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Increased urine output and antenatal bladder compression from the fetus cause urgency antibiotics for acne boils buy cheap fucidin on line. The depression of cell-mediated and humoral immunity during the third trimester prevents fetal rejection virus protection for windows xp discount 10 gm fucidin free shipping, but increases viral infections (especially varicella/chicken pox and colds) infection game tips buy fucidin 10 gm on-line. Over one-half of eclamptic deaths occur following only one or two fits bacteria exponential growth order fucidin overnight delivery, and so convulsions should be controlled (Bewley 1997) infection white blood cells fucidin 10 gm order on line. Delivery is essential to resolve eclampsia, so that Caesarian section or termination of pregnancy are usually necessary (Fraser & Saunders 1990). Eclamptic fits can also occur up to ten days following delivery (Abbott 1997), and so monitoring should be continued. Acute fatty liver is a rare variant of pre-eclampsia; gross microvascular fatty infiltration occurs, without hepatic necrosis or inflammation. Normal hepatic function resumes postnatally (Kaplan 1985b), so that early delivery resolves the problem (Sussman 1996). Hypertension should be controlled; antenatally, placental perfusion must be maintained. Eclampsia should be controlled with intravenous/intramuscular magnesium (Eclampsia Trial Collaborative Group, 1995; DoH, 1996b); doses vary, but most texts recommend plasma levels of 2–4 mmol/l (Idama & Lindow 1998). Toxicity (>5 mmol/l) can cause the loss of tendon reflexes (Idama & Lindow 1998) and respiratory paralysis in both mother and newborn (Adam & Osborne 1997), so that 1 g calcium gluconate should be immediately available (Idama & Lindow 1998). Analgesia should be given both for humanitarian reasons and to reduce sympathetic stimulation (stress response), which contributes to hypertension. Plasmapheresis (see Chapter 35) can remove mediators, preventing preeclampsia from progressing to eclampsia or other complications (e. Animal studies with clear amniotic fluid are rarely symptomatic (Gin & Ngan Kee 1997), but uterine/cervical rupture (e. Pulmonary artery catheterisation can detect complications and enable the reduction of mortality (Vanmaele et al. Bleeding from normal third-stage labour is reduced by arterial constriction and the development of a fibrin mesh over the placental site; placental circulation, about 600 ml/minute at term (Lindsay 1997), is autotransfused by uterine contraction. Platelet activation causes thrombi in small blood vessels, while narrowed lumens trigger erythrocyte haemolysis, further reducing haemoglobin levels (aggravating hypoxia) and raising serum bilirubin levels (Turner 1997). Treatments include: ■ urgent delivery of fetus (induction, Caesarian section) (Sibai 1994) ■ antithrombotic agents (heparin, prostacyclin, fresh frozen plasma) Intensive care nursing 404 ■ plasmapheresis (removes circulating mediators) (Sibai 1994; Turner 1997) ■ system support (e. Although rare events, the admission of brain- dead mothers creates stress for families and places nurses in a similar (but more prolonged) situation to that of caring for organ donors (see Chapter 43). Drugs and pregnancy Additional considerations when giving drugs during pregnancy include: ■ will they cross the placenta? Antenatal admissions should consider fetal health; however, most admissions are postnatal and, as the precipitating cause (fetus/placenta) has been delivered, system support may be all that is required until homeostasis is restored, although some problems may require more aggressive treatments. Clinical scenario Elizabeth Franklin, a multiparous 37-year-old, presented in labour at 35 weeks gestation. Elizabeth was ventilated and intravenous infusions of hydralazene, magnesium, phenytoin were commenced. What modifications or adaptations to normal procedures are made for pregnant or postpartum patients and why? Consider how you would check their effectiveness and monitor for potential adverse effects or signs of toxicity. Chapter 43 Transplants Fundamental knowledge Brainstem and cranial nerve function Introduction Since the introduction of the immunosuppressant cyclosporin A and the University of Wisconsin preservation solution, transplantation has become a viable treatment for endstage failure of all major body systems (except the brain), and increasing numbers of other pathologies are treated by donor grafts (e. Yet increasing donor shortage is causing increased waiting time which, with endstage failure, often means increased mortality. Few centres currently perform lung transplantation; although the quality of life is improved (MacNaughton et al. Cadaver lungs are usually split, enabling two patients to receive transplants from one donor (Dark 1997). Brainstem death Historically, death was synonymous with cessation of breathing and/or heartbeat. The development of technologies to replace breathing (ventilators) and heartbeat (pacing) coincided with the transfer of organ donation from science fiction to science fact, necessitating a revision of the concepts of death. The brainstem, extending between the cerebrum and spinal cord and consisting of the pons, medulla oblongata and midbrain, contains the vital centres (respiratory, cardiac and other), so that if the brainstem is dead, higher consciousness and control cannot be regained. Any medical conditions that could prevent brainstem function must be excluded (see Table 43. The reflexes and responses of each cranial nerve are then tested (individually or in combination; see Table 43. If higher centre responses are absent, brainstem death may be diagnosed; any response from higher centres (however abnormal or limited) prohibits brainstem death diagnosis. The legal time of death is the first test, although death is not pronounced until confirmed by the second test (DoH 1998b). Timing between the two sets of tests is often relatively brief, partly to facilitate the presence of the same team and partly to reduce anxiety for families waiting for confirmation of death, but it should be long enough to ensure that the second set of tests is meaningful. The Human Tissues Act (1961) established that after death the body becomes the property of the next of kin, and so they must not object to the donation (Morgan 1995). The Human Organ Transplants Act (1989) legislated against making or receiving payment for organs so that unrelated living people cannot become donors during their lifetime (living related donors are discussed below). Nursing care Caring for donors and their families can be psychologically stressful. Unlike other terminal care, where (hopefully) peaceful death is followed by the last offices, the diagnosis of brainstem death is followed by the process of optimising organ function for harvest. While logical, this conflicts with normal nursing values where actions should be to the benefit of the patients being cared for. Once death has been diagnosed, and following harvest of the organ(s), the body is then normally transferred to the mortuary; the last offices (‘letting go’) are performed elsewhere. During this dehumanising experience, nurses are usually supporting the donor’s family; less than one-half of Watkinson’s (1995) sample of nurses found caring for donors to be a rewarding experience. In such potentially undignified situations, nurses should optimise their patient’s dignity, both before and after the diagnosis of death. Privacy can be helped by drawing curtains around patients’ beds or transferring them into siderooms. Relatives facing bereavement should be allowed to grieve; they may also gain comfort from knowing their loved one’s organs will help others to live. Relatives’ responses vary; transplant Intensive care nursing 410 coordinators are experienced at comforting relatives and may prove a valuable resource, although some relatives prefer to speak to staff with whom they have already established a strong rapport and trust. Donation criteria attempt to optimise the supply of viable transplantable organs/tissue without endangering recipients. What is viable varies with specific organs or tissue, but in many respects medical progress has enabled progressive relaxation of donation criteria. Normally, transplant coordinators can clarify whether potential donors