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Nursing the- Syntactical and Conceptual Structures ories form the bases for many of the major contri- Syntactical and conceptual structures are essential butions to the literature malegra dxt plus 160mg with amex, conferences order malegra dxt plus 160mg online, societies buy 160 mg malegra dxt plus visa, and to the discipline and are inherent in each of the other communication networks of the nursing dis- nursing theories malegra dxt plus 160 mg. This struc- The tradition and history of the nursing discipline ture is grounded in the metaparadigm and is evident in study of nursing theories that have philosophies of nursing proven malegra dxt plus 160 mg. There is recognition that relates concepts within nursing theories, and it is theories most useful today often have threads of from this structure that we learn what is and what connection with theoretical developments of past is not nursing. For example, many theorists have acknowl- nurses and other professionals understand the tal- edged the influence of Florence Nightingale and ents, skills, and abilities that must be developed have acclaimed her leadership in influencing nurs- within the community. In addition, nursing has a rich scriptions of data needed from research as well as heritage of practice. Nursing’s practical experience evidence required to demonstrate the impact of and knowledge have been shared, transformed into nursing practice. It is only by being Values and Beliefs thoroughly grounded in the discipline’s concepts, substance, and modes of inquiry that the bound- Nursing has distinctive views of persons and strong aries of the discipline, however tentative, can be un- commitments to compassionate and knowledge- derstood and possibilities for creativity across able care of persons through nursing. Nurses often interdisciplinary borders can be created and ex- express their love and passion for nursing. The state- concepts, language, and forms of data that reflect ments of values and beliefs are expressed in the new ways of thinking and knowing in nursing. The philosophies of nursing that are essential under- complex concepts used in nursing scholarship and pinnings of theoretical developments in the disci- practice require language that can be used and un- pline. The language of nursing theory facilitates Systems of Education communication among members of the discipline. Expert knowledge of the discipline is often required Nursing holds the stature and place of a discipline for full understanding of the meaning of special of knowledge and professional practice within in- terms. A distinguishing mark of any disci- This attribute calls attention to the array of books, pline is the education of future and current mem- periodicals, artifacts, and aesthetic expressions, as bers of the community. These indicators in- Closely aligned with attributes of nursing as a dis- clude procedures, tools, and instruments to cipline previously described is consideration of determine the impact of nursing practice and are nursing as a professional practice. Professional essential to research and management of outcomes practice includes clinical scholarship and processes of practice (Jennings & Staggers, 1998). Resulting of nursing persons, groups, and populations who data form the basis for improving quality of nurs- need the special human service that is nursing. Theory-based research is needed in ery and interdisciplinary work demands practice order to explain and predict nursing outcomes es- from a theoretical perspective. Nursing’s discipli- sential to the delivery of nursing care that is both nary focus is essential within an interdisciplinary humane and cost-effective (Gioiella, 1996). Because environment (Allison & McLaughlin-Renpenning, nursing theory exists to improve practice, the test of 1999). Nursing actions reflect nursing concepts and nursing theory is a test of its usefulness in profes- thought. Careful, reflective, and critical thinking is sional practice (Fitzpatrick, 1997; Colley, 2003). Chapters in and use of nursing theory offer opportunity for the remaining sections of this book highlight use of successful collaboration with related disciplines nursing theories in nursing practice. From the viewpoint of practice, know what they are doing, why they are doing what Gray and Forsstrom (1991) suggest that through they are doing, what may be the range of outcomes use of theory, nurses find different ways of looking of nursing, and indicators for measuring nursing’s at and assessing phenomena, have rationale for impact. These nursing theoretical frameworks serve their practice, and have criteria for evaluating out- in powerful ways as guides for articulating, report- comes. Recent studies reported in the literature af- ing, and recording nursing thought and action. Further, these tion and refinement through research, must be re- studies illustrate that nursing theory can stimulate turned to practice (Dickoff, James, & Wiedenbach, creative thinking, facilitate communication, and 1968). Within nursing as a practice discipline, nurs- clarify purposes and relationships of practice. The ing theory is stimulated by questions and curiosi- practicing nurse has an ethical responsibility to use ties arising from nursing practice. Development of the discipline’s theoretical knowledge base, just as it nursing knowledge is a result of theory-based nurs- is the nurse scholar’s ethical responsibility to de- ing inquiry.

