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By T. Ernesto. Saint Thomas University.

Toffler (1970) remains challenging order fildena with american express causes of erectile dysfunction in 30s, developing wider perspectives (although providing little immediate help for nurses wishing to make changes) purchase 25mg fildena overnight delivery how to get erectile dysfunction pills. The problems of ritualised nursing are illustrated by Walsh and Ford (1989) and Ford and Walsh (1994) best 100mg fildena erectile dysfunction symptoms age. Journals specialising in nursing management frequently include articles on change management (e discount fildena 50mg visa erectile dysfunction at the age of 21. How are nurses or other members of healthcare teams (doctors, pharmacists, cleaners, porters) affected by these changes? Using your own example: (a) Identify the style and approaches used (top-down, bottom-up, etc. This chapter provides a trouble-shooting introduction for staff not normally in charge of their units (hence the direct address to readers). The terms manager and management in this chapter normally refer to the nurse-in-charge of the shift, rather than to more senior management; where appropriate, senior management is specifically identified. Some information may be factual, but much of it will be a matter of sharing experience and ideas in order to help others make clinical decisions. Hence, for the most part, options, rather than answers, are provided, and the issues will serve their purpose if they help readers to clarify their own values. Starting to manage Much has been written about management, mostly from industrial perspectives, although there is a growing body of literature on health service management. Vaughan and Pilmoor (1989) suggest that management is getting the work done through people. The nurse-in-charge should establish constructive working conditions at the start of the shift, enabling the development of the individual strengths and skills of staff, while recognising individual needs and limitations. Managers should individually assess and proactively plan and respond to needs for each shift, rather than seeking to impose their own agendas on staff. You may remember most patients from your previous shift; if not, briefly assess patients before taking handover. You may need to walk through your unit to take handover, but if not a brief look at the unit can suggest both the number and dependency of patients (high-dependency patients usually have more equipment and people at a bedspace). Since managers rely on their staff to achieve the work, staff are the manager’s most important resource. Staff numbers are important—are there enough staff for patients already on the unit and the expected/potential admissions? Some staff need more support than others; each has different experience, knowledge and skills to draw on. Most staff will probably be known to you and so scanning the off-duty roster helps your planning; with new or unfamiliar (e. Allocation of staff may be guided by managerial structures such as named and team nursing; specific allocation should consider: ■ the need to maintain patient safety ■ the optimisation of patient treatment ■ the development and support of staff. The most experienced member of staff may be able to give the best care to the sickest patient, but without gaining experience of nursing very sick patients, junior staff will be denied opportunities to develop their skills. If they are continually denied developmental experience, they may become demotivated and leave, or be unable to care safely for the sicker patients when more experienced staff are not available. Safety during break cover should also be considered: two junior nurses may safely manage adjacent patients when both are present, but become unsafe if caring for two patients when covering each other’s breaks. The Health and Safety at Work Act (1974) places specific requirements on managers (and employees) to ensure workplaces are safe; the nurse-in-charge also has wider moral responsibilities for the health and safety of their staff and patients. Fire exits should remain clear and accessible at all times, and safety and emergency equipment should be Intensive care nursing 458 complete and in working order. Emergency equipment varies between units, but may include the resuscitation trolley, emergency intubation trolley and, on cardiothoracic units, thoracotomy pack. The nurse-in-charge is responsible for all patients on their unit, even if some responsibilities are devolved to team/area sub-managers. Following handover, the nurse- in-charge should visit each patient to make their own assessment, identify the needs of each bedside nurse, and pass on any relevant additional information/expectations. Sufficient time should be allowed for bedside nurses to take individual handovers, complete their own safety checks and make their own patient assessment; seeking information before bedside nurses can fully assimilate it can create stress for the nurse without providing the manager with full information. Looking through each patient’s notes gives bedside nurses time to complete their initial assessment and checks, while giving managers information that may have been missed in handover (relevant points should then be passed on to the bedside nurse). The nurse-in-charge should ensure that imminent shifts are adequately covered by checking staff numbers and initiating the booking of any additional staff required. Many agencies provide their main service during office hours, and so planning should include all shifts until the agency’s next ‘working’ period; on-call services may be able to provide emergency cover, but they often have few remaining staff to allocate. However, this can cause a conflict of roles between their responsibility to the unit as a whole (as manager) and individual responsibility to their patient; it also limits their availability to other members of staff. Instead, it may be reasonable to allocate two patients to one member of staff; the appropriateness or otherwise of assuming direct patient care necessarily remains an individual decision, based on resources available and remembering that the nurse-in- charge remains accountable for whatever decision is made. Managers need to maintain clinical skills and credibility; with career progression and increasing management duties, staff may need to identify shifts when they assume direct patient care without unit management responsibilities. Staff morale Managers are responsible for enabling others to achieve their work goals, and so need to motivate and communicate (Drucker 1974). Nursing demands a high level of cognitive, affective and psychomotor skills, and the ability of staff to realise their potential is affected by their morale. Maintaining staff and unit morale is therefore an important management skill; loyal staff are more likely to support managers during crises. It follows that managers need good interpersonal skills and respect for, as well as of, their staff. If aware of unsatisfactory practices, they should approach staff constructively, identifying why staff are acting that way (rationale, knowledge base), treating the incident as a developmental learning opportunity rather than a belittling and humiliating experience for the junior nurse (or possibly the manager); if patient safety is compromised, managers may need to act before any discussion. Delayed, compromised or missed breaks often cause dissatisfaction, so that ensuring the smooth (and safe) organisation of breaks for staff is an important duty of managers. Organising break relief varies between units and shifts; where units have a system that works and is familiar to staff, this should be followed. Managers may need to assume some direct patient responsibilities to cover breaks; this can also provide them with valuable opportunities to assess patients and the nurse’s skills and needs. However, possible conflicts with managerial duties (see above) should be considered, especially if providing relief in inaccessible areas (e. When situations are particularly stressful, managers may be able to support staff by offering additional ‘stress breaks’, making themselves (and other experienced staff) available when necessary, and by acknowledging the stress of the situation. Managers who are unable to offer ideal support to staff can still build team rapport and loyalty by acknowledging the stress of others. Opinions vary about staff consuming tea and coffee at bedsides; concerns usually include infection and