meet the required criteria. Medical ethics requires that any treatment must be for the patient’s benefit: intubation and ventilation cannot be initiated in a living person solely to preserve organs for harvest (DoH 1998b). Donor pools are therefore largely limited to patients who are already being artificially ventilated (i. While reduced mortality is commendable, this has reduced organ availability for transplant. Austria, which operates a system of presumed consent, has the highest transplant rate in Europe (27. Inevitably, regional variations exist, sometimes from pragmatic considerations (e. Ethical issues Transplantation has always maintained a high public profile, ensuring widespread discussion of ethical issues. Organ donation relies on public goodwill, and so healthcare staff should encourage public awareness. Nurses experienced in caring for donors tend to Transplants 411 display more positive attitudes towards donation (Duke et al. Organ donation can literally be life-saving; the moral duty to facilitate transplantation creates dilemmas between whether the onus should fall on society or on individuals. Some nations, such as France, Belgium, Austria, Sweden and Norway, operate systems of presumed consent, whereby people have to actively opt-out if they do not wish to donate. Rather than asking relatives for their consent to organ donation, it would probably be preferable if they were asked to indicate their lack of objection (DoH 1998b); this change of approach could possibly reduce the incidence of relatives posthumously over-ruling a patient’s wishes, and might also reduce the feelings of guilt often experienced by relatives and ease the dilemma in which they find themselves. Except for Rastafarians, none of the major religions opposes organ donation (Randhawa 1997), although some ministers (e. Distressed relatives, facing inevitable bereavement, may not think to ask about organ donation, but may subsequently find not having been approached more stressful than being asked (Pelletier 1992). They should be approached openly, without coercion; the best time for doing this will be individual to each case, but the approach will probably benefit from Intensive care nursing 412 teamwork, possibly involving the transplant coordinators. It should be remembered, however, that if subsequent tests exclude the possibility of donation, relatives may then feel rejected, although, if criteria do prove problematic, the donation of tissue (e. It is normal for transplant coordinators to thank the donor families by letter, describing beneficiaries, without directly identifying them (for mutual safety). The letters are sent out at an early stage in case the recipients suffer rejection of the organs. Macro-economically, transplant surgery can be highly cost-effective by replacing the cost of years of chronic treatment (e. The Spanish transplant coordination services (established in 1989) employ a coordinator in every hospital (Talbot 1998), which enables closer supervision of potential donors and provides more support for staff. Thus, investment in the transplantation services may increase the supply of donor organs (although like Austria, Spanish road deaths in 1995 were 15 per 100,000 population (Caldwell et al. Live donors The limitation of cadaver organs has encouraged the use of live donors; this is especially true for renal transplants, but it is also the case for liver, lung and pancreas transplants. However, this experiment was ended by a Department of Health letter which stated that proxy consent was only valid when procedures were in a patient’s interest (Dunstan 1997). The British Transplantation Society protocols were subsequently amended in 1995, limiting elective ventilation for harvest to terminal conditions following spontaneous intracranial haemorrhage, preferably after cessation of spontaneous breathing (Dunstan 1997). Transplants 413 Asystolic donors Patients who do not survive cardiopulmonary resuscitation provide another source of potential donors. As warm ischaemia adversely affects the function of harvested organs, external compression pumps (mechanical cardiac compression) can perfuse organs until harvested, with oxygen provided through an endotracheal catheter or ventilation and metabolism reduced through induced hypothermia (Kootstra et al. Kootstra and colleagues report function (usually delayed) in 60 per cent of asystolic (non-heart- beating) donor kidneys. However, since asystolic donors will not have been diagnosed brainstem dead, some hospitals delay touching cadavers for a stated time (Kootstra et al. Xenografts Genetic engineering has made xenografting (animal tissue) a realistic option. Cloning could resolve the problems of supply, but macro-ethical concerns surrounding animal rights and genetic engineering were illustrated by ‘Dolly’ (the cloned sheep), and legislation on xenografting is currently being considered (Fulbrook & Wilkinson 1997). The possibility of widespread xenografting in the near future means that nurses need to clarify their own values on these issues. The (usually) close rapport with families enables nurses to offer valuable support during crises and discussion. Nurses are normally present during brainstem death testing, and so should be aware of the Code of Practice (DoH 1998b) and its requirements. Articles by transplant coordinators, such as Gibson (1996) and Morgan (1995), offer useful insights. Johnson (1992) outlines nursing care of donors and their families, while Randhawa (1997) provides a wider nursing review. Ethical dilemmas raised by non-therapeutic ventilation are discussed by Shaw (1996). While her condition was at its most critical her parents brought up the topic of organ donation (see scenarios for Chapters 31 and 41). How do you think such a request would be dealt with in your own clinical practice area? This chapter outlines early care following hepatic transplantation; while much care is similar to that of patients following any post-transplant care, hepatic surgery has been selected as it is performed at fewer centres than cardiac or renal transplantation. This chapter provides an insight for nurses unfamiliar with or new to post-transplant care. Most early hepatic transplants attempted to cure liver cancer, but the cancer usually recurred within two years (Klintmalm 1998). In recent years, a number of developments—namely, cyclosporin A, venovenous bypass and the University of Wisconsin preservation solution—have combined to make hepatic transplantation viable treatment for endstage failure. Although most patients develop complications, there is a one-year survival rate of 70–80 per cent (Reich et al. Ideally, grafts should be of a similar size (within 10 per cent) to that of the recipient’s premorbid one, but, as with other graft organs, the demand exceeds supply. Splitting livers between two or more recipients (Coinaud, a French surgeon, has divided a single liver into eight segments) can provide additional grafts (Malago et al. Despite recent advances in genetic engineering, xenografting remains experimental with hepatic complement production causing complications. Perioperatively, circulation is hyperdynamic, and major haemorrhage can occur peri- and postoperatively. Twenty units of blood are normally crossmatched, and clotting times should be closely monitored. In addition to an arterial line for monitoring, patients have a second (unheparinised) line for sampling; both lines remain in place postoperatively. The removal of positive pressure ventilation improves venous return and splanchnic perfusion, and removes one source of infection (ventilator-associated pneumonia). Complications Rejection is classified as follows: ■ Hyperacute rejection occurs within minutes of anastomosis, with pre-existing mediators provoking thrombotic occlusion of graft vasculature and irreversible ischaemia ■ Acute rejection occurs with necrosis of individual cells ■ Chronic rejection is caused by fibrosis and loss of normal organ structure Although hyperacute rejection is rare, the failure of grafts necessitates retransplantation. Most patients experience acute rejection; immunosuppression therapy usually enables graft survival, but predisposes patients to infection, especially from bacteria. Vascular occlusion (hepatic artery, portal vein) rapidly leads to hepatic necrosis, necessitating urgent retransplantation.


