Mark Corson

By B. Yasmin. Mercy College.

A classic sign of hypothyroidism is the delayed relaxation phase of the ankle jerk purchase lady era 100 mg on line quiz menstrual cycle. Other neuro- logical syndromes which may occur in association with hypothyroidism include carpal tunnel syndrome 100mg lady era with amex gender bias and women's health issues, a cerebellar sydrome or polyneuritis buy lady era 100mg lowest price women's health clinic kilkenny. Patients may present with psychi- atric illnesses including psychoses (‘myxoedema madness’). Clues to the diagnosis in the investigations are the normochromic, normocytic anaemia, marginally raised creatinine, and hypercholesterolaemia. The anaemia of hypothyroidism is typically normochromic, normocytic or macrocytic; microcytic anaemia may occur if there is menorrhagia. Renal blood flow is reduced in hypothyroidism, and this can cause the creatinine to be slightly above the normal range. The most severe cases of hypothyroidism present with myxoedema coma, with bradycar- dia, reduced respiratory rate and severe hypothermia. The most common cause of hypothyroidism is autoimmune thyroiditis and the patient should have thyroid autoantibodies assayed. Causes of hypothyroidism • Panhypopituitarism • Autoimmune thyroiditis • Post-thyroidectomy • Post-radio-iodine treatment for thyrotoxicosis • Drugs for treatment of hyperthyroidism: carbimazole, propylthiouracil • Amiodarone, lithium • Dietary iodine deficiency • Inherited enzyme defects 56 Treatment is with T4 at a maintenance dose of 75–200 &g/day. Elderly patients or those with coronary heart disease should be started cautiously on T4 because of the risk of precipitating myocardial ischaemia. The swelling started at the ankles but now his legs, thighs and genitals are swollen. He had hypertension diagnosed 13 years ago, and a myocardial infarction 4 years previously. He continues to smoke 30 cigarettes a day, and drinks about 30 units of alcohol a week. Examination On examination there is pitting oedema of the legs which is present to the level of the sacrum. His apex beat is not displaced, and auscultation reveals normal heart sounds and no murmurs. The liver, spleen and kidneys are not palpable, but ascites is demonstrated by shifting dullness and fluid thrill. Unilateral oedema is most likely to be due to a local problem, whereas bilateral leg oedema is usually due to one of the med- ical conditions listed above. Pitting oedema needs to be distinguished from lymphoedema which is characteristically non-pitting. If the oedema is pitting, an indentation will be present after pressure is removed. The major differ- ential diagnoses are cardiac failure, renal failure, nephrotic syndrome, right heart failure (cor pulmonale) secondary to chronic obstructive airways disease or decompensated chronic liver disease. The frothy urine is a clue to the diagnosis of nephrotic syndrome and is com- monly noted by patients with heavy proteinuria. The jugular venous pressure would be expected to be more raised, and there should have been signs of tricuspid regurgitation (prominent ‘v’ wave, pansystolic murmur loudest on inspiration) and cardiomegaly if the patient had cor pulmonale or biventricular cardiac failure. The patient has signs of bilateral pleural effusions which may occur in nephrotic syndrome, if there is sufficient fluid retention. The bruising and peri-orbital purpura is classically seen in patients with nephrotic syndrome secondary to amyloidosis. The normochromic, normocytic anaemia is typical of chronic disease and is a clue to the underlying diagnosis of amyloidosis. Patients with amyloido- sis may have raised serum transaminase levels due to liver infiltration by amyloid. The patient should have a renal biopsy to delineate the cause of the nephrotic syndrome. The exception is the patient with long-standing diabetes mellitus, with concomitant retinopathy and neuropathy, who almost certainly has diabetic nephropathy. A bone marrow aspirate showed the presence of an excessive number of plasma cells, consistent with an underlying plasma cell dyscrasia. Patients with amyloi- dosis should have an echocardiogram to screen for cardiac infiltration, and if the facilities are available a serum amyloid P scan should be arranged which assesses the distribution and total body burden of amyloid. The initial treatment of this patient involves fluid and salt restriction, and diuretics to reduce the oedema. He should be anticoagulated to reduce the risk of deep vein thrombosis or pul- monary embolus. Definitive treatment is by chemotherapy supervised by the haematologists to suppress the amyloidogenic plasma cell clone. Patients with nephrotic syndrome secondary to amyloidosis usually progress to end-stage renal fail- ure relatively quickly. The man has recently retired, and returned 2 weeks ago from a coach trip to Eastern Europe and Russia. Staphylococcal food poisoning occurs within a few hours and typically presents abruptly and may be severe but short-lived. Campylobacter, Salmonella and Shigella cause more severe symptoms than viral gastroenteritis. The incubation period for giardiasis is typ- ically about 2 weeks, but varies from 3 days to 6 weeks. Giardia lamblia infects the small intestine and causes a watery, yellow, foul-smelling diarrhoea. Symptoms usually improve after 2–3 weeks, but can persist, in some cases causing lactose intolerance. The history should try to distinguish between the small- and large-bowel origin of the diar- rhoea.