professionalism. Ideally, staff should take breaks (at least every four hours) away from their workspace, but busy shifts (especially 12-hour shifts) may prevent this. If full breaks cannot be taken, providing refreshments at the bedside (this task could be delegated) may help staff to function safely, and also maintain morale. Anything brought into the bedspace may introduce infection, but, on the other hand, stressed nurses are more likely to work inefficiently, possibly skipping more important infection control measures (e. What is ‘unprofessional’ is a value judgement, but professional images may be less important than meeting the basic physiological needs of staff. Relatives, and patients who are able, may also be offered refreshments, and anecdotal experience suggests that they do not mind, or feel any less confidence in, nurses drinking at bedsides. Staff who are needing a break are likely to function inefficiently, give less empathy to others and be more difficult to motivate. This ideal is not always achieved, but if managers consider unit, patient or staff safety is compromised through inadequate staffing (or any other problem they are unable to resolve), they should inform senior managers, who have (higher) responsibility for the unit. During the shift The manager who has established mechanisms for staff to work effectively has achieved their most important role, but throughout the remainder of the shift managers should ensure that the unit continues to run smoothly, solving problems as they occur and providing a resource (knowledge, experience) for, and support to, more junior staff. Intensive care nursing 460 Staff need to have confidence in their manager; while managers usually have more experience and knowledge than their staff, each member of staff has potential to contribute knowledge, experience or values, and managers should be prepared to learn from, as well as guide and teach, their staff. Staff also need to feel that they can approach their manager, so that managers should show positive attitudes and remain accessible (this includes spending most of their time in the main patient-care area). If the medical review of patients does not involve bedside nurses, managers often become the links between medical and nursing staff. Similarly, information to and from other hospital departments, or telephone messages from family members, are often ciphered through the nurse-in-charge. This decision includes imminent shifts dependency of patients already on the unit skills of staff available The manager is professionally accountable for decisions about nursing management on the unit, but if faced with coercion or moral blackmail may need considerable skills in assertiveness. Good managers may inspire loyalty in their staff, but being in charge can isolate managers from other support mechanisms. Managers also need their breaks: a stressed manager is less likely to be able to support their staff. Time put 2 Using the cues below, jot down plans for your professional development over the next six months. Be realistic, setting out sufficient aims to help you develop, but not too many to achieve (six aims is often a reasonable target, but the number and scope will vary between individuals). You may wish to share all or part of this with your manager/mentor/colleagues, or retain this as a private document in your professional profile. You may wish to divide aims between short term (a few weeks), medium term (up to six months) and long term (after six months), or cover all aims together. Long-terms aims will not be achieved fully by the time of your six-month review, but you may have partially progressed towards them. Over the next six months I would like to achieve (include target times): I would like to achieve these because: To achieve these I will need (include people and resources): I will know I have achieved these aims because (i. Much has been written elsewhere on wider management issues and theory; nurses developing management careers may need to develop this knowledge further, but should first gain practical management skills through structured experiential programme. The nurse-in-charge is morally and professionally responsible and accountable for their managerial decisions.

Inevitably cheap 50 mg fildena amex erectile dysfunction boyfriend, investigators usually have clear understanding this means that the sponsor’s representative has to and strategy for the above activities buy fildena online from canada purchase erectile dysfunction drugs. Examples of conduct study initiation activities at the institution the questions that require answering during pre- with some key staff buy fildena 25 mg visa erectile dysfunction causes high blood pressure. Some objective measure of the availability of the correct patient population is important during a Conducting study initiation pre-study visit order fildena 100mg without a prescription erectile dysfunction leakage. The sponsor’s representative can often best accomplish this through a chart or hos- The study initiation visit is sometimes confused pital census review. The purpose of the study initiation visit is to orient the study staff (sub- investigators, study coordinators, etc. At the point of the How will the protocol specifically operate at the study initiation visit, the study site should be fully prospective center? All study staff who will have direct involvement How many studies is the investigator conducting in the trial should participate in the study initiation currently? In addition, a monitor needs to have excel- presentation, participants may raise important lent interpersonal communication and problem- medical or logistical issues that have or have not solving skills. It is Clinical monitoring requires clinical, interpretive important to note these concerns and communicate and administrative skills. Quality monitoring will always include tent in the basic medical and scientific issues of and confirm the following activities: the investigational product and protocol, know the target disease or symptoms, be able to train the properly obtained informed consent; investigative staff on the conduct of the study, confirm facility capabilities, conduct the site initia- adherence to the protocol procedures and inclu- tion meeting, describe adverse event reporting sion/exclusion criteria; requirements and be able to resolve protocol issues during and after meeting. Monitoring permits an supplies; in-process assessment of the quality of the data being collected. The frequency of clinical monitoring depends on Monitoring clinical studies involves the act of the actual accrual rate of the subjects. Monitors studies may need to be visited more frequently ensure that the study is conducted, recorded and depending on the accrual rate of subjects, the 3. The monitors should anticipate suffi- Local language Route of administration cient time for good monitoring practices. Name of investigator Dosage Following a monitoring visit, the monitor will Study number Dosage form prepare a monitoring report for sponsor records Bottle number Quantity or volume and follow up correspondence to the trial site. Lot number Storage precautions The monitor may need to plan intervention and Drug name or code Directions for use possible replacement of nonperforming or non- Manufacturer name Note: ‘For Clinical Trial’ compliant trial centers. Manufacturer address Caution statement Local affiliate name Expiry date Managing drug accountability identical within multicenter trials. Regulatory The sponsor is responsible for providing the investi- documents required for investigational drug use gator with investigational product. Both the sponsor in the core countries must be anticipated and and investigator have a role in drug accountability. Once the study is underway, the investigator’s The monitor reconciles investigational product staff must account for the use of the investigational shipped, dispensed and returned, arranges for ship- drug. Subjects should return unused medication ment of investigational product to core country or and empty containers to the investigator. The investigative sites, checks investigational product amount of drug dispensed and the amount used supplies at site against enrollment and withdra- by the patients are compared for discrepancies. Monitors must also check that inventory problems, implements tracking system drug supplies are being kept under the required for investigational product management on a study storage conditions. Failure to do so can result product supplies and ensures final reconciliation