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Treatment is incision and drainage or needle aspiration discount 15 mg prevacid free shipping, fol- lowed by high-dose penicillin or clindamycin order prevacid 15mg without a prescription. Patients present with erythematous tonsils, tonsillar exudates, enlarged and tender anterior cervical lymph nodes. This patient has several of these factors and should, therefore, be admitted for further management. Surgical drainage or salpingectomy and oophorec- tomy may be required in resistant cases. Other symptoms include weakness, myalgias, dyspnea, chest pain, cough, headache, and anorexia. Neurologic signs and symptoms (eg, confusion, personality changes, decreased level of consciousness, and focal motor deficits) are seen in 30% to 40% of patients. Vasculitic lesions, including petechiae, splinter hemorrhages, tender fingertip nodules (Osler nodes), and nontender palmar plaques (Janeway lesions) are seen in 35% of patients. Splenomegaly, new heart murmur, and retinal hemorrhages may also be detected on physical examination. Bacteria and enteroviruses, especially Coxsackie B virus and adenovirus, predominate as causative agents. Often myocarditis presents with flu-like complaints, including fever, fatigue, and myalgias. Tachycardia out of proportion to the temperature or clinical picture may be present. The etiology is broad, including infection, trauma, metabolic diseases (eg, uremia), medications, systemic autoimmune diseases, and most often the cause is idiopathic. The condition is better described as an osteitis of the underlying bone of the external auditory canal caused by P aeruginosa. It is distinguished by fever, intense ear pain, erythema, edema, and granulation tissue in the external canal. The same drugs can be used for the second stage of disease, but their course of therapy needs to be longer. Fever Answers 205 (a) This patient has Lyme disease, which is seen in the late spring and early summer. The lesion is characterized by a bright red border and central clearing and quickly spreads outward. Sero- logic testing may be positive weeks after inoculation, but a biopsy of the rash would neither be necessary nor informative. In this case, however, the patient has a clear history and characteristic rash for Lyme disease with- out meningeal signs or focal neurological signs. Serum immunofluorescent antibody assays are usually nega- tive until approximately 6 weeks, when immunoglobulin M (IgM) peaks and indicates active disease. Syphilis can cause false-positive titers, but the different clinical presentations should distinguish the diseases. It affects all age groups with the highest incidence in males 20 to 40 years of age. While no causative factor can be found in 50% of cases, known trig- gers include infection, especially Mycoplasma and herpes simplex virus, drugs, especially anticonvulsants and antibiotics, and malignancies. Culture results are often negative; culture results’ yield may be improved, however, by placing 10 mL of ascitic fluid in a blood culture bottle. Gram-negative Enterobacteriaceae (eg, E coli, Klebsiella) account for 63% of all cases. For the past 2 days he has been feeling weak and over the last 6 hours he has noticed that his heart is racing. You are a passenger aboard an airplane and a 78-year-old woman is complaining of chest pain and difficulty breathing. On examination, the patient is in obvious dis- tress, but able to answer basic questions. You confirm that his airway is patent, breath sounds are equal bilaterally, and his abdomen is soft and nontender. His right leg is shorter than his left leg, slightly angu- lated, and swollen in his anterior thigh area. You are called to the bedside of a hypotensive patient with altered mental status. You feel that the patient is unstable and elect to perform emergency cardioversion. Paramedics bring in a 54-year-old man who was found down in his apartment by his wife. Records indicate that he has a past medical history of hyper- tension, diabetes, dementia, and benign prostatic hypertrophy. His lungs are clear to auscultation, with scant crack- les at the bases, and his abdomen is soft, nontender, and nondistended. The nurse places the patient on a cardiac monitor and begins to get his vital signs.

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Eclampsia should be controlled with intravenous/intramuscular magnesium (Eclampsia Trial Collaborative Group cheap prevacid 30 mg without a prescription, 1995; DoH discount 30 mg prevacid with amex, 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.

