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The basic assumption of the M-C 1[10] is that participants who answer in a socially desirable manner are highly likely to answer in a similar manner on all self-report measures buy genuine tegretol on line. Low scores on the M-C 1[10] scale reflect socially undesirable or honest answers purchase tegretol with amex, high scores reflect socially desirable or dishonest answers order tegretol 200 mg with mastercard, and middle scores reflect a combination of both ("Social desirability scale") purchase tegretol with mastercard. Of all the participants, 63% (n=51) scored in the middle range (4-7) while 19% (n=15) scored in the low range (0-3), and 18% (n=14) scored in the high range (8-10). Participants who engaged in significant amounts of socially desirable responding were not discarded from the study. These data were used to provide a measure to gauge the likelihood that participants were providing honest responses to the self-report measure. Marlowe-Crowne Social Desirability (M-C 1[10] scale was significantly associated with three of the instruments used in this study (see Table 9). A weak negative association was noted with the verbal subscale and total scale of the Therapeutic Reactance Scale. This correlation implies that participants who demonstrated higher verbal and total scale reactance scores tend to be honest. These data imply that participants who reported nonadherence to medication-taking and those who 140 reported depressive symptoms were truthful. Participants were mostly single or married, with a mean age of 48 years and employed full-time. Cardiovascular disease risk factors such as physical inactivity, overweight/obese, and a history of smoking were prevalent in the sample. In the optimal predictive model, only age and trust in health care provider significantly predicted medication adherence. In addition, this study explored the relationship between reactant behaviors and medication adherence. This chapter provides an interpretation of the findings and implications for nursing practice. Element of Health Outcome: Adherence to the Recommended Health Regimen Medication adherence. In the current study, one-fourth of the sample reported total adherence to their antihypertensive medication regimen as indicated by a perfect adherence score (9) on the medication subscale of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. In comparison, almost half of the nonadherent group reported they were not faithful in taking their antihypertensive medications consistently. In addition to adherence issues, the appropriateness of pharmacological management should be evaluated. However, in the optimal predictive model, only age and trust in health care provider significantly predicted medication adherence. Each of these predictors is discussed in more detail under the elements of client singularity. If we use these guidelines for Black women, almost one-third of the participants in this study would meet this criterion. Results of this study found that age was both a univariable predictor of medication adherence and a predictor in the final model. Though all age groups were less likely to be adherent to their antihypertensive medications, the greatest predictor was participants aged 40 to 49. In contrast, Weingarten & Cannon (1988) reported that lower adherence to antihypertensive 147 medications was associated with younger clients up to age 55 and older clients over age 65. In the current study, one explanation for less adherence to antihypertensive medications among those aged 40 to 49 could be related to the fact that these women were more likely to be married or separated, work full- or part-time, and live in households with more people (1 to 8) than those in the other age groups. The stressors of marriage, working, and family responsibilities may be all consuming to the point where women in this age group may overlook their own self-care needs, thus contributing to nonadherence to the treatment regimen. Other reasons for these varied findings are the measurements of medication adherence. Thus multiple factors may be associated with varied results when looking at age and adherence. Several studies show that clients self-reporting high medication adherence may not be reflective of their actual medication-taking (Choo et al. The high school completion rate for this sample was slightly higher than the national average of 80% for Blacks (Crissey, 2009), and more than half of this sample had greater than a high school education. In the current study, there was no statistically significant association between education and medication adherence. Results of this study suggest that educational level does not necessarily have an effect on antihypertensive medication adherence. In contrast, a study on medication adherence to antihypertensive medication in a Nigerian population found that higher education predicted medication adherence (Ikechuwku, Obinna, & Ogochukwu, 2010). In contrast, women with less than a high school education were less adherent than women with higher education. These results suggest that there may be a disconnect between educational obtainment and adherence. Increased levels of education may not necessarily provide an assurance of adherence. In fact, Braverman and Dedier (2009) reported that clients with higher education may better understand content only to become argumentative and resistive to the information provided. This perspective closely resembles reactance behaviors whereby if a client is told what to do; he/she is likely to do the opposite (J. However, no studies