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Cell number is mainly determined by genetics; however antibiotic chart buy fucidin amex, when the existing number of cells have been used up antibiotics with or without food generic fucidin 10 gm line, new fat cells are formed from pre-existing preadipocytes antibiotic resistance symptoms generic fucidin 10 gm overnight delivery. Most of this growth in the number of cells occurs during gestation and early childhood and remains stable once adulthood has been reached antibiotic yellow teeth purchase fucidin without a prescription. Although the results from studies in this area are unclear antibiotic guide pdf fucidin 10 gm purchase fast delivery, it would seem that if an individual is born with more fat cells then there are more cells immediately available to fill up. In addition, research suggests that once fat cells have been made they can never be lost (Sjostrom 1980). An obese person with a large number of fat cells, may be able to empty these cells but will never be able to get rid of them. Appetite regulation A genetic predisposition may also be related to appetite control. Over recent years researchers have attempted to identify the gene, or collection of genes, responsible for obesity. Although some work using small animals has identified a single gene that is associated with profound obesity, for humans the work is still unclear. Two children have, however, been identified with a defect in the ‘ob gene’, which produces leptin which is responsible for telling the brain to stop eating (Montague et al. To support this, researchers have given these two children daily injections of leptin, which has resulted in a decrease in food intake and weight loss at a rate of 1–2 kg per month (Farooqi et al. Despite this, the research exploring the role of genetics on appetite control is still in the very early stages. Behavioural theories Behavioural theories of obesity have examined both physical activity and eating behaviour. Further, at present only 20 per cent of men and 10 per cent of women are employed in active occupations (Allied Dunbar National Fitness Survey 1992) and for many people leisure times are dominated by inactivity (Central Statistical Office 1994). Although data on changes in activity levels are problematic, there exists a useful database on television viewing which shows that whereas the average viewer in the 1960s watched 13 hours of television per week, in England this has now doubled to 26 hours per week (General Household Survey 1994). This is further exacerbated by the increased use of videos and computer games by both children and adults. In a survey of adolescent boys in Glasgow in 1964 and 1971, whereas daily food diaries indicated a decrease in daily energy intake from 2795 kcals to 2610 kcals, the boys in 1971 showed an increase in body fat from 16. This suggests that decreased physical activity was related to increased body fat (Durnin et al. To examine the role of physical activity in obesity, research has asked ‘Are changes in obesity related to changes in activity? This question can be answered in two ways: first using epidemiological data on a population and second using prospective data on individuals. In 1995, Prentice and Jebb presented epidemiological data on changes in physical activity from 1950 to 1990, as measured by car ownership and television viewing, and compared these with changes in the prevalence of obesity. The results from this study suggested a strong association between an increase in both car ownership and televi- sion viewing and an increase in obesity (see Figure 15. They commented that ‘it seems reasonable to conclude that the low levels of physical inactivity now prevalent in Britain must play an important, perhaps dominant role in the development of obesity by greatly reducing energy needs’ (Prentice and Jebb 1995). Therefore, it remains unclear whether obesity and physical activity are related (the third factor problem – some other variable may be determining both obesity and activity) and whether decreases in activity cause increases in obesity or whether, in fact, increases in obesity actually cause decreases in activity. In addition, the data is at the population level and therefore could miss important individual differ- ences (i. In an alternative approach to assessing the relationship between activity and obesity a large Finnish study of 12,000 adults examined the association between levels of physical activity and excess weight gain over a five-year follow-up period (Rissanen et al. The results showed that lower levels of activity were a greater risk factor for weight gain than any other baseline measures. However, although this data was pro- spective it is still possible that a third factor may explain the relationship (i. Unless experimental data is collected, conclusions about causality remain problematic. Research has also examined the relationship between activity and obesity using a cross-sectional design to examine differences between the obese and non-obese. In particular, several studies in the 1960s and 1970s examined whether the obese exercised less than the non-obese. They reported that during swimming the obese girls spent less time swimming and more time floating, and while playing tennis the obese girls were inactive for 77 per cent of the time compared with the girls of normal weight, who were inactive for only 56 per cent of the time. In addition, research indicates that the obese walk less on a daily basis than the non-obese and are less likely to use stairs or walk up escalators. However, whether reduced exercise is a cause or a consequence of obesity is unclear. The relationship between exercise and food intake is complex, with research suggesting that exercise may increase, decrease or have no effect on eating behaviour. For example, a study of middle-aged male joggers who ran approximately 65km per week, suggested that increased calorie intake was related to increased exercise with the joggers eating more than the sedentary control group (Blair et al. However, another study of military cadets reported that decreased food intake was related to increased exercise (Edholm et al. Much research has also been carried out on rats, which shows a more consistent relationship between increased exercise and decreased food intake. However, the extent to which such results can be generalized to humans is questionable. For example, 10 minutes of sleeping uses up to 16 kcals, standing uses 19 kcals, running uses 142 kcals, walking downstairs uses 88 kcals and walking upstairs uses 229 kcals (Brownell 1989). In addition, the amount of calories used increases with the individual’s body weight. However, the number of calories exercise burns up is relatively few com- pared with those in an average meal. However, only intense and prolonged exercise appears to have an effect on metabolic rate. There appears to be an association between population decreases in activity and increases in obesity. In addition, prospective data support this association and highlight lower levels of activity as an important risk factor. Further, cross-sectional data indicate that the obese appear to exercise less than the non-obese. It is possible that an unidentified third factor may be creating this association, and it is also debatable whether exercise has a role in reducing food intake and promoting energy expenditure. However, exercise may have psychological effects, which could benefit the obese either in terms of promoting weight loss or simply by making them feel better about themselves (see Chapter 7 for the effects of exercise on mood). Eating behaviour In an alternative approach to understanding the causes of obesity, research has exam- ined eating behaviour. Research has asked ‘Are changes in food intake associated with changes in obesity? The results from this data- base illustrate that, although overall calorie consumption increased between 1950 and 1970, since 1970 there has been a distinct decrease in the amount we eat (see Figure 15. Prentice and Jebb (1995) examined the association between changes in food intake in terms of energy intake and fat intake and changes in obesity. Their results indicated no obvious association between the increase in obesity and the changes in food intake (see Figure 15. Therefore, using population data there appears to be no relationship between changes in food intake and changes in obesity. Throughout the 1960s and 1970s theories of eating behaviour emphasized the role of food intake in predicting weight. Original studies of obesity were based on the assumption that the obese ate for different reasons than people of normal weight (Ferster et al. Schachter’s externality theory suggested that, although all people were responsive to environmental stimuli such as the sight, taste and smell of food, and that such stimuli might cause overeating, the obese were highly and sometimes uncontrollably responsive to external cues. It was argued that normal weight individuals mainly ate as a response to internal cues (e. Within this per- spective, research examined the eating behaviour and eating style of the obese and non- obese in response to external cues such as the time of day, the sight of food, the taste of food and the number and salience of food cues (e. Research exploring the amount eaten by the obese has either focused on the amount consumed per se or on the type of food consumed. Because it was believed that the obese ate for different reasons than the non-obese it was also believed that they ate more. Research therefore explored the food intake of the obese in restaurants and at home, and examined what food they bought. They weighed all members of the families and found no relationship between body size and the mass and type of food they consumed at home. In an attempt to clarify the problem of whether the obese eat more than the non-obese, Spitzer and Rodin (1981) examined the research into eating behaviour and suggested that ‘of twenty nine studies examining the effects of body weight on amount eaten in laboratory studies. Therefore, the answer to the question ‘do the obese eat more/differently to the non- obese? Over recent years, research has focused on the eating behaviour of the obese not in terms of calories consumed, or in terms of amount eaten, but more specifically in terms of the type of food eaten. Population data indicates that calorie consumption has decreased since the 1970s and that this decrease is unrelated to the increase in obesity (see Figures 15. However, this data also shows that the ratio between carbohydrate consumption and fat consumption has changed; whereas we now eat less carbohydrate, we eat proportionally more fat (Prentice and Jebb 1995). One theory that has been developed is that, although the obese may not eat more than the non-obese overall, they may eat proportionally more fat. Further, it has been argued that not all calories are equal (Prentice 1995) and that calories from fat may lead to greater weight gain than calories from carbohydrates. To support this theory, one study of 11,500 people in Scotland showed that men consuming the lowest proportion of carbohydrate in their diets were four times more likely to be obese than those consuming the highest pro- portion of carbohydrate. A similar relationship was also found for women, although the difference was only two- to three-fold. Therefore, it was concluded that relatively lower carbohydrate consumption is related to lower levels of obesity (Bolton-Smith and Woodward 1994). A similar study in Leeds also provided support for the fat proportion theory of obesity (Blundell and Macdiarmid 1997). This study reported that high fat eaters who derived more than 45 per cent of their energy from fat were 19 times more likely to be obese than those who derived less than 35 per cent of their energy from fat. Therefore, these studies suggest that the obese do not eat more overall than the non-obese, nor do they eat more calories, carbohydrate or fat per se than the non- obese. But they do eat more fat compared with the amount of carbohydrate; the proportion of fat in their diet is higher. As a possible explanation of these results, 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.