For of age and walk by the middle of the second year buy prevacid 15 mg low cost, any example buy 30 mg prevacid amex, if people were not responsible for negative be- child who was more than five or six months delayed in haviors, they should not be punished, for they had no attaining those two milestones would probably be classi- control over their behaviors. Instead, the environment fied as developmentally delayed and the parents should that reinforced the unwanted behaviors should be consult the pediatrician. There- the unconscious and contended that behavior is caused fore, any child who is not speaking words or sentences by internal, mental mechanisms. In some ways, Freud by the third birthday would be considered developmen- was more extreme than Skinner, who acknowledged that tally delayed and, as in motor development delay, the some behaviors are not predictable. Thus, Thus, the small group of children with autism do not even though Freudians and Skinnerians differ on almost show normal social development but these children are every conceivable dimension, they have at least one usually called disabled or autistic rather than develop- commonality in their reliance on determinism. Similarly, most children are able to Those scientists who believe that behaviors are de- read single words by the second grade of elementary termined have recognized the difficulty in making ex- school. Thus, they have developed the concept dyslexic or learning disabled, or in some cases academi- of statistical determinism. Possible problems are indi- of them unknown, affect actions, which result in general- cated by muscles that are either too limp or too tight. The recently developed theory of or uncertain movements are another cause for concern, as chaos relates to making predictions about complex are abnormalities in reflexes. This theory suggests that in a ment may indicate the presence of a neurological condi- cause-effect situation, small differences in initial condi- tion such as mild cerebral palsy or Tourette’s syndrome. This theory Neurological problems may also be present when a child’s supports the notion that behaviors may not be complete- head circumference is increasing either too fast or too ly predictable even though they may be dictated by fixed slowly. Further Reading Important cognitive attainments that physicians look Doob, Leonard William. Inevitability: Determinism, Fatalism, for in infants in the first 18 months include object perma- and Destiny. Cognitive delays can signal a wide variety of problems, including fetal alco- hol syndrome and brain dysfunction. Developmental Developmental delay milestones achieved and then lost should also be investi- gated, as the loss of function could be sign of a degener- Any delay in a child’s physical, cognitive, behav- ative neurological condition. Delays in social and emotional development can be among the most difficult for parents, who feel rejected by Developmental delay refers to any significant retar- a child’s failure to respond to them on an emotional level. The two most frequent calization, and cuddling, and may feel angry or frustrated reasons for classing a child as having developmental when their children do not respond. However, a delay in delay involve those psychological systems for which social responses can be caused by a number of factors, in- there are good norms. This is especially true for motor cluding prenatal stress or deprivation, prematurity, birth development and language development. Reading disabilities have been classified as either Many physicians routinely include developmental dyseidetic, dysphonetic, or mixed. Parents concerned seidetic type are able to sound out individual letters pho- about any aspect of their child’s development are gener- netically but have trouble identifying patterns of letters ally advised to seek the opinion of a pediatrician or ap- when they are grouped together. Specific assessment instruments phonic readers have difficulty relating letters to sounds, such as the Gesell Development Scales and the Bayley so their spelling is totally chaotic. Children with mixed Scales of Infant Development are used to help deter- reading disabilities have both the dyseidetic and dyspho- mine whether an infant is developing at a rate appropri- nic types of reading disorder. A variety of causes have been advanced for develop- Further Reading mental reading disorder. The Education of Children with Motor and cal explanation have cited heredity, minimal brain dys- Neurological Disabilities. Developmental reading disorder is often identified in the first grade, when reading instruction begins. Children with reading disabilities lag behind their peers in reading Developmental reading progress and have serious spelling problems. They also disorder tend to have trouble writing (many have poor handwrit- ing), have an unusually small vocabulary, and favor activ- A condition in which reading ability is significantly ities that do not require verbal skills. Also, like children below the norm in relation to chronological age and overall intellectual potential. Even at the preschool Also referred to as reading disability,reading diffi- stage, there are certain problems, such as trouble sound- culty, and dyslexia,developmental reading disorder is ing out words and difficulty understanding words or con- the most commonly diagnosed learning disability in cepts, which may foreshadow a reading disability. Estimates of its prevalence vary wide- ly, ranging from 4% of children—the figure given by The outcome of treatment for reading disabilities the American Psychiatric Association’s Diagnostic varies, depending on the quality of the remedial reading and Statistical Manual—to 20%, the figure given by a program, the severity of the disorder, and the motivation 1995 study directed by Sally E. According to the latter figure, some 10 million help, some children with reading disabilities have been children in the United States have some form of reading able to successfully complete high school, college, and disability. Most reading disabilities were formerly grouped Further Reading together under the term dyslexia, which has largely fall- Goldsworthy, Candace L. Developmental Reading Disorders: en out of favor with educators and psychologists because A Language-Based Treatment Approach. San Diego: Sin- of confusion over widespread and inconsistent use of the gular Publishing Group, 1996. Assessment and In- tal reading disorder is distinct from alexia, which is the struction of Reading Disability: An Interactive Approach. Literacy Disorders: Holistic Diagnosis and Re- alexia have helped researchers better understand reading mediation.