The rest is history and is recorded in my books and articles over the past 30 years (King cheap lady era 100 mg fast delivery menstrual jewelry, 1986a) discount 100 mg lady era otc women's health kate beckinsale. Use of King’s Conceptual In the 1970s buy lady era 100mg otc breast cancer emblem, the professional nursing staff at System and Theory the National League for Nursing conducted con- ferences to disseminate information about the cur- Over the years of presenting my ideas at theory riculum process for developing or revising a conferences throughout the world, nurses have baccalaureate nursing program (King, 1978). The asked many excellent questions, which I have tried major components in a curriculum discussed to answer. Initially, the questions pertained to, How at these conferences were “a philosophy, concep- does one implement this in practice? This moti- tual framework, course objectives, and evaluation vated me to design the documentation system to of the curriculum” (National League for Nurs- show the relationship between the nursing process ing, 1978). Prior The scope of knowledge is so vast that it is im- to presenting this at a national meeting, several staff possible to teach students everything they need to nurses tested this and suggested this system be im- learn to begin to practice nursing today and tomor- plemented in practice. It is imperative that nursing curricula be based they were not applying a theory, but were applying on a conceptual framework. This has structured to provide students with the essential become a repetitive statement of mine; that is, one concepts, skills, and values that serve as founda- cannot apply an abstraction, which is what concep- tions and as catalysts to continue to learn after tual frameworks, models, and theories represent. What one applies is the knowledge of the concepts As a participant observer who provided admin- of the structure and process proposed in the ab- istrative support for a faculty engaged in construct- stractions. Before retiring from a full-time teaching ing a new undergraduate curriculum, I witnessed position, the last thing I had to do was design an in- the development of a curriculum that moved nurs- strument to measure goal attainment. The use of ing education into the future (Daubenmire & King, my ideas in practice, education, administration, 1973). King’s Theory of Goal Attainment 241 based on my conceptual framework, was published between associate degree nursing programs and in 1989. A curriculum model and reasonable articulation between the two pro- which is conceptually based allows for updating grams when the same conceptual framework is content and skills without the necessity for major used. The philosophy When curricula are developed that identify is essential for faculty to identify a conceptual common concepts (knowledge), skills, and profes- framework and program objectives. A study was sional values, the practice of professional nursing conducted in order to identify the major terms will be the center of health care in the twenty-first used in stated philosophies in nursing programs to century. Increased technology and knowledge re- attempt to describe the philosophical foundations quire a conceptually based curriculum for the of nursing. A In the past 10 years, nurses have published their use pilot study was conducted from which a classifica- of my conceptual system and Theory of Goal tion resulted in the formation of 12 categories Attainment in practice. A table of random numbers was knowledge of the concepts to implement theory- used to select 20 percent of the schools within each based practice (Coker & Schreiber, 1989; Hanna, category and were distributed according to region 1995; Messmer, 1995; Smith, 1988). The conclusion reported dif- Nursing’s goal is to help individuals and groups ferences in use of the terms man, health, perception, attain, maintain, and regain a healthy state: “In role, social systems, and God by program type and by location of the program in a university, commu- Nursing’s goal is to help individuals and nity college, and hospital. The findings of this groups attain, maintain, and regain a national survey provided some information about healthy state. The terms nursing, envi- ronment, and interpersonal relations did not differ nursing situations where life and health goals significantly, which indicated a few commonalities are influenced by a severe illness, nurses give in those three programs. My statements of philosophy imply differences in cur- systems framework has described a holistic view of ricula, which in turn provide different kinds of the complexity in nursing within various groups, education for different kinds of nursing practice. This This study, done over 15 years ago, raised the ques- framework differs from other conceptual schema tions, What is the philosophy of nursing education? They determined The use of my conceptual system and Theory of that nurses could identify the published nursing di- Goal Attainment in family health was suggested agnoses in 1990 with the concepts in the frame- (King, 1983). Nurses in Canada, in social environment in which individuals grow and which two hospitals were involved at a distance develop and learn through interactions to set from each other, used the conceptual framework to goals. Nurses work with families and with