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Hall reflected on or her medical antibiotic list drugs fucidin 10 gm on line, surgical infection ear 10 gm fucidin purchase with visa, and rehabilitative care in the value of the therapeutic use of self by the pro- the role of comforter and nurturer infection x private server 10 gm fucidin amex. What made the love and trust the patient enough to work with him Loeb Center uniquely different was the model of professional nursing that was implemented under Lydia Hall’s guidance antimicrobial keyboard covers fucidin 10 gm low price. The center’s guiding philos- The nurse who knows self by the same ophy was Hall’s belief that during the rehabilitation token can love and trust the patient phase of an illness experience liquid antibiotics for acne fucidin 10 gm without a prescription, professional nurses enough to work with him professionally, were the best prepared to foster the rehabilitation rather than for him technically, or at him process, decrease complications and recurrences, vocationally. Her goals cease being tied up with She saw this being accomplished by the “where can I throw my nursing stuff around,”or “how special and unique way nurses work with can I explain my nursing stuff to get the patient to do patients in a close interpersonal process what we want him to do,” or “how can I understand with the goal of fostering learning, growth, my patient so that I can handle him better. In She saw this being accomplished by the special and this way, the nurse recognizes that the power to heal unique way nurses work with patients in a close in- lies in the patient and not in the nurse unless she is terpersonal process with the goal of fostering learn- healing herself. At the Loeb Center, ability to help the patient tap this source of power in nursing was the chief therapy, with medicine and his continuous growth and development. A new comes comfortable working cooperatively and con- model of organization of nursing services was im- sistently with members of other professions, as she plemented and studied at the center. Hall stated: meshes her contributions with theirs in a concerted program of care and rehabilitation. She will facilitates the interpersonal process and invited the be involved not only in direct bedside care but she will patient to learn to reach the core of his difficulties also be the instrument to bring the rehabilitation while seeing him through the cure that is possible. Specialists in re- Through the professional nursing process, the pa- lated therapies will be available on staff as resource tient has the opportunity of making the illness a persons and as consultants. The 80-bed unit The Loeb Center for Nursing was staffed with 44 professional nurses employed and Rehabilitation around the clock. Professional nurses gave direct patient care and teaching and were responsible for Lydia Hall was able to actualize her vision of nurs- eight patients and their families. Senior staff nurses ing through the creation of the Loeb Center for were available on each ward as resources and men- Nursing and Rehabilitation at Montefiore Medical tors for staff nurses. The center’s major orientation was rehabil- nurses there was one nonprofessional worker called itation and subsequent discharge to home or to a a “messenger-attendant. Doctors referred patients to the center, and Instead, they performed such tasks as getting linen a professional nurse made admission decisions. Morning and evening shifts were the teachings of Harry Stack Sullivan, Carl Rogers, staffed at the same ratio. Nurses were taught to less; however, Hall (1965) noted that there were use a nondirective counseling approach that em- “enough nurses at night to make rounds every hour phasized the use of a reflective process. Within this and to nurse those patients who are awake around process, it was important for nurses to learn to the concerns that may be keeping them awake” know and care for self so that they could use the self (p. In most institutions of that time, the number therapeutically in relationship with the patient of nurses was decreased during the evening and (Hall, 1965, 1969). Hall reflected: night shifts because it was felt that larger numbers If the nurse is a teacher, she will concern herself with of nurses were needed during the day to get the the facilitation of the patient’s verbal expressions and work done. Hall took exception to the idea that will reflect these so that the patient can hear what he nursing service was organized around work to be says. Through this process, he will come to grips with done rather than the needs of the patients. Lydia Hall directed the Loeb Center from 1963 Rather than strict adherence to institutional rou- until her death in 1969. Genrose Alfano succeeded tines and schedules, patients at the Loeb Center her in the position of director until 1984. At this were encouraged to maintain their own usual pat- time, the Loeb Center became licensed to operate as terns of daily activities, thus promoting independ- a nursing home, providing both subacute and long- ence and an easier transition to home. Additionally, Center, its daily operations, and the nursing work there were no doctor’s progress notes or nursing that was done from 1963 to 1984 (Alfano, 1964, notes. Instead, all charting was done on a form en- 1969, 1982; Bowar, 1971; Bowar-Ferres, 1975; titled “Patient’s Progress Notes. Hall believed that what was important to record was the patient’s progress, Implications for not the duties of the nurse or the progress of the Nursing Practice physician. Patients were also encouraged to keep their own notes to share with their caregivers. The stories and case studies written by nurses who Referring back to Hall’s care, core, and cure worked at Loeb provide the best testimony of the model, the care circle enlarges at Loeb. The cure cir- implications for nursing practice at the time cle becomes smaller, and the core circle becomes (Alfano, 1971; Bowar, 1971; Bowar-Ferres, 1975; very large. Griffiths and Wilson-Barnett (1998) the patient’s person through the closeness of inti- noted: “The series of case studies from staff at the mate bodily care and comfort. The interpersonal Loeb illustrate their understanding of this practice process established by the professional nurse dur- and describe a shift in the culture of care both be- ing the provision of care was the basis for rehabili- tween nurses and patient and within the nursing tation and learning on the part of the patient. Before hiring, the phi- tors included economic incentives that favored losophy of nursing and the concept of professional keeping the patient in an acute care bed, and the practice were discussed with the applicant. Alfano difficulties encountered in maintaining a popula- stated: “If she agrees to try the nondirective ap- tion of short-term rehabilitation patients in the ex- proach and the reflective method of communica- tended care unit. Pearson (1984) suggested that the tion, and if she’s willing to exercise all her nursing philosophy of the center may have been “threaten- skills and to reach for a high level of clinical prac- ing to established hierarchies and power relation- tice, then we’re ready to join forces” (1964, p. Administration its time” and that dissatisfaction with nursing worked with nurses in the same manner in which homes, the nation’s excess hospital bed capacities, they expected nurses to work with patients, empha- and an increasing emphasis on rehabilitation might sizing growth of self. Bowar (1971) described the contribute to replication of the Loeb model in the role of senior resource nurse as enabling growth future. Two Staff conferences were held at least twice weekly British nurses, Peter Griffiths and Alan Pearson, as forums to discuss concerns, problems, or ques- both traveled to the Loeb Center in preparation for tions. In a comprehensive review of the published by nurses who worked at Loeb describe literature, Griffiths and Wilson-Barnett (1998) nursing situations that demonstrate the effect of identify several nursing-led in-patient units, in- professional nursing on patient outcomes. The operational definition of nursing-led 1971; Bowar, 1971; Bowar-Ferres, 1975; Englert, in-patient units derived from this study includes 1971). Alfano stated: “The successful implementa- the following characteristics: tion of the professional nursing role at Loeb was 1. In-patient environment offering active treat- associated with an institutional philosophy of nurs- ment ing autonomy and with considerable authority 2. Case mix based on nursing need afforded clinical nurses in their practice” (1982, 3. The model of professional nursing practice cal team developed at Loeb has been compared to primary 4. Nursing is conceptualized as the predominant nursing (Griffiths & Wilson-Barnett, 1998). Nurses have authority to admit and discharge Loeb Center was not replicated in other facilities. Foremost among these was her belief that many people were not convinced that it Unencumbered at the present time by the finan- was essential for professional nurses to provide di- cial constraints