in some of the data having to be discarded during of investigational product supplies. This issue can prove to be Good clinical practices require sponsors to be problematic when a single site is studying patients able to account for the drug supplies prepared and at different locations. Finally, the double-blind shipped to the investigator, the investigator’s use of code must not be broken except when essential those supplies and the return and destruction of for the management of adverse events. Planning drug supplies ing of treatment codes can make that patient’s data is a detailed and complex activity. Safety concerns are present throughout the drug Drug packaging should follow as consistent a development process. To be successful, monitors need to be com- Management of safety is a principal responsi- petent in bility of the sponsor monitor. The monitor has responsibility for informing the investigator basic medicine and therapeutics; about the safety requirements of the study. This will include a discussion of expected and unex- recognizing clinical signs and symptoms; pected adverse events, how to report adverse events should they occur and how to characterize interpretation of laboratory findings; the adverse events in terms of project-specific definitions. In source documents, safety issues The sponsor needs to provide ongoing review of may be uncovered in the progress notes of hospital safety data for investigational products. Monitors must be alert to exaggerated changes from baseline with expected pharmacolo- Closing down a study is important because it may gical effects, acute and chronic effects and multiple represent the sponsor’s last best chance to obtain drug treatment reactions. The study closedown Monitors are often the first company representa- (closeout) visit usually occurs after the last subject tives to learn about an adverse event. The timeliness has completed the trial including any posttreatment of reporting the event to sponsor safety group is follow-up visits. Drug supplies should be recon- important in satisfying regulatory reporting require- ciled, and the integrity of the double-blind treat- ments. Failure to adhere to the reporting timelines clinical study report is available, it should be given required for regulatory authorities is evidence of to the investigator for signature. The sponsor trials, a single lead investigator may sign a pooled monitor is responsible for assuring adherence to study report. The cases must be While the goal of monitoring is to provide ‘clean’ followed to completion. Computerized checking programs including the intent-to-treat analysis population and edit checks make the process more value- and the safety data listings. Each module satisfies a specific drafting of assigned study report sections documentation need. The modules are generally according to the clinical study report prototype; organized as follows: interpretation of adverse events; Module I: Includes a basic summary of the study not unlike a publication. The clin- not just a summary but also a critical assessment of ical representative should be able to interpret clin- the clinical evaluation of the drug. The ability to report provides an independent assessment of the understand computer-generated clinical output and risk-to-benefit ratio of the drug and its use. Quite apart from established in-house training Most vendors advertise widely in the trade programs, there is a wide selection of vendors journals, and many of their courses are tailored offering competency-based training. The format to meet the several certifications that are now of their programs may include: available in clinical research or regulatory affairs. A better almost every new chemical entity deviates from question, given the huge attrition rates in drug these general principles because special studies are development, might be: What governs whether a needed in pursuit of product-specific issues that are chemical becomes a medicine? Neither book covers all those disciplines and processes that can such custom-designed studies be generalized are needed for this putative transmogrification. This can also be called the ‘pre-marketing’ Regulatory affairs are so fundamental to precli- phase of the drug life cycle. It should be noted nical and clinical development that it deserves a that although all this is necessary, it is certainly section of this book to itself. Two major active relationship between regulation and the limitations then automatically arise. This is inten- smaller limitation is well illustrated by the disci- tional and again reinforces how an integrated pline of toxicology. In this case, the general prin- approach must be taken in drug development for ciples are fairly easily to enunciate, and have been there to be any chance at all of eventual success. In ancient directed at an identified pathological process, and/or times, and even today, tribal people knew the heal- specific receptors controlling these pathologies. The knowledge was accumu- safer, and are likely to have fewer adverse events lated through generations, recorded by chant and (side effects)ina largerpatient populationthanthose living memory and was derived largely from with multiple pharmacological properties. Although many of the drugs Research and development leading to a new, in use today were discovered by chance, most well-targeted pharmaceutical product is a long, drug discovery scientists engage in directed complex and expensive process. Historically, the research, based on a series of steps, each requiring cost of a new drug has been escalating by close to substantial scientific input. Average development some obvious, generally applicable milestones in time is 7–10 years, although some ‘blockbuster’ this process that facilitate the discovery of thera- drugs have taken 20 years. Targeted medicines and their Hence, the drug discovery and development implications process is a two-part exercise in mitigating the economic punishment to product sponsors while The understanding and use of medicines by physi- maximizing the probability that something that can ciansandhealershaveevolvedsignificantly,keeping be developed successfully is actually found. As few in step with technological and biological break- as 1% of promising lead molecules will be tested in throughs. From the use of herbal remedies to toxic human beings; fewer than one-third of those tested Principles and Practice of Pharmaceutical Medicine, 2nd Edition Edited by L. Some think that only about a half will produce financial returns that modern biology as well as other fields have only are disproportionately higher than their costs of increased the numbers of ‘hits’ overall, whereas development. Larger companies will rarely fund inter- nal research for drug discovery of orphan drug All drug discovery projects depend on luck to be products (or products targeting diseases with few successful, but research and careful planning can patients). On the other hand, small market niche improve chances of success and lower the cost. These tools are drawn from the repertoires tified, and a particular therapeutic area chosen, the of modern biology, chemistry, robotics and com- biological research begins. In comparison with older pro- stage of drug discovery that anecdotal clinical cesses of in vivo screening of huge numbers of observations, empirical outcomes and ‘data’ from molecules, however, these innovations have not folk medicine are often employed, if only as beenassociatedwithshorteningof thedevelopment direction-finding tools. Human disease or pathology is usually multifac- Molecular targets are not always obvious, even torial, and the first task of the researcher is to though cellular and histological disease patholo- narrow down the search by defining the molecular gies have been well described in the literature. At mechanisms better; optimally this will be a small this point, the researcher returns to the labora- number of pathophysiologically observable pro- tory bench to design critical experiments (see cesses, for example the pinpointing of one or two Figure 4. Taking cancer as an exam- difference is significant and can be reproducibly ple, malignant cells often contain over-expressed, observed in the laboratory, it can be exploited for mutated or absent ‘oncogenes’ (i. In other diseases, the cell which is code for particular proteins or receptors in normal identified can be normal but activated to a destruc- cells, but are mutated, and thus cause pathological tive state by stimulation with disease pathogens.

