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The drugs involved most commonly were per capita increases to 32% of the surviving popu- benzodiazepines buy inderal 40 mg line arrhythmia associates of south texas, warfarin inderal 80mg without a prescription arteria auditiva, digoxin and nonster- lation at ages 80–85 (and declines rapidly after age oid anti-inflammatories (Denham and Barnet purchase online uroxatral, 85). This causes enormous cited reports of adverse events causing 5–23% of detriment to the surviving spouse and family and hospitalizations, nearly 2% of ambulatory visits to family finances, and must eventually impact and 1 in 1000 deaths in the general population. In perceived concerns of both investigators and phar- addition, 31% take alcohol frequently (Conn, 1992). There are very increase the bleeding tendency, and not just from fit 80-year-olds who climb mountains, and young the stomach. Antacids can decrease the excretion children dying from genetic advanced aging (pro- of antidepressant tricyclics, quinidine, pseudoe- geria). So many of the above concerns can be the absorption of digoxin and b-blocker hyperten- reduced by selecting ‘uncomplicated, healthy’ sive medication. These are only a few of the older patients in phase I studies, who are increas- multitude of interactive drug effects. This is ingly available due to the success of medicines and imposed on the reduced efficacy of hepatic meta- preventative medicine. For the elderly, of equal importance to life exten- sion and cure is improvement or preservation of their activities. Traditionally, elderly subjects were frequently excluded from clinical drug development (unless 15. The reasons given were that the By the 1980s, most of the new medicines still had elderly suffer from too many other diseases, little or no information on elderly dosing or con- require concomitant medicines, are more frail tained disclaimers. All that 30% of prescription drugs by then were con- these can cause ‘static’ in the interpretation of the sumed by just 12% of the population (those over data, and give undue weightage to adverse events 65 years), a new guideline was issued. The tripartite guidance, Studies in Support of Special patients must be in ‘steady state’. The agency followed up with specific requirements on content and format of labeling 6. Usually, differences in the therapeutic response or adverse events are too small to detect at an equivalent plasma level between ordinary adult 15. Studies should include patients 65 years and lized by the liver, the effect of drug enzyme older, and preferably patients aged 75 or older, inducers and inhibitors should be explored. Finally, other common the increasing importance of medicines for the drugs most likely to be used with the test drug graying population of United States. There is also a unique form called 1993) showed that, for 11 drugs recently approved isolated systolic hypertension, which affects 9% or awaiting approval of New Drug Applications, in of the geriatric population and is growing as the seven applications 30–36% of patients were aged population ages. In one application, a study on a drug for this area increase with the age of patients admitted, prostate cancer, 76% of patients were, not surpris- which correlates with increased concomitant med- ingly, over 60 years old (Everitt and Avorn, 1986).

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How can the information be evalu- brief space of a few decades discount generic inderal canada arrhythmia 1, the acquisition generic inderal 40mg without prescription prehypertension blood pressure diet, stor- ated? Given the complexity of data now available order 25mg benadryl mastercard, age, and retrieval of information has been trans- can nursing theory resources even be evaluated formed from the realm of a labor-intensive manual across various types of media? Will the process be process to that of a digital, multidimensional vir- congruent with the theory and the values of the re- tual medium. The guide for evaluation of theory Nursing exists on the cusp of continual change, resources presented within this chapter moves to- with interfacing technological revolutions taking ward a realistic appraisal by the researcher of the place in nursing education, practice, and research. The rapid advance and integration of technology has not only affected practice (Sparks, 1999), but has also affected ways in which nurses investigate, eval- Theory as a Guiding Framework uate, think, and speak about practice (Turley, 1996). The framework for practice also becomes nursing knowledge is enhanced by the quality of a framework for education, research, and adminis- the resources used. A call for books, journals, and media recordings, emphasis nursing is also a call for transforming knowledge rests upon evaluation of the author and contents of and information; therefore, the response from each resource. In the utilization of the Internet as a nursing should be with clarity, conviction, and resource for “discovery” (Boyer, 1996, p. In this way, nursing theory is inte- dimension requiring evaluation is realized: The grated, lived out in the personhood of the nurse host of the virtual environment, now ubiquitous and continues to shape, guide, and focus the nurse and often fleeting, also must be identified, exam- in all activities. Authorial responsibility and sources is therefore an extension and affirmation of veracity in books and journals that are closely scru- the values grounding the practice of nursing. Role-blurring between Web media routinely complement traditional textbooks site author and owner is subtle yet insistent. The with the virtual world of Internet Web sites that author of the Web pages, or the “webmaster,” is offer sensate immersion in motion, color, and most often another party hired to create and main- sound. Browsing on the Internet frequently results tain the look of the Web site environment and is in traveling through a succession of hyperlinks that therefore not responsible for the content. The thoughtful sible data has also created a paradox: The sheer vol- study of nursing theory, therefore, includes not ume of information has created a gap in the human only consideration of works contributed by the the- ability to process and evaluate it (Jenkins, 2001). To practitioners who are the sources of disseminated whom or what does one respond or carry concerns nursing knowledge. A framework of non-nursing tion resources are exactly alike, guidelines for eval- values is engineered and deeply embedded in elec- uation need to be flexible and adaptable. Conceptual frameworks The thoughtful nurse researcher should proceed in the nurse’s mind provide the means of interfac- flexibly in the research and evaluation process ing and transforming these values embedded in the using “alternating rhythms” (Mayeroff, 1971, p. The challenge for the nurse is to analyze, rower frameworks to comprehend how one aspect is connected with the whole. Evaluation may be un- derstood as alternating between two overlapping The challenge for the nurse is to analyze, phases: The first phase is one in which technical de- evaluate, and transform non-nursing values sign, organization, and aesthetic comportment of embedded in electronic media into a con- the Web site are considered in relation to the con- ceptual framework of human values that tent.

