By F. Aidan. Trinity International University.

Reimbursement: Patient records are used to summary of a patient’s condition and care when demonstrate to payers that patients received the transferring or discharging patients generic 250mg antabuse amex medications prescribed for depression. Historical document: Because the notations in Nurses must keep the patient’s family and signifi- patient records are dated quality antabuse 250mg treatment lead poisoning, they provide a chrono- cant others updated about the patient’s condition logic account of services provided quality antabuse 250 mg medications made easy. Incident reports: A tool used by healthcare agen- and state their relationship to the patient. Nurses should report concisely and accurately the out of the ordinary that results in or has the change in the patient’s condition and what has potential to result in harm to a patient, already been done in response to this change. Nurses should record concisely the time and date they lie outside the scope of independent nurs- of the call, what was said to the physician, and ing practice, they make referrals to other profes- the physician’s response. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Notations are entered chronologically, with most recent entry being nearest the front of the record. Disadvantages: Data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals. Advantages: Entire healthcare team works together in identifying a master list of patient problems and contributes collaboratively to plan of care. Advantages: It promotes continuity of care and saves time since there is no separate plan of care. Disadvantages: Nurses need to read all the nursing notes to determine problems and planned interventions before initiating care. A focus column is used that incorporates many aspects of a patient and patient care. Advantages: Holistic emphasis on the patient and patient’s priorities; ease of charting. Advantages: Decreased charting time, greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standardized assessment, greater communication, better tracking of important responses and lower costs. Collaborative pathway is part of a computerized system that integrates the collaborative pathway and documentation flowsheets designed to match each day’s expected outcomes. Advantages: Reduced charting time by 40% and increased staff satisfaction with the amount of paperwork from 0–85%. Advantages: The nurse can call up the admission assessment tool and key in the patient data, develop the plan of care using computerized care plans, add new data to the patient data base, receive a work list showing treatments, procedures and medications, and document care immediately. Disadvantages: Policies should specify what type of patient information can be retrieved, by whom, and for what purpose (privacy). Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Baron’s medication administration and any follow-up appointments should be discussed and written in the discharge summary. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Latent stage Genital stage Eric Erikson Based on Freud, expanded to include Trust vs. Havighurst Living and growing are based on learning; Infancy and early childhood Developmental tasks person must continually learn to adjust to Middle childhood changing social conditions, developmental Adolescence tasks Young adulthood Middle adulthood Later maturity Jean Piaget Learning occurs as result of internal Sensorimotor stage Cognitive development organization of an event, which forms Preoperational stage a mental schemata and serves as a base for Concrete operational stage further schemata as one grows and develops. Formal operational stage Lawrence Kohlberg Levels closely follow Piaget’s; preconventional Preconventional level Moral development level, conventional level, postconventional Stage 1: punishment and level; moral development influenced by cultural obedience orientation effects on perceptions of justice or interpersonal Stage 2: instrumental relationships relativist orientation conventional level Stage 3: “good boy– good girl” orientation Stage 4: “law and order” orientation Postconventional level Stage 5: social contract, utilitarian orientation Stage 6: universal ethical principle orientation Carol Gilligan Conception of morality from female point of Level 1—selfishness Moral development view (ethic of care); selfishness, goodness, Level 2—goodness nonviolence; female: morality of response and Level 3—nonviolence care; male: morality of justice. James Fowler Theory of spiritual identity of humans; faith is Intuitive–projective faith Faith development reason one finds life worth living; six stages Mythical–literal faith of faith. Synthetic–conventional faith Individuative–reflective faith Conjunctive faith Universalizing faith Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Conventional level: This level is obtained when According to Havighurst, the developmental tasks person becomes concerned with identifying with of later adulthood include adjusting to decreasing significant others and shows conformity to their physical strength and health, adjusting to retirement expectations. Example: A college student gets all and reduced income, and establishing physical A’s in college so his parents will think he is a living arrangements. Postconventional level: This level is associated of dependency on healthcare providers and his with moral judgment that is rational and inter- family. The nurse could then base the nursing plan nalized into one’s standards or values. Example: of care on interventions to foster feelings of A bank teller resists the urge to steal money from personal dignity and worth. Logan states that he is willing to participate in latency stage and will be experiencing increased his care plan and do everything in his power to interest in gender differences and conflict and adjust to his situation by accepting the assistance of resolution of that conflict with parent of same others when necessary sex. Erikson: The 6-year-old is becoming achievement ethical/legal competencies are most likely to bring oriented, and the acceptance of parents and about the desired outcome? Havighurst: The 6-year-old is ready to learn the mental theories to nurse care planning developmental tasks of developing physical Technical: ability to provide technical nursing assis- skills, wholesome attitudes toward self, getting tance to Mr. Logan as needed along with peers, sexual roles, conscience, moral- Interpersonal: ability to use therapeutic communi- ity, personal independence, and so on. An illness cation to meet the emotional and spiritual needs of could stall these processes. Piaget: The 6-year-old is in the preoperational Ethical/Legal: ability to advocate for the unmet stage, including increased language skills and developmental needs of Mr. Kohlberg: Moral development is influenced by Home healthcare services, community services, cultural effects on perceptions of justice in inter- support groups personal relationships.