In four-dimensional universe” (cited in McEvoy cheap fildena american express impotence causes and cures, 1990 order fildena without a prescription impotence for males, yet another panel discussion in 1991 order 100mg fildena mastercard erectile dysfunction treatment medicine, Rogers ex- p purchase 100mg fildena with visa impotence and prostate cancer. Death itself is a transition, not an end, a plained that greater diversity necessitates “services manifestation of increasing diversity as energy that are far more individualized than we have ever fields transform. Rogers’ third theory, Rhythmical Correlates of Rogers consistently identified the need for indi- Change, was changed to “Manifestations of Field vidualized, community-based health services in- Patterning in Unitary Human Beings,” discussed corporating noninvasive modalities. Here Rogers suggested that evolution is an examples from those currently in use, such as ther- irreducible, nonlinear process characterized by in- apeutic touch, meditation, imagery, humor, and creasing diversity of field patterning. She offered laughter, while stating her belief that new ones will some manifestations of this relative diversity, in- emerge out of the evolution toward spacekind cluding the rhythms of motion, time experience, (Rogers, 1994b). The principles of homeodynamics and sleeping-waking, encouraging others to suggest provide a way to understand the process of human- further examples. The next part of this chapter cov- environmental change, paving the way for Rogerian ers Rogerian science-based practice and research in theory-based practice. Rogers maintained that both qualitative Nurses must use “nursing knowledge in and quantitative research methods were non-invasive ways in a direct effort to appropriate for Rogerian science–based promote well-being. She said that nurses must use “nursing knowledge in non-invasive ways in a direct effort to promote well-being” (Rogers, 1994a, p. This focus gives Rogerian science–based research, with the nature of nurses a central role in health care rather than the question and the phenomena under investiga- medical care. Rogers urged Pattern manifestations have provided a com- nurses to develop autonomous, community-based mon research focus, highlighting the need for tools nursing centers. Some comments on the theoretical basis to measure awareness of the infinite wholeness of of nursing practice. For public safety: Higher education’s re- Pattern Scale explores diverse pattern changes and sponsibility for professional education in nursing. New York: oped the Person-Environment Participation Scale American Nurses’ Association. Regional planning for graduate education Currently, researchers are using Rogerian tools in nursing. Proceedings of the National Committee of Deans of Schools of Nursing having accredited graduate programs in such as those described, developing new Rogerian nursing. Yesterday a nurse—today a manager— daily as nurses apply the knowledge gained through what now? Nurses’ expanding role and other eu- been eagerly taken up by a community of commit- phemisms. The family coping with a surgical crisis: Analysis and application of Rogers’ theory of nursing. Notes on nursing: science postulates a pandimensional universe of What it is, and what it is not (Commemorative edition, pp. The science of unitary human beings: tive, increasingly diverse, creative, and unpre- Current perspectives. The human and environ- that practice and research methods must be consis- mental fields are inseparable, so one cannot “come tent with the Science of Unitary Human Beings in between. Therefore, inconsistent with Rogers’ principle of helicy: that Rogerian practice and research methods must be expected outcomes infer predictability. The princi- congruent with Rogers’ postulates and principles if ple of helicy describes the nature of change as being they are to be consistent with Rogerian science. Within an energy-field perspective, nurses in mutual process assist clients in actual- izing their field potentials by enhancing their Practice ability to participate knowingly in change (Butcher, 1997). The goal of nursing practice is the promotion of Given the inconsistency of the traditional nurs- well-being and human betterment. Nursing is a ing process with Rogers’ postulates and principles, service to people wherever they may reside. Since the 1960s, the nursing process practice methods have been derived from Rogers’ has been the dominant nursing practice method. The nursing process is an appropriate practice methodology for many nursing theories. But currently the most widely used Rogerian practice in later years she asserted that nursing diagnoses model. Barrett’s (1988) practice model was derived were not consistent with her scientific system. Barrett [N]ursing diagnosis is a static term that is quite inap- (1998) expanded and updated the methodology by propriate for a dynamic system... Pattern manifestation knowing is Furthermore, nursing diagnoses are particular- the continuous process of apprehending the istic and reductionistic labels describing cause and human and environmental field (Barrett, 1998). The nursing ian position of the nurse, whereas “knowing” process is a stepwise sequential process inconsistent means to recognize the nature, achieve an under- with a nonlinear or pandimensional view of reality. Intervention means tinuous process whereby the nurse assists clients in to “come, appear, or lie between two things” freely choosing—with awareness—ways to partici- (American Heritage Dictionary, 2000, p. The nurse does not gathered from and about the client, family, or com- invest in changing the client in a particular direc- munity—including sensory information, feelings, tion, but rather facilitates and mutually explores thoughts, values, introspective insights, intuitive with the client options and choices and provides in- apprehensions, lab values, and physiological meas- formation and resources so the client can make in- ures—are viewed as “energetic manifestations” formed decisions regarding his or her health and emerging from the human/environmental mutual well-being. Fifth, all pattern infor- not consistent with Rogers’ postulate of pandimen- mation has meaning only when conceptualized and sionality and principles of integrality and helicy. Synopsis and Rather, acausality allows for freedom of choice and synthesis are requisites to unitary knowing. The goal of Synopsis is a process of deliberately viewing to- voluntary mutual patterning is the actualization of gether all aspects of a human experience (Cowling, potentialities for well-being through knowing par- 1997). The constituents for the development of Rogerian prac- human and environmental fields are inseparable. Cowling (1993b, 1997) refined the Thus, any information from the client is also a re- template and proposed that “pattern appreciation” flection of his or her environment. Physiological