of the American health-care sys- rect patient care. Additionally, she postulated that tem, the potential for the further development of others did not share the definition of the term “pro- nursing-led in-patient centers in the United fessional nursing practice” that was espoused by Kingdom seems promising. In doing so, we will begin to understand the re- Nursing Research sources and methods of nursing care necessary to ensure positive patient outcomes. In addition to case study research by nurses who worked at Loeb, an 18-month follow-up study of the outcomes of care was funded by the Depart- ment of Health, Education and Welfare. Currently, nurses practice in a health-care en- The purpose of the longitudinal study was to com- vironment driven by financial gain, where pare selected outcomes of two groups of patients quality is sacrificed and the patient is lost in a exposed to different nursing environments (the world of mismanaged care. Outcomes ex- these alarming trends indicate a need to re- amined were cost of hospital stay, hospital readmis- turn to the basic premise of Hall’s philoso- sions, nursing home admissions, mortality, and phy—patient-centered, therapeutic care. Overall, find- According to Griffiths (1997a), however, the ings suggested that the Loeb group achieved better Loeb Center presently reflects little resem- outcomes at less overall cost. It now provides part subacute and part long-term care and, in fact, appears remarkably like the kind of sys- Overall, findings suggested that the Loeb tem that Hall was trying to alter. Nursing is group achieved better outcomes at less bogged down in a morass of paperwork, and overall cost. How would Lydia Hall react to these con- The findings of several other studies in nurse- ditions, and what response might we expect if led units lend further support to the benefit of the she spoke with us today? We believe she structure to patient outcomes, including preven- would be appalled by the diminished pres- tion of complications (Daly, Phelps, & Rudy, 1991; ence of professional nurses in health-care fa- Griffiths, 1996; Griffiths & Wilson-Barnett, 1998; cilities and the impediments confronting Rudy, Daly, Douglas, Montenegro, Song, & Dyer, those who remain. There is a critical need for research examin- to explore new ways to provide needed nurs- ing the effect of professional nursing care on pa- ing care within an existing chaotic climate. In a recent study She would lead us in challenging the status involving 506 hospitals in 10 states, Kovner and quo and speak of the necessity for nursing Gergen (1998) reported that patients who have sur- leaders to have a clear vision of nursing prac- gery done in hospitals with fewer registered nurses tice and a willingness to advocate for nursing per patient run a higher risk of developing avoid- regardless of external forces seeking to un- able complications following their operation. Patients dresses outcomes of care and validates the in hospitals with fewer full-time registered nurses impact of professional nursing, particularly per in-patient day had a greater incidence of uri- in long-term care settings. She would agree nary tract infections, pneumonia, thrombosis, that the improvement of care to elders in pulmonary congestion, and other lung-related nursing homes is a significant ethical issue problems following major surgery. The authors for society and that nurses, the largest group suggested that these complications can be pre- of care providers to elders in nursing homes, vented by hands-on nursing practices and that this play a vital role in the improvement of care. Clinical outcomes for nurse-led in-patient this population consists only of bed and body care. The effectiveness of bly envision it as a means for highly educated “nursing beds”: A review of the literature. Journal of Advanced nurses to use their expertise more effectively Nursing, 27, 1184–1192. She would encourage advanced prac- dress before a meeting of the Department of Baccalaureate and Higher Degree Programs of the New Jersey League for tice nurses to continue to develop knowledge Nursing, February 7, 1955, at Seton Hall University, Newark, related to the nursing discipline and the New Jersey. Montefiore Medical Center Archives, Bronx, New unique contribution of nursing to the health York. Montefiore nity nursing organizations as an opportunity Medical Center Archives, Bronx, New York. Summary of project report: Loeb for nurses to coordinate and deliver continu- Center for Nursing and Rehabilitation. Summary of project report: Loeb Center Finally, she would urge nurses to recapture for Nursing and Rehabilitation. The Loeb Center for Nursing and Rehabilita- tion, Montefiore Hospital and Medical Center, Bronx, New York. Image: Journal of Nursing Scholarship, 30, Nursing Clinics of North America, 6, 273–280. Record Hearings before the Special Subcommittee on Intermediate Care of the Committee on Veterans’ Affairs. Josephine Paterson is originally from the East were the positions they held when I met them as a Coast where she attended a diploma school of graduate student in psychiatric mental health nurs- nursing in New York City. Paterson agreed to work with me as my her bachelor’s degree in nursing education from St. In her graduate work at Johns The following two years brought me a world of Hopkins University, she focused on public health enrichment. Zderad, those nursing and then earned her doctor of nursing sci- years culminated in their retirement and relocation ence degree from Boston University. She later spired me to carry on their work, using it in my earned her bachelor’s degree in nursing education nursing situations, whether in clinical, administra- from Loyola University of Chicago. In her graduate tive, or most recently, with nursing students, and to work she majored in psychiatric nursing at the share what I have come to know. She subsequently The Humanistic Nursing Theory was originally earned her doctor of philosophy from Georgetown formulated as a way for nurses to define nursing. That is, a way to illuminate the values and mean- Josephine Paterson and Loretta Zderad met in ings central to nursing experiences. Zderad were nursing visionaries who emphasized Their joint project was to create a new program synthesis and wholeness rather than reduction and that would encompass the community health com- logical/mathematical analysis. They challenged the ponent and the psychiatric component of the notion that the reductionistic approach is the graduate program. This started a collaboration, di- touchstone of explanatory power, and they postu- alogue, and friendship that has lasted for over 45 lated an “all-at-once” character of existence in years. They shared and developed their concepts, nurses’ experiences of being in the world. They led approaches, and experiences of “existential phe- the way to many of the contemporary nursing the- nomenology,”which evolved into the formal Theory ories that emphasize the caring aspects of nursing of Humanistic Nursing. It speaks to the essences of nursing and embraces They were hired as “nursologists” by a forward- the dynamics of being, becoming, and change. It is also a theory that provides a three-pronged approach to the improvement of pa- methodological bridge between theory and practice tient care through clinical practice, education, and by providing a broad guide for nursing “dialogue” research. Nursing, as seen through Humanistic Nursing They worked with the nurses at Northport from Theory, is the ability to struggle with another 1971 until 1978 on this project, running workshops through “peak experiences related to health and suf- that incorporated their theory. In 1978 there was a fering in which the participants are and become in change in hospital administration that entailed a accordance with their human potential” (Paterson reorganization of services. According to Josephine Paterson and community, or from humanity for help Loretta Zderad, in nursing, the purpose of this dia- with some health-related issue. A nurse, a logue, or intersubjective relating, is, “nurturing the group of nurses, or the community of well-being and more-being of persons in need” nurses hearing and recognizing that call respond in a manner that is intended to In nursing, the purpose of this dialogue, or help the caller with the health-related intersubjective relating, is,“nurturing the need. What happens during this dialogue, well-being and more-being of persons in the “and” in the “call and response,” the need. Humanistic Nursing Theory is dialogue, the “and” in the “call and response,” the grounded in existentialism and emphasizes the “between,” is nursing. The method is phenomenological in- The new adventurer in Humanistic Nursing quiry (Paterson & Zderad, 1976 p. Engaging Theory may at first find some of these terms and in the phenomenological process sensitizes the in- phrases awkward. When I spoke to a colleague of quiring nurse to the excitement, anticipation, and the “moreness” and of “relating all at once,” she re- uncertainty of approaching the nursing situation marked, “Oh, oh, you’re beginning to sound just openly.