were found that examined the association of reactance behaviors to higher educational levels. One issue that may help to explain medication nonadherence is illiteracy and education, in those with less than and greater than a high school education. With the advent of inflated grades in the educational system, illiteracy may be problematic for clients with low educational levels as well as those with higher education. Thus, educational level may not be a good surrogate model of a client‘s intelligence and ability to learn, apply knowledge, and choose appropriate lifestyle modifications. Therefore, other models of educational attainment may be necessary to assess literacy, especially as it pertains to a client‘s basic medical knowledge. The current study examined the relationship between medication adherence and religion. Religion and spirituality are frequently used interchangeably but are different terms. Whereby religion is overtly expressed in adherence behaviors to prescribed religious beliefs, spirituality is inwardly expressed but not tangible (L. Just as God allows people to freely choose to adhere or not adhere to His laws, the same freedom to adhere or not adhere to the treatment regimen is available. While nonadherence to God‘s laws has consequences, the same holds true for nonadherence to the health care regimen. Both religion and health promoting behaviors employ similar characteristics in that both require people to be doers of prescribed beliefs or the prescribed treatment regimen to achieve optimal benefits. In the current study, there was no statistically significant association between religion and medication adherence. These results suggest that religion does not necessarily have an effect on antihypertensive medication adherence. The majority of the sample was recruited by snowball or social nomination from church members. Therefore, 150 all participants reported affiliation with a religious denomination even though a small percentage of the sample did not identify membership in a church or place of worship. However, no studies were found that explored if adherence to religious activity is associated with adherence to the prescribed treatment regimen. A study of this nature may help clarify the true nature of a client‘s claim to religiosity or spirituality versus an affiliation with a religious group that serves as a social club. Conversely, if a client is not truly adherent to their religious practice, this may be evident in other areas of their lives. Yet, there is an underlining assumption that reported adherence to religious activity equates to adherence to other activities. Because religious principles and medication adherence are both predicated on the multifaceted nature of 151 human behavior that is impacted by social, psychological, physical, and environmental stimuli, oftentimes the rationale and mechanisms that drive free choice are not easily understood, predicted, or responsive to change.

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Criticizing yourself for the sabotage you notice yourself committing only leads to more sab- otage cheap tegretol online american express. Chapter 3: Overcoming Obstacles to Change 41 Worksheet 3-14 My Self-Sabotage Diary Day Self-Sabotage Response to Self-Sabotage Sunday Monday Tuesday Wednesday Thursday Friday Saturday You can download extra copies of this form at www order tegretol australia. Rewriting your self-sabotaging scripts Our minds create stories — about ourselves cheap tegretol express, our lives purchase tegretol with visa, and our worlds. For example, you may have a long- running play in your mind that has you as its central character. Try creating a new story about you and your life that allows you to ultimately succeed. But remember, in addition to success, the new story needs to contain realistic struggle and difficulty. Part I: Analyzing Angst and Preparing a Plan 42 Worksheet 3-15 Molly’s Current Life-Script I might have money and a little prestige, but I deserve none of it. Although it takes her a while to start believing it, gradually she begins to see her life in a new light. Worksheet 3-16 Molly’s New Life-Script I have a good job, and I worked very hard to get it. Besides, I’m capable of learning new behaviors, and I’m working on my irritability. This will be a struggle for me, but I see myself cutting back a little on my work and making new friends. In Worksheet 3-17, write your current life-script, including how you see yourself today and in the future. Be sure to include your thoughts on hope, change, possibilities, as well as struggle. Worksheet 3-17 My Current Life-Script Worksheet 3-18 My New Life-Script Chapter 4 Minding Your Moods In This Chapter Listening to your body Figuring out your feelings Connecting events and feelings Tracking thoughts, events, and feelings ou can’t overcome anxiety and depression by running on autopilot. In this chapter, we provide instructions for observing the relationships among your feelings, your thoughts, and the happenings in your life. This information helps you become more aware of the physical components of depression and anxiety. Some people aren’t very good at identifying their feelings, so we help you by providing a list of feeling words. Finally, we show you how to become aware of how thoughts link up with feelings, events, and bodily sensations. Deciphering Body Signals Your heart may race or your hands may sweat when you feel anxious. Monitoring your bodily sensations gives you an early warning that a storm of emotional distress is brewing. Tyler begins to understand his body’s signals by