlewomen in Distressed did not think that she could be married and also do Circumstances during Illness,” located at 1 Harley God’s will. After six months at Harley Street, Calabria and Macrae (1994) note that for Nightingale wrote in a letter to her father: “I am in Nightingale there was no conflict between science the hey-day of my power” (Nightingale, cited in and spirituality; actually, in her view, science is nec- Woodham-Smith, 1983, p. The development of science allows for the concept of one perfect God who regulates the uni- verse through universal laws as opposed to random Spirituality happenings.

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Patients at greatest risk from alveolar trauma usually have poor compliance generic cyklokapron 500 mg line, low functional lung volumes and hypoxia purchase 500mg cyklokapron visa, creating dilemmas between adequate oxygenation and risks of lung damage discount 500 mg cyklokapron. When patient-initiated negative pressure exceeds the set trigger level, patients can ‘breath through’ the ventilator. With most ventilatory modes, triggered breaths are in addition to preset volumes, but included in measured expired minute volume. Incorporating triggering/sensitivity into ventilators aids weaning and facilitates patient comfort by overcoming the problems of ‘fighting’. At rest, self-ventilation negative pressure is approximately −3 mmHg (Adam &; Osborne 1997); trigger levels below this can cause discomfort (fighting). Early methods of immersing expiratory port tubing into water (hence measurement in cmH2O) have been replaced by resistance valves (usually incorporated into ventilators). However, frequent small tidal volumes may achieve minute volume limits without clearing airway dead space. Once a breath is triggered, pressure support delivers gas until the preset peak airway pressure is reached. Thus pressure support encourages patients to initiate breaths, but replaces shortfall in volume from weak respiratory muscles. However tidal volumes are sufficiently consistent; alveolar ventilation is optimised (Bohm & Lachmann 1996) with minimal barotrauma. Flow-by Triggering (and pressure support) require sufficient negative pressure to open a closed valve, causing a delay in ventilation, increasing work of breathing and causing possible distress to patients. Flow-by provides a continuous flow of gas (5–20 litres per minute) through ventilator circuits (Kalia &: Webster 1997) to prevent these problems occurring. Inspiratory:expiratory ratio A breath has three potential parts: ■ inspiration ■ pause/plateau ■ expiration Oxygen transfer occurs primarily during inspiration and plateau; incomplete expiration (e. Changing inspiration to expiration (I:E) ratio therefore manipulates alveolar gas exchange. Some ventilators determine breath pattern by adjusting two of the parts as percentages of the whole breath; other ventilators set an I:E (inspiratory to expiratory) ratio, with separate control for pause/plateau time. Sigh Normal respiration includes a physiological sigh every 5 to 10 minutes (Hough 1996). Ratios between intra-alveolar pressure and volume differ between inspiration and expiration (hysteresis); lung expansion during inspiration increases alveolar surface area, facilitating adsorption of new surfactant adsorbed onto alveolar surfaces; this reduces surface tension during deflation by up to one-fifth (Drummond 1996). Occasional hyperinflation (sigh) prevents atelectasis during shallow respirations (Hough 1996), increases compliance, and so prevents infection. Since physiological sighs are lost with unconsciousness (Hough 1996), mechanical sighs were incorporated into ventilator technology, often delivering double tidal volumes. Bersten and Oh (1997) suggest that with use of smaller tidal volumes, sigh use requires reassessment. Independent lung ventilation With single-lung pathology, patients may benefit from different modes of ventilation being used to each lung. Independent lung ventilation requires double lumen endotracheal Artificial ventilation 33 tubes, one lumen entering each bronchus. Independent ventilators, each using any available mode, may then be used for each lung. Independent lung ventilation may be impractical due to: ■ insufficient ventilators available ■ increased costs and workload (e. However, as air leaks are invariably present and the airway is unprotected, with no access for suction (Elliott et al. Noninvasive ventilation is not intended for prolonged use, although it may facilitate weaning (Wedzicha 1992). The availability of non-invasive ventilation extends ethical dilemmas about decisions not to ventilate. Such decisions should be taken by the multidisciplinary team, nurses being potentially valuable patient advocates. Physiological complications All body systems are affected by artificial ventilation. Although this description is reductionist, and further complications are identified in Chapter 5 and elsewhere, it should be remembered that there are cumulative effects on the whole person. Conversely, positive pressure ventilation ■ impedes venous return ■ increases right ventricular workload ■ causes cardiac tamponade resulting in reduced arterial pressure and extravasation of plasma into interstitial spaces (oedema, including pulmonary).