was a method for unitary knowing in both and other reductionistic measures have new mean- Rogerian nursing research and practice. For preferred the term “appreciation” rather than “as- example, a blood pressure measurement inter- sessment” or “appraisal” because appraisal is associ- preted within a unitary context means the blood ated with evaluation. Appreciation has broader pressure is a manifestation of pattern emerging meaning, which includes “being full aware or sensi- from the entire human/environmental field mutual tive to or realizing; being thankful or grateful for; process rather than being simply a physiological and enjoying or understanding critically or emo- measure. Pattern apprecia- unitary and not particular by reflecting the unitary tion has a potential for deeper understanding. The first constituent for unitary pattern appreci- The sixth constituent in Cowling’s practice ation identifies the human energy field emerging method describes the format for documenting and from the human/environment mutual process as presenting pattern information. Pattern manifestations emerging nursing diagnoses and reporting “assessment data” from the human/environment mutual process are in a format that is particularistic and reductionistic the focus of nursing care. Next, the person’s experi- by dividing the data into categories or parts, the ences, perceptions, and expressions are unitary nurse constructs a “pattern profile. Third, “pattern appreciation rizing the client’s experiences, perceptions, and requires an inclusive perspective of what counts as expression inferred from the pattern appreciation pattern information (energetic manifestations)” process. Cowling (1990, 1993b) also identified additional forms of pattern profiles, in- Pattern manifestation knowing and appreciation cluding single words or phrases and listing pattern is the process of identifying manifestations of information, diagrams, pictures, photographs, or patterning emerging from the human/environmen- metaphors that are meaningful in conveying the tal field mutual process and involves focusing on themes and essence of the pattern information. Verifying manifestations (Barrett, 1988), whereas “apprecia- can occur by sharing the pattern profile with the tion” seeks for a perception of the “full force of pat- client for revision and confirmation. Sharing the pattern profile with the client en- enced, perceived, and expressed is a manifestation hances participation in the planning of care and facilitates the client’s knowing participation in the Pattern is the distinguishing feature of change process (Cowling, 1997). Everything The eighth constituent identifies knowing par- experienced, perceived, and expressed is a ticipation in change as the foundation for health manifestation of patterning. Knowing participation in change is being aware of what one is choosing to do, feeling free to do it, doing it intentionally, and being ac- of patterning. The purpose festation knowing and appreciation, the nurse and of health patterning is to assist clients in knowing client are coequal participants. Ninth, pat- tice, nursing situations are approached and guided tern appreciation incorporates the concepts and by a set of Rogerian-ethical values, a scientific base principles of unitary science, and approaches for for practice, and a commitment to enhance the health patterning are determined by the client. The unitary mism, humor, unity, transformation, and celebra- pattern-based practice method consists of two non- tion intentional in the human/environmental field linear and simultaneous processes: pattern manifes- mutual process (Butcher, 1999b, 2000). The focus of nursing care ing an atmosphere of openness and freedom so guided by Rogers’ nursing science is on recognizing clients can freely participate in the process of manifestations of patterning through pattern mani- knowing participation in change. Compassion includes energetic acts ment/health situation is relevant, various health as- of unconditional love and means (a) recognizing sessment tools, such as the comprehensive holistic the interconnectedness of the nurse and client by assessment tool developed by Dossey, Guzzetta, and being able to fully understand and know the suffer- Keegan (2000), may also be useful in pattern know- ing of another, (b) creating actions designed to ing and appreciation. However, all information transform injustices, and (c) not only grieving in must be interpreted within a unitary context. A another’s sorrow and pain, but also rejoicing in an- unitary context refers to conceptualizing all infor- other’s joy (Butcher, 2002b). All information is in- terconnected, is inseparable from environmental context, unfolds rhythmically and acausally, and re- Pattern manifestation knowing and appre- flects the whole. Data are not divided or under- ciation involves focusing on the experi- stood by dividing information into physical, ences, perceptions, and expressions of a psychological, social, spiritual, or cultural cate- health situation, revealed through a rhyth- gories. From a unitary perspec- perceptions, and expressions of a health situation, tive, what may be labeled as abnormal processes, revealed through a rhythmic flow of communion nursing diagnoses, illness or disease are conceptual- and dialogue. In most situations, the nurse can ini- ized as episodes of discordant rhythms or nonhar- tially ask the client to describe his or her health sit- monic resonancy (Bultemeier, 2002). The dialogue is guided toward A unitary perspective in nursing practice leads focusing on uncovering the client’s experiences, to an appreciation of new kinds of information that perceptions, and expressions related to the health may not be considered within other conceptual ap- situation as a means to reaching a deeper under- proaches to nursing practice. Humans are con- using multiple forms of knowing, including pandi- stantly all-at-once experiencing, perceiving, and mensional modes of awareness (intuition, medita- expressing (Cowling, 1993a). Experience involves tive insights, tacit knowing) throughout the pattern the rawness of living through sensing and being manifestation knowing and appreciation process. Pattern information tion of his or her health situation includes his or concerning time perception, sense of rhythm or her experiences. Perception is making and sense of integrity are relevant indicators of sense of the experience through awareness, appre- human/environment/health potentialities (Madrid hension, observation, and interpreting. A person’s hopes and clients about their concerns, fears, and observations dreams, communication patterns, sleep-rest is a way of apprehending their perceptions. In ipation in change provide important information addition, expressions are any form of information regarding each client’s thoughts and feelings con- that comes forward in the encounter with the cerning a health situation.