Osteoblasts entering with the blood supply attach to the membrane buy malegra dxt plus 160mg with visa, ossifying from the center of the bone out- ward buy malegra dxt plus 160mg on line. The edges of the skull’s bones don’t completely ossify to allow for molding of the head during birth malegra dxt plus 160 mg line. Instead generic malegra dxt plus 160 mg free shipping, six soft spots buy generic malegra dxt plus 160 mg on-line, or fontanels, are formed: one frontal or anterior, two sphenoidal or anterolateral, two mastoidal or posterolat- eral, and one occipital or posterior. Once formed, bone is surrounded by the periosteum, which has both a vascular layer (remember the Latin word for “vessel” is vasculum) and an inner layer that contains the osteoblasts needed for bone growth and repair. A penetrating matrix of connective tissue called Sharpey’s fibers connects the periosteum to the bone; inside the bone, the medullary cavity is lined by a thin membrane called the endosteum (from the Greek endon, meaning “within,” and, of course, that ever-present Greek word osteon). Following are the basic terms used to identify bone landmarks or surface features: Process: A broad designation for any prominence or prolongation Spine: An abrupt or pointed projection Trochanter: A large, usually blunt process Tubercle: A smaller, rounded eminence Tuberosity: A large, often rough eminence Crest: A prominent ridge Head: A large, rounded articular end of a bone; often set off from the shaft by a neck Condyle: An oval articular prominence of a bone Facet: A smooth, flat or nearly flat articulating surface Fossa: A deeper depression Sulcus: A groove Foramen: A hole Meatus: A canal or opening to a canal Chapter 5: A Scaffold to Build On: The Skeleton 65 Q. Remember that description root blast in biological terms refers of the structural part of the bone, to growth or formation, and the the Haversian system? And check Latin root clast refers to breaking out that root osteo, which comes or fragmentation. Blood vessels entering through Volkmann’s canals reach the bone cells through the a. Fill in the blanks to complete the following sentences: Bones are first laid down as 15. The epiphyseal and diaphyseal areas remain separated by a layer of uncalcified cartilage called the 20. Chapter 5: A Scaffold to Build On: The Skeleton 67 Another very large cell that enters with the blood supply is the 21. Later it helps absorb bone tissue from the center of the long bone’s shaft, forming the 22. After ossification, the spaces that were formed by the osteoclasts join together to form 23. Unlike bones in the rest of the body, those of the skull and mandible (lower jaw) are first laid down as 24. In the skull, the edges of the bone don’t ossify in the fetus but remain membranous and form 25. Use the terms that follow to identify the regions and structures of the long bone shown in Figure 5-1. Compact bone tissue Chapter 5: A Scaffold to Build On: The Skeleton 69 Axial Skeleton: Keeping It All in Line Just as the Earth rotates around its axis, the axial skeleton lies along the midline, or center, of the body. Think of your spinal column and the bones that connect directly to it — the rib (thoracic) cage and the skull. The tiny hyoid bone, which lies just above your larynx, or voice box, also is considered part of the axial skeleton, although it’s the only bone in the entire body that doesn’t connect, or articulate, with any other bone. There are a total of 80 named bones in the axial skeleton, which supports the head and trunk of the body and serves as an anchor for the pelvic girdle. In addition to the hyoid bone, 8 bones form the cranium to house and protect the brain, 14 form the face, and 6 bones make it pos- sible for you to hear. Making a hard head harder Fortunately for the cramming student, most of the bones in the skull come in pairs. In the cranium there’s just one of each of the following: frontal bone (forehead), occipital bone (back and base of the skull), ethmoid bone (made of several plates, or sections, between the eye orbits in the nasal cavity), and