Potentially treatment for dogs eating chocolate purchase fucidin on line, a newly board-certifed forensic odontologist can appear in court to testify in only the second bitemark case for which he or she is the primary investigator virus 85 cheap 10 gm fucidin. He or she would be testifying to material that may infuence a jury that has the ability to sentence a person to punishments that include loss of liberty and antimicrobial on air filters studies about cheap fucidin 10 gm without prescription, in federal courts and some state courts infection tattoo generic fucidin 10 gm line, death antimicrobial resins best order for fucidin. As stated in Chapter 14, the authors and editors are of the opinion that the current requirements do not provide or ensure a level of experience in bite- mark analysis, bitemark case management, and expert witness testimony to justify this level of responsibility. Currently boarded forensic odontologists must be tested for profciency in all phases of forensic dentistry in a manner that realistically tests their knowledge and skill and periodically be retested to ensure that they are remaining current and profcient. Te above-mentioned “causes” of the past have manifested a present forensic odontology that can only be classifed as a 410 Forensic dentistry “mixed bag. Many individuals and families have expressed their gratitude to forensic dentists who have helped with difcult problems at difcult times. Tey cannot disregard that those mistakes have severely and negatively impacted fellow humans’ lives. Te wrongful conviction of a person for any crime not only deprives the innocent person of freedom or life but also leaves the actual criminal free to commit similar or worse mayhem—again. Giving an expert opinion that connects a person in a cause-efect relationship to criminal activity is a tremendous responsibility that all forensic odontolo- gists must consider very seriously. Te challenge to forensic odontologists is to embrace the positive accom- plishments of the past, study and understand the errors that have occurred, and make the needed changes now, in the present, to optimize the future of forensic dentistry. Tose changes include ensuring that scientifc research is encour- aged, supported, and performed to substantiate the procedures promoted and approved by forensic dentists and forensic odontology organizations. Te forensic odontology certifying organizations must ascertain that their policies and procedures promote and ensure the highest levels of profciency possible. If these difcult but necessary steps are taken, the future of forensic den- tistry should remain deservedly bright. With the concerted efort of those involved in the forensic sciences and forensic odontology, the editors are con- fdent in the bright future of forensic odontology. State, 411 responsibility, 361 423 424 index Attrition cases, 306–332 age progression and, 288 chronology of, 306–308 crown changes and, 283 management of, 337–351 extensive, 283 evidence analysis in, 344–348 occlusal, 281, 286 evidence collection in, 337–344 Automated Fingerprint Identifcation injury vs. State, 417 preparing for, 396 “Bar code” efect, 152 recording and collecting in, Bass v. See Skeletal remains Caries, 28, 283, 293 Booth, John Wilkes, 17 interproximal, 190 Bouie v. State, 412 multicolored, 376 ChemFinder, 125 photographing, 208 Child abuse, 370 Bufin v. State, 414 Quality Assurance Standards, 113 Cremains, 180, 183, 392 Commonwealth v. State, 22, 307, 308–309, 365, 390, conducting fnal survey in, 403–404 391, 393, 411 diagram or sketch, 399–401 Doyle v. State, 420 399 Drug intoxication, 55 preparing for, 396 Drug-related death, 51, 55 recording and collecting in, 402–403 DuBoise v. State, 415 Forensic dentist(s) Friction ridge skin, 83–84 civil litigation and, 385–388 bifurcations, 84 as defendants, 388 comparison and identifcation of as expert witness defendants, 390 impressions of, 86–89 as expert witnesses, 388 detail and structure, 84 as fact witnesses, 388 dividing ridges, 84 malpractice, 381, 386, 388–389 ending ridges, 84 personal injury litigation, 389–390 individuality, 88–89 Forensic dentistry inspecting and cleansing, 90 certifying organizations and methodology in examination of, 86–87 certifcation, 407–409 analysis, 86 dry fngered, 25 comparison, 86–87 forensic identifcation and, 4–8 evaluation, 87 history, 12–23 exclusion, 87 legal issues in, 384–392 individualization, 87 case law, 390–392 verifcation, 87 civil litigation, 385–388 persistency, 89 expert witnesses, 384–385 reconditioning compromised, 90–94 index 431 recording postmortem impressions, Human identifcation. See Identifcation of 94–96 remains ridge arrangements, 84–85 Human remains substructure, 84 adolescent, 144 Frye v. State, 419 of children, 144 fetal, 144 G medicolegal signifcance, 140 of young adults, 144 Garrison v. State, 414 age determination in, 144–146 Gross, Winfeld, 16–17 birthmarks in, 67 Guerin, 14 circumstances of death as aid to , 64–65 Gunshot injury, 150–151 establishing positive, 63–64 Gustafson method, 281–284 external characteristics in, 66–70 fngerprints and, 79–100 (See also H Fingerprint(s)) human vs. Constitution and, 382 Incised wound, 345 criminal litigation, 380 Injured skin, 207–211 Liquid chromatography mass spectrometry Injury patterns, 203–204 analyzer, 55 in blunt trauma, 374 Litaker v. State, 412 Missing Person File, 75 Milone, Richard, 320–322 Unidentifed Person File, 75 Milone v. Milone, 307, 312, 316, 320–322, Organ dissection, 54 366, 411 Osteon fragments, 146 People v. Krone, 308, 316 112, 130–131 index 435 Pregnancy, abuse during, 371–372 Shoulder, bitemarks, 221, 230, 337, 347, 374 Pseudoborne objects, 139 Simmons v. Sager, 411 root resorption, 283 index 437 root transparency, 283 Unidentifed persons, 76 secondary dentin, 282 United State v. Randolph Valentino Kills in Water, Tooth decay, 182 419 Tooth eruption/tooth emergence, 264–269 U. Studnicka, 420 Tooth mineralization, 269–279 Tooth numbering system, 20 Tooth wear, 286–288 V Torgerson, Frederick Fasting, 316–320 Valenti v. State, 421 death-induced, 45, 50, 55 Vinyl polysiloxane, 340 detection, 55 disfgurement due to , 61 emotional, of family members, 164 W evidence, 53 Wade v. State, 413 facial, 61, 164, 369, 375 Walsh, Caroline, 14 inficted, 370, 372 Walters v. State, 418 perimortem, 150–154 Warren Joseph, 13 postmortem, 154–155 Washington v. Several programs are available that provide three-dimensional rendering of the soft tissue. There are two green sensitive pixels for each red and blue pixel because the human eye is more sensitive to green. Strickland, Executive editor While every effort has been made to ensure the reliability of the infor- mation presented in this publication, Gale Group does not guarantee the accuracy of the data contained herein. Errors brought to the attention of the Christine Jeryan, Managing editor publisher and verified to the satisfaction of the publisher will be cor- Melissa C. Deirdre Blanchfield, Assistant editor This publication is a creative work fully protected by all applicable Mark Springer, Editorial Technical Trainer copyright laws, as well as by misappropriation, trade secret, unfair com- petition, and other applicable laws. Yarrow, Manager, Multimedia and imaging have added value to the underlying factual material herein through one content or more of the following: unique and original selection, coordination, Robyn V. Young, Senior editor, Imaging acquisitions expression, arrangement, and classification of the information. Robert Duncan, Senior imaging specialist All rights to this publication will be vigorously defended. Kenn Zorn, Product design manager Copyright 2001 Marie Claire Krzewinski, Cover design Gale Group Marie Claire Krzewinski and Michelle DiMercurio, 27500 Drake Rd. Melson, Buyer Tables by Mark Berger, Standley Publishing, Ferndale, Library of Congress Cataloging-in-Publication Data Michigan The Gale encyclopedia of psychology / Bonnie R. Slap Dianne Daeg de Mott Jane Spear Jill De Villiers Laurence Steinberg Marie Doorey Judith Turner Catherine Dybiec Holm Cindy Washabaugh Lindsay Evans Janet A. This number repre- • See also references at the end of entries point the sents one-third more entries than the first edition. Almost terms is included to help the reader understand key 65% of the entries are entirely new or updated concepts. Almost everyone seems interested in understand- first looked at the stars to predict and control their des- ing his or her own behavior, as well as the actions of oth- tiny and the science of astronomy was born. Psychology is, by far, the most popular of the social ics was necessary to count and measure, and eventually and behavioral sciences and one of the most attractive to the physical sciences, such as physics, chemistry, and bi- those who are interested in knowing more about people ology, emerged. It has only been a bit over a centu- gy has been one of the most popular majors for over ry since scientists and philosophers turned their eyes three decades, and students are more likely to take an from the planets to people and tried to understand human elective course in psychology than one from any other behavior in a systematic, scientific way. Not surprisingly, psychology has also become a century, philosophers and physiologists began to exam- popular high school offering. How do individuals use their senses of Initially, psychology courses at the secondary school sight, hearing, and touch to make sense of the world? We are living in In the late second half of the 1800s, a number of times of dramatic social change. Each of us continually young North American men and a few women traveled faces new challenges about how we will make