Help client understand that this was an event to which most people Anxiety Disorders ● 167 would have responded in like manner cheap 25 mg fildena otc erectile dysfunction pills free trials. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues buy discount fildena 100 mg erectile dysfunction medication injection. Teach signs and symptoms of escalating anxiety best 100mg fildena erectile dysfunction doctors in baltimore, and ways to interrupt its progression (e purchase on line fildena erectile dysfunction hand pump. Client is able to maintain anxiety at level in which problem solving can be accomplished. Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level. Possible Etiologies (“related to”) Phobic stimulus [Being in place or situation from which escape might be difficult] [Causing embarrassment to self in front of others] Defining Characteristics (“evidenced by”) [Refuses to leave own home alone] [Refuses to eat in public] [Refuses to speak or perform in public] [Refuses to expose self to (specify phobic object or situation)] Identifies object of fear [Symptoms of apprehension or sympathetic stimulation in presence of phobic object or situation] Goals/Objectives Short-term Goal Client will discuss phobic object or situation with nurse or therapist within 5 days. Long-term Goal Client will be able to function in presence of phobic object or situation without experiencing panic anxiety by time of dis- charge from treatment. Explore client’s perception of threat to physical integrity or threat to self-concept. It is important to understand the client’s perception of the phobic object or situation in order to assist with the desensitization process. Discuss reality of the situation with client in order to rec- ognize aspects that can be changed and those that cannot. Client must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can progress. Include client in making decisions related to selection of alternative coping strategies. If the client elects to work on elimination of the fear, tech- niques of desensitization may be employed. This is a sys- tematic plan of behavior modification, designed to expose the individual gradually to the situation or object (either in reality or through fantasizing) until the fear is no longer experienced. This is also sometimes accomplished through implosion therapy, in which the individual is “flooded” with stimuli related to the phobic situation or object (rather than in gradual steps) until anxiety is no longer experienced in relation to the object or situation. Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under non- threatening conditions. Encourage client to explore underlying feelings that may be contributing to irrational fears. Help client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues. Client does not experience disabling fear when exposed to phobic object or situation, or 2. Client verbalizes ways in which he or she will be able to avoid the phobic object or situation with minimal change in lifestyle. Client is able to demonstrate adaptive coping techniques that may be used to maintain anxiety at a tolerable level. Possible Etiologies (“related to”) [Underdeveloped ego; punitive superego] [Fear of failure] Situational crises Maturational crises [Personal vulnerability] [Inadequate support systems] [Unmet dependency needs] Defining Characteristics (“evidenced by”) [Ritualistic behavior] [Obsessive thoughts] Inability to meet basic needs Inability to meet role expectations Inadequate problem solving [Alteration in societal participation] Goals/Objectives Short-term Goal Within 1 week, client will decrease participation in ritualistic behavior by half. Long-term Goal By time of discharge from treatment, client will demonstrate abil- ity to cope effectively without resorting to obsessive-compulsive behaviors or increased dependency. Try to determine the types of situations that increase anxiety and result in ritualistic behav- iors. Recognition of precipitating factors is the first step in teaching the client to interrupt the escalating anxiety. Encour- age independence and give positive reinforcement for inde- pendent behaviors. Sudden and complete elimination of all avenues for dependency would create intense anxiety on the part of the client. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. Client may be unaware of the relationship between emotional problems and compulsive behaviors. Provide structured schedule of activities for the client, includ- ing adequate time for completion of rituals. Gradually begin to limit the amount of time allotted for ritualistic behavior as client becomes more involved in unit activities. Anxiety is minimized when client is able to replace ritualistic behaviors with more adaptive ones. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. Encourage recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Client is able to verbalize signs and symptoms of increasing anxiety and intervene to maintain anxiety at manageable level. Client demonstrates ability to interrupt obsessive thoughts and refrain from ritualistic behaviors in response to stressful situations. Possible Etiologies (“related to”) Lifestyle of helplessness [Fear of disapproval from others] [Unmet dependency needs] [Lack of positive feedback] [Consistent negative feedback] Defining Characteristics (“evidenced by”) Verbal expressions of having no control (e. Long-term Goal Client will be able to effectively problem-solve ways to take con- trol of his or her life situation by discharge, thereby decreasing feelings of powerlessness. Allow client to take as much responsibility as possible for own self-care practices. Respect client’s right to make those decisions independently, and refrain from attempting to influence him or her toward those that may seem more logical. Unrealistic goals set the client up for failure and reinforce feelings of powerlessness. Client’s emotional condition interferes with his or her ability to solve problems. Assistance is required to perceive the benefits and consequences of available alternatives accurately. Help client identify areas of life situation that are not with- in his or her ability to control. Encourage verbalization of feelings related to this inability in an effort to deal with unresolved issues and accept what cannot be changed. Encourage par- ticipation in these activities, and provide positive reinforce- ment for participation, as well as for achievement. Client verbalizes choices made in a plan to maintain control over his or her life situation. Client verbalizes honest feelings about life situations over which he or she has no control. Client is able to verbalize system for problem-solving as required for adequate role performance. Possible