monitoring phys- ical sensations on a daily basis. He jots down any time that he feels something uncomfortable in his body and includes information about what was going on at the time. Worksheet 4-1 Tyler’s Body Responses Tracking Sheet Body Response How did my body feel? Breathing/ I could tell my Tuesday evening while talking with Increased heart breathing was rapid my ex-wife. Headaches None this week Posture I noticed I’m walking I notice this mostly after lunch on around stooped Thursday and Friday. Other: Dizziness, Spacey and Saturday morning before paying sweating, lightness, light-headed bills. Worksheet 4-2 Tyler’s Reflections I noticed that my body seems to react to what’s going on in my life. These sensations aren’t very pleasant, and maybe the doc is right that I’m depressed. I realize that talking with my ex-wife and my boss both make me feel pretty weird and stressed. Now that I know all this, I really want to do something to get myself to a better place. Now fill out your own Body Responses Tracking Sheet (see Worksheet 4-3) and record your reflections on the exercise (see Worksheet 4-4). If you experienced a reaction in a given category, elaborate and specify how your body reacted (in the middle column). Chapter 4: Minding Your Moods 45 Worksheet 4-3 My Body Responses Tracking Sheet Body Response How did my body feel? Muscle tightness Breathing Stomach symptoms Fatigue Headaches Posture Other: Dizziness, lightness, tingling, constriction in throat or chest, or feeling spacey and disoriented Visit www. We recommend stashing a couple of them in your purse or briefcase so they’re handy whenever you experi- ence unpleasant physical sensations. Part I: Analyzing Angst and Preparing a Plan 46 Worksheet 4-4 My Reflections Connecting the Mind and Body After you become more observant of your body’s signals, it’s time to connect your mental and physical states. If you’re unac- customed to describing your feelings, spend some time looking over the list of words in the following chart and ponder whether they apply to you. Track your feelings every day for a week using the Daily Unpleasant Emotions Checklist in Worksheet 4-5. At the end of the week, look back over your checklist and tally the most prevalent feelings. Worksheet 4-5 Daily Unpleasant Emotions Checklist Day Sadness Fear Shame Anger Sunday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Monday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Tuesday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Chapter 4: Minding Your Moods 47 Day Sadness Fear Shame Anger Wednesday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Thursday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Friday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Saturday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Worksheet 4-6 My Reflections Putting Events, Feelings, and Sensations Together As you work through this chapter, you should become more aware of how your body reacts to events in your life. And thanks to the Daily Unpleasant Emotions Checklist in the previous section, you have feeling words to label your mental and physical states. It’s time to connect these body sensations and feeling words to the events that trigger them. Part I: Analyzing Angst and Preparing a Plan 48 Jasmine suffers from constant worry and anxiety. She thinks that her worries mainly center on her children, but at times she has no idea where her anxiety comes from. She pays special attention to her body’s signals and writes them down when- ever she feels something unpleasant. She rates the emotions and sensations on a scale of 1 (almost undetectable) to 100 (maximal). Worksheet 4-7 is a sample of Jasmine’s Mood Diary; specifically, it’s a record of four days on which Jasmine noticed undesirable moods. Worksheet 4-7 Jasmine’s Mood Diary Day Feelings and Sensations (Rated 1–100) Corresponding Events Sunday Apprehension, tightness in my I was thinking about going to chest (70) work tomorrow morning. Thursday Worry, tightness in my chest My middle child has a cold, and (60) I’m worried she’ll have an asthma attack. Saturday Nervous, tension in my I have a party to go to, and I shoulders (55) won’t know many people there. After studying her complete Mood Diary, she comes to a few conclusions (see Worksheet 4-8). This exercise can provide you with invaluable information about patterns and issues that consistently cause you dis- tress. For at least one week, pay attention to your body’s signals and write them down whenever you feel something unpleasant. Refer to the Daily Unpleasant Emotions Checklist earlier in this chapter for help finding the right feeling words. Rate your feeling on a scale of intensity from 1 (almost undetectable) to 100 (maximal). Ask yourself what was going on when you started noticing your emotions and body’s signals. The corresponding event can be something happening in your world, but an event can also be in the form of a thought or image that runs through your mind. Be concrete and specific; don’t write something overly general such as “I hate my work. Look over your Mood Diary to see if you can draw any conclusions or come up with any new insights into where your body signals come from. Worksheet 4-9 My Mood Diary Day Feelings and Sensations (Rated 1–100) Corresponding Events Sunday Monday Tuesday Wednesday Thursday Friday Saturday Visit www. Part I: Analyzing Angst and Preparing a Plan 50 Worksheet 4-10 My Reflections Becoming a Thought Detective Imagine yourself in a parking lot at night. Or do you feel dis- traught and upset with yourself because you believe you were careless?