our place in to Germany to study with Wilhelm Wundt, who had es- the world. As the discipline of psychology matured, ad- tablished a laboratory and the first graduate program of justment courses gave way to substantive content courses study in psychology at the University of Leipzig in Ger- that offered not just psychology’s latest findings about de- many. They returned to teach psychology and train other velopmental and identity issues, but also featured those students in the major universities of this country with the more traditional areas of cognitive, experimental, physio- intent of quantifying individual differences and impor- logical, and social psychology. The advances in the scientific side lished a Psychological Clinic at the University of Penn- of psychology were paralleled by the remarkable growth sylvania to help children who were having difficulty in of counseling, clinical, and school psychology. To keep up with the rapidly expanding field, the Being a psychologist, he assumed that his new pro- newly revised second edition of the Gale Encyclopedia fession—dedicated to learning and memory—would of Psychology has added about a third more entries and help him assist children who were having trouble read- biographies. Coverage includes the key concepts on ing, writing, spelling, and remembering information. Clinical information is broadly plex, theoretical notions within the experimental labora- covered, noting the various psychological theories and tories, and he turned to schoolteachers and social work- techniques currently in use and the scientific evidence ers for practical advice. Biographical profiles of major figures in the field of psychology are included, ranging from the Thus began the long struggle between the scientific earliest historical pioneers to current clinicians. On the battle- experiments are valid and replicable (that is, others pur- field, clinicians were helping troops who were experienc- suing the same questions with appropriate methods ing “traumatic neurosis, ” originally called “shell shock” would find the same results). They sometimes feel that in the First World War and now known as post-traumatic clinicians, for example, use psychotherapy techniques stress disorder. When the soldiers returned home, they led that have not been proven to be useful and may even be therapy groups for wounded military personnel. The Veteran’s Hospitals, in The earliest psychologists worked primarily with chil- particular, needed well-trained personnel to provide men- dren, usually those who were delinquent or having trouble tal health services for their patients. They were particularly taken with assessing in- ence held in Boulder, Colorado established standards of telligence and translated a test developed by a Frenchman, education and training for clinical psychologists. They began testing soldiers recruited for the First internship and receive the Ph. According to their tests, they found almost half of newer of training are available for students who want to the young, white male recruits and some 80% of Eastern place more emphasis on practice and less on doing re- European immigrants to be “morons. In addition to university graduate programs, a think the uses of intelligence tests, especially because of large number of professional schools have been estab- opinions like that of journalist Walter Lippman, who rec- lished, often offering a Psy. D (doctor of psychology) de- ommended that the “intelligence testers and their tests gree. Currently, some 4,000 students graduate each year should be sunk without warning in the… sea. The over- denied entrance into this country, and intelligence testing whelming majority of these graduates go into clinical or laid the base for human eugenics laws that allowed individ- applied work, although changing conditions in the health uals who were found “intellectually unfit” to be sterilized. With the introduction of psy- A field as broad as psychology, which stretches from choanalysis into this country, people wanted to “adjust” the study of brain cells to that of prison cells, is an active, through self-examination and the probing of the uncon- argumentative, and exciting adventure that offers oppor- scious. The scientific psychologists were dismayed at the tunities in science, practice, and social policy. Most of the excesses of pseudopsychologists, whose ranks included pressing economic and social issues of our generation, mind readers and charlatans. Psychological clinicians such as the environment, health needs, poverty, and vio- were concerned as well and took steps to develop a stan- lence, will only be alleviated if we understand the ways in dard of ethics and ways of identifying appropriately which people create or creatively solve the problems that trained psychologists. The student who is interested in unraveling the secrets of the human brain to see the mind With the advent of the Second World War, psycholo- at work, who is fascinated about how children grow up gists joined the military effort and were surprised them- and become competent adults, who is dedicated to bring- selves by how much they had to offer. Human factors psy- ing people together to resolve conflict, who is committed chologists designed airplane cockpits and the lighting on to helping people with physical, emotional, or behavioral runways that we still use today. Gestalt psychologists difficulties, or who is challenged by the desire to develop taught American citizens how to identify enemy planes social policy in the public interest is welcomed in psy- should they fly overhead. We hope this encyclopedia will provide useful guide missiles toward enemy targets. Psychologists information that will help students and others understand worked for the Office of Strategic Services (which eventu- this fascinating field and its opportunities. Division of Clinical Psychology and the American Asso- She has been on the faculties of Emory University and the ciation for Applied and Preventive Psychology; she was a University of Massachusetts in Amherst as a teacher, re- Founder and on the first Board of Directors of the Ameri- searcher, administrator, clinician, and consultant. An advocate for minority con- Diplomate in Clinical Psychology, she has also been in cerns, she has published more than a hundred scholarly practice for over 35 years. Abnormal behavior is defined as behavior that is The capacity to learn, commonly known as aptitude, considered to be maladaptive or deviant by the social and the demonstration of skills and knowledge already culture in which it occurs. Though disagreement exists learned, called achievement, are among the factors used regarding which particular behaviors can be classified as to evaluate intelligence. When evaluating or comparing abnormal, psychologists have defined several criteria for subjects, two kinds of abilities are considered: verbal purposes of classification. One is that the behavior oc- ability, including reading comprehension, ability to con- curs infrequently and thus deviates from statistical verse, vocabulary, and the use of language; and problem- norms. Another is that the behavior deviates from social solving ability, which includes a person’s capacity to norms of acceptable behavior. Lastly, abnormal- Relatively straightforward tests of ability are often ity may be defined based on the subjective feelings of used by employers to determine an applicant’s skills. For misery, depression, or anxiety of an individual rather example, a person applying for a job as a word processor than any behavior he exhibits. See also Achievement tests; Scholastic Assessment Test; Stanford-Binet intelligence scales; Vocational Apti- While psychologists use similar criteria to diagnose tude Test abnormal behavior, their perspectives in understanding and treating related disorders vary greatly. For instance, Further Reading a psychologist with a psychoanalytic approach would ex- Atkinson, Rita L. And a psychologist While abortion is practiced throughout society, in all with a biological perspective would consider a chemical socioeconomic strata, poor women are three times more imbalance in the nervous system of a depressed individ- likely to have an abortion than their well-off counterparts. Many studies have White women have 63% of all abortions, but the shown that a number of these factors may come into play non-white abortion rate is more than twice the white in the life of an individual suffering from a mental disor- rate—54 per 1,000 versus 20 per 1,000. Social reasons include fear of motherhood, fear of los- Personality Disorders and the Five-Factor Model of Personality. Abortion is a complex issue that raises a plethora of medical, ethical, political, legal, and psychological ques- Abortion tions, and is viewed by proponents and opponents as one of society’s fundamental problems. Invasive procedure resulting in pregnancy termina- Simmons has written (Butler and Walbert, 1992), “is re- tion and death of the fetus. More than half (53%) of the unplanned the two camps has been difficult, seemingly impossible, pregnancies happen among the 10% of women who prac- because opinions are often based on strong feelings and tice no contraception. An additional obstacle to dialogue is the fact that young: 55% are under 25, including 21% teenagers. Pro-life discourse often draws its strength from the Christian axiom about the sanctity of life, while pro- choice thinking proceeds from the belief that an individ- ual woman has the freedom to act in her best interest. Vulsellum Vagina While vulnerable to moral condemnation, and even ha- rassment, adult women have the protection of liberal legisla- Uterus tion in seeking an abortion (in Roe v.

