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The human becoming theory and its re- Education: A Call for Substance: Preparing Leaders for Global search and practice methodologies purchase liv 52 100 ml with amex. Illuminations: Newsletter for the International Consortium of Parse Scholars cheap liv 52 120 ml with visa, Newsletter for the International Consortium of Parse Scholars, 11(3/4), 1. Nursing sionals can do to move toward a more personal and meaning- Science Quarterly, 14, 273. An ethical framework for nursing prac- Newsletter for the International Consortium of Parse Scholars, tice: Parse’s human becoming theory. Introducing the Theorist I don’t like deceiving, withholding, or treating people as subjects or objects. The foundation for the theory of Health as I don’t like acting as an objective non-person. Expanding Consciousness was laid prior to the I do like interacting authentically, listening, under- time Margaret Newman entered nursing school at standing, communicating freely. Caring for her Several of Martha Rogers’ assumptions became mother was transformative for Margaret Newman. First and foremost, realizations: that simply having a disease does not Rogers saw health and illness not as two separate make you unhealthy, and that time, movement, and realities, but rather as a unitary process. This was space are in some way interrelated with health, congruent with Margaret Newman’s earlier experi- which can be manifested by increased connected- ence with her mother and with her patients. In caring for her but rather health and illness are both manifesta- physically immobilized mother, Newman experi- tions of a greater whole. One can be very healthy in enced similar alterations in movement, space, time, the midst of a terminal illness. In the midst Second, Rogers argued that all of reality is a uni- of this terminal disease, both mother and daughter tary whole and that each human being exhibits a experienced a greater sense of connectedness and unique pattern. Rogers (1970) saw energy fields to increased insight into the meaning of their experi- be the fundamental unit of all that is living and ence and into the meaning of health. In defining field, Rogers Unitary Human Beings theory resonated with wrote: “Field is a unifying concept. Energy signifies Newman’s conceptualizations of nursing and the dynamic nature of the field. She designed an experimental study that ma- sional energy field identified by pattern nipulated participants’ movement and then and manifesting characteristics that are measured their perception of time. Her results specific to the whole and which cannot be showed a changing perception of time across the predicted from knowledge of the parts. Although her re- sults seemed to support what she later would term Rogers defined the unitary human being as “[a]n “health as expanding consciousness,” at that time irreducible, indivisible, pandimensional energy she felt they did little to inform or shape nursing field identified by pattern and manifesting charac- practice (Newman, 1997a). Finally, Rogers saw the life Introducing the Theory process as showing increasing complexity. This assumption, along with the work of Itzhak Newman’s theory is a composite of her early influ- Bentov (1978), which viewed life as a process of ex- ences and life and practice experiences. Newman’s Theory of Health as Expanding Consciousness and Its Applications 219 in New York. In her address each client situation, (Newman, 1978) and in a written overview of the • the sequential configurations of pattern evolv- address (Newman, 1979), Newman outlined the ing over time, basic assumptions that were integral to her theory. They defined the focus of the Newman’s presentation drew thunderous ap- nursing discipline to be caring in the human health plause as she ended with “[t]he responsibility of the experience, which they saw as the common um- brella under which three distinct paradigmatic per- spectives fell: the particulate-deterministic, the “[t]he responsibility of the nurse is not to interactive-integrative, and the unitary-transfor- make people well, or to prevent their get- mative (with the first word indicating the nature of ting sick, but to assist people to recognize reality and the second word indicating the nature the power that is within them to move to of change in each paradigm). Relationships getting sick, but to assist people to recognize the between entities are seen as orderly, predictable, power that is within them to move to higher levels linear, and causal (i. In this perspective, Although Margaret Newman never set out health is dichotomized with clearly defined charac- to become a nursing theorist, in that 1978 presen- teristics that are either healthy or unhealthy, and tation in New York City she articulated a theory change occurs in a manner that is