sphenoid bone (a butterfly-shaped structure that forms the floor of the cranial cavity). But there are two temporal (hous- ing the hearing organs in the auditory meatus) and parietal (roof and sides of the skull) bones. These bones are attached along sutures called coronal (located at the top of the skull), squamosal (located on the sides of the head surrounding the temporal bone), sagittal (along the midline atop the skull located between the two parietal bones), and lambdoidal (forming an upside-down V — the shape of the Greek letter lambda — on the back of the skull). In the face, there’s only one mandible (jawbone) and one vomer dividing the nostrils, but there are two each of maxillary (upper jaw), zygomatic (cheekbone), nasal, lacrimal (a small bone in the eye socket), palatine (which makes up part of the eye socket, nasal cavity, and roof of the mouth), and inferior nasal concha, or turbinated, bones. Inside the ear, there are two each of three ossicles, or bonelets, which also happen to be the smallest bones in the human body: the malleus, incus, and stapes. The cranial cavity contains several openings, or foramina (the singular is foramen), in the floor of the cranial cavity that allow various nerves and vessels to connect to the brain. The holes in the ethmoid bone’s cribriform plate allow olfactory — or sense of smell — receptors to pass through to the brain. A large hole in the occipital bone called the foramen magnum allows the spinal cord to connect with the brain. The optic foramen allows passage of the optic nerves, whereas the jugular foramen allows passage of the jugular vein and several cra- nial nerves. The foramen rotundum allows passage of the trigeminal nerve, which is the chief sensory nerve to the face and controls the motor functions of chewing.

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Since thermoregulatory impairment may cause febrile convulsions order 160mg malegra dxt plus free shipping, pyrexial children should be monitored frequently cheap malegra dxt plus 160mg with amex. Older people may have impaired thermoregulation due to reduced metabolism; thus when feeling cold generic 160 mg malegra dxt plus, they may appreciate additional bedding purchase 160 mg malegra dxt plus with amex. Pyrexia and temperature control 73 Pyrexia Body temperature fluctuates during each day (circadian rhythm) and in different parts of the body so that monitoring temperature trends is more important than absolute figures; the sites chosen affect measurement (e buy 160 mg malegra dxt plus visa. Analysing blood gases by different body temperatures will give different results, even though the only change may be the removal of a pulmonary artery catheter. Holtzclaw (1992) describes three stages to the febrile response: ■ chill phase: discrepancy between existing body temperature and the new hypothalamic set point; the person feels cold, shivering to increase hypermetabolism ■ plateau: temperature overshoots the new set point, triggering heat loss mechanisms; endogenous pyrogen levels also start to fall ■ diaphoresis and flushing: heat loss through evaporation, with massive reduction in endogenous pyrogen levels, which causes uneven resolution of pyrexia Fever is a symptom, not a disease; attempts to cool patients, whether by reducing bedding or through active interventions such as tepid sponging, may stimulate further hypothalamus-mediated heat production (Bartlett 1996) and so become self-defeating. Shivering increases metabolism three- to fivefold, consuming oxygen and nutrients needed for tissue repair, while increasing carbon dioxide production. Fever can be protective as it: ■ inhibits bacterial and viral growth by restricting supply of iron and zinc (needed for cell growth) (Ganong 1995); most micro-organisms cannot replicate in temperatures above 37°C (Murray et al. Mild to moderate fevers are therefore beneficial and should remain untreated (Rowsey 1997b). However, fever and hypermetabolism create physiological stress because: ■ each 1°C increases oxygen consumption by 13 per cent (Nowak & Handford 