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Ayitos, 56 years: Adefovir is eliminated antiviral activity, namely 2 5-oligoadenylate synthetase (which unchanged by the kidney with a mean elimination t1/2 of 5–7. Creativity tests have Crisis or suicide hotlines offer immediate support to also been criticized for unclear instructions, lack of suit- individuals in acute distress. All staff should wear gloves when in contact with the detainee or when handling clothing and bedding, and contaminated articles should be laundered or incinerated.

Zarkos, 28 years: Nurses also use pounds when calculating a dose that is based on a patient’s weight. Label the container using a lead pencil ™ Amies will help the pathogens to survive and from being overgrown by fast-multiplying commensas. It is considered to be involved in the microadjustment of the body condition, circulation and endocrine functions.

Baldar, 42 years: In doing so, the nurse must follow precautions to assure that the medication is administered safely. The ability to crawl, walk, and talk are procedures, and these skills are easily and efficiently developed while we are children despite the fact that as adults we have no conscious memory of having learned them. Images may have been collected with a Polaroid or other snapshot-type camera, perhaps without a scale or ruler, and at a distance and angle that precludes proper analysis.

Kapotth, 35 years: Kava-kava (see Chapter 10) is a recreational herb used widely by Pacific Islanders. Based on the possibility of civil litigation, prudence would dictate sufciently broad professional liability insurance coverage for these activities. He was known to say, “As many According to the introduction in the book’s trans- faiths, so many paths” and “Man’s upliftment is the lation by Swami Paramananda, these scriptures main goal in life.

Gelford, 64 years: Multivitamin/mineral complex: Ensures that your body will get all essential nutrients. In terms of habit, research indicates a role in explaining condom use (Trafimow 2000) and that habit reduces people’s use of information (Aarts et al. Ring, inguinal Aqueduct Adduction of fingers 395 – tympanic, of newborn 33 – cerebral 65, 73 ff, 86, 90, 94, 99, 112, 116, Adductor hiatus 453 Anus 350 ff, 354, 361 ff, 366 121 Adhesion, interthalamic 86, 107 Aorta 16 f – of cochlea 129 Adnexa of uterus 359 ff – abdominal 16, 210, 245, 256, 278, 292, 296, – of vestibule 27, 129 Air cells 300, 302, 329 ff, 348, 359 f Arachnoid mater 84 f, 89, 92, 100, 118 – ethmoidal 28, 36, 38, 41 f, 44 f, 48, 53, 135 – – subtraktion angiography 328 – spinal 230, 232, 474 – – openings 144 – ascending 243, 245, 252 ff, 260, 266, 272, Arbor vitae of cerebellum 94, 116 – mastoid 70, 125 ff 284, 396 Arch Ala s.

Kerth, 34 years: A 65-year-old man with a hearing skills: impairment: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. In some cases, the opposite occurs and food passage slows, causing dry, hard stools and constipation. A separate poses personal questions, the study begins when investigator agreement, specifying all responsi- those procedures are undertaken.

Finley, 61 years: However they are classified or regulated, Similar growth in R&D investment has been new therapeutic agents will continue to be needed, seen outside United States, for example in the health benefits to deliver now and to be potentially United Kingdom. Although those detained in police custody are usually young, there remains the potential for considerable morbidity and mortality among this group. Again, this model describes the individual as self-regulatory and as motivated to maintain the status quo.

Ningal, 29 years: Tese results counter balance the years of assured self-confdence shown by the dentists testifying on bite mark Bitemarks 357 evidence. He fills out a Thought Tracker (see “From Arraignment to Conviction: Thought Court” ear- lier in this chapter) and identifies his most malicious thought: “I’ll make a fool out of myself. At times you have serious doubts as to whether you have made the right decision or done the right thing.

Pavel, 57 years: The problem is that when we see others around, it is easy to assume that they are going to do something, and that we don‘t need to do anything ourselves. Since pharmaceutical medicine in United Kingdom (2), that time several similar courses have been founded Switzerland, Belgium, Spain (2) and Sweden. For example, from the name, pyridine, where the suffix is -ine, one can understand that this heterocyclic compound contains nitrogen, has a six- membered ring system and is unsaturated.

Leon, 54 years: Provide 24-hour services and hot lines for people who are suicidal, who are abusing e. To strike a balance between torsional strain and angle strain, and to achieve more stability, cyclohexane attains various conformations, among which the chair and boat conformations are most significant. They realize pain increases as the disease progresses and they are fearful that the medication will lose its effectiveness.

Tragak, 53 years: Sweat and salivary glands are not a major route of drug elimination because elimination depends on the diffusion of lipid-soluble drugs through the epithe- lial cells of the glands. Intestinal fluids are rich in water, sodium, potassium, and bicarbonate, and diarrhea can cause minor or severe dehydration and electrolyte imbalances. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement.

Karrypto, 51 years: It is often adulterated with other white powders, such as qui- Complete abstinence is emphasized for nicotine, alcohol or nine (which is bitter, like opiates), caffeine, lactose and even cocaine addiction, whereas for heroin addiction many patients chalks, starch and talc. For example, (À)-a-bisabolol and its derivatives have potent anti-inflammatory and spasmolytic proper- ties, and artemisinin is an antimalarial drug. The role of past behaviour Most research assumes cognitions predict behavioural intentions, which in turn predict behaviour.

Ismael, 38 years: Small alcohols are miscible with water, but solubility decreases as the size of the alkyl group increases. Thus, depending on the substrates E1 reaction forms a mixture of cis (Z) and trans (E) products. This Act requires employers to continue employment of a substance abuser as long as the employee can perform their job function and is not a threat to safety or property.

Dargoth, 48 years: Anthropologists are increasingly summoned by arson investigators for in situ examination and recovery of fragile remains prior to transport. Parse’s Theory of Human (Bunkers, Nelson, Leuning, Crane, & Josephson, Becoming is not a model for nursing practice that 1999; Williamson, 2000). Levodopa is a natural substance found in plants and animals that is converted into dopamine by nerve cells in the brain.

Kan, 21 years: Although people usually think of the biceps brachii in the arm, you can’t forget about the biceps femoris at the back of the thigh. Leukotriene Modifiers Bronchoconstrictors cause the contraction of smooth muscle around the bronchi restricting airflow to the lungs. C Top Recommended Supplements Digestive enzymes: May be depleted in those with celiac; they aid proper digestion of food and are particularly important in newly diagnosed individuals.

Norris, 63 years: This concept utilizes local chronic or acute infections with the aim of achieving inflammation surrounding, or direct infection of, tumor cells re- sulting in their cytolytic destruction. Although tradition- ally used to exclude matches, some have successfully employed video super- imposition to achieve positive identifcations when a complete skull and good quality photographs from several angles are available. However, there are basic consistencies in the goals and practice of good quality death investigation, and thanks to organizations such as the National Association of Medical Examiners, uniform medical practice standards and accredita- tion criteria are now published, serving as a benchmark for the nationwide evaluation of forensic pathology and death investigation practice.

Diego, 58 years: Middle Generativity versus The person develops an interest in guiding the development of adulthood 40 to 65 years stagnation the next generation, often by becoming a parent. Chemistry for Pharmacy Students Satyajit D Sarker and Lutfun Nahar # 2007 John Wiley & Sons, Ltd. Long-term Goal By time of discharge from treatment, client will demonstrate ability to carry on a verbal communication in a socially accept- able manner with staff and peers.

Ballock, 27 years: He has been a chef all his working life, without exception in fashionable restaurants. Studies related to safety pharmacology (sometimes Drug metabolism is a highly specialized field confusingly termed ‘general pharmacology’studies) and is increasing in sophistication all the time. Arguably, research-based approaches conflict with humanism’s fundamental beliefs in individualism; Rogers’ early work did attempt to adapt traditional scientific research processes to humanism, but his later work adopts more discursive, subjective approaches.

Ford, 45 years: They are synthesized in glands and delivered by the bloodstream to target tissues to stimulate or inhibit some process. At the anterior end (head end), the oral cavity, nasal passages, and salivary glands develop from a small depression called a stomodaeum in the ectoderm (outer germinal layer). Three types of melanin — black, brown, and yellow — combine in different quantities for each individual to pro- duce different hair colors ranging from light blonde to black.

Copper, 31 years: Tey and computer-assisted technologies must be explored, developed, and implemented. Client is able to verbalize the names of support people from whom he or she may seek help when the desire for substance use is intense. After ossification, the spaces that were formed by the osteoclasts join together to form 23.

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