individ- design a system for delivery of nursing care ual family members. The of nursing research and education in a large mu- family is also viewed as an interpersonal system. Congruence in ment used my framework and Theory of Goal perceptions of nurse and family members helps in Attainment (Benedict & Frey, 1995). The Theory of assessing a situation to identify concerns and/or Goal Attainment was used in adult orthopedic problems in the interpersonal system. Two cases were presented and the use Sneed (1991) stated that my interactive systems ap- of the Theory of Goal Attainment was described in proach of goal attainment is an ideal basis for each situation. This group used Community Health my theory with inpatient juvenile sexual offenders, offenders in maximum security, and community Community health nursing involves a variety of parolees. For example, school nurses must understand the edu- Continuous Quality Improvement cation system. Occupational health nurses must Continuous quality improvement in nursing and understand the political system, the economic sys- health care is a reality. Structure provides an overall organi- health programs as they interact and set goals with zation of the program. Process relates to nursing interdisciplinary teams to manage health care activities. Outcomes are separate from but related (Hampton, 1994; Sowell & Fuszard, 1989; Sowell & to performance criteria for evaluation of nursing Lowenstein, 1994). In this sense, they system provides structure for a continuous quality- are relating to the interpersonal systems in the improvement program (King, 1994). This is done within a variety of social action Process Model in my Theory of Goal systems in the community. Although the focus is Attainment gives a process that leads to goal attain- groups, nurses work with individuals for whom ment that represents outcomes.

Patients seldom volunteer information concerning any traditional medicines being taken cheap lady era 100mg mastercard menopause exhaustion. A case has been reported in which a woman receiving chemotherapy for Hodgkin’s disease supple- mented her treatment with at least nine different ayurvedic medicines cheap lady era 100mg otc workout tips women's health. Pharmacists can provide an extremely valuable function in this respect by intervening with advice whenever they consider it to be appropriate buy lady era 100mg cheap pregnancy medicaid. An interaction between the fruit karela (Momordica charantia), an ingredient of curries, and chlorpropamide has been reported. There are a number of other close relatives of this plant that are also used by hakims to treat diabetes, including crushed seed kernels of the marrow (Curcubita pepo) and the honeydew melon (Cucumis melo). There is a danger that some patients may be treating their diabetes with both allopathic and traditional remedies without realising the risk of interaction. Indian ayurvedic medicine | 213 Betel nut (see above) is prescribed by hakims either alone or in mixtures. There may be a risk of interactions between this herbal medicine and orthodox drugs. Safety of surgical and manipulative procedures The inclusion of surgical techniques adds another potential danger from non-sterile instruments and consulting environments, and incompetent procedures. There is also a risk from undue pressure or incorrect manipulation by inexperienced practitioners. Evidence There are difficulties in applying western methods to proving the effective- ness of traditional therapies. Data from both animal and human trials suggesting efficacy of ayurvedic interventions in managing diabetes have been published. There are some encouraging results for its effectiveness in treating various ailments, including chronic disorders associated with the ageing process. Pilot studies have also been conducted on depression, anxiety, sleep disorders, hypertension, Parkinson’s disease and Alzheimer’s disease. This group contains experts in pharmacognosy, toxicology, pharma- cology and clinical pharmacology, as well as clinicians and experts in standardisation and quality control. All trials are comparative, controlled, randomised and double blind unless there is a reason for carrying out a single-blind study. The trials are planned by the whole group but carried out at the centres of allopathic medicine with established investigators. There are over 20 clinical trial centres throughout the country for carrying out the multicentre studies. Using this network the council has shown the efficacy of several traditional medicines, including Picrorhiza kurroa in hepatitis and Pterocarpus marsupium in diabetes. The Central Council of India’s systems of medicine oversee research insti- tutes, which evaluate treatments. The government is adding 10 traditional medicines into its family welfare programme, funded by the World Bank and the Indian government. These medicines are for anaemia, oedema during pregnancy, postpartum problems such as pain, uterine and abdominal com- plications, difficulties with lactation, nutritional deficiencies and childhood diarrhoea. The regulations outline requirements for infrastructure, labour, quality control and authenticity of raw materials, and absence of contamina- tion. Of the 9000 licensed manufacturers of traditional medicines, those who qualify can immediately seek certification for good manufacturing