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Delta waves demarcate the thought cheap 30mg prevacid with amex, memory buy 30mg prevacid with amex, and perception, are particularly deepest levels of sleep, when heart rate, respiration, tem- known for their consciousness-altering properties. They perature, and blood flow to the brain are reduced and can produce distortion of one’s body image, loss of growth hormone is secreted. In the comes from the Greek word for sleep (hypnos), hypno- United States, for example, hallucinations are devalued tized people are not really asleep. Their condition resem- by mainstream culture as a bizarre sign of insanity, bles sleep in that they are relaxed and out of touch with whereas the youth counterculture of the 1960s viewed ordinary environmental demands, but their minds remain drug-induced hallucinations as enlightening, “mind-ex- active and conscious. In certain other societies, halluci- include lack of initiative, selective redistribution of at- nations are respected as an important therapeutic tool tention, enhanced ability to fantasize, reduced reality used by ritual healers. Also, hypnosis is often followed by post-hypnotic amnesia, in which the Further Reading person is unable to remember what happened during the Dennett, D. It person lives in New York, that person needs a winter must study economics and culture too. The So- Psychology views certain factors that include: 1) The ciety for Consumer Psychology is a division of the Gestalt principle. The restaurant is popular, it is important to understand what group’s main focus is conducting scientific research, cultural implications are present beside the food; 2) The development and practice in the field. What could be the superficial or seem- journal, Journal of Consumer Psychology as well as an- ingly rational reason a person might have for making a other publication, Journal of Consumer Research and purchase (the need)? What other factors (wants) influence Psychology and Marketing, periodically serves as the it? For instance, even if shoes are purchased as foot pro- voice of those engaged in the understanding of why tection, the desired shoe may be open-toed, strapless, and people buy what they buy. New York: John sons to the picture on a candy bar wrapper, the ever-elu- Wiley & Sons 1994. He urged consumers to be Further Information cautious and not fall prey to hidden meanings or symbols Society for Consumer Psychology of the American Psycholog- in advertising, and pointed out less-than-honest repre- ical Association. Contrast Psychologists understand that in the burgeoning econ- The relative difference in intensity between two omy of the early twenty-first century people’s needs and stimuli and their effect on each other. In the 1970s and early 1980s, household items such as computers and video Contrast, or contrast effect, is the effect a visual recorders were new, and counted as luxuries. When one stimulus is present, it virtue of a changing society, those items had become more affects the other. As can be seen in this illustration, two than simple luxuries, as schools and businesses often came gray boxes of equal intensity are surrounded by, in one to require their use. Complex human behavior can take one case, a white field, and in the other, a black field. They have discovered that often in the most depressed eco- These tests are used in the study of visual perception nomic times, the sales of luxury items go up. For Consumer psychology is a pursuit that is likely to ex- example, black and yellow have the lowest contrast ef- pand now that an estimated $5 billion worth of products fect, which means the largest percentage of the popula- were purchased online by the spring of 2000. Online shop- tion can clearly detect the difference between these two ping habits might differ drastically from catalogue sales or colors. These trends are just beginning to be to mark school buses and many traffic signs. Jane Spear Control group Further Reading In an experiment that focuses on the effects of a Asker, Jennifer L. In such an experiment, in Conversion reaction which there are two groups of subjects, the group that is A psychological disorder characterized by physical exposed to the condition or factor is called the experi- symptoms for which no physiological cause can be mental group. For example, in a hypothetical study of the influence of the presence This condition was first described by Sigmund of loud music on the test performances of children, the Freud as conversion hysteria because it involved the control group would consist of the group of children not conversion of a repressed emotional problem to a physi- exposed to the loud music during the test. Today, conversion reaction is