1994); more carbon dioxide is also produced; ■ increased intracranial pressure from hypermetabolism (Morgan 1990) may compound problems for patients with neurological pathologies and head injuries; ■ permanent brain damage may be caused by protein denaturation (the mechanism inhibiting bacterial growth) (Gloss 1992), although there is no evidence of neural damage from brief pyrexias of up to 42°C (Styrt & Sugarman 1990). Intensive care nursing 74 Hyperpyrexia Hyperpyrexia (also called ‘heatstroke’ and ‘severe hyperthermia’) is a temperature of 40. Incidence of hyperpyrexia is increasing, largely due to use of the recreational ‘ecstasy’ (see Chapter 41). At 42°C autoregulation fails, enzymes become dysfunctional and membrane permeability increases (causing electrolyte imbalance and further cell dysfunction—see Chapter 23). Measurement Hypothalamic temperature (site of the thermoregulatory centre) is the ideal core measurement. Pulmonary artery temperature, the closest measurable site to hypothalamic temperature (Bartlett 1996), remains the ‘gold standard’ (Fulbrook 1993), although catheter calibration is rarely checked on insertion, and impractical afterwards. Since pulmonary artery catheters are highly invasive, temperature measurement alone does not justify their use. Studies assessing accuracy of other sites frequently identify drifts of about 1°C from the pulmonary artery temperature, leaving the choice largely to personal preference. Smith’s (1998) paediatric study found significant differences between mercury-in-glass and electronic/tympanic thermometers, but since neither were compared with pulmonary artery temperature, Smith’s conclusions about the unsuitability of electronic thermometry are unfounded. Erickson and Kirklin (1993) found good correlation between tympanic and pulmonary artery measurement. Some anecdotal reports suggest inaccuracies, although Board’s (1995) small study found them to be accurate; Erickson et al. Like mercury-in-glass thermometers, chemical thermometers rely on visual interpretation and so can be subjective. Rectal temperature measurement causes emotional trauma for children (Rogers 1992) and should therefore be avoided, while with adults it is undignified and so should only be used if benefits can be justified. The proximity of the axillary artery to the skin surface should make axillary temperature similar to central temperature provided the thermometer tips maintain skin contact (hollow axillary pockets, more frequent in older people, make contact difficult). Fulbrook (1993) found axillary measurement compared favourably with pulmonary artery temperature provided thermometers were left in place for 12 minutes (Rogers (1992) cites only 5 minutes), but Fulbrook subsequently (1997) identified discrepancies of between 1. Since the tympanic membrane shares carotid artery blood supply with the hypothalamus (Klein et al. Tympanic thermometers use infrared light to detect thermal radiation, and many devices include facilities to allow readings to be adjusted to equivalent core temperatures. Fulbrook (1997) questions whether cerumen (earwax) affects readings, citing Doezema et al. Bladder temperature can be measured by probes attached to urinary catheters; Earp and Finlayson (1992) and Bartlett (1996) found good correlation with pulmonary artery temperature. Noninvasive skin probes, usually on patients’ feet, can measure peripheral temperature; when compared with central temperature, the difference indicates perfusion/warming. Intensive care nursing 76 Treatment The appropriateness of treating pyrexia necessitates individual assessment and evidence- based practice. With pyrexias of infective origin, microorganisms can often be destroyed more safely by antibiotics than by endogenous pyrexia. As pyrexia is controlled by the hypothalamus, peripheral cooling increases stimuli for centrally regulated heat production/conservation. Vasoconstriction increases differences between core and peripheral temperatures, pooling heat centrally, and so exposing the main organs to further protein denaturation and damage.