But he discovered that no matter where he removed brain tissue discount cyklokapron 500mg with amex, the rats retained at least some memory of the maze buy cheap cyklokapron 500 mg, leading him to conclude that memory isn‘t located in a single place in the brain discount cyklokapron 500mg overnight delivery, but rather is distributed around it. Long-term potentiation occurs as a result of changes in the synapses, which suggests that chemicals, particularly neurotransmitters and hormones, must be involved in memory. Glutamate, a neurotransmitter and a form of the amino acid glutamic acid, is perhaps the most important neurotransmitter in memory (McEntee & [25] Crook, 1993). When animals, including people, are under stress, more glutamate is secreted, [26] and this glutamate can help them remember (McGaugh, 2003). The neurotransmitter serotonin is also secreted when animals learn, andepinephrine may also increase memory, particularly for stressful events (Maki & Resnick, 2000; Sherwin, [27] 1998). Estrogen, a female sex hormone, also seems critical, because women who are experiencing menopause, along with a reduction in estrogen, frequently report memory [28] difficulties (Chester, 2001). Our knowledge of the role of biology in memory suggests that it might be possible to use drugs to improve our memories, and Americans spend several hundred million dollars per year on memory supplements with the hope of doing just that. Yet controlled studies comparing memory enhancers, including Ritalin, methylphenidate, ginkgo biloba, and amphetamines, with placebo drugs find very little evidence for their effectiveness (Gold, Cahill, & Wenk, 2002; McDaniel, [29] Maier, & Einstein, 2002). Memory supplements are usually no more effective than drinking a sugared soft drink, which also releases glucose and thus improves memory slightly. This is not to say that we cannot someday create drugs that will significantly improve our memory. Although the most obvious potential use of drugs is to attempt to improve memory, drugs might also be used to help us forget. Although there are no existing therapies that involve using drugs to help people forget, it is possible that they will be available in the future. These possibilities will raise some important ethical issues: Is it ethical to erase memories, and if it is, is it desirable to do so? In addition to the cortex, other parts of the brain, including the hippocampus, cerebellum, and the amygdala, are also important in memory. Case studies of patients with amnesia can provide information about the brain structures involved in different types of memory. Plan a course of action to help you study for your next exam, incorporating as many of the techniques mentioned in this section as possible. What are the contents of each schema, and how might you use the schema to help you remember new information? In the film “Eternal Sunshine of the Spotless Mind,” the characters undergo a medical procedure designed to erase their memories of a painful romantic relationship. The association of elaborative or maintenance rehearsal with age, reading comprehension and verbal working memory performance. Semantic memory content in permastore: Fifty years of memory for Spanish learned in school. Mood and memory at 26: Revisiting the idea of mood mediation in drug-dependent and place-dependent memory. Contextual prerequisites for understanding: Some investigations of comprehension and recall. Memory and the hippocampus: A synthesis from findings with rats, monkeys, and humans. Long-term potentiation in the amygdala: A cellular mechanism of fear learning and memory. Failure to acquire new semantic knowledge in patients with large medial temporal lobe lesions. The effects of cerebral lesions subsequent to the formation of the maze habit: Localization of the habit. In Brain mechanisms and intelligence: A quantitative study of injuries to the brain (pp. Describe the representativeness heuristic and the availability heuristic and explain how they may lead to errors in judgment. They fail in part due to our inadequate encoding and storage, and in part due to our inability to accurately retrieve stored information. But memory is also influenced by the setting in which it occurs, by the events that occur to us after we have experienced an event, and by the cognitive processes that we use to help us remember. Although our cognition allows us to attend to, rehearse, and organize information, cognition may also lead to distortions and errors in our judgments and our behaviors. In this section we consider some of the cognitive biases that are known to influence humans.