classified as scores would be compared with the experimental group, a somatoform disorder in the American Psychiatric As- the group of children who were exposed to loud music sociation’s Diagnostic and Statistical Manual of Men- during the test. Conversion reaction is a very rare condition, ac- counting for about 2 percent of all psychiatric diag- Further Reading noses, and usually first appears during adolescence or Atkinson, Rita L. San early adulthood, generally when an individual is under Diego: Harcourt Brace Jovanovich, 1987. Another source of “secondary gain” is the attraction of attention, sympathy, and sup- port that the patient may need but is unable to obtain in Convergent thinking other ways. The ability to narrow the number of possible solu- tions to a problem by applying logic and knowl- Some of the most common symptoms of conversion edge. Other physical com- ford, a psychologist well-known for his research on cre- plaints include tremors, abdominal pain, and speech im- ativity. Guilford posited that a prime component of cre- pairments such as aphonia, the inability to speak above ativity is divergent thinking, the capacity to arrive at a whisper.

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The term “deficit” refers Nursing to a particular relationship between self-care agency and self-care demand that is said to exist when capabilities for engaging in self-care are less Theory than the demand for self-care purchase prevacid 30mg without a prescription. Isenberg The comprehensive development of the self-care concepts enhances the usefulness of the Self-Care Deficit Nursing Theory as a guide to nursing prac- tice situations involving individuals across the life span who are experiencing health or illness generic prevacid 15 mg on line, and to Research nurse-client situations aimed at health promotion, health restoration, or health maintenance. Practice According to this theory, nurses use their spe- cialized capabilities to create a helping system in Summary Nurses use their specialized capabilities to References create a helping system in situations where persons are deemed to have an existent or potential self-care deficit. According to Orem (2001), it is the special focus on human beings that distinguishes or differenti- situations where persons are deemed to have an ex- ates nursing from other human services. When the answer is the nurse, a wholly tions of the Self-Care Deficit Nursing Theory pro- compensatory system of helping is appropriate. The aspect situations, the goal of nursing is to empower of the Self-Care Deficit Nursing Theory that has the person to meet their self-care requirements by generated the most research of this type is the doing for (wholly compensatory system), doing relationship posited between basic conditioning with (partly compensatory system), or developing factors and self-care agency. Dorothy Johnson (1959), in the Self-Care Deficit Nursing Theory states that in- her treatise on nursing theory development, viewed dividuals’ abilities to engage in self-care (self-care this attribute of a theory as its value for the profes- agency) are conditioned by age, developmental sion, its social utility. This proposition offers direction to nurses Research interested in engaging in theory-based research. Basic conditioning factors are defined as “condi- Dorothea Orem’s theory is offering clear direction tions or events in a time-place matrix that affect the to nurses in the advancement of nursing science in value of person’s abilities to care for themselves” this millennium. It is important to note that the influence of tical science that is comprised of both theoretical the basic conditioning factors on self-care agency is and practical knowledge, a point of view that is not assumed to be operative at all times. There the basic conditioning factors assumed to be oper- are parallels between Orem’s description of nursing ative at all times. Because the influence of these fac- as a practical science and Donaldson and Crowley’s tors occurs within a time-place matrix, research is discussion of nursing as a professional discipline. Both perspectives address the between the basic conditioning factors and the sub- need for nurses to develop both theoretical and stantive structure of self-care agency can then be practical knowledge. Scholarly work of this type is vital to kinds of knowledge about persons with existent or the advancement of the theoretical knowledge of potential health-related self-care deficits. The theory is the result singularly and in combination, on individuals’ self- of Stage 1. Several studies (1981) studied the influence of family as a social designed to determine the nature of the influence of support system on the self-care agency