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Considerable advances in controlling drug release from delivery systems have been made; such systems are described in detail in Chapters 3 proven tegretol 400 mg, 4 and 16 cheap 200mg tegretol with visa. By effective management of the dose size and the dose frequency order tegretol 100mg without a prescription, it is possible to achieve therapeutic steady-state levels of a drug by giving repeated doses purchase tegretol 400mg with mastercard. An example of the type of plasma profile obtained after repeated oral dosing of a drug is shown in Figure 1. However, multiple oral dosing is associated with disadvantages: • The drug concentration does not actually remain constant in the plasma, but fluctuates between maximum (peak) and minimum (trough) values (Figure 1. These fluctuations in plasma concentration may mean that drug levels may swing too high, leading to toxic side-effects; alternatively drug levels may fall too low, leading to a lack of efficacy. An alternative approach to overcome these limitations is to use a delivery system which provides zero-order controlled release of the drug (Figure 1. Zero-order controlled release offers the advantage of improved control over drug plasma levels: the peaks and troughs of conventional therapy are avoided and constant plasma levels are attained. The risk of side- effects is minimized since possible toxic peak drug plasma levels are never obtained and the total amount of drug administered is lower than with frequent repeated dosing. There is also a reduction in symptom breakthrough which can occur if plasma concentrations drop too low. Furthermore, patient compliance is also improved as a result of the reduction in the number and frequency of doses required to maintain therapeutic efficacy. For example, the problem of dosing through the night is eliminated since the drug is slowly released in vivo. A wide variety of drug delivery systems have been developed to achieve zero-order controlled release and are discussed further in the relevant chapters. Situations in which changing levels of response may be required include: Circadian rhythms Biological processes are frequently associated with rhythms of a predictable period. Some of these rhythms have periods of less than a second, others are ultradian (a period ranging from a few minutes to a 31 Figure 1. The intensity of the disease state and associated symptomatology may vary over a 24 h period. For example, in hypertension, blood pressure is lower during the night and increases early in the morning, therefore optimal therapy should facilitate maximum drug levels in the morning. Approximately 80% of insulin-dependent diabetics experience the dawn phenomenon, a rapid rise in serum glucose levels in the dawn hours. At this time interval, the insulin dose should be increased to meet the biological need. Variation in the pharmacokinetics of a drug may also occur (chronopharmacokinetics) which is directly related to the time of day that the drug is administered. The responsiveness of the biological systems (chronopharmacodynamics) may also vary depending on the time of day that the drug is administered, thereby possibly resulting in altered efficacy and/or altered intensity of side-effects. This in turn has created huge challenges, but also exciting opportunities for drug delivery. The goal is to tailor drug input to match these complex, newly defined time courses. There are already some examples of chronotherapeutics in the literature, including the timed administration of theophylline and corticosteroids to asthmatics, treatment of hypertension and, increasingly, the administration of cytotoxic drugs. However, this is still a new, and as yet, poorly understood area of study with much progress to be made. Fluctuating metabolic needs Insulin causes a decrease in blood glucose concentrations. Physiologically, insulin delivery is modulated on a minute-to-minute basis as the hormone is secreted into the portal circulation and requirements vary widely and critically with nutrient delivery, physical activity and metabolic stress. Ideally, an insulin 32 delivery system should be instantaneously responsive to these fluctuating metabolic needs. A variety of other drugs such as calcitonin and growth hormone also demand complex release requirements. Pulsatile release Many endogenous peptides and proteins are released in a pulsatile fashion and subject to complex feedback control mechanisms, consequentially, drug timing plays a crucial role in determining the observed effect. The precise molecular site of action of this process is unclear, but it is thought to involve an initial loss of receptors, followed by an uncoupling of receptors from their effector systems. Chronic administration is used clinically in the treatment of sex- hormone responsive tumors such as prostate and breast cancer. Again, the challenge for drug delivery is to match drug input with the desired therapeutic outcome. Research is currently concentrated in two main areas: • peptides and proteins; • nucleic acid therapies. These new biotherapeutics are discussed briefly below, with particular reference to the problems associated with their successful drug delivery and targeting. However, significant 33 advances in recent years in the fields of biotechnology and molecular biology have led to the