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It is natural to be depressed buy discount malegra dxt plus 160 mg online, particularly in the long winter nights order malegra dxt plus 160mg with mastercard, but how severe should this depression be buy 160mg malegra dxt plus mastercard, and how long should it last? If the negative feelings last for an extended time and begin to lead the person to miss work or classes discount malegra dxt plus 160 mg on line, then they may become symptoms of a mood disorder buy malegra dxt plus 160 mg line. It is normal to worry about things, but when does worry turn into a debilitating anxiety disorder? And what about thoughts that seem to be irrational, such as being able to “speak the language of angels‖? Are they indicators of a severe psychological disorder, or part of a normal religious experience? Again, the answer lies in the extent to which they are (or are not) interfering with the individual‘s functioning in society. Another difficulty in diagnosing psychological disorders is that they frequently occur together. For instance, people diagnosed with anxiety disorders also often have mood disorders (Hunt, [7] Slade, & Andrews, 2004), and people diagnosed with one personality disorder frequently suffer from other personality disorders as well. Comorbidity occurs when people who suffer from one disorder also suffer at the same time from other disorders. Because many psychological disorders are comorbid, most severe mental disorders are concentrated in a small group of people Attributed to Charles Stangor Saylor. Psychology in Everyday Life: Combating the Stigma of Abnormal Behavior Every culture and society has its own views on what constitutes abnormal behavior and what causes it (Brothwell, [9] 1981). The Old Testament Book of Samuel tells us that as a consequence of his sins, God sent King Saul an evil spirit to torment him (1 Samuel 16:14). Ancient Hindu tradition attributed psychological disorder to sorcery and witchcraft. During the Middle Ages it was believed that mental illness occurred when the body was infected by evil spirits, particularly the devil. Remedies included whipping, bloodletting, purges, and trepanation (cutting a hole in the skull) to release the demons. Until the 18th century, the most common treatment for the mentally ill was to incarcerate them in asylums or “madhouses. In France, one of the key reformers was Philippe Pinel (1745–1826), who believed that mental illness was caused by a combination of physical Attributed to Charles Stangor Saylor. Pinel advocated the introduction of exercise, fresh air, and daylight for the inmates, as well as treating them gently and talking with them. In America, the reformers Benjamin Rush (1745–1813) and Dorothea Dix (1802–1887) were instrumental in creating mental hospitals that treated patients humanely and attempted to cure them if possible. These reformers saw mental illness as an underlying psychological disorder, which was diagnosed according to its symptoms and which could be cured through treatment. Despite the progress made since the 1800s in public attitudes about those who suffer from psychological disorders, people, including police, coworkers, and even friends and family members, still stigmatize people with psychological disorders. A stigma refers to a disgrace or defect that indicates that person belongs to a culturally devalued social group. In some cases the stigma of mental illness is accompanied by the use of disrespectful and dehumanizing labels, including names such as ―crazy,‖ ―nuts,‖ ―mental,‖ ―schizo,‖ and ―retard. On a community level, stigma can affect the kinds of services social service agencies give to people with mental illness, and the treatment provided to them and their families by schools, workplaces, places of worship, and health-care providers. Stigma about mental illness also leads to employment discrimination, despite the fact that with appropriate support, even people with severe psychological disorders are able to hold a job (Boardman, Grove, [11] Perkins, & Shepherd, 2003; Leff & Warner, 2006; Ozawa & Yaeda, 2007; Pulido, Diaz, & Ramirez, 2004). The mass media has a significant influence on society‘s attitude toward mental illness (Francis, Pirkis, Dunt, & Blood, [12] 2001). While media portrayal of mental illness is often sympathetic, negative stereotypes still remain in newspapers, magazines, film, and television. Burger King recently ran an ad called ―The King’s Gone Crazy,‖ in which the company’s mascot runs around an office complex carrying out acts of violence and wreaking havoc. The most significant problem of the stigmatization of those with psychological disorder is that it slows their recovery. People with mental problems internalize societal attitudes about mental illness, often becoming so embarrassed or ashamed that they conceal their difficulties and fail to seek treatment. Stigma leads to lowered self-esteem, increased Attributed to Charles Stangor Saylor. Despite all of these challenges, however, many people overcome psychological disorders and go on to lead productive lives.

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