of adults variations in health state on self-care abilities are re- with diabetes mellitus. Research suggests influence of basic conditioning factors on the self- that this relationship is particularly salient in prac- care agency of persons enrolled in a weight-loss tice situations in which persons are experiencing program. The work of selected in- of family variables and caregiver variables on the vestigators is presented here to exemplify this line of self-care abilities of the spouses of patients with a inquiry. Baker (1991) explored the predic- the self-care abilities of persons with coronary tive effect of basic conditioning factors on the self- artery disease has been studied with both American care agency and self-care in adolescents with cystic and Dutch adult patient populations (Isenberg, fibrosis. Across these ence of basic conditioning factors on the self-care studies, changes in health state were found to be capabilities of unmarried women at risk for sexu- critical determinants of the quality of the self-care ally transmitted disease. As the health tualized personality as a basic conditioning factor state of patients improved, so did their capabili- and tested the model with a healthy population and ties for self-care. Conversely, self-care capabilities a comparative clinical population with chronic tended to decline as patients experienced recur- renal disease. The findings re- ence of basic conditioning factors on the self-care vealed a positive relationship between health state abilities of a healthy and clinical adult population and self-care agency in patients with cardiac disease. In addition to the study of variation in health Baiardi (1997) explored the influence of health state due to pathophysiology, the conditioning in- state and caregiving factors on the self-care agency fluence of health state on self-care agency has also of the caregivers of cognitively impaired elders. West ined the influence of personal and environmental (1993) investigated the influence of clinical varia- factors on the self-care behaviors among patients tions in the level of depression, conceptualized as a with congestive heart failure. In a study with Dutch psychiatric patients, Deficit Nursing Theory have been greatly enhanced Brouns (1991) also reported that variations in men- by the measurement work with self-care concepts tal health state significantly influenced patients’ that has transpired over the past 20 years. In both studies a positive rela- portant to note that the theory-testing studies cited tionship between health state and self-care agency above were made possible by the development and was revealed. Higher levels of mental health were psychometric testing of instruments to measure the correlated with higher self-care agency scores. Instruments are currently These findings verified the conditioning influence available to measure the self-care agency of adoles- of health state on the self-care agency of patients’ cent populations (Denyes, 1982), adult populations experience variations in physical and mental health. The availability The conditioning influence of other basic fac- of valid and reliable measures of self-care agency tors on the self-care abilities of clinical and non- has been vital to the advancement of the theoretical clinical populations has been the focus of inquiry component of self-care nursing science. Intervention studies therapeutic self-care demand, self-care agency, and designed to enhance self-care performance are also the self-care actions of individuals with chronic ob- under way. Health state was found to gram of research focused on the self-care of cancer offer significant explanation of variations in the patients who were receiving chemotherapy or radi- self-care actions of this population. Her early descriptive studies clarified universal, developmental, and health deviation self- the health-deviation self-care requisites of this pop- care requisites, Riley (1996) developed a tool to ulation and documented the therapeutic self-care measure the performance and frequency of the self- demand (Dodd, 1982, 1984). More recent work de- care actions of patients with chronic obstructive scribed specific self-care behaviors initiated by pa- lung disease. This tool has the potential to be useful tients receiving these therapies and led to the as an outcome measure in future intervention stud- identification of a patient profile of self-care that ies designed to enhance the self-care abilities of this can be used in practice to target specific patient population. Dodd’s intervention studies Nursing Theory as the basis for her program of re- demonstrated that with targeted information, search with children.

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