availability of large quantities of pure, potent and highly specific peptide and protein drugs, often with modified or “super- agonist” properties, for a wide variety of therapeutic and diagnostic indications (Box 1. However, there exists a large number of barriers to their successful delivery: In vitro stability barriers Peptides and proteins possess an inherent instability due to the chemical reactivity of certain amino acids. This results in degradation reactions such as transpeptidation, side-chain hydrolysis, diketopiperazine formation, disulphide exchange, oxidation and racemization. Stability is affected by environmental factors, including pH, organic acids, ionic strength, metal ions, detergents, temperature, pressure, interfaces and agitation. Exopeptidases cleave at N- and C- termini and endopeptidases cleave at an internal peptide bond example, susceptibility of proteins to thermal inactivation can seriously limit the range of methods that can be used in their sterilization, as well as in the fabrication of their delivery systems. Freezing concentrates the protein, buffer salts, other electrolytes and may dramatically shift pH. Peptide and protein instability in vitro is manifested by the tendency of such molecules to undergo self- association in solution, resulting in the formation of multimers and, in the extreme, aggregation and precipitation. For example, insulin at pH 7 exists predominantly as hexameric aggregates, which are too large to be absorbed. Proteins tend to undergo denaturation in vitro, the rates of interfacial denaturation are strongly dependent on the specific protein and on such solution properties as temperature, pH and salt concentration. For example, human growth hormone undergoes only limited, and fully reversible, denaturation between pH 1. Various approaches have been attempted to prevent loss of protein by adsorption to glass and plastic, including treating surfaces with proteins such as bovine serum albumin, fibrinogen and ovalbumin, or modifying the solvent by adding surfactants or glycerol. Potential peptide and protein drugs are subject to degradation by numerous enzymes or enzyme systems throughout the body. Small peptides are relatively resistant to the action of endopeptidases but their activity is significant for large peptides. By considering these features, the enormous difficulties associated with overcoming the enzymatic barrier to peptide and protein delivery should be apparent. Degradation usually occurs at the site of administration and is possible in every anatomical site en route to the target receptor. Furthermore, protecting a single bond on a peptide or protein drug from a particular type of enzyme is insufficient to confer protection on the entire drug from enzymatic hydrolysis—other enzymes may attack the protected bond and the other unprotected bonds on the drug are still vulnerable. Several methods of modifying peptide structure to improve metabolic stability have been investigated, including: • substitution of an unnatural amino acid in the primary structure; • introduction of conformational constraints; • reversal of the direction of the peptide backbone; • acylation or alkylation of the N-terminus; • reduction of the carboxy-terminus; formation of an amide. However, even extensive modifications of peptide structure can only afford relative, rather than absolute, protection from enzyme attack. In the gastrointestinal tract, the enzymatic barrier is probably the most significant obstacle to the successful oral delivery of peptides and proteins, as demonstrated by the following observations: • The rate of hydrolysis of peptides is inversely related to the amount transported across the intestine. Luminal activity from the pancreatic proteases trypsin, chymotrypsin, elastase and carboxypeptidase A is mainly directed against large dietary proteins. The main enzymatic activity against small bioactive peptides is derived from the brush border of the enterocyte. Intracellular degradation is most specific against di-peptides and occurs mainly in lysosomes, but also in other intracellular organelles. In comparison to the oral route, much less is known about the nature of the enzymatic barrier to therapeutic peptides and proteins in alternative routes such as the buccal, nasal, pulmonary, dermal and 36 vaginal routes. As a first step in characterizing the proteolytic barrier, the proteolytic activity in various mucosal tissues can be determined by incubating a peptide or protein in epithelial tissue homogenates. However, care should be exercised in interpreting studies of this kind as peptides are often exposed to a wide range enzymes, including both extra- and intracellular enzymes, present in a homogenate of epithelial tissue. The actions of intracellular enzymes will not be significant if the peptide is absorbed by the paracellular route, never coming into contact with the inside of the cell. Studies on characterizing the enzymatic barrier at each delivery site have investigated the pattern of cleavage of enkephalins, substance P, insulin and proinsulin, and have demonstrated the presence of both exo- and endo-peptidases in the various epithelial tissues. What distinguishes one route from another is probably the relative proportion of these proteases, as well as their subcellular distribution.

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