Etiologies (“related to”) [Panic level of anxiety] [Past experiences of difficulty in interactions with others] [Need to engage in ritualistic behavior in order to keep anxiety under control] [Repressed fears] Defining Characteristics (“evidenced by”) [Stays alone in room] Uncommunicative Withdrawn No eye contact Developmentally [or culturally] inappropriate behaviors Preoccupation with own thoughts; repetitive, meaningless actions Expression of feelings of rejection or of aloneness imposed by others Experiences feelings of differences from others Insecurity in public Goals/Objectives Short-term Goal Client will willingly attend therapy activities accompanied by trusted support person within 1 week. Long-term Goal Client will voluntarily spend time with other clients and staff members in group activities by time of discharge from treatment. Be with the client to offer support during group activities that may be frightening or difficult for him or her. The pres- ence of a trusted individual provides emotional security for the client. Short-term use of antianxiety medications, such as diaze- pam, chlordiazepoxide, or alprazolam, helps to reduce level of anxiety in most individuals, thereby facilitating interactions with others. Discuss with client the signs of increasing anxiety and techniques for interrupting the response (e. Maladaptive behaviors, such as withdrawal and sus- piciousness, are manifested during times of increased anxiety. Give recognition and positive reinforcement for client’s volun- tary interactions with others. Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors. When anxiety is high, client may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions. Client may be unable to tolerate large amounts of food at mealtimes and may therefore require additional nourishment at other times during the day to receive adequate nutrition. Assist client to bathroom on hourly or bihourly schedule, as need is determined, until he or she is able to fulfill this need without assistance. Client maintains optimal level of personal hygiene by bathing daily and carrying out essential toileting procedures without assistance. They are classified as mental disorders because patho- physiological processes are not demonstrable or understandable by existing laboratory procedures, and there is either evidence or strong presumption that psychological factors are the major cause of the symptoms. It is now well documented that a large proportion of clients in general medical outpatient clinics and private medical offices do not have organic disease requiring medical treatment. It is likely that many of these clients have somatoform disorders, but they do not perceive themselves as having a psychiatric problem and thus do not seek treat- ment from psychiatrists. Symptoms can represent virtu- ally any organ system but commonly are expressed as neuro- logical, gastrointestinal, psychosexual, or cardiopulmonary dis- orders. Onset of the disorder is usually in adolescence or early adulthood and is more common in women than in men.

Nurses are recommended to hold their own breath during each pass: when they need oxygen discount fildena online master card erectile dysfunction remedy, so will their patient purchase fildena overnight delivery best erectile dysfunction pills side effects. Hypoxia from bronchoconstriction (sympathetic stress response) usually follows endotracheal suction safe 25mg fildena erectile dysfunction protocol free. Although Wood’s review (1998) found no proven benefit to routine preoxygenation order fildena with american express erectile dysfunction injections australia, evidence is sparse, and failure to preoxygenate is probably more dangerous than routine preoxygenation. Many ventilators include time-limited control for delivery of 100 per cent oxygen; using these prevents inadvertent delivery of toxic levels continuing after stabilisation. If FiO2 is increased manually, it should be returned to baseline levels once PaO2 is restored. Catheters Removing oral secretions is easiest and safest with Yankauer catheters; angling the head to enable drainage of secretions into the cheek avoids trauma to the delicate soft palate. Endotracheal (soft) catheters should remove the maximum amount of secretions in the quickest possible time with minimal trauma. The practice of reusing disposable catheters for more than one pass seems to be based on anecdotal evidence that infection risks are not increased. Without substantive evidence, nurses reusing catheters should consider their professional accountability, and the legal liabilities of reusing equipment labelled by manufacturers as single-use (de Jong 1996). Using clean (rather than sterile) gloves for suction similarly appears based on anecdotal claims that infection rates are not significantly increased. Gloves of any sort protect (universal precautions) nurses, and clean gloves are both quicker to put on and cheaper; with gloved hands not touching catheter tips, infection risks appear small, but any substantive evidence to support this is lacking (Odell et al. Ventilation continues during catheter insertion and so catheters should be advanced more carefully to reduce trauma (passes should not be slowed so much that patient discomfort is increased). Concerns that they create reservoirs for microbial colonisation appear to be unfounded (Adams et al. Nurses’ concerns that closed circuit catheters may be more difficult to manipulate (Graziano et al. Closed circuit systems can be cost effective if they replace sufficient numbers of disposable items. Most manufacturers recommend replacement after 24 hours; Quirke (1998) found 48-hour changes safe and suggests that further research may support weekly changes; however, staff should remember their legal liability if flouting manufacturer’s recommendations. Widespread practice of saline instillation to loosen secretions has little support beyond anecdotal literature. Mucus is not water soluble and so will not easily mix with saline; encrustations on dentures can be difficult to remove after soaking overnight, and a few seconds contact with saline seems unlikely to significantly loosen airway encrustations. Ackerman (1993) found saline instillation reduced PaO2, possibly from bronchospasm or creating a fluid barrier to gas perfusion. However Ackerman’s methodology alternated use and non-use of saline in the same patients, ignoring possible late complications of consolidation through inadequate removal of mucus. Temperature differentials between cold fluids and airways may trigger bronchospasm so that warming fluids (from hand heat) may reduce complications (Gunderson & Stoeckle 1995). There may be individual cases where saline is indicated, but