practice. The remainders have 2 years to comply with the regulations and to obtain certification. The government has also established 10 new drug-testing laboratories for Indian systems of medicine and is upgrading existing laboratories to provide high-quality evidence to the licensing authorities of the safety and quality of herbal medicines. Randomised controlled clinical trials of selected prescriptions for Indian systems of medicine have been initiated. These will document the safety and efficacy of the prescriptions and provide the basis for their international licensing as medicines rather than simply as food supplements. Other trials have shown some promise in the treatment of bronchial asthma34,35 and angina. Most of the physicians are based in London but some of them are in areas that have a large Asian community such as Leicester, Birmingham and Bradford. However, many ayurvedic physicians use their education and knowledge in combination with their other healthcare-related licensed credentials. Integration with western medicine The Indian Medicine Central Council was established by a 1970 act to oversee the development of Indian systems of medicine and to ensure good Indian ayurvedic medicine | 215 standards of training and practice. Training for Indian medicine is given in separate colleges, which offer a basic biosciences curriculum followed by training in a traditional system. Recently the Department of Indian Systems of Medicine has expressed concern over the substandard quality of educa- tion in many colleges, which in the name of integration have produced hybrid curricula and graduates, unacceptable to either modern or tradi- tional standards. The department has made it a priority to upgrade training in Indian systems of medicine. Such clinical evaluation is essential because the remedies used in these systems will not be used in allopathic hospitals in a country such as India unless they have shown efficacy in well-controlled trials. However, carrying out randomised, double-blind, multicentre trials with standardised extracts is a slow and laborious process. Furthermore, not all herbal medicines need to undergo this rigorous trial because these preparations are already in use. The situa- tion is still further complicated because the randomised trial may not be totally appropriate for the evaluation of medicines from the traditional systems, where the prakriti (ayurveda system) or mijaj (unani system) of the individual determines the specific therapy to be used. Ayurvedic medicines Herbal drugs constitute a major share of all the officially recognised systems of health in India: ayurveda, yoga, unani, siddha, homoeopathy and natur- opathy.

Family nurses shared their understanding the interrelatedness of time generic 100mg lady era visa menstrual odor treatment, move- stories of the families with the research group buy generic lady era 100 mg line pregnancy 40 weeks, who ment purchase lady era 100 mg mastercard pregnancy 31 weeks, space, and consciousness as manifestations reflected together on the families’ changing of health. These studies pointed to the need to look predicaments and the whole picture of family living at health as expanding consciousness using a re- in terms of how each family moved in time and search methodology that acknowledges, under- place. The research surgery experience could be put in proper context group found that families became more open and and appropriate care provided. Nursing presurgical spontaneous through the process of pattern recog- visits were emphasized. Flanagan reported that the nition, and their interactions evidenced more nursing staff was exuberant to be free to be a nurse focus, purposefulness, and cooperation. In analyz- once again, and patients frequently stopped by to ing costs of medical care for one participating fam- comment on their preoperative experience and ily, it was estimated that a 3 to 13 percent savings evolving life changes. Based on Litchfield’s practice and the sense of connectedness among work with families with complex health predica- staff, families, and residents—each became more ments, the government has funded a large demon- peaceful, relaxed, and loving. These nurses are free to focus on family community pattern of rising youth homicide rates health as defined and experienced by the families by conducting a study with incarcerated teens con- themselves. Endo and colleagues (Endo, Minegishi, & Kubo, When the experiences of meaningful events and 2004; Endo, Miyahara, Suzuki, & Ohmasa, 2004) in relationships were compared across participants, Japan have expanded their work to incorporate the pattern of disconnection with the community the pattern-recognition process at the hospital became evident and various aspects of the commu- nursing unit level. Insights transformed commu- journals and come together to reflect on the expe- nity responses to youths at risk for violent per- rience of expanding consciousness in their patients petration. Endo, Miyahara, Suzuki, and pattern-recognition process to be transformative, Ohmasa (2004) conclude: “Retrospectively it was and expanding consciousness was visible in changed found through dialogue in the research/project behaviors, increased connectedness, and more meetings that in the usual nurse-client relation- loving attention to meaningful relationships. Pharris (2004) and an amazing experience with clients’ transforma- colleagues are extending the community pattern- tions. The nurses’ transformation occurred con- recognition process in a partnership with a multi- comitantly, and they were free to follow the clients’ ethnic community interested in understanding paths and incorporate all realms of nursing inter- and transforming patterns of racism and health ventions in everyday practice into the unitary disparities. Newman’s Theory of Health as Expanding Consciousness and Its Applications 231 several weeks to gain insight into patterns of mean- of expanding consciousness for the young man. He ingful people and events in his life, the process reflected that he wished he had had a nurse to talk seemed to be blocked, with the pattern not emerg- with prior to “catching his case” (being arrested for ing and little insight being gained. He had been seen by a nurse in the juve- he felt he had lost himself several years back when nile detention center, who did a physical exam and he went from being a straight A student from a sta- gave him aspirin for a headache. A few days before ble family to stealing cars, drinking, getting into the murder, he saw a nurse practitioner in a clinic fights, and eventually murdering someone. One who wrote a prescription for antibiotics and talked week he walked into the room where the nurse was with him about safe sex. These interactions are waiting and his movements seemed more con- explicate patterns of the implicate order of the trolled and labored; he sat with his arms tightly U. He talked as usual in a very de- the physical realm, and nurses operating out of the tached manner, but his words came out in bursts. She re- insights arising in their dialogue shed light on an flected that he seemed to be exerting a great deal of expanded horizon of potential actions (Newman, energy holding back something that was erupting 1997a; Litchfield, 1999). With this insight, he was quiet for a few Another example, at the community level, arises minutes and tears began rolling down his cheeks. It became obvious that the participants to suffering and physical deterioration experience of covering up the abuse had been so and at the same time introduced greater sensitivity all-encompassing that it was suppressing his pat- and openness to themselves and to others. This young man had reached a choice point at on the work of cultural historian William Irwin which he realized his old ways of interacting with Thompson, systems theorist Will McWhinney, and others were no longer serving him, and he chose to musician David Dunn, Lamendola and Newman, interact with his environment in a different way. By state: the next meeting, his movements had become They [Thompson, McWhinney, and Dunn] see the smooth and sure, his complexion had cleared up, loss of membranal integrity as a signal of the loss of he was now able to reflect on his insights, and he no autopoetic unity analogous to the breaking down of longer was involved in the chaos and fighting in his boundaries at a global level between countries, ide- cellblock. In their subse- pathogen not as an object but as heralding the need for living together characterized by a symbiotic rela- quent work together, this young man and the nurse tionship. Since that time, the young community, and global level, Lamendola and man has been able to transcend previous limita- Newman quote Thompson (1989, p. She finding greater meaning in life, and of reach- found that the nursing partnership was very impor- ing new dimensions of connectedness with tant to the families as they struggled to make sense other people and the world” (1). The evolving pattern of these families included the social and political forces within the educational, disabilities support, and health care systems, as well as community patterns References of caring, prejudice, and racism (Falkenstern, 2003). Expanding the dialogue on praxis in nursing logue as these stories are shared and reflected upon. Pattern recognition as a nursing intervention ing communities in dialogue about what is mean- with Japanese women with ovarian cancer. Creating action re- on the task of engaging her or his country’s nurses search teams: A praxis model of care. Partnering of researcher and practicing nurses for transfor- doubt experience an expanded sense of health. Creating a healing environment for staff and practice and in the lives of their patients. The focus is not on predetermined monary obstructive disease: Isolation and being closed in. Life patterns of people with chronic ob- on fixing the patient, but rather is on part- structive pulmonary disease: Isolation and being closed in. Journal of Advanced Nursing, states, “The theory asserts that every person 47(3), in press. Symposium presentation at the International Council of Nurses 22nd versal process of expanding consciousness— Quadrennial Congress, Copenhagen, Denmark. Newman’s Theory of Health as Expanding Consciousness and Its Applications 233 Kiser-Larson, N. Evolution of the theory of health as doctoral thesis, University of Minnesota, Minneapolis. The process of health patterning in fam- Nursing Education, The nurse theorists: Portraits of excellence ilies with young children who have been repeatedly hospitalized. Unpublished doctoral thesis, University of New York: National League for Nursing Press.