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Sigh Normal respiration includes a physiological sigh every 5 to 10 minutes (Hough 1996) discount antabuse 250 mg mastercard symptoms 4 days after conception. Ratios between intra-alveolar pressure and volume differ between inspiration and expiration (hysteresis); lung expansion during inspiration increases alveolar surface area order 500 mg antabuse overnight delivery moroccanoil treatment, facilitating adsorption of new surfactant adsorbed onto alveolar surfaces; this reduces surface tension during deflation by up to one-fifth (Drummond 1996) buy cheap antabuse 500mg on-line treatment meaning. Occasional hyperinflation (sigh) prevents atelectasis during shallow respirations (Hough 1996), increases compliance, and so prevents infection. Since physiological sighs are lost with unconsciousness (Hough 1996), mechanical sighs were incorporated into ventilator technology, often delivering double tidal volumes. Bersten and Oh (1997) suggest that with use of smaller tidal volumes, sigh use requires reassessment. Independent lung ventilation With single-lung pathology, patients may benefit from different modes of ventilation being used to each lung. Independent lung ventilation requires double lumen endotracheal Artificial ventilation 33 tubes, one lumen entering each bronchus. Independent ventilators, each using any available mode, may then be used for each lung. Independent lung ventilation may be impractical due to: ■ insufficient ventilators available ■ increased costs and workload (e. However, as air leaks are invariably present and the airway is unprotected, with no access for suction (Elliott et al. Noninvasive ventilation is not intended for prolonged use, although it may facilitate weaning (Wedzicha 1992). The availability of non-invasive ventilation extends ethical dilemmas about decisions not to ventilate. Such decisions should be taken by the multidisciplinary team, nurses being potentially valuable patient advocates. Physiological complications All body systems are affected by artificial ventilation. Although this description is reductionist, and further complications are identified in Chapter 5 and elsewhere, it should be remembered that there are cumulative effects on the whole person. Conversely, positive pressure ventilation ■ impedes venous return ■ increases right ventricular workload ■ causes cardiac tamponade resulting in reduced arterial pressure and extravasation of plasma into interstitial spaces (oedema, including pulmonary). Although maintaining patency of airways, rigid endotracheal tubes (and other ventilator circuitry) create resistance, usually of 5–10 cmH2O (Bersten & Oh 1997). Airway resistance increases work of breathing with patient-initiated breath, unless compensated (e. Intensive care nursing 34 The work of breathing at rest consumes 1–3 per cent of total oxygen consumed; with respiratory failure, the work of breathing may consume one-quarter of total body oxygen (Hinds & Watson 1996), depriving other vital organs of oxygen. Modes incorporating some patient-initiated breaths increase work of breathing so that patients showing signs of exhaustion, or who are tachypnoeic but with low tidal volumes, should be given more artificial support. Implications for practice ■ any machine can be inaccurate or fail; nurses should check all alarms and safety equipment at the start of each shift; ventilator function should be checked through recorded observations (at least hourly) and continuously by visual observation and setting appropriate alarm parameters (often within 10 per cent); remember alarms may also fail ■ check monitor circuits for leaks by assessing air entry ■ most modern ventilators include default settings—know your machine and check these ■ familiarise yourself with all ventilators used on your unit ■ positive pressure ventilation affects all body systems; function of other systems should be continuously and holistically assessed ■ ventilation often increases the need for fundamental aspects of care (e. This chapter has discussed the main principles of ventilation design; material on specific models should be available on units where they are used. Despite technological development, artificial ventilation continues to cause many problems for patients, which are identified in this and many later chapters. What nursing strategies can minimise potential complications (suggest changes to ventilator settings)? His family brings in an Advanced Directive signed by Mr Webb stating that he does not wish to be invasively ventilated. Despite the frequency of endotracheal suction, substantive evidence for many aspects is usually lacking or not translated into practice. The lack of substantive evidence makes many recommendations for practice in this chapter necessarily tentative. Intubation Traditionally intubation could be: ■ oral ■ nasal ■ tracheostomy Unless specific surgery or pathophysiology necessitated a specific route, oral tubes were usually used for short-term, nasal tubes for medium-term and tracheostomies for prolonged intubation, practice often being guided by protocols that specified time limits for each method. Tracheostomy avoids many complications of oral and nasal intubation, and reduces dead space by up to half (Pritchard 1994), but necessitates surgery, leaving a residual Intensive care nursing 38 wound. Heffner (1993) suggests tracheostomies should ideally be performed after 21 days, but most intensivists now determine changes by the individual needs of patients rather than by protocols. Mini-tracheostomies, initially developed to facilitate the removal of secretions, can also be used for high frequency ventilation. Non-invasive positive pressure ventilation and laryngeal masks (see below) may avoid the necessity for intubation. The cricoid cartilage (just below the ‘Adam’s apple’) forms a complete ring, so cricoid pressure (pressing the cricoid cartilage down with three fingers towards the patient’s head) compresses the pharynx against cervical vertebra, preventing gastric reflux and aspiration. Accidental single bronchus intubation usually occurs in the right main bronchus, due to its gentler angle from the carina. Endotracheal tubes are manufactured in a single (long) length and so almost invariably require cutting to minimise ventilatory dead space, usually to 21 cm (female) and 23 cm (male). Childrens’ airways differ from those of adults (see Chapter 13) and so, in order to prevent excessive pressure on tracheal tissue, uncuffed endotracheal tubes should be used with children under 8 years old (James 1991); nasal intubation with Tunstall connector fixation can prevent damage from tube movement. Problems Intubation is often a necessary medical solution which creates various nursing problems. Airway sensory nerve stimulation causes a cough reflex, involving vagal afferent pathways, the cough centre and motor nerves of the diaphragm, abdomen, intercostal muscles and larynx.