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Chinn • What about the environment was important to and Kramer (2004) apply Carper’s patterns of the needs for nursing and to my nursing re- knowing to develop a framework for nursing sponses? Consider Chapter 4 of this text employs patterns of knowing that values and beliefs are the basis for our nursing buy inderal 40mg line blood pressure medication ringing in ears. Using this frequent in nursing situations in which even pattern of knowing in nursing order inderal 40 mg visa arrhythmia blog, the client is not momentary connection and genuine presence seen as an object but as a person moving toward between the nursing and client is realized buy 70 mg fosamax free shipping. The • Reflecting on the experience of nursing is nurse is also recognized as always learning and primary in understanding esthetic knowing. Reflecting on a person as a client and a per- that nursing practice has in fact been created, son as a nurse in the nursing situation can that each instance of nursing is unique, and that enhance understanding of nursing practice and outcomes of nursing cannot be precisely pre- the centrality of relationships in nursing. Nurses often express esthetic knowing insights are useful for choosing and studying through use of an art form, and thus recreate nursing theory. Empirical knowing concerns nursing theory that emphasizes presence and the science of nursing; the nurse uses empirical perhaps spirituality in the relationship of nurse knowing to access data from nursing, from re- and client. The amount and quality of em- selecting a nursing theory to study and consider for pirical knowing can guide selection of a nursing guiding practice. You will want to answer these theory as a way to frame and use empirics for questions: nursing purposes. According • What theories do I believe are consistent with to Carper (1978), ethics in nursing is the moral my personal values and society’s beliefs? Ethical knowing informs • Given my reflection on a nursing situation, do I us of what is right, what is our obligation, what want theory to support this description of my the nurse ought to do in this situation. These commitments of experience of practice for myself and for my pa- the nurse may be the focus of reflection and may tients? Search the Internet and use on- as highly valued as the science and ethics of line resources for information on nursing theories nursing. However, many nurses realize that es- and their use in practice, research, education, and thetic knowing subsumes all other patterns of administration. You and your tion, consider the level and scope of the theory, as colleagues may seek consultation for assistance discussed in the previous chapter. Is the theory a with analysis and evaluation of specific nursing grand nursing theory? Not all as- pects of theory described in an evaluation guide will be evident in all levels of theory. Whall (1996) recognizes this in offering guides for analysis and evaluation of nursing the- particular guides for analysis and evaluation that ory. Done individually or as a group, this is an ad- vary according to three types of nursing theory: ditional opportunity to learn and to share. This is models, middle-range theories, and practice theo- demanding work, but along with the challenge, this ries.

How often are intravenous administration sets for blood transfusions used with more than one unit of blood and/or non-blood products (e purchase generic inderal from india arteria ethmoidalis posterior. Justify this practice with reference to physiology discount inderal 40 mg with amex heart attack 5 fragger, patient safety 120 mg allegra visa, manufacturer’s information, hospital or unit policy, established practices in your area. Chapter 46 Stress management Fundamental knowledge ‘Fight or flight’ response—see Chapter 3 Introduction Stress is a widely used word, but concepts of stress are often poorly defined. Physiological and psychological effects of stress on patients were discussed in Chapter 3. Stress management, at all levels, is therefore fundamental to both good nursing and good health. Although a popular topic, much literature on stress remains anecdotal, cathartic or dubious. Human responses to stress change little between generations, and so the literature dates less quickly than with most topics in this book; however, contexts of practice do change so that older literature should be placed within the context of changes in nursing practice. Stress: a problem Nurses experiencing distress work less efficiently, and are less able to support others; unresolved distress usually escalates. The Office of Population Census Surveys for 1979– 1990 identified an average yearly suicide rate of 29 female nurses every year; this rate increased to 50 per year between 1990 and 1992 (Seymour 1995b). While not all suicides necessarily result from work-related pressures, nurses need to look after themselves as well as others, and need staff support systems. Psychological aspects of stress are less precise as stress is an individual subjective response, so that while stressors may be common, what one person finds stressful another person may enjoy (e. Eustress (eu=good) is stress that stimulates people to function more efficiently and enjoy life; ‘distress’ is a familiar concept. Because responses to stressors are individual, what is eustressful and distressful will vary between people; excessive exposure to eu-stimuli can become distressful. If relatives perceive nurse-stress, their loss of confidence may accentuate their own stress levels (although Ramos’s (1992) American study of general nurses suggested emotional involvement with patients provided potential support). Developing technical skills can obscure the human focus central to nursing (see Chapter 1); however nurses choose to develop their knowledge, they should ensure that they maintain and develop the interpersonal/human skills they already possess. Stimulus-based model Following the behaviourist philosophy (see Chapter 2), stressful stimuli would cause a response of stress. Therefore, reducing environmental stressors should reduce stress (Lloyd-Jones 1994). However, this approach fails to recognise the individuality of people and their stress responses (Lloyd-Jones 1994. Intensive care nursing 434 Response-based model This model focuses on internal responses: fear (stimulus) causes cate-cholamine-induced hypertension (response). Selye’s General Adaptive Syndrome (1976) has three stages: ■ alarm reaction ■ resistance ■ exhaustion. Transactional model This theory largely combines the previous two: stress results from dynamic interaction between both stressors and individuals.