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In addition to multisystem physiological problems (not usually occurring in younger people) discount 500mg cyklokapron amex, users (and friends) often experience anxiety or guilt 500mg cyklokapron fast delivery. Care is needed generic cyklokapron 500mg with amex, therefore, to integrate urgent multisystem physiological support with skilful psychological care. Caring for such patients is challenging and can cause distress, but holistic nursing care can contribute significantly to every aspect of recovery. Useful contacts Families Anonymous: 0207 498–4680 Drugline Ltd, Drug Advisory Bureau: 0208 692–4975 Turning Point, Grove Park, Camberwell, London: 0207 274–4883 Intensive care nursing 398 Further reading Useful specialist nursing articles include Jones & Owens (1996), Wake (1995) and Cunningham (1997)). For other fields, Cook (1995) is brief, but gives information for health promotion, while Tober (1994) is an excellent piece of research. Explain why Kelly became euphoric, hypermetabolic, hyperthermic, tachycardic, hypotensive, acidotic and low blood sugar, etc. Evaluate advice and support offered to patients such as Kelly in your clinical practice area. Review the availability of specialist referrals, resources, discharge clinics, support groups. The Department of Health’s triennial report Confidential Enquiries into Maternal Deaths in the United Kingdom (DoH 1996b) provides valuable information on obstetric mortality. Fetal mortality may occur in addition to, or independently of, maternal mortality. Postnatal admission is usually necessitated by complications such as respiratory or cardiovascular failure. Thus, while pregnancy and delivery may trigger crises, medical and nursing care centres on complications, medical treatments supporting failing systems Intensive care nursing 400 (e. Midwives visit between 10 and 28 days following delivery, and so should be actively involved in the multidisciplinary teams. Midwifery expertise may provide both psychological reassurance and practical care (e. Normal pregnancy Normal physiological changes during pregnancy favour fetal growth but place stress on the mother’s body, altering ‘normal’ biochemical/haematological values from non- pregnant levels. In the first trimester (weeks 1–12) the cardiovascular system becomes hyperdynamic: ■ blood volume increases by up to one-half ■ stroke volume and heart rate increase ■ thus, cardiac output increases about 40 per cent (McNabb 1997) and ■ systemic vascular resistance increases. If cardiac reserve is limited, increased cardiac work may precipitate cardiac failure. Patients should not be nursed supine as aortocaval compression may compromise circulation to both mother and fetus (Bird 1997). Reduced colloid osmotic pressure (dilution), hypertension and vasoconstriction encourage oedema formation, including ■ pulmonary oedema (impairing gas exchange) ■ airway oedema (obstructing airways) ■ cerebral oedema (causing intracranial hypertension). Erythropoietin levels rise during trimesters 2 and 3, but erythrocyte count increases by only one-quarter, creating (dilutional) anaemia; reduced blood viscosity improves capillary flow, and so (highly vascular) placental perfusion but, with increased systemic vascular resistance from prostacyclin, reduces the mother’s peripheral perfusion; auscultation for diastolic blood pressure may be difficult and expose mothers with pregnancy-induced hypertension to the risk of undetected strokes. In first stage labour, pain and anxiety increase circulating catecholamines, increasing cardiac output by nearly one-half. Second stage labour (contractions and delivery) creates a valsalva effect, reducing both venous return and cardiac output. Third stage labour (delivery of placenta) causes a 500-ml autotransfusion from uterine contraction. Maternal hearts are usually robust enough to cope with demands of pregnancy, but the number of maternal deaths from congenital defects is increasing (DoH 1996b), a trend likely to continue as the advances made in neonatal surgery 20–30 years ago allow more survivors to reach childbearing age. Increased maternal oxygen demand (up by one-third during pregnancy, and a further 60 per cent during labour) increases the respiratory and cardiovascular workload. However, functional residual capacity, and thus respiratory reserve, is reduced by one-fifth from the upward displacement of the diaphragm (4–7 cm (Zerbe 1995)) by fetal growth, while pulmonary oedema impairs gas exchange (especially oxygen). Nasal and airway mucosa become more vascular and oedematous, increasing the risk of epistaxis (Zerbe 1995), and necessitating smaller endotracheal tubes (especially with nasal intubation) while increasing airway resistance and pressures. Neurological changes are not normally seen, but cerebral oedema and hypoxia can cause fitting from eclampsia (see below). Gastrointestinal motility is reduced, contributing to nausea/vomiting, malnutrition and potential acid aspiration (‘Mendelsohn’s syndrome’).

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