predictable and that resonated with what was meaningful in the causal in nature. Nurses wanted to go beyond combating stems from the particulate-deterministic, views re- diseases; they wanted to accompany their patients ality as multidimensional and contextual. Multiple in the process of discovering meaning and antecedents and probabilistic relationships are be- wholeness in their lives. Relationships may be reciprocal, and sub- was to focus on how to test the theory with nursing jective data are seen as legitimate. It is identified by ness and is able to sense how physical signs, emo- pattern and by interaction with the larger whole” tional conveyances, spiritual insights, physical (Newman, Sime, & Corcoran-Perry, 1991, p. Newman, Sime, and Corcoran-Perry (1991) Knowledge is arrived at through pattern recogni- concluded that the knowledge generated by the tion and reflects both the phenomenon viewed and particulate-deterministic paradigm and the inter- the viewer. In a later work, Newman (1997a) larger unitary field that combines person, family, asserted that knowledge emanating from the uni- and community all at once. A nurse operating out tary-transformative paradigm is the knowledge of of the unitary-transformative paradigm does not the discipline and that the focus, philosophy, and think of mind, body, spirit, and emotion as separate theory of the discipline must be consistent with entities, but rather sees them as an undivided each other and therefore cannot flow out of differ- whole. Newman states: Newman’s theory (1979, 1990, 1994a, 1997a, The paradigm of the discipline is becoming clear. The nurse and client things to attending to the meaning of the whole, from form a mutual partnership to attend to the pattern hierarchical one-way intervention to mutual process of meaningful relationships and experiences in the partnering. In this way, a patient who has had a of health that focuses on power, manipulation, heart attack can understand the experience of the and control and move to one of reflective, compas- heart attack in the context of all that is meaningful sionate consciousness.
Te setting of a mass disaster morgue is more likely to destroy a tube head than working on typical dental patients 60 ml liv 52 with mastercard, where the time for placing flms afer each exposure helps protect the duty cycle buy 60 ml liv 52 amex. Te resulting x-ray beam is comprised of millions of photons of vary- ing energy (wavelengths) and is referred to as having a continuous or poly- chromatic spectrum. Older x-ray units produce even more variation in the uniformity of the beam as the alternating current rises and falls. Tese units are more ef- cient and provide more high-energy, diagnostically useful photons and cut exposure times roughly in half. Older units also have difculty in producing the extremely short exposure times (usually tenths of a second) required by digital x-ray sensors, which require signifcantly less radiation than flm. One very simple but efective method to accomplish this is to cover the opening of the tube head collimator in an old unit with round sections of rare earth screen material until the beam is weakened sufciently to allow longer expo- sure settings comparable to the unit’s timer capabilities. Terefore, there is always a varying amount of magnifcation of the object in any plane flm image. Te degree of magnifcation is determined by the ratio of the x-ray source-to-object distance and source-to-flm distance. Te larger the distance from the source to the image receptor, the less magnifcation occurs. Likewise, the closer the object to the receptor, the less the magnif- cation and the sharper the image will be. Tat is because the energy of the quickly diverging beam will weaken mathematically as a square of its distance. Terefore, changing the distance of an individual to the x-ray source from 1 foot to 4 feet reduces the dose or intensity of the radiation to 1/16th of the original dose. New technology in the form of handheld generators that are truly pow- ered by direct current from rechargeable batteries is now in great use in forensic dentistry (Aribex™ Nomad™) but will be discussed further later in this chapter and in other chapters in this textbook. Terefore, the total of the external and internal structures of the object is represented in the image and not simply the surface area. Tis is signifcant in that a radiographic image reveals objects that cannot be per- ceived with the naked eye. Tis also means, however, that dental radiographic images require interpretation by the observer because the image is presented as a two-dimensional representation of a three-dimensional object. Radiographic images of the teeth and maxillofacial structures can only be created due to the fact that the beam of electromagnetic energy is attenu- ated in varying degrees, depending on the