what those indications currently are remains unclear. Substantial research evidence is needed before saline instillation can be recommended. Nebulisation produces smaller droplets which should reach distal bronchioles, but Asmundsson et al. Hyperinflation Hyperinflation (‘bagging’, to loosen secretions) can be achieved with manual (‘rebreathe’) bags or through most modern ventilators (e. Muscle recoil following hyperinflation mimics the cough reflex and so loosens secretions. It also potentially ■ removal raises intrathoracic pressure ■ removal reduces cardiac return ■ causes (mechanical) vagal stimulation (resulting in bradycardia) ■ causes barotrauma. Manual rebreathe bags are available in various sizes; adult systems should include ■ pressure escape valves ■ oxygen reservoirs if patients normally receive high concentration oxygen ■ 2-litre bags (ideal hyperinflation volume is 1. Relative merits of manual and mechanical hyperinflation remain debated (Robson 1998), but ventilator-controlled hyperinflation leaves nurses’ hands free while ensuring hyperinflation volume is both controlled and measured (limiting barotrauma). Children’s tracheas are smaller and so where 1 mm of oedema might cause slight hoarseness in adults, it would obstruct three-quarters of a child’s airway (Marley 1998). Despite the frequency and long history of mechanical ventilation, many dilemmas of nursing management remain unresolved, influenced more by tradition or small-scale (often inhouse) studies than substantial research and meta- analysis. No aspect of airway management should be considered routine; as with all other aspects of care, frequent assessment enables the individualisation of care in order to meet the patient’s needs. Overviews are usually best obtained from books, but many articles usefully pursue aspects in detail. Wood (1998) provides an extensive literature review on dilemmas of endotracheal suction. Reviewing literature for developing departmental guidelines, McKelvie (1998) gives a reliable overview. Identify those effects that you have observed in your own clinical practice and those from the literature. Lighter sedation ■ enables patients to remain semiconscious, thus reducing psychoses while promoting autonomy ■ reduces hypotensive and cardioinhibitory effects caused by most sedatives Light sedation is a narrow margin between over- and under-sedation. The focus is therefore a nursing one rather than pharmacological, although some widely used sedatives are described. Neuromuscular blockade, once a common adjunct of sedation therapy, is also mentioned. Shelly (1998) stresses that comfort (in its widest sense) can be achieved through sedation. Sedation is now usually only necessary for ventilation if patients have: ■ tachypnoea, which will cause exhaustion ■ discomfort from artificial ventilation (usually from oral endotracheal tubes; also for brief procedures such as cardioversion and bronchoscopy). There are some specific pathologies, such as intracranial hypertension, where sedation is therapeutic. Some authors suggest that potential line displacement justifies sedation (Shelly 1994). Amnesia prevents recall of often horrific procedures, but inability to recall experiences, however horrific, may cause greater psychological trauma (Perrins et al. Prolonged benzodiazepine use causes receptor growth and down-regulation (tolerance), necessitating higher doses (Eddleston et al. Endorphins (endogenous opiates) contribute to sedative effects of critical illness. Midazolam is largely hepatically metabolised and renally excreted, so failure of these organs may cause accumulation of active metabolites (especially with older people, who usually have reduced renal clearance); causing unpredictable increases in half-life with critical illness (Bion & Oh 1997). Being relatively cheap, midazolam is still used by many units for prolonged sedation. Flumazenil’s effect is far shorter than benzodiazepines (half-life under one hour (Armstrong et al. Opiates Most opiates have sedative effects; as analgesia is usually necessary, this ‘side effect’ can be beneficial, provided it is remembered when assessing sedation. Opiates may become Sedation 51 the most important part of sedative regimes (Bion & Oh 1997). Morphine remains one of the most powerful opiates, but newer drugs, such as fentanyl, achieve rapid sedation with strong respiratory depression (which facilitates ventilation). Propofol Propofol’s lipid emulsion facilitates transfer across the blood-brain barrier, achieving rapid sedation. Inactivity of metabolites (Sherry 1997) and rapid redistribution into fatty tissue (Eddleston et al. Widely used for short- term sedation, Propofol is relatively expensive and so some units restrict use to circumstances where sedation is planned to last less than one day. Propofol depresses cerebral metabolism, thus reducing both cerebral oxygen consumption and intracranial pressure (Viney 1996). A number of disadvantages have been reported with propofol: ■ bradycardia from resetting of carotid receptors (Sherry 1997) ■ hypotension from resetting of baroreceptors, sympathetic inhibition and increased venous capacitance (Robinson et al. Use of any drug or equipment beyond a manufacturer’s licence places the onus of legal liability on the users (see Chapter 45). Since propofol does not have any analgesic effect, concurrent analgesia should be given. Intensive care nursing 52 Bolus sedation The introduction of shorter-acting sedatives together with the improvement of infusion pump technology has largely replaced the use of bolus sedation with continuous infusions. Like analgesia, bolus sedation can cause fluctuations between under- and over- sedation (Shelly 1998). Where sedative effects are prolonged, constant infusion can result in over-sedation (Shelly 1998). The lighter levels of sedation now preferred create relatively narrow margins between over-sedation and under-sedation. Over-sedation is arguably inhumane, depriving patients of life awareness, but it also causes respiratory and cardiovascular depression (compromising tissue perfusion) and so it potentially prolongs recovery. Drugs also increase the costs of patient care, placing further burdens on (usually) stretched unit budgets. Thus unnecessary drugs are psychologically, physiologically and financially undesirable. Increased protein (muscle) breakdown from stress-induced hypermetabolism (see Chapter 3) prolongs ventilatory weaning and (eventual) ambulation, thus increasing the risk of later complications such as pneumonia and thromboses. However, sedation is difficult to measure, both because the needs of patients vary (Shelly 1998) and because of the discrepancies between different assessors (Westcott 1995).