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Aversion therapy is a type of behavior therapy in which positive punishment is used to reduce the frequency of an undesirable behavior best 250 mg antabuse 9 medications that cause fatigue. An unpleasant stimulus is intentionally paired with a harmful or socially unacceptable behavior until the behavior becomes associated with unpleasant sensations and is hopefully reduced 500 mg antabuse free shipping medicine 230. A child who wets his bed may be required to sleep on a pad that sounds an alarm when it senses moisture antabuse 250 mg mastercard medicine river animal hospital. Over time, the positive punishment produced by [12] the alarm reduces the bedwetting behavior (Houts, Berman, & Abramson, 1994). Aversion [13] therapy is also used to stop other specific behaviors such as nail biting (Allen, 1996). In a standard approach, patients are treated at a hospital where they are administered a drug, antabuse, that makes them nauseous if they consume any alcohol. The technique works [15] very well if the user keeps taking the drug (Krampe et al. In cognitive therapy the therapist helps the patient develop new, healthier ways of thinking about themselves and about the others around them. The goal of cognitive therapy is not necessarily to get people to think more positively but rather to think more accurately. For instance, a person who thinks “no one cares about me‖ is likely to feel rejected, isolated, and lonely. If the therapist can remind the person that she has a mother or daughter who does care about her, more positive feelings will likely follow. Similarly, changing beliefs from “I have to be perfect‖ to “No one is always perfect—I‘m doing pretty good,‖ from “I am a terrible student‖ to “I am doing well in some of my courses,‖ or from “She did that on purpose to hurt me‖ to “Maybe she didn‘t realize how important it was to me‖ may all be helpful. Beck and the psychologist Albert Ellis (1913–2007) together provided [16] the basic principles of cognitive therapy. Ellis noticed that people experiencing strong negative emotions tend to personalize and overgeneralize their beliefs, leading to an inability to see situations [17] accurately (Leahy, 2003). His goal was to develop a short-term therapy for depression that would modify these unproductive thoughts. Beck‘s approach challenges the client to test his beliefs against concrete evidence. If a client claims that “everybody at work is out to get me,‖ the therapist might ask him to provide instances to corroborate the claim. At the same time the therapist might point out contrary evidence, such as the fact that a certain coworker is actually a loyal friend or that the patient‘s boss had recently praised him. For bipolar disorder, for instance, the therapist may use both psychological skills training to help the patient cope with the severe highs and lows, but may also suggest that the patient consider biomedical drug therapies (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, [19] 2002). Consider this description, typical of the type of borderline patient who arrives at a therapist‘s office: Even as an infant, it seemed that there was something different about Bethany. She had very severe separation anxiety—if her mother left the room, Bethany would scream until she returned. She started acting out more and more—yelling at her parents and teachers and engaging in impulsive behavior such as promiscuity and running away from home. At times Bethany would have a close friend at school, but some conflict always developed and the friendship would end. She was fighting with her parents almost daily, and the fights often included violent behavior on Bethany’s part. At times she seemed terrified to be without her mother, but at other times she would leave the house in a fit of rage and not return for a few days. When confronted about them, Bethany said that one night she just got more and more lonely and nervous about a recent breakup until she finally stuck a lit cigarette into her arm. She said ³I didn’t really care for him that much, but I had to do something dramatic. Her suicide attempt was not successful, but the authorities required that she seek psychological help. Most therapists will deal with a case such as Bethany‘s using an eclectic approach. First, because her negative mood states are so severe, they will likely recommend that she start taking antidepressant medications. These drugs are likely to help her feel better and will reduce the possibility of another suicide attempt, but they will not change the underlying psychological problems. The first sessions of the therapy will likely be based primarily on creating trust. Person-centered approaches will be used in which the therapist attempts to create a therapeutic alliance conducive to a frank and open exchange of information. If the therapist is trained in a psychodynamic approach, he or she will probably begin intensive face-to-face psychotherapy sessions at least three times a week. The therapist may focus on childhood experiences related to Bethany‘s attachment difficulties but will also focus in large part on the causes of the present behavior. The therapist will understand that because Bethany does not have good relationships with other people, she will likely seek a close bond with the therapist, but the therapist will probably not allow the transference relationship to develop fully. The therapist will also realize that Bethany will probably try to resist the work of the therapist. For one, cognitive therapy will likely be used in an attempt to change Bethany‘s distortions of reality.

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