absorption characteristics of dif- ferent structures through which it passes, and that recording media will react diferently depending on the energy received. Tus, an amalgam restoration 190 Forensic dentistry absorbs much more energy than its surrounding enamel and dentin, allow- ing less energy to reach the receptor at that location and creating an invisible latent image. Trough some mode of processing of the receptor, the amalgam will later be displayed in an image that can be detected visually. With dental flm the processing involves chemicals; with digital sensors it may involve modern electronics and lasers. Dental x-ray “receptors” have undergone numerous changes over the history and advances in dental radiography. Film is inex- pensive, easy to place, and produces an exceptional image if proper tech- niques are used, but requires several minutes of chemical processing, ideally in a darkroom setting. Most agree that direct digital is the best image receptor in a mass fatality incident due to it providing an immedi- ate image and dealing efectively with the exaggerated fow of victims in the morgue setting (Figure 10. Phosphor technology provides an excellent image with placement ease similar to that of flm but requires several minutes of processing time as the plate must be scanned by a laser drum to produce the image. Te phosphor plates also scratch easily and must be replaced fairly frequently, depending on care of handling. While humans and some computer monitors cannot discern that many gray levels, interpre- tive sofware can. Tis may eventually lead to sofware with the ability to “match” dental images in determining a dental identifcation at a rate that would far exceed human ability. To ensure interoperability with third-party Forensic dental radiography 191 Figure 10. Finally, if direct digital radiography is not available, scanning traditional radiographs into digital format with a digital fatbed scanner is an alternate technique. Once digitized, these images can be integrated with any sofware system used in forensic dentistry with abilities equal to direct digital. In general, manual processing of radiographs at 70°F requires a fve-minute development cycle followed by a thirty-second rinse and a ten-minute fxation cycle. If not washed thoroughly, the fxer solu- tion will continue to act on the flm afer processing and will eventually tint or discolor the image and can destroy its diagnostic content. Automatic pro- cessors most commonly produce a dry, processed flm in about fve minutes.
But they do eat more fat compared with the amount of carbohydrate; the proportion of fat in their diet is higher cheap liv 52 200 ml otc. As a possible explanation of these results discount liv 52 200 ml without prescription, research has examined the role of fat and carbohydrates in appetite regulation. First, it has been suggested that it takes more energy to burn carbohydrates than fat. Further, as the body prefers to burn carbohydrates than fat, carbohydrate intake is accompanied by an increase of carbohydrate oxidation. In contrast, increased fat intake is not accom- panied by an increase in fat oxidation. Second, it has been suggested that complex carbohydrates (such as bread, potatoes, pasta, rice) reduce hunger and cause reduced food intake due to their bulk and the amount of fibre they contain. Third, it has been suggested that fat does not switch off the desire to eat, making it easier to eat more and more fat without feeling full. The evidence for the causes of obesity is therefore complex and can be summarized as follows: s There is good evidence for a genetic basis to obesity. Perhaps an integration of all theories is needed before proper conclusions can be drawn. Treatment approaches therefore focused on encouraging the obese to eat ‘normally’ and this consistently involved putting them on a diet. Stuart (1967) and Stuart and Davis (1972) developed a behavioural programme for obesity involving monitoring food intake, modifying cues for inappropriate eating and encouraging self-reward for appropriate behaviour, which was widely adopted by hospitals and clinics. The programme aimed to encourage eating in response to physiological hunger and not in response to mood cues such as boredom or depression, or in response to external cues such as the sight and smell of food or the sight of other people eating. In 1958, Stunkard concluded his review of the past 30 years’ attempts to promote weight loss in the obese with the statement, ‘Most obese persons will not stay in treatment for obesity. Of those who stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it’ (Stunkard 1958). More recent evaluations of their effectiveness indicate that although traditional behavioural therapies may lead to initial weight losses of on average 0. Therefore, traditional behavioural programmes make some unsubstantiated assumptions about the causes of obesity by encouraging the obese to eat ‘normally’ like individuals of normal weight. Multidimensional behavioural programmes The failure of traditional treatment packages for obesity resulted in longer periods of treatment, an emphasis on follow-up and the introduction of a multidimensional perspective to obesity treatment. Recent comprehensive, multidimensional cognitive– behavioural packages aim to broaden the perspective for obesity treatment and combine traditional self-monitoring methods with information, exercise, cognitive restructuring, attitude change and relapse prevention (e. Brownell and Wadden (1991) emphasized the need for a multidimensional approach, the importance of screen- ing patients for entry onto a treatment programme and the need to match the individual with the most appropriate package. State-of-the-art behavioural treatment programmes aim to encourage the obese to eat less than they do usually rather than encouraging them to eat less than the non-obese. Analysis of the effectiveness of this treatment approach suggests that average weight loss during the treatment programme is 0. In a comprehensive review of the treat- ment interventions for obesity, Wilson (1994) suggested that although there has been an improvement in the effectiveness of obesity treatment since the 1970s, success rates are still poor. Wadden (1993) examined both the short- and long-term effectiveness of both mod- erate and severe caloric restriction on weight loss. He reviewed all the studies involving randomized control trials in four behavioural journals and compared his findings with those of Stunkard (1958). Wadden (1993) concluded that, ‘Investigators have made significant progress in inducing weight loss in the 35 years since Stunkard’s review. Therefore, modern methods of weight loss produce improved results in the short term. However, Wadden also con- cludes that ‘most obese patients treated in research trials still regain their lost weight’. The review examined the effectiveness of dietary, exercise, behavioural, pharmacological and surgical interventions for obesity and concluded that ‘the majority of the studies included in the present review demonstrate weight regain either during treatment or post intervention’. Accordingly, the picture for long-term weight loss is as pessimistic as it ever was. Traditional treatment programmes aimed to correct the obese individual’s abnormal behaviour, and recent packages suggest that the obese need to readjust their energy balance by eating less than they usually do. But both styles of treatment suggest that to lose weight the individual must impose cognitive restraint upon their eating behaviour. They recommend that the obese deny food and set cognitive limits to override physio- logical limits of satiety. And this brings with it all the problematic consequences of restrained eating (see Chapter 6). In addition, results from a study by Loro and Orleans (1981) indicated that obese dieters report episodes of bingeing precipitated by ‘anxiety, frustration, depression and other unpleasant emotions’. This suggests that the obese respond to dieting in the same way as the non-obese, with lowered mood and episodes of overeating, both of which are detrimental to attempts at weight loss. The obese are encouraged to impose a cognitive limit on their food intake, which introduces a sense of denial, guilt and the inevitable response of overeating.
It is a two-part process 60 ml liv 52 with amex, involving both the cre- ation of art and the discovery of its meaning cheap liv 52 100 ml line. Rooted in Sigmund Freud and Carl Jung’s theories of the sub- Benefits conscious and unconscious,art therapy is based on the • Self-discovery. At its most successful, art therapy trig- premise that visual symbols and images are the most ac- gers an emotional catharsis (a sense of relief and well- cessible and natural form of communication to the being through the recognition and acknowledgement of human experience. The resulting artwork is then re- can build confidence and nurture feelings of self-worth. The Personal fulfillment comes from both the creative and analysis of the artwork typically enables a patient to gain the analytical components of the process. Art therapy can help individuals visual- to work through these issues in a constructive manner. Chronic stress can be for these activities, an important feature of effective talk harmful to both mind and body. It can weaken and therapy is that the patient/artist, not the therapist, direct damage the immune system, cause insomnia and de- the interpretation of their artwork. When used alone or in combination with tion of specific types of mental illness or traumatic other relaxation techniques such as guided imagery, art events. In the late 19th century, French psychiatrists Am- therapy can be a potent stress reliever. Art therapy ies on the visual characteristics of and symbolism in the can also help individuals cope with pain and promote artwork of the mentally ill. They found that there were physiological healing by identifying and working recurring themes and visual elements in the drawings of through anger and resentment issues and other emo- patients with specific types of mental illness. Art and healing: using expressive art to heal situations which they must interpret, thus projecting their your body, mind, and spirit. The test subject describes his or her reactions to elaborate inkblots presented on a se- ries of ten cards. Responses are interpreted with atten- Assessment, psychological tion to three factors: what parts or parts of each inkblot the The assessment of personality variables. In this test, the subject ods fall into one of three categories: observational meth- is shown a series of pictures, each of which can be inter- ods, personality inventories, or projective techniques. Responses tend to reflect a person’s Observational assessment is performed by a trained problems, motives, preoccupations, and interpersonal professional either in the subject’s natural setting (such skills. Projective tests require skilled, trained examiners, as a classroom), an experimental setting, or during an in- and the reliability of these tests is difficult to establish due terview. Assessments may vary widely dard agenda, or unstructured, allowing the subject to de- among different examiners. Scoring systems for particular termine much of what is discussed and in what order. Expectations of the observer, conveyed directly or See also Personality inventory; Rorschach technique through body language and other subtle cues, may influ- ence how the interviewee performs and how the observer Further Reading records and interprets his or her observations. Personality inventories consist of questionnaires on Personality and Ability: The Personality Assessment System. One taking in new information and incorporating it into exist- problem with personality inventories is that people may ing ways of thinking about the world. Conversely, ac- try to skew their answers in the direction they think will commodation is the process of changing one’s existing help them obtain their objective in taking the test, ideas to adapt to new information. When an infant first whether it is being hired for a job or being admitted to a learns to drink milk from a cup, for example, she tries to therapy program. Validity scales and other methods are assimilate the new experience (the cup) into her existing commonly used to help determine whether an individual way of ingesting milk (sucking). The elder Mill proposed a mechanistic In the context of personality, the term “assimila- theory that linked ideas together in “compounds,” espe- tion” has been used by Gordon Allport (1897-1967) to cially through the principle of contiguity. The younger describe the tendency to fit information into one’s own Mill, whose defining metaphor for the association of attitudes or expectations. In the study of attitudes and ideas was “mental chemistry,” differed from his father in attitude change, it means adopting the attitudes of peo- claiming that the mind played an active rather than a ple with whom we identify strongly. He also suggested that a whole idea may amount to more than the sum of Further Reading its parts, a concept similar to that later advocated by Allport, G. Aside from similarity and contiguity, other gov- erning principles have been proposed to explain how Associationism ideas become associated with each other. These in- The view that mental processes can be explained clude temporal contiguity (ideas or sensations formed in terms of the association of ideas. In its original empiricist context, it ationism is behaviorism, whose principles of condi- was a reaction against the Platonic philosophy of innate tioning are based on the association of responses to ideas that determined, rather than derived from, experi- stimuli (and on one’s association of those stimuli with ence. Instead, the associationists proposed that ideas positive or negative reinforcement). Also, like associ- originated in experience, entering the mind through the ationism, behaviorism emphasizes the effects of envi- senses and undergoing certain associative operations. Association appears in other modern contexts as well: The philosopher John Locke (1632-1704) intro- the free association of ideas is a basic technique in the duced the term “association of ideas” in the fourth edi- theory and practice of psychoanalysis, and association tion of his Essay Concerning Human Understanding plays a prominent role in more recent cognitive theo- (1700), where he described it as detrimental to rational ries of memory and learning.
Noise Noise (undesired sound) is subjective: what is useful or enjoyable for one person can annoy others (e cheap 60 ml liv 52 with mastercard. However purchase liv 52 200 ml online, ‘unnecessary noise is the most cruel absence of care which can be inflicted on either sick or well’ (Nightingale [1859] 1980:5); nurses should actively seek to reduce unnecessary noise. Even whispers usually cause 30 dB, enough to disturb sleep (Wood 1993), and exceeding the International Noise Council’s night-time limit of 20 dB. Conversation cannot be avoided, and appropriate conversation can benefit patients, but volume, tone and pitch of speech vary between individuals, and nurses coordinating care should ensure that both content and timing of conversation is appropriate. Sensory imbalance 23 Suction catheters (with vacuum running) under pillows places noise near patients’ ears; suction units are also usually near patients’ heads. An average quiet bedroom at home might measure 20–30 dB overnight (Krachman et al. Children have fewer coping mechanisms than adults (Bood 1996) and so may be more susceptible to disturbed sleep. Childrens’ normal circadian rhythm and psychological health may be helped by play, an essential need during prolonged admissions (Palmer 1996), but adult nurses are often less able than paediatric nurses to meet children’s play and other needs, and may have less access to play therapists. Post-discharge support may include: ■ follow-up clinics ■ discharge liaison nurses ■ inviting patients to return or telephone the unit While potentially easing psychological trauma, nurses should be confident that they have the knowledge and skills needed to provide adequate support, including providing psychologically ‘safe’ environments (confidentiality, privacy) and meeting local ethical requirements; unit managers should be able to guide staff on such issues. Implications for practice ■ sensory imbalance is a symptom of psychological pain, provoking a stress response; alleviating pain provides both humanitarian and physiological benefits, so should be fundamental to nursing assessment and care ■ monitors should be sited unobtrusively ■ facilitating sleep is usually the nurse’s most important role overnight ■ sleep is individual, so each patient’s normal sleep pattern should be assessed ■ whenever possible, planned care should include 4 sleep cycles, each lasting at least 90 minutes (patients remaining undisturbed during this time) ■ circadian rhythm can be facilitated through daylight, interesting views and, overnight, by dimming lights as much as is safely possible ■ relatives should be encouraged to participate in care, and encouraged to share news and use touch. Maintaining sensory balance helps to maintain psychological health and reduces complications from stress responses. Many factors contribute to sensory imbalance, including sleep deprivation (quality or quantity) and noise. Nurses should assess each individual patient’s needs; while safety and physiological needs of critically ill patients necessarily compromise psychological care, nurses can humanise even the most technological environments. Sensory imbalance 25 Further Reading Much has been written on sensory imbalance: West (1996) and Granberg et al. Detrimental physiological effects of stress are described by Torpy and Chrousos (1997). Clinical scenario Edward Creighton is a 20-year-old university student admitted with bacterial meningitis. He is sedated, paralysed and given intravenous antibiotics (Cefotaxime 2 g, 8 hourly). Edward recovers, but may be left with some long-term neurological complications (e. Chapter 4 Artificial ventilation Fundamental knowledge Respiratory physiology Normal (negative pressure) breathing Dead space Normal lung volumes Experience of nursing ventilated patients Introduction Intensive care units developed from respiratory units: the provision of mechanical ventilation, and thus the care of ventilated patients, is fundamental to intensive care nursing. Nurses should have a safe working knowledge of whichever ventilators they use— manufacturers’ literature and company representatives are usually the best source for this. This chapter discusses the main components of ventilation (tidal volume, I:E ratio) and the more commonly used modes. The chapter ends by identifying the complication of positive pressure ventilation on other body systems. Artificial ventilation should meet physiological deficits (metabolic oxygen demand and carbon dioxide elimination). These terms are therefore not used here, but readers should be aware of their existence and meanings. Carbon dioxide removal requires active tidal ventilation and so is affected by inspiratory pressure tidal volumes expiratory time. Manipulating these factors can optimise ventilation while minimising complications. Normal adult alveolar ventilation is about four litres each minute; normal cardiac output is about five litres each minute. Shunting can also occur at tissue level (reduced oxygen extraction ratio, see Chapter 20). Care of ventilated patient The care of ventilated patients should be holistic—the sum of many chapters in this book, especially in Part I. Artificial ventilation causes potential problems with: ■ safety ■ replacing normal functions ■ system complications Ventilated patients have respiratory failure, so ventilator failure or disconnection may be fatal. Modern ventilators include alarms and default settings, but each nurse should check, and where appropriate reset, alarm limits for each patient; Pierce (1995) recommends a ‘rule of thumb’ margin of 10 per cent for alarm settings. Alarms may fail and so nurses should observe ventilated patients both aurally and visually. This necessitates appropriate layout of bed areas to minimise the need for nurses to turn their backs on their patients. Back-up facilities in case of ventilator, power or gas failure should include: ■ manual rebreathing bag, with suitable connections ■ oxygen cylinders ■ equipment for reintubation Additional safety equipment may also be needed (e. Positive pressure ventilation is unphysiological; increased intrathoracic pressure compromises many other body systems (especially